Insulin lispro protamine, human
Humalog Mix75/25™ [75% insulin lispro protamine suspension and 25% insulin lispro injection, (rDNA origin)] is a mixture of insulin lispro solution, a rapid-acting blood glucose-lowering agent and insulin lispro protamine suspension, an intermediate-acting blood glucose-lowering agent. Chemically, insulin lispro is Lys(B28), Pro(B29) human insulin analog, created when the amino acids at positions 28 and 29 on the insulin B-chain are reversed. Insulin lispro is synthesized in a special non-pathogenic laboratory strain of Escherichia coli bacteria that has been genetically altered by the addition of the gene for insulin lispro. Insulin lispro protamine suspension (NPL component) is a suspension of crystals produced from combining insulin lispro and protamine sulfate under appropriate conditions for crystal formation.
Insulin lispro has the following primary structure:
Insulin lispro has the empirical formula C 257 H 383 N 65 O 77 S 6 and a molecular weight of 5808, both identical to that of human insulin.
Humalog Mix75/25 disposable insulin delivery devices contain a sterile suspension of insulin lispro protamine suspension mixed with soluble insulin lispro for use as an injection.
Each milliliter of Humalog Mix75/25 injection contains insulin lispro 100 Units, 0.28 mg protamine sulfate, 16 mg glycerin, 3.78 mg dibasic sodium phosphate, 1.76 mg m -cresol, zinc oxide content adjusted to provide 0.025 mg zinc ion, 0.715 mg phenol, and water for injection. Humalog Mix75/25 has a pH of 7.0-7.8. Hydrochloric acid 10% and/or sodium hydroxide 10% may have been added to adjust pH.
Antidiabetic Activity --The primary activity of insulin, including Humalog Mix75/25, is the regulation of glucose metabolism. In addition, all insulins have several anabolic and anti-catabolic actions on many tissues in the body. In muscle and other tissues (except the brain), insulin causes rapid transport of glucose and amino acids intracellularly, promotes anabolism, and inhibits protein catabolism. In the liver, insulin promotes the uptake and storage of glucose in the form of glycogen, inhibits gluconeogenesis, and promotes the conversion of excess glucose into fat.
Insulin lispro, the rapid-acting component of Humalog Mix75/25, has been shown to be equipotent to regular human insulin on a molar basis. One unit of Humalog has the same glucose-lowering effect as one unit of regular human insulin, but its effect is more rapid and of shorter duration. Humalog Mix75/25 has a similar glucose-lowering effect as compared to Humulin 70/30 on a unit for unit basis.
Absorption --Studies in nondiabetic subjects and patients with type 1 (insulin-dependent) diabetes demonstrated that Humalog, the rapid-acting component of Humalog Mix75/25, is absorbed faster than regular human insulin (U-100). In nondiabetic subjects given subcutaneous doses of Humalog ranging from 0.1-0.4 U/kg, peak serum concentrations were observed 30-90 minutes after dosing. When nondiabetic subjects received equivalent doses of regular human insulin, peak insulin concentrations occurred 50-120 minutes after dosing. Similar results were found in patients with type 1 diabetes.
Humalog Mix75/25 has two phases of absorption. The early phase represents insulin lispro and its distinct characteristics of rapid onset. The late phase represents the prolonged action of insulin lispro protamine suspension. In 30 nondiabetic subjects given subcutaneous doses (0.3 U/kg) of Humalog Mix75/25, peak serum concentrations were observed 30 to 240 minutes (median, 60 minutes) after dosing ( Figure 2 ). Identical results were found in patients with type 1 diabetes. The rapid absorption characteristics of Humalog are maintained with Humalog Mix75/25 ( Figure 2 ).
Figure 2 represents serum insulin concentration versus time curves of Humalog Mix75/25 and Humulin 70/30. Humalog Mix75/25 has a more rapid absorption than Humulin 70/30, which has been confirmed in patients with type 1 diabetes.
Distribution --radiolabeled distribution studies of Humalog Mix75/25 have not been conducted. However, the volumeof distribution following injection of Humalog is identical to that of regular human insulin, with a range of 0.26-0.36 L/kg.
Metabolism --Human metabolism studies of Humalog Mix75/25 have not been conducted. Studies in animals indicate that the metabolism of Humalog, the rapid-acting component of Humalog Mix75/25, is identical to that of regular human insulin.
Elimination --Humalog Mix75/25 has two absorption phases, a rapid and a prolonged phase, representative of the insulin lispro and insulin lispro protamine suspension components of the mixture. As with other intermediate-acting insulins, a meaningful terminal phase half-life cannot be calculated after administration of Humalog Mix75/25 because of the prolonged insulin lispro protamine suspension absorption.
Pharmacodynamics --Studies in nondiabetic subjects and patients with diabetes demonstrated that Humalog has a more rapid onset of glucose-lowering activity, an earlier peak for glucose lowering, and a shorter duration of glucose-lowering activity than regular human insulin. The early onset of activity of Humalog Mix75/25 is directly related to the rapid absorption of Humalog. The time course of action of insulin and insulin analogs such as Humalog (and hence Humalog Mix75/25) may vary considerably in different individuals or within the same individual. The parameters of Humalog Mix75/25 activity (time of onset, peak time, and duration) as presented in Figures 2 , 3 , and 4 should be considered only as general guidelines. The rate of insulin absorption and consequently the onset of activity is known to be affected by the site of injection, exercise, and other variables ( see General under PRECAUTIONS ).
In a glucose clamp study performed in 30 nondiabetic subjects, the onset of action and glucose-lowering activity of Humalog, Humalog Mix75/25, Humalog Mix50/50™ and insulin lispro protamine suspension were compared ( Figure 3 ). Graphs of mean glucose infusion rate versus time showed a distinct insulin activity profile for each formulation. The rapid onset of glucose-lowering activity characteristic of Humalog was maintained in Humalog Mix75/25.
In separate glucose clamp studies performed in nondiabetic subjects, glucodynamics of Humalog Mix75/25 and Humulin 70/30 were assessed and are presented in Figure 4 . Humalog Mix75/25 has a duration of activity similar to that of Humulin 70/30.
Figure 3 shows the time activity profiles of Humalog, Humalog Mix75/25, Humalog Mix50/50, and insulin lispro protamine suspension (NPL component).
Age and Gender --Information on the effect of age on the pharmacokinetics of Humalog Mix75/25 is unavailable. Pharmacokinetic and pharmacodynamic comparisons between men and women administered Humalog Mix75/25 showed no gender differences. In large Humalog clinical trials, subgroup analyses based upon age and gender demonstrated that differences between Humalog and regular human insulin in postprandial glucose parameters are maintained across sub-groups.
Smoking --The effect of smoking on the pharmacokinetics and glucodynamics of Humalog Mix75/25 has not been studied.
Pregnancy --The effect of pregnancy on the pharmacokineticsand glucodynamics of Humalog Mix75/25 has not been studied.
Obesity --The effect of obesity and/or subcutaneous fat thickness on the pharmacokinetics and glucodynamics of Humalog Mix75/25 has not been studied. In large clinical trials, which included patients with Body-Mass-Index up to and including 35 kg/m 2 , no consistent differences were observed between Humalog and Humulin R with respect to postprandial glucose parameters.
Renal Impairment --The effect of renal impairment on the pharmacokinetics and glucodynamics of Humalog Mix75/25 has not been studied. In a study of 25 patients with type 2 diabetes and a wide range of renal function, the pharmacokinetic differences between Humalog and human regular insulin were generally maintained. However, the sensitivity of the patients to insulin did change, with an increased response to insulin as the renal function declined. Careful glucose monitoring and dose reductions of insulin, including Humalog Mix75/25, may be necessary in patients with renal dysfunction.
Hepatic Impairment --Some studies with human insulin have shown increased circulating levels of insulin in patients with hepatic failure. The effect of hepatic impairment on the pharmacokinetics and glucodynamics of Humalog Mix75/25 has not been studied. However, in a study of 22 patients with type 2 diabetes, impaired hepatic function did not affect the subcutaneous absorption or general disposition of Humalog when compared to patients with no history of hepatic dysfunction. In that study, Humalog maintained its more rapid absorption and elimination when compared to regular human insulin. Careful glucose monitoring and dose adjustments of insulin, including Humalog Mix75/25, may be necessary in patients with hepatic dysfunction.
Indications and Usage
Humalog Mix75/25, a mixture of 75% insulin lispro protamine suspension and 25% insulin lispro, is indicated in the treatment of patients with diabetes mellitus for the control of hyperglycemia. Humalog Mix75/25 has a more rapid onset of glucose-lowering activity compared to Humulin 70/30 while having a similar duration of action. This profile is achieved by combining the rapid onset of Humalog with the intermediate action of insulin lispro protamine suspension.
Humalog Mix75/25 is contraindicated during episodes of hypoglycemia and in patients sensitive to insulin lispro or any of the excipients contained in the formulation.
Humalog differs from regular human insulin by its rapid onset of action as well as a shorter duration of activity. Therefore, the dose of Humalog Mix75/25 should be given within 15 minutes before a meal.
Hypoglycemia is the most common adverse effect associated with the use of insulins, including Humalog Mix75/25. As with all insulins, the timing of hypoglycemia may differ among various insulin formulations. Glucose monitoring is recommended for all patients with diabetes.
Any change of insulin should be made cautiously and only under medical supervision. Changes in insulin strength, manufacturer, type (e.g., regular, NPH, analog), species (animal, human), or method of manufacture (rDNA versus animal-source insulin) may result in the need for a change in dosage.
General --Hypoglycemia and hypokalemia are among the potential clinical adverse effects associated with the use of all insulins. Because of differences in the action of Humalog Mix75/25 and other insulins, care should be taken in patients in whom such potential side effects might be clinically relevant (e.g., patients who are fasting, have autonomic neuropathy, or are using potassium-lowering drugs or patients taking drugs sensitive to serum potassium level). Lipodystrophy and hypersensitivity are among other potential clinical adverse effects associated with the use of all insulins.
As with all insulin preparations, the time course of action of Humalog Mix75/25 may vary in different individuals or at different times in the same individual and is dependent on site of injection, blood supply, temperature, and physical activity.
Adjustment of dosage of any insulin may be necessary if patients change their physical activity or their usual meal plan. Insulin requirements may be altered during illness, emotional disturbances, or other stress.
Hypoglycemia --As with all insulin preparations, hypoglycemic reactions may be associated with the administration of Humalog Mix75/25. Rapid changes in serum glucose concentrations may induce symptoms of hypoglycemia in persons with diabetes, regardless of the glucose value. Early warning symptoms of hypoglycemia may be different or less pronounced under certain conditions, such as long duration of diabetes, diabetic nerve disease, use of medications such as beta-blockers, or intensified diabetes control.
Renal Impairment --As with other insulins, the requirements for Humalog Mix75/25 may be reduced in patients with renal impairment.
Hepatic Impairment --Although impaired hepatic function does not affect the absorption or disposition of Humalog, careful glucose monitoring and dose adjustments of insulin, including Humalog Mix75/25, may be necessary.
Allergy-- Local Allergy --As with any insulin therapy, patients may experience redness, swelling, or itching at the site of injection. These minor reactions usually resolve in a few days to a few weeks. In some instances, these reactions may be related to factors other than insulin, such as irritants in the skin cleansing agent or poor injection technique.
Systemic Allergy --Less common, but potentially more serious, is generalized allergy to insulin, which may cause rash (including pruritus) over the whole body, shortness of breath, wheezing, reduction in blood pressure, rapid pulse, or sweating. Severe cases of generalized allergy, including anaphylactic reaction, may be life threatening. Localized reactions and generalized myalgias have been reported with the use of cresol as an injectable excipient.
Antibody Production --In clinical trials, antibodies that cross react with human insulin and insulin lispro were observed in both human insulin mixtures and insulin lispro mixtures treatment groups.
Information for Patients --Patients should be informed of the potential risks and advantages of Humalog Mix75/25 and alternative therapies. Patients should not mix Humalog Mix75/25 with any other insulin. They should also be informed about the importance of proper insulin storage, injection technique, timing of dosage, adherence to meal planning, regular physical activity, regular blood glucose monitoring, periodic glycosylated hemoglobin testing, recognition and management of hypo- and hyperglycemia, and periodic assessment for diabetes complications.
Patients should be advised to inform their physician if they are pregnant or intend to become pregnant.
Refer patients to the Information for the Patient insert for information on normal appearance, proper resuspension and injection techniques, timing of dosing (within 15 minutes before a meal), storing, and common adverse effects.
Use of the Humalog Pen: Patients should read the "Information for the Patient" insert and the "Disposable Insulin Delivery Device User Manual" before starting therapy with a Humalog Pen and re-read them each time the prescription is renewed. Patients should be instructed on how to properly use the delivery device (refer to "Disposable Insulin Delivery Device User Manual"), prime the pen, and properly dispose of needles. Patients should be advised not to share their pens with others.
Laboratory Tests --As with all insulins, the therapeutic response to Humalog Mix75/25 should be monitored by periodic blood glucose tests. Periodic measurement of glycosylated hemoglobin is recommended for the monitoring of long-term glycemic control.
Drug Interactions --Insulin requirements may be increased by medications with hyperglycemic activity such as corticosteroids, isoniazid, certain lipid-lowering drugs (e.g., niacin), estrogens, oral contraceptives, phenothiazines, and thyroid replacement therapy.
Insulin requirements may be decreased in the presence of drugs with hypoglycemic activity, such as oral antidiabetic agents, salicylates, sulfa antibiotics, certain antidepressants (monoamine oxidase inhibitors), certain angiotensin-converting-enzyme inhibitors, beta-adrenergic blockers, inhibitors of pancreatic function (e.g., octreotide), and alcohol. Beta-adrenergic blockers may mask the symptoms of hypoglycemia in some patients.
Carcinogenesis, Mutagenesis, Impairment of Fertility --Long-term studies in animals have not been performed to evaluate the carcinogenic potential of Humalog or Humalog Mix75/25. Insulin lispro was not mutagenic in a battery of in vitro and in vivo genetic toxicity assays (bacterial mutation tests, unscheduled DNA synthesis, mouse lymphoma assay, chromosomal aberration tests, and a micronucleus test). There is no evidence from animal studies of impairment of fertility induced by insulin lispro.
Pregnancy--Teratogenic Effects--Pregnancy Category B --Reproduction studies with insulin lispro have been performed in pregnant rats and rabbits at parenteral doses up to 4 and 0.3 times, respectively, the average human dose (40 units/day) based on body surface area. The results have revealed no evidence of impaired fertility or harm to the fetus due to insulin lispro. There are, however, no adequate and well-controlled studies with Humalog or Humalog Mix75/25 in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.
Nursing Mothers --It is unknown whether insulin lispro is excreted in significant amounts in human milk. Many drugs, including human insulin, are excreted in human milk. For this reason, caution should be exercised when Humalog Mix75/25 is administered to a nursing woman. Patients with diabetes who are lactating may require adjustments in Humalog Mix75/25 dose, meal plan, or both.
Pediatric Use --Safety and effectiveness of Humalog Mix75/25 in patients less than 18 years of age have not been established.
Geriatric Use --Clinical studies of Humalog Mix75/25 did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently than younger patients. In general, dose selection for an elderly patient should take into consideration the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy in this population.
Clinical studies comparing Humalog Mix75/25 with human insulin mixtures did not demonstrate a difference in frequency of adverse events between the two treatments.
Adverse events commonly associated with human insulin therapy include the following:
Body as a Whole --allergic reactions ( see PRECAUTIONS )
Skin and Appendages --injection site reaction, lipodystrophy, pruritus, rash
Hypoglycemia may occur as a result of an excess of insulin relative to food intake, energy expenditure, or both. Mild episodes of hypoglycemia usually can be treated with oral glucose. Adjustments in drug dosage, meal patterns, or exercise, may be needed. More severe episodes with coma, seizure, or neurologic impairment may be treated with intramuscular/subcutaneous glucagon or concentrated intravenous glucose. Sustained carbohydrate intake and observation may be necessary because hypoglycemia may recur after apparent clinical recovery.
Dosage and Administration
Humalog Mix75/25 is intended only for subcutaneous administration. Humalog Mix75/25 should not be administered intravenously. Dosage regimens of Humalog Mix75/25 will vary among patients and should be determined by the health care professional familiar with the patient's metabolic needs, eating habits, and other lifestyle variables. Humalog has been shown to be equipotent to regular human insulin on a molar basis. One unit of Humalog has the same glucose-lowering effect as one unit of regular human insulin, but its effect is more rapid and of shorter duration. Humalog Mix75/25 has a similar glucose-lowering effect as compared to Humulin 70/30 on a unit for unit basis. The quicker glucose-lowering effect of Humalog is related to the more rapid absorption rate of insulin lispro from subcutaneous tissue.
Humalog Mix75/25 starts lowering blood glucose more quickly than regular human insulin, allowing for convenient dosing immediately before a meal (within 15 minutes). In contrast, mixtures containing regular human insulin should be given 30-60 minutes before a meal.
The rate of insulin absorption and consequently the onset of activity are known to be affected by the site of injection, exercise, and other variables. As with all insulin preparations, the time course of action of Humalog Mix75/25 may vary considerably in different individuals or within the same individual. Patients must be educated to use proper injection techniques.
Humalog Mix75/25 should be inspected visually before use. Humalog Mix75/25 should be used only if it appears uniformly cloudy after mixing. Humalog Mix75/25 should not be used after its expiration date.
Humalog Mix75/25 vials are available in the following package size:
100 units per mL (U-100)
10 mL vials
NDC 0002-7511-01 (VL-7511)
Humalog Mix75/25 Pen, a disposable insulin delivery device, is available in the following package size:
5 × 3 mL disposable insulin delivery devices
NDC 0002-8794-59 (HP-8794)
Storage --Humalog Mix75/25 should be stored in a refrigerator (2° to 8°C [36° to 46°F]) before use, but not in the freezer. However, vials of Humalog Mix75/25 in use can be kept unrefrigerated at room temperature for up to 28 days, as long as they are kept as cool as possible and away from direct heat and light. Humalog Mix 75/25 Pens in use can be kept unrefrigerated at room temperature for up to 10 days, as long as they are kept as cool as possible and away from direct heat and light. Unrefrigerated vials and Pens must be used within the specified time period or be discarded. Do not use Humalog Mix 75/25 if it has been frozen.
Literature revised May 31, 2002
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