What adjustments should be made to the current NPH (Neutral Protamine Hagedorn) insulin regimen for a patient with hyperglycemia, currently taking 18 units?

NPH Insulin Dose Adjustment for Hyperglycemia

Increase your NPH insulin dose by 2 units every 3 days until blood glucose levels reach target range, given your current readings of 226 and 257 mg/dL on 18 units. 1

Immediate Titration Strategy

Your blood glucose readings (226 and 257 mg/dL) indicate inadequate glycemic control requiring dose escalation:

• Increase NPH by 2 units every 3 days using the evidence-based titration algorithm until fasting plasma glucose reaches target without hypoglycemia 1
• This means your next dose should be 20 units, then reassess in 3 days 1
• Continue this stepwise increase until blood glucose consistently falls below 130 mg/dL fasting 1

Alternative Approach: Consider Converting to Twice-Daily NPH

If you're currently taking bedtime NPH and glucose remains elevated despite titration:

• Convert to twice-daily NPH regimen using 80% of your current total daily dose 1
• For your current 18 units: Total dose = 14.4 units (round to 14 units) 1
• Give 2/3 in the morning (approximately 10 units) and 1/3 at bedtime (approximately 5 units) 1
• This split-dose approach provides better 24-hour coverage for persistent hyperglycemia 1

Adding Prandial Insulin if NPH Titration Insufficient

If A1C remains above goal after optimizing NPH:

• Add 4 units of rapid-acting insulin with the largest meal or 10% of your basal dose (approximately 2 units) 1
• Prandial insulin can be dosed individually or mixed with NPH 1
• If already on bedtime NPH when adding prandial coverage, strongly consider the twice-daily NPH conversion above 1

Monitoring and Safety Parameters

Critical monitoring points:

• Check blood glucose before each meal and at bedtime during titration 2
• If hypoglycemia occurs (blood glucose <70 mg/dL), reduce dose by 10-20% immediately 1
• Assess for signs of overbasalization: basal dose exceeding 0.5 units/kg/day, high glucose variability, or frequent hypoglycemia 1

When to Consider Alternative Therapies

Add a GLP-1 receptor agonist if you're not already on one and A1C remains above goal despite NPH optimization 1

Switch to a long-acting basal analog (insulin glargine or degludec) if you develop recurrent hypoglycemia or frequently miss evening NPH doses 1

Common Pitfalls to Avoid

• Don't remain at 18 units with these glucose readings - therapeutic inertia worsens long-term outcomes 1
• Don't increase by more than 2 units every 3 days initially to avoid overcorrection and hypoglycemia 1
• Don't forget to prescribe glucagon for emergency hypoglycemia treatment 1
• If converting to twice-daily NPH, don't use 100% of the original dose - always reduce to 80% of total to prevent hypoglycemia 1