The objective of this page is to provide you sample cases to practice insulin adjustment. This page is in development and will grow. For access to formal online learning modules for healthcare providers with automatically marked quizzes, please click here.
MEDICATIONS
ARTHUR: What do you suggest for an insulin dose tonight?
- 38 years old, DM x 5 years, 68 kg, lean and active (may be LADA)
- Started detemir (Levemir) a few days ago as fasting readings were 10-11 mmol/L.
- Currently 7 units basal insulin at night.
- Metformin 1000 mg b.i.d.
- Secretagogue: Gliclazide (Diamicron®) 160 mg b.i.d.
- DPP-4i: Sitagliptin (Januvia®) 100 mg daily
- A1c 7.6%
- Current glucose readings, since starting insulin, are below.
| Breakfast | Lunch | Supper | Bed | |
| Tues | 9.9 | 7.1 | 8.1 | |
| Wed | 10.7 | 6.8 | ||
| Thur | 10.3 | 7.9 | ||
| Frid | 11.2 |
This patient's glucose readings are rising overnight. He has elevated fasting readings.
A common adjustment is 1-2 units. Another is 10% of the dose, sometimes 20% if past increases haven't moved blood glucose levels much. This patient started on 7 units and his readings didn't seem to change.
Keep in mind, in theory, his starting dose could have been one of these:
- Diabetes Canada: 10 units
- Conservative BBIT Guideline (DCC): 68 kg = 7-14 units approx.
There is no one right answer for how much to increase. Much depends on the patient's thoughts on increasing as well as the clinician's judgment & comfort. Some possibilities include adding:
- 1 unit
- 1 unit, but suggest he do so each night until FBS are under 7 mmol/L
- 2 units
- Some clinicians may feel comfortable increasing by more than 2 units, given the start doses derived from formulas above, or if the patient admitted to trying a higher dose with better results one day and no hypoglycemia.
However, if a clinician is unsure, especially since the patient is lean and active, it might be wise to stay at 1-2 units but call the patient frequently for adjustments. Early experience with hypoglycemia when starting insulin may make the patient hesitant to increase future doses. This can have an impact for years to come.
SHREK: What do you suggest for an insulin dose tonight?
- 122 kg. He started on 10 units levemir at HS with his oral agents and has not done any self adjustment. In the past month, his educator has increased his dose up to his current dose of 18 units.
- Target A1c is 7% or less
- Glucose readings haven't changed much since starting insulin a month ago.Here is his Ambulatory Glucose Profile (AGP). You can visit the Pattern Analysis page if you wish help interpretting this.
A common adjustment is 1-2 units. Another is 10% of the dose, sometimes 20% if past increases haven't moved blood glucose levels much. This patient started on 10 units and his readings didn't seem to change. He was since increased to 18 units, with little improvement. Given his weight, he is likely quite insulin resistant.
In theory, his starting dose could have been one of these:
- Diabetes Canada: 10 units
- Conservative BBIT Guideline (DCC): 122 kg = 12 - 24 units approx.
There is no one right answer. Much depends on the patient's thoughts on increasing as well as the clinician's judgment & comfort. Some possibilities include adding:
- 2 units which is 10% adjustment
- 4 units which is a 20% adjustment
- Some clinicians may feel comfortable increasing by more than 4 units, given the start doses derived from formulas above (e.g. BBIT) or if the patient admitted to trying a higher dose with better results one day and no hypoglycemia. However, if a clinician is unsure, it might be wise to stay at 2 units but call him frequently for adjustments eg. every 1-2 days.
MOHAMMAD:
- How many units do you suggest he reduce his insulin by tonight?
- How many days might you wait before making another adjustment?
- What safety advice around food would you provide, given he's on degludec (Tresiba) and having "lows"?
- Metformin max, once weekly GLP-1a, degludec (Tresiba®) 40 units at night
- Started exercising a few weeks back and his glucose levels improved dramatically.
- Target < 7%
Resource:
- Complete Medications Table, Basal Insulin section, scroll down to find degludec (Tresiba®) comments.
Even without checking the guidelines for the ultra-long acting degludec (Tresiba®), we know that 10% of 40 units is 4 units. This would likely be the minimum reduction.
When titrating Tresiba, the comments in the Complete Medication Table are "Diabetes Canada titration suggestions: 2 units every 3-4 days or 4 units a week."
Important Safety Advice: The patient will likely still have episodes of low blood sugar in the next few days because of the long action of this insulin. He'll need to be warned of this and given instruction on how to prevent them in the morning e.g. for the next few nights, consider a snack or bigger snack at night. (Of course, all the regular instructions about low blood sugar as well as driving would be good to review as well.)
PAULINE:
- How many units do you suggest she add tonight?
- Would you have any other medication suggestions? If so, what?
- 77 years old, type 2 x 9 years
- 107 kg
- A1c 8.2%, eGFR 55 mL/min/1.73m2
- Metformin 1000 mg bid
- Gliclazide extended release (Diamicron MR®) 120 mg
- Glargine (Lantus®) 30 units at bedtime
- Past stroke. Cognitive deficits & severe physical deficits. She is not able to walk independently (in wheelchair) and is dependent on her wife's support for all daily activities. She is frail.
- Her readings are listed below. Not unusual to have pc readings 12-13 mmol/L, whenever they've checked that.
- Since she has severe deficits from her stroke and relies on her wife as caregiver, her A1c is likely at target. She may need no increase to insulin. According to the Clinical Frailty Score sheet on our Targets webpage she's likely at level 7.
- Using the Targets webpage and with the knowledge of her frailty score, we learn from the Table with Individualized A1c and Blood Glucose Targets that her targets are likely:
- A1c 7.1 - 8.5% which corresponds to:
- before meal readings 6-9 mmol/L
- pc readings under 14 mmol/L.
- Other things to consider:
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- The addition of an SGLT-2i for renal and CV protection
- The addition of a select GLP-1a for CV protection
- The removal of gliclazide to lower the risk of hypoglycemia.
- The likely need to reduce insulin if adding one or more agents for renal and/or CV protection. She still has adequate renal function so an SGLT-2 would also lower glucose readings, not just protect renal function.
- Resource: See Topic Catalogue: Medication Resources for Med Class Benefits to learn which SGLT-2 or the section on Choosing Next Line agents on the Intro to Medications page.
Ha Yoon presents with the following glucose data and history. What do you suggest for medication changes?
- Type 2 diabetes, age 51, weight 70 kg, active, portions reasonable
- Metformin 1000 mg b.i.d (almost max, another 500mg not likely to impact)
- Repaglinide (Gluconorm®) 4 mg q.i.d. as has 3 meals + HS snack (max)
- Dapagliflozin (Forxiga®) 10 mg daily (max)
- Semaglutide (Ozempic®) 1.0 mg sc once weekly (max)
- 50 units degludec (Tresiba®) each night.
Her glucose readings are rising over the day despite being active, having reasonable portions, being on the max of other agents in addition to 50 units of degludec (Tresiba®).
It's likely she needs the addition of bolus insulin, given the above and since she's on over 0.5 units basal per kg.
For this question, you may wish for your learning experience to:
- Decide where in the day to add the bolus insulin
- Use the formulas for adding bolus insulin (here) to determine how much basal insulin to suggest for a starting dose
- Of note, repaglinide would need to be discontinued upon starting bolus insulin
Phee (they/their) is on basal, bolus insulin therapy (BBIT) with an evening basal dose and rapid insulin at meals. Target A1c is 7%. They report being able to sense lows. No history severe hypo.
1.What is their pattern? (no poll in workshop)
- A. Lows, more than 2-3 per week or severe/unaware
- B. High pattern in 1 or 2 places
- C. High everywhere
- D. Erratic at each time of the day (half target & half high)
2.What insulin would you adjust first? (poll in workshop)
- A. Breakfast meal bolus
- B. Lunch meal bolus
- C. Supper meal bolus
- D. HS basal
Resource: Insulin Adjustments, section and TABLE (here) on Adjusting for Hyperglycemia
Answers are highlighted and explained in green.
1.What is their pattern?
- A. Lows
- B. HIGH PATTERN in 1 or 2 places
--Primarily high readings at supper (half and half at bedtime) - C. High everywhere
- D. Erratic (half & half)
2.What insulin would you adjust first?
- A. Breakfast meal bolus
- B. LUNCH MEAL BOLUS
--Since the predominant pattern is highs at supper, start with increasing lunch bolus according to the basic insulin adjustment table here (Insulin Adjustments Page) - C. Supper meal bolus
- D. HS basal
Resource: Insulin Adjustments, section (here) on Adjusting for Hyperglycemia
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1. What is the main problem or pattern? (no poll in workshop)
- A. Lows
- B. High pattern in 1 or 2 places
- C. High everywhere
- D. Erratic at each time of day (1/2 target & 1/2 high)
2. What do you suggest to address the pattern? There may be a few correct answers, but choose only one. Remember, TDD = 120 units. Total daily basal =90 units. (poll in workshop)
- A. Add agent other than insulin
- B. Increase basal dose if < 40%-60% TDD
- C. Increase bolus insulins if basal is > 60% TDD
- D. Pick the highest of the high readings to target first
- E. Address fasting glucose first
- F. Increase one of the meal boluses (patient choice) to break the pattern.
Resources:
1. What is the main problem or pattern?
- C. High everywhere
2. What do you suggest to address the pattern?
Remember, there isn't always one "right" answer as choices depend on patient input as well. However, in this case, we are trying to simulate basal-bolus insulin therapy according to most people's physiological needs. That means about 40-60% of insulin as basal (or half basal, half bolus - the basal-bolus "split"). With that in mind, the answer in green may be the most appropriate.
TDD is 120 units. Total basal insulin 90 units. Resources: Insulin Adjustment page (here) or the Desktop Insulin Adjustment Guidelines.
- A. Add agent other than insulin
No more options to try currently! - B. Increase basal dose if < 40%-60% TDD
--This may be easy, but it's not moving towards physiological needs as her basal insulin is currently 75% of TDD (90 units basal/120 units TDD = 0.75 x 100= 75%). Increasing basal may be appropriate if increasing bolus is too complicated for the patient, eg elderly, difficulty with math, etc. - C. Increase bolus insulin(s) if basal is > 60% TDD.
--Explanation: Currently, basal is 75% of TDD
90 units basal divided by TDD 120 units = 0.75 X 100 = 75% of current insulin is basal.
She is "basal heavy". Adding bolus insulin is reasonable if patient is agreeable and this is not too complex for the patient. - D. Pick the highest of the high readings to target first
--Possible option, may appeal to the patient if making changes at all meals is overwhelming. - E. Address fasting glucose first
--Not the most likely. Her current basal insulin is holding her readings stable overnight which is the ultimate goal of a basal dose for most people on BBIT. She does not have a bedtime snack. (If she did, it's possible she'd need a bolus with that bedtime snack. This option would likely require some overnight testing to be sure and safe.) - F. Increase one of the meal boluses (patient choice) to break the pattern.
--Possible option, may appeal to the patient if making changes at all meals is overwhelming.
Hedra has high readings everywhere, mostly 11-13 mmol/L. Currently her basal insulin makes up 75% of her TDD. Hence, she needs more bolus insulin. This could be meal bolus and/or correction bolus insulin. You decide to focus on meal bolus insulin to start as you aren't keen to move her ISF to 1, not yet anyway.
- Meals: 10 units "set" or "base" dose per meal (she eats consistent carb)
- Correction: ISF 2 (1 unit to drop 2 mmol)
- Usual correction around 3 units at meals
12 mmol/L (current) - 6 mmol/L (target) = 6 mmol/L to drop ÷ ISF of 2 = 3 units correction
How could you calculate her new "base" meal bolus doses? Choose all that apply. (poll workshop)
- A. Add 10 – 20% to each of her base meal doses.
- B. Add the correction dose from the subsequent meal to each base meal dose.
- C. Find meals where her total meal + correction dose held her readings stable to the next meal. This becomes her new base meal dose.
- D. Any of the above.
What do you suggest for the new "base" meal bolus per meal? Remember: Currently 10 units/meal, frequently running 11-13 mmol/L premeal; target = 6 mmol/L. (NO poll, workshop)
- A. 11 units
- B. 12 units
- C. 13 units
- D. Any of the above
Resource: Bolus Insulin Adjustment on Insulin Adjustments Page
1. How would you calculate her new meal bolus doses?
- A. Add 10-20% to each of her base meal doses.
- B. Add the correction dose from each subsequent meal to each base meal dose.
- C. Find meals where her total meal + correction dose held her readings stable to the next meal. This becomes her new base meal dose.
- D. ANY OF THE ABOVE
This is the answer. Please visit Adjusting Set Meal Boluses on the Insulin Adjustments page here for examples of A, B, C.
2. What do you suggest for her new base meal bolus at each meal?
Currently, she takes 10 units; target is 6 mmol/L; she's frequenlty running 11-13 mmol/L at meals/bedtime.
- A. 11 units
- B. 12 units
- C. 13 units
- D. ANY OF THE ABOVE
11 units if 10%,
12 units if 20%
13 units if taking her 3 correction units from the following meals and adding to her base meal bolus. (e.g. 12 mmol/L correcting to 6 mmol/L with ISF of 2). For an example case, see Please visit Adjusting Set Meal Boluses on the Insulin Adjustments page here
- Rose-Henna is a young entrepreneur who Zooms to review glucose readings with you
- Type 2 diabetes, BMI 36.6 e.g. obese (4'10" tall, weight 175 lbs)
- 9 -10 mmol/L before meals and bed. She's stable overnight. Target A1c 7%
- Max metformin, SLGT-2, GLP-1
- TDD = 75, Detemir 12 units B’fast, 25 units HS
- ICR =1:12 (rapid), ISF of 3, no snacks, she's great at carb counting!
- She has reasonable portions and is not interested in decreasing. Although adding physical acitvity appeals to her, she realizes she won't start this until she's finished some big projects in 6 months. She's agreeable to insulin changes today.
- A. Basal
- B. Bolus
- C. Either
- D. Both
Resource: Insulin Adjustment Page, Adjusting for Hyperglycemia
2. You focus on bolus insulins because something caught your eye. Her ISF = 3 but, usually that’s seen in leaner or more active people. That’s not Rose-Henna (obese, sedentary, TDD 75). Her current ICR is 1:12. Choose all of the bolus options you might consider presenting to her. (poll workshop)
- A. ISF of 1 according to 100/TDD
- B. ISF of 2
- C. ISF of 4
- D. ICR of 1:10
- E. ICR of 1:15
- F. Recalculate ICR using the 500 rule
.
Resources:
1. Which insulin would you ideally increase?
- A. Basal
- B. Bolus
- C. Either
- D. Both
In theory, "A, B or C" are likely best options since her basal insulin is 49% of her TDD.
Total daily basal = 12 units (am) + 25 units (hs) = 37 units.
37 units basal / TDD of 75 = 0.49 X 100 = 49%
"A" - increase basal - e.g. by 10%. Total daily basal is 37 units, so roughly a 4 unit increase. Likely these units would be added to the morning basal, since the bedtime dose is holding her stable overnight (the goal of evening basal in BBIT).
"B" - increase bolus.. A quick glance at her ISF shows it likely needs tweaking if we are referencing the standard formula for ISF. It appears to be off by a lot for a woman who is not lean or active. The same is true for her meal bolus insulin.
"D" is less likely as it could be too aggressive to change both. It might be an option if her glucose readings were much higher than her current 9-10 mmol/L. Although, some patients and clinicians may feel comfortable with adjusting both at once, if the patient has already tried some increases with success and no lows.
2. You focus on bolus insulins because something caught your eye. Her ISF = 3 but, usually that’s seen in leaner or more active people. That’s not Rose-Henna (obese, sedentary, TDD 75). Her current ICR is 1:12. Choose all of the bolus options you might consider presenting to her.
- A. ISF of 1 according to 100/TDD
--Although ISF formula is 100/TDD, it may be too big a leap for safety to move from an ISF of 3 to an ISF of 1. - B. ISF of 2
--This is a safe change to ISF, to start anyway. - C. ISF of 4
--This would give her less insulin for corrections. Usually this ISF is seen in those who are very lean or very active e.g. athletes. - D. ICR of 1:10
--This is a reasonable drop in carbohydrate (increase in insulin). However, have patient demonstrate understanding by calculating a meal dose for a typical supper using new ICR. See if the new ICR gives a reasonable increase in insulin to address the problem sugars. Otherwise, she might need ICR of 1:9, or 1:8... - E. ICR of 1:15
--This would be giving her more carb (and less insulin) which would raise her sugars further. - F. Recalculate ICR using the 500 rule... maybe
--The 500 rule might be too agressive to start with. 500/TDD of 75 = ICR of 1:7 approx. It might be where she ends up at though. Still, there's nothing wrong with calculating through a typical of meal of hers to see how many extra units it would provide. Also a great idea to ask what she's tried in the past; if she's tried this and it worked, it could be safe to jump to right away.
Remember, you will ask the patient to do demo calculations on a sample meal for their understanding (and to check if your suggestion is appropriate so don't be worried if this isn't second nature to you yet.) .
Type 1 x 18 yrs, A1c 6.2%, 70 kg. More active at work recently and no plans for this to stop. He doesn’t want to eat more as a permanent solution. He senses his lows and has never had a severe low. Degludec (Tresiba) 39 units qam; ICR 1:10; ISF=2; TDD = 62 units
1. What is the main glucose problem or pattern? (NO poll workshop)
- A. Low pattern at 1 time of day
- B. Low pattern every 1 day of the week (e.g. every Wed)
- C. Significant lows everywhere in day
- D. Highs – a pattern of high everywhere
- E. Erratic at each time of day (1/2 target and 1/2 high)
2. These are some suggestions from the Insulin Adjustment page for the pattern he's experiencing. What do you suggest? Remember: Tresiba 39 units/day. TDD = 62 units. Senses lows. No severe hypo. More active at work with no plans for this to stop. Pick 1 answer. (poll workshop)
- A. If hypo unawareness or recurrent severe lows set a higher target & find an option below.
- B. If events are explainable (exercise, vacuuming, over-bolused, under-ate, alcohol, weight loss), ask patient about methods to prevent lows. It may or may not include insulin adjustment.
- C. If a pattern at one time of day exists, reduce insulin most responsible (eg. lows at supper, reduce lunch bolus)
- D. If significant low readings over the entire day (low everywhere), either decrease basal dose if > 60% TDD or decrease bolus insulins if basal is < 40% TDD.
- E. If lows follow high readings assess ISF and check that client is not stacking corrections
Resource: Adjusting for hypoglycemia on Insulin Adjustments page
1. What is the main glucose problem or pattern?
- C. Significant lows everywhere in day
2. These are some suggestions from the Insulin Adjustment page for the pattern he's experiencing. What do you suggest? Remember: Tresiba 39 units/day. TDD = 62 units. Senses lows. No severe hypo. More active at work with no plans for this to stop. Pick 1 answer.
- A. If hypo unawareness or recurrent severe lows set a higher target & find an option below.
- B. If events are explainable (exercise, vacuuming, over-bolused, under-ate, alcohol, weight loss), ask patient about methods to prevent lows. It may or may not include insulin adjustment.
- C. If a pattern at one time of day exists, reduce insulin most responsible (e.g. lows at supper, reduce lunch bolus)
- D. If significant low readings over the entire day (low everywhere), either decrease basal dose if > 60% TDD or decrease bolus insulins if basal is < 40% TDD.
--this option is the most likely. He's "basal heavy"
39 units basal / TDD of 62 = 0.629 x 100 = 63% of TDD is basal
HOWEVER, it may take 3-4 days for a reduction in the ultra long acting Tresiba (degludec) to raise his glucose readings. He will need to be instructed to eat extra for a few days to avoid lows. - E. If lows follow high readings assess ISF and check that client is not stacking corrections
- F. If no pattern consider asking client to keep detailed records of events preceding each low.
- G. If using a bolus/correction scale, see if lows relate to using one or two rows of the scale. E.g. 11.1 -13 mmol/L range of the supper scale. See adjusting correction scales on ISF page.
Resource: Adjusting for hypoglycemia (here) on Insulin Adjustments page
Sullivan has type 1 diabetes and is targeting A1c < 7.0%. When over target, he gives correction insulin unless he's made a comment otherwise. You clarified that all of the readings below are before meals e.g. at least 3 hours since food.
Remember the steps: (After assessing for safety and verifying this is erratic and no patterns.)
1: Assess overnight basal
2: Assess meal boluses
3: Assess ISF
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If it was a sensor, the AGP would like similar to below.
What do you suggest to address the problem? Pick one.
- A. Increase basal insulin (degludec)
- B. Change ICR to give more bolus
- C. Change ICR to give less bolus
- D. Change ISF
Resources:
2. What do you suggest to address the pattern?
Remember, there isn't always one "right" answer as choices depend on patient input as well. With that in mind, the answer in green may be the most appropriate.
- A. Increase basal insulin
This may not be the best option. You can see that glucose level at bedtime is similar to the next morning indicating stable control overnight and adequate basal insulin. - B. Change ICR to give more bolus:
You can see that when Sullivan's blood sugars are in target before meals, that they are usually high by the next meal. We see this at all 3 meals so we can safely adjust the ICR for all meals. - C. Change ICR to give less bolus.
No, Sullivan needs more bolus, not less. - D. Change ISF
No clear need for change to correction insulin. You can see on Saturday that Sullivan gave only correction insulin (no meal bolus) and this worked well.
You clarified that all of the readings below are before meals e.g. at least 3 hours since food. All meal bolus and correction insulins are given according to formulas, unless noted otherwise.
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What changes do you suggest to address the problems? (You can pick more than one)
- A. Increase basal insulin (basaglar)
- B. Change ICR to give more bolus at one of the meals
- C. Change ICR to give less bolus at one of the meals
- D. Change ISF
Resources:
What do you suggest to address the pattern?
Remember, there isn't always one "right" answer as choices depend on patient input as well. With that in mind, the answers in green (B and D) may be the most appropriate.
- A. Increase basal insulin
This may not be the best option. You can see that glucose level at bedtime is similar to the next morning indicating stable control overnight and adequate basal insulin. - B. Change ICR to give more bolus at one meal:
You can see that when Twyla's blood sugars are in target before breakfast and lunch she is usually in target the next meal. When she is in target before supper, she is high by bedtime. We would suggest she change her ICR at supper to give more bolus. - C. Change ICR to give less bolus.
No, Twyla needs more bolus at supper, not less. - D. Change ISF
Yes. You can see that whenever Twyla is high, she stays high by the next meal. The only time she comes down from a high is when she has decided to 'give extra'.
You clarified that all of the readings below are before meals e.g. at least 3 hours since food. All meal bolus and correction insulins are given according to formulas, unless noted otherwise.
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1. What is the one best insulin to change?
- A. Basal insulin dose.
- B. Meal bolus (Carb Ratio)
- C. Correction dose (ISF)
Remember the steps:
- Assess if overnight basal is holding stable.
- When start in target at meals, assess if meal boluses are working to keep in target (or close) by next meal assuming no snack.
- If Carb Ratio is working, assess ISF by looking at high readings to see if they corrected by next meal assuming no snack.
2. Choose the dose change you would suggest Beecher try.
- A. Carb Ratio 13
- B. Carb Ratio 8
- C. ISF 4
- D. ISF 2
- E. Levemir 28 units
Remember, there isn't always one "right" answer as choices depend on patient input as well. With that in mind, the answers in green (1 C and 2 D) may be the most appropriate.
1. Which is the one best insulin to change?
A. Basal insulin
This may not be the best option to change. There are three evening readings that you can use to assess basal (12.3 mmol/L no correction, 6.5 mmol/L, 14.5 no correction). The glucose levels at bedtime stayed stable until the morning within a few mmol/L (The evenings that Beecher went for walk or ate pizza could not be used to assess basal insulin. Neither could the evenings where there was no FBS the following morning.)
B. Meal Bolus (Carb Ratio)
This may not be best option. If you look at in 'target' glucose level before a meal, it usually stays in target by the next meal. This suggests the meal bolus insulin (Carb Ratio) is appropriate.
C. Correction (ISF)
Yes, this would likely be the best insulin to change. When Beecher has a high glucose, he is still high by the next meal (unless he went for walk or took extra insulin). Yet, we know that his meal bolus insulin is not to blame as it keeps him in target when he starts the meal in target. Hense, it is likely the correction insulin that is inadequate.
2. Choose the one dose change you would suggest Beecher try.
A. Carb Ratio 13
The 10 Carb Ratio seems to be working well most meals so no need to change.
B. Carb Ratio 8
The 10 Carb Ratio seems to be working well most meals so no need to change.
C. ISF 4
No, this would be a 'weaker' ISF and provide less correction insulin.
D. ISF 2
This would likely be the best dose change to suggest. It would provide more correction insulin to help Beecher's glucose levels come down.
E. Levemir 28 units.
Glucose levels stable overnight so may not need to increase Levemir dose.