What adjustments should be made to the insulin regimen for a 70-year-old patient on Insulatard (NPH insulin) with Hyperglycemia?

Insulin Regimen Adjustment for 70-Year-Old with Hyperglycemia

For a 70-year-old patient on Insulatard 8 units at bedtime with a current RBS of 11 mmol/L, the dose should be increased by 2 units to 10 units before sleep, as the fasting glucose is above target range. 1, 2

Assessment of Current Regimen

• Current regimen: Insulatard (NPH insulin) 8 units before sleep
• Current random blood sugar (RBS): 11 mmol/L (198 mg/dL)
• This indicates inadequate glycemic control as the target range for older adults should be 5.0-8.3 mmol/L (90-150 mg/dL) 1

Recommended Adjustment

Immediate Adjustment

• Increase Insulatard dose from 8 to 10 units before sleep 1, 2
• This follows the evidence-based titration algorithm of increasing basal insulin by 2 units when blood glucose values are consistently above target 1

Monitoring Protocol

• Monitor fasting blood glucose daily for one week 1
• Target fasting glucose: 5.0-8.3 mmol/L (90-150 mg/dL) for older adults 1, 2

Further Titration Guidelines

• If 50% of fasting glucose readings remain above 8.3 mmol/L (150 mg/dL) after one week, increase dose by another 2 units 1, 2
• If any fasting glucose readings fall below 4.4 mmol/L (80 mg/dL), decrease dose by 2 units 1
• Adjust no more frequently than every 3-7 days to avoid stacking of insulin effects 2

Special Considerations for Older Adults

Hypoglycemia Prevention

• Higher risk of hypoglycemia in older adults necessitates cautious titration 1, 2
• Consider less aggressive targets (5.0-8.3 mmol/L) compared to younger patients 1
• Monitor for nocturnal hypoglycemia, particularly between 2-4 AM 2

Timing Considerations

• If the patient experiences frequent nocturnal hypoglycemia or forgets evening doses, consider switching from bedtime NPH to morning administration 1
• Morning administration of NPH may provide better coverage for daytime hyperglycemia 2

Alternative Approaches if Current Adjustment Fails

Regimen Modification Options

1. Split NPH dosing: If single bedtime dose is insufficient after titration, consider converting to twice-daily NPH regimen (2/3 morning, 1/3 evening) 1
2. Add prandial insulin: If fasting glucose improves but post-meal glucose remains elevated, consider adding short-acting insulin with largest meal 1
3. Consider basal analog: If hypoglycemia occurs despite careful titration, switching to a long-acting analog like insulin glargine may reduce hypoglycemia risk 2

Simplified Correction Scale for Hyperglycemia

For blood glucose values above target:

• 13.9 mmol/L (>250 mg/dL): Add 2 units of rapid-acting insulin

• 19.4 mmol/L (>350 mg/dL): Add 4 units of rapid-acting insulin 1, 2

Follow-up Plan

• Reassess glycemic control in 1-2 weeks 2
• Evaluate for symptoms of hypoglycemia (confusion, sweating, tremors)
• Consider HbA1c testing after 3 months to assess overall control 2

Remember that insulin requirements may change with illness, changes in activity level, or concurrent medications, so regular monitoring and adjustment are essential for maintaining optimal glycemic control in this older adult.