What is the recommended initial dosing and management strategy for a patient with type 2 diabetes, coronary artery disease, and hypertension starting on Lantus (insulin glargine) insulin?

Lantus (Insulin Glargine) Initial Dosing and Management for Type 2 Diabetes with Coronary Artery Disease and Hypertension

Initial Dosing Strategy

Start Lantus at 10 units once daily OR 0.1-0.2 units/kg body weight, administered at the same time each day, while continuing metformin unless contraindicated. 1

• For patients with severe hyperglycemia (blood glucose ≥300-350 mg/dL or HbA1c ≥9%), consider higher starting doses of 0.3-0.4 units/kg/day 1
• Administer at any consistent time of day, though bedtime is often preferred for convenience 2, 3
• Continue metformin at maximum tolerated dose (up to 2000-2550 mg daily) as this combination reduces total insulin requirements, minimizes weight gain, and provides superior glycemic control compared to insulin alone 1, 4

Dose Titration Algorithm

Increase Lantus by 2-4 units every 3 days based on fasting glucose patterns until reaching target of 80-130 mg/dL. 1

Specific Titration Schedule:

• If fasting glucose 140-179 mg/dL: Increase by 2 units every 3 days 1
• If fasting glucose ≥180 mg/dL: Increase by 4 units every 3 days 1
• If hypoglycemia occurs: Reduce dose by 10-20% immediately 1
• If more than 2 fasting values per week <80 mg/dL: Decrease by 2 units 1

Daily fasting blood glucose monitoring is essential during titration 1

Critical Threshold: When to Stop Escalating Basal Insulin

When Lantus 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 Signs 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 10% of current basal dose 1
• Titrate prandial insulin by 1-2 units every 3 days based on 2-hour postprandial glucose readings 1
• Consider adding prandial insulin if HbA1c remains above target after 3-6 months despite achieving fasting glucose goals 1

Cardiovascular Risk Factor Management

Blood Pressure Control:

Target blood pressure <130/80 mmHg in this patient with diabetes, coronary artery disease, and hypertension. 5, 6

• ACE inhibitors or ARBs are preferred antihypertensive agents in diabetic patients 5
• ACE inhibitors provide additional renoprotective benefits and reduce recurrent cardiovascular events in patients with established coronary disease 6
• Most patients require two or more antihypertensive agents to achieve target 6

Lipid Management:

Target LDL-C <1.8 mmol/L (<70 mg/dL) given very high cardiovascular risk from diabetes plus coronary artery disease. 5

• Statins are the preferred lipid-lowering drugs 5
• Start with moderate-intensity statin and adjust based on response 5
• If LDL-C remains elevated after 3 months, consider adding additional lipid-lowering agents 5

Antiplatelet Therapy:

• Aspirin therapy should be prescribed for secondary prevention in patients with established coronary artery disease 5
• Clinically, more active prescription of aspirin therapy is recommended in diabetic patients with cardiovascular disease 5

Hypoglycemia Prevention and Management

Recognition and Treatment:

• Hypoglycemia alert value: Blood glucose ≤3.9 mmol/L (70 mg/dL) 5
• Clinically significant hypoglycemia: Blood glucose <3.0 mmol/L (54 mg/dL) 5
• Treatment: 15-20 grams of glucose-containing food (glucose preferred) for conscious patients 5
• Recheck blood glucose every 15 minutes after treatment 5

Advantages of Lantus:

Insulin glargine provides a relatively constant basal insulin level over 24 hours with no pronounced peak, resulting in significantly less hypoglycemia (especially nocturnal episodes) compared to NPH insulin while achieving equivalent glycemic control 2, 7. The risk of severe hypoglycemia is reduced by 46% and severe nocturnal hypoglycemia by 59% compared to NPH insulin 7.

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
• Never discontinue metformin when starting insulin unless contraindicated, as this leads to higher insulin requirements and more weight gain 1, 4
• Never continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia, as this causes overbasalization with increased hypoglycemia risk and suboptimal control 1
• Never use sliding scale insulin as monotherapy, as it treats hyperglycemia reactively rather than preventing it, leading to dangerous glucose fluctuations 1
• Avoid intramuscular injections, especially with long-acting insulins, as severe hypoglycemia may result 4

Monitoring Requirements

• Daily fasting blood glucose during titration phase 1
• HbA1c every 3 months during intensive titration 1
• Reassess insulin dose at every clinical visit 1
• Monitor for signs of overbasalization at each assessment 1
• Check blood pressure at each visit with target <130/80 mmHg 5
• Monitor lipid panel and adjust statin therapy to achieve LDL-C <1.8 mmol/L 5