Insulin Basics

Which insulins are rapid-acting (generics)?

Insulin aspart, lispro, and glulisine

What is the brand name for the following insulins?

1. Lispro

2. Aspart

3. Glulisine

1. Humalog and Admelog

2. Novolog

3. Apidra

What is the role of rapid-acting insulin?

Mealtime (bolus) insulin that mimics pancreatic insulin release in response to food

What are the onset, peak, and duration of rapid-acting insulin?

Onset ~15 min; peak 1–2 hr; duration 3–5 hr

Which insulin is short-acting?

Regular insulin U-100

What are the brand names of short acting (regular) insulins?

Humulin R

Novolin R

What are the onset, peak, and duration of regular insulin U-100?

Onset ~30 min; peak ~2 hr; duration 6–10 hr

Which insulin is intermediate-acting?

NPH insulin

What are the brand names of NPH insulin?

Humulin N

Novolin N

What are the basal insulins?

intermediate acting, long acting, and ultra long acting insulins

What are the bolus (mealtime) insulins?

rapid acting and short acting insulins

What are the onset, peak, and duration of NPH insulin?

Onset 1–2 hr; peak 4–12 hr; duration 14–24 hr

Why can NPH insulin increase the risk of hypoglycemia?

It has a pronounced peak at 4–12 hours and unpredictable duration of action

What does the "P" in NPH stand for and what is its MOA?

Protamine; it delays absorption and extends duration of effects

What are lispro-protamine and aspart-protamine?

Protamine-containing insulins available only in premixed products that have the same onset, peak, and duration as NPH

Which insulins are long-acting and ultra-long-acting?

Glargine is long-acting; degludec is ultra-long-acting

What is the distinguishing pharmacokinetic property of insulin glargine and insulin degludec?

they are “peakless”, Onset 3–4 hr; duration ≥24 hr

According to the insulin activity graph, approximately how long can degludec last?

Up to ~42 hours

What is regular U-500 insulin and compare it to regular U-100 insulin?

How is it dosed?

A very concentrated form of regular insulin;

Same onset as regular U-100 but duration closer to NPH;

can last up to 24 hr

Twice daily or TID before meals

What is the role of inhaled insulin?

Mealtime insulin with fast absorption through the lungs

Put the following insulin in order from fastest to slowest onset

• NPH

• glargine

• aspart

• regular

1. aspart

2. regular

3. NPH

4. glargine

Which insulin type is most associated with controlling fasting BG?

Which insulin type is most associated with controlling postprandial BG?

Basal insulin

Bolus insulin

What is the contraindication for injectable insulin?

Do not administer during episodes of hypoglycemia

What are 2 major warnings associated with insulin and why?

Hypoglycemia and hypokalemia

insulin increases K entry into the cells

What are some common side effects of insulin?

weight gain

lipoatrophy

lipohypertrophy

Why can insulin cause weight gain?

It moves excess glucose into adipose cells and increases body fat, lean mass, and appetite

Insulin can lead to lipoatrophy and lipohypertrophy, both of which can be avoided by which administration technique?

rotating injection sites

What are the typical sizes of insulin vials and pens?

Most vials = 10 mL;

most pens = 3 mL

What is the usual concentration of insulin unless otherwise specified?

100 units/mL (U-100)

Describe insulin storage techniques

do not freeze and do not expose to extreme heat

store unopened vials or pens in the fridge

open vial or pens can be kept at room temperature

Describe insulin administration techniques

suspensions should be turned up and down slowly or rolled

do not shake

warm up insulin before injection (cold insulin hurts)

Which insulins can be mixed with NPH in the same syringe? and what is the proper way to do so?

Regular or rapid-acting insulin

draw up clear insulin first, then cloudy NPH

What mnemonic helps remember the order for mixing clear and cloudy insulin?

Clear before cloudy

What are common brand names for the following rapid acting insulins?

1. insulin aspart

2. insulin lispro

1. Novolog, Novolog FlexPen, Fiasp

2. Humalog, Humalog KwikPen, Admelog, Lyumjev

What is the brand name for the following rapid acting insulins

1. insulin lispro U-200

2. Insulin Glulisine

1. Humalog U-200

2. Apidra, Apidra Solostar

Which rapid-acting insulins are interchangeable biosimilars to Novolog?

Kirsty and Merilog

What are the main uses of rapid-acting insulin?

Prandial insulin and correction doses when BG is high

When should standard rapid-acting insulin generally be injected relative to meals and why?

SC 5–15 minutes before meals;

so insulin is available when glucose from the meal is absorbed

Which rapid acting insulins have alternative administration timings and what are they?

Lispro: right after eating

Fiasp and Lyumjev: With the first bite or within 20 minutes of starting the meal

Which insulin type is preferred for insulin pumps?

Rapid-acting insulin

1. What makes Fiasp faster acting than standard insulin aspart?

2. What makes Lyumjev faster acting than standard insulin lispro?

1. It is formulated with niacinamide (vitamin B3)

2. It is formulated with treprostinil and citrate

What is the brand name of inhaled insulin?

Afrezza

Afrezza:

1. contraindications

2. ADE

3. monitoring

4. how often to replace?

1. Patients with lung disease, including asthma and COPD

2. acute bronchospasm, cough, throat pain

3. pulmonary function tests (FEV1)

4. every 15 days

What is the appearance of rapid acting, regular, and long acting insulin?

Clear and colorless

Which types of insulins are available OTC and Rx?

regular insulin

NPH

premixed 70/30

What is Myxredlin?

A ready-to-use regular insulin IV solution in a 100-mL bag

What are the main uses of regular insulin?

Prandial insulin, correction doses (SS), and IV insulin

When should regular insulin be administered and why?

SC 30 minutes before meals so insulin is available for when glucose from the meal is absorbed

Which insulin is preferred for IV infusions and why?

Regular insulin; can be used with parenteral nutrition, cheaper, immediate onset when IV admin

What type of container should be used to prepare IV regular insulin?

A non-PVC container

How may a regular insulin + NPH regimen be administered? which part covers lunch?

Twice daily, 30 minutes before breakfast and dinner;

NPH plus possibly residual regular insulin

Compare regular U-500 with regular U-100 insulin.

5 times as concentrated ad U-100

many safety risks

rec only if pts require > 200 u/day

must be Rx specific syringe

cannot be mixed with any other insulin

only admin as SC

What is the brand name of concentrated regular U-500 insulin?

Humulin R U-500

What is the appearance of NPH insulin?

Cloudy

How is NPH typically dosed when used as basal insulin?

Twice daily

What is an advantage and disadvantage of NPH compared with long-acting basal insulin?

Less expensive but causes more hypoglycemia

if patient experiences nocturnal hypoglycemia, doses can be spilt as 2/3 QAM and 1/3 QHS

What are common brands of insulin glargine?

Lantus, Toujeo, Basaglar

Which insulin glargine products are interchangeable biosimilars to Lantus?

Rezvoglar and Semglee

How often is insulin glargine usually injected?

Once daily

What is the concentration of the following long acting insulins?

1. lantus

2. toujeo

1. 100 units/mL (U-100)

2. 300 units/mL

When may Toujeo be an option instead of Lantus? and when does it reach its max effect?

When >20 units/day of insulin glargine is needed; By the 5th day

Can insulin glargine be mixed with other insulins?

No

Insulin Degludec:

1. brand name

2. vial concentration

3. pen concentration

4. when to use

1. Tresiba

2. 100 units/mL

3. 100 and 200 units/mL

4. if glargine causes nocturnal hypoglycemia

What are the three premixed insulin ratios that should be recognized for NAPLEX?

70/30, 75/25, and 50/50

Premixed insulins are written so that the% of ____ insulin is first and the % of ____ insulin is second

NPH or protamine insulin; short acting or rapid acting

What does 70/30 insulin contain?

70% NPH + 30% regular insulin

What are the brand names of 70% NPH/30% regular premixed insulins?

Humulin 70/30

Novolin 70/30

What is the brand name of 70% aspart protamine + 30% aspart premixed insulin?

Novolog Mix 70/30

What does Humalog Mix 75/25 contain?

What does Humalog Mix 50/50 contain?

75% lispro protamine + 25% lispro;

50% lispro protamine + 50% lispro

How are premixed insulins commonly dosed?

BID before breakfast and dinner; sometimes TID if the mix contains rapid-acting insulin

When should a premixed insulin be administed if it contains

1. rapid acting insulin

2. regular insulin

1. 15 minutes before a meal

2. 30 mins before a meal

Why are NPH- and protamine-containing premixed insulins cloudy?

NPH or protamine causes the cloudy appearance

Which insulins can be sold OTC?

Regular, NPH, and premixed 70% NPH/30% regular insulin

Are long-acting and rapid-acting insulins available OTC?

No; they require a prescription