Insulin Regular

Get emergency medical help if you have signs of insulin allergy: redness or swelling where an injection was given, itchy skin rash over the entire body, trouble breathing, fast heartbeats, feeling like you might pass out, or swelling in your tongue or throat.

Call your doctor at once if you have:

• low potassium--leg cramps, constipation, irregular heartbeats, fluttering in your chest, increased thirst or urination, numbness or tingling, muscle weakness or limp feeling.

Common side effects may include:

• low blood sugar;

• swelling in your hands or feet;

• weight gain; or

• thickening or hollowing of the skin where you injected the medicine.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Usual Adult Dose for Diabetes Type 1:

Note: Regular human insulin is available in 2 concentrations: 100 units of insulin per mL (U-100) and 500 units of insulin per mL (U-500)

Individualize dose based on metabolic needs and frequent monitoring of blood glucose
-Total daily insulin requirements are generally between 0.5 to 1 unit/kg/day
-Most individuals with type 1 diabetes should be treated with multiple-daily insulin (MDI) injections or continuous subcutaneous insulin infusion (CSII)

MDI Regimens: Utilizing a combination of prandial (i.e., bolus, rapid, or short-acting insulins) and basal (i.e., intermediate or long acting insulin) insulin, administer 3 to 4 injections per day; regular human insulin is a short-acting prandial insulin.
--Administer U-100 insulin subcutaneously 3 or more times a day approximately 30 minutes prior to start of a meal
--Administer U-500 insulin subcutaneously 2 to 3 times a day approximately 30 minutes prior to start of a meal

CSII (Insulin Pump) Therapy: U-100 insulin only
-Initial programming should be based on the total daily insulin dose of previous MDI regimen; check with pump labeling to ensure pump has been evaluated with the specific insulin to be used (e.g., Novolin(R) is not recommended for use in insulin pumps due to risk of precipitation).
-While there is significant interpatient variability, approximately 50% of the total dose is provided as meal-related boluses and the remainder as a basal infusion.

Intravenous Administration: U-100 insulin only;
-Closely monitor blood glucose and serum potassium during IV administration
-Humulin(R): Dilute to a concentration of 0.1 to 1 unit/mL in an infusion system using polyvinyl chloride infusion bags; this insulin is stable in normal saline
-Novolin(R): Dilute to a concentration of 0.05 to 1 unit/mL in an infusion system using polypropylene infusion bags; this insulin is stable in normal saline, 5% dextrose, or 10% dextrose with 40 mmol/L potassium chloride

Comments:
-Most people with type 1 diabetes should use insulin analogs to reduce hypoglycemic risk.
-Most people with type 1 diabetes should be educated in how to match prandial insulin dose to carbohydrate intake, pre-meal blood glucose, and anticipated activity.
-Insulin resistant patients that require daily insulin doses of more than 200 units may find U-500 insulin to be useful as large doses may be administered subcutaneously in a reasonable volume.
-To avoid any mix-up with the availability of 2 different regular human insulin concentrations, insulin doses should always be ordered in units not in volume.

Use: To improve glycemic control in adult patients with diabetes mellitus.

Usual Adult Dose for Diabetes Type 2:

Note: Regular human insulin is available in 2 concentrations: 100 units of insulin per mL (U-100) and 500 units of insulin per mL (U-500)

Individualize dose based on metabolic needs and frequent monitoring of blood glucose
-Initial doses are often in the range of 0.2 to 0.4 units/kg/day
-Use HbA1c values to guide therapy; consult current guidelines for optimal target ranges

Multiple-daily insulin (MDI) injections U-100 or U-500 insulin:
-Administer U-100 insulin subcutaneously 3 or more times a day approximately 30 minutes prior to start of a meal
-Administer U-500 insulin subcutaneously 2 to 3 times a day approximately 30 minutes prior to start of a meal
-May be used in combination with oral antihyperglycemic agents or longer-acting basal insulin

Continuous Subcutaneous Insulin Infusion (Insulin Pump) U-100 insulin only:
-Initial programming should be based on the total daily insulin dose of previous MDI regimen; check with pump labeling to ensure pump has been evaluated with specific insulin to be used (e.g., Novolin(R) is not recommended for use in insulin pumps due to risk of precipitation)
-While there is significant interpatient variability, approximately 50% of the total dose is provided as meal-related boluses and the remainder as a basal infusion.

Intravenous Administration U-100 insulin only:
-Closely monitor blood glucose and serum potassium during IV administration
-Humulin(R): Dilute to a concentration of 0.1 to 1 unit/mL in an infusion system using polyvinyl chloride infusion bags; this insulin is stable in normal saline
-Novolin(R): Dilute to a concentration of 0.05 to 1 unit/mL in an infusion system using polypropylene infusion bags; this insulin is stable in normal saline, 5% dextrose, or 10% dextrose with 40 mmol/L potassium chloride

Comments:
-For people with type 2 diabetes, a patient-centered approach to care should guide choice of pharmacologic agents; considerations include efficacy, cost, potential side effects, weight, comorbidities, hypoglycemic risk, and patient preference.
-Insulin resistant patients that require daily insulin doses of more than 200 units may find U-500 insulin to be useful as large doses may be administered subcutaneously in a reasonable volume.
-To avoid any mix-up with the availability of 2 different regular human insulin concentrations (U-100 and U-500), insulin doses should always be ordered in units not in volume.

Use: To improve glycemic control in adult patients with diabetes mellitus.

Usual Adult Dose for Diabetic Ketoacidosis:

Successful treatment of hyperglycemic emergencies such as diabetic ketoacidosis (DKA) requires frequent monitoring of clinical and laboratory parameters while carefully correcting volume deficits, managing electrolytes, and normalizing blood glucose. Insulin therapy is used to slowly correct high glucose levels; consult current treatment protocols for specific guidance on fluid and electrolyte management.

Initiate insulin infusion 1 to 2 hours after starting fluid replacement therapy.
-Dose: 0.14 unit/kg/hour IV; alternatively, a bolus of 0.1 unit/kg followed by an infusion of 0.1 unit/kg/hr has been used
-Blood glucose should drop 50 to 75 mg/dL per hour, if this drop does not occur in the first hour; administer bolus of 0.14 unit/kg while continuing the insulin infusion.
-When blood glucose concentration reaches 200 mg/dL, decrease the insulin infusion to 0.02 to 0.05 unit/kg/hr; dextrose should be added to the IV fluids to maintain a blood glucose between 150 and 200 mg/dL until resolution of DKA (serum bicarbonate level 15 mEq/L or greater, venous pH greater than 7.3, and a calculated anion gap in the normal range)

In circumstances where continuous IV infusion is not possible and DKA is uncomplicated, rapid and short-acting insulins have been administered subcutaneously or intramuscularly. See rapid-acting (lispro, aspart, or glulisine) insulin monographs for dosing of rapid-acting insulin.

Subcutaneous regular human insulin: 0.1 unit/kg subcutaneously every 1 to 2 hours; when blood glucose is less than 250 mg/dL (14 mmol/L), give glucose-containing fluids orally and reduce insulin to 0.05 unit/kg subcutaneously as needed to keep blood glucose around 200 mg/dL (11 mmol/L) until resolution of DKA.

Comments:
-An endocrinologist or critical care specialist with training and expertise in the management of DKA should direct care; frequent monitoring of clinical and laboratory parameters is necessary as well as identification and correction of precipitating event.
-Starting insulin therapy before IV fluid replacement may precipitate shock, and increase the risk of hypokalemia and cerebral edema.
-To prevent rebound hyperglycemia, initiate subcutaneous insulin 15 to 30 minutes (rapid-acting) or 1 to 2 hours (regular insulin) before stopping the insulin infusion; alternatively, basal insulin may be administered in the evening and the insulin infusion stopped the next morning.

Use: Treatment of diabetic ketoacidosis (DKA)

Usual Adult Dose for Insulin Resistance:

Patients with insulin-resistant type 1 or type 2 diabetes who require daily insulin doses of more than 200 units may find U-500 insulin to be useful; larger doses may be administered subcutaneously in a reasonable volume.

Usual Adult Dose for Nonketotic Hyperosmolar Syndrome:

Successful treatment of hyperglycemic emergencies hyperglycemic hyperosmolar state (HHS) requires frequent monitoring of clinical and laboratory parameters while carefully correcting volume deficits, managing electrolytes, and normalizing blood glucose. Insulin therapy is used to slowly correct high glucose levels; consult current treatment protocols for specific guidance on fluid and electrolyte management.

Initiate insulin infusion 1 to 2 hours after starting fluid replacement therapy
-Dose: 0.14 unit/kg/hour IV; alternatively, a bolus of 0.1 unit/kg followed by an infusion of 0.1 unit/kg/hr has been used
-If blood glucose does not fallen by 10% in first hour, give bolus of 0.14 units/kg while continuing insulin infusion
-When blood glucose concentration reaches 300 mg/dL or less, decrease the insulin infusion to 0.02 to 0.05 unit/kg/hr; dextrose should be added to the IV fluids to maintain blood glucose between 250 and 300 mg/dL until resolution of HHS.

Comments:
-An endocrinologist or critical care specialist with training and expertise in the management of HHS should direct care; frequent monitoring of clinical and laboratory parameter is necessary as well as identification and correction of precipitating event.
-Starting insulin therapy before IV fluid replacement may precipitate shock, and increase the risk of hypokalemia and cerebral edema.
-To prevent rebound hyperglycemia, initiate subcutaneous insulin 15 to 30 minutes (rapid-acting) or 1 to 2 hours (regular insulin) before stopping the insulin infusion; alternatively, basal insulin may be administered in the evening and the insulin infusion stopped the next morning.

Use: Treatment of hyperglycemic hyperosmolar state (also known as hyperosmolar non-ketotic coma (HONK); hyperosmolar hyperglycemic nonketotic syndrome)

Usual Pediatric Dose for Diabetes Type 1:

Note: Regular human insulin is available in 2 concentrations: 100 units of insulin per mL (U-100) and 500 units of insulin per mL (U-500); U-500 insulin has not been adequately studied in pediatric patients.

Individualize dose based on metabolic needs and frequent monitoring of blood glucose
-Total daily insulin requirements are usually between 0.5 to 1 unit/kg/day
-Insulin requirements during the honeymoon phase (period of partial remission) are usually less than 0.5 units/kg/day and may be much lower
-Insulin requirements in pre-pubertal children who are outside the partial remission phase are usually from 0.7 to 1 unit/kg/day
-Insulin requirements in patients with insulin resistance (e.g., during puberty or due to obesity) may be substantially higher than 1 unit/kg/day (up to 2 units/kg/day)
-Use HbA1c values to guide therapy; consult current guidelines for optimal target ranges
-Most individuals with type 1 diabetes should be treated with multiple-daily insulin (MDI) injections or continuous subcutaneous insulin infusion (CSII)

MDI Regimens: Utilizing a combination of prandial (i.e., bolus, rapid, or short-acting insulins) and basal (i.e., intermediate or long acting insulin) insulin, administer 3 to 4 injections per day; regular human insulin is a short-acting prandial insulin.
--Administer U-100 insulin subcutaneously 3 or more times a day approximately 30 minutes prior to start of a meal

CSII (Insulin Pump) U-100 insulin:
-Initial programming should be based on the total daily insulin dose of previous MDI regimen; check with pump labeling to ensure pump has been evaluated with specific insulin to be used (Novolin(R) is not recommended for use in insulin pumps due to risk of precipitation)
-While there is significant interpatient variability, approximately 50% of the total dose is provided as meal-related boluses and the remainder as a basal infusion.

Intravenous Administration: U-100 insulin:
-Closely monitor blood glucose and serum potassium during IV administration
-Humulin(R): Dilute to a concentration of 0.1 to 1 unit/mL in an infusion system using polyvinyl chloride infusion bags; this insulin is stable in normal saline
-Novolin(R): Dilute to a concentration of 0.05 to 1 unit/mL in an infusion system using polypropylene infusion bags; this insulin is stable in normal saline, 5% dextrose, or 10% dextrose with 40 mmol/L potassium chloride

Comments:
-Most people with type 1 diabetes should use insulin analogs to reduce hypoglycemic risk.
-Most people with type 1 diabetes should be educated in how to match prandial insulin dose to carbohydrate intake, pre-meal blood glucose, and anticipated activity.
-Insulin resistant patients that require daily insulin doses of more than 200 units may find U-500 insulin to be useful as large doses may be administered subcutaneously in a reasonable volume.
-To avoid any mix-up with the availability of 2 different regular human insulin concentrations, insulin doses should always be ordered in units not in volume.
-Insulin therapy should be initiated in children and adolescents for whom the distinction between type 1 diabetes mellitus and type 2 diabetes mellitus is unclear, specifically those with a random venous or plasma blood glucose concentration of 250 mg/dL or greater, or those who HbA1c is greater than 9%.

Use: To improve glycemic control in pediatric patients with diabetes mellitus.

Usual Pediatric Dose for Diabetes Type 2:

Note: Regular human insulin is available in 2 concentrations: 100 units of insulin per mL (U-100) and 500 units of insulin per mL (U-500); U-500 insulin has not been adequately studied in pediatric patients.

Individualize dose based on metabolic needs and frequent monitoring of blood glucose
-Initial doses are often in the range of 0.2 to 0.4 units/kg/day
-Use HbA1c values to guide therapy; consult current guidelines for optimal target ranges

Multiple-Daily Insulin (MDI) injections: Utilizing a combination of prandial (i.e., bolus, rapid, or short-acting insulins) and basal (i.e., intermediate or long acting insulin) insulin, may administer 3 to 4 injections per day; regular human insulin is a short-acting prandial insulin
--Administer U-100 insulin subcutaneously 3 or more times a day approximately 30 minutes prior to start of a meal

Continuous Subcutaneous Insulin Infusion (CSII) - Insulin Pump Therapy:
-Initial programming should be based on the total daily insulin dose of previous MDI regimen; check with pump labeling to ensure pump has been evaluated with specific insulin to be used (Novolin(R) is not recommended for use in insulin pumps due to risk of precipitation)
-While there is significant interpatient variability, approximately 50% of the total dose is provided as meal-related boluses and the remainder as a basal infusion.

Intravenous Administration: U-100 insulin:
-Closely monitor blood glucose and serum potassium during IV administration
-Humulin(R): Dilute to a concentration of 0.1 to 1 unit/mL in an infusion system using polyvinyl chloride infusion bags; this insulin is stable in normal saline
-Novolin(R): Dilute to a concentration of 0.05 to 1 unit/mL in an infusion system using polypropylene infusion bags; this insulin is stable in normal saline, 5% dextrose, or 10% dextrose with 40 mmol/L potassium chloride

Comments:
-Insulin therapy should be initiated in children and adolescents for whom the distinction between type 1 diabetes mellitus and type 2 diabetes mellitus is unclear, specifically those with a random venous or plasma blood glucose concentration of 250 mg/dL or greater, or those who HbA1c is greater than 9%.
-May administer in combination with oral antidiabetic agents.

Use: To improve glycemic control in pediatric patients with diabetes mellitus.

Usual Pediatric Dose for Diabetic Ketoacidosis:

Successful treatment of hyperglycemic emergencies such as diabetic ketoacidosis (DKA) requires frequent monitoring of clinical and laboratory parameters while carefully correcting volume deficits, managing electrolytes, and normalizing blood glucose. Insulin therapy is used to slowly correct high glucose levels; consult current treatment protocols for specific guidance on fluid and electrolyte management.

Initiate insulin infusion 1 to 2 hours after starting fluid replacement therapy.
-Dose: 0.1 unit/kg/hour IV until resolution of DKA (pH greater than 7.3, bicarbonate greater than 15 mmol/L and/or closure of the anion gap); resolution of DKA takes longer than normalization of blood glucose concentrations.
-For patients with marked sensitivity to insulin, decrease insulin to 0.05 units/kg/hour or less provided the metabolic acidosis continues to resolve.

In circumstances where continuous IV infusion is not possible and DKA is uncomplicated, may administer regular insulin subcutaneously at 0.1 unit/kg every 1 to 2 hours; when blood glucose is less than 250 mg/dL (14 mmol/L), give glucose-containing fluids orally and reduce insulin to 0.05 unit/kg as needed to keep blood glucose around 200 mg/dL (11 mmol/L) until resolution of DKA.

Comments:
-An endocrinologist or critical care specialist with training and expertise in the management of DKA should direct care; frequent monitoring of clinical and laboratory parameters is necessary as well as identification and correction of precipitating event.
-Starting insulin therapy before IV fluid replacement may precipitate shock, and increase the risk of hypokalemia and cerebral edema.
-During initial volume expansion the plasma glucose falls steeply, thereafter expect decreases in the range of 36 to 90 mg/dL/hr (2 to 5 mmol/L/hr); to prevent too rapid a decrease in plasma glucose and hypoglycemia, 5% glucose should be added to the IV fluid when the plasma glucose falls to 250 to 300 mg/dL (14 to 17 mmol/L) or sooner if the rate of fall is precipitous.
-To prevent rebound hyperglycemia, initiate subcutaneous insulin 15 to 30 minutes (rapid-acting) or 1 to 2 hours (regular insulin) before stopping the insulin infusion; alternatively, basal insulin may be administered in the evening and the insulin infusion stopped the next morning.

Use: Treatment of diabetic ketoacidosis

(IN soo lin REG yoo ler)

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Injection:

HumuLIN R: 100 units/mL (3 mL, 10 mL) [contains metacresol, phenol]

NovoLIN R: 100 units/mL (10 mL) [contains metacresol]

NovoLIN R ReliOn: 100 units/mL (10 mL) [contains metacresol]

Solution, Subcutaneous:

HumuLIN R U-500 (CONCENTRATED): 500 units/mL (20 mL) [contains metacresol]

Solution Pen-injector, Subcutaneous:

HumuLIN R U-500 KwikPen: 500 units/mL (3 mL) [contains metacresol]

• Insulin, Short-Acting

IV: U-100: 2 to 6 hours

SubQ: U-100: 4 to 12 hours (may increase with dose); U-500: 13 to 24 hours

Half-Life Elimination

IV: ~0.5 to 1 hour (dose-dependent); SubQ: 1.5 hours

There are no dosage adjustments provided in the manufacturer's labeling; dosage requirements may be reduced and patients may require more frequent dose adjustment and glucose monitoring.

Frequency not always defined.

Cardiovascular: Peripheral edema

Dermatologic: Erythema at injection site, injection site pruritus

Endocrine & metabolic: Hypoglycemia, hypokalemia, weight gain

Hypersensitivity: Anaphylaxis, hypersensitivity, hypersensitivity reaction

Local: Hypertrophy at injection site, lipoatrophy at injection site

Critically ill patients receiving insulin infusion: Blood glucose every 1 to 2 hours. Note: Every 4 hour blood glucose monitoring is not recommended unless a low hypoglycemia rate is demonstrated with the insulin protocol used. Arterial or venous whole blood sampling is recommended for patients in shock, on vasopressor therapy, or with severe edema, and when on a prolonged insulin infusion (SCCM [Jacobi 2012]).

Diabetes mellitus: Plasma glucose, electrolytes, HbA1c (at least twice yearly in patients who have stable glycemic control and are meeting treatment goals; quarterly in patients not meeting treatment goals or with therapy change [ADA 2016c])

DKA/HHS: Serum electrolytes, glucose, BUN, creatinine, osmolality, venous pH (repeat arterial blood gases are generally unnecessary), anion gap, urine output, urinalysis, mental status

Hyperkalemia: Serum potassium and glucose must be closely monitored to avoid hypokalemia, rebound hyperkalemia, and hypoglycemia.

Regular pork insulin is obtained from pork pancreas. Regular Iletin II (purified insulin, Lilly) consists of zinc-insulin crystals dissolved in a clear fluid. Regular Iletin II has had nothing added to change the speed or length of its action. It takes effect rapidly and has a relatively short duration of activity (4 to 12 hours) as compared with other insulins. The time course of action of any insulin may vary considerably in different individuals or at different times in the same individual. As with all insulin preparations, the duration of action of Regular Iletin II is dependent on dose, site of injection, blood supply, temperature, and physical activity. Regular Iletin II is a sterile solution and is for subcutaneous injection. It should not be used intramuscularly. The concentration of Regular Iletin II is 100 units/mL (U-100).

Identification

This insulin, manufactured by Eli Lilly and Company, has the trademark Iletin II and is available in various types--Regular, NPH, and Lente. Your doctor has prescribed the type of insulin that he/she believes is best for you. DO NOT USE ANY OTHER INSULIN EXCEPT ON HIS/HER ADVICE AND DIRECTION.

Always check the carton and the bottle label for the name and letter designation of the insulin you receive from your pharmacy to make sure it is the same as that your doctor has prescribed.

Always examine the appearance of your bottle of insulin before withdrawing each dose. Regular Iletin II is a clear and colorless liquid with a water-like appearance and consistency. Do not use if it appears cloudy, thickened, or slightly colored or if solid particles are visible. Always check the appearance of your bottle of insulin before using, and if you note anything unusual in the appearance of your insulin or notice your insulin requirements changing markedly, consult your doctor.

Storage

Insulin should be stored in a refrigerator but not in the freezer. If refrigeration is not possible, the bottle of insulin that you are currently using can be kept unrefrigerated as long as it is kept as cool as possible (below 86°F [30°C]) and away from heat and light. Do not use insulin if it has been frozen. Do not use a bottle of insulin after the expiration date stamped on the label.

INJECTION PROCEDURES

Correct Syringe

Doses of insulin are measured in units. U-100 insulin contains 100 units/mL (1 mL = 1 cc). With Regular Iletin II, it is important to use a syringe that is marked for U-100 insulin preparations. Failure to use the proper syringe can lead to a mistake in dosage, causing serious problems for you, such as a blood glucose level that is too low or too high.

Syringe Use

To help avoid contamination and possible infection, follow these instructions exactly.

Disposable syringes and needles should be used only once and then discarded.

NEEDLES AND SYRINGES MUST NOT BE SHARED.

Reusable syringes and needles must be sterilized before each injection. Follow the package directions supplied with your syringe. Described below are 2 methods of sterilizing.

Boiling

1. Put syringe, plunger, and needle in strainer, place in saucepan, and cover with water. Boil for 5 minutes.
2. Remove articles from water. When they have cooled, insert plunger into barrel, and fasten needle to syringe with a slight twist.
3. Push plunger in and out several times until water is completely removed.

Isopropyl Alcohol

If the syringe, plunger, and needle cannot be boiled, as when you are traveling, they may be sterilized by immersion for at least 5 minutes in Isopropyl Alcohol, 91%. Do not use bathing, rubbing, or medicated alcohol for this sterilization. If the syringe is sterilized with alcohol, it must be absolutely dry before use.

Preparing the Dose

1. Wash your hands.
2. Inspect the insulin. Regular Iletin II should look clear and colorless. Do not use Regular Iletin II if it appears cloudy, thickened, or slightly colored or if solid particles are visible.
3. If using a new bottle, flip off the plastic protective cap, but do not remove the stopper. When using a new bottle, wipe the top of the bottle with an alcohol swab.
4. If you are mixing insulins, refer to the Warnings below.
5. Draw air into the syringe equal to your insulin dose. Put the needle through rubber top of the insulin bottle and inject the air into the bottle.
6. Turn the bottle and syringe upside down. Hold the bottle and syringe firmly in 1 hand.
7. Making sure the tip of the needle is in the insulin, withdraw the correct dose of insulin into the syringe.
8. Before removing the needle from the bottle, check your syringe for air bubbles which reduce the amount of insulin in it. If bubbles are present, hold the syringe straight up and tap its side until the bubbles float to the top. Push them out with the plunger and withdraw the correct dose.
9. Remove the needle from the bottle and lay the syringe down so that the needle does not touch anything.

WARNINGS--SEE ADDITIONAL WARNINGS ABOVE

Patients who have been directed by their doctors to mix 2 types of insulin should be aware that insulin hypodermic syringes of different manufacturers may vary in the amount of space between the bottom line and the needle.

Because of this, do not change:

1. The order of mixing that the doctor has prescribed or
2. The model and brand of syringe or needle without first consulting your doctor.

The mixing should be done immediately prior to injection. Failure to heed this warning could result in a dosage error.

Injection

Cleanse the skin with alcohol where the injection is to be made. Stabilize the skin by spreading it or pinching up a large area. Insert the needle as instructed by your doctor. Push the plunger in as far as it will go. Pull the needle out and apply gentle pressure over the injection site for several seconds. Do not rub the area. To avoid tissue damage, give the next injection at a site at least 1/2" from the previous site.

DOSAGE

Your doctor has told you which insulin to use, how much, and when and how often to inject it. Because each patient's case of diabetes is different, this schedule has been individualized for you.

Your usual insulin dose may be affected by changes in your food, activity, or work schedule. Carefully follow your doctor's instructions to allow for these changes. Other things that may affect your insulin dose are:

Illness

Illness, especially with nausea and vomiting, may cause your insulin requirements to change. Even if you are not eating, you will still require insulin. You and your doctor should establish a sick day plan for you to use in case of illness. When you are sick, test your blood/urine frequently and call your doctor as instructed.

Pregnancy

Good control of diabetes is especially important for you and your unborn baby. Pregnancy may make managing your diabetes more difficult. If you are planning to have a baby, are pregnant, or are nursing a baby, consult your doctor.

Medication

Insulin requirements may be increased if you are taking other drugs with hyperglycemic activity, such as oral contraceptives, corticosteroids, or thyroid replacement therapy. Insulin requirements may be reduced in the presence of drugs with hypoglycemic activity, such as oral hypoglycemics, salicylates (for example, aspirin), sulfa antibiotics, and certain antidepressants. Always discuss any medications you are taking with your doctor.

Exercise

Exercise may lower your body's need for insulin during and for some time after the activity. Exercise may also speed up the effect of an insulin dose, especially if the exercise involves the area of injection site (for example, the leg should not be used for injection just prior to running). Discuss with your doctor how you should adjust your regimen to accommodate exercise.

Travel

Persons traveling across more than 2 time zones should consult their doctor concerning adjustments in their insulin schedule.

COMMON PROBLEMS OF DIABETES

Hypoglycemia (Insulin Reaction)

Hypoglycemia (too little glucose in the blood) is one of the most frequent adverse events experienced by insulin users. It can be brought about by:

1. Taking too much insulin
2. Missing or delaying meals
3. Exercising or working more than usual
4. An infection or illness (especially with diarrhea or vomiting)
5. A change in the body's need for insulin
6. Diseases of the adrenal, pituitary, or thyroid gland, or progression of kidney or liver disease
7. Interactions with other drugs that lower blood glucose, such as oral hypoglycemics, salicylates (for example, aspirin), sulfa antibiotics, and certain antidepressants
8. Consumption of alcoholic beverages

Symptoms of mild to moderate hypoglycemia may occur suddenly and can include:

• sweating
• dizziness
• palpitation
• tremor
• hunger
• restlessness
• tingling in the hands, feet, lips, or tongue
• lightheadedness
• inability to concentrate
• headache
• drowsiness
• sleep disturbances
• anxiety
• blurred vision
• slurred speech
• depressive mood
• irritability
• abnormal behavior
• unsteady movement
• personality changes

Signs of severe hypoglycemia can include:

• disorientation
• unconsciousness
• seizures
• death

Therefore, it is important that assistance be obtained immediately.

Early warning symptoms of hypoglycemia may be different or less pronounced under certain conditions, such as long duration of diabetes, diabetic nerve disease, medications such as beta-blockers, change in insulin preparations, or intensified control (3 or more insulin injections per day) of diabetes.

Without recognition of early warning symptoms, you may not be able to take steps to avoid more serious hypoglycemia. Be alert for all of the various types of symptoms that may indicate hypoglycemia. Patients who experience hypoglycemia without early warning symptoms should monitor their blood glucose frequently, especially prior to activities such as driving. If the blood glucose is below your normal fasting glucose, you should consider eating or drinking sugar-containing foods to treat your hypoglycemia.

Mild to moderate hypoglycemia may be treated by eating foods or taking drinks that contain sugar. Patients should always carry a quick source of sugar, such as candy mints or glucose tablets. More severe hypoglycemia may require the assistance of another person. Patients who are unable to take sugar orally or who are unconscious require an injection of glucagon or should be treated with intravenous administration of glucose at a medical facility.

You should learn to recognize your own symptoms of hypoglycemia. If you are uncertain about these symptoms, you should monitor your blood glucose frequently to help you learn to recognize the symptoms that you experience with hypoglycemia.

If you have frequent episodes of hypoglycemia or experience difficulty in recognizing the symptoms, you should consult your doctor to discuss possible changes in therapy, meal plans, and/or exercise programs to help you avoid hypoglycemia.

Hyperglycemia and Diabetic Acidosis

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin. Hyperglycemia can be brought about by:

1. Omitting your insulin or taking less than the doctor has prescribed
2. Eating significantly more than your meal plan suggests
3. Developing a fever or infection

In patients with insulin-dependent diabetes, prolonged hyperglycemia can result in diabetic acidosis. The first symptoms of diabetic acidosis usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With acidosis, urine tests show large amounts of glucose and acetone. Heavy breathing and a rapid pulse are more severe symptoms. If uncorrected, prolonged hyperglycemia or diabetic acidosis can result in loss of consciousness or death. Therefore, it is important that you obtain medical assistance immediately.

Lipodystrophy

Rarely, administration of insulin subcutaneously can result in lipoatrophy (depression in the skin) or lipohypertrophy (enlargement or thickening of tissue). If you notice either of these conditions, consult your doctor. A change in your injection technique may help alleviate the problem.

Allergy to Insulin

Local Allergy --Patients occasionally experience redness, swelling, and itching at the site of injection of insulin. This condition, called local allergy, usually clears up in a few days to a few weeks. In some instances, this condition may be related to factors other than insulin, such as irritants in the skin cleansing agent or poor injection technique. If you have local reactions, contact your doctor.

Systemic Allergy --Less common, but potentially more serious, is generalized allergy to insulin, which may cause rash over the whole body, shortness of breath, wheezing, reduction in blood pressure, fast pulse, or sweating. Severe cases of generalized allergy may be life threatening. If you think you are having a generalized allergic reaction to insulin, notify a doctor immediately.

ADDITIONAL INFORMATION

Additional information about diabetes may be obtained from your diabetes educator.

DIABETES FORECAST is a national magazine designed especially for patients with diabetes and their families and is available by subscription from the American Diabetes Association, National Service Center, 1660 Duke Street, Alexandria, Virginia 22314.

Another publication, DIABETES COUNTDOWN, is available from the Juvenile Diabetes Foundation International (JDF), 120 Wall Street, 19th Floor, New York, New York 10005, 1-800-JDF-CURE (1-800-533-2873).

Additional information about Iletin can be obtained by calling 1-888-88-LILLY (1-888-885-4559).

Literature revised August 13, 1999

PA 8487 AMP

Copyright © 1985, 1999, Eli Lilly and Company. All rights reserved.