How to manage a patient with type 2 diabetes on Lantus (insulin glargine) 12 units who will be nothing by mouth (NPO) at midnight?

Managing Lantus (Insulin Glargine) for a Type 2 Diabetes Patient Who Will Be NPO at Midnight

For a patient with type 2 diabetes on Lantus 12 units who will be NPO at midnight, administer the full dose of Lantus as scheduled, as basal insulin should be continued even during periods of fasting to prevent hyperglycemia. 1

Rationale for Continuing Basal Insulin During NPO Status

• Lantus (insulin glargine) is a long-acting basal insulin with no peak action time and a duration of approximately 24 hours, designed to provide steady background insulin levels 2
• Basal insulin should be continued during periods of fasting as it controls hepatic glucose production, not just meal-related glucose excursions 1
• Abrupt discontinuation of basal insulin can lead to hyperglycemia and potentially diabetic ketoacidosis, which poses greater risks than potential hypoglycemia 3

Specific Recommendations for NPO Status

• Maintain the usual 12 units of Lantus at the regular administration time 1
• Increase blood glucose monitoring frequency during the NPO period to every 4-6 hours to detect any hypoglycemia early 2
• Have rapid-acting glucose sources (glucose tablets, IV dextrose) available to treat any hypoglycemia that may occur 2

Hypoglycemia Risk Assessment and Management

• At 12 units (likely less than 0.2 units/kg for most adults), this is a relatively modest dose of basal insulin with lower hypoglycemia risk 2
• If blood glucose falls below 70 mg/dL during the NPO period:
  • For mild hypoglycemia: administer 15-20g of glucose orally if oral intake is permitted 2
  • For severe hypoglycemia or if truly NPO: use IV dextrose or glucagon 2
• If hypoglycemia occurs, consider reducing the next day's Lantus dose by 10-20% 1

Special Considerations

• If the patient will be NPO for an extended period (more than 24 hours):
  • Consider reducing the Lantus dose by 20% if the patient has good glycemic control (HbA1c <7%) 2
  • Maintain the current dose if the patient has suboptimal control (HbA1c >7%) 2
• For elderly patients or those with renal impairment, consider a more conservative approach with a 20-25% dose reduction due to higher hypoglycemia risk 2

Common Pitfalls to Avoid

• Completely stopping basal insulin during NPO status is a dangerous practice that can lead to significant hyperglycemia 1
• Failing to increase monitoring frequency during NPO periods can result in undetected hypoglycemia 2
• Not having a hypoglycemia treatment protocol in place before the NPO period begins 2

Resuming Normal Insulin Regimen

• Once the patient resumes oral intake, continue the regular Lantus dosing schedule 1
• If any dose adjustments were made during the NPO period, gradually titrate back to the usual dose over 2-3 days 2
• Monitor blood glucose closely during the transition back to normal eating patterns 2