insulin (mixtures)

Absorption: Well absorbed from SUBQ administration sites.

Distribution: Widely distributed.

Metabolism/Excretion: Metabolized by liver, spleen, kidney, and muscle.

Half-Life: 5–6 min (prolonged in patients with diabetes; biologic half-life is 1–1.5 hr).

Time/Action Profile ⬆ ⬇

(hypoglycemic effect)

ROUTE	ONSET	PEAK	DURATION
Insulin aspart protamine suspension/ insulin aspart injection mixture SUBQ	15 min	1–4 hr	18–24 hr
Insulin lispro protamine suspension/ insulin lispro injection mixture SUBQ	15–30 min	2.8 hr	24 hr
NPH/regular insulin mixture SUBQ	30 min	2–12 hr	24 hr

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypoglycemia;
Allergy or hypersensitivity to a particular type of insulin, preservatives, or other additives.

Use Cautiously in:

Stress and infection (may temporarily ↑ insulin requirements);
Renal/hepatic impairment (may ↓ insulin requirements);
Concomitant use with pioglitazone (↑ risk of fluid retention and worsening HF);
OB: Pregnancy may temporarily insulin requirements;
Lactation: Use while breastfeeding only if potential maternal benefit justifies potential risk to infant;
Pedi: Safety of Humalog not established.

Adv. Reactions/Side Effects ⬆ ⬇

Endo: HYPOGLYCEMIA

F and E: hypokalemia

Local: cutaneous amyloidosis, erythema, lipodystrophy, pruritus, swelling

Misc: HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS)

Interactions ⬆ ⬇

Drug-drug:

Beta blockers and clonidine may mask some of the signs and symptoms of hypoglycemia.
Corticosteroids, thyroid supplements, estrogens, isoniazid, niacin, phenothiazines, and rifampin may ↑ insulin requirements.
Alcohol, ACE inhibitors, MAO inhibitors, octreotide, oral hypoglycemic agents, and salicylates may ↓ insulin requirements.
Concurrent use with pioglitazone may ↑ risk of fluid retention and worsening HF.

Drug-Natural Products:

Glucosamine may worsen blood glucose control.
Fenugreek, chromium, and coenzyme Q-10 may produce additive hypoglycemic effects.

Route/Dosage ⬆ ⬇

Dose depends on blood glucose, response, and many other factors
SC (Adults and Children ): 0.5–1 unit/kg/day. Adolescents during rapid growth: 0.8–1.2 units/kg/day.

Availability ⬆ ⬇

Insulin aspart protamine suspension/insulin aspart injection mixture: 70% insulin aspart protamine suspension and 30% insulin aspart inection—NovoLog Mix 70/30 100 units/mL (vials and prefilled pens)
Insulin lispro protamine suspension/insulin lispro injection mixture: 75% insulin lispro protamine suspension and 25% insulin lispro injection—Humalog Mix 75/25 100 units/mL (vials and prefilled pens); 50% insulin lispro protamine suspension and 50% insulin lispro injection—Humalog Mix 50/50 100 units/mL (vials and prefilled pens)
NPH insulin/regular insulin suspension mixture: 70 units NPH/30 units regular insulin/mL—Novolin 70/30, Humulin 70/30 (100 units/mL total) (vials and prefilled pens)

Assessment ⬆ ⬇

Assess for symptoms of hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; excessive hunger; headache; irritability; nightmares or trouble sleeping; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait) and hyperglycemia (confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; nausea; vomiting; unusual thirst) periodically during therapy.
Monitor body weight periodically. Changes in weight may necessitate changes in insulin dose.

Lab Test Considerations:

Monitor blood glucose every 6 hr during therapy, more frequently in ketoacidosis and times of stress. Hemoglobin A_1C may also be monitored every 3–6 mo to determine effectiveness
- Monitor serum potassium in patients at risk for hypokalemia (those using potassium-lowering agents, those receiving IV insulin) periodically during therapy.

Toxicity and Overdose:

Overdose is manifested by symptoms of hypoglycemia. Mild hypoglycemia may be treated by ingestion of oral glucose. Severe hypoglycemia is a life-threatening emergency; treatment consists of IV glucose, glucagon, or epinephrine.

Implementation ⬆ ⬇

Insulin-related medication errors have resulted in patient harm and death. Clarify ambiguous orders; do not accept orders using the abbreviation "u" for units (can be misread as a zero or the numeral 4; has resulted in tenfold overdoses).
- Insulins are available in different types and strengths. Check type, dose, and expiration date with another licensed nurse. Do not interchange insulins without consulting health care professional.
- Do not confuse Humulin 70/30 with Humalog Mix 75/25. Do not confuse Novolin 70/30 with Novolog Mix 70/30. Do not confuse Novolog Mix 70/30 Flexpen with Novolog Flexpen.
Use only insulin syringes to draw up dose. The unit markings on the insulin syringe must match the insulin’s units/mL.
- Insulin should be stored in a cool place but does not need to be refrigerated. Follow manufacturer's instructions regarding storage of insulin and insulin pens before and after use. Do not use if cloudy, discolored, or unusually viscous.
- NPH insulins should not be used in the management of ketoacidosis.
SC: Rotate injection sites to prevent lipodystrophy and cutaneous amyloidosis. Repeated insulin injections into areas of localized cutaneous amyloidosis may cause hyperglycemia; a sudden change to an unaffected injection site may cause hypoglycemia.
- Administer into abdominal wall, thigh, or upper arm SUBQ.

Patient/Family Teaching ⬆ ⬇

Instruct patient on proper technique for administration. Include type of insulin, equipment (syringe, cartridge pens, alcohol swabs), storage, and place to discard syringes. Discuss the importance of not changing brands of insulin or syringes, selection and rotation of injection sites, and compliance with therapeutic regimen. Caution patient that insulin pens should not be shared with others, even if clean needles are used.
Caution patient not to share pen device with another person, even if needle is changed; may risk transmission of bloodborne pathogens.
Explain to patient that this medication controls hyperglycemia but does not cure diabetes. Therapy is long term.
Instruct patient in proper testing of serum glucose and ketones. These tests should be closely monitored during periods of stress or illness and health care professional notified of significant changes.
Emphasize the importance of compliance with nutritional guidelines and regular exercise as directed by health care professional.
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other Rx, OTC, herbal products, or alcohol.
Advise patient to notify health care professional of medication regimen prior to treatment or surgery.
Advise patient to notify health care professional if nausea, vomiting, or fever develops, if unable to eat regular diet, or if blood glucose levels are not controlled.
Instruct patient on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur.
Patients with diabetes mellitus should carry a source of sugar (candy, glucose gel) and identification describing their disease and treatment regimen at all times.
Rep: Advise patient to notify health care professional if pregnancy is planned or suspected, or if breastfeeding.
Emphasize the importance of regular follow-up, especially during first few wk of therapy.

Evaluation/Desired Outcomes ⬆ ⬇

Control of blood glucose levels in diabetic patients without the appearance of hypoglycemic or hyperglycemic episodes.

US Brand Names ⬆

insulin aspart protamine suspension/insulin aspart injection mixtures, rDNA origin: NovoLOG Mix 70/30, NovoLOG Mix 70/30 FlexPen,

insulin lispro protamine suspension/insulin lispro injection mixtures, rDNA origin: HumaLOG Mix 75/25, HumaLOG Mix 50/50,

NPH/regular insulin mixtures: HumuLIN 70/30, NovoLIN 70/30

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇