Jasmine D. Gonzalvo, PharmD, and Dhiren Patel, PharmD, offer their perspectives on important counseling and medication therapy management considerations with U-500 insulin therapy.
Jasmine D. Gonzalvo, PharmD: What’s important about taking U-500 insulin would be that it does need to be taken with a meal. We do want it ideally 30 minutes before a meal, but for most patients I can say, “Take it right before you eat, somewhere within that timeframe.” It’s difficult for a lot of people to take it specifically 30 minutes before a meal, but some time before a meal would be ideal. From there, the pen can be stored once opened. Once you’ve used it, it can be stored outside of the fridge for 28 days. And with the vial, once opened it can be stored outside of the fridge for 40 days. Keep it away from extreme temperatures of course—too hot, too cold—those things need to be considered. But for the most part, the biggest thing to take home for our patients is really just that they need to be taking it with a meal to prevent hypoglycemia. That is what we’d be most afraid about.
Dhiren Patel, PharmD: When initiating U-500, it’s important to talk to the patient, but also the provider in many cases. The reason that’s important is because it’s different from many other insulins given the fact that it’s indicated for monotherapy use. So, a patient might be on a regimen of basal/bolus and getting close to that 200-unit mark where patients would be getting converted over to U-500. In many cases, in most of my clinical scenarios, I have patients who are just on U-500 monotherapy, but it’s important to ask that question because I also have a handful of patients who are not on monotherapy.
They’re on U-500, but they’re also on prandial, rapid-acting, insulin in addition to that. And in those unique situations, you could be discontinuing a medication that the patient should be on when they need that in addition to the U-500. But a majority of them do come in. They stopped their prior therapy and they switched over to monotherapy of U-500. But in different cases, because of treatment intensification needs, you may need to add back a certain insulin. In many cases, it might be a prandial insulin that gets added back on.
As pharmacists, double-check those prescriptions. If you have prescriptions that are for auto-refill, make sure that the prior ones get discontinued. When this new therapy gets started, the conversion—even in terms of the syringes—needs to happen. The counseling points change from prior to what they are currently using. Especially if they’re going to the KwikPen, the titration of that is going to be different because they’re only allowed 500-unit increment titrations. The day’s supply would also be different because of the box. You get 2 pens that are available to you, each with 1500 units in a box. And so, you’re dealing with 3000 units whereas in the vial you’re dealing with a 20-mL vial, and so the math and the calculation there is also different for the patient as well as the pharmacist.
Patients who are on U-500 I’ve noticed have also had improved glycemic control, and that improved glycemic control is basically with the same amount of total daily insulin that patient was previously on. But U-500 allows them to overcome this insulin resistance. In some cases, I’ve had to either dose adjust the background medications or the U-500 doses, where I’ve converted them unit-for-unit based off of the algorithms and the dosing calculations. Anecdotally, we’ve seen improved glycemic control. In those situations, right at transition or initiation, you may want to follow those patients a little more closely and make that outreach with a phone call from the pharmacies to see how that patient is doing and make sure that they aren’t hypoglycemic or hyperglycemic.