II. Technique

  1. Injection sites: Abdomen, outer thigh, back of arm, flank and buttocks
  2. Insert needle at 90 degree angle into skin
  3. Hold needle in place for 5-10 seconds after injection to prevent leakage of Insulin
  4. Rotate injection sites to prevent lipohypertrophy (see adverse effects below)

III. Preparations: Insulin Selection

  1. New Insulin anologues are preferred
    1. More consistent absorption than traditional Insulin
    2. Bolus analogues have more rapid onset
    3. Basal agents release at more constant rate
    4. Only disadvantage is anologues double price
  2. Combination agents are discouraged unless noncompliant
    1. Reduces flexibility in meal and activity timing

IV. Preparations: Insulin Pens

  1. Supplied
    1. Insulin Pens are supplied in boxes of 5 pens each containing 3 ml at 100 units Insulin per ml
  2. Precautions
    1. Insulin Pens appear similar to one another despite containing different Insulins (basal or bolus)
    2. Read each syringe carefully (and note its color) prior to each injection to prevent Overdose errors
    3. Prepare cloudy Insulins (e.g. NPH) by gently rolling and inverting the pen 10 times prior to injection
    4. Confirm proper use by asking the patient to demonstrate preparation and injection at clinic visits
  3. Technique
    1. Attach a new needle to Insulin Pen before each use
    2. Prime the new needle with 2 units prior to use (removes air bubbles)
    3. Dial the dose
    4. Apply to pen to injection site, press the button, and hold in place for 5-10 seconds
    5. Discard the used needle

V. Drug Interactions: Diabetes Agents

  1. Agents safe to use with Insulin
    1. Metformin
    2. Thiazolidinediones
    3. Alpha-glucosidase Inhibitors
    4. Sitagliptin (Januvia)
  2. Agents safe to use with basal Insulin (Lantus, Levemir); avoid or use caution if used with bolus Insulin (Lispro, Aspart)
    1. Sulfonylureas
    2. Glitinides

VI. Agents: Intravenous Regular Insulin

  1. Note that all other Insulins listed on this page are subcutaneous
  2. See Insulin Drip
  3. Onset: Immediate
  4. Half-life: 5-10 minutes

VII. Precautions: Insulin-Related Errors

  1. Insulin errors result in >100,000 emergency visits (typically Hypoglycemia related) annually in United States
  2. Wrong Insulin (bolus Insulin mistakenly taken)
    1. Prescribers should carefully check prescriptions and home instructions for errors (e.g. Lispro prescribed instead of Lantus)
    2. Patients should check Insulin label everytime they inject (bolus Insulin in vials and pen devices may be easily mistaken for basal Insulin devices)
  3. Wrong time
    1. Patients must eat following bolus Insulin (e.g. Lispro) or do not take bolus Insulin if plan to skip the meal
  4. Wrong dose
    1. Decrease Insulin for anticipated decreased oral intake
    2. Assist patients with poor vision or dexterity who have difficulty drawing the correct dose
      1. Consider syring magnifier, pen device which click per unit, count-a-dose syringe
  5. Wrong technique
    1. Mix Insulin suspensions before use (e.g. NPH Insulin, Premixed Insulin such as Insulin 70/30)
      1. Roll vials or pens 10 times to mix
    2. Clinic staff should periodically observe patient's technique
      1. Obtaining fingerstick Glucose
      2. Calculating their Insulin dose with expected oral intake
      3. Drawing up Insulin dose
      4. Injecting Insulin
  6. References
    1. (2014) Presc Lett 21(7): 40

VIII. Agents: Bolus Insulins (Meal-time Insulin)

  1. Traditional Insulins
    1. Regular Insulin (Novolin R, Humulin R)
      1. Onset: 15 to 30 minutes
      2. Peak: 2.5 to 5 hours
      3. Duration: 6 to 8 hours
      4. Avoid in Stage IV or Stage V significant Chronic Kidney Disease
      5. Avoid if history of severe Hypoglycemia
  2. Analogue Insulins (Rapid, consistent absorption)
    1. Glulisine (Apidra)
      1. Onset: 5 to 15 minutes
      2. Peak: 1 to 2 hours
      3. Duration: 3 to 5 hours
      4. Similar to other bolus analogues
      5. FDA approved to take after meal
        1. Other analogues expected with same effect
    2. Lispro (Humalog)
      1. Onset: 5 to 15 minutes
      2. Peak: 1 to 2 hours
      3. Duration: 3 to 5 hours
    3. Aspart (Novolog)
      1. Onset: 5 to 15 minutes
      2. Peak: 1 to 2 hours
      3. Duration: 3 to 5 hours

IX. Agents: Basal Insulins

  1. Traditional Insulins
    1. NPH Insulin, Novolin N, Humulin N, Humulin L (Lente)
      1. Onset: 1 to 2 hours
      2. Peak: 6 to 8 hours
        1. Peak time is higher risk of hypoglcemia
        2. Consider snack at 6 hours after dose
      3. Duration: 10 to 16 hours (Lente slightly longer)
      4. Humulin L (Lente) discontinued in U.S. in 2006
    2. Ultralente Insulin (extended Insulin zinc suspension)
      1. Discontinued in U.S. in 2006
      2. Significant inconsistent effect even in same person
      3. Onset: 6-10 hours
      4. Peak: No peak
      5. Duration: 18 to 24 hours
  2. Analogue Insulins
    1. Detemir (Levemir)
      1. Onset: 2-4 hours
      2. Peak: 6-8 hours
      3. Duration: 12 to 20 hours (varies by dosage)
    2. Glargine (Lantus)
      1. Onset: 1-2 hours
      2. Duration: 21 to 24 hours
      3. Peak: No peak (flat action curve mimics continuous Insulin Infusion)

X. Combination Agents (Type II Diabetes if poor compliance)

  1. NPH 50/Regular 50
  2. NPH 70/Regular 30 (Humulin 70/30 or Novolin 70/30)
  3. NPL 75/Lispro 25 (Humalog Mix 75/25)
  4. NPH 70/Aspart 30 (Novolog Mix 70/30)

XI. Adverse Effects

  1. Hypoglycemia
    1. Increased risk when Hemoglobin A1C <7.4%
    2. Decreased risk with analogue Insulins
    3. Higher risk with severe Renal Insufficiency
      1. Insulin is excreted by the Kidney (30% of total)
      2. Gluconeogenesis occurs in the Kidney (30% of total)
  2. Weight gain (Excess of 4 kg over 10 years)
    1. Countered with Metformin in type 2 diabetics
    2. Countered with diet and Exercise
    3. Benefits of Glucose control outweigh weight risks
  3. Lipohypertrophy
    1. Localized fat hypertrophy and scar tissue from repeated injections in the same area
    2. Results in variable Insulin absorption as below
    3. Prevent by rotating injection sites (see below)
    4. Medical providers should examine injection sites
  4. Variable Insulin absorption
    1. Insulin absorption varies by body site
      1. Abdomen (best absorption)
      2. Arms
      3. Thigh
      4. Buttocks (least absorption)
    2. Variable absorption at lipohypertrophy sites
      1. Poor absorption causes early postprandial Hyperglycemia
      2. Depot formation causes delayed Hypoglycemia
    3. Site rotation (prevents lipohypertrophy - see above)
      1. Rotate injections within same body region
        1. Avoids Insulin absorption variability
      2. Rotate to widely different sites within region
        1. Example: Abdomen rotate to LUQ, RUQ, LLQ, RLQ

Images: Related links to external sites (from Google)

Cost: Medications

Insulin Syringe/Needle (on 2/9/2012 at DrugStore.com)
Insulin Syringe/Needle 100 28g X 1/2"1ml Miscellaneous Box #1 for $22.99 ($22.99/unit)
UltiGuard Insulin Syringe (on 2/9/2012 at DrugStore.com)
UltiGuard Insulin Syringe 100 "30g X 1/2"""1ml Miscellaneous Box #1 for $27.99 ($27.99/unit)
BD Insulin Syringe (on 2/9/2012 at DrugStore.com)
BD Insulin Syringe 100 "29g X 1/2"""1ml Miscellaneous Box #1 for $45.99 ($45.99/unit)
BD Insulin Syringe 100 25g X 1"1ml Miscellaneous Box #1 for $33.99 ($33.99/unit)
Sure Comfort Insulin Syringe (on 2/9/2012 at DrugStore.com)
Sure Comfort Insulin Syringe 100 "31g X 5/16"""0.3ml Miscellaneous Box #1 for $26.99 ($26.99/unit)
Sure Comfort Insulin Syringe 100 "30g X 5/16"""1ml Miscellaneous Box #1 for $24.99 ($24.99/unit)
NovoLIN R (on 2/9/2012 at DrugStore.com)
NovoLIN R 100unit/ml Solution 10ml Vial #1 for $75.99 ($75.99/unit)
NovoLIN N (on 2/9/2012 at DrugStore.com)
NovoLIN N 100unit/ml Suspension 10ml Vial #1 for $74.99 ($74.99/unit)
NovoLIN 70/30 (on 2/9/2012 at DrugStore.com)
NovoLIN 70/30 70-30% Suspension 10ml Vial #1 for $75.99 ($75.99/unit)
HumuLIN R (on 2/9/2012 at DrugStore.com)
HumuLIN R 100unit/ml Solution 10ml Vial #1 for $73.99 ($73.99/unit)
HumuLIN N (on 2/9/2012 at DrugStore.com)
HumuLIN N 100unit/ml Suspension 10ml Vial #1 for $73.99 ($73.99/unit)
HumuLIN R U-500 (Concentrated) (on 2/9/2012 at DrugStore.com)
HumuLIN R U-500 (Concentrated) 500unit/ml Solution 20ml Vial #1 for $443.01 ($443.01/unit)
HumuLIN 70/30 (on 2/9/2012 at DrugStore.com)
HumuLIN 70/30 70-30% Suspension 10ml Vial #1 for $73.99 ($73.99/unit)
HumuLIN 70/30 Pen (on 2/9/2012 at DrugStore.com)
HumuLIN 70/30 Pen 70-30% Suspension 3ml Pen #10 for $451.98 ($45.20/unit)
NovoLOG PenFill (on 2/9/2012 at DrugStore.com)
NovoLOG PenFill 100unit/ml Solution 3ml Cartridge #5 for $264.59 ($52.92/unit)
NovoLOG Mix 70/30 (on 2/9/2012 at DrugStore.com)
NovoLOG Mix 70/30 70-30% Suspension 10ml Vial #1 for $137.55 ($137.55/unit)
NovoLOG Mix 70/30 FlexPen (on 2/9/2012 at DrugStore.com)
NovoLOG Mix 70/30 FlexPen 70-30% Suspension 3ml Pen #5 for $258.98 ($51.80/unit)
NovoLOG FlexPen (on 2/9/2012 at DrugStore.com)
NovoLOG FlexPen 100unit/ml Solution (five 3ml Syringes Per Box) #1 for $268.99 ($268.99/unit)
NovoLOG (on 2/9/2012 at DrugStore.com)
NovoLOG 100unit/ml Solution 10ml Vial #1 for $140.70 ($140.70/unit)
HumaLOG (on 2/9/2012 at DrugStore.com)
HumaLOG 100unit/ml Solution 10ml Vial #1 for $137.98 ($137.98/unit)
HumaLOG 100unit/ml Solution 1 Box = Five 3ml Cartridges = 15ml #1 for $258.00 ($258.00/unit)
HumaLOG Mix 75/25 KwikPen (on 2/9/2012 at DrugStore.com)
HumaLOG Mix 75/25 KwikPen 75-25% Suspension Five 3ml Pen Per Box = 15ml #1 for $281.43 ($281.43/unit)
HumaLOG Mix 50/50 KwikPen (on 2/9/2012 at DrugStore.com)
HumaLOG Mix 50/50 KwikPen 50-50% Suspension Five 3ml Pens Per Box = 15ml #1 for $271.00 ($271.00/unit)
HumaLOG KwikPen (on 2/9/2012 at DrugStore.com)
HumaLOG KwikPen 100unit/ml Solution (1box = 5 Pens = 15ml) #1 for $268.99 ($268.99/unit)
Apidra SoloStar (on 2/9/2012 at DrugStore.com)
Apidra SoloStar 100unit/ml Solution 3ml Pen #1 for $47.99 ($47.99/unit)

Ontology: Humulin insulin (C0020171)

Concepts Amino Acid, Peptide, or Protein (T116) , Pharmacologic Substance(T121) , Hormone(T125)
MSH D007328
SnomedCT 350348002
English Humulin insulin, insulin, human (Humulin), insulin humulin, humulin, humulin insulin, Humulin insulin (substance)
Spanish Humulin insulin (substance), Humulin insulin
French Humulin
Czech Humulin

Ontology: Insulin (C0021641)

Definition (CSP) protein hormone secreted by beta cells of the pancreas; insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose and is also an important regulator of protein and lipid metabolism; insulin is used as a drug to control insulin-dependent diabetes mellitus.
Definition (NCI) A short-acting form of insulin. Regular insulin is obtained from animal or recombinant sources. The onset of action of regular insulin occurs at 30-90 minutes after injection; its effect lasts for 6 to 8 hours. Endogenous human insulin, a pancreatic hormone composed of two polypeptide chains, is important for the normal metabolism of carbohydrates, proteins and fats; it has anabolic effects on many types of tissues. (NCI04)
Definition (NCI) Human insulin protein (110 aa, 12 kDa) is encoded by the human insulin (INS) gene. This cytosolic protein, a heterodimer of disulfide-linked alpha and beta chains, is produced in pancreatic islet beta cells. Binding of insulin to its receptor stimulates glucose uptake, accelerates both glycolysis and the pentose phosphate cycle and increases glycogen synthesis in the liver. Insulin regulates protein and lipid metabolism. It also decreases blood glucose concentration by shuttling molecules into cells to be used for energy. Decreased expression of insulin protein causes familial hyperproinsulinemia.
Definition (MSH) A 51-amino acid pancreatic hormone that plays a major role in the regulation of glucose metabolism, directly by suppressing endogenous glucose production (GLYCOGENOLYSIS; GLUCONEOGENESIS) and indirectly by suppressing GLUCAGON secretion and LIPOLYSIS. Native insulin is a globular protein comprised of a zinc-coordinated hexamer. Each insulin monomer containing two chains, A (21 residues) and B (30 residues), linked by two disulfide bonds. Insulin is used as a drug to control insulin-dependent diabetes mellitus (DIABETES MELLITUS, TYPE 1).
Concepts Amino Acid, Peptide, or Protein (T116) , Pharmacologic Substance(T121) , Hormone(T125)
MSH D007328
SnomedCT 67866001, 39487003, 412222002
English Insulin, insulin, INSULIN PREPARATIONS, Insulin preparation, NOS, Regular Insulin, Regular insulin preparation, Unmodified insulin preparation, Insulin Regular, INSULIN, insulin preparations, insulin preparations (medication), A22 INSULIN PREPARATIONS, insulin regular, Insulin (ox), 8A-L-threonine-10A-L-isoleucine-30B-L-threonine-, Insulin [Chemical/Ingredient], [HS501] INSULIN, Insulin regular, insulin products, insulin preparation, insulin product, regular insulin, insulins, Insulin, Soluble, Soluble Insulin, Insulin, Regular, Insulin product, Insulin (substance), Insulin preparation, Insulin product (product), Regular insulin product, Unmodified insulin product, Insulin preparation (substance), Regular insulin (substance), Regular insulin
Swedish Insulin
Czech insulin, inzulin
Finnish Insuliini
French Insuline ordinaire, Insuline
Russian INSULIN, ИНСУЛИН
Spanish producto con insulina (producto), preparado insulínico, insulina (producto), producto con insulina, insulina (sustancia), insulina, preparado de insulina (producto), preparado de insulina (sustancia), preparado de insulina cristalina de cinc, preparado de insulina cristalina de zinc, preparado de insulina no modificada, preparado de insulina, insulina regular (sustancia), insulina regular, Insulina
Italian Insulina regolare, Insulina
Croatian INZULIN
Polish Insulina
Japanese インスリン, インスリン亜鉛水性懸濁液, インシュリン
German Insulin
Portuguese Insulina

Ontology: Novolin (C0028467)

Concepts Amino Acid, Peptide, or Protein (T116) , Pharmacologic Substance(T121)
MSH D007328
French Novolin
English novolin, Novolin

Ontology: Insulin Lispro (C0293359)

Definition (NCI) A recombinant therapeutic agent which is chemically identical to or similar to endogenous human insulin. In lispro insulin, the amino acid proline at B-28 and the amino acid lysine at B-29 are reversed, resulting in the rapid dissolution of this insulin to a monomer that is absorbed rapidly after subcutaneous administration. Lispro insulin is equipotent to human insulin on a molar basis but its effects are faster and of shorter duration. Endogenous insulin, a pancreatic hormone composed of two polypeptide chains, is important in the normal metabolism of carbohydrates, proteins and fats, promoting glucose utilization and protein synthesis; it has anabolic effects on many types of tissues. (NCI04)
Definition (MSH) Insulin that has been modified so that the B-chain contains a LYSINE at position 28 instead of a PROLINE and a PROLINE at position 29 instead of a LYSINE.
Concepts Amino Acid, Peptide, or Protein (T116) , Pharmacologic Substance(T121) , Hormone(T125)
MSH D061268
SnomedCT 388454007, 412210000, 125703000
English Insulin Lispro, Insulin lispro, insulin lispro, insulin LISPRO, lispro, 28(B)-Lys-29(B)-Pro-insulin, insulin LISPRO [Chemical/Ingredient], insulin, lysine(B28)-proline(B29), 28(B)-lysine-29(B)-prolineinsulin, insulin, lysyl(28B)-prolyl(28B)-, insulin, Lys(B28)-Pro(B29), B28-Lys-B29-Pro-insulin, insulin, Lys(28B)-Pro(29B)-, insulin human lispro, lispro human insulin, lispro insulin, INSULIN LISPRO, Lispro, 28(B)-Lys-29(B)-Pro-Insulin, LYSPRO, Lispro, Insulin, 28(B)-Lysine-29(B)-Prolineinsulin, Insulin, Lysyl(28B)-Prolyl(28B)-, Insulin, Lys(28B)-Pro(29B)-, Lispro insulin (product), Lispro insulin, Lispro insulin (substance), INSULIN,LISPRO,HUMAN/rDNA
Spanish insulina lispro (producto), insulina lispro, insulina lispro (sustancia)

Ontology: Humalog (C0528249)

Concepts Amino Acid, Peptide, or Protein (T116) , Pharmacologic Substance(T121)
MSH D061268
English humalog, HumaLOG, Humalog, Eli Lilly brand of Insulin Lispro

Ontology: NovoLog (C0939412)

Concepts Amino Acid, Peptide, or Protein (T116) , Pharmacologic Substance(T121)
MSH D061267
English Novolog, novolog, novorapid, NovoLOG, NovoRapid, Novo Nordisk Brand of Insulin Aspart, NovoLog