insulins (long -acting)

( hypoglycemic effect)

ROUTE	ONSET	PEAK	DURATION
Insulin degludec	within 2 hr	12 hr	up to 42 hr*
Insulin glargine	3–4 hr	none‡	24 hr

* Following discontinuation after chronic use.

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

‡Duration is dose dependent; duration ↑ as dose ↑.

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);
Patients with visual impairment who may rely on audible clicks to dial their dose (Toujeo and Tresiba);
OB: Pregnancy may temporarily ↑ insulin requirements;
Pedi: Children <18 yr (Toujeo), <6 yr (Basaglar, Rezvoglar, or Semglee), or <1 yr (degludec) (safety 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.
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

Insulin Degludec

SUBQ (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 (remainder of insulin dose should be given as a short-acting insulin and divided between each daily meal) (usual starting total daily insulin dose = 0.2–0.4 units/kg); Type 2 diabetes (insulin naive): 10 units once daily; then adjust on the basis of patient’s needs; Type 1 or 2 diabetes (and already on insulin): Give the same dose as the total daily dose of the long-acting or intermediate-acting insulin once daily; then adjust on the basis of patient’s needs.
SUBQ (Children ≥1 yr): Type 1 or 2 diabetes (and already on insulin): Give 80% of the total daily dose of the long-acting or intermediate-acting insulin once daily; then adjust on the basis of patient’s needs.

Insulin Glargine (Basaglar, Rezvoglar, or Semglee)

SUBQ (Adults and Children ≥6 yr): Type 1 diabetes (insulin naive):⅓ of 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 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.

Insulin Glargine (Toujeo)

SUBQ (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 ⬆ ⬇

Insulin Degludec

Solution for injection: 100 units/mL (prefilled pens and vials); 200 units/mL (prefilled pens)
In combination with:
liraglutide (Xultophy). See Combination Drugs

Insulin Glargine

Solution for injection (Basaglar, Rezvoglar): 100 units/mL (prefilled pens)
Solution for injection (Semglee): 100 units/mL (prefilled pens and vials)
Solution for injection (Toujeo): 300 units/mL (prefilled pens)
In combination with:
lixisenatide (Soliqua). See Combination Drugs.

Assessment ⬆ ⬇

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 concentrating; 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 may necessitate changes in insulin dose.
Assess for signs/symptoms 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 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.

Implementation ⬆ ⬇

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 Toujeo with Tradjenta, Tresiba, or Trulicity. Do not confuse Tresiba with Tarceva, Toujeo, Tradjenta, or Trulicity.
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. Before withdrawing dose, rotate vial between palms to ensure uniform solution; do not shake.
- Use 100 units/mL vial for children requiring <5 units of insulin degludec each day.
- Do not mix insulin glargine with any other insulin or solution or use syringes containing any other medicinal product or residue. If giving with a short-acting insulin, use separate syringes and different injection sites. Solution should be clear and colorless with no particulate matter.
- Do not use if cloudy, discolored, or unusually viscous. Store unopened vials and cartridges of insulin glargine in the refrigerator; do not freeze. If unable to refrigerate, the 10-mL vial of insulin glargine can be kept in a cool place unrefrigerated for up to 28 days. Once the cartridge is placed in a pen, do not refrigerate. Insulin degludec pens may be stored in the refrigerator or kept at room temperature for up to 56 days. Do not store in-use cartridges and prefilled syringes in refrigerator or with needle in place. Keep away from direct heat and sunlight.
- 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%.
SUBQ: Inject 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.
- Administer insulin glargine and insulin degludec once daily at the same time each day.
- Do not administer insulin degludec or insulin glargine IV or in insulin pumps.

Patient/Family Teaching ⬆ ⬇

Explain purpose and side effects of medication to patient. Advise patient to read Patient Information before starting therapy. Advise 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.
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.
Advise patient not to share pen device with another person, even if needle is changed; may risk transmission of bloodborne pathogens.
Advise to patient that this medication controls hyperglycemia but does not cure diabetes. Therapy is long term.
Advise 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 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.
Advise 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.
Emphasize the importance of regular follow-up, especially during 1st few weeks of therapy.
Rep: Advise women of reproductive potential to notify health care provider if pregnancy is planned or suspected or if breastfeeding.

section name header

Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇