What are the subcutaneous (subq) dosing options for a nothing by mouth (NPO) patient during hospitalization?

Subcutaneous Medication Dosing for NPO Hospitalized Patients

For NPO hospitalized patients, a basal plus correction insulin regimen is the preferred subcutaneous dosing approach, consisting of basal insulin (0.1-0.25 U/kg/day) plus corrective doses of rapid-acting insulin based on glucose levels. 1, 2

Insulin Management for NPO Patients

Basal Plus Correction Insulin Regimen

• Initial dosing:

  • Basal insulin: 0.1-0.25 U/kg/day (glargine or detemir once daily)
  • Correction doses: Rapid-acting insulin (lispro, aspart, or glulisine) based on glucose levels
  • Monitor glucose every 4-6 hours 1, 2

• Dose adjustments:

  • For patients with risk factors (older age, renal insufficiency), reduce initial dose to 0.15 U/kg/day (basal only) 2
  • Adjust basal insulin dose every 1-2 days based on glucose patterns
  • Target glucose: <140 mg/dL preprandial, <180 mg/dL random 1

Important Considerations

• Traditional sliding-scale insulin regimens (without basal insulin) are strongly discouraged as they are ineffective and can lead to rapid glucose fluctuations 1, 2
• Intravenous insulin infusion is preferred for critically ill patients, DKA, hyperosmolar states, or perioperative management 1

Other Subcutaneous Medications for NPO Patients

Corticosteroids

• For acute gout in NPO patients:
  • Subcutaneous synthetic ACTH: Initial dose 25-40 IU, with repeat doses as clinically indicated (Evidence A) 1
  • Alternative: Intra-articular corticosteroid injection for 1-2 affected joints 1

Anticoagulants

• Enoxaparin available in multiple subcutaneous dosing options:
  • 30 mg/0.3 mL, 40 mg/0.4 mL, 60 mg/0.6 mL, 80 mg/0.8 mL, 100 mg/1 mL, 120 mg/0.8 mL, 150 mg/1 mL 3
  • Dosing must be adjusted based on indication, weight, and renal function
  • Studies show subcutaneous enoxaparin is as effective as IV administration 4

Other Common Subcutaneous Medications

• Darbepoetin alfa (for anemia in CKD):
  • 0.45 mcg/kg subcutaneously weekly or 0.75 mcg/kg every 2 weeks 5

Practical Administration Tips

Subcutaneous Administration Technique

• Rotate injection sites to prevent lipohypertrophy
• Administer at 45-90 degree angle depending on patient's subcutaneous tissue
• Pinch skin fold for thinner patients
• No need to aspirate before injection

Common Pitfalls to Avoid

1. Avoid using sliding-scale insulin alone without basal coverage, which leads to poor glycemic control 1
2. Avoid excessive dosing in patients with risk factors for hypoglycemia (renal impairment, advanced age, liver disease)
3. Monitor for hypoglycemia especially during periods of reduced oral intake, emesis, or interruption of nutrition 1
4. Don't delay dose adjustments - insulin requirements may change rapidly during hospitalization

Special Populations

• Elderly patients: Start with lower doses (0.1-0.15 U/kg/day of basal insulin)
• Renal impairment: Reduce doses of insulin and medications cleared by kidneys
• Liver disease: Use caution with medications metabolized by the liver

By following these evidence-based guidelines for subcutaneous medication administration in NPO hospitalized patients, clinicians can maintain effective treatment while minimizing complications associated with the NPO status.