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 weight and degree of hyperglycemia to determine 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 1.
Key Considerations for Glargine Initiation
- 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 is crucial to achieve optimal glycemic control 1
- Control of fasting glucose can be achieved with human NPH insulin or a long-acting insulin analog, such as glargine 1
- Longer-acting basal analogs (U-300 glargine or degludec) may convey a lower hypoglycemia risk compared with U-100 glargine when used in combination with oral agents 1
Monitoring and Safety
- Regular blood glucose monitoring is essential during initiation to guide appropriate dose titration and ensure safety 1
- Patients should be educated on recognizing and treating low blood sugar episodes, as hypoglycemia is the main risk associated with glargine insulin 1
- Clinicians should be aware of the potential for overbasalization with insulin therapy and evaluate for clinical signals such as basal dose greater than 0.5 units/kg, high bedtime–morning or postprandial glucose differential, hypoglycemia, and high variability 1
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 can be initiated in patients with type 2 diabetes who are insufficiently controlled by oral antidiabetic agents (OADs) 2.
- The initiation of insulin glargine can be done by adding it to the existing OADs, such as metformin and sulfonylurea, or by switching to premixed insulin 2.
- Studies have shown that initiating insulin glargine once daily to glimepiride plus metformin treatment is safer and more effective than beginning twice-daily injections of 70/30 and discontinuing OADs in type 2 diabetic patients inadequately controlled with OADs 2.
- Different algorithms for initiation and titration of insulin glargine have been compared, and the results show that simpler algorithms can result in similar levels of glycemic control with lower rates of hypoglycemia 3.
Comparison with Other Insulins
- Insulin glargine has been compared with NPH insulin in several studies, and the results show that insulin glargine reduces the risk of hypoglycemia, particularly nocturnal hypoglycemia, compared with NPH insulin 4, 5.
- A meta-analysis of controlled trials has shown that insulin glargine given once daily reduces the risk of hypoglycemia compared with NPH insulin, which can facilitate more aggressive insulin treatment to a HbA(1c) target of < or =7.0% in patients with type 2 diabetes 5.
Clinical Outcomes
- The initiation of insulin glargine has been shown to improve glycemic control, with significant reductions in HbA1c levels compared with conventional therapy with oral agents 6.
- Insulin glargine has also been shown to reduce fasting plasma glucose (FPG) levels and improve treatment satisfaction compared with conventional therapy with oral agents 6.
- However, the initiation of insulin glargine can result in weight gain, which should be monitored and managed accordingly 6, 4.