My son just switched to Lantus a month ago. He takes Humalog with meals on a sliding scale and 60 units of Lantus at night. His morning readings are in the low 200s mg/dl [11.1 to 12.5 mmol/L]. Does he need to add Humalog to the nighttime shot on a sliding scale? He also takes metformin. He is supposed to take it in the morning and supper. He doesn’t take it in the morning because he doesn’t want to eat breakfast. We switched the pill to bedtime because he was taking it then when he was on NPH. The reason at night is to try to avoid to shots at once. What time should he take the pill to help with morning highs? Metformin 1000 is supposed to be twice a day but he only takes it once. The reason for the pill is for insulin resistance. He was getting better blood readings with the pill when blood was drawn in clinic than without.

It is difficult to answer any specific dose questions without a lot of pre and post prandial blood glucose readings to look for patterns, plus several middle of the night blood sugar readings as well. Many of our patients use Lantus twice-a-day with usually a larger dose at evening and smaller dose in the morning. Some only need morning Lantus. It is extremely variable and there is no set pattern. Some even have a reverse pattern. But, all such decisions would be based not dogmatically but by review of detailed and frequent blood sugar readings to look and identify patterns. Similarly, if he is showing rising blood glucose levels after bedtime snack, one can either stop the bedtime snack completely, since there is no bedtime NPH needing “coverage,” or add bedtime Humalog to cover the immediate rise. Same as before, no dogma, but respond to the actual pre and post-meal blood sugar readings to make such decisions. If you are having problems, and it is not obvious, then bring the frequent blood sugar readings to your diabetes team and they can review with you.

SB