Don't Resist Using U-500 Insulin and Pramlintide for Severe Insulin Resistance

  1. Virginia Valentine, CNS, BC-ADM, CDE, FAADE

We have all had that patient: you keep increasing the insulin doses, and now they add up to > 200 units/day. And yet, blood glucose levels are still beyond the goal range. The patient says, “Maybe insulin doesn't work for me,” and you and the patient both feel hopeless and helpless.

It is important to help such patients understand that it is not their fault. Insulin resistance is frustrating for both patients and health care professionals (HCPs) and requires a multipronged approach: first, finding the right combination of medications to manage the glucose levels, and, second, addressing lifestyle issues that can help reduce insulin resistance.

This is the time to consider using U-500 regular insulin. U-500 is an insulin formulation that is five times more concentrated than usual U-100 insulin. Made by Eli Lilly, it is the only concentrated insulin currently available in the United States.

Potential Advantages of U-500 Insulin

Concentrated U-500 insulin allows people who require very high doses of insulin to get their doses in a lower volume. For example, a patient who is taking 100 units of U-100 insulin would take an injection with a 20-unit volume of U-500 insulin.

U-500 is a human regular insulin, but its time action is not the same as the usual U-100 formulation. It has the same peak as U-100 regular insulin, but its duration is more like that of NPH insulin, ~ 12 hours. Given these characteristics, U-500 works as both basal and prandial (bolus) insulin, so patients who use it not only take less insulin by volume, but also typically need only one type of insulin.

Another major difference is the cost. Although patients may be shocked to learn that the cost of a 20-ml vial (twice the amount of a usual 10-ml vial) is ~ $500, it is actually equivalent unit …

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  1. doi: 10.2337/diaclin.30.2.80 Clinical Diabetes vol. 30 no. 2 80-84