What is the recommended initial dose of glargine (insulin glargine) for a 58 kg patient with diabetes and severe impaired renal function?

Initial Glargine Dosing for 58 kg Patient with Severe Renal Impairment

For a 58 kg patient with severe renal impairment, start insulin glargine at 0.1-0.15 units/kg/day (approximately 6-9 units once daily), which is substantially lower than standard dosing to prevent hypoglycemia. 1, 2

Specific Dose Calculation

• Start with 6-9 units of glargine once daily (0.1-0.15 units/kg for 58 kg patient) 1
• Administer at the same time each day, subcutaneously into the abdominal area, thigh, or deltoid 3
• For patients with severe renal impairment requiring insulin, the evidence-based starting dose is 0.25 units/kg/day total daily insulin, with approximately 50% as basal insulin 2
  • This translates to 7-8 units of glargine for this 58 kg patient (0.25 × 58 = 14.5 units total daily dose ÷ 2 = 7.25 units basal)

Critical Renal Impairment Considerations

• Reduce standard insulin doses by 50% in patients with severe renal impairment to prevent hypoglycemia 2
• A randomized trial demonstrated that using 0.25 units/kg/day (versus 0.5 units/kg/day) in patients with glomerular filtration rate <45 mL/min reduced hypoglycemia by 50% without compromising glycemic control 2
• Insulin clearance decreases with declining kidney function, requiring closer monitoring for hypoglycemia 1
• For CKD Stage 5 specifically, total daily insulin dose should be reduced by 50% for type 2 diabetes 1

Titration Protocol for Renal Impairment

• Increase dose by only 2 units every 3 days (not the standard 4 units) when fasting glucose remains elevated 1
• Target fasting glucose of 80-130 mg/dL, but consider slightly higher targets (100-150 mg/dL) in high-risk patients with severe renal impairment 1
• Monitor fasting blood glucose daily during titration 1
• If hypoglycemia occurs (glucose <70 mg/dL), reduce dose by 10-20% immediately 1

Essential Monitoring Requirements

• Check fasting glucose daily during the titration phase 1
• Monitor for hypoglycemia more frequently than in patients with normal renal function 2
• Assess kidney function before any dose increases, as declining eGFR fundamentally changes insulin requirements 4
• Watch for signs of hypoglycemia unawareness, which may develop with repeated episodes 5

Common Pitfalls to Avoid

• Never use standard weight-based dosing (0.2 units/kg) in severe renal impairment - this doubles hypoglycemia risk without improving glycemic control 2
• Do not titrate aggressively with 4-unit increments as recommended for patients with normal renal function 1
• Avoid administering glargine intravenously or via insulin pump 3
• Do not dilute or mix glargine with any other insulin or solution 3
• Never delay dose reduction when hypoglycemia occurs - 75% of hospitalized patients who experienced hypoglycemia had no insulin dose adjustment before the next administration 1

Type 1 vs Type 2 Diabetes Distinction

• For type 1 diabetes with severe renal impairment: Start with approximately one-third of total daily insulin requirements as glargine, with the remainder as short-acting insulin 3
• For type 2 diabetes with severe renal impairment: Start with 6-9 units once daily as described above 1, 2
• Type 1 diabetes patients require concomitant short-acting insulin at mealtimes 3

Expected Outcomes

• With appropriate conservative dosing (0.25 units/kg/day total), mean blood glucose of 174 mg/dL is achievable with only 15.8% experiencing hypoglycemia 2
• Standard dosing (0.5 units/kg/day) achieves similar glycemic control but with 30% hypoglycemia rate 2
• HbA1c reduction of approximately 1.2% is achievable over 24 weeks in patients with Stage 3-4 CKD 6