How should I titrate Lantus (insulin glargine) 20 units for a patient with an Hemoglobin A1c (HbA1c) level of 7.9 who is also taking lispro (insulin lispro)?

Titration of Lantus (Insulin Glargine) for Patient with A1c 7.9% on Lispro

For a patient with an A1c of 7.9% currently on Lantus 20 units and insulin lispro, you should increase the Lantus dose by 2 units every 3 days until reaching the fasting plasma glucose goal without hypoglycemia.

Basal Insulin Titration Approach

• Start with the current dose of 20 units of Lantus (insulin glargine) 1
• Set a fasting plasma glucose (FPG) goal based on individualized glycemic targets 1
• Implement an evidence-based titration algorithm: increase Lantus by 2 units every 3 days until reaching the FPG goal without hypoglycemia 1
• If hypoglycemia occurs, determine the cause; if no clear reason is identified, lower the dose by 10-20% 1

Assessment of Insulin Regimen

• Evaluate the adequacy of the basal insulin dose at every visit 1
• Look for clinical signals of overbasalization such as:
  • Elevated bedtime-to-morning glucose differential
  • Postprandial-to-preprandial glucose differential
  • Hypoglycemia (aware or unaware)
  • High glucose variability 1
• Consider that the need for prandial insulin therapy becomes more likely as the daily basal insulin dose exceeds 0.5 units/kg/day, especially as it approaches 1 unit/kg/day 1

Optimizing Basal-Bolus Therapy

• Since the patient is already on both basal insulin (Lantus) and prandial insulin (lispro), ensure appropriate balance between the two 1
• If A1c remains above target after optimizing basal insulin, focus on adjusting the prandial insulin (lispro) doses 1
• For prandial insulin adjustment:
  • Target the meal with the largest glucose excursion 1
  • Consider dosing prandial insulin at 10-15% of the total daily basal dose 1
  • Adjust prandial insulin based on pre-meal and post-meal glucose patterns 1

Monitoring and Follow-up

• Equip the patient with an algorithm for self-titration of insulin doses based on self-monitoring of blood glucose (SMBG) to improve glycemic control 1
• Increase the frequency of blood glucose monitoring during changes to the insulin regimen 2
• Assess A1c after 3 months of therapy adjustment 3
• Regularly reassess every 3-6 months to avoid therapeutic inertia 3

Common Pitfalls to Avoid

• Avoid therapeutic inertia - not advancing therapy despite not meeting glycemic targets 3
• Don't overlook the risk of hypoglycemia when titrating insulin - always balance aggressive titration with safety 1, 2
• Be cautious about weight gain with insulin dose increases, which can occur especially with prandial insulin adjustments 4, 5
• Avoid using insulin as a threat or describing it as a sign of personal failure or punishment to the patient 1

Special Considerations

• If hypoglycemia becomes problematic with Lantus titration, consider adding a GLP-1 receptor agonist instead of increasing insulin doses, as this can provide similar glycemic control with less hypoglycemia and potential weight benefits 4, 5
• For patients with significant postprandial hyperglycemia despite adequate fasting control, focus on optimizing the prandial insulin (lispro) component rather than continuing to increase basal insulin 1