Switching insulsin

Feb 21st, 2016
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  1. Diabetic on Insulin
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  3. Erin Walker
  4. Message 1 of 10 , Feb 1 3:43 PM
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  6. Hi NatChatters and Dr. Mona -
  7. I have a patient who is fairly stable on Humalog 50/50 as his fast acting insulin. His insurance is no longer going to be covering this medication and are encouraging a switch to Novalog (which according to the pharmacist is a 70/30). The pharmacist and I are struggling to find a conversion table for you have recommendations? Is it unit for unit? (of course I am appealing the insurance.....).
  9. Thank you in advance.
  11. Erin Walker, ND
  12. Canby, Or
  15. Mona Morstein
  16. Message 2 of 10 , Feb 2 5:43 AM
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  18. Ugh! Get him off mixed insulin. Put him on straight Novalog or Humalog and either Lantus or Levemir instead.
  20. Mona Morstein, ND, DHANP
  21. Tempe, AZ
  23. Official Sponsor of NatChat—Doctor’s Data Labs
  26. Erin Walker
  27. Message 3 of 10 , Feb 3 8:40 AM
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  29. Dr. Morstein, Thank you for your reply. So I am to 'wing it' when I convert him from humalog to novalog? Or is there a standard conversion? Thank you.
  31. Erin Walker, ND
  32. Canby, Or
  35. Mona Morstein
  36. Message 4 of 10 , Feb 3 5:52 PM
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  38. Hello, Erin,
  40. How comfortable are you with knowledge of being the primary prescriber of insulin. Do you know how to teach patients how to dose, change doses, treat hypoglycemia, hyperglycemia, etc? If you are not comfortable with your insulin knowledge, I’m not sure you should take primary responsibility for changing a patient’s insulin, as then you are in reality taking over their insulin care.
  42. You might wish to listen to my insulin lectures on the webinar series I am giving.
  44. Mona Morstein, ND, DHANP
  45. Tempe, AZ
  47. Official Sponsor of NatChat—Doctor’s Data Labs
  50. weyrich_comp
  51. Message 5 of 10 , Feb 4 9:00 PM
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  53. not found. Is there a typo?
  55. I have a related question: I don't normally prescribe insulin, but have a patient who has asked me to do so (diet and meds has failed to control glucose). She has been on insulin before and doesn't like the weight gain, but is now convinced she needs to get her glucose under control. Invokana worked VERY effectively for her, but she had problems with UTI. She does know how to monitor blood glucose. Patient is in Payson; else I would happily refer her to you in Tempe!
  57. I am comfortable with prescribing glargine (or is detamir better?) per protocols published by Medscape:
  59. A starting dose of [glargine] 0.1 to 0.2 unit/kg is recommended in patients with an HbA1c lower than 8%,
  60. and a dose of 0.2 to 0.3 unit/kg if HbA1c is between 8% and 10%. This starting insulin dose is
  61. seldom sufficient to achieve metabolic control, so dose should be adjusted at regular and fairly short
  62. intervals to achieve glucose targets. The regimen is to either increase the dose by 2 units every 3 days
  63. until fasting glucose is less than 100-140 mg/dL or add 1 unit daily until target fasting glucose levels
  64. are achieved [MedScape CME "Intensifying Therapy in Type 2 Diabetes Safely and Effectively"]
  66. My question is exactly how to write the prescription? A pen? A vial and a standard syringe? (do all insurance companies cover the pens, or do the ObamaCare/AHCCCS ones only cover vial and syringe?
  68. Can you give me a typical script boilerplate to adapt?
  70. Thanks
  72. Orville Weyrich, PhD NMD
  73. Phoenix/Payson AZ
  76. Mona Morstein
  77. Message 6 of 10 , Feb 5 10:37 AM
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  79. Hello, Orville,
  81. It’s a pretty simple drive from Payson to Tempe. I’m happy to get her on insulin and deal with all the responsibilities which come with it.
  83. Mona Morstein, ND, DHANP
  84. Tempe, AZ
  86. Official Sponsor of NatChat--Doctors Data Labs
  89. Erin Walker
  90. Message 7 of 10 , Feb 13 8:36 AM
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  92. Hi Dr. Mona - Thanks again for the information. I am a primary care physician, and would never claim to be a diabetes expert more so than any other ND. However, there are a few patients who are interested in having me take over their insulin Rx. With the state of the US and the rise in diabetes, I feel it is important to be able to be able to educate patients and feel more comfortable with prescribing. The patients I do see monitor their glucose closely and do use glucose tabs, diet, exercise, sleep, etc to help maintain healthy levels. They also bring in diet diary's and their values to each appointment.
  94. I did take your diabetes seminar via webinar this past fall, and have had further training in insulin, pumps, prescribing, guidelines, and patient monitoring through OHSU CE. Unfortunately, there do not seem to be adequate conversions for the blends (50/50, 70/30) over to bolus insulin. The general response I have received between you and other specialists (including endocrinology) is 'well, good luck'. The particular patient is on basal as well.
  96. I was thinking with all of your diabetes experience in getting people off their blends, you may have some insight to share with the conversion. It seems, however, it is a matter of being careful, monitoring, and patient education. If there are further insights you can provide, that would be helpful. Thank you,
  98. Erin Walker, ND
  99. Canby, Or
  102. Mona Morstein
  103. Message 8 of 10 , Feb 14 7:13 AM
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  105. I have transfered many patients from combinations to single use, Erin. Tell me again what the combo is and I can get you started.
  107. Mona Morstein, ND, DHANP
  108. Tempe, AZ
  110. Official Sponsor of NatChat—Doctor’s Data Labs
  113. Erin Walker
  114. Message 9 of 10 , Feb 17 5:38 PM
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  116. Hi Mona, Thanks for jumping in on the case.
  117. The patient is as follows:
  118. Fasting glucose is as low as 65-75 in the mornings if he does not eat much at night. It will usually be between 102-110. If he eats more at night and is not physically active, it will be as high as 200.
  120. Basal Insulin is Lantus 10 units at night and 10 units in the morning.
  122. He is using Humalog for Bolus Insulin 2-3 units at breakfast and supper, and 1-2 units at lunch.
  124. My plan was (and correct any of this you feel it is in error) to switch from the Humalog 50/50 to Novolog and use Novolog 1 unit 15-30 min before meals (as he is doing with Humalog) and monitor blood glucose. If the morning fasting increases, I would then bump up his basal insulin. If he is high before a meal (over 150), he could add another unit at that meal. He is very good at monitoring and sees the value of diet and exercise (but does not always implement these 100%).
  126. Again, I appreciate your insight.
  128. Erin Walker, ND
  129. Canby, Or
  132. manifesting_health
  133. Message 10 of 10 , Feb 18 4:42 PM
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  135. Just a recommendation that Dr. Morstein's current multi-week webinar CE class on Diabetes has been so far AMAZING.
  136. Eli Camp - thanks for organizing it and Mona, thank you so much for sharing your knowledge. The detail is incredible and I am so appreciative of the chance to learn weekly. I know this information could be done at a seminar, but it is nice to mull it over for a week between classes.
  138. I think that the information provided in this class is a good first start to learning in the in's and outs of insulin prescribing. I'm also glad that I'll be able to pick Mona's brain when I actually prescribe it, if needed.
  140. The link to Medicine Professional Talk is
  142. Sara Rodgers, ND
  143. Boise, ID
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