How to switch from NPH (Neutral Protamine Hagedorn) insulin to a basal analog insulin?

From the Guidelines

When switching from NPH insulin to a basal analog insulin, reduce the total daily NPH dose by 10-20% for the initial basal analog dose, as this approach has been demonstrated to reduce the risk of hypoglycemia and improve glycemic control 1. To initiate the switch, calculate the total daily dose of NPH insulin and apply the reduction. For example, if a patient takes 30 units of NPH daily, start with 24-27 units of the basal analog. If the NPH was given twice daily, combine the total daily dose, apply the reduction, and administer the basal analog once daily (for glargine or degludec) or according to the specific analog's dosing schedule. Some key points to consider when making this switch include:

• Basal analogs should be injected at the same time each day, with glargine and degludec typically given once daily, while detemir may require once or twice daily dosing depending on the patient's needs.
• Monitor blood glucose closely during the transition, especially fasting levels, and adjust the dose by 2-4 units every 3-7 days until target glucose levels are achieved.
• Be aware of the potential for overbasalization with insulin therapy, which can be indicated by clinical signals such as high bedtime-to-morning or preprandial-to-postprandial glucose differential, hypoglycemia, and high glucose variability 1. The advantages of basal analogs over NPH insulin include less nocturnal hypoglycemia, more predictable absorption, and longer duration of action, although they typically cost more than NPH insulin 1.

From the FDA Drug Label

When switching from: • Once-daily NPH insulin to once-daily Insulin Glargine-yfgn, the recommended starting Insulin Glargine-yfgn dosage is the same as the dosage of NPH that is being discontinued. • Twice-daily NPH insulin to once-daily insulin Glargine-yfgn, the recommended starting insulin Glargine-yfgn dosage is 80% of the total NPH dosage that is being discontinued

To switch from NPH (Neutral Protamine Hagedorn) insulin to a basal analog insulin, such as Insulin Glargine-yfgn, the following steps can be taken:

• If the patient is currently taking once-daily NPH insulin, the recommended starting dosage of Insulin Glargine-yfgn is the same as the dosage of NPH that is being discontinued.
• If the patient is currently taking twice-daily NPH insulin, the recommended starting dosage of Insulin Glargine-yfgn is 80% of the total NPH dosage that is being discontinued. It is essential to monitor blood glucose levels closely during the transition and adjust the dosage as needed to achieve glycemic targets 2.

From the Research

Switching from NPH to Basal Analog Insulin

To switch from NPH (Neutral Protamine Hagedorn) insulin to a basal analog insulin, several factors should be considered, including the patient's lifestyle, preferences, and health insurance plan formularies 3.

• Initiation and Titration: Basal insulin is usually initiated at a conservative dose of 10 units/day or 0.1-0.2 units/kg/day, then titrated thereafter over several weeks or months, based on patients' self-measured fasting plasma glucose, to achieve an individualized target (usually 80-130 mg/dL) 4.
• Choosing the Right Basal Analog Insulin: Long-acting insulin analogs, such as detemir and glargine, have relatively flat time-action profiles and last up to 24 hours, thus simulating endogenous basal insulin more precisely than NPH insulin and producing less nocturnal hypoglycemia 5, 6, 7.
• Switching Between Basal Insulins: Although a unit-to-unit switching approach is usually recommended, this conversion strategy may not be appropriate for all patients and types of insulin 3. Glycemic control and risk of hypoglycemia must be closely monitored by health care providers during the switching process.
• Benefits of Basal Analog Insulins: Basal analog insulins offer many benefits over human insulins, including improved physiologic profile, greater convenience, reduced risk of hypoglycemia, and, in some instances, less weight gain 5, 7.
• Monitoring and Adjustment: The dose of basal insulin should be increased as required up to approximately 0.5-1.0 units/kg/day in some cases, and overbasalization (continuing to escalate dose without a meaningful reduction in fasting plasma glucose) should be avoided 4.

Key Considerations

• Individualized Treatment: Insulin therapy should be individualized, and several factors influence the choice of basal insulin 3.
• Patient Education: Patients should be educated on how to self-manage insulin injections and monitor their blood glucose levels 4.
• Healthcare Provider Guidance: Healthcare providers should provide explicit guidance to patients when switching between basal insulins 3, 4.