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Insulin Glargine Insulin Glargine Special Alerts Insulin Pen Safety Alert October 2017 The Institute for Safe Medication Practices (ISMP) National Medication Errors Reporting Program (MERP) has issued a safety alert regarding reports of patients incorrectly using insulin pens at home, resulting in severe cases of hyperglycemia. Patients were not removing the inner cover of a standard insulin pen needle prior to attempting to administer the insulin, and thus were not receiving insulin doses. Health care professionals should instruct patients on the proper use of insulin pens and require patient demonstration to verify understanding. They should also verify which pen needles patients will be using at home, either standard pens or pens with automatic needle retraction devices, and tailor instruction accordingly. More information can be found at http://www.ismp.org/NAN/files/NAN-20171012.pdf. Brand Names: US Basaglar KwikPen Lantus Lantus SoloStar Toujeo SoloStar Pharmacologic Category Insulin, Long-Acting Dosing: Adult Note: Insulin glargine is a long-acting insulin administered by SubQ injection. Insulin glargine is approximately equipotent to human insulin, but has a slower onset, no pronounced peak, and a longer duration of activity. Insulin requirements vary dramatically between patients and dictates frequent monitoring and close medical supervision. Diabetes mellitus, type 1: SubQ: Insulin glargine-specific dosing: Initial dose: Approximately one-third to one-half of the total daily insulin requirement administered once daily. A rapid-acting or short-acting insulin should also be used to complete the balance (~1/2 to 2/3) of the total daily insulin requirement. Adjust dosage according to patient response. Conversion to insulin glargine from other insulin therapies: Converting from once-daily NPH insulin to insulin glargine: May be substituted on an equivalent unit-per-unit basis Converting from twice-daily NPH insulin to insulin glargine: Initial dose: Use 80% of the total daily dose of NPH (eg, 20% reduction); administer once daily; adjust dosage according to patient response Conversion between Toujeo, Lantus, and Basaglar: Conversion from once-daily Toujeo to once-daily Lantus or once-daily Basaglar: Initial dose: Use 80% of the dose of Toujeo (eg, 20% reduction); adjust dosage according to patient blood glucose response. Conversion from once-daily Lantus to once-daily Toujeo or once-daily Basaglar: Initial dose: May be substituted on an equivalent unit-per- unit basis; however, generally a higher daily dosage of Toujeo will be required to achieve the same level of glycemic control as with Lantus. General insulin dosing (off-label): Type 1: SubQ: Note: Multiple daily doses are utilized and guided by blood glucose monitoring. Combinations of insulin formulations are commonly used. The daily doses presented below are expressed as the total units/kg/day of all insulin formulations used. Insulin glargine must be used in combination with a rapid- or short-acting insulin. Initial total insulin dose: 0.2 to 0.6 units/kg/day in divided doses. Conservative initial doses of 0.2 to 0.4 units/kg/day are often recommended to avoid the potential for hypoglycemia. Usual maintenance range: 0.5 to 1 units/kg/day in divided doses. An estimate of anticipated needs may be based on body weight and/or activity factors as follows: Nonobese: 0.4 to 0.6 units/kg/day Obese: 0.8 to 1.2 units/kg/day Division of daily insulin requirement ("conventional therapy"): Generally, 50% to 75% of the total daily dose (TDD) is given as an intermediate-acting or a long-acting form of insulin (eg, insulin glargine) (in 1 to 2 daily injections). The remaining portion of the TDD is then divided and administered before or at mealtimes (depending on the formulation) as a rapid-acting (eg, lispro, aspart, glulisine) or short-acting (regular) form of insulin. Division of daily insulin requirement ("intensive therapy"): Basal insulin delivery with 1 or 2 doses of intermediate-acting or long- acting insulin formulations superimposed with doses of short-acting (regular) insulin or rapid-acting insulin (eg, lispro, aspart, glulisine) formulations 3 or more times daily. Dosage adjustment: Dosage must be titrated to achieve glucose control and avoid hypoglycemia. Adjust dose to maintain premeal and bedtime glucose in target range. Since combinations of agents are frequently used, dosage adjustment must address the individual component of the insulin regimen which most directly influences the blood glucose value in question, based on the known onset and duration of the insulin component. Diabetes mellitus, type 2: SubQ: Insulin glargine-specific dosing: Manufacturer’s labeling: Initial basal insulin dose: 0.2 units/kg once daily; for Lantus or Basaglar, up to 10 units/day initially is recommended. Adjust dosage according to patient response Conversion to insulin glargine from other insulin therapies: Converting from once-daily NPH insulin to insulin glargine: May be substituted on an equivalent unit-per-unit basis Converting from twice-daily NPH insulin to insulin glargine: Initial dose: Use 80% of the total daily dose of NPH (eg, 20% reduction); administer once daily; adjust dosage according to patient response Conversion between Toujeo, Lantus, or Basaglar: Conversion from once-daily Toujeo to once-daily Lantus or once-daily Basaglar: Initial dose: Use 80% of the dose of Toujeo (eg, 20% reduction); adjust dosage according to patient blood glucose response. Conversion from once-daily Lantus to once-daily Toujeo or once-daily Basaglar: Initial dose: May be substituted on an equivalent unit-per- unit basis; however, generally a higher daily dosage of Toujeo will be required to achieve the same level of glycemic control as with Lantus Alternate recommendations (off-label): Initial: 10 units or 0.1 to 0.2 units/kg once daily, usually in combination with metformin +/- other noninsulin agent (ADA 2017f). Alternatively, if HbA1c >8% prior to initiation of basal insulin, 0.2 to 0.3 units/kg once daily is recommended (Garber [AACE/ACE 2016]). Dosage adjustment: To reach fasting blood glucose target: Adjust dose by 10% to 15% or 2 to 4 units; may adjust at weekly or twice weekly intervals (ADA 2017f) For hypoglycemia: If no clear reason for hypoglycemia, decrease dose by 4 units or by 10% to 20% (ADA 2017f) Surgical patients: On the morning of surgery or procedure, give 60% to 80% of the usual dose of long-acting analogs (eg, detemir, glargine, or degludec) (ADA 2017d) General considerations for insulin use in type 2 diabetes (off-label): Timing of initiation: Dual therapy (metformin + a second antihyperglycemic agent) and then triple therapy (metformin + two antihyperglycemic agents) is recommended in patients who fail to achieve glycemic goals after ~3 months with lifestyle intervention and metformin monotherapy or dual therapy, respectively (unless contraindications to metformin exist). Preference is not given for which agent(s) should be added to metformin (drug choice should be individualized based on patient characteristics). If HbA1c target not achieved after ~3 months of triple therapy, consider initiating basal insulin (usually with metformin +/- other noninsulin agent) or if patient already receiving an optimally titrated basal insulin (ie, a long-acting insulin such as glargine, degludec, or detemir) as part of their regimen, consider combination injectable therapy (ADA 2017f). Combination injectable therapy: If HbA1c target has not been met with basal insulin (ie, long-acting insulin such as glargine, degludec or detemir) (usually combined with metformin +/- other noninsulin agent), despite titrating basal insulin to provide acceptable fasting blood glucose concentrations, combination injectable therapy should be considered. Options include: adding a rapid-acting insulin (eg, lispro, aspart, glulisine) prior to largest meal or adding a GLP-1 receptor agonist or changing from basal insulin to a twice daily premixed insulin. If HbA1c still not adequately controlled, consider advancing from one rapid-acting insulin prior to largest meal to ‘basal-bolus’ regimen (ie, rapid-acting insulin administered before ≥2 meals) or consider advancing from a twice daily premixed insulin to a 3 times daily premixed insulin (ADA 2017f). Patients with elevated HbA1C at therapy initiation: If HbA1c is ≥9% at initiation of therapy, dual therapy (metformin + a second antihyperglycemic agent) should be considered. If HbA1c ≥10%, blood glucose is ≥300 mg/dL or if patient is symptomatic (eg, polyuria, polydipsia), insulin therapy (with or without additional agents) should be considered (ADA 2017f). Dosing: Geriatric Refer to adult dosing. Dosing: Pediatric Insulin glargine is a long-acting insulin administered by SubQ injection. Insulin glargine is approximately equipotent to human insulin, but has a slower onset, no pronounced peak, and a longer duration of activity. Changing the basal insulin component from another insulin to insulin glargine can be done on a unit-to-unit basis. Insulin requirements vary dramatically between patients and dictates frequent monitoring and close medical supervision. See Insulin Regular for additional information. Insulin glargine-specific dosing: Type 1 diabetes mellitus: Children ≥6 years and Adolescents: SubQ: Initial dose: Approximately one-third of the total daily insulin requirement; a rapid-acting or short-acting insulin should also be used. Type 1 or type 2 diabetes; previously receiving basal insulin plus bolus insulin (eg, NPH + regular insulin): Children <6 years:
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