What is the recommended dosing for Lyumjev (insulin lispro-aabc), a rapid-acting insulin, in an adult patient with diabetes?

Lyumjev (Insulin Lispro-aabc) Dosing

For adults with diabetes, Lyumjev dosing follows the same weight-based and titration principles as standard rapid-acting insulin analogs, with starting doses of 4 units per meal, 0.1 units/kg, or 10% of basal insulin dose for prandial coverage, though Lyumjev's ultra-rapid pharmacokinetics may provide superior postprandial glucose control compared to standard lispro. 1, 2

Initial Dosing Strategy

Type 1 Diabetes

• Start with a total daily insulin dose of 0.5 units/kg/day, dividing approximately 50% as basal insulin and 50% as prandial insulin distributed among three meals 1
• For metabolically stable patients, 0.5 units/kg/day is typical, though total requirements range from 0.4-1.0 units/kg/day 1
• Lyumjev should be administered immediately before meals (0-15 minutes) to effectively manage postprandial glucose 1

Type 2 Diabetes

• When adding prandial insulin to existing basal insulin therapy, start with 4 units of Lyumjev before the largest meal, or use 10% of the current basal insulin dose 1, 2
• For premeal glucose >250 mg/dL, give 2 units of rapid-acting insulin 2
• For premeal glucose >350 mg/dL, give 4 units of rapid-acting insulin 2

Titration Protocol

• Increase prandial insulin doses by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings 1
• Target premeal glucose range: 90-150 mg/dL 2
• If 50% of premeal fingerstick values over 2 weeks are above goal, increase the dose by 2 units 2
• If >2 premeal fingerstick values/week are <90 mg/dL, decrease the dose 2

Carbohydrate Coverage Calculation

• A common starting insulin-to-carbohydrate ratio is 1 unit per 10-15 grams of carbohydrate 1
• Calculate using the formula: 450 ÷ total daily dose for rapid-acting analogs 1
• Adjust the carbohydrate-to-insulin ratio if glucose after meals is consistently out of target 1

Correction Dosing

• Calculate insulin sensitivity factor (ISF) using: 1500 ÷ Total Daily Dose 1
• If correction doses consistently fail to bring glucose into target range, adjust the ISF rather than basal insulin 1
• Avoid "stacking" correction doses, as insulin from the previous dose may still be active 1

Clinical Advantages of Lyumjev

• In hybrid closed-loop systems, Lyumjev increased time in range by 2.5 percentage points compared to standard lispro (78.7% vs 76.2%, P=0.005) with no difference in hypoglycemia 3
• Lyumjev significantly reduced postprandial glucose excursions, with iAUC-2h decreased by 92 mmol/L per 2 hours after breakfast compared to standard lispro (P<0.001) 4
• Time in target range for 4 hours postprandially increased by 6.7 percentage points after breakfast and 5.7 percentage points after evening meals with Lyumjev 4
• In pump therapy with Control-IQ technology, Lyumjev increased time 70-180 mg/dL from 65% to 67% (P=0.004) with improved treatment satisfaction scores 5

Critical Timing Considerations

• In hyperglycemic patients (glucose >10 mmol/L), administering lispro insulin 15 minutes before meals significantly improved postprandial glucose excursion compared to injection at mealtime (P<0.002) 6
• Injecting 30 minutes before meals provided maximal postprandial benefit but carried risk of loss of glucose control at 4 hours postmeal in some patients 6
• Do not use rapid-acting insulin at bedtime due to risk of nocturnal hypoglycemia 2

Safety Monitoring

• The proportion of time with sensor glucose <3.9 mmol/L was similar between Lyumjev and standard lispro (2.3% vs 2.1%, P=0.33) 3
• In a 13-week trial, only 1.7% (3 participants) experienced severe hypoglycemia with Lyumjev, attributed to override boluses or missed meals 5
• Two participants stopped Lyumjev due to infusion-site discomfort, and one due to rash 5

Common Pitfalls to Avoid

• Stop sliding scale insulin when adding scheduled prandial insulin, as sliding scale monotherapy is explicitly condemned by all major diabetes guidelines 1
• Avoid continuing to escalate basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia with prandial insulin 1
• Do not delay addition of prandial insulin when basal insulin has been optimized but HbA1c remains above target after 3-6 months 1
• Maintain metformin therapy unless contraindicated when adding or intensifying insulin 1

Special Populations

• For patients with A1C <8% when starting mealtime bolus insulin, consider decreasing the basal insulin dose 2
• Pediatric patients with type 1 diabetes have highly variable insulin requirements, with higher doses often needed during puberty 1
• Young children and those in the honeymoon phase may require doses as low as 0.2-0.6 units/kg/day 1