What is the recommended increment for Lantus (insulin glargine) dose titration?

Lantus (Insulin Glargine) Dose Titration Guidelines

Lantus (insulin glargine) should be increased by 2 units if 50% of fasting finger-stick glucose values over a week are above the target goal. 1

Standard Titration Protocol

• For patients with diabetes, Lantus dose should be adjusted based on fasting glucose measurements taken over a period of one week 1
• If 50% of the fasting finger-stick glucose values are over the goal, increase the dose by 2 units 1
• If more than 2 fasting finger-stick values per week are <80 mg/dL (<4.4 mmol/L), decrease the dose by 2 units 1
• The American Diabetes Association recommends starting with 10 units per day or 0.1-0.2 units/kg per day for insulin-naïve patients 2

Patient-Specific Considerations

• For older adults, a simplified titration approach is recommended with fasting glucose goals of 90–150 mg/dL (5.0–8.3 mmol/L) 1
• Goals may be adjusted based on overall health status and individual care objectives 1
• Patients with retinopathy may require a lower starting dose (0.120 U/kg/day) compared to the standard 0.15 U/kg/day 3
• Patients with eGFR <60 mL/min/1.73 m² should start with a lower dose (0.114 U/kg/day) 3
• Women (0.135 U/kg/day) and patients taking sulfonylureas (0.132 U/kg/day) may also benefit from slightly reduced starting doses 3

Monitoring and Adjustment Schedule

• Titrate dose of basal insulin based on fasting finger-stick glucose test results collected over a week 1
• Dose adjustments should be made every 3-7 days until target glucose levels are achieved 2
• If hypoglycemia occurs without a clear reason, reduce the dose by 10-20% 2
• Assess adequacy of insulin dose at every clinical visit 2

Administration Timing

• Lantus can be administered at breakfast, dinner, or bedtime with similar effectiveness in controlling overall glycemia 4
• Morning administration of Lantus may result in fewer nocturnal hypoglycemic events compared to dinner or bedtime dosing 4

Practical Formula for Dose Calculation

• A simplified formula for determining optimal Lantus dose: Starting dose (0.15 × weight in kg) + incremental dose (baseline HbA1c - target HbA1c + 2) 3
• This formula provides a practical approach to both initial dosing and subsequent titration 3

Common Pitfalls to Avoid

• Delaying dose adjustments when glucose targets are not met can lead to therapeutic inertia 2
• Continuing with the same dose after hypoglycemia occurs instead of reducing by 10-20% 2
• Using rapid-acting insulin at bedtime in older adults, which increases risk of nocturnal hypoglycemia 5
• Failure to monitor for signs of overbasalization (elevated bedtime-to-morning glucose differential, hypoglycemia, high glucose variability) 2

Remember that consistent monitoring of fasting glucose levels is essential for effective and safe titration of Lantus doses to achieve optimal glycemic control while minimizing the risk of hypoglycemia.