How much should the insulin dose be increased for a patient with hyperglycemia?

Insulin Dose Adjustment for Hyperglycemia

For patients with hyperglycemia, insulin doses should be increased by 1-2 units or 10-15% of the current dose, with adjustments based on the severity of hyperglycemia and the patient's current insulin regimen. 1

Initial Assessment and Approach

• For patients with persistent hyperglycemia ≥180 mg/dL (10.0 mmol/L), insulin therapy should be initiated after confirming elevated glucose on two occasions 1
• Target glucose range should be 140-180 mg/dL (7.8-10.0 mmol/L) for most hospitalized patients 1
• More stringent targets (110-140 mg/dL) may be appropriate for selected patients, such as those post-cardiac surgery, if achievable without significant hypoglycemia 1

Insulin Dose Adjustment Algorithm

For Patients on Basal Insulin:

• Increase basal insulin dose by 2 units every 3 days until fasting plasma glucose target is reached without hypoglycemia 1
• If hypoglycemia occurs, determine the cause; if no clear reason, reduce the dose by 10-20% 1

For Patients on Prandial Insulin:

• Increase prandial insulin dose by 1-2 units or 10-15% twice weekly 1
• Initial prandial insulin dose should be 4 units per day or 10% of the basal insulin dose 1
• If hypoglycemia occurs, reduce the corresponding dose by 10-20% 1

For Insulin-Naïve Patients:

• Start with 10 units per day of basal insulin or 0.1-0.2 units/kg per day 1
• For patients requiring prandial coverage, consider a total daily insulin dose of 0.3-0.5 units/kg 1
• Allocate half to basal insulin and half to prandial insulin (divided into three pre-meal doses) 1

Special Considerations

For Hospitalized Patients:

• For patients with higher doses of insulin at home (≥0.6 units/kg/day), reduce the total daily insulin dose by 20% to prevent hypoglycemia due to poor oral intake 1
• For patients with mild hyperglycemia (<200 mg/dL), consider a basal-plus approach with a single dose of basal insulin (0.1-0.25 units/kg/day) plus correction doses 1
• For severe hyperglycemia (>300 mg/dL), a full basal-bolus regimen is indicated 1

For Patients on NPH Insulin:

• If converting from bedtime NPH to twice-daily NPH: use 80% of current bedtime NPH dose, with 2/3 given before breakfast and 1/3 given before dinner 1
• When adding prandial insulin to NPH regimen, add 4 units of short/rapid-acting insulin to each injection or 10% of the reduced NPH dose 1

Monitoring and Adjustment

• Assess adequacy of insulin dose at every visit 1
• Monitor for signs of overbasalization: elevated bedtime-to-morning glucose differential, hypoglycemia, or high glucose variability 1
• For hospitalized patients who are eating, perform point-of-care glucose monitoring before meals; for those not eating, monitor every 4-6 hours 1
• If A1C remains above goal despite basal insulin optimization, consider adding GLP-1 RA or progressing to prandial insulin coverage 1

Avoiding Hypoglycemia

• Lower insulin doses (by 10-20%) for patients at higher risk of hypoglycemia: elderly (>65 years), those with renal failure, or poor oral intake 1
• Avoid sliding scale insulin alone for patients with type 1 diabetes or significant hyperglycemia 1
• Premixed insulin therapy has been associated with higher rates of hypoglycemia and is generally not recommended in the hospital setting 1

By following this structured approach to insulin dose adjustment, hyperglycemia can be effectively managed while minimizing the risk of hypoglycemia, leading to improved patient outcomes.