At these doses, the volume of U insulin is physically too large for single subcutaneous administration, and multiple injections are required to deliver a single dose.
With more injections, compliance suffers and poor glycemic control results. Fortunately, an alternative exists to treat highly insulin-resistant patients more efficiently. U insulin, manufactured by Eli Lilly, contains U of regular insulin per mL. U is intended only for subcutaneous administration. IV use is not recommended due to risk of overdose.
It is available in 20 mL vials only. U is nonmodified regular insulin. Its pharmacokinetics, however, resemble basal rate delivery similar to NPH insulin. There are no large prospective trials investigating U; however, data available from a handful of small studies confirm its safety and efficacy. As is typical in clinical practice, the trials involve switching a small number of insulin-resistant patients from U to U Neal reported an average HbA 1C decrease of 1.
Hypoglycemic episodes were either not reported or deemed insignificant compared to standard regimens. The trials confirm improvement in glycemic targets for difficult-to-control patients with diabetes switched from standard insulin to U without significant adverse effect. Increased patient satisfaction related to fewer and lower-volume injections is contributory to the improvements in glycemic control seen with U insulin. U insulin represents an efficient option for insulin pump patients who require high doses of insulin.
Highly insulin-resistant patients using standard insulin are inconvenienced by frequent reservoir changing, thereby diminishing the practicality of an insulin pump. A few trials demonstrate efficacy and support use of U via continuous subcutaneous infusion. Therefore, one must remember to multiply the units displayed by five when U is loaded in an insulin pump. Also, bolus dosing in a pump is calibrated for rapid-acting insulin, so the clinician must take into account the delayed activity of U when programming.
There are various dosing algorithms for converting from standard insulin to U insulin. One approach is by Garg et al. Next, divide by to arrive at the number of mL to administer per day. Finally, divide this daily total in 2 to 3 doses. For example, a patient injecting a total of U of U converts to 0.
When converting a patient to U, all other insulin preparations are discontinued. Oral antidiabetic drugs that increase insulin sensitivity should be continued and are especially valuable for obese patients. U dose adjustments are not made based on solitary blood glucose readings or carbohydrate counting.
Rather, the clinician looks for weekly patterns in glucose readings. Conversely, if glucose readings are consistently high, the preceding insulin dose is adjusted upward.
Guidelines of pump dosing are available in the original reference, but were not included in this review. U insulin represents a cost advantage over standard insulin.
Other cost savings are realized because U is utilized as the sole insulin, compared to standard insulin regimens utilizing basal and bolus insulin. Finally, fewer injections per day translate to decreased cost of syringes and supplies. It is not difficult to imagine the potential for errors or adverse effects when utilizing concentrated U insulin. Fortunately, due to the highly insulin-resistant nature of U patients, hypoglycemia is not a common problem.
One area for mishap surrounds the type of syringe utilized. Standard insulin syringes are marked for U, so when filled with U insulin, the dose injected does not equal the units printed on the syringe.
The doses are, in fact, five times greater. The authors of this study noted a variety of other vulnerabilities with the U syringe and offered helpful recommendations for improving its design. What about an insulin pen for U? Given that far fewer patients receive U insulin than U insulin, and given the well known confusion brought about by not having a corresponding U syringe, at the present time we believe a U insulin pen would be the best option, despite our recommendation earlier this year to consider transitioning away from insulin pen use in hospitals.
Unfortunately, Lilly and BD will not provide information about whether this is in the works, and FDA is unable to comment on any products that may or may not be under development. However, there are additional strengths of insulin now under development that will only add to the confusion if a pen is not made available. Given the syringe selection issues raised in the U insulin study, we strongly recommend that these new products be available in the US only in a pen.
Indeed, mix-ups between syringe types were common when U and U insulins were available for a time, along with U insulins. One final issue with U insulin that perhaps can also lead to confusion is name similarity. It is time to rethink this, as name similarity has contributed to product selection errors from the shelf during dispensing and from the computer screen while prescribing, as well as communication errors during medication reconciliation.
The same issue could arise with the new higher strength insulins e. Since the use of U insulin is not as common as the use of U insulin, some health professionals may not be aware of it. This by itself increases the chance of dispensing errors. The main problem with U insulin is the risk of a mix-up between the insulin U and insulin U versions. If this occurs, it can result in very dangerous low blood sugar or very high blood sugar.
A mix-up between the two insulin concentrations may occur if doctors or pharmacists select the wrong concentration for example, selecting the U regular insulin from computer screen instead of U Sometimes the two concentrations appear one line apart on the computer screen, which sets up the possibility of selection errors.
Depending on the screen size, the prescriber may see only the first few words of the product listing, so the drug concentration is not seen. Prescribers may assume the patient needs U and may not even look for the concentration on the screen. A mix-up may also occur if U insulin and U insulin are stored next to each other at the pharmacy, in the hospital or even in your home. Although the colors of the vials are different, if someone is not aware to look out for the concentration on the vials, the vials could be confused for one another.
As of November , a new syringe to administer concentrated Humulin R U insulin regular has been made available from the manufacturer, BD. The syringe measures U insulin doses ranging from 25 units to units in 5-unit segments.
Prior to the release of the U syringe, it was recommended to use a U syringe or tuberculin syringe to administer U insulin. But dosing errors frequently occurred to patients who drew doses from a vial into a U or tuberculin syringe. Every unit on the U syringe scale is equal to 5 units of U insulin.
With a tuberculin syringe, the U insulin dose has to be measured in mL, not units.
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