What adjustments should be made to an adult diabetic patient's insulin regimen, currently taking Lantus (insulin glargine) 8 units, who is experiencing overnight hypoglycemia with a blood glucose level of 70 mg/dL?

Immediate Insulin Dose Reduction Required

For a patient experiencing overnight blood glucose of 70 mg/dL on Lantus 8 units, immediately reduce the Lantus dose by 10-20% (to 6-7 units) to prevent severe nocturnal hypoglycemia. 1

Understanding the Clinical Urgency

Blood glucose of 70 mg/dL represents biochemical hypoglycemia requiring urgent intervention. 1 While this may seem "borderline," overnight hypoglycemia in particular carries significant risk for severe episodes that can cause seizures, coma, and sudden death during sleep when the patient cannot recognize or treat symptoms. 1

Specific Dose Adjustment Protocol

• Reduce Lantus from 8 units to 6-7 units immediately (representing a 12.5-25% reduction). 1
• The American Diabetes Association explicitly recommends decreasing insulin dose by 10-20% when hypoglycemia occurs without clear precipitating cause. 1
• This reduction should be implemented tonight—do not wait to see if the pattern continues. 1

Critical Monitoring Requirements

• Check blood glucose at bedtime, 3 AM, and upon waking for at least 1 week after this dose adjustment. 1
• Document all episodes of blood glucose <100 mg/dL and adjust insulin accordingly. 1
• Target fasting glucose should be 80-130 mg/dL, but in the context of recent hypoglycemia, temporarily accept values up to 150-180 mg/dL until the pattern stabilizes. 2

Immediate Hypoglycemia Treatment Plan

• Treat any blood glucose <70 mg/dL with 15-20 grams of oral glucose immediately. 2
• Recheck glucose after 15 minutes—additional treatment may be necessary as blood glucose may only be temporarily corrected. 2
• Glucose tablets or gel are preferred over juice or milk, as pure glucose produces a greater rise in plasma glucose. 2

Essential Safety Measures

• Obtain a glucagon emergency kit and train household members on administration for severe nocturnal hypoglycemia when the patient cannot self-treat. 1
• Instruct the patient to carry glucose tablets at all times. 3
• Set an alarm to check blood glucose at 3 AM for the next week to detect nocturnal hypoglycemia patterns. 1

Common Pitfalls to Avoid

• Do not maintain the current 8-unit dose despite "acceptable" overnight values—70 mg/dL represents dangerous hypoglycemia, not adequate control. 1
• Do not pursue tight glycemic control (HbA1c <7%) if this patient has risk factors for severe hypoglycemia such as elderly age, cognitive impairment, renal disease, or food insecurity. 1, 3
• Do not wait for multiple episodes before reducing the dose—a single episode of nocturnal hypoglycemia warrants immediate action. 1

When to Contact Healthcare Provider

• If blood glucose remains <70 mg/dL despite dose reduction. 1
• If severe hypoglycemia occurs (requiring assistance, loss of consciousness, or seizure). 4
• If fasting glucose consistently exceeds 180 mg/dL after dose reduction, indicating the need for more gradual titration. 5

Reassessment Timeline

• Reassess the insulin regimen after 1 week of stable overnight glucose readings. 1
• Once hypoglycemia resolves, Lantus can be cautiously uptitrated by 2 units every 3 days if fasting glucose remains >130 mg/dL. 5