What is the recommended premix 30/70 insulin regimen for a patient with fluctuating blood glucose levels, currently on Actrapid (regular human insulin)?

Premix 30/70 Insulin Regimen Plan

Based on this patient's glucose pattern showing fasting values of 114-164 mg/dL and pre-dinner values of 118-183 mg/dL while on multiple daily Actrapid injections, I recommend initiating premix 30/70 insulin at a total daily dose of approximately 24-28 units, divided as 16-18 units before breakfast and 8-10 units before dinner.

Dose Calculation Rationale

• Total current Actrapid usage: The patient received approximately 4-8 units per injection, with an average of 6 units given 2-3 times daily, totaling roughly 12-18 units daily 1

• Conversion to premix 30/70: When converting from multiple daily injections to twice-daily premixed insulin, use approximately 80% of the current total daily dose as the starting point, then distribute as 2/3 before breakfast and 1/3 before dinner 1

• Starting calculation: If total daily Actrapid was ~18 units, then 80% = 14.4 units. However, given suboptimal control, start at 100% of current dose (18 units) or slightly higher at 24-28 units total 1

Specific Dosing Schedule

Morning dose (before breakfast):

• Start with 16-18 units of premix 30/70 insulin
• This provides both basal coverage throughout the day and prandial coverage for breakfast 1

Evening dose (before dinner):

• Start with 8-10 units of premix 30/70 insulin
• This provides prandial coverage for dinner and basal coverage overnight 1

Titration Protocol

Adjust every 3 days based on glucose patterns 1:

• For fasting glucose >150 mg/dL: Increase evening premix dose by 2 units 1
• For pre-dinner glucose >150 mg/dL: Increase morning premix dose by 2 units 1
• For glucose <90 mg/dL: Decrease corresponding dose by 10-20% 1, 2

Target glucose goals 1, 2:

• Fasting: 90-150 mg/dL
• Pre-dinner: 90-150 mg/dL

Monitoring Requirements

• Check fasting glucose daily to guide evening dose adjustments 1
• Check pre-dinner glucose daily to guide morning dose adjustments 1
• Reassess every 2 weeks and adjust doses if 50% of readings are above target 1, 2
• Monitor for hypoglycemia: If >2 readings per week are <90 mg/dL, reduce the corresponding dose 1, 2

Important Clinical Considerations

Advantages of premix 30/70 for this patient 3, 4:

• Reduces injection burden from 2-3 daily injections to 2 injections
• Provides both basal and prandial coverage with each dose
• Simplifies regimen, potentially improving adherence 3

Critical warnings 1:

• Premixed insulin carries higher hypoglycemia risk than basal-only regimens in hospitalized patients, but this patient appears to be outpatient 1
• Ensure patient understands timing: inject immediately before meals (within 15 minutes) 3
• Do not use rapid- or short-acting insulin at bedtime 1, 2

When to reassess the regimen 1:

• If total daily dose exceeds 0.5 units/kg/day without achieving target A1C, consider switching to basal-bolus regimen 1
• If persistent hypoglycemia occurs despite dose reductions, consider alternative regimen 1
• If pre-lunch glucose becomes problematic, may need to add pre-lunch monitoring and consider basal-bolus approach 1

Alternative Consideration

If premix 30/70 proves inadequate 1:

• Consider basal insulin (NPH or long-acting analog) plus prandial rapid-acting insulin, which allows more flexible dose adjustments for individual meals 1
• This would involve converting to approximately 50% basal insulin (once or twice daily) and 50% divided among meals as rapid-acting insulin 1