The Pharmaceutical Journal
Vol 270 No 7237 p267
22 February 2003
PDF* 85K
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The Pharmaceutical Journal |
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PDF* 85K |
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OFT report
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DiabetesCovering the optionsFrom Mrs I. Gummerson, MRPharmS Neil Caldwell, commenting on "rapid-acting insulin", eg, Humalog (PJ, 15 February, p228) stated that the recommended time of administration of a rapid-acting insulin analogue is immediately before a meal (to limit the post-prandial rise in blood glucose). The BNF states "shortly before meals or when necessary shortly after meals, according to requirement". However, I do not know how many people find it necessary to inject rapid-acting analogues after meals although I can think of two possible reasons why they might need to. First, they might need to inject after a meal of high fat/low carbohydrate content (not generally recommended for people with diabetes), where the food is retained in the stomach for longer and the post-prandial rise in blood glucose is delayed. In this situation, the risk of post-prandial hypoglycaemia would be increased if they inject too early, especially in individuals who have good glycaemic control. Secondly, people who have slow absorption of food due to delayed gastric emptying caused by autonomic dysfunction (sometimes observed in people who have had type 1 diabetes for many years) might need to inject thus. So for the rapid-acting analogue insulin perhaps "inject shortly before meals, or as directed" would cover the options? I would be interested to hear from pharmacists with diabetes who inject after meals and why. Irene Gummerson Insulin confusionFrom Mr D. M. Wilkes, MRPharmS, and others We would like to share the following experiences regarding confusion between insulin glargine (Lantus) and insulin lispro (Humalog) that have occurred within Ceredigion. Insulin glargine is a long-acting insulin analogue launched in Britain by Aventis in August 2002. Lantus insulin cartridges (3ml) are used with the Optipen Pro 1 insulin delivery pen. Insulin lispro is an insulin analogue of a faster onset and shorter duration than soluble insulin. Humalog insulin cartridges (3ml) are used with the Humapen Ergo insulin delivery pen. An initial concern has been the fact that Lantus is a clear solution similar to a short-acting insulin, unlike existing long-acting insulins, which are cloudy suspensions. Because of the risk of confusion, all diabetes specialist nurses and pharmacists have been advised to ensure that any patients prescribed Lantus are counselled about this risk. Incidents have occurred when patients have put the Humalog cartridge into the Optipen Pro 1 in error and, consequently, have administered the wrong insulin. This has occurred because although the Lantus and Humalog cartridges have the name of the insulin and have different colour-coded bands on them, they are the same size and shape and are interchangeable. Following the first incident, all patients prescribed Lantus in this area were contacted to receive extra counselling. Despite this, another three incidents occurred. Fortunately, no one has suffered any long-lasting side effects. Patients have, however, experienced a loss of diabetic control, with hypoglycaemic episodes at night and raised blood sugar levels during the day. These incidents did not cause them any harm at the time, but other patients may not be as fortunate. Aventis reported that it has only had one report of this happening and this was in the United States. We believe that the number of incidences is probably a lot higher than this. Either patients in Ceredigion (a sample of 92,000-registered population) are not as careful as the rest of the population or prescribers and nurses are not considering the possibility of this mix up occurring when patients are presenting with poor diabetic control while on Lantus and Humalog. Local general practitioners and pharmacists have been asked to ensure that all patients receiving both Lantus and Humalog are counselled about the risks of confusing the cartridges. The specialist diabetic nurse at the local hospital is now recommending that Humalog disposable pens are prescribed for new patients. Existing patients will remain on disposable cartridges. Until the design is changed these patients will still be at risk of administering the wrong insulin. As this is a patient safety/clinical governance issue, should the companies concerned not be pressured into changing the design of their cartridges to remove the risk identified? We would be grateful to hear from other pharmacists or diabetic nurse specialists as to whether they have experienced similar incidents. Don Wilkes Rachel Russell Shirley Oliver |
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