What is the starting dose of Toujeo (insulin glargine) for once daily dosing when transitioning from BID 70/30 insulin at 113 units/day?

Transitioning from 70/30 BID to Toujeo: Starting Dose Recommendation

Start Toujeo at approximately 80% of the basal component of the current 70/30 regimen, which would be approximately 63 units once daily, then titrate based on fasting glucose monitoring.

Calculating the Initial Toujeo Dose

When transitioning from premixed 70/30 insulin to a basal-only insulin like Toujeo (insulin glargine 300 U/mL), you need to account for the fact that 70/30 contains both basal (70% NPH) and prandial (30% regular) components:

• Current total daily dose: 113 units/day of 70/30 insulin
• Basal component: Approximately 70% = 79 units/day
• Recommended starting dose: 80% of basal component = 63 units of Toujeo once daily 1

This 20% reduction is recommended to prevent hypoglycemia during the transition, particularly in patients who may have reduced oral intake or are at higher risk 2, 1.

Important Considerations for Toujeo Specifically

Toujeo is NOT bioequivalent to standard insulin glargine (Lantus) and typically requires slightly higher doses to achieve the same glycemic control 3. However, when initiating from another insulin type, standard conversion principles apply initially, with subsequent titration as needed.

• Toujeo has a flatter, longer pharmacokinetic profile (>24 hours) with less intra- and inter-patient variability 3
• The more stable profile translates to lower nocturnal hypoglycemia risk 3, 4

Critical Gap: Prandial Coverage

You must address the loss of prandial insulin coverage. The patient is losing 30% of their 70/30 insulin (approximately 34 units/day of prandial coverage). You have three options:

1. Add rapid-acting insulin before meals: Start with 4 units, 0.1 units/kg, or 10% of the basal dose before each meal 2, 1

2. Add a single injection of rapid-acting insulin before the largest meal: This is a reasonable intermediate step if full basal-bolus seems too complex 2

3. Monitor closely and add prandial insulin only if postprandial glucose remains elevated: This conservative approach may work if the patient's current A1C is near target 2

Titration Protocol

After initiating Toujeo:

• Increase by 2 units every 3 days to reach fasting glucose target without hypoglycemia 1
• Target fasting plasma glucose ≤6.1-7.2 mmol/L (110-130 mg/dL) 4
• If hypoglycemia occurs, reduce dose by 10-20% 1
• Reinforce blood glucose monitoring during the transition 3

Common Pitfalls to Avoid

• Do not use a 1:1 unit conversion from total 70/30 dose to Toujeo—this will cause significant hypoglycemia as you'd be replacing prandial insulin with basal insulin 2
• Do not forget prandial coverage—premixed insulins provide both basal and prandial components; Toujeo provides only basal coverage 2
• Do not use sliding scale insulin alone as the prandial replacement—this reactive approach is strongly discouraged and leads to poor glycemic control 2
• Monitor for nocturnal hypoglycemia even though Toujeo has a lower risk profile—the transition period carries increased risk 3, 4

Patient Education Essentials

Provide comprehensive education on:

• Self-monitoring of blood glucose, particularly fasting and pre-meal values 2
• Recognition and treatment of hypoglycemia 2
• The need for dose adjustments during the transition period 3
• Dietary considerations now that prandial coverage may be different 2