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Table of Contents
ORIGINAL ARTICLE
Year : 2015  |  Volume : 19  |  Issue : 5  |  Page : 625-629

Posology of insulins: A review of standard textbooks and product inserts


1 Department of Pharmacology, BPS GMC for Women, Khanpur Kalan, Sonepat, Haryana, India
2 Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India

Date of Web Publication19-Aug-2015

Correspondence Address:
Garima Bhutani
H. No. 517, Sector 15-A, Hisar, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-8210.163181

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   Abstract 

Objectives: The study is aimed to assess whether the information contained in standard pharmacology, endocrinology, and diabetology textbooks regarding timings of administration, frequency and dose of various insulins is adequate and also to see whether the information contained in these texts is concordant with product inserts. Materials and Methods: Four standard textbooks of pharmacology, two of diabetology and three of endocrinology were assessed for the published information regarding dose, timing, and frequency of insulin administration. The product inserts of commonly available insulins in India were also studied for the same. Results: Various omissions and disparities could be seen in the coverage of insulins in standard textbooks. Posology information about premixed insulins and basal insulins have been omitted by the majority of the textbooks. Details about dose, frequency and timings of ultra-short acting insulins have also not been covered by all textbooks. Some discrepancies regarding prescribing information was also noted in product inserts, especially in case of newer insulins. Conclusions: Thus, this article stresses upon the need of a uniform source of information for providing adequate and standardized knowledge regarding timing, frequency, and dose of insulins.

Keywords: Insulins, patient information leaflet, posology, product insert


How to cite this article:
Bhutani G, Kalra S. Posology of insulins: A review of standard textbooks and product inserts. Indian J Endocr Metab 2015;19:625-9

How to cite this URL:
Bhutani G, Kalra S. Posology of insulins: A review of standard textbooks and product inserts. Indian J Endocr Metab [serial online] 2015 [cited 2020 Feb 28];19:625-9. Available from: http://www.ijem.in/text.asp?2015/19/5/625/163181


   Introduction Top


Insulin therapy is often an important part of diabetes treatment. The purpose of giving insulin in diabetes mellitus is to restore metabolism to normal, avoid symptoms due to hyperglycemia and glucosuria and to prevent short-term and long-term sequelae of diabetes. In order to reach these goals and to avoid potentially dangerous side-effects like hypoglycemia, it is vital to administering insulin in appropriate dose and frequency and at correct timings. This is possible only with accurate knowledge about the posology of various commercially available insulin preparations.

Pharmacology, diabetology and endocrinology textbooks are an important and reliable source of such information, both for students and clinicians. This article aims at assessing the adequacy of the knowledge provided by these textbooks regarding posology that is, dose, frequency, and timing of insulins. Apart from textbooks, package inserts, and patient information leaflets also play an important role in spreading knowledge and awareness, especially among patients. In this article, we would also focus on assessing the information contained in the package inserts and see if this information is concordant with the information given in the textbooks.


   Materials and Methods Top


Some of the most popular and most commonly read textbooks of pharmacology, diabetology, and endocrinology, were included in this study. Four standard textbooks of pharmacology (2 by Indian authors and 2 by US authors) were analyzed. Two textbooks of diabetology were also studied of which 1 textbook is by Indian author and other is by US author. Three textbooks of endocrinology (2 US and 1 Indian in origin) were also assessed for the desired information. Apart from this, information contained in the package inserts of some of the common commercially available drugs in India was also studied.


   Results Top


The results of the analysis are tabulated in [Table 1] and [Table 2]. [Table 1] shows the comparison of information about insulins available in different textbooks. [Table 2] shows information available on the package inserts of some of the most commonly used insulins in India.
Table 1: Comparison of information about insulins in pharmacology, diabetology and endocrinology text books

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Table 2: Compendium of dosing information in package inserts of glucose lowering drugs

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   Discussion Top


Insulin is a molecule which is now available in multiple formulations and analogs. Almost all text books cover insulin extensively, but information regarding timing of the injection is often discordant. While most authors suggest injecting insulin aspart, lispro or glulisine ≤ 15 min before a meal, others advise immediately preprandial, and postprandial dosage. The recommendations for regular human insulin are uniform in 8 books. Virtually no book mentions premixed insulin analogs and their method of administration. This may be due to the fact that premixed insulins are not frequently used in the US. It must be mentioned, here, however, that premixed insulins are the most commonly prescribed injectable therapy for diabetes in India. It is expected, therefore that Indian books cover this aspect of insulin pharmacotherapy adequately.

Basal insulin analogs are covered by five books while neutral protamine Hagedorn (NPH) insulin is mentioned only by three. The pharmacology books offer varied advice for the dosage of NPH. The novel insulin degludec is covered in current editions of Indian endocrinology and diabetology texts.

The newer insulins analogs present a challenge for the clinical diabetologist. While it is assumed that all analogs share the same prescribing information the product inserts reveal otherwise. Product insert guidelines [Table 2] should be followed while advising the use of all insulins.


   Conclusion Top


This study stresses upon the need to have standardized, uniform sources of information regarding posology of insulins. Such information is vital for the better education of students and clinicians, which in turn would ensure the better health care of the patients.

Limitations

The missing information as highlighted in the results and discussion may be available in the new upcoming editions of the textbooks. Only the more commonly used textbooks of pharmacology, diabetology and endocrinology were analyzed for the purpose of this study. [22]

 
   References Top

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Powers AC, D′Alessio D. Endocrine pancreas and pharmacotherapy of diabetes mellitus and hypoglycaemia. In: Brunton LL, Chabner BA, Knollmann BC, editors. Goodman and Gilman′s the pharmaceutical basis of therapeutics. 12 th ed. New York: Tata McGraw Hill; 2011. p. 1237-74.  Back to cited text no. 1
    
2.
Nolte MS. Pancreatic hormones and anti diabetic drugs. In: Katzung BG, Masters SB, Trevor AJ, editors. Basic and Clinical Pharmacology. 11 th ed. New York: Tata McGraw Hill; 2009. p. 727-52.  Back to cited text no. 2
    
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Buse GB. Management of Type 2 Diabetes Mellitus. In: De Groot LJ, James LS, editors. Endocrinology. 12 th ed. Philadelphia: Elsevier Saunders; 2006. p. 1231-48.  Back to cited text no. 5
    
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Heinemann L. Insulin pharmacology. In: Pickup JC, Williams G, editors. Textbook of Diabetes. 3 rd ed. Malden, MA: Blackwell Science Ltd.; 2003. p. 42.1-42.15.  Back to cited text no. 6
    
7.
Jain SM. Insulin therapy. In: Chandalia HB, editor. RSSDI Textbook of Diabetes Mellitus. 3 rd ed. New Delhi: Jaypee Brothers Medical Publishers; 2014. p. 572-91.  Back to cited text no. 7
    
8.
Bajaj S, editor. Manual of Clinical Endocrinology. 2 nd ed. New Delhi: Jaypee Brothers Medical Publishers; 2014. p. 81-108.  Back to cited text no. 8
    
9.
Eisenbarth GS, Buse JB. Type 1 diabetes mellitus. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, editors. Williams Textbook of Endocrinology. 12 th ed. Philadelphia: Elsevier Saunders; 2011. p. 1436-61.  Back to cited text no. 9
    
10.
Package Leaflet: Information for the User NovoRapid® FlexPen® 100 Units/ml Solution for Injection in Pre-filled Pen Insulin Aspart. Available from: http://www.medicines.ie/medicine/11542/PIL/NovoRapid+FlexPen/. [Last cited on 2014 Dec 24].  Back to cited text no. 10
    
11.
Patient Information Humalog® Insulin Lispro Injection, USP (rDNA Origin). Available from: http://www.medicines.org.uk/emc/PIL.20946.latest.pdf. [Last cited on 2014 Dec 24].  Back to cited text no. 11
    
12.
Package Leaflet: Information for the User Apidra®100 Units/ml Solution for Injection in a Cartridge Insulin Glulisine. Available from: http://www.medicines.org.uk/emc/PIL.18422.latest.pdf. [Last cited on 2014 Dec 24].  Back to cited text no. 12
    
13.
Patient Information Humulin® R Regular Insulin Human Injection, USP (rDNA Origin) 100 Units per ml (U-100). Available from: http://www.pi.lilly.com/us/humulin-r-ppi.pdf. [Last cited on 2014 Dec 24].  Back to cited text no. 13
    
14.
Package Leaflet: information for the User Humulin® I (Isophane) KwikPen™ 100 IU/ml Suspension for Injection (Insulin, Human). Available from: http://www.medicines.org.uk/emc/PIL.23661.latest.pdfttps:/. [Last cited on 2015 Jan 27].  Back to cited text no. 14
    
15.
Lantus® 100 Units/ml Solution for Injection in a Cartridge Insulin Glargine. Available from: http://www.medicines.org.uk/emc/PIL.18419.latest.pdf. [Last cited on 2014 Dec 24].  Back to cited text no. 15
    
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Levemir. Available from: http://www.rxlist.com/levemir-drug/consumer-uses.htm. [Last cited on 2014 Dec 24].  Back to cited text no. 16
    
17.
Package Leaflet: Information for the Patient Tresiba® Solution for Injection in Cartridge Insulin Degludec. Available from: http://www.medicines.org.uk/emc/PIL.27361.latest.pdf. [Last cited on 2014 Dec 24].  Back to cited text no. 17
    
18.
Package Leaflet: information for the User Humalog® Mix25™ 100 U/ml KwikPen™, Suspension for Injection Insulin Lispro. Available from: http://www.medicines.org.uk/emc/PIL.20947.latest.pdf. [Last cited on 2014 Dec 24].  Back to cited text no. 18
    
19.
Package Leaflet: information for the User Humalog® Mix50™ 100 U/ml KwikPen™, Suspension for Injection Insulin Lispro. Available from: http://www.medicines.org.uk/emc/PIL.20946.latest.pdf">http://www.medicines.org.uk/emc/PIL.20946.latest.pdf. [Last cited on 2014 Dec 24].  Back to cited text no. 19
    
20.
Package Leaflet: Information for the User NovoMix® 30 Penfill® 100 Units/ml Suspension for Injection in a Cartridge. Available from: http://www.medicines.ie/medicine/11538/PIL/NovoMix+30+Penfill. [Last cited on 2014 Dec 24].  Back to cited text no. 20
    
21.
Actrapid® Penfill® Protaphane Penfill® Mixtard 30/70 Penfill® Mixtard 50/50 Penfill® Human Insulin (rys) Consumer Medicine Information. Available from: http://www.mydr.com.au/medicines/cmis/mixtard-30-70-penfill-3-ml-injection. [Last cited on 2014 Dec 24].  Back to cited text no. 21
    
22.
Ryzodeg Insulin Degludec/Insulin Aspart. Available from: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Summary_for_the_public/human/002499/WC500139014.pdf. [Last cited on 2014 Dec 24].  Back to cited text no. 22
    



 
 
    Tables

  [Table 1], [Table 2]



 

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