Usual Adult Dose for Diabetes Type 1

Note: Regular human insulin is available in 2 concentrations: 100 units of insulin per mL (U-100) and 500 units of insulin per mL (U-500)

Doses should be individualized based on patient's metabolic needs, blood glucose monitoring results, and glycemic goals

• Total daily insulin requirements are generally between 0.5 to 1 unit/kg/day

Insulin U-100 (Humulin R; Novolin R):
SUBCUTANEOUS Administration: Inject subcutaneously approximately 30 minutes prior to a meal

• Insulin U-100 should generally be used in a regimen with an intermediate or long-acting (basal) insulin

INTRAVENOUS Administration: Administer only under medical supervision with close monitoring of blood glucose and serum potassium

• Humulin R: Dilute to a concentration of 0.1 to 1 unit/mL in an infusion system using polyvinyl chloride infusion bags; this insulin is stable in normal saline
• Novolin R: Dilute to a concentration of 0.05 to 1 unit/mL in an infusion system using polypropylene infusion bags; this insulin is stable in normal saline, 5% dextrose, or 10% dextrose with 40 mmol/L potassium chloride

Insulin U-500 (Humulin R U-500): For subcutaneous administration only

• Administer U-500 insulin subcutaneously 2 to 3 times a day approximately 30 minutes prior to start of a meal
• The safety and efficacy in combination with other insulins has not been determined.

Comments:

• Patients should be instructed to always check insulin label prior to administration to confirm the correct insulin product is being used.
• During changes to a patient's insulin regimen, increase the frequency of blood glucose monitoring.
• Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function, changes in medications, or during acute illness to minimize the risk of hypoglycemia or hyperglycemia.
• Continuous Subcutaneous Insulin Infusion (CSII) Insulin Pump Therapy: Use of regular insulin (U-100) is not recommended because of the risk of precipitation; use of concentrated insulin (U-500) has not been studied and is not recommended.

Uses: To improve glycemic control in patients with diabetes mellitus; U-500 insulin is for use in patients requiring more than 200 units of insulin per day.

Usual Adult Dose for Diabetes Type 2

Note: Regular human insulin is available in 2 concentrations: 100 units of insulin per mL (U-100) and 500 units of insulin per mL (U-500)

Doses should be individualized based on patient's metabolic needs, blood glucose monitoring results, and glycemic goals

• Initial doses are often in the range of 4 to 6 units or 0.1 units/kg or 10% of basal insulin dose
• Use HbA1c values to guide therapy; consult current guidelines for optimal target ranges

Insulin U-100 (Humulin R; Novolin R):
SUBCUTANEOUS Administration: Inject subcutaneously approximately 30 minutes prior to a meal

• Insulin U-100 should generally be used in a regimen with an intermediate or long-acting (basal) insulin

INTRAVENOUS Administration: Administer only under medical supervision with close monitoring of blood glucose and serum potassium

• Humulin R: Dilute to a concentration of 0.1 to 1 unit/mL in an infusion system using polyvinyl chloride infusion bags; this insulin is stable in normal saline
• Novolin R: Dilute to a concentration of 0.05 to 1 unit/mL in an infusion system using polypropylene infusion bags; this insulin is stable in normal saline, 5% dextrose, or 10% dextrose with 40 mmol/L potassium chloride

Insulin U-500 (Humulin R U-500): For subcutaneous administration only

• Administer U-500 insulin subcutaneously 2 to 3 times a day approximately 30 minutes prior to start of a meal
• The safety and efficacy in combination with other insulins has not been determined.

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.
• Patients should be instructed to always check insulin label prior to administration to confirm the correct insulin product is being used.
• During changes to a patient's insulin regimen, increase the frequency of blood glucose monitoring.
• Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function, changes in medications, or during acute illness to minimize the risk of hypoglycemia or hyperglycemia.
• Continuous Subcutaneous Insulin Infusion (CSII) Insulin Pump Therapy: Use of regular insulin (U-100) is not recommended because of the risk of precipitation; use of concentrated insulin (U-500) has not been studied and is not recommended.

Uses: To improve glycemic control in patients with diabetes mellitus; U-500 insulin is for use in patients requiring more than 200 units of insulin per day.

Usual Adult Dose for Diabetic Ketoacidosis

Successful treatment of hyperglycemic emergencies such as diabetic ketoacidosis (DKA) 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.

Initiate insulin infusion 1 to 2 hours after starting 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
• Blood glucose should drop 50 to 75 mg/dL per hour, if this drop does not occur in the first hour; administer bolus of 0.14 unit/kg while continuing the insulin infusion.
• 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)

In circumstances where continuous IV infusion is not possible and DKA is uncomplicated, rapid and short-acting insulins have been administered subcutaneously or intramuscularly. See rapid-acting (lispro, aspart, or glulisine) insulin monographs for dosing of rapid-acting insulin.

Subcutaneous regular human insulin: 0.1 unit/kg subcutaneously every 1 to 2 hours; when blood glucose is less than 250 mg/dL (14 mmol/L), give glucose-containing fluids orally and reduce insulin to 0.05 unit/kg subcutaneously as needed to keep blood glucose around 200 mg/dL (11 mmol/L) until resolution of DKA.

Comments:

• An endocrinologist or critical care specialist with training and expertise in the management of DKA should direct care; frequent monitoring of clinical and laboratory parameters 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 diabetic ketoacidosis (DKA)

Usual Adult Dose for Insulin Resistance

Patients with insulin-resistant type 1 or type 2 diabetes who require daily insulin doses of more than 200 units may find U-500 insulin to be useful; larger doses may be administered subcutaneously in a reasonable volume (See Usual Adult Dose).

Usual Adult Dose for Nonketotic Hyperosmolar Syndrome

Successful treatment of hyperglycemic emergencies such as hyperglycemic 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.

Initiate insulin infusion 1 to 2 hours after starting 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 does not fall by 10% in first hour, give bolus of 0.14 units/kg while continuing insulin infusion
• 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.

Comments:

• An endocrinologist or critical care specialist with training and expertise in the management of 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 hyperosmolar state (also known as hyperosmolar non-ketotic coma (HONK); hyperosmolar hyperglycemic nonketotic syndrome)

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

Note: Regular human insulin is available in 2 concentrations: 100 units of insulin per mL (U-100) and 500 units of insulin per mL (U-500)

Doses should be individualized based on patient's metabolic needs, blood glucose monitoring results, and glycemic goals

• Total daily insulin requirements are generally between 0.5 to 1 unit/kg/day

Insulin U-100 (Humulin R; Novolin R):
SUBCUTANEOUS Administration: Inject subcutaneously approximately 30 minutes prior to a meal

• Insulin U-100 should generally be used in a regimen with an intermediate or long-acting (basal) insulin

INTRAVENOUS Administration: Administer only under medical supervision with close monitoring of blood glucose and serum potassium

• Humulin R: Dilute to a concentration of 0.1 to 1 unit/mL in an infusion system using polyvinyl chloride infusion bags; this insulin is stable in normal saline
• Novolin R: Dilute to a concentration of 0.05 to 1 unit/mL in an infusion system using polypropylene infusion bags; this insulin is stable in normal saline, 5% dextrose, or 10% dextrose with 40 mmol/L potassium chloride

Insulin U-500 (Humulin R U-500): For subcutaneous administration only

• Administer U-500 insulin subcutaneously 2 to 3 times a day approximately 30 minutes prior to start of a meal
• The safety and efficacy in combination with other insulins has not been determined.

Comments:

• Patients should be instructed to always check insulin label prior to administration to confirm the correct insulin product is being used.
• During changes to a patient's insulin regimen, increase the frequency of blood glucose monitoring.
• Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function, changes in medications, or during acute illness to minimize the risk of hypoglycemia or hyperglycemia.
• Continuous Subcutaneous Insulin Infusion (CSII) Insulin Pump Therapy: Use of regular insulin (U-100) is not recommended because of the risk of precipitation; use of concentrated insulin (U-500) has not been studied and is not recommended.

Uses: To improve glycemic control in patients with diabetes mellitus; U-500 insulin is for use in patients requiring more than 200 units of insulin per day.

Usual Pediatric Dose for Diabetes Type 2

Note: Regular human insulin is available in 2 concentrations: 100 units of insulin per mL (U-100) and 500 units of insulin per mL (U-500)

Doses should be individualized based on patient's metabolic needs, blood glucose monitoring results, and glycemic goals

• Initial doses are often in the range of 4 to 6 units or 0.1 units/kg or 10% of basal insulin dose
• Use HbA1c values to guide therapy; consult current guidelines for optimal target ranges

Insulin U-100 (Humulin R; Novolin R):
SUBCUTANEOUS Administration: Inject subcutaneously approximately 30 minutes prior to a meal

• Insulin U-100 should generally be used in a regimen with an intermediate or long-acting (basal) insulin

INTRAVENOUS Administration: Administer only under medical supervision with close monitoring of blood glucose and serum potassium

• Humulin R: Dilute to a concentration of 0.1 to 1 unit/mL in an infusion system using polyvinyl chloride infusion bags; this insulin is stable in normal saline
• Novolin R: Dilute to a concentration of 0.05 to 1 unit/mL in an infusion system using polypropylene infusion bags; this insulin is stable in normal saline, 5% dextrose, or 10% dextrose with 40 mmol/L potassium chloride

Insulin U-500 (Humulin R U-500): For subcutaneous administration only

• Administer U-500 insulin subcutaneously 2 to 3 times a day approximately 30 minutes prior to start of a meal
• The safety and efficacy in combination with other insulins has not been determined.

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.
• Patients should be instructed to always check insulin label prior to administration to confirm the correct insulin product is being used.
• During changes to a patient's insulin regimen, increase the frequency of blood glucose monitoring.
• Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function, changes in medications, or during acute illness to minimize the risk of hypoglycemia or hyperglycemia.
• Continuous Subcutaneous Insulin Infusion (CSII) Insulin Pump Therapy: Use of regular insulin (U-100) is not recommended because of the risk of precipitation; use of concentrated insulin (U-500) has not been studied and is not recommended.

Uses: To improve glycemic control in patients with diabetes mellitus; U-500 insulin is for use in patients requiring more than 200 units of insulin per day.

Usual Pediatric Dose for Diabetic Ketoacidosis

Successful treatment of hyperglycemic emergencies such as diabetic ketoacidosis (DKA) 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.

Initiate insulin infusion 1 to 2 hours after starting fluid replacement therapy.

• Dose: 0.1 unit/kg/hour IV until resolution of DKA (pH greater than 7.3, bicarbonate greater than 15 mmol/L and/or closure of the anion gap); resolution of DKA takes longer than normalization of blood glucose concentrations.
• For patients with marked sensitivity to insulin, decrease insulin to 0.05 units/kg/hour or less provided the metabolic acidosis continues to resolve.

In circumstances where continuous IV infusion is not possible and DKA is uncomplicated, may administer regular insulin subcutaneously at 0.1 unit/kg every 1 to 2 hours; when blood glucose is less than 250 mg/dL (14 mmol/L), give glucose-containing fluids orally and reduce insulin to 0.05 unit/kg as needed to keep blood glucose around 200 mg/dL (11 mmol/L) until resolution of DKA.

Comments:

• An endocrinologist or critical care specialist with training and expertise in the management of DKA should direct care; frequent monitoring of clinical and laboratory parameters 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.
• During initial volume expansion the plasma glucose falls steeply, thereafter expect decreases in the range of 36 to 90 mg/dL/hr (2 to 5 mmol/L/hr); to prevent too rapid a decrease in plasma glucose and hypoglycemia, 5% glucose should be added to the IV fluid when the plasma glucose falls to 250 to 300 mg/dL (14 to 17 mmol/L) or sooner if the rate of fall is precipitous.
• 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 diabetic ketoacidosis

Renal Dose Adjustments

Use caution; patients with renal impairment are at increased risk of hypoglycemia and may require more frequent dose adjustments and more frequent blood glucose monitoring

Liver Dose Adjustments

Use caution; patients with hepatic impairment are at increased risk of hypoglycemia and may require more frequent dose adjustments and more frequent blood glucose monitoring

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

Regular human insulin is available over-the-counter in the US

Safety and efficacy of U-500 insulin have not been established in patients younger than 18 years.

Consult WARNINGS section for additional precautions.

Dialysis

No data available

Other Comments

Administration advice: Always double check insulin labels before administration

• U-100 regular human insulin: May administer IV or subcutaneously
• U-500 regular human insulin: Subcutaneously only; do not give IV

Due to a risk for transmission of blood-borne pathogens:

• Do not share multi-dose insulin pens between patients, even if the needle is changed
• When using vials, never share needles or syringes between patients

Multiple-daily insulin (MDI) injections:

• Ensure patients have been educated as to proper injection technique
• Administer subcutaneously into the abdomen, buttocks, thigh, or upper arm within 30 minutes before a meal; rotate injection sites within same region to reduce the risk of lipodystrophy
• U-100 regular human insulin may be mixed with NPH insulin; draw the shorter acting insulin (U-100 regular) into the syringe first to prevent contamination of the vial by the longer-acting (NPH) insulin; administer immediately after mixing.
• U-500 regular human insulin should not be mixed with other insulins as there is no data to support such use
• Patients should be aware of the differences between insulin and tuberculin syringes for measuring insulin doses, especially if prescribed U-500 regular human insulin; consult U-500 manufacturer's product labeling for a dosing table that provides dosing information for both U-100 insulin syringe and tuberculin syringe.

Continuous Subcutaneous Insulin Infusion (CSII) - Insulin Pump Therapy: Use of regular insulin is not recommended because of the risk of precipitation.

Intravenous Administration: U-100 insulin only

• Closely monitor blood glucose and serum potassium during IV administration
• Humulin R: Dilute to a concentration of 0.1 to 1 unit/mL in an infusion system using polyvinyl chloride infusion bags; this insulin is stable in normal saline
• Novolin R: Dilute to a concentration of 0.05 to 1 unit/mL in an infusion system using polypropylene infusion bags; this insulin is stable in normal saline, 5% dextrose, or 10% dextrose with 40 mmol/L potassium chloride
• U-500 regular human insulin should not be administered IV.

Storage requirements:

• Unopened: Store in refrigerator (36F to 46F (2C to 8C)), do not freeze; discard if frozen
• Novolin R: Unrefrigerated vial (opened or unopened): Use within 42 days; keep as cool as possible (not above 77F (25C)); do not expose to excessive heat or light
• HumulinR: Unrefrigerated vial (opened or unopened): Use within 31 days; keep as cool as possible (not above 86F (30C)); do not expose to excessive heat or light

Infusion Fluids:

• Humulin R: Diluted to a concentration of 0.1 to 1 unit/mL in an infusion system using polyvinyl chloride infusion bags: Stable for 48 hours when refrigerated (36F to 46F (2C to 8C)) and then may be used at room temperature for up to an additional 48 hours
• Novolin R: Dilute to a concentration of 0.05 to 1 unit/mL in an infusion system using polypropylene infusion bags: Stable at room temperature for 24 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 insulin will vary according to dose, injection site, blood flow, temperature, and level of physical activity.
• Regular human insulin is generally the preferred insulin for IV administration
• As a meal time insulin, rapid-acting insulin analogs are generally preferred over regular human insulin as analogs have been shown to reduce hypoglycemic risk.
• 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, especially in patients at risk of low potassium and for those receiving IV insulin.
• 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 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 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 understand that hypoglycemia impairs the ability to concentrate and react; blood glucose monitoring should be done prior to engaging in tasks that require these skills such as driving and operating hazardous 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)?
• 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?
• Can regular and lispro insulin (Humalog) be mixed?