What is the best way to prescribe Lantus (insulin glargine) as a pen to a patient?

Prescribing Lantus (Insulin Glargine) as a Pen

For most patients with type 2 diabetes, prescribe Lantus SoloStar prefilled pens starting at 10 units once daily (or 0.1-0.2 units/kg body weight), administered subcutaneously at the same time each day, with dose titration by 2-4 units every 3 days until fasting blood glucose reaches 80-130 mg/dL. 1, 2

Initial Dosing Strategy

Type 2 Diabetes (Insulin-Naive Patients)

• Start with 10 units once daily or 0.1-0.2 units/kg body weight, administered at the same time each day 1, 2
• Continue metformin unless contraindicated, and possibly one additional non-insulin agent 1
• For patients with 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 1, 3

Type 1 Diabetes

• Start with approximately one-third of total daily insulin requirements as Lantus 2
• Total daily insulin typically ranges from 0.4-1.0 units/kg/day, with approximately 50% as basal insulin 1, 4
• Must be used concomitantly with rapid-acting insulin at mealtimes 2

Pen-Specific Administration Instructions

Using the SoloStar Prefilled Pen

• Never share pens between patients, even if the needle is changed - this poses a risk for transmission of blood-borne pathogens 2
• The SoloStar pen dials in 1-unit increments and can deliver doses from 1 to 80 units 2
• Use with caution in visually impaired patients who may rely on audible clicks to dial their dose 2
• Each pen contains 300 units total (3 mL at 100 units/mL concentration) 2

Injection Technique

• Administer subcutaneously into the abdominal area, thigh, or deltoid 2
• Rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis 3, 2
• Do not inject into areas of lipodystrophy, localized cutaneous amyloidosis, or where skin is tender, bruised, scaly, hard, or damaged 3, 2
• Keep the needle embedded within the skin for 5 seconds after complete delivery of the insulin dose 3

Storage and Handling

• Do not dilute or mix Lantus with any other insulin or solution due to its low pH 3, 2
• Visually inspect before administration - only use if the solution is clear and colorless with no visible particles 2
• Do not roll or shake Lantus (unlike NPH insulin) - it is a clear solution that does not require resuspension 3

Dose Titration Algorithm

Standard Titration Protocol

• Increase by 2 units every 3 days if fasting glucose is 140-179 mg/dL 1, 4
• Increase by 4 units every 3 days if fasting glucose is ≥180 mg/dL 1, 4
• Target fasting plasma glucose: 80-130 mg/dL 1, 4
• If hypoglycemia occurs without clear cause, reduce dose by 10-20% immediately 1, 4
• If more than 2 fasting values per week are <80 mg/dL, decrease dose by 2 units 1

Patient Self-Titration

• Most patients can be taught to uptitrate their own insulin dose, typically adding 1-2 units (or 5-10% for higher doses) once or twice weekly if fasting glucose levels remain above target 1
• Daily fasting blood glucose monitoring is essential during titration 1, 4

Critical Threshold: Recognizing Overbasalization

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 rather than continuing to escalate basal insulin alone 1, 4
• Clinical signals of overbasalization include: 1
  • Basal dose >0.5 units/kg/day
  • Bedtime-to-morning glucose differential ≥50 mg/dL
  • Hypoglycemia episodes
  • High glucose variability

Adding Prandial Insulin

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

Prescription Writing Specifics

Calculating Monthly Supply

• For a patient requiring 20 units daily: 20 units/day × 30 days = 600 units per month 5
• Each SoloStar pen contains 300 units, so prescribe 2-3 pens per month depending on dose 5
• For a 96 kg patient at 0.2 units/kg/day: 19.2 units/day × 30 = 576 units = 2 pens per month initially 5
• Account for dose titration by prescribing 3 pens per month to provide adequate coverage 5

Sample Prescription Format

• Lantus SoloStar 100 units/mL prefilled pen
• Dispense: 3 pens (or quantity based on calculated need)
• Sig: Inject [X] units subcutaneously once daily at [specific time], rotating injection sites
• Include pen needles prescription separately (typically 4mm or 5mm needles) 3

Common Pitfalls to Avoid

Critical Errors

• Do not administer intravenously or via an insulin pump 2
• Do not use a syringe to remove insulin from the pen - this can lead to dosing errors 2
• Do not reuse needles - this increases infection risk and may cause dosing inaccuracies 3
• Do not delay insulin initiation in patients not achieving glycemic goals with oral medications 1

Dosing Mistakes

• 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 1, 4
• Not adjusting doses based on self-monitoring of blood glucose levels 1
• Failing to reduce home insulin doses by 20% when admitting patients on high-dose insulin (≥0.6 units/kg/day) to prevent hypoglycemia 1

Special Populations

High-Risk Patients

• Elderly patients (>65 years), those with renal failure, or poor oral intake require lower doses (0.1-0.25 units/kg/day) to prevent hypoglycemia 1
• For hospitalized patients on high-dose home insulin (≥0.6 units/kg/day), reduce total daily dose by 20% upon admission 1

Patients on Enteral/Parenteral Feeding

• A reasonable starting point is 10 units of insulin glargine every 24 hours 1
• Basal insulin needs are typically 30-50% of total daily insulin requirement 1

Monitoring Requirements

During Titration Phase

• Daily fasting blood glucose monitoring is essential 1, 4
• Assess adequacy of insulin dose at every clinical visit 1, 4
• Reassess every 3 days during active titration 4
• Check A1C every 3 months during intensive titration 1

Long-Term Monitoring

• Reassess and modify therapy every 3-6 months once stable 4
• Monitor for signs of overbasalization at each assessment 1
• Increase frequency of blood glucose monitoring during changes to insulin regimen 2