Do you ever hold Lantus?

[SleeepyRN]

My understanding is that you do not hold lantus. (I'm a new grad just started in LTC). BG WAS 126 after having dipped tp 67. I raised his glucose to 126 and administered the Lantus. I'm an RN, and the oncoming nurse was an LPN. He was irritated with the fact that I gave the Lantus. I respect LPNs experience and I do learn from them, but there is a reason why RNs are needed. That last year of nursing school, you grow and learn so much that LPNs do not get in the LTC setting. What are your thoughts on holding Lantus?

[Havin' A Party!, ASN, RN]

Sam J. said:

Funny- I thought physicians decided (by way of orders) what meds to give, and when, and when not...

Will not sidetrack the thread, but only make the passing remark that, of course, there are times when nurses will be the ones to originally decide to hold a med or to provide another intervention.

[Archerlpvn, LPN, LVN]

I am an LPN as well, and I never hold lantus. I don't think that was decision based solely off being an LPN, that was just bad nursing judgement across the board in general that any individual RN or LPN can have in my opinion.

[delphine22]

You can't hold Lantus unless there are parameters (there usually aren't, because it shouldn't be held). It's not sliding scale, you don't have permission to just withhold it without speaking to the MD -- otherwise you're practicing medicine without a license, just like you wouldn't hold any other scheduled med without parameters. One hospital I worked at, that had paper MARs, even went so far as to write under the Lantus/Levemir doses "do not hold without MD order," which when you think about it is redundant, but RNs did it all the time (and I as the following nurse always had to deal with resulting spike in blood sugar).

That said, when I see a poor effect, I call the doc. They want to be called; they want to know when things need to be adjusted, rather than having the nurses hold stuff willy-nilly. I work night shift, and if the pt is NPO after midnight and still has HS Lantus ordered, I will call the provider and verify if they want to give the full dose, half, etc.

[MunoRN, RN]

delphine22 said:

You can't hold Lantus unless there are parameters (there usually aren't, because it shouldn't be held). It's not sliding scale, you don't have permission to just withhold it without speaking to the MD -- otherwise you're practicing medicine without a license, just like you wouldn't hold any other scheduled med without parameters. One hospital I worked at, that had paper MARs, even went so far as to write under the Lantus/Levemir doses "do not hold without MD order," which when you think about it is redundant, but RNs did it all the time (and I as the following nurse always had to deal with resulting spike in blood sugar).

That said, when I see a poor effect, I call the doc. They want to be called; they want to know when things need to be adjusted, rather than having the nurses hold stuff willy-nilly. I work night shift, and if the pt is NPO after midnight and still has HS Lantus ordered, I will call the provider and verify if they want to give the full dose, half, etc.

You should always notify the MD if you're going to hold a med, but nurse's aren't actually required to give any and all ordered meds, a basic role of an RN is to determine the appropriateness of giving a medication and not give it if they can't be convinced it is appropriate. That's not practicing medicine, it's practicing nursing.

If a nurse gives a med against their judgement just because there is an order to give the med they are putting their license on the line. If the physician can't alleviate a nurse's concerns about giving a med then the physician can give the med themselves.

[whitevigilants]

We dont withhold lantus /levemir/glargine because its a long acting insulin . It's the only insulin that will be continued even if the patient is on a sliding scale. Insulin is not to be omitted . If hypoglycemia happens,we treat the hypoglycrmia then we give the insulin.

[Mudwoman]

Lantus is a basal insulin. It acts the way the pancreas acts between meals and during the night. It lasts 24 hours. It is important that it be given at about the same time each day. The dose may need to be reduced, but never "held". Give the patient an additional snack of 30 grams of carbs if there is worry about hypoglycemia, but never, ever not give the Lantus (or Levemir).

Unless there are standing orders on parameters for holding insulin, you would never not give insulin without consulting the doctor or APN and getting an order to do so.

[adnrnstudent, ASN, RN]

If a patient went to bed at 120 and woke up at 50 and I had the patient the next night and the Lantus order didn't change, there is a case where I would hold it if I couldn't get a hold of Doc.

[jeseale123]

Insulin glargine has no peak and should be administered even if the current blood glucose level is within normal limits.

[RNinNYC]

Lantus should not be held. It is used to cover the glucose produced by the liver, which is an ongoing occurrence.

[RNGummy40]

When reading your post, I immediately thought about the NCLEX Exam questions that ended in absolute terms like NEVER and ALWAYS.

The answer to your question will ALWAYS be found in the total assessment of your specific patient. Diabetic management is not universal, and the World Health Organization emphasizes a unique care plan for each patient, to manage and treat diabetes.

When giving insulin, safety is always the top priority. Insulin is a drug that can tip the scale at any point in time, causing complications for your patient and requiring nursing interventions, ranging from simple to complex. Insulin is a high risk drug. Whether it is short or long acting, the significance of potential harm is not limited to those factors alone.

Context is always needed when administering insulin. In the long term care setting it is important to know if your patient is eating. Are they eating carbohydrates, which type of carbohydrates, are they consuming fiber and protein with carbohydrates. Are there any GI abnormalities including gastric bypass, peg tubes, j tubes, NG tubes, or on a dysphagia diet. Is the patient sick, experiencing diarrhea, emesis, and or dehydration. Does the patient ambulate and or physically active. What is the mental status of the patient? Are they confused, forgetful, disorganized, mood fluctuation, and or suicidal.

Any barriers towards maintaining food intake would should cause the administrator of scheduled insulin to Stop, Think, Act, and Review concerns.

Additional factors to review, especial if the patients is under the care of endocrinologist or their have been new changes to their diabetic treatment including: is the patient on oral hypoglycemics with insulin management, what is their insulin to carbohydrate ratio, is the patient still producing their own insulin, or are they switching from oral to insulin management.

The diagnosis of the diabetic is another factor: are they Type 1, Type 2, converting from Type 2 to Type 1 (their are additional types)? What is their HA1C level? Do they have comorbid cardiovascular complications? Does the patient have hypoglycemic awareness? If not, that a problem, but if so, number of recent hypoglycemic events.

When testing their blood glucose before meals what is the value? It is consistent with their daily checks. Is it an upward trend or downward trend. Classic hypoglycemia starts less then 70 mg/dl, if you get a glucose value between 70 and 150 you have to verify other factors mentioned.

What is the hypoglycemic protocol if the patient is over insulated? Can you start an IV, do you have glucogon? Do you have simple sugars available?

When administering Long Acting Insulin should you hold it? Well, what is the dosage and what are the trending numbers? How does the Dawn Effect alter your patient's blood glucose levels? If your patient is waking up to low numbers: 70's 80' (60's Bad), are you wondering what their blood glucose level is at 3AM? Are you concerned about the Somogyi effect? Are they waking up to higher blood glucose levels, are they making more food requests during the day? Did they experience recent increases to their insulin management?

Can long acting insulin cause hypoglycemia? ABSOLUTELY!!! If the drug manufacturer warns the user in bold print, believe it. I have taken 80's 90' even 200mg/dl blood glucose levels from patient's and given just Lantus or Levemir and I my patients have have experienced hypoglycemia (some have experienced relative hypoglycemia as well). Professionally, do I want to hold their long acting insulin: ABSOLUTELY NOT. Specifically Lantus I don't want to hold because EBP has shown that it does slow the progressing of diabetes and minimizes the number of protein-glucose or glucose-lipid chains which causes organ damage.

But, I will hold and call the provider with my findings and recommend changes (SBAR) to prevent an hypoglycemic event.

Complicated patients including patients with a mental health diagnosis can certainly provided evidence to hold insulin, verify meal consumption. Depending on the diagnosis and behaviors of the patient, they may not be prescribed long acting insulin because they have a documented history of high risk behaviors.

It is easier to treat a patient with short acting insulin when their are complications present. If you remember when taking care of patients on TPN, only short acting or regular insulin is used.

Again, diabetes is complicated, so absolute solutions are far and few. If your patient was hypoglycemic why were they hypoglycemic. Holding the long acting insulin would make sense till you could explain why, otherwise you could be back to treating hypoglycemia again. Did you explain to the LPN your rational fore why you think she was hypoglycemic? Need more info. Hope you can understand why your LPN would be concerned.

[Spitfire27]

I wouldn't say that you NEVER hold lantus. Even the company who makes Lantus says it's contradicted during episodes of hypoglycemia and it can be life threatening if given during these episodes.