What is the recommended initial dosing for Lantus (insulin glargine)?

Initial Dosing of Lantus (Insulin Glargine)

For insulin-naive patients with type 2 diabetes, start Lantus at 10 units once daily or 0.1-0.2 units/kg/day, administered at the same time each day, typically in conjunction with metformin. 1, 2

Standard Starting Doses by Clinical Scenario

Type 2 Diabetes - Insulin Naive

• Start with 10 units once daily or 0.1-0.2 units/kg body weight 1, 2
• Continue metformin unless contraindicated 1
• May add one additional non-insulin agent 1
• For a 50 kg patient, this translates to 10 units daily 2

Type 2 Diabetes - Severe Hyperglycemia

• Consider higher starting doses of 0.3-0.4 units/kg/day for patients with HbA1c ≥9%, blood glucose ≥300-350 mg/dL, or symptomatic/catabolic features 2
• These patients may require immediate basal-bolus regimen rather than basal insulin alone 1, 2

Type 1 Diabetes

• Total daily insulin requirement: 0.4-1.0 units/kg/day, with 0.5 units/kg/day typical for metabolically stable patients 3, 2
• Approximately 40-50% should be given as Lantus (basal insulin) with the remainder as rapid-acting prandial insulin 1, 2
• Patients in honeymoon phase may require lower doses of 0.2-0.6 units/kg/day 2

Hospitalized Patients

• For insulin-naive or low-dose insulin patients: 0.3-0.5 units/kg total daily dose, with half as basal insulin 1, 2
• For elderly patients or those with poor oral intake: reduce to 0.1-0.15 units/kg/day, given mainly as basal insulin 1
• For patients on high-dose home insulin (≥0.6 units/kg/day), reduce total daily dose by 20% to prevent hypoglycemia 2

Titration Algorithm

Increase the dose by 2-4 units (or 10-15%) once or twice weekly until fasting blood glucose reaches 80-130 mg/dL 1, 3, 2

Specific Titration Guidelines

• If fasting glucose ≥180 mg/dL: increase by 4 units every 3 days 3, 2
• If fasting glucose 140-179 mg/dL: increase by 2 units every 3 days 3, 2
• If >2 fasting values/week are <80 mg/dL: decrease dose by 2 units 3
• If hypoglycemia occurs: reduce dose by 10-20% 3, 2

Daily self-monitoring of fasting blood glucose is essential during titration 3, 2

Timing of Administration

Lantus can be administered at any consistent time of day - before breakfast, before dinner, or at bedtime - with equivalent efficacy 4, 5

• Morning administration resulted in significantly fewer nocturnal hypoglycemia episodes (59.5%) compared to dinner (71.9%) or bedtime (77.5%) administration in type 1 diabetes patients 4
• In type 2 diabetes, morning versus bedtime administration showed equivalent nocturnal hypoglycemia rates and glycemic control 5

Critical Decision Point: When to Add Prandial Insulin

Once basal insulin dose exceeds 0.5 units/kg/day and HbA1c remains above target despite controlled fasting glucose, add prandial insulin rather than continuing to escalate basal insulin 3, 2

Signs of "Overbasalization" to Watch For:

• Basal insulin dose >0.5 units/kg/day 3, 2
• Bedtime-to-morning glucose differential ≥50 mg/dL 3, 2
• Hypoglycemia episodes 3, 2
• High glucose variability 3, 2

Start prandial insulin with 4 units before the largest meal or 10% of the basal dose 1, 2

Common Pitfalls to Avoid

• Do not delay insulin initiation in patients not achieving glycemic goals with oral medications 2
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia, as this leads to suboptimal control and increased hypoglycemia risk 3, 2
• Do not mix or dilute Lantus with any other insulin or solution due to its low pH 2
• Do not use premixed insulin formulations in hospitalized patients, as they result in threefold higher hypoglycemia rates compared to basal-bolus regimens 1
• Do not wait longer than 3 days between dose adjustments in stable patients, as this unnecessarily prolongs time to glycemic targets 2

Supporting Evidence from Clinical Trials

Research demonstrates that appropriate starting dosage and subsequent dose adjustment are essential to achieve target HbA1c <7% 6. Patient-driven titration algorithms resulted in greater HbA1c reductions (-1.8%) compared to clinic-driven algorithms (-1.5%) with <1% incidence of severe hypoglycemia 7. Meta-analysis data confirm that insulin glargine reduces overall symptomatic hypoglycemia by 11%, nocturnal hypoglycemia by 26%, and severe hypoglycemia by 46% compared to NPH insulin 8.