Tessa Quinn
Insulin glargine is a long-acting insulin that is used to improve glycemic control in patients with diabetes mellitus. It is typically administered once or twice a day, and the dosage depends on various factors such as the patient's metabolic needs, blood glucose levels, and glycemic control goals. When adjusting insulin glargine in a hospital setting, it is important to monitor blood glucose levels closely and make adjustments under medical supervision. The insulin regimen may vary depending on whether the patient is undergoing surgery, starting tube feeds, or has other medical conditions that affect glucose metabolism. Additionally, the timing and dosage of insulin glargine may need to be adjusted when transitioning from other insulin therapies or when using different concentrations, such as switching between U-100 and U-300 formulations.
| Characteristics | Values |
|---|---|
| Recommended starting dose | 0.2 Units/kg or up to 10 Units once daily |
| Frequency | Once or twice a day |
| Time | Same time every day |
| Injection site | Tummy, sides of thighs or buttocks |
| Injection technique | Insulin pen, vial and syringe |
| Adjustments | Changes in physical activity, meal patterns, acute illness, renal or hepatic function |
| Drugs affecting glucose metabolism | Beta-blockers, clonidine, guanethidine, reserpine |
| Adverse reactions | Hypoglycemia, allergic reactions, injection site reactions, lipodystrophy, pruritus, rash, edema, weight gain |
| Basal insulin | Adjust based on fasting glucose levels |
| Correctional insulin | Based on BMI |
| Nutritional insulin | Based on appetite and pre-meal BG levels |
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What You'll Learn
Adjusting insulin glargine for patients with type 2 diabetes
Insulin glargine is a recombinant human insulin analog that is commonly used in patients with type 2 diabetes. It has an onset of action ranging from 1.2 to 1.8 hours, with a duration of 18 to 26 hours. Due to its long duration of action, insulin glargine is typically prescribed once daily. However, in some cases, switching from once-daily to twice-daily dosing may be necessary to improve glucose control.
When initiating insulin glargine therapy in patients with type 2 diabetes, the recommended starting dose is 0.2 Units/kg or up to 10 Units once daily, adjusted to the patient's appropriate FPG target. This starting dose should be approximately one-third of the total daily insulin requirements. Individualization is crucial, and adjustments should be made based on the patient's metabolic needs, blood glucose monitoring results, and glycemic control goals.
For patients with type 2 diabetes who are already on insulin glargine therapy, adjustments may be required in several scenarios. Firstly, during hospitalization, insulin doses must be reevaluated daily to adapt to the patient's changing clinical situation. This includes considering factors such as BG levels, home BG control, appetite, renal function, and the risk of hypoglycemia.
Additionally, adjustments may be needed when there are changes in physical activity levels, meal patterns, acute illnesses, or alterations in renal or hepatic function. Furthermore, certain drugs can influence glucose metabolism, necessitating insulin dose adjustments and close monitoring of blood glucose levels.
It is important to note that insulin regimen changes, including modifications in strength, manufacturer, type, injection site, or method of administration, may require adjustments to the insulin dose or concomitant medications. These adjustments should always be made under medical supervision, and blood glucose levels must be closely monitored during insulin therapy.
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Reducing the risk of hypoglycaemia
Uncontrolled blood glucose levels in hospitalised patients with diabetes can lead to harmful effects such as delayed wound healing, an increased risk of infection, and delays in surgical procedures or discharge from the hospital. Therefore, it is important to reduce the risk of hypoglycaemia in patients.
Firstly, it is important to note that the patient's insulin dosing depends on their previous experience with insulin, baseline diabetes control, and renal function. Other factors to consider include the patient's current oral intake, comorbidities, and other medications. For insulin-naive patients or those treated with low doses of insulin, a total daily insulin dose between 0.3 and 0.5 U/kg is recommended, with half of the total daily insulin dose allocated to basal insulin dosing and the other half to rapid-acting insulin. Lower doses are reserved for patients with a higher risk of hypoglycaemia, such as older patients, those with renal failure, and those with poor oral intake.
Secondly, basal insulin should be adjusted based on the patient's fasting blood sugars. The dose should be increased if the fasting glucose is above target (e.g. >140 mg/dL) or decreased if the fasting glucose is below target (e.g. <110 mg/dL). Pre-emptive adjustments may be made as the patient recovers and the stress response wanes. For example, if a patient's steroid dose is lowered, the insulin dose should also be lowered to avoid hypoglycaemia.
Thirdly, to reduce the risk of in-hospital hypoglycaemia, it is recommended to start with a 20-30% reduction in the total insulin dose compared to their home regimen. Additionally, for patients treated with higher doses of insulin at home, a 20% reduction in the total daily insulin dose is recommended while they are in the hospital to prevent hypoglycaemia in patients with poor oral intake.
Finally, it is important to avoid the use of sulfonylurea medications in the hospital, especially in very sick and unstable patients. These medications, including glyburide, glipizide, and glimeperide, increase the risk of hypoglycaemia if a patient misses a meal or consumes fewer carbohydrates than usual.
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Adjusting insulin glargine for patients with type 1 diabetes
Insulin glargine is a synthetic version of human insulin that is FDA-approved to treat adults and children with type 1 diabetes. It is a long-acting insulin injected once daily and provides basal insulin levels throughout the day. Regimens often combine it with rapid-acting insulin to obtain optimal glycemic control.
The recommended starting dose of insulin glargine in patients with type 1 diabetes who are not currently treated with insulin is 0.2 units/kg or up to 10 units once daily, adjusted to the patient's appropriate FPG target. The dose should be individualized based on clinical response and metabolic needs, blood glucose measurements, and glycemic goals. It should be administered subcutaneously once a day at any time of the day, but at the same time every day.
When initiating insulin glargine treatment, the dose of basal insulin may need to be adjusted, and the amount and timing of shorter-acting insulins and doses of any oral anti-diabetic drugs may also need to be modified. During illness, stress, pregnancy, obesity, trauma, or the use of medications with hyperglycemic effects, daily insulin requirements may increase. On the other hand, exercise, weight loss, calorie-restricted diets, or medications with hypoglycemic effects may decrease daily insulin requirements.
To adjust insulin doses for inpatients with type 1 diabetes, the following guidelines can be followed:
- Day 1: Order a correctional sliding scale for before meals and bedtime based on BMI.
- Day 2: If BG pre-meals are >150 mg/dL, add nutritional insulin based on appetite. If AM fasting BG is >150 mg/dL, add bedtime basal insulin (glargine) dosed at 0.1-0.2 unit/kg.
- Day 3: Adjust insulin doses based on BG patterns: increase or decrease basal insulin based on AM fasting BG, and adjust nutritional insulin based on pre-meal BG levels.
Other considerations:
- Monitor blood glucose levels in all patients treated with insulin.
- Changes in insulin regimen may require adjustments in insulin dose or concomitant medications.
- Rotate injection sites to avoid lipodystrophy.
- Certain drugs may affect glucose metabolism, requiring insulin dose adjustments and close monitoring of blood glucose.
- Glucocorticoids may increase postprandial BG levels, so nutritional insulin doses may need to be increased.
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Converting from other insulin therapies
The recommended starting dose of Lantus in patients with type 2 diabetes who are not currently treated with insulin is 0.2 units/kg or up to 10 units once daily, adjusted to the patient’s appropriate FPG target. One may need to adjust the amount and timing of short- or rapid-acting insulins and dosages of any oral anti-diabetic drugs. The recommended starting dose of Lantus should be approximately 1/3 of the total daily insulin requirements. Individualize and adjust the dosage of Lantus based on the individual’s metabolic needs, blood glucose monitoring results, and glycemic control goal.
To convert from insulin pump therapy back to Multiple Daily Injections (MDI)/Insulin pens, you will need to calculate a background insulin dose to replace the pump basal rate and use your insulin-to-carbohydrate ratios and insulin sensitivity factor to calculate bolus insulin injections. You can download your meter and/or pump regularly or keep written records of your pump doses, including your average total daily dose and the total daily basal insulin dose.
If basal/background insulin is Levemir or Lantus, add 10% to this amount, and this will be the dose in units. If basal/background insulin is Tresiba, deduct 10% from this amount, and this will be the dose in units.
Certain drugs may affect glucose metabolism, requiring insulin dose adjustment and close monitoring of blood glucose. The signs of hypoglycemia may be reduced in patients taking anti-adrenergic drugs (e.g., beta-blockers, clonidine, guanethidine, and reserpine). It is important to note that many herbal remedies are advertised to help control diabetes, and some have been shown to reduce blood glucose levels. If you take insulin, never start or stop taking a herbal remedy without first getting advice from your doctor, pharmacist, or diabetes nurse.
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Adjusting insulin glargine for hospitalised patients
Adjusting insulin glargine doses for hospitalised patients requires caution and constant monitoring of blood glucose levels. It is essential to tailor the treatment to the patient's metabolic needs, blood glucose monitoring results, and glycemic control goals.
When adjusting insulin glargine doses, it is important to consider the patient's basal, nutritional, and correctional requirements. Basal insulin, such as glargine, is needed even when the patient is not eating to control gluconeogenesis or fasting glucose levels. Nutritional insulin is required to cover carbohydrate intake from food, and correctional insulin is used to manage blood glucose levels before meals and bedtime.
On the morning of a procedure, it is recommended to decrease the usual dose of morning glargine by 25%. Stop nutritional insulin during this time, but continue with the usual correctional insulin. For patients who are not eating, a correctional insulin dose of 0 units is administered before meals. As meal consumption increases, the pre-meal dose of nutritional insulin should be adjusted accordingly.
When transitioning from another insulin to glargine, the initial dose of U-100 insulin glargine should be approximately 0.2 units/kg or up to 10 units once daily, adjusted to the patient's appropriate FPG target. This is approximately one-third of the total daily insulin requirement. If switching from U-300 to U-100, the initial U-100 dose should be 80% of the U-300 dose to reduce the risk of hypoglycemia.
It is important to note that insulin regimens should only be modified under medical supervision. Additionally, insulin doses must be reevaluated on a daily basis, and orders should be rewritten to adapt to the patient's changing clinical situation.
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Frequently asked questions
The recommended starting dose is 0.2 units/kg or up to 10 units once daily, adjusted to the patient’s appropriate FPG target.
If you're admitted to the hospital, make sure to inform the staff about your insulin treatment.
Insulin glargine dosage may need to be adjusted due to changes in physical activity, meal patterns, acute illness, or renal/hepatic function. Additionally, certain drugs may affect glucose metabolism, requiring dose adjustments.
