Reduce Lantus Dose by 10-20% Immediately
For this 67-year-old male experiencing nocturnal hypoglycemia (blood glucose in the 60s) on 8 units of Lantus, reduce the dose by 1-2 units (approximately 10-20% reduction) immediately. 1
Immediate Dose Adjustment
Decrease Lantus from 8 units to 6-7 units to prevent recurrent nocturnal hypoglycemia, which is common (incidence 14-47%) and may be asymptomatic or present with nightmares, restless sleep, and morning confusion 1
The 20% dose reduction is specifically recommended for hospitalized patients on higher insulin doses with poor oral intake, but this principle applies to outpatients experiencing hypoglycemia 1
For elderly patients (age >65 years) like this patient, lower insulin doses (0.1-0.15 units/kg/day) are recommended to minimize hypoglycemia risk 1
Timing Considerations
Consider switching administration time from overnight to evening meal or bedtime if not already doing so, as this may provide better glycemic control with reduced nocturnal hypoglycemia risk 2
Bedtime blood glucose levels are poor predictors of nocturnal hypoglycemia, so the timing change alone may not prevent episodes 1
Alternative Basal Insulin Options
If hypoglycemia persists after dose reduction:
Consider switching to newer basal insulin analogs (insulin degludec or glargine U300), which have demonstrated 25-59% reduction in nocturnal hypoglycemia compared to standard glargine U100 1, 3, 4
Insulin degludec specifically reduced nocturnal symptomatic hypoglycemia by 42% (rate ratio 0.58) in patients with type 2 diabetes and hypoglycemia risk factors 4
One case report showed a 28-year-old switching from Lantus U100 to Toujeo U300 reduced nocturnal hypoglycemia episodes by 2.5 per week 3
Monitoring Strategy
Increase blood glucose monitoring frequency, particularly checking fasting blood glucose and 3 AM glucose levels to identify the nadir and pattern of nocturnal hypoglycemia 1
Assess for hypoglycemia unawareness at every visit, as repeated episodes can lead to defective glucose counterregulation requiring more frequent monitoring 1
Consider continuous glucose monitoring (CGM) if available, as it can alert to impending hypoglycemia and has been shown to decrease hypoglycemic episodes 1
Treatment of Acute Episodes
When hypoglycemia occurs (glucose <70 mg/dL):
Administer 15-20 grams of glucose (preferred) or any carbohydrate containing glucose 1, 2
Recheck blood glucose in 10-20 minutes; additional treatment may be necessary as blood glucose may only be temporarily corrected 1
Evaluate again at 60 minutes, as continued observation and additional carbohydrate intake may be necessary to avoid recurrence 2
Common Pitfalls to Avoid
Do not continue the same dose hoping hypoglycemia will resolve spontaneously—nocturnal hypoglycemia has impaired counterregulatory responses during sleep and requires dose adjustment 1
Avoid premixed insulin formulations, which have unacceptably high rates of hypoglycemia (threefold higher than basal-bolus with analogs in elderly patients) 1
Do not rely solely on bedtime glucose readings to predict nocturnal hypoglycemia, as they are poor predictors 1
In elderly patients, severe hypoglycemia can lead to increased morbidity and mortality, so err on the side of slightly higher glucose targets rather than risking recurrent hypoglycemia 1