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How to adjust your lantus dose

It’s understandable if you are wondering about the difference between Lantus® and Toujeo®. After all, both Lantus and Toujeo contain the same insulin, called insulin glargine. Insulin glargine was introduced in the year 2000. This was a huge advancement because it was the first long-acting basal insulin. Before the development of insulin glargine, doctors did not have many types of insulins to choose from.

Insulin Glargine: Toujeo vs Lantus

Glargine (the insulin in both Lantus and Toujeo) is an insulin analogue—meaning it has been modified from regular insulin to change its structure and the way it is absorbed. Insulin glargine is still available in its original formulation as Lantus, most commonly prescribed as the Lantus Solostar® pen. Insulin is classically prescribed at a very specific concentration called U-100. The U stands for units. The 100 stands for the number of units present in the liquid (1 milliliter). U-100 insulin has 100 units in 1 milliliter. U-100 is also referred to as “regular” insulin, but this can be confusing since many different types of insulin come in this concentration.

Fast forward a decade and a half later, and insulin glargine (originally Lantus) has reinvented itself. Toujeo (U-300) insulin glargine was approved by the FDA in late February of 2015, making it the first long-acting concentrated insulin available on the market. It is available in insulin pen form only as the Toujeo SoloStar. What researchers discovered was that if they made glargine more concentrated, it lasts slightly longer in the body. That’s right, Toujeo IS GLARGINE, just in the concentrated form of U-300. This means Toujeo is three times more concentrated than Lantus . Some people think Toujeo is stronger than Lantus, but this not true. Toujeo is more concentrated than Lantus, but this does not make it a stronger insulin (learn more about concentrated insulin here). Three times higher concentration means that the same amount of liquid (one milliliter) contains three times the amount of insulin. Toujeo is more concentrated, so the amount (or volume) of the injected medicine is three times less than that of Lantus, but the strength of the medication is the same.

How to adjust your lantus dose

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One of the most important aspects of learning about insulin is knowing how to adjust your dose. In brief, raised blood sugars need a HIGHER dose of insulin and Low blood sugars need a LOWER dose of insulin. It is important to adjust doses on the basis of several results and not just one. This document will give you the necessary information on how to make safe and effective changes.

Once Daily Insulin

A single daily dose of basal insulin which provides a background level of insulin continuously throughout the day and night. If the pre breakfast blood sugar is raised, then increase your insulin dose.

If the pre-breakfast blood sugars are between 7-10mmols, then increase by 2 units, if 10 and above increase by 4 units. Allow 4-6 days before making further increases. If your blood sugars are too low, then reduce your insulin.

Aim for pre-breakfast blood sugar levels to be between 5-7mmols.

Twice Daily Insulin

Your morning dose of insulin controls your daytime blood sugar, before lunch and before your evening meal.

Your evening dose of insulin controls your blood sugar after your evening meal and overnight. If your teatime blood sugars are raised then increase your morning dose.

If your pre-breakfast blood sugars are high, then increase your evening dose by 2-4 units only.

Allow 3-4 days before increasing your dose further. If your blood sugars are above 15mmols increase by 4 units.

Generally you should aim for pre-meal blood sugars between 5-7mmols. Blood sugar 2 hours after meal should be 9-10mmols.

Four Times Daily Insulin (Basal Bolus)

Your basal insulin taken once a day, which will usually be Insulin Glargine (Lantus) or Insulin Detemir (Levemir), controls your background blood sugar. This dose of insulin does not usually need changing often. However, if your blood sugar is either too high or too low during the night or up until pre-breakfast, then this insulin needs to be adjusted.

Breakfast insulin (usually Novorapid or Humalog) needs adjusting if your blood sugar mid morning or pre lunch is not in target range.

Lunchtime insulin (Usually Novorapid or Humalog) needs adjusting if your blood sugar mid afternoon or pre evening meal is not in target range.

Teatime or evening meal insulin (usually Novorapid or Humalog) needs adjusting if your blood sugar mid evening or before bed is not in target range.

Generally you should aim for pre-meal blood sugars to be between 5-7mmols and blood sugars 2 hours after a meal should usually be no higher than 9-10mmols.

If your blood sugars are 9-15mmols or above, increase your insulin by 2 units, if 15mmols or above, increase your insulin by 4 units at the appropriate time.

If you are ill

If you are unwell, you will need to follow the sick day rules. You can find these on www.diabetesuffolk.com or contact your GP, Diabetes Specialist Nurse or NHS direct on 0845 4647

Some do’s and don’ts

Do make small changes which are based on trends in your blood sugar patterns.

Do monitor your blood sugars for a couple of days after making any change.

Don’t adjust your insulin too frequently on the basis of your blood sugars.

Don’t omit your insulin because your blood sugar is within the normal range.

Liz Hartley – Diabetes Specialist Nurse
Nishan Wijenaike – Consultant Physician
West Suffolk Hospitals NHS Trust
Bury St Edmunds
January 2006

Long-Acting Insulin Self-Adjustment ("Three By Three") [link url="//www.soapnote.org/endocrine-metabolic/long-acting-insulin-adjustment-calc/" memo="try the interactive version at //goo.gl/69rRR1"]
Note: These instructions are designed to help you adjust your own insulin. These instructions only apply for long-acting insulins like Lantus or Levemir and do not apply to NPH, Insulin 70/30, or short-acting insulins like Regular or Humalog.

Your long-acting insulin is [select value="Glargine (brand name is Lantus)|Detemir (brand name is Levemir)"]
Your dose of long-acting insulin is [text size=5] units [select value="every morning|every evening|every morning and evening"].

ADJUSTING YOUR OWN INSULIN
1. Check your morning blood sugar everyday prior to eating or drinking anything (fasting).
2. Know your goals! Goal fasting blood sugar less than [text default="130"].
3. Adjust your long-acting insulin every 3 days as follows:
—————————————-
If ALL of your blood sugars greater than [text default="130"]. –> INCREASE by 3 units
If ALL of your blood sugars between [text default="80 and 130"]. –> NO CHANGE
If ANY of your blood sugars less than [text default="80"]. –> DECREASE by 3 units
—————————————-
4. Tell your medical provider how much insulin you are taking at every office visit.
5. Bring your meter, diary, or log of your blood sugars to every office visit.

practical answers to practical questions for the medical trainee

Insulin management, in truth, deserves a whole chapter of a textbook, but here are a few quick-and-dirty methods I’ve learned for type 2 diabetics in the hospital:

Selecting a type of insulin:

  • I often try to use lantus over NPH if I have a choice, because lantus is longer-acting and doesn’t have a peak-decrease response
  • I also avoid 70/30 mixed insulin unless a patient uses that at home because 70/30 is more prone to giving people labile blood sugars
  • Short acting insulins, like aspart (lispro) and humalog (humulin) I think of as more interchangeable

Humalog
Novolog
Apidra

(Table credit: The Joslin Center)

Calculating an initial dose of long acting (basal) insulin: Body weight (kg) x 0.2 if insulin naive; and x 0.5 if already on insulin.

Calculating the appropriate sliding scale instead of using your hospital’s predetermined one: 5% of total daily insulin requirement. For example, someone who requires 20 units of basal insulin should start with a sliding scale of 1 unit when glucose 150-200, 3 units when 201-249, etc.

Adjusting insulin on a daily basis: Add up the sliding scale units they received over the last 24 hours. Assign 50% to long-acting insulin and 50% to mealtime insulin. So, if someone is getting 10 units long-acting insulin and 2 units mealtime, and required an extra 12 units yesterday, they should now get 13 units long-acting insulin and 4 units at each mealtime.

For children with diabetes, blood glucose levels can go up and down a lot. Often, these changes happen at the same time of day, like at meal times or bedtime. As time goes on, you will be able to find these patterns in blood glucose changes more easily. It is important that you know how to make the right changes to your child’s or your own basal and bolus insulin doses for these patterns. This will help keep blood glucose levels in the right place (target range). The Diabetes Team will work with you and your family to help make the right insulin dose changes.

What You Need

Before you start you will need to have these supplies and information ready.

You will need to:

  • Have a blood glucose log – Record your blood glucose results here. You should be checking blood glucose before all three meals and before going to bed.
  • Know your insulin doses – You will have two different types of insulin doses:
    • Basal insulin – This is the Lantus® insulin that works over a long period of time.
    • Bolus insulin – This is the Novolog® or Humalog® insulin that is based on how many carbohydrates you are eating and how high your blood glucose is.
    • Birth to 5 years: 100-180 mg/dL
    • 6 to 9 years: 80-140 mg/dL
    • 10 years and older: 70-120 mg/dL

    How to Find Blood Glucose Patterns

    Many different things can make blood glucose go up or down, like exercise, food, or stress.

    1. Review the past week’s blood glucose levels in your log. Look at the same times of day tested for each day of the week, like breakfast, lunch, dinner, or bedtime.
    2. Look for blood glucose numbers that are above or below your target range.

    Look for patterns in the blood glucose numbers.

    -Are they below target range? Are they below target at a certain time of day?

    -Are they above target range? Are they above target at a certain time of day?

    -Is there no clear pattern?

    Look for other things that may make blood glucose numbers out of range unexpectedly. These may not be good reasons to change an insulin dose.

    -Dirty fingers at the time of testing

    -Wrong carbohydrate counting or eating more or less than expected

    -Timing of meals

    -Expired insulin or test strips

    -Meter not working

    A change in the insulin dose may be needed if:

    -You are using the correction factor often.

    -You are treating low blood glucose often.

    When To Change Your Basal Insulin Dose (Lantus®)

    If you find a pattern that your blood glucose is above or below target range before breakfast, you may want to change your basal insulin. Changing your basal insulin will help keep your blood glucose in target range during the night.

    Step 1: Change Your Basal Insulin Dose (Lantus®).

    • For blood glucose that is above target –> Increase your basal dose (see chart below).
    • For blood glucose that is below target –> Decrease your basal dose (see chart below).

    Use the chart below to change your basal insulin dose.

    Current Basal Dose (Lantus®) For Basal Dose Increases For Basal Dose Decreases
    1 to 5 units Increase by 1/2 unit Decrease by 1/2 unit
    6 to 15 units Increase by 1 unit Decrease by 1 unit
    16 to 25 units Increase by 2 units Decrease by 2 units
    26 to 35 units Increase by 3 units Decrease by 3 units
    36 to 45 units Increase by 4 units Decrease by 4 units
    46 units or more Increase by 5 units Decrease by 5 units

    Step 2: Check 3 a.m. Blood Glucoses.

    It is important to make sure the basal insulin change is right for you. You will want to check your blood glucose at 3:00 a.m. for 2 to 3 days after you make a change to your Lantus®.

    • If your blood glucose is below target range at 3:00 a.m., then decrease your basal dose.
    • If your blood glucose is above target range at 3:00 a.m., then increase your basal dose.

    When To Change Your Bolus Insulin Dose (Humalog®/Novolog®)

    If your blood glucose is above or below the target range, you may need to make changes to your bolus insulin dose. Follow the steps below to see how to understand blood glucose patterns and how to change your bolus insulin dose.

    Step 1: Check Your Blood Glucose

    Check your blood glucose before lunch, dinner, and bedtime.

    Step 2: Read the Results

    If your blood glucose is above or below your target range before lunch, dinner, or bedtime, you may need to make changes to your bolus insulin dose.

    It is important to change bolus insulin doses if blood glucose is:

    • Below target range for 2 days in a row –> Decrease bolus insulin (See Step 3a)
    • Above target range for 3 days in a row –> Increase bolus insulin (See Step 3b)

    Step 3a: Decrease Your Bolus Insulin Dose (Humalog®/Novolog®)

    You know to decrease the bolus insulin dose if your blood glucose has been below target for 2 days in a row. Now you need to know when and how much to change it. Changing this dose is based on your Insulin to Carb Ratio.

    • First , know your current Insulin to Carb Ratio. Your Insulin to Carb Ratio is _____.
    • Next , use the chart below to know when to decrease your bolus insulin dose.
    • Last, use the scale below to INCREASE your Insulin to Carb Ratio by one level from your current ratio. Increasing your Insulin to Carb Ratio means you will be giving less insulin.

    Step 3b: Increase Your Bolus Insulin Dose (Humalog®/Novolog®).

    You know to increase the bolus insulin dose if your blood glucose has been above target for 3 days in a row. Now you need to know when and how much to change it. Changing this dose is based on your Insulin to Carb Ratio.

    • First , know your current Insulin to Carb Ratio. Your Insulin to Carb Ratio is _____.
    • Next , use the chart below to know when to increase your bolus insulin dose.
    • Last , use the scale below to DECREASE your Insulin to Carb Ratio by one level from your current ratio. Decreasing your Insulin to Carb Ratio means you will be giving more insulin.

    What To Do After an Insulin Change

    Continue to monitor blood glucose levels.

    • If glucoses continue to be below target range after 2 days, decrease insulin again.
    • If glucoses continue to be above target range after 3 to 5 days, increase insulin again.

    When to Call the Doctor

    Always call the doctor if you are not sure about how to change your basal or bolus insulin doses.

    1. Changing basal insulin dose for long-term, background effect

    • If taking less than 10 units, increase by ½ unit at a time (ask the team for a ½ unit pen).
    • If taking 10-20 units, increase by 1 unit at a time
    • If taking more than 20 units, increase by 2 units at a time

    2. Changing bolus insulin dose for carbohydrate at meals

    How to adjust your lantus dose

    If the blood glucose level is high for four or more days in a week before a particular meal, increase the insulin dose for the meal eaten earlier in the day BEFORE the high levels (for example, if the level is high before lunchtime, increase the breakfast dose). By giving more insulin for the same amount of food, you are effectively increasing the carbohydrate ratio for that meal.

    If you are using a glucose meter that provides advice to guide dosing, then the insulin to carbohydrate ratio will need to be changed. The table below gives you some information on how to do this. If you are not sure about this then please call a member of the team to discuss how to do this.

    How to adjust your lantus dose

    3. Correction boluses for high blood glucose results

    This is given, in addition to the bolus insulin to cover carbohydrate, to ‘correct’ pre meal blood glucose readings that are above the target of 7mmol/L.

    If you are using a glucose meter that gives dosing advice, then this correction factor is automatically calculated. The correction factor (also called “insulin sensitivity”) needs to be changed according to how much insulin you are taking. If you are not sure about this then please call a member of the team to discuss how to do this.

    Remember to check ketones if the blood glucose is more than 14 mmol/l and follow the sick day rules if unwell.

    Worked example

    Glucose meters that provide dosing advice take into account how much carbohydrate you are about to eat; your insulin to carbohydrate ratio; and the correction factor required. It automatically does a calculation to provide a suggested dose of insulin.

    The following example is given to show how the smart meter does this:

    How to adjust your lantus dose

    This example is purely for illustration purposes. If your meter provides dosing advice, all you need to know is how much carbohydrate you are about to eat and what your glucose level is.

    You can keep track of your insulin to carbohydrate ratio and correction factor by either printing out and completing an Insulin to Carbohydrate ratio paper form, or completing the electronic form below – all the information submitted is then automatically emailed to you.

    When undergoing surgery or another medical procedure, here are some important things you should consider about medication and/or insulin.

    Diabetes pills or non-insulin injectable medications

    (Symlin, Byetta/ Bydureon, Victoza, Trulicity or Ozempic)

    • During a clear liquid diet: stop diabetes medication other than insulin ( see below for specifics on insulins ). Use glucose-containing clear liquids as needed to maintain blood sugar, not just diet beverages.
    • Other than insulin, do not take diabetes medication on the morning of your procedure.

    Basal insulins and basal combination products

    (Lantus, Levemir, Basaglar, Tresiba, Soliqua or Xultophy)

    • During a clear liquid diet: take 2/3 of your usual basal dose for a colonoscopy or similar procedures. Use glucose-containing clear liquids as needed to maintain blood sugar, not just diet beverages.
    • Morning of the procedure: take 2/3 of your usual morning basal dose. Evening of the procedure, take your usual dose.

    NPH insulin

    (Novolin or Humulin N) For mixed insulins 70/30 or 75/25 ask your provider

    • During a clear liquid diet: take 1/2 dose of usual N insulin dose for colonoscopy or similar procedures. Use glucose-containing clear liquids as needed to maintain blood sugar, not just diet beverages.
    • Morning of the procedure: take 1/2 dose of usual N insulin dose. For mixed insulins, omit the morning dose, take 1/2 dose when eating well.

    Bolus insulin: Injections

    (Humulin, Novulin R, Humalog, NovoLog, Apidra or Fiasp)

    • Do not take usual doses of these fast-acting insulins while NPO (when told to withhold food and fluids) or on clear liquids.
    • You may require supplemental fast-acting insulin for blood sugars over 200. If you have a blood glucose correction scale use 1/2 usual doses to correct high blood sugars.

    Bolus insulin: Insulin Pump

    • During a clear liquid diet: set a temporary basal rate of 65% for a colonoscopy or similar procedures. Use glucose-containing clear liquids as needed to maintain blood sugar, not just diet beverages.
    • Morning of the procedure: set a temporary basal rate of 65%.
    • For high blood sugar: use only 50% of recommended bolus dose with a blood sugar target of 120-180 mg/dl.

    When to resume your normal doses

    Go back to your usual medications after the procedure when you are eating normally.

    It is very common for people to have variation in their basal requirements during the day (diabetic and non-diabetic). Most diabetics actually find that their basal requirements are higher overnight, particularly in the early morning as the Darn Phenomenon kicks in. To treat this (as a Lantus user), you have two basic options, split dosing, and supplemental dosing. Supplemental dosing would add something like an intermediate (NPH) typically overnight to add a boost onto your basal for 4-12 hours. Split dosing breaks your basal into two individual doses that are either different in size or staggered in time. The end effect is that your profile is not longer flat.

    So with a basal insulin like lantus, it is quoted to last 24 hours and splitting your doses into separate sizes, like 60% morning/40% evening will increase your morning levels over your evening levels only if you have a non-flat response to the insulin. Instead, with lantus, it is more effective to stagger the doses, leaving one window "stacked" and another uncovered. So the graphic (ok those graphs s*ck, but I don’t have patience to fix them now) below illustrates the net effect of two doses 12 hours apart and two doses at an staggered time split.

    dose 1 ______________________
    dose 2 _________________
    Net _______________________________________

    dose 1 _____________________
    dose 2 ___ _______________
    Net XXX__________________ _______________

    Ok, so if you are routinely high at 4-6 am and are going low at 4-6 pm, you could take you lantus (remember lantus peaks in 1-2 hr) with a evenly split dose at 2 am and taking your other dose at 10am, giving you a 4 hr window in the early morning with a higher basal and a 4hr window in the afternoon with a lower basal. Most people find this sort of thing inconvenient and instead, take their evening basal before bed and their morning basal when they wake up. But remember, this results in a larger 6-8 hr window of higher basal overnight, and you may need to consume a snack before bed of complex carbs or protein to avert a hypo.

    All this discussion is focused on overnight highs. The original posters question was different. He seems to be low in the evening and high during the day. My first comment would be that the likely reason this is occuring is that you are using the basal to cover the carbs you eat during the day and by increasing the basal to higher and higher amounts you have markedly exceeded your basal requirements. So the first suggestion is cut back on your basal so that your basal properly meets your fasting requirements. Then cut back on the carbs and/or use a bolus to cover the carbs. If you continue to use a higher and higher basal to cover the carbs you eat, you will gain weight and experience wide swings in your blood sugar. Don’t do it.

    That being said, should you just be a unique individual who has their Darn Phenomenon during the day and goes low at night, you can split the doses as I have described above but in reverse. Take half the lantus when you first awake, and then the second half in the middle of the day.