UM UPPER CHESAPEAKE HEALTH Humulin R U-500 SQ Insulin Place patient label here ADJUSTMENTS ONLY (Page 1 of 1) Open box equals Prescriber’s option; must check to order. Checked boxes = automatically initiated unless unchecked. Date: _______________________ Time: _______________ draft Apr 4, 2019 ****This order set is RESTRICTED to Endocrinologists only.**** – note new watermark Note: All dose changes after completion of the Humulin R U500 INITIAL order set, including “Now” doses, “One Time Only” doses, and Home medication DOSE ADJUSTMENTS requires use of this order set. Indications: This order set is indicated for Humulin R U-500 dose ADJUSTMENTS ONLY. It should NOT be used for the initial hospital orders for Humulin R U-500. (Use the Humulin R U-500 SQ INITIAL order set instead) It should NOT be used to continue a patient’s home medication. If a non-endocrinologist provider is placing these orders, CONSULT with the Endocrinologist is required before each dosage change. The INITIAL Humulin R U-500 medication orders MUST be discontinued. DO NOT discontinue the non- medication orders from the Humulin R U-500 INITIAL order set. Unit Secretary: Please transcribe the non-medication orders below into the Humulin R U500 SQ Insulin CPOE order set Provider: Reorder the complete 24h dosing schedule when making an adjustment to any dose. Humulin R-U500 Insulin Dose ADJUSTMENT Orders: Administer dose Provider: (Req’d) subcutaneously with U500 PEN 30 minutes prior to meal as indicated. Indicate name of endocrinologist Start new dose regimen with NEXT MEAL after this date/time: _____________(date) _________ (time) consulted about these dose revisions: _________________ Discontinue Fixed U500 previous Breakfast Lunch Dinner Bedtime Insulin Doses U500 insulin (or 0600 if Enteral (or 1800 if Enteral Feeding) Feeding) by Meal MEDICATION order.Maintain ____ units ____ units ____ units ____ units the associated orders. -OR- Discontinue U500 Breakfast Lunch Dinner Bedtime previous If Blood glucose: If Blood glucose: If Blood glucose: If Blood glucose: Insulin U500 insulin MEDICATION 70-119 mg/dL, 70-119 mg/dL, 70-119 mg/dL, 70-119 mg/dL, Correctional order. Maintain the give ___units give ___units give ___units give ___units associated Scale Doses 120-159 orders. 120-159 mg/dL, 120-159 mg/dL, 120-159 mg/dL, mg/dL, By Meal: give___ units give___ units give___ units give___ units 160-199 160-199 mg/dL, 160-199 mg/dL, 160-199 mg/dL, mg/dL, give ___units give ___units give ___units give ___units 200 mg/dL or 200 mg/dL or 200 mg/dL or 200 mg/dL or greater, greater, greater, greater, give___ units give___ units give___ units give___ units -OR- One time dose: Humulin R-U500 Insulin SQ __units: NOW –or- (specify date/time) _____________ Endocrinologist Signature: ____________________________________ Date: _____________Time:______ 31MU500A 04/19* (for verbal/phone orders) Reference: Humulin R U-500 Information A. Humulin R U500 insulin is concentrated regular insulin used for both type 1 and type 2 diabetes patients that require more than 200 units of insulin daily and are very insulin resistant. B. Humulin R U500 insulin, manufactured by Eli Lilly, is dispensed in 20ml vials or an aqua blue insulin pen. C. NEW U500 syringes have green cap and label; each line on the syringe measures 5 units of insulin. U100 syringes have orange cap and each unit marking measures 5units of insulin. D. U500 insulin has 500 units of insulin/ml of liquid; it is 5 times stronger than U100 insulin. E. U500 insulin may be administered subcutaneously by injection and in insulin pumps F. U500 insulin serves as both basal/bolus insulin, dosed 2-4 times daily (duration of action: 13-24h) G. Recommend doses be given no less than 5 hours apart (peak: 4-8h) H. U500 insulin IS NOT RECOMMENDED FOR IV USE. Conversion Table for Humulin R U-500 (Concentrated) Insulin Dose [IMPORTANT: Do NOT convert if patient uses the Pen or U500 syringe with the U500 vial] Humulin R U-500 dose Humulin R U-500 dose per U-500 Insulin Pen per U-500 Vial + or Vial and U500 Syringe (green cap) U100 Syringe (orange cap) = Pen and DELETE entire table Vial using U500 syringes are dosed U100 Syringe in units. is dosed in unit-markings. NO CONVERSION CONVERSION REQUIRED REQUIRED .