Case Study: U500 Insulin. Davida F. Kruger, MSN,APN-BC,BC-ADM Certified Nurse Practitioner Division of Endocrinology, Diabetes, Bone and Mineral Disorders Henry Ford Health System Detroit, Michigan. John S. 48 year old, white male Married. Wife has type 2 diabetes Works as a mechanic
Davida F. Kruger, MSN,APN-BC,BC-ADM
Certified Nurse Practitioner
Division of Endocrinology, Diabetes, Bone and Mineral Disorders
Henry Ford Health System
48 year old, white male
Married. Wife has type 2 diabetes
Works as a mechanic
Reports packing lunch of sandwich, fruit , chips and a few healthy snacks
Has seen dietian, working on portion size and carbohydrate content of meal ( was consuming 200 grams per meal)
Not physically active
SMBG 2-4 times daily, records in diary
Hypertension (20 years)
Dyslipidemia (20 years)
Recent MI (2010)
Stent December (2010)
Married, children grown
Social drinker (rare)
Basal Insulin 200 units in divided dose, 100 units at breakfast and 100 units at 10 pm
Meal time insulin: 50 units at breakfast, 40 units at lunch, 50 units at dinner
Blood glucose monitoring consistent with A1c
Add more basal insulin ?
Add more meal time insulin ?
Switch to an insulin pump ?
Switch to U-500 insulin ?
For more resistant patients, U-100 insulin both impractical and inconvenient
When over 100 units (1mL) required at one time, would need more than one injection
Large volume of insulin painful
Large depot of insulin impedes absorption making it unpredictable (a more concentrated insulin should be more predictable at these doses)
Non-Syndromic Insulin Resistance
Obesity with T2DM requiring > 200 u/day
Post-op or post-transplant state
High-dose steroids or pressors
Pregnancy with underlying T2DM
It is BOTH!
Lag times never studied, but it only makes sense that when used as mealtime insulin timing between injection and eating is even more important than with U-100 regular (or analogue)
Main secret for success with U-500 insulin
Two ways: “units” on a U-100 insulin syringe or volume (mL) on a tuberculin syringe
Ideally, would be nice if everyone used both; most patients will discuss this in units
My compromise with patients and in charting: always note U-500.
Like most insulin management, what we do with U-500 is generally anecdotal. The good news: these patients don’t generally get hypoglycemic!
GIRs for different doses of glargine injected into the abdomen
1.0, 1.5, and 2.0 units/kg > GIR than 0.5 units/kg, but not than each other!
Wang Z. Diabetes Care. 2010;33:1555-1560
Tally his total daily insulin intake of u-100 insulin:
Basal 200 units plus 140 units of meal time insulin: 340 of u-100 insulin
340 ./. 5 = 68 units of u-500 insulin
Start by providing half at breakfast and half at dinner
34 units of u-500 insulin at breakfast and dinner using a u-100 syringe
Corrects bed and fasting blood glucose
Corrects after breakfast, before lunch and perhaps after lunch and before dinner.
Corrects after lunch and before dinner blood glucose
From drugstore.com, 4/27/11*
*U-500 cost at 3 pharmacies