What adjustments should be made to a diabetic patient's treatment plan with a history of diabetes, currently managed with a carbohydrate to insulin ratio of 1:10, who has a blood glucose level of hyperglycemia after carbohydrate coverage?

Immediate Insulin Dose Adjustment Required

Your carbohydrate-to-insulin ratio of 1:10 is insufficient for your current needs, and you require both correction insulin now and adjustment of your insulin regimen.

Immediate Correction Dose

• For a blood glucose of 289 mg/dL, you need correction insulin immediately using a rapid-acting insulin (aspart, glulisine, or lispro) 1
• Calculate your correction dose: (289 - 120) ÷ 30 = approximately 5-6 units of rapid-acting insulin 1
• The insulin sensitivity factor of 1:30 (meaning 1 unit lowers glucose by 30 mg/dL) is a reasonable starting estimate, though this varies by individual 1
• Recheck your blood glucose in 2-4 hours to assess effectiveness and watch for hypoglycemia 2, 1

Adjusting Your Carbohydrate Coverage Ratio

Your 1:10 ratio is clearly inadequate since you developed hyperglycemia after carbohydrate coverage:

• If you consistently experience post-meal hyperglycemia with your current 1:10 ratio, tighten the ratio to 1:8 or 1:7 (meaning 1 unit per 8 or 7 grams of carbohydrate instead of per 10 grams) 1
• The carbohydrate-to-insulin ratio should be recalculated using the formula: 450 ÷ total daily insulin dose for rapid-acting analogs 1
• Adjust the ratio by 1-2 grams at a time and monitor 2-hour postprandial glucose readings for 3 days before making further changes 1

Evaluating Your Basal Insulin Coverage

Blood glucose of 289 mg/dL after carbohydrate coverage suggests two possible problems:

• Inadequate basal insulin: If your fasting glucose is consistently above 130 mg/dL, increase your basal insulin (Lantus/Levemir) by 2-4 units every 3 days until fasting glucose reaches 80-130 mg/dL 1, 3
• Insufficient meal coverage: The 1:10 ratio is not covering your carbohydrate intake adequately, requiring the adjustment described above 1

Critical Monitoring Requirements

• Check your blood glucose before each meal and 2 hours after meals for the next 3-7 days to identify patterns 1
• Document all carbohydrate intake, insulin doses, and corresponding glucose readings to guide further adjustments 2
• If you experience blood glucose below 70 mg/dL, treat immediately with 15-20 grams of fast-acting carbohydrate (glucose tablets preferred) and recheck in 15 minutes 2

When Basal Insulin Alone Is Insufficient

If your basal insulin dose exceeds 0.5 units/kg/day and you continue having elevated post-meal glucose:

• This indicates "overbasalization" - you need prandial (mealtime) insulin coverage rather than more basal insulin 1, 3
• Clinical signals include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, and high glucose variability 1
• Add prandial insulin starting with 4 units before your largest meal, then titrate by 1-2 units every 3 days based on 2-hour post-meal readings 1

Common Pitfalls to Avoid

• Do not continue using the same 1:10 ratio if it consistently results in hyperglycemia - this prolongs exposure to high glucose and increases complication risk 1
• Avoid "insulin stacking" by waiting at least 3-4 hours between correction doses, as insulin from the previous dose may still be active 1
• Do not blame the carbohydrate coverage for fasting hyperglycemia - fasting glucose reflects basal insulin adequacy, not meal coverage 1
• Never use protein-rich foods to treat hypoglycemia; use 15 grams of pure glucose or fast-acting carbohydrates instead 2, 1