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 InsulinHuman Zinc; Insulin; Insulin Human; InsulinZinc; Insulin Human Zinc; Isophane Insulin; IsophaneInsulin Human; Isophane Insulin Human andInsulin 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, insulinworks by causing sugar (glucose) to go from the blood into our body's cellsto 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 takeit by injection.

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

To work properly, the amount of insulin you use must be balanced againstthe amount and type of food you eat and the amount of exercise you do. Ifyou change your diet, your exercise, or both without changing your insulindose, your blood glucose level can drop too low or rise too high. A prescriptionis not necessary to purchase most insulin. However, your doctor must firstdetermine your insulin needs and provide you with special instructions forcontrol of your diabetes.

Insulin can be obtained from beef or pork pancreas glands. Another typeof insulin that you may use is called human insulin. It is just like the insulinmade by humans but it is made by methods called semi-synthetic or recombinantDNA. All types of insulin must be injected because, if taken by mouth, insulinis 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 beweighed against the good it will do. This is a decision you and your doctorwill make. For insulin, the following should be considered:

Allergies?Tell your doctor if you have ever had any reactionsto 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 andafter pregnancy. It is especially important for your health and your baby'shealth that your blood sugar be closely controlled. Close control of yourblood sugar can reduce the chance of your baby gaining too much weight, havingbirth defects, or having high or low blood sugar. Be sure to tell your doctorif you plan to become pregnant or if you think you are pregnant.

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

Children?Children are especially sensitive to the effectsof 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 needmay be higher during puberty and lower after puberty.

Older adults?Use in older adults is similar to usein other age groups. However, sometimes the first signs of low or high bloodsugar are missing or not easily seen in older patients. This may increasethe chance of low blood sugar during treatment. Also, some older people mayhave vision problems or other medical problems that make it harder for themto measure and inject the medicine. Special training and equipment may beneeded.

Other medicines?Althoughcertain medicines should not be used together at all, in other cases two differentmedicines may be used together even if an interaction might occur. In thesecases, your doctor may want to change the dose, or other precautions may benecessary. Do not take any other medicine, unless prescribedor approved by your doctor. When you are using insulin, it is especiallyimportant that your health care professional know if you are taking any ofthe following:

• Alcohol?Small amounts of alcohol taken with meals do not usuallycause a problem; however, larger amounts of alcohol taken for a long timeor in one sitting without food can increase the effect of insulin to lowerthe blood sugar level. This can keep the blood sugar low for a longer periodof 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 increasethe chance of developing either high or low blood sugar levels. Also, theycan cover up symptoms of low blood sugar (such as fast heartbeat). Becauseof this, a person with diabetes might not recognize that he or she has lowblood sugar and might not take immediate steps to treat it. Beta-adrenergicblocking agents can also cause a low blood sugar level to last longer thannormal

• Corticosteroids (e.g., prednisone or other cortisone-like medicines)?Corticosteroidstaken 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 dosesof insulin may be needed during corticosteroid treatment and for a periodof time after corticosteroid treatment ends

• Pentamidine (e.g., NebuPent)?Your dose of pentamidine or insulinor both may need to be adjusted if your pancreas can still make some insulinbecause 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 youneed. 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 conditionsincrease 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, andincrease 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?Theseconditions may slow the time it takes to break down and absorb your meal fromyour 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, andincrease the need to take blood sugar tests

• Injury or
• Surgery?Effects of insulin may be increased or decreased; theamount 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 changethe amount of insulin you need

• Overactive thyroid, not properly controlled?Effects of insulinmay be increased or decreased, partly because of faster removal of insulinfrom the body. Until your thyroid condition is controlled, the amount of insulinyou need may change, make it necessary to change the time when you injectthe 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 conditionslower blood sugar and may lower the amount of insulin you need, make it necessaryfor you to change the time when you inject the insulin dose, and increasethe need to take blood sugar tests

Proper Use of This Medicine

Make sure you have the type (beefand pork, pork, or human) and the strength of insulin that your doctor orderedfor you. You may find that keeping an insulin label with you is helpfulwhen buying insulin supplies.

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

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

There are several important steps that will help yousuccessfully prepare your insulin injection. To draw the insulin upinto 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 surethat it is completely mixed. Mix the insulin by slowly rolling the bottlebetween 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 unusuallythick, sticks to the bottle, or seems to be even a little discolored. Do notuse the insulin if it contains crystals or if the bottle looks frosted. Regularinsulin (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 onetype of insulin:

• Draw air into the syringe by pulling back on the plunger. The amountof air should be equal to your insulin dose.
• Gently push the needle through the top of the rubber stopper withthe 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 thetip of the needle is covered by the insulin. With your other hand, draw theplunger back slowly to draw the correct dose of insulin into the syringe.
• Check your dose. Hold the syringe with the scale at eye level tosee that the proper dose is withdrawn and to check for air bubbles. Tap gentlyon the measuring scale of the syringe to move any bubbles to the top of thesyringe near the needle. Then, push the insulin slowly back into the bottleand draw up your dose again.
• If your dose measures too low in the syringe, withdraw more solutionfrom the bottle. If there is too much insulin in the syringe, put some backinto 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 twotypes 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 notmatter 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. Othersmay be stable for longer periods of time, which means that you can wait beforeyou inject the mixture. Check with your health care professional to find outwhich type you have.
• Draw air into the syringe by pulling back on the plunger. The amountof air in the syringe should be equal to the part of the dose that you willbe taking from the first bottle. Inject the air into the first bottle. Do not draw the insulin yet. Next, draw into the syringean amount of air equal to the part of the dose that you will be taking fromthe second bottle. Inject the air into the secondbottle.
• Return to the first bottle of the combination. With the plunger atzero, 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 tohelp 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 thetop of the syringe near the needle.
• At this point, if the first part of the dose measures too low inthe syringe, you can withdraw more solution from the bottle. If there is toomuch insulin in your syringe, put some back into the bottle. Then check yourdose again.
• Then, without moving the plunger, insert the needle into the secondbottle of insulin and withdraw the dose. Sometimes withdrawing a little bitmore insulin from the second bottle than needed will help you correct thesecond dose more easily when you remove the air bubbles.
• Again, check that the proper dose is withdrawn. The syringe willnow contain two types of insulin. It is important not to squirt any extra solution from thesyringe 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 filledsyringe back and forth to remix the insulins before you inject them. Do notshake the syringe.

How to inject your insulin dose:

• After you have prepared your syringe and chosen the area of yourbody 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 alcoholswab or with soap and water. Let the area dry.
  • Pinch up a large area of skin and hold it firmly. With your otherhand, hold the syringe like a pencil. Push the needle straight into the pinched-upskin 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 onthe syringe each time to check for blood (also called routine aspiration).
  • Push the plunger all the way down, using less than 5 seconds to injectthe dose. Let go of the skin. Hold an alcohol swab near the needle and pullthe needle straight out of the skin.
  • Press the swab against the injection area for several seconds. Donot rub.
  • If you are either thin or greatly overweight, you may be given specialinstructions for giving yourself insulin injections.

How to use special injection devices:

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

For patients using an automatic injector (witha disposable syringe):

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

For patients using a continuous subcutaneous infusioninsulin pump:

• Buffered regular human insulin, when available, is the recommendedinsulin 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 thatis 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 mealtimeto release an extra insulin dose.
• It is important to follow the pump manufacturer's directions on howto load the syringe and/or pump reservoir. If you do not load the syringeand/or pump properly, you may not get the correct insulin dose.
• Check the infusion tubing and infusion-site dressing as often asyour health care professional recommends to make sure the pump is workingproperly.

For patients using disposable syringes:

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

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

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

For patients using nondisposable syringes (glasssyringe and metal needle):

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

For patients using a spray injector (devicewithout needles):

• The dose is measured by rotating part of the device. Insulin is drawnup into the spray device from an insulin bottle. Pressing a button forcefullysprays the insulin dose into the skin. This involves a wider area of skinthan 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 actionsincrease the chances of a needle-stick injury. It is best to put used syringesand needles in a disposable container that is puncture-resistant (such asan empty plastic liquid laundry detergent or bleach bottle) or to use a needle-clippingdevice. The chance of a syringe being reused by someone else is smaller ifthe plunger is taken out of the barrel and broken in half when you disposeof a syringe.

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

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

• Diet?The daily number of calories in the meal plan shouldbe adjusted by your doctor or a registered dietitian to help you reach andmaintain a healthy body weight. In addition, regular meals and snacks arearranged to meet the energy needs of your body at different times of the day. It is very important that you carefully follow your mealplan.
• Exercise?Ask your doctor what kind of exercise to do, the besttime to do it, and how much you should do each day.
• Blood tests?This is the best way to tell whether your diabetesis being controlled properly. Blood sugar testing helps you and your healthcare team adjust your insulin dose, meal plan, and exercise schedule.
• Changes in dose?Your doctor may change the first dose of theday. A change in the first dose of the day might change your blood sugar laterin the day or change the amount of insulin you should use in other doses laterthat day. That is why your doctor should know any timeyour dose changes, even temporarily, unless you have been told otherwise.
• On sick days?When you become sick with a cold, fever, or theflu, you need to take your usual insulin dose, even if you feel too ill toeat. This is especially true if you have nausea, vomiting, or diarrhea. Infectionusually 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, nondietsoft drinks, or clear soups, or eat small amounts of bland foods. A dietitianor your doctor can give you a list of foods and the amounts to use for sickdays.
  Test your blood sugar level at least every 4 hours while you are awakeand check your urine for ketones. If ketones are present, call your doctorat 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 ofthese medicines will be different for different patients. Follow your doctor's orders or the directions on the label. The followinginformation applies to the average doses of these medicines. If your dose is different, do not change it unless your doctor tellsyou to do so.

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

For regular insulin (R)?Crystalline zinc, humanbuffered, and human regular insulins

• For injection dosage form:
  • For treating sugar diabetes (diabetes mellitus):
    • Adults and teenagers?The dose is based on your blood sugarand must be determined by your doctor. The medicine is injected under theskin 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 weightand must be determined by your doctor.

For isophane insulin (NPH)?Isophane and humanisophane insulins

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

For isophane insulin human/insulin human (NPH/R)?Humanisophane/human regular insulin

• For injection dosage form:
  • For treating sugar diabetes (diabetes mellitus):
    • Adults and teenagers?The dose is based on your blood sugarand must be determined by your doctor. The medicine is injected under theskin fifteen to thirty minutes before breakfast. You may need a dose beforeanother meal or at bedtime. Also, your doctor may want you to use more thanone type of insulin.
    • Children?Dose is based on your blood sugar and body weightand 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 sugarand must be determined by your doctor. The medicine is injected under theskin thirty minutes before breakfast. You may need a dose before another mealand/or a bedtime snack. Also, your doctor may want you to use more than onetype of insulin.
    • Children?Dose is based on your blood sugar and body weightand must be determined by your doctor.

For insulin zinc extended (U)?Ultralente andhuman ultralente insulins

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

Storage?To store this medicine:

• Unopened bottles of insulin should be refrigerated until needed andmay be used until the printed expiration date on the label. Insulin shouldnever be frozen. Remove the insulin from the refrigerator and allow it toreach room temperature before injecting it.
• An insulin bottle in use may be kept at room temperature for up to1 month. Insulin that has been kept at room temperature for longer than amonth should be thrown away.
• Storing prefilled syringes in the refrigerator with the needle pointedup reduces problems that can occur, such as crystals forming in the needleand 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 yourdoctor check your progress at regular visits, especially during thefirst few weeks of insulin treatment.

It is very important to follow carefully any instructionsfrom 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 suddenlystop, 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 havebeen discussed with your doctor. This especially includes nonprescriptionmedicines 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 preventside effects or help with side effects if they occur. Also, patients withdiabetes, especially teenagers, may need special counseling about insulindosing changes that might occur because of lifestyle changes, such as changesin exercise and diet. Furthermore, counseling on contraception and pregnancymay be needed because of the problems that can occur in women with diabeteswho become pregnant.
• Travel?Keep a recent prescription and your medical historywith you. Be prepared for an emergency as you would normally. Make allowancesfor changing time zones, keep your meal times as close as possible to yourusual meal times, and store insulin properly.

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

• Wear a medical identification (ID) bracelet or neck chain at alltimes. Also, carry an ID card in your wallet or purse that says that you havediabetes and lists all of your medicines.
• Keep an extra supply of insulin and syringes with needles on handin 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 orinsulin reaction). Symptoms of low blood sugar must betreated before they lead to unconsciousness (passing out). Differentpeople may feel different symptoms of low blood sugar. It is important that you learn what symptoms of low blood sugar you usuallyhave so that you can treat it quickly.

• Symptoms of low blood sugar can include: anxious feeling, behaviorchange similar to being drunk, blurred vision, cold sweats, confusion, coolpale skin, difficulty in concentrating, drowsiness, excessive hunger, fastheartbeat, 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 resultfrom:
  • 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 someform of quick-acting sugar when symptoms of low blood sugar first appear willusually prevent them from getting worse. Good sources of sugar include:
  • Glucose tablets or gel, fruit juice or nondiet soft drink (4 to 6ounces [one-half cup]), corn syrup or honey (1 tablespoon), sugar cubes (sixone-half inch size), or table sugar (dissolved in water).
    • If a snack is not scheduled for an hour or more you should also eata light snack, such as cheese and crackers, half a sandwich, or drink an 8-ounceglass of milk.
    • Do not use chocolate because its fat slows down the sugar enteringinto 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. Membersof your household also should know how and when to use it.

High blood sugar (hyperglycemia) is another problem related to uncontrolleddiabetes. If you have any symptoms of high blood sugar,contact your health care team right away. If high blood sugar is nottreated, severe hyperglycemia can occur, leading to ketoacidosis (diabeticcoma) and death.

• The symptoms of mild high blood sugar appear more slowly than thoseof low blood sugar. Symptoms can include: blurred vision; drowsiness; drymouth; flushed and dry skin; fruit-like breath odor; increased urination (frequencyand 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 diabeticcoma) that need immediate hospitalization include: flushed and dry skin, fruit-likebreath odor, ketones in urine, passing out, and troubled breathing (rapidand 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 recommendchanges in your insulin dose or meal plan to avoid high blood sugar. Symptomsof high blood sugar must be corrected before they progress to more seriousconditions. Check with your doctor often to make sure you are controllingyour blood sugar. Your doctor might discuss the following with you:
  • Increasing your insulin dose when you plan to eat an unusually largedinner, such as on holidays. This type of increase is called an anticipatorydose.
  • Decreasing your dose for a short time for special needs, such aswhen you cannot exercise as you normally do. Changing only one type of insulindose (usually the first dose) and anticipating how the change may affect otherdoses during the day. Contacting your doctor if you need a permanent changein dose.
  • Delaying a meal if your blood glucose is over 200 mg/dL to allowtime for your blood sugar to go down. An extra insulin dose may be neededif your blood sugar does not come down shortly.
  • Not exercising if your blood glucose is over 240 mg/dL and reportingthis 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 mayneed medical attention.

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

More common

Convulsions (seizures); unconsciousness

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

More common

Low blood sugar (mild), including anxious feeling, behavior changesimilar to being drunk, blurred vision, cold sweats, confusion, cool paleskin, difficulty in concentrating, drowsiness, excessive hunger, fast heartbeat,headache, nausea, nervousness, nightmares, restless sleep, shakiness, slurredspeech, unusual tiredness or weakness; weight gain

Rare

Depressed skin at the place of injection; swelling of face, fingers, feet, or ankles; thickeningof the skin at the place of injection

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

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

Additional Information

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

• 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 relatingto proper use, precautions, or side effects for this use.