How do you instruct an adult patient with type 2 diabetes to titrate Lantus (insulin glargine) for blood sugar management?

How to Instruct a Patient to Titrate Lantus for Blood Sugar Management

Start Lantus at 10 units once daily (or 0.1-0.2 units/kg body weight) at the same time each day, then increase by 2 units every 3 days if fasting glucose is 140-179 mg/dL, or by 4 units every 3 days if fasting glucose is ≥180 mg/dL, until fasting blood glucose consistently reaches 80-130 mg/dL. 1, 2

Initial Dosing and Administration

• Administer Lantus subcutaneously once daily at any time of day, but must be at the same time every day 3
• Inject into the abdominal area, thigh, or deltoid, rotating injection sites within the same region to reduce risk of lipodystrophy 3
• Never dilute or mix Lantus with any other insulin or solution due to its low pH formulation 3, 4
• Continue metformin (unless contraindicated) and possibly one additional non-insulin agent when starting Lantus 1, 2

Patient Self-Titration Algorithm

Teach patients to adjust their own dose using this evidence-based protocol: 1, 2

Upward Titration Based on Fasting Glucose:

• If fasting glucose 140-179 mg/dL: Increase Lantus by 2 units every 3 days 1, 2
• If fasting glucose ≥180 mg/dL: Increase Lantus by 4 units every 3 days 1, 2
• Target fasting glucose: 80-130 mg/dL 1, 2

Downward Adjustment for Hypoglycemia:

• If more than 2 fasting glucose values per week are <80 mg/dL: Decrease by 2 units 2
• If any hypoglycemia occurs without clear cause: Reduce dose by 10-20% immediately 1, 2

Daily Monitoring Requirements

• Check fasting blood glucose every morning during the titration phase 1, 2
• Record all fasting glucose values to guide dose adjustments every 3 days 1, 2
• Continue daily monitoring until fasting glucose consistently reaches target for at least 1 week 1, 2

Critical Threshold: When to Stop Escalating Basal Insulin

When Lantus dose exceeds 0.5 units/kg/day (approximately 35 units for a 70 kg patient) and blood glucose remains elevated, this signals the need for mealtime insulin coverage rather than further basal insulin increases. 1, 2

Clinical Signs of "Overbasalization" (Too Much Basal Insulin):

• Basal insulin dose >0.5 units/kg/day 1, 2
• Large difference between bedtime and morning glucose (≥50 mg/dL drop overnight) 1, 2
• Episodes of hypoglycemia 1, 2
• High glucose variability throughout the day 1, 2

At this point, contact your healthcare provider to discuss adding rapid-acting insulin before meals rather than continuing to increase Lantus. 1, 2

Hypoglycemia Recognition and Treatment

Recognize Hypoglycemia When Blood Glucose ≤70 mg/dL:

• Symptoms include shakiness, sweating, confusion, rapid heartbeat, dizziness 2
• Treat immediately with 15 grams of fast-acting carbohydrate (glucose tablets, 4 oz fruit juice, regular soda, or hard candy) 1, 2
• Recheck glucose after 15 minutes and repeat treatment if still <70 mg/dL 1
• Always carry a source of fast-acting carbohydrates 1

Special Situations Requiring Dose Adjustment

Reduce Lantus Dose When:

• Starting or increasing exercise routines (may need 10-20% reduction) 2
• During acute illness with poor oral intake 2
• If elderly (>65 years) or have kidney disease 2
• Before surgery (reduce by approximately 25% the evening before) 2

Increase Lantus Dose When:

• Starting corticosteroids (may need 40-60% increase in total insulin) 5
• During acute illness with infection 2
• With significant weight gain 2

Common Pitfalls to Avoid

• Never skip the same-time-daily administration - inconsistent timing reduces effectiveness 3
• Do not blame missed meal coverage for high fasting glucose - fasting glucose reflects basal insulin adequacy, not meal insulin 2
• Do not continue escalating Lantus beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia, as this leads to increased hypoglycemia risk without improved control 1, 2
• Do not stop metformin when starting insulin unless contraindicated, as the combination provides superior control with less weight gain 1, 2
• Do not wait longer than 3 days between dose adjustments in stable patients, as this unnecessarily prolongs time to achieve targets 2

When to Contact Healthcare Provider

• Fasting glucose remains >180 mg/dL after 2-3 weeks of titration 1, 2
• Experiencing frequent hypoglycemia (>2 episodes per week) 2
• Lantus dose exceeds 0.5 units/kg/day without achieving fasting glucose targets 1, 2
• Blood glucose levels in the 200s mg/dL despite adequate fasting control (indicates need for mealtime insulin) 2, 5
• Any episode of severe hypoglycemia requiring assistance 2

Reassessment Schedule

• Every 3 days during active titration to adjust dose 1, 2
• Every 3-6 months once stable to reassess overall glycemic control and HbA1c 1, 2
• Consider adding prandial insulin if HbA1c remains above target after 3-6 months despite achieving fasting glucose goals 1, 2