What is the recommended starting dose of Toujeo (insulin glargine) for an adult patient with type 2 diabetes and no significant renal or hepatic impairment?

Toujeo (Insulin Glargine 300 U/mL) Dosing Guidelines

Starting Dose for Type 2 Diabetes

For insulin-naïve adults with type 2 diabetes and no significant renal or hepatic impairment, start Toujeo at 10 units once daily or 0.1-0.2 units/kg body weight, administered at the same time each day. 1

• Continue metformin unless contraindicated, and possibly one additional non-insulin agent when initiating Toujeo 1
• For patients with more severe hyperglycemia (A1C ≥9% or blood glucose ≥300-350 mg/dL), consider higher starting doses of 0.3-0.4 units/kg/day 1
• Patients with A1C ≥10-12% with symptomatic or catabolic features require immediate basal-bolus insulin therapy rather than basal insulin alone 1

Critical Difference: Toujeo vs Lantus Dosing

Toujeo requires approximately 10-18% higher daily insulin doses compared to Lantus (insulin glargine 100 U/mL) to achieve equivalent glycemic control, due to differences in bioavailability. 2, 3

• When switching from Lantus to Toujeo, expect to need dose adjustments upward 2
• The two formulations are not bioequivalent despite containing the same insulin molecule 2
• Toujeo has a flatter, more prolonged pharmacokinetic profile with duration exceeding 24 hours 3

Dose Titration Algorithm

Increase Toujeo by 2-4 units every 3 days until fasting blood glucose reaches 80-130 mg/dL. 1

• If fasting glucose is 140-179 mg/dL: increase by 2 units every 3 days 1
• If fasting glucose is ≥180 mg/dL: increase by 4 units every 3 days 1
• If hypoglycemia occurs without clear cause: reduce dose by 10-20% immediately 1
• Daily fasting blood glucose monitoring is essential during titration 1

Critical Threshold: When to Stop Escalating Basal Insulin

When Toujeo exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, add prandial insulin rather than continuing to escalate basal insulin alone. 1

Clinical Signals of "Overbasalization":

• Basal insulin 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

Adding Prandial Insulin:

• Start with 4 units of rapid-acting insulin before the largest meal, or use 10% of 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

Toujeo-Specific Advantages

Toujeo demonstrates a lower risk of nocturnal hypoglycemia compared to Lantus in insulin-experienced patients with type 2 diabetes, with greater flexibility in injection timing. 2, 3

• More stable and reproducible pharmacokinetic/pharmacodynamic profile with less intra-/inter-individual variability 2
• Slightly smaller weight gain compared to Lantus 2
• Duration of glucose-lowering activity exceeds 24 hours, providing more consistent coverage 3

Common Pitfalls to Avoid

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

• Do not discontinue metformin when starting Toujeo unless contraindicated—the combination provides superior control with less weight gain 1
• Do not continue escalating Toujeo 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—scheduled basal insulin with correction doses as adjunct only is superior 1

Special Populations

For elderly patients (>65 years), those with renal failure, or poor oral intake, use lower starting doses of 0.1-0.25 units/kg/day to prevent hypoglycemia. 1

• For hospitalized patients on high-dose home insulin (≥0.6 units/kg/day), reduce total daily dose by 20% upon admission 1
• For patients with CKD Stage 5 and type 2 diabetes, reduce total daily insulin dose by 50% 1

Monitoring Requirements

Check fasting blood glucose daily during titration, and reassess adequacy of insulin dose at every clinical visit. 1

• Reassess and modify therapy every 3-6 months once stable to avoid therapeutic inertia 1
• Look specifically for signs of overbasalization at each assessment 1
• If A1C remains above goal after 3-6 months despite achieving fasting glucose targets, consider adding prandial insulin or GLP-1 receptor agonist 1