insulin regular

Therapeutic Classification: antidiabetics, hormones

Pharmacologic Classification: pancreatics

BEERS REMS, High Alert

Type 1 or type 2 diabetes mellitus.

Concentrated regular insulin U-500

Only for use in patients with insulin requirements >200 units/day.

Unlabeled Use:

Hyperkalemia.

Lowers blood glucose by:
- stimulating glucose uptake in skeletal muscle and fat,
- inhibiting hepatic glucose production.
Other actions of insulin:
- inhibition of lipolysis and proteolysis,
- enhanced protein synthesis.

Therapeutic effects:

Control of hyperglycemia in diabetic patients.

Absorption: Rapidly absorbed from SUBQ administration sites. U-100 regular insulin is absorbed slightly more quickly than U-500. IV administration results in complete bioavailability.

Distribution: Identical to endogenous insulin.

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

Half-Life: 30–60 min.

(hypoglycemic effect)

ROUTE	ONSET	PEAK	DURATION
IV	10–30 min	15–30 min	30–60 min
SUBQ	30–60 min	2–4 hr	5–7 hr

Contraindicated in:

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

Use Cautiously in:

Stress or infection—may temporarily ↑ insulin requirements;
Renal impairment (may ↓ insulin requirements);
Hepatic impairment (may ↓ insulin requirements);
OB: Pregnancy may temporarily ↑ insulin requirements;
Geri: Appears on Beers list. ↑ risk of hypoglycemia in older adults. Avoid use of regimens containing only short- or rapid-acting insulin without concurrent use of basal or long-acting insulin

Endo: HYPOGLYCEMIA

F and E: hypokalemia

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

Misc: HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS)

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.

Dose depends on blood glucose, response, and many other factors

Ketoacidosis—Regular (100 units/mL) Insulin Only

IV (Adults ): 0.1 unit/kg/hr as a continuous infusion.
IV (Children ): Loading dose—0.1 unit/kg, then maintenance continuous infusion 0.05–0.2 unit/kg/hr, titrate to optimal rate of ↓ of serum glucose of 80–100 mg/dL/hr.

Maintenance Therapy

SC (Adults and Children ): 0.5–1 unit/kg/day in divided doses. Adolescents during rapid growth: 0.8–1.2 unit/kg/day in divided doses.

Treatment of Hyperkalemia

SC IV (Adults and Children ): Dextrose 0.5–1 g/kg combined with insulin 1 unit for every 4–5 g dextrose given.

Premixed infusion: 100 units/100 mL 0.9% NaCl
Solution for injection (vials and prefilled pens): 100 units/mL^OTC
Solution for injection (concentrated) (vials and prefilled pens): 500 units/mL
In combination with: NPH insulins (Humulin 70/30, Novolin 70/30).

Assess patient periodically for symptoms of hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; 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; unusual thirst) 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. A1C may 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.

High Alert: Medication errors involving insulins have resulted in serious patient harm and death. Clarify all ambiguous orders and do not accept orders using the abbreviation "u" for units, which can be misread as a zero or the numeral 4 and 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 regular concentrated (U-500) insulin with regular insulin.To prevent errors between regular U-100 insulin and concentrated U-500 insulin, concentrated U-500 insulin is marked with a band of diagonal brown strips and "U-500" is highlighted in red on the label and a conversion chart should always be available.
Do not confuse Humulin with Humalog or Novolin. Do not confuse Novolin with Novolog.
Use only insulin syringes to draw up dose. The unit markings on the insulin syringe must match the insulin’s units/mL. Special syringes for doses <50 units and U-500 insulin are available. Prior to withdrawing dose, rotate vial between palms to ensure uniform solution; do not shake.
- When mixing insulins, draw regular insulin into syringe first to avoid contamination of regular insulin vial.
- Insulin should be stored in a cool place but does not need to be refrigerated. Once opened, store at room temperature. Follow manufacturer's instructions regarding storage of insulin and insulin pens before and after use.
SC: Administer regular insulin within 30 min before a meal into the thigh, upper arm, abdomen, or buttocks. Rotate sites with each injection 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.

IV Administration:

IV: Do not use if cloudy, discolored, or unusually viscous. High Alert: Do not administer regular (concentrated) insulin U-500 IV.
IV Push: Diluent: May be administered IV undiluted directly into vein or through Y-site.
Rate: Administer up to 50 units over 1 min.
Continuous Infusion: Diluent: May be diluted in 0.9% NaCl using polyvinyl chloride infusion bags.Concentration: 0.1 unit/mL to 1 unit/mL in infusion systems with the infusion fluids.
Rate: Place on an IV pump for accurate administration.
- Rate of administration should be decreased when serum glucose level reaches 250 mg/dL.
Y-Site Compatibility:
- acetaminophen
- acyclovir
- aminophylline
- amphotericin B lipid complex
- anidulafungin
- argatroban
- arsenic trioxide
- ascorbic acid
- atropine
- azathioprine
- aztreonam
- benztropine
- bivalirudin
- bleomycin
- bumetanide
- buprenorphine
- calcium chloride
- calcium gluconate
- carboplatin
- carmustine
- caspofungin
- cefazolin
- cefepime
- ceftaroline
- ceftazidime
- ceftolozane/tazobactam
- ceftriaxone
- cefuroxime
- chloramphenicol
- clindamycin
- cyanocobalamin
- cyclophosphamide
- cytarabine
- dacarbazine
- dactinomycin
- daptomycin
- daunorubicin hydrochloride
- dexamethasone
- dexmedetomidine
- dexrazoxane
- docetaxel
- doxorubicin liposomal
- doxycycline
- enalapril
- ephedrine
- epirubicin
- epoetin alfa
- eravacycline
- ertapenem
- erythromycin
- esmolol
- esomeprazole
- etoposide
- etoposide phosphate
- fentanyl
- fluconazole
- fludarabine
- folic acid
- foscarnet
- fosphenytoin
- ganciclovir
- gemcitabine
- granisetron
- hetastarch
- hydrocortisone
- hydromorphone
- ibuprofen lysine
- idarubicin
- ifosfamide
- imipenem/cilastatin
- indomethacin
- irinotecan
- isavuconazonium
- ketorolac
- LR
- leucovorin calcium
- lidocaine
- linezolid
- lorazepam
- magnesium sulfate
- mannitol
- meperidine
- meropenem
- meropenem/vaborbactam
- mesna
- methadone
- methotrexate
- methylprednisolone
- metoclopramide
- metoprolol
- metronidazole
- milrinone
- mitoxantrone
- moxifloxacin
- mycophenolate
- nalbuphine
- naloxone
- nitroglycerin
- nitroprusside
- octreotide
- oritavancin
- oxacillin
- oxaliplatin
- paclitaxel
- palonosetron
- pamidronate
- papaverine
- pemetrexed
- penicillin G
- pentobarbital
- phenobarbital
- phytonadione
- plazomicin
- potassium acetate
- potassium chloride
- procainamide
- promethazine
- propofol
- pyridoxine
- remifentanil
- sodium bicarbonate
- sufentanil
- tacrolimus
- tedizolid
- terbutaline
- theophylline
- thiamine
- thiotepa
- tigecycline
- tirofiban
- topotecan
- vancomycin
- vecuronium
- verapamil
- vinblastine
- vincristine
- vinorelbine
- voriconazole
- zoledronic acid
Y-Site Incompatibility:
- alemtuzumab
- butorphanol
- cefoxitin
- chlorpromazine
- cisplatin
- dantrolene
- diazepam
- diphenhydramine
- gemtuzumab ozogamicin
- glycopyrrolate
- hydroxyzine
- isoproterenol
- ketamine
- labetalol
- micafungin
- minocycline
- mitomycin
- pentamidine
- phentolamine
- phenylephrine
- phenytoin
- piperacillin/tazobactam
- prochlorperazine
- propranolol
- protamine
- rocuronium
- trimethoprim/sulfamethoxazole
Additive Compatibility: May be added to total parenteral nutrition solutions.

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. Opened, unused insulin vials should be discarded 1 mo after opening.
Demonstrate technique for mixing insulins by drawing up regular insulin first and rolling intermediate-acting insulin vial between palms to mix, rather than shaking (may cause inaccurate dose).
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.
Rep: Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding.
Patients with diabetes mellitus should carry a source of sugar (candy, glucose gel) and identification describing their disease and treatment regimen at all times.
Emphasize the importance of regular follow-up, especially during first few wk of therapy.

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

HumuLIN R, HumuLIN R U-500 (Concentrated), HumuLIN R U-500 KwikPen (Concentrated), Myxredlin, NovoLIN R, NovoLIN R FlexPen

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