What is the recommended dosing regimen for a patient with impaired renal function who wants to switch to a once-daily NPH (Neutral Protamine Hagedorn) insulin regimen?

Once-Daily NPH Insulin Regimen for Patients with Impaired Renal Function

For patients with impaired renal function who want to switch to a once-daily NPH insulin regimen, morning administration is recommended over bedtime dosing to reduce the risk of nocturnal hypoglycemia and improve safety while maintaining glycemic control. 1

Initial Dosing and Conversion Strategy

• Start with 10 units per day OR 0.1-0.2 units/kg per day when initiating NPH insulin in the morning 1
• If converting from bedtime NPH to morning NPH:
  • Use 80% of the current bedtime NPH dose to reduce hypoglycemia risk 1
  • Consider morning dosing especially for patients with impaired renal function to allow for better monitoring of hypoglycemic events during daytime 1

Titration Protocol

• Set appropriate fasting plasma glucose (FPG) goals based on individual factors, considering the increased risk of hypoglycemia in renal impairment 1
• Use an evidence-based titration algorithm: increase by 2 units every 3 days until reaching target FPG without hypoglycemia 1
• If hypoglycemia occurs, determine the cause; if no clear reason is identified, reduce the dose by 10-20% 1

Special Considerations for Renal Impairment

• Patients with impaired renal function have increased risk of hypoglycemia due to decreased insulin clearance and impaired renal gluconeogenesis 1
• Morning NPH administration allows for:
  • Better monitoring of glucose response during waking hours 1
  • Reduced risk of undetected nocturnal hypoglycemia 1
  • More predictable insulin action profile in the setting of variable renal function 1

Monitoring and Follow-up

• Assess adequacy of insulin dose at every visit 1
• Monitor for clinical signals of overbasalization:
  • Elevated bedtime-to-morning glucose differential
  • Hypoglycemia (aware or unaware)
  • High glucose variability 1
• Consider more frequent blood glucose monitoring in patients with renal impairment, particularly during initial titration 1

When to Consider Alternative Approaches

• If glycemic targets are not achieved with once-daily morning NPH, consider:
  • Adding a GLP-1 receptor agonist if appropriate (with dose adjustment for renal function) 1
  • Converting to a twice-daily NPH regimen with 2/3 of the dose in the morning and 1/3 in the evening 1
• Consider switching to a long-acting basal analog if the patient experiences frequent hypoglycemia despite dose adjustments 1

Common Pitfalls and Caveats

• Avoid bedtime NPH in patients with impaired renal function due to increased risk of undetected nocturnal hypoglycemia 1
• Do not use the same dose when converting from bedtime to morning NPH; use 80% of the bedtime dose initially 1
• Be aware that insulin requirements may fluctuate with changes in renal function, requiring more frequent monitoring and dose adjustments 1
• Consider prescription of glucagon for emergent hypoglycemia, particularly important for patients with renal impairment 1