When should Novolog (insulin aspart) be held in a patient with type 2 diabetes and poorly controlled blood sugar levels, taking Lantus (insulin glargine) and Ozempic (semaglutide)?

When to Hold Novolog (Insulin Aspart)

Immediate Situations Requiring Novolog to Be Held

Hold Novolog immediately if the patient is NPO (nothing by mouth), has hypoglycemia (blood glucose ≤70 mg/dL), or cannot eat within 15 minutes of administration. 1

Critical Hypoglycemia Thresholds

• Hold all prandial insulin when blood glucose is ≤70 mg/dL and treat with 15 grams of fast-acting carbohydrate before any insulin administration 2
• If the patient experiences severe hypoglycemia requiring assistance, reduce the total insulin dose by 10-20% immediately and reassess the entire regimen 2
• Hold Novolog if the patient has recurrent hypoglycemia (multiple episodes <70 mg/dL in recent days), as this indicates the current regimen is too aggressive 2

NPO Status and Reduced Oral Intake

• Hold all prandial insulin (Novolog) when the patient is NPO for procedures, surgery, or acute illness 1
• During perioperative periods, basal insulin (Lantus) should be reduced by approximately 25% the evening before surgery, but prandial insulin should be completely held 2
• For hospitalized patients with poor oral intake, hold Novolog and use only basal insulin at reduced doses (0.1-0.25 units/kg/day for high-risk patients) 2

Specific Clinical Scenarios

Perioperative Management

• Stop Novolog on the morning of surgery while continuing basal insulin at a reduced dose 1
• The patient should remain on basal insulin only (Lantus reduced by 25%) until oral intake resumes, at which point Novolog can be restarted with meals 1, 2
• Regional anesthesia is preferred when possible, as it allows better postoperative pain control and facilitates earlier resumption of normal eating patterns 1

Acute Illness with Nausea/Vomiting

• Hold Novolog if the patient develops nausea, vomiting, or abdominal pain, especially if taking Ozempic (semaglutide), as GLP-1 agonists can cause gastrointestinal side effects that prevent adequate oral intake 1
• If ketoacidosis symptoms develop (dyspnea, nausea, vomiting, abdominal pain), hold all oral medications and Novolog, and seek immediate medical attention 1

Medication Interactions and Regimen Changes

When adding or optimizing Ozempic (semaglutide) to the regimen, reduce or discontinue Novolog if adequate glycemic control is achieved, due to severe hypoglycemia risk. 1, 3

• The combination of basal insulin (Lantus) plus GLP-1 agonist (Ozempic) often provides adequate glycemic control without requiring prandial insulin 3, 2
• If HbA1c reaches target (<7-8%) on Lantus plus Ozempic, Novolog should be discontinued or significantly reduced 1
• When HbA1c falls below 6.5%, deintensify treatment by reducing or stopping Novolog to prevent hypoglycemia 1

Monitoring Requirements Before Each Dose

Pre-Meal Blood Glucose Checks

• Always check blood glucose immediately before administering Novolog 2
• Hold the dose if blood glucose is <100 mg/dL and the patient is eating a small meal or has unpredictable carbohydrate intake 2
• Adjust or hold the dose if the patient's meal size is significantly smaller than usual 2

Timing Considerations

• Novolog must be given 0-15 minutes before meals, not after eating 2
• If the patient cannot eat within 15 minutes of administration, hold the dose until they are ready to eat 2

Common Pitfalls to Avoid

• Never continue Novolog at full doses when Ozempic is achieving glycemic targets, as this combination dramatically increases hypoglycemia risk 1, 3
• Do not hold basal insulin (Lantus) when holding Novolog—basal insulin should be continued (possibly at reduced doses) even when NPO 1, 2
• Avoid using sliding scale insulin as a substitute for properly timed Novolog doses, as this reactive approach is explicitly condemned by all major diabetes guidelines 2
• Do not restart Novolog at previous doses after an episode of severe hypoglycemia without reducing the total insulin regimen by 10-20% 2

Special Considerations for This Patient

Given this patient is on Lantus (basal insulin) and Ozempic (GLP-1 agonist) with poorly controlled blood sugar, the priority should be optimizing Lantus dosing (increasing by 2-4 units every 3 days until fasting glucose reaches 80-130 mg/dL) before adding or continuing Novolog 2. If Novolog is currently being used, it should be held or reduced if hypoglycemia occurs, and the entire regimen should be reassessed to ensure the basal insulin is adequately titrated first 3, 2.