What is the recommended dosage of Novorapid (insulin aspart) for controlling blood sugar levels in a patient with diabetes?

Novorapid (Insulin Aspart) Dosing for Blood Sugar Control

Administration Timing and Route

Novorapid must be administered subcutaneously within 5-10 minutes before a meal, not after eating, to effectively manage postprandial glucose levels. 1

• Inject into the abdominal area, thigh, buttocks, or upper arm, rotating injection sites within the same region to reduce risk of lipodystrophy 1
• Novorapid should generally be used in regimens with an intermediate- or long-acting basal insulin 1

Initial Dosing Strategy

For Type 2 Diabetes (Adding Prandial Insulin to Basal Insulin)

Start with 4 units of Novorapid before the largest meal, or use 10% of the current basal insulin dose. 2, 3

• This applies when basal insulin has been optimized (fasting glucose 80-130 mg/dL) but HbA1c remains above target after 3-6 months 3
• Alternatively, when basal insulin exceeds 0.5 units/kg/day without achieving glycemic targets, adding prandial insulin becomes more appropriate than continuing to escalate basal insulin alone 3

For Type 1 Diabetes (Basal-Bolus Regimen)

The total daily insulin requirement is typically 0.5 units/kg/day, with approximately 50% as basal insulin and 50% as prandial insulin (Novorapid) divided among three meals. 3, 4

• For a 70 kg patient, this translates to approximately 35 units total daily: 17.5 units basal insulin and 17.5 units Novorapid split across meals (approximately 6 units per meal) 3
• Metabolically stable patients with type 1 diabetes typically require 0.5 units/kg/day, though this may range from 0.4-1.0 units/kg/day 3, 4

For Severe Hyperglycemia (HbA1c ≥10-12%)

Start with basal-bolus therapy immediately at 0.3-0.5 units/kg/day total daily dose, split 50:50 between basal insulin and Novorapid. 2, 3

• For a 70 kg patient with severe hyperglycemia, this means 21-35 units total daily: 10.5-17.5 units basal and 10.5-17.5 units Novorapid divided among three meals 3

Titration Protocol

Increase Novorapid by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings, targeting postprandial glucose <180 mg/dL. 3, 4

• If hypoglycemia occurs without clear cause, reduce the corresponding dose by 10-20% immediately 3
• Check pre-meal and 2-hour postprandial glucose to guide prandial insulin adjustments 3

Carbohydrate Coverage (Advanced Dosing)

A common starting insulin-to-carbohydrate ratio is 1 unit per 10-15 grams of carbohydrate. 3

• The formula for insulin-to-carbohydrate ratio is 450 ÷ total daily dose for rapid-acting analogs like Novorapid 3
• For example, if total daily insulin is 45 units, the ratio would be 450 ÷ 45 = 10 grams of carbohydrate per 1 unit of Novorapid 3

Correction Doses

For patients not counting carbohydrates, use a simplified approach: add 2 units of Novorapid for pre-meal glucose >250 mg/dL, and 4 units for pre-meal glucose >350 mg/dL. 3

• The insulin sensitivity factor (correction factor) can be calculated as 1500 ÷ total daily dose 3
• Correction insulin should be used as an adjunct to scheduled doses, not as monotherapy 3

Special Populations

Hospitalized Patients

For hospitalized patients requiring basal-bolus therapy, use 0.3-0.5 units/kg/day total daily dose, split 50:50 between basal insulin and Novorapid divided among three meals. 3, 4

• For high-risk patients (elderly >65 years, renal failure, poor oral intake), reduce starting dose to 0.1-0.25 units/kg/day 3, 4
• For patients on high-dose home insulin (≥0.6 units/kg/day), reduce total daily dose by 20% upon hospitalization to prevent hypoglycemia 3, 4

Patients with Renal Impairment

For patients with CKD Stage 5 and type 2 diabetes, reduce total daily insulin dose by 50%; for type 1 diabetes, reduce by 35-40%. 3

• Titrate conservatively in patients with eGFR <45 mL/min/1.73 m² to avoid hypoglycemia 3

Patients on Corticosteroids

Increase prandial Novorapid by 40-60% or more in addition to basal insulin for patients on steroids. 3

• Current guidelines recommend basal-bolus insulin at 0.3-0.5 units/kg/day, split 50:50 between basal (Optisulin/glargine) and Novorapid with each meal for severe steroid-induced hyperglycemia 2

Continuous Subcutaneous Insulin Infusion (Pump Therapy)

Novorapid can be used in insulin pumps labeled for use with NovoLog, with approximately 40-60% of total daily dose as basal delivery and the remainder as mealtime and correction boluses. 3, 1

• Change the Novorapid in the reservoir at least every 7 days 1
• Do not dilute or mix Novorapid when administering by continuous subcutaneous infusion 1
• Do not expose Novorapid in the pump reservoir to temperatures greater than 98.6°F (37°C) 1

Critical Thresholds and Warning Signs

When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, adding or intensifying Novorapid becomes more appropriate than continuing to escalate basal insulin alone. 3

• Clinical signals of "overbasalization" include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 3
• These signs indicate the need for mealtime insulin coverage rather than further basal insulin increases 3

Common Pitfalls to Avoid

• Never use sliding scale insulin as monotherapy – it treats hyperglycemia reactively rather than preventing it, leading to dangerous glucose fluctuations 3
• Never give Novorapid at bedtime – rapid-acting insulin at bedtime significantly increases nocturnal hypoglycemia risk 3
• Never continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia – this leads to overbasalization with increased hypoglycemia risk and suboptimal control 3
• Never mix Novorapid with other insulins in an insulin pump – it should only be mixed with NPH insulin for subcutaneous injection, and only when withdrawn into the syringe first 1

Monitoring Requirements

Check fasting blood glucose daily and pre-meal/2-hour postprandial glucose to guide Novorapid adjustments during titration. 3

• Assess adequacy of insulin dose at every clinical visit, looking for signs of overbasalization 3
• Reassess and modify therapy every 3-6 months once stable to avoid therapeutic inertia 3

Hypoglycemia Management

Treat hypoglycemia at blood glucose ≤70 mg/dL with 15 grams of fast-acting carbohydrate. 3

• If hypoglycemia occurs, determine the cause and reduce the Novorapid dose by 10-20% 3
• Scrupulous avoidance of hypoglycemia for 2-3 weeks can reverse hypoglycemia unawareness if present 3