Objectives
- Review order requirements for patients needing testing supplies and injectable diabetes medications
- Introduce the various forms of injectable medication delivery and continuous glucose monitoring (CGM) devices
- Review common trouble spots for injectables and testing supplies
Checking Blood Sugar
Your patient will need prescriptions for the following:
- Glucometer
- Lancets
- Test strips
- Control solution
- Alcohol swabs (maybe—see below under glucometer pearls)
Example order on Epic:
- Pro tip: The above order set is saved in Epic under Matt’s preference lists. To copy, go to Personalize at the top of your Epic screen, then click Preference List Composer, then click Copy User Lists at the bottom and search for Matt in the “From User” box.
Your prescriptions will need:
- Testing frequency
- Diagnosis code
Prescribing limitations:
- Last meter fill date
- Insurance testing frequency restrictions
- Brand restrictions
- The control solution is often forgotten, but it’s the FDA-recommended way to check whether a glucometer is providing accurate readings.
- Finger pricks can be difficult and painful. Counsel patients to prick the sides of their fingers as opposed to the finger pads. The sides of the fingers actually have better blood flow and pricks in this area cause less pain!
- Alcohol is an astringent, and can make finger pricks more difficult and painful. Washing hands with soap and water prior to finger pricks may make the process easier and less painful.
Continuous Glucose Monitoring (CGM)
FreeStyle Libre CGM
- Libre 14-day reader or phone app
- Libre 14-day sensors
- Precision Neo test strips
- Freestyle lancets
Dexcom G6 CGM
- Transmitter (3 months)
- Receiver or phone app
- Sensors (10 days)
Troubleshooting Testing Supplies:
- Test strip integrity
- Use the control solution
- Matching code/manufacturer
- Residue on unwashed fingers
- Proximity to insulin pumps/connectivity issues
- Example: A pump and a CGM should be separated by at least 3 inches from one another on the body
- Insufficient blood draw
- Appropriate lancing device/location
- Poor circulation
- Insufficient lancet gauge/depth
- Reusing supplies
- Is it working and the patient does not know?
- Visual impairment (Prodigy voice meter)
Starting an Injectable Medication for DM
The ADA has great easy-to-read information for patients available online!
To start an injectable medication for DM, patients need prescriptions for the following:
- Insulin or other non-insulin injectable DM drug
- Insulin syringes for vial preparations
- Pen needle for pen formulations
- Note that Ozempic does NOT need a prescription for pen needles
- Alcohol swabs
Example order on Epic:
- Pro tip: Check the patient’s insurance and corresponding online formulary (e.g., NHPRI formularies) to determine which type of insulin (e.g., Lantus, Basaglar) is covered. Alternatively, ask the Medication Access team to determine the best option for your patient!
Insulin Prescriptions & Injections
Insulin Pens & Syringes
- Insulin comes in 3 forms: syringes, pens, or pumps. (Insulin pumps are typically managed by our endocrinology colleagues, so we won’t focus on them here.)
- Insulin syringes come in 3 sizes: 0.3, 0.5, or 1 mL.
- 0.3 and 0.5 mL syringes are graduated in 1-unit intervals.
- 1 mL syringes are graduates in 2-unit intervals.
- Each size is best for different insulin doses
- 0.3 mL syringes are best for doses <30 units
- 0.5 mL syringes are best for doses of 30-50 units
- 1 mL syringes are best for doses >50 units
- Insulin pens can make taking insulin more convenient because they combine the medication and syringe into one handy unit, but they tend to cost more than syringes. Pens come in 2 forms: reusable pens (used with insulin cartridges) or pre-filled disposable pens.
- Pen needles screw onto the top of an insulin pen. Patients should change the needle after each injection or at least once daily. Fresh, sharp needles mean shots that are less painful.
- Most brands of pen needles fit any of the insulin pens. Pen needles come in different lengths (generally 4-12 mm) and gauges (i.e., thickness).
- A shorter needle is effective for all body types.
- Location matters! Insulin enters the blood at different speeds when injected at different sites. Insulin shots work fastest when given in the abdomen whereas it arrives in the blood a little more slowly from the upper arms and even more slowly from the thighs and buttocks.
- Injecting insulin consistently in the same general area is recommended. This is because the insulin will reach the blood with about the same speed with each insulin shot.
- Patients should not inject insulin in exactly the same spot each time, but should move around the same area.
Insulin Storage & Dispensing
- Although manufacturers recommend storing your insulin in the refrigerator, injecting cold insulin can sometimes make the injection more painful. To avoid this, many providers suggest storing the bottle of insulin you are using at room temperature.
- When insulin is kept in the fridge, it will last until its expiration date.
- In general, insulin kept at room temperature will last approximately 28 days (see specifics in the table below).
- Check out these additional recommendations on insulin storage.
Non-insulin Injectable Medications
There are multiple subcutaneous GLP-1 receptor agonists for DM on the market:
- Semaglutide (Ozempic)
- Dosing is once weekly (see figure below)
- Dulaglutide (Trulicity)
- Dosing is once weekly
- Liraglutide (Victoza)
- Dosing is once daily
- Exenatide (Byetta)
- Dosing is twice daily
Troubleshooting Injectable Medications:
- Where is the medication being stored?
- Does the patient have the appropriate ancillary supplies to complete injections?
- Are they prescribed?
- Is it the right size?
- Is the patient assembling the product correctly?
- Is the patient injecting in the proper sites?
- Angle/placement
- Sufficient units on insulin rx
- Priming inclusion
Blog post based on Med-Peds Forum talk by Kat Duprey, Med-Peds Clinical Pharmacist