What is the recommended initial dose and management plan for a 60-year-old patient with type 2 diabetes and impaired renal function starting on Basiglar (insulin glargine)?

Initial Dosing and Management of Basiglar in a 60-Year-Old with Type 2 Diabetes and Impaired Renal Function

Start Basiglar at 0.1 units/kg/day (approximately 6-10 units once daily) rather than the standard 0.2 units/kg/day, given the impaired renal function which significantly increases hypoglycemia risk. 1, 2

Initial Dose Calculation

• For patients with impaired renal function, use the lower end of the dosing range: 0.1 units/kg/day or a flat dose of 10 units once daily 1, 2
• Standard dosing for type 2 diabetes without renal impairment is 0.2 units/kg or up to 10 units once daily, but renal insufficiency requires dose reduction 1, 3
• A randomized trial specifically in patients with chronic kidney disease (GFR <45 mL/min) demonstrated that starting at 0.25 units/kg/day reduced hypoglycemia by 50% compared to 0.5 units/kg/day, without compromising glycemic control 2

Administration Guidelines

• Administer Basiglar subcutaneously once daily at the same time every day 1, 3
• Inject into the abdominal area, thigh, or deltoid, rotating injection sites within the same region 1
• Do not dilute or mix with any other insulin or solution 1, 3
• Do not administer intravenously or via insulin pump 1

Titration Protocol

Increase the dose by 2 units every 3 days if fasting glucose is 140-179 mg/dL, or by 4 units every 3 days if fasting glucose ≥180 mg/dL, targeting fasting plasma glucose of 80-130 mg/dL 3, 4

Specific Titration Steps:

• If fasting glucose 140-179 mg/dL: increase by 2 units every 3 days 3
• If fasting glucose ≥180 mg/dL: increase by 4 units every 3 days 3
• If >2 fasting glucose values per week are <80 mg/dL: decrease by 2 units 5, 3
• If hypoglycemia occurs without clear cause: reduce dose by 10-20% immediately 3

Renal Function-Specific Considerations

Monitor closely for hypoglycemia as insulin clearance is reduced in renal impairment 2, 5

• For CKD Stage 3 (eGFR 30-44 mL/min): initiate and titrate conservatively to avoid hypoglycemia 5
• For CKD Stage 4 (eGFR 15-29 mL/min): use even more conservative dosing (0.1-0.15 units/kg/day) 5, 2
• For CKD Stage 5 (eGFR <15 mL/min): reduce total daily insulin dose by 50% 6
• A study in patients with Stage 3-4 CKD showed that starting glargine at 10 units daily with careful titration achieved 1.2% HbA1c reduction with acceptable hypoglycemia rates 7

Foundation Therapy

Continue metformin if eGFR ≥45 mL/min at a reduced dose of 1000 mg/day maximum 5

• If eGFR 30-44 mL/min: reduce metformin to maximum 1000 mg/day 5
• If eGFR <30 mL/min: metformin is contraindicated 5
• Continue metformin when adding insulin unless contraindicated, as it reduces total insulin requirements 3, 5

Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during titration 3, 4
• Check HbA1c every 3 months during dose adjustment 3
• Reassess adequacy of insulin dose at every clinical visit 3
• Monitor for signs of hypoglycemia, especially nocturnal hypoglycemia which is more common with renal impairment 2

Critical Threshold: When to Advance Therapy

When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, add prandial insulin rather than continuing to escalate Basiglar alone 3, 4

• Start prandial insulin with 4 units of rapid-acting insulin before the largest meal, or use 10% of the current basal dose 3
• Alternatively, consider adding a GLP-1 receptor agonist if eGFR permits (generally ≥30 mL/min for most agents) 5, 3

Common Pitfalls to Avoid

• Do not use standard weight-based dosing (0.2 units/kg/day) in patients with renal impairment—this doubles hypoglycemia risk 2
• Do not delay dose adjustments; titrate every 3 days based on fasting glucose patterns 3, 4
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia 3, 4
• Do not discontinue metformin when starting insulin if eGFR permits its use 5, 3
• Avoid injecting into areas of lipodystrophy, as this causes erratic absorption and hyperglycemia 1

Patient Education Essentials

• Proper injection technique and site rotation 3
• Recognition and treatment of hypoglycemia (15 grams of fast-acting carbohydrate for glucose <70 mg/dL) 3
• Self-monitoring of blood glucose 3
• "Sick day" management rules 3
• Insulin storage and handling 3