Insulin Dose Adjustment for Hyperglycemia
For a patient on 20 units of Lantus with blood sugars in the 300s, you should increase the dose by 4 units (20% of current dose) and continue to titrate by 2 units every 3 days until reaching target fasting glucose levels. 1
Initial Dose Adjustment
- For patients with persistent hyperglycemia (blood sugars in 300s) on basal insulin, an immediate dose increase of 20% (4 units in this case) is recommended to address the significant hyperglycemia 1
- After the initial adjustment, implement a structured titration algorithm: increase by 2 units every 3 days until reaching target fasting plasma glucose without hypoglycemia 1
- Set a fasting glucose target of 90-150 mg/dL (5.0-8.3 mmol/L) to achieve optimal glycemic control 1
Monitoring and Further Adjustments
- Monitor fasting finger-stick glucose values over a week to guide further dose adjustments 1
- If 50% of fasting glucose values remain above target, continue increasing by 2 units 1
- If any fasting glucose readings fall below 80 mg/dL (4.4 mmol/L) more than twice in a week, decrease the dose by 2 units 1
- Assess for clinical signs of overbasalization (elevated bedtime-morning differential, hypoglycemia, high glucose variability) 1
Considerations for Persistent Hyperglycemia
- If blood sugars remain elevated after basal insulin optimization (dose approaching 0.5 units/kg/day), consider adding prandial insulin or non-insulin agents 1
- For significant postprandial hyperglycemia, consider adding prandial insulin starting with one dose at the largest meal (4 units or 10% of basal dose) 1
- If initiating prandial insulin, consider reducing basal insulin dose by 10% to prevent hypoglycemia 1
Special Considerations
- Weight-based titration can be an effective alternative approach, with increases of 0.1 units/kg daily until target is reached 2
- Insulin glargine (Lantus) has a lower risk of nocturnal hypoglycemia compared to NPH insulin, which allows for more aggressive titration 3
- For obese, insulin-resistant patients with persistently high glucose levels, consider splitting the total daily dose into two separate injections for better coverage 4
Practical Tips to Avoid Complications
- Always check for hypoglycemic episodes before increasing insulin dose 1
- Document blood glucose patterns to distinguish between fasting and postprandial hyperglycemia, which may require different management approaches 1
- Consider patient's renal function, as impaired kidney function increases hypoglycemia risk and may require more cautious titration 1
- Ensure patient is properly educated on injection technique, timing, and storage of insulin to maximize effectiveness 1