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Medications> Glucose-lowering>
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Insulins (Bolus): Rapid- and Short-acting  

Nadeen Hosein, M.D. and Brian Pinto, Pharm.D.
01-31-2011

INDICATIONS

FDA

  • Type 1 diabetes mellitus (T1DM)
  • Type 2 diabetes mellitus (T2DM)
  • Gestational diabetes mellitus (GDM)
  • Diabetic ketoacidosis (DKA)
  • Use in insulin pumps
  • Use subcutaneously or intravenously
NON-FDA APPROVED USES

MECHANISM

  • Facilitates glucose uptake into muscle and fat
  • Reduces hepatic glucose output
  • Inhibits lipolysis
  • Inhibits protein breakdown and promotes protein synthesis

USUAL ADULT DOSING

  • Rapid-acting insulins (aspart, lispro, and glulisine): administer SQ 0-15 mins before meals (usually preferred), or immediately after meals (may be preferred in patients with unpredictable food intake).
  • Short-acting insulin (regular): Recommend using SQ 30 mins before meals   
  • Refer to modules on "Insulin initation in type 2 diabetes" and "Insulin treatment in type 1 diabetes" for specific insulin dosing information.
  • May be used for patients with diabetes who are NPO and receiving total parenteral nutrition; refer to module on "Hospital management of diabetes" for specific insulin dosing information.
  • Refer to modules on GDM, DKA, or hyperosmolar hyperglycemic coma for further insulin dosing information in these conditions.
  • If using U-500 insulin instead of U-100 insulin, be sure to divide the normal dose by 5, as the U-500 insulin is 5 times more concentrated than the U-100 insulin.

FORMS

brand 
name
 
generic 
Mfg 
brand 
forms
 
cost* 
NovoLogaspart insulin (recombinant analog)Novo NordiskSQ
solution, 100 U/mL, vial
10 mL vial (1000 U)
$112
      SQ
solution, 100 U/mL, NovoLog FlexPen disposable prefilled pens
box of five 3 mL pens (15 mL, 1500 U)
$219
      SQ
solution, 100 U/mL, NovoLog cartridges, for use in any reusable NovoPen which must be obtained separately
box of five 3 mL cartridges (15 mL, 1500 U)
$201
Humaloglispro insulin (recombinant analog)Eli LillySQ
solution, 100 U/mL, vial
10 mL vial (1000 U)
$104
      SQ
solution, 100 U/mL, Humalog KwikPen disposable prefilled pens
box of five 3 mL pens (15 mL, 1500 U)
$198
      SQ
solution, 100 U/mL, Humalog original Pen disposable prefilled pens
box of five 3 mL pens (15 mL, 1500 U)
$208
      SQ
solution, 100 U/mL, Humalog cartridges, for use in the HumaPen Memoir reusable pen or the HumaPen Luxura HD reusable pen which must be obtained separately
box of five 3 mL cartridges (15 mL, 1500 U)
$199
Apidraglulisine insulin (recombinant analog)Sanofi-Aventis USSQ
solution, 100 U/mL, vial
10 mL vial (1000 U)
$102
      SQ
solution, 100 U/mL, Apidra SoloStar disposable prefilled pens
box of five 3 mL pens (15 mL, 1500 U)
 $207
      SQ
solution, 100 U/mL, Apidra cartridges, for use in the OptiClik reusable pen which must be obtained separately
box of five 3 mL cartridges (15 mL, 1500 U)
$196
Novolin Rregular insulin (recombinant human insulin)Novo NordiskSQ
solution, 100 U/mL, vial
10 mL vial (1000 U)
$58
Humulin Rregular insulin (recombinant human insulin)Eli LillySQ
solution, 100 U/mL, vial
10 mL vial (1000 U)
$57
Humulin R Concentrated U-500concentrated regular insulin (recombinant human insulin)Eli LillySQ
solution, 500 U/mL, vial
20 mL vial (10,000 U)
$261

*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP). AWP Prices were obtained and gathered by Lakshmi Vasist Pharm D using the Red Book, manufacturer's information, and the McKesson database.

^Dosage is indicated in mg unless otherwise noted.

DOSING IN SPECIAL POPULATIONS

RENAL

  • Dose reductions may be needed since insulin is metabolized by the kidneys, and may have a longer half life in patients with renal impairment.
HEPATIC

  • Dose reductions may be needed, since insulin is metabolized by the liver and also because most gluconeogenesis occurs in the liver.
PREGNANCY

  • Aspart insulin: FDA category B
  • Lispro insulin: FDA category B
  • Glulisine insulin: FDA category C
  • Regular insulin: FDA category B
BREASTFEEDING

  • Aspart, lispro, and glulisine insulins: infant risk cannot be ruled out (Thomson Lactation Ratings)
  • Regular insulin: unknown

ADVERSE DRUG REACTIONS

COMMON

  • Hypoglycemia
  • Weight gain
  • Injection site pain, minimized by thin needle and/or use of pens
OCCASIONAL

  • Local injection site reactions (redness, itching, swelling)
  • Lipoatrophy (loss of adipose tissue) at injection site (to avoid, rotate sites frequently)
  • Lipohypertrophy (area of fat hypertrophy) at injection site (to avoid, rotate sites frequently)
RARE

  • Immune hypersensitivity reactions
  • Hypokalemia
  • Increased risk for overdose and irreversible "insulin shock" with regular insulin U-500 concentration (500 U/mL); use carefully

DRUG INTERACTIONS

  • Any drug which also lowers blood glucose (e.g. sulfonylureas), when used in a patient on insulin, could result in additive hypoglycemia

PHARMACOKINETIC

COMMENTS

  • Commonly used in insulin pumps: aspart, lispro, glulisine.
  • Most patients prefer using insulin pens (disposable ones, or reusable ones with replaceable insulin cartridges) to drawing up insulin from traditional vials using syringes. Insulin pen needles must be prescribed and purchased separately, as they do not come packaged with the insulin pens. Refer to the "FORMS" table above to see which bolus insulin preparations are available in pen form.
  • Alcohol can have a hypoglycemic effect in people taking insulin and should be used, if at all, in moderation and with caution.
  • Regular insulin may have a duration of action lasting up to 8 hours, so doses given before each meal may overlap ("stack") in their duration of action.

REFERENCES

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