Should Toujeo (insulin glargine) 93 units be administered in one dose or split into two doses for a 52-year-old obese female patient with poorly controlled diabetes?

Toujeo 93 Units: Single Daily Dose Recommended

Toujeo (insulin glargine U-300) 93 units should be administered as a single daily dose, not split into two doses. 1

Why Single Daily Dosing is Appropriate

Toujeo U-300 provides longer duration of action than standard U-100 glargine formulations, offering more stable 24-hour coverage with a single injection. 1 The concentrated formulation (U-300) was specifically designed to extend the duration of action beyond that of U-100 glargine (Lantus), making once-daily dosing effective even at higher absolute doses. 1

For this 52-year-old obese female patient requiring 93 units:

• 93 units represents approximately 0.9-1.1 units/kg/day (assuming body weight of 85-105 kg for an obese female), which falls within typical maintenance ranges for type 2 diabetes patients with insulin resistance. 1
• Toujeo's pharmacokinetic profile supports once-daily dosing regardless of the absolute dose number—there is no specific dose threshold that mandates splitting. 1

When to Consider Twice-Daily Dosing

The 2022 ADA guidelines explicitly recognize that basal insulin may require twice-daily dosing when once-daily administration fails to provide 24-hour coverage. 1 However, this decision should be based on glycemic patterns, not on reaching a particular dose number. 1

Consider splitting to twice-daily Toujeo only if:

• Persistent nocturnal hypoglycemia occurs with morning hyperglycemia (suggesting insulin "wearing off" before 24 hours). 1
• Type 1 diabetes with high glycemic variability despite optimized once-daily dosing. 1
• Documented inadequate 24-hour coverage with glucose monitoring showing consistent pre-injection hyperglycemia. 1

Critical Threshold Consideration

Before implementing twice-daily dosing, recognize that this patient may be approaching overbasalization. When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, adding prandial insulin or a GLP-1 receptor agonist becomes more appropriate than manipulating the basal insulin regimen. 1, 2

Clinical signals of overbasalization include:

• Basal dose >0.5 units/kg/day. 1
• Bedtime-to-morning glucose differential ≥50 mg/dL. 1
• Hypoglycemia episodes. 1
• High glucose variability. 1

Practical Recommendation

Maintain Toujeo 93 units once daily at the same time each day. 3 If glycemic control remains inadequate despite this dose:

1. First, verify fasting glucose is at target (80-130 mg/dL)—if not, continue titrating Toujeo by 4 units every 3 days until fasting glucose reaches target. 1

2. If fasting glucose is controlled but HbA1c remains elevated, add prandial insulin coverage starting with 4 units of rapid-acting insulin before the largest meal, rather than splitting the basal insulin. 1, 2

3. Alternatively, consider adding a GLP-1 receptor agonist to basal insulin, which provides potent glucose-lowering with less weight gain and hypoglycemia compared to intensified insulin regimens. 1

Common Pitfall to Avoid

Do not split Toujeo to twice-daily dosing simply because the dose seems "high." 1 The absolute dose number (93 units) does not determine whether splitting is necessary—glycemic patterns and 24-hour coverage determine this. 1 Splitting basal insulin when once-daily dosing provides adequate 24-hour coverage creates unnecessary complexity without clinical benefit. 1