Wisconsin Diabetes Mellitus Essential Care Guidelines 2012 ...Wisconsin Diabetes Mellitus Essential Care Guidelines • 2012 42 DIABETES MELLITUS MEDICATIONS 2012 INJECTABLE NON-INSULIN

ToolsWisconsin Diabetes Mellitus Essential Care Guidelines • 2012

40

DIA

BET

ES M

ELLI

TUS

MED

ICAT

ION

S 20

12O

RA

L G

LUC

OSE

-LO

WER

ING

AG

ENTS

RX

Avai

l. D

osag

eIn

itial

Dos

eIn

itial

Dos

e (e

lder

ly)

Dos

e A

djus

tmen

t S

ched

ule

Usu

al

Mai

nt.

Dos

age

Max

. E

ffect

tive

Dos

e

A1C

Lo

wer

ing

Wt

Ren

al

Dos

ing

Hep

atic

D

osin

gLa

b M

onito

ring

Com

mon

Sid

e E

ffect

sC

ontra

indi

catio

ns/ P

reca

utio

ns

Dru

g C

lass

: Sul

fony

urea

sA

ctio

ns: S

timul

ates

insu

lin s

ecre

tion;

low

ers

fast

ing

plas

ma

gluc

ose

Indi

catio

ns: T

ype

2 di

abet

es a

s m

onot

hera

py o

r in

com

bina

tion

with

insu

lin, m

etfo

rmin

, DP

P-IV

inhi

bito

rs, i

ncre

tin m

imet

ics,

or T

ZDs

Glip

izid

e5

mg

10 m

g5

mg

2.5

mg/

day

Incr

ease

by

2.5

to 5

mg

(> 1

5 m

g/da

y =

BID

) af

ter 1

-2 w

ks

5-15

mg/

day

20 m

g/da

y

1.0-

2%+

N/A

Sta

rt at

2.

5 m

g/da

y

N/A

• hyp

ogly

cem

ia

• wei

ght g

ain

• Use

cau

tion

in p

eopl

e w

ith s

ulfa

al

lerg

ies

• Use

gly

burid

e w

ith c

autio

n du

e to

gr

eate

r ris

k of

hyp

ogly

cem

ia• U

se c

autio

n w

ith re

nal o

r hep

atic

in

suffi

cien

cy (g

lipiz

ide

or g

limep

iride

pr

efer

red

choi

ces)

• Im

med

iate

rele

ase

and

exte

nded

re

leas

e gl

ipiz

ide

dose

s ar

e no

t eq

uivi

vale

nt

Glip

izid

e E

R2.

5 m

g5

mg

10 m

g 5

mg/

day

Incr

ease

by

5 m

g af

ter 1

-2

wks

5-10

mg/

day

20 m

g/da

y

Glim

epiri

de1

mg

2 m

g 4

mg

1-2

mg

1 m

gIn

crea

se b

y 1

-2

mg

afte

r 1-2

w

ks

1-4

mg/

day

8 m

g/da

y

Sta

rt at

1

mg/

day

and

mon

itor

Mild

--st

art

at 1

mg

(mon

itor)

S

ever

e--

avoi

d

Gly

burid

e1.

25 m

g 2.

5 m

g 5

mg

2.5-

5 m

g1.

25 m

g/da

y

Incr

ease

by

2.5-

5 m

g af

ter

1-2

wks

1.25

-10

mg/

day

10 m

g/da

y

Do

NO

T us

e if

CrC

l < 5

0 m

l/min

Con

ser-

vativ

e 1.

25 m

g/da

y

Dru

g C

lass

: Big

uani

des

Act

ions

: Tar

gets

hep

atic

cel

ls; d

ecre

ases

hep

atic

glu

cose

pro

duct

ion;

doe

s no

t stim

ulat

e in

sulin

sec

retio

n; lo

wer

s fa

stin

g pl

asm

a gl

ucos

eIn

dica

tions

: Typ

e 2

diab

etes

as

mon

othe

rapy

or i

n co

mbi

natio

n w

ith a

ny o

ther

age

nt o

r ins

ulin

; ove

rwei

ght;

dysl

ipid

emic

; chi

ldre

n (a

ppro

ved

for ≥

age

10)

Met

form

in50

0 m

g85

0 m

g10

00 m

g50

0 m

g B

ID

Use

with

ca

utio

n,

espe

cial

ly if

>

80 y

ears

Incr

ease

by

500

mg

afte

r 1-2

w

ks

1000

-200

0 m

g/da

y

2550

mg/

day

(10-

16 y

o =

2000

mg/

day)

1.0-

2%0/

-

Con

train

-di

cate

d if

SC

r ≥

1.5

mal

es,

≥ 1.

4 fe

mal

es

or e

GFR

<

50

Avoi

d du

e to

risk

of

lact

ic

acid

osis

BUN, Cr & CBC: prior to initiation then yearly.LFTs: prior to initiation.Vitamin B12 levels: every year for those at high risk of Vitamin. B12 deficiency

• dia

rrhe

a• n

ause

a• a

bdom

inal

bl

oatin

g• a

nore

xia

• Do

not u

se w

ith h

epat

ic in

suf-

ficie

ncy

• Con

sult

with

dia

bete

s sp

ecia

list

is re

com

men

ded

for S

Cr >

1.5

or

eGFR

< 5

0• U

ncom

pens

ated

CH

F• E

xces

sive

alc

ohol

inta

ke• O

ver a

ge 8

0 (c

autio

n)• A

ceta

zola

mid

e• W

ithho

ld th

erap

y fo

r 48

hour

s af

ter

iodi

nate

d co

ntra

st m

edia

is u

sed

• May

cau

se o

vula

tion

to re

sum

e in

an

ovul

ator

y, p

rem

enop

ausa

l wom

en

Met

form

in

ER

500

mg

750

mg

500

mg

500-

2000

m

g/da

y20

00 m

g/da

y

Dru

g C

lass

: TZD

(Thi

azol

idin

edio

nes)

Act

ions

: Reg

ulat

es in

sulin

resp

onsi

ve g

enes

nec

essa

ry fo

r glu

cose

and

lipi

d m

etab

olis

m; i

mpr

oves

sen

sitiv

ity to

insu

lin in

ske

leta

l and

adi

pose

tiss

ueIn

dica

tions

: Typ

e 2

diab

etes

as

mon

othe

rapy

or i

n co

mbi

natio

n w

ith a

ny o

ther

age

nts;

Act

os is

als

o ap

prov

ed fo

r use

with

insu

linN

ote:

Ros

iglit

azon

e is

not

list

ed o

n th

is c

hart

due

to re

stric

ted

use

by F

DA

. For

mor

e in

form

atio

n, s

ee: h

ttp://

ww

w.fd

a.go

v/D

rugs

/Dru

gSaf

ety/

Pos

tmar

ketD

rugS

afet

yInf

orm

atio

nfor

Pat

ient

sand

Pro

vide

rs/u

cm22

6976

.htm

piog

litaz

one

(Act

os)

15 m

g30

mg

45 m

g15

-30

mg

Sam

eIn

crea

se b

y 15

mg

6-12

wks

15-4

5 m

g/da

y

45 m

g/da

y (3

0 m

g if

on

insu

lin)

1-1.

5%+

N/A

Do

NO

T us

e if

ALT

>

2.5X

U

LN

LFTs: prior to initiation then periodically

• wei

ght g

ain,

ed

ema

• hea

rt fa

ilure

sy

mpt

oms,

m

acul

ar e

dem

a• i

ncre

ased

fra

ctur

e ra

te• i

ncre

ase

risk

of

blad

der c

ance

r

• CH

F III

& IV

or a

ny s

ympt

omat

ic

hear

t fai

lure

• Clin

ical

evi

denc

e of

live

r dis

ease

or

ALT

> 2

.5 U

LN• D

o no

t use

rosi

glita

zone

in c

ombi

na-

tion

with

insu

lin o

r nitr

ates

(may

in

crea

se ri

sk o

f MI)

• Use

cau

tion

in fe

mal

es a

t hig

h ris

k fo

r fra

ctur

es• M

onito

r for

incr

ease

ede

ma

• May

cau

se o

vula

tion

to re

sum

e in

an

ovul

ator

y, p

rem

enop

ausa

l wom

en

ToolsWisconsin Diabetes Mellitus Essential Care Guidelines • 2012

41

DIA

BET

ES M

ELLI

TUS

MED

ICAT

ION

S 20

12O

RA

L G

LUC

OSE

-LO

WER

ING

AG

ENTS

RX

Avai

l. D

osag

eIn

itial

Dos

eIn

itial

Dos

e (e

lder

ly)

Dos

e A

djus

tmen

t S

ched

ule

Usu

al

Mai

nt.

Dos

age

Max

. E

ffect

tive

Dos

e

A1C

Lo

wer

ing

Wt

Ren

al

Dos

ing

Hep

atic

D

osin

gLa

b M

onito

ring

Com

mon

Sid

e E

ffect

sC

ontra

indi

catio

ns/ P

reca

utio

ns

Dru

g C

lass

: Meg

litin

ides

Act

ions

: Aug

men

ts g

luco

se in

duce

d in

sulin

out

put;

mor

e ra

pid

onse

t of e

ffect

and

sho

rter d

urat

ion

of a

ctio

n th

an s

ulfo

nylu

reas

Indi

catio

ns: T

ype

2 di

abet

es a

s m

onot

hera

py o

r in

com

bina

tion

with

oth

er o

ral a

gent

s; p

eopl

e w

ith s

ulfa

alle

rgie

s; h

ypog

lyce

mia

on

low

dos

es o

f sul

fony

lure

as

repa

glin

ide

(Pra

ndin

)

0.5

mg

1 m

g2

mg

A1C

< 8

%:

0.5

mg

w/

each

mea

lA

1c>8

:1-2

m

g w

/eac

h m

eal

Sam

e(c

autio

n if

Ren

al D

z)

Dou

ble

afte

r 1-2

w

ks

0.5-

4 m

g be

fore

m

eals

16 m

g/da

y1-

1.5%

+/-

CrC

l < 4

0 m

l/min

, st

art a

t 0.

5 m

gU

se

Cau

tion

N/A

• hyp

ogly

cem

ia• w

eigh

t gai

n

• nat

eglin

ide:

act

ive

met

abol

ites,

rena

l ex

cret

ion

• rep

aglin

ide:

no

activ

e m

etab

olite

s,

min

imal

rena

l exc

retio

n, m

ore

effe

ctiv

e th

an n

ateg

linid

e in

clin

ical

tri

als

nate

glin

ide

(Sta

rlix)

60 m

g12

0 m

g

60-1

20

mg

befo

re

mea

ls

Sam

e (c

autio

n if

Live

r Dz)

Incr

ease

by

60m

g at

eac

h m

eal a

fter 1

-2

wks

60-1

20

mg

befo

re

mea

ls12

0 m

g TI

D0.

5-1%

N/A

Dru

g C

lass

: Alp

ha-g

luco

sida

se In

hibi

tors

Act

ions

: Slo

ws

abso

rptio

n of

car

bohy

drat

es; r

educ

es p

ost-p

rand

ial b

lood

glu

cose

Indi

catio

ns: T

ype

2 di

abet

es a

s m

onot

hera

py o

r in

com

bina

tion

with

sul

fony

lure

a,m

etfo

rmin

or i

nsul

in; p

ost-p

rand

ial h

yper

glyc

emia

acar

bose

(P

reco

se)

25 m

g50

mg

100

mg

25 m

g TI

D

with

mea

lsS

ame

Dou

ble

curr

ent

dosi

ng re

gim

en

afte

r 4-8

wks

25-1

00 m

g TI

D w

ith

mea

ls

Wt.

< 60

kg

= 5

0 m

g TI

D W

t. >

60 k

g =

100

mg

TID

0.5-

1%0

Trea

t-m

ent n

ot

reco

m-

men

ded

if S

Cr >

2

N/A

Ser

um

Tran

sam

inas

es

q 3

mo.

X 1

ye

ar

• fla

tule

nce

• dia

rrhe

a• a

bdom

inal

pai

n (le

ss s

ever

e if

titra

ted

slow

ly)

• The

mec

hani

sm o

f act

ion

show

s th

e co

rrec

tion

of h

ypog

lyce

mia

so

treat

hy

pogl

ycem

ia w

ith g

luco

se ta

blet

s• C

hron

ic in

test

inal

dis

ease

• Ren

al d

ysfu

nctio

n • (

crea

tinin

e >

2.0)

(Gly

set)

• Cirr

hosi

s (P

reco

se)

mig

litol

(G

lyse

t)

50-1

00 m

g TI

D w

ith

mea

ls10

0 m

g TI

DN

/A

Dru

g C

lass

: Dip

eptid

yl P

eptid

ase

4 In

hibi

tors

(DP

P-IV

)A

ctio

ns: I

ncre

ases

insu

lin re

leas

e an

d de

crea

ses

gluc

agon

leve

ls in

the

circ

ulat

ion

in a

glu

cose

-dep

ende

nt m

anne

rIn

dica

tions

: Typ

e 2

diab

etes

as

mon

othe

rapy

or i

n co

mbi

natio

n w

ith s

ulfo

nylu

reas

, met

form

in, o

r TZD

s

sita

glip

tin

(Jan

uvia

)

25 m

g50

mg

100

mg

100

mg

daily

Sam

eIf

mak

ing

adju

stm

ents

, w

ait 4

-6 w

ks

100

mg

daily

100

mg

daily

0.6-

0.8%

0/-

CrC

l 30

-50

ml/

min

: 50

mg

daily

C

rCl <

30

ml/m

in:

25 m

g da

ily

N/A

BU

N, C

r prio

r to

initi

atio

n th

en

year

ly• h

eada

che,

nas

o-• p

hary

ngiti

s,

uppe

r res

pira

tory

tra

ct in

fect

ion

• rar

ely

seve

re

alle

rgic

reac

tions

• If

usin

g in

com

bina

tion

with

so

lfonu

ylur

ea a

nd m

etgl

itini

de, m

ay

need

low

er d

ose

of s

ulfo

nylu

rea

to

prev

ent h

ypog

lyce

mia

• At t

he re

duce

d do

ses

sugg

este

d fo

r sta

ge 4

or w

orse

CK

D, t

he

med

icat

ions

may

be in

effe

ctiv

e; u

se

with

ext

rem

e ca

utio

n, if

at a

ll in

S

tage

5 C

KD

.vsa

xagl

iptin

(O

ngly

za)

2.5

mg

5 m

g

2.5

or 5

m

g da

ily

(2.5

mg

for r

enal

im

pairm

ent

of if

giv

en

with

a

CY

P3A

4/5

Inhi

bito

r)

Sam

eN

/A5

mg

daily

5 m

g da

ily0.

5-0.

8%0

CrC

l < 5

0 m

l/min

: 2.

5 m

g da

ily

N/A

BU

N, C

r prio

r to

initi

atio

n an

d th

en y

early

linag

liptin

(T

radj

enta

)5

mg

5 m

g da

ily

with

or

with

out

food

Sam

eN

/A5

mg

daily

5 m

g da

ily0.

4%

mon

o-th

erap

y0

No

ad-

just

men

t ne

eded

N/A

N/A

• nas

opha

ryng

itis

5.8%

, m

onot

hera

py

(pla

cebo

5.5

%-

not s

tatis

tical

ly

sign

ifica

nt)

• If u

sed

with

sul

fony

lure

a or

m

etgl

itini

de, c

onsi

der l

ower

ing

dose

to

pre

vent

hyp

ogly

cem

ia• S

trong

P-g

lyco

prot

ein/

CY

P 3A

4 in

duce

r

v B

ased

on

expe

rt op

inio

n.

ToolsWisconsin Diabetes Mellitus Essential Care Guidelines • 2012

42

DIA

BET

ES M

ELLI

TUS

MED

ICAT

ION

S 20

12IN

JEC

TAB

LE N

ON

-INSU

LIN

GLU

CO

SE-L

OW

ERIN

G A

GEN

TSR

XAv

ail.

Dos

age

Initi

al D

ose

Dos

e A

djus

tmen

t S

ched

ule

Max

. D

ose

Mea

l Tim

ing

A1C

Lo

wer

ing

Wt

Ren

al

Dos

ing

Hep

atic

D

osin

gLa

b M

onito

ring

Sta

bilit

yC

omm

on

Sid

e E

ffect

sC

ontra

indi

catio

ns/

Pre

caut

ions

Dru

g C

lass

: GLP

-1 a

goni

stA

ctio

ns: s

timul

ates

the

panc

reas

to in

crea

se in

sulin

pro

duct

ion

and

supp

ress

glu

cago

n se

cret

ion.

S

econ

dary

act

ions

incl

ude

inhi

bitio

n of

gas

tric

empt

ying

and

redu

ctio

n of

app

etite

and

food

inta

ke.

Indi

catio

ns: T

ype

2 di

abet

es a

s m

onot

hera

py o

r in

com

bina

tion

with

sul

fony

lure

as, m

etfo

rmin

, or T

ZDs.

Se

e in

divi

dual

dru

g in

sert

reco

mm

enda

tions

for w

hen

it is

app

ropr

iate

to u

se w

ith a

spe

cific

type

of b

asal

insu

lin in

adu

lts w

ith ty

pe 2

dia

bete

s. N

ot a

ppro

ved

for u

se w

ith ty

pe 1

dia

bete

s.

exen

atid

e (B

yetta

)

5 m

cg p

er

dose

, 60

dose

s, 1

.2

mL

prefi

lled

pen

10 m

cg

per d

ose,

60

dose

s, 2

.4

mL

prefi

lled

pen

Type

2 D

M:

5 m

cg B

ID a

t any

tim

e w

ithin

the

60-m

inut

e pe

riod

befo

re th

e 2

mai

n m

eals

of t

he d

ay,

appr

oxim

atel

y 6

hour

s or

mor

e ap

art

Type

2 D

M:

May

be

incr

ease

d to

10

mcg

BID

af

ter o

ne m

onth

of

ther

apy

10 m

cg

twic

e a

day

With

in 6

0 m

inut

e pe

riod

befo

re

mor

ning

an

d ev

enin

g m

eals

1%-

Do

not u

se

if C

rCl <

30

ml/m

inN

/A

Mon

itor

INR

for

patie

nts

on

war

farin

Sto

re u

nuse

d pe

n in

re

frige

rato

r.A

fter f

irst u

se,

may

be

kept

at

room

tem

p

(up

to 7

7° F

) for

up

to 3

0 da

ys.

• nau

sea

• oth

er G

I di

stur

banc

e

• Sev

ere

gast

ro-e

soph

agea

l re

flux

diso

rder

(GE

RD

)• G

astro

pare

sis

• Pan

crea

titis

exen

atid

e ex

tend

ed-

rele

ase

(Byd

ureo

n)

2 m

g si

ngle

do

se tr

ays

2 m

g ev

ery

7 da

ysN

one

2 m

g/

wee

kIn

depe

nden

t of

mea

ls1.

60%

-

Do

not u

se

if C

rCl <

30

ml/m

in U

se

with

cau

tion

if 30

- 50

C

rCl

N/A

Mon

itor

INR

for

patie

nts

on

war

farin

Adm

inis

tor

imm

edia

tely

af

ter

susp

ensi

on

• nau

sea,

ot

her G

I di

stur

banc

e • I

njec

tion

site

nod

ules

• Avo

id u

se in

peo

ple

with

risk

for p

ancr

eatit

is,

prev

ious

pan

crea

titis

an

d or

ver

y el

evat

ed

trigl

ycer

ides

• Avo

id in

peo

ple

with

risk

fo

r pan

crea

titis

• Sev

ere

gast

ro-e

soph

agea

l re

flux

diso

rder

(GE

RD

)• G

astro

pare

sis

• Pan

crea

titis

• See

Bla

ck B

ox W

arni

ng:

Thyr

oid

C-C

ell T

umor

s,

Med

ulla

ry T

hyro

id

Car

cino

ma

(MTC

) and

M

ultip

le E

ndoc

rine

Neo

plas

ia S

yndr

ome

Type

2-

(ME

N 2

)

lirag

lutid

e (V

icto

za)

0.6

mg/

mL

3 m

L pr

efill

ed

syrin

ges

Type

2 D

M:

0.6

mg

subc

uta-

neou

sly

once

a

day

for 1

wee

k¥

Type

2 D

M:

Titra

te to

1.2

mg

afte

r 1 w

eek

then

m

ay in

crea

se to

1.

8 m

g if

1.2

mg

reve

als

no s

igni

fi-ca

nt c

hang

es

1.8

mg

one

time

daily

Inde

pend

ent

of m

eals

1-1.

5%-

No

dosa

ge

adju

stm

ent

nece

ssar

y.

Cau

tion

w/ r

enal

im

pairm

ent

N/A

No

dosa

ge

adju

stm

ent

nece

ssar

y,

caut

ion

w/

hepa

tic

impa

irmen

t

N/A

Sto

re u

nuse

d pe

n in

re

frige

rato

r. A

fter f

irst u

se

can

be k

ept i

n re

frige

rato

r or

room

tem

p

(up

to 8

6° F

) for

up

to 3

0 da

ys.

Kee

p pe

n ca

p on

.

• nau

sea

• oth

er G

I di

stur

banc

e

Dru

g C

lass

: Am

ylin

ana

logu

eA

ctio

ns: s

low

s ga

stric

em

ptyi

ng, d

ecre

ases

glu

cago

n se

cret

ion,

cen

trally

mod

ulat

es a

ppet

iteIn

dica

tions

: Typ

e 1

& 2

dia

bete

s as

adj

unct

trea

tmen

t to

thos

e w

ho u

se m

eal-t

ime

insu

lin a

nd fa

il to

ach

ieve

pos

tpra

ndia

l glu

cose

con

trol

Not

e: A

spe

cial

ist s

houl

d pr

escr

ibe

Sym

lin d

ue to

the

com

plex

ity o

f dos

ing

guid

elin

es.

pram

lintid

e (S

ymlin

)

0.6

mg/

mL

5 m

L vi

als

1 m

g/m

L pr

efill

ed p

ens

Type

1 D

M:

15 m

cg

imm

edia

tely

prio

r to

maj

or m

eals

Ty

pe 2

DM

: 60

mcg

im

med

iate

ly p

rior

to m

ajor

mea

ls z

Type

1 D

M:

Titra

te a

t 15

mcg

in

crem

ents

to

a m

aint

enan

ce

dose

of 3

0 or

60

mcg

, as

tole

rate

dTy

pe 2

DM

:In

crea

se to

a

dose

of 1

20 m

cg

as to

lera

ted v

120

mcg

be

fore

m

ajor

m

eals

Imm

edia

tely

be

fore

mea

ls

cont

aini

ng

≥ 25

0 kc

al o

r ≥

30 g

ram

s of

car

bo-

hydr

ate

0.4

– 0.

6%0/

-N

/AN

/AN

/A

Dis

card

28

days

af

ter f

irst u

se.

Ope

n bo

ttles

m

ay b

e re

frige

rate

d or

ke

pt a

t roo

m

tem

p.

• nau

sea

• Avo

id c

ombi

natio

n w

ith

GLP

-1 a

goni

st• G

astro

pare

sis

¥ M

ay b

e gi

ven

at a

ny ti

me

of d

ay in

depe

nden

t of m

eals

z R

educ

e pr

epra

ndia

l, ra

pid-

actin

g or

sho

rt-ac

ting,

insu

lin d

osag

es, i

nclu

ding

fixe

d-m

ix in

sulin

s by

50%

v D

ose

titra

tions

sho

uld

occu

r onl

y w

hen

no c

linic

ally

sig

nific

ant n

ause

a ha

s be

en s

een

for 3

day

s

ToolsWisconsin Diabetes Mellitus Essential Care Guidelines • 2012

43

INSU

LIN

¤ T

HER

APY

201

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LAS

S

INS

ULI

N T

YP

E

BR

AN

D

FOR

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5-15

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15 m

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imm

edia

tely

af

ter

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ar

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art

Nov

olog

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ials

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lisin

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pidr

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ials

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With

in 1

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ials

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tridg

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hour

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8 ho

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10- 2

0 ho

urs

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al

With

in 1

5 m

in b

efor

e m

eals

w

hen

mix

ed w

ith ra

pid-

actin

g in

sulin

; 30

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ore

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ls

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n m

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regu

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N

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Det

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Leve

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ls, p

en

1-2

hour

s 6-

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D

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t #

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ar

Long

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, pen

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2 ho

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en

1-2

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s 6-

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D

ose-

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B

asal

N

/A

Com

bina

tion

70 N

PH

/30

Reg

ular

H

umul

in 7

0/30

<

Via

ls, p

ens

30-6

0 m

in

10-1

6 ho

urs

A

ppro

xim

atel

y 30

min

bef

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ls

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spar

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tam

ine/

30

insu

lin a

spar

t N

ovol

og M

ix 7

0/30

V

ials

, car

tridg

es,

pens

10

-20

min

W

ithin

15

min

of m

eal

75 li

spro

pro

tam

ine/

25

lispr

o H

umal

og M

ix

75/2

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ials

, pen

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ss th

an

30 m

in

15

-18

hour

s

Hig

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treng

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sulin

R

egul

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Hum

ulin

RU

-500⌘

V

ials

30

min

2-

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urs

6.5-

8 ho

urs

Bas

al/

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us

Var

ies⌘

C

lear

¤ T

he ti

me

cour

se o

f act

ion

(ons

et o

f act

ion,

pea

k, d

urat

ion

of a

ctio

n) o

f any

insu

lin m

ay v

ary

in d

iffer

ent i

ndiv

idua

ls o

r at d

iffer

ent t

imes

in th

e sa

me

indi

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al a

nd c

an s

omet

imes

be

depe

nden

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dose

. Tim

e pe

riods

indi

cate

d

sho

uld

be c

onsi

dere

d a

gene

ral g

uide

onl

y. T

ime

may

var

y ba

sed

on in

itial

and

sub

sequ

ent d

oses

. Con

sult

with

insu

lin p

acka

ge in

sert

for a

dditi

onal

info

rmat

ion.

⌘ U

-500

is a

hig

h-st

reng

th c

once

ntra

tion

of in

sulin

(5-fo

ld h

ighe

r con

cent

ratio

n th

an U

-100

insu

lin) a

nd ty

pica

lly u

sed

in p

eopl

e w

ith v

ery

high

insu

lin re

sist

ance

; con

sulta

tion

with

a d

iabe

tes

spec

ialis

t is

reco

mm

ende

d. S

ee S

ectio

n 4:

G

lyce

mic

Con

trol f

or m

ore

info

rmat

ion

rela

ted

to U

-500

use

and

pre

caut

ions

. u S

ome

peop

le m

ay h

ave

a pe

ak a

t 10-

14 h

ours

and

the

dura

tion

may

be

<24

hour

s.

# D

ose

resp

onse

stu

dies

indi

cate

an

appr

oxim

ate

dura

tion

of a

ctio

n of

6-1

2 ho

urs

for D

etem

ir do

se o

f <0.

4 un

its/k

g an

d du

ratio

n of

act

ion

of 2

0-24

hou

rs fo

r Det

emir

dose

of ≥

0.4

units

/kg.

H

A

4-5

hou

r ons

et o

f act

ion

with

initi

al d

osin

g m

ay o

ccur

bas

ed o

n ex

pert

opin

ion.

⏏

Som

e pe

ople

may

ben

efit

from

a B

ID d

ose

sche

dule

. <

Ava

ilabl

e in

Hum

ulin

®/R

eliO

n® in

sulin

man

ufac

ture

d fo

r Wal

mar

t by

Eli

Lilly