Conversion : Novomix to Mixtard

• A more rapid onset-of-action means that the newer analogue premixed insulins are more effective at lowering post-prandial rises in glucose. 
• Rapid-acting analogues have a shorter duration of action than human insulin, there is a much lower risk of hypoglycaemia, especially in the hours prior to the next meal. 
• In a meta-analysis, Davidson et al (2009) found that premixed insulin containing the analogue aspart was associated with 50% reduced rates of nocturnal hypoglycaemia and 65% less major hypoglycaemia than human premixed insulin.

Dose Equivalence

• Unit to unit equivalent
• However, Novomix (analgoues) have a faster onset of reactions  
• Ensure patients are counselled, especially on the importance of initial blood glucose monitoring following the switch and monitored for compliance and adverse events.

 

 
Premixed-Insulin as TDS Dosing

• not recommended by manufacturer or guides
• however a study on thrice daily biphasic human insulin regimen showed it is non-inferior to the basal bolus insulin analogue regimen in terms efficacy and safety in patients with poorly controlled T2DM (dose split by 40:20:40) 

References:

1. Wu T (2016) Premixed insulin analogues: A new look at an established option. Diabetes & Primary Care Australia 1: 129–33
2. Clinical Resource, Initiation and Adjustment of Insulin Regimens for Type 2 Diabetes. Pharmacist’s Letter/Prescriber’s Letter. March 2017 
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307189/
4. http://www.gpnotebook.co.uk/simplepage.cfm?ID=x20160214160507771435

Interaction: Warfarin and Liver

• Liver is often seen suggested as a source of vitamin K2 and beef liver in particular has been recommended as a good dietary source. 
• From the tables below it seems that while the beef liver tested contains mk-4, it is not a particularly good source 
• However, most studies have not tested for long-chain menaquinones, mk-6 to mk-13, which are produced by the bacterial fermentation in the stomachs of cattle and provide them with a readily absorbable source of vitamin K2. 
• When absorbed from the gut these reach the liver first where they appear to remain. 
• This can be seen as very little long chain menaquinones were detected in any of the other meat or organs of cattle. 
• The only small study that has tested for these found quite high levels of menaquinones 11, 12, and 13

as a comparison, a 100g of cabbage/brocoli has 100mcg of vitamin K, while that of spinach contains 200mcg.

References:

1. Vitamin K. Academic Press, 3 Mar 2008
2.  https://honey-guide.com/2014/03/10/menaquinones-k2-and-phylloquinone-k1-content-of-animal-products-and-fermented-foods/ 
3. http://apjcn.nhri.org.tw/server/info/books-phds/books/foodfacts/html/data/data3e.html