What is the recommended course of action for a patient with uncontrolled Diabetes Mellitus (DM) presenting with hyperglycemia, recently initiated on Lantus (Insulin Glargine) 10 units, and experiencing symptoms of increased thirst, blurry vision, weakness, and fatigue?

From the Guidelines

The patient's Lantus dose should be increased from 10 units to 15 units daily, and a rapid-acting insulin such as Novolog or Humalog should be started at 4 units before meals to address postprandial hyperglycemia, as the current regimen is insufficient to establish glycemic control, with blood glucose readings consistently above 300 mg/dL 1. The patient should continue taking Lantus at 8:30 pm daily and maintain blood glucose monitoring at least twice daily (fasting and 2 hours after a meal). Key points to consider in the management of this patient's diabetes include:

• The patient's blood glucose readings are consistently elevated, with levels above 300 mg/dL, indicating a need for adjustment of the insulin regimen 1.
• The patient has recently started taking Lantus, and the current dose may not be sufficient to establish glycemic control, particularly given the presence of symptoms such as increased thirst and blurry vision 1.
• The addition of a rapid-acting insulin such as Novolog or Humalog before meals can help address postprandial hyperglycemia and improve overall glycemic control 1.
• The patient should be reminded to maintain adequate hydration, continue monitoring for symptoms of hyperglycemia, and seek emergency care if experiencing severe symptoms such as vomiting, severe abdominal pain, or altered mental status 1.
• The patient should follow up in one week to reassess glycemic control and adjust insulin doses as needed, with consideration of further adjustments to the treatment regimen if glycemic targets are not met 1.

From the FDA Drug Label

For patients with type 2 diabetes, dosage adjustments of concomitant oral and antidiabetic products may be needed.

The risk of hypoglycemia after an injection is related to the duration of action of the insulin and, in general, is highest when the glucose lowering effect of the insulin is maximal

Patients and caregivers must be educated to recognize and manage hypoglycemia. Self-monitoring of blood glucose plays an essential role in the prevention and management of hypoglycemia

The patient has just started taking Lantus 10u on 4/2/25 and has consistently elevated blood sugar levels >300s. Given that the patient has just started insulin therapy, it is essential to closely monitor blood glucose levels and adjust the dosage as needed to prevent hypoglycemia. The patient should continue to self-monitor blood glucose levels and report any changes or concerns to the healthcare provider.

• Key considerations:
  • Closely monitor blood glucose levels
  • Adjust insulin dosage as needed
  • Educate patient on recognizing and managing hypoglycemia
  • Increase frequency of blood glucose monitoring to prevent hypoglycemia 2 2
• Recommendation: Continue with current insulin regimen and closely monitor blood glucose levels. Adjust dosage as needed to achieve optimal blood glucose control. 2

From the Research

Patient's Current Condition

The patient has been diagnosed with uncontrolled diabetes mellitus (DM) and has recently started checking her blood sugar (BS) levels. Her BS readings have been consistently elevated, with values above 300 mg/dL. She has also started taking Lantus (insulin glargine) 10 units once daily in the evening, with the first dose administered on 4/2/25.

Symptoms and Side Effects

The patient reports increased thirst, which may be related to her recently diagnosed thrush. She also experiences blurry vision, but attributes this to her broken glasses. Additionally, she reports weakness and fatigue, which she believes are due to a recent lung infection. However, she does not exhibit any severe symptoms such as shortness of breath, difficulty breathing, or chest pain.

Lantus Administration and Dosage

According to the study by 3, Lantus is a long-acting insulin analogue that provides a relatively constant basal level of circulating insulin with no pronounced peak. The patient's current dosage of 10 units once daily is within the recommended initial dose range of 10 units/day or 0.1-0.2 units/kg/day, as suggested by 4.

Glycemic Control and Titration

The patient's BS readings indicate poor glycemic control, with values consistently above 300 mg/dL. The study by 5 suggests that Lantus may be a better choice for patients with well-controlled type 2 diabetes, as it shows lower mean blood glucose levels and reduced glycemic variability compared to other basal insulins. However, the patient's current dosage may need to be adjusted to achieve better glycemic control. According to 4, the dose of basal insulin should be increased as required, up to approximately 0.5-1.0 units/kg/day, to achieve target fasting plasma glucose levels.

Potential Benefits and Risks

The addition of Lantus to the patient's treatment regimen may lead to improved glycemic control, as seen in the studies by 6 and 7. However, the patient should be monitored for potential side effects, such as hypoglycemia, and her dosage should be adjusted accordingly. The study by 6 shows that the initiation of once-daily Lantus with oral antidiabetic agents results in significant reduction of HbA1c with a low risk of hypoglycemia.

Key Considerations

• The patient's BS readings should be closely monitored to assess the effectiveness of the current treatment regimen.
• The dosage of Lantus may need to be adjusted to achieve better glycemic control.
• The patient should be educated on the potential benefits and risks of Lantus therapy and the importance of regular monitoring and follow-up appointments.
• The patient's overall health and well-being should be taken into consideration when adjusting her treatment regimen, including her recent lung infection and thrush diagnosis.