insulins (rapid -acting)

Therapeutic Classification: antidiabetics, hormones

Pharmacologic Classification: pancreatics

High Alert

Type 1 or type 2 diabetes mellitus.

Lower blood glucose by
- stimulating glucose uptake in skeletal muscle and fat,
- inhibiting hepatic glucose production.
Other actions:
- inhibition of lipolysis and proteolysis,
- enhanced protein synthesis.
These are rapid-acting insulins with a more rapid onset and shorter duration than regular insulin; should be used with an intermediate- or long-acting insulin.

Therapeutic effects:

Control of hyperglycemia in diabetic patients.

Absorption: Very rapidly absorbed from SUBQ administration sites.

Distribution: Widely distributed to tissues.

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

Half-Life: Insulin aspart: 1–1.5 hr; Insulin glulisine: 42 min; Insulin lispro: 1 hr.

( hypoglycemic effect)

ROUTE	ONSET	PEAK	DURATION
Insulin aspart	within 15 min	1–2 hr	3–4 hr
Insulin glulisine	within 15 min	1–2 hr	3–4 hr
Insulin lispro	within 15 min	1–2 hr	3–4 hr

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 impairment (may ↓ insulin requirements);
Hepatic impairment (may ↓ insulin requirements);
OB: Pregnancy may temporarily ↑ insulin requirements;
Pedi: Safety not established in children <1 yr (Lyumjev), <3 yr (Admelog and Humalog), <4 yr (insulin glulisine), or <6 yr (for insulin aspart).

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.
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. Only insulin aspart and insulin glulisine can be administered IV. Lyumjev has faster onset of action and greater blood glucose-lowering effect than Admelog or Humalog on a unit-to-unit basis
SUBQ (Adults and Children ): Total insulin dose determined by needs of patient; generally 0.5–1 unit/kg/day; 50–70% of this dose may be given as meal-related boluses of rapid-acting insulin, and the remainder as an intermediate or long-acting insulin. SUBQ infusion pump:∼50% of total dose can be given as meal-related boluses and ∼50% of total dose can be given as basal infusion.

Insulin Aspart

Solution for injection: 100 units/mL (vials, prefilled cartridges, and prefilled pens)

Insulin Glulisine

Solution for injection: 100 units/mL (vials and prefilled pens)

Insulin Lispro

Solution for injection (Admelog): 100 units/mL (vials, prefilled cartridges, and prefilled pens)
Solution for injection (Humalog, Lyumjev): 100 units/mL (vials, prefilled cartridges, and prefilled pens); 200 units/mL (prefilled pens)

Assess for signs/symptoms of hypoglycemia (anxiety; restlessness; mood changes; 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; nausea; vomiting; tiredness; unusual thirst) periodically during therapy.
Monitor body weight periodically. Changes in weight, meal patterns, and physical activity levels may necessitate changes in insulin dose.
Assess patient for signs of allergic reactions (rash, shortness of breath, wheezing, rapid HR, sweating, low BP) during therapy.

Lab Test Considerations:

Monitor blood glucose every 6 hr during therapy, more frequently in ketoacidosis and times of stress.
- Monitor serum A1c twice yearly or every 3 mo when not meeting glycemic goals or change in therapy.
- 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 dextrose or glucagon. Octreotide may help stabilize blood glucose concentrations after prolonged hypoglycemia. Early signs of hypoglycemia may be less pronounced due to long duration of diabetes, diabetic nerve disease, and use of beta blockers; may result in loss of consciousness prior to patient’s awareness of hypoglycemia.

High Alert: 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 provider.
Do not confuse Humalog with Humulin or Novolog. Do not confuse Novolog with Novolin. Do not confuse Apidra with Spiriva.
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 are available. Do not draw up dose into a syringe from the Kwik Pens; syringe markings do not match up and could lead to a medication error. Use only U-100 insulin syringes to draw up insulin lispro dose. Prior to withdrawing dose, rotate vial between palms to ensure uniform solution; do not shake.
- Insulin aspart,insulin glulisine, and insulin lispro may be mixed with NPH insulin. When mixing insulins, draw insulin aspart, insulin glulisine, or insulin lispro into syringe first to avoid contamination of rapid-acting insulin vial. Mixed insulins should never be used in a pump or for IV infusion.
- Store vials in refrigerator. Vials may also be kept at room temperature for up to 28 days. Do not use if cloudy, discolored, or unusually viscous. Store cartridges and pens at room temperature and use within 28 days. Never use the PenFill cartridge after the expiration date on the PenFill cartridge or on the box.
- Because of their short duration, insulin lispro, insulin glulisine, and insulin aspart must be used with a longer-acting insulin or insulin infusion pump. In patients with type 2 diabetes, insulin lispro may be used without a longer-acting insulin when used in combination with an oral sulfonylurea agent.
- Humalog U-200 and Lyumjev U-200 should not be mixed with other insulins, administered IV, or used in insulin pumps.
SUBQ: Administer into abdominal wall, thigh, or upper arm SUBQ. 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 insulin aspart within 5–10 min before a meal. Administer Fiasp at the start of a meal or within 20 min after starting a meal.
- When used as meal-time insulin, administer insulin glulisine 15 min before or within 20 min after starting a meal.
- Administer insulin lispro: Admelog and Humalog within 15 min before or immediately after a meal. Administer Lyumjev at the start of a meal or within 20 min after starting a meal.
- May also be administered SUBQ via external insulin pump. Do not mix with other insulins or solution when used with a pump. Change the solution in the reservoir at least every 6 days (Lyumjev at least every 9 days), change the infusion set, and the infusion set insertion site at least every 3 days. Do not mix with other insulins or with a diluent when used in the pump.
Y-Site Compatibility:
- imipenem/cilastatin/relebactam
Y-Site Incompatibility:
- posaconazole
Y-Site Compatibility:
- imipenem/cilastatin/relebactam
Y-Site Compatibility:
- ceftaroline
- imipenem/cilastatin/relebactam

IV Administration:

Insulin Aspart

IV: May be administered IV in selected situations under appropriate medical supervision. Diluent: Dilute with 0.9% NaCl or D5W in infusion systems using polypropylene infusion bags; stable for 24 hr at room temperature. Concentration: 0.05–1 unit/mL.

IV Administration:

Insulin Glulisine

IV: May be administered IV in selected situations under appropriate medical supervision. Diluent: Dilute with 0.9% NaCl, using polyvinyl chloride (PVC) Viaflex infusion bags and PVC tubing (Clearlink System Continu-Flo solution set) with a dedicated infusion line. Concentration: 0.05–1 unit/mL.

IV Administration:

Insulin Lispro

IV: Insulin lispro (100 units/mL) can be administered IV under medical supervision ONLY with close monitoring of blood glucose and potassium levels to avoid hypoglycemia and hypokalemia. Concentration: 0.1–1 unit/mL. Diluent: 0.9% NaCl. Solution can be stored for 48 hr in refrigerator and then used at room temperature for another 48 hr.

Explain the purpose and side effects of rapid-acting insulins. Instruct patient on proper technique for administration. Tell patient to administer <15 min before or <20 min after starting a meal, depending on product. Include type of insulin, equipment (syringe, cartridge pens, external pump, 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. Keep out of children’s reach. Advise patient to read Patient Information before starting and with each Rx refill in case of changes.
Instruct patient using an external insulin pump to change the insulin in the reservoir at least every 7 days or according to the pump user manual. Patient should not use mixed or diluted insulin in a pump. An alternate source of insulin should be available in case of pump failure.
Emphasize the importance of regular follow-up to assess effectiveness, especially during first few weeks of therapy. Periodic lab tests will be needed.
Demonstrate technique for mixing insulins by drawing up insulin aspart, insulin glulisine, or insulin lispro first. Roll 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 and clean needles are used; may be harmful and ↑ risk of transmitting bloodborne pathogens.
Instruct patient in prompt identification and correction of the cause of hyperglycemia or ketosis. Pump or infusion set malfunctions can lead to a rapid onset of hyperglycemia and ketoacidosis. Interim therapy with SUBQ injection may be required. Patients using continuous SUBQ insulin infusion pump therapy must be trained to administer insulin by injection and have alternate insulin therapy available in case of pump failure.
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 provider notified of significant changes.
Emphasize the importance of compliance with nutritional guidelines and regular exercise as directed by health care provider.
Advise patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care provider before taking other medications or alcohol.
Advise patient to notify health care provider of medication regimen prior to treatment or surgery.
Advise patient to notify health care provider 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 women to notify health care provider if pregnancy is planned or suspected or if breastfeeding.

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

insulin aspart: Fiasp, Fiasp FlexTouch, Fiasp PenFill, Fiasp PumpCart, Merilog, Merilog SoloStar, NovoLOG, NovoLOG FlexPen, NovoLOG PenFill,

insulin glulisine: Apidra, Apidra SoloStar,

insulin lispro: Admelog, Admelog SoloStar, HumaLOG, HumaLOG Junior KwikPen, HumaLOG KwikPen, Lyumjev, Lyumjev KwikPen

insulin aspart: Kirsty, NovoRapid, Trurapi, Trurapi Solostar

section name header

Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇

Interactions ⬆ ⬇

Route/Dosage ⬆ ⬇

Availability ⬆ ⬇

Assessment ⬆ ⬇

Implementation ⬆ ⬇

Patient/Family Teaching ⬆ ⬇

Evaluation/Desired Outcomes ⬆ ⬇

US Brand Names ⬆ ⬇

Canadian Brand Names ⬆