What is the proper dosing and titration for initiating insulin 70/30 (Novolin 70/30, NPH insulin (Novolin N) and Regular insulin) and Basaglar (insulin glargine) or Lantus (insulin glargine) therapy?

Insulin 70/30 and Basal Insulin (Basaglar/Lantus) Prescribing Guide

For patients requiring insulin therapy, initiate basal insulin at 10 units per day or 0.1-0.2 units/kg per day, then titrate by increasing 2 units every 3 days to reach fasting plasma glucose goals without hypoglycemia. 1

Basal Insulin (Basaglar/Lantus) Initiation and Titration

Initial Dosing

• Start with 10 units per day OR 0.1-0.2 units/kg per day 1, 2
• Administer at the same time each day (typically bedtime)
• Set a fasting plasma glucose (FPG) goal (typically 80-130 mg/dL) 1, 2

Titration Protocol

• Increase dose by 2 units every 3 days until FPG goal is reached 1
• For hypoglycemia: determine cause; if no clear reason, lower dose by 10-20% 1
• Continue titration until target FPG is achieved without hypoglycemia
• Assess adequacy of insulin dose at every visit 1

Warning Signs of Overbasalization

• Elevated bedtime-to-morning glucose differential
• Elevated postprandial-to-preprandial glucose differential
• Hypoglycemia (aware or unaware)
• High glucose variability
• Basal dose exceeding ~0.5 units/kg/day 1

Insulin 70/30 (NPH/Regular) Initiation and Titration

Initial Dosing

• If converting from basal insulin to 70/30:
  • Total daily dose = 80% of current basal insulin dose 1
  • Divide as: 2/3 before breakfast, 1/3 before dinner 1

Titration Protocol

• Adjust dose based on pre-meal and bedtime glucose readings
• For pre-breakfast hyperglycemia: adjust evening 70/30 dose
• For pre-dinner hyperglycemia: adjust morning 70/30 dose
• Increase dose by 2 units every 3 days until target is reached 1
• For hypoglycemia: determine cause; if no clear reason, lower corresponding dose by 10-20% 1

When to Consider 70/30 vs. Basal-Bolus Regimen

Consider 70/30 when:

• Patient requires simplified regimen with fewer injections
• Patient has predictable eating patterns
• Patient has difficulty managing multiple insulin types
• HbA1c remains above target on basal insulin alone

Consider basal-bolus (Basaglar/Lantus + prandial insulin) when:

• Patient has variable eating patterns
• More precise glucose control is needed
• Patient can manage multiple daily injections
• Patient has significant postprandial glucose excursions

Adding Prandial Insulin to Basal Insulin

If HbA1c remains above goal on optimized basal insulin:

• Start with one dose at largest meal or meal with greatest postprandial excursion 1
• Initial dose: 4 units per day or 10% of basal insulin dose 1
• Titrate by increasing 1-2 units or 10-15% twice weekly 1
• For hypoglycemia: determine cause; if no clear reason, lower corresponding dose by 10-20% 1

Important Considerations

• Maintain metformin when starting insulin therapy when possible 2
• Monitor blood glucose with 4 or more tests daily, including fasting and postprandial measurements 2
• Consider discontinuing sulfonylureas, DPP-4 inhibitors, and GLP-1 receptor agonists when using complex insulin regimens 1, 2
• Consider adding a GLP-1 RA if A1C remains above goal on basal insulin 1
• Patient-led titration can be as effective as physician-led titration with proper education 3, 4
• Prescribe glucagon for emergency hypoglycemia management 1
• Educate patients on hypoglycemia recognition and management 2

Practical Titration Algorithm

1. Start with basal insulin (Basaglar/Lantus) at 10 units or 0.1-0.2 units/kg once daily
2. Increase by 2 units every 3 days until fasting glucose is 80-130 mg/dL
3. If fasting glucose remains at target but HbA1c is still elevated, consider:
   • Adding 70/30 insulin (replacing basal insulin)
   • Adding prandial insulin to basal insulin
4. For 70/30 insulin, divide total daily dose as 2/3 morning, 1/3 evening
5. Titrate each component based on pre-meal glucose values

This structured approach to insulin initiation and titration will help optimize glycemic control while minimizing the risk of hypoglycemia in patients requiring insulin therapy.