How do I adjust insulin for a patient on 80 units of Lantus (insulin glargine) BID and a sliding scale Humalog (insulin lispro) with meals who is experiencing morning hypoglycemia?

Reduce the Evening Dose of Lantus to Address Morning Hypoglycemia

For a patient on 80 units of Lantus BID experiencing morning hypoglycemia, reduce the evening (bedtime) dose of Lantus by 10-20% (8-16 units) while maintaining the morning dose unchanged. 1

Understanding the Problem

Your patient is experiencing morning hypoglycemia, which indicates excessive basal insulin action overnight from the evening Lantus dose. This is a common issue with twice-daily basal insulin regimens where the evening dose peaks during the early morning hours. 2, 3

Specific Adjustment Strategy

Immediate Action

• Reduce the evening Lantus dose by 10-20% (from 80 units to 64-72 units) 1
• Keep the morning dose at 80 units unchanged initially 1
• Monitor fasting blood glucose closely over the next 3-7 days 1

Titration Approach

• If morning hypoglycemia persists after the initial reduction, decrease the evening dose by an additional 10-20% 1
• If fasting glucose becomes too high (>130-150 mg/dL), increase the evening dose by 2 units every 3 days 1
• Continue adjusting until fasting glucose reaches target without hypoglycemia 1

Important Considerations About This Regimen

The BID Lantus Issue

This patient's regimen is unusual and potentially problematic. Lantus (insulin glargine) is designed as a once-daily basal insulin with a relatively flat 24-hour action profile and no pronounced peak. 4, 5 Using it twice daily at such high doses (160 units total daily) suggests:

• Possible overbasalization - using excessive basal insulin to compensate for inadequate mealtime coverage 1
• The total basal dose of 160 units/day is extremely high and likely exceeds 0.5 units/kg for most patients 1

Signs of Overbasalization Present

Your patient demonstrates classic signs of overbasalization: 1

• Hypoglycemia (morning lows)
• Likely high bedtime-to-morning glucose differential
• Excessively high basal insulin doses

Consider Regimen Restructuring

After Addressing Immediate Hypoglycemia

Once morning hypoglycemia is controlled, strongly consider converting to a more physiologic insulin regimen: 1

1. Consolidate to once-daily Lantus (typically given at bedtime or morning, same time daily) 4, 5

   • Start with 80% of current total daily basal dose (128 units once daily) 1
   • This reduces overlapping insulin action that causes hypoglycemia 5, 3

2. Intensify mealtime insulin coverage instead of relying on excessive basal insulin 1

   • Increase Humalog doses at meals using insulin-to-carbohydrate ratios 1
   • Add 4 units or 10% of basal dose to the largest meal initially 1
   • Titrate prandial doses by 1-2 units every 3 days based on post-meal glucose 1

3. Alternative: Consider adding a GLP-1 RA before further intensifying insulin 1

   • This can improve postprandial control while reducing insulin requirements and hypoglycemia risk 1

Monitoring Requirements

• Check fasting blood glucose daily during dose adjustments 1
• Monitor for hypoglycemia symptoms, especially overnight 1, 5
• Assess bedtime glucose to evaluate if it's dropping too much overnight 1
• Review glucose patterns after 3-7 days before making further changes 1

Common Pitfalls to Avoid

• Don't reduce both morning and evening doses simultaneously - this will cause daytime hyperglycemia 1
• Don't ignore the underlying overbasalization - simply adjusting doses without addressing the regimen structure perpetuates the problem 1
• Don't assume Lantus BID is optimal - while some patients benefit from twice-daily dosing, most achieve better control with once-daily administration 4, 5, 6
• Don't forget to address mealtime coverage - sliding scale alone is inadequate for physiologic insulin replacement 1