What adjustments should be made to the treatment plan for a patient with hyperglycemia while on Lantus (insulin glargine) 60 units daily?

Insulin Dose Adjustment for Suboptimal Glycemic Control

Increase the Lantus dose by 6-8 units immediately, as the fasting blood glucose of 178 mg/dL (9.9 mmol/L) is significantly above target and requires aggressive titration. 1

Current Clinical Situation

This patient's overnight blood glucose of 178 mg/dL indicates inadequate basal insulin coverage despite a substantial dose of 60 units daily (approximately 0.63 units/kg for a 95 kg patient). 1 The fasting glucose is well above the recommended target of 80-130 mg/dL (4.4-7.2 mmol/L). 2

Recommended Dose Adjustment Strategy

Immediate titration approach:

• For fasting glucose ≥180 mg/dL (≥10 mmol/L), increase the insulin dose by 6-8 units. 3
• Since this patient's fasting glucose is 178 mg/dL, a 6-unit increase to 66 units daily is appropriate. 3
• Alternatively, increase by 10-15% of the current dose (6-9 units) once or twice weekly until fasting blood glucose target is met. 1

Ongoing titration protocol:

• Continue adjusting the dose every 3 days based on the mean fasting glucose over the previous 3 days. 3
• If mean fasting glucose remains ≥140-180 mg/dL (7.8-10.0 mmol/L), increase by 4 units. 3
• If mean fasting glucose is ≥120-140 mg/dL (6.7-7.8 mmol/L), increase by 2 units. 3
• Target fasting glucose should be <100 mg/dL (5.5 mmol/L) to achieve HbA1c <7%. 3

Important Considerations for This Patient

High basal insulin dose concerns:

• At 60 units (0.63 units/kg), this patient is approaching the threshold where prandial insulin may be needed. 2
• When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, consider adding mealtime insulin rather than continuing to escalate basal insulin alone. 2
• Watch for signs of "overbasalization": bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, or high glucose variability. 1

Assess for additional factors:

• Verify the patient is on metformin unless contraindicated, as this should be the foundation of type 2 diabetes therapy. 2
• Confirm proper injection technique, site rotation, and that insulin is being administered at the same time daily. 4
• Rule out lipodystrophy or localized cutaneous amyloidosis at injection sites, which can impair insulin absorption. 4

When to Consider Adding Prandial Insulin

If after 3-6 months of basal insulin optimization:

• Fasting glucose reaches target but HbA1c remains above goal. 2
• Significant postprandial glucose excursions occur (>180 mg/dL). 2
• Large glucose drops occur overnight or between meals as basal insulin is increased. 2

Initial prandial insulin approach:

• Start with 4 units or 10% of the basal dose before the largest meal. 1
• Add prandial insulin before the meal causing the greatest glucose excursion. 2

Common Pitfalls to Avoid

• Timid titration: Delaying aggressive dose adjustments prevents patients from reaching glycemic goals and increases long-term complications. 1
• Ignoring the need for prandial insulin: Continuing to escalate basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia leads to suboptimal control and increased hypoglycemia risk. 2, 1
• Inadequate monitoring: Daily self-monitoring of fasting blood glucose is essential during titration. 2
• Missing hypoglycemia: If any hypoglycemia occurs, reduce the dose by 10-20% and reassess. 1