Insulin Cocktails
| Author: Judy Kohn, RN, BSN, CDE |
| Last Updated: Friday, March 31, 2006 |
Q: "Would you explain the term "insulin cocktail" where regular and Humalog® are mixed to handle unusual BG patterns?"
A: Although the term "insulin cocktails" has been around for a while-and I used to assist patients using this regimen-- I have had difficulty finding a valid reference for you. The term originally appeared in an article in the American Diabetes Association's (ADA) Diabetes Forecast magazine, when Humalog was first introduced. But searching the ADA's Internet archives failed to produce that article.
As you said in your question, "insulin cocktail" referred to the practice of mixing Humalog and Regular together. The reason for this was that many people found using regular insulin alone too cumbersome and ineffective for the following reasons:
- Ideally, you needed to inject regular insulin ½-1 hour before eating to get the maximum benefit.
- Regular insulin did not peak quickly enough to control the post-meal glucose which would cause early post-meal hyperglycemia, yet it would often peak too late, with the potential to later cause post-meal hypoglycemia, 4-5 hours after the meal.
- The action of regular insulin was dosage dependent, meaning that the more you took, the longer it would last-in fact Regular insulin could last 6-16 hours, depending on the dose, site of injection, and individual variability.
Humalog has the advantages of:
- It peaks twice as high in less than half the time, allowing one to inject Humalog 5-15 minutes before the meal.
- The improved peak results in improved post-meal glucose levels, with reduced risk of hypoglycemia later on.
However, many people soon discovered that although Regular insulin took too long to work and lasted too long, Humalog "ran out too soon" if there weren't adequate basal insulin coverage, such as what you could obtain from using an insulin pump. Also, the concept of insulin cocktails originated prior to the availability of Lantus®.
So healthcare professionals started experimenting by having their patients try a combination of Humalog mixed with Regular (the proportion varied, but often started at 50% of each), taking this regimen before each meal, while using NPH or Lente® at bed. (Note: Lente was discontinued in 2005). Generally, the Regular would be a fixed dose before each meal, while the Humalog would be varied based on the amount of carbohydrate consumed, as well as the current glucose level.
When I published a home study course for nurses on principles of insulin adjustment, I could find no official article recommending the above regimen even though it was a practice used in many diabetes centers and discussed at various conferences. Instead, I could only find a reference to a study that suggested mixing Humalog (60-80%) and small amounts of NPH (20-40%) with each meal, with NPH at bedtime. Although this regimen was used with some children, my own experience with patients was that mixing Humalog and Regular worked better than mixing Humalog with NPH, likely due to the potential variability of NPH.
Current Practices:
Since the concept of insulin cocktails first surfaced, I would say that the practice is not as popular or common anymore for the following reasons:
- NovoLog® and Apidra ® are now other options for rapid-acting insulins.
- Lantus® (insulin Glargine) became available in the U.S. in 2001, which provides better basal insulin, thereby usually negating the need for the "insulin cocktail." Detemir® (Levemir) is a similar long-acting insulin that became available in the U.S. in 2006.
- A study reported in the May 2003 issue of Diabetes Care compared
two regimens:
- Humalog with meals and Lantus at bed;
- Humalog combined with NPH before each meal, and NPH at bed.
The conclusions were that both regimens were effective and resulted in improved control, however the Lantus regimen had several advantages:
- The Lantus group had lower fasting, premeal, and postmeal blood glucose results compared with the NPH group.
- The Lantus group had a greater percentage of glucose values in the target range, primarily in the fasting state, before meals, and at night.
- The Lantus group had a greater reduction in A1C.
- The Lantus group had a lower frequency of hypoglycemia primarily at night.
- The Lantus group had less variability of blood glucose at night.
- The time of evening administration of Lantus (i.e. dinnertime versus bedtime) did not make a difference in terms of control. So whereas NPH should preferably be given at bedtime to reduce the frequency of nighttime hypoglycemia, Lantus can be injected either at dinnertime or bedtime without compromising control.
As always, you need to discuss these various options with your healthcare team to determine what is the best option for you.
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