When should you hold insulin glargine (long-acting insulin analog)?

When to Hold Insulin Glargine

Hold insulin glargine on the day of surgery or procedures (giving only 60-80% of the usual dose), when blood glucose levels are low, or during acute dehydrating illnesses with inability to eat or drink normally. 1

Perioperative Management

For surgical procedures:

• Withhold the full dose and give only 60-80% of the usual long-acting insulin dose on the day of surgery 1
• A 25% reduction in the insulin dose given the evening before surgery is more likely to achieve perioperative blood glucose levels in the target range with decreased risk for hypoglycemia 1
• Monitor blood glucose at least every 4-6 hours while NPO and dose with short-acting insulin as needed 1
• Target perioperative glycemic control of 80-180 mg/dL (4.4-10.0 mmol/L), as tighter targets do not improve outcomes and increase hypoglycemia risk 1

Sick Day Management

During acute dehydrating illnesses:

• Hold insulin glargine if blood glucose levels are low until blood glucose levels recover 1
• If blood glucose is more elevated than usual, increase basal insulin doses by 10-20% rather than holding 1
• Resume insulin within 24-48 hours of resolution of symptoms and when eating and drinking normally 1
• Ensure frequent glucose monitoring, checking ketones, adequate fluid intake, and consumption of food to prevent hypoglycemia during illness 1

Hypoglycemia Risk

When blood glucose is low:

• Hold insulin glargine until blood glucose levels recover to prevent severe hypoglycemia 1
• This is particularly important given that insulin glargine has a duration of action of up to 24 hours, meaning held doses will continue to have residual effects 2, 3

Important Clinical Caveats

Supplemental coverage considerations:

• When reducing or holding long-acting insulin, supplemental insulin coverage with short-acting insulin correction doses may be needed if hyperglycemia develops 4
• Failing to adjust mealtime insulin when long-acting insulin is held or reduced can lead to inadequate glucose control 4
• Monitor closely for hyperglycemia when insulin glargine is held, as it provides basal glucose control for approximately 24 hours 5

Type 1 diabetes special considerations:

• Management of type 1 diabetes requires individualized approaches with higher risk of diabetic ketoacidosis, and advice should be given early and directly from the patient's healthcare provider 1
• Never completely discontinue all insulin in type 1 diabetes, as this can precipitate diabetic ketoacidosis 1