How to titrate the insulin glargine dose for a patient with elevated glucose levels?

Insulin Glargine Dose Titration for Persistent Hyperglycemia

Increase your insulin glargine by 4 units to 22 units once daily at bedtime, given that your fasting glucose levels are consistently in the 167-214 mg/dL range.

Immediate Dose Adjustment

Your current glucose trends (214-202-167-202-208 mg/dL) indicate inadequate basal insulin coverage, with all values well above the target fasting glucose range of 80-130 mg/dL 1.

The evidence-based titration algorithm specifies:

• When fasting glucose is ≥180 mg/dL, increase basal insulin by 4 units every 3 days until target glucose levels are reached 1
• When fasting glucose is 140-179 mg/dL, increase by 2 units every 3 days 1
• Since your values range from 167-214 mg/dL (with most ≥180 mg/dL), the 4-unit increase is appropriate 1

Titration Schedule Going Forward

After increasing to 22 units, continue monitoring fasting glucose daily and adjust as follows 1:

• If fasting glucose remains ≥180 mg/dL: Increase by another 4 units every 3 days 1
• If fasting glucose is 140-179 mg/dL: Increase by 2 units every 3 days 1
• If >2 fasting values per week are <80 mg/dL: Decrease dose by 2 units 2
• Target fasting glucose: 80-130 mg/dL 1

Critical Monitoring Points

Watch for overbasalization as your dose increases 1:

• If your basal insulin exceeds 0.5 units/kg/day and fasting glucose reaches target but overall control remains poor, you will need prandial (mealtime) insulin rather than further basal increases 1
• Signs of overbasalization include: basal dose >0.5 units/kg/day, large bedtime-to-morning glucose differential (≥50 mg/dL), hypoglycemia, and high glucose variability 1

When to Add Mealtime Insulin

If after 3-6 months of basal insulin optimization:

• Your fasting glucose reaches 80-130 mg/dL but HbA1c remains above goal, add prandial insulin before the largest meal 1
• Start with 4 units of rapid-acting insulin before the meal causing greatest glucose excursion 1
• When basal insulin approaches 0.5-1.0 units/kg/day without achieving A1C goal, adding prandial insulin becomes necessary rather than continuing to escalate basal insulin 1

Essential Foundation Therapy

Ensure you are taking metformin unless contraindicated, as it should remain the foundation of type 2 diabetes therapy even when intensifying insulin 1.

Practical Implementation

• Continue taking glargine at the same time each bedtime for consistent 24-hour coverage 3
• Rotate injection sites within the same region (abdomen, thigh, or deltoid) to reduce lipodystrophy risk 3
• Monitor fasting glucose daily during this titration phase 1
• Reassess every 3 days during active titration 1