What is the dosage and management of TOUJEO (insulin glargine) for diabetes?

TOUJEO (Insulin Glargine U-300) Dosing and Management

TOUJEO is a concentrated formulation (300 units/mL) of insulin glargine that requires approximately 10-20% higher daily doses than standard U-100 glargine but offers lower nocturnal hypoglycemia risk and more stable 24-hour coverage. 1

Key Differences: TOUJEO vs Standard Insulin Glargine

TOUJEO and standard insulin glargine (U-100) are NOT bioequivalent and require dose conversion when switching. 2

Pharmacokinetic Advantages of TOUJEO

• Duration of action exceeds 24 hours with a flatter, more stable pharmacokinetic profile than U-100 glargine 3, 4
• Lower intra- and inter-patient variability, providing more reproducible glucose control 4
• Reduced nocturnal hypoglycemia risk compared to U-100 glargine, particularly in insulin-experienced type 2 diabetes patients 1, 3

Dosing Guidelines

Starting Doses for Insulin-Naive Patients

Type 1 Diabetes:

• Start with approximately one-third of total daily insulin requirements as basal insulin 2
• Total daily insulin typically 0.4-1.0 units/kg/day, with 0.5 units/kg/day as standard starting point 5
• Must be combined with short-acting prandial insulin 2

Type 2 Diabetes:

• Start with 0.2 units/kg or up to 10 units once daily 2
• Can be used alone or with oral agents/GLP-1 receptor agonists 5

Converting FROM Other Insulins TO TOUJEO

Critical conversion rules to prevent hypoglycemia: 2

• From U-100 glargine to TOUJEO: Convert unit-for-unit initially, but expect to need 10-18% higher doses with TOUJEO to achieve equivalent control 3, 4
• From TOUJEO to U-100 glargine: Use 80% of the TOUJEO dose 2
• From NPH once-daily: Same dose as NPH 2
• From NPH twice-daily: Use 80% of total NPH dose 2
• From insulin detemir or U-300 glargine: Reduce dose by 10-20% for patients in tight control or at high hypoglycemia risk 1

Dose Titration Strategy

Increase glucose monitoring frequency during any insulin regimen changes. 2

• Titrate based on fasting blood glucose and A1C targets 5
• Adjust for changes in physical activity, meal patterns, acute illness, or renal/hepatic function 2
• Higher doses needed during puberty, pregnancy, and medical illness 5

Administration Guidelines

Administer subcutaneously once daily at the same time each day (can be any time, but must be consistent). 2

Injection Technique

• Rotate sites within same region (abdomen, thigh, or deltoid) to prevent lipodystrophy 2
• Never inject into areas of lipodystrophy or localized cutaneous amyloidosis - this causes erratic absorption and hyperglycemia 2
• If switching from lipodystrophic areas to normal tissue, monitor closely for hypoglycemia 2

Critical Safety Rules

• Do NOT dilute or mix with any other insulin or solution 2
• Do NOT administer intravenously or via insulin pump 2
• Never share pens, needles, or syringes between patients 2
• Solution must be clear and colorless with no particles 2

When to Intensify Beyond Basal Insulin

If basal insulin dose exceeds 0.5 units/kg/day and A1C remains above target, advance to combination therapy. 1, 5

Signs of Overbasalization (Excessive Basal Insulin)

Watch for these red flags indicating need for prandial coverage rather than more basal insulin: 1

• Bedtime-to-morning glucose differential ≥50 mg/dL (≥2.8 mmol/L)
• Hypoglycemia (aware or unaware)
• High glucose variability
• Large preprandial-to-postprandial glucose differences

Intensification Options

Prioritize GLP-1 receptor agonists or dual GIP/GLP-1 agonists before adding prandial insulin to minimize hypoglycemia and weight gain risk. 1

If prandial insulin needed:

• Start with 4 units or 10% of basal dose at largest meal 1
• Consider reducing basal insulin when adding significant prandial doses, especially with evening meal 5

Special Considerations

Hypoglycemia Risk Management

• TOUJEO demonstrates lower nocturnal hypoglycemia rates than U-100 glargine in insulin-experienced type 2 diabetes patients 1, 3
• Risk similar between formulations in insulin-naive type 2 diabetes and type 1 diabetes patients 3
• All insulin glargine formulations have lower hypoglycemia risk than NPH insulin 1, 6, 7

Weight Considerations

Insulin promotes weight gain; use judiciously at lowest effective dose. 1

• TOUJEO associated with slightly less weight gain than U-100 glargine 4
• In obese patients with type 2 diabetes, prioritize weight-loss medications (tirzepatide, semaglutide) before or alongside insulin 1

Twice-Daily Dosing

While TOUJEO typically provides >24-hour coverage, consider splitting to twice-daily if: 5

• Once-daily dosing fails to provide adequate 24-hour coverage
• High total daily doses exceed absorption capacity
• Persistent glycemic variability despite optimization
• Refractory hypoglycemia with once-daily regimen

However, once-daily dosing remains standard; exhaust optimization before splitting doses. 5

Common Pitfalls to Avoid

• Failing to increase TOUJEO dose adequately: Remember TOUJEO requires ~10-18% higher doses than U-100 glargine for equivalent effect 3, 4
• Continuing to increase basal insulin when prandial coverage is needed: Recognize overbasalization signs 1
• Not reducing dose when switching FROM TOUJEO to U-100: Use 80% conversion to prevent hypoglycemia 2
• Mixing or diluting TOUJEO: This is contraindicated due to pH properties 2
• Injecting into lipodystrophic areas: Causes unpredictable absorption 2