Usual Adult Dose for Diabetes Type 1

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

• Total daily insulin requirements 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 insulin lispro subcutaneously within 15 minutes before a meal or immediately after a meal
• Administer insulin lispro-aabc subcutaneously at the start of 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): insulin lispro U-100 only

• 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 insulin to be used
• While there is significant interpatient variability, approximately 50% of the total dose is provided as meal-related boluses and the remainder as a basal infusion

Intravenous Administration: U-100 concentration only

• Dilute insulin lispro to a concentration of 0.1 to 1 unit/mL in normal saline
• Dilute insulin lispro-aabc to a concentration of 1 unit/mL in normal saline or 5% dextrose injection
• Closely monitor blood glucose and serum potassium during administration

Comments:

• Insulin labels should be checked prior to each administration to prevent medication errors.
• The dose window of the prefilled insulin pen shows the number of units that will be injected.

Use: To improve glycemic control in adult patients with type 1 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 insulin lispro subcutaneously within 15 minutes before a meal or immediately after a meal
• Administer insulin lispro-aabc subcutaneously at the start of a meal or within 20 minutes after starting a meal
• Generally use in combination with an intermediate-acting or long-acting basal insulin or oral antidiabetic 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 insulin to be used
• While there is significant interpatient variability, approximately 50% of the total dose is provided as meal-related boluses and the remainder as a basal infusion

Intravenous Administration: U-100 concentration only

• Dilute insulin lispro to a concentration of 0.1 to 1 unit/mL in normal saline
• Dilute insulin lispro-aabc to a concentration of 1 unit/mL in normal saline or 5% dextrose injection
• Closely monitor blood glucose and serum potassium during administration

Comments:

• Insulin labels should be checked prior to each administration to prevent medication errors.
• The dose window of the prefilled insulin pen shows the number of units that will be injected.

Use: To improve glycemic control in patients with type 2 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 Adult Dose for Hyperkalemia

10 units IV bolus

Comments:

• Due to the urgency of treatment and risks associated with potential errors in insulin administration, standard hyperkalemia protocols should be available and followed.
• Protocols should specify insulin type, dose, and route of administration, how to flush IV line or access site (to ensure small volume has been fully administered); concomitant dextrose concentration, volume, and route of administration; and specific doses and administration for all other pharmacological interventions.
• Following insulin administration, adequate glucose monitoring will be necessary for several hours.

Use: For the treatment of hyperkalemia.

Usual Pediatric Dose for Diabetes Type 1

3 years and older: U-100 insulin lispro only
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 of a meal or immediately after 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
• While there is significant interpatient variability, approximately 50% of the total dose is provided as meal-related boluses and the remainder as a basal infusion

Intravenous Administration

• Dilute to a concentration of 0.1 to 1 unit/mL in normal saline; closely monitor blood glucose and serum potassium during administration

Use: To improve glycemic control in pediatric patients 3 years or older with type 1 diabetes mellitus.

Renal Dose Adjustments

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

Liver Dose Adjustments

Use with caution; frequent glucose monitoring and insulin dose adjustments 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

CONTRAINDICATIONS:

• Hypersensitivity to insulin lispro or any of the excipients
• During episodes of hypoglycemia

Safety and efficacy of insulin lispro U-100 have not been established in patients younger than 3 years.
Safety and efficacy of insulin lispro for the treatment of type 2 diabetes mellitus have not been established in patients younger than 18 years.
Safety and efficacy of insulin lispro U-200 and insulin lispro-aabc U-100 and U-200 have not been established in patients younger than 18 years.

Consult WARNINGS section for additional precautions.

Dialysis

Data not available

Other Comments

Administration advice:

• Insulin labels should be checked prior to each administration
• Insulin pens, vials, syringes, and needles should not be shared between patients as this presents a risk for transmission of blood-borne pathogens

Subcutaneous Administration: Insulin lispro U-100 (adults and pediatrics); Insulin lispro U-200 (adults only); Insulin lispro-aabc U-100 and U-200 (adults only)

• Insulin lispro: Administer subcutaneously into abdomen, thigh, upper arm, or buttocks within 15 minutes before a meal or immediately after a meal
• Insulin lispro-aabc: Administer subcutaneously into abdomen, thigh, upper arm, or buttocks at start of meal or within 20 after starting a meal
• The dose window of the U-100 and U-200 insulin pens shows the number of insulin units that will be delivered and therefore it is not necessary to perform dose conversions
• Rotate injection sites within same region to reduce the risk of lipodystrophy
• Ensure patients have been educated as to proper injection technique
• Rapid-acting insulin should generally be used in regimens with intermediate or long-acting insulin

Continuous Subcutaneous Infusion (Insulin pump): Insulin lispro U-100

• Infusion sets should be inserted into the subcutaneous fat layer of the abdominal wall; rotate sites to avoid lipodystrophy
• Check pump labeling to ensure the pump has been evaluated with insulin lispro; do not fill pump reservoir with U-200 insulin, diluted U-100 insulin, intermediate-acting, long-acting, or combination insulins
• Change insulin in the reservoir at least every 7 days or after exposure to temperatures that exceed 98.6F (37C); infusion sets and insertion site should be changed at least every 3 days.
• Remind patients on insulin pump therapy that they must have an alternative insulin delivery system available in case of pump system failure

Intravenous Infusion: U-100

• Insulin lispro: Administer by IV infusion at a concentration of 0.1 to 1 unit/mL in normal saline
• Insulin lispro-aabc: Administer by IV infusion at a concentration of 1 unit/mL in normal saline or 5% dextrose injection
• Administer under medical supervision; closely monitor glucose and serum potassium
• U-200 insulin and combination insulins should not be administered intravenously

Dilution of Humalog U-100:

• Insulin lispro U-100 (Humalog may be diluted with Insulin Diluting Medium for Humalog to provide concentrations of U-10 or U-50: a dilution of 1 part Humalog to 9 parts diluent results in a U-10 concentration, a dilution of 1 part Humalog to 1 part diluent results in a U-50 concentration
• Humalog U-100 may be mixed with NPH insulin; draw Humalog U-100 into syringe first and administer immediately after mixing

Dilution of Admelog U-100:

• Insulin lispro U-100 (Admelog may be diluted with 0.9% sodium chloride to provide concentration of U-50: a dilution of 1 part Admelog to 1 part diluent results in a U-50 concentration

Preparation and Instructions for Use: The manufacturer product information should be consulted.

• To avoid contamination, pens should be used by a single patient only: always remove needle from delivery device after use and pens should be stored without a needle attached; always use a new needle for each injection.

• For IV infusion : Dilute to a concentration of 0.05 to 1 unit/mL in normal saline in infusion systems using polypropylene infusion bags; stable in 0.9% sodium chloride at room temperature for 24 hours.

Storage requirements:

• Unopened: Store in refrigerator 2C to 8C (36F to 46F); do not freeze, discard if frozen; stable until expiration date
• Opened (in-use) 3 and 10 mL vials: Store in refrigerator or at room temperature (below 30C [86F]); use within 28 days
• Opened (in-use) Cartridge Systems, Pens: Store below 30C (86F); Do not refrigerate; use within 28 days; protect from direct heat and light

Diluted Humalog:

• Concentrations of U-10 or U-50 when prepared with insulin diluting medium may be used for up to 28 days when stored below 5C (41F) OR for 14 days when stored at 30C (86F)

Diluted Admelog:

• Concentration of U-50 may be used for up to 24 hours when stored in a refrigerator (36F to 46F [2C to 8C]) or for up to 4 hours when stored at room temperature (86F [30C])

Infusion Fluids:

• Humalog: Infusion bags when mixed in normal saline and refrigerated (2C to 8C [36F to 46F]) are stable for 48 hours, and then may be used at room temperature for up to an additional 48 hours
• Admelog: Infusion bags are stable in the refrigerator (36F to 46F [2C to 8C]) for 24 hours or may be used at room temperature for up to 4 hours
• Lyumjev: Infusion bags are stable for up to 4 days when refrigerated at 36F to 46F (2C to 8C) or may be used stored at room temperature for up to 12 hours 68F to 77F (20C to 25C)

Pump:

• Discard insulin in pump reservoir after 7 days or after exposure to temperatures that exceed 37C (98.6F)

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.
• Insulin lispro 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. Insulin lispro-aabc is formulated with citrate and treprostinil to provide and even faster onset 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 instructed to read the US FDA-approved patient labeling (Patient Information and Instructions for Use).
• 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 reminded to always check insulin labels before injection, especially if they are using more than 1 type of insulin.
• 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.
• 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 is the difference between regular insulin and lispro (Humalog)?
• Humalog vs Novolog (Novalog): What's the difference?
• Can Trulicity be used with insulin?
• How and where should I inject insulin?
• What are the different types of insulin?
• When does insulin lispro peak / how long does it last?
• Can regular and lispro insulin (Humalog) be mixed?
• Does Admelog need to be refrigerated?
• What type of insulin is Humalog?
• Can Admelog (insulin lispro) be used in insulin pumps?
• Is Admelog fast-acting insulin?
• How fast does insulin lispro work?