How to Switch Insulin Products

Full update May 2023

Switching insulins should always be done with prescriber approval and close monitoring. Advise patients to closely monitor blood glucose levels after switching insulins. Pharmacists may need to contact the prescriber before switching, depending on state/provincial regulations. Our FAQ, Facts About Biosimilars, addresses questions that may arise about interchangeability. See our chart, Comparison of Insulins (US) (Canada), for meal timing, onset, peak, duration of action, and other information.

Clinical Scenario

Recommendation/Comments

NPH to long-acting

NPH to insulin detemir (Levemir)

 

  • Convert unit-per-unit.5
  • Some patients may require more insulin detemir than NPH.5
  • Give insulin detemir once daily, or divide twice daily.1,10
  • Do not mix insulin detemir with other insulins.1,10

NPH to insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US])

 

NPH to insulin glargine U-300 (Toujeo)

  • NPH once daily:  convert unit-per-unit to U-100 insulin glargine and give once daily.5
  • NPH twice daily:  reduce total daily dose by 20% and give insulin glargine once daily.5
  • It may take ≥5 days to see the maximum effect of the selected dose of Toujeo.13,14  Do not increase the Toujeo dose more often than every 
    3 to 4 days.13,14
  • Do not mix insulin glargine with other insulins.12-14,18,23,30,32,33,35

Long-acting to NPH

Insulin detemir (Levemir) to NPH

  • Convert unit-per-unit,or reduce dose by 20%.27
  • Give NPH twice daily (e.g., 50:50 or 2/3 in AM and 1/3 before dinner or at bedtime).3,4,26,27

 

Insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US]) to NPH

 

Insulin glargine U-300 (Toujeo) to NPH

 

  • Insulin glargine U-100: convert unit-per-unit,or reduce dose by 20%.27
  • Toujeo:     reduce dose by 20%.27
  • Give NPH twice daily (e.g., 50:50 or 2/3 in AM and 1/3 before dinner or at bedtime).3,4,26,27

Long-acting to long-acting

Insulin glargine U-100 (Lantus) to/from insulin glargine U-100 (Basaglar, Semglee, Rezvoglar [US])

 

  • Convert unit-per-unit.5

Insulin detemir (Levemir) to insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US])

 

  • Consider converting unit-per-unit.A lower daily dose may be needed.7
  • Give once daily.5,18,30,35
  • Do not mix insulin glargine with other insulins.12,18,23,30,32,33,35

Insulin detemir (Levemir) to insulin glargine U-300 (Toujeo)

 

  • Levemir once daily: convert unit-per-unit and give Toujeo once daily.13,14
  • Levemir twice daily: reduce total daily dose by 20% and give Toujeo once daily.13,14
  • It may take ≥5 days to see the maximum effect of the selected dose of Toujeo.13,14  Do not increase the Toujeo dose more often than every 
    3 to 4 days.13,14
  • Do not mix insulin glargine with other insulins.13,14

Insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US]) to insulin glargine U-300 (Toujeo)

  • Convert unit-per-unit and give once daily.13,14,28
  • Expect that a higher daily dose (about 10% to 18%) of Toujeo will be needed to maintain control.17
  • It may take ≥5 days to see the maximum effect of the selected dose of Toujeo.13,14 Do not increase the Toujeo dose more often than every 
    3 to 4 days.13,14
  • Do not mix insulin glargine with other insulins.13,14

 

Insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US]) to insulin detemir (Levemir)

 

  • Convert unit-per-unit.5
  • Give insulin detemir once daily, or divide twice daily.1,10 If divided twice daily, a higher daily insulin detemir dose may be needed.7
  • Do not mix insulin detemirwith other insulins.1,10

 

Long-acting to long-acting

Insulin glargine U-300 (Toujeo) to insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US]) or insulin detemir (Levemir)

  • Reduce dose by 20%.5

NPH or long-acting to ultra-long acting

NPH, insulin detemir (Levemir), insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US]), or insulin glargine U-300 (Toujeo) to insulin degludec (Tresiba)

  • Convert total daily dose unit-per-unit and give once daily,or reduce dose by 20% (for patients with type 1 diabetes [Canada], twice-daily basal insulin [Canada], or pediatrics [US]) and give once daily.19,34
  • Do not increase the Tresiba dose more often than every 3 to 4 days.19

 

Ultra-long acting to NPH or long-acting

Insulin degludec (Tresiba) to NPH, insulin detemir (Levemir), insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US]), or insulin glargine U-300 (Toujeo)

  • Reduce dose by 20%.27
  • Give once daily, or divide Levemir twice daily.5
    • If converting from Tresiba >80 units/day, divide U-100 insulin twice daily.27
  • Give NPH twice daily (e.g., 50:50 or 2/3 in AM and 1/3 before dinner or at bedtime).3,4,26,27

 

Regular to rapid-acting

Regular human insulin (Humulin R [US], Novolin R [US], Novolin ge Toronto [Canada], Myxredlin [Canada], Hypurin Regular [Canada]) to rapid-acting insulin analog (insulin aspart [NovoLog (US), NovoRapid (Canada), Trurapi (Canada), Fiasp, Kirsty (Canada)], insulin glulisine [Apidra], insulin lispro [Humalog, Admelog, Lyumjev])

 

  • Convert unit-per-unit.3,20-22,29,31,36
  • Rapid-acting insulin analogs have a faster onset of action and a shorter duration of action than human regular insulin.3  See Comparison of Insulins (US) (Canada)for specifics of meal timing.

Regular to inhaled insulin

Regular human insulin (Humulin R [US], Novolin R [US]) to mealtime insulin inhalation powder (Afrezza [US])

 

  • Round each mealtime insulin dose up to the nearest 4 units, then convert unit-per-unit to the Afrezza dose (available in 4-unit and 8-unit cartridges).15

 

Rapid-acting to regular

Insulin aspart (NovoLog [US], NovoRapid [Canada], Trurapi [Canada], Fiasp, Kirsty [Canada]), insulin glulisine (Apidra), or insulin lispro (Humalog, Admelog, Lyumjev) to regular human insulin (Humulin R [US], Novolin R [US], Novolin ge Toronto [Canada], Myxredlin [Canada], Hypurin Regular [Canada])

 

  • Convert unit-per-unit.3,20-22,29,31,36
  • Rapid-acting insulin analogs have a faster onset of action and a shorter duration of action than human regular insulin.3 See Comparison of Insulins (US) (Canada) for specifics of meal timing.

Rapid-acting to rapid-acting

Insulin aspart (NovoLog [US], NovoRapid [Canada], Trurapi [Canada], Fiasp, Kirsty [Canada]), insulin glulisine (Apidra), or insulin lispro (Humalog, Admelog, Lyumjev) to insulin aspart (NovoLog [US], NovoRapid [Canada], Trurapi [Canada], Fiasp, Kirsty [Canada]), insulin glulisine (Apidra), or insulin lispro (Humalog, Admelog, Lyumjev)

 

  • Convert unit-per-unit.3,16,20-22,29,31,36
  • See Comparison of Insulins (US) (Canada) for specifics of meal timing.

 

Rapid-acting to inhaled insulin

Insulin aspart (NovoLog, Fiasp), insulin glulisine (Apidra), or insulin lispro (Humalog, Admelog, Lyumjev) to mealtime insulin inhalation powder (Afrezza [US])

 

  • Round each mealtime insulin dose up to the nearest 4 units, then convert unit-per-unit to the Afrezza dose (available in 4-unit and 8-unit cartridges).15

Inhaled insulin to rapid-acting or regular

Insulin inhalation powder (Afrezza [US]) to insulin aspart (NovoLog, Fiasp), insulin glulisine (Apidra), insulin lispro (Humalog, Admelog, Lyumjev), regular human insulin (Humulin R, Novolin R)

 

  • Convert unit-per-unit.15
  • See Comparison of Insulins (US) (Canada) for specifics of meal timing.

 

Regular to long-acting or ultra-long acting

Regular human insulin (Humulin R [US], Novolin R [US], Novolin ge Toronto [Canada], Myxredlin [Canada], Hypurin Regular [Canada]) to insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US]), insulin glargine U-300 (Toujeo), insulin detemir (Levemir), insulin degludec (Tresiba), or NPH

 

  • Calculate the average of the daily insulin requirement over the past five to seven days.     Start with 70% to 75% as basal insulin.11
  • Cover meals with oral antidiabetics or mealtime insulin.11

NPH, long-acting, or ultra-long acting to premixed

NPH, insulin detemir (Levemir), insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US]), insulin glargine U-300 (Toujeo), or insulin degludec (Tresiba) to premixed NPH/regular insulin (Humulin 70/30 [US], Humulin 30/70 [Canada], Novolin 70/30 [US], Novolin ge 30/70 [Canada], Novolin ge 40/60 [Canada], Novolin ge 50/50 [Canada]), premixed protamine/rapid-acting analog (insulin lispro protamine/insulin lispro [Humalog Mix 75/25 (US), Humalog Mix 25 (Canada), Humalog Mix 50/50 (US), Humalog Mix 50 Canada)], insulin aspart protamine/insulin aspart [NovoLog Mix 70/30 (US), NovoMix 30 (Canada)])

 

  • Give same total daily dose,6 or reduce dose by 20%.27 Give half with breakfast and half with dinner.6
  • No specific information for switching from Toujeo or Tresiba. Consider 20% dose reduction.27

 

Premixed to NPH

Premixed NPH/regular insulin (Humulin 70/30 [US], Humulin 30/70 [Canada],Novolin 70/30 [US], Novolin ge 30/70 [Canada]), premixed protamine/rapid-acting analog (insulin lispro protamine/insulin lispro [Humalog Mix 75/25 (US), Humalog Mix 25 (Canada)], or insulin aspart protamine/insulin aspart [NovoLog Mix 70/30]) to NPH

 

 

  • Add up the total units and give 70% to 75%  as NPH.3
  • Give 25% to 30% of each premix dose as prandial insulin (regular or rapid-acting analog) before the meal(s) before which the premix was usually taken.3
  • Give NPH twice daily (e.g., 50:50 or 2/3 in AM and 1/3 before dinner or at bedtime).3,4,26,27

Premixed to long-acting

Premixed NPH/regular insulin (Humulin 70/30 [US], Novolin 70/30 [US], Humulin 30/70 [Canada], Novolin ge 30/70 [Canada]), premixed protamine/rapid-acting analog (insulin lispro protamine/insulin lispro [Humalog Mix 75/25 (US), Humalog Mix 25 (Canada)], or insulin aspart protamine/insulin aspart [NovoLog Mix 70/30 (US), NovoMix 30 (Canada)]) to insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US]), or insulin detemir (Levemir)

 

  • Add up the total units for each dose and give 70% to 75% as long-acting insulin U-100 (once daily or divided twice daily [insulin detemir]).1,3,10
  • Give 25% to 30% of each premix dose as prandial insulin (regular or rapid-acting analog) before the meal(s) before which the premix was usually taken.3

 

 

Premixed NPH/regular insulin (Humulin 70/30 [US], Humulin 30/70 [Canada], Novolin 70/30 [US], Novolin ge 30/70 [Canada], Novolin ge 40/60 [Canada], Novolin ge 50/50 [Canada]), premixed protamine/rapid-acting analog (insulin lispro protamine/insulin lispro [Humalog Mix 75/25 (US), Humalog Mix 25 (Canada), Humalog Mix 50/50 (US), Humalog Mix 50 (Canada)], insulin aspart protamine/insulin aspart [NovoLog Mix 70/30 (US), NovoMix 30 (Canada)]) to insulin glargine U-300 (Toujeo)

 

 

  • No specific guidance is available. Consider:
    • converting to Toujeo once daily unit-per-unit based on the long-acting component of the premix insulin, if the premix insulin is given once daily.5
    • giving 80% of the long-acting component as Toujeo once daily, if the premix insulin is given twice daily.5
    • adding prandial insulin, if desired.
  • Do not increase the Toujeo dose more often than every 3 to 4 days.14

 

Premixed to ultra-long acting

Premixed NPH/regular insulin (Humulin 70/30 [US], Humulin 30/70 [Canada], Novolin 70/30 [US], Novolin ge 30/70 [Canada], Novolin ge 40/60 [Canada], Novolin ge 50/50 [Canada]), premixed protamine/rapid-acting analog (insulin lispro protamine/insulin lispro [Humalog Mix 75/25 (US), Humalog Mix 25 (Canada), Humalog Mix 50/50 (US), Humalog Mix 50 (Canada)], insulin aspart protamine/insulin aspart [NovoLog Mix 70/30 (US), NovoMix 30 (Canada)]) to insulin degludec (Tresiba)

  • No specific guidance is available. Consider switching based on the long-acting component of the premix insulin, unit-per-unit5 or with a 20% reduction in dose,27 then add prandial insulin if desired.
  • Do not increase the Tresiba dose more often than every 3 to 4 days.19

 

Premixed to premixed

Premixed NPH/regular insulin (Humulin 70/30 [US], Humulin 30/70 [Canada], Novolin 70/30 [US], Novolin ge 30/70 [Canada], Novolin ge 40/60 [Canada], Novolin ge 50/50 [Canada]) to premixed protamine/rapid-acting analog (insulin lispro protamine/insulin lispro [Humalog Mix 75/25 (US), Humalog Mix 25 (Canada), Humalog Mix 50/50 (US), Humalog Mix 50 (Canada)], insulin aspart protamine/insulin aspart [NovoLog Mix 70/30 (US), NovoMix 30 (Canada)])

 

  • Convert unit-per-unit,or reduce dose by 20%.27
  • Premix analogs have a faster onset but similar duration compared to human premixes.3  See Comparison of Insulins (US) (Canada) for specifics of meal timing.

 

Premixed protamine/rapid-acting analog (insulin lispro protamine/insulin lispro [Humalog Mix 75/25 (US), Humalog Mix 25 (Canada), Humalog Mix 50/50 (US), Humalog Mix 50 (Canada)], insulin aspart protamine/insulin aspart [NovoLog Mix 70/30 (US), NovoMix 30 (Canada)]) to premixed NPH/regular insulin (Humulin 70/30 [US], Humulin 30/70 [Canada], Novolin 70/30 [US], Novolin ge 30/70 [Canada], Novolin ge 40/60 [Canada], Novolin ge 50/50 [Canada])

 

  • Convert unit-per-unit,or reduce dose by 20%.27
  • Premix analogs have a faster onset but similar duration compared to human premixes.3  See Comparison of Insulins (US) (Canada) for specifics of meal timing.

 

Premixed to inhaled insulin

Premixed NPH/regular insulin (Humulin 70/30, Novolin 70/30), premixed protamine/rapid-acting analog (insulin lispro protamine/insulin lispro [Humalog Mix 75/25, Humalog Mix 50/50], or insulin aspart protamine/insulin aspart [NovoLog Mix 70/30]) to mealtime insulin inhalation powder (Afrezza [US])

 

  • Divide half the total daily insulin dose equally among the three meals of the day, and round each mealtime insulin dose up to the nearest 
    4 units, then convert unit-per-unit to the Afrezza dose (available in 4-unit and 8-unit cartridges).15
  • Give the other half of the total daily insulin dose as basal insulin 
    (e.g., NPH, insulin glargine, or insulin detemir).15

 

U-100 insulin to U-500 insulin

All types of U-100 insulin to Humulin R U-500 (US) or Entuzity (Canada)

 

 

  • U-500 insulin is only for patients needing >200 units of insulin daily.2,8  See our checklist, Tips to Improve Insulin Safety, for special considerations with U-500 insulin.
  • Determine the total daily dose from all insulin sources combined.2,8 Round down to the nearest 5 units.8
  • If A1c is ≤8%, reduce the dose by 20%.2,8
  • Divide the dose two or three times daily, given 30 minutes before a meal.2,8 Recommended dosing ratios are 60:40 (for breakfast/dinner dosing) or 40:30:30 (for breakfast/lunch/dinner dosing).2,8 Other ratios may be appropriate.
  • It is recommended that daily doses of ≥300 to 750 units be divided three times daily.9     For doses >750 units, divide four times daily (with meals and at bedtime), with the bedtime dose being smaller than the mealtime doses.9
  • For a titration algorithm, see https://www.humulin.com/hcp/dosing-titration#insulin-activity.

Long-acting or ultra-long acting to long-acting + GLP-1 agonist

Insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US]), insulin detemir (Levemir), insulin glargine U-300 (Toujeo), or insulin degludec (Tresiba) to insulin glargine U-100 + lixisenatide (Soliqua 100/33 [US])

  • Information not based on any specific long- or ultra-long acting insulin product. Conversions are simply for patients uncontrolled on basal insulin ≤60 units/day.24
  • For patients on basal insulin <30 units/day, the recommended starting dose is 15 units insulin glargine/5 mcg lixisenatide once daily, given within one hour prior to the first meal of the day.24
  • For patients on basal insulin 30 units/day to 60 units/day, convert to 30 units insulin glargine/10 mcg lixisenatide once daily, given within one hour prior to the first meal of the day.24
  • Soliqua has not been studied with prandial insulins.24
  • Do not mix Soliqua with other insulins.24
  • Titrate doses weekly by 2 to 4 units of insulin glargine (equals 0.66 mcg to 1.32 mcg of lixisenatide component).24
  • Maximum daily dose is 60 units insulin glargine/20 mcg lixisenatide.24

 

Insulin glargine U-100 (Lantus, Basaglar, Semglee, Rezvoglar [US]), insulin detemir (Levemir), insulin glargine U-300 (Toujeo), or insulin degludec (Tresiba) to insulin degludec + liraglutide (Xultophy [US])

 

  • Dosing recommendations are the same regardless of previous insulin dose.25
  • Start with 16 units insulin degludec/0.58 mg liraglutide given once daily.25
  • Do not mix Xultophy with other insulins.25
  • Titrate doses weekly or every three to four days, by 2 units insulin degludec (equals 0.072 mg liraglutide).25
  • Maximum daily dose is 50 units insulin degludec/1.8 mg liraglutide.25

References

  1. Product information for Levemir. Novo Nordisk. Plainsboro, NJ 08536. December 2022.
  2. Product monograph for Entuzity. Eli Lilly Canada. Toronto, ON M5X 1B1. March 2021.
  3. FDA. Information regarding insulin storage and switching between products in an emergency. Content current as of September 19, 2017. http://www.fda.gov/Drugs/EmergencyPreparedness/ucm085213.htm. (Accessed April 19, 2023).
  4. Goldman JD, Patel D, Schnee D. Diabetes mellitus. In: Zeind CS, Carvalho MG, editors. Applied Therapeutics: the Clinical Use of Drugs. 11h ed. Philadelphia, PA: Wolters Kluwer Health, 2018:1071-147.
  5. Mehta R, Goldenberg R, Katselnik D, Kuritzky L. Practical guidance on the initiation, titration, and switching of basal insulins: a narrative review for primary care. Ann Med. 2021 Dec;53(1):998-1009.
  6. Wu T, Betty B, Downie M, et al. Practical Guidance on the Use of Premix Insulin Analogs in Initiating, Intensifying, or Switching Insulin Regimens in Type 2 Diabetes. Diabetes Ther. 2015 Sep;6(3):273-87.
  7. Rosenstock J, Davies M, Home PD, et al. A randomised, 52-week, treat-to-target trial comparing insulin detemir with insulin glargine when administered as add-on to glucose-lowering drugs in insulin-naive people with type 2 diabetes. Diabetologia. 2008 Mar;51(3):408-16.
  8. Eli Lilly. Humulin R U-500 dosage and titration. https://www.humulin.com/hcp/dosing-titration#insulin-activity. (Accessed April 20, 2023).
  9. Cochran E, Musso C, Gorden P. The use of U-500 in patients with extreme insulin resistance. Diabetes Care. 2005 May;28(5):1240-4. Erratum in: Diabetes Care. 2007 Apr;30(4):1035.
  10. Product monograph for Levemir. Novo Nordisk Canada. Mississauga, ON L5n 6M1. August 2021.
  11. Munshi MN, Florez H, Huang ES, et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care. 2016 Feb;39(2):308-18.
  12. Product information for Basaglar. Eli Lilly and Company. Indianapolis, IN 46285. July 2021.
  13. Product monograph for Toujeo. Sanofi-Aventis Canada. Laval, QC H7V 0A3. October 2019.
  14. Product information for Toujeo. Sanofi-Aventis US. Bridgewater, NJ 08807. August 2022.
  15. Product information for Afrezza. MannKind Corporation. Danbury, CT 06810. February 2023.
  16. Product monograph for Trurapi. Sanofi-Aventis Canada. Lava, QC H7V 0A3. July 2022.
  17. European Medicines Agency. CHMP post-authorization summary of positive opinion for Toujeo. February 26, 2015. http://www.ema.europa.eu/docs/en_GB/document_library/Summary_of_opinion/human/000309/WC500183282.pdf. (Accessed April 10, 2023).
  18. Product monograph for Semglee. BGP Pharma ULC. Etobicoke, ON M8Z 2S6 September 2022.
  19. Product information for Tresiba. Novo Nordisk. Plainsboro, NJ 08536. July 2022.
  20. Product information for Lyumjev. Eli Lilly and Company. Indianapolis, IN 46285. October 2022.
  21. Product monograph for Fiasp. Novo Nordisk Canada. Mississauga, ON L5N 6M1. July 2021.
  22. Product information for Fiasp. Novo Nordisk. Princeton, NJ 08540. November 2022.
  23. Product monograph for Basaglar. Eli Lilly Canada. Toronto, ON M5X 1B1. August 2022.
  24. Product information for Soliqua. Sanofi-Aventis. Bridgewater, NJ 08807. June 2022.
  25. Product information for Xultophy. Novo Nordisk. Plainsboro, NJ 08536. June 2022.
  26. Davidson MB. Insulin Therapy: A Personal Approach. Clin Diabetes. 2015 Jul;33(3):123-35.
  27. Information for health care professionals. Switching between insulin products in disaster response situations. Approved by the American Diabetes Association, the Endocrine Society and JDRF. August 2020. https://diabetes.org/sites/default/files/2020-09/Switching%20Between%20Insulin%20Products%20in%20Disaster%20Response%20Situations%202020%20-%20English.pdf. (Accessed April 19. 2023).
  28. Sanofi-Aventis US. Toujeo-Conversion from insulin glargine 100 U/mL BID to Toujeo QD. https://www.sanofiusmedicalinformation.com. (Accessed April 20, 2023).
  29. Product monograph for Admelog. Sanofi-Aventis Canada. Laval, QC H7V 0A3. December 2021.
  30. Product information for Semglee. Mylan Specialty. Morgantown, WV 26505. October 2022.
  31. Product information for Admelog. Sanofi-Aventis US. Bridgewater, NJ 08807. December 2020.
  32. Product information for Lantus. Sanofi-Aventis US. Bridgewater, NJ 08807. June 2022.
  33. Product monograph for Lantus. Sanofi-Aventis Canada. Laval, QC H7V 0A3. December 2021.
  34. Product monograph for Tresiba. Novo Nordisk Canada. Mississauga, ON L5N 6M1. October 2022.
  35. Product information for Rezvoglar. Eli Lilly and Company. Indianapolis, IN 46285. November 2022.
  36. Product monograph for Lyumjev. Eli Lilly Canada. Toronto, ON M5X 1B1. September 2021.

 

Cite this document as follows:  Clinical Resource, How to Switch Insulin Products.  Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber’s Letter.  May 2023.  [390524]

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