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Insulin Degludec

Medically reviewed by Drugs.com. Last updated on Mar 3, 2019.

Pronunciation

See also: Basaglar

(IN su lin de GLOO dek)

Index Terms

  • Degludec Insulin

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Subcutaneous:

Tresiba: 100 units/mL (10 mL) [contains metacresol, phenol]

Solution Pen-injector, Subcutaneous:

Tresiba FlexTouch: 100 units/mL (3 mL); 200 units/mL (3 mL) [contains metacresol, phenol]

Brand Names: U.S.

  • Tresiba
  • Tresiba FlexTouch

Pharmacologic Category

  • Insulin, Long-Acting

Pharmacology

Insulin acts via specific membrane-bound receptors on target tissues to regulate metabolism of carbohydrate, protein, and fats. Target organs for insulin include the liver, skeletal muscle, and adipose tissue.

Within the liver, insulin stimulates hepatic glycogen synthesis. Insulin promotes hepatic synthesis of fatty acids, which are released into the circulation as lipoproteins. Skeletal muscle effects of insulin include increased protein synthesis and increased glycogen synthesis. Within adipose tissue, insulin stimulates the processing of circulating lipoproteins to provide free fatty acids, facilitating triglyceride synthesis and storage by adipocytes; also directly inhibits the hydrolysis of triglycerides. In addition, insulin stimulates the cellular uptake of amino acids and increases cellular permeability to several ions, including potassium, magnesium, and phosphate. By activating sodium-potassium ATPases, insulin promotes the intracellular movement of potassium.

Normally secreted by the pancreas, insulin products are manufactured for pharmacologic use through recombinant DNA technology using either E. coli or Saccharomyces cerevisiae. Insulin degludec differs from human insulin by the omission of the amino acid threonine in position B-30 of the B-chain, and the subsequent addition of a side chain composed of glutamic acid and a C16 fatty acid. Insulins are categorized based on the onset, peak, and duration of effect (eg, rapid-, short-, intermediate-, and long-acting insulin). Insulin degludec is a long-acting, human insulin analog.

Onset of Action

~1 hour

Time to Peak

9 hours

Half-Life Elimination

~25 hours (independent of dose)

Protein Binding

>99% (albumin)

Use: Labeled Indications

Diabetes mellitus: To improve glycemic control in patients 1 year of age and older with type 1 or type 2 diabetes mellitus

Contraindications

Hypersensitivity to insulin degludec or any component of the formulation; during episodes of hypoglycemia

Documentation of allergenic cross-reactivity for insulin is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Dosing: Adult

Note: Insulin degludec is a long-acting insulin. Insulin requirements vary dramatically between patients and dictates frequent monitoring and close medical supervision.

Diabetes mellitus, type 1: SubQ:

Note: Insulin degludec must be used concomitantly with rapid- or short-acting insulins (ie, multiple daily injection regimen). The total daily doses (TDD) presented below are expressed as the total units/kg/day of all insulin formulations combined.

General insulin dosing:

Initial TDD: ~0.4 to 0.5 units/kg/day (AACE/ACE [Handelsman 2015]; ADA 2018); conservative initial doses of 0.2 to 0.4 units/kg/day may be considered to avoid the potential for hypoglycemia; higher initial doses may be required in patients who are obese, sedentary, or presenting with ketoacidosis (AACE/ACE [Handelsman 2015]; ADA 2018).

Usual TDD maintenance range: 0.4 to 1 units/kg/day in divided doses (ADA 2018)

Division of TDD (multiple daily injections):

Basal insulin: Generally, 40% to 50% of the TDD is given as basal insulin (intermediate- or long-acting) (AACE/ACE [Handelsman 2015]; ADA 2018). Insulin degludec is administered once daily.

Prandial insulin: The remaining portion (ie, 50% to 60%) of the TDD is then divided and administered before or at mealtimes (depending on the formulation) as a rapid-acting (eg, aspart, glulisine, lispro; insulin for inhalation) or short-acting (regular) insulin (AACE/ACE [Handelsman 2015]; ADA 2018).

Dosage adjustment: Dosage must be titrated to achieve glucose control and avoid hypoglycemia. Adjust dose to maintain premeal and bedtime glucose in target range. Since combinations of agents are frequently used, dosage adjustment must address the individual component of the insulin regimen that most directly influences the blood glucose value in question, based on the known onset and duration of the insulin component. Treatment and monitoring regimens must be individualized. To minimize hypoglycemia risk, basal insulins are generally titrated once or twice weekly (eg, every 3 to 7 days) (ADA 2018; McCall 2012).

Diabetes mellitus, type 2: SubQ: Note: Basal insulin therapy is usually initiated if adequate glycemic control has not been achieved with step-wise trials of metformin ± other noninsulin agents. However, if HbA1c ≥10%, blood glucose is ≥300 mg/dL or if patient is symptomatic (eg, polyuria, polydipsia), insulin (with or without additional agents) should be considered as part of initial therapy (ADA 2018). Use of long-acting basal analogs may be preferred if minimization of hypoglycemia is a primary concern (ADA-EASD [Davies 2018]).

Initial: 10 units once daily or 0.1 to 0.2 units/kg once daily (ADA 2018; manufacturer labeling). If HbA1c >8% prior to initiation of basal insulin, 0.2 to 0.3 units/kg once daily is recommended (AACE/ACE [Garber 2018]).

Dosage adjustment:

To reach fasting blood glucose target: Adjust dose by 10% to 15% or 2 to 4 units; may adjust at weekly or twice weekly intervals

For hypoglycemia: If no clear reason for hypoglycemia, decrease dose by 4 units or by 10% to 20%

Dosage adjustment when adding prandial insulin (ADA/EASD [Davies 2018]):Consider reducing the basal insulin dose by 4 units (or ~10%) if HbA1c is <8% when initiating prandial insulin.

Patients with diabetes receiving enteral feedings (ADA 2018): Note: TDD of insulin is divided into a basal component (intermediate- or long-acting insulin) and nutritional and correctional components (regular insulin or rapid-acting insulins). Basal component: SubQ: Continue previous basal insulin dose or administer 30% to 50% of current TDD as insulin degludec; if basal insulin naive, administer insulin degludec 10 units once daily.

Patients with diabetes undergoing surgery (ADA 2018): SubQ: On the morning of surgery or procedure, give 60% to 80% of the usual dose of long-acting analogs (eg, degludec, detemir, or glargine).

Conversion from other long or intermediate-acting insulins to insulin degludec: Initiate insulin degludec with the same unit dose as the total daily long or intermediate-acting insulin unit dose from which the patient is being converted.

Missed dose: Administer as soon as possible; ensure at least 8 hours between consecutive doses.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

The general objective of insulin replacement therapy is to approximate the physiologic pattern of insulin secretion. This requires a basal level of insulin throughout the day, supplemented by additional insulin at mealtimes. Since combinations using different types of insulins are frequently used, dosage adjustment must address the individual component of the insulin regimen which most directly influences the blood glucose value in question, based on the known onset and duration of the insulin component. The frequency of doses and monitoring must be individualized in consideration of the patient's ability to manage therapy.

Insulin degludec is a long-acting insulin administered by SubQ injection. When compared to insulin regular, insulin degludec has a slower onset and a longer duration of activity. Changing the basal insulin component from another insulin to insulin degludec requires a dose reduction to minimize the risk of hypoglycemia. Insulin requirements vary dramatically between patients and dictates frequent monitoring and close medical supervision.

Note: U-200 FlexTouch pens do not allow odd numbered dosing of insulin units; patients requiring odd numbered doses should use the U-100 FlexTouch pen.

Type 1 diabetes mellitus: Children and Adolescents: Note: Multiple daily doses are utilized and guided by blood glucose monitoring. Combinations of insulin formulations are commonly used. The daily doses presented below are expressed as the total units/kg/day of all insulin formulations used. Insulin degludec must be used in combination with a short-acting insulin.

General insulin dosing:

Usual maintenance range: SubQ: 0.5 to 1 unit/kg/day in divided doses; doses must be individualized; however, an estimate can be determined based on phase of diabetes and level of maturity (ISPAD [Couper 2014]; ISPAD [Danne 2014])

Partial remission phase (Honeymoon phase): <0.5 units/kg/day

Prepubertal children (not in partial remission): 0.7 to 1 units/kg/day

Pubescent Children and Adolescents: During puberty, requirements may substantially increase to >1.2 unit/kg/day and in some cases up to 2 units/kg/day

Division of daily insulin requirement ("conventional therapy"): Generally, 50% to 75% of the daily insulin dose is given as an intermediate- or long-acting form of insulin (in 1 to 2 daily injections). The remaining portion of the 24-hour insulin requirement is divided and administered as either regular insulin or a rapid-acting form of insulin at the same time before breakfast and dinner.

Division of daily insulin requirement ("intensive therapy"): Basal insulin delivery with 1 or 2 doses of intermediate- or long-acting insulin formulations superimposed with doses of rapid- or very rapid-acting insulin formulations 3 or more times daily

Adjustment of dose: Dosage must be titrated to achieve glucose control and avoid hypoglycemia. Adjust dose to maintain premeal and bedtime glucose in target range. Since combinations of agents are frequently used, dosage adjustment must address the individual component of the insulin regimen which most directly influences the blood glucose value in question, based on the known onset and duration of the insulin component.

Insulin degludec-specific dosing: Children and Adolescents: SubQ: Note: Not recommended for patients requiring less than 5 units of insulin degludec.

Insulin-naive patients: Approximately one-third to one-half of the total daily insulin requirement administered as insulin degludec once daily; remainder of total daily dose should be given as a short- or rapid-acting insulin and divided between each daily meal (general rule for initial total daily insulin dose: 0.2 to 0.4 units/kg/day).

Insulin-experienced patients: Initiate insulin degludec at 80% of the total daily long- or intermediate-acting insulin unit dose from which the patient is being converted.

Dosage adjustment: Individualize and titrate dose every 3 to 4 days based on patient’s metabolic needs, blood glucose monitoring results, and glycemic control goal.

Type 2 diabetes mellitus: Children ≥10 years and Adolescents: Note: Not recommended for patients requiring less than 5 units of insulin degludec.

General insulin dosing: SubQ: The goal of therapy is to achieve an HbA1c <6.5% as quickly as possible using the safe titration of medications. Initial therapy in metabolically unstable patients (eg, plasma glucose ≥250 mg/dL, HbA1c >9% and symptoms excluding acidosis) may include once daily intermediate acting insulin or basal insulin in combination with lifestyle changes and metformin. In patients who fail to achieve glycemic goals with metformin and basal insulin, may consider initiating prandial insulin (regular insulin or rapid acting insulin) and titrate to achieve goals. Once initial goal reached, insulin should be slowly tapered and the patient transitioned to lowest effective doses or metformin monotherapy if able (AAP [Copeland 2013]; ISPAD [Zeitler 2014]). Note: Patients who are ketotic or present with ketoacidosis require aggressive management as indicated.

Insulin degludec-specific dosing: Note: Not recommended for patients requiring less than 5 units of insulin degludec.

Insulin-naive patients: Initial: 10 units once daily

Insulin-experienced patients: Initiate insulin degludec at 80% of the total daily long- or intermediate-acting insulin unit dose from which the patient is being converted

Dosage adjustment: Individualize and titrate dose every 3 to 4 days based on patient’s metabolic needs, blood glucose monitoring results, and glycemic control goal

Administration

Subcutaneous: For subcutaneous administration into the thigh, upper arm, or abdomen; do not administer IM or IV, or in an insulin infusion pump. Absorption rates vary amongst injection sites; be consistent with area used while rotating injection sites within the same region to reduce the risk of lipodystrophy. Insulin degludec should be administered once daily at any time of the day. Multidose vials should be used in patients requiring <5 units per day.

FlexTouch pens: Do not perform dose conversion when using the FlexTouch pen. The dose window for both U-100 and U-200 FlexTouch pens show the number of insulin units to be delivered and no conversion is needed. U-200 FlexTouch pens do not allow odd numbered dosing of insulin units; patients requiring odd numbered doses should use the U-100 FlexTouch pen. Do not dilute or mix insulin degludec with any other insulin formulation or solution; do not transfer from the FlexTouch pen into a syringe for administration.

Vials: Administer using U-100 insulin syringes.

Dietary Considerations

Individualized medical nutrition therapy (MNT) based on ADA recommendations is an integral part of therapy.

Storage

Store not in use (unopened) pens or vials at 2°C to 8°C (36°F to 46°F) until expiration date, or at room temperature below 30°C (86°F) for up to 56 days (8 weeks). Do not freeze or use if solution has been frozen. Do not store pens or vials directly adjacent to the refrigerator cooling element. Store vials in original carton to protect from light.

Store in use (opened) pens or vials at 2°C to 8°C (36°F to 46°F) or at room temperature (below 30°C [86°F]) for up to 56 days (8 weeks); protect from direct heat and light.

Drug Interactions

Alpha-Lipoic Acid: May enhance the hypoglycemic effect of Antidiabetic Agents. Monitor therapy

Androgens: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Exceptions: Danazol. Monitor therapy

Antidiabetic Agents: May enhance the hypoglycemic effect of Hypoglycemia-Associated Agents. Monitor therapy

Beta-Blockers: May enhance the hypoglycemic effect of Insulins. Exceptions: Levobunolol; Metipranolol. Monitor therapy

Dipeptidyl Peptidase-IV Inhibitors: May enhance the hypoglycemic effect of Insulins. Management: Consider a decrease in insulin dose when initiating therapy with a dipeptidyl peptidase-IV inhibitor and monitor patients for hypoglycemia. Consider therapy modification

Direct Acting Antiviral Agents (HCV): May enhance the hypoglycemic effect of Antidiabetic Agents. Monitor therapy

Edetate CALCIUM Disodium: May enhance the hypoglycemic effect of Insulins. Monitor therapy

Glucagon-Like Peptide-1 Agonists: May enhance the hypoglycemic effect of Insulins. Management: Consider insulin dose reductions when used in combination with glucagon-like peptide-1 agonists. Avoid the use of lixisenatide in patients receiving both basal insulin and a sulfonylurea. Exceptions: Liraglutide. Consider therapy modification

Guanethidine: May enhance the hypoglycemic effect of Antidiabetic Agents. Monitor therapy

Herbs (Hypoglycemic Properties): May enhance the hypoglycemic effect of Hypoglycemia-Associated Agents. Monitor therapy

Hyperglycemia-Associated Agents: May diminish the therapeutic effect of Antidiabetic Agents. Monitor therapy

Hypoglycemia-Associated Agents: May enhance the hypoglycemic effect of other Hypoglycemia-Associated Agents. Monitor therapy

Hypoglycemia-Associated Agents: Antidiabetic Agents may enhance the hypoglycemic effect of Hypoglycemia-Associated Agents. Monitor therapy

Liraglutide: May enhance the hypoglycemic effect of Insulins. Management: If liraglutide is used for the treatment of diabetes (Victoza), consider insulin dose reductions. The combination of liraglutide and insulin should be avoided if liraglutide is used exclusively for weight loss (Saxenda). Consider therapy modification

Macimorelin: Insulins may diminish the diagnostic effect of Macimorelin. Avoid combination

Maitake: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy

Metreleptin: May enhance the hypoglycemic effect of Insulins. Management: Insulin dosage adjustments (including potentially large decreases) may be required to minimize the risk for hypoglycemia with concurrent use of metreleptin. Monitor closely. Consider therapy modification

Monoamine Oxidase Inhibitors: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy

Pegvisomant: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy

Pioglitazone: May enhance the adverse/toxic effect of Insulins. Specifically, the risk for hypoglycemia, fluid retention, and heart failure may be increased with this combination. Management: If insulin is combined with pioglitazone, dose reductions should be considered to reduce the risk of hypoglycemia. Monitor patients for fluid retention and signs/symptoms of heart failure. Consider therapy modification

Pramlintide: May enhance the hypoglycemic effect of Insulins. Management: Upon initiation of pramlintide, decrease mealtime insulin dose by 50% to reduce the risk of hypoglycemia. Monitor blood glucose frequently and individualize further insulin dose adjustments based on glycemic control. Consider therapy modification

Prothionamide: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy

Quinolones: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Quinolones may diminish the therapeutic effect of Blood Glucose Lowering Agents. Specifically, if an agent is being used to treat diabetes, loss of blood sugar control may occur with quinolone use. Monitor therapy

Ritodrine: May diminish the therapeutic effect of Antidiabetic Agents. Monitor therapy

Rosiglitazone: Insulins may enhance the adverse/toxic effect of Rosiglitazone. Specifically, the risk of fluid retention, heart failure, and hypoglycemia may be increased with this combination. Avoid combination

Salicylates: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy

Selective Serotonin Reuptake Inhibitors: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy

Sodium-Glucose Cotransporter 2 (SLGT2) Inhibitors: May enhance the hypoglycemic effect of Insulins. Management: Consider a decrease in insulin dose when initiating therapy with a sodium-glucose cotransporter 2 inhibitor and monitor patients for hypoglycemia. Consider therapy modification

Thiazide and Thiazide-Like Diuretics: May diminish the therapeutic effect of Antidiabetic Agents. Monitor therapy

Adverse Reactions

10%:

Central nervous system: Headache (9% to 12%)

Endocrine & metabolic: Severe hypoglycemia (type 1 diabetics on combination insulin therapy: 10% to 18%; type 2 diabetics on combination therapy: ≤5%)

Immunologic: Antibody development

Respiratory: Nasopharyngitis (13% to 24%), upper respiratory tract infection (8% to 12%)

1% to 10%:

Cardiovascular: Peripheral edema (type 2 diabetes: 3%; type 1 diabetes: <1%)

Gastrointestinal: Diarrhea (type 2 diabetes: 6%), gastroenteritis (type 1 diabetes: 5%)

Local: Injection site reaction (4%; including discoloration, erythema, hematoma, hemorrhage, mass, nodules, pain, pruritus)

Respiratory: Sinusitis (type 1 diabetes: 5%)

Frequency not defined: Endocrine & metabolic: Hypokalemia, weight gain

<1%, postmarketing and/or case reports: Hypersensitivity reaction, hypertrophy at injection site (lipohypertrophy), lipoatrophy at injection site, urticaria

Warnings/Precautions

Concerns related to adverse effects:

• Glycemic control: Hyper- or hypoglycemia may result from changes in insulin strength, manufacturer, type, and/or administration method. The most common adverse effect of insulin is hypoglycemia. The timing of hypoglycemia differs among various insulin formulations. Hypoglycemia may result from changes in meal pattern (eg, macronutrient content, timing of meals), changes in the level of physical activity, increased work or exercise without eating, or changes to coadministered medications. Use of long-acting insulin preparations (eg, insulin degludec, insulin detemir, insulin glargine) may delay recovery from hypoglycemia. Patients with renal or hepatic impairment may be at a higher risk. Symptoms differ in patients and may change over time in the same patient; awareness may be less pronounced in those with long-standing diabetes, diabetic nerve disease, patients taking beta-blockers, or in those who experience recurrent hypoglycemia. Profound and prolonged episodes of hypoglycemia may result in convulsions, unconsciousness, temporary or permanent brain damage, or even death. Insulin requirements may be altered during illness, emotional disturbances, or other stressors. Instruct patients to use caution with ethanol; may increase risk of hypoglycemia. In clinical trials insulin NPH has been associated with a modestly increased risk of hypoglycemia (including nocturnal hypoglycemia) compared with long-acting analogs (Lipska 2017; Rosenstock 2005; Rys 2015; Singh 2009). However, an observational study in patients with type 2 diabetes from a large health care delivery system found no difference in the incidence of ER visits or hospitalization for hypoglycemia with NPH compared with glargine/detemir when treating to conventional targets in a real world setting (Lipska 2018).

• Hypersensitivity: Severe, life-threatening allergic reactions, including anaphylaxis, may occur. If hypersensitivity reactions occur, discontinue therapy.

• Hypokalemia: Insulin (especially IV insulin) causes a shift of potassium from the extracellular space to the intracellular space, possibly producing hypokalemia. If left untreated, hypokalemia may result in respiratory paralysis, ventricular arrhythmia and even death. Use with caution in patients at risk for hypokalemia (eg, loop diuretic use). Monitor serum potassium and supplement potassium when necessary.

Disease-related concerns:

• Diabetic ketoacidosis: Should not be used in patients with diabetic ketoacidosis (DKA); use of an IV rapid acting or short acting insulin is preferred.

• Hepatic impairment: Use with caution in patients with hepatic impairment. Dosage requirements may be reduced.

• Renal impairment: Use with caution in patients with renal impairment. Dosage requirements may be reduced.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Hospitalized patients with diabetes: Exclusive use of a sliding scale insulin regimen (insulin regular) in the inpatient hospital setting is strongly discouraged. In the critical care setting, continuous IV insulin infusion (insulin regular) has been shown to best achieve glycemic targets. In noncritically ill patients with either poor oral intake or taking nothing by mouth, basal insulin or basal plus bolus is preferred. In noncritically ill patients with adequate nutritional intake, a combination of basal insulin, nutritional, and correction components is preferred. An effective insulin regimen will achieve the goal glucose range without the risk of severe hypoglycemia. A blood glucose value <70 mg/dL should prompt a treatment regimen review and change, if necessary, to prevent further hypoglycemia (ADA 2018).

• Obesity: A decrease in glucose lowering effect of insulin degludec with increasing body mass index (BMI) has been observed.

Dosage form specific issues:

• Multiple dose injection pens: According to the Centers for Disease Control and Prevention (CDC), pen-shaped injection devices should never be used for more than one person (even when the needle is changed) because of the risk of infection. The injection device should be clearly labeled with individual patient information to ensure that the correct pen is used (CDC 2012).

Other warnings/precautions:

• Administration: Insulin degludec is a clear solution, but it is NOT intended for IV or IM administration or via an insulin pump.

• Patient education: Diabetes self-management education (DSME) is essential to maximize the effectiveness of therapy.

Monitoring Parameters

Plasma glucose, electrolytes, HbA1c (at least twice yearly in patients who have stable glycemic control and are meeting treatment goals; quarterly in patients not meeting treatment goals or with therapy change [ADA 2018]), lipid profile, renal function, hepatic function, weight

Pregnancy Considerations

Adverse events were observed in animal reproduction studies secondary to maternal hypoglycemia.

In women with diabetes, maternal hyperglycemia can be associated with congenital malformations as well as adverse effects in the fetus, neonate, and the mother (ACOG 2005; ADA 2018; Metzger 2007). To prevent adverse outcomes, prior to conception and throughout pregnancy maternal blood glucose and HbA1c should be kept as close to target goals as possible but without causing significant hypoglycemia (ADA 2018; Blumer 2013; Lambert 2013).

Insulin requirements tend to fall during the first trimester of pregnancy and increase in the later trimesters, peaking at 28 to 32 weeks' gestation. Following delivery, insulin requirements decrease rapidly (ACOG 2005).

Insulin therapy is the preferred treatment of type 1 and type 2 diabetes in pregnant women, as well as GDM when pharmacologic therapy is needed (ACOG 190 2018; ADA 2018). Information specific to insulin degludec use in pregnant women is limited (Milluzzo 2017).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience rhinitis, pharyngitis, headache, diarrhea, or injection site irritation. Have patient report immediately to prescriber signs of low blood sugar (dizziness, headache, fatigue, feeling weak, shaking, a fast heartbeat, confusion, hunger, or sweating), signs of low potassium (muscle pain or weakness, muscle cramps, or an abnormal heartbeat), vision changes, chills, severe dizziness, passing out, seizures, change in skin to thick or thin at injection site, mood changes, slurred speech, shortness of breath, excessive weight gain, or swelling of arms or legs (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience,and judgment in diagnosing, treating, and advising patients.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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