What is the starting dose of Lantus (insulin glargine) for inpatients with type 2 diabetes based on insulin requirements?

Starting Dose of Lantus for Inpatients with Type 2 Diabetes Based on Insulin Requirements

The recommended starting dose of Lantus (insulin glargine) for inpatients with type 2 diabetes is 0.1-0.2 units/kg/day based on the degree of hyperglycemia and the patient's current insulin requirements. 1, 2

Dosing Algorithm Based on Patient Characteristics

• For insulin-naive patients or those with mild hyperglycemia (<200 mg/dL or <11.1 mmol/L): Start with a lower dose of 0.1 units/kg/day or up to 10 units once daily 1, 2
• For patients with moderate hyperglycemia (201-300 mg/dL or 11.2-16.6 mmol/L): Start at 0.2-0.3 units/kg/day 1
• For patients with severe hyperglycemia (>300 mg/dL or >16.6 mmol/L) or those using high doses of insulin at home (>0.6 units/kg/day): Consider a basal-bolus regimen with Lantus providing approximately 50% of the total daily insulin dose 1
• When transitioning from IV insulin: Calculate the total daily dose of IV insulin over the previous 24 hours and administer 80% of this amount as the total daily subcutaneous insulin dose, with approximately 50% given as basal insulin (Lantus) 1

Adjusting for Special Populations

• For elderly patients or those at high risk of hypoglycemia: Reduce the starting dose to 0.1 units/kg/day to minimize hypoglycemia risk 1
• For patients with renal or hepatic impairment: Start with a lower dose (0.1 units/kg/day) and titrate more cautiously 2
• For patients transitioning from twice-daily NPH insulin: Start with 80% of the total NPH dose 2

Titration and Monitoring

• Dose adjustments: Titrate the dose by 2-4 units every 3-7 days based on fasting blood glucose levels 1, 3
• Target fasting glucose: Aim for fasting glucose of 100-140 mg/dL (5.6-7.8 mmol/L) in most inpatients 1
• Monitoring frequency: Check blood glucose at least 4 times daily (before meals and at bedtime) during dose titration 1

Important Considerations

• Timing of administration: Lantus should be administered at the same time each day to maintain consistent glycemic control 2
• Concurrent oral agents: Consider continuing metformin if no contraindications exist; other oral agents may need to be discontinued depending on the complexity of the insulin regimen 4
• Patient education: Provide education about self-monitoring, diet, and hypoglycemia management before discharge 1

Common Pitfalls to Avoid

• Overbasalization: Be cautious of excessive basal insulin doses (>0.5 units/kg) which may lead to hypoglycemia, especially overnight 1
• Inadequate prandial coverage: Lantus alone may not adequately control postprandial hyperglycemia; consider adding prandial insulin if needed 1, 5
• Fixed sliding scale regimens: Avoid relying solely on sliding scale insulin without basal insulin as this leads to poor glycemic control 1
• Failure to adjust for changing clinical status: Insulin requirements may change with improving clinical status, changes in diet, or addition/removal of medications that affect insulin sensitivity 2

By following this structured approach to Lantus dosing in inpatients with type 2 diabetes, clinicians can achieve optimal glycemic control while minimizing the risk of hypoglycemia, ultimately improving patient outcomes.