What adjustments can be made to a patient's insulin regimen taking Novolog (insulin aspart protamine/insulin aspart) 70/30 at a high dose of 120 units daily?

Adjusting High-Dose Novolog 70/30 Insulin Regimen

For a patient on 120 units of Novolog 70/30 daily, the most effective approach is to consider transitioning to a basal-bolus regimen with addition of a GLP-1 receptor agonist to improve glycemic control while potentially reducing insulin requirements. 1

Assessment of Current Regimen

• Evaluate for signs of overbasalization: elevated bedtime-to-morning glucose differential, postprandial-to-preprandial glucose differential, hypoglycemic episodes, or high glucose variability 1
• Assess adequacy of current insulin dose by reviewing blood glucose patterns, particularly fasting and postprandial values 1
• Consider if the high dose (120 units daily) indicates insulin resistance that might benefit from adjunctive therapy 1

Recommended Adjustments

Option 1: Optimize Current Premixed Insulin Regimen

• Split the total daily dose into two injections if not already done:
  • 2/3 of total dose before breakfast (80 units)
  • 1/3 of total dose before dinner (40 units) 1
• Titrate each component based on pre-meal and bedtime glucose values 1
• For hypoglycemia: determine cause and lower corresponding dose by 10-20% 1, 2

Option 2: Transition to Basal-Bolus Regimen (Preferred)

• Convert to basal insulin plus prandial insulin for better glycemic control:
  • Calculate total NPH component (84 units) and reduce by 20% (67.2 units) for basal insulin 1
  • Distribute remaining insulin as prandial doses before meals 1
• Consider using a long-acting basal analog instead of NPH to reduce hypoglycemia risk 1, 2
• Add prandial insulin at each meal, starting with 4 units or 10% of basal dose 1

Option 3: Add GLP-1 Receptor Agonist

• Add a GLP-1 receptor agonist while maintaining or reducing insulin dose 1
• This combination has shown greater efficacy, durability of glycemic effect, weight benefits, and reduced hypoglycemia compared to insulin intensification alone 1
• Consider fixed-ratio combination products (IDegLira or iGlarLixi) if appropriate 1

Monitoring and Titration

• Set specific fasting and postprandial glucose targets 1
• Increase prandial insulin by 1-2 units or 10-15% twice weekly until targets are reached 1
• Monitor for hypoglycemia and reduce dose by 10-20% if it occurs without clear reason 1, 2
• Assess adequacy of insulin dose at every visit 1

Important Considerations

• High insulin requirements (>0.5 units/kg/day) suggest the need for adjunctive therapy 1
• Insulin 70/30 plus metformin has been shown to be as effective as triple oral therapy with better cost-effectiveness 3
• Biphasic insulin aspart 30/70 (Novolog 70/30) has demonstrated improved glycemic control and reduced hypoglycemia compared to biphasic human insulin in some patient groups 4
• Consider prescription of glucagon for emergency hypoglycemia management given the high insulin dose 1, 2

Potential Pitfalls

• Avoid simply increasing the total dose without addressing the insulin distribution pattern 1
• Be cautious about hypoglycemia risk, especially nocturnal hypoglycemia with high doses of premixed insulin 2, 4
• Don't overlook the potential benefits of newer insulin formulations or combination therapy approaches that may reduce total insulin requirements 1, 5
• Remember that insulin dose titration is important; adjustments may be necessary in both mealtime and basal components 1