Usual Adult Dose for Diabetes Type 1

Individualize dose based on metabolic needs and frequent monitoring of blood glucose

• Total daily insulin requirements (prandial plus basal) are generally between 0.5 to 1 unit/kg/day
• Use HbA1c values to guide therapy; consult current guidelines for optimal target ranges

Multiple-daily injection (MDI):

• Administer subcutaneously within 15 minutes before a meal or within 20 minutes after starting a meal
• Match prandial insulin dose to carbohydrate intake, pre-meal blood glucose, and anticipated activity
• Use in combination with an intermediate-acting or long-acting basal insulin

Continuous Subcutaneous Infusion (Insulin Pump)

• Initial programming should be based on the total daily insulin dose of previous MDI regimen; check with pump labeling to ensure the pump has been evaluated with this insulin

Intravenous Administration

• Dilute to a concentration of 0.05 to 1 unit/mL in normal saline in an infusion system using polyvinyl chloride (PVC) bags; closely monitor blood glucose and serum potassium during administration

Use: To improve glycemic control in adult patients with diabetes mellitus.

Usual Adult Dose for Diabetes Type 2

Individualize dose based on metabolic needs and frequent monitoring of blood glucose

• Use HbA1c values to guide therapy; consult current guidelines for optimal target ranges.

Prandial Insulin:

• Administer subcutaneously within 15 minutes before a meal or within 20 minutes after starting a meal
• Use in combination with an intermediate-acting or long-acting basal insulin and/or with other anti-diabetic agents

Continuous Subcutaneous Infusion (Insulin Pump)

• Initial programming should be based on the total daily insulin dose of previous MDI regimen; check with pump labeling to ensure the pump has been evaluated with this insulin

Intravenous Administration

• Dilute to a concentration of 0.05 to 1 unit/mL in normal saline in an infusion system using polyvinyl chloride (PVC) bags; closely monitor blood glucose and serum potassium during administration

Use: To improve glycemic control in patients with diabetes mellitus.

Usual Adult Dose for Diabetic Ketoacidosis

Successful treatment of hyperglycemic emergencies such as diabetic ketoacidosis (DKA) and hyperosmolar state (HHS) requires frequent monitoring of clinical and laboratory parameters while carefully correcting volume deficits, managing electrolytes, and normalizing blood glucose. Insulin therapy is used to slowly correct high glucose levels; consult current treatment protocols for specific guidance on fluid and electrolyte management.

Intravenous:

• IV insulin infusion is generally started 1 to 2 hours after initiating fluid replacement therapy
• Dose: 0.14 unit/kg/hour IV; alternatively, a bolus of 0.1 unit/kg followed by an infusion of 0.1 unit/kg/hr has been used
• If blood glucose has not fallen by 10% in first hour, give bolus of 0.14 units/kg while continuing insulin infusion.

DKA: When blood glucose concentration reaches 200 mg/dL, decrease the insulin infusion to 0.02 to 0.05 unit/kg/hr; dextrose should be added to the IV fluids to maintain a blood glucose between 150 and 200 mg/dL until resolution of DKA (serum bicarbonate level 15 mEq/L or greater, venous pH greater than 7.3, and a calculated anion gap in the normal range)

HHS: When blood glucose concentration reaches 300 mg/dL or less, decrease the insulin infusion to 0.02 to 0.05 unit/kg/hr; dextrose should be added to the IV fluids to maintain blood glucose between 250 and 300 mg/dL until resolution of HHS.

Subcutaneous:

• Rapid acting insulin analogs (lispro, aspart, and glulisine) have been used in studies for the treatment of uncomplicated mild to moderate DKA. The following regimens have been used:
• Initial dose of 0.2 unit/kg followed by 0.1 unit/kg every hour subcutaneously until blood glucose decreased below 250 mg/dL, then 0.05 unit/kg every hour until DKA resolved
• Initial dose of 0.3 units/kg followed by 0.2 unit/kg every 2 hours until blood glucose decreased below 250 mg/dL then 0.1 unit/kg every 2 hours until DKA resolved

Comments:

• An endocrinologist or critical care specialist with training and expertise in the management of DKA or HHS should direct care; frequent monitoring of clinical and laboratory parameter is necessary as well as identification and correction of precipitating event.
• Starting insulin therapy before IV fluid replacement may precipitate shock, and increase the risk of hypokalemia and cerebral edema.
• To prevent rebound hyperglycemia, initiate subcutaneous insulin 15 to 30 minutes (rapid-acting) or 1 to 2 hours (regular insulin) before stopping the insulin infusion; alternatively, basal insulin may be administered in the evening and the insulin infusion stopped the next morning.

Use: Treatment of hyperglycemic emergencies.

Usual Adult Dose for Nonketotic Hyperosmolar Syndrome

Successful treatment of hyperglycemic emergencies such as diabetic ketoacidosis (DKA) and hyperosmolar state (HHS) requires frequent monitoring of clinical and laboratory parameters while carefully correcting volume deficits, managing electrolytes, and normalizing blood glucose. Insulin therapy is used to slowly correct high glucose levels; consult current treatment protocols for specific guidance on fluid and electrolyte management.

Intravenous:

• IV insulin infusion is generally started 1 to 2 hours after initiating fluid replacement therapy
• Dose: 0.14 unit/kg/hour IV; alternatively, a bolus of 0.1 unit/kg followed by an infusion of 0.1 unit/kg/hr has been used
• If blood glucose has not fallen by 10% in first hour, give bolus of 0.14 units/kg while continuing insulin infusion.

DKA: When blood glucose concentration reaches 200 mg/dL, decrease the insulin infusion to 0.02 to 0.05 unit/kg/hr; dextrose should be added to the IV fluids to maintain a blood glucose between 150 and 200 mg/dL until resolution of DKA (serum bicarbonate level 15 mEq/L or greater, venous pH greater than 7.3, and a calculated anion gap in the normal range)

HHS: When blood glucose concentration reaches 300 mg/dL or less, decrease the insulin infusion to 0.02 to 0.05 unit/kg/hr; dextrose should be added to the IV fluids to maintain blood glucose between 250 and 300 mg/dL until resolution of HHS.

Subcutaneous:

• Rapid acting insulin analogs (lispro, aspart, and glulisine) have been used in studies for the treatment of uncomplicated mild to moderate DKA. The following regimens have been used:
• Initial dose of 0.2 unit/kg followed by 0.1 unit/kg every hour subcutaneously until blood glucose decreased below 250 mg/dL, then 0.05 unit/kg every hour until DKA resolved
• Initial dose of 0.3 units/kg followed by 0.2 unit/kg every 2 hours until blood glucose decreased below 250 mg/dL then 0.1 unit/kg every 2 hours until DKA resolved

Comments:

• An endocrinologist or critical care specialist with training and expertise in the management of DKA or HHS should direct care; frequent monitoring of clinical and laboratory parameter is necessary as well as identification and correction of precipitating event.
• Starting insulin therapy before IV fluid replacement may precipitate shock, and increase the risk of hypokalemia and cerebral edema.
• To prevent rebound hyperglycemia, initiate subcutaneous insulin 15 to 30 minutes (rapid-acting) or 1 to 2 hours (regular insulin) before stopping the insulin infusion; alternatively, basal insulin may be administered in the evening and the insulin infusion stopped the next morning.

Use: Treatment of hyperglycemic emergencies.

Usual Pediatric Dose for Diabetes Type 1

4 years and older: Individualize dose based on metabolic needs and frequent monitoring of blood glucose

• Use HbA1c values to guide therapy; consult current guidelines for optimal target ranges

Multiple-daily injection (MDI):

• Administer subcutaneously within 15 minutes before a meal or within 20 minutes after starting a meal
• Match prandial insulin dose to carbohydrate intake, pre-meal blood glucose, and anticipated activity
• Use in combination with an intermediate-acting or long-acting basal insulin

Continuous Subcutaneous Infusion (Insulin Pump)

• Initial programming should be based on the total daily insulin dose of previous MDI regimen; check with pump labeling to ensure the pump has been evaluated with this insulin

Intravenous Administration

• Dilute to a concentration of 0.05 to 1 unit/mL in normal saline in an infusion system using polyvinyl chloride (PVC) bags; closely monitor blood glucose and serum potassium during administration

Use: To improve glycemic control in pediatric patients 4 years or older with type 1 diabetes mellitus.

Renal Dose Adjustments

Use with caution; frequent glucose monitoring and insulin dose reduction may be required

Liver Dose Adjustments

Use with caution; frequent glucose monitoring and insulin dose reduction may be required

Dose Adjustments

• Daily insulin requirements may be higher during illness, stress, pregnancy, in obese patients, trauma, during concurrent use with medications having hyperglycemic effects, or after surgery
• Daily insulin requirements may be lower with exercise, weight loss, calorie restricted diets, or during concurrent use of medications having hypoglycemic effects.

Supplemental doses may be prescribed during illness
Patients with type 2 diabetes receiving oral medications may be switched to insulin therapy temporarily.

Dosage adjustments may be required when the brand, type, or species of insulin is changed; oral antidiabetic treatment may need to be adjusted as well.

Precautions

Safety and efficacy in patients with type 1 diabetes mellitus have not been established in patients younger than 4 years.
Safety and efficacy in patients with type 2 diabetes mellitus have not been established in patients younger than 18 years.

Consult WARNINGS section for additional precautions.

Dialysis

Data not available

Other Comments

Administration advice:

• May be administered IV or subcutaneously
• Never share an insulin pen between patients, even if the needle is changed; do not reuse or share needles or syringes between patients as this presents a risk for transmission of blood-bourne pathogens.

Multiple-daily injections:

• Administer subcutaneously into the abdomen, thigh, or upper arm up to 15 minutes before a meal or within 20 minutes of starting a meal
• Rotate injection sites to reduce the risk of lipodystrophy
• Ensure patients have been educated as to proper injection technique
• This insulin may be mixed in the same syringe with NPH human insulin; if mixed, insulin glulisine should be drawn into syringe first; administer immediately after mixing

Continuous Subcutaneous Infusion (Insulin pump)

• Infusion sets should be inserted into the subcutaneous fat layer of the abdominal wall; rotate sites to avoid lipodystrophy
• Do not use diluted or mixed insulins
• Insulin glulisine is recommended for use in Disetronic H-Tron(R) plus V100 and D-Tron(R) with Disetronic catheters (Rapid (TM), Rapid C(TM), Rapid D(TM), and Tender(TM) and MiniMed Models 506, 507, 507c, and 508 with MiniMed catheters (Sof-set Ultimate QR(TM), and Quick-set(TM)); if a different insulin pump is to be used, check pump labeling to ensure the pump has been evaluated with insulin glulisine.
• Infusion sets (reservoirs, tubing, and catheter) should be replaced at least every 48 hours; discard insulin in reservoir after 48 hours or after exposure to temperatures that exceed 37C (98.6F)
• Remind patients on insulin pump therapy that they must have an alternative insulin delivery system available in case of pump system failure.

Intravenous:

• Administer by IV infusion at a concentration of 0.05 to 1 unit/mL in normal saline under medical supervision
• Closely monitor glucose and serum potassium
• Use polyvinyl chloride (PVC) bags
• Insulin mixtures should not be administered intravenously

Storage requirements:

• Unopened vial/cartridge system/SoloStar: Store in refrigerator, do not freeze, discard if frozen, use within 28 days if not refrigerated
• Open (in-use) Vial: Use within 28 days
• Open (in-use) Cartridge System and SoloStar prefilled pen: Do not refrigerate and discard within 28 days
• Discard insulin in reservoir after 48 hours or after exposure to temperatures that exceed 37C (98.6F)
• Intravenous use: If prepared as indicated, stable at room temperature for 48 hours.

Reconstitution/preparation techniques:

• To avoid contamination, pens should be used by a single patient only.
• Insulin cartridges are to be used only in conjunction with the OptiPen, ClikSTAR, Autopen 24, Tactipen, AllSTar or Junior STAR; use as directed in the information provided by the device manufacturer.
• For IV infusion : Dilute to a concentration of 0.05 to 1 unit/mL in normal saline in infusion systems using polyvinyl chloride (PVC) bags; stable at room temperature for 48 hours.

General:

• Insulin requirements may be altered during stress, major illness, or with changes in exercise, meal patterns, or coadministered drugs; duration of action of this insulin will vary according to dose, injection site, blood flow, temperature, and level of physical activity.
• This insulin is a rapid-acting insulin analog that is equipotent to human insulin when administered IV; when administered subcutaneously, it has a more rapid onset of action and a shorter duration of action.
• Rapid acting insulin analogs are superior to regular insulin when administered subcutaneously because they are more predictable.
• Hypoglycemia is the most common adverse reaction of insulin therapy; the timing generally reflects the time-action profile of the administered insulin.

Monitoring:

• Blood glucose monitoring is essential for patients receiving insulin therapy.
• Closely monitor blood glucose and potassium in patients receiving IV insulin.
• Urine ketone testing is recommended for patients with type I diabetes if they develop symptoms of colds, influenza, nausea, vomiting, or other illnesses, polyuria, or if blood glucose levels are unexpectedly high or inconsistent.
• Glycosylated hemoglobin measurements are recommended every 3 months.

Patient advice:

• Patients should be advised to never share an insulin pen with another person, even if the needle is changed; patients should understand that sharing needles or syringes with another person carries a risk for transmission of blood-borne pathogens.
• Patients should be instructed on glucose monitoring, proper injection technique, and the management of hypoglycemia and hyperglycemia.
• Patients should be instructed on how to handle situations which may affect their insulin requirements.
• Remind patients to check insulin labels before injection to avoid medication errors.
• Patients should check blood sugar prior to driving a car or operating machinery.
• Advise patient to speak to physician or health care professional if pregnant or if they intend to become pregnant.

Frequently asked questions

• What are the different types of insulin?