From the Guidelines
Lantus (insulin glargine) can be administered twice daily in certain situations, particularly for patients who experience a "waning" effect before their next scheduled dose or require large insulin doses, to improve glycemic control and reduce the risk of overnight hypoglycemia. The main advantages of twice-daily Lantus include improved glycemic control, reduced risk of overnight hypoglycemia, and potential benefits for patients with dawn phenomenon (early morning blood sugar spikes) 1. However, there are several disadvantages to consider, such as:
- Less convenience, requiring additional injections which may reduce adherence
- Increased risk of dosing errors
- Potential raises in treatment costs
- More frequent hypoglycemic episodes due to overlapping insulin activity
When implementing twice-daily Lantus, the total daily dose is typically split into two equal injections given approximately 12 hours apart (morning and evening), though the split doesn't always need to be even 1. Patients should monitor blood glucose more frequently when starting this regimen to avoid hypoglycemia and allow for appropriate dose adjustments. This approach should be initiated under healthcare provider supervision with regular follow-up to ensure safety and effectiveness. According to the 2017 American Diabetes Association standards of medical care in diabetes, basal insulin plus a single injection of rapid-acting insulin administered at the largest meal is noninferior to basal insulin plus a GLP-1–receptor agonist or 2 daily injections of premixed insulins 1.
Key considerations for twice-daily Lantus include:
- Patient selection: those who experience a "waning" effect or require large insulin doses
- Dose titration: important to adjust doses based on blood glucose levels and pharmacodynamic profile
- Monitoring: frequent blood glucose monitoring to avoid hypoglycemia and adjust doses
- Healthcare provider supervision: regular follow-up to ensure safety and effectiveness.
From the Research
Pros of Lantus Twice Daily
- Reduced hypoglycemia risk: A study found that twice-daily injection with insulin glargine resulted in the resolution of hypoglycemia in a patient who experienced significant morning hypoglycemia despite titration of insulin dose 2.
- Improved glycemic control: Twice-daily Lantus may provide more flexible and effective glycemic control for some patients, especially those who experience hypoglycemia with once-daily dosing 2.
- Increased success in achieving glycemic targets: The increased frequency of administration may result in a greater success in achieving glycemic targets, despite a slight increase in cost and inconvenience for the patient 2.
Cons of Lantus Twice Daily
- Increased cost and inconvenience: Twice-daily administration of Lantus may be more costly and inconvenient for patients compared to once-daily dosing 2.
- Limited studies: There are limited studies on the use of Lantus twice daily, and more research is needed to fully understand its effects and benefits 2.
- Potential for increased hypoglycemia risk: While twice-daily Lantus may reduce hypoglycemia risk in some patients, it may also increase the risk of hypoglycemia in others, particularly if the dose is not adjusted correctly 3.
General Information on Lantus
- Lantus is a long-acting insulin analogue that provides a relatively constant basal level of circulating insulin with no pronounced peak 4.
- It is well tolerated and elicits less hypoglycemia, especially nocturnal episodes, than NPH insulin, with similar levels of glycemic control 4.
- Lantus can be used in combination with short-acting insulin analogues in patients with type 1 diabetes, and can be added to oral hypoglycaemic agents in patients with type 2 diabetes where these agents are failing 4.