Usual Adult Dose for Diabetes Type 1

Individualize dose based on metabolic needs and frequent monitoring of blood glucose; consult current guidelines for optimal target ranges.

• Administer subcutaneously 1 to 2 times a day

• NPH insulin provides the basal requirement of a basal-bolus regimen, also known as Multiple Daily Insulin (MDI) injections.
• MDI regimens are 3 to 4 insulin injections per day consisting of a combination of basal (intermediate or long acting) and bolus (rapid, or short-acting) insulins; this regimen provides a steady insulin supply overnight and between meals (basal) as well as mealtime (bolus) injections to meet the rise and fall of insulin needs with meals.
• MDI regimens are individualized to match a patient's dietary/exercise habits and prevailing glucose trends.

Comments:

• Total daily insulin requirements are generally between 0.5 to 1 unit/kg/day.
• Most patients with type 1 diabetes mellitus should be treated with MDI or continuous subcutaneous insulin infusion (CSII).
• According to the American Diabetes Association, most people with type 1 diabetes should use insulin analogs to reduce hypoglycemic risk.

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; consult current guidelines for optimal target ranges.

• Initial dose: 0.1 to 0.2 units/kg subcutaneously once or twice a day

Comments:

• For people with type 2 diabetes, a patient-centered approach to care should guide choice of pharmacologic agents; considerations include efficacy, cost, potential side effects, weight, comorbidities, hypoglycemic risk, and patient preference.
• Unless a patient is markedly hyperglycemic and/or symptomatic, basal insulin alone can provide relatively uniform insulin coverage throughout the day and night; NPH or long-acting insulin (insulin glargine or insulin detemir) can be used; long-acting insulins are associated with modestly less overnight hypoglycemia, but are more expensive.
• Basal insulin is generally prescribed in conjunction with metformin and possibly 1 additional non-insulin agent; more complex insulin strategies may be needed when the basal insulin has been titrated to an acceptable fasting blood glucose but the HbA1c remains above target.
• Due to the progressive beta cell dysfunction that characterizes type 2 diabetes mellitus, insulin replacement therapy is frequently required.

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

Usual Pediatric Dose for Diabetes Type 1

Individualize dose based on metabolic needs and frequent monitoring of blood glucose; consult current guidelines for optimal target ranges.

• Administer subcutaneously 1 to 2 times a day

• NPH insulin provides the basal requirement of a basal-bolus regimen, also known as Multiple Daily Insulin (MDI) injections.
• MDI regimens are 3 to 4 insulin injections per day consisting of a combination of basal (intermediate or long acting) and bolus (rapid, or short-acting) insulins; this regimen provides a steady insulin supply overnight and between meals (basal) as well as mealtime (bolus) injections to meet the rise and fall of insulin needs with meals.
• MDI regimens are individualized to match a patient's dietary/exercise habits and prevailing glucose trends.

Comments:

• Total daily insulin requirements are usually between 0.5 to 1 unit/kg/day
• Insulin requirements during the honeymoon phase (period of partial remission) are usually less than 0.5 units/kg/day and may be much lower
• Insulin requirements in pre-pubertal children who are outside the partial remission phase are usually from 0.7 to 1 unit/kg/day
• Insulin requirements in patients with insulin resistance (e.g., during puberty or due to obesity) may be substantially higher than 1 unit/kg/day (up to 2 units/kg/day)
• Most patients with type 1 diabetes mellitus should be treated with MDI or continuous subcutaneous insulin infusion (CSII).
• According to the American Diabetes Association, most people with type 1 diabetes should use insulin analogs to reduce hypoglycemic risk.
• Insulin therapy should be initiated in children and adolescents for whom the distinction between type 1 diabetes mellitus and type 2 diabetes mellitus is unclear, specifically those with a random venous or plasma blood glucose concentration of 250 mg/dL or greater, or those who HbA1c is greater than 9%.

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

Usual Pediatric Dose for Diabetes Type 2

Individualize dose based on metabolic needs and frequent monitoring of blood glucose; consult current guidelines for optimal target ranges.

• Initial dose: 0.1 to 0.2 units/kg subcutaneously once or twice a day

Comments:

• Insulin therapy should be initiated in children and adolescents for whom the distinction between type 1 diabetes mellitus and type 2 diabetes mellitus is unclear, specifically those with a random venous or plasma blood glucose concentration of 250 mg/dL or greater, or those who HbA1c is greater than 9%.
• Unless a patient is markedly hyperglycemic and/or symptomatic, basal insulin alone can provide relatively uniform insulin coverage throughout the day and night; NPH or long-acting insulin (insulin glargine or insulin detemir) can be used; long-acting insulins are associated with modestly less overnight hypoglycemia, but are more expensive.

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

Renal Dose Adjustments

Use caution; dose reduction may be required in patients with renal impairment

Liver Dose Adjustments

Use caution; dose reduction may be required in patients with hepatic impairment

Dose Adjustments

Elderly: Use caution due to the potential for decreased renal function.

• 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

NPH human insulin is available over-the-counter in the U.S.

Consult WARNINGS section for additional precautions.

Dialysis

Data not available

Other Comments

Administration advice:

• For subcutaneous administration only; do not give IV, IM, or use in an insulin pump

• Never share an insulin pen between patients (even if the needle is changed) and do not reuse or share needles or syringes between patients when using vials as both present a risk for transmission of blood-borne pathogens.
• Ensure patients have been educated as to proper injection technique.
• Instruct patients to always check labels prior to use, especially if they use more than 1 type of insulin.
• Administer subcutaneously into the abdomen, buttocks, thigh, or upper arm; rotate injection sites within same region to reduce the risk of lipodystrophy.

Preparation Techniques:

• Prior to measuring dose, gently roll vial or pen between palms of the hands at least 10 times and then invert at least 10 times; do not shake.
• After mixing, contents should look white and cloudy; do not use if contents are clear or contain any lumps or particles.
• Insulin Pens: Consult the manufacturer product information for specific instructions for use.

Compatibility:

• Short and rapid acting insulins may be mixed with NPH insulin; draw the shorter acting insulin into syringe first to prevent contamination of the vial by the longer-acting (NPH) insulin; administer immediately after mixing.

Storage requirements: Protect from heat and light; do not freeze (do not use if frozen)

• Unopened vials and pens: Store in refrigerator 36F to 46F (2C to 8C)
• Open (in-use) vials: Humulin N: Store below 77F (25C) and use within 31 days; alternatively, may refrigerate, discard unused portion after 31 days
• Open (in-use) vials: Novolin N: Store below 86F (30C) and use within 42 days; alternatively, may refrigerate, discard unused portion after 42 days
• Open (in-use) Humulin N pens: Do not refrigerate after opening; use within 14 days; discard unused portion

General:

• Insulin requirements may be altered during stress, major illness, or with changes in exercise, meal patterns, or coadministered drugs; duration of action of insulin will vary according to dose, injection site, blood flow, temperature, and level of physical activity.
• 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.
• Potassium levels should be monitored in patients at risk for hypokalemia
• Monitor urine ketones when blood glucose levels are unexpectedly high or inconsistent, and as clinically indicated.
• 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

• Can Trulicity be used with insulin?
• How and where should I inject insulin?
• What are the different types of insulin?
• How long can Humulin be unrefrigerated?
• How long does Humulin last?
• Is Humulin fast or long-acting insulin?