U-500 Insulin

4/3/2015
Donovan Victorine Pharm.D. BCACP
Clinical Pharmacy Specialist
Boise VA Medical Center
U-500 Insulin
• Understand differences between U-500 concentrated
insulin and standard insulin formulations
• Recognize benefits and risks associated with U-500
insulin use
• Understand typical U-500 dosing regimen
Objectives
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4/3/2015
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•
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58 yo male
Wt 298 lbs (140 kg), BMI 42
12 year history of DM2
PMH
• CAD, HTN, hyperlipidemia,
peripheral neuropathy, DM2, sleep
apnea
Patient Case: Mr. S.
• Current Insulin
• NPH insulin 80 units BID
• Aspart insulin 42 units with breakfast
and lunch, 65 units with evening meal
• HgbA1c
• 8.4%
8.8%
9.1%
10.7%
• Daily BG readings
•
Average:
Morning Noon Evening
259
275
339
Bed
280
Patient Case: Mr. S.
2
4/3/2015
• Increasing obesity epidemic and increasing occurrence of
insulin resistance with uncontrolled diabetes
• Escalating insulin dose requirements, usually associated
with poor diabetes control
• Excessive number of daily injections
• Absorption of high insulin volumes becomes
unpredictable
Introduction
Insulin Resistance Dose Response
4. Cochran E, Musso C, Gorden P.
3
4/3/2015
• U-500 regular insulin
(u500R)
• Available since the
1950’s
• Humulin R – 1997
• Five-fold
concentrated insulin
What is it
U-500 Insulin
Standard Insulin
• 500 units / mL
• 10,000 units per 20mL
vial
• 100 units / mL
• 1000 units per 10mL vial
What is it
4
4/3/2015
• Higher Concentration of U-500 alters its pharmacokinetic
profile
• Onset of action within 30 minutes
• Peak action 8 hours
• Duration of action 12 hours (reports of up to 24 hours)
• Onset of action similar to Regular (U-100) Insulin
• Duration of action similar to Neutral Protamine Hagedorn
(NPH) Insulin
• Has action resembling both basal & bolus insulin
What is it
Insulin Duration of Action
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4/3/2015
Insulin Duration of Action
• Those with high dose requirements – severe insulin resistance
• Greater than 200 - 300 units per day
• (2 units/kg/day)
• Multiple daily injections required to achieve dose
• Assess the ability of patient to appropriately monitor and
manage dosing
• Rule out
• Cushings, acromegaly, glucagonoma, pheochromocyctoma
• Other high resistance syndromes
Who gets it
6
4/3/2015
•
•
•
•
58 yo male
Wt 298 lbs (140 kg), BMI 42
12 year history of DM2
PMH
• CAD, HTN, hyperlipidemia,
peripheral neuropathy, DM2, sleep
apnea
Patient Case: Mr. S.
• Current Insulin
• NPH insulin 80 units BID
• Aspart insulin 42 units with breakfast
and lunch, 65 units with evening meal
• HgbA1c
• 8.4%
8.8%
9.1%
10.7%
• Daily BG readings
•
Average:
Morning Noon Evening
259
275
339
Bed
280
Patient Case: Mr. S.
7
4/3/2015
• Current Insulin
• NPH insulin 80 units BID
• Aspart insulin 42 units with breakfast and
lunch, 65 units with evening meal
• Total daily dose 309 units
• HgbA1c
• 8.4%
8.8%
9.1%
10.7%
• Daily BG readings
•
Average:
Morning Noon Evening
259
275
339
Bed
280
Uncontrolled daily bg levels, rising A1c,
despite escalating insulin dose
Patient Case: Mr. S.
No Formal dosing guidelines
Total Daily Dose
(percent of total daily dose divided with meals)
150-300 units
Twice Daily Injections (60 / 40)
May Consider Three Daily Injections
(40 / 30 / 30), (45 / 35 / 20), (40 / 40 / 20)
300-600 units
Three Daily Injections
May Consider Four Daily Injections (30 / 30 / 30 / 10)
Greater than 600 units
Four Daily Injections
(30 / 30 / 30 / 10), (25 / 25 / 25 / 25)
How to use it
Adapted from 7. Reutrakul S, Wroblewski K, Brown R.
8
4/3/2015
• Dosage adjustment similar to standard insulin
• Titrate by percentage of total dose
• 10% of total daily dose
• Alternate dosing methods
• Insulin pump
• Basal / bolus regimens
How to use it
• *HIGH POTENTIAL FOR ERROR*
• Use tuberculin syringe for administration
• Prescribe by both volume and actual units
• FDA issued safety label changes to express the prescribed
dose in actual units of U-500 along with corresponding
markings on the syringe the patient is using
• Provide a dose conversion chart
What is it
9
4/3/2015
Example U-500 dose conversion chart
U-500 actual unit dose
U-100 syringe unit
marking
Volume of tuberculin
syringe (ml)
25 units
5
0.05
50 units
10
0.1
75 units
15
0.15
100 units
20
0.2
Adapted from 7. Reutrakul S, Wroblewski K, Brown R.
• Current Insulin
• NPH insulin 80 units BID
• Aspart insulin 42 units with breakfast and lunch,
65 units with evening meal
• HgbA1c
• 8.4%
8.8%
9.1%
10.7%
• Daily BG readings
•
Average:
Morning Noon Evening
259
275
339
Bed
280
Patient Case: Mr. S.
10
4/3/2015
Total Daily Insulin Dose = 309 units
• 20% reduction
• 20% reduction
• 247 units == BID dosing
• 145 units (0.29 ml) U-500
insulin with breakfast
• 100 units (0.2 ml) u-500
insulin with dinner
• 247 units == TID dosing
• 100 units (0.2 ml) U-500
insulin with breakfast
• 100 units (0.2 ml) u-500
insulin with lunch
• 45 units (0.09 ml) u-500
insulin with dinner
Dose Initiation
• Reduced from 5 injection a day to
2 (or 3) daily injections
• Reduced total daily volume of
injections from 3.09 ml to 0.49 ml
• Additional room for dose titration
to reach target BG goals
Mr. S. Case
11
4/3/2015
• Discuss properties of U-500 concentrated insulin
• Clear liquid, concentrated form comes in a larger bottle and has a
small red triangle to mark it as U-500 concentrated insulin
• Store U-500 concentrated insulin away from other insulin products
• Use of tuberculin syringes, including drawing up appropriate and
precise amount of insulin
• Hold U-500 concentrated insulin for skipped meals
• Hypoglycemia treatment
• Importance of carrying information letter indicating that patient uses
U-500 concentrated insulin and explaining conversion with
tuberculin syringes
• Contact information to call during business hours or emergencies
Patient Education Points
Boise VA Medical Center Criteria for Use U-500 Concentrated Insulin
• Five times more concentrated than regular U-100 insulin
(500 units/mL)
• Supplied as 20 mL vials (10,000 units per vial)
• For subcutaneous use only
• Pharmacokinetics with onset similar to Regular Insulin
and duration similar to NPH Insulin
• Dose typically given twice daily (dosing customized to
patient case)
• Due to prolonged duration of action, hypoglycemic
reactions may develop 18-24 hours after injection
Take away points
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4/3/2015
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1. Boise VA Medical Center Criteria for Use U-500 Concentrated Insulin. August 2014
2. Boldo A, Comi R. Clinical Experience with u500 Insulin: Risks and Benefits. Endocr Pract.
2012;18(No.1):56-61
3. Cochran E, Gorden P. Use of U-500 Insulin in the Treatment of Severe Insulin Resistance.
Insulin. 2008;3(4):211-218
4. Cochran E, Musso C, Gorden P. The Use of U-500 Insulin in Patients with Extreme Insulin
Resistance. Diabetes Care. 2005;28(5):1240-1244.
5. Lane W, et al. High-Dose Insulin Therapy: Is It Time for U-500 Insulin? Endocr Pract.
2009;15(1):71-79
6. Lowery J, et al. U-500 Insulin as a Component of Basal Bolus Insulin Therapy in Type 2
Diabetes. Diabetes Technology & Therapeutics. 2012;14(6):505-507
7. Reutrakul S, Wroblewski K, Brown R. Clinical Use of U-500 Regular Insulin: Review and
Meta-Analysis. J Diabetes Sci Technol. 2012;6(2):412-420
8. Ziesmer A, et al.U500 Regular Insulin Use In Insulin Resistant Type 2 Diabetic Veteran
Patients. Endocr Pract. 2012;18(No.1):34-38
References
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