Is it appropriate to start someone on 15 units of basal insulin, such as insulin glargine (Lantus), as an initial dose?

Starting Basal Insulin Therapy: Initial Dosing Recommendations

Starting with 15 units of basal insulin is appropriate for many patients, though the American Diabetes Association recommends initiating at 10 units per day or 0.1-0.2 units/kg per day with subsequent titration based on blood glucose response. 1

Initial Dosing Guidelines

• The American Diabetes Association (ADA) recommends starting basal insulin at 10 units per day OR 0.1-0.2 units/kg per day for most patients 1
• For insulin-naive patients with type 2 diabetes, the FDA-approved starting dose for insulin glargine is 0.2 units/kg or up to 10 units once daily 2
• A typical adult starting dose is often approximately 10 units, but clinical judgment may warrant higher initial doses in some cases 3
• For patients with severe hyperglycemia (A1C >10% or blood glucose ≥300 mg/dL), consider starting at the higher end of the recommended range 1

When 15 Units May Be Appropriate

• For patients with higher body weight (e.g., >75 kg), 15 units would fall within the recommended 0.1-0.2 units/kg dosing range 4
• For patients with significant insulin resistance, such as those with obesity or on glucocorticoid therapy, a higher starting dose may be warranted 1
• If the patient has been requiring >20 units of correction insulin daily, starting with 15 units of basal insulin would be reasonable 3

Titration After Initiation

• After initiating basal insulin, implement an evidence-based titration algorithm, such as increasing by 2 units every 3 days until reaching fasting plasma glucose goals (typically 80-130 mg/dL) without hypoglycemia 1
• If hypoglycemia occurs, determine the cause; if no clear reason is identified, lower the dose by 10-20% 1
• Monitor blood glucose regularly during titration, with particular attention to overnight values 1

Special Considerations

• For hospitalized patients on enteral/parenteral feeding with no prior insulin use, a more conservative approach is recommended: 5 units NPH/detemir every 12 hours or 10 units glargine daily 1
• For patients with type 1 diabetes, basal insulin should represent approximately one-third of the total daily insulin requirements 2
• Patients transitioning from sliding scale insulin to basal insulin should have their total daily correction insulin requirements calculated to guide basal insulin dosing 3
• Avoid "overbasalization" by recognizing when basal insulin dose increases no longer improve fasting glucose control 4

Administration Timing

• Basal insulin (glargine/Lantus) can be administered at any time of day, but should be given at the same time each day for consistency 5
• Morning administration of insulin glargine may result in fewer nocturnal hypoglycemic events compared to evening or bedtime administration 5

Monitoring and Follow-up

• Assess adequacy of insulin dose at every follow-up visit 1
• Consider adding GLP-1 receptor agonists rather than increasing basal insulin beyond 0.5-1.0 units/kg/day if glycemic targets are not met 4
• For patients with persistent postprandial hyperglycemia despite optimized basal insulin, consider adding prandial insulin or other agents 1

Remember that while 15 units is within the acceptable range for many patients, individualizing the dose based on body weight, degree of hyperglycemia, and insulin sensitivity remains the optimal approach to minimize both hyperglycemia and hypoglycemia risk.