What is the starting dose of Lantus (insulin glargine) for insulin-naive patients?

Starting Dose of Lantus (Insulin Glargine)

Recommended Initial 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. 1, 2

Type 2 Diabetes (Insulin-Naive Patients)

• Standard starting dose: 10 units once daily OR 0.1-0.2 units/kg/day 1, 2
• For a 50 kg patient, this translates to 10 units once daily 1
• Administer at the same time each day (can be morning, evening, or any convenient time) 1

Type 1 Diabetes

• Total daily insulin requirement: 0.4-1.0 units/kg/day, with approximately 50% as basal insulin (Lantus) 1, 2
• For metabolically stable patients, 0.5 units/kg/day total insulin is typical, meaning approximately 0.25 units/kg/day as basal 1, 3
• Higher doses required immediately following diabetic ketoacidosis 2

Severe Hyperglycemia (Type 2 Diabetes)

• For patients with HbA1c ≥9%, blood glucose ≥300-350 mg/dL, or symptomatic/catabolic features: consider higher starting doses of 0.3-0.4 units/kg/day 1
• May require immediate basal-bolus regimen rather than basal insulin alone 1

Dose Titration Algorithm

Increase by 2-4 units every 3 days until fasting blood glucose reaches 80-130 mg/dL 1, 2

Specific Titration Guidelines

• If fasting glucose ≥180 mg/dL: increase by 4 units every 3 days 1
• If fasting glucose 140-179 mg/dL: increase by 2 units every 3 days 1
• If fasting glucose <80 mg/dL on >2 occasions per week: decrease by 2 units 1
• Alternative approach: increase by 10-15% once or twice weekly 1

Target Fasting Glucose

• 80-130 mg/dL (4.4-7.2 mmol/L) 1, 3

Special Populations Requiring Lower Starting Doses

• Elderly patients (>65 years): 0.1-0.25 units/kg/day 1
• Patients with renal failure: 0.1-0.25 units/kg/day 1
• Patients with poor oral intake: 0.1-0.25 units/kg/day 1
• Patients with retinopathy: 0.12 units/kg/day 4
• Patients with eGFR <60 mL/min/1.73 m²: 0.114 units/kg/day 4
• Women: slightly lower at 0.135 units/kg/day 4

Critical Dosing Thresholds

When basal insulin exceeds 0.5 units/kg/day and HbA1c remains elevated despite controlled fasting glucose, add prandial insulin rather than continuing to escalate basal insulin. 1, 3

Signs of Overbasalization (Excessive Basal Insulin)

• Basal dose >0.5 units/kg/day without achieving glycemic targets 1
• Bedtime-to-morning glucose differential ≥50 mg/dL 1
• Hypoglycemia episodes 1
• High glucose variability 1

When to Add Prandial Insulin

• After 3-6 months of basal optimization, if fasting glucose is controlled but HbA1c remains above goal 1
• When basal insulin approaches 0.5-1.0 units/kg/day without achieving targets 1, 3
• Start with 4 units of rapid-acting insulin before the largest meal OR 10% of basal dose 1

Common Pitfalls to Avoid

• Do not delay insulin initiation in patients not achieving glycemic goals with oral medications 1
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia—this leads to overbasalization, suboptimal control, and increased hypoglycemia risk 1, 3
• Do not wait longer than 3 days between dose adjustments in stable patients—this unnecessarily prolongs time to target 1
• If hypoglycemia occurs, reduce dose by 10-20% immediately 1, 3

Monitoring Requirements

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

Foundation Therapy

• Continue metformin unless contraindicated when initiating or intensifying insulin therapy 1
• Metformin remains the foundation of type 2 diabetes therapy 1