High Insulin Dosages

[megahew]

Hey everyone,

The other night I had patients who were ordered an outrageously high dosage of insulin for mealtimes plus sliding scale coverage. 100 units and 75 units of humalin R for each patient. Is this legitamite- has anyone ever given this much insulin before?

I ended up not giving the insulin. And on one of the patients, I got the md to dc the mealtime coverage.

But geez, even in a type 1 diabetic, I would think you'd kill the patient with that much insulin...

[blondy2061h, MSN, RN]

Some patients are extremely insulin resistant and require high doses. Usually these patients are type 2 diabetics, not type 1 diabetics. Type 2 diabetes is a disease of insulin resistance.

Before just asking for the coverage to be d/c'd, did you check to see if the patient has been getting that much? Ask the patient what they took at home? Question the physician?

[smf0903]

They don't make 100 unit syringes for nothin'

We have two patients who come in and bring their home insulin (U500)...I swear I have like 5 people check and check and check again because it's a crazy amount of insulin--something like 35 units of U500 before meals.

No way would I hold that...maybe I'd double/triple check the order, ask the patient what they normally take, etc.

[megahew]

Well, I mean, I did question the physician and they dc'd it. Their blood sugars were running 150-200. Later, one of my patients blood sugar was in the 70s with only sliding scale coverage.

But thank you, I'll keep that in mind. I had never seen regular insulin ordered that highly and the other nurses I was with didn't know either! Just wanted to know that it wasn't a mistake and it wouldn't harm the patient if I gave it.

[Sour Lemon]

I've seen a few "outrageous" doses, but don't remember the exact numbers. I verify the orders and usually try to get them decreased, at least temporarily. People usually eat very differently while they're hospitalized.

[NuGuyNurse2b]

Well, I mean, I did question the physician and they dc'd it. Their blood sugars were running 150-200.

perhaps they were much higher previously? hence the high doses. And even if this is their normal range because they're so insulin resistant, I still would've double checked a dose that high given the blood sugar readings you gave. I think you did the right thing in this case.

[blondy2061h, MSN, RN]

Perhaps there eating quite differently in the hospital.

[blondy2061h, MSN, RN]

We have two patients who come in and bring their home insulin (U500)...I swear I have like 5 people check and check and check again because it's a crazy amount of insulin--something like 35 units of U500 before meals.

To expand on this, I'm assuming they were getting to the 35 unit mark on a U-100 syringe worth of insulin in U-500 insulin, or 175 units. This is where insulin dosing can get confusing. A lot of newer U-200 and U-300 insulins are coming out and only in pen form to keep it simpler.

[Agatha12]

I have seen like 100u in two divided doses. I was also surprised about it because when I was a student in my country of origin. I have never seen more than 20u at once.

[smf0903]

To expand on this, I'm assuming they were getting to the 35 unit mark on a U-100 syringe worth of insulin in U-500 insulin, or 175 units. This is where insulin dosing can get confusing. A lot of newer U-200 and U-300 insulins are coming out and only in pen form to keep it simpler.

Yes, 175 units. I hate the U500 and am glad we only rarely see it. I swear I have every nurse that's working check it and then have the patient check it as well (those patients probably think I am an idiot but I'd rather look like a moron than overdose someone with insulin).

[KatieMI, BSN, MSN, RN]

It is named "insulin resistance" and a frequent symptom of DM type II, much more rarely of type I.

Pancreas makes about 50 units/24h, normally. In highly resistant patients,

that might be not enough for basal coverage, and if they are sick or take steroids, the requirements might get ridiculously high. I'd seen over 300 units/day and 100 units plus "super-high" coverage for meals. These super-resistant people are usually also morbidly obese, so standard ADA diets are not applicable to them. A patient weighting 500 lbs has to take 3000 kcal/24 hours just to stay alive. 4 carbs/meal diet means starvation for them.

There is no such thing as "legal dose of insulin". As with many other drugs, the correct dose is "just enough of it".

[CKPM2RN, ASN, EMT-P]

I have one patient whose meal time sliding scale goes up to 50 units (novolog). That's on top of his twice-daily lantus. There are people with huge insulin use but I agree, when I see an amount like that I still do a double take and then triple check it.