Is it appropriate to start a patient on Lantus (insulin glargine) 10 units once a day?

Starting a Patient on Lantus 10 Units Once Daily

Yes, starting a patient on Lantus (insulin glargine) 10 units once daily is an appropriate initial dosing strategy for most patients requiring basal insulin therapy.

Evidence-Based Rationale

According to the American Diabetes Association (ADA) guidelines, when initiating basal insulin therapy:

• For insulin-naive patients, the recommended starting dose of insulin glargine is 0.1-0.2 units/kg/day or 10 units once daily 1
• In hospitalized patients without previous insulin dosing, a reasonable starting point is 10 units of insulin glargine every 24 hours 2
• The FDA-approved labeling for insulin glargine states that for patients with type 2 diabetes who are not currently treated with insulin, the recommended starting dosage is 0.2 units/kg or up to 10 units once daily 1

Dosing Considerations

Patient-Specific Factors

Consider adjusting the starting dose in these situations:

• Lower starting dose (0.1-0.15 units/kg) for:

  • Patients with retinopathy (0.12 units/kg) 3
  • Patients with renal impairment (eGFR <60 mL/min/1.73m²) (0.114 units/kg) 3
  • Women (0.135 units/kg) 3
  • Elderly patients at higher risk of hypoglycemia 2

• Higher starting dose (0.3-0.4 units/kg) may be reasonable for:

  • Patients with more severe hyperglycemia 2

Titration Protocol

After initiating Lantus at 10 units daily:

• Monitor fasting blood glucose daily
• Adjust dose every 3-7 days based on fasting glucose patterns:
  • 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% 4

Administration Guidance

• Administer subcutaneously into the abdomen, thigh, or deltoid 1
• Rotate injection sites within the same region to reduce risk of lipodystrophy 1
• Can be administered at any time of day, but should be given at the same time every day for consistency 1, 5
• For patients with nocturnal hyperglycemia, consider morning administration rather than evening 4

Common Pitfalls to Avoid

1. Failure to titrate: The initial 10-unit dose is rarely the final effective dose. Regular titration based on blood glucose monitoring is essential for achieving glycemic targets 2.

2. Overbasalization: Increasing basal insulin beyond 0.5 units/kg/day without adding prandial insulin may lead to overnight hypoglycemia without adequately controlling daytime glucose 2.

3. Inadequate monitoring: During initiation and titration, daily self-monitoring of blood glucose is necessary 2.

4. Mixing with other insulins: Lantus should not be mixed with other insulins in the same syringe 1.

5. Discontinuing oral agents prematurely: When starting Lantus in type 2 diabetes, metformin should generally be continued 2.

Special Situations

• Type 1 diabetes: Lantus must be used concomitantly with short-acting insulin 1
• Hospitalized patients: A basal-plus approach (basal insulin with correctional doses) is preferred over sliding scale insulin alone 2
• Patients on glucocorticoids: May require higher doses and different insulin regimens to manage steroid-induced hyperglycemia 2

Starting with 10 units of Lantus once daily provides a safe initial approach that can be titrated based on individual response, minimizing the risk of hypoglycemia while beginning to address hyperglycemia.