Starting Dose of Novolog for Mealtime Use with Lantus 44 Units Daily
For a patient on 44 units of Lantus (insulin glargine) daily, the appropriate starting dose of Novolog (insulin aspart) for mealtime use is 4 units per meal or 10% of the basal insulin dose (approximately 4-5 units per meal).
Rationale for Mealtime Insulin Dosing
When initiating mealtime insulin for a patient already on basal insulin, the following approach is evidence-based:
- The American Diabetes Association recommends starting prandial insulin at 4 units per day or 10% of the basal insulin dose 1
- This translates to approximately 4-5 units of Novolog per meal for a patient on 44 units of Lantus
- When adding prandial insulin, it's often best to start with one dose at the largest meal or the meal with the greatest postprandial glucose excursion 1
Titration Algorithm
After initiating Novolog, the dose should be adjusted based on blood glucose patterns:
- Increase dose by 1-2 units or 10-15% twice weekly if postprandial glucose remains elevated 1
- For pre-meal glucose values >250 mg/dL, add 2 units; for values >350 mg/dL, add 4 units 2
- If hypoglycemia occurs, determine the cause and reduce the corresponding dose by 10-20% 1
Basal-Bolus Balance Considerations
When transitioning to a full basal-bolus regimen:
- The total daily insulin dose is typically distributed as 50% basal (Lantus) and 50% prandial (Novolog) 2
- For a patient on 44 units of Lantus, this would eventually mean approximately 22 units of Lantus and 22 units of Novolog distributed across meals
- However, it's safer to start with a lower prandial dose and titrate up gradually
Special Considerations
- Novolog should be administered immediately before meals due to its rapid onset of action (5 minutes) 1
- The peak effect occurs at 1-2 hours with a duration of 3-4 hours 1
- Monitor for hypoglycemia, especially 1-2 hours after injection when Novolog reaches peak effect
- Consider reducing the Lantus dose by 10-20% when adding mealtime insulin to reduce the risk of hypoglycemia 2
Monitoring Recommendations
- Check blood glucose before meals and 2 hours after meals to assess the effectiveness of the Novolog dose
- Target postprandial glucose levels should be <180 mg/dL
- Adjust the dose based on patterns observed over 3-7 days rather than single readings
- Be particularly vigilant about nocturnal hypoglycemia when adding prandial insulin to a basal regimen
By starting with 4 units or 10% of the basal dose (4-5 units) of Novolog per meal and following a structured titration protocol, patients can safely transition to a basal-bolus insulin regimen with improved glycemic control.