Can Novolog (insulin aspart) 70/30 or Lantus (insulin glargine) be used in a patient with End-Stage Renal Disease (ESRD) on dialysis three times a week?

Insulin Use in ESRD Patients on Hemodialysis

Both NovoLog 70/30 and Lantus can be used in patients with ESRD on dialysis, but insulin is the preferred antidiabetic agent in this population and requires careful dose adjustment to prevent hypoglycemia. 1

General Principles for Insulin in ESRD

Insulin is the preferred treatment for patients with ESRD and diabetes mellitus requiring medication. 1 The 2022 ADA/KDIGO consensus guidelines recommend that insulin should be "initiated and titrated conservatively to avoid hypoglycemia" in patients with advanced CKD and ESRD. 2

Key Physiologic Considerations

• Both uremia and dialysis complicate glycemic control by affecting insulin secretion, clearance, and peripheral tissue sensitivity 3
• Insulin requirements are unpredictable in ESRD patients due to altered insulin metabolism and clearance 3, 4
• The risk of hypoglycemia is significantly elevated in dialysis patients compared to those with normal kidney function 5, 6

NovoLog 70/30 (Insulin Aspart 70/30) in ESRD

NovoLog 70/30 can be used but requires dose reduction on dialysis days. The premixed formulation contains 70% intermediate-acting insulin and 30% rapid-acting insulin, both of which are affected by dialysis.

Dosing Strategy

• Reduce the total daily insulin dose by 25% on the day of dialysis to prevent hypoglycemia during and after the dialysis session 6
• Standard dosing can be used on non-dialysis days 6
• Monitor blood glucose at least 4 times daily: before breakfast, before dinner, at bedtime, and when suspecting hypoglycemia 7

Important Caveats

• The fixed 70/30 ratio offers less flexibility for dose adjustments, which is problematic given the variable insulin requirements in ESRD patients 7
• Hypoglycemia incidence per dialysis session is significantly higher (3.3% vs 0.7%) when insulin doses are not adjusted on dialysis days 6
• The intermediate-acting component (NPH) carries particular risk for nocturnal hypoglycemia 7

Lantus (Insulin Glargine) in ESRD

Lantus is metabolized by the liver and can be used in ESRD without dose adjustment based on renal function alone, though conservative titration is essential. 2

Advantages in ESRD

• Basal insulins like Lantus are not cleared by hemodialysis due to high molecular weight, wide tissue distribution, and hepatic metabolism 2
• Provides more predictable basal coverage compared to premixed insulins 8
• Allows for independent adjustment of basal insulin without affecting prandial coverage 8

Practical Management

• Initiate conservatively at 10 units or 0.1-0.2 units/kg daily 7
• Titrate based on fasting glucose targets of 90-130 mg/dL 7
• Consider reducing dose by 25% on dialysis days if hypoglycemia occurs, though this is less critical than with premixed insulins 6
• If adding prandial insulin, use rapid-acting analogs (like NovoLog) rather than the premixed formulation for better flexibility 8

Monitoring Requirements

Intensive glucose monitoring is mandatory in ESRD patients on insulin:

• Check glucose at minimum 4 times daily: fasting, pre-dinner, bedtime, and when symptomatic 7
• Increase monitoring frequency during dialysis days and dose adjustments 7
• Monitor at the 2nd hour of dialysis, as this is when hypoglycemia risk peaks 6
• Never skip bedtime testing to prevent nocturnal hypoglycemia 7

Clinical Algorithm for Insulin Selection

For ESRD patients on dialysis requiring insulin:

1. First-line approach: Use basal insulin (Lantus) alone if fasting hyperglycemia is the primary issue 2, 1

   • Easier to adjust for dialysis-related changes
   • Lower hypoglycemia risk than premixed insulins

2. If postprandial control needed: Add rapid-acting insulin (NovoLog) at meals rather than using premixed 70/30 8

   • Provides flexibility to adjust individual components
   • Allows 25% dose reduction of prandial insulin on dialysis days without affecting basal coverage

3. Consider premixed 70/30 only if: Patient requires simplified regimen and can reliably reduce dose by 25% on dialysis days 6

   • Less optimal due to fixed ratio and increased hypoglycemia risk
   • Requires strict adherence to dose adjustment protocol

Critical Safety Warnings

• Current treatment approaches to hyperglycemic emergencies in ESRD patients are suboptimal and associated with higher rates of adverse glucose events 5
• Hypoglycemia symptoms may be blunted in ESRD patients, making glucose monitoring even more critical 6, 3
• Volume shifts during dialysis can cause rapid glucose fluctuations independent of insulin action 3
• Always educate patients on hypoglycemia recognition and treatment with 15-20g fast-acting carbohydrates 9