What is the best way to initiate Lantus (insulin glargine) therapy in a patient with elevated HbA1c on sliding scale Novolog (insulin aspart) insulin?

Initiating Lantus Therapy in a Patient with HbA1c 8.6% on Sliding Scale Novolog

Immediate Regimen Change Required

You must discontinue the sliding scale Novolog regimen immediately and transition to scheduled basal insulin (Lantus) with or without prandial coverage, as sliding scale insulin alone is strongly discouraged and ineffective for glycemic management in both hospitalized and outpatient settings. 1

Starting Lantus Dose

Begin Lantus at 10 units once daily at bedtime, or calculate 0.2 units/kg/day if the patient weighs more than 50 kg. 2 The FDA-approved starting dose for insulin-naive type 2 diabetes patients is 0.2 units/kg or up to 10 units once daily 2. For a patient with HbA1c 8.6%, this conservative starting dose minimizes hypoglycemia risk while establishing basal coverage 3.

Titration Protocol

Increase the Lantus dose by 2 units every 3 days until fasting blood glucose consistently reaches 80-130 mg/dL (4.4-7.2 mmol/L). 4, 3, 2 This patient-driven titration algorithm has been shown to achieve greater HbA1c reductions compared to clinic-driven titration (-1.5% vs -1.3%) with acceptable hypoglycemia rates 5, 6.

• The patient should check fasting glucose every morning before breakfast to guide dose adjustments 3
• If any blood glucose reading is <70 mg/dL, reduce the Lantus dose by 10-20% 3, 7
• Maximum basal dose should not exceed 0.5 units/kg/day to avoid overbasalization 3

Concurrent Medication Management

Continue or initiate metformin at 1000 mg twice daily unless contraindicated, as this reduces insulin requirements and limits weight gain. 4, 3 Metformin should remain the foundation of therapy even when insulin is added 4.

Discontinue any sulfonylureas if present, as combining them with insulin significantly increases hypoglycemia risk. 4, 1

Deciding on Prandial Insulin

For HbA1c 8.6%, you have two evidence-based options:

Option 1 (Preferred for simplicity): Start with basal insulin (Lantus) alone and reassess in 2-3 months. If HbA1c remains >7% despite optimized basal insulin (fasting glucose at target), then add prandial insulin 4, 1.

Option 2 (For faster control): Start both basal and prandial insulin simultaneously. Add 4 units of rapid-acting insulin (Novolog) before the largest meal, representing approximately 10% of the basal dose 1, 3. Increase prandial insulin by 1-2 units twice weekly based on 2-hour postprandial glucose readings 1, 3.

The choice depends on symptom severity: if the patient is symptomatic with polyuria/polydipsia, use Option 2; if asymptomatic, Option 1 is reasonable 4.

Critical Patient Education

Before discharge or at the first visit, provide comprehensive education on:

• Insulin injection technique: Administer Lantus subcutaneously into the abdomen, thigh, or deltoid at the same time each day, rotating sites within the same region 2
• Self-monitoring: Check fasting glucose daily and maintain a log for dose adjustments 3
• Hypoglycemia recognition and treatment: Provide glucose tablets or gel and instruct on treating blood glucose <70 mg/dL with 15-20g fast-acting carbohydrate 4, 1
• Self-titration algorithm: Give written instructions for the 2-unit every 3-day increase protocol 3, 5

Expected Outcomes and Follow-up

• Target fasting glucose (80-130 mg/dL) should be achieved within 2-4 weeks with proper titration 3
• Expected HbA1c reduction of 1.0-1.5% over 3 months with basal insulin alone 4, 5
• Reassess glycemic control every 2-3 months 4, 3
• If HbA1c remains >7% after 3 months despite fasting glucose at target, add prandial insulin at the largest meal 4, 1

Common Pitfalls to Avoid

• Do not continue sliding scale insulin as the primary regimen—it only treats hyperglycemia reactively rather than preventing it 1, 3
• Do not delay insulin intensification for months while trying additional oral agents at this HbA1c level 1
• Do not administer Lantus intravenously, via insulin pump, or mix it with other insulins 2
• Do not inject into areas of lipodystrophy, as this causes erratic absorption and hyperglycemia 2
• Do not share insulin pens between patients even if the needle is changed 2