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March 4, 2011

Daily Care, Insulin

Question from Bogota, Colombia:

In October 2010, I started my treatment with an insulin pump due to severe hypoglycemia without symptoms. Pump treatment here in Colombia is a new tool to control diabetes; here, in our country, there are only 300 Medtronic pump users. The team of doctors validating the amount of insulin that I have to use recommended lispro (Humalog). I use more than one 10 ml bottle monthly, but the pharmacy will give me only one bottle per month. According to my calculations, the minimum amount of lispro that I am using is 0.9 ml each for three days. Adding up a month's worth comes to 9 ml, but there are times when I need to increase my dose for highs, so I don't have enough. Is there a study where I can show the average need for the additional insulin? It is important to note that the doctor needs to report the amount of insulin that I need by meal (bolus), but with this concept, they are forgetting the daily basals, which in my case total 5 units. In Novemer, I reported the problem. To solve the situation, I was using a reserve that I kept for long travels or broken bottles instances. However, the reserve is on minimum limits and I need this amount for the cases of severe highs, when the pump recommends injections. Can I exchange the lispro insulin with Regular insulin, some of which I have and which has not yet expired?

Answer:

Many of our patients use more than one vial per month of insulin. Each patient is unique in their level of insulin resistance and, therefore, how much insulin they require. In our country, prescribing rules require us to indicate the daily insulin requirements so that validation of the insulin amount for prescribing can occur. You are correct in that there are days you use more and the average may not fit. This would seem to be a typical issue and one that we do not hold in stone in the U.S. There are additional uses for the insulin, such as priming the tubing or insulin lost at the end of three days that does not get used. I would ask whether the rule that allows only one vial to be distributed per month is a rationing policy or a cost control mechanism. Additionally, is it expected that patients pay for any additional amounts used? The use of Regular insulin has totally different patterns of action and it would be dangerous to use this type of insulin after using lispro most of the time. It may be necessary for you to purchase a vial every other month or so to have enough or to notify the pharmacy of your prescription plan and have them help you. Again, this is a minor issue in the U.S. It is accepted that some patients may use more insulin than one vial per month.

JTL