NPH Insulin Dose Adjustment for Steroid-Induced Hyperglycemia with Dialysis
Increase the NPH dose from 20 units to 28–30 units (a 40–50% increase) given as a single morning dose to match the peak hyperglycemic effect of prednisone 60 mg. 1
Rationale for the Dose Increase
High-dose glucocorticoids (prednisone 60 mg) require 40–60% higher insulin doses than standard recommendations due to severe insulin resistance, making your current 20 units inadequate for glucose levels reaching 200–325 mg/dL 1
The current glucose elevations (200–325 mg/dL) indicate your basal insulin is covering only about 60–70% of actual requirements; a 40–50% dose increase (to 28–30 units) directly addresses this deficit 1
NPH insulin is the preferred formulation for steroid-induced hyperglycemia because its 4–6 hour peak aligns with the midday-to-midnight hyperglycemia pattern characteristic of prednisone 1, 2
Timing and Administration
Administer the entire NPH dose in the morning (ideally when the prednisone is given) to match the pharmacokinetic profile of daily glucocorticoid therapy 1
Morning dosing specifically targets the "midday to midnight" hyperglycemia surge that prednisone causes, which explains why your glucose spikes to 200–325 mg/dL during the day 1
Dialysis-Specific Considerations
Dialysis itself does not require NPH dose reduction—in fact, the procedure may transiently worsen insulin resistance through inflammatory cytokine release and glucose absorption from dialysate 1
Continue the increased NPH dose on dialysis days; monitor glucose every 2–4 hours during and immediately after dialysis to identify any unexpected patterns 1, 3
If hypoglycemia occurs post-dialysis (uncommon but possible if dialysate is glucose-free), reduce the NPH dose by 10–20% for subsequent dialysis days 1
Titration Protocol Going Forward
If glucose remains >180 mg/dL after 3 days on the new dose, increase NPH by an additional 2 units every 3 days until daytime glucose consistently stays 140–180 mg/dL 1, 4
If any hypoglycemia occurs (<70 mg/dL), immediately reduce the NPH dose by 10–20% without waiting for the next scheduled adjustment 1
Target glucose range for hospitalized patients on steroids is 140–180 mg/dL during the day, with fasting <130 mg/dL acceptable but not mandatory given the steroid effect 1, 5
Alternative Strategy if Morning-Only Dosing Fails
If glucose control remains suboptimal after reaching 35–40 units of morning NPH, consider splitting to twice-daily NPH (2/3 morning, 1/3 evening) rather than continuing to escalate a single dose 1
This split-dose approach may be necessary if overnight glucose also becomes problematic, though prednisone's effect typically wanes by bedtime 1
Common Pitfalls to Avoid
Do not use long-acting basal insulin (glargine/detemir) as the primary agent for steroid-induced hyperglycemia—these lack the daytime peak needed to counter prednisone's effect, and studies show NPH requires lower total daily doses (0.27 vs 0.34 units/kg) with equivalent glycemic control 6
Avoid "overbasalization" (continuing to escalate NPH beyond 0.5–1.0 units/kg/day without improvement)—at that point, add correctional rapid-acting insulin rather than further increasing basal insulin 1, 4
When prednisone is eventually tapered or stopped, reduce NPH by 20% for each 50% reduction in steroid dose to prevent severe hypoglycemia, as insulin requirements may drop 50–70% within 24–48 hours of steroid discontinuation 1