What is the recommended dosing adjustment for Lantus (insulin glargine) in a patient with hyperglycemia?

Lantus Dosing for Blood Glucose Consistently in the 200s

For patients with persistent blood glucose in the 200s, start Lantus at 0.2 units/kg or 10 units once daily and titrate by 2-4 units every 3 days until fasting blood glucose targets are achieved. 1

Initial Dosing Recommendations

• For insulin-naive patients with type 2 diabetes and persistent hyperglycemia, the recommended starting dose of Lantus (insulin glargine) is 0.1-0.2 units/kg or up to 10 units once daily 1, 2
• For a patient with blood glucose consistently in the 200s, consider starting at the higher end of the initial dosing range (0.2 units/kg) due to the degree of hyperglycemia 1
• Administer Lantus subcutaneously once daily at any time of day, but maintain consistency in timing for optimal glycemic control 2
• For patients with more severe hyperglycemia (>300 mg/dL), higher initial doses (0.3-0.4 units/kg/day) may be appropriate 1

Dose Titration Protocol

• Increase the dose by 2-4 units every 3 days until fasting blood glucose reaches target range (80-130 mg/dL) 1
• For blood glucose readings ≥180 mg/dL, consider increasing the dose by 4 units 1
• An alternative approach is to increase the dose by 10-15% once or twice weekly until fasting blood glucose target is met 1
• Daily self-monitoring of blood glucose is essential during the titration phase to guide dose adjustments 1

When Basal Insulin Alone Is Insufficient

• If A1C remains above goal after 3-6 months of basal insulin titration despite reaching fasting glucose targets, consider adding prandial insulin 1
• 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 1
• If adding prandial insulin, start with 4 units per day or 10% of the basal dose with the largest meal 3
• Consider adding a GLP-1 receptor agonist before adding prandial insulin if A1C remains above goal 3

Administration Considerations

• Lantus provides 24-hour coverage with once-daily administration regardless of dose 4
• Administer Lantus subcutaneously into the abdominal area, thigh, or deltoid, and rotate injection sites to reduce the risk of lipodystrophy 2
• Do not mix Lantus with any other insulin or solution 2
• Visually inspect Lantus vials and SoloStar prefilled pens for particulate matter and discoloration prior to administration 2

Special Considerations

• For patients transitioning from oral medications to insulin therapy, 5 units of Lantus nightly may be appropriate, though this would likely be insufficient for blood glucose consistently in the 200s 1
• For patients transitioning from twice-daily NPH insulin to once-daily Lantus, the recommended starting Lantus dosage is 80% of the total NPH dosage 2
• For patients on glucocorticoids with hyperglycemia, a higher proportion of prandial insulin may be needed (25% basal and 75% prandial) 3

Monitoring and Avoiding Common Pitfalls

• Assess adequacy of insulin dose at every visit, looking for clinical signals of overbasalization (elevated bedtime-to-morning glucose differential, hypoglycemia, high glucose variability) 3, 1
• Avoid delaying insulin therapy in patients not achieving glycemic goals 1
• Lantus has been shown to reduce the risk of hypoglycemia, particularly nocturnal episodes, compared to NPH insulin 5
• Morning or bedtime administration of Lantus produces similar glycemic control, allowing for flexibility in dosing time 6

Advantages of Lantus

• Lantus provides a relatively constant basal level of circulating insulin with no pronounced peak, unlike NPH insulin 7
• Once-daily Lantus achieves equivalent glycemic control to NPH insulin given once or twice daily with less risk of hypoglycemia 7, 5
• The reduced risk of hypoglycemia with Lantus allows for more aggressive titration to achieve target blood glucose levels 7