Lantus and NPH question

  1. Hi all I'm new to long term care, worked Med/Surg last 13 years, as a MDS coordinator so I'm seeing some things for the first time. I've never used Lantus in conjunction with NPH for blood sugar control but the MDs here are ordering it this way. I know you can't mix them in the same syringe but do they counteract each other in the system? The blood sugars here are a little out of control (avg A1C 8.6) and I'm wondering if this is why? Anyone have any info on this or where I may be able to find some? Any help would be greatly appreciated!
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    About MDS_Coordinator

    Joined: Mar '09; Posts: 2

    13 Comments

  3. by   blondy2061h
    Lantus is a long acting (24 hr) that generally has a flat profile. NPH is an intermediate acting insulin (lasting 6-8 hrs) that peaks in action at about 4 hrs.



    Lantus is overall a much better choice for basal coverage as it's more steadily absorbed (NPH is very variable based on injection site and activity) and the peak can be a killer. Ideally on Lantus, one should be able to skip meals and not go low.

    The best insulin plan short of a pump is Lantus or Levemir once or twice a day with coverage for meals based on bg and carb intake with Apidra, Humalog, or Novolog. However, this means an injection of Lantus once or twice daily, plus a injection every time food is eaten and when bg is high. This often meals 4+ shots a day, and some people aren't willing to do that.

    Enter in NPH. Notice that nice spike NPH has? If injected in the morning, that spike can be used to cover lunch. It's much hard to work than a fast acting insulin, as activity and carb intake need to be consistent, and it can't be used to cover an already high bg, but it can save someone a shot.

    Also, some people have Dawn Phenomenon, and if injected at bedtime, NPH's peak can cover the 3am spike some people tend to have.

    So in short, it has it's purpose. It may be used in conjunction with Lantus if the person overall needs more insulin coverage than their NPH dose can provide without the peak causing lows.

    NPH and Lantus can work, but it takes careful bg analysis and trial an error. It's not going to be a good regimen for most people. From the sounds of it, between the quite bad a1c you quote (8.6 is very out of control, not a little) and the fact that it sounds like you have many patients on it, I'm guessing your prescribers just don't know how to use insulin well (a common problem).
  4. by   MDS_Coordinator
    Thanks very much and yeah the fact that I'm dealing with LTC MDs is one of the things that's taking some getting used to they are not very receptive to suggestions that require additional work on their part... no w/e, no holidays, no rotation may not be worth it in the long run... well again thanks!!
  5. by   classicdame
    also, Lantus is an analog, while NPR is regular insulin with protamine added to "slow it down". That is why they cannot be mixed. Mixing changes the action of both.
  6. by   CoffeeRTC
    I've seen both used.
  7. by   blondy2061h
    Quote from michelle126
    I've seen both used.
    Together?
  8. by   CoffeeRTC
    NPH at breakfast and dinner and normally Lantus at night. They might also be on a sliding scale.
  9. by   Ms.RN
    Whare are the difference between Humulin, Novolin insulin? theres also different insulins like Levimir, Apidra
    Last edit by Ms.RN on Jun 1, '09
  10. by   blondy2061h
    Quote from Ms.RN
    Whare are the difference between Humulin, Novolin insulin? theres also different insulins like Levimir, Apidra
    Humulin and Novolin are different brands of insulin. Humulin is made by Eli Lily and Novolin by Novo Nordisk. Both come in NPH and R formulas. Eli Lily also makes Humalog, which is rapid acting. Novo Nordisk also makes Novolog which has action similar to Humalog. Novo's last insulin is Levemir, similar action to Lantus but shorter acting, and not very commonly used, it seems. Finally, Aventis makes Lantus and Apidra, with Apidra having similar action to Humalog and Novolog.
  11. by   kids
    This is why I never accept an insulin order by brand name *twitch*
  12. by   blondy2061h
    Quote from kids
    This is why I never accept an insulin order by brand name *twitch*
    Well "Novolin R" or "Humulin R" would be acceptable orders, as would "Novolog" or "Humalog" but just "Novolin" wouldn't be. And of course we haven't touched on mixes. "Novolin 70/30" or "Novolog 70/30" would be examples here. Those are just pre-mixed insulins with one percent being rapid or fast acting and one percent being NPH. In Novolin or Humulin mixes the fast acting portion is Regular and in the 'logs the fast acting is just the name of the mix- Humalog or Novolog.

    Most hospitals will either have Novolin/Novolog on formulary or Humulin/Humalog on, and pharmacy will auto-substitute.
  13. by   Cassaundra
    Here's a little tid-bit I learned in Clinicals one night:

    Humulin R: Manufactured by adding human genes to E. Coli. Can be used in an insulin pump.

    Novolin R: Manufactured by changing yeast components. Can not be used in an insulin pump.

    Main difference is that if someone is on either one of these they should not be switched to a different regular insulin because the action of onset and duration is somewhat different.
    Last edit by Cassaundra on Jun 2, '09 : Reason: typo
  14. by   blondy2061h
    Quote from Cassaundra
    Here's a little tid-bit I learned in Clinicals one night:

    Humulin R: Manufactured by adding human genes to E. Coli. Can be used in an insulin pump.

    Novolin R: Manufactured by changing yeast components. Can not be used in an insulin pump.

    Main difference is that if someone is on either one of these they should not be switched to a different regular insulin because the action of onset and duration is somewhat different.
    I'm not sure where your professor learned that. Humulin and Novolin R are identical insulins.

    I've used Novolin R, Humalog, Apidra, and Novolog all in my pump on various points in time. Novolin R and Humulin R aren't really preferred for pumps any more due to their longer action profile.

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