Pronounciation
Trade Name(s)
- Humulin R, Novolin ge Toronto
Myxredlin
Only regular human insulin aspart or insulin lispro is given by IV method.
Dose varies greatly. Individualize dose based on route of administration, patient’s metabolic needs, blood glucose monitoring results, and glycemic control goal. It is imperative that dosing is individualized and adjusted based on blood glucose determinations because of the marked loss of insulin from adsorption to glass and plastic infusion containers and tubing; see Precautions. Several protocols have been published. Review institution-specific protocol if available.
Diabetic ketoacidosis or hyperosmolar hyperglycemic state (unlabeled):
Administer a bolus dose of 0.1 unit/kg (optional) followed by a continuous infusion of 0.1 to 0.14 unit/kg/hr. If serum glucose does not fall by at least 10% in the first hour, administer an IV bolus of 0.14 unit/kg and continue the infusion. In addition, if serum glucose does not fall by 50 to 75 mg/dL in the first hour, increase the insulin infusion rate hourly until a steady glucose decline is achieved. The insulin infusion should be continued at a fixed dose until the anion gap has closed in DKA and glucose is not a factor for conversion to SC. (UK [see citation later in this comment] uses ketone <0.3 mmol/L and venous pH >7.3.) If the glucose has declined to less than ∼250 mg/dL, additional dextrose should be given as an infusion, or the insulin infusion rate may be reduced from 0.1 to 0.05 unit/kg/hr.
Hyperkalemia (unlabeled):
Insulin may be used in patients with or without diabetes mellitus to treat hyperkalemia. Must be administered with a dextrose solution in nondiabetic patients. 0.1 unit/kg (not to exceed 10 units) as an IV bolus followed by dextrose 25 Gm IV (25 Gm of dextrose is 500 mL of 5% dextrose or 250 mL 10% dextrose or 50 mL of 50% dextrose) over 5 minutes is an example of one regimen in use.
Diabetic ketoacidosis (unlabeled):
Administer 0.05 to 0.1 unit/kg/hr as a continuous infusion until resolution of ketoacidosis. Transition to a subcutaneous insulin regimen.
Hyperosmolar hyperglycemic state (unlabeled):
Administer 0.025 to 0.05 unit/kg/hr. Titrate infusion rate to achieve a decrease in serum glucose concentration at a rate of 50 to 75 mg/dL/hr.
Administer 0.1 unit/kg of insulin with 400 mg/kg of glucose; usual ratio of combination therapy of insulin to glucose is 1 unit of insulin for every 4 Gm of glucose.
Dose adjustments may be needed with changes in physical activity, changes in meal patterns, changes in renal or hepatic function, or during acute illness.
■ A reduced dose of insulin may be indicated when infusions are discontinued and SQ administration is indicated; see comments under Usual Dose.
■ Dose requirements may be reduced in patients with renal or hepatic impairment.
■ Dose adjustment may be indicated if it is necessary to change from one insulin product to another.
■ Dose adjustment may be needed when coadministered with certain drugs; see Drug/Lab Interactions.
Use only if clear. Dilute with NS to a concentration from 0.1 unit/mL to 1 unit/mL. 100 units of insulin (1 mL) to 100 mL of NS will yield a solution with a final concentration of 1 unit/mL. Also available in a Galaxy premixed single-dose container containing 100 units/100 mL of NS (Myxredlin).
Store unopened vials in refrigerator. A vial that is in use may be stored at RT for 31 days (regular insulin). Protect from sunlight and freezing.
Some insulin may be initially adsorbed to the material of the infusion bag. Regular insulin: Infusion bags prepared as indicated in dilution are stable for 48 hours refrigerated and then may be used at RT for up to an additional 48 hours.
Store in refrigerator in original carton to protect from light until administration. May be stored at RT up to 25° C (77° F) for up to 30 days in original carton. Do not place back in refrigerator. Discard after 30 days if stored at RT. Do not freeze and do not use if it has been frozen. Do not shake. Discard any unused portion.
Do not add supplementary medication or additives.
Other sources suggest specific compatibilities for regular insulin dependent on concentration and manufacturer; consult a pharmacist.
When given in an IV infusion, the rate should be ordered by the physician and will depend on insulin and fluid needs. High-dose insulin is an antidote in calcium channel blocker or beta-blocker overdose treatment. After a bolus of 1 unit/kg IV continuous infusion doses may range from 0.5 to 5 unit/kg/hr (or sometimes higher) in conjunction with dextrose infusion to maintain euglycemia. Use in conjunction with a local Poison Control Center protocol and very close monitoring. See Dilution for example. Follow an insulin infusion protocol for infusion titration based on measured blood glucose.
For DKA/HHS, follow physician orders for fixed-rate insulin infusion and concurrent dextrose replacement when blood glucose is less than 250 mg/dL.
A hormone produced by the pancreas that controls the storage and metabolism of carbohydrates, proteins, and fat. Responsible for regulation of glucose metabolism. Binds to insulin receptors on muscle and fat cells and lowers blood glucose by facilitating cellular uptake of glucose and inhibiting hepatic glucose production. Also inhibits lipolysis, proteolysis, and gluconeogenesis and enhances protein synthesis and conversion of excess glucose into fat. Rapidly and widely distributed. The glucose-lowering activities of regular insulin, insulin aspart, insulin glulisine, and insulin lispro are equipotent when administered by the IV route. The average elimination half-life is dose dependent and ranges from 0.25 to 1 hour depending on dose and product.
Treatment of patients with diabetes mellitus to improve glycemic control, to treat DKA/HHS, or as an antidote in calcium channel or beta-blocker severe toxicity. Usually used as part of a SQ injection regimen or as a SQ infusion administered via an external insulin pump. May be given IV via push using an insulin-specific luer tip syringe through a needleless injection port or continuous infusion. Consistent glucose monitoring is required to prevent hypoglycemia and hypokalemia.
Contraindicated during episodes of hypoglycemia and in patients hypersensitive to regular human insulin, insulin aspart, insulin glulisine, insulin lispro, or one of the excipients of any of these products.
Concomitant oral antidiabetic treatment may need to be adjusted.
■ Hypoglycemia and hypokalemia are potential side effects of insulin therapy. Use caution in patients in whom these side effects may be clinically relevant (e.g., patients who are fasting, have autonomic neuropathy, are using potassium-lowering drugs [e.g., diuretics], or are taking drugs sensitive to serum potassium levels [e.g., digoxin]).
■ Severe hypoglycemia may lead to unconsciousness and/or convulsions and may result in temporary or permanent impairment of brain function or death. Early warning symptoms of hypoglycemia may be different or less pronounced under certain conditions, such as long-standing diabetes, diabetic nerve disease, and the use of medications such as beta-blockers.
■ Untreated hypokalemia may cause respiratory paralysis, ventricular arrhythmia, and death.
■ Use with caution in patients with renal or hepatic impairment; may be at a higher risk of hypoglycemia; see Dose Adjustments. Frequent monitoring may be required.
■ Insulin requirements may be altered during illness or stress.
■ Anti-insulin antibodies have been reported. Clinical significance of anti-insulin antibodies is unknown.
■ Systemic hypersensitivity reactions have been reported. May include hypotension, pruritus, rash, shortness of breath, sweating, tachycardia, and/or wheezing. Anaphylaxis has occurred.
■ See Drug/Lab Interactions.
Insulin potency may be reduced by at least 20% and possibly up to 80% via the glass or plastic infusion container and plastic IV tubing before it actually reaches the venous system when given by infusion. The percentage adsorbed is inversely proportional to the concentration of insulin (the larger the dose, the less adsorption) and takes place within 30 to 60 minutes. Insulin infusion guidelines suggest priming new IV tubing with 20 mL of the insulin infusion solution prior to attaching the tubing to the patient. Do not add other medications or electrolytes to an insulin infusion. Other methods of compensation for insulin loss include the addition of added insulin to saturate binding sites or the use of a syringe pump (instead of infusion containers) to reduce surface area for adsorption.
Depending on indication for use, response to insulin may be measured by blood glucose, blood pH, ketones, BUN, SCr, fluid status, sodium, potassium, chloride, osmolality, anion gap, and mental status. Monitor patient carefully in all situations.
■ Glucose and potassium levels must be monitored closely during IV administration of insulin to avoid potentially fatal hypoglycemia and hypokalemia.
■ Glycosylated hemoglobin (HgbA1c) may be measured to assess long-term glycemic control.
■ See Drug/Lab Interactions.
Monitor blood glucose as directed.
■ Adhere to consistent diet and exercise programs.
■ Avoid alcohol.
■ Review medications or changes in medication regimen with a health care professional.
■ Review S/S of hypoglycemia and hyperglycemia with a health care professional. Be familiar with the treatment for each.
■ Insulin requirements may change with onset of illness. Monitor glucose carefully and adjust insulin therapy as required.
Insulin therapy is the preferred treatment of type 1 and type 2 diabetes during pregnancy. Regular insulin is used IV for glycemic control during labor. Poorly controlled diabetes in pregnancy increases the maternal risk for diabetic ketoacidosis, pre-eclampsia, spontaneous abortions, preterm delivery, stillbirth, and delivery complications. Poorly controlled diabetes increases the fetal risk for major birth defects, stillbirth, and macrosomia-related morbidity. Monitor carefully; insulin requirements may change at different stages of pregnancy and may drop immediately postpartum.
■ Use caution in breast-feeding.
■ Breast-feeding may decrease insulin requirements.
■ Inadequately controlled maternal blood glucose late in pregnancy may cause increased insulin production in the fetus. Monitor and treat neonatal hypoglycemia postpartum.
No overall differences in safety or effectiveness were observed between elderly patients and younger patients. Elderly patients may be at increased risk of hypoglycemia due to comorbid conditions and concomitantly administered medications; see Dose Adjustments and Drug/Lab Interactions. Initial dosing, dose increments, and maintenance dosage should be conservative to avoid hypoglycemia.
Hypoglycemic effect may be potentiated by ACE inhibitors, anabolic steroids, angiotensin II receptor–blocking agents, disopyramide, fluoxetine, fibrates, guanethidine, MAO inhibitors, oral antidiabetic agents, pentoxifylline, salicylates, sulfonamides, and many others. Dose adjustment and increased frequency of glucose monitoring may be required with concomitant use.
■ Drugs that may reduce blood glucose-lowering effect include atypical antipsychotic medications, corticosteroids, danazol, diuretics, estrogen, glucagon, isoniazid (INH), niacin, oral contraceptives, phenothiazine derivatives, protease inhibitors, somatropin, sympathomimetic agents, thyroid preparations, and others. Dose adjustment and increased frequency of glucose monitoring may be required with concomitant use.
■ Alcohol, beta-adrenergic blockers including ophthalmics, clonidine, and lithium may either potentiate or inhibit the blood glucose-lowering effect of insulin. Dose adjustment and increased frequency of glucose monitoring may be required with concomitant use.
■ Will affect serum potassium levels; use caution in patients taking digoxin.
■ Octreotide may alter insulin, glucagon, and growth hormone secretion, resulting in hypoglycemia or hyperglycemia. Monitor serum glucose and adjust insulin dose as indicated.
■ Pentamidine is toxic to the beta cells of the pancreas. Patients may develop hypoglycemia initially as insulin is released. This may be followed by hypoinsulinemia and hyperglycemia with continued pentamidine therapy.
■ S/S of hypoglycemia may be masked in the presence of beta-blockers, clonidine, guanethidine. Increased frequency of glucose monitoring may be required with concomitant use.
■ Thiazolidinediones (TZDs) can cause dose-related fluid retention, particularly when used in combination with insulin. Fluid retention may lead to or exacerbate heart failure. Patients receiving concomitant therapy should be monitored for S/S of heart failure. Dose reduction or discontinuation of the TZD may be indicated if heart failure develops.
The most common adverse reactions with IV administration of insulin include hypersensitivity reactions, hypoglycemia, pruritus, and rash. Other commonly reported reactions are hypokalemia, injection site reactions, peripheral edema, and weight gain. Additional side effects reported in studies include abdominal pain, arthralgia, asthenia, back pain, chest pain, diarrhea, dysmenorrhea, fever, headache, hypertension, hyporeflexia, influenza, myalgia, nasopharyngitis, nausea, onychomycosis, pain, sensory disturbances, sinusitis, skin disorders, upper respiratory infections, and urinary tract infections. Severe hypersensitivity reactions may include anaphylaxis, angioedema, bronchospasm, generalized skin reactions, rash, hypotension, and shock.
Severe hypoglycemia and hypokalemia. Severe hypoglycemia may result in coma, seizures, or neurologic impairment. Severe, untreated hypokalemia may lead to respiratory paralysis, ventricular arrhythmia, and death.
Discontinue the drug immediately and notify physician of adverse reactions or hypoglycemia. Glucagon 1 to 2 mg IM or SQ is the specific antidote for insulin overdose. It may be supplemented by dextrose 50% IV. Oral carbohydrates such as glucose tablets or gel or orange juice may be sufficient to combat early symptoms of mild hypoglycemia. Correct hypokalemia as indicated. Hypersensitivity reactions usually respond to symptomatic treatment.