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Choose Humulin R U-500 Insulin for treatment of patients with diabetes with a high daily insulin requirement

His daily insulin dose is above 200 units, but he continues to face challenges

Rising insulin needs
Needs >200 units of insulin per day (e.g., 100 units of basal/day and 35 units of U-100 insulin at each meal)

Rising A1C levels
Has an A1C above target and hasn’t improved despite increases in insulin

Rising frustration
Is discouraged that 5 or more injections a day are not helping enough

*Hypothetical patient

Indication for Humulin® R U-500

  • Humulin R U-500 is a concentrated human insulin indicated to improve glycemic control in adults and children with diabetes mellitus requiring more than 200 units of insulin per day.
  • Limitations of Use: The safety and efficacy of Humulin R U-500 used in combination with other insulins, or when delivered by continuous subcutaneous infusion, has not been determined.

Select Important Safety Information

Contraindications
Humulin® R U-500 is contraindicated during episodes of hypoglycemia and in patients hypersensitive to Humulin R U-500 or any of its excipients.

Humulin R U-500 is the only insulin studied in a randomized clinical trial of patients requiring >200 units/day1

Trial Objective

The Humulin R U-500 Initiation Trial was a 24-week, open-label, randomized study conducted in the United States and Puerto Rico. This study compared 2 treatment regimens (TID versus BID) for U-500 insulin for replacement of high-dose U-100 insulin.

The trial included a 4-week lead-in period followed by a 12-week intensive dose titration period and subsequent 12-week maintenance phase using R U-500 either TID or BID 30 minutes before meals and dosing titration algorithms based on 4-times-daily self-monitored plasma glucose (SMPG) values. Initial dosing proportions were 40:30:30 (breakfast:lunch:dinner) and 60:40 (breakfast:dinner) for the TID and BID regimens, respectively.

Trial Participants

  • Had uncontrolled type 2 diabetes with A1C ≥7.5% and ≤12.0% (mean 8.7%)
  • Were taking >200 and ≤600 units/day of U-100 insulin with or without oral antidiabetes drugs (mean 287.5 units/day)
  • Injected U-100 insulin 2-10 times a day pretrial (median: 5)
  • Had a BMI ≥25 kg/mg2 (mean 41.9 kg/m2)
  • Were 18-75 years of age (mean 55.4 years; ≥65 years = 20.3%)
  • Had type 2 diabetes for approximately 15 years

Trial Summary

In this trial, initiation and titration of U-500 using either algorithm improved glycemic control from baseline with 2 or 3 injections in patients with type 2 diabetes previously uncontrolled on high-dose/high-volume U-100 insulin.3

  1. Hood RC, Arakaki RF, Wysham C, et al. Two treatment approaches for human regular U-500 insulin in patients with type 2 diabetes not achieving adequate glycemic control on high-dose U-100 insulin therapy with or without oral agents: a randomized, titration-to-target clinical trial. Endocr Pract. 2015;21(7):782-793. Erratum, 2016;22(7):905.
  2. Wysham C, Hood RC, Warren ML, et al. Effect of total daily dose on efficacy, dosing, and safety of 2 dose titration regimens of human regular U-500 insulin in severely insulin-resistant patients with type 2 diabetes. Endocr Pract. 2016;22(6):653-665.

  3. Hood RC, Arakaki RF, Wysham C, et al. Two treatment approaches for human regular U-500 insulin in patients with type 2 diabetes not achieving adequate glycemic control on high-dose U- 100 insulin therapy with or without oral agents: a randomized, titration-to-target clinical trial. Endocr Pract. 2015;21(7):782-793. Erratum, 2016;22(7):905.

Demonstrated efficacy as insulin monotherapy injected 2 or 3 times a day1

LS = least squares; MMRM = mixed-model repeated measures; TID = three times a day; BID = two times a day.
The difference in least squares mean (LSM) A1C change from baseline between treatment groups (BID vs TID) was -0.10%.
The 95% CI (-0.33% to 0.12%) fell within the range established by the noninferiority margin (0.4%), demonstrating clinical equivalence of the 2 treatment regimens.
• Mean A1C at baseline for both groups was 8.7%
• Mean A1C at endpoint was 7.5% for TID and 7.4% for BID

All efficacy analyses were conducted using the full analysis set defined as all randomized patients receiving at least one dose of study drug at baseline.

Study conducted with U-100 insulin syringes and Humulin R U-500 vials.

The Humulin R U-500 Initiation Trial was a 24-week, open-label, randomized trial to compare the efficacy and safety of 2 dosing regimens (TID, n=162 vs BID, n=163) for U-500 insulin replacing high-dose U-100 insulin (>200 units per day) with or without oral antihyperglycemic drugs in adult patients with uncontrolled type 2 diabetes. These regimens were found to be equivalent for A1C reduction over 24 weeks, and both were efficacious.1

Select Safety Information for Humulin R U-500

Hyperglycemia, Hypoglycemia, or Death Due to Dosing Errors With Vial Presentation

  • Can be life-threatening. Overdose has occurred as a result of dispensing, prescribing, or administration errors. Attention to details at all levels is required to prevent these errors.
  • Patients should be prescribed U-500 syringes for use with Humulin R U-500 vials. Do not use any other type of syringe to administer Humulin R U-500.
  • If using the Humulin R U 500 KwikPen®, patients should be counseled to dial and dose the prescribed number of units of insulin.
  • Do NOT perform dose conversion when using the Humulin R U-500 KwikPen.
  • Do NOT perform dose conversion when using a U-500 insulin syringe.

Humulin R U-500 helped the majority of patients reach glycemic targets1

NOTE: There was no statistically significant difference in percent-to-target results achieved between TID and BID dosing.

All efficacy analyses were conducted using the full analysis set defined as all randomized patients receiving at least one dose of study drug at baseline.

Approximately 70% of patients reached A1C <8.0%. *At 24 weeks for those not at target at randomization. Patients at target (%) at baseline: 24.8% (<8.0%), 9.9% (<7.5%), and 1.9% (<7.0%).

Hypoglycemia rates and incidence

*Events/patients/30 days.

Rates are geometric least squares means } SE (documented symptomatic and nocturnal) or means } SD (severe).

NOTE: During this trial, hypoglycemia was categorized as documented symptomatic, nocturnal, or severe hypoglycemia.

Documented symptomatic hypoglycemia was defined as signs or symptoms associated with hypoglycemia and a plasma glucose ≤70 mg/dL or <50 mg/dL. Nocturnal hypoglycemia was defined as documented symptomatic hypoglycemia occurring between bedtime and waking. By definition, severe hypoglycemia required assistance from another person for treatment and was accompanied by neurologic/cognitive impairment. Incidence is reported as the number of patients with at least one hypoglycemic episode.

All hypoglycemic analyses were performed using the full analysis set defined as all randomized patients receiving at least one dose of study drug.

Leading endocrinologists discuss experience with high-dose patients

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INDICATION AND IMPORTANT SAFETY INFORMATION
Indication for Humulin® R U-500

Humulin R U-500 is a concentrated human insulin indicated to improve glycemic control in adults and children with diabetes mellitus requiring more than 200 units of insulin per day.

Limitations of Use: The safety and efficacy of Humulin R U-500 used in combination with other insulins, or when delivered by continuous subcutaneous infusion, has not been determined.

Contraindications
Humulin R U-500 is contraindicated during episodes of hypoglycemia and in patients hypersensitive to Humulin R U-500 or any of its excipients.
Warnings and Precautions
Hyperglycemia, Hypoglycemia, or Death Due to Dosing Errors With Vial Presentation
  • Can be life-threatening. Overdose has occurred as a result of dispensing, prescribing, or administration errors. Attention to details at all levels is required to prevent these errors.
  • Patients should be prescribed U-500 syringes for use with Humulin R U-500 vials. Do not use any other type of syringe to administer Humulin R U-500.
  • If using the Humulin R U-500 KwikPen®, patients should be counseled to dial and dose the prescribed number of units of insulin and NO dose conversion is required.

DO NOT transfer Humulin R U-500 from the KwikPen into any syringe for administration. Overdose and severe hypoglycemia can occur.


Never share a KwikPen or U-500 syringe between patients, even if the needle is changed, to avoid risk of transmission of blood-borne pathogens.


Hyperglycemia or Hypoglycemia With Changes in Insulin Regimen

  • Changes in insulin, manufacturer, type, or method of administration should be made cautiously and only under close medical supervision with increased frequency of blood glucose monitoring.

Hypoglycemia

  • Hypoglycemia is the most common adverse reaction associated with insulin, including Humulin R U-500. Severe hypoglycemia can cause seizures, may be life-threatening, or cause death.
  • Increase monitoring with changes to insulin dosage, co-administered glucose-lowering medications, meal patterns, physical activity, and in patients with renal or hepatic impairment or hypoglycemia unawareness. To minimize risk of hypoglycemia, do not administer Humulin R U-500 intravenously, intramuscularly, or in an insulin pump or dilute or mix with other products, including other insulins.
  • Patients and caregivers must be educated to recognize and manage hypoglycemia. Self-monitoring of blood glucose plays an essential role in the prevention and management of hypoglycemia. In patients at higher risk for hypoglycemia and patients who have reduced symptomatic awareness of hypoglycemia, increased frequency of blood glucose monitoring is recommended.

Hypersensitivity and Allergic Reactions

  • Severe, life-threatening, generalized allergy, including anaphylaxis, can occur with insulin products, including Humulin R U-500. If hypersensitivity reactions occur, discontinue Humulin R U-500; treat per standard of care and monitor until symptoms and signs resolve.

Hypokalemia

  • May be life-threatening. Monitor potassium levels in patients at risk for hypokalemia and treat if indicated.

Fluid Retention and Heart Failure With Concomitant Use of Thiazolidinediones (TZDs)

  • Thiazolidinediones (TZDs) can cause dose-related fluid retention, particularly when used in combination with insulin. Observe for signs and symptoms of heart failure and consider reduction or discontinuation if heart failure occurs.
Adverse Reactions
Other adverse reactions include allergic reactions, lipodystrophy, injection site reactions, pruritus, and rash.
Drug Interactions
  • Some medications may alter glucose metabolism and may necessitate insulin dose adjustment.
  • Particularly close glucose monitoring may be required when Humulin R U-500 is co-administered with drugs such as antiadrenergic agents that can alter the signs of hypoglycemia.
Additional Information

HM U500 HCP ISI 22JAN2019


For more information, see Full Prescribing Information, including Patient Information and Instructions for Use for the KwikPen and vial.

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