Insulin Dose Adjustment for Poorly Controlled Diabetes
Yes, you should increase the Humulin 70/30 insulin dose from 17 units to 19 units BID for a patient with blood sugars ranging from 250-450 mg/dL. This 2-unit increase is appropriate and follows evidence-based guidelines for insulin titration.
Rationale for Dose Adjustment
- Blood glucose levels between 250-450 mg/dL indicate significant hyperglycemia requiring intervention
- The American Diabetes Association recommends adjusting insulin doses when glycemic targets are not met 1
- A structured approach to insulin titration suggests increasing the dose by 2 units when 50% of blood glucose readings are above target 2, 1
Insulin Adjustment Protocol
- Current situation: Patient on 17 units Humulin 70/30 BID with persistent hyperglycemia (250-450 mg/dL)
- Recommended action: Increase to 19 units BID (2-unit increment)
- Monitoring: Check blood glucose before meals and at bedtime to assess response
- Follow-up: Re-evaluate in 3-7 days; further adjustments may be needed
Evidence Supporting This Approach
The Lancet Diabetes and Endocrinology guidelines recommend a structured approach to insulin adjustment rather than reactive sliding scale insulin, which has been associated with poor glycemic control 2. While premixed insulin like Humulin 70/30 is generally not preferred for inpatient management due to hypoglycemia risk 2, for outpatients already established on this regimen, careful dose titration is appropriate.
Important Considerations
- Hypoglycemia risk: Monitor for signs of hypoglycemia, especially if the patient has irregular eating patterns
- Timing: Administer doses consistently in relation to meals
- Patient education: Ensure the patient understands the dose change and monitoring requirements
- Complementary measures: Consider reviewing diet, physical activity, and medication adherence
Potential Pitfalls to Avoid
- Too aggressive titration: Increasing by more than 2 units at once could increase hypoglycemia risk
- Ignoring pattern recognition: Ensure hyperglycemia is consistent throughout the day, not just at specific times
- Overlooking other factors: Illness, stress, or medication changes can affect glucose control
Long-term Management
If blood glucose remains uncontrolled after multiple adjustments to the premixed insulin regimen, consider:
- Switching to a basal-bolus regimen for better glycemic control 1
- Adding non-insulin agents if appropriate 2
- Referral to an endocrinologist for complex cases
The 2-unit increment approach is supported by diabetes care guidelines and represents a safe, measured response to the patient's current hyperglycemia while minimizing the risk of overcorrection.