Glargine: A New Basal Insulin, A New Opportunity

Insulin analogs have made a dramatic entrance into the diabetes management armamentarium. Most attention has focused on short-acting insulin analogs. Recently, a new long-acting insulin analog, glargine (Lantus), has been introduced for patient use.Both of the patients presented in this article have type 1 diabetes. Case 1 demonstrates the conversion from twice-daily ultralente to glargine. The patient in Case 2 had a significant allergic reaction to previous insulin therapy. She was converted from seven doses a day of lispro to a basal-bolus therapy using glargine and lispro. The considerations related to dosing and the key points for patient education are similar for patients whether they have type 1 or type 2 diabetes. Case 1R.L. is a 66-year-old man who has had type 1 diabetes for 32 years. He has been on a basal-bolus regimen for 6 years using lispro and ultralente. He has had widely fluctuating blood glucose levels including significant hypoglycemia, and he has hypoglycemia unawareness. His only diabetes complication is diabetic gastroparesis.His glargine dose was determined by decreasing by 20% his total ultralente dose of 32 units split into breakfast and bedtime doses. He took lispro after meals instead of the more common pre-meal dosing because of his gastroparesis. His lispro doses (12 units after breakfast, 10 units after lunch, and 10 units after dinner) were unchanged with initiation of glargine.Because R.L. was on twice-daily ultralente and had already taken his morning dose, he was instructed to use about half of the glargine dose on the first night (12 units). He began taking the full prescribed dose of 25 units of glargine on the second night.R.L.’s blood glucose levels for the first day were: fasting, 99 mg/dl; 2-h postprandial breakfast, 124 mg/dl; 2-h postprandial lunch, 146 mg/dl; and bedtime, 80 mg/dl. Needless to say, he …