What is the recommended starting dose of Lantus (insulin glargine) for patients with type 1 or type 2 diabetes?

Recommended Starting Dose of Lantus (Insulin Glargine)

For insulin-naive patients with type 2 diabetes starting basal insulin therapy, initiate Lantus at 0.15 U/kg/day (approximately 10 units for a 70 kg patient) administered once daily, then titrate upward based on fasting plasma glucose levels to achieve target HbA1c <7.0% while minimizing hypoglycemia risk. 1

Starting Dose Calculation

• Standard starting dose: 0.15 U/kg/day for most patients with type 2 diabetes initiating basal-supported oral therapy 1
• Reduced starting doses are required for specific populations:
  • Patients with retinopathy: 0.12 U/kg/day 1
  • Patients with eGFR <60 mL/min/1.73 m²: 0.114 U/kg/day 1
  • Women: 0.135 U/kg/day 1
  • Patients on sulfonylureas: 0.132 U/kg/day 1

Dose Titration Algorithm

Use a structured titration approach to reach fasting plasma glucose <110 mg/dL (ideally <100 mg/dL) for optimal HbA1c control:

• Clinic-managed titration (Treat-to-Target protocol): Adjust insulin dose every 3 days based on mean fasting plasma glucose over the previous 3 days 2:

  • If FPG ≥180 mg/dL: increase by 6-8 units
  • If FPG 140-179 mg/dL: increase by 4 units
  • If FPG 120-139 mg/dL: increase by 2 units
  • If FPG 100-119 mg/dL: increase by 0-2 units
  • If FPG <72 mg/dL: hold titration 2

• Patient-managed titration: Increase dose by 2 units every 3 days until fasting glucose targets are met, provided no hypoglycemia (<72 mg/dL) occurs 2

A pragmatic dose calculation formula derived from Japanese clinical practice data: Optimal daily dose at 24 weeks = starting dose (0.15 × weight in kg) + incremental dose (baseline HbA1c - target HbA1c + 2) 1

Type 1 Diabetes Considerations

• For patients with type 1 diabetes, Lantus must be combined with rapid-acting insulin as part of a basal-bolus regimen 3
• The total daily insulin requirement is typically 0.4-1.0 U/kg/day, with approximately 40-50% given as basal insulin 4

Monitoring Requirements

• Assess efficacy and safety at least monthly for the first 3 months, then at least quarterly thereafter 3
• Increase frequency of blood glucose monitoring during insulin initiation and dose adjustments 3
• Target fasting plasma glucose should be decreased to ≤110 mg/dL to achieve HbA1c <7.0% 5

Key Safety Considerations

• Reduce concomitant sulfonylurea or glinide dose by 50% when adding Lantus to minimize hypoglycemia risk 6
• Reduce total daily insulin dose by 20% if adding other glucose-lowering agents 6
• Lantus demonstrates 26% lower risk of nocturnal hypoglycemia and 46% lower risk of severe hypoglycemia compared to NPH insulin while achieving equivalent glycemic control 7

Common Pitfalls to Avoid

• Inadequate dose titration is the most common reason for failure to reach HbA1c targets; patients achieving HbA1c <7.0% required significantly greater dose adjustments (+5.0 U/day) compared to those who failed to reach target (+1.1 U/day) 5
• Starting doses that are too conservative delay achievement of glycemic control 1
• Failure to adjust doses for renal impairment or retinopathy increases hypoglycemia risk 1