Maximum Lantus & NPH doses?

allnurses Guide · Nov 28, 2014

I'm a new NP and picking my way through diabetes management. I'll simply say that if I am confused, I can't imagine how patient feel!
My question is: is there a maximum dose of Lantus or detimir, or do you just keep increasing the dose until the blood glucose is within target parameters?
I have the same question regarding NPH.
On a related note, what is the highest Lantus or NPH dose you have seen a patient on?
TIA

You are approaching the question wrong.

What's the patient's starting A1C? Staring oral meds? Starting BeAM? Patient's weight?

There really isn't any primary care need for NPH use.

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Pachinko · Nov 28, 2014

Thanks, but I think you're reading too much into the question. I am familiar with the protocols of diabetes treatment, when to start insulin, using oral meds, etc. It simply is, is there a maximum dose of Lantus that can be prescribed, as there is for other meds (including metformin).

I work in an underserved area, so NPH is still very much a part of the mix (unfortunately). UpToDate lists it as a viable alternative and cost effective. I at least have to trial patients on NPH before moving them to Lantus.

Advanced Practice Columnist / Guide · Nov 29, 2014

There is no maximum Lantus dose in the literature although a subset of patients appear to benefit from BID dosing instead of daily. I work in Critical Care and with hard to control diabetics, we add a short acting predetermined nutritional dose of Aspart in addition to a sliding scale dose. That's a way for us to slowly maximize uptitration of the Lantus while keeping glucose at goal. Obviously, this may not be practical in the out-patient realm.

Is there a maximum insulin glargine (Lantus) dose? - ClinCalc

allnurses Guide · Nov 29, 2014

do you just keep increasing the dose until the blood glucose is within target parameters?

See my previous questions as they are clinically relevant.

Simply:

You don't "just keep increasing the dose" to control an A1C. You can pile on hundreds of units of Lantus and it won't budge the A1C; there is a point of diminishing returns, hence the BeAM calculation to determine the basal vs prandial control.

You need to take even more care with NPH as studies have proven that the risk of hypoglycemic events is significantly higher than Lantus/Levemir.

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honeykrown, MSN, NP · Nov 29, 2014

I do understand that there is no max dose for lantus and levemir but my rotation in DM education states that sometimes there is only so much absorption that could occur from a site. So giving a pt 100u of lantus may not be beneficial if all injected in one site. They might need to be divided up BID or given at two different sites at once. So increasing the dose without much absorption might not show changes to their blood glucose reading.

And then sometimes we use 70/30 BID

mammac5 · Nov 29, 2014

I work in both inpatient and outpatient DM mgmt. There is theoretically no limit to the doses of basal insulin...no upper safe dose to prescribe the way we think of meds like METFORMIN. Having said that, I normally will have pts split a large dose into 2 injection sites for better absorption...say, if they are injecting 80 units total I would have them inject that into two sites, but they can do so at the same time.

Patients who require 200 or more total daily units of insulin may do much better with U-500 insulin since the volume injected is much smaller and seems to be better absorbed/assimilated. I live/practice in an area of the country with high insulin resistance and actually use quite a bit of U-500. We still use NPH for some patients, as well. Especially since it is dirt cheap at Walmart pharmacies...not as great a basal insulin as LANTUS or LEVEMIR (which usually should be dosed BID) but cheap = the only way to go for many patients.

Pachinko · Nov 30, 2014

Thanks for all the feedback. BonstonFNP, I had never heard of the BeAM factor. That is helpful, thanks.