Novomix Dosage for an 86kg Patient
For an 86kg patient starting Novomix (biphasic insulin aspart), initiate at 0.1-0.2 units/kg/day, which translates to 9-17 units daily, typically divided as two-thirds (6-11 units) in the morning and one-third (3-6 units) in the evening. 1, 2
Initial Dosing Calculation
Start with 10 units once daily or use weight-based dosing of 0.1-0.2 units/kg/day for insulin-naive patients with type 2 diabetes. 1, 3, 2
For this 86kg patient, the calculation yields:
When using premixed insulin like Novomix, divide the total daily dose as approximately two-thirds before breakfast and one-third before dinner. 2
For severe hyperglycemia (HbA1c ≥9%, blood glucose ≥300-350 mg/dL), consider higher starting doses of 0.3-0.5 units/kg/day (26-43 units for this patient). 1, 3, 2
Titration Protocol
Increase the dose by 2 units every 3 days if fasting glucose is 140-179 mg/dL, or by 4 units every 3 days if fasting glucose is ≥180 mg/dL. 3, 2
Target fasting plasma glucose of 80-130 mg/dL (4.4-7.2 mmol/L). 3, 2
If hypoglycemia occurs without clear cause, reduce the dose by 10-20% immediately. 3, 2
Daily fasting blood glucose monitoring is essential during the titration phase. 3, 2
Foundation Therapy Considerations
Continue metformin (unless contraindicated) when initiating or intensifying insulin therapy, as it reduces total insulin requirements and provides complementary glucose-lowering effects. 3, 2
Metformin should be dosed at least 1000mg twice daily (2000mg total) for optimal effect, with a maximum effective dose of up to 2500mg/day. 3
Important Clinical Considerations
Novomix should be administered immediately before meals (0-15 minutes), not 30 minutes before like regular human insulin. 4, 5
The biphasic formulation contains both rapid-acting and intermediate-acting insulin components, providing both prandial and basal coverage. 4
Premixed insulins like Novomix have suboptimal pharmacodynamic profiles for covering postprandial glucose excursions compared to basal-bolus regimens. 1
Critical Pitfalls to Avoid
Do not delay insulin therapy in patients not achieving glycemic goals with oral medications alone. 1, 3
Avoid using premixed insulins in hospitalized patients due to unacceptably high rates of iatrogenic hypoglycemia. 3, 2
When basal insulin exceeds 0.5 units/kg/day (43 units for this patient) without achieving targets, consider transitioning to a basal-bolus regimen rather than continuing to escalate the premixed insulin. 3
Never convert from NPH to Novomix on a 1:1 basis—always use 80% of the NPH dose to prevent hypoglycemia. 2
Patient Education Requirements
Teach proper insulin injection technique and site rotation to prevent lipohypertrophy. 3
Educate on recognition and treatment of hypoglycemia, including having glucose tablets or fast-acting carbohydrates readily available. 3
Instruct on self-monitoring of blood glucose, "sick day" management rules, and proper insulin storage. 3