Transcript Humulin Regular U-500 Insulin:Practical Application in the

Humulin Regular U-500 Insulin:
Practical Application in the
Outpatient Setting
Karen McAvoy RN, MSN, CDE
Joslin Diabetes Center
Affiliate at The Hospital of Central Connecticut
January 22, 2013
Objectives:
• Identify the challenges of using large does of U-100
insulin in insulin resistant patients
• Discuss candidates for U 500 insulin therapy or when
to initiate or transition a patient to U500 insulin
• List the advantages and disadvantages of using U-500
insulin
• Discuss the recommended dosing of U-500 insulin in
insulin resistant patients.
• State the importance of patient education in the safety
and use of U500 insulin therapy.
Challenges of Large Dose U-100
• Absorption is significantly reduced at high doses of insulin
• Pain at the injection site due to large volumes of insulin
• Increased number of injections per day
– Large doses are split up more
• Insulin pens only carry 300 units with a maximum of 60 to 80
units in a dose
– Multiple injections per dose (and multiple pens) if patient
is taking more than 200 units/day
• Cost becomes an issue with such large doses of insulin
– Increased insulin amount
– Need for more supplies
• Syringes, pens, and needles
Candidates for U-500 Insulin
Therapy
• Initial years of using U500 were for Type 1 patients
with severe insulin resistance with receptor
abnormalities Now….for …….
Type 2 diabetes with insulin resistance requiring large
doses of insulin
Poor glycemic control despite > 200 units of insulin per
day
Large doses of insulin that need to reduce the amount
of injections and cost
Pain at the injection site due to large volumes of insulin
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Vial/Box Appearance1
1.
Data on File. Eli Lilly and Company.
Why U-500?
• Less volume can improve the absorption of insulin and
improve insulin metabolism because U 500 insulin is
very concentrated…U-500 is an insulin formulation that
is 5 times more concentrated than usual U-100 insulin.
• U-500 insulin has the same peak as the usual U-100
regular insulin, but its duration is more like that of
NPH, thus works as both basal and bolus insulin, so
patients take less insulin by volume, and typically only
one type of insulin.
• Cost
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Volume Differences Between U100 and
U500 Insulin
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Humulin R U500 Insulin Action:
How Does it
Work?
• onset: 30 minutes
• There is potential for
severe hypoglycemia—18
– 24 hours after the
initial injection
• Peak: 1.75 – 4 hours
(mean about 3 hours)
• Duration of Action: 6 –
10 hours but could last
up to 24 hours
• The action is similar to
both Regular and NPH
• Both Basal and Bolus
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Advantages of switching to U-500
• Allows the patient to receive much larger doses
of insulin with less volume (for example, 100
units U 100 is 20 units of U-500 insulin)
–Will improve absorption at the site
–Decreased pain at injection site
• Fewer daily injections
• Only one kind of insulin-both basal and bolus
• A Decrease in A1C
–Average drop is 1.6% at same TDD of U-100
Disadvantages of U-500 Insulin
• Does not come in a pen, no U-500 syringe, low vision
or impaired dexterity may need device—magni-guide
works and magnifies 1.7 times!!
• Can use U-100 or tuberculin syringe, the ½ cc insulin
is easier to obtain and easier for insurance coverage
• Hypoglycemia – potential for severe 18 – 24 hours
after the initial injection, especially if skipped meal or
unexpected activity
– Hypoglycemia
• Hypoglycemia may increase upon initiation but reduce in
frequency with increased duration of use
– Weight gain
• Average weight is 4.2 kg (9.33 lbs)
Dosing recommendations
• Insulin is administered two to four times a day depending
on the TDD
• It is not recommended to use in combination with other
insulins
• To determine the starting dose the TDD of U-100 insulin
can be converted 1:1
• Greater percentage of TDD is administered in the morning
• Adjustments to therapy are based on weekly trends of
pre-meal and bedtime glucose
– 2 hr postprandial readings cannot be relied on due to
action profile of the insulin
Dosing for a TDD of 200-299 units
• Twice daily injections recommended
– 60% of the TDD in the morning and 40% in the
evening
• Three daily injections can be used
– 40% to 45% of TDD with breakfast
– 30% to 40% of TDD at lunch
– 20% to 30% of TDD at supper
• If readings are less than 50 points from goal the
adjustment increment is 5 points
• If readings are more than 50 points above target the
adjustment increment is 10 points
Dosing for a TDD of 300-599 units
• Three daily injections with meals are recommended
– 40% to 45% of TDD with breakfast
– 30% to 40% of TDD at lunch
– 20% to 30% of TDD at supper
• Four daily injections can be used
– 30% of the TDD is administered before each meal
– 10% of the TDD is a bedtime injection
• If the readings are less than100 points from goal the dose
is adjusted by 25 units
• If the readings are more than 100 points from goal the
dose is adjusted by 50 units
Dosing for a TDD greater than 600 units
• Four daily injections is recommended
– 30% of the TDD is administered before each meal
– 10% of the TDD is a bedtime injection
• If blood glucose readings are not at goal then adjustments
are made in 50 unit increments
Accurate Prescriptions
• Complete:
Humulin R U-500 (concentrated)
150 units at breakfast draw to 30 unit mark on ½ ml U100
insulin syringe
80 units at dinner draw to 16 unit mark on ½ ml U 100
insulin syringe
Disp: 1 vial
Other tips: Patient Education about prescription
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Patient Education: Important Points
• 5 Times stronger
• Humulin R U-500 insulin is dispensed as a 20 ml vial. It
may take a few days for you to obtain the Humulin R
U-500 from your pharmacy.
• Never adjust the dose, unless directed
• Take 30 minutes before the meal
• Do not mix U-500 insulin with any other insulin.
• Blood sugar levels under 70/always carry something
with you.
• Adjusting for special circumstances.
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Handouts Also Include…….
• Card to identify use of Humulin R U-500 insulin.
Present the card at the Emergency Department or the
Hospital
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Practical tips…………….
You can use a magni guide with Humulin R U-500 insulin
Unopened vials in refrigerator, once opened room temperature for
28 days
• Take 30 minutes before meals
• Important to continue working with people on lifestyle
modification including physical acitivity
• Wallet Card
• Free sample voucher for Lily for 1 vial of Humulin R U-500 Insulin
Your suggestions to add to this list??
•
•
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References
• Taylor S. U-500 Concentrated Regular Insulin: Practical
Application in the Outpatient Setting. The Nurse
Practitioner 2012; 37 (9): 47-52
• Segal A, Brunner J, Burch FT, Jackson J. Use of
Concentrated Insulin Human Regular (U-500) for
Patients with Diabetes. Am J Health-Syst Pharm 2010;
67: 1526-1535
• Valentine, V. Don’t Resist Using U-500 Insulin and
Pramlintide for Severe Insulin Resistance. Clinical
Diabetes 2012. Vol 30: 80- 84.
Vial/Box Appearance1
1.
Data on File. Eli Lilly and Company.