insulin, regular

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insulin, regular (insulin injection)

Humulin R, Humulin-R Regular U-500 (concentrate), Insulin-Toronto (CA)

insulin (lispro)

Humalog, Humalog Pen

insulin glulisine, recombinant

Apidra, Apidra SoloSTAR

insulin lispro protamine, human

Humalog Mix 50/50, Humalog Mix 75/25

isophane insulin suspension (NPH insulin)

Humulin N, Novolin N

isophane insulin suspension (NPH) and insulin injection (regular)

Humulin 70/30 (70% isophane insulin and 30% insulin injection), Humulin 70/30 PenFill, Novolin 70/30, Novolin 70/30 PenFill

Pharmacologic class: Pancreatic hormone

Therapeutic class: Hypoglycemic

Pregnancy risk category B

Action

Promotes glucose transport, which stimulates carbohydrate metabolism in skeletal and cardiac muscle and adipose tissue. Also promotes phosphorylation of glucose in liver, where it is converted to glycogen. Directly affects fat and protein metabolism, stimulates protein synthesis, inhibits release of free fatty acids, and indirectly decreases phosphate and potassium.

Availability

Glulisine, recombinant: 100 units/ml in 10-ml vials, 100 units/ml in 3-ml cartridge system, 100 units/ml in 3-ml prefilled pen

Isophane suspension, injection (regular): 70 units NPH and 30 units regular insulin/ml (100 units/ml total), 50 units NPH and 50 units regular insulin/ml (100 units/ml total)

Isophane suspension (NPH insulin): 100 units/ml

Lispro: 100 units/ml in 10-ml vials and 1.5-ml cartridges

Regular insulin injection: 100 units/ml

Regular U-500 (concentrated), insulin human injection: 500 units/ml

Zinc suspension, extended (ultralente): 100 units/ml

Zinc suspension (lente insulin): 100 units/ml

Indications and dosages

Type 1 (insulin-dependent) diabetes mellitus; type 2 (non-insulin-dependent) diabetes mellitus unresponsive to diet and oral hypoglycemics

Adults and children: In newly diagnosed diabetes, total of 0.5 to 1 unit/kg/day subcutaneously as part of multidose regimen of short- and long-acting insulin. Dosage individualized based on patient's glucose level, adjusted to premeal and bedtime glucose levels. Reserve concentrated insulin (500 units/ml) for patients requiring more than 200 units/day.

Diabetic ketoacidosis

Adults and children: Loading dose of 0.15 units/kg (nonconcentrated regular insulin) I.V. bolus, followed by continuous infusion of 0.1 unit/kg/hour until glucose level drops. Then administer subcutaneously, adjusting dosage according to glucose level.

Contraindications

• Hypersensitivity to drug or its components

• Hypoglycemia

Precautions

Use cautiously in:

• hepatic or renal impairment, hypothyroidism, hyperthyroidism

• elderly patients

• pregnant or breastfeeding patients

• children.

Administration

Be aware that insulin is a high-alert drug whether given subcutaneously or I.V.

Don't give insulin I.V. (except nonconcentrated regular insulin), because anaphylactic reaction may occur.

• When mixing two types of insulin, draw up regular insulin into syringe first.

• For I.V. infusion, mix regular insulin only with normal or half-normal saline solution, as prescribed, to yield a concentration of 1 unit/ml. Give every 50 units I.V. over at least 1 minute.

• Rotate subcutaneous injection sites to prevent lipodystrophy.

• Administer mixtures of regular and NPH or regular and lente insulins within 5 to 15 minutes of mixing.

Adverse reactions

Metabolic: hypokalemia, sodium retention, hypoglycemia, rebound hyperglycemia (Somogyi effect)

Skin: urticaria, rash, pruritus

Other: edema; lipodystrophy; lipohypertrophy; erythema, stinging, or warmth at injection site; allergic reactions including anaphylaxis

Interactions

Drug-drug. Acetazolamide, albuterol, antiretrovirals, asparaginase, calcitonin, corticosteroids, cyclophosphamide, danazol, dextrothyroxine, diazoxide, diltiazem, diuretics, dobutamine, epinephrine, estrogens, hormonal contraceptives, isoniazid, morphine, niacin, phenothiazines, phenytoin, somatropin, terbutaline, thyroid hormones: decreased hypoglycemic effect

Anabolic steroids, angiotensin-converting enzyme inhibitors, calcium, chloroquine, clofibrate, clonidine, disopyramide, fluoxetine, guanethidine, mebendazole, MAO inhibitors, octreotide, oral hypoglycemics, phenylbutazone, propoxyphene, pyridoxine, salicylates, sulfinpyrazone, sulfonamides, tetracyclines: increased hypoglycemic effect

Beta-adrenergic blockers (nonselective): masking of some hypoglycemia symptoms, delayed recovery from hypoglycemia

Lithium carbonate: decreased or increased hypoglycemic effect

Pentamidine: increased hypoglycemic effect, possibly followed by hyperglycemia

Drug-diagnostic tests. Glucose, inorganic phosphate, magnesium, potassium: decreased levels

Liver and thyroid function tests: interference with test results

Urine vanillylmandelic acid: increased level

Drug-herbs. Basil, burdock, glucosamine, sage: altered glycemic control Chromium, coenzyme Q10, dandelion, eucalyptus, fenugreek, marshmallow: increased hypoglycemic effect

Garlic, ginseng: decreased blood glucose level

Drug-behaviors. Alcohol use: increased hypoglycemic effect

Marijuana use: increased blood glucose level

Smoking: increased blood glucose level, decreased response to insulin

Patient monitoring

• Monitor glucose level frequently to assess drug efficacy and appropriateness of dosage.

• Watch blood glucose level closely if patient is converting from one insulin type to another or is under unusual stress (as from surgery or trauma).

Monitor for signs and symptoms of hypoglycemia. Keep glucose source at hand in case hypoglycemia occurs.

Assess for signs and symptoms of hyperglycemia, such as polydipsia, polyphagia, polyuria, and diabetic ketoacidosis (as shown by blood and urinary ketones, metabolic acidosis, extremely elevated blood glucose level).

• Monitor for glycosuria.

• Closely evaluate kidney and liver function test results in patients with renal or hepatic impairment.

Patient teaching

• Teach patient how to administer insulin subcutaneously as appropriate.

• Advise patient to draw up regular insulin into syringe first when mixing two types of insulin. Caution him not to change order of mixing insulins.

• Instruct patient to rotate subcutaneous injection sites and keep a record of sites used, to prevent fatty tissue breakdown.

Teach patient how to recognize and report signs and symptoms of hypoglycemia and hyperglycemia. Advise him to carry a glucose source at all times.

• Instruct patient to store insulin in refrigerator (not freezer).

• Teach patient how to monitor and record blood glucose level and, if indicated, urine glucose and ketone levels.

• Tell patient that dietary changes, activity, and stress can alter blood glucose level and insulin requirements.

• Instruct patient to wear medical identification stating that he is diabetic and takes insulin.

• Advise patient to have regular medical, vision, and dental exams.

• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.

insulin, regular (injection, concentrated)

(in-su-lin) ,

HumuLIN R

(trade name),

Insulin-Toronto

(trade name),

NovoLIN R

(trade name),

HumuLIN R Regular U-500 (Concentrated)

(trade name)

Classification

Therapeutic: antidiabetics
Pharmacologic: pancreatics
Pregnancy Category: B
See for more information concerning insulins

Indications

Control of hyperglycemia in patients with diabetes mellitus.Concentrated regular insulin U-500: Only for use in patients with insulin requirements >200 units/day.Treatment of hyperkalemia.

Action

Lowers blood glucose by:
  • stimulating glucose uptake in skeletal muscle and fat,
  • inhibiting hepatic glucose production.
Other actions of insulin:
  • inhibition of lipolysis and proteolysis,
  • enhanced protein synthesis.

Therapeutic effects

Control of hyperglycemia in diabetic patients.

Pharmacokinetics

Absorption: Rapidly absorbed from subcutaneous administration sites. U-100 regular insulin is absorbed slightly more quickly than U-500.
Distribution: Identical to endogenous insulin.
Metabolism and Excretion: Metabolized by liver, spleen, kidney, and muscle.
Half-life: 30–60 min.

Time/action profile (hypoglycemic effect)

ROUTEONSETPEAKDURATION
Regular insulin IV10–30 min15–30 min30–60 min
Regular insulin subcutaneous30–60 min2–4 hr5–7 hr

Contraindications/Precautions

Contraindicated in: Hypoglycemia;Allergy or hypersensitivity to a particular type of insulin, preservatives, or other additives.
Use Cautiously in: Stress or infection—may temporarily ↑ insulin requirements;Renal/hepatic impairment—may ↓ insulin requirements;Concomitant use with pioglitazone or rosiglitazone (↑ risk of fluid retention and worsening HF) Obstetric: Pregnancy may temporarily ↑ insulin requirements.

Adverse Reactions/Side Effects

Endocrinologic

  • hypoglycemia (life-threatening)

Local

  • lipodystrophy
  • pruritus
  • erythema
  • swelling

Miscellaneous

  • allergic reactions including anaphylaxis (life-threatening)

Interactions

Drug-Drug interaction

Beta blockers, clonidine, and reserpine may mask some of the signs and symptoms of hypoglycemia.Corticosteroids, thyroid supplements, estrogens, isoniazid, niacin, phenothiazines, and rifampin may ↑ insulin requirements.Alcohol, ACE inhibitors, MAO inhibitors, octreotide, oral hypoglycemic agents, and salicylates, may ↓ insulin requirements.Concurrent use with pioglitazone or rosiglitazone may ↑ risk of fluid retention and worsening HFGlucosamine may worsen blood glucose control.Fenugreek, chromium, and coenzyme Q-10 may produce additive hypoglycemic effects.

Route/Dosage

Dose depends on blood glucose, response, and many other factors

Ketoacidosis—Regular (100 units/mL) Insulin Only

Intravenous (Adults) 0.1 unit/kg/hr as a continuous infusion.
Intravenous (Children) Loading dose-0.1 unit/kg, then maintenance continuous infusion 0.05–0.2 unit/kg/hr, titrate to optimal rate of decrease of serum glucose of 80–100 mg/dL/hr.

Maintenance Therapy

Subcutaneous (Adults and Children) 0.5–1 unit/kg/day in divided doses. Adolescents during rapid growth—0.8–1.2 unit/kg/day in divided doses.

Treatment of Hyperkalemia

Subcutaneous Intravenous (Adults and Children) dextrose 0.5–1 g/kg combined with insulin 1 unit for every 4–5 g dextrose given.

Availability

Insulin injection (regular insulin): 100 units/mL OTC
Regular (concentrated) insulin injection: 500 units/mL
In combination with: NPH insulins (Humulin 70/30, Novolin 70/30).

Nursing implications

Nursing assessment

  • Assess patient periodically for symptoms of hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait) and hyperglycemia (confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; unusual thirst) during therapy.
  • Monitor body weight periodically. Changes in weight may necessitate changes in insulin dose.
  • Lab Test Considerations: Monitor blood glucose every 6 hr during therapy, more frequently in ketoacidosis and times of stress. A1C may be monitered every 3–6 mo to determine effectiveness.
  • Overdose is manifested by symptoms of hypoglycemia. Mild hypoglycemia may be treated by ingestion of oral glucose. Severe hypoglycemia is a life-threatening emergency; treatment consists of IV glucose, glucagon, or epinephrine.

Potential Nursing Diagnoses

Noncompliance (Patient/Family Teaching)

Implementation

  • high alert: Medication errors involving insulins have resulted in serious patient harm and death. Clarify all ambiguous orders and do not accept orders using the abbreviation "u" for units, which can be misread as a zero or the numeral 4 and has resulted in tenfold overdoses. Insulins are available in different types and strengths. Check type, dose, and expiration date with another licensed nurse. Do not interchange insulins without consulting health care professional. Do not confuse regular concentrated (U-500) insulin with regular insulin.To prevent errors between regular U-100 insulin and concentrated U-500 insulin, concentrated U-500 insulin is marked with a band of diagonal brown strips and "U-500" is highlighted in red on the label and a conversion chart should always be available.
  • Do not confuse Humulin with Humalog. Do not confuse Novolin with Novolog.
  • Use only insulin syringes to draw up dose. The unit markings on the insulin syringe must match the insulin’s units/mL. Special syringes for doses <50 units are available. Prior to withdrawing dose, rotate vial between palms to ensure uniform solution; do not shake.
    • When mixing insulins, draw regular insulin into syringe first to avoid contamination of regular insulin vial.
    • Insulin should be stored in a cool place but does not need to be refrigerated.
  • Subcutaneous: Administer regular insulin within 15–30 min before a meal.
  • Intravenous Administration
  • Intravenous: Do not use if cloudy, discolored, or unusually viscous. high alert: Do not administer regular (concentrated) insulin U-500 IV.
  • Diluent: May be administered IV undiluted directly into vein or through Y-site.
  • Rate: Administer up to 50 units over 1 min.
  • Continuous Infusion: Diluent: May be diluted in 0.9% NaCl using polyvinyl chloride infusion bags.Concentration: 0.1 unit/mL to 1 unit/mL in infusion systems with the infusion fluids.
  • Rate: Rate should be ordered by health care professional, and infusion placed on an IV pump for accurate administration.
    • Rate of administration should be decreased when serum glucose level reaches 250 mg/dL.
  • Y-Site Compatibility: acyclovir, alfentanil, aminophylline, amphotericin B lipid complex, anidulafungin, argatroban, ascorbic acid, atropine, azathoprine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, calcium chloride, calcium gulconate, carboplatin, carmustine, caspofungin, cefazolin, cefepime, ceftaroline, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, clindamycin, cyanocobalamin, cyclophosphamide, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, dexrazoxane, docetaxel, doripenem, doxapram, doxorubicin liposomal, doxycycline, enalapril, ephedrine, epirubicin, epoetin alfa, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, fenoldopam, fentanyl, fluconazole, fludarabine, folic acid, foscarnet, ganciclovir, gemcitabine, granisetron, hetastarch, hydrocortisone, hydromorphone, ibuprofen, idarubicin, ifosfamide, imipenem-cilastatin, indomethacin, irinotecan, ketorolac, leucovorin calcium, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, meropenem, methotrexate, methyldopate, methylprednisolone, metoclopramide, metoprolol, metronidazole, milrinone, mitoxantrone, moxifloraxin, mycophenolate, nalbuphine, naloxone, nitroglycerin, nitroprusside, octreotide, oxacillin, oxaliplatin, paclitaxel, palonosetron, pamidronate, pancuronium, papaverine, pemetrexed, penicilin G, pentazocine, pentobarbital, phenobarbital, phytonadione, potassium acetate, potassium chloride, procainamide, promethazine, propofol, pyridoxime, remifentanil, sodium bicarbonate, streptokinase, sufentanil, tacrolimus, teniposide, terbutaline, theophylline, thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tolazoline, vancomycin, vecuronium, verapamil, vinblastine, vincristine, vinorelbine, vitamin B complex with C, voriconazole, zoledronic acid
  • Y-Site Incompatibility: alemtuzumab, butorphanol, cefoperazone, cefoxitin, chlorpromazine, cisplatin, dantrolene, diazepam, diazoxide, diphenhydramine, hydroxyzine, isoproterenol, ketamine, labetalol, micafungin, nesiritide, pentamidine, phentolamine, phenylephrine, phenytoin, piperacillin/tazobactam, prochlorperazine, propranolol, protamine, quinupristin/dalfopristin, rocuronium, trimethoprim/sulfamethoxazole
  • Additive Compatibility: May be added to total parenteral nutrition (TPN) solutions.

Patient/Family Teaching

  • Instruct patient on proper technique for administration. Include type of insulin, equipment (syringe, cartridge pens, alcohol swabs), storage, and place to discard syringes. Discuss the importance of not changing brands of insulin or syringes, selection and rotation of injection sites, and compliance with therapeutic regimen. Opened, unused insulin vials should be discarded 1 mo after opening.
  • Demonstrate technique for mixing insulins by drawing up regular insulin first and rolling intermediate-acting insulin vial between palms to mix, rather than shaking (may cause inaccurate dose).
  • Explain to patient that this medication controls hyperglycemia but does not cure diabetes. Therapy is long term.
  • Instruct patient in proper testing of serum glucose and ketones. These tests should be closely monitored during periods of stress or illness and health care professional notified of significant changes.
  • Emphasize the importance of compliance with nutritional guidelines and regular exercise as directed by health care professional.
  • Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other Rx, OTC, herbal products, or alcohol.
  • Advise patient to notify health care professional of medication regimen prior to treatment or surgery.
  • Advise patient to notify health care professional if nausea, vomiting, or fever develops, if unable to eat regular diet, or if blood glucose levels are not controlled.
  • Instruct patient on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur.
  • Advise patient to notify health care professional if pregnancy is planned or suspected or if breast feeding or planning to breast feed.
  • Patients with diabetes mellitus should carry a source of sugar (candy, glucose gel) and identification describing their disease and treatment regimen at all times.
  • Emphasize the importance of regular follow-up, especially during first few weeks of therapy.

Evaluation/Desired Outcomes

  • Control of blood glucose levels in diabetic patients without the appearance of hypoglycemic or hyperglycemic episodes.