Consensus On Insulin Treatment in Type 2 Diabetes

Download as pdf or txt
Download as pdf or txt
You are on page 1of 8
 
Endocrinología,
 
Diabetes
 
 y
 
Nutrición
CONSENSUSDOCUMENT
Consensus
 
on
 
insulin
 
treatmentin
 
type2
 
diabetes
,

Consenso
 
sobre
 
tratamiento
 
con
 
insulina
 
en
 
la
 
diabetes
 
tipo
 
2
JuanGirbésBorrás
a
,
,
 
JavierEscaladaSanMartín
b
,
c
,ManelMataCases
d
,
e
,
,Fernando
 
Gomez-Peralta
g
,
 
SaraArtolaMendez
h
,
i
,DiegoFerndezGarcía
,
k
,Carlos
 
OrtegaMillán
l
,FernandoAlvarezGuisasola
m
,
n
,JuanCarlosFerrer
 
García
o
,Patxi
 
EzkurraLoiola
i
,
p
,FernandoEscobarJinez
q
,José
 
AntonioFornosrez
r
,
s
,
t
,
u
,MercedesGalindoRubio
v
,
w
,
 
ItxasoRicaEchevarría
,
x
,
y
,EdelmiroMenéndezTorre
z
a
Unidad 
 
de
 
Endocrinología
 
 
Nutrición,
 
Servicio
 
de
 
Endocrinología
 
 
Nutrición,
 
Hospital
 
 Arnau
 
de
 
Vilanova,
 
Valencia,
 
Spain
b
Departamento
 
de
 
Endocrinología
 
 
Nutrición,
 
Clínica
 
Universidad 
 
deNavarra,
 
Pamplona,
 
Navarra,
 
Spain
c
Centro
 
de
 
Investigación
 
Biomédica
 
en
 
Red-Fisiopatología
 
dela
 
Obesidad 
 
 
Nutrición
 
(CIBERobn),
 
Instituto
 
de
 
Salud 
 
Carlos
 
III,Madrid,Spain
d
Centro
 
de
 
 Atención
 
Primaria
 
LaMina,
 
Gerència
 
d’Àmbit
 
d’Atenció
 
Primària
 
Barcelona
 
Ciutat,
 
Institut
 
Català
 
dela
 
Salut,
 
Sant Adriàde
 
Besòs,
 
Barcelona,
 
Spain
e
Grupo
 
DAP-Cat,
 
Unitat
 
deSuport
 
a
 
la
 
Recerca
 
Barcelona
 
Ciutat,
 
Institut
 
Universitari
 
d’Investigació
 
en
 
 Atenció
 
Primària
 
 JordiGol(IDIAP 
 
 Jordi
 
Gol),
 
Barcelona,
 
Spain
f
Centro
 
de
 
Investigación
 
Biomédica
 
enRe
 
de
 
Diabetes
 
 
Enfermedades
 
Metabólicas
 
 Asociadas
 
(CIBERdem),
 
Instituto
 
de
 
Salud CarlosIII,
 
Madrid,
 
Spain
g
Unidad 
 
de
 
Endocrinología
 
 
Nutrición,
 
Hospital
 
General
 
de
 
Segovia,
 
Segovia,
 
Spain
h
Medicina
 
Familiar 
 
 
Comunitaria,
 
Centro
 
deSalu
 
 José
 
Marvá,
 
Madrid,
 
Spain
i
Red 
 
de
 
Grupos
 
de
 
Estudio
 
de
 
la
 
Diabetes
 
enAtención
 
Primaria
 
dela
 
Salud 
 
(RedGDPS),
 
Spain
j
Servicio
 
Endocrinología
 
 
Nutrición,
 
Hospital
 
Virgen
 
dela
 
Victoria,
 
Málaga,
 
Spain
k
Servicio
 
de
 
Endocrinología
 
 
Nutrición,
 
Hospital
 
Vithas-Xanit,
 
Benalmádena,
 
Málaga,
 
Spain
l
Medicina
 
Familiar 
 
 
Comunitaria,
 
Centro
 
deSalu
 
de
 
Pozoblanco,
 
Pozoblanco,
 
Córdoba,
 
Spain
m
Medicina
 
Familiar 
 
 
Comunitaria,
 
Centro
 
de
 
Salud 
 
Ribera
 
del
 
Órbigo,
 
Benavides
 
deÓrbigo,
 
León,
 
Spain
n
Sociedad 
 
Espa˜nola
 
de
 
Diabetes
 
 
Sociedad 
 
Espa˜nola
 
deMedicina
 
Familiar 
 
 
Comunitaria,
 
Spain
o
Unidad 
 
de
 
Endocrinología
 
 
Nutrición,
 
Consorcio
 
Hospital
 
General
 
Universitario
 
de
 
Valencia,
 
Valencia,
 
Spain
p
Medicina
 
Familiar 
 
 
Comunitaria,
 
Centro
 
de
 
Salud 
 
deZumaia-Gipuzkoa,
 
Zumaya,
 
Guipúzcoa,
 
Spain
q
Servicio
 
de
 
Endocrinología
 
 
Nutrición,
 
Hospital
 
Clínico
 
San
 
Cecilio,
 
Universidad 
 
deGranada,
 
Granada,
 
Spain
r
Grupo
 
Berbés
 
de
 
Investigación
 
 
Docencia,
 
Spain
s
Grupo
 
de
 
Diabetes
 
de
 
SEFAC,
 
Spain
t
Fundación
 
Pharmaceutical
 
Care,
 
Spain
Pleasecitethisarticleas:GirbésBorrásJ,EscaladaSanMartínJ,MataCasesM,Gomez-PeraltaF,ArtolaMendezS,FernándezGarcíaD,etal.Consensosobretratamientoconinsulinaenladiabetestipo2.EndocrinolDiabetesNutr.2018;65:1---8.

ThecompleteConsensusDocumentisavailableat:http://www.seen.esandhttp://www.sediabetes.org,andasadditionalmaterialin theJournalwebpage.
Correspondingauthor.
E-mailaddress:
jgirbesb@yahoo.es(J.GirbésBorrás).https://doi.org/10.1016/j.endien.2018.01.0032530-0180/©2018SEENandSED.PublishedbyElsevierEspa˜na,S.L.U.All
 
rightsreserved.
 
2
 
J.
 
Girbés
 
Borrás
 
et
 
al.
u
Universidad 
 
deSantiago
 
de
 
Compostela,
 
Santiago
 
deCompostela,
 
La
 
Coru˜na,
 
Spain
v
Servicio
 
de
 
Endocrinología
 
 
Nutrición,
 
Hospital
 
Clínico
 
San
 
Carlos,
 
Madrid,
 
Spain
w
Facultad 
 
de
 
Enfermería,
 
Fisioterapia
 
 
Podología,
 
Universidad 
 
Complutense
 
deMadrid,
 
Madrid,
 
Spain
x
Sección
 
de
 
Endocrinología
 
Pediátrica,
 
Hospital
 
Universitario
 
de
 
Cruces,
 
Baracaldo,
 
Vizcaya,
 
Spain
y
Centro
 
de
 
Investigación
 
Biomédica
 
en
 
Red 
 
de
 
Enfermedades
 
Raras
 
(CIBERER),
 
Valencia,
 
Spain
z
Servicio
 
deEndocrinología
 
 
Nutrición,
 
Hospital
 
Universitario
 
Central
 
deAsturias,
 
Oviedo,
 
 Asturias,
 
Spain
Introduction
In
 
2010,
 
the
 
Working
 
Group
 
on
 
Consensus
 
andClinical
 
Guide-lines
 
of
 
theSpanish
 
Society
 
of
 
Diabetes
 
(SED)
 
published
 
aconsensus
 
on
 
drug
 
treatment
 
intype
 
2
 
diabetes
 
mellitus(T2DM)
 
which
 
was
 
approved
 
bydifferent
 
scientific
 
bodies.
1
The
 
Working
 
Group
 
thought
 
that
 
itwould
 
be
 
useful
 
to
 
pub-lish
 
a
 
consensus
 
document
 
specifically
 
addressed
 
to
 
insulintherapy
 
in
 
T2DM.This
 
document
 
is
 
anexecutive
 
summary
 
of
 
amore
 
com-prehensive
 
document
 
approved
 
by
 
theboards
 
oftheSEDand
 
the
 
Spanish
 
Society
 
of
 
Endocrinology
 
and
 
Nutrition.
 
Thecomplete
 
version
 
may
 
be
 
found
 
on
 
the
 
websites
 
of
 
both
 
soci-eties
 
 
on
 
those
 
of
 
all
 
the
 
other
 
scientific
 
bodieswhich
 
adhereto
 
the
 
consensus.
Criteriaforinsulin
 
therapystartandwithdrawal
When
 
and
 
how
 
should
 
insulin
 
therapy
 
be
 
given
Start
 
of 
 
insulin
 
therapy
Insulin
 
therapy
 
may
 
be
 
started
 
at
 
diagnosis
 
orduringfollow-up.
2
---
 
At
 
the
 
start
 
ofthe
 
disease,
 
if
 
there
 
is
 
weight
 
loss,
 
severeketonuria,
 
or
 
cardinal
 
symptoms
 
of
 
diabetes,
 
especiallywithHbA
1c
 >
 
9%.---During
 
follow-up,
 
transient
 
or
 
permanent
 
insulin
 
therapymay
 
be
 
required.
How
 
should
 
insulin
 
therapy
 
be
 
given
There
 
are
 
several
 
options
 
forstarting
 
insulin
 
therapy:---
 
Basal
 
insulin.
 
Oneor
 
two
 
doses
 
of
 
NPH
 
insulin,
 
or
 
onedoseof
 
a
 
basal
 
analogue:
 
glargine,
 
detemir,
 
and
 
degludec.---
Prandial
 
insulin.
 
Three
 
doses
 
of
 
rapid-acting
 
insulin
 
or
 
anultra-rapid
 
analogue
 
before
 
meals.---
 
Insulin
 
mixtures.
 
Two
 
or
 
more
 
doses
 
offixed
 
mixturesof
 
rapid-acting
 
or
 
ultra-rapid
 
insulin
 
with
 
intermediate-acting
 
insulin.The
 
first
 
optionis
 
currently
 
theregimen
 
of
 
choice.
Inasymptomatic
 
patients,
 
adoseof
 
10
 
Uor
 
0.2
 
U/kg
 
inobesepatients
 
of
 
basal
 
insulin
 
at
 
bedtime
 
may
 
be
 
used
 
1).The
 
dose
 
is
 
adjusted
 
based
 
on
 
basalblood
 
glucose
 
levelevery
Table
 
1
 
Basal
 
insulin
 
therapy.
 Adjustment
 
ofnon-insulin
 
drugs:
---
 
Continue
 
with
 
the
 
same
 
dose:
 
metformin,
 
DPP-4i,GLP-1
 
RA
 
and/or
 
SGLT2i---
 
Consider
 
discontinuation
 
or
 
a
 
dose
 
reduction
 
ofsulfonylureas,
 
glinides,
 
and
 
pioglitazone
Start
 
with
 
10 
 
Uor 
 
0.2
 
U/kg
---
 
NPH
 
or
 
detemir
 
atbedtime---
 
Glargina
 
at
 
any
 
time---
 
Degludec
 
atany
 
time
 Adjust
 
the
 
insulin
 
dose
 
based 
 
on
 
BGIncrease
 
the
 
insulin
 
dose
 
every 
 
3days
 
(provided 
 
there
 
isnohypoglycemia):
--- By2
 
U
 
when
 
thegoal
 
levels
 
are
 
exceeded
 
for
 
3
 
daysconsecutively--- By4
 
U
 
when
 
basal
 
blood
 
glucose
 
>
 
180
 
mg/dL
Decrease
 
the
 
insulin
 
dose
 
every 
 
3---5days
---By
 
2
 
U
 
when
 
BG
 
isbelow
 
a
 
pre-established
 
limit
 
(usually70---90mg/dL)
 
for
 
2---3
 
consecutive
 
days
Ifhypoglycemia
 
occurs,
 
decrease
 
the
 
dose
 
by 
 
4Uo
 
10% 
 
of the
 
basal
 
insulin
 
dose.
BG:
 
basalbloodglucoselevel.
three
 
days
 
 
Duly
 
trained
 
patients
 
may
 
also
 
performtitration.If
 
glucose
 
goals
 
are
 
notachieved
 
with
 
basal
 
insulins
 
atdoses
 
higher
 
than
 
0.5
 
U/kg
 
in
 
3---4
 
months,
 
treatment
 
inten-sification
 
shouldbe
 
considered.In
 
highly
 
symptomatic
 
patients
 
with
 
marked
 
basal
 
hyper-glycemia
 
(>280---300
 
mg/dL)
 
or
 
ketonuria,
 
two
 
doses
 
of
 
basalinsulin,
 
a
 
biphasic
 
regimen,
 
or
 
basal/bolus
 
treatment
 
may
 
berequired.
Discontinuation
 
of 
 
insulin
 
therapy
 
in
 
patients
 
withT2DM
Insomepatients,
 
insulin
 
may
 
be
 
discontinued
 
and/orreplaced
 
by
 
other
 
antidiabetic
 
drugs.
 
Some
 
variables
 
maypredict
 
theefficacy
 
ofreplacing
 
insulin
 
by
 
other
 
antidia-betic
 
drugs:
 
a)
 
insulin
 
therapy
 
during
 
hospital
 
admission
 
orconcomitant
 
disease
 
with
 
adequate
 
prior
 
blood
 
glucose
 
con-trol
 
with
 
antidiabetic
 
drugsother
 
than
 
insulin;
 
b)
 
insulintherapy
 
from
 
thestartwith
 
sustained
 
adequate
 
control;
 
c)adequate
 
control
 
with
 
nottoo
 
high
 
doses
 
(<0.5
 
U/kg/day)
5
 
Consensus
 
on
 
insulin
 
treatment
 
intype
 
2diabetes
 
3and
 
diabetes
 
duration<10
 
years;
 
and
 
d)
 
patients
 
undergoingbariatric
 
surgery.Reduction
 
should
 
be
 
gradual,
 
e.g.4Uper
 
week.Finally,
 
the
 
decision
 
should
 
be
 
agreed
 
with
 
thepatient.If
 
hyperglycemic
 
decompensation
 
occurs,
 
insulin
 
should
 
berestarted.
 
Insulin
 
may
 
be
 
required
 
again
 
inthe
 
eventofconcomitant
 
disease.
Insulin
 
therapy
 
regimens
Basalinsulin
2shows
 
the
 
insulins
 
available.
 
Basalinsulins
 
tryto
 
sim-ulate
 
the
 
basal
 
pattern
 
to
 
maintain
 
patients
 
close
 
tonormalfasting
 
bloodglucose
 
levels.
Types
 
of 
 
basal
 
insulin
---
 
NPH 
 
insulin.
 
The
 
peakaction
 
of
 
NPH
 
insulin
 
occurs
 
at4---6
 
h,and
 
its
 
effective
 
duration
 
of
 
action
 
is
 
12
 
h.Itmaybe
 
administered
 
as
 
oneor
 
two
 
doses,
 
combined
 
with
 
oraldrugs.
 
It
 
may
 
be
 
used
 
inpregnancy.---
 
Insulin
 
detemir 
 
is
 
asoluble
 
insulin
 
analogue.
 
The
 
durationof
 
action
 
is
 
dose-dependent:
 
12
 
h
 
for
 
doses
 
of0.2
 
U/kg
 
and20
 
h
 
for
 
doses
 
of
 
0.4
 
U/kg.Inone
 
thirdof
 
patients,
 
twodoses
 
are
 
required
 
to
 
cover
 
the24
 
h
 
period.---
 
Insulin
 
 glargine
 
U-100 
 
is
 
ananalogue
 
with
 
a
 
slower
 
onsetof
 
action
 
than
 
NPH
 
and
 
a
 
smoother
 
action
 
profile,withno
 
peaks
 
andaction
 
lasting
 
upto
 
18---24
 
h.
 
Itshould
 
beadministered
 
once
 
daily,
 
atthe
 
same
 
time
 
every
 
day.---
 
Biosimilar 
 
insulin
 
 glargine.
 
The
 
summaries
 
of
 
the
 
productcharacteristics
 
of
 
glargine
 
U-100and
 
biosimilar
 
glargine100
 
U/mL
 
are
 
almost
 
superimposable.---
 Insulinglargine
 
U-300.
 
Glargine
 
formulation
 
with
 
aconcentration
 
of
 
300U/mL.
 
It
 
has
 
aatter
 
and
 
longerpharmacodynamic
 
and
 
pharmacokinetic
 
profile
 
thanglargine
 
U-100andis
 
associated
 
with
 
less
 
risk
 
ofhypoglycemia
andsimilar
 
HbA
1c
 reductions
 
in
 
patientswith
 
T2DM.
9
Inclinical
 
trials,
 
basal
 
doses
 
10---18%
 
higherwere
 
needed
 
on
 
average
 
as
 
compared
 
toglargine
 
U-300.---
 
Insulin
 
degludec
 
is
 
ananalogue
 
with
 
a
 
duration
 
of
 
actionlonger
 
than
 
42h
 
with
 
an
 
intrapatient
 
variability
 
four
 
timeslower
 
as
 
compared
 
to
 
glargine
 
U-100,
 
with
 
the
 
same
 
effi-cacy
 
but
 
less
 
nocturnal
 
hypoglycemia.
 
Insulin
 
degludecshould
 
be
 
administered
 
daily
 
and
 
allows
 
forhighly
 
flexi-ble
 
administration,
 
with
 
dosing
 
intervals
 
ranging
 
from
 
8to
 
40
 
h.It
 
is
 
not
 
reimbursed
 
inSpain
 
as
 
a
 
starting
 
insulin.
Choice
 
ofstarting
 
insulinregimen
All
 
basal
 
insulins
 
have
 
thesame
 
efficacy,
but
 
there
 
aredifferences
 
regarding
 
therisk
 
of
 
hypoglycemia,
 
especiallynocturnal
 
hypoglycemia.
 
Anychoice
 
must
 
be
 
basedon
 
thepatient
 
profile
 
in
 
terms
 
of
 
safety
 
and
 
the
 
cost
 
of
 
the
 
treat-ment.
Insulincombined
 
with
 
other
 
drugs
Basal
 
insulin
 
therapy
 
is
 
usually
 
the
 
treatment
 
ofchoice
 
afterdrugs
 
other
 
than
 
insulin
 
have
 
failed.
As
 
regards
 
drugs
 
thatmay
 
be
 
used
 
incombination
 
with
 
basal
 
insulin,
 
there
 
are
 
twooptions
 
Start
 
of 
 
insulintherapy
 
with
 
basal
 
insulin
If
 
thepatient
 
is
 
receiving
 
metformin,
 
DPP-4
 
inhibitors
 
(DPP-4i),
 
GLP-1
 
receptor
 
agonists
 
GLP-1
 
RAs),
 
and/or
 
SGLT-2inhibitors
 
(SGLT-2i),
 
these
 
shouldbe
 
continued,
 
andthediscontinuation
 
ofpioglitazone
 
should
 
be
 
considered.
 
Ifsul-fonylureas
 
(SUs)
 
are
 
discontinued,
 
aninitial
 
blood
 
glucoseimpairment
 
may
 
occur.
 
IfSUs
 
are
 
continued,
 
a
 
reduction
 
inthe
 
doseis
 
advised
 
because
 
of
 
therisk
 
ofhypoglycemia
3
1A).
Intensification
 
of 
 
basalinsulin.
 
Which
 
non-insulin
 
drugsshould
 
beused?
Usually,
 
patients
 
are
 
already
 
receiving
 
an
 
oral
 
antidiabetic,generally
 
metformin
 
with
 
or
 
without
 
SUs
 
or
 
DPP-4i.The
 
mostrecent
 
guidelines
recommend
 
theaddition
 
ofa
 
GLP-1
 
RAor
 
SGLT-2i
 
as
 
analternative
 
to
 
theaddition
 
ofnew
 
insulininjections.
Basal-plus
 
insulin
 
regimen
This
 
consists
 
ofthe
 
progressive
 
addition
 
of
 
doses
 
of
 
prandialinsulin
 
(or
 
analogue),
 
starting
 
with
 
themeal
 
with
 
the
 
great-est
 
impact
 
onpostprandial
 
blood
 
glucose,
 
while
 
maintainingbasal
 
insulin.
 
Non-insulin
 
drugs
 
may
 
be
 
continued,
 
butSUdiscontinuation
 
is
 
preferred
 
because
 
ofthe
 
increased
 
risk
 
ofhypoglycemia.
Before
 
prandial
 
insulin
 
is
 
started,
 
thebasalglucose
 
goalshould
 
have
 
been
 
achieved.
 
Subsequently,
 
if
 
HbA
1c
 is
 
ele-vated,
 
rapid-acting
 
insulin
 
(oranalogue)
 
should
 
be
 
added.As
 
regards
 
the
 
starting
 
dose,Appendix
 
A,
 
Table
 
3
 
(Supple-mentary
 
material)
 
shows
 
four
 
options.
The
 
doses
 
shouldsubsequently
 
be
 
adjusted
 
(usually
 
every
 
oneor
 
two
 
weeks)until
 
anindividualized
 
postprandial
 
blood
 
glucose
 
goal
 
isachieved.
 
Appendix
 
A,
 
Table
 
4
 
(Supplementary
 
material)shows
 
several
 
possibilities.Once
 
the
 
postprandial
 
goal
 
isachieved,
 
if
 
thegoal
 
HbA
1c
has
 
not
 
been
 
reached,
 
an
 
additional
 
dose
 
of
 
prandial
 
insulinshould
 
be
 
given
 
at
 
another
 
meal.
Basal-bolus
 
insulin
 
regimen
When
 
treatment
 
with
 
basal
 
insulin
 
or
 
premixed
 
insulins
 
doesnotachieve
 
the
 
control
 
goal
 
inT2DM,
 
theclinical
 
practiceguidelines
 
recommend
 
the
 
addition
 
of
 
rapid-acting
 
insulinbeforemeals.
4
Meta-analyses
 
have
 
not
 
confirmed
 
a
 
greaterhypoglycemic
 
potency,
 
but
 
have
 
reported
 
alower
 
hypo-glycemia
 
rate
 
as
 
compared
 
toother
 
regimens.
2shows
 
apractical
 
algorithm
 
for
 
regimen
 
start
 
andadjust-ment.Practical
 
recommendations:
Bolus
 
dose
 
calculation.
 
Different
 
systems
 
have
 
been
 
pro-posed
 
(Appendix
 
A,
 
Table
 
3ofSupplementary
 
material).
 
Ourworking
 
group
 
considers
 
thefirst
 
two
 
to
 
be
 
themost
 
prudentoptions.
Start
 
in
 
 patients
 
usingbasal/NPH 
 
insulin.
 
A
 
switch
 
to
 
abasal
 
analogue
 
and
 
a20%
 
reduction
 
of
 
theprevious
 
dose
 
ofslow-acting
 
insulin
 
are
 
advisedif
 
control
 
was
 
close
 
to
 
thegoal
 
or
 
a
 
high
 
risk
 
of
 
hypoglycemia
 
exists.
Start
 
in
 
 patients
 
usingpremixe
 
insulin.
 
Administer
 
50%as
 
a
 
slow-acting
 
insulin
 
andtheother
 
50%
 
as
 
three
 
injectionsof
 
rapid-acting
 
insulin
 
before
 
themain
 
meals.
 
Depending
5
 
4
 
J.
 
Girbés
 
Borrás
 
et
 
al.
Table
 
2
 
Classification
 
and
 
presentation
 
of
 
insulins
 
inSpain
 
(December
 
2017).Product
 
Trade
 
name
 
How
 
supplied
Ultra-rapid-acting
 
insulins
 
(onset
 
ofaction:
 
<15min;
 
usual
 
duration:
 
3---5
 
h)
LisproHumalog
®
KwikPen
®
Five
 
3-mL
 
prefilled
 
pensHumalog
®
vial 10-mL
 
vialHumalog
®
200
 
KwikPen
®
Five
 
3-mL
 
prefilled
 
pensAspartNovoRapid
®
FlexPen
 
Five
 
3-mL
 
prefilled
 
pensNovoRapid
®
vial 10-mL
 
vialNovoRapid
®
Penfill
®
Five
 
3-mL
 
cartridgesNovoRapid
®
PumpCart
®
Five
 
1.6-mL
 
cartridgesGlulisineApidra
®
SoloStar
®
Five
 
3-mL
 
prefilled
 
pensApidraJuniorStar
 
cartridge
®
Five
 
3-mL
 
cartridgesApidra
®
solution
 
for
 
injection
 
10-mL
 
vial
Rapid-acting
 
insulins
 
(onset
 
of 
 
action:
 
30 
 
min;
 
usual
 
duration:
 
6---8
 
h)
RegularActrapid
®
InnoLet
®
Five
 
3-mL
 
prefilled
 
pensActrapid
®
vial
 
10-mL
 
vialHumulin
 
regular
®
10-mL
 
vial
Intermediate-action
 
insulins
 
(onset
 
of 
 
action:
 
1
 
h;
 
usual
 
duration
 
12---18
 
h)
NPHInsulatard
®
FlexPen
®
Five
 
3-mL
 
prefilled
 
pensInsulatard
®
vial
 
10-mL
 
vialHumulina
®
NPH
 
KwikPen
®
Six
 
3-mL
 
prefilled
 
pensHumulina
®
NPH
 
vial
 
10-mL
 
vialInsulindetemir Levemir
®
FlexPen
®
Five
 
3-mL
 
prefilled
 
pensLevemir
®
InnoLet
®
Five
 
3-mL
 
prefilled
 
pens
Long-actinginsulins
 
(onset
 
of 
 
action:
 
1h;
 
usual
 
duration
 
22---26
 
h)
Glargine
 
Lantus
®
SoloStar
®
Five
 
3-mL
 
prefilled
 
pensLantus
®
JuniorStar
 
cartridges
®
Five
 
3-mL
 
prefilled
 
pensLantus
®
vial
 
10-mL
 
vialGlargineU-300
 
Toujeo
®
SoloStar
®
Three
 
1.5-mL
 
prefilled
 
pensGlargine(biosimilar)
 
Abasaglar
®
KwikPen
 
Five
 
3-mL
 
prefilled
 
pensDegludecTresiba
®
Flex
 
Touch
®
Five
 
3-mL
 
prefilled
 
pens
 Allinsulins
 
are
 
supplied 
 
at
 
concentrations
 
of100U/mL
 
except
 
 for 
 
Humalog
 
KiwkPen
 
200 
 
U,
 
with
 
a
 
concentration
 
of 200U/mL,
 
and 
 
Toujeo
 
Solostar,
 
with
 
a
 
concentration
 
of 
 
300 
 
U/mL.
 
Standard 
 
insulin
 
syringes
 
are
 
 prepared 
 
 for concentrations
 
of 
 
100 
 
U/mL.
 
Thus,
 
drawing
 
insulin
 
 from
 
these
 
 pens
 
would 
 
multiply 
 
the
 
dose
 
by 
 
three
 
or 
 
by 
 
two,
 
with
 
theresultant
 
risk
 
of 
 
hypoglycemia.Insulin
 
Lantus
 
100U/mL
 
and 
 
 Abasaglar 
 
(biosimilar)
 
are
 
not
 
exchangeable.
 
They 
 
should 
 
be
 
 prescribed 
 
by 
 
brand 
 
name.Premixedcombinations
Regular
 
30%
 
+
 
NPH
 
70%
 
Humulina
®
30:70
 
KwikPen
®
Six
 
3-mL
 
prefilled
 
pensMixtard
®
30
 
InnoLet
®
Five
 
3-mL
 
prefilled
 
pensHumulin
®
30:70
 
vial
 
10-mL
 
vialMixtard
®
30
 
vial
 
10-mL
 
vialLispro25%+Lispro
 
protamine
 
75%
 
Humalog
®
Mix
 
25
TM
KiwkPen
®
Five
 
3-mL
 
pensLispro50%+Lispro
 
protamine
 
50%
 
Humalog
®
Mix
 
50
TM
KwikPen
®
Five
 
3-mL
 
prefilled
 
pensAspart30%+Aspart-protamine
 
70%
 
NovoMix
®
30
 
FlexPen
®
Five
 
3-mL
 
prefilled
 
pensAspart50%+Aspart-protamine
 
50% NovoMix
®
50
 
FlexPen
®
Five
 
3-mL
 
prefilled
 
pensAspart70%+Aspart-protamine
 
30%
 
NovoMix
®
70
 
FlexPen
®
Five
 
3-mL
 
prefilled
 
pens
5
5
5
5
5

Reward Your Curiosity

Everything you want to read.
Anytime. Anywhere. Any device.
No Commitment. Cancel anytime.
576648e32a3d8b82ca71961b7a986505