What dose of Lantus (insulin glargine) should a patient with type 2 diabetes start with after 6 units of Novolog (insulin aspart) lowered their blood glucose from 295 to 118?

Starting Lantus Dose After Novolog Response

Start with 10 units of Lantus once daily at the same time each day. 1, 2

Rationale for This Recommendation

The patient's response to 6 units of Novolog (blood glucose dropping from 295 to 118 mg/dL, a reduction of 177 mg/dL) demonstrates significant insulin sensitivity, suggesting they are likely insulin-naive or on minimal insulin therapy. 1

Standard Initial Dosing Guidelines

• For insulin-naive patients with type 2 diabetes, the American Diabetes Association recommends starting Lantus at 10 units once daily or 0.1-0.2 units/kg body weight. 1, 2
• The FDA label for Lantus specifies a starting dose of 0.2 units/kg or up to 10 units once daily for type 2 diabetes patients not currently treated with insulin. 2
• The 10-unit starting dose is the most commonly recommended and safest initial approach, particularly when body weight is unknown. 1

Why Conservative Dosing is Critical Here

• The dramatic 177 mg/dL drop from just 6 units of rapid-acting insulin indicates this patient has good insulin sensitivity. 1
• Using the insulin sensitivity factor formula (1500 ÷ Total Daily Dose), if we estimate their sensitivity, they appear to be highly responsive to insulin, making aggressive initial dosing inappropriate. 1
• Starting with 10 units minimizes hypoglycemia risk while providing adequate basal coverage. 1, 3

Titration Protocol After Initiation

Increase Lantus by 2-4 units every 3 days based on fasting glucose patterns until reaching target of 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

Essential Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during the titration phase. 1
• Administer Lantus at the same time every day (can be any time, but must be consistent). 2
• Check for signs of overbasalization when dose exceeds 0.5 units/kg/day, including bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia episodes, or high glucose variability. 1

Critical Threshold to Watch

When Lantus dose approaches 0.5-1.0 units/kg/day without achieving glycemic targets, adding prandial insulin becomes more appropriate than continuing to escalate basal insulin alone. 1 This prevents "overbasalization" which leads to increased hypoglycemia risk without improved control. 1

Foundation Therapy Considerations

• Continue metformin (unless contraindicated) when starting Lantus, as this combination provides superior glycemic control with reduced insulin requirements and less weight gain. 1
• Consider discontinuing sulfonylureas when starting insulin to reduce hypoglycemia risk. 1

Common Pitfalls to Avoid

• Never start with aggressive dosing (>0.2 units/kg/day) in patients demonstrating high insulin sensitivity like this one. 1
• Do not delay dose titration—adjust every 3 days based on fasting glucose patterns, not weekly or monthly. 1
• Never rely solely on correction insulin (sliding scale) without adequate basal coverage. 1