What is the typical starting dose of Insulin Mixtard (Novomix, insulin aspart and insulin aspart protamine) for patients with diabetes?

Starting Dose of Insulin Mixtard for Patients with Diabetes

The typical starting dose of Insulin Mixtard (premixed insulin containing 30% rapid-acting insulin aspart and 70% intermediate-acting insulin aspart protamine) for patients with diabetes is 10 units per day or 0.1-0.2 units/kg/day, administered twice daily.

Initial Dosing Considerations

For Insulin-Naive Patients:

• Start with 10 units per day or 0.1-0.2 units/kg/day 1, 2
• Typically administered as twice-daily injections (before breakfast and before dinner)
• For patients with type 2 diabetes with mild-to-moderate hyperglycemia, the lower end of the range (0.1-0.2 units/kg/day) is appropriate
• For patients with more severe hyperglycemia (HbA1c ≥9%), consider starting at the higher end of the dosing range 1

For Patients Already on Insulin:

• When transitioning from basal-bolus regimen to premixed insulin, calculate the total daily dose (TDD) from previous insulin regimen
• Use approximately 80% of the previous TDD when converting to Mixtard 1
• Divide the dose with approximately 2/3 given before breakfast and 1/3 given before dinner 1

Titration Guidelines

• Adjust dose by 2-4 units once or twice weekly based on blood glucose monitoring results 2
• Target fasting and pre-dinner glucose levels between 80-130 mg/dL (4.4-7.2 mmol/L)
• If hypoglycemia occurs, determine the cause and reduce the corresponding dose by 10-20% 1
• Monitor both fasting and postprandial glucose levels to guide adjustments

Special Populations

• Elderly patients: Start at lower doses (0.3 units/kg/day) to minimize hypoglycemia risk 1, 2
• Renal impairment: Use lower starting doses (0.3 units/kg/day) 1
• Poor oral intake: Reduce initial dose to minimize hypoglycemia risk 1
• Children with type 1 diabetes: May require higher doses (0.5-1.0 units/kg/day) due to growth and hormonal factors 1, 3

Common Pitfalls to Avoid

1. Overbasalization: Continuing to escalate dose without meaningful reduction in fasting plasma glucose 4

   • If dose exceeds 0.5 units/kg/day without adequate control, reevaluate the regimen

2. Sliding scale insulin alone: This approach is insufficient for adequate glycemic control and should not be used as the sole treatment strategy, especially in type 1 diabetes 1

3. Abrupt discontinuation of oral medications: When initiating insulin therapy in type 2 diabetes, oral medications should not be abruptly discontinued due to risk of rebound hyperglycemia 3

4. Inadequate monitoring: Blood glucose monitoring is essential for effective insulin therapy and dose adjustments 3

Monitoring and Follow-up

• Monitor blood glucose before meals and 2 hours after meals
• Adjust doses based on patterns observed in glucose readings
• Evaluate HbA1c every 3 months to assess overall glycemic control
• Educate patients on proper injection technique and hypoglycemia management
• Ensure patients understand the importance of consistent meal timing when using premixed insulin

Mixtard insulin provides a convenient option for patients who need both basal and prandial coverage but prefer fewer daily injections. The fixed ratio (30/70) works well for many patients, but it's important to recognize that this formulation offers less flexibility than separate basal and bolus insulin regimens.