Increase Lantus by 4 Units Every 3 Days Until Fasting Glucose Reaches 80-130 mg/dL
For overnight blood glucose levels of 205-212 mg/dL on Lantus 30 units, increase the dose by 4 units every 3 days until fasting glucose consistently reaches 80-130 mg/dL. 1, 2
Immediate Dose Adjustment
- Increase Lantus from 30 units to 34 units tonight 1
- Blood glucose ≥180 mg/dL warrants a 4-unit increment rather than the smaller 2-unit adjustment used for glucose 140-179 mg/dL 1
- Continue this aggressive titration schedule, adding 4 units every 3 days, until fasting glucose consistently falls within the 80-130 mg/dL target range 1, 2
Daily Monitoring Requirements
- Check fasting blood glucose every morning during the titration phase 1
- Record all fasting values to guide dose adjustments every 3 days 1
- If any hypoglycemia occurs (glucose <70 mg/dL), immediately reduce the dose by 10-20% 1
Critical Threshold Warning: Watch for Overbasalization
When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, adding prandial insulin becomes more appropriate than continuing to escalate basal insulin alone. 1
Clinical signals of overbasalization include: 1
- Basal dose >0.5 units/kg/day
- Bedtime-to-morning glucose differential ≥50 mg/dL (large overnight drop)
- Episodes of hypoglycemia
- High glucose variability throughout the day
When to Add Prandial Insulin
If after 3-6 months of basal insulin optimization: 1
- Fasting glucose reaches 80-130 mg/dL target BUT HbA1c remains above goal
- Basal insulin dose approaches 0.5-1.0 units/kg/day without achieving HbA1c targets
Start prandial insulin with 4 units of rapid-acting insulin before the largest meal, or use 10% of the current basal dose. 1
Foundation Therapy Must Continue
- Continue metformin at maximum tolerated dose (up to 2000-2500 mg daily) unless contraindicated 1
- Metformin combined with insulin provides superior glycemic control with reduced insulin requirements and less weight gain compared to insulin alone 3
- Never discontinue metformin when intensifying insulin therapy unless contraindicated 1
Common Pitfalls to Avoid
- Do not wait longer than 3 days between dose adjustments in stable patients, as this unnecessarily prolongs time to achieve glycemic targets 1
- Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia, as this leads to overbasalization with increased hypoglycemia risk 1
- Do not use sliding scale insulin as monotherapy - it treats hyperglycemia reactively rather than preventing it 1