For a hospitalized patient on Lantus (insulin glargine) 16 units and Actrapid (novorapid, insulin aspart) 4-4-4 units with elevated fasting blood glucose, should the Actrapid dose be increased to 6-6-4 units or remain at 4-4-4 units?

Insulin Dose Adjustment for Hospitalized Patient with Elevated Fasting Glucose

Increase Actrapid to 6-6-4 Units on Day 3

For this hospitalized patient with fasting glucose of 210 mg/dL after increasing Lantus from 12 to 16 units, you should increase the Actrapid dose to 6-6-4 units to maintain the 50:50 basal-bolus ratio. 1

Rationale for Dose Adjustment

Basal-Bolus Ratio Maintenance

• Current guidelines recommend basal-bolus insulin with a 50:50 split between basal (Lantus/Optisulin) and bolus (Actrapid/Novorapid) insulin for hospitalized patients requiring insulin therapy 2
• With Lantus increased to 16 units on night of day 2, the total basal insulin is now 16 units 1
• To maintain the 50:50 ratio, total bolus insulin should also equal 16 units daily 1
• Increasing Actrapid from 4-4-4 (12 units total) to 6-6-4 (16 units total) achieves this 50:50 split 1

Hospitalized Patient Dosing Principles

• For hospitalized patients who are insulin-naive or on low-dose insulin, the recommended total daily dose is 0.3-0.5 units/kg, with half as basal insulin and half as bolus insulin 1
• The current regimen of Lantus 16 units plus Actrapid 12 units (total 28 units) was already suboptimal with unequal distribution 1
• The elevated fasting glucose of 210 mg/dL indicates inadequate basal coverage, which you correctly addressed by increasing Lantus 1

Titration Algorithm for Day 3 and Beyond

Basal Insulin Adjustment

• Continue increasing Lantus by 4 units every 3 days if fasting glucose remains ≥180 mg/dL (as in this case with 210 mg/dL) 1, 3
• Target fasting glucose of 80-130 mg/dL 1, 3
• If hypoglycemia occurs, reduce the dose by 10-20% immediately 1

Bolus Insulin Adjustment

• Adjust Actrapid doses based on pre-meal and 2-hour postprandial glucose readings 3
• Increase by 1-2 units or 10-15% every 3 days if postprandial glucose remains elevated 3
• The 6-6-4 distribution allows for differential adjustment if one meal causes greater glucose excursions 3

Critical Monitoring Requirements

• Check fasting blood glucose daily to guide basal insulin titration 1, 3
• Monitor pre-meal and 2-hour postprandial glucose to guide bolus insulin adjustments 3
• Reassess the insulin regimen every 3 days during active titration 1
• Watch for signs of hypoglycemia and adjust doses immediately if it occurs 1

Common Pitfall to Avoid

Do not leave the Actrapid at 4-4-4 units when increasing basal insulin, as this creates an imbalanced regimen that deviates from the evidence-based 50:50 split and may lead to suboptimal glycemic control 2, 1. The 50:50 ratio is specifically recommended for hospitalized patients requiring basal-bolus therapy 2, 1.