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

NPH Insulin Dose Adjustment for Hyperglycemia

For a patient receiving 10 units of NPH with blood glucose levels of 229 and 244 mg/dL, increase the NPH dose by 2 units (to 12 units total). 1

Recommended Dose Adjustment Protocol

• Increase NPH insulin by 1-2 units or 10-15% of the current dose when blood glucose remains above target. 1
• For this patient on 10 units, a 2-unit increase represents a 20% adjustment, which falls within the recommended range 1
• The American Diabetes Association specifically recommends increasing the dose by 2 units every 3 days until target blood glucose is achieved 2, 3

Target Blood Glucose Range

• Target fasting and pre-meal blood glucose should be 80-180 mg/dL for most hospitalized patients 3
• The current readings of 229 and 244 mg/dL are significantly above target, warranting dose adjustment 1

Titration Schedule

• Reassess blood glucose after 2-3 days on the new dose 2, 3
• If more than 50% of fasting glucose values remain above 150 mg/dL over 2-3 days, increase NPH by another 2 units 4
• Continue this pattern of increasing by 2 units every 3 days until glycemic targets are achieved 2, 3

Monitoring for Hypoglycemia

• If hypoglycemia occurs during titration, determine the cause 1, 2
• If no clear reason for hypoglycemia is identified, reduce the NPH dose by 10-20% 1, 2, 3
• Monitor blood glucose before each meal and at bedtime during dose adjustments 4

Special Considerations

• If the patient is on morning NPH for steroid-induced hyperglycemia, the same 2-unit increment applies 2
• For patients requiring more aggressive control, consider splitting to twice-daily NPH (2/3 morning, 1/3 evening) if once-daily dosing proves insufficient 1, 2
• The total daily insulin dose may need to reach 0.5-0.7 units/kg/day for adequate control in insulin-resistant patients 5, 6

Common Pitfalls to Avoid

• Do not use sliding-scale insulin alone without adjusting basal NPH dose—this reactive approach fails to prevent hyperglycemia 6
• Avoid waiting too long between dose adjustments; reassess every 2-3 days rather than weekly 2, 3
• Do not increase by more than 2-4 units at a time to minimize hypoglycemia risk 1, 4