Insulin Glargine (Basaglar) Dosing for a 30‑kg Child with Type 1 Diabetes
For a 30‑kg child with type 1 diabetes, start with a total daily insulin dose of 15 units (0.5 units/kg/day), allocating approximately 6–7.5 units (40–50 %) as once‑daily basal insulin glargine and 7.5–9 units (50–60 %) as rapid‑acting prandial insulin divided among three meals. 1
Initial Total Daily Dose Calculation
- The American Diabetes Association recommends a starting dose of 0.5 units/kg/day for metabolically stable pediatric patients with type 1 diabetes, which equals 15 units/day for a 30‑kg child. 1
- The acceptable range is 0.4–1.0 units/kg/day (12–30 units/day for this child), with higher doses required during puberty (up to 1.5 units/kg/day) due to growth hormone and sex hormone effects. 1
- Children in the "honeymoon phase" with residual beta‑cell function may need lower doses of 0.2–0.6 units/kg/day (6–18 units/day). 1
Basal Insulin (Glargine) Allocation
- Allocate 40–50 % of the total daily dose to basal insulin glargine, resulting in 6–7.5 units once daily for a 30‑kg child on 15 units/day total. 1
- Administer glargine at the same time each day—typically at bedtime—though morning administration is equally effective if preferred. 1, 2
- Glargine provides a peakless, 24‑hour basal insulin profile that suppresses hepatic glucose production overnight and between meals. 2, 3, 4
Prandial Insulin Allocation
- The remaining 50–60 % of the total daily dose (7.5–9 units) should be given as rapid‑acting insulin (lispro, aspart, or glulisine) divided among three meals. 1
- For a 30‑kg child on 15 units/day total, this translates to approximately 2.5–3 units per meal. 1
- Administer prandial insulin 0–15 minutes before meals for optimal post‑prandial glucose control. 1
Basal Insulin Titration Protocol
- Increase glargine by 1–2 units every 3 days if fasting glucose is 140–179 mg/dL. 5
- Increase glargine by 2–4 units every 3 days if fasting glucose is ≥180 mg/dL. 5
- Target fasting glucose: 80–130 mg/dL. 1, 5
- If any unexplained hypoglycemia (glucose < 70 mg/dL) occurs, reduce the current glargine dose by 10–20 % immediately. 5
Prandial Insulin Titration Protocol
- Adjust each meal dose by 1 unit (≈10–15 %) every 3 days based on the 2‑hour post‑prandial glucose reading. 5
- Target post‑prandial glucose: < 180 mg/dL. 1, 5
- If post‑prandial hypoglycemia occurs, reduce the implicated meal dose by 1 unit (10–20 %). 5
Monitoring Requirements
- Check fasting glucose daily during titration to guide basal insulin adjustments. 5
- Measure pre‑meal glucose before each meal to calculate correction doses when needed. 5
- Obtain 2‑hour post‑prandial glucose after each meal to assess prandial insulin adequacy. 1, 5
- Reassess HbA1c every 3 months during intensive titration. 1, 5
- Children with type 1 diabetes should perform 6–10 glucose checks per day (pre‑meal, bedtime, occasional post‑prandial, pre‑exercise, or when hypoglycemia is suspected). 1
Special Considerations for Pediatric Patients
- Insulin requirements are highly variable in children and increase significantly during puberty, potentially reaching 1.5 units/kg/day (45 units/day for a 30‑kg child). 1
- Young children and those in the honeymoon phase may require doses as low as 0.2–0.6 units/kg/day (6–18 units/day). 1
- In very young children with erratic eating, lispro can be administered after meals to more accurately match actual food intake and minimize hypoglycemia risk. 1
- For children with more predictable eating habits, premeal insulin dosing results in lower post‑prandial glucose values. 1
Pharmacokinetic Profile of Glargine
- Glargine has an onset of action at approximately 1 hour, a peakless profile, and a duration of action up to 24 hours, making it suitable for once‑daily dosing. 2, 3, 4
- The absence of a peak reduces the risk of hypoglycemia compared with NPH insulin, particularly nocturnal hypoglycemia. 2, 3, 4
- In some pediatric patients, glargine may not last a full 24 hours, and dividing the dose into two daily injections should be considered if fasting glucose remains elevated despite titration. 1, 6
Administration Guidelines
- Do not dilute or mix glargine with any other insulin due to its acidic pH (≈4.0), which would alter its pharmacokinetic profile. 6, 7
- Rotate injection sites within the same region (abdomen, thigh, or deltoid) to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. 7
- Do not inject into areas of lipodystrophy, as this can cause erratic absorption and hyperglycemia. 7
Hypoglycemia Management
- Treat glucose < 70 mg/dL immediately with 15 g of fast‑acting carbohydrate (e.g., 4 glucose tablets or 4 oz juice), recheck in 15 minutes, and repeat if needed. 5
- Never use rapid‑acting insulin at bedtime as a sole correction dose, as this markedly raises nocturnal hypoglycemia risk. 5
- Scrupulous avoidance of hypoglycemia for 2–3 weeks can reverse hypoglycemia unawareness if present. 5
Critical Pitfalls to Avoid
- Do not use sliding‑scale insulin as monotherapy in type 1 diabetes, as it can precipitate diabetic ketoacidosis. 5
- Do not delay insulin initiation or prescribe inadequate doses; immediate basal‑bolus therapy is required for type 1 diabetes. 5
- Do not administer rapid‑acting insulin at bedtime for correction alone, due to heightened nocturnal hypoglycemia risk. 5
- Do not continue escalating basal insulin beyond 0.5 units/kg/day (15 units for a 30‑kg child) without addressing post‑prandial hyperglycemia, to prevent over‑basalization. 5
Expected Clinical Outcomes
- With properly implemented basal‑bolus therapy, ≈68 % of patients achieve mean glucose < 140 mg/dL, compared with ≈38 % on inadequate regimens. 5
- HbA1c reductions of 2–3 % are achievable over 3–6 months with intensive titration. 5
- Correctly executed basal‑bolus regimens do not increase overall hypoglycemia incidence compared with inadequate approaches. 5