What is the initial dosage and titration schedule for Lantus (insulin glargine) in a 252-pound male patient with type 2 diabetes?

Starting Lantus Dosage and Titration for a 252 lb Male

For a 252-pound (114 kg) insulin-naive male with type 2 diabetes, start Lantus at 10 units once daily OR 0.1-0.2 units/kg body weight (11-23 units), administered at the same time each day, and titrate by 2-4 units every 3 days until fasting glucose reaches 80-130 mg/dL. 1, 2

Initial Dosing Strategy

Weight-based calculation for this patient:

• 252 lbs = 114 kg
• Conservative starting dose: 0.1 units/kg = 11 units once daily
• Higher starting dose (for more severe hyperglycemia): 0.2 units/kg = 23 units once daily 3, 1

For patients with severe hyperglycemia (A1C ≥9%, blood glucose ≥300-350 mg/dL, or symptomatic/catabolic features), consider starting with 0.3-0.5 units/kg/day (34-57 units) as total daily insulin using a basal-bolus regimen from the outset rather than basal insulin alone. 1, 2

Evidence-Based Titration Algorithm

Titrate every 3 days based on fasting glucose:

• If fasting glucose is 140-179 mg/dL: increase by 2 units 1
• If fasting glucose is ≥180 mg/dL: increase by 4 units 1
• Target fasting glucose: 80-130 mg/dL 1
• If hypoglycemia occurs without clear cause: reduce dose by 10-20% immediately 1

Patient self-titration improves glycemic control—equip patients with this algorithm and daily fasting glucose monitoring. 3, 1

Critical Threshold: When to Stop Escalating Basal Insulin

When Lantus exceeds 0.5 units/kg/day (57 units for this patient) and approaches 1.0 units/kg/day (114 units), STOP escalating basal insulin and ADD prandial insulin instead. 3, 1

Clinical signals of "overbasalization" requiring prandial insulin addition:

• Basal dose >0.5 units/kg/day 1
• Bedtime-to-morning glucose differential ≥50 mg/dL 1
• Episodes of hypoglycemia 1
• High glucose variability throughout the day 1
• Fasting glucose controlled but A1C remains above target after 3-6 months 1

Adding Prandial Insulin Coverage

When basal insulin is optimized but A1C remains elevated, start prandial insulin with 4 units of rapid-acting insulin before the largest meal OR 10% of the current basal dose. 1

Titrate prandial insulin by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings. 1

Foundation Therapy Requirements

Continue metformin at maximum tolerated dose (up to 2000-2550 mg daily) when initiating Lantus unless contraindicated—this combination provides superior glycemic control with reduced insulin requirements and less weight gain. 1

Consider discontinuing sulfonylureas when starting insulin to reduce hypoglycemia risk, but maintain metformin. 1

Monitoring Requirements

Daily fasting blood glucose monitoring is essential during titration. 1

Reassess adequacy of insulin dose at every clinical visit, looking specifically for signs of overbasalization. 1

Check A1C every 3 months during intensive titration. 1

Administration Guidelines

Administer Lantus subcutaneously once daily at the same time each day into the abdominal area, thigh, or deltoid. 2

Rotate injection sites within the same region to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 2

Do NOT administer intravenously, via insulin pump, or mix with other insulins. 2

Common Pitfalls to Avoid

Never delay insulin initiation in patients not achieving glycemic goals with oral medications—this prolongs hyperglycemia exposure and increases complication risk. 1

Never discontinue metformin when starting insulin unless contraindicated—this leads to higher insulin requirements and more weight gain. 1

Never continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia—this causes overbasalization with increased hypoglycemia risk and suboptimal control. 1

Never wait longer than 3 days between basal insulin adjustments in stable patients—this unnecessarily prolongs time to achieve glycemic targets. 1

Patient Education Essentials

Teach recognition and treatment of hypoglycemia: treat at blood glucose ≤70 mg/dL with 15 grams of fast-acting carbohydrate. 1

Provide instruction on proper insulin injection technique, site rotation, self-monitoring of blood glucose, "sick day" management rules, and insulin storage/handling. 1

Ensure patient carries a source of fast-acting carbohydrates at all times. 1