used to think the plethora of oral and non-insulin injectable medications was becoming too overwhelming to keep straight, between brand names and scientific names – there are so many options from which to choose. Insulin was relatively easy; there were a few companies making insulins and a limited number of options to choose from for our patients. The hard part was not the choice of insulin, but the daily dosing challenges.
Now enter U200, U300 and ultra-long lasting insulins. It is wonderful to have all these options, but determining what is best for the patient can be a challenge even when working one on one with them. This becomes even more of a challenge as the patient enters the hospital.
U500 has always been a challenge. Historically, that was a situation that occurred infrequently.
However, with more and more patients having larger body habitus – prescriptions for U500 insulin along with other concentrated insulins – are on the rise. Many hospitals do not have the advantage of a diabetes or glycemic team to provide input on how to transfer the patient’s present insulin regimen to hospital formularies. Hospitalists have started to understand the conversion of U500 insulin when the patient states they are taking “20 units” by insulin syringe and are able to translate that to 100 units of U100 insulin. However, confusion mounts as a patient arrives on an insulin pump using U500 insulin, particularly if the patient is transferred to subcutaneous U100 insulin injections while hospitalized.
Options are fantastic if they help a patient achieve blood glucose levels that maximize their diabetes management, but they do add to dosing confusion, particularly when that patient is hospitalized
To add to the quagmire, patients can now use the U500 insulin pen (a great delivery method). This means the hospitalist must determine the insulin delivery system (pen, insulin syringe, TB syringe) to calculate the actual units of insulin the patient is receiving at home.
Now enter the patient who is on long lasting U300 insulin and states he is taking 22 units with an insulin pen – and the doctor immediately assumes that he means 66 units of insulin. Another patient is on ultra-long acting insulin. As a patient enters the hospital and is transferred to a “standard” long acting insulin on our formulary (and needs 50 percent less insulin due to changes in metabolic status or dietary intake) how will the ultra-long acting insulin play into the dosing?
Don’t get me wrong, I think options are fantastic if they help a patient achieve blood glucose levels that maximize their diabetes management, but they do add to dosing confusion, particularly when that patient is hospitalized and we, as diabetes educators and “insulin dosing coaches”, need to recognize the challenges they pose.
I recently met with the hospitalist staff to discuss all the options for insulin concentrations, duration of insulin action, and mixed insulins. They were surprised by all the options, and recognized they would need coaching from our diabetes team (an educator and PA with endocrinology consults available) when a patient on “non-traditional” insulins is admitted to hospital care. By transferring all patients while hospitalized to our hospital formularies, hospitalists, specialists and nursing staff can all understand the dosing schedule and in the end, help to minimize any dosing errors.
It truly is a new diabetes world. As diabetes educators we need to be advocates for our patient, but also remind them that they also need to understand the type of insulin they are on and be advocates for themselves.
How have you addressed this issue at your hospital, particularly those in rural areas without a glycemic/diabetes team?
About the Author:
Carla Cox is a registered dietitian and certified diabetes educator. She has been a certified diabetes educator for over 25 years, and served as an assistant adjunct professor for 14 years, teaching in areas of sports nutrition and exercise physiology. Currently she works in Missoula, Montana as a diabetes educator in both in- and outpatient settings.