How should I increase the dose of Basaglar (insulin glargine) in an adult patient?

How to Increase Basaglar (Insulin Glargine) Dose

Increase Basaglar by 2 units every 3 days if fasting glucose is 140–179 mg/dL, or by 4 units every 3 days if fasting glucose is ≥180 mg/dL, targeting a fasting range of 80–130 mg/dL. 1

Standard Titration Protocol

Dose Adjustment Based on Fasting Glucose

• Fasting glucose 140–179 mg/dL: Increase by 2 units every 3 days 1, 2
• Fasting glucose ≥180 mg/dL: Increase by 4 units every 3 days 1, 2
• Target fasting glucose: 80–130 mg/dL 1, 2, 3
• If hypoglycemia occurs (glucose <70 mg/dL): Immediately reduce dose by 10–20% 1, 2

Monitoring Requirements

• Check fasting glucose daily during titration to guide adjustments 1, 2
• Continue dose increases every 3 days until fasting glucose consistently reaches target 1, 2
• Reassess every 3–6 months once stable to review HbA1c and overall control 1, 2

Critical Threshold: When to STOP Increasing Basal Insulin

When Basaglar reaches approximately 0.5 units/kg/day (or approaches 1.0 units/kg/day) without achieving glycemic targets, STOP further basal increases and add prandial (mealtime) insulin instead. 1, 2, 4

Signs of "Over-Basalization" (Stop Increasing Basal)

• Basal dose >0.5 units/kg/day without meeting HbA1c goal 1, 2
• Bedtime-to-morning glucose drop ≥50 mg/dL 1, 2
• Recurrent hypoglycemia despite overall hyperglycemia 1, 2
• High day-to-day glucose variability 1, 2

What to Do Instead

• Add 4 units of rapid-acting insulin (lispro, aspart, or glulisine) before the largest meal 1, 2
• Alternatively, start with 10% of current basal dose as prandial insulin 1, 2
• Titrate prandial insulin by 1–2 units every 3 days based on 2-hour post-meal glucose 1, 2

Special Situations Requiring Higher Starting Doses

Severe Hyperglycemia (HbA1c ≥9% or glucose ≥300 mg/dL)

• Start Basaglar at 0.3–0.4 units/kg/day rather than the standard 10 units 1, 2
• Consider immediate basal-bolus therapy (50% basal, 50% prandial) for HbA1c ≥10% with symptoms 1

High-Risk Patients (Elderly, Renal Impairment, Poor Oral Intake)

• Start with lower doses of 0.1–0.25 units/kg/day to minimize hypoglycemia risk 1
• Titrate more conservatively (smaller increments, longer intervals) 1

Patient Self-Titration Instructions

Patients can safely adjust their own Basaglar dose using this algorithm:

1. Measure fasting glucose every morning and record values 1, 2
2. Every 3 days, calculate average fasting glucose from past 3 days 1, 2
3. If average is 140–179 mg/dL: Add 2 units to current dose 1, 2
4. If average is ≥180 mg/dL: Add 4 units to current dose 1, 2
5. If any reading <80 mg/dL: Decrease by 2 units 1
6. If any reading <70 mg/dL: Decrease by 10–20% and contact provider 1, 2

Common Pitfalls to Avoid

• Do NOT continue increasing Basaglar beyond 0.5–1.0 units/kg/day without addressing post-meal hyperglycemia—this causes over-basalization with increased hypoglycemia risk and poor control 1, 2, 4
• Do NOT discontinue metformin when increasing insulin unless contraindicated—metformin reduces insulin requirements by 20–30% and improves outcomes 1
• Do NOT use sliding-scale insulin as monotherapy while titrating basal insulin—this reactive approach is condemned by major guidelines 1
• Do NOT wait longer than 3 days between adjustments in stable patients—this unnecessarily delays achieving glycemic targets 1

Administration Considerations

• Administer Basaglar once daily at the same time each day (morning, evening, or bedtime—patient's choice, but must be consistent) 2, 3
• Inject subcutaneously into abdomen, thigh, or deltoid, rotating sites within the same region 3
• Do NOT mix or dilute Basaglar with any other insulin or solution 3
• In select cases (type 1 diabetes with high variability), may split total daily dose into two equal injections 12 hours apart 2

When to Contact Healthcare Provider

• Fasting glucose remains >180 mg/dL after 2–3 weeks of titration 2
• Basaglar dose >0.5 units/kg/day without achieving fasting glucose targets 2
• Any severe hypoglycemic event (glucose <70 mg/dL) 2
• HbA1c remains above target after 3–6 months despite achieving fasting glucose goals 1, 2