Dispense a needle with that pen

A diabetic patient visited an endocrinologist at an academic medical center, where she was prescribed HUMULIN R (insulin regular concentrate) U-500 pens. The patient was to administer 140 units 3 times a day. The prescription was dispensed by the medical center’s ambulatory pharmacy, where the patient was given the pens but no pen needles. Since she didn’t have any needles for the pens, when she got home she used one of her U-100 syringes that she had used with her previous U-100 insulin to draw her insulin dose from the U-500 insulin pen cartridge (essentially using the pen as a vial). It’s possible that she may have measured and administered as much as “140” units (700 units of U-500). Her daughter found her unresponsive and called for an ambulance. When emergency medical technicians arrived, they gave the patient 12.5 g of 50% dextrose and transported her to the hospital, where she fully recovered.

Similarly, in our June 16, 2016 issue, we described a patient who was previously using insulin glargine U-100 but switched to TOUJEO (insulin glargine U-300). In this case, he was given pen needles to use with Toujeo, but at home, he decided to use up the remaining supply of U-100 syringes. Using the insulin pen cartridge as a vial, he drew up a dose, filling the U-100 syringe to the 100 unit mark—the same daily Lantus dose (100 units) he had been taking. This resulted in a dose of 300 units of Toujeo, not the prescribed 100 units, which led to hypoglycemia requiring hospital admission.

Plans are underway at the medical center where the most recent error was reported to give pharmacists authority to dispense pen needles without a prescription whenever insulin pens are prescribed. Perhaps insurance providers that currently require a prescription for needles should take note and allow pharmacists to dispense appropriate pen needles whenever a pen device has been prescribed. Also, it is critical for prescribers, nurses, and pharmacists to educate patients about the proper use of insulin pen devices, the importance of using the correct pen needle with the device, and to never use the insulin pen cartridge as a vial. In addition, a process should be in place prior to discharge to ensure that patients have the medications or prescriptions, equipment, and supplies needed at home to manage their insulin therapy (e.g., insulin, syringes or pen needles, blood glucose meter and strips, lancets, lancing device, glucagon emergency kit).