What is the appropriate increase in the Lantus (insulin glargine) dose for a patient with diabetes, currently taking 16 units, who has a morning blood glucose level of 240 mg/dL?

Lantus Dose Adjustment for Morning Hyperglycemia

Immediate Dose Increase Recommendation

Increase your Lantus dose by 4 units (from 16 to 20 units) immediately, and continue increasing by 4 units every 3 days until your fasting blood glucose consistently reaches 80-130 mg/dL. 1

Your morning blood glucose of 240 mg/dL falls into the category requiring aggressive titration. The American Diabetes Association recommends increasing basal insulin by 4 units every 3 days when fasting glucose is ≥180 mg/dL. 1, 2

Titration Algorithm Moving Forward

• If fasting glucose remains ≥180 mg/dL: Increase Lantus by 4 units every 3 days 1, 2
• If fasting glucose is 140-179 mg/dL: Increase Lantus by 2 units every 3 days 1, 2
• Target fasting glucose: 80-130 mg/dL 1, 2
• If hypoglycemia occurs (blood glucose <70 mg/dL): Reduce dose by 10-20% immediately 1

Daily Monitoring Requirements

• Check your fasting blood glucose every morning during this titration phase 1, 2
• Record all fasting glucose values to guide your dose adjustments every 3 days 1
• Continue adjusting every 3 days until you consistently achieve fasting glucose of 80-130 mg/dL 1, 2

Critical Threshold to Watch For

Stop escalating Lantus if your dose exceeds 0.5 units/kg/day (approximately 36 units for a 160-pound person) without achieving target glucose levels. At this point, you need mealtime insulin coverage rather than more basal insulin. 1, 2

Clinical signals that you've reached this threshold include:

• Basal insulin dose >0.5 units/kg/day 1
• Large overnight glucose drop (≥50 mg/dL from bedtime to morning) 1
• Episodes of hypoglycemia 1
• High glucose variability throughout the day 1

Foundation Therapy Verification

Ensure you are taking metformin (unless contraindicated), as it should be continued when intensifying insulin therapy and provides complementary glucose-lowering effects with reduced insulin requirements. 1

When to Contact Your Healthcare Provider

• If fasting glucose remains >180 mg/dL after 2-3 weeks of titration 1
• If your Lantus dose exceeds 0.5 units/kg/day without achieving fasting glucose targets 1
• If you experience any hypoglycemia episodes 1
• If your HbA1c remains above target after 3-6 months despite achieving fasting glucose goals, as this indicates you may need mealtime insulin coverage 1

Common Pitfall to Avoid

Do not continue escalating Lantus 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