What dose of insulin glargine should be given for a blood glucose of 365 mg/dL?

Immediate Correction Dose for Blood Glucose of 365 mg/dL

For a blood glucose of 365 mg/dL, administer 4 units of rapid-acting insulin (lispro, aspart, or glulisine) immediately as a correction dose, but recognize that this single correction is insufficient—the patient requires a scheduled basal-bolus insulin regimen to prevent recurrent hyperglycemia. 1

Understanding the Correction Dose Protocol

• For pre-meal glucose >350 mg/dL, give 4 units of rapid-acting insulin as a correction dose in addition to any scheduled insulin. 1
• A glucose of 365 mg/dL falls into the >350 mg/dL category, warranting the 4-unit correction. 1
• This correction dose must supplement—not replace—a scheduled basal-bolus regimen; relying solely on correction insulin is condemned by all major diabetes guidelines. 1, 2

Critical Problem: Correction Insulin Alone Is Inadequate

• Sliding-scale insulin used as monotherapy achieves target glucose (<140 mg/dL) in only 38% of patients, versus 68% with scheduled basal-bolus therapy. 1, 2
• A glucose of 365 mg/dL signals complete inadequacy of the current insulin regimen—this is not merely a need for correction dosing but rather a fundamental failure of diabetes management. 1
• Correction insulin treats hyperglycemia reactively after it occurs rather than preventing it, leading to dangerous glucose fluctuations. 1, 2

Immediate Regimen Restructuring Required

Basal Insulin (Glargine) Initiation or Escalation

• Start basal insulin at 0.3–0.5 units/kg/day for severe hyperglycemia (glucose ≥300 mg/dL), with 50% given as basal insulin once daily. 1
• Increase basal insulin by 4 units every 3 days when fasting glucose is ≥180 mg/dL, targeting fasting glucose of 80–130 mg/dL. 1
• Stop basal escalation when dose approaches 0.5 units/kg/day; further glucose control should be achieved by adding prandial insulin to avoid "over-basalization." 1

Prandial (Rapid-Acting) Insulin Addition

• Begin rapid-acting insulin at 4 units before each of the three largest meals (or 10% of the basal dose). 1
• Administer rapid-acting insulin 0–15 minutes before meals for optimal postprandial control. 1
• Titrate each meal dose by 1–2 units every 3 days based on 2-hour postprandial glucose, targeting <180 mg/dL. 1

Monitoring Requirements

• Check fasting glucose daily to guide basal insulin adjustments. 1
• Measure pre-meal glucose before each meal to calculate correction doses. 1
• Obtain 2-hour postprandial glucose after each meal to assess prandial adequacy. 1

Assessment for Diabetic Ketoacidosis

• Check for ketones (urine or blood) immediately if glucose >300 mg/dL with symptoms (nausea, vomiting, abdominal pain, altered mental status). 1
• For any patient with glucose >300 mg/dL, obtain a ketone measurement regardless of diabetes type. 1
• If ketonuria is present or ketonemia ≥0.5 mmol/L, treat as early ketoacidosis and summon a physician promptly. 1

Common Pitfalls to Avoid

• Never use sliding-scale insulin as monotherapy—this approach is explicitly condemned by the American Diabetes Association and leads to treatment failure rates of 19% versus 0% with basal-bolus therapy. 1, 2
• Do not delay transition to scheduled insulin when glucose values are consistently >250 mg/dL; prolonged hyperglycemia increases complication risk. 1
• Do not administer rapid-acting insulin at bedtime as a sole correction dose, as this markedly raises nocturnal hypoglycemia risk. 1
• Do not assume that a 4-unit correction is adequate for sustained control—such dosing indicates fundamental under-dosing of the scheduled regimen. 1

Expected Outcomes with Proper Basal-Bolus Therapy

• With appropriately implemented basal-bolus therapy, 68% of patients achieve mean glucose <140 mg/dL versus 38% on sliding-scale alone. 1, 2
• Basal-bolus therapy does not increase hypoglycemia incidence compared with inadequate sliding-scale approaches when properly implemented. 1
• For non-critically ill hospitalized patients, the target glucose range is 140–180 mg/dL. 1