From the Guidelines
Glargine insulin should be initiated at a dose of 0.1–0.2 units/kg/day, with individualized titration over days to weeks as needed, to minimize the risk of hypoglycemia and optimize glycemic control. When initiating glargine insulin, it is essential to consider the patient's body weight and degree of hyperglycemia to estimate the starting dose 1. The principal action of basal insulin, such as glargine, is to restrain hepatic glucose production and limit hyperglycemia overnight and between meals.
Some key points to consider when initiating glargine insulin include:
- Starting doses can be estimated based on body weight (0.1–0.2 units/kg/day) and the degree of hyperglycemia 1
- Individualized titration over days to weeks as needed to achieve target fasting blood glucose levels
- Monitoring blood glucose levels regularly, particularly fasting levels, to guide dose adjustments
- Educating patients about symptoms and management of low blood sugar, as hypoglycemia is the main risk when initiating insulin therapy
- Considering the potential for overbasalization with insulin therapy, with clinical signals including basal dose greater than 0.5 units/kg, high bedtime-morning or postprandial glucose differential, hypoglycemia, and high variability 1
The most recent and highest quality study, published in 2023, supports the use of long-acting basal analogs, such as glargine, to reduce the risk of symptomatic and nocturnal hypoglycemia compared with NPH insulin 1. However, it is crucial to balance the benefits of glargine insulin with the potential risks and consider individual patient factors, such as cost concerns and insulin resistance, when making treatment decisions.
From the FDA Drug Label
2.3 Initiation of Insulin Glargine Therapy
The FDA drug label does not answer the question.
From the Research
Glargine Initiation
- Insulin glargine initiation in patients with type 2 diabetes can be achieved through various titration algorithms, with the goal of attaining blood glucose targets 2.
- A study comparing three algorithms for initiation and titration of insulin glargine found that all three algorithms resulted in similar levels of glycemic control, with lower rates of hypoglycemia for patients treated using simpler algorithms 2.
- Another study found that insulin glargine 100U/mL (Gla-100) and neutral protamine Hagedorn (NPH) insulin had similar efficacy in reducing HbA1c and FPG, but Gla-100 had a lower risk of overall and nocturnal hypoglycemia 3.
Titration Algorithms
- A review of titration algorithms for insulin glargine found that adequate titration of the insulin dose, either by physicians or by patients, can help patients reach treatment goals, including HbA1c <7% and FBG <5.5 mmol/L (<100 mg/dL) 4.
- The choice between algorithms may depend on clinical circumstance and a patient's willingness and ability to become more involved in management of therapy 4.
- A study comparing insulin glargine with NPH insulin in combination with metformin found that both treatments achieved good glycemic control, but insulin glargine reduced symptomatic hypoglycemia during the first 12 weeks and dinner time hyperglycemia 5.
Comparison with Other Insulins
- A randomized clinical trial found that insulin degludec had a lower rate of overall symptomatic hypoglycemia compared to insulin glargine U100 in patients with type 2 diabetes 6.
- The trial also found that insulin degludec had a lower rate of nocturnal symptomatic hypoglycemia and a lower proportion of patients with severe hypoglycemia compared to insulin glargine U100 6.