How to counsel CNP?

[RxBPharm]

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Recently I had a hard time explaining a CNP about usage of U-500 insulin. Here is what happened... The script called in for 30 Units of U-500 TID, ~30 DAY SUPPLY. The patient says that he is using U-100 syringe and injecting 30 units or 0.3 ml of U-500 insulin. This would mean he is injecting 150 units everytime. I wanted to calrify with CNP if she wants to give 150 unites 3 times a day or less. CNP is rude did not listen or try to understand and said that she will check with patient and get back to us. She left a voice mail latter in a very rude tone saying the same thing as original script and says that adds up to 150 units.

Although patients blood glucose is stable, everytime the patient comes in for refill one has to do overide with the insurance. I have also heard patient saying that insurance company is saying that he is consuming it too fast.

Can anyone suggest how should I give this RUDE nurse 101 for writting correct U-500 insulin prescription?

 

[bananaface]

here is what I would do:

Tell her you need the Rx written in volume rather than unit form, since the patient's measuring device is made for U-100 insulin rather than U-500 insulin. Ask her to also include the total number of units as a secondary notation, since this is an oddball and high risk concentration of insulin. If her numbers don't agree, then you can point that out and hopefully that will prompt her to listen.

 

[RxBPharm]

Thanks for the advice. When I called her the first time I was explaining her very systematically but she did not care to listen to me. I told her exactly the way you suggested that write in milliliters.... Since she did not give any attention to my advice I sent her a fax in writting. The fax that I send clearly wrote the maths involved with easy calculation for her to understand. All these efforts have fallen on deaf ears since it did not seem to bother her and she continues to write the way she has been writting.

 

[bananaface]

In that case, I would do the math myself, write the Rx out, and fax it to her for verification. Paper documentation is probably best if there is a potential interpretation issue anyway.

 

[haokiet]

pls correct me if im wrong..
converting 500-U to 100-U insulin..

30 --> 500-U
x ---> 100-U
x= 6.

if the pt is using 100-U insulin, he needs to measure
6 units of it.. right?

 

[RxBPharm]

6 units is is correct however U-100 syringe is not meant for injecting 6 units of U-500 insulin. 6 units = 0.06 ml

 

[Aznfarmerboi]

Tough situation. If you did your best to communicate to the CRNA on your part, nothing much you could have done. It seems like you handled everything properly. I probably would have flipped out.

 

[Old Timer]

They key thing you need to do is to document your interactions with the CNP. This will be invaluable when you are audited by the insurance company and it will also be invaluable if there is ever a lawsuit. No better way to get yourself out of trouble than having contemporaneous notes warning the physician and the patient of the dangers of the dosage in question.

 

[WVUPharm2007]

If it was the 1800s you could just challenge him to a duel. If it was the caveman days, you could just beat him with a stick. Sucks to be in the 21st century. You just have to deal with it, I guess.

 

[pharmacogenomic]

Sorry - I'm just not getting this problem.😳

You've got a pt using U-500 insulin. The dose is 150 units three times daily - right? Total of 13,500 units/month or thereabout....????

So....you take the rx as a verbal to that effect. The pt will require 3 vials of U-500 insulin per month - right? (27ml = 30 ml functionally).

So.....is your issue with the insulin or with the syringes?

Sorry if I'm just not getting it, but it doesn't seem to matter to me how it is written - you can convert/change the actual rx to what you're going to write on the label & give as "days supply" to the insurance company. Do the rx as a verbal & write it the way you want & the way it will survive an audit.

I've done these & have not run into any issues. My only issues are when someone uses both Humalog or Novolog pens & vials. Some insurances just don't see the difference nor need for both. We work it out by maximizing the time intervals, sometimes an override...but not as often as I used to have to do.

I do have one kid though who seems to break his Humalog vials. He's growing out of that slowly (he's 13), but it drove his mom crazy when he'd just throw it into his backpack & it would end up broken.🙂

 

[Starlix]

Sorry i donot understand too, actually i donot see what is wrong...
The Rx called for 30 units U-500 tid---->that means 90 Units daily, right?
By using U-500:
500 units --->1 ml
30 units----> X ------> X=0.06 ml


Upon using 100-U syringe
100 U----> 1 ml
X ----> 0.06ml -----> X=6 U

But we need 30 units

6 U ----->0.06ml
30 U----> X X=0.3ml

So to get 30 units out of 500-U insulin using 100-U syringe, I would pull out 0.3 ml. Please correct me if i am wrong.

To me it seems ok what the patient is doing, he is getting 30 U TID.

 

[bananaface]

It sounded to me as if the pt is injecting 0.3mL while the order calls for 30 units of U-500 insulin, which is actually 0.06mL. So, if the pt is really supposed to be injecting 30 units he needs to be talked to and if the pt is really supposed to be injecting 150 units, the order needs to be revised to reflect the true dose. It's probably supposed to be 150 units, otherwise he wouldn't need U-500 insulin. But, there still needs to be a clear order on record. The prescriber is apparently unwilling to give a verbal order of clarification.

 

[littleaznpharm]

Thank you for this post. I never heard of U-500 until I saw your post.

There's data in diabetic journal articles that mention the use of U-500. 150U Three times a day for U-500 is not an uncommon does. It's for the ppl that require more than 300-750 U of total daily dose of insulin. U-500 is for patients that need EXTREME insulin therapy. Insurance companies hate these patients. Come on! You have to special order 3 vials a month. ONLY 1 phamaceutical company makes it. Dude it's gonna cost A LOT!!! 😀

***Subsituting U-100 for U-500 is not adviseable. Even thou they are both regular insulin. U-500 works similiar to NPH. It last longer in the body than U-100.***

 

[RxBPharm]

Hello friends,

The CNP called today and apologized for her past behavior.

She further said that she was being MATH dumb and she wanted to prescribe 150 units (0.3 ml) 3 times a day and NOT 30 units TID of U-500 Insulin.

She basically gave a new prescription over the phone.

Now everything is straight.

Hence it was CNP's prescription writting typographical/mathematical mistake.

Thanks everyone for inputs !!!

 

[PharmDstudent]

Notes say:
1 U = 36 mcg, i.e. 28U/mg

What?