What is the initial dosing strategy for Tujeo (insulin glargine) in a diabetic patient with considerations for age, weight, and impaired renal function?

Tujeo (Insulin Glargine 300 U/mL) Dosing Strategy

Initial Dosing for Type 2 Diabetes

For insulin-naive patients with type 2 diabetes, start Tujeo at 0.2 units/kg once daily or up to 10 units once daily, administered at the same time each day. 1

• Continue metformin (unless contraindicated) and possibly one additional non-insulin agent when initiating Tujeo 2
• Administer subcutaneously into the abdominal area, thigh, or deltoid, rotating injection sites within the same region 1
• For patients with severe hyperglycemia (HbA1c ≥9% or blood glucose ≥300-350 mg/dL), consider higher starting doses of 0.3-0.5 units/kg/day as total daily insulin, using a basal-bolus regimen from the outset 2

Initial Dosing for Type 1 Diabetes

Start Tujeo at approximately one-third of the total daily insulin requirements, using short-acting premeal insulin to satisfy the remainder. 1

• Total daily insulin requirements typically range from 0.4 to 1.0 units/kg/day, with 0.5 units/kg/day being typical for metabolically stable patients 2
• Approximately 40-60% should be given as basal insulin (Tujeo) and 50-60% as prandial insulin divided among meals 2

Dose Titration Algorithm

Increase Tujeo by 2-4 units every 3 days until fasting blood glucose reaches 80-130 mg/dL. 2

• If fasting glucose is 140-179 mg/dL: increase by 2 units every 3 days 2
• If fasting glucose is ≥180 mg/dL: increase by 4 units every 3 days 2
• If hypoglycemia occurs without clear cause, reduce the dose by 10-20% immediately 2
• Daily fasting blood glucose monitoring is essential during titration 2

Critical Threshold: When to Stop Escalating Basal Insulin

When Tujeo exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, add prandial insulin rather than continuing to escalate basal insulin alone. 2

• Clinical signals of overbasalization include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 2
• Start prandial insulin with 4 units of rapid-acting insulin before the largest meal, or use 10% of the current basal dose 2
• Titrate prandial insulin by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings 2

Special Population Adjustments

Renal Impairment

• For patients with CKD Stage 5 and type 2 diabetes, reduce total daily insulin dose by 50% 2
• For type 1 diabetes with CKD Stage 5, reduce total daily insulin dose by 35-40% 2
• Use lower doses (0.1-0.25 units/kg/day) for high-risk patients: elderly (>65 years), renal failure, or poor oral intake 2

Elderly Patients

• Consider less aggressive HbA1c targets (<8.0% rather than <7.0%) for elderly patients with multiple comorbidities, cognitive impairment, or limited life expectancy 2
• Start with lower doses (0.1-0.25 units/kg/day) to prevent hypoglycemia 2

Hospitalized Patients

• For insulin-naive or low-dose insulin patients: start with 0.3-0.5 units/kg/day total daily dose, with half as basal insulin 2
• For patients on high-dose home insulin (≥0.6 units/kg/day): reduce total daily dose by 20% to prevent hypoglycemia 2

Important Dosing Considerations for Tujeo vs. Lantus

Tujeo requires approximately 10-18% higher daily insulin doses compared to Lantus (insulin glargine 100 U/mL) to achieve equivalent glycemic control. 3, 4

• When switching from Lantus to Tujeo: expect to need higher doses 3
• When switching from Toujeo to Lantus: start Lantus at 80% of the Toujeo dose being discontinued 1
• Tujeo has a more stable and prolonged pharmacokinetic/pharmacodynamic profile with duration exceeding 24 hours 3, 4

Common Pitfalls to Avoid

• Never delay insulin initiation in patients not achieving glycemic goals with oral medications—this prolongs hyperglycemia exposure and increases complication risk 2
• Never discontinue metformin when starting insulin unless contraindicated—this leads to higher insulin requirements and more weight gain 2
• Never continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia—this causes overbasalization with increased hypoglycemia risk 2
• Never dilute or mix Tujeo with any other insulin or solution 1
• Never administer Tujeo intravenously or via an insulin pump 1

Monitoring Requirements

• Check fasting blood glucose daily during titration 2
• Increase frequency of blood glucose monitoring during changes to insulin regimen 1
• Reassess adequacy of insulin dose at every clinical visit 2
• Check HbA1c every 3-6 months once stable 2