Adjusting for Hyperglycemia

Insulin doses will be adjusted upward when a pattern demonstrating hyperglycemia at a given time of day is present for 2 to 3 days in a row at the same time of day and the hyperglycemia is unexplained by increased food intake, inactivity, or the somogyi phenomenon (rebound hyperglycemia).

If the hyperglycemia is explained by an increased food intake or a decline in physical activity, it is preferable to correct the underlying lifestyle indiscretion rather than to raise the insulin dose(s). If fasting hyperglycemia is present, and particularly if fasting hyperglycemia is seen in association with wide variation in BG values, including the presence of normal and/or lower values, one must exclude the possibility that the highs represent rebound in response to nocturnal hypoglycemia. This distinction is accomplished by asking the patient to check a BG reading between 2 and 3 AM to see if it is normal. If the overnight BG is high, then it is appropriate to adjust the basal insulin dose upward to move BG levels toward the desired target range. If this value is low, it demonstrates that nocturnal hypoglycemia with subsequent rebound is the likely cause of the fasting highs, and the appropriate insulin adjustment is a reduction by 10% to 20% in the basal insulin that is acting at this time of night, e.g., once daily glargine or detemir dose or the evening dose of twice daily dosed insulin NPH or detemir.

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