What would be a suggested Lantus (insulin glargine) sliding scale insulin for a sedentary diabetic male with an A1C of 8.5, and frequent postprandial blood glucose of 180 to 250 mg/dL?

Lantus Dosing for Sedentary Diabetic Male with A1C 8.5% and Postprandial Glucose 180-250 mg/dL

Important Clarification on "Sliding Scale"

Lantus (insulin glargine) is a basal insulin that should NOT be used as a sliding scale—it must be dosed as a fixed once-daily dose at the same time each day, not adjusted based on individual glucose readings. 1 Sliding scale refers to correction insulin using rapid-acting insulin, which is a separate component of therapy. 2, 3

Recommended Lantus Starting Dose

Start Lantus at 10 units once daily OR 0.1-0.2 units/kg body weight, administered at the same time every day (evening or morning, patient's choice for consistency). 2, 4, 1 For weight-based dosing, if the patient weighs 200 lbs (approximately 91 kg), this translates to 9-18 units, making 10 units a reasonable conservative starting point. 4

Titration Protocol

Increase the Lantus dose by 2 units every 3 days until fasting blood glucose reaches 80-130 mg/dL (4.4-7.2 mmol/L). 2, 3, 4 This evidence-based titration algorithm should continue systematically until the fasting glucose target is achieved without hypoglycemia. 3, 4

• If fasting glucose remains ≥180 mg/dL, increase by 4 units every 3 days for more aggressive titration. 3, 4
• If hypoglycemia occurs, determine the cause and reduce the dose by 10-20%. 2, 4

Critical Issue: Postprandial Hyperglycemia Requires Additional Therapy

With postprandial glucose of 180-250 mg/dL and A1C 8.5%, Lantus alone will be insufficient—you must add prandial (mealtime) insulin coverage. 2, 3 The elevated postprandial readings indicate that basal insulin optimization alone cannot achieve glycemic targets. 3, 4

Adding Prandial Insulin

• Start with 4 units of rapid-acting insulin (aspart, lispro, or glulisine) before the largest meal or the meal causing the greatest postprandial glucose excursion. 2, 3, 4
• Alternatively, use 10% of the basal insulin dose as the starting prandial dose. 2, 3
• Titrate prandial insulin by 1-2 units or 10-15% twice weekly based on postprandial glucose readings 2 hours after meals. 3, 4

Foundation Therapy Requirements

Ensure the patient is on metformin (unless contraindicated) as it remains the foundation of type 2 diabetes therapy and should be continued when adding insulin. 2, 3, 4 Metformin provides complementary mechanisms to insulin and helps reduce total daily insulin requirements. 3

Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during the titration phase. 3, 4
• Check postprandial glucose 2 hours after meals to guide prandial insulin adjustments. 3
• Reassess A1C every 3 months to evaluate overall glycemic control. 2
• Provide glucagon prescription for emergent hypoglycemia. 2

Common Pitfalls to Avoid

• Do NOT continue escalating Lantus beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia with prandial insulin. 3, 4 This leads to "overbasalization" with increased hypoglycemia risk and suboptimal control. 3, 4
• Do NOT rely solely on correction ("sliding scale") insulin without optimizing basal insulin first. 3, 4 Scheduled insulin regimens with basal and prandial components are superior to correction-only approaches. 3
• Do NOT mix or dilute Lantus with any other insulin or solution due to its low pH. 4, 1
• Rotate injection sites within the same region (abdomen, thigh, or deltoid) to prevent lipodystrophy. 1

Patient Education Essentials

• Proper insulin injection technique and site rotation 3, 4
• Recognition and treatment of hypoglycemia 3, 4
• Self-monitoring of blood glucose 3, 4
• "Sick day" management rules 3
• Insulin storage and handling 3

Expected Outcomes

With this regimen, the A1C of 8.5% should decrease toward the target of <7% over 3-6 months. 2 The combination of optimized basal insulin plus prandial coverage addresses both fasting and postprandial hyperglycemia, which is necessary given the current glucose patterns. 2, 3