Lantus (Insulin Glargine): Scratching The Surface

Many patients and some healthcare workers are puzzled by basal insulins, and as a result, do not understand how the body responds to them. Basal insulin meets the basal metabolic needs of the body during times when the person is not eating. The purpose of this article is to discuss the significance of Lantus as a slow-acting insulin. Nurses Announcements Archive Article

Lantus (Insulin Glargine): Scratching The Surface

The cells of the human body require a continual stream of energy at all times in the form of glucose, and insulin is the the vehicle that allows this glucose to enter the cells. The pancreas of a healthy non-diabetic person has two mechanisms of insulin secretion: basal insulin production and bolus insulin (a.k.a. prandial insulin) production.

Basal insulin is constantly produced by the pancreas in small amounts and is in the bloodstream at all times, whereas bolus insulin is secreted in bursts to address the postprandial spikes in blood glucose levels that are caused by eating. In other words, the insulin that a healthy person's pancreas makes has two separate functions: basal, which is for all-day baseline action, and bolus, which is for sudden mealtime action.

For effective blood glucose control, the diabetic patient might be prescribed a basal insulin (such as Lantus) and a bolus insulin such as Humalog or regular insulin. This regimen is designed to mimic the secretory response of the healthy non-diabetic pancreas.

According to Newton (2007), basal-bolus insulin is one of the most advanced approaches to diabetes care, offering a way to closely simulate natural insulin delivery. Basal insulin controls blood glucose levels in response to the constant low-level supply of glucose made by the liver, whereas bolus insulin responds to rises in blood sugar due to food intake.

Lantus is a slow-acting basal insulin. Many patients and some healthcare workers do not realize that Lantus is a basal insulin and conclude that if they administer it to replace the insulin that the pancreas no longer secretes, that it is enough to result in normal blood glucose levels. However, Lantus is absorbed slowly over an extended period of time and does not address the mealtime spikes.

In addition, some nurses will hold Lantus if a patient's most recent blood glucometer reading is in the 90s or low 100s with the mistaken belief that this type of insulin will lead to dangerous lows. However, nursing staff is mystified when the same patient's blood glucometer readings are extremely elevated on the next day. Holding Lantus is comparable to depriving the body of its supply of basal insulin.

Never mix Lantus with any other insulin because this action deactivates it. Lantus is for subcutaneous injection only and generally does not have a peak. According to Thompson (2008), the safest time of day to administer Lantus and Levemir is before bedtime. However, many patients experience successful outcomes when they take their basal insulin once daily in the morning. In addition, some physicians advise patients to divide their daily dose into two injections that are spaced 12 hours apart.

Since diabetes mellitus is so prevalent in healthcare settings, it is imperative that nurses and other healthcare workers are knowledgeable about the action of Lantus and other basal insulins. Knowledge is power, and together we can bestow our expertise upon our patients and their families to assist in warding off devastating complications.

References

Why Basal-Bolus Insulin Therapy May Be The Best Choice For Type 2 Diabetes.

Hold the Insulin! Or Maybe Not.

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TheCommuter

About TheCommuter, BSN, RN

TheCommuter, BSN, RN, CRRN is a longtime physical rehabilitation nurse who has varied experiences upon which to draw for her articles. She was an LPN/LVN for more than four years prior to becoming a Registered Nurse.

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Thanks for the article! I would clarify, though, that the body does not secrete "two types of insulins," rather, the healthy pancreas secretes more insulin at times of specific need.

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
Thanks for the article! I would clarify, though, that the body does not secrete "two types of insulins," rather, the healthy pancreas secretes more insulin at times of specific need.

Thanks for the clarification. :)

I had used the official Lantus website as a resource and it is possible that I did not interpret the information correctly. Every single day presents opportunities for new learning experiences.

A normal pancreas delivers 2 basic forms of insulin: a 24-hour-a-day, low-level supply known as basal insulin, and prandial (bolus) insulin, the large doses it releases in response to meals.

http://www.lantus.com/hcp/basal-insulin.aspx

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Specializes in Trauma, ER, ICU, CCU, PACU, GI, Cardiology, OR.

enlightening article~

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Specializes in Acute Care Psych, DNP Student.

This reminds me of a discussion I got into with another nurse at work. I had a patient whose blood glucose numbers were dipping into the low 50s each evening. He was eating normally. He had recently been switched from 70/30 to lantus. I held his PM lantus and called the on-call doc to get an order. The 2-3 previous days the nurse gave the lantus even though the PM blood glucose was in the low 50s. She said it didn't matter because it's basal.

I know it's a basal insulin. However, if the values are consistently low, wouldn't lantus just push it low...consistently?

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
I know it's a basal insulin. However, if the values are consistently low, wouldn't lantus just push it low...consistently?
If the patient is getting too much Lantus, then yes, the glucose levels will remain consistently low.

The patient whose glucometer readings are 50+/- every night probably needs a permanent reduction in the dose of Lantus that they are receiving. For instance, instead of 45 units subcut. at HS, the dose likely needs to be titrated downward each night until these lows are no longer an issue.

When I have a patient with a low glucometer reading and a dose of Lantus that is due, I'll call the internal medicine physician for orders. Although the doctor might give a telephone order to decrease the amount of Lantus given, no doctor has ever given me an order to hold the Lantus, even with a low blood glucose.

The doctor will usually reduce the dose of Lantus and instruct me to give the the patient a high-protein bedtime snack to ward off any extreme lows.

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Specializes in Acute Care Psych, DNP Student.

That's what happened. I held the lantus until I could get the on-call doc. I got an order to reduce the units of lantus. The nurse I was working with who had given lantus when the blood glucose was in the low 50s on the prior evenings said she didn't understand why it couldn't wait until the physician rounded in a few days because it's just lantus.

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This reminds me of a discussion I got into with another nurse at work. I had a patient whose blood glucose numbers were dipping into the low 50s each evening. He was eating normally. He had recently been switched from 70/30 to lantus. I held his PM lantus and called the on-call doc to get an order. The 2-3 previous days the nurse gave the lantus even though the PM blood glucose was in the low 50s. She said it didn't matter because it's basal.

I know it's a basal insulin. However, if the values are consistently low, wouldn't lantus just push it low...consistently?

Your co-worker is right that lantus could theoretically be given to a low patient because it's activation time is 1-2 hours after dosing. HOWEVER, in real life the low needs to be treated right away by being given 15 - 30g of carb. Test in 15 minutes and determine if blood sugar is rising or if more carbs are needed. Patient usually recovers in 15 - 30 minutes and then the lantus can be given.

If the patient is having consistent lows it is because the Lantus dose or timing of the dose is off and the MD should reevaluate the orders.

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Specializes in Medical-Surgical, Hemodialysis.

Very informative! Thank you for sharing.

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I have been on Lantus for at least 3 to 5 years and I never knw it did not address mealtime spikes.....all this time I have been thinking I was covered when I did not have my Novalog......you live and you learn!!

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
I have been on Lantus for at least 3 to 5 years and I never knw it did not address mealtime spikes.....all this time I have been thinking I was covered when I did not have my Novalog......you live and you learn!!

I find it interesting and somewhat tragic that your doctor did not take five minutes to explain how Lantus works. After all, (s)he prescribed it, so I feel that (s)he has a duty to explain the 'hows' and 'whys' surrounding this type of insulin.

How do we expect patients to succeed at self-management of diabetes if they are not receiving adequate education regarding their medications, diet, exercise, and so forth?

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I find it interesting and somewhat tragic that your doctor did not take five minutes to explain how Lantus works. After all, (s)he prescribed it, so I feel that (s)he has a duty to explain the 'hows' and 'whys' surrounding this type of insulin.

How do we expect patients to succeed at self-management of diabetes if they are not receiving adequate education regarding their medications, diet, exercise, and so forth?

Chances are that it was actually explained and the patient just forgot afterward. This is exceedingly common in the clinic. Heck, even for simple things like what time of the day to take statins, I've had to explain to the same patients multiple times because they tend to quickly dump whatever's explained to them out of their memory once they leave the clinic.

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