What additional insulin can be added to Novolin 70/30 for a patient with HbA1c of 12.8?

Adding Insulin to Novolin 70/30 for Better Glycemic Control

For a patient with HbA1c of 12.8% on Novolin 70/30 (60 units morning, 30 units bedtime), the most effective additional insulin regimen would be adding prandial rapid-acting insulin before meals, particularly starting with the largest meal of the day.

Understanding the Current Regimen and Need for Intensification

The patient's extremely elevated HbA1c of 12.8% indicates poor glycemic control despite being on a twice-daily premixed insulin regimen. Novolin 70/30 contains:

• 70% intermediate-acting NPH insulin
• 30% short-acting regular insulin

This fixed combination provides both basal and prandial coverage but clearly isn't sufficient for this patient.

Step-by-Step Approach to Intensification

1. Evaluate the Current Regimen

• Maintain the current Novolin 70/30 doses (60 units morning, 30 units bedtime)
• The high HbA1c suggests significant postprandial hyperglycemia that isn't adequately controlled

2. Add Prandial Insulin

• Initial approach: Add rapid-acting insulin analog (aspart, lispro, or glulisine) before the largest meal 1
• Starting dose: 4 units or 10% of the basal component of the current regimen 1
• Titration: Increase by 1-2 units or 10-15% twice weekly based on postprandial glucose readings 1

3. Progressive Intensification if Needed

• If glycemic targets aren't met, add prandial insulin before additional meals in a stepwise manner 1
• Eventually progress to a full basal-bolus regimen if necessary

Alternative Approaches

Option 1: Convert to Basal-Bolus Regimen

If the patient has very irregular meal patterns or the above approach is insufficient:

• Switch from Novolin 70/30 to:
  • Basal insulin (glargine, detemir, or degludec) once or twice daily
  • Rapid-acting insulin before each meal
• This provides more flexibility but requires more injections 2

Option 2: Consider Adding a GLP-1 Receptor Agonist

• For patients who might benefit from weight loss or have concerns about hypoglycemia
• Can be used in combination with basal insulin 1, 2
• Fixed-ratio combinations are available (insulin glargine/lixisenatide or insulin degludec/liraglutide) 2

Important Considerations

Hypoglycemia Risk

• Monitor closely for hypoglycemia when adding prandial insulin
• If hypoglycemia occurs, reduce the corresponding dose by 10-20% 1
• Elderly patients may need more conservative targets and careful titration 1

Meal Timing and Consistency

• Premixed insulins work best with consistent meal timing and carbohydrate content
• Irregular meal patterns may require a more flexible insulin regimen 2

Patient Education

• Ensure the patient understands the importance of proper timing of insulin in relation to meals
• Teach proper injection technique and rotation of injection sites
• Instruct on recognition and management of hypoglycemia

Monitoring and Follow-up

• Self-monitoring of blood glucose before and 2 hours after meals
• Adjust doses based on patterns rather than single readings
• Consider more frequent follow-up visits during insulin intensification

By adding prandial insulin to the existing Novolin 70/30 regimen, starting with the largest meal and progressively adding to other meals if needed, the patient's glycemic control can be significantly improved while minimizing the risk of hypoglycemia.