Lantus Dose Adjustment for Inadequate Basal Coverage
Increase Lantus by 10-12 units immediately (to approximately 20-22 units total), then continue aggressive titration by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL. 1
Rationale for Aggressive Dose Increase
Your patient's previous pump basal requirements of 19-29 units clearly demonstrate they need substantially more than the 10 units of Lantus currently prescribed. 1 The fasting glucose of 220 mg/dL and overnight glucose of 179 mg/dL indicate severe underdosing of basal insulin. 1
The American Diabetes Association recommends increasing basal insulin by 4 units every 3 days when fasting glucose is ≥180 mg/dL. 1 However, given this patient was abruptly transitioned from a pump delivering 19-29 units of basal insulin to only 10 units of Lantus, a more substantial initial correction is warranted to avoid prolonged hyperglycemia. 1
Specific Titration Algorithm
Immediate adjustment: Increase Lantus from 10 units to 20-22 units (matching the lower end of their previous pump basal range). 1
Ongoing titration schedule: Increase by 4 units every 3 days if fasting glucose remains ≥180 mg/dL. 1
Target fasting glucose: 80-130 mg/dL. 1
If hypoglycemia occurs: Reduce dose by 10-20% immediately and determine the cause. 1
Critical Monitoring Requirements
Daily fasting blood glucose monitoring is essential during this titration phase. 1 The patient should check fasting glucose every morning and adjust accordingly. 2
Reassess every 3 days during active titration to ensure progress toward target without hypoglycemia. 1
Continue metformin (if the patient is on it) unless contraindicated, as it reduces total insulin requirements. 1
Important Considerations for Pump-to-MDI Transitions
When transitioning from pump therapy, patients typically require similar total basal insulin doses as their pump settings indicated. 1 This patient's pump was delivering 19-29 units basally, so starting at only 10 units represents a 50-70% reduction in basal coverage—explaining the hyperglycemia. 1
The standard starting dose of 10 units or 0.1-0.2 units/kg/day is intended for insulin-naive patients, not those transitioning from established pump therapy with known insulin requirements. 1 This is a common pitfall that leads to inadequate glycemic control. 1
When to Consider Prandial Insulin
Monitor for signs that basal insulin alone is insufficient: If after optimizing Lantus to achieve fasting glucose 80-130 mg/dL, the patient still has significant postprandial excursions (>180 mg/dL) or HbA1c remains above goal after 3-6 months. 2
Watch for overbasalization: If Lantus dose exceeds 0.5 units/kg/day without achieving targets, adding prandial insulin becomes more appropriate than continuing to escalate basal insulin alone. 1