Insulin Glargine Titration Protocol for Type 2 Diabetes
Basal insulin glargine should be initiated at 10 units per day or 0.1-0.2 units/kg/day, depending on the degree of hyperglycemia, and titrated based on fasting blood glucose monitoring. 1, 2
Initial Dosing
- Start insulin glargine at 10 units once daily or 0.1-0.2 units/kg/day, administered at the same time each day 1, 2
- Higher starting doses (0.2 units/kg or up to 10 units) are recommended for patients with more severe hyperglycemia 3
- When switching from NPH insulin to glargine, use the same dose if previously on once-daily NPH, or 80% of the total dose if previously on twice-daily NPH 3
- Administer subcutaneously into the abdominal area, thigh, or deltoid, rotating injection sites to reduce risk of lipodystrophy 3
Titration Protocol
- Equip patients with a self-titration algorithm based on self-monitoring of blood glucose (SMBG) to improve glycemic control 1
- Adjust dose every 3-7 days until target fasting blood glucose is achieved 4, 2
- A common titration algorithm increases insulin dose by:
- 0-2 units if fasting glucose is 5.6-6.7 mmol/L (100-120 mg/dL)
- 2 units if fasting glucose is 6.7-7.8 mmol/L (120-140 mg/dL)
- 4 units if fasting glucose is 7.8-10.0 mmol/L (140-180 mg/dL)
- 6-8 units if fasting glucose is >10.0 mmol/L (>180 mg/dL) 5
- Decrease dose by 2-4 units if fasting glucose is <4.0 mmol/L (<72 mg/dL) 5
Monitoring and Adjustment
- Target fasting blood glucose of 5.5 mmol/L (100 mg/dL) to achieve HbA1c <7% 5
- Increase frequency of blood glucose monitoring during dose titration and regimen changes 3
- If basal insulin has been titrated to an acceptable fasting blood glucose level but HbA1c remains above target, consider advancing to combination injectable therapy to cover postprandial glucose excursions 1
- Options for combination therapy include adding a GLP-1 receptor agonist or mealtime insulin 1
Concomitant Medications
- Continue metformin when initiating insulin glargine 4, 2
- Consider continuing one additional non-insulin agent with basal insulin 1
- Sulfonylureas, DPP-4 inhibitors, and GLP-1 receptor agonists are typically discontinued when more complex insulin regimens beyond basal insulin are used 4
- Thiazolidinediones or SGLT2 inhibitors may help improve glucose control and reduce total daily insulin dose, but use with caution due to potential side effects 1
Common Pitfalls to Avoid
- Avoid delaying insulin therapy in patients not achieving glycemic goals 1
- Do not mix insulin glargine with any other insulin or solution 3
- Avoid using insulin as a threat or describing it as a sign of personal failure 4, 2
- Be aware of the risk of hypoglycemia, especially within the first four weeks after switching to insulin glargine 6
- Ensure comprehensive patient education on blood glucose monitoring, diet, exercise, and hypoglycemia management 1
By following this structured approach to insulin glargine initiation and titration, patients with type 2 diabetes can achieve improved glycemic control with minimal risk of hypoglycemia.