Insulin Regimen for Type 2 Diabetes with HbA1c 11.9%
For a patient with Type 2 diabetes with HbA1c of 11.9%, BMI 23, and weight 71.6 kg, the recommended Lantus starting dose is 14-15 units daily, with a carbohydrate ratio of 1:10 and a correction factor of 1 unit for every 50 mg/dL above target glucose. 1, 2
Initial Insulin Dosing
- Lantus (insulin glargine) starting dose should be 0.2 units/kg or up to 10 units once daily for insulin-naïve patients with type 2 diabetes 1, 2
- For this 71.6 kg patient with very poor glycemic control (HbA1c 11.9%), calculate: 71.6 kg × 0.2 units/kg = 14.3 units, rounded to 14-15 units of Lantus daily 2
- Administer Lantus subcutaneously once daily at the same time every day, preferably into the abdominal area, thigh, or deltoid 2
- With HbA1c >10%, basal insulin plus mealtime insulin is often the preferred initial regimen 1
Carbohydrate Ratio and Correction Scale
- Initial carbohydrate ratio: Start with 1:10 (1 unit of rapid-acting insulin for every 10 grams of carbohydrate) 1
- Correction factor: Begin with 1 unit of rapid-acting insulin for every 50 mg/dL above target blood glucose 1
- Target pre-meal glucose: 90-130 mg/dL 1
- Target post-meal glucose: <180 mg/dL 1
Titration Algorithm
- Adjust Lantus dose by 2-4 units every 3-4 days until fasting blood glucose consistently reaches 90-130 mg/dL 1, 2
- If severe hypoglycemia occurs or blood glucose falls below 70 mg/dL, reduce the Lantus dose by 10-20% 2
- Equip patient with self-titration algorithm based on self-monitoring of blood glucose to improve glycemic control 1
Comprehensive Management Approach
- With HbA1c 11.9%, this patient requires aggressive glycemic management to reduce risk of complications 1
- Target HbA1c should be <7% given the patient's normal BMI and absence of information suggesting limited life expectancy or advanced complications 1
- Continue metformin if already prescribed and not contraindicated 1
- Monitor for hypoglycemia, especially at night, as this is less common with insulin glargine compared to NPH insulin but still a significant risk 3
Follow-up and Monitoring
- Check HbA1c every 3 months until target is achieved 1
- Assess for symptoms of hypoglycemia and hyperglycemia at each visit 2
- If basal insulin has been titrated to acceptable fasting blood glucose but HbA1c remains above target, consider advancing to combination injectable therapy with mealtime insulin 1
- Consider consulting with endocrinology if glycemic targets are not achieved despite appropriate insulin titration 1
Common Pitfalls to Avoid
- Inadequate initial dosing: Starting with too low a dose in a patient with HbA1c 11.9% will delay improvement 4
- Failure to adjust: Not titrating insulin doses frequently enough based on blood glucose patterns 1
- Overlooking patient education: Ensure patient understands injection technique, hypoglycemia recognition and management 1
- Ignoring comprehensive care: Remember to address cardiovascular risk factors and screen for complications 1