insulin glargine

Absorption: Provides slower prolonged absorption and a relatively constant concentrations over 24 hr.

Distribution: Identical to endogenous insulin.

Metabolism/Excretion: Partially metabolized at the site of injection to active insulin metabolites. Metabolized by liver, spleen, kidney, muscle.

Half-Life: 5–6 min (prolonged in diabetic patients; biological half-life is longer).

Time/Action Profile ⬆ ⬇

(hypoglycemic effect)

ROUTE	ONSET	PEAK	DURATION
SUBQ	3–4 hr	none‡	24 hr

‡Small amounts of insulin glargine are slowly released resulting in a relatively constant effect over time.

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity;
Hypoglycemia.

Use Cautiously in:

Stress and infection, which may temporarily ↑ insulin requirement);
Renal/hepatic impairment (may ↓ insulin requirements);
Patients with visual impairment who may rely on audible clicks to dial their dose (Toujeo);
OB: Pregnancy may temporarily insulin requirements;
Lactation: Use while breastfeeding only if maternal benefit justifies potential risk to infant;
Pedi: Safety and effectiveness not established in children 18 yr (Toujeo) or 6 yr (Basaglar, Rezvoglar, and Semglee);
Geri: Older adults may have risk of hypoglycemia.

Adv. Reactions/Side Effects ⬆ ⬇

Endo: HYPOGLYCEMIA

F and E: hypokalemia

Local: cutaneous amyloidosis, lipodystrophy, pruritus, erythema, 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 ⬆ ⬇

Toujeo has a lower glucose lowering effect than Basaglar, Rezvoglar, or Semglee on a unit-to-unit basis.

Basaglar, Rezvoglar, or Semglee

SC (Adults and Children ≥6 yr): Type 1 diabetes (insulin naive): ⅓of the total daily insulin dose given once daily; then adjust on the basis of patient's needs (remainder of insulin dose should be given as a short-acting insulin) (usual starting total daily insulin dose = 0.2–0.4 units/kg); Type 2 diabetes (insulin naive): 0.2 units/kg or up to 10 units once daily; then adjust on the basis of patient's needs; Type 1 or 2 diabetes (and converting from Toujeo): Give 80% of Toujeo dose as Basaglar, Lantus, or Semglee once daily; then adjust on the basis of patient's needs; Type 1 or 2 diabetes (and converting from once daily NPH): Give the same dose once daily; then adjust on the basis of patient's needs; Type 1 or 2 diabetes (and converting from twice daily NPH): Give 80% of the total daily NPH dose once daily; then adjust on the basis of patient's needs.

Toujeo

SC (Adults ): Type 1 diabetes (insulin naive): ⅓–½ of the total daily insulin dose given once daily; then adjust on the basis of patient's needs (range = 1–80 units/day), (remainder of insulin dose should be given as a short-acting insulin) (usual starting total daily insulin dose = 0.2–0.4 units/kg); Type 2 diabetes (insulin naive): 0.2 units/kg once daily; then adjust on the basis of patient's needs; Type 1 or 2 diabetes (and converting from intermediate or long-acting insulin): Use same total daily dose and give once daily; then adjust on the basis of patient's needs;Type 1 or 2 diabetes (and converting from NPH insulin): Use 80% of the total daily NPH and give once daily; then adjust on the basis of patient's needs.

Availability ⬆ ⬇

Solution for injection (Basaglar, Rezvoglar): 100 units/mL (prefilled pens)
Solution for injection (Semglee): 100 units/mL (vials and prefilled pens)
Solution for injection (Toujeo): 300 units/mL (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; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness)and hyperglycemia (confusion; drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing; polyuria; loss of appetite; 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 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. Recovery from hypoglycemia may be delayed due to the prolonged effect of SUBQ insulin glargine.

Implementation ⬆ ⬇

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 Toujeo with Tradjenta, Tresiba, or Trulicity
When transferring from once-daily NPH human insulin to insulin glargine, the dose usually remains unchanged. When transferring from twice-daily NPH human insulin to insulin glargine, the initial dose of insulin glargine is usually ↓ by 20%.
- Do not mix insulin glargine with any other insulin or solution or use syringes containing any other medicinal product or residue. Solution should be clear and colorless with no particulate matter.
- Use only insulin syringes to draw up dose. Insulin syringe or SoloStar can be used for administration. Prior to withdrawing dose, rotate vial between palms to ensure uniform solution; do not shake.
- Store unopened vials and cartridges in the refrigerator; do not freeze. If unable to refrigerate, the 10-mL vial can be kept in a cool place unrefrigerated for up to 28 days. Once the cartridge is placed in an SoloStar, do not refrigerate.
SC: Administer SUBQ once daily at any time during the day, but at the same time each day in abdominal area, thigh, buttocks or upper arms, and rotate injection sites with each injection to reduce the risk of lipodystrophy and localized 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.Do not administer IV or use with insulin pumps.

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 selection and rotation of injection sites and compliance with therapeutic regimen.
Caution patient not to share pen device with another person, even if needle is changed; may risk transmission of blood-borne 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.
Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications 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 sugar 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.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇