Blood Glucose Monitoring for Patients on Lantus with History of Hypoglycemia
Yes, you must order blood glucose checks for any patient on Lantus (insulin glargine), and this is especially critical for patients with a history of hypoglycemia. All patients with diabetes on insulin therapy should have an order for blood glucose monitoring with results available to all members of the healthcare team 1.
Mandatory Monitoring Requirements
Frequency of Blood Glucose Testing
- Patients on basal insulin should assess fasting blood glucose levels at minimum to guide dose titration and prevent hypoglycemia 1.
- Daily fasting blood glucose monitoring is essential during the titration phase of Lantus therapy 2.
- For patients with type 1 diabetes on Lantus, blood glucose testing should occur at least 3 times daily, including before and after exercise, before driving, when uncertain about glucose levels, and especially at bedtime since nocturnal symptoms may go unnoticed 1.
- If bedtime glucose drops below 100 mg/dL (5.6 mmol/L), the patient should eat a small snack to prevent nocturnal hypoglycemia 1.
Special Considerations for Hypoglycemia History
Patients with a history of hypoglycemia require heightened vigilance because:
- Early warning symptoms of hypoglycemia may be different or less pronounced in patients with long duration of diabetes, diabetic nerve disease, or those on medications like beta-blockers 3.
- These situations can result in severe hypoglycemia (and possibly loss of consciousness) prior to the patient's awareness of hypoglycemia 3.
- Insulin glargine reduces the risk of hypoglycemia compared to NPH insulin, with 26% reduction in nocturnal hypoglycemia and 46% reduction in severe hypoglycemia 4, but monitoring remains essential.
Hospital Setting Requirements
All patients with diabetes admitted to the hospital should have an order for blood glucose monitoring 1.
Specific Hospital Monitoring Protocols
- A hypoglycemia management protocol should be adopted and implemented, with episodes of hypoglycemia documented in the medical record and tracked 1.
- If more than 2 fasting glucose values per week are less than 80 mg/dL, decrease the basal insulin dose by 2 units 2.
- If hypoglycemia occurs without clear cause, reduce the Lantus dose by 10-20% immediately 2.
Titration Monitoring Schedule
During active dose titration:
- Increase basal insulin by 2 units every 3 days if fasting glucose is 140-179 mg/dL 2.
- Increase by 4 units every 3 days if fasting glucose is ≥180 mg/dL until reaching target of 80-130 mg/dL 2.
- Reassess adequacy of insulin dose at every clinical visit, looking specifically for signs of overbasalization 2.
Critical Pitfalls to Avoid
Never rely on symptoms alone to detect hypoglycemia in patients with a history of hypoglycemia, as they may have hypoglycemia unawareness 3. The FDA label explicitly warns that hypoglycemia is the most common adverse effect of insulin therapy and that glucose monitoring is recommended for all patients with diabetes 3.
Do not delay ordering blood glucose monitoring - the 2008 ADA Standards explicitly state this should be ordered for all patients with diabetes on insulin 1. Failure to monitor adequately contributed to 75% of hospitalized patients experiencing hypoglycemia without subsequent dose adjustment 2.