Ethan Rhodes
Insulin glargine is a synthetic version of human insulin that is FDA-approved to treat adults and children with type 1 and type 2 diabetes. It is a long-acting insulin that is injected once daily and provides basal insulin throughout the day. The dosage of insulin glargine can vary depending on the patient's condition, weight, blood sugar levels, and other factors. It is important to monitor blood glucose levels and make adjustments to the insulin regimen under medical supervision. When administered in a hospital setting, insulin glargine can be given as a subcutaneous injection, an insulin infusion, or mixed with tube feed formula. It is important to consider the patient's nutritional and correctional insulin requirements and adjust the dosage accordingly.
| Characteristics | Values |
|---|---|
| Brand Name | Lantus, Toujeo |
| Drug Class | Long-acting insulin |
| Dosage | Depends on individual needs, including weight, blood sugar levels, and other tests |
| Frequency | Once or twice a day |
| Time | Same time each day if once a day; 12 hours apart if twice a day |
| Injection Site | Abdomen, thighs, upper arms, buttocks |
| Injection Technique | Use insulin pen, dial dose, inject at right angle to skin, push plunger slowly, hold pen in place for 10 seconds, remove, dispose of needle |
| Adjustments | May be needed due to changes in physical activity, meal patterns, acute illness, renal or hepatic function, injection site |
| Contraindications | Hypoglycemia, hypersensitivity to insulin glargine or excipients in Lantus, diabetic ketoacidosis |
| Drug Interactions | Antidiabetic drugs, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, fibrates, fluoxetine, etc. |
| Inpatient Guidelines | Continue home regimen if well-controlled, but consider reducing to 80% to prevent hypoglycemia; bedtime glargine or NPH dosed at 0.2 units/kg |
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What You'll Learn
Dosage adjustments
Insulin glargine is a synthetic version of human insulin that helps improve and maintain glycemic control in adults and children with type 1 diabetes and adults with type 2 diabetes. It is a long-acting insulin injected once daily and provides basal insulin levels throughout the day. The dosage of insulin glargine can vary depending on the patient's condition and individual needs. Doctors typically start patients on a low dosage and gradually adjust it over time to reach the optimal dose.
When initiating insulin glargine therapy, it is important to consider the patient's current insulin regimen and metabolic needs. The starting dose is usually about one-third of the total daily insulin requirement, which is approximately 0.2 units/kg (up to 10 units) or 0.4 to 0.5 units/kg per day of total insulin. This may vary depending on the patient's weight, blood sugar levels, and other individual factors.
During clinical trials, patients receiving insulin glargine U-300 required a higher dose than those on U-100, with a 17.5% greater dose in one study and an 11-15% higher basal insulin dose in another. Therefore, when switching between U-100 and U-300, it is important to closely monitor blood glucose levels and make adjustments as needed.
Additionally, dosage adjustments may be necessary in cases of renal or hepatic impairment, as a reduction in the Lantus dose may be required in such cases. Furthermore, changes in physical activity, meal patterns, acute illness, or renal/hepatic function can also impact insulin requirements, necessitating dosage adjustments. It is important to closely monitor blood glucose levels and make adjustments under medical supervision to ensure optimal glycemic control and avoid hypoglycemic episodes.
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Switching insulin types
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.
Switching from U-100 to U-300
Initiate the U-300 dose at the same level as the U-100 dose. However, a higher daily dose of U-300 will be needed to maintain the same level of glycemic control.
Switching from once-daily intermediate or long-acting insulin to U-100
The U-100 dose may need to be adjusted. The amount and timing of the shorter-acting insulins may need to be adjusted.
Switching from once-daily intermediate or long-acting insulin to U-300
Initiate the U-300 dose at the same level as the once-daily intermediate or long-acting insulin dose.
Switching from twice-daily long or intermediate-acting insulin to U-300
Initiate the U-300 dose at 80% of the total daily twice-daily long or intermediate-acting insulin.
Switching from once-daily NPH to U-100
Initiate the U-100 dose at the same level as the NPH dose.
Switching from twice-daily NPH to U-100
Initiate the U-100 dose at 80% of the total NPH dose.
Switching from twice-daily NPH to Lantus
Initiate the Lantus dosage at 80% of the total NPH daily dosage. However, a healthcare provider may determine a different Lantus dosage depending on the patient's needs.
Switching from once-daily NPH to Lantus
Initiate the Lantus dosage at the same dose as the NPH insulin.
General considerations when switching insulin types
- The initial dosing, dose increments, and maintenance dosage should be conservative to avoid hypoglycemic reactions.
- When changing treatment regimens, the dose and frequency of short-acting insulins and doses of any oral anti-diabetic drugs may need to be adjusted.
- To minimize hypoglycemia, closely monitor blood glucose, especially when changing regimens.
- The maximum glucose-lowering effect of insulin glargine U-300 may take 5 days to fully manifest and the first dose may be insufficient to cover metabolic needs during the first 24 hours; monitor closely.
- Dose titration should occur no more frequently than every 3 to 4 days due to the longer time for U-300 to achieve a steady state.
- The total daily dose of insulin should be calculated based on the most recent insulin infusion rate. For safety purposes, take 80% of that dose.
- The daily basal dose is half of 80% of the total daily dose.
- If the patient is eating, divide 80% of the total daily dose by 6 for the pre-meal dose.
- If the patient is receiving tube feeds, divide 80% of the total daily dose by 10 for the nutritional dose, to be given every 4 hours.
- If the patient is not receiving nutrition, do not order nutritional insulin.
- Give the first basal insulin injection 1-2 hours before the infusion is discontinued.
- If the transition is being made in the morning, consider using a one-time AM NPH injection or half of the daily glargine or detemir dose to bridge until the morning of the transition.
- If the patient is taking sulfonylureas, these should only be used if doses are held on days when nutritional intake is decreased due to the risk of hypoglycemia.
- Thiazolidinediones may contribute to fluid overload or severe heart failure.
- Glucagon-like peptide 1 receptor agonists may result in nausea and therefore should be avoided when nutritional intake is reduced.
- The use of oral diabetes medications, particularly metformin, in hospitalized patients is controversial. Multiple guidelines recommend stopping these medications at admission because of inpatient factors that can increase the risk of renal or hepatic failure. However, oral diabetes medications have important non-glycemic benefits and reduce the risk of widely fluctuating blood glucose levels.
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Avoiding overdose
Insulin glargine is a synthetic version of human insulin used to treat type 1 and type 2 diabetes in adults and children. It is a long-acting insulin injected once daily to maintain glycemic control. While insulin glargine is effective in managing blood sugar levels, it is crucial to be cautious to avoid an overdose, which can lead to hypoglycemia. Here are some essential guidelines for avoiding an overdose when dosing insulin glargine in a hospital setting:
Patient Education and Monitoring
Patient education is vital to prevent insulin overdose. Patients should be instructed to always verify the insulin label before each injection to prevent accidental mix-ups between basal insulin products and other insulins, especially rapid-acting ones. Additionally, patients should be advised to rotate injection sites to avoid lipodystrophy and closely monitor their blood glucose levels, especially when changing insulin regimens.
Individualized Dosing
There is no standard or maximum dosage of insulin glargine. Dosing should be individualized based on each patient's clinical response, metabolic needs, blood glucose measurements, and glycemic goals. Doctors will typically start patients on a low dosage of insulin glargine and gradually adjust it over time to reach the optimal dose for the patient.
Dose Adjustments
When changing treatment regimens, the dose and frequency of short-acting insulins and oral anti-diabetic drugs may need to be adjusted. Dose adjustments should be made cautiously while closely monitoring blood glucose levels. Any changes in insulin regimen, including strength, manufacturer, type, injection site, or method of administration, may require dose adjustments.
Co-administration of Medications
The risk of hypoglycemia may increase when co-administering certain medications with insulin glargine. These include antidiabetic drugs, other insulins, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, fibrates, and salicylates, among others. Additionally, the effectiveness of insulin glargine may diminish when administered with corticosteroids, diuretics, and estrogens. Therefore, it is crucial to consider potential drug interactions and adjust insulin dosing accordingly.
Correctional Insulin
When a patient is made NPO (nothing by mouth) for a procedure, they will still require their basal insulin to avoid hypoglycemia. The night before the procedure, the usual dose of bedtime NPH can be given, or the usual dose of bedtime glargine can be decreased by 25%. On the morning of the procedure, decrease the usual dose of morning NPH by 50%, or decrease the usual dose of morning glargine by 25%. Stop nutritional insulin but continue correctional insulin.
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Inpatient diabetes guidelines
Inpatient diabetes treatment should be tailored to the patient's individual needs, with input from diabetes care and education specialists (DCESs) and health care professionals knowledgeable in insulin pump therapy.
Initial evaluation should determine the type of diabetes (type 1, type 2, gestational, pancreatogenic, drug-related, or nutrition-related). The patient's blood sugar levels and other tests will inform the insulin dosage, which should be the smallest dosage that provides the desired effect.
For patients with type 1 diabetes, the starting dose of Lantus is usually about one-third of the total daily insulin dose. In a basal-bolus regimen, insulin glargine provides approximately one-third to one-half of the total daily insulin requirement, with pre-meal insulin satisfying the remainder.
For patients with type 2 diabetes who are not currently taking insulin, the recommended starting dosage of Lantus is 0.2 units/kg or 10 units once per day. The maximum starting dosage is 10 units per day.
In the case of non-critically ill (non-ICU) individuals, a glycemic goal of 100-180 mg/dL (5.6-10.0 mmol/L) is recommended, provided it can be achieved without significant hypoglycemia. Intravenously administered insulin is the preferred method to achieve the recommended glycemic target in the ICU.
It is important to closely monitor blood glucose, especially when changing insulin regimens, to prevent hypoglycemia.
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Managing hypoglycaemia
The initial management of hypoglycaemia depends on the severity of the case, whether the patient has intravenous (IV) access, and if they can take food and/or drink by mouth. If the patient is alert, oriented, and able to take food and drink by mouth, they should be administered oral fast-acting carbohydrates. For adults over 50 kg, this should be 15-20 g, and for children under 50 kg, 0.3 g/kg. If a patient is unresponsive, has neuroglycopenic symptoms, or is unable/unwilling to take food or drink, they must be treated with either IV dextrose or glucagon.
To prevent hypoglycaemia, hospitals should have detailed protocols in place, and hypoglycaemia management protocols should be nurse-driven and standardised. All patients at high risk for hypoglycaemia should have glucagon available, and family members, friends, and caregivers should know where it is stored and how to administer it in an emergency.
Inpatient teams can prevent or reduce hypoglycaemic events by recognising triggering events, ordering appropriate insulin or anti-diabetic oral agents, monitoring blood glucose at the bedside, educating patients and staff about symptom recognition and treatment, providing appropriate nutritional requirements, and applying systems to reduce medication errors.
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Frequently asked questions
The recommended starting dose of insulin glargine is 0.2 units/kg or 10 units once per day. The maximum starting dosage is 10 units per day.
Insulin glargine is typically administered once per day at the same time of day.
The dose of insulin glargine should be adjusted according to metabolic needs, blood glucose measurements, and glycemic goals. It may also depend on the patient's weight, insulin history, and other medications.
Insulin glargine may cause hypoglycemia, especially during changes in treatment regimens or when co-administered with certain medications. Overdose can lead to severe and persistent hypoglycemia.
Insulin glargine should be injected subcutaneously, rotating injection sites to avoid lipodystrophy. Common injection sites include the thighs, upper arms, buttocks, or abdomen.
