How to switch an adult patient with type 2 diabetes from Novo Mix (insulin aspart protamine/insulin aspart) to insulin aspart and insulin glargine as an inpatient?

Switching from NovoMix to Insulin Aspart and Glargine in Hospitalized Patients

Calculate Total Daily Dose from Current NovoMix Regimen

Start by determining the patient's current total daily insulin dose from their NovoMix regimen, as this forms the foundation for the conversion. 1

• Add up all NovoMix doses administered in 24 hours to get the total daily dose (TDD)
• For hospitalized patients who are insulin-naive or on low-dose insulin at home, use 0.3-0.5 units/kg as TDD, with half as basal insulin 2
• For patients on high-dose home insulin (≥0.6 units/kg/day), reduce the TDD by 20% upon hospitalization to prevent hypoglycemia 2, 1

Split the Total Daily Dose: 50% Basal, 50% Bolus

Divide the calculated TDD using a 50:50 split between basal glargine and prandial aspart, as this ratio is specifically recommended for hospitalized patients requiring basal-bolus therapy. 1

• Give 50% of TDD as insulin glargine once daily (typically in the evening) 1, 2
• Divide the remaining 50% equally among three meals as insulin aspart 1, 2
• Example: If TDD = 60 units, give glargine 30 units once daily + aspart 10 units before each meal 2

Adjust for High-Risk Populations

For elderly patients (>65 years), those with renal failure, or poor oral intake, use lower starting doses of 0.1-0.25 units/kg/day to prevent hypoglycemia. 1, 2

• Reduce the calculated TDD by 20-50% in these high-risk groups 1, 2
• Monitor more frequently (every 4-6 hours if poor oral intake) 1

Titration Protocol After Conversion

Adjust basal glargine every 3 days based on fasting glucose patterns, targeting 80-130 mg/dL. 2, 1

• If fasting glucose 140-179 mg/dL: increase glargine by 2 units every 3 days 2
• If fasting glucose ≥180 mg/dL: increase glargine by 4 units every 3 days 2
• Adjust prandial aspart by 1-2 units every 3 days based on 2-hour postprandial glucose, targeting <180 mg/dL 1

Add Correction Insulin

Implement a correction insulin protocol using aspart for premeal glucose >180 mg/dL, separate from scheduled doses. 1

• Use simplified sliding scale: 2 units aspart for glucose >250 mg/dL, 4 units for glucose >350 mg/dL 1
• Never rely on correction insulin alone—scheduled basal-bolus therapy must remain the foundation 1

Critical Threshold Warning

When basal glargine exceeds 0.5 units/kg/day without achieving glycemic targets, intensify prandial insulin rather than continuing to escalate basal insulin alone, as this leads to "overbasalization" with increased hypoglycemia risk. 2, 1

• Clinical signals of overbasalization include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia episodes, and high glucose variability 2

Special Considerations for Poor Oral Intake

If the patient develops poor oral intake after conversion, immediately reduce TDD to 0.1-0.15 units/kg/day given primarily as basal insulin, with correctional aspart only for glucose >180 mg/dL. 1

• Continue basal insulin coverage even with minimal intake, rather than stopping all insulin 1
• Check glucose every 4-6 hours instead of premeal 1

Avoid Common Pitfalls

• Never use sliding scale insulin as monotherapy—this approach is explicitly condemned by all major guidelines and leads to dangerous glucose fluctuations 1
• Never give rapid-acting insulin at bedtime—this increases nocturnal hypoglycemia risk 1
• Never continue premixed insulin (NovoMix) in hospitalized patients—randomized trials show significantly increased hypoglycemia rates compared to basal-bolus regimens 1
• If hypoglycemia occurs, reduce the relevant insulin component by 10-20% immediately 2, 1