Concentrated Insulin
Concentrated insulin doses can be especially problematic. “The national epidemic of diabetes and the exposure of Vietnam veterans to Agent Orange has led to insulin resistance requiring concentrated insulin (U-500 regular [U-500R] insulin) for glycemic control,” VA Pittsburgh Healthcare System researchers wrote in a study two years ago.2
In their report in the journal Clinical Diabetes, the study team described how to overcome potential health care disparities and improve patient safety, and a program was developed ensuring that all clinicians could co-manage U-500R insulin. “Primary care providers and other clinicians are relatively unfamiliar with this concentrated insulin formulation,” according to study authors. “Education plays a key role in the use of U-500R insulin for both clinicians and patients to ensure patient safety. A key to improving patient safety with U-500R insulin includes the use of the correct syringe for this insulin. At the time of this program, no U-500R insulin syringe existed, and often U-100R insulin syringes were used, resulting in errors. To avoid potential errors, tuberculin syringes should have been used, and the dose should have been written in units with the corresponding volume written in milliliters.”
The VA website said its healthcare system now has standardized the prescribing and dispensing of U-500 insulin at VA facilities according to ISMP guidelines.
Despite problems with how they are used on occasion, the ISMP noted that, in the inpatient setting, insulin pens offer some advantages over vials beyond dosing accuracy, convenience, and ease of use:
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Pens are already labeled by the manufacturer with the product name and product barcode;
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Each pen can be individually labeled with the patient’s name and a patient-specific barcode;
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The pen provides the patient’s insulin in a form ready for administration;
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The pen saves nursing time, because they are already prepared and easy to administer; and
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Pens reduce medication waste that can occur when dispensing 10 mL-sized insulin vials for each patient.
Errors related to pen design and injection technique have been reported, however, according to the ISMP. For example, Needlestick injuries have also been reported after misaligning the angle of the injection, which allows the needle to travel through the patient’s skin and into a nurse’s finger. In addition, insulin cartridges within pens have been misused as multiple-dose vials when staff who preferred to administer insulin using a conventional syringe attempted to withdraw an insulin dose from the pen’s cartridge. That is dangerous, according to the ISMP, because the practice could introduce air into the cartridge or reservoir, leading to subsequent insulin under-doses and subcutaneous injection of air. It also warned that, improper sharing of insulin pens among multiple patients has exposed patients to bloodborne pathogens, as potentially occurred at the VA.
Guidelines from the American Diabetes Association recommended that, outside of critical care units, scheduled insulin regimens should be used to manage hyperglycemia in patients with diabetes; it added that regimens using insulin analogs and human insulin result in similar glycemic control in the hospital setting.
The ADA explained that The use of subcutaneous rapid- or short-acting insulin before meals or every four to six hours, if no meals are given or if the patient is receiving continuous enteral/parenteral nutrition is indicated to correct hyperglycemia.
Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill hospitalized patients with poor oral intake or those who are taking nothing by mouth, or NPO, while an insulin regimen with basal, prandial and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake, according to the guidelines.
The ADA cited a randomized controlled trial showing that basal-bolus treatment improved glycemic control and reduced hospital complications compared with sliding scale insulin in general surgery patients with Type 2 diabetes and strongly urged against sole use of prolonged sliding scale insulin in the inpatient hospital setting.
Intravenous Insulin
In the critical care setting, according to the guidelines, “continuous intravenous insulin infusion has been shown to be the best method for achieving glycemic targets. Intravenous insulin infusions should be administered based on validated written or computerized protocols that allow for predefined adjustments in the infusion rate, accounting for glycemic fluctuations and insulin dose.”
Another set of issues occurs with intravenous insulin administration, however. A 2014 ISMP survey of pharmacists and nurses found that intravenous insulin ranked first, and subcutaneous insulin ranked ninth among nearly 40 drugs and drug classes identified as high-alert medications that concerned practitioners.
ISMP has urged that verbal orders should not be accepted for IV insulin, preferring that the orders should be faxed when the prescriber is off-site. If no other alternative exists, emergency telephone orders should be accepted with a second person listening, transcribing the order directly onto an order form and repeating it back for clarification. It also urged that all insulin infusions be prepared in the pharmacy and emphasized that insulin must never be dispensed or administered without an independent check, using the actual order and verifying that the patient needs insulin or has hyperglycemia.
A possible solution to avoiding IV errors is using products that are already prepared for IV infusion in hospitals and other acute-care settings.
Last summer, the Food and Drug Administration approved the first and only ready-to-use insulin for IV infusion. The product, Myxredlin (Insulin Human in 0.9% Sodium Chloride Injection) has an extended shelf life of 30 days at room temperature (77° F [25°C]) or 24 months if refrigerated (36° F to 46° F [2° C to 8° C]) in the original carton to protect from light.
It is provided in a standardized concentration of 100 units/100 mL in a flexible plastic container.
“Insulin is in the top five drug classes involved with medication errors, and more than 30% of those errors result in patient harm,” pointed out Robert Felicelli, president, pharmaceuticals, Baxter. “When a patient requires intravenous insulin in the hospital, pharmacists have to manually admix insulin for treatment. With the launch of Myxredlin, clinicians will have access to a convenient, reliable presentation of ready-to-use insulin that can help ensure faster delivery to patients, streamlined workflow for pharmacists and nurses, and less waste for hospitals.”
Myxredlin, for use only in acute care settings under medical supervision, is indicated for use as a short-acting human insulin to improve glycemic control in adults and pediatric patients with diabetes mellitus.
- Anderson TS, Lee S, Jing B, et al. Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals. JAMA Netw Open. 2020;3(3):e201511. doi:10.1001/jamanetworkopen.2020.1511.
- Lutz-McCain SJ, Bandi A, Larson M. Advancing Patient Safety and Access to Concentrated Insulin (U-500 Regular Insulin) in the Veterans Health Administration: A Clinician Education Program in the Primary Care Setting. Clinical Diabetes : a Publication of the American Diabetes Association. 2018 Jul;36(3):244-250. DOI: 10.2337/cd17-0033.
- American Diabetes Association. 15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42(Suppl 1):S173–S181. doi:10.2337/dc19-S015.
