What is the typical dosing regimen for Lantus (insulin glargine)?

Lantus (Insulin Glargine) Dosing

For insulin-naive patients with type 2 diabetes, start Lantus at 10 units once daily or 0.1-0.2 units/kg body weight, administered at the same time each day, and titrate by 2-4 units every 3 days until fasting glucose reaches 80-130 mg/dL. 1

Initial Dosing by Patient Type

Type 2 Diabetes (Insulin-Naive)

• Start with 10 units once daily or 0.1-0.2 units/kg body weight 1
• Administer at the same consistent time each day (morning or bedtime both effective) 2, 3
• Typically combined with metformin and possibly one additional non-insulin agent 1

Type 2 Diabetes (Severe Hyperglycemia)

• Consider higher initial doses of 0.3-0.4 units/kg/day for patients with HbA1c ≥9%, blood glucose ≥300-350 mg/dL, or symptomatic/catabolic features 1
• May require basal-bolus regimen from the start rather than basal-only approach 1

Type 1 Diabetes

• Total daily insulin requirement: 0.4-1.0 units/kg/day (0.5 units/kg/day typical for metabolically stable patients) 1, 2
• Basal insulin comprises 40-60% of total daily dose in multiple daily injection regimens 2
• Must be combined with rapid-acting prandial insulin at mealtimes 1
• Higher doses required immediately following ketoacidosis presentation 1

Hospitalized Patients

• For insulin-naive or low-dose patients: 0.3-0.5 units/kg total daily dose, with half as basal insulin 4
• For patients on high-dose home insulin (≥0.6 units/kg/day): reduce total daily dose by 20% to prevent hypoglycemia 4
• Lower doses (0.1-0.25 units/kg/day) for high-risk patients: elderly (>65 years), renal failure, poor oral intake 4

Enteral/Parenteral Nutrition

• Start with 10 units of glargine every 24 hours as a reasonable starting point 1
• Basal insulin typically represents 30-50% of total daily insulin requirement in these patients 1

Dose Titration Algorithm

Standard Titration Protocol

• Increase by 2 units every 3 days if fasting glucose 140-179 mg/dL 1
• Increase by 4 units every 3 days if fasting glucose ≥180 mg/dL 1
• Target fasting plasma glucose: 80-130 mg/dL 1
• Continue titration until target reached without hypoglycemia 1

Alternative Titration Approach

• Increase by 10-15% or 2-4 units once or twice weekly until fasting blood glucose target met 4, 1
• Most patients can self-titrate by adding 1-2 units (or 5-10% for higher doses) once or twice weekly if fasting glucose remains above target 1

Hypoglycemia Management

• If hypoglycemia occurs: determine cause and reduce dose by 10-20% 1

When to Advance Beyond Basal-Only Insulin

Critical Threshold: Overbasalization

When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, add prandial insulin rather than continuing to escalate basal insulin alone. 1, 2

Clinical Signals of Overbasalization

• Basal dose >0.5 units/kg/day 1
• High bedtime-to-morning glucose differential (≥50 mg/dL) 1
• Hypoglycemia episodes 1
• High glucose variability 1
• Fasting glucose controlled but HbA1c remains elevated after 3-6 months 1

Adding Prandial Insulin

• Start with 4 units of rapid-acting insulin before the largest meal (or 10% of basal dose) 1
• Add to other meals based on glucose patterns 1
• Consider decreasing basal insulin dose when significant prandial doses added, particularly with evening meal 2

Alternative to Prandial Insulin

• Consider adding GLP-1 receptor agonist to basal insulin regimen to improve HbA1c while minimizing weight gain and hypoglycemia risk 1

Administration Guidelines

Timing and Flexibility

• Administer at the same time each day for optimal efficacy 2
• Morning or bedtime administration equally effective for glycemic control and hypoglycemia risk 3
• Duration of action: up to 24 hours with peakless profile 2
• Onset of action: approximately 1 hour 2

Critical Mixing Restriction

• Do not dilute or mix Lantus with any other insulin or solution due to its low pH 4, 2
• This necessitates separate injections when using basal-bolus regimens 5

Twice-Daily Dosing Considerations

• Reserve twice-daily glargine for patients who fail to achieve 24-hour coverage with once-daily dosing 2
• Particularly useful for type 1 diabetes patients with persistent glycemic variability or those requiring high basal doses 2
• Split total daily basal dose between morning and evening administrations 2

Special Populations and Situations

Glucocorticoid-Induced Hyperglycemia

• For patients without diabetes on steroids: single morning dose of NPH may be appropriate 4
• For patients with diabetes on steroids: add 0.1-0.3 units/kg/day glargine to usual insulin regimen, with doses determined by steroid dose and oral intake 4

Pregnancy and Puberty

• Higher doses may be needed during these periods 2

Lower Weight Patients

• Use lower end of dosing range (closer to 0.1 units/kg) due to increased insulin sensitivity and higher hypoglycemia risk 1

Clinical Advantages Over NPH Insulin

• 26% reduction in nocturnal hypoglycemia compared to NPH 6
• 46% reduction in severe hypoglycemia overall 6
• 59% reduction in severe nocturnal hypoglycemia 6
• More consistent absorption and peakless profile providing stable 24-hour coverage 2, 5

Common Pitfalls to Avoid

Critical Errors

• Delaying insulin initiation in patients not achieving glycemic goals 1
• 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 1
• Not adjusting doses based on self-monitoring of blood glucose levels 1
• Using sliding scale insulin alone in patients with established diabetes (associated with poor glycemic control) 4

Monitoring Requirements

• Daily fasting blood glucose monitoring essential during titration phase 1
• Reassess every 3 days during active titration 1
• Reassess every 3-6 months once stable 1

Dose Adjustment Failures

• Failing to reduce mealtime insulin when long-acting insulin is held or reduced leads to inadequate glucose control 2
• Not recognizing that insulin requirements change with weight changes, illness, or physical activity alterations 1