What adjustments should be made to the basal insulin regimen for a patient with hyperglycemia, currently on Lantus (insulin glargine) 20 units?

Basal Insulin Dose Adjustment for Persistent Hyperglycemia

Increase your Lantus dose by 4 units every 3 days until your fasting blood glucose consistently reaches 80-130 mg/dL, as your current fasting glucose of 199 mg/dL indicates inadequate basal insulin coverage. 1

Immediate Titration Protocol

Your blood glucose readings (overnight 208 mg/dL, fasting 199 mg/dL) clearly indicate that 20 units of Lantus is insufficient for your basal insulin needs. The American Diabetes Association provides a specific evidence-based algorithm for this situation:

• Increase Lantus by 4 units every 3 days when fasting glucose is ≥180 mg/dL 1
• Continue this aggressive titration until fasting glucose reaches the target range of 80-130 mg/dL 1
• If hypoglycemia occurs without clear cause, reduce the dose by 10-20% immediately 1

Daily Monitoring Requirements

• Check fasting blood glucose every morning during this titration phase 1
• Record all fasting glucose values to guide your dose adjustments every 3 days 1
• This daily monitoring is essential and non-negotiable during active titration 1

Critical Threshold to Watch For

When your Lantus dose exceeds 0.5 units/kg/day (approximately 36 units for a 72 kg/160 lb person), this signals you may need mealtime insulin coverage rather than further basal insulin increases. 1 Clinical signs that you've reached this threshold include:

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

Foundation Therapy Considerations

Continue metformin (unless contraindicated) even while intensifying insulin therapy, as this combination provides superior glycemic control with reduced insulin requirements and less weight gain compared to insulin alone. 1 If you're not currently on metformin, discuss adding it with your healthcare provider. 1

When to Add Mealtime Insulin

If after 3-6 months of basal insulin optimization your fasting glucose reaches 80-130 mg/dL but your HbA1c remains above target, or if your Lantus dose approaches 0.5-1.0 units/kg/day without achieving glycemic goals, you will need to add prandial (mealtime) insulin rather than continuing to escalate Lantus alone. 1 Start with 4 units of rapid-acting insulin before your largest meal, or use 10% of your basal dose. 1

Common Pitfalls 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
• Do not wait longer than 3 days between dose adjustments in stable patients, as this unnecessarily prolongs the time to achieve glycemic targets 1
• Do not stop metformin when starting or intensifying insulin unless contraindicated 1

Hypoglycemia Management

• Treat any blood glucose ≤70 mg/dL immediately with 15 grams of fast-acting carbohydrate 1
• Always carry a source of fast-acting carbohydrates with you 1
• If hypoglycemia occurs, determine the cause (missed meal, increased activity, timing issues) and reduce your Lantus dose by 10-20% if no clear reason is identified 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 recurrent hypoglycemia 1
• For reassessment every 3-6 months once stable to evaluate overall glycemic control and HbA1c 1