A patient on hemodialysis received 60 mg prednisone at 8 am and 30 U neutral protamine Hagedorn (NPH) insulin with a carbohydrate‑to‑insulin ratio of 1 U per 8 g carbohydrates, resulting in progressive hyperglycemia throughout the day. What NPH insulin dose and carbohydrate‑to‑insulin ratio should be used today while continuing prednisone 60 mg?

NPH Insulin Dose and Carbohydrate Ratio Adjustment for Steroid-Induced Hyperglycemia

Increase the morning NPH dose from 30 U to 48–54 U (approximately 60–80% increase) and tighten the carbohydrate ratio from 1:8 to 1:5 to adequately cover the severe hyperglycemia induced by prednisone 60 mg. 1

Rationale for Aggressive Dose Escalation

Your patient's progressive hyperglycemia (268 → 251 → 351 → 421 mg/dL) demonstrates profound insulin resistance from high-dose prednisone that was grossly undertreated with 30 U NPH. The pattern of worsening hyperglycemia from afternoon through midnight is classic for prednisone-induced diabetes, which peaks 4–8 hours after morning administration. 2

Why Such a Large Increase Is Necessary

• High-dose glucocorticoids (60 mg prednisone) require 40–60% or more additional insulin beyond baseline requirements due to severe insulin resistance. 2, 1
• Your patient's glucose trajectory reaching 421 mg/dL indicates the initial 30 U dose provided less than half the needed coverage. 1
• NPH insulin must be administered concurrently with the morning prednisone dose so its 4–6 hour peak aligns with the steroid's metabolic effect. 2, 1

Specific Dosing Recommendations

NPH Insulin Adjustment

• Start with 48 U NPH this morning (60% increase from 30 U), given at the same time as prednisone 60 mg at 8 AM. 1
• If glucose remains >250 mg/dL this afternoon/evening, increase to 54 U tomorrow morning. 1
• Do not split the NPH into twice-daily doses initially—a single morning injection is specifically designed to match morning-administered prednisone's pharmacokinetic profile. 1, 3

Carbohydrate Ratio Adjustment

• Change from 1:8 to 1:5 (approximately 60% increase in prandial insulin), meaning 1 unit of rapid-acting insulin per 5 grams of carbohydrate. 1
• This tighter ratio addresses the marked prandial insulin resistance caused by high-dose steroids. 1

Correction Scale Protocol

Add aggressive correction insulin every 4 hours when glucose exceeds 150 mg/dL: 1

Glucose (mg/dL)	Correction Dose (units)
150–200	2
201–250	4
251–300	6
301–350	8
>350	10 + notify provider

Monitoring Protocol

• Check blood glucose every 2–4 hours for the first 48 hours after implementing these adjustments to identify patterns and guide further titration. 1, 3
• Target daytime glucose 140–180 mg/dL and fasting <130 mg/dL. 1
• The most critical readings are 2 hours after lunch (around 2–3 PM) and evening values, which capture the steroid's peak hyperglycemic effect. 3, 4

Hemodialysis Considerations

• Dialysis days may transiently lower glucose due to glucose removal in the dialysate, but this does not reduce the underlying steroid-induced insulin resistance. 1
• Maintain the higher NPH dose even on dialysis days, but monitor closely for post-dialysis hypoglycemia (typically 2–4 hours after treatment ends). 1
• If glucose drops <70 mg/dL post-dialysis, reduce the NPH dose by 10–20% but do not delay the upfront aggressive dosing needed for steroid coverage. 1

Critical Pitfalls to Avoid

• Do not rely on fasting glucose alone—this will miss the afternoon/evening peak and lead to dangerous undertreatment. 1, 3
• Do not use the same NPH dose employed for routine diabetes management—steroid-induced insulin resistance necessitates substantially higher doses. 1
• Do not delay aggressive dosing when glucose exceeds 350 mg/dL—an upfront increase is required rather than gradual titration. 1
• Avoid using only sliding-scale correction insulin, which is associated with poor glycemic control and discouraged in guidelines. 4

When to Escalate Care

• If glucose remains >360 mg/dL (>20 mmol/L) or the meter displays "HI" despite these adjustments, the patient requires hospital admission for continuous IV insulin infusion to evaluate for hyperosmolar hyperglycemic state. 4
• Consider endocrinology consultation if glucose stays >270 mg/dL (>15 mmol/L) after 48 hours of the adjusted regimen. 4

Future Dose Adjustments

• When prednisone is tapered or discontinued, insulin needs will drop by 50–70% within 24–48 hours—immediately reduce both NPH and prandial insulin by 30–40% to prevent severe hypoglycemia. 1, 4
• Until then, increase NPH by 2 units every 3 days if afternoon/evening glucose remains >180 mg/dL. 1, 3