Question

Medications 15. The prescriber ordered NPH human insulin 15 units subcut ac break fast. Read the label in Figure 9.44 and determine how many doses are contained in the pen. NPH human insulin (rDNA origin) isophane suspension prefilled insulin delivery device Figure 9.44 Drug label for NPH human insulin.

Answer 1

Subcutaneous dosage

Adults

Insulin requirement range: 0.1 to 2.5 units/kg/day. Most patients require 0.5 to 1.2 units/kg/day. Average initial dose for type 1 DM: 0.5 to 0.6 units/kg/day. The total daily dose is given as 1 to 2 injections per day, given 30 to 60 minutes before a meal or bedtime. Some patients may initially be given a single daily dose of 30 to 60 minutes before breakfast, but 24-hour blood glucose control may not be possible with this regimen. Thus, a second injection given 30 to 60 minutes before dinner or bedtime may be required. When used for intensive insulin therapy, NPH insulin is frequently mixed with quick-acting insulin and given twice daily, although some patients will require more than 2 injections of NPH insulin daily when used as basal insulin. A common regimen is to give NPH and quick-acting insulin (e.g., insulin aspart, insulin lispro, insulin glulisine, or regular insulin) concomitantly and give 2 injections per day. About two-thirds of the daily insulin dose is given before breakfast, and about one-third is given before the evening meal. Initially, an intermediate-to-quick-acting insulin ratio of 2:1 can be given before breakfast and an intermediate-to-quick-acting insulin ratio of 1:1 can be given before dinner. The dosage and ratio can be adjusted, if necessary, based on the patient's blood glucose. If regular insulin is given as the quick-acting insulin, administer 30 to 60 minutes before meals. If insulin aspart is given as the quick-acting insulin, administer within 5 to 10 minutes before the start of the meal. If insulin lispro or insulin glulisine is given as the quick-acting insulin, administer 15 minutes before the start of the meal. Another common regimen is to administer both a quick-acting and intermediate-acting insulin before breakfast (e.g., regular with NPH), quick-acting insulin before dinner, and intermediate-acting insulin alone at bedtime. Additional regimens include regular insulin, insulin aspart, insulin glulisine, or insulin lispro at each meal and a dose of NPH insulin at supper or bedtime.

Infants, Children, and Adolescents

Insulin requirements are highly variable and must be individualized based on patient-specific factors and type of insulin regimen. During partial remission phase, total combined daily insulin requirement is often less than 0.5 units/kg/day. Prepubertal children (outside the partial remission phase) usually require 0.7 to 1 unit/kg/day. During puberty, insulin requirements are much greater, often between 1 and 2 units/kg/day. Use isophane insulin (NPH) in combination with rapid- or short-acting insulin as part of twice-daily regimens or basal-bolus regimens. Twice daily insulin regimens consist of 2 subcutaneous insulin injections given per day; approximately two-thirds of the total daily insulin dose is given in the morning and one-third in the evening. Initially, for each insulin dose, approximately one-third is given as a rapid-acting insulin and the other two-thirds is an intermediate-acting insulin. These ratios may change based on individual response. Basal-bolus regimens typically consist of 4 to 5 subcutaneous insulin injections given per day; 1 to 2 as an intermediate- or long-acting insulin plus 3 to 4 pre-meal rapid-acting insulin doses. The proportion supplied as the basal insulin usually ranges from 40% to 60% of the total daily dose.

For the treatment of gestational diabetes or for the treatment of patients with pre-existing diabetes mellitus (type 1 or type 2) who are now pregnant.

For pregnant patients with gestational-onset diabetes not controlled by diet-therapy alone.

Subcutaneous dosage (human regular and NPH insulin combination therapy)

Adults and Adolescents (pregnant females)

Dosage guidelines are variable and must be individualized. Initial suggested daily insulin requirements are roughly 0.3 to 0.7 units/kg/day; requirements usually increase during the second and third trimesters (i.e., 0.8 units/kg/day or more). The daily dose is usually divided in 2 to 3 doses and administered in varying ratios of NPH:regular insulin. Intensive therapy (more than 3 daily injections) is rarely needed. Dose adjustments are based on fasting and postprandial blood glucose level. Per goals defined in ADA or ACOG guidelines, typical 2-hour postprandial glucose goals are 120 mg/dL or less. To prevent fetal and maternal complications, meticulous blood glucose control and monitoring is required. During labor, insulin requirements decrease and usually return to normoglycemia several days postpartum. Insulin is often discontinued during or after labor; monitor blood glucose during labor and the days postpartum; follow-up at 6 weeks postpartum.

For pregnant patients with preexisting diabetes prior to pregnancy.

Subcutaneous dosage (human regular and NPH insulin combination therapy)

Adults and Adolescents (pregnant females)

While initial suggested daily insulin requirements are roughly 0.5 to 0.7 units/kg of IBW/day in the first trimester; insulin needs may initially be lower than prepregnancy levels; individualize dosage. Daily requirements are higher in the second and third trimesters; roughly 0.6 to 0.8 units/kg (second trimester), and 0.9 to 1 units/kg (third trimester). The daily dose is usually divided in 2 to 3 doses and administered in varying ratios of NPH:regular insulin, dependent on individual patient needs. Dose adjustments are based on fasting and postprandial blood glucose as per goals defined in ADA and ACOG guidelines. To prevent fetal and maternal complications, meticulous blood glucose control and monitoring is required. At the onset of labor, insulin requirements typically decrease but must be carefully monitored and adjusted. Due to increased insulin sensitivity, insulin is usually held immediately postpartum until the blood glucose is 180 mg/dL or more. Insulin is then reinitiated at 90% or less of prepregnancy levels.

For the treatment of type 2 diabetes mellitus inadequately managed by diet, exercise, and oral hypoglycemics.

Subcutaneous dosage

Adults

Insulin requirement range: 0.1 to 2.5 units/kg/day. Most patients require 0.5 to 1.2 units/kg/day. Average initial dose for type 2 DM: 0.2 to 0.6 units/kg/day. The total daily dose is given as 1 to 2 injections per day, given 30 to 60 minutes before a meal or bedtime. Some patients may initially be given a single daily dose 30 to 60 minutes before breakfast, but 24-hour blood glucose control may not be possible with this regimen. Thus, a second injection given 30 to 60 minutes before dinner or bedtime may be required. When oral agents are used concomitantly in type 2 DM, a low initial dose of NPH insulin (e.g., 10 units) is often given in the evening. When used for intensive insulin therapy, NPH insulin is frequently mixed with quick-acting insulin and given twice daily, although some patients will require more than 2 injections of NPH insulin daily when used as basal insulin. A common regimen is to give NPH and quick-acting insulin (e.g., insulin aspart, insulin lispro, insulin glulisine, or regular insulin) concomitantly and give 2 injections per day. About two-thirds of the daily insulin dose is given before breakfast, and about one-third is given before the evening meal. Initially, an intermediate-to-quick-acting insulin ratio of 2:1 can be given before breakfast and an intermediate-to-quick-acting insulin ratio of 1:1 can be given before dinner. The dosage and ratio can be adjusted, if necessary, based on the patient's blood glucose. If regular insulin is given as the quick-acting insulin, administer 30 to 60 minutes before meals. If insulin aspart is given as the quick-acting insulin, administer within 5 to 10 minutes before the start of the meal. If insulin lispro or insulin glulisine is used as the quick-acting insulin, administer 15 minutes before the start of the meal. Another common regimen is to administer both a quick-acting and intermediate-acting insulin before breakfast (e.g., regular with NPH), quick-acting insulin before dinner, and intermediate-acting insulin alone at bedtime. Additional regimens include regular insulin, insulin aspart, insulin glulisine, or insulin lispro at each meal and a dose of NPH insulin at supper or bedtime.

Children and Adolescents

Dosage varies depending on previous regimen, concurrent medications, lifestyle, etc; initial total daily insulin doses have been reported to be in the range of 0.1 to 0.5 units/kg/day. Isophane insulin may be used alone, in combination with oral medications (e.g., metformin), or with short-acting insulins for the treatment of type 2 diabetes mellitus if treatment goals are not met with oral medications alone. Regimens may range from once daily therapy to intensive management using basal-bolus regimens. Specific dosage recommendations are not available; dosage should be individualized according to age, weight, activity level, and dietary habits. Titrate dosage according blood glucose and A1C goals.

MAXIMUM DOSAGE

Specific maximum dosage information is not available. Individualize dosage based on careful monitoring of blood glucose and other clinical parameters in all patient populations.