Should the patient's current dose of 30 units (u) of Lantus (insulin glargine) be increased to 34u or 35u?

Insulin Dose Adjustment for Patient on Lantus

Yes, increasing the patient's Lantus (insulin glargine) dose from 30 units to 34-35 units is appropriate if the patient's blood glucose levels remain above target despite the current dose. 1

Insulin Dose Titration Guidelines

When adjusting basal insulin like Lantus (insulin glargine), follow these evidence-based principles:

• For patients already on insulin therapy, dose adjustments should be made in small increments of 1-2 units (or 5-10% of the total daily dose for those on higher doses) once or twice weekly if fasting glucose levels remain above target 2
• The American Diabetes Association recommends adjusting basal insulin every 3 days to achieve target fasting glucose levels (80-130 mg/dL) without hypoglycemia 1
• The proposed increase from 30u to 34-35u represents approximately a 13-17% increase, which falls within the recommended adjustment range 2, 1

Implementation Strategy

1. Titration approach:

   • Increase to 32u first for 3-7 days
   • If fasting glucose remains above target without hypoglycemia, increase to 34-35u
   • Monitor blood glucose daily during dose adjustment period 2

2. Monitoring for effectiveness:

   • Target fasting glucose: 80-130 mg/dL (90-150 mg/dL for older adults) 1
   • Assess pattern of glucose readings before further adjustments
   • Consider HbA1c testing after 2-3 months on stable dose

3. Safety considerations:

   • Watch for hypoglycemia, especially nocturnal episodes (a key advantage of insulin glargine is lower risk of nocturnal hypoglycemia compared to NPH insulin) 3, 4
   • Downward adjustment is advisable if any hypoglycemia occurs 2

Important Considerations

• Administration timing: Administer Lantus at the same time each day for consistent effect 1
• Total daily insulin requirement: Typically 0.4-1.0 units/kg/day for most patients 1
• Prandial coverage: If fasting glucose reaches target but HbA1c remains elevated after 3-6 months of basal insulin titration, consider adding prandial insulin 2
• Split dosing consideration: If the daily dose exceeds 0.5 units/kg/day (especially approaching 1.0 units/kg/day), consider evaluating the need for prandial insulin coverage 2

Potential Pitfalls

• Hypoglycemia risk: Patients with decreased kidney function (eGFR <60 mL/min/1.73m²) have increased risk of hypoglycemia due to decreased insulin clearance and require more frequent monitoring 1
• Insulin potency issues: If unexplained increases in blood glucose occur despite dose increases, consider replacing the insulin vial 1
• Injection technique: Ensure proper rotation of injection sites to prevent lipohypertrophy, which can affect insulin absorption 1

The proposed increase to 34-35 units is reasonable and follows established guidelines for insulin dose titration, assuming the patient's blood glucose levels remain above target on the current 30-unit dose.