How should I start insulin glargine in a 62‑kg male?

Starting Insulin Glargine in a 62-kg Male

For a 62-kg male with type 2 diabetes who is insulin-naïve, start insulin glargine at 10 units once daily (or 0.1–0.2 units/kg/day, which equals 6–12 units) administered at the same time each day, and titrate by 2–4 units every 3 days until fasting glucose reaches 80–130 mg/dL. 1

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Initial Dosing Strategy

• Standard starting dose: Begin with 10 units once daily or use weight-based dosing of 0.1–0.2 units/kg/day (6–12 units for a 62-kg patient). 2, 1
• Timing: Administer at a consistent time each day—typically at bedtime (20:00 h)—to maintain stable basal insulin levels throughout the 24-hour period. 1, 3
• Continue metformin: Unless contraindicated, maintain metformin at the maximum tolerated dose (up to 2,000–2,550 mg/day) when starting basal insulin, as this combination reduces total insulin requirements by 20–30% and improves glycemic control. 1

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Titration Protocol

• Increase by 2 units every 3 days if fasting glucose is 140–179 mg/dL. 1
• Increase by 4 units every 3 days if fasting glucose is ≥180 mg/dL. 1
• Target fasting glucose: 80–130 mg/dL. 1
• If hypoglycemia occurs (glucose <70 mg/dL) without a clear cause, reduce the dose by 10–20% immediately. 1

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Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during the titration phase to guide dose adjustments. 1
• Reassess adequacy of insulin dose at every clinical visit, looking for signs of overbasalization (basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, or high glucose variability). 1
• Check HbA1c every 3 months during intensive titration. 1

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Critical Threshold: When to Stop Escalating Basal Insulin Alone

• When basal insulin approaches 0.5–1.0 units/kg/day (31–62 units for a 62-kg patient) without achieving glycemic targets, add prandial insulin or a GLP-1 receptor agonist rather than continuing to escalate basal insulin alone. 1
• Signs of "overbasalization" include basal dose >0.5 units/kg/day, large bedtime-to-morning glucose drop (≥50 mg/dL), hypoglycemia episodes, and high glucose variability. 1

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Special Considerations for Higher Starting Doses

• For severe hyperglycemia (HbA1c ≥9%, blood glucose ≥300–350 mg/dL, or symptomatic/catabolic features), consider starting with 0.3–0.5 units/kg/day (19–31 units for a 62-kg patient) as part of a basal-bolus regimen from the outset, with 50% as basal insulin and 50% as prandial insulin divided among three meals. 1

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Patient Education Essentials

• Injection technique: Teach proper subcutaneous injection technique and site rotation (abdomen, thigh, or deltoid) to prevent lipohypertrophy. 1
• Hypoglycemia recognition and treatment: Treat any glucose <70 mg/dL immediately with 15 g of fast-acting carbohydrate, recheck in 15 minutes, and repeat if needed. 1
• Self-titration: Equip patients with self-titration algorithms based on self-monitoring of blood glucose to improve glycemic control. 1
• Sick-day management: Continue basal insulin even if not eating, check glucose every 4–6 hours, and maintain hydration. 1

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Common Pitfalls to Avoid

• Do not delay insulin initiation in patients not achieving glycemic goals with oral medications, as this prolongs hyperglycemia exposure and increases complication risk. 1
• Do not discontinue metformin when starting insulin unless contraindicated, as this leads to higher insulin requirements and more weight gain. 1
• Do not continue escalating basal insulin beyond 0.5–1.0 units/kg/day without addressing postprandial hyperglycemia, as this leads to overbasalization with increased hypoglycemia risk and suboptimal control. 1
• Do not mix or dilute insulin glargine with any other insulin or solution due to its low pH. 1, 3

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Expected Clinical Outcomes

• With appropriate basal insulin titration, 68% of patients achieve mean glucose <140 mg/dL versus 38% with sliding-scale insulin alone. 1
• HbA1c reduction of 1–2% is achievable over 3–6 months with proper basal insulin titration. 1
• Insulin glargine is associated with significantly lower rates of nocturnal hypoglycemia compared with NPH insulin while achieving equivalent glycemic control. 4, 5, 6