Can I give 4 additional units of insulin on top of 5 units at bedtime for a glucose level of 450?

Management of High Blood Glucose at Bedtime

Do not administer additional rapid-acting or short-acting insulin at bedtime for a glucose of 450 mg/dL, as this practice is specifically contraindicated in current diabetes guidelines. 1

Rationale for Avoiding Bedtime Rapid-Acting Insulin

The 2024 American Diabetes Association (ADA) Standards of Care explicitly states that rapid-acting and short-acting insulin should not be used at bedtime 1. This recommendation is consistent across multiple years of guidelines 1 and is designed to prevent dangerous nocturnal hypoglycemia.

Appropriate Management Algorithm for High Bedtime Glucose

1. Assess for ketones and symptoms of diabetic ketoacidosis (DKA)

   • If positive for ketones or symptoms of DKA (vomiting, abdominal pain, fruity breath), seek emergency care

2. For non-emergency hyperglycemia at bedtime:

   • Ensure adequate hydration
   • If on basal insulin, adjust the basal insulin dose according to pattern management:
     • If 50% of fasting glucose readings are consistently elevated over a week, increase basal insulin by 2 units 1
     • Do not make immediate large adjustments based on a single reading

3. For ongoing management:

   • Consider implementing a simplified sliding scale for pre-meal (not bedtime) glucose:
     • For pre-meal glucose >250 mg/dL: add 2 units of rapid/short-acting insulin
     • For pre-meal glucose >350 mg/dL: add 4 units of rapid/short-acting insulin 1
   • Adjust basal insulin timing if needed - morning administration may be preferable to bedtime for some patients 1

Important Safety Considerations

• Rapid glucose corrections at bedtime significantly increase the risk of nocturnal hypoglycemia, which can be particularly dangerous during sleep
• The risk of severe hypoglycemia outweighs the benefit of rapid correction of hyperglycemia at bedtime
• Insulin adjustments should be made systematically based on glucose patterns over days, not reactively to single readings 1

Alternative Approaches

If hyperglycemia is persistent, consider:

• Evaluating the overall insulin regimen with healthcare provider
• Assessing for insulin resistance factors (illness, medications, stress)
• Reviewing carbohydrate intake at dinner and evening snacks
• Checking insulin storage and administration technique

Remember that a single elevated glucose reading, while concerning, does not require immediate aggressive correction at bedtime. The focus should be on pattern management and adjusting the overall treatment plan to prevent recurrent hyperglycemia.