Lantus (Insulin Glargine) Titration Protocol
The recommended titration protocol for Lantus (insulin glargine) is to start with 10 units or 0.1-0.2 units/kg once daily and increase by 2 units every 3 days until reaching the fasting plasma glucose target, without hypoglycemia. 1, 2
Initial Dosing
- Start with 10 units per day or 0.1-0.2 units/kg body weight once daily, administered at the same time each day 2, 1
- For patients with more severe hyperglycemia (A1C >10% or blood glucose ≥300 mg/dL), consider higher initial doses (0.3-0.4 units/kg/day) 2, 1
- Administer subcutaneously into the abdominal area, thigh, or deltoid 3
- Do not dilute or mix with any other insulin or solution 3
Titration Algorithm
- Set a fasting plasma glucose (FPG) goal based on individualized glycemic targets (typically 80-130 mg/dL) 2
- Increase dose by 2 units every 3 days until reaching the FPG target without hypoglycemia 2, 1
- For patients with persistent hyperglycemia, consider the following structured approach:
- For hypoglycemia (blood glucose <70 mg/dL): determine cause and if no clear reason, reduce dose by 10-20% 2, 4
Self-Titration vs. Physician-Led Titration
- Both patient-led and physician-led titration approaches are effective 5, 6
- Patient-led titration (increasing dose by 2 units every 3 days if FPG remains above target) has shown greater A1C reductions in some studies 5, 6
- Daily self-monitoring of blood glucose is essential during the titration phase 2, 4
- Maintain frequent contact with healthcare providers during self-titration 2
Important Considerations
- Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis 3
- Administer at the same time every day, though the specific time (morning or bedtime) can be flexible based on patient preference 7
- Avoid excessive dose increases (>10% at once) as this increases hypoglycemia risk 4
- Be aware that once daily basal insulin dose exceeds 0.5 units/kg/day, addition of prandial insulin may be more appropriate than further basal insulin increases 2
Monitoring and Adjustments
- Monitor fasting blood glucose daily during titration 2, 4
- After the insulin dose is stabilized, the frequency of monitoring can be reviewed 2
- Assess adequacy of insulin dose at every visit, looking for clinical signals of overbasalization (elevated bedtime-to-morning glucose differential, hypoglycemia, high glucose variability) 2
- If A1C remains above goal after 3-6 months of basal insulin titration despite reaching FPG targets, consider adding prandial insulin 2
Common Pitfalls to Avoid
- Delaying appropriate dose adjustments, which can lead to prolonged hyperglycemia 1
- Not recognizing when basal insulin alone is insufficient (when A1C remains elevated despite normalized fasting glucose) 2, 4
- Failure to recognize that insulin requirements may change with weight changes, illness, or changes in physical activity 1
- Overbasalization - using higher than necessary basal insulin doses that can mask insufficient mealtime insulin coverage 1
By following this structured titration protocol, most patients can achieve optimal glycemic control with Lantus while minimizing the risk of hypoglycemia.