Adjust Morning Basal Insulin to Prevent Early‑Morning Hypoglycemia
Reduce the evening Lantus dose by 10–20 % immediately (from 36 units to approximately 29–32 units) and administer it at the same time each evening. This reduction addresses the recurrent early‑morning hypoglycemia while maintaining adequate basal coverage throughout the day. 1
Immediate Dose Adjustment
- Decrease Lantus from 36 units to 29–32 units once daily (a 10–20 % reduction) to prevent further nocturnal hypoglycemia. 1
- Any unexplained hypoglycemic episode (glucose < 70 mg/dL) mandates an immediate 10–20 % reduction in the implicated insulin dose before the next administration. 1, 2
- If more than two fasting glucose values per week fall below 80 mg/dL, reduce the basal dose by 2 units. 2
Rationale for Basal Insulin Reduction
- 78 % of hospitalized patients on basal insulin experience nocturnal hypoglycemia (midnight–6 AM), yet 75 % receive no basal insulin dose adjustment before the next dose—a common management gap that must be avoided. 1
- Morning hypoglycemia in a patient on once‑daily evening Lantus indicates that the basal insulin effect is excessive during the overnight period. 1, 2
- The current dose of 36 units may exceed the patient's true basal insulin requirement, especially if she is physically active or has stable weight, both of which improve insulin sensitivity and reduce insulin needs. 2
Monitoring Requirements During Titration
- Check fasting glucose daily to guide further basal insulin adjustments. 1, 2
- Measure glucose before each meal and at bedtime (minimum four times daily) to detect patterns of hypoglycemia or hyperglycemia. 1, 2
- If fasting glucose remains 80–130 mg/dL for three consecutive days after the dose reduction, the new dose is appropriate. 2
- If fasting glucose rises above 180 mg/dL after the reduction, increase Lantus by 2 units every 3 days until fasting glucose returns to the target range of 80–130 mg/dL. 1, 2
Prandial Insulin (Lispro) Adjustment
- Continue lispro 10 units before each meal unless hypoglycemia occurs within 2–4 hours after a meal, in which case reduce that specific meal dose by 1–2 units (10–15 %). 1, 2
- Lispro should be administered 0–15 minutes before meals (ideally immediately before eating) to achieve optimal post‑prandial glucose control. 1, 2
- If post‑prandial glucose consistently exceeds 180 mg/dL, increase the corresponding meal dose by 1–2 units every 3 days. 1, 2
Sliding‑Scale Insulin: Proper Role
- Correction insulin must supplement a scheduled basal‑bolus regimen, never replace it. 1, 2
- Use correction doses only when pre‑meal glucose exceeds predefined thresholds (e.g., 2 units for glucose > 250 mg/dL, 4 units for glucose > 350 mg/dL), in addition to scheduled prandial insulin. 1, 2
- Sliding‑scale insulin as monotherapy is condemned by major diabetes guidelines because it reacts to hyperglycemia rather than preventing it, leading to dangerous glucose fluctuations. 1, 2
Hypoglycemia Management Protocol
- Treat any glucose < 70 mg/dL immediately with 15 g of fast‑acting carbohydrate (e.g., 4 glucose tablets, 4 oz juice), recheck in 15 minutes, and repeat if needed. 1, 2
- If hypoglycemia occurs without an obvious precipitant (e.g., missed meal, increased exercise), reduce the implicated insulin dose by 10–20 % promptly. 1, 2
- Recurrent nocturnal hypoglycemia (midnight–6 AM) specifically warrants a 10–20 % reduction in the evening Lantus dose and reassessment within 3 days. 1, 2
Alternative Timing Consideration (If Hypoglycemia Persists)
- If morning hypoglycemia continues despite dose reduction, consider administering Lantus in the morning instead of the evening to shift the insulin effect away from the overnight period. 1, 3
- Morning administration of basal insulin can reduce the risk of early‑morning hypoglycemia by providing peak basal coverage during the daytime when meals and activity increase insulin requirements. 1, 3
- However, evening administration remains the standard approach for most patients with type 1 diabetes, and timing should only be changed if dose reduction alone fails to resolve nocturnal hypoglycemia. 3, 4
Critical Pitfalls to Avoid
- Do not delay dose reduction when hypoglycemia occurs; studies show that 75 % of hospitalized patients with hypoglycemia receive no basal insulin adjustment before the next dose, perpetuating the problem. 1
- Do not rely solely on correction insulin without adjusting scheduled basal and prandial doses; this reactive strategy is ineffective and unsafe. 1, 2
- Never use rapid‑acting insulin (lispro) at bedtime as a sole correction dose, as this markedly raises the risk of nocturnal hypoglycemia. 1, 2
- Do not discontinue basal insulin entirely in a patient with type 1 diabetes, even if hypoglycemia occurs, as this can precipitate diabetic ketoacidosis. 1, 2
Expected Clinical Outcomes
- With a 10–20 % reduction in Lantus, fasting glucose should stabilize in the 80–130 mg/dL range within 3–7 days without further hypoglycemic episodes. 1, 2
- If the reduced dose is insufficient to prevent hyperglycemia, titrate upward by 2 units every 3 days until fasting glucose reaches the target range. 1, 2
- Properly adjusted basal insulin should provide consistent 24‑hour coverage without causing nocturnal hypoglycemia or early‑morning hyperglycemia. 1, 2, 4
Special Considerations for Type 1 Diabetes
- Type 1 diabetes patients require approximately 0.4–1.0 units/kg/day of total insulin, with 40–50 % as basal insulin and 50–60 % as prandial insulin. 2, 4
- For a 59‑year‑old woman weighing approximately 60–70 kg, the total daily insulin requirement is typically 24–70 units/day, with 10–35 units as basal insulin. 2, 4
- The current regimen (36 units Lantus + 30 units lispro = 66 units total) is within the expected range, but the basal component (36 units) may be excessive if it is causing nocturnal hypoglycemia. 2, 4