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will require a prescription and will not be available over-the-counter.
The Humulin R U-500 pen dials and doses the insulin units that are prescribed. It is a different color than other pens to minimize confusion, allows up to 300 units per injection, and holds 1,500 units of insulin in each pen. It dials in 5 unit increments.9
The U-500 insulin syringe features a 6 mm x 31 G syringe needle. The U-500 Insulin syringe also has clearly marked dosage labeling designed to distinguish between other syringes, to help prevent confusion and incorrect dosing. The syringe package and components are color coded to align with the Humulin-R U-500 insulin green and aqua color scheme.12
SUGGESTIONS
with U-500 insulin, we are suggesting the following initiatives be enacted.
The use of U-100 insulin syringes for dosing U-500 insulin be discontinued. There are acceptable alternatives now
REFERENCES
1. Daily AM, Gilbert JA, Tannock LR. Durability of glycemic control using U-500 insulin. Diabetes Res Clin Pract. 2012;95:340-344.
2. Reutrakul S, Wroblewski K, Brown RL. Clinical use of U-500 regular insulin: review and meta-analysis. J Diabetes Sci Technol. 2012;6:412-420.
3. Lane WS, Cochran EK, Jackson JA, et al. High dose insulin therapy: is it time for U-500 insulin? Endocr Pract. 2009; 15:71-79.
4. De la Pena A, Riddle M, Morrow LA, et al. Pharmakokinetics and pharmacodynamics
of high-dose human regular U-500 insulin versus human regular U-100 in health obese subjects. Diabetes Care. 2011;34:2496-501.
5. Eby EL, Wang P, Curtis BH, et al. Cost, healthcare utilization, and adherence of individuals with diabetes using U-500 or
and the ongoing use of this delivery method will lead to needless confusion. Whether a patient or health care provider chooses to use an insulin pen or a dedicated U-500 syringe is dependent upon personal preference, manual dexterity issues, and insulin coverage by their insurance company.
U-500 insulin should be dosed by the total units. This will require some education for the provider and the patient if they are used to describing U-500 insulin doses based
on the markings on a U-100 syringe or a volumetric TB syringe.
Every hospital system needs to adopt
settings. This may include the continued use of the volume of U-500 insulin. It seems likely, however, that if all parties involved are describing U-500 insulin based on the total units in either a pen or a dedicated syringe, the volume of U-500 insulin will become of less value.
The use and ordering of U-500 insulin should be limited to practitioners who
are knowledgeable about this product. A
involve practitioners who are unfamiliar with the insulin.
CONCLUSION
The use of supersaturated insulin such as U-500 insulin is likely to become more common as this insulin is used more often in cases of obesity and type 2 diabetes. The previous regimen included many areas where confusion was possible, leading
to the risk of under- or overdosing. We propose that all U-500 insulin prescriptions, both inpatient and outpatient, be converted to the total number of units being delivered in an injection.
■ M. JAMES LENHARD, MD is the Medical Director of Metabolic Health Services at Christiana Care Health System in Wilmington, Del.
■ KAREN ROCKWELL, NP is a Nurse Practitioner at the Wilmington VA Hospital in Wilmington, Del.
■ KIM TRAN, R.Ph., MBA is Director of Metabolic Health Services at Christiana Care Health System in Wilmington, Del.
10. Hood RC, Arakaki RC, Wysham C, Li YG, Settles JA, Jackson JA. Two treatment approaches for human regular U-500 insulin in patients with type 2 diabetes
not achieving adequate glycemic control
on high-dose U-100 insulin therapy with
or without oral agents: a randomized, titration-to-target clinical trial. Endocr Pract. 2015;21:782-793.
11. Ziesmer AE, Kelly KC, Guerra PA, George KG, Dunn FL. U-500 regular insulin use in insulin-resistant type 2 diabetic veteran patients. Endocr Pract. 2012;18:34-38.
12. Available at https://www.ismp.org/ newsletters/acutecare/showarticle. aspx?id=62. Accessed September 28, 2016, and at https://www.bd.com/ press/2016/BD-Receives-FDA-Clearance- for-New-Syringe.aspx. Accessed September 28, 2016.
CONTRIBUTING AUTHORS
6.
7.
8.
9.
U-100 insulin; A retrospective database analysis. J Med Econ. 2013;16:529-38.
Jones P, Idris I. The use of U-500 regular insulin in the management of patients with obesity and insulin resistance. Diabetes Obes Metab. 2013;15:882-887.
Galloway JA, Spradlin CT, Nelson RL, Wentworth SM, Davidson JA, Swarner JL. Factors influencing the absorption, serum insulin concentration, and blood glucose responses after injections of regular insulin and various insulin mixtures. Diabetes Care. 1981;4:366-376.
Davidson MB, Navar MD, Echeverry D, Duran P. U-500 regular insulin: clinical experience and pharmacokinetics in obese, severely insulin-resistant type 2 diabetic patients. Diabetes Care. 2010;33:281-283.
Humulin R U-500 [Prescribing Information], Indianapolis, IN: Lilly USA, LLC, 2016.
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