A 52-year-old type 2 diabetic on NPH insulin twice daily has fasting glucose of 210 mg/dL and post-dinner glucose of 95 mg/dL. To address the fasting hyperglycemia without increasing hypoglycemia risk, which adjustment is most appropriate?

• A Increase the morning NPH dose
• B Add a second morning dose of NPH
• C Switch evening NPH to a rapid-acting insulin
• D Increase the evening NPH dose ✓

Explanation

NPH insulin given at bedtime covers the fasting period by peaking during early morning hours (4-6 AM). The evening NPH dose controls fasting glucose, while the morning dose controls afternoon/evening glucose. Since fasting glucose is high and post-dinner glucose is controlled, the evening NPH dose should be increased. Increasing morning NPH would increase daytime hypoglycemia risk.

Reference: Katzung Basic and Clinical Pharmacology, 15th ed.

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