Adjustment for Nocturnal Hypoglycemia on 75/25 Humalog Mix

Understanding the Problem

The American Diabetes Association recommends reducing the evening dose of 75/25 Humalog Mix by 10-20% to address nocturnal hypoglycemia, as the 75% protamine component provides overnight basal coverage that is causing the middle-of-night blood sugar drops 1
Nocturnal hypoglycemia is common with premixed insulins, with reported incidence of 14-47%, and may be asymptomatic or present with nightmares, restless sleep, or morning headaches 3, 4

The American Diabetes Association suggests decreasing the evening dose by 10-20% initially, which means reducing from 60 units to 48-54 units at the evening meal 5
The American Diabetes Association recommends keeping the morning dose at 60 units initially, as this is not contributing to nocturnal hypoglycemia 1

The American Diabetes Association recommends checking blood glucose at 2-3 AM for several nights to confirm resolution of nocturnal hypoglycemia 3
The American Diabetes Association suggests monitoring fasting glucose daily to ensure it remains <130 mg/dL 2
The American Diabetes Association recommends assessing for hypoglycemia symptoms at every visit 3, 4

The American Diabetes Association advises against reducing both doses simultaneously, as the morning dose is not causing nocturnal hypoglycemia; only adjust the evening dose 1
The American Diabetes Association warns against skipping the evening dose entirely, as this will cause uncontrolled fasting hyperglycemia and increase risk of DKA 1
The American Diabetes Association recommends ensuring consistent meal timing, as premixed insulins require relatively consistent mealtimes and carbohydrate intake 1, 6

The American Diabetes Association suggests treating nocturnal hypoglycemia with 15-20g of fast-acting carbohydrates 2
The American Diabetes Association recommends rechecking blood glucose after 15 minutes 2
The American Diabetes Association advises administering glucagon 1 mg subcutaneously for severe hypoglycemia with altered consciousness 3, 4