Toujeo (Insulin Glargine 300 U/mL) Dosing
For insulin-naive patients with type 2 diabetes, start Toujeo at 0.2 units/kg once daily (or 10 units if weight-based dosing is impractical), administered at the same time each day, and titrate by 10-15% or 2-4 units every 3 days based on fasting glucose until reaching target of 80-130 mg/dL. 1
Initial Dosing Strategy
Type 2 Diabetes (Insulin-Naive)
- Start with 0.1-0.2 units/kg/day once daily at a consistent time each day 1, 2
- For practical purposes, 10 units once daily is a reasonable starting dose for most patients 1
- Administer with metformin and possibly one additional non-insulin agent 1
Type 2 Diabetes (More Severe Hyperglycemia)
- For patients with HbA1c ≥9%, glucose ≥300-350 mg/dL, or HbA1c 10-12% with symptomatic features, consider higher initial doses of 0.3-0.4 units/kg/day 1
- These patients may require a basal-bolus regimen from the start 1
Type 1 Diabetes
- Total daily insulin requirement: 0.4-1.0 units/kg/day, with 0.5 units/kg/day typical for metabolically stable patients 1, 2
- Basal insulin comprises 40-60% of total daily dose (the remainder as prandial insulin) 1, 2
- Requires combination with rapid-acting insulin at mealtimes 1
Critical Titration Algorithm
Standard Titration Protocol
- Increase dose by 2-4 units every 3 days until fasting glucose reaches 80-130 mg/dL 1
- If fasting glucose ≥180 mg/dL: increase by 4 units every 3 days 1
- If fasting glucose 140-179 mg/dL: increase by 2 units every 3 days 1
- Patients can be taught to self-titrate, adding 1-2 units (or 5-10% for higher doses) once or twice weekly 1
When to Stop Escalating Basal Insulin
- Do not exceed 0.5-1.0 units/kg/day of basal insulin alone 1, 2
- Once basal insulin approaches 0.5 units/kg/day and fasting glucose is controlled but HbA1c remains elevated, add prandial insulin or GLP-1 receptor agonist rather than continuing to increase basal insulin 1, 2
- Continuing to escalate basal insulin beyond this threshold leads to "overbasalization" with increased hypoglycemia risk and poor postprandial control 1
Toujeo-Specific Considerations
Pharmacokinetic Differences from Lantus
- Toujeo (300 U/mL) has a flatter, more prolonged profile exceeding 24 hours compared to Lantus (100 U/mL) 3, 4
- Not bioequivalent to Lantus: Toujeo requires approximately 10-18% higher daily doses to achieve comparable glycemic control 3, 4
- Lower risk of nocturnal hypoglycemia, especially in insulin-experienced type 2 diabetes patients 3, 4
Switching from Lantus to Toujeo
- When transitioning from Lantus 100 U/mL, expect to need dose adjustment upward 4
- Reinforce blood glucose monitoring during the transition period 4
- The concentrated formulation offers greater flexibility in injection timing 4
Monitoring and Safety
Essential Monitoring
- Daily fasting blood glucose monitoring during titration phase 1
- Reassess every 3 days during active titration 1
- Once stable, reassess every 3-6 months 1
Hypoglycemia Management
- If hypoglycemia occurs, determine the cause and reduce dose by 10-20% 1
- Toujeo demonstrates lower nocturnal hypoglycemia rates compared to Lantus 100 U/mL in insulin-experienced type 2 diabetes patients 3, 5
Common Pitfalls to Avoid
- Delaying insulin initiation in patients not achieving glycemic goals 1
- Overbasalization: continuing to increase basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia 1
- Ignoring signs of overbasalization: bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, high glucose variability 1
- Failing to add prandial insulin when basal insulin is optimized but HbA1c remains above target after 3-6 months 1
- Not adjusting for weight changes, illness, or physical activity changes 1
Special Populations
Enteral/Parenteral Nutrition
- Start with 10 units of insulin glargine every 24 hours for patients on tube feeding 1
- Basal insulin typically represents 30-50% of total daily insulin requirement in these patients 1