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INSULIN (Systemic)

Some commonly used brand names are:

In the U.S.—

• Humulin 50/50 ¹⁴
• Humulin 70/30 ¹⁴
• Humulin 70/30 Pen ¹⁴
• Humulin L ¹⁰
• Humulin N ¹³
• Humulin N Pen ¹³
• Humulin R ⁷
• Humulin R, Regular U-500 (Concentrated) ⁷
• Humulin U ⁵
• Lente Iletin II ⁸
• Lente ⁸
• Novolin 70/30 ¹⁴
• Novolin L ¹⁰
• Novolin N ¹³
• Novolin N PenFill ¹³
• Novolin N Prefilled ¹³
• Novolin 70/30 PenFill ¹⁴
• Novolin 70/30 Prefilled ¹⁴
• Novolin R ⁷
• Novolin R PenFill ⁷
• Novolin R Prefilled ⁷
• NPH Iletin II ¹¹
• NPH Purified Insulin ¹¹
• Regular (Concentrated) Iletin II, U-500 ⁶
• Regular Iletin II ⁶
• Regular Insulin ⁶
• Velosulin BR ¹

In Canada—

• Humulin 10/90 ¹⁴
• Humulin 20/80 ¹⁴
• Humulin 30/70 ¹⁴
• Humulin 40/60 ¹⁴
• Humulin 50/50 ¹⁴
• Humulin-L ¹⁰
• Humulin-N ¹³
• Humulin-R ⁷
• Humulin-U ⁵
• Lente Iletin ⁸
• Lente Iletin II ⁸
• Novolin ge 30/70 ¹⁴
• Novolin ge Lente ¹⁰
• Novolin ge NPH ¹³
• Novolin ge NPH Penfill ¹³
• Novolin ge 10/90 Penfill ¹⁴
• Novolin ge 20/80 Penfill ¹⁴
• Novolin ge 30/70 Penfill ¹⁴
• Novolin ge 40/60 Penfill ¹⁴
• Novolin ge 50/50 Penfill ¹⁴
• Novolin ge Toronto ⁷
• Novolin ge Toronto Penfill ⁷
• Novolin ge Ultralente ⁵
• NPH Iletin ¹¹
• NPH Iletin II ¹¹
• Regular Iletin II ⁶
• Velosulin Human ¹

Other commonly used names are:

• Lente insulin, L
• NPH insulin, NPH
• Regular insulin, R
• Semilente insulin, S
• Ultralente insulin, U

Category

• Antidiabetic agent—Buffered Insulin Human; Extended Insulin Zinc; Extended Insulin Human Zinc; Insulin; Insulin Human; Insulin Zinc; Insulin Human Zinc; Isophane Insulin; Isophane Insulin Human; Isophane Insulin Human and Insulin Human; Prompt Insulin Zinc; Buffered Insulin Human; Insulin; Insulin Human
• Diagnostic aid, pituitary growth hormone reserve

Description

Insulin (IN-su-lin) is one of many hormones that helps the body turn the food we eat into energy. Also, insulin helps us store energy that we can use later. After we eat, insulin works by causing sugar (glucose) to go from the blood into our body"s cells to make fat, sugar, and protein. When we need more energy between meals, insulin will help us use the fat, sugar, and protein that we have stored. This occurs whether we make our own insulin in the pancreas gland or take it by injection.

Diabetes mellitus (sugar diabetes) is a condition in which the body does not make enough insulin to meet its needs or does not properly use the insulin it makes. Without insulin, glucose cannot get into the body"s cells. Without glucose, the cells will not work properly.

To work properly, the amount of insulin you use must be balanced against the amount and type of food you eat and the amount of exercise you do. If you change your diet, your exercise, or both without changing your insulin dose, your blood glucose level can drop too low or rise too high. A prescription is not necessary to purchase most insulin. However, your doctor must first determine your insulin needs and provide you with special instructions for control of your diabetes.

Insulin can be obtained from beef or pork pancreas glands. Another type of insulin that you may use is called human insulin. It is just like the insulin made by humans but it is made by methods called semi-synthetic or recombinant DNA. All types of insulin must be injected because, if taken by mouth, insulin is destroyed in the stomach.

Insulin is available in the following dosage forms:

• Parenteral
• Buffered Insulin Human (a regular insulin)
  • Injection (U.S. and Canada)
• Extended Insulin Zinc (an ultralente insulin)
  • Injection
• Extended Insulin Human Zinc (an ultralente insulin)
  • Injection (U.S. and Canada)
• Insulin (a regular insulin)
  • Injection (U.S. and Canada)
• Insulin Human (a regular insulin)
  • Injection (U.S. and Canada)
• Insulin Zinc (a lente insulin)
  • Injection (U.S. and Canada)
• Insulin Human Zinc (a lente insulin)
  • Injection (U.S. and Canada)
• Isophane Insulin (an NPH insulin)
  • Injection (U.S. and Canada)
• Isophane Insulin Human (an NPH insulin)
  • Injection (U.S. and Canada)
• Isophane Insulin Human and Insulin Human (an NPH and a regular insulin)
  • Injection (U.S. and Canada)
• Prompt Insulin Zinc (a semilente insulin)
  • Injection

Before Using This Medicine

In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make. For insulin, the following should be considered:

Allergies—Tell your doctor if you have ever had any reactions to insulin, especially in the skin area where you injected the insulin. Also, tell your health care professional if you are allergic to any other substances, such as foods, preservatives, or dyes.

Pregnancy—The amount of insulin you need changes during and after pregnancy. It is especially important for your health and your baby"s health that your blood sugar be closely controlled. Close control of your blood sugar can reduce the chance of your baby gaining too much weight, having birth defects, or having high or low blood sugar. Be sure to tell your doctor if you plan to become pregnant or if you think you are pregnant.

Breast-feeding—Insulin does not pass into breast milk and will not affect the nursing infant. However, most women need less insulin while breast-feeding than they needed before. You will need to test your blood sugar often for several months in case your insulin dose needs to be changed.

Children—Children are especially sensitive to the effects of insulin before puberty (the time when sexual changes occur). Therefore, low blood sugar may be especially likely to occur.

Use in teenagers is similar to use in older age groups. The insulin need may be higher during puberty and lower after puberty.

Older adults—Use in older adults is similar to use in other age groups. However, sometimes the first signs of low or high blood sugar are missing or not easily seen in older patients. This may increase the chance of low blood sugar during treatment. Also, some older people may have vision problems or other medical problems that make it harder for them to measure and inject the medicine. Special training and equipment may be needed.

Other medicines—Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. Do not take any other medicine, unless prescribed or approved by your doctor . When you are using insulin, it is especially important that your health care professional know if you are taking any of the following:

• Alcohol—Small amounts of alcohol taken with meals do not usually cause a problem; however, larger amounts of alcohol taken for a long time or in one sitting without food can increase the effect of insulin to lower the blood sugar level. This can keep the blood sugar low for a longer period of time than normal

• Beta-adrenergic blocking agents (acebutolol [e.g., Sectral], atenolol [e.g., Tenormin], betaxolol [e.g., Kerlone], bisoprolol [e.g., Zebeta], carteolol [e.g., Cartrol], labetalol [e.g., Normodyne], metoprolol [e.g., Lopressor], nadolol [e.g., Corgard], oxprenolol [e.g., Trasicor], penbutolol [e.g., Levatol], pindolol [e.g., Visken], propranolol [e.g., Inderal], sotalol [e.g., Sotacor], timolol [e.g., Blocadren])—Beta-adrenergic blocking agents may increase the chance of developing either high or low blood sugar levels. Also, they can cover up symptoms of low blood sugar (such as fast heartbeat). Because of this, a person with diabetes might not recognize that he or she has low blood sugar and might not take immediate steps to treat it. Beta-adrenergic blocking agents can also cause a low blood sugar level to last longer than normal

• Corticosteroids (e.g., prednisone or other cortisone-like medicines)—Corticosteroids taken over several weeks, applied to the skin over a long period of time, or injected into a joint may increase the blood sugar level. Higher doses of insulin may be needed during corticosteroid treatment and for a period of time after corticosteroid treatment ends

• Pentamidine (e.g., NebuPent)—Your dose of pentamidine or insulin or both may need to be adjusted if your pancreas can still make some insulin because pentamidine may cause your pancreas to release its insulin too fast. This effect at first lowers the blood sugar but then causes high blood sugar

Other medical problems—The presence of other medical problems may affect the dose of insulin you need. Be sure to tell your doctor if you have any other medical problems, especially:

• Changes in female hormones for some women (e.g., during puberty, pregnancy, or menstruation) or
• High fever or
• Infection, severe or
• Mental stress or
• Overactive adrenal gland, not properly controlled or
• Other conditions that cause high blood sugar—These conditions increase blood sugar and may increase the amount of insulin you need to take, make it necessary to change the time when you inject the insulin dose, and increase the need to take blood sugar tests

• Diarrhea or
• Gastroparesis (slow stomach emptying) or
• Intestinal blockage or
• Vomiting or
• Other conditions that delay food absorption or stomach emptying—These conditions may slow the time it takes to break down and absorb your meal from your stomach or intestines, which may change the amount of insulin you need, make it necessary to change the time when you inject the insulin dose, and increase the need to take blood sugar tests

• Injury or
• Surgery—Effects of insulin may be increased or decreased; the amount and type of insulin you need may change rapidly

• Kidney disease or
• Liver disease—Effects of insulin may be increased or decreased, partly because of slower removal of insulin from the body; this may change the amount of insulin you need

• Overactive thyroid, not properly controlled—Effects of insulin may be increased or decreased, partly because of faster removal of insulin from the body. Until your thyroid condition is controlled, the amount of insulin you need may change, make it necessary to change the time when you inject the insulin dose, and increase the need to take blood sugar tests

• Underactive adrenal gland, not properly controlled or
• Underactive pituitary gland, not properly controlled or
• Other conditions that cause low blood sugar—These conditions lower blood sugar and may lower the amount of insulin you need, make it necessary for you to change the time when you inject the insulin dose, and increase the need to take blood sugar tests

Proper Use of This Medicine

Make sure you have the type (beef and pork, pork, or human) and the strength of insulin that your doctor ordered for you . You may find that keeping an insulin label with you is helpful when buying insulin supplies.

The concentration (strength) of insulin is measured in USP Insulin Units and USP Insulin Human Units and is usually expressed in terms such as U-100 insulin. Insulin doses are measured and injected with specially marked insulin syringes. The appropriate syringe is chosen based on your insulin dose to make measuring the dose easy to read. This helps you measure your dose accurately . These syringes come in three sizes: 3/10 cubic centimeters (cc) measuring up to 30 USP Units of insulin, 1/2 cc measuring up to 50 USP Units of insulin, and 1 cc measuring up to 100 USP Units of insulin.

It is important to follow any instructions from your doctor about the careful selection and rotation of injection sites on your body.

There are several important steps that will help you successfully prepare your insulin injection . To draw the insulin up into the syringe correctly, you need to follow these steps:

• Wash your hands with soap and water.
• If your insulin contains zinc or isophane (normally cloudy), be sure that it is completely mixed. Mix the insulin by slowly rolling the bottle between your hands or gently tipping the bottle over a few times.
• Never shake the bottle vigorously (hard).
• Do not use the insulin if it looks lumpy or grainy, seems unusually thick, sticks to the bottle, or seems to be even a little discolored. Do not use the insulin if it contains crystals or if the bottle looks frosted. Regular insulin (short-acting) should be used only if it is clear and colorless.
• Remove the colored protective cap on the bottle. Do not remove the rubber stopper.
• Wipe the top of the bottle with an alcohol swab.
• Remove the needle cover from the insulin syringe.

How to prepare your insulin dose if you are using one type of insulin :

• Draw air into the syringe by pulling back on the plunger. The amount of air should be equal to your insulin dose.
• Gently push the needle through the top of the rubber stopper with the bottle standing upright.
• Push plunger in all the way to inject air into the bottle.
• Turn the bottle with syringe upside down in one hand. Be sure the tip of the needle is covered by the insulin. With your other hand, draw the plunger back slowly to draw the correct dose of insulin into the syringe.
• Check your dose. Hold the syringe with the scale at eye level to see that the proper dose is withdrawn and to check for air bubbles. Tap gently on the measuring scale of the syringe to move any bubbles to the top of the syringe near the needle. Then, push the insulin slowly back into the bottle and draw up your dose again.
• If your dose measures too low in the syringe, withdraw more solution from the bottle. If there is too much insulin in the syringe, put some back into the bottle. Then check your dose again.
• Remove the needle from the bottle and re-cover the needle.

How to prepare your insulin dose if you are using two types of insulin :

• When you mix regular insulin with another type of insulin, always draw the regular insulin into the syringe first. When you mix two types of insulins other than regular insulin, it does not matter in what order you draw them into the syringe.
• After you decide on a certain order for drawing up your insulin, you should use the same order each time.
• Some mixtures of insulins have to be injected immediately. Others may be stable for longer periods of time, which means that you can wait before you inject the mixture. Check with your health care professional to find out which type you have.
• Draw air into the syringe by pulling back on the plunger. The amount of air in the syringe should be equal to the part of the dose that you will be taking from the first bottle. Inject the air into the first bottle. Do not draw the insulin yet . Next, draw into the syringe an amount of air equal to the part of the dose that you will be taking from the second bottle. Inject the air into the second bottle.
• Return to the first bottle of the combination. With the plunger at zero, draw the first insulin dose of the combination (usually regular insulin) into the syringe.
• Check your dose. Hold the syringe with the scale at eye level to help you see that the proper dose is withdrawn and to check for air bubbles. Tap gently on the measuring scale of the syringe to move any bubbles to the top of the syringe near the needle.
• At this point, if the first part of the dose measures too low in the syringe, you can withdraw more solution from the bottle. If there is too much insulin in your syringe, put some back into the bottle. Then check your dose again.
• Then, without moving the plunger, insert the needle into the second bottle of insulin and withdraw the dose. Sometimes withdrawing a little bit more insulin from the second bottle than needed will help you correct the second dose more easily when you remove the air bubbles.
• Again, check that the proper dose is withdrawn. The syringe will now contain two types of insulin. It is important not to squirt any extra solution from the syringe back into the bottle. Doing so might change the insulin in the bottle. Throw away any extra insulin in the syringe.
• If you are not sure that you have done this correctly , throw away the dose into the sink and begin the steps again. Do not place any of the solutions back into either bottle . You can use the same syringe to begin the procedure again.
• If you prepared your mixture ahead of time, gently turn the filled syringe back and forth to remix the insulins before you inject them. Do not shake the syringe.

How to inject your insulin dose :

• After you have prepared your syringe and chosen the area of your body to inject, you are ready to inject the insulin into the fatty skin.
  • Clean the area where the injection is to be given with an alcohol swab or with soap and water. Let the area dry.
  • Pinch up a large area of skin and hold it firmly. With your other hand, hold the syringe like a pencil. Push the needle straight into the pinched-up skin at a 90-degree angle for an adult or at a 45-degree angle for a child. Be sure the needle is all the way in. It is not necessary to draw back on the syringe each time to check for blood (also called routine aspiration).
  • Push the plunger all the way down, using less than 5 seconds to inject the dose. Let go of the skin. Hold an alcohol swab near the needle and pull the needle straight out of the skin.
  • Press the swab against the injection area for several seconds. Do not rub.
  • If you are either thin or greatly overweight, you may be given special instructions for giving yourself insulin injections.

How to use special injection devices :

• It is important to follow the information that comes with your insulin and with the device you use for injecting your insulin. This will ensure proper use and proper insulin dosing. If you need more information about this, ask your health care professional.

For patients using an automatic injector (with a disposable syringe):

• After the dose is drawn, the disposable syringe is placed inside the automatic injector. Pressing a button on the device quickly plunges the needle into the skin, releasing the insulin dose.

For patients using a continuous subcutaneous infusion insulin pump :

• Buffered regular human insulin, when available, is the recommended insulin for insulin pumps. Otherwise non-buffered regular insulin can be used.
• The pump consists of a tube, with a needle on the end of it that is taped to the abdomen, and a computerized device that is worn at the waist. Insulin is received continuously from the pump. A button is pressed at mealtime to release an extra insulin dose.
• It is important to follow the pump manufacturer"s directions on how to load the syringe and/or pump reservoir. If you do not load the syringe and/or pump properly, you may not get the correct insulin dose.
• Check the infusion tubing and infusion-site dressing as often as your health care professional recommends to make sure the pump is working properly.

For patients using disposable syringes :

• Manufacturers of disposable syringes recommend that they be used only once, because the sterility of a reused syringe cannot be guaranteed. However, some patients prefer to reuse a syringe until its needle becomes dull. Most insulins have chemicals added that keep them from growing the bacteria that are usually found on the skin. However, the syringe should be thrown away when the needle becomes dull, has been bent, or has come into contact with any surface other than the cleaned and swabbed area of skin. If you plan to reuse a syringe, the needle must be recapped after each use. Check with your health care professional to find out the best way to reuse syringes.

For patients using an insulin pen device (cartridge and disposable needles):

• Change the dose by rotating the head of the pen. Put the pen next to your skin and press the plunger to inject the medicine. Some pen devices can only inject certain doses of insulin with each injection. Injection amounts can be different for different pen devices. To receive the right dose, you might have to count the number of times you press the plunger. Also, these devices use special cartridges of isophane insulin (NPH), regular insulin (R), or a mixture of these two types.

For patients using nondisposable syringes (glass syringe and metal needle):

• These types of syringes and needles may be used repeatedly if they are sterilized after each use. You should get an instruction sheet that tells you how to do this. If you need more information about this, ask your health care professional.

For patients using a spray injector (device without needles):

• The dose is measured by rotating part of the device. Insulin is drawn up into the spray device from an insulin bottle. Pressing a button forcefully sprays the insulin dose into the skin. This involves a wider area of skin than an injection would.

Laws in some states require that used insulin syringes and needles be destroyed. Be careful when you recap, bend, or break a needle, because these actions increase the chances of a needle-stick injury. It is best to put used syringes and needles in a disposable container that is puncture-resistant (such as an empty plastic liquid laundry detergent or bleach bottle) or to use a needle-clipping device. The chance of a syringe being reused by someone else is smaller if the plunger is taken out of the barrel and broken in half when you dispose of a syringe.

Use this medicine only as directed. Do not use more or less insulin than recommended by your doctor . To do so may increase the chance of serious side effects.

Your doctor will give you instructions about diet, exercise, how to test your blood sugar levels, and how to adjust your dose when you are sick.

• Diet—The daily number of calories in the meal plan should be adjusted by your doctor or a registered dietitian to help you reach and maintain a healthy body weight. In addition, regular meals and snacks are arranged to meet the energy needs of your body at different times of the day. It is very important that you carefully follow your meal plan .
• Exercise—Ask your doctor what kind of exercise to do, the best time to do it, and how much you should do each day.
• Blood tests—This is the best way to tell whether your diabetes is being controlled properly. Blood sugar testing helps you and your health care team adjust your insulin dose, meal plan, and exercise schedule.
• Changes in dose—Your doctor may change the first dose of the day. A change in the first dose of the day might change your blood sugar later in the day or change the amount of insulin you should use in other doses later that day. That is why your doctor should know any time your dose changes, even temporarily, unless you have been told otherwise .
• On sick days—When you become sick with a cold, fever, or the flu, you need to take your usual insulin dose, even if you feel too ill to eat. This is especially true if you have nausea, vomiting, or diarrhea. Infection usually increases your need for insulin. Call your doctor for specific instructions.
  Continue taking your insulin and try to stay on your regular meal plan. However, if you have trouble eating solid food, drink fruit juices, nondiet soft drinks, or clear soups, or eat small amounts of bland foods. A dietitian or your doctor can give you a list of foods and the amounts to use for sick days.
  Test your blood sugar level at least every 4 hours while you are awake and check your urine for ketones. If ketones are present, call your doctor at once. If you have severe or prolonged vomiting, check with your doctor. Even when you start feeling better, let your doctor know how you are doing.

Dosing—The dose of these medicines will be different for different patients. Follow your doctor"s orders or the directions on the label . The following information applies to the average doses of these medicines. If your dose is different, do not change it unless your doctor tells you to do so.

The number of injections that you receive each day depends on the strength or type of the medicine. Also, the number of doses you receive each day, the time allowed between doses, and the length of time you receive the medicine depend on the amount of sugar in your blood or urine .

For regular insulin (R)—Crystalline zinc, human buffered, and human regular insulins

• For injection dosage form:
  • For treating sugar diabetes (diabetes mellitus):
    • Adults and teenagers—The dose is based on your blood sugar and must be determined by your doctor. The medicine is injected under the skin fifteen or thirty minutes before meals and/or a bedtime snack. Also, your doctor may want you to use more than one type of insulin.
    • Children—Dose is based on your blood sugar and body weight and must be determined by your doctor.

For isophane insulin (NPH)—Isophane and human isophane insulins

• For injection dosage form:
  • For treating sugar diabetes (diabetes mellitus):
    • Adults and teenagers—The dose is based on your blood sugar and must be determined by your doctor. The medicine is injected under the skin thirty to sixty minutes before a meal and/or a bedtime snack. Also, your doctor may want you to use more than one type of insulin.
    • Children—Dose is based on your blood sugar and body weight and must be determined by your doctor.

For isophane insulin human/insulin human (NPH/R)—Human isophane/human regular insulin

• For injection dosage form:
  • For treating sugar diabetes (diabetes mellitus):
    • Adults and teenagers—The dose is based on your blood sugar and must be determined by your doctor. The medicine is injected under the skin fifteen to thirty minutes before breakfast. You may need a dose before another meal or at bedtime. Also, your doctor may want you to use more than one type of insulin.
    • Children—Dose is based on your blood sugar and body weight and must be determined by your doctor.

For insulin zinc (L)—Lente and human lente insulins

• For injection dosage form:
  • For treating sugar diabetes (diabetes mellitus):
    • Adults and teenagers—The dose is based on your blood sugar and must be determined by your doctor. The medicine is injected under the skin thirty minutes before breakfast. You may need a dose before another meal and/or a bedtime snack. Also, your doctor may want you to use more than one type of insulin.
    • Children—Dose is based on your blood sugar and body weight and must be determined by your doctor.

For insulin zinc extended (U)—Ultralente and human ultralente insulins

• For injection dosage form:
  • For treating sugar diabetes (diabetes mellitus):
    • Adults and teenagers—The dose is based on your blood sugar and must be determined by your doctor. The medicine is injected under the skin thirty to sixty minutes before a meal and/or a bedtime snack. Your doctor may want you to use more than one type of insulin.
    • Children—Dose is based on your blood sugar and body weight and must be determined by your doctor.

For prompt insulin zinc (S)—Semilente insulin

• For injection dosage form:
  • For treating sugar diabetes (diabetes mellitus):
    • Adults and teenagers—The dose is based on your blood sugar and must be determined by your doctor. The medicine is injected under the skin thirty to sixty minutes before breakfast. You may need a dose thirty minutes before another meal and/or a bedtime snack. Your doctor may want you to use more than one type of insulin.
    • Children—Dose is based on your blood sugar and body weight and must be determined by your doctor.

Storage—To store this medicine:

• Unopened bottles of insulin should be refrigerated until needed and may be used until the printed expiration date on the label. Insulin should never be frozen. Remove the insulin from the refrigerator and allow it to reach room temperature before injecting it.
• An insulin bottle in use may be kept at room temperature for up to 1 month. Insulin that has been kept at room temperature for longer than a month should be thrown away.
• Storing prefilled syringes in the refrigerator with the needle pointed up reduces problems that can occur, such as crystals forming in the needle and blocking it up.
• Do not expose insulin to extremely hot temperatures or to sunlight. Extreme heat will cause insulin to become less effective much more quickly.

Precautions While Using This Medicine

It is very important that your doctor check your progress at regular visits , especially during the first few weeks of insulin treatment.

It is very important to follow carefully any instructions from your health care team about :

• Alcohol—Drinking alcohol may cause severe low blood sugar. Discuss this with your health care team.
• Tobacco—If you have been smoking for a long time and suddenly stop, your dosage of insulin may need to be reduced. If you decide to quit, tell your doctor first.
• Other medicines—Do not take other medicines unless they have been discussed with your doctor. This especially includes nonprescription medicines such as aspirin, and medicines for appetite control, asthma, colds, cough, hay fever, or sinus problems.
• Counseling—Other family members need to learn how to prevent side effects or help with side effects if they occur. Also, patients with diabetes, especially teenagers, may need special counseling about insulin dosing changes that might occur because of lifestyle changes, such as changes in exercise and diet. Furthermore, counseling on contraception and pregnancy may be needed because of the problems that can occur in women with diabetes who become pregnant.
• Travel—Keep a recent prescription and your medical history with you. Be prepared for an emergency as you would normally. Make allowances for changing time zones, keep your meal times as close as possible to your usual meal times, and store insulin properly.

In case of emergency —There may be a time when you need emergency help for a problem caused by your diabetes. You need to be prepared for these emergencies. It is a good idea to:

• Wear a medical identification (ID) bracelet or neck chain at all times. Also, carry an ID card in your wallet or purse that says that you have diabetes and lists all of your medicines.
• Keep an extra supply of insulin and syringes with needles on hand in case high blood sugar occurs.
• Keep some kind of quick-acting sugar handy to treat low blood sugar.
• Have a glucagon kit available in case severe low blood sugar occurs. Check and replace any expired kits regularly.

Too much insulin can cause low blood sugar (also called hypoglycemia or insulin reaction). Symptoms of low blood sugar must be treated before they lead to unconsciousness (passing out) . Different people may feel different symptoms of low blood sugar. It is important that you learn what symptoms of low blood sugar you usually have so that you can treat it quickly .

• Symptoms of low blood sugar can include: anxious feeling, behavior change similar to being drunk, blurred vision, cold sweats, confusion, cool pale skin, difficulty in concentrating, drowsiness, excessive hunger, fast heartbeat, headache, nausea, nervousness, nightmares, restless sleep, shakiness, slurred speech, and unusual tiredness or weakness.
• The symptoms of low blood sugar may develop quickly and may result from:
  • delaying or missing a scheduled meal or snack.
  • exercising more than usual.
  • drinking a significant amount of alcohol.
  • taking certain medicines.
  • using too much insulin.
  • sickness (especially with vomiting or diarrhea).
• Know what to do if symptoms of low blood sugar occur. Eating some form of quick-acting sugar when symptoms of low blood sugar first appear will usually prevent them from getting worse. Good sources of sugar include:
  • Glucose tablets or gel, fruit juice or nondiet soft drink (4 to 6 ounces [one-half cup]), corn syrup or honey (1 tablespoon), sugar cubes (six one-half inch size), or table sugar (dissolved in water).
    • If a snack is not scheduled for an hour or more you should also eat a light snack, such as cheese and crackers, half a sandwich, or drink an 8-ounce glass of milk.
    • Do not use chocolate because its fat slows down the sugar entering into the blood stream.
  • Glucagon is used in emergency situations such as unconsciousness. Have a glucagon kit available and know how to prepare and use it. Members of your household also should know how and when to use it.

High blood sugar (hyperglycemia) is another problem related to uncontrolled diabetes. If you have any symptoms of high blood sugar, contact your health care team right away . If high blood sugar is not treated, severe hyperglycemia can occur, leading to ketoacidosis (diabetic coma) and death.

• The symptoms of mild high blood sugar appear more slowly than those of low blood sugar. Symptoms can include: blurred vision; drowsiness; dry mouth; flushed and dry skin; fruit-like breath odor; increased urination (frequency and volume); loss of appetite; stomachache, nausea, or vomiting; tiredness; troubled breathing (rapid and deep); and unusual thirst.
• Symptoms of severe high blood sugar (called ketoacidosis or diabetic coma) that need immediate hospitalization include: flushed and dry skin, fruit-like breath odor, ketones in urine, passing out, and troubled breathing (rapid and deep).
• High blood sugar symptoms may occur if you:
  • have diarrhea, a fever, or an infection.
  • do not take enough insulin or skip a dose of insulin.
  • do not exercise as much as usual.
  • overeat or do not follow your meal plan.
• Know what to do if high blood sugar occurs. Your doctor may recommend changes in your insulin dose or meal plan to avoid high blood sugar. Symptoms of high blood sugar must be corrected before they progress to more serious conditions. Check with your doctor often to make sure you are controlling your blood sugar. Your doctor might discuss the following with you:
  • Increasing your insulin dose when you plan to eat an unusually large dinner, such as on holidays. This type of increase is called an anticipatory dose.
  • Decreasing your dose for a short time for special needs, such as when you cannot exercise as you normally do. Changing only one type of insulin dose (usually the first dose) and anticipating how the change may affect other doses during the day. Contacting your doctor if you need a permanent change in dose.
  • Delaying a meal if your blood glucose is over 200 mg/dL to allow time for your blood sugar to go down. An extra insulin dose may be needed if your blood sugar does not come down shortly.
  • Not exercising if your blood glucose is over 240 mg/dL and reporting this to your doctor immediately.
  • Being hospitalized if ketoacidosis or diabetic coma occurs.

Side Effects of This Medicine

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur:

Also, check with your doctor as soon as possible if any of the following side effects occur:

Not all of the side effects listed above have been reported for each of these medicines, but they have been reported for at least one of them. All of the insulins are similar, so any of the above side effects may occur with any of these medicines.

Other side effects not listed above may also occur in some patients. If you notice any other effects, check with your doctor.

Additional Information

Once a medicine has been approved for marketing for a certain use, experience may show that it is also useful for other medical problems. Although this use is not included in product labeling, regular insulin is used in certain patients:

• To treat high blood sugar (hyperglycemia) in low birth weight infants.
• To test for growth hormone deficiency
• To prevent complications of diabetes, including eye problems (retinopathy), kidney disease (nephropathy), and nerve damage (neuropathy)

Other than the above information, there is no additional information relating to proper use, precautions, or side effects for this use.

Revised: 04/03/2002

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