Novolog Starting Dose
For insulin-naive adults with type 2 diabetes, start Novolog Mix 70/30 at 10 units once daily (or 0.1-0.2 units/kg/day), administered before the largest meal, and titrate by 2-4 units every 3 days until fasting glucose reaches 80-130 mg/dL. 1
Initial Dosing by Clinical Scenario
Type 2 Diabetes - Insulin Naive
- Standard starting dose: 10 units once daily or 0.1-0.2 units/kg/day 1
- Administer before the largest meal when using Novolog Mix 70/30 2
- For patients with severe hyperglycemia (A1C ≥9%, glucose ≥300-350 mg/dL), consider higher starting doses of 0.3-0.4 units/kg/day 1
Type 1 Diabetes
- Total daily insulin requirement: 0.4-1.0 units/kg/day, with 0.5 units/kg/day typical for metabolically stable patients 3, 4
- Divide approximately 50% as basal insulin and 50% as prandial insulin 4
- Higher doses required immediately following ketoacidosis presentation 3
Adding Prandial Novolog to Existing Basal Insulin
- Start with 4 units before the largest meal, or use 10% of current basal insulin dose 1, 4
- Add prandial insulin when basal insulin exceeds 0.5 units/kg/day and A1C remains elevated despite controlled fasting glucose 1
Dose Titration Algorithm
Rapid-Acting Novolog (Aspart)
- Increase by 1-2 units or 10-15% every 3 days based on pre-meal and 2-hour postprandial glucose readings 4
- Target 2-hour postprandial glucose values for optimal titration 4
Novolog Mix 70/30 (Biphasic Formulation)
- Increase by 4 units weekly until fasting blood glucose reaches 6.6-8 mmol/L (119-144 mg/dL), then by 2 units weekly to maintain fasting glucose 4.5-6.7 mmol/L (81-121 mg/dL) 2
- Can be administered either preprandially (within 5 minutes before meal) or postprandially (15-20 minutes after meal onset) in elderly patients, though preprandial dosing provides slightly better glucose control 5
Pharmacokinetic Profile
Novolog has a rapid onset of action within 5 minutes, peaks at 1-2 hours, and has a duration of 3-4 hours, making it ideal for mealtime glucose control 3, 4, 6
Special Populations
Hospitalized Patients
- Insulin-naive or low-dose insulin users: 0.3-0.5 units/kg/day total daily dose, with half as basal insulin 1
- High-dose home insulin users (≥0.6 units/kg/day): Reduce total daily dose by 20% to prevent hypoglycemia 1
- High-risk patients (elderly >65 years, renal failure, poor oral intake): 0.1-0.25 units/kg/day 1
Continuous Subcutaneous Insulin Infusion (Pump Therapy)
- Novolog is particularly suitable for insulin pump use due to its rapid onset and shorter duration 3
- Provides better glycemic control than multiple daily injections in type 1 diabetes 6
Critical Pitfalls to Avoid
Overbasalization
- Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia 1
- Clinical warning signs include: bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 1
- When basal insulin approaches 0.5 units/kg/day and A1C remains elevated, add prandial Novolog rather than increasing basal insulin further 1
Delayed Insulin Initiation
- Do not delay insulin therapy in patients not achieving glycemic goals with oral medications 1
- Start immediately in patients with A1C ≥9%, glucose ≥300-350 mg/dL, or symptomatic/catabolic features 1
Hypoglycemia Prevention
- If more than 2 fasting glucose values per week are <80 mg/dL, decrease insulin dose by 2 units 1
- Hypoglycemia incidence with Novolog is lower than regular human insulin in multiple studies 6
- Ensure patients are educated on recognition and treatment: 4-8 oz juice/soda, recheck glucose in 15-20 minutes 4
Foundation Therapy Considerations
Continue metformin when initiating or intensifying insulin therapy unless contraindicated, as it remains the foundation of type 2 diabetes management and reduces insulin requirements 1, 2
When combined with metformin and/or glimepiride, insulin requirements are significantly lower (23-51 units daily) compared to insulin monotherapy (82 units daily), with less weight gain and fewer hypoglycemic episodes 2