Use: For the treatment of hyperkalemia. 40-50 min. Dosage adjustment when adding prandial insulin: Consider reducing the basal insulin dose by 4 units (or ~10%) if HbA1c is <8% when initiating prandial insulin (ADA 2020). If excess insulin is produced, the utilization of sugar in the body will be too high and its level falls in the blood (hypoglycemia) which upsets nerve and muscle functioning. -Glycosylated hemoglobin measurements are recommended every 3 months. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect: • Low blood sugar like dizziness, headache, fatigue, feeling weak, shaking, fast heartbeat, confusion, increased hunger, or sweating. Use: Treatment of diabetic ketoacidosis (DKA). SubQ: For subcutaneous administration into the thigh, upper arm, buttocks, or abdomen; do not administer IM or IV, or in an insulin pump. -Total daily insulin requirements are generally between 0.5 to 1 unit/kg/day -Regular human insulin is generally the preferred insulin for IV administration Use: To improve glycemic control in pediatric patients with diabetes mellitus. -An endocrinologist or critical care specialist with training and expertise in the management of DKA should direct care; frequent monitoring of clinical and laboratory parameters is necessary as well as identification and correction of precipitating event. -Insulin resistant patients that require daily insulin doses of more than 200 units may find U-500 insulin to be useful as large doses may be administered subcutaneously in a reasonable volume. Management: Consider insulin dose reductions when used in combination with glucagon-like peptide-1 agonists. -May administer in combination with oral antidiabetic agents. Evaluate risk versus benefit of long-term postoperative use and consider alternative therapy due to potential for insulin-induced weight gain (Apovian 2015). Alternatively, if you measure your body weight in kilograms: Total Daily Insulin Requirement (in units of insulin… -To avoid any mix-up with the availability of 2 different regular human insulin concentrations (U-100 and U-500), insulin doses should always be ordered in units not in volume. However, an observational study in patients with type 2 diabetes from a large health care delivery system found no difference in the incidence of ER visits or hospitalization for hypoglycemia with NPH compared with glargine/detemir when treating to conventional targets in a real world setting (Lipska 2018). Once punctured (in use), Humulin vials, cartridges and pens should be stored at room temperature <25°C (<77°F) for up to 4 weeks. 1:31. Insulin requirements may be altered during illness, emotional disturbances, or other stressors. Insulin NPH is an intermediate-acting insulin formulation which is usually administered subcutaneously once or twice daily. Dose titration: Treatment and monitoring regimens must be individualized to maintain premeal and bedtime glucose in target range, titrate dose to achieve glucose control, and avoid hypoglycemia. Medically reviewed by In the critical care setting, continuous IV insulin infusion (insulin regular) has been shown to best achieve glycemic targets. • Hepatic impairment: Use with caution in patients with hepatic impairment. Intravenous Administration U-100 insulin only: Multiple-Daily Insulin (MDI) injections: Utilizing a combination of prandial (i.e., bolus, rapid, or short-acting insulins) and basal (i.e., intermediate or long acting insulin) insulin, may administer 3 to 4 injections per day; regular human insulin is a short-acting prandial insulin -Closely monitor blood glucose and serum potassium during IV administration Dividing the total daily dose of insulin NPH into 3 or 4 doses per day may reduce hypoglycemic risk and establish a more consistent basal insulin profile (Peters 2013). Intravenous Administration: U-100 insulin only; While taking additional insulin (insulin replacement /injection) is very common in people with type-1 diabetes, do people with type-2 also need to take it? Comments: Cartridges [Canadian product] should be inverted 180° at least ten times. -Following insulin administration, adequate glucose monitoring will be necessary for several hours. -May be used in combination with oral antihyperglycemic agents or longer-acting basal insulin Prospective Diabetes Study, patients with type 2 diabetes who were taking insuli… Usual total daily maintenance range: SubQ: Doses must be individualized; however, an estimate can be determined based on phase of diabetes and level of maturity (ISPAD [Danne 2018]; ISPAD [Sundberg 2017]): Partial remission phase (Honeymoon phase): <0.5 units/kg/day. Children ≥10 years and Adolescents with ketosis/ketoacidosis/ketonuria: SubQ: Initial: 0.25 to 0.5 units/kg/dose once daily; use in in combination with lifestyle changes and metformin to achieve goals (ISPAD [Zeitler 2018]). -Most people with type 1 diabetes should be educated in how to match prandial insulin dose to carbohydrate intake, pre-meal blood glucose, and anticipated activity. Avoid the use of bolus insulin injections or dose conservatively with close clinical monitoring in the early phases after surgery. Avoid combination, Salicylates: May enhance the hypoglycemic effect of Agents with Blood Glucose Lowering Effects. • Hospitalized patients with diabetes: Exclusive use of a sliding scale insulin regimen (insulin regular) in the inpatient hospital setting is strongly discouraged. Individualize dose based on metabolic needs and frequent monitoring of blood glucose Use with caution in patients at risk for hypokalemia (eg, loop diuretic use). -Potassium levels should be monitored, especially in patients at risk of low potassium and for those receiving IV insulin. -Closely monitor blood glucose and serum potassium during IV administration Note: This is not a comprehensive list of all side effects. Afternoon procedure: Administer 70% to 100% of the usual morning dose of insulin NPH depending on the amount of breakfast allowed. Prepubertal children (not in partial remission): Infants ≥6 months and Children ≤6 years: 0.4 to 0.8 units/kg/day, Pubescent Children and Adolescents: During puberty, requirements may substantially increase to >1 unit/kg/day and in some cases up to 2 units/kg/day. Monitor patients for fluid retention and signs/symptoms of heart failure, and consider pioglitazone dose reduction or discontinuation if heart failure occurs Consider therapy modification, Pramlintide: May enhance the hypoglycemic effect of Insulins. Quinolones may diminish the therapeutic effect of Agents with Blood Glucose Lowering Effects. Patients with renal or hepatic impairment may be at a higher risk. Novolin N FlexPen: Store unopened pen in the refrigerator between 2°C and 8°C (36°F to 46°F) until product expiration date or at room temperature <30°C (<86°F) for 28 days; do not freeze; keep away from heat and sunlight. Within the liver, insulin stimulates hepatic glycogen synthesis. Consider therapy modification, Thiazide and Thiazide-Like Diuretics: May diminish the therapeutic effect of Antidiabetic Agents. Insulin secretion and sensitivity may be partially or completely restored after these procedures (Korner 2009; Peterli 2012). If heart failure develops, consider PPAR-gamma agonist dosage reduction or therapy discontinuation. Since combinations of agents are frequently used, dosage adjustment must address the individual component of the insulin regimen which most directly influences the blood glucose value in question, based on the known onset and duration of the insulin component. Patient advice: If so, when does type-2 diabetes require this insulin replacement? Initiate insulin infusion 1 to 2 hours after starting fluid replacement therapy This type of insulin is often used with longer-acting insulin. Safety and efficacy of U-500 insulin have not been established in patients younger than 18 years. • Renal impairment: Use with caution in patients with renal impairment. According to Health Central, the levels should be about 10-20 mcU/ml, while a Dr. Mercola says the normal levels should be under 5 mcU/ml. Use: To improve glycemic control in adult patients with diabetes mellitus. Insulin Regular (U-100) Cartridges & Prefilled Pens. Administration advice: Always double check insulin labels before administration Note: Regular human insulin is available in 2 concentrations: 100 units of insulin per mL (U-100) and 500 units of insulin per mL (U-500); U-500 insulin has not been adequately studied in pediatric patients. Dosage adjustment: Dosage must be titrated to achieve glucose control and avoid hypoglycemia. Based on the American College of Obstetricians and Gynecologists Practice Bulletin for the management of gestational diabetes mellitus (GDM) and the American Diabetes Association Standards of Medical Care for the management of diabetes in pregnancy, insulin may be used to treat GDM when nutrition and exercise therapy are not effective. SubQ: For subcutaneous administration into the thigh, upper arm, buttocks, or abdomen; do not administer IM or IV, or in an insulin pump. Initial therapy in metabolically unstable patients (eg, plasma glucose ≥250 mg/dL, HbA1c >9% and symptoms excluding acidosis) may include once daily intermediate-acting insulin or basal insulin in combination with lifestyle changes and metformin. -Patients should be aware of the differences between insulin and tuberculin syringes for measuring insulin doses, especially if prescribed U-500 regular human insulin; consult U-500 manufacturer's product labeling for a dosing table that provides dosing information for both U-100 insulin syringe and tuberculin syringe. – Type 2 diabetes, hypoglycemia: Closely monitor insulin dose requirement throughout active weight loss with a goal of eliminating antidiabetic therapy or transitioning to agents without hypoglycemic potential; hypoglycemia after gastric bypass, sleeve gastrectomy, and gastric band may occur (Mechanick 2013). This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment. Today's insulin is safer, more effective, and easier to use than the insulin first used by people with diabetes in 1922, which was extracted from an ox. -Use HbA1c values to guide therapy; consult current guidelines for optimal target ranges Monitor therapy, Antidiabetic Agents: May enhance the hypoglycemic effect of Hypoglycemia-Associated Agents. The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. The goal of insulin therapy is to keep your blood sugar levels within a target range. Patients using twice daily insulin NPH: Consider intensification of therapy with additional agents that target postprandial glucose rather than continuing to increase the insulin NPH dose (AACE/ACE [Garber 2020]; ADA 2020). Weight gain associated with insulin therapy is due to the anabolic effects of insulin, increased appetite, defensive eating from hypoglycemia, and increased caloric retention related to decreased glycosuria. Most people with type 2 diabetes will eventually require insulin, and the transition is easier than you might think. Note: Regular human insulin is available in 2 concentrations: 100 units of insulin per mL (U-100) and 500 units of insulin per mL (U-500) Insulin therapy is used to slowly correct high glucose levels; consult current treatment protocols for specific guidance on fluid and electrolyte management. A blood glucose value <70 mg/dL should prompt a treatment regimen review and change, if necessary, to prevent further hypoglycemia (ADA 2020). -To prevent rebound hyperglycemia, initiate subcutaneous insulin 15 to 30 minutes (rapid-acting) or 1 to 2 hours (regular insulin) before stopping the insulin infusion; alternatively, basal insulin may be administered in the evening and the insulin infusion stopped the next morning. -Insulin requirements in pre-pubertal children who are outside the partial remission phase are usually from 0.7 to 1 unit/kg/day The easiest way to lookup drug information, identify pills, check interactions and set up your own personal medication records. Adjust dose to maintain premeal and bedtime glucose in target range. Last updated on Apr 6, 2020. Treatment and monitoring regimens must be individualized. Table 1 summarizes the most important relationships among various components of the insulin prescription, their injection times, and the most appropriate self-monitoring of blood glucose (SMBG) test to judge their effects. Target organs for insulin include the liver, skeletal muscle, and adipose tissue. Subscribe to newsletters for the latest medication news, new drug approvals, alerts and updates. Regular insulin is short-acting and starts to work within 30 minutes after injection, peaks in 2 to 3 hours, and keeps working for up to 8 hours. Insulin dose reduction of ≥75% has been suggested after gastric bypass for patients without severe β-cell failure (fasting c-peptide <0.3 nmol/L) (Cruijsen 2014). The injection device should be clearly labeled with individual patient information to ensure that the correct pen is used (CDC, 2012). -Insulin therapy should be initiated in children and adolescents for whom the distinction between type 1 diabetes mellitus and type 2 diabetes mellitus is unclear, specifically those with a random venous or plasma blood glucose concentration of 250 mg/dL or greater, or those who HbA1c is greater than 9%. Excipient information presented when available (limited, particularly for generics); consult specific product labeling. -Humulin(R): Unrefrigerated vial (opened or unopened): Use within 31 days; keep as cool as possible (not above 86F (30C)); do not expose to excessive heat or light Once punctured (in use), should be stored below 30°C (86°F) for up to 14 days. Consider therapy modification, Guanethidine: May enhance the hypoglycemic effect of Antidiabetic Agents. • Cardiac disease: Concurrent use with peroxisome proliferator-activated receptor (PPAR)-gamma agonists, including thiazolidinediones (TZDs) may cause dose-related fluid retention and lead to or exacerbate heart failure, particularly when used in combination with insulin. Once punctured (in use), store vials at room temperature ≤25°C (≤77°F) for up to 42 days; refrigeration of in-use vials is not recommended. To minimize hypoglycemia risk, basal insulins are generally titrated once or twice weekly (eg, every 3 or 7 days) (ADA 2019; McCall 2012). Insulin resistance may not cause any noticeable symptoms, so you can have insulin resistance and not know it. Individualized medical nutrition therapy (MNT) based on ADA recommendations is an integral part of therapy. Know about early signs and find out what you can do to identify the condition as soon as possible. The proper functioning of Insulin … Poorly controlled diabetes during pregnancy can be associated with an increased risk of adverse maternal and fetal outcomes, including diabetic ketoacidosis, preeclampsia, spontaneous abortion, preterm delivery, delivery complications, major birth defects, stillbirth, and macrosomia (ACOG 201 2018). In a healthy individual, insulin production and release is a tightly regulated process, allowing the body to balance its metabolic needs. Insulin is a protein composed of two chains, an A chain (with 21 amino acids) and a B chain (with 30 amino acids), which are linked together by sulfur atoms. Per the manufacturer labeling, Humulin N from a vial may be mixed with insulin lispro or insulin regular and Novolin N from a vial may be mixed only with insulin regular. Consider therapy modification, Alpha-Lipoic Acid: May enhance the hypoglycemic effect of Antidiabetic Agents. Use: Treatment of hyperglycemic hyperosmolar state (also known as hyperosmolar non-ketotic coma (HONK); hyperosmolar hyperglycemic nonketotic syndrome). Pain, weight gain, and hypoglycemia may occur with insulin therapy. Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances. Multiple-daily insulin (MDI) injections: Comments: The most common adverse effect of insulin is hypoglycemia. Monitor therapy, Pegvisomant: May enhance the hypoglycemic effect of Agents with Blood Glucose Lowering Effects. Patients with diabetes receiving enteral feedings (ADA 2020): Note: TDD of insulin is divided into a basal component (intermediate- or long-acting insulin) and nutritional and correctional components (regular insulin or rapid-acting insulins). Initial TDD: ~0.4 to 0.5 units/kg/day; conservative initial doses of 0.2 to 0.4 units/kg/day may be considered to avoid the potential for hypoglycemia; higher initial doses may be required in patients who are obese, sedentary, or presenting with ketoacidosis (AACE [Handelsman 2015]; ADA 2020). Management: Upon initiation of pramlintide, decrease mealtime insulin dose by 50% to reduce the risk of hypoglycemia. -As a meal time insulin, rapid-acting insulin analogs are generally preferred over regular human insulin as analogs have been shown to reduce hypoglycemic risk. Monitor therapy, Metreleptin: May enhance the hypoglycemic effect of Insulins. Insulin has three characteristics: Onset is the length of time before insulin reaches the bloodstream and begins lowering blood sugar. What does insulin do? For elevated HbA1c despite achieving fasting plasma glucose target: Patients using once daily insulin NPH (eg, at bedtime): Consider switching to a twice daily regimen by administering ~80% of the current bedtime dose in 2 divided doses (one example division would be 2/3 of the dose in the morning and 1/3 of the dose at bedtime) (ADA 2020). Continuous Subcutaneous Insulin Infusion (CSII) - Insulin Pump Therapy: Use of regular insulin is not recommended because of the risk of precipitation. What is the role of insulin in diabetes treatment? Insulin production is regulated based on blood sugar levels and other hormones in the body. -Administer U-100 insulin subcutaneously 3 or more times a day approximately 30 minutes prior to start of a meal Diabetes mellitus: Plasma glucose (typically before meals and snacks and at bedtime; occasionally additional monitoring may be required), electrolytes, HbA1c (at least twice yearly in patients who have stable glycemic control and are meeting treatment goals; quarterly in patients not meeting treatment goals or with therapy change [ADA 2020]); renal function, hepatic function, weight. -When blood glucose concentration reaches 200 mg/dL, decrease the insulin infusion to 0.02 to 0.05 unit/kg/hr; dextrose should be added to the IV fluids to maintain a blood glucose between 150 and 200 mg/dL until resolution of DKA (serum bicarbonate level 15 mEq/L or greater, venous pH greater than 7.3, and a calculated anion gap in the normal range) Insulin is a kind of hormone that has crucial function to help cells of the body in absorbing glucose or sugar from the bloodstream. Individualize dose based on metabolic needs and frequent monitoring of blood glucose -If blood glucose does not fall by 10% in first hour, give bolus of 0.14 units/kg while continuing insulin infusion Management: Consider reducing the liraglutide dose if coadministered with insulin.