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Understanding Pharm: Insulin regimens

Who uses insulin?

  • Type 1 diabetics
  • Type 2 diabetics who cannot control sugars with lifestyle and oral anti-hyperglycemics
  • Any severe hyperglycemia where rapid blood sugar reduction is required

Types of insulin – brand name (generic)

Rapid acting (manufacturer + log)

  • Novolog or Novorapid (aspart)
  • Humalog (lispro)
  • Apidra (glulisine)

Short acting

  • Humulin R (regular insulin)
  • Novolin ge Toronto (regular insulin)

Intermediate acting

  • Humulin N (NPH)
  • Novolin ge NPH (NPH)

Long acting

  • Lantus (glargine)
  • Levemir (detemir)

Ultra-long acting

  • Tresiba (Degludec)

What is premixed insulin?

  • Typically used in conventional insulin therapy in type II diabetics who need insulin
  • Used twice daily with no other insulin, and can be used with oral hypoglycemics
  • Used for patients who want to avoid more than 2 injections (to start), easier to use and more convenient
  • Consists of a mixture of long and short acting insulin
    • Rapid acting insulin + rapid acting insulin that has been crystallized with protamine in order to make it more like NPH insulin
  • Options
    • LISPRO + LISPRO PROTAMINE SUSPENSION (rapid + intermediate)
      • Humalog Mix25 – short:long is 25:75
      • Humalog Mix50 – short:long is 50:50
    • ASPART + ASPART PROTAMINE SUSPENSION (rapid + intermediate)
      • NovoMix 30 – short:long is 30:70
    • Short acting + intermediate premixed insulin injections are also available but are not used as common
  • How to administer dose?
    • 2/3 of dose in the morning injection
    • 1/3 of dose in the evening injection

Insulin regimens

  • Depends on whether the patient is type I or type II diabetic (type I requires stricter sugar control)
  • Type I diabetic insulin regimen
    • Multiple daily injections
      • Basal insulin 1-2x / day
      • Bolus insulin 3 times daily
      • DO NOT use premixed insulin for type I diabetic insulin regimens as it does not allow for modification to the ratio of the insulins which may be required
    • Start with 0.3 – 0.5 units/kg per day
    • Ranges from 0.5 units to 1 unit / kg per day
  • Type II diabetic insulin regimen
    • Existing anti-hyperglyemic agents, except for sulfonylureas are continued when insulin is started
    • Progression of disease from top to bottom
      • Bedtime basal insulin
        • NPH, glargine (lantus), detemir (levimir)
      • Premixed insulin (basal + bolus insulin)
        • Commonly twice daily (pre-breakfast + pre-dinner)
      • Multiple daily injections
        • Basal insulin 1-2x / day
        • Bolus insulin 3 times daily
        • Discontinue all anti-hyperglycemics except for metformin
        • Start with 0.3 – 0.5 units/kg per day
        • Ranges from 0.5 to 1 unit / kg per day (more than 1 unit may be required in obese + insulin resistant patients
  • Characterizing regimens in a different way – by number of injections
    • 2 injection regimen
      • 1 pre-breakfast premixed insulin injection (66 % of dose)
      • 1 pre-dinner premixed insulin injection (33 % of dose)
    • 3 injection regimen
      • 3 premixed insulin injections (66 % + 17 % + 17 %)
    • 4 injection regimen (split 50/50 between basal and bolus doses)
      • 1 rapid-acting insulin injection before breakfast (17 % of dose)
      • 1 rapid-acting insulin injection before lunch (17 % of dose)
      • 1 rapid-acting insulin injection before dinner (17 % of dose)
      • 1 long-acting insulin injection before sleep (50 % of dose)
    • 5 injection regimen (rarely used by type II diabetics)
      • 1 rapid-acting insulin injection before breakfast (17 % of dose)
      • 1 rapid-acting insulin injection before lunch (17 % of dose)
      • 1 rapid-acting insulin injection before dinner (17 % of dose)
      • 1 long-acting insulin injection before sleep (25 % of dose)
      • 1 long-acting insulin injection in the morning (25 % of dose)