How should I manage my diabetes while taking Lantus (insulin glargine) 44 units AM and 46 units PM for 90 days?

Managing Diabetes on Lantus 44 Units AM and 46 Units PM

Critical Problem: This Regimen is Incorrect

Your current prescription of Lantus twice daily at these doses is highly unusual and likely represents either overbasalization or an inappropriate dosing schedule that needs immediate reassessment. Lantus (insulin glargine) is designed as a once-daily basal insulin that provides relatively constant insulin levels over 24 hours without pronounced peaks 1, 2, 3. Your total daily dose of 90 units split twice daily suggests a fundamental problem with your diabetes management approach.

Immediate Actions Required

1. Contact Your Healthcare Provider Urgently

You must contact your prescribing physician before continuing this regimen. The following issues need immediate clarification:

• Total daily dose of 90 units is extremely high - If you weigh less than 180 kg (396 lbs), this dose exceeds 0.5 units/kg/day, which is a critical threshold indicating potential overbasalization 1, 4
• Twice-daily Lantus dosing at these amounts is not standard - While twice-daily glargine can be used in select cases where once-daily dosing doesn't provide 24-hour coverage, the split you're using (44 AM/46 PM) is nearly equal and suggests this may not be the intended approach 5, 4
• You likely need prandial (mealtime) insulin added rather than such high basal doses 1

2. Assess for Signs of Overbasalization

Watch for these clinical signals that indicate your basal insulin is too high 1, 4:

• Hypoglycemia (blood sugar <70 mg/dL), especially at night - symptoms include dizziness, sweating, confusion, shakiness, fast heartbeat 2
• Large glucose swings - bedtime-to-morning glucose difference ≥50 mg/dL 4
• High glucose variability throughout the day despite high insulin doses 1
• Postprandial hyperglycemia (high blood sugar after meals) while fasting glucose is controlled 4

If you experience hypoglycemia without clear cause, reduce your dose by 10-20% immediately and contact your provider 1.

What Your Regimen Should Likely Be Instead

Standard Lantus Dosing Approach

For most patients, Lantus should be given once daily at the same time each day 1, 2, 3:

• Typical starting dose: 10 units once daily OR 0.1-0.2 units/kg/day 1, 4
• Can be given morning or bedtime - timing flexibility is acceptable as long as it's consistent 6, 2
• Titrate by 2-4 units every 3 days until fasting blood glucose reaches 80-130 mg/dL 1, 4

When Twice-Daily Lantus is Appropriate

Twice-daily dosing is only indicated in specific situations 5, 4:

• When once-daily dosing doesn't provide full 24-hour coverage (rare)
• In highly insulin-resistant patients requiring very high volumes
• In labile type 1 diabetes with extreme variability

Even in these cases, the doses are typically unequal (e.g., 2/3 morning, 1/3 evening for NPH-like patterns), not the near-equal split you're using 5.

Adding Prandial Insulin Instead

When basal insulin exceeds 0.5 units/kg/day (approximately 40-50 units for most adults), adding mealtime insulin is more appropriate than increasing basal further 1, 4:

• Start with 4 units of rapid-acting insulin (like Humalog, Novolog) before your largest meal 1
• Alternatively, use 10% of your basal dose as the starting prandial dose 1, 4
• Titrate prandial insulin by 1-2 units every 3 days based on post-meal glucose readings 1

Essential Monitoring and Self-Management

Blood Glucose Monitoring

Check your blood sugar at these critical times 1, 4:

• Fasting (before breakfast) - target 80-130 mg/dL 1, 4
• Before each meal - to guide prandial insulin dosing if added 1
• 2 hours after meals - to assess postprandial control 4
• Bedtime - to prevent nocturnal hypoglycemia 1
• Anytime you feel symptoms of low blood sugar 2

Injection Technique

Proper administration is critical 2:

• Inject subcutaneously in upper thighs, upper arms, or abdomen 2
• Rotate injection sites within the same area to prevent lipodystrophy (skin pits or lumps) 2
• Use a new needle for each injection - reusing needles increases infection risk and can cause blocked needles leading to incorrect dosing 2
• Do NOT mix Lantus with any other insulin - its acidic pH makes it incompatible 2, 4

Hypoglycemia Management

Always be prepared to treat low blood sugar 2:

• Recognize symptoms: dizziness, sweating, confusion, shakiness, fast heartbeat, hunger 2
• Treat immediately with 15-20 grams of fast-acting carbohydrates (glucose tablets, juice, regular soda)
• Recheck in 15 minutes and repeat treatment if still low
• Your provider should prescribe glucagon for emergency use 1

Foundation Therapy Requirements

Continue Metformin

Unless contraindicated, you should be on metformin as the foundation of type 2 diabetes therapy 1, 4. Metformin should be continued even when intensifying insulin therapy 4.

Consider GLP-1 Receptor Agonists

If you're not already on a GLP-1 RA (like Ozempic, Trulicity, Mounjaro), this should be discussed with your provider 1:

• GLP-1 RAs can improve A1C while minimizing weight gain and hypoglycemia risk that comes with high insulin doses 1, 4
• May allow reduction in insulin doses while maintaining or improving control 1
• Particularly important if you have cardiovascular disease - some GLP-1 RAs have proven cardiovascular benefits 1

Lifestyle Modifications During This 90-Day Period

Dietary Considerations

• Consistent carbohydrate intake at meals helps predict insulin needs
• Avoid skipping meals when on basal insulin to prevent hypoglycemia
• Limit alcohol - increases hypoglycemia risk 2

Activity and Exercise

• Your insulin needs may decrease with increased physical activity 2
• Check blood sugar before, during, and after exercise if engaging in prolonged activity
• Carry fast-acting carbohydrates during exercise 2

Sick Day Management

Illness can dramatically affect insulin requirements 2:

• Never stop insulin even if not eating well
• Check blood sugar more frequently (every 2-4 hours)
• Contact your provider if blood sugars are consistently >250 mg/dL or you're unable to eat

Common Pitfalls to Avoid

Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia - this leads to suboptimal control and increased hypoglycemia risk 4. At 90 units total daily dose, you're likely already past this threshold.

Do not delay adding prandial insulin when signs of overbasalization are present 4. Your current regimen suggests this transition should have already occurred.

Do not drive or operate heavy machinery until you know how this insulin regimen affects you, especially given the high doses and risk of hypoglycemia 2.

What to Discuss at Your Next Appointment

Bring these specific questions to your provider 1, 4:

1. What is my weight-based insulin dose (units/kg/day)?
2. Am I showing signs of overbasalization?
3. Should I transition to once-daily Lantus with added prandial insulin?
4. What is my A1C goal and current A1C?
5. Should I be on a GLP-1 receptor agonist?
6. Do I need a glucagon prescription for emergencies?