What is the recommended starting dose for Lantus (insulin glargine)?

Starting Dose for Lantus (Insulin Glargine)

Recommended Starting Doses by Diabetes Type

For insulin-naive patients with type 2 diabetes, start Lantus at 10 units once daily OR 0.1-0.2 units/kg body weight once daily, administered at the same time each day. 1, 2, 3

Type 2 Diabetes - Standard Initiation

• The FDA-approved starting dose is 0.2 units/kg or up to 10 units once daily for patients not currently treated with insulin 3
• The American Diabetes Association supports a starting range of 0.1-0.2 units/kg/day, with 10 units once daily being typical for most patients 1, 2
• Continue metformin (unless contraindicated) and possibly one additional non-insulin agent when initiating basal insulin 1

Type 2 Diabetes - Severe Hyperglycemia

• For patients with blood glucose ≥300-350 mg/dL and/or HbA1c ≥10-12% with symptomatic or catabolic features, start with basal-bolus insulin immediately rather than basal insulin alone 1
• For marked hyperglycemia with HbA1c ≥9%, consider more aggressive starting doses of 0.3-0.4 units/kg/day 1

Type 1 Diabetes - Starting Dose

• The recommended starting dose is approximately one-third of the total daily insulin requirements, with short-acting premeal insulin satisfying the remainder 3
• Total daily insulin typically ranges from 0.4-1.0 units/kg/day, with 0.5 units/kg/day being typical for metabolically stable patients 1, 2
• Divide approximately 40-50% as basal insulin (Lantus) and 50-60% as prandial insulin 1

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 Guidelines

• If fasting glucose is 140-179 mg/dL: increase by 2 units every 3 days 1
• If fasting glucose is ≥180 mg/dL: increase by 4 units every 3 days 1
• If hypoglycemia occurs without clear cause: reduce dose by 10-20% immediately 1
• If more than 2 fasting glucose values per week are <80 mg/dL: decrease dose by 2 units 1

Critical Threshold: 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

Signs of Overbasalization

• Basal insulin dose >0.5 units/kg/day 1
• Bedtime-to-morning glucose differential ≥50 mg/dL 1
• Hypoglycemia episodes 1
• High glucose variability 1

Adding Prandial Insulin

• Start with 4 units of rapid-acting insulin before the largest meal OR 10% of current basal dose 1
• Increase prandial insulin by 1-2 units or 10-15% every 3 days based on postprandial glucose readings 1

Special Population Adjustments

Lower Starting Doses Required For:

• Patients with retinopathy: 0.12 units/kg/day 4
• Patients with eGFR <60 mL/min/1.73 m²: 0.114 units/kg/day 4
• Elderly patients (>65 years) or those with poor oral intake: 0.1-0.25 units/kg/day 1
• Women: 0.135 units/kg/day 4
• Patients on sulfonylureas: 0.132 units/kg/day 4

Hospitalized Patients

• For insulin-naive or low-dose insulin patients: start with 0.3-0.5 units/kg total daily dose, with half 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 1

Administration Guidelines

Administer Lantus subcutaneously once daily at any time of day, but at the same time every day 1, 3

Key Administration Points

• Inject into abdominal area, thigh, or deltoid, rotating sites within the same region 3
• Do NOT administer intravenously or via insulin pump 3
• Do NOT dilute or mix with any other insulin or solution 3
• Lantus can be given at breakfast, dinner, or bedtime with similar efficacy, though morning administration results in significantly less nocturnal hypoglycemia (59.5% vs 71.9-77.5%) 5

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 1
• Do not wait longer than 3 days between basal insulin adjustments in stable patients 1
• Do not ignore the need for prandial insulin when signs of overbasalization are present 1
• Always reduce home insulin doses by 20% when admitting patients on high-dose insulin (≥0.6 units/kg/day) 1

Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during titration 1
• Assess adequacy of insulin dose at every clinical visit, looking for signs of overbasalization 1
• Increase frequency of blood glucose monitoring during any changes to insulin regimen 3