What adjustments should be made to a patient's insulin glargine (long-acting insulin) regimen, currently 35 units at night, to improve glycemic control and minimize glucose variability?

Adjusting Insulin Glargine Dosing for a Patient on 35 Units at Night

For a patient currently on 35 units of insulin glargine at night with suboptimal glycemic control, the most effective adjustment would be to split the dose into twice-daily administration, with approximately 50-60% in the morning and 40-50% in the evening to improve glucose stability throughout the 24-hour period. 1

Assessment of Current Regimen

The current regimen of 35 units of insulin glargine at night may be causing:

• Inadequate coverage throughout the full 24-hour period
• Potential early morning hyperglycemia (dawn phenomenon)
• Possible afternoon glucose excursions
• Risk of nocturnal hypoglycemia with higher single doses

Recommended Adjustments

Option 1: Split Dosing (Preferred)

• Morning dose: 18-21 units (50-60% of total)
• Evening dose: 14-17 units (40-50% of total)
• Total daily dose remains 35 units initially

Split dosing provides several advantages:

• More consistent 24-hour insulin coverage 2
• Reduced risk of nocturnal hypoglycemia 3
• Better control of fasting and pre-meal glucose levels 4
• Smoother glucose profile throughout the day 5

Option 2: Dose Adjustment with Once-Daily Administration

If split dosing is not feasible:

• Increase evening dose to 40 units if fasting hyperglycemia persists
• Consider changing administration time to morning if evening dosing causes nocturnal hypoglycemia 4

Monitoring and Further Adjustments

• Check blood glucose before breakfast daily during titration 1
• Additional checks before lunch and dinner to assess 24-hour control
• Increase dose by 2 units every 3 days until target fasting glucose is reached without hypoglycemia 1
• If hypoglycemia occurs, reduce dose by 10-20% 1

Special Considerations

For Patients on Corticosteroids

• If the patient is on corticosteroids, higher insulin requirements may be needed, particularly in the afternoon and evening 6
• For steroid-induced hyperglycemia, consider NPH insulin twice daily at 0.3 units/kg/day (2/3 in morning, 1/3 in evening) 6

For Patients with Variable Schedules

• Morning administration may be better for those with unpredictable evening schedules
• Evening administration typically provides better fasting glucose control 6

Pitfalls to Avoid

1. Underdosing: Insufficient total daily insulin can lead to persistent hyperglycemia
2. Overdosing: Excessive single doses increase hypoglycemia risk
3. Poor timing: Administering at inconsistent times reduces efficacy
4. Inadequate monitoring: Failure to check glucose patterns limits ability to optimize dosing
5. Not considering other factors: Diet, exercise, stress, and concurrent medications all affect insulin requirements

Remember that insulin glargine should be administered subcutaneously into the abdomen, thigh, or deltoid, with rotation of injection sites to reduce the risk of lipodystrophy 7. Proper patient education regarding glucose monitoring, insulin injection technique, and hypoglycemia recognition/treatment is essential for successful management 6.