MON-152 Less Is More: Human Regular U-500 Insulin

Abstract

Introduction: Human Regular U-500 Insulin is used to control high blood glucose in diabetic patients who need more than 200 units of insulin daily. High-dose insulin therapy may be limited because the volumes of insulin necessary to achieve these very high doses are difficult to administer subcutaneous and there is a decrease in the absorption rate. We report a case of a woman with DM2 and severe insulin resistance who achieved glycemic control using off-label U-500 via continuous subcutaneous insulin infusion (CSII) but with fixed bolus given manually by patient and remained controlled over the next six years. Clinical Case: A 66-year-old woman with DM2, HTN, metabolic syndrome and adiposity based chronic disease referred to endocrinologist office for glycemic control. Patient treated for diabetes with metformin and premixed insulin and HTN treated with CCB/ACE inhibitor and beta blocker/thiazide combinations. Clinical examination reveals an obese female (BMI: 37.9kg/m2) with acanthosis nigricans. Initial laboratory test showed HbA1c of 13.9%, FBS 293mg/dL, cholesterol 195mg/dL, TGs 147mg/dL and LDL 103mg/dL. Patient was treated with multiple insulin regimens, including U-500 insulin by subcutaneous route of administration and oral antihyperglycemic agents including followed up by nutritionist, where the lowest HbA1c was 9.1%. Patient total daily dose of insulin was 220 units. Although U-500 insulin is not FDA-approved for use in CSII and the ideal candidate should be intellectually able to deal with insulin pump therapy, this treatment was effective for our patient who required high insulin doses and failing other treatment regimen, achieving glycemic control and weight loss in six weeks. The only way this patient used this mode of insulin administration was on a single basal rate and fixed insulin bolus doses before each meal and with bedtime snack. All of these parameters were adjusted by 5 for the use of concentrated insulin in the pump device. HbA1c decreased from 10.5% to 8.5% with only six weeks of treatment and at one year decreased to even more 7.0%. Currently patient had been using CSII with U-500 for six years and patient HbA1c range is between 7.5-7.9% evaluated approximately every 3 months. Conclusion: The increase in the prevalence of obesity and diabetes has been an issue in treating patients who require high doses of insulin. The use of U-500 for CSII allows for better absorption of high insulin doses and improvement of glycemic control thus improving quality of life, weight loss, decreasing multiple daily injections and preventing diabetes complications. To our knowledge this is the first case report demonstrating long-term glycemic control with U-500 via CSII and on a fixed dose regimen on CSII without using carb counting or corrections to make this regimen easier for certain patients without the knowledge for complicated regimens.