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CLINICAL PHARMACOLOGY Mechanism Of Action The primary activity of Novolin R is the regulation of glucose metabolism. Insulins, including Novolin R, bind to insulin receptors on muscle and adipocytes and lower blood glucose by facilitating the cellular uptake of glucose and simultaneously inhibiting the output of glucose from the liver. Pharmacodynamics Novolin R is a short-acting insulin. When injected subcutaneously, the glucose-lowering effect of Novolin R begins approximately 30 minutes post-dose, is maximal between 1.5 and 3.5 hours post-dose and terminates approximately 8 hours post-dose. The onset of action of Novolin R, when administered intravenously, is more rapid in comparison to the subcutaneous administration. When injected subcutaneously, Novolin R has a slower onset of action and longer duration of action compared to the rapid-acting insulin analogs. Pharmacokinetics After single subcutaneous administration of 0.1 unit/kg of Novolin R to healthy subjects, peak insulin concentrations occurred between 1.5 to 2.5 hours post-dose. On average, insulin concentrations returned to baseline at around 5 hours post-dose. The effects of sex, age, obesity, ethnic origin, renal and hepatic impairment, pregnancy, and smoking, on the pharmacodynamics and pharmacokinetics of Novolin R have not been studied. Clinical Studies Please see CLINICAL PHARMACOLOGY for information on the pharmacokinetics and pharmacodynamics of Novolin R. Type 1 Diabetes Mellitus (Adults) Two six-month, open-label, active-controlled studies were conducted to compare the safety and efficacy of Novolin R and insulin aspart in adults with type 1 diabetes. Insulin aspart was administered by subcutaneous injection immediately prior to meals and Novolin R was administered by subcutaneous injection 30 minutes before meals. Both treatment groups also received subcutaneous injections of NPH insulin in either single or divided daily doses. Because the two study designs and results were similar, data are shown for only one study (see Table 6) Table 6: Subcutaneous Novolin R Administration in Type 1 Diabetes (24 weeks; N=882) Novolin R + NPH N=286 Insulin aspart + NPH N=596 Baseline HbA1c (%)* 8.0 ± 1.2 7.9 ±1.1 Change from Baseline HbA1c (%)* 0.0 ± 0.8 -0.1 ± 0.8 Treatment Difference in HbA1c, Mean (95% confidence interval) Novolin R - insulin aspart group 0.2 [0.1; 0.3] Baseline, total insulin dose (units/kg/day)* 0.7 ± 0.2 0.7 ± 0.2 End-of-Study, total insulin dose (units/kg/day)* 0.7 ± 0.2 0.7 ± 0.2 Baseline body weight (kg)* 75.9 ± 13.1 75.3 ± 14.5 Weight Change from baseline (kg)* 0.9 ± 2.9 0.5 ± 3.3 *Values are Mean ± SD Type 2 Diabetes Mellitus (Adults) A six-month, open-label, active-controlled study was conducted to compare the safety and efficacy of Novolin R and insulin aspart in adults with type 2 diabetes (Table 7). Insulin aspart was administered by subcutaneous injection immediately prior to meals and Novolin R was administered by subcutaneous injection 30 minutes before meals. Both treatment groups also received subcutaneous injections of NPH insulin in either single or divided daily doses. Table 7: Subcutaneous Novolin R Administration in Type 2 Diabetes (24 weeks; N=182) Novolin R + NPH N = 91 Insulin aspart + NPH N = 91 Baseline HbA1c (%)* 7.8 ± 1.1 8.1 ± 1.2 Change from Baseline HbAic (%)* -0.1 ± 0.8 -0.3 ± 1.0 Treatment Difference in HbAic, Mean (95% confidence interval) Novolin R - insulin aspart group 0.1 [-0.1; 0.4] Baseline, total insulin dose (units/kg/day)* 0.6 ± 0.3 0.6 ± 0.3 End-of-Study, total insulin dose (units/kg/day)* 0.7 ± 0.3 0.7 ± 0.3 Baseline body weight (kg)* 85.8 ± 14.8 88.4 ± 13.3 Weight Change from baseline (kg)* 0.4 ± 3.1 1.2 ± 3.0 *Values are Mean ± SD Type 1 Diabetes Mellitus (Children and Adolescents) A six-month, open-label, active-controlled study was conducted to compare the safety and efficacy of Novolin R and insulin aspart in children and adolescents aged 6-18 years with type 1 diabetes (Table 8). Insulin aspart was administered by subcutaneous injection immediately prior to meals and Novolin R was administered by subcutaneous injection 30 minutes before meals. Both treatment groups also received subcutaneous injections of NPH insulin. Table 8: Subcutaneous Novolin R Administration in Children and Adolescents with Type 1 Diabetes (24 weeks; N=283) Novolin R + NPH N=96 Insulin aspart + NPH N=187 Baseline HbAic (%)* 8.3 ± 1.3 8.3 ± 1.2 Change from Baseline HbAic (%)* 0.1 ± 1.1 0.1 ± 1.0 Treatment Difference in HbAic, Mean (95% confidence interval) Novolin R - insulin aspart group # 0.2 [-0.1; 0.5] Baseline, total insulin dose (units/kg/day)* 1.0 ± 0.4 1.0 ± 0.3 End-of-Study, total insulin dose (units/kg/day)* 1.2 ± 0.4 1.2 ± 0.4 Diabetic ketoacidosis n (%) 2 (2%) 10 (5%) Baseline body weight (kg)* 48.7 ± 15.8 50.6 ± 19.6 Weight Change from baseline (kg)* 2.4 ± 2.6 2.7 ± 3.5 * Values are Mean ± SD # The treatment difference and corresponding 95% confidence interval is based on the Analysis of Covariance Model Novolin R and insulin aspart have also been compared in an open-label, randomized, crossover trial in 26 children with type 1 diabetes aged 2-6 years. Patients received each treatment for 12 weeks. Insulin aspart was administered by subcutaneous injection immediately prior to meals and Novolin R was administered by subcutaneous injection 30 minutes before meals. Both treatment groups also received subcutaneous injections of NPH insulin. In this study, the mean baseline HbA1c was 7.8%. The estimated HbA1c at end of treatment was 7.6% with Novolin R and 7.7% with insulin aspart.

Find Lowest Prices on Novolin® R (Regular, Human Insulin [rDNA origin] USP) Solution for Subcutaneous or Intravenous Use DESCRIPTION Novolin R (Regular Human Insulin Injection [Recombinant DNA origin] United States Pharmacopeia) is a polypeptide hormone structurally identical to native human insulin and is produced by recombinant DNA technology, utilizing Saccharomyces cerevisiae (baker's yeast) as the production organism. Novolin R has the empirical formula C257H383N65O77S6 and a molecular weight of 5808. Figure 1: Structural formula of Novolin R Novolin R is a sterile, clear, aqueous, and colorless solution that contains human insulin (rDNA origin) 100 units/mL, glycerol 16 mg/mL, metacresol 3 mg/mL, zinc chloride approximately 7 mcg/mL and water for injection. The pH is adjusted to 7.4. Hydrochloric acid 2N or sodium hydroxide 2N may be added to adjust pH.

INDICATIONS Treatment Of Diabetes Mellitus Novolin R is indicated to improve glycemic control in adults and children with diabetes mellitus. DOSAGE AND ADMINISTRATION Dosing The dosage and timing of Novolin R must be individualized. Blood glucose monitoring is essential for all patients receiving insulin therapy. Total daily insulin requirements vary and are usually between 0.5 and 1.0 units/kg/day. Insulin  requirements may be altered during stress, major illness, or with changes in exercise, meal patterns, or  coadministered medications. Subcutaneous Injection Novolin R should generally be injected approximately 30 minutes prior to the start of a meal. Novolin R given by subcutaneous injection should generally be used in regimens that include an intermediate or long-acting insulin [see HOW SUPPLIED/Storage and Handling].   Novolin R should be administered by subcutaneous injection in the abdominal region, buttocks,  thigh, or the upper arm. Subcutaneous injection into the abdominal wall is generally associated with  faster absorption than other injection sites. Injection sites should be rotated within the same region to  reduce the risk of lipodystrophy. Injection into a lifted skin fold minimizes the risk of intramuscular injection. Intravenous Use Novolin R can be administered intravenously under medical supervision for glycemic control,  with close monitoring of blood glucose and potassium concentrations to avoid hypoglycemia and hypokalemia [see WARNINGS AND PRECAUTIONS, HOW SUPPLIED/Storage and Handling]. Intravenous administration of insulin is commonly used in the treatment of diabetic ketoacidosis, peri-operative management of diabetes, and maintenance of glycemic control during labor in pregnant  diabetic women. For intravenous use, Novolin R should be used at concentrations from 0.05 units/mL to 1.0 unit/mL in infusion systems using polypropylene infusion bags. Novolin R can be used with the following infusion fluids: 0.9% sodium chloride, 5% dextrose, or 10% dextrose with 40 mmol/L potassium chloride. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Never use Novolin R if it has become viscous or cloudy; use Novolin R only if it is clear and colorless. Vials should not be used if leakage is observed. Novolin R should not be used after the printed expiration date. The onset of action of Novolin R, when administered intravenously, is more rapid in comparison to subcutaneous administration. Use In Insulin Pumps Use of Novolin R in insulin pumps is not recommended because of the risk of precipitation. HOW SUPPLIED Dosage Forms And Strengths Novolin R is available in 10 mL vials. The concentration of Novolin R is 100 USP units of human insulin (rDNA origin)/mL. Storage And Handling Novolin R is available in 10 mL vials (NDC 0169-1833-11 and ReliOn® brand NDC 0169-183302). The concentration of Novolin R is 100 USP units of human insulin (rDNA origin)/mL. One vial is provided in each sale pack. Recommended Storage Unopened Novolin R vials should be stored in the refrigerator (36° -46°F [2° -8°C]). If carried as a spare or if refrigeration is not possible, unopened Novolin R vials can be kept at room temperature provided they are kept as cool as possible (not above 77°F [25°C]). If kept at room temperature, Novolin R vials must be discarded after 42 days even if they are unopened. Do not freeze and do not use Novolin R if it has been frozen. In addition, unopened Novolin R vials should be kept in their cartons so that they will stay clean and protected from light. They should not be exposed to heat or light. An opened (In use) Novolin R vial can be kept at room temperature provided it is kept as cool as possible (below 77°F [25°C]) and away from heat or light. Do not refrigerate after first use. Unopened and opened (In use) Novolin R vials must be discarded 42 days after they are first kept out of the refrigerator, even if they still contain Novolin R insulin. Table 9: Storage Conditions for Novolin R vials Unopened (Refrigerated) Unopened (Room Temperature up to 77°F [25°C]) Opened (In use) (Room Temperature below 77°F [25°C]) Until expiration date 42 days* 42 days* * The total time allowed at room temperature (up to 25°C) is 42 days regardless of whether the product is unopened or opened (In use) Infusion bags prepared as indicated under DOSAGE AND ADMINISTRATION (2.3) are stable at room temperature for 24 hours. A certain amount of insulin will be initially adsorbed to the material of the infusion bag. Always remove the needle after each injection. Always use a new disposable syringe and needle for each injection to prevent contamination. Never use insulin after the expiry date which is printed on the label and carton. Manufactured by: Novo Nordisk A/S DK-2880 Bagsvaerd, Denmark. For information about Novolin® R contact: Novo Nordisk Inc. 800 Scudders Mill Road Plainsboro, New Jersey 08536. Revised: Jan 2016

PATIENT INFORMATION NOVOLIN®R (NO-voe-lin) (Regular, Human Insulin Injection [recombinant DNA origin] USP) Solution for Subcutaneous Injection Read the Patient Information leaflet that comes with Novolin® R before you start taking it and each time you get a refill. There may be new information. This leaflet does not take the place of talking with your healthcare provider about your diabetes or your treatment. Make sure you know how to manage your diabetes. Ask your healthcare provider if you have any questions about managing your diabetes. What is Novolin® R? Novolin® R is a man-made insulin (recombinant DNA origin) that is used to control high blood sugar in adults and children with diabetes mellitus. Who should not use Novolin® R? Do not take Novolin® R if: Your blood sugar is too low (hypoglycemia). After treating your low blood sugar, follow your healthcare provider's instructions on the use of Novolin® R. You are allergic to any of the ingredients in Novolin® R. See the end of this leaflet for a complete list of ingredients in Novolin® R. Check with your healthcare provider if you are not sure. What should I tell my healthcare provider before taking Novolin® R? Before you take Novolin® R, tell your healthcare providers if you: have liver or kidney problems. take any other medicines, especially ones commonly called TZDs (thiazolidinediones). have heart failure or other heart problems. If you have heart failure, it may get worse while you take TZDs with Novolin® R. have any other medical conditions. Medical conditions can affect your insulin needs and your dose of Novolin® R. are pregnant or plan to become pregnant. Talk to your healthcare provider if you are pregnant or plan to become pregnant. You and your healthcare provider should talk about the best way to manage your diabetes while you are pregnant. are breast-feeding or plan to breast-feed. It is not known if Novolin® R passes into breast milk. You and your healthcare provider should decide if you will take Novolin® R while you breast-feed. Tell your healthcare provider about all of the medicines you take, including prescription and nonprescription medicines, vitamins and herbal supplements. Novolin® R may affect the way other medicines work, and other medicines may affect how Novolin® R works. Know the medicines you take. Keep a list of your medicines with you to show all your healthcare providers and pharmacist when you get a new medicine. How should I take Novolin® R? Novolin® R comes in 10 mL vials for use with a syringe. Take Novolin® R exactly as prescribed. Your healthcare provider will tell you how much Novolin® R to take and when to take it. Do not make any changes to your dose or type of insulin unless you are told to do so by your healthcare provider. The effects of Novolin® R usually start working within about 30 minutes after your injection and usually lasts for up to 8 hours. While using Novolin® R your healthcare provider may change your total dose of insulin, your dose of Novolin® R, your dose of longer-acting insulin, or the number of injections of insulin you use. Do not mix Novolin® R with any insulins other than NPH in the same syringe. Inject Novolin® R under your skin (subcutaneously) of your abdomen (stomach area), upper arms, buttocks or upper legs. Novolin® R may affect your blood sugar levels faster if you inject it into the skin of your abdomen (stomach area). Never inject Novolin® R into a vein or into a muscle. Do not use Novolin® R in an insulin pump. Change (rotate) your injection site within the chosen area (for example, stomach or upper arm) with each dose. Do not inject into the same spot for each injection. Read the instructions for use that comes with your Novolin® R. Talk to your healthcare provider if you have any questions. Your healthcare provider should show you how to inject Novolin® R before you start taking it. If you take too much Novolin® R, your blood sugar may fall too low (hypoglycemia). You can treat mild low blood sugar (hypoglycemia) by drinking or eating something sugary right away (fruit juice, sugar candies, or glucose tablets). It is important to treat low blood sugar (hypoglycemia) right away because it could get worse and could lead to passing out (loss of consciousness), seizures and death. If you forget to take your dose of Novolin® R, your blood sugar may go too high (hyperglycemia). If high blood sugar (hyperglycemia) is not treated it can lead to serious problems, like loss of consciousness (passing out), coma or even death. Follow your healthcare provider's instructions for treating high blood sugar. Know your symptoms of high blood sugar which may include: increased thirst high amounts of sugar and ketones in your urine frequent urination and dehydration confusion or drowsiness nausea, vomiting (throwing up) or stomach pain loss of appetite a hard time breathing fruity smell on breath Do not share needles or syringes with others. You may give an infection to them or get an infection from them. Check your blood sugar levels. Ask your healthcare provider what your blood sugars should be and how often you should check your blood sugar levels for hypoglycemia (too low blood sugar) and hyperglycemia (too high blood sugar). Your insulin dosage may need to change because of: illness change in diet stress change in physical activity or exercise other medicines you take surgery See the end of this patient information for instructions about preparing and giving the injection. What should I avoid while taking Novolin® R? Drinking alcohol. Alcohol may affect your blood sugar when you take Novolin® R. This could lead to blood sugar that is too low (hypoglycemia). Driving and operating machinery. You may have trouble paying attention or reacting if you have low blood sugar (hypoglycemia). Be careful when you drive a car or operate machinery. Ask your healthcare provider if it is alright for you to drive if you often have: low blood sugar decreased or no warning signs of low blood sugar What are the possible side effects of Novolin® R? Novolin® R may cause serious side effects, including: Low blood sugar (hypoglycemia). The general symptoms of low blood sugar (hypoglycemia) may be one or more of the following: sweating shakiness dizziness or lightheadedness hunger fast heart beat blurred vision tingling in your hands, feet, lips or tongue slurred speech anxiety, irritability or mood changes trouble concentrating or confusion headache Very low blood sugar (hypoglycemia) can cause loss of consciousness (passing out), seizures, temporary or permanent brain problems or death. Talk to your healthcare provider about how to tell if you have low blood sugar and what to do if this happens while taking Novolin® R. Know your symptoms of low blood sugar. Follow your healthcare provider's instructions for treating low blood sugar. Talk to your healthcare provider if low blood sugar is a problem for you. Your dose of Novolin® R may need to be changed. Low blood potassium (hypokalemia). A decrease of potassium in your blood can cause breathing problems, a change in your heartbeat and death. Serious allergic reaction (whole body reaction). You can have a serious allergic reaction that may be life-threatening. Get medical help right away if you have any of these symptoms of an allergic reaction: a rash over your body have trouble breathing a fast heartbeat sweating feel faint Swelling of your hands and feet. Heart Failure. Taking certain diabetes pills called thiazolidinediones or “TZDs” with Novolin® R may cause heart failure in some people. This can happen even if you have never had heart failure or heart problems before. If you already have heart failure it may get worse while you take TZDs with Novolin® R. Your healthcare provider should monitor you closely while you are taking TZDs with Novolin® R. Tell your healthcare provider if you have any new or worse symptoms of heart failure including: shortness of breath swelling of your ankles or feet sudden weight gain Treatment with TZDs and Novolin® R may need to be adjusted or stopped by your healthcare provider if you have new or worse heart failure. Other side effects of Novolin® R may include: Reactions at the injection site (local allergic reaction). You may get redness, swelling, and itching at the injection site. If you keep having skin reactions, or they are serious, talk to your healthcare provider. You may need to stop using Novolin® R and use a different insulin. Do not inject insulin into skin that is red, swollen, or itchy. Changes at the injection site (lipodystrophy). The fatty tissue under the skin may shrink (lipoatrophy) or thicken (lipohypertrophy) at the injection site. Change (rotate) the site where you inject your insulin to help reduce the chance of developing these skin changes. Do not inject insulin into this type of skin. Weight gain. Swelling of your arms and legs. Tell your healthcare provider if you have any side effect that bothers you or that does not go away. These are not all of the possible side effects from Novolin® R. Ask your healthcare provider or pharmacist for more information. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. How should I store Novolin® R? Unopened Novolin® R: Unopened Novolin® R should be kept in the refrigerator between 36°F to 46°F (2° to 8°C). Unopened vials can be used until the expiration date on the Novolin® R label, if the medicine has been stored in a refrigerator. If refrigeration is not possible or if you want to carry a spare Novolin® R vial you can keep the unopened vial at room temperature for up to 42 days, as long as it is kept at or below 77°F (25°C). Throw away the vial 42 days after it is first kept out of the refrigerator, even if the vial is unopened. Do not freeze. Do not use Novolin® R if it has been frozen. Keep unopened Novolin® R in the carton to protect it from light. Novolin® R in use: Keep at room temperature below 77°F (25°C). Keep vials away from heat or light. Do not refrigerate an opened vial. Throw away the vial 42 days after it is first kept out of the refrigerator, even if there is insulin left in the vial. Never use insulin after the expiration date which is printed on the label and carton. General information about Novolin® R Medicines are sometimes prescribed for conditions that are not mentioned in the patient leaflet. Do not use Novolin® R for a condition for which it was not prescribed. Do not give Novolin® R to other people, even if they have the same symptoms you have. It may harm them. This leaflet summarizes the most important information about Novolin® R. If you would like more information about Novolin® R or diabetes, talk with your healthcare provider. You can ask your healthcare provider or pharmacist for information about Novolin® R that is written for healthcare professionals. For more information about Novolin® R, call 1-800-727-6500 or go to www.novonordisk-us.com. What are the ingredients in Novolin® R? Active ingredient: Regular Human Insulin Injection (recombinant DNA origin) USP. Inactive ingredients: glycerol, metacresol, zinc chloride, water for injection, hydrochloric acid and sodium hydroxide may be added.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Administration Subcutaneous injection of Novolin R should be followed by a meal. Patients should wait approximately 30 minutes after injection before starting the meal [see DOSAGE AND ADMINISTRATION].   Any change of insulin dose should be made cautiously and only under medical supervision. Changing from one insulin product to another or changing the insulin strength may result in the need for a change in dosage. As with all insulin preparations, the time course of Novolin R action may vary in different individuals or at different times in the same individual and is dependent on many conditions, including dosage, the site of injection, local blood supply, temperature, and physical activity. Patients who change their level of physical activity or meal plan may require adjustment of insulin dosages. Insulin requirements may be altered during illness, emotional disturbances, or other stresses. Hypoglycemia Hypoglycemia is the most common adverse reaction of all insulin therapies, including Novolin R. Severe hypoglycemia may lead to unconsciousness, convulsions, temporary or permanent impairment of brain function or death. Severe hypoglycemia requiring the assistance of another person, parenteral glucose infusion, and glucagon administration has been observed in clinical trials with insulin, including trials with Novolin R. The timing of hypoglycemia usually reflects the time-action profile of the administered insulin formulations [see CLINICAL PHARMACOLOGY]. Other factors such as changes in food intake (e.g., amount of food or timing of meals), injection site, exercise, and concomitant medications may also alter the risk of hypoglycemia [see DRUG INTERACTIONS]. As with all insulins, use caution in patients with hypoglycemia unawareness and in patients who may be predisposed to hypoglycemia (e.g., patients who are fasting or have erratic food intake, pediatric patients, and the elderly). The patient's ability to concentrate and react may be impaired as a result of hypoglycemia. This may present a risk in situations where these abilities are especially important, such as driving or operating other machinery. Rapid changes in serum glucose concentrations may induce symptoms of hypoglycemia in patients with diabetes, regardless of the glucose value. Early warning symptoms of hypoglycemia may be different or less pronounced under certain conditions, such as longstanding diabetes, diabetic neuropathy, use of medications such as beta-blockers, or intensified glycemic control [see DRUG INTERACTIONS]. These situations may result in severe hypoglycemia (and, possibly, loss of consciousness) prior to the patient's awareness of hypoglycemia. Intravenously administered insulin has a more rapid onset of action than subcutaneously administered insulin, requiring more close monitoring for hypoglycemia. Hypokalemia All insulins, including Novolin R, cause a shift in potassium from the extracellular to intracellular space, possibly leading to hypokalemia that, if left untreated, may cause respiratory paralysis, ventricular arrhythmia, and death. Use caution in patients who may be at risk for hypokalemia (e.g., patients using potassium-lowering medications and patients taking medications sensitive to serum potassium concentrations). Monitor glucose and potassium frequently when Novolin R is administered intravenously. Hyperglycemia, Diabetic Ketoacidosis, And Hyperosmolar Hyperglycemic Non-Ketotic Syndrome Hyperglycemia, diabetic ketoacidosis, or hyperosmolar hyperglycemic non-ketotic syndrome may develop in patients who take less insulin than needed to control blood glucose. These conditions can be precipitated by illness, infection, dietary indiscretion, or omission or improper administration of the prescribed insulin dose. Renal Or Hepatic Impairment As with other insulins, the dose requirements for Novolin R may be reduced in patients with renal or hepatic impairment. Hypersensitivity And Allergic Reactions Local Reactions As with other insulins, patients may experience redness, swelling, or itching at the site of injection of Novolin R. These reactions usually resolve in a few days to a few weeks, but in some occasions, may require discontinuation of Novolin R. In some instances, these reactions may be related to factors other than insulin, such as irritants in a skin cleansing agent or poor injection technique. Localized reactions and generalized myalgias have been reported with the use of metacresol, which is an excipient in Novolin R. Systemic Reactions Severe, life-threatening, generalized allergy, including anaphylaxis may occur with any insulin, including Novolin R. Generalized allergy to insulin may manifest as a whole body rash (including pruritus), dyspnea, wheezing, hypotension, tachycardia, or diaphoresis. Mixing Of Insulins If Novolin R is mixed with NPH human insulin, Novolin R should be drawn into the syringe first and the mixture should be injected immediately after mixing. Insulin mixtures should not be administered intravenously. Antibody Production Increases in titers of anti-insulin antibodies that react with human insulin have been observed in patients treated with Novolin R. Data from a 12-month controlled trial in patients with type 1 diabetes suggest that the increase in these antibodies is transient. The clinical significance of these antibodies is not known but does not appear to cause deterioration in glycemic control or necessitate increases in insulin dose. Fluid Retention And Heart Failure With Concomitant Use Of PPAR-gamma Agonists Thiazolidinediones (TZDs), which are peroxisome proliferator-activated receptor (PPAR) gamma agonists, can cause dose-related fluid retention, particularly when used in combination with  insulin. Fluid retention may lead to or exacerbate heart failure. Patients treated with insulin, including NOVOLIN R, and a PPAR-gamma agonist should be observed for signs and symptoms of heart failure. If heart failure develops, it should be managed according to current standards of care, and discontinuation or dose reduction of the PPAR-gamma agonist must be considered. Patient Counseling Information See FDA-Approved Patient Labeling (Patient Information and Instructions for Use) Instructions For All Patients Maintenance of normal or near-normal glucose control is a treatment goal in diabetes mellitus and has been associated with a reduction in some diabetic complications. Patients should be informed about potential risks and benefits of Novolin R therapy including possible adverse reactions. Patients should also be offered continued education and advice on insulin therapies, injection technique, lifestyle management, regular glucose monitoring, periodic glycosylated hemoglobin testing, recognition and management of hypo-and hyperglycemia, adherence to meal planning, complications of insulin therapy, timing of dose, instruction in the use of injection devices, and proper storage of insulin. Patients should be informed that frequent, patient-performed blood glucose measurements are needed to achieve optimal glycemic control and avoid both hyper-and hypoglycemia. The patient's ability to concentrate and react may be impaired as a result of hypoglycemia. This may present a risk in situations where these abilities are especially important, such as driving or operating other machinery. Patients who have frequent hypoglycemia or reduced or absent warning signs of hypoglycemia should be advised to use caution when driving or operating machinery. Female patients should be advised to tell their physician if they intend to become, or if they become pregnant. Patients should be instructed to always carefully check that they are administering the correct insulin to avoid medication errors between Novolin R and other insulins. Patients should check the label for the drug name Novolin R, the enlarged R letter, and the blue horizontal bar. If a prescription for Novolin R is needed, it should be written clearly to avoid confusion with other insulin products. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility Standard 2-year carcinogenicity studies in animals have not been performed to evaluate the carcinogenic potential of Novolin R. Novolin R is not mutagenic in the following in vitro tests: The chromosomal aberration assay in human lymphocytes, the micronucleus assay in mouse polychromatic erythrocytes, and the mutation frequency assay in Chinese hamster cells. Standard reproduction and teratology studies in animals, including fertility assessments have not been conducted with Novolin R. Use In Specific Populations Pregnancy Pregnancy Category B: All pregnancies have a background risk of birth defects, loss, or other adverse outcome regardless of drug exposure. This background risk is increased in pregnancies complicated by hyperglycemia and may be decreased with good glycemic control. It is essential for patients with diabetes or a history of gestational diabetes to maintain good glycemic control before conception and throughout pregnancy. Insulin requirements may decrease during the first trimester, generally increase during the second and third trimesters, and rapidly decline after delivery. Careful monitoring of glucose control is important during pregnancy in patients with diabetes. Therefore, women should be advised to tell their healthcare provider if they intend to become, or if they become, pregnant while taking Novolin R. No reproductive toxicity studies have been performed with Novolin R. Nursing Mothers It is unknown whether Novolin R is excreted in breast milk. Small amounts of human insulin are secreted into breast milk, the significance of which is not known. Use of Novolin R is compatible with breastfeeding, but insulin doses may need to be adjusted because lactation can reduce insulin requirements. Pediatric Use The safety and effectiveness of subcutaneous injections of Novolin R have been established in pediatric patients (ages 2 to18 years) with type 1 diabetes [see Clinical Studies]. Novolin R has not been studied in pediatric patients younger than 2 years of age. Novolin R has not been studied in pediatric patients with type 2 diabetes. In general, pediatric patients with type 1 diabetes are more susceptible to hypoglycemia than adult patients with type 1 diabetes. As in adults, the dosage of Novolin R must be individualized in pediatric patients based on metabolic needs and frequent monitoring of blood glucose [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS]. Geriatric Use In 3 controlled clinical trials 18 of 1285 patients (1.4%) with type 1 diabetes treated with Novolin R and insulin aspart were ≥ 65 years of age. In 4 controlled clinical trials 151 of 635 patients (24%) with type 2 diabetes were ≥ 65 years of age. Therefore, conclusions are limited regarding the efficacy and safety of Novolin R in patients ≥ 65 years of age, particularly in patients with type 1 diabetes. Pharmacokinetic/pharmacodynamic studies to assess the effect of age on Novolin R have not been performed. Use caution in patients with advanced age, due to the potential for decreased renal function in this population [see WARNINGS AND PRECAUTIONS].