In a patient receiving norepinephrine and dexamethasone 40 mg, currently on a daytime insulin drip of 3–6 U, 55 U neutral protamine Hagedorn (NPH) and 35 U insulin glargine (Lantus) nightly, how much should the NPH and insulin glargine doses be increased when transitioning to comfort‑focused care?

Insulin Dose Adjustments for Comfort Care Transition

Direct Recommendation

In a patient transitioning to comfort care on dexamethasone 40 mg with current insulin requirements of 3-6 units/hour on drip, increase NPH to 70 units and Lantus to 45 units to maintain adequate glycemic control while minimizing symptomatic hyperglycemia.

Calculating Total Daily Insulin Requirements

The first step is to calculate the 24-hour insulin requirement from the current drip:

• Average insulin drip rate: 4.5 units/hour (midpoint of 3-6 units)
• 24-hour total: 4.5 × 24 = 108 units/day 1
• This represents the patient's total daily dose (TDD) under current high-dose dexamethasone 1

Current subcutaneous insulin totals only 90 units (55 NPH + 35 Lantus), creating an 18-unit deficit that explains ongoing drip requirements 1

Recommended Dose Increases

For NPH insulin:

• Current dose: 55 units
• Increase to 70 units (approximately 27% increase)
• This accounts for the daytime hyperglycemia pattern from dexamethasone 40 mg, which causes peak glucose elevation between midday and midnight 1, 2

For Lantus (insulin glargine):

• Current dose: 35 units
• Increase to 45 units (approximately 29% increase)
• This provides adequate basal coverage for the overnight period when dexamethasone effect wanes 1, 3

Rationale for This Approach

High-dose dexamethasone (40 mg) creates severe insulin resistance requiring 40-60% higher insulin doses than standard recommendations 3:

• The patient's current requirement of ~1.5 units/kg/day (assuming ~70 kg weight) is appropriate for this steroid dose 1, 4
• Dexamethasone causes predominantly afternoon and evening hyperglycemia, making NPH the preferred daytime insulin 1, 2
• The combination of NPH (for daytime steroid effect) plus Lantus (for basal coverage) addresses the biphasic hyperglycemic pattern 5, 6

Comfort Care Considerations

In the comfort care setting, the goal shifts from tight glycemic control to preventing symptomatic hyperglycemia 1:

• Target glucose range can be liberalized to 140-250 mg/dL to avoid both symptomatic hyperglycemia and hypoglycemia
• These doses should prevent glucose levels >300 mg/dL, which cause polyuria, polydipsia, and decreased comfort
• Monitoring frequency can be reduced to every 6-12 hours rather than every 2-4 hours 2

Critical Pitfalls to Avoid

Do not underdose insulin in comfort care 3, 4:

• Severe hyperglycemia (>300 mg/dL) causes significant discomfort from osmotic symptoms
• The recommended increases account for the patient's demonstrated insulin requirement on drip

Watch for rapid changes if dexamethasone is discontinued 1, 2:

• Insulin requirements can decline by 50-70% within 24-48 hours of stopping dexamethasone
• If steroids are stopped, immediately reduce both NPH and Lantus by 30-40% to prevent hypoglycemia

Avoid premixed insulin formulations (70/30) in this setting 1:

• Associated with unacceptably high rates of hypoglycemia
• Less flexible for dose adjustments as clinical status changes

Monitoring and Adjustment Protocol

Initial 24-48 hours after transition 2:

• Check glucose every 6-12 hours (pre-breakfast, pre-dinner, bedtime)
• If glucose consistently >250 mg/dL, increase NPH by 5-10 units
• If glucose <100 mg/dL, reduce the corresponding insulin by 10-20% 2, 7

If hypoglycemia occurs (<70 mg/dL) 2, 7:

• Immediately reduce the insulin dose by 10-20%
• For morning hypoglycemia: reduce Lantus
• For afternoon/evening hypoglycemia: reduce NPH

The total recommended regimen is NPH 70 units in the morning and Lantus 45 units at bedtime, totaling 115 units/day, which appropriately covers the calculated 108-unit requirement with a small buffer for comfort care flexibility 1, 3.