1. By: Kristin Izzo, Intern Preceptor: Mary M. Julius, RD, LD, CDE and Neal Kurmas, MS, RD, LD, CDE

2. Citation  Granata, J., Nawarskas, A., Resch, N., Vigil, J. Evaluating the Effect of U-500 Insulin Therapy on Glycemic Control in Veterans With Type 2 Diabetes. Clinical Diabetes Journal. 2015; 33: 14-33.

3. BACKGROUND 2,4  What is U-500 Concentrated insulin for extremely insulin resistant 1 unit U-500 = 5 unit U-100  Indications Extreme endogenous hyperinsulinemia or hyperglycemic High insulin resistance ○ Subset obese type 2 diabetes Need exogenous insulin >200 units/day (adults) Need insulin >3 units/kg (pediatrics)

5. OBJECTIVE 4  Determine glycemic effect for Veterans with T2DM converting from U-100 to U- 500 DESIGN  Single-Center Retrospective Chart Review

6. PARTICIPANTS/SETTING  VA hospital – New Mexico  25 patients Aged 41-70 96% Male Races represented: White (60%), black (4%), Native American (4%) and undisclosed (32%)  Those transitioning from U-100 to U-500 between April 2009 and February 2013  No intervention – retrospective chart review

7. MEASURES A1c % Contacts (per month) Hypoglycemia (per month) Insulin total daily dose (units/day) Injections (n/day) Weight

8. STATISTICAL ANALYSIS  Paired t- test Parametric data  Wilcoxon signed rank test Outliers  Spearman’s rank correlation Determined presence of correlation between variables  P>/0.05  Statistical Analysis System (SAS0

9. RESULTS  Patients converting from U-100 to U-500 were able to relatively improve glycemic control with significantly increasing: Incidence of hypoglycemia Daily insulin dose

10. CONCLUSIONS  According to this review: Converting to U-500 from U-100 insulin can be an effective alternative for diabetes management  Limitations of this study Sample size Bolus injections Weight gain

11. Case study Veteran RS – 59 y/o obese WM BMI = 50.6 DM2 since 1996-97, A1c 8.5 Insulin pump – U500 + Aspart inj ~1 hypoglycemic event per month requiring help from another person Comorbidities Medications

12. Case Study Cont’d  Pump initiated 2006

13. PRACTICAL APPLICATION 3  Risks v. Benefits? Weight gain in obese patients Risk of hypoglycemic events 3

14. REFERENCES 1. American Diabetes Association. Using U-500 Insulin 2. Cochran, E., Musso, C. Gorden, P. The use of Insulin U-500 in patients with 3. Dailey AM, Gibert JA, Tannock LR. Durability of Glycemic Control using U-500 Insulin. Diabetes Research and Clinical Practice. 2012;95(3):340-344. doi:10.1016/j.diabres.2011.10.030. 4. Granata, J., Nawarskas, A., Resch, N., Vigil, J. Evaluating the Effect of U-500 Insulin Therapy on Glycemic Control in Veterans With Type 2 Diabetes. Clinical Diabetes Journal. 2015; 33: 14-33.