What is the bid NPH insulin dose carbohydrate ratio and correction scale for a patient on Ozempic (semaglutide) and Lantus (insulin glargine) with a given clinical profile?

NPH Insulin Regimen for a Patient on Ozempic with Tube Feeding

For a 61-year-old male (110 kg, BMI 34) on Ozempic 2 mg with A1C 5.7, creatinine 0.93, currently receiving tube feeding providing 227g of carbohydrates daily and on Lantus 30 units daily, the recommended BID NPH regimen is 20 units in the morning and 10 units in the evening, with a carbohydrate ratio of 1:10 and a correction scale of 1 unit for every 25 mg/dL above 150 mg/dL.

NPH Insulin Dosing

• NPH insulin is the preferred formulation for managing hyperglycemia in patients receiving enteral nutrition due to its intermediate-acting profile that peaks at 4-6 hours, which aligns well with tube feeding schedules 1
• For patients receiving enteral nutrition, the recommended approach is to continue prior basal insulin or calculate from total daily dose (TDD), considering 5 units NPH/detemir every 12 hours or 10 units glargine/degludec daily 1
• For this patient, the current Lantus dose of 30 units can be converted to a twice-daily NPH regimen using a 2:1 morning:evening distribution (20 units AM, 10 units PM) to provide better coverage for daytime tube feeding 1, 2
• The American Diabetes Association recommends NPH insulin two or three times daily (every 8 or 12 hours) to cover individual requirements for patients receiving enteral nutrition 1

Carbohydrate Ratio

• For patients receiving enteral nutrition, the nutritional insulin component should be calculated as 1 unit of insulin for every 10-15 grams of carbohydrate in the formula 1
• Given this patient's obesity (BMI 34) and relatively high carbohydrate intake (227g daily), a more aggressive carbohydrate ratio of 1:10 (1 unit per 10g of carbohydrate) is appropriate 1, 3
• For continuous enteral feedings, regular insulin every 6 hours or rapid-acting insulin every 4 hours should be administered based on this carbohydrate ratio 1
• The patient's use of Ozempic (semaglutide) may help improve insulin sensitivity, but the high carbohydrate load from tube feeding still necessitates adequate insulin coverage 4

Correction Scale

• For correction insulin, a starting point of 1 unit for every 25 mg/dL above target is appropriate for this patient with obesity 5, 3
• The recommended correction scale is:
  • Blood glucose 150-175 mg/dL: 1 unit 5
  • Blood glucose 176-200 mg/dL: 2 units 5
  • Blood glucose 201-225 mg/dL: 3 units 5
  • Blood glucose 226-250 mg/dL: 4 units 5
  • Blood glucose 251-275 mg/dL: 5 units 5
  • Blood glucose >275 mg/dL: 6 units and reassess 5
• Correction insulin should be administered subcutaneously every 6 hours using regular insulin or every 4 hours using rapid-acting insulin 1

Monitoring and Adjustment

• Blood glucose should be monitored every 4-6 hours while on enteral nutrition to guide insulin adjustments 1
• If hypoglycemia occurs, determine the cause; if no clear reason is found, lower the NPH dose by 10-20% 2
• For persistent hyperglycemia, consider increasing the NPH dose by 2 units every 3 days until target blood glucose is achieved 2
• Target blood glucose range should be 100-180 mg/dL for this hospitalized patient receiving enteral nutrition 1

Special Considerations

• If enteral nutrition is interrupted, a dextrose infusion should be started immediately to prevent hypoglycemia 1
• The patient's well-controlled A1C of 5.7% while on Ozempic suggests good baseline glycemic control, but the high carbohydrate load from tube feeding necessitates adequate insulin coverage 4
• The presence of Ozempic (semaglutide) therapy may reduce overall insulin requirements compared to patients not on GLP-1 receptor agonists, but careful monitoring is still essential 4
• Consider the potential for weight loss with semaglutide, which may necessitate future adjustments to the insulin regimen 4

Common Pitfalls to Avoid

• Failing to match the timing of NPH insulin with enteral feeding schedules can lead to inadequate coverage of carbohydrate-induced hyperglycemia 2
• Underestimating insulin needs for tube feeding can result in persistent hyperglycemia, while overestimating can cause dangerous hypoglycemia, especially if tube feeding is interrupted 1
• Not accounting for the glucose-lowering effect of semaglutide when calculating insulin doses could increase hypoglycemia risk 4
• Inadequate monitoring of blood glucose levels during enteral nutrition can lead to undetected hyper- or hypoglycemia 1