What is the initial dose of glargine (insulin glargine) for a patient with hyperglycemia (elevated blood sugar) in the early to mid 200s?

Initial Insulin Glargine Dosing for Blood Sugar in Early to Mid 200s

For patients with blood sugar in the early to mid 200s mg/dL, the recommended initial dose of insulin glargine is 10 units per day or 0.1-0.2 units/kg/day. 1, 2

Dosing Algorithm

1. Starting dose calculation options:

   • Fixed dose: 10 units once daily 1
   • Weight-based: 0.1-0.2 units/kg/day 1, 2

2. Administration timing:

   • Administer at the same time each day for consistency
   • Can be given at any time of day, but bedtime administration is common practice 1

3. Dose titration:

   • Adjust dose every 3 days based on fasting blood glucose (FBG) patterns 3:
     • FBG ≥180 mg/dL: Increase by 6-8 units
     • FBG 140-179 mg/dL: Increase by 4 units
     • FBG 120-139 mg/dL: Increase by 2 units
     • FBG 100-119 mg/dL: Maintain or increase by 0-2 units
     • FBG <100 mg/dL: Decrease by 2-4 units
     • Any hypoglycemia (<70 mg/dL): Decrease by 10-20%

Special Considerations

Patient-Specific Factors

• Renal impairment: Start with lower doses (e.g., 0.1 units/kg) due to decreased insulin clearance 3
• Elderly patients: Start with lower doses to minimize hypoglycemia risk 3
• Insulin-naïve patients: The FDA label specifically recommends 0.2 units/kg or up to 10 units once daily for insulin-naïve type 2 diabetes patients 2

Monitoring Requirements

• Check blood glucose at least 4 times daily (before meals and at bedtime) 3
• Add occasional 2-hour postprandial checks to evaluate meal coverage
• Increase monitoring frequency during dose adjustments to minimize hypoglycemia risk

Additional Treatment Considerations

• Metformin: Continue metformin if already prescribed and tolerated 1
• Meal-time insulin: Consider adding if basal insulin alone doesn't achieve glycemic targets 1
• Combination therapy: When blood glucose levels are 300-350 mg/dL or higher, consider starting with both basal and mealtime insulin 1

Common Pitfalls to Avoid

1. Overbasalization: Increasing basal insulin excessively can lead to nocturnal hypoglycemia without addressing daytime hyperglycemia 3

   • Signs include large drops between bedtime and morning glucose levels

2. Delayed titration: Timely dose adjustments are critical for achieving glycemic targets 1

   • Follow the structured titration schedule rather than waiting for clinic visits

3. Inadequate monitoring: Insufficient glucose monitoring can lead to undetected hypoglycemia 3

   • Ensure patients have access to and understand how to use glucose monitoring devices

4. Fixed dosing in all patients: The weight-based approach (0.1-0.2 units/kg) may be more appropriate than the fixed 10-unit dose for patients with higher body weight 4

The evidence strongly supports starting with a conservative dose and systematically titrating upward based on glucose monitoring results. This approach minimizes hypoglycemia risk while progressively improving glycemic control.