What is the appropriate titration schedule for insulin glargine U‑300 (Toujeo) in a 280‑lb (≈127 kg) patient with an A1C of 11.1% who is currently on 30 units daily?

Toujeo Titration for a 280-lb Patient with A1C 11.1%

For a 127-kg (280-lb) patient with an A1C of 11.1% currently on 30 units of Toujeo daily, immediately increase the dose by 4 units every 3 days until fasting glucose consistently reaches 80–130 mg/dL, while simultaneously adding prandial insulin coverage because this degree of hyperglycemia requires both basal and mealtime insulin. 1

Immediate Dose Adjustment

• Increase Toujeo from 30 units to 34 units today, then continue escalating by 4 units every 3 days as long as fasting glucose remains ≥180 mg/dL. 1
• This aggressive 4-unit increment is specifically indicated when A1C ≥9% or fasting glucose ≥180 mg/dL, reflecting severe hyperglycemia that demands rapid correction. 1
• For a 127-kg patient with A1C 11.1%, the expected total daily insulin requirement is 0.3–0.5 units/kg/day (approximately 38–64 units total), split between basal and prandial components. 1

Critical Threshold: When to Stop Basal Escalation

• Cease further Toujeo increases once the dose approaches 0.5 units/kg/day (approximately 64 units for this patient) and instead add or intensify prandial insulin to avoid "over-basalization." 1, 2
• Clinical signals that basal insulin has reached its limit include: dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, any hypoglycemia episodes, or high glucose variability. 1
• Continuing to escalate basal insulin beyond this threshold without addressing post-prandial hyperglycemia leads to increased hypoglycemia risk and suboptimal control. 1

Adding Prandial Insulin Coverage

• Begin rapid-acting insulin (lispro, aspart, or glulisine) at 4 units before each of the three largest meals as soon as Toujeo reaches approximately 50–60 units, or immediately if post-prandial glucose exceeds 180 mg/dL. 1
• An A1C of 11.1% indicates both inadequate fasting control and uncontrolled post-prandial hyperglycemia, necessitating combined basal-bolus therapy rather than basal insulin alone. 1
• Administer prandial insulin 0–15 minutes before meals for optimal post-prandial control. 1
• Titrate each mealtime dose by 1–2 units every 3 days based on 2-hour post-prandial glucose readings, targeting <180 mg/dL. 1

Toujeo-Specific Dosing Considerations

• Toujeo (insulin glargine U-300) requires approximately 10–18% higher doses than standard glargine U-100 (Lantus) to achieve equivalent glycemic control due to its more gradual absorption profile. 3, 4
• The more concentrated formulation provides flatter, more prolonged basal coverage over 24+ hours with potentially less hypoglycemia, particularly beneficial for patients requiring higher insulin doses. 3, 4
• Do not split Toujeo into twice-daily dosing unless once-daily optimization has been exhausted; the U-300 formulation is specifically designed for once-daily administration with extended duration of action. 2, 3

Monitoring Protocol

• Check fasting glucose daily to guide Toujeo dose adjustments every 3 days. 1
• Once prandial insulin is added, measure pre-meal glucose before each meal and obtain 2-hour post-prandial glucose after meals to assess prandial adequacy. 1
• Target fasting glucose 80–130 mg/dL and post-prandial glucose <180 mg/dL. 1
• Reassess A1C every 3 months during intensive titration; expect a reduction of 2–3% (from 11.1% to approximately 8–9%) over 3–6 months with proper basal-bolus therapy. 1

Metformin Optimization

• Continue or up-titrate metformin to at least 2000 mg daily (1000 mg twice daily) unless contraindicated, as this reduces total insulin requirements by 20–30% and provides superior glycemic control. 1
• Metformin should not be discontinued when intensifying insulin therapy. 1

Hypoglycemia Management

• Treat any glucose <70 mg/dL immediately with 15 g of fast-acting carbohydrate, recheck in 15 minutes, and repeat if needed. 1
• If unexplained hypoglycemia occurs, reduce the implicated insulin dose by 10–20% promptly. 1

Common Pitfalls to Avoid

• Do not continue escalating Toujeo beyond 0.5–1.0 units/kg/day (64–127 units) without adding prandial insulin; this causes over-basalization with increased hypoglycemia and poor control. 1, 2
• Do not delay adding prandial insulin when A1C is 11.1%; this level of hyperglycemia mandates both basal and mealtime coverage from the outset. 1
• Never rely solely on correction (sliding-scale) insulin without scheduled basal and prandial doses; major diabetes guidelines condemn this reactive approach as ineffective and unsafe. 1
• Do not assume Toujeo and Lantus are interchangeable unit-for-unit; Toujeo requires approximately 10–18% higher doses. 3, 4

Expected Clinical Outcomes

• With properly implemented basal-bolus therapy using Toujeo, approximately 68% of patients achieve mean glucose <140 mg/dL, compared with only 38% using inadequate basal-only regimens. 1
• The lower hypoglycemia rate with Toujeo compared to standard glargine may provide additional safety during aggressive titration in this severely hyperglycemic patient. 3, 4