Increase NPH Insulin Dose
The NPH insulin dose should be increased by 2 units every 3 days until fasting blood glucose reaches target without hypoglycemia. 1
Current Situation Assessment
Your patient on 6 units of NPH with blood glucose levels of 214 and 221 mg/dL demonstrates inadequate glycemic control requiring dose titration. 1 These values are well above the target range and indicate the current insulin dose is insufficient. 1
Specific Titration Protocol
Increase the NPH dose by 2 units every 3 days until the fasting plasma glucose reaches your individualized target (typically 80-130 mg/dL for most patients). 1 This evidence-based titration algorithm balances efficacy with hypoglycemia prevention. 1
Monitoring Requirements
- Check fasting blood glucose daily during titration to guide dose adjustments 1
- If hypoglycemia occurs at any point, determine the cause and if no clear reason exists, reduce the dose by 10-20% 1
- Continue titrating upward by 2-unit increments every 3 days as long as glucose remains elevated and no hypoglycemia occurs 1
Expected Dose Range
The current 6-unit dose is likely well below what this patient needs. 1 For context:
- Standard starting doses are 10 units per day or 0.1-0.2 units/kg per day 1
- Many patients require 0.3-0.5 units/kg per day or more to achieve adequate control 1
- Doses exceeding 0.5 units/kg per day often signal the need for prandial insulin coverage 1
When to Consider Additional Therapy
If blood glucose remains above target despite basal insulin titration to 0.5 units/kg per day, or if large postprandial excursions occur (>180 mg/dL), consider adding prandial insulin or a GLP-1 receptor agonist. 1
Signs of Overbasalization
Watch for these indicators that prandial insulin is needed rather than more basal insulin: 1
- Elevated bedtime-to-morning glucose differential
- Large drops in glucose between meals despite elevated HbA1c
- Hypoglycemia occurring as basal dose increases
- High glucose variability throughout the day
Common Pitfalls to Avoid
- Do not use sliding-scale insulin alone as the primary management strategy—it is ineffective and associated with poor glycemic control in 51-68% of patients 2
- Do not delay dose adjustments—therapeutic inertia is common, with studies showing 81% of patients never having their insulin regimen adjusted despite persistent hyperglycemia 2
- Do not add prandial insulin before optimizing basal insulin—the fasting glucose should be at target first 1
- Do not stop oral medications abruptly when intensifying insulin therapy, as this risks rebound hyperglycemia 3
Combination Therapy Considerations
If the patient is not already on metformin, adding it to the insulin regimen decreases weight gain, lowers required insulin doses, and reduces hypoglycemia compared to insulin alone. 3 Continue metformin unless contraindicated. 1