What is the recommended dosing for Lantus (insulin glargine) in type 2 diabetes patients?

Lantus (Insulin Glargine) Dosing for Type 2 Diabetes

The recommended starting dose of Lantus (insulin glargine) for patients with type 2 diabetes who are not currently treated with insulin is 0.2 units/kg or up to 10 units once daily. 1

Initial Dosing and Administration

• Lantus should be administered subcutaneously once daily at any time of day, but at the same time every day for consistent glycemic control 1
• Injection sites include the abdominal area, thigh, or deltoid, with rotation of injection sites within the same region to reduce the risk of lipodystrophy 1
• When switching from:
  • Once-daily NPH insulin to once-daily Lantus: use the same dose as the NPH dose being discontinued 1
  • Twice-daily NPH insulin to once-daily Lantus: use 80% of the total NPH dose that is being discontinued 1

Dose Titration

• Dose adjustments should be made under medical supervision with appropriate glucose monitoring 1
• A simple and effective titration algorithm involves adjusting the daily insulin dose based on fasting blood glucose levels over the previous 3 days 2:
  • Increase by 0-2 units if FBG is ≥5.6-<6.7 mmol/L (≥100-<120 mg/dL)
  • Increase by 2 units if FBG is ≥6.7-<7.8 mmol/L (≥120-<140 mg/dL)
  • Increase by 4 units if FBG is ≥7.8-<10.0 mmol/L (≥140-<180 mg/dL)
  • Increase by 6-8 units if FBG is ≥10.0 mmol/L (≥180 mg/dL)
  • No increase if any plasma glucose reading is <4.0 mmol/L (<72 mg/dL)

Patient vs. Clinician-Managed Titration

• Patient-managed titration (increasing insulin dose by 2 units every 3 days if blood glucose remains elevated) has shown greater HbA1c reductions compared to clinic-managed titration 2
• However, clinic-managed titration may result in fewer hypoglycemic episodes 2
• The choice between titration approaches depends on the patient's ability and willingness to participate in their diabetes management 2

Advantages of Lantus Over NPH Insulin

• Lantus provides a relatively constant basal level of circulating insulin with no pronounced peak, unlike NPH insulin 3
• Reduced risk of hypoglycemia, particularly nocturnal hypoglycemia (26% reduction in nocturnal and 46% reduction in severe hypoglycemia compared to NPH) 4
• Once-daily dosing is sufficient for basal insulin coverage, improving convenience and adherence 3, 5

Combination Therapy

• In patients with type 1 diabetes, Lantus must be used with short-acting insulin 1
• In type 2 diabetes, Lantus can be used:
  • As monotherapy when oral agents are no longer effective 3
  • In combination with oral hypoglycemic agents 6
  • As part of a basal-bolus regimen with rapid-acting insulin if basal insulin alone is insufficient 7

Safety Considerations

• Hypoglycemia is the most common adverse effect; risk is reduced compared to NPH insulin 4
• Titration of the insulin dose to an appropriate level over several weeks is essential for successful use in type 2 diabetes 5
• Long-term studies (up to 39 months) have shown continued glycemic control without new or unexpected adverse events 6
• Weight gain is a common side effect, typically around 2 kg during initial treatment, with minimal additional weight gain with continued use 6

Monitoring and Follow-up

• Increase the frequency of blood glucose monitoring during changes to insulin regimen 1
• Assess efficacy and safety at least monthly for the first 3 months and at least quarterly thereafter 7
• Early responders (typically defined as >5% weight loss after 3 months) have improved long-term outcomes 7

Remember that insulin requirements may change with physical activity, meal patterns, during acute illness, or with changes in renal or hepatic function 1. Proper patient education on self-monitoring, diet, and hypoglycemia recognition/treatment is essential for successful insulin therapy.