Insulin Dose Adjustment for Overnight Hyperglycemia
Increase your Lantus dose by 4 units (from 24 to 28 units) and continue this adjustment every 3 days until your fasting blood glucose consistently reaches 80-130 mg/dL. 1
Immediate Titration Protocol
Your blood glucose of 165 mg/dL overnight indicates inadequate basal insulin coverage and requires dose escalation. The evidence-based approach is straightforward:
- For fasting glucose ≥140 mg/dL but <180 mg/dL, increase Lantus by 2 units every 3 days 1
- For fasting glucose ≥180 mg/dL, increase Lantus by 4 units every 3 days 1, 2
- Target fasting plasma glucose: 80-130 mg/dL 1
Since your overnight glucose of 165 mg/dL falls in the 140-179 mg/dL range, a 2-4 unit increase is appropriate, with the higher increment (4 units) justified given you're starting from a relatively modest dose of 24 units 1.
Self-Titration Instructions
You can adjust your own insulin dose using this algorithm rather than waiting for clinic visits, which achieves better glycemic control 2:
- Check your fasting blood glucose daily 1
- Every 3 days, if your average fasting glucose remains >140 mg/dL and you've had no blood glucose <80 mg/dL, increase your Lantus by 2-4 units 1, 2
- If you experience any blood glucose <80 mg/dL, decrease your dose by 2 units 1
- Continue this pattern until you consistently achieve fasting glucose 80-130 mg/dL 1
Critical Threshold to Monitor
Watch for the 0.5 units/kg/day threshold where further basal insulin escalation becomes counterproductive 1. If you weigh approximately 100 kg (220 lbs), this threshold would be around 50 units daily. At that point, if your fasting glucose is controlled but overall diabetes control remains inadequate, adding mealtime insulin becomes more appropriate than continuing to increase Lantus 1.
Clinical signals that you're approaching this threshold include:
- Basal insulin dose >0.5 units/kg/day 1
- Large difference between bedtime and morning glucose (≥50 mg/dL drop overnight) 1
- Episodes of low blood glucose 1
Foundation Therapy Considerations
Ensure you're taking metformin (unless contraindicated) at an adequate dose of at least 1000 mg twice daily, as this reduces insulin requirements and improves outcomes when combined with insulin therapy 1. Metformin should be continued even as you intensify insulin 1.
Safety Monitoring
- If you experience blood glucose <80 mg/dL without clear cause, immediately reduce your Lantus dose by 10-20% (approximately 2-5 units from your current dose) 1
- Continue daily fasting glucose monitoring throughout this titration phase 1
- Carry a source of fast-acting carbohydrates (15-20 grams of glucose tablets or juice) to treat any hypoglycemia 3
Common Pitfall to Avoid
Do not delay dose adjustments waiting for your next clinic visit. The evidence shows that timely self-titration every 3 days achieves superior glycemic control compared to clinic-managed adjustments 2. Your current dose of 24 units is likely insufficient given your fasting glucose of 165 mg/dL, and prolonged exposure to this level of hyperglycemia increases complication risk 1.