Should I add a PM dose of NPH (Neutral Protamine Hagedorn) insulin for a patient with hyperglycemia (blood glucose level of 400)?

Managing Hyperglycemia with NPH Insulin

Yes, adding an evening dose of NPH insulin is appropriate for a patient with a blood glucose of 400 mg/dL, as NPH's peak action aligns well with the hyperglycemic pattern often seen in patients requiring additional glycemic control. 1

Rationale for NPH Insulin Addition

NPH insulin is particularly beneficial in this scenario because:

• It has an intermediate-acting profile with peak action at 4-6 hours post-administration 1
• It provides coverage during periods when hyperglycemia is most pronounced, especially in patients on glucocorticoid therapy 2
• It can help address severe hyperglycemia (BG 400 mg/dL) that requires additional insulin coverage beyond existing regimens

Dosing Recommendations

For a patient with blood glucose of 400 mg/dL:

• Start with 10 units of NPH insulin or 0.1-0.2 units/kg in the evening 1
• For elderly patients, begin at the lower end of the dosing range (0.1 units/kg) 1
• Titrate by increasing 2 units every 3 days until target blood glucose is achieved 1
• If the patient is on steroids, administer NPH concomitantly with steroid doses to match the peak insulin action with peak steroid-induced hyperglycemia 2, 1

Monitoring Protocol

• Check blood glucose every 4-6 hours during initial therapy 1
• Monitor particularly for:
  • Fasting morning glucose levels
  • Nocturnal hypoglycemia (a risk with NPH compared to longer-acting insulins) 3
  • Post-dinner glucose control

Special Considerations

For Patients on Glucocorticoids

• NPH insulin is particularly effective for steroid-induced hyperglycemia as its peak action (4-6 hours) aligns with the peak hyperglycemic effect of steroids like prednisone 2, 1
• For patients on once- or twice-daily steroids, NPH administration concomitant with steroids is the standard approach 2

For Patients on Enteral/Parenteral Nutrition

• For patients receiving nocturnal tube feeding, NPH insulin administered with the initiation of feeding is recommended to cover this nutritional load 2
• This helps prevent the sustained hyperglycemia that can occur with continuous nutritional support

Avoiding Pitfalls

1. Nocturnal Hypoglycemia Risk: NPH has a more pronounced peak than long-acting insulin analogs, which increases risk of overnight hypoglycemia 3

   • Consider using a slightly lower evening dose initially
   • Ensure patient has access to rapid glucose sources overnight

2. Rebound Hyperglycemia: The Somogyi phenomenon can occur if nocturnal hypoglycemia leads to counter-regulatory hormone release 4

   • This can manifest as morning hyperglycemia despite evening insulin
   • Monitor for this pattern if morning glucose remains elevated despite NPH addition

3. Dawn Phenomenon: Early morning increases in insulin resistance may require adjustment of NPH timing or dosing 4

   • Consider whether the timing of NPH administration (early evening vs. bedtime) needs adjustment based on glucose patterns

By adding an evening dose of NPH insulin for a patient with significant hyperglycemia (BG 400 mg/dL), you can provide targeted coverage during periods of highest insulin need while establishing a foundation for improved overall glycemic control.