What is the initial dose of 70/30 insulin and when to review for a 92.2kg patient with severe hyperglycemia?

Initial Insulin Dosing for Severe Hyperglycemia in a 92.2kg Patient

For a 92.2kg patient with severe hyperglycemia, initiate 70/30 insulin at 18-28 units twice daily (0.2-0.3 units/kg/day), with review within 3 days. A stat dose of 10 units of soluble insulin can be given initially to rapidly address severe hyperglycemia.

Initial Insulin Dosing Calculation

The appropriate initial insulin dosing for this patient should be based on weight and severity of hyperglycemia:

• For patients with severe hyperglycemia, insulin is typically started at 0.2-0.3 units/kg/day 1
• For a 92.2kg patient:
  • Low-end dose: 92.2kg × 0.2 units/kg/day = 18.4 units/day
  • High-end dose: 92.2kg × 0.3 units/kg/day = 27.7 units/day

70/30 Insulin Administration

• 70/30 insulin contains 70% NPH (intermediate-acting) and 30% regular insulin (short-acting)
• This premixed insulin should be administered twice daily, typically before breakfast and dinner
• Initial dosing recommendation: 18-28 units twice daily, divided equally between morning and evening doses

Stat Dose of Soluble Insulin

A stat dose of 10 units of soluble (regular) insulin is appropriate in this scenario:

• For patients with marked hyperglycemia, immediate correction with soluble insulin helps rapidly reduce blood glucose levels 1
• The 10-unit stat dose will help address acute hyperglycemia while the 70/30 insulin regimen is being established
• This approach aligns with guidelines for managing severe hyperglycemia at presentation 1

Follow-up and Monitoring

• Review the patient within 3 days to assess response to therapy 1
• During follow-up:
  • Evaluate fasting and postprandial glucose readings
  • Adjust insulin dose based on blood glucose patterns
  • Consider increasing dose by 10-30% if glycemic targets are not met 1

Titration Algorithm

Adjust the 70/30 insulin dose based on blood glucose readings:

• If fasting glucose ≥180 mg/dL: Increase by 6-8 units
• If fasting glucose 140-179 mg/dL: Increase by 4 units
• If fasting glucose 120-139 mg/dL: Increase by 2 units
• If fasting glucose 100-119 mg/dL: Maintain or increase by 0-2 units
• If fasting glucose <100 mg/dL: Decrease by 2-4 units
• Any hypoglycemia (<70 mg/dL): Decrease by 10-20% 2

Important Considerations

• Ensure frequent blood glucose monitoring (at least 4 times daily) during initial therapy
• Educate the patient on hypoglycemia recognition and management
• If glycemic targets are not achieved with 70/30 insulin despite dose optimization, consider transitioning to a basal-bolus regimen 1
• For patients with persistent hyperglycemia despite basal insulin doses exceeding 0.5 units/kg/day, consider adding prandial insulin coverage 1

This approach provides immediate management of severe hyperglycemia while establishing a sustainable insulin regimen that can be adjusted based on the patient's response.