What adjustments should be made to Insulatard (NPH insulin) dose in a 70-year-old patient with a current Random Blood Sugar (RBS) level of hyperglycemia, recently started on 8 units of Insulatard?

Insulin Dose Adjustment for Elderly Patient with Hyperglycemia

The Insulatard (NPH insulin) dose should be increased from 8 units to 10 units daily, with subsequent adjustments of 2 units every 3 days based on fasting blood glucose monitoring until target range of 90-150 mg/dL is achieved. 1, 2

Assessment of Current Situation

• 70-year-old patient recently started on Insulatard (NPH insulin) 8 units
• Current Random Blood Sugar (RBS) of 11 (likely mmol/L, equivalent to approximately 198 mg/dL)
• This indicates inadequate glycemic control requiring dose adjustment

Recommended Dose Adjustment Protocol

1. Initial adjustment:

   • Increase Insulatard dose from 8 to 10 units daily
   • Administer at the same time each day for consistency 2

2. Ongoing titration:

   • Monitor fasting blood glucose levels daily
   • Adjust dose every 3 days based on patterns 2
   • If 50% of fasting glucose readings are above target (90-150 mg/dL), increase by 2 units
   • If more than 2 fasting readings per week are below 80 mg/dL, decrease by 2 units 1

3. Target glucose range:

   • For older adults (70 years), aim for fasting glucose of 90-150 mg/dL 1, 2
   • This is more appropriate than stricter targets that increase hypoglycemia risk

Special Considerations for Elderly Patients

• Hypoglycemia risk: Older adults have increased risk of hypoglycemia due to:

  • Decreased renal function affecting insulin clearance
  • Impaired counter-regulatory responses
  • Possible cognitive impairment affecting self-management 2

• Monitoring frequency:

  • Check blood glucose before breakfast daily during titration
  • Consider additional checks before lunch and dinner to assess 24-hour control 1
  • Monitor for symptoms of hypoglycemia (confusion, sweating, tremors)

• Medication administration:

  • Ensure proper insulin injection technique
  • Use short needles (4-mm) to avoid intramuscular injection
  • Rotate injection sites to prevent lipohypertrophy 2

Patient Education

• Teach recognition and management of hypoglycemia
• Always carry quick-acting carbohydrates (glucose tablets, juice)
• Proper insulin storage (refrigerate unopened insulin, avoid extreme temperatures)
• Importance of consistent meal timing with NPH insulin
• When to contact healthcare provider (recurrent hypoglycemia, persistent hyperglycemia) 2

Avoiding Common Pitfalls

• Don't make large dose adjustments: Increase by only 2 units at a time to avoid hypoglycemia risk 2
• Don't ignore timing: NPH insulin has peak action 4-10 hours after injection, so timing affects hypoglycemia risk
• Don't overlook monitoring: Regular glucose monitoring is essential during dose adjustment
• Don't aim for overly strict targets: Targeting fasting glucose <90 mg/dL increases hypoglycemia risk without significant benefit in elderly patients 1

By following this structured approach to insulin dose adjustment, you can improve glycemic control while minimizing the risk of hypoglycemia in this elderly patient.