Immediate Insulin Dose Adjustment Required
Your blood glucose of 245 mg/dL two hours after 8 units of Actrapid (regular insulin) indicates inadequate insulin coverage and requires immediate adjustment of your insulin regimen. 1
Understanding the Problem
Your current situation suggests one of two scenarios:
- If you're on basal insulin only: A glucose of 245 mg/dL indicates you need both increased basal insulin AND the addition of prandial (mealtime) insulin coverage 1, 2
- If this was a correction dose: 8 units of Actrapid was insufficient to bring your glucose to target, and your insulin sensitivity factor needs recalculation 1
Immediate Action Steps
If You Have Type 1 Diabetes or Are Insulin-Dependent
Check for ketones immediately - with glucose this elevated, you need to rule out diabetic ketoacidosis, especially if you have nausea, vomiting, or abdominal pain 3
Basal Insulin Adjustment (If Applicable)
If you're taking long-acting basal insulin (like Lantus or Levemir):
- Increase your basal insulin by 4 units every 3 days until your fasting glucose consistently reaches 80-130 mg/dL 1, 4
- This aggressive titration is warranted when glucose levels remain ≥180 mg/dL 1
- Continue monitoring fasting glucose daily during this titration phase 1, 4
Adding Prandial Insulin Coverage
You likely need mealtime insulin in addition to basal insulin 1, 2:
- Start with 4 units of rapid-acting insulin (like Humalog, NovoLog, or Apidra) before your largest meal 1, 5
- Alternatively, use 10% of your current basal insulin dose as your starting prandial dose 1, 5
- Increase prandial insulin by 1-2 units every 3 days based on your 2-hour post-meal glucose readings 1, 5
- Target post-meal glucose should be less than 180 mg/dL 1, 2
Critical Threshold Warning
If your basal insulin dose exceeds 0.5 units/kg/day (approximately 36 units for a 72 kg person), do NOT continue increasing it 1, 4. Instead, add or intensify prandial insulin coverage, as further basal insulin escalation leads to "overbasalization" with increased hypoglycemia risk without improved control 1, 5.
Foundation Therapy
Continue metformin (if you're taking it and have no contraindications) even when intensifying insulin therapy, as this combination reduces total insulin requirements and provides better glucose control with less weight gain 1, 2
Monitoring Requirements
- Check fasting glucose every morning 1, 4
- Check pre-meal glucose before each meal 1
- Check 2-hour post-meal glucose to guide prandial insulin adjustments 1, 5
- Target fasting/pre-meal glucose: 80-130 mg/dL 1, 2
- Target 2-hour post-meal glucose: <180 mg/dL 1, 2
Common Pitfalls to Avoid
Do not rely on correction insulin alone - sliding scale insulin as monotherapy is explicitly condemned by all major diabetes guidelines and leads to dangerous glucose fluctuations 1, 2
Do not give rapid-acting insulin at bedtime to correct this elevated glucose, as this significantly increases nocturnal hypoglycemia risk 1
Do not delay adding prandial insulin when blood glucose remains in the 200s despite basal insulin optimization 1, 4
When to Seek Immediate Medical Attention
Contact your healthcare provider or go to the emergency department if:
- You have ketones >2 mmol/L or moderate/large ketones on urine testing 3
- Blood glucose persistently >300 mg/dL 3
- You experience nausea, vomiting, or abdominal pain 3
- You have altered mental status 3
Expected Timeline
With appropriate insulin intensification using the algorithm above, you should see fasting glucose reach target within 1-2 weeks of consistent titration 1, 4. HbA1c reduction of 2-3% is achievable with proper basal-bolus insulin therapy 1.