Sunday, October 28, 2012

Pharmacy Consult: We accidentally just gave insulin aspart IV… Is that bad?

Open the Pyxis or Omnicell or fridge in your ED where insulin is stored. How many different vials are stocked? If you’re like most other EDs in the USA you’ll find a rapid acting insulin (aspart, glulisine, lispro) mainly used for hospital sliding scale regimens, insulin regular (fast acting) for IV use, an insulin mix (NPH or aspart/aspart protamine), and a long acting insulin (glargine or detemir) for maintenance.  With similar sounding, appearing and often stored next to each other products, it’s not surprising that insulin is the number 1 drug related to medication errors in US hospitals.  Consolidating the insulin products may be a solution, reducing the risk of grabbing the wrong vial. 

In pharmacy school and in residency, its rammed down your throat that your IV insulin is insulin regular. But there is no conceivable reason why rapid acting insulins (aspart, glulisine or lispro) cannot be given IV.  Right in the package insert of all places, IV administration is listed as a route of administration.

From an evidence-based perspective, there are two studies that compared the effects of IV aspart to IV regular and IV lispro to IV regular [1,2].  The two studies were methodologically similar.  Each conducted in healthy individuals, primarily measured glycemic threshold for onset of the clinically detectable autonomic reaction to hypoglycemia induced by aspart, lispro or regular human insulin and utilized the same dosing of 2 units/kg/min.  The blood glucose/time profiles were near identical between the different insulin products – practically speaking, this translates into a 1:1 dose conversion.

{From Frier BM, et al}

I have not yet been able to convince anyone in the hospital pharmacy to eliminate insulin regular from the formulary.  I suppose there are some valid reasons to have multiple insulin products stocked hospital wide, but at least in the ED, I think we could get away with keeping one (aspart or lispro) on hand. 

Aspart (Novolog)
Glulisine (Apidra)
Lispro (Humalog)
Regular (Humalin R/ Novolin R)
Mixes: (NPH, Humulin 50/50, Humulin 70/30…)
Glargine (Lantus)
Detemir (Levemir)

Fun pharmacy fact: NPH (neutral protamine hagedorn)

1. Frier BM, Ewing FM, Lindholm A, Hylleberg B, Kanc K. Symptomatic and counterregulatory hormonal responses to acute hypoglycaemia induced by insulin aspart and soluble human insulin in Type 1 diabetes. Diabetes Metab Res Rev. 2000 Jul-Aug;16(4):262-8.
2. McCrimmon RJ, Frier BM. Symptomatic and physiological responses to hypoglycaemia induced by human soluble insulin and the analogue Lispro human insulin. Diabet Med. 1997 Nov;14(11):929-36.

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