What is the recommended initial dose of Lantus (insulin glargine)?

Initial Dosing of Lantus (Insulin Glargine)

Start Lantus at 10 units once daily OR 0.1-0.2 units/kg body weight once daily for insulin-naive patients with type 2 diabetes, administered at the same time each day. 1, 2

Type 2 Diabetes: Standard Initiation

For most insulin-naive patients with type 2 diabetes:

• Begin with 10 units once daily as the most convenient starting point, particularly for patients with moderate hyperglycemia 1
• Alternatively, use 0.1-0.2 units/kg/day based on the degree of hyperglycemia—use the higher end (0.2 units/kg) for more severe elevations 1, 2
• Continue metformin (unless contraindicated) and possibly one additional non-insulin agent when initiating basal insulin 1

Severe Hyperglycemia Requires Higher Starting Doses

For patients with blood glucose ≥300-350 mg/dL and/or A1C ≥10-12% with symptomatic or catabolic features, start with basal-bolus insulin immediately rather than basal insulin alone 1

When severe hyperglycemia is present but not requiring immediate basal-bolus:

• Consider starting doses of 0.3-0.4 units/kg/day for patients with marked hyperglycemia 2
• This more aggressive approach helps achieve glycemic targets faster in patients with A1C ≥9% 1

Type 1 Diabetes: Different Dosing Strategy

For type 1 diabetes, total daily insulin requirements are 0.4-1.0 units/kg/day, with approximately 50% given as basal insulin (Lantus) 2, 3

• Typical starting dose is 0.5 units/kg/day total insulin for metabolically stable patients, with half as Lantus 2, 3
• For a 70 kg patient, this translates to approximately 17-18 units of Lantus daily 2, 3
• Higher doses are required immediately following diabetic ketoacidosis 3

Dose Titration Algorithm

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

Specific titration based on fasting glucose levels:

• If fasting glucose 140-179 mg/dL: increase by 2 units every 3 days 2
• If fasting glucose ≥180 mg/dL: increase by 4 units every 3 days 2
• If hypoglycemia occurs: reduce dose by 10-20% immediately 2

Critical Threshold: Recognizing When to Stop Escalating Basal Insulin

When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, add prandial insulin rather than continuing to escalate basal insulin alone 1, 2

Signs of "overbasalization" that indicate need for prandial insulin instead of more basal insulin:

• Basal dose >0.5 units/kg/day with A1C still above target 2
• Bedtime-to-morning glucose differential ≥50 mg/dL 2
• Hypoglycemia episodes occurring 2
• High glucose variability 2

Special Populations Requiring Lower Starting Doses

For high-risk patients, start with lower doses of 0.1-0.25 units/kg/day 2:

• Elderly patients (>65 years) 2
• Patients with renal failure (eGFR <60 mL/min/1.73 m²) 2, 4
• Patients with retinopathy 4
• Patients with poor oral intake 2

Women and patients on sulfonylureas may require slightly lower starting doses (0.13-0.14 units/kg/day) 4

Administration Timing

Lantus can be administered at any time of day (morning, bedtime, or other convenient time) as long as it is given at the same time each day 2, 5, 6

• Morning versus bedtime administration shows equivalent glycemic control and hypoglycemia rates 5
• Do not mix Lantus with other insulins or solutions due to its low pH 2

Common Pitfalls to Avoid

• Do not delay insulin initiation in patients not achieving glycemic goals with oral medications—this worsens long-term outcomes 2
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia with prandial insulin 2
• Do not stop metformin when adding insulin unless contraindicated 2
• Equip patients with self-titration algorithms based on self-monitoring of blood glucose—this improves glycemic control 1