BNF for Children 2011-2012

352 6.1.1 Insulins BNFC 2011–20126 Endocrine systemlife and if premature. If intravenous glucose is necessarye.g. for total parenteral nutrition, infuse at a lower ratefor 6–12 hours and the glucose intolerance shouldresolve. Insulin is not needed for such transient glucoseintolerance, but may be needed if blood-glucose concentrationis persistently high.Neonatal diabetes Neonatal diabetes is a rare conditionthat presents with acidosis, dehydration, hyperglycaemia,and rarely ketosis; it responds to continuousinsulin infusion. When the neonate is stable, treatmentcan be switched to subcutaneous insulin given once ortwice a day. Treatment is normally required for 4–6weeks in transient forms, but may be required permanentlyin some cases.6.1.1.1 Short-acting insulinsSoluble insulin is a short-acting form of insulin. Formaintenance regimens it is usual to inject it 15 to 30minutes before meals.Soluble insulin is the most appropriate form of insulinfor use in diabetic emergencies and at the time ofsurgery. It can be given intravenously and intramuscularly,as well as subcutaneously.When injected subcutaneously, soluble insulin has arapid onset of action (30 to 60 minutes), a peak actionbetween 2 and 4 hours, and a duration of action of up to8 hours.When injected intravenously, soluble insulin has a veryshort half-life of only about 5 minutes and its effectdisappears within 30 minutes.The rapid-acting human insulin analogues, insulinaspart, insulin glulisine, and insulin lispro, have afaster onset (10–20 minutes) and shorter duration ofaction (2–5 hours) than soluble insulin; as a result,compared with soluble insulin, fasting and preprandialblood-glucose concentrations are a little higher, postprandialblood-glucose concentration is a little lower,and hypoglycaemia occurs slightly less frequently.These rapid-acting insulins are ideal for prandial dosingin a multiple injection regimen in combination with along-acting insulin once or twice daily. Insulin aspart,insulin glulisine, and insulin lispro can be administeredby subcutaneous infusion (see Insulin Administration,above). Insulin aspart and insulin lispro can also beadministered intravenously and can be used as alternativesto soluble insulin for diabetic emergencies andat the time of surgery.INSULIN(Insulin Injection; Neutral Insulin; SolubleInsulin)A sterile solution of insulin (i.e. bovine or porcine) orof human insulin; pH 6.6–8.0Cautions section 6.1.1; interactions: Appendix 1(antidiabetics)Hepatic impairment section 6.1.1Renal impairment section 6.1.1Pregnancy section 6.1.1Breast-feeding section 6.1.1Side-effects see notes above; transient oedema; localreactions and fat hypertrophy at injection site; rarelyhypersensitivity reactions including urticaria, rash;overdose causes hypoglycaemiaIndication and doseHyperglycaemia during illness, neonatal diabetes,neonatal hyperglycaemia. By intravenous infusionNeonate 0.02–0.125 units/kg/hour, adjustedaccording to blood-glucose concentration, see alsonotes aboveChild 1 month–18 years 0.025–0.1 units/kg/hour, adjusted according to blood-glucose concentration,see also notes aboveDiabetes mellitus. By subcutaneous injectionAccording to requirements (see notes above)Note Rotate injection site to reduce local reactions andfat hypertrophyDiabetic ketoacidosis section 6.1.3Surgery in children with diabetes section 6.1.1Administration For intravenous infusion, dilute to aconcentration of 1 unit/mL with Sodium Chloride0.9% and mix thoroughly; insulin may be adsorbed byplastics, flush giving set with 5 mL of infusion fluidcontaining insulin.Neonatal intensive care, dilute 5 units to a finalvolume of 50 mL with infusion fluid; an intravenousinfusion rate of 0.1 mL/kg/hour provides a dose of0.01 units/kg/hourHighly purified animalCounselling Show container to child or carer and confirmthe expected version is dispensedHypurin c Bovine Neutral (Wockhardt) AInjection, soluble insulin (bovine, highly purified)100 units/mL. Net price 10-mL vial = £18.48; cartridges(for Autopen c Classic) 5 3 mL = £27.72Hypurin c Porcine Neutral (Wockhardt) AInjection, soluble insulin (porcine, highly purified)100 units/mL. Net price 10-mL vial = £16.80; cartridges(for Autopen c Classic) 5 3 mL = £25.20Human sequenceCounselling Show container to child or carer and confirmthe expected version is dispensedActrapid c (Novo Nordisk) AInjection, soluble insulin (human, pyr) 100 units/mL.Net price 10-mL vial = £7.48Note Not recommended for use in subcutaneous insulininfusion pumps—may precipitate in catheter or needleHumulin S c (Lilly) AInjection, soluble insulin (human, prb) 100 units/mL.Net price 10-mL vial = £15.68; 5 3-mL cartridge (forAutopen c Classic or HumaPen c ) = £19.08Insuman c Rapid (Sanofi-Aventis) AInjection, soluble insulin (human, crb) 100 units/mL,net price 5 3-mL cartridge (for ClikSTAR c andOptiPen c Pro 1, and Autopen c 24) = £17.50; 5 3-mL Insuman c Rapid OptiSet c prefilled disposableinjection devices (range 2–40 units, allowing 2-unitdosage adjustment) = £17.50Note Not recommended for use in subcutaneous insulininfusion pumpsMixed preparationsSee Biphasic Isophane Insulin (section 6.1.1.2)