How do you titrate Humulin 70/30 (human insulin (NPH/regular))?

Titrating Humulin 70/30 Insulin

For patients requiring Humulin 70/30 insulin therapy, start with a dose of 10 units per day or 0.1-0.2 units/kg per day, typically administered in a 2/3 morning and 1/3 evening split, and adjust by 2 units every 3 days until reaching target fasting glucose levels without hypoglycemia. 1

Initial Dosing Strategy

Starting Dose

• Begin with 10 units per day OR 0.1-0.2 units/kg per day 1
• For a typical twice-daily regimen, divide the total daily dose:
  • Morning dose: 2/3 of total daily dose (before breakfast)
  • Evening dose: 1/3 of total daily dose (before dinner) 1, 2

Administration Timing

• Administer Humulin 70/30 approximately 30 minutes before meals 3
• This timing is critical as the premixed formulation contains both NPH (intermediate-acting) and regular (short-acting) insulin components

Titration Algorithm

Monitoring Parameters

• Set a fasting plasma glucose (FPG) goal (typically 90-150 mg/dL for most adults, may be higher for older adults) 1
• Monitor both fasting and postprandial glucose levels
• Use 3-day averages of glucose readings to guide adjustments

Adjustment Schedule

1. Evaluate glucose patterns every 3 days
2. If 50% of fasting glucose values are above target:
   • Increase evening dose by 2 units 1
3. If 50% of pre-dinner glucose values are above target:
   • Increase morning dose by 2 units
4. For hypoglycemia (glucose <80 mg/dL or symptomatic):
   • Determine cause
   • If no clear reason, reduce the corresponding dose by 10-20% 1

Special Considerations

For Older Adults

• Consider a more conservative target range (90-150 mg/dL) 1
• When simplifying regimens for older adults:
  • Morning dose: Maintain at approximately 2/3 of total daily dose
  • Evening dose: Maintain at approximately 1/3 of total daily dose 1
• For frail elderly patients, consider even more conservative targets and smaller dose adjustments (1 unit at a time) 1

For Steroid-Induced Hyperglycemia

• If patient is on morning steroids, consider giving a larger proportion of the total daily dose in the morning to counteract steroid-induced afternoon hyperglycemia 4
• For patients on steroids, more frequent monitoring is required (every 2-4 hours initially) 4
• When tapering steroids, insulin must be reduced proportionally to prevent hypoglycemia 4

Common Pitfalls to Avoid

1. Overbasalization: Avoid excessive reliance on the NPH component by monitoring both pre-meal and post-meal glucose levels 1

2. Hypoglycemia risk: Be vigilant about:

   • Nocturnal hypoglycemia (particularly with evening doses)
   • Delayed meals after insulin administration
   • Exercise within 1-2 hours of insulin administration 1

3. Inconsistent timing: Maintain consistent injection-to-meal timing (30 minutes before meals) to ensure proper insulin action 3

4. Inadequate monitoring: Always evaluate both fasting and postprandial glucose values when titrating premixed insulin 1

5. Meal inconsistency: Advise patients to maintain consistent carbohydrate intake at meals, especially when using fixed premixed insulin regimens 1

When to Consider Regimen Changes

• If unable to achieve target glucose levels despite appropriate titration:

  • Consider switching to a different insulin ratio (e.g., 50/50 instead of 70/30) 5
  • Consider advancing to a basal-bolus regimen 1
  • Consider adding non-insulin agents (particularly metformin if not contraindicated) 6, 7

• If experiencing frequent hypoglycemia despite dose reductions:

  • Evaluate for overbasalization
  • Consider switching to analog insulins which have less pronounced peaks 6

By following this structured approach to titrating Humulin 70/30, you can optimize glycemic control while minimizing the risk of hypoglycemia and other adverse events.