What to do for a patient with hyperglycemia (blood sugar level of 340 mg/dL) at 10 p.m. who is on a regimen of regular insulin (8 units - 8 units - 8 units)?

Immediate Management of Nocturnal Hyperglycemia (BSL 340 mg/dL at 10 PM)

Give an immediate correction dose of 4-6 units of regular insulin now, then aggressively increase the basal insulin dose starting tomorrow morning. 1, 2

Immediate Correction Dose (Tonight at 10 PM)

• Administer 4-6 units of regular insulin subcutaneously immediately to address the current severe hyperglycemia of 340 mg/dL 1, 2
• Using the insulin sensitivity factor formula (1500 ÷ total daily dose of 24 units = ~60 mg/dL drop per unit), 4-6 units should lower glucose by approximately 240-360 mg/dL, bringing the patient closer to target range 2
• Regular insulin peaks in 2-4 hours, so this dose will work overnight without excessive hypoglycemia risk if given at 10 PM 3
• Do NOT give rapid-acting insulin at bedtime as this significantly increases nocturnal hypoglycemia risk 1

Urgent Basal Insulin Adjustment (Starting Tomorrow)

• The current regimen of 8 units three times daily (24 units total) is grossly inadequate for a patient with fasting/evening glucose of 340 mg/dL 1, 2
• Immediately increase the basal insulin dose by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL, as this patient has severe hyperglycemia (≥180 mg/dL) 1, 2
• The patient likely needs 0.3-0.5 units/kg/day as total daily insulin given the severity of hyperglycemia, which is substantially more than the current 24 units 1, 2

Critical Problem with Current Regimen

• Regular insulin 8-8-8 is being used as a prandial-only regimen without any basal insulin coverage, which explains the severe nocturnal hyperglycemia 1
• This patient needs immediate conversion to a proper basal-bolus regimen with approximately 50% of total daily dose as basal insulin (given once daily as glargine or detemir) and 50% as prandial insulin divided among meals 1, 2
• Sliding scale insulin as monotherapy is explicitly condemned by all major diabetes guidelines and leads to dangerous glucose fluctuations like this patient is experiencing 1

Recommended Insulin Regimen Restructuring (Starting Tomorrow Morning)

• Start basal insulin (glargine or detemir) at 15-20 units once daily in the morning or evening, based on an estimated total daily dose of 30-40 units for severe hyperglycemia 1, 2
• Continue regular insulin 6-8 units before each meal as prandial coverage (this represents the other 50% of total daily dose) 1, 2
• Add correction insulin using a simplified sliding scale: 2 units for premeal glucose >250 mg/dL, 4 units for premeal glucose >350 mg/dL, given in addition to scheduled doses 1, 2

Monitoring Requirements

• Check fasting blood glucose every morning during titration to guide basal insulin adjustments 1, 2
• Check premeal glucose before each meal to calculate correction doses and assess adequacy of basal coverage 1, 2
• Increase basal insulin by 4 units every 3 days if fasting glucose remains ≥180 mg/dL 1, 2

Critical Threshold Warning

• When basal insulin exceeds 0.5 units/kg/day (approximately 35-40 units for an average adult), adding or intensifying prandial insulin becomes more appropriate than continuing to escalate basal insulin alone 1, 2
• Watch for signs of "overbasalization": bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 2

Common Pitfalls to Avoid

• Never rely on correction insulin alone without scheduled basal and prandial insulin, as this treats hyperglycemia reactively after it occurs rather than preventing it 1
• Do not give rapid-acting insulin at bedtime for correction unless closely monitored, as this significantly increases nocturnal hypoglycemia risk 1
• Do not delay aggressive insulin intensification in patients with severe hyperglycemia, as prolonged exposure to glucose >300 mg/dL increases complication risk 1

When to Seek Emergency Care

• Check for diabetic ketoacidosis if the patient has nausea, vomiting, abdominal pain, or altered mental status by checking urine or blood ketones immediately 1
• Marked hyperglycemia accompanied by ketosis, vomiting, or altered consciousness requires immediate medical attention 1