What is the recommended dose of Toujeo (insulin glargine)?

Toujeo (Insulin Glargine 300 U/mL) Dosing

Toujeo should be initiated at 10 units once daily or 0.1-0.2 units/kg/day in insulin-naïve patients with type 2 diabetes, with the understanding that Toujeo requires approximately 10-18% higher daily doses compared to Lantus (insulin glargine 100 U/mL) to achieve equivalent glycemic control. 1, 2, 3

Initial Dosing Strategy

For Insulin-Naïve Type 2 Diabetes Patients

• Start with 10 units once daily or 0.1-0.2 units/kg/day, administered at the same time each day 1
• For patients with severe hyperglycemia (HbA1c ≥9%, blood glucose ≥300-350 mg/dL), consider higher starting doses of 0.3-0.4 units/kg/day 1
• Lower doses (0.1-0.25 units/kg/day) should be used in high-risk patients including elderly (>65 years), those with renal failure, or poor oral intake 1

For Type 1 Diabetes Patients

• Total daily insulin requirement is typically 0.4-1.0 units/kg/day, with 0.5 units/kg/day being standard for metabolically stable patients 1
• Approximately 40-50% of total daily dose should be given as basal insulin (Toujeo), with the remainder as prandial insulin 1
• Patients in honeymoon phase may require lower doses of 0.2-0.6 units/kg/day 1

For Patients Switching from Lantus to Toujeo

• Expect to increase the dose by 10-18% when transitioning from Lantus 100 U/mL to Toujeo 300 U/mL, as the formulations are not bioequivalent 2, 3
• Reinforce blood glucose monitoring during the transition period 3

Dose Titration Protocol

Standard Titration Algorithm

• Increase by 2-4 units every 3 days until fasting blood glucose reaches target of 80-130 mg/dL 1
• If fasting glucose is ≥180 mg/dL, increase by 4 units every 3 days 1
• If fasting glucose is 140-179 mg/dL, increase by 2 units every 3 days 1
• Alternative approach: increase by 10-15% once or twice weekly until target is achieved 1

Hypoglycemia Management

• If more than 2 fasting glucose values per week are <80 mg/dL, decrease the dose by 2 units 1
• If hypoglycemia occurs, determine the cause and reduce dose by 10-20% immediately 1

Critical Threshold: Recognizing When to Add Prandial Insulin

Signs of Overbasalization

• Basal insulin dose exceeds 0.5 units/kg/day without achieving HbA1c goal 1
• Bedtime-to-morning glucose differential ≥50 mg/dL 1
• Fasting glucose controlled (80-130 mg/dL) but HbA1c remains elevated after 3-6 months 1
• Presence of hypoglycemia with high glucose variability 1

When to Add Prandial Coverage

• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day if HbA1c remains above target 1
• Add 4 units of rapid-acting insulin before the largest meal, or use 10% of current basal dose 1
• Titrate prandial insulin by 1-2 units or 10-15% every 3 days based on postprandial glucose readings 1

Toujeo-Specific Pharmacologic Considerations

Key Differences from Lantus

• Toujeo has a flatter and more prolonged pharmacodynamic profile with duration exceeding 24 hours 2, 3
• Lower intra- and inter-patient variability, making glucose control more reproducible 3
• Reduced risk of nocturnal hypoglycemia in insulin-experienced type 2 diabetes patients compared to Lantus 2
• Greater flexibility in injection timing due to extended duration of action 3

Administration Guidelines

• Toujeo cannot be diluted or mixed with other insulins due to its formulation 1
• Administered via optimized SoloStar pen device 3
• Can be given at any time of day, but must be at the same time daily 1

Common Pitfalls to Avoid

• Delaying insulin initiation in patients not achieving glycemic goals with oral medications leads to prolonged hyperglycemia and complications 1
• Treating Toujeo and Lantus as equivalent: Toujeo requires higher daily doses (10-18% more) to achieve similar glycemic control 2, 3
• Continuing to escalate basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia results in overbasalization, increased hypoglycemia risk, and suboptimal control 1
• Not adjusting doses based on self-monitoring of fasting blood glucose leads to poor glycemic control 1
• Premature discontinuation before adequate titration (minimum 3 months) prevents achievement of glycemic targets 1

Monitoring Requirements

• Daily fasting blood glucose monitoring during titration phase 1
• Reassess every 3 days during active titration 1
• Once stable, reassess every 3-6 months 1
• Monitor for signs of overbasalization at every clinical visit 1

Foundation Therapy

• Continue metformin unless contraindicated, even when initiating or intensifying insulin therapy 1
• Metformin remains the foundation of type 2 diabetes therapy and should not be discontinued when adding Toujeo 1