Adult Dosing

Diabetes Mellitus

Novolin R, Humulin R

• Individualizing regimens with an intermediate or long-acting insulin plus a rapid-acting insulin before meals is common
• 50%-70% of total insulin requirements are usually provided by rapid/ultra-short insulin, with the remaining 30%-50% provided by intermediate or long-acting insulin
• Usual total daily insulin requirements are 0.5-1 U/kg/day SC divided 2-4 times daily; give <15 min before meals
• May infuse SC by an external insulin pump. Diluted insulin should not be used in external insulin pumps. Programming insulin infusion pumps is based on the patient’s usual total daily insulin dose
• Onset approx 15-30 minutes (regular insulin 30-60 minutes), peak approx 1-3 hours, duration 3-5 hours for rapid-acting insulins
• Patient’s need to be aware that insulin dose changes should be done based upon an agreed upon protocol under medical supervision

Diabetic ketoacidosis

Novolin R

• 0.05-1 U/mL/day IV
• Notes
• Insulin regular is a short acting insulin and can be used when a little longer duration of action is required
• Rapid Insulin may be administered IV, diluted in 0.9% sodium chloride in concentrations of 0.05-1 unit/mL
• Any change of insulin dose should be made with careful consideration of glucose levels, current dosage and patterns of high and/or low blood glucose levels
• Safety and efficacy in pediatric patients <2 yrs has not been established

• Continuous subcutaneous infusion pump
• Avoid mixing or diluting when using in an external insulin infusion pump

• Intravenous infusion
• Dilute to 0.05-1 unit/mL for IV administration in 0.9% sodium chloride in polyvinyl chloride infusion bags
• Dosing typically 0.1 U/kg/hr as an IV infusion (for DKA) [see separate topic on DKA]
• As with all IV uses of insulin; carefully monitor glycemic response and potassium levels

Pediatric Dosing

Diabetes Mellitus-Children >2 yrs

Novolin R, Humulin R

• Individualizing regimens with an intermediate or long-acting insulin plus a rapid-acting insulin before meals is common
• 50%-70% of total insulin requirements are usually provided by rapid/ultra-short insulin, with the remaining 30%-50% provided by intermediate or long-acting insulin
• Usual total daily insulin requirements are 0.5-1 U/kg/day SC divided 2-4 times daily; give <15 min before meals
• May infuse SC by an external insulin pump. Diluted insulin should not be used in external insulin pumps. Programming insulin infusion pumps is based on the patient’s usual total daily insulin dose
• Onset approx 15-30 minutes (regular insulin 30-60 minutes), peak approx 1-3 hours, duration 3-5 hours for rapid-acting insulins
• Patient’s need to be aware that insulin dose changes should be done based upon an agreed upon protocol under medical supervision

Diabetic ketoacidosis

Novolin R

• 0.05-1 U/mL/day IV
• Notes
• Rapid Insulin may be administered IV, diluted in 0.9% sodium chloride in concentrations of 0.05-1 unit/mL
• Any change of insulin dose should be made with careful consideration of glucose levels, current dosage and patterns of high and/or low blood glucose levels
• Safety and efficacy in pediatric patients <2 yrs has not been established

• Continuous subcutaneous infusion pump
• Avoid mixing or diluting when using in an external insulin infusion pump

• Intravenous infusion
• Dilute to 0.05-1 unit/mL for IV administration in 0.9% sodium chloride in polyvinyl chloride infusion bags
• Dosing typically 0.1 U/kg/hr as an IV infusion (for DKA) [see separate topic on DKA]
• As with all IV uses of insulin; carefully monitor glycemic response and potassium levels

[Outline]

• Adult Dosing
• Pediatric Dosing

• Type I & II Diabetes mellitus
• Diabetic ketoacidosis

• Hypersensitivity to any of the ingredients of the product
• Episodes of hypoglycemia

• N/A

Renal Dose Adjustment

• Renal impairment: Dose reduction recommended, dose adjustments not defined

Hepatic Dose Adjustment

• Hepatic impairment: Dose reduction recommended, dose adjustments not defined

See Supplemental Patient Information

• Hypoglycemia is the most common adverse effect of insulin. Change in insulin strength, timing of dosing, or frequency may require a change in the dosage. Concomitant oral treatment may need to be changed
• Check blood sugar frequently and watch for signs of hypoglycemia. Any change in insulin strength, manufacturer, type, species, or method of administration should be made cautiously and only under medical supervision
• Unexplained hyperglycemia or ketosis characterized as drowsy feeling, flushed face, thirst, loss of appetite, fruity odor of the breath, heavy breathing and a rapid pulse can occur. Prompt identification and correction of the cause is necessary. Provide interim therapy with subcutaneous insulin injections
• Insulin therapy can cause hypokalemia that can lead to respiratory paralysis, ventricular arrhythmia, and death, and is more likely to occur after intravenous administration. Closely monitor potassium levels and use cautiously in patients at risk of hypokalemia
• Dose adjustment is required if there is any change in physical activity or usual meal plan, and also during illness, emotional disturbances, or other stress
• If lipoatrophy or lipohypertrophy occur following subcutaneous insulin administration, change the injection technique
• Local or serious systemic allergic reactions can occur with insulin administration. Provide immediate treatment in case of allergic reaction
• In patients with hepatic and renal impairment, consider dose reduction and frequent glucose monitoring
• Concomitant use of oral antihyperglycemic drugs is not recommended
• Concomitant use of thiazolidinediones can cause dose-related fluid retention, which may lead to or exacerbate heart failure. Monitor for signs and symptoms of heart failure and treat accordingly or consider discontinuation or dose reduction

Cautions: Use cautiously in

• Renal Impairment
• Hepatic Impairment
• Infection, stress, or illness
• Hypokalemia
• Concomitant use of potassium-lowering drugs
• Diabetic nerve disease

Supplemental Patient Information

• Training on injection and signs of hypoglycemia is essential

Pregnancy Category:B

Breastfeeding: No specific data available on the use of insulin during breastfeeding. No adverse reactions have been reported due to insulin in breastmilk, infact insulin in breastmilk may decrease the risk of type 1 diabetes in breastfed infants. In general mothers with diabetes using insulin may nurse their infants. As per one study insulin requirements are reduced postpartum in women with type I diabetes. The lower basal insulin requirement was thought to be caused by glucose use for milk production. This information is based upon LactMed database (available at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT last accessed 28 April 2011).

• METABOLIC: Hypoglycemia, hypokalemia, weight gain
• MISC: Hypersensitivity and allergic reactions, peripheral edema, infection
• LOCAL: Lipodystrophy, injection site reaction

• Short acting insulin; regulates glucose metabolism, stimulates peripheral glucose uptake by skeletal muscle and fat, inhibits hepatic glucose production. inhibits lipolysis and proteolysis
• Metabolism/ Excretion: Cleared by metabolic degradation via a receptor-mediated process
• Half-life: 141 mins

US Trade Name(s)

• Humulin R
• Humulin R Pen
• Novolin R

US Availability

Humulin R

• INJ: 500 U/mL (20 mL vial)
• OTC INJ: 100 U/mL (3, 10 mL vials)

Humulin R Pen

• OTC INJ: 100 U/mL

Novolin R

• OTC INJ: 100 U/mL (3 mL cartridge)

Canadian Trade Name(s)

• Humulin R
• Novolin GE

Canadian Availability

Humulin R

• INJ: 100 U/mL (3, 10 mL vials)
• INJ: 100 U/mL (3 mL cartridge)

Novolin GE

• INJ: 100 U/mL (10 mL vials)
• INJ: 100 U/mL (3 mL cartridge)
• Novolin GE FlexPen: 100 units/mL (3mL prefilled disposable injection device)
• Novolin ge InnoLet: 100 units/mL (3mL prefilled disposable injection device)

UK Trade Name(s)

• Actrapid
• Humulin S
• Insulatard
• Insuman Rapid

UK Availability

Actrapid

• INJ: 100 U/mL (10 mL vials)

Humulin S

• INJ: 100 U/mL (10 mL vials)
• INJ: 100 U/mL (3 mL cartridge)

Insulatard

• INJ: 100 U/mL (10 mL vials)
• INJ: 100 U/mL (3 mL cartridge)
• Insulatard InnoLet: 100 units/mL (3mL prefilled disposable injection device)

Insuman Rapid

• INJ: 100 U/mL (3 mL cartridge)
• Optiset pens: 100 units/mL (3mL prefilled disposable injection device)

Australian Trade Name(s)

• Actrapid
• Humulin R

Australian Availability

Actrapid

• INJ: 100 U/mL (10 mL vials)
• INJ: 100 units/mL (3mL prefilled disposable injection device)

Humulin R

• INJ: 100 U/mL (10 mL vials)
• INJ: 100 U/mL (3 mL cartridge)

[Outline]

Endocrine/Metabolic

Antidiabetic Agents

Insulins

Endocrine/Metabolic

Antidiabetics

Insulins

Pricing data from www.DrugStore.com in U.S.A.

• NovoLIN R 100 UNIT/ML SOLN [Vial] (NOVO NORDISK)
  10 ml = $75.99
  30 ml = $203.97
• HumuLIN R 100 UNIT/ML SOLN [Vial] (LILLY)
  10 ml = $73.99
  30 ml = $201.97
• HumuLIN R U-500 (Concentrated) 500 UNIT/ML SOLN [Vial] (LILLY)
  20 ml = $443.01
  60 ml = $1298.03

Warning: This pricing information is subject to change at the sole discretion of DS Pharmacy. For the most current and up-to-date pricing information, please visit drugstore.com.