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Lantus Missed-Dose Protocol: What to Do When You Skip Insulin Glargine

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At a glance

  • Drug / insulin glargine, a long-acting basal insulin (Lantus, Basaglar, Semglee, Rezvoglar, Toujeo)
  • Schedule in the labels / once daily, same time every day [2][3]
  • Duration in a clamp study / effect ended at about 22 hours in 20 adults with type 1 diabetes [4]
  • Most common adverse reaction / hypoglycemia, which can be life-threatening [2]
  • Type 1 diabetes / the label says it must be used with a short-acting mealtime insulin [2]
  • Toujeo / 300 units/mL, three times the concentration of Lantus [5][1]

What do the insulin glargine labels say about timing?

The Lantus label directs injection under the skin once daily at the same time every day, into the abdomen, thigh or deltoid, with injection sites rotated. Semglee and Rezvoglar, which are FDA-approved biosimilars of Lantus, carry the same instruction: once daily at any time of day, but at the same time every day [2][3].

The dosage sections cover starting doses, switching from other insulins and dose individualization. The labels also say never to dilute or mix glargine with any other insulin and never to give it intravenously or by insulin pump.

How long does one glargine injection last?

The Lantus label reports a median duration of effect of 24 hours in type 1 diabetes (range 10.8 to more than 24 hours), compared with 14.5 hours for NPH insulin.

In a 24-hour glucose clamp study of 20 C-peptide-negative adults with type 1 diabetes, glargine 0.3 units/kg had no peak and began lowering glucose at about 1.5 hours. Its effect ended at about 22 hours on average, against about 14 hours for NPH insulin [4]. This was a single-dose physiology study, not a study of late or missed injections.

What do the labels say about hypoglycemia?

The Semglee and Rezvoglar labels say hypoglycemia is the most common adverse reaction. They say severe hypoglycemia can cause seizures and may be life-threatening or cause death, and that the long-acting effect may delay recovery [2][3]. The labels list insulin glargine as contraindicated during an episode of hypoglycemia [2].

National surveillance data for all insulin products (not glargine alone) estimate 97,648 emergency department visits a year for insulin-related hypoglycemia and errors, with 29.3% ending in hospitalization. Reduced food intake and administration of the wrong insulin product were the most commonly identified precipitants [6].

Type 1 diabetes and ketoacidosis

The label says insulin glargine is not recommended for treating diabetic ketoacidosis and that in type 1 diabetes it must be used with a short-acting mealtime insulin [2]. It also warns that changes in insulin strength, manufacturer, type or injection site can cause hyperglycemia or hypoglycemia. It says such changes should be made under close medical supervision with more frequent glucose monitoring [2].

Toujeo is a different concentration

Toujeo is insulin glargine at 300 units/mL, three times the concentration of Lantus at 100 units/mL [5][1].

Frequently asked questions

What should I do if I miss my Lantus dose?
The labels give no hour cutoff or partial-dose amount for a missed dose [2][3]. They direct once-daily injection at the same time every day, and they call for more frequent glucose monitoring when insulin dosage, meal pattern, physical activity or other drugs change [2].
How long does a Lantus injection last?
The Lantus label reports a median duration of effect of 24 hours in type 1 diabetes, with a wide range (10.8 to more than 24 hours). In a clamp study of 20 adults with type 1 diabetes, the effect of glargine 0.3 units/kg ended at about 22 hours on average [4].
Should I double the next dose after a missed one?
The dosage sections do not describe taking two doses to make up for one [2][3]. Hypoglycemia is the most common adverse reaction, can be life-threatening, and glargine's long action may delay recovery; the label lists glargine as contraindicated during an episode of hypoglycemia [2].
What does the label say about ketoacidosis and type 1 diabetes?
The label says insulin glargine is not recommended for treating ketoacidosis and that in type 1 diabetes it must be used with a short-acting mealtime insulin [2]. It also warns that changes in insulin regimen can cause hyperglycemia or hypoglycemia [2].
Does Toujeo follow the same rules as Lantus?
Toujeo is insulin glargine at 300 units/mL, three times the concentration of Lantus at 100 units/mL [5][1]. It is a separate product with a different concentration [5][1].

References

  1. Drugs@FDA: FDA-Approved Drugs. Drugs@FDA: FDA-Approved Drugs
  2. U.S. National Library of Medicine, DailyMed. Semglee insulin glargine-yfgn (Biocon) prescribing information. Semglee insulin glargine-yfgn (Biocon) label
  3. U.S. National Library of Medicine, DailyMed. Rezvoglar KwikPen insulin glargine-aglr (Lilly) prescribing information. Rezvoglar KwikPen insulin glargine-aglr (Lilly) label
  4. Lepore M, Pampanelli S, Fanelli C, Porcellati F, Bartocci L, Di Vincenzo A, et al. Pharmacokinetics and pharmacodynamics of subcutaneous injection of long-acting human insulin analog glargine, NPH insulin, and ultralente human insulin and continuous subcutaneous infusion of insulin lispro. Diabetes. 2000;49(12):2142-8. Pharmacokinetics and pharmacodynamics of subcutaneous injection of long-acting human insulin analog glargine, NPH insulin, and ultralente human insulin and continuous subcutaneous infusion of insulin lispro
  5. Drugs@FDA: FDA-Approved Drugs. Drugs@FDA: FDA-Approved Drugs
  6. Geller AI, Shehab N, Lovegrove MC, Kegler SR, Weidenbach KN, Ryan GJ, et al. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Intern Med. 2014;174(5):678-86. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations
Evidence overview for insulin glargine: Lantus Missed-Dose Protocol: What to Do When You Skip Insulin Glargine