What is the recommended dose of insulin glargine (insulin glargine) for glucose control?

Insulin Glargine Dosing for Glucose Control

Starting Dose Recommendations

For insulin-naive patients with type 2 diabetes, start insulin glargine at 10 units once daily or 0.1-0.2 units/kg body weight, administered at the same time each day. 1, 2, 3, 4

Type 2 Diabetes Initial Dosing

• Standard initiation: 10 units once daily or 0.1-0.2 units/kg/day for patients with mild-to-moderate hyperglycemia 1, 2, 3, 4
• Severe hyperglycemia (A1C ≥9%, blood glucose ≥300-350 mg/dL, or symptomatic/catabolic features): Consider higher starting doses of 0.3-0.5 units/kg/day as part of a basal-bolus regimen rather than basal insulin alone 2, 3
• Continue metformin unless contraindicated when initiating insulin therapy 1, 2, 3

Type 1 Diabetes Initial Dosing

• Total daily insulin requirement: 0.4-1.0 units/kg/day, with 0.5 units/kg/day typical for metabolically stable patients 2, 3
• Basal insulin component: Approximately one-third to 50% of total daily insulin as insulin glargine 2, 3, 4
• Prandial insulin: Remainder as rapid-acting insulin divided among meals 2, 3, 4
• Higher doses (up to 1.5 units/kg/day) may be required during puberty due to hormonal influences 2

Dose Titration Algorithm

Increase insulin glargine by 2-4 units every 3 days until fasting blood glucose reaches 80-130 mg/dL. 1, 2, 3

Specific Titration Schedule

• Fasting glucose 140-179 mg/dL: Increase by 2 units every 3 days 2, 3
• Fasting glucose ≥180 mg/dL: Increase by 4 units every 3 days 2, 3
• Fasting glucose <80 mg/dL (more than 2 values per week): Decrease by 2 units 3
• Hypoglycemia without clear cause: Reduce dose by 10-20% immediately 2, 3

Alternative Titration Approach

• Increase by 10-15% of current dose once or twice weekly until target is met 1, 2
• Patient self-titration using home glucose monitoring improves glycemic control 1

Critical Dosing 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 or a GLP-1 receptor agonist rather than continuing to escalate basal insulin alone. 1, 2, 3

Signs of "Overbasalization"

• Basal insulin dose >0.5 units/kg/day 2, 3
• Bedtime-to-morning glucose differential ≥50 mg/dL 2, 3
• Hypoglycemia episodes 2, 3
• High glucose variability 2, 3
• Fasting glucose at target but A1C remains elevated after 3-6 months 2, 3

Adding Prandial Coverage

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

Special Populations and Situations

Hospitalized Patients

• Insulin-naive or low-dose insulin: 0.3-0.5 units/kg/day total daily dose, with half as basal insulin 3
• High-dose home insulin (≥0.6 units/kg/day): Reduce total daily dose by 20% to prevent hypoglycemia 3
• High-risk patients (elderly >65 years, renal failure, poor oral intake): 0.1-0.25 units/kg/day 2, 3

Switching from Other Insulins

• From NPH once daily: Use same dose 4
• From NPH twice daily: Use 80% of total NPH dose 4
• From U-300 glargine (Toujeo): Use 80% of Toujeo dose 4

Twice-Daily Dosing Considerations

• Consider splitting the dose when once-daily administration fails to provide 24-hour coverage 2, 3
• Particularly useful in type 1 diabetes with high glycemic variability 2, 3
• May be needed when total daily dose exceeds absorption capacity for once-daily administration 2

Administration Guidelines

Timing and Technique

• Administer subcutaneously once daily at the same time each day 1, 2, 4
• Inject into abdominal area, thigh, or deltoid 4
• Rotate injection sites within the same region to reduce lipodystrophy risk 4
• Do not dilute or mix with any other insulin or solution due to low pH 2, 4
• Do not administer intravenously or via insulin pump 4

Pharmacokinetic Profile

• Onset of action: approximately 1 hour 1, 2
• Duration: up to 24 hours with peakless profile 1, 2, 5, 6, 7
• More consistent absorption than NPH insulin 1, 2

Monitoring Requirements

During Titration

• Daily fasting blood glucose monitoring is essential 2, 3
• Increase frequency of monitoring during regimen changes 4
• Assess adequacy of insulin dose at every clinical visit 2, 3
• Check A1C every 3 months during intensive titration 3

Long-Term Monitoring

• Reassess and modify therapy every 3-6 months once stable 3
• Monitor for signs of overbasalization at each visit 2, 3

Common Pitfalls to Avoid

Dosing Errors

• Not delaying insulin initiation in patients not achieving glycemic goals with oral medications 3
• Continuing to escalate basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia leads to suboptimal control and increased hypoglycemia risk 2, 3
• Failing to add prandial insulin when blood glucose remains elevated despite optimized basal insulin 2, 3
• Not reducing dose by 10-20% when hypoglycemia occurs 2, 3

Foundation Therapy

• Always continue metformin unless contraindicated, even when intensifying insulin therapy 2, 3
• Metformin reduces total insulin requirements and provides complementary glucose-lowering effects 3

Patient Education Essentials

• Proper injection technique and site rotation 3
• Recognition and treatment of hypoglycemia 3
• Self-monitoring of blood glucose 3
• "Sick day" management rules 3
• Insulin storage and handling 3

Clinical Advantages Over NPH Insulin

Insulin glargine provides significantly fewer episodes of nocturnal hypoglycemia compared to NPH insulin while achieving equivalent glycemic control. 1, 2, 6, 7, 8

• More stable, peakless 24-hour coverage 1, 2, 5, 6, 7
• Lower overall hypoglycemia risk, especially nocturnal episodes 1, 2, 6, 7, 8
• More consistent absorption pattern 1, 2
• Higher patient treatment satisfaction 6