What is the best course of action for a patient with hyperglycemia, taking 30 units of Lantus (insulin glargine) daily, with a fasting blood sugar level of hyperglycemia?

Increase Lantus by 4 Units Every 3 Days Until Fasting Glucose Reaches 80-130 mg/dL

For a patient taking 30 units of Lantus daily with a fasting blood sugar of 200 mg/dL, immediately increase the dose by 4 units every 3 days until fasting glucose consistently reaches 80-130 mg/dL. 1

Immediate Dose Adjustment Protocol

• Increase Lantus from 30 units to 34 units tonight, as fasting glucose ≥180 mg/dL warrants a 4-unit increment rather than the smaller 2-unit adjustment used for fasting glucose 140-179 mg/dL 1
• Continue this aggressive titration schedule, adding 4 units every 3 days, until fasting glucose consistently falls within the target range of 80-130 mg/dL 1
• If hypoglycemia occurs (blood glucose <70 mg/dL) without clear cause, immediately reduce the dose by 10-20% 1

Daily Monitoring Requirements

• Check fasting blood glucose every morning during this titration phase to guide dose adjustments 1
• Record all fasting glucose values to track patterns and ensure appropriate dose escalation 1
• Reassess the insulin regimen every 3 days during active titration 1

Foundation Therapy Verification

• Confirm the patient is on metformin at therapeutic doses (at least 2000 mg daily) unless contraindicated, as metformin should be continued when intensifying insulin therapy to reduce total insulin requirements and provide complementary glucose-lowering effects 1, 2
• If the patient is on a sulfonylurea, consider discontinuing it if basal insulin escalation continues beyond simple basal-only therapy, as the combination significantly increases hypoglycemia risk 1, 2

Critical Threshold Warning: Watch for Overbasalization

• When Lantus dose exceeds 0.5 units/kg/day (approximately 36 units for a 72 kg patient), stop escalating basal insulin and add prandial insulin instead 1
• Clinical signals that indicate the need for prandial insulin rather than further basal insulin increases include:
  • Basal insulin dose >0.5 units/kg/day 1
  • Bedtime-to-morning glucose differential ≥50 mg/dL (large overnight glucose drop) 1
  • Episodes of hypoglycemia 1
  • High glucose variability throughout the day 1
  • Fasting glucose at target but HbA1c remains elevated after 3-6 months 1

Adding Prandial Insulin When Needed

• If basal insulin approaches 0.5-1.0 units/kg/day without achieving glycemic targets, start with 4 units of rapid-acting insulin before the largest meal, or use 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
• Add prandial insulin to additional meals sequentially if HbA1c remains elevated after optimizing coverage at one meal 1

Alternative Consideration: GLP-1 Receptor Agonist

• Before continuing to escalate basal insulin beyond 0.5 units/kg/day, consider adding a GLP-1 receptor agonist to address postprandial hyperglycemia while minimizing hypoglycemia and weight gain risks 1
• The combination of basal insulin plus GLP-1 receptor agonist provides potent glucose-lowering with superior outcomes compared to basal-bolus insulin regimens 1

Common Pitfalls to Avoid

• Do not use sliding scale insulin as monotherapy—it treats hyperglycemia reactively rather than preventing it and leads to dangerous glucose fluctuations 1, 2
• Do not delay dose adjustments—waiting longer than 3 days between basal insulin adjustments in stable patients unnecessarily prolongs the 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 and suboptimal control 1
• Do not discontinue metformin when intensifying insulin unless contraindicated, as this leads to higher insulin requirements and more weight gain 1, 2

Expected Outcomes

• With appropriate titration using this algorithm, most patients achieve fasting glucose targets within 2-4 weeks 1
• The incidence of severe hypoglycemia with this approach is <1% when properly implemented 3
• Patient-managed titration (where patients adjust their own doses based on fasting glucose) achieves greater HbA1c reductions than clinic-managed titration (-1.22% vs -1.08%) 4