Technician Tutorial: Dispensing Insulin and Other Injectable Meds

Transcription

1 (Page 1 of 6) Technician Tutorial: Dispensing Insulin and Other Injectable Meds Insulin is a hormone secreted by the pancreas. It helps the body use glucose as an energy source. Insulin acts like a key that allows glucose to enter the body s tissues. People with diabetes either don t produce insulin (type 1) or don t produce enough insulin at the right times to meet the body s needs (type 2). Without the right amounts of insulin, glucose builds up in the blood and other organs and causes tissue damage or death. Although type 2 diabetes can sometimes be managed with oral medications, many type 2 patients and all type 1 patients will require injections of insulin. There are many types of insulin available to meet patients individual needs. There are also other injectable drugs used to treat diabetes besides insulin. They include exenatide (Byetta), exenatide extended-release (Bydureon-U.S. only), liraglutide (Victoza), albiglutide (Tanzeum-U.S. only), and dulaglutide (Trulicity-U.S. only). These meds help increase the body s own natural secretion of insulin. Pramlintide (Symlin-U.S. only) is another injectable diabetes med. It helps reduce blood glucose in a different way than increasing insulin levels. Insulins are considered high-risk medications because they are frequently implicated in serious medication errors. With high-risk meds, even small errors can be lethal. Examples of how these errors can happen with insulin include confusion between insulin products or dosage forms, and use of dangerous abbreviations such as u for units on prescriptions for insulin. U can be mistaken for a number 4, or a zero, resulting in an overdose. You must be vigilant when dispensing insulin and other injectable diabetes meds, and question any part of an order or prescription that seems inappropriate or unclear. Mrs. Franklin, a 55-year-old female patient, presents an Rx for Humulin R, one vial, to be used as directed. You notice that the abbreviation ud meaning use as directed could easily be mistaken for 4 days or 40. You also see that the R in the drug name is sloppily written and could therefore be misread as N. This could lead to incorrect interpretation of the prescription as being written for Humulin N instead of Humulin R, which could cause the patient s blood sugar to drop for a longer period of time than expected. What information should you ask when a patient drops off an Rx for insulin or another injectable diabetes med? Patients with newly diagnosed diabetes, or patients with long-standing diabetes starting on insulin or another injectable diabetes med, may have anxiety about injections. These patients often have many questions. The pharmacist may need to spend extra time counseling such patients. It will help the pharmacist if you ask patients some basic questions to clarify their educational needs. For example,

2 (Page 2 of 6) have you ever used insulin or an injectable medication before? You may also want to ask if the patient knows how much of the medication to use, especially if the prescription is written use as directed. (Insurers frown on a sig of use as directed and the pharmacist may need to clarify the exact directions for use with the prescriber.) The pharmacist will also want to know if the patient has any questions about checking their blood sugar (i.e., glucose). Inquire if the patient needs any other diabetes supplies (e.g., alcohol swabs, syringes, glucose meter strips, lancets, needles, sharps container). You know that Mrs. Franklin has not purchased insulin at your pharmacy before. You ask her if she knows how much to take and her response is I think so. Based on this answer, you ask her if she would like to speak to the pharmacist and she says, yes. What should be considered when entering an insulin prescription or a prescription for another injectable diabetes med into the computer? Choose the correct product in the computer. Some brands of insulin such as Lantus come in both a vial and as a pen. Watch out for mix-ups between look-alike, sound-alike drug names such as Byetta and Bydureon. Byetta is dosed twice daily. Bydureon is dosed once per week. Humulin and Humalog mixups are common. Levemir and Lantus can also be confused. Lantus has even been confused with Humalog even though they look and sound different. Enter dosing instructions completely. Insulin prescriptions may have especially complex instructions. Pay special attention when entering dosing instructions for these prescriptions into the computer. Make sure the prescription label reads exactly as it is written on the prescription. Additional label space may be required for detailed instructions. As mentioned, a prescriber might write the prescription instructions for insulin as use as directed, allowing changes to be communicated directly to the patient. (Once again, insurers frown on using use as directed, and the pharmacist may need to clarify instructions for use with the prescriber.) Patients may be instructed by the prescriber on how to vary the dose of their short-acting (e.g., Humulin R) or rapid-acting insulin (e.g., Humalog) depending on what they will be eating at each meal. This is sometimes called carb counting. You may also see prescriptions written for SS or sliding scale insulin. This is more common in the hospital or nursing home setting. A sliding scale means the dose of insulin varies depending on the patient s blood sugar. Enter an accurate quantity to be dispensed. One vial of insulin typically contains 10 ml of insulin. Prescription quantities for liquids are usually entered as the number of ml instead of the number of vials or packages dispensed for reimbursement purposes. In this case, entering the quantity dispensed as 1 for the number of insulin vials dispensed may cause inadequate reimbursement since this may be communicated as 1 ml being dispensed, instead of the full 10 ml contained in one vial. For pens that come in multipacks such as Victoza, make sure to enter the total number of ml in the whole box or carton instead of the number of pens or the number of ml in one pen. For example, a two-pack of pens that contain 3 ml of drug each will require entering a dispense quantity of 6 ml. Enter an accurate days supply. When specific dosing instructions are included, a days supply value can be calculated. Example: For a patient using 100 units of insulin per day, how long would one vial of insulin 100 units/ml last? 100 units/ml x 10 ml/vial = 1000 units/vial 1000 units/vial x 1 day/100 units = 10 days

3 (Page 3 of 6) When specific dosing instructions are NOT provided on the prescription, you ll need to clarify this information with the prescriber s office. You can also consider asking the patient how they have been advised to dose the medication to help you determine how long the medication should last. An incorrect days supply entered on dispensing can cause future third-party problems. Insurance companies will often reject a claim with a refill too soon message if a claim is transmitted before the previous prescription s days supply has passed. For example, if an Rx is entered for a 30-day supply, the insurance will not pay for a refill of that medication if the patient runs out in just 14 days. Also, billing incorrectly can lead to audits or paybacks. For Mrs. Franklin s prescription you enter the quantity dispensed as 10 ml. You do not know how much insulin she will be using each day, so you ask. Mrs. Franklin says that she expects to use about 40 units each day. You enter a days supply of 25 days (1000 units/vial x 1 day/40 units = 25 days). What should be considered when selecting insulin or another injectable diabetes med from the fridge? Insulins differ from each other in regard to source (e.g., human, human insulin analog, pork [Canada only]) and duration of action (e.g., rapid-, short-, intermediate-, or long-acting). Human insulin does not actually come from humans; it is genetically engineered, but it is identical to the insulin produced by the human pancreas. Human insulin analogs are human insulin that has been modified to make the insulin act more quickly for use around mealtimes (e.g., Humalog, Apidra) or last longer (e.g., Levemir, Lantus). Mixtures of short- and longer-acting insulins are also available to reduce the number of injections for patients requiring both types. For example, Humulin 70/30 is 70% NPH (an intermediate-acting insulin) and 30% regular insulin (a short-acting insulin). It s a good idea to use separate bins or shelf alerts to distinguish among products that look similar. Insulin most commonly comes in a concentration of 100 units per ml. This strength is referred to as U Vials contain 10 ml, or 1000 units (100 units/ml x 10 ml/vial = 1000 units). A 500 unit per ml Humulin R (referred to as U-500) is available by prescription in the U.S. for people requiring large doses. In Canada, U-500 insulin is only available through Health Canada s Special Access Programme. If this very concentrated insulin is available in your pharmacy, it should be kept in a special place in the fridge to avoid mix-ups. Mistakenly dispensing 500 units per ml Humulin R in place of the 100 units per ml strength could result in a five-fold overdose. The patient s blood sugar could plummet, which could be fatal. Some insulins such as Humalog, Lantus, and NovoLog (U.S.) are available as pre-filled pens, or as cartridges to be used with a reusable pen. Exenatide (Byetta), liraglutide, and pramlintide also come as pre-filled pens. With pens, patients just dial up the dose they need and inject it. For more details about all the insulins and the other injectable meds for diabetes, including formulations, storage, administration devices, cost, etc., see our PL Chart, Comparison of Insulins and Injectable Diabetes Meds (U.S. subscribers; Canadian subscribers). If you see that a patient is switching from one pen device to another, such as from Levemir FlexPen to the newer Levemir FlexTouch (U.S.), let the pharmacist know so that he or she can make sure the patient knows the proper technique for using the new pen. To fill Mrs. Franklin s Rx, you choose Humulin R, which is regular human insulin. When you remove the insulin from the refrigerator, you take care not to confuse Humulin R with Humulin N (an intermediate-acting insulin), Humalog (a rapid-acting analog), or a Humulin or Humalog mixture. You also make sure you have U-100 and not the higher strength U-500.

4 (Page 4 of 6) What should be considered when labeling insulin and other injectable diabetes meds? When labeling insulin and other injectable diabetes meds, take care not to cover the name of the product, storage information, expiration date, and NDC code (DIN in Canada) that may be printed on the box. If more than one vial or package of pens is needed to fill a prescription, print duplicate labels. A label with a use by date is helpful for the patient, since these meds are usually good for around a month (often less than this for pens) once they are dispensed and stored at room temperature. For patients who get a supply of multiple vials or pens to last for a few months, a refrigerate label is helpful to remind them to keep the med in the fridge until they start using it. Our PL Chart, Comparison of Insulins and Injectable Diabetes Meds (U.S. subscribers; Canadian subscribers) has information on room temperature stabilities. It s important to note that most insulins and other injectable meds that come in pens should not be placed back in the refrigerator once they are in use. At this point, they should only be stored at room temperature. Storing them in the fridge can actually cause the pen to malfunction and leak. (Symlin and Victoza are two exceptions.) In the hospital setting, keep in mind the mantra one pen, one patient. It is important to label insulin pens for individual patients. Make sure a patient-specific label is attached to the pen itself and not just to the cap or the bag it is delivered in to help prevent mix-ups between patients. Even if the needle on a pen is changed, there is still a risk for cross contamination between patients. Nurses should never use one patient s pen to administer insulin to another patient. Although Humulin R requires refrigeration while stored in the pharmacy, it can be kept at room temperature for up to 28 days once in use. You place a label indicating this on Mrs. Franklin s Rx. When the pharmacist counsels Mrs. Franklin, he also gives her information regarding correct storage. What are some workflow considerations that apply to insulin and other injectable diabetes meds? Once the prescription is ready, it should be stored in the refrigerator until it s picked up by the patient. Workflow for storage and retrieval of refrigerated prescriptions such as insulin varies among pharmacies. Many pharmacies place an empty bag, label, and receipt in an alphabetized bin near the cash register, but store medication in a patient pickup bin in the refrigerator. With this method, prescription bags are easily located in the normal pharmacy storage area, while insulin is safely stored in the fridge. Make sure to use a refrigerate sticker or another reminder notation on the receipt and bag with this method to ensure that the insulin is retrieved from the refrigerator when the patient pays for the prescription. Other pharmacies using barcode systems may have a separate storage area in the refrigerator for labeled and bagged prescriptions that are ready to be picked up. Use our PL Technician Tutorial, Stay Cool: Storing Meds in the Fridge or Freezer, for more information. What should be considered when dispensing insulin syringes and pen needles? In some locations, insulin syringes require a prescription, or can only be dispensed along with insulin, either by law or by store policy. A prescription is required for third-party coverage. Be sure to enter the insulin prescription in the computer before dispensing syringes or other diabetes supplies. Some thirdparty payers reject coverage for diabetes supplies until the insulin prescription has been entered because the computer does not detect an active insulin prescription to justify the diabetes supplies. Insulin syringes are marked in units, not in ml like most other syringes. Insulin syringes are designed to be used with insulin vials containing insulin at a concentration of 100 units per ml. Insulin syringes

5 (Page 5 of 6) differ in the total amount of insulin they can hold (e.g., 100 units [1 ml], 50 units [0.5 ml], 30 units [0.3 ml]). Insulin syringes come with a needle attached. The gauge of the needle tells you how fine, or thin, the needle is. The larger the gauge, the thinner the needle. For example, 31 gauge needles are thinner than 28 gauge needles. Thinner needles may be more comfortable for the patient, they also get bent more easily. Needles also differ in regard to the length. Common needle lengths are ½ inch (12.7 mm), 5/16 inch (8 mm), and 3/16 inch (5 mm). Some patients prefer shorter needles for comfort. But shorter needles may not be long enough for overweight patients. Patients should not change needle lengths without discussing it with their prescriber. Unlike insulin syringes, insulin pens and other injectable diabetes meds require needles. When dispensing an insulin pen, be sure to choose the correct pen needle for the specific pen. Pen needles come in different sizes. If you are unsure of which brand name or needle type a patient s pen requires, check with the pharmacist. Process the pens and pen needles as two separate prescriptions. Even though pen needles are OTC, most insurances will cover them as long as the patient has a prescription for them. Patients should be discouraged from reusing their pen needles or leaving them on their pen. Reuse can increase the risk of injection pain and infection. Leaving them on can cause air bubbles, leaks, or clogging of the pen. Mrs. Franklin returns the next day with the following prescription, which she forgot to bring in before: Lantus 15 units at bedtime, dispense a one-month supply, with three refills. Lantus is insulin glargine, a long-acting insulin. You know that it s not unusual for a patient to use more than one insulin product at a time. How do you calculate how much insulin to dispense? How is this entered into the computer? Mrs. Franklin will need 15 units per day for 30 days. You calculate that she will need 450 units for a 30-day supply (15 units/day x 30 days = 450 units). You know that each 10 ml insulin vial contains 1000 units of insulin (100 units/ml x 10 ml/vial = 1000 units/vial), so you dispense one vial of Lantus for a one-month supply. However, since Lantus vials must be discarded after 28 days once they are in use, you enter a 28-day supply into the computer. Keep insulin storage and stability in mind when entering days supply for insulin prescriptions. In the above example, Mrs. Franklin will only use approximately one-half of one Lantus vial in 30 days at her current dose of 15 units daily. When entering the days supply amount for this prescription, it would seem logical that one vial is enough insulin for two months. However, any in-use Lantus vials should be discarded after 28 days. As such, this prescription should be entered into the computer as being for one 10 ml vial and a 28-day supply.

6 (Page 6 of 6) Also be alert for patients requiring multiple vials for a one-month supply of insulin. For example, if this prescription had been for 40 units at bedtime, two vials (20 ml) would be dispensed (40 units/day x 30 days = 1200 units, requiring two vials). Also consider the patient s third-party coverage. In some cases, the patient will pay less if they get a 90-day supply all at one time. For Mrs. Franklin, a 90-day supply of Lantus would be three vials, taking the 28-day expiration for an in use vial into account. The pharmacist would instruct Mrs. Franklin to keep the unused vials in the refrigerator until she needs them. Dispensing pens and refill cartridges can be tricky. For example, Lantus SoloStar pens contain 3 ml (300 units) of Lantus each. Each box contains five pens, for a total of 15 ml (1500 units) of insulin. 3 ml/pen x 5 pens/box = 15 ml/box Check with your pharmacist about the best way to enter the quantity for an insulin pen or refill cartridge prescription. In most cases, the quantity in this example would be entered as 15 ml when dispensing a carton of five cartridges or pens, reflecting the total volume dispensed in ml (as calculated above). It is best not to break a carton or box of insulin cartridges or pens for inventory reasons. So if Mrs. Franklin s prescription were for the pens, it would be best to dispense 15 ml, which would be about a three-month supply, if possible. 100 units/ml x 15 ml/box = 1500 units/box 1500 units/box x 1day/15 units = 100 days/box Can insulin be dispensed without a prescription? In the U.S., some insulins are nonprescription. Humulin R is one example. Other insulins, such as Lantus, require a prescription in the U.S. For third-party coverage, a prescription is necessary, even for OTC insulins. In Canada, all insulins are nonprescription/schedule II (i.e., only available with pharmacist assistance). Project Leader in preparation of this PL Technician Tutorial: Stacy A. Hester, R.Ph., BCPS, Assistant Editor Cite this document as follows: PL Technician Tutorial, Dispensing Insulin and Other Injectable Meds. Pharmacist s Letter/Pharmacy Technician s Letter. December 2014.