U‐500 insulin: why, when and how to use in clinical practice

Abstract

Some patients with type 2 diabetes mellitus (T2DM) have severe insulin resistance. Their insulin requirements are significantly greater. These patients need to take 2-3 injections at the same time to take the correct insulin dose or to redial the insulin pen. When daily insulin requirements are in excess of 300 units/day, the volume of the injected insulin becomes an issue. Large-volume injection can cause discomfort and lead to poor concordance with treatment. Using high-strength insulin e.g. U-500 insulin can reduce the volume of the injected insulin. Despite publications of small case reports or case series, no universal guidelines exist on the use of U-500 insulin. We discuss common sense approaches when considering the use of U-500 insulin in clinical practice.

U-500 Insulin as a Component of Basal Bolus Insulin Therapy in Type 2 Diabetes

“…[7][8][9] Increases in TDD observed in this and prior reports runs counter to the clinical expectation that administering similar insulin doses at reduced volume would allow reductions in insulin requirements. 3,6 Severe insulin resistance has been defined as the requirement for > 200 units of insulin/day. 1,4,7,8,10 The average insulin dose in patients in this report was 2.5 units/kg/day, similar to what has been reported in prior studies of U500 (range, 1.5-3.6 units/kg/day).…”

“…1,2 In selected patients, U-500 regular insulin (U500) allows for administration of high TDD at volumes lower than that required with standard U-100 insulin (U100) preparations. 3 This higher insulin concentration alters the pharmacokinetic properties of regular insulin to that of an intermediate-or long-acting insulin (LAI) preparation. [4][5][6][7][8] Standard recommendations for U500 suggest that it be administered in divided doses of two or three injections per day as the sole insulin preparation to meet both basal and meal-related insulin requirements.…”

“…[4][5][6][7][8] Standard recommendations for U500 suggest that it be administered in divided doses of two or three injections per day as the sole insulin preparation to meet both basal and meal-related insulin requirements. 2,3 Others have suggested that it be administered as a component of a basal/bolus insulin (BBI) regimen in combination with either rapid-acting insulin (RAI) or LAI preparations. [3][4][5][6][7] These suggestions result in uncertainty and variability among clinicians in how to optimally prescribe and implement U500.…”

“…2,3 Others have suggested that it be administered as a component of a basal/bolus insulin (BBI) regimen in combination with either rapid-acting insulin (RAI) or LAI preparations. [3][4][5][6][7] These suggestions result in uncertainty and variability among clinicians in how to optimally prescribe and implement U500.…”

Extreme Insulin Resistance: Indications and Approaches to the Use of U-500 Insulin in Type 2 Diabetes Mellitus

“…Administration of large volumes of insulin can lead to leakage and poor absorption. Additionally, large-volume injections can cause discomfort and lead to poor compliance with treatment [6].…”