How to Switch Insulin Products

Switching insulins should always be done with prescriber approval and close monitoring. Advise patients to closely monitor blood glucose levels after switching insulins. If switching between human insulin brands (e.g., Humulin R to Novolin R, Humulin N to Novolin N, or Humulin N/R or Novolin N/R to “store brand” N/R), keep the number of units each day the same. However, because these brands are not AB rated pharmacists may need to contact the prescriber before switching. See our chart, Comparison of Insulins, for meal timing, onset, peak, duration of action, and other information. Also see our algorithm, Initiation and Adjustment of Insulin Regimens for Type 2 Diabetes.

 

Clinical Scenario

Recommendation/Comments

NPH to long-acting

NPH to insulin detemir (Levemir)

Convert unit-per-unit.1

Some patients may require more insulin detemir than NPH.1

Give insulin detemir once daily, or divide twice daily.1

Do not mix insulin detemir with other insulins.1

NPH to insulin glargine U-100 (Lantus, Basaglar, Semglee)

NPH to insulin glargine U-300 (Toujeo)

NPH once daily: convert unit-per-unit to Lantus, Semglee, or Toujeo and give once daily.2,14,30 No specific information to guide NPH once daily to Basaglar switch. Consider conversion as for Lantus, given Lantus/Basaglar dose equivalency.12

NPH twice daily: reduce total daily dose by 20% and give Lantus, Basaglar, Semglee, or Toujeo once daily.2,12,14,30

May take ≥5 days to see the max effect of the selected dose of Toujeo.14 Do not increase dose more often than every 3 to 4 days.16

Do not mix insulin glargine with other insulins.2,12,14,30

Long-acting to NPH

Insulin detemir (Levemir) to NPH

Convert unit-per-unit,3 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) to NPH

Insulin glargine U-300 (Toujeo) to NPH

Convert unit-per-unit from Lantus,3 or reduce dose by 20%.27

No specific information to guide Basaglar or Semglee to NPH switch. Consider conversion as for Lantus, given Lantus/Basaglar/Semglee dose equivalency.12,30

Consider 20% dose reduction when switching from Toujeo to NPH to be conservative.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)

Convert unit-per-unit.12,30

Insulin detemir (Levemir) to insulin glargine U-100 (Lantus, Basaglar, Semglee)

Consider converting unit-per-unit to Lantus.3,5 A lower daily dose may be needed.7

No specific information to guide Levemir to Basaglar or Semglee switch. Consider conversion as for Lantus, given Lantus/Basaglar/Semglee dose equivalency.12,30

Give once daily.5,12,30

Do not mix insulin glargine with other insulins.2,12,30

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

Levemir once daily: convert unit-per-unit and give once daily.16

Levemir twice daily: reduce total daily dose by 20% and give once daily.18

May take ≥5 days to see the max effect of the selected dose of Toujeo.14 Do not increase dose more often than every 3 to 4 days.16

Do not mix insulin glargine with other insulins.14

Insulin glargine U-100 (Lantus, Basaglar, Semglee) to insulin glargine U-300 (Toujeo)

Lantus once daily: convert unit-per-unit and give once daily.16

Lantus twice daily: convert unit-per-unit (or reduce by about 10% or less) and give once daily.29

For patients controlled on Lantus, expect that a higher daily dose (about 10% to 18%) of Toujeo will be needed to maintain control.17

No specific information to guide Basaglar or Semglee to Toujeo switch. Consider conversion as for Lantus, given Lantus/Basaglar/Semglee dose equivalency.12,30

May take ≥5 days to see the max effect of the selected dose of Toujeo.14 Do not increase dose more often than every 3 to 4 days.16

Do not mix insulin glargine with other insulins.14

Insulin glargine U-100 (Lantus, Basaglar, Semglee) to insulin detemir (Levemir)

Convert unit-per-unit from Lantus.1,5

No specific information to guide Basaglar or Semglee to Levemir switch. Consider conversion as for Lantus, given Lantus/Basaglar/Semglee dose equivalency.12,30

Give once daily, or divide twice daily.1

If divided twice daily, a higher daily dose may be needed.7

Do not mix insulin detemir with other insulins.1

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

Reduce dose by about 20% when converting.2,12,27,30

NPH or long-acting to ultra-long acting

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

Convert total daily dose unit-per-unit and give once daily,19 or consider a 20% dose reduction.21,27

Do not increase the dose more often than every 3 to 4 days.19

No specific information to guide Semglee to Tresiba switch. Consider conversion as for other NPH/long-acting products, given Semglee dose equivalency to other insulin glargine 100 unit/mL products.30

Ultra-long acting to NPH or long-acting

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

Reduce dose by 20%.27,30

Give Levemir, Lantus, Basaglar, Semglee, or Toujeo once daily, or divide Levemir twice daily.1,2,12,14,30

  • If converting from Tresiba >80 units/day, divide 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, Novolin R) to rapid-acting insulin analog (insulin aspart [NovoLog, Fiasp], insulin glulisine [Apidra], insulin lispro [Humalog, Admelog, Lyumjev])

Convert unit-per-unit.3,8-10,20,22,31

Rapid-acting insulin analogs have a faster onset of action and a shorter duration of action than human regular insulin. See Comparison of Insulins for specifics of meal timing.11

Regular to inhaled insulin

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

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, Fiasp), insulin glulisine (Apidra), or insulin lispro (Humalog, Admelog, Lyumjev) to regular human insulin (Humulin R, Novolin R)

Convert unit-per-unit.3,8-10,20,22

Rapid-acting insulin analogs have a faster onset of action and a shorter duration of action than human regular insulin. See Comparison of Insulins for specifics of meal timing.11

Rapid-acting to rapid-acting

Insulin aspart (NovoLog, Fiasp), insulin glulisine (Apidra), or insulin lispro (Humalog, Admelog, Lyumjev) to insulin aspart (NovoLog, Fiasp), insulin glulisine (Apidra), or insulin lispro (Humalog, Admelog, Lyumjev)

Convert unit-per-unit.3,8-10,20,22,31

See Comparison of Insulins for specifics of meal timing.11

Rapid-acting to inhaled insulin

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

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) 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 for specifics of meal timing.11

Regular to long-acting or ultra-long acting

Regular human insulin (Humulin R, Novolin R) to insulin glargine U-100 (Lantus, Basaglar, Semglee), insulin glargine U-300 (Toujeo), insulin detemir (Levemir), insulin degludec (Tresiba), or NPH

Add up the total daily dose and start with 50% as intermediate, long-acting, or ultra-long acting insulin, or start an initial insulin regimen, as suggested in our algorithm, Initiation and Adjustment of Insulin Regimens for Type 2 Diabetes.6

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

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

Switch to premix twice daily. Give same total daily dose as basal but give 2/3 in the morning and 1/3 with dinner, or give half with breakfast and half with dinner.6

No specific information for switching from Toujeo or Tresiba. Consider dose reduction.

No specific information to guide switch from Semglee. Consider conversion as for other NPH/long-acting products, given Semglee dose equivalency to other insulin glargine 100 unit/mL products.30

Premixed to NPH

Premixed NPH/regular insulin (Humulin 70/30, Novolin 70/30), premixed protamine/rapid-acting analog (insulin lispro protamine/insulin lispro [Humalog Mix 75/25], 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 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

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 to long-acting

Premixed NPH/regular insulin (Humulin 70/30, Novolin 70/30), premixed protamine/rapid-acting analog (insulin lispro protamine/insulin lispro [Humalog Mix 75/25], or insulin aspart protamine/insulin aspart [NovoLog Mix 70/30]) to insulin glargine U-100 (Lantus, Basaglar, Semglee), 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 or reduce dose by 20%.27

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

No specific information to guide switch to Semglee. Consider conversion as for other long-acting products, given Semglee dose equivalency to other insulin glargine 100 unit/mL products.30

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

If the premix is given once daily, convert to Toujeo once daily unit-per-unit based on the long-acting component of the premix insulin.28

If the premix is given twice daily, give 80% of the long-acting component as Toujeo once daily.28

Do not increase dose more often than every 3 to 4 days.16

Add prandial insulin if desired.

Premixed to ultra-long acting

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

No specific guidance is available. Consider switching unit-per-unit based on the long-acting component of the premix insulin.19

Do not increase dose more often than every 3 to 4 days.19

Add prandial insulin if desired.

Premixed to premixed

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

Convert unit-per-unit,3 or reduce dose by 20%.27

Premix analogs have a faster onset but similar duration compared to human premixes.10,13 See Comparison of Insulins for specifics of meal timing.11

Premixed protamine/rapid-acting analog (insulin lispro protamine/insulin lispro [Humalog Mix 75/25], insulin aspart protamine/insulin aspart [NovoLog Mix70/30]) to premixed NPH/regular insulin (Humulin 70/30, Novolin 70/30)

Convert unit-per-unit,3 or reduce dose by 20%.27

Premix analogs have a faster onset but similar duration compared to human premixes.10,13 See Comparison of Insulins for specifics of meal timing.11

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], or insulin aspart protamine/insulin aspart [NovoLog Mix 70/30]) to mealtime insulin inhalation powder (Afrezza)

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 other U-100 insulins to Humulin R U-500

Determine the total daily dose of U-500 used by adding the units of all types of other insulins given in one day (i.e., unit-per-unit conversion).23

Divide the total daily dose of U-500 into a two or three times a day regimen (given 30 minutes before meals) for most patients.23 See our chart, Tips to Improve Insulin Safety, for suggested starting points based on total daily dose.

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

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

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

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

Patients on basal insulin 30 units/day to 60 units/day, convert to 30 units insulin glargine/10 mcg lixisenatide once daily, 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

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

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

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 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


Project Leader in preparation of this clinical resource (350802): Melanie Cupp, Pharm.D., BCPS; Last modified July 2020.

References

  1. Product information for Levemir. Novo Nordisk. Princeton, NJ 08540. March 2020.
  2. Product information for Lantus. Sanofi-Aventis U.S. Bridgewater, NJ 08807. November 2019.
  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 July 14, 2019).
  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. King AB. Once-daily insulin detemir is comparable to once-daily insulin glargine in providing glycaemic control over 24 h in patients with type 2 diabetes: a double-blind, randomized, crossover study. Diabetes Obes Metab 2009;11:69-71.
  6. Clinical Resource, Initiation and Adjustment of Insulin Regimens for Type 2 Diabetes. Pharmacist’s Letter/Prescriber’s Letter. March 2017.
  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;51:408-16.
  8. Product information for Humalog. Eli Lilly and Company. Indianapolis, IN 46285. November 2019.
  9. Product information for Apidra. Sanofi-Aventis U.S. Bridgewater, NJ 08807. November 2019.
  10. Product information for NovoLog. Novo Nordisk. Princeton, NJ 08540. November 2019.
  11. Clinical Resource, Comparison of Insulins. Pharmacist’s Letter/Prescriber’s Letter. November 2019.
  12. Product information for Basaglar. Eli Lilly and Company. Indianapolis, IN 46285. November 2019.
  13. Product information for Humalog Mix 75/25. Eli Lilly and Company. Indianapolis, IN 46285. November 2019.
  14. Product information for Toujeo. Sanofi-Aventis U.S. Bridgewater, NJ 08807. December 2019.
  15. Product information for Afrezza. MannKind Corporation. Danbury, CT 06810. October 2018.
  16. Sanofi-Aventis U.S. Toujeo. Find your patients’ dosing. https://www.toujeopro.com/toujeo-insulin-dosing-and-titration-calculator. (Accessed June 1, 2019).
  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 June 1, 2019).
  18. Sanofi-Aventis U.S. Conversion from other insulin therapies to Toujeo. Last updated June 9, 2018. https://www.sanofiusmedicalinformation.com. (Accessed June 1, 2019).
  19. Product information for Tresiba. Novo Nordisk, Inc. Plainsboro, NJ 08536. November 2019.
  20. Product information for Lyumjev. Eli Lilly and Company. Indianapolis, IN 46285. June 2020.
  21. Vora J, Cariou B, Evans M, et al. Clinical use of insulin degludec. Diabetes Res Clin Pract 2015;109:19-31.
  22. Product information for Fiasp. Novo Nordisk. Princeton, NJ 08540. December 2019.
  23. Clinical Resource, Tips to Improve Insulin Safety. Pharmacist’s Letter/Prescriber’s Letter. April 2016.
  24. Product information for Soliqua. Sanofi-Aventis. Bridgewater, NJ 08807. November 2019.
  25. Product information for Xultophy. Novo Nordisk. Plainsboro, NJ 08536. November 2019.
  26. Davidson MB. Insulin therapy: a personal approach. Clin Diabetes 2015;33:123-35.
  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 2018. https://www.diabetes.org/sites/default/files/2019-08/switching-between-insulin.pdf. (Accessed June 3. 2019).
  28. Sanofi-Aventis U.S. Conversion from premixed insulin. Last updated June 9, 2018. https://www.sanofiusmedicalinformation.com. (Accessed June 3, 2019).
  29. Personal communication (written). Faircloth JP, Pharm.D., Lead Global Information Content, DCV. Sanofi-Aventis U.S. Bridgewater, NJ 08807. June 4, 2019.
  30. Product information for Semglee. Mylan Specialty. Morgantown, WV 26505. June 2020.
  31. Product information for Admelog. Sanofi-Aventis U.S. Bridgewater, NJ 08807. November 2019.

Cite this document as follows: Clinical Resource, How to Switch Insulin Products. Pharmacist’s Letter/Prescriber’s Letter. August 2019.

Related Articles