Lantus (Insulin Glargine): Scratching The Surface

[TheCommuter]

The cells of the human body require a continual stream of energy at all times in the form of glucose, and insulin is the the vehicle that allows this glucose to enter the cells. The pancreas of a healthy non-diabetic person has two mechanisms of insulin secretion: basal insulin production and bolus insulin (a.k.a. prandial insulin) production.

Basal insulin is constantly produced by the pancreas in small amounts and is in the bloodstream at all times, whereas bolus insulin is secreted in bursts to address the postprandial spikes in blood glucose levels that are caused by eating. In other words, the insulin that a healthy person's pancreas makes has two separate functions: basal, which is for all-day baseline action, and bolus, which is for sudden mealtime action.

For effective blood glucose control, the diabetic patient might be prescribed a basal insulin (such as Lantus) and a bolus insulin such as Humalog or regular insulin. This regimen is designed to mimic the secretory response of the healthy non-diabetic pancreas.

According to Newton (2007), basal-bolus insulin is one of the most advanced approaches to diabetes care, offering a way to closely simulate natural insulin delivery. Basal insulin controls blood glucose levels in response to the constant low-level supply of glucose made by the liver, whereas bolus insulin responds to rises in blood sugar due to food intake.

Lantus is a slow-acting basal insulin. Many patients and some healthcare workers do not realize that Lantus is a basal insulin and conclude that if they administer it to replace the insulin that the pancreas no longer secretes, that it is enough to result in normal blood glucose levels. However, Lantus is absorbed slowly over an extended period of time and does not address the mealtime spikes.

In addition, some nurses will hold Lantus if a patient's most recent blood glucometer reading is in the 90s or low 100s with the mistaken belief that this type of insulin will lead to dangerous lows. However, nursing staff is mystified when the same patient's blood glucometer readings are extremely elevated on the next day. Holding Lantus is comparable to depriving the body of its supply of basal insulin.

Never mix Lantus with any other insulin because this action deactivates it. Lantus is for subcutaneous injection only and generally does not have a peak. According to Thompson (2008), the safest time of day to administer Lantus and Levemir is before bedtime. However, many patients experience successful outcomes when they take their basal insulin once daily in the morning. In addition, some physicians advise patients to divide their daily dose into two injections that are spaced 12 hours apart.

Since diabetes mellitus is so prevalent in healthcare settings, it is imperative that nurses and other healthcare workers are knowledgeable about the action of Lantus and other basal insulins. Knowledge is power, and together we can bestow our expertise upon our patients and their families to assist in warding off devastating complications.

References

Why Basal-Bolus Insulin Therapy May Be The Best Choice For Type 2 Diabetes.

Hold the Insulin! Or Maybe Not.

[Klimpys]

Thank you for posting this! I am the mother of a child with Type 1 diabetes. He was diagnosed 1.5 years ago when he was 13. I am not a nurse yet, I just finished doing my pre-reqs and will be starting the nursing program next month. I am a member of the Children with Diabetes website, and I remember reading threads about parents needing to advocate for their children if they are ever hospitalized because the staff is usually not overly knowledgeable about diabetes. No offense! Nurses have so much to learn, and have so much on their plate. Type 1 diabetes is a freaking roller coaster! There are so many variables that can contribute to high and low blood sugars it is ridiculous! Nurses, please take into consideration what the patient/parent may tell you regarding their doses and how they feel. They live with the disease and most (there are exceptions) know what works for them. If you want to know more about Type 1 diabetes visit the CWD site.

[Klimpys]

Chances are that it was actually explained and the patient just forgot afterward. This is exceedingly common in the clinic. Heck, even for simple things like what time of the day to take statins, I've had to explain to the same patients multiple times because they tend to quickly dump whatever's explained to them out of their memory once they leave the clinic.

In a previous post I mentioned that I have a son with Type 1 diabetes. We were basically given some training in the hospital (he was in DKA when admitted), a prescription for insulin, and sent home when he was stabilized. There was so much to learn on our own, and so much that we are still learning 1.5 years later. I know they can't prepare/teach patients everything because if they did, no one would want to leave! It is overwhelming!

[blondy2061h, MSN, RN]

As a type 1 diabetic, thank you, Thank You, THANK YOU!

[Maremma]

Thank you for the article. I am currently doing deeper research into diabetes, different types of insulin, drugs that affect blood sugars etc. This was perfect timing for me to read this!

My patients seem to have diabetes in epidemic proportions and quite a few are brittle. I need to be able to be a better advocate for my diabetic patients.

Has anyone found any articles dealing specifically with the percentages of diabetics that have their blood sugars affected by specific drugs? I found lists of drugs that can cause hypo or hyperglycemia but not specifics in numbers affected either way, length of time on both before it would affect them, doses required to cause effects etc.

For example we all know that diabetics requiring steroids may need increased amounts of insulins but is that ALL patients that also take steroids of any dose for any length of time?

Roxanol is another big concern for me due to it's ability to caused hypoglycemia and the common use of this drug by our Dr's. I currently have a patient that I am trying to get the Dr to change her insulin regime to sliding scale only due to this problem affecting her so drastically.

[Klimpys]

For example we all know that diabetics requiring steroids may need increased amounts of insulins but is that ALL patients that also take steroids of any dose for any length of time?

My son had to take steroids due to a nasty case of poison ivy. His blood sugar levels doubled! He was only on them for about a week, but we battled his numbers for several more. Before we went to the pediatrician I had read up the effects of steroids on Type 1 diabetics. It did seem that some people poo-pooed the notion that there would be any effect, but I know other wise.

[Maremma]

Indeed yes I am fully convinced steroids surely cause increased blood sugars. I have my third patient in six months that has had this issue. The last one "only" had a cortisone injection in her knee and here we are two weeks later still giving 15 units of insulin with meals plus the sliding scale!

She also takes 68 units of lantus qhs. I am not sure whether she has always taken that dose as she came in already on it and already having had the shot in her knee but I do know she said she used to only need sliding scale at meals.

It may be common in some places for the patients to "forget" what the Dr tells them but I know from experience there are many times the Dr does not explain anything to the patient concerning their illness much less their treatments! They simply precribed the meds and send them on their way. I myself have had this happen to me more than once and that was before nursing school so the excuse cannot be used "oh the Dr probably thought you already knew it already".

There are still a lot of Dr's that have the "Only I need to know and you just do as I say" mentality. This is one of the reasons I am so determined to deepen my own knowledge base. How can we expect compliance if they don't understand the illness nor why they have to do or not do certain things.

[EmTheNewRN]

Heck, even for simple things like what time of the day to take statins, I've had to explain to the same patients multiple times because they tend to quickly dump whatever's explained to them out of their memory once they leave the clinic.

This is why I feel strongly that people should be provided with written info on new diagnoses/treatments/advice. Not everyone is an auditory learner to begin with, but when faced with the stress of a health problem, it's even harder to learn.

If we had info sheets on Lantus, both the staff and patients could easily learn and keep a reminder of how it works. i.e. if there is an incidental low blood sugar, withholding Lantus will only cause high blood sugar the next day. If there is repeated low blood sugar at non-meal times, Lantus may need to be adjusted. And that Lantus doesn't control post-meal highs.

This is also where some nursing pharmacology education would be beneficial. My mother is in pharmacy school and is learning how insulins work. I forget the name of the insulin, but I watched an educational video with her about one of the long-acting insulins. Only the single-molecule form can act on cells, but the insulin randomly forms/breaks hexamers in the bloodstream, making molecules only periodically available as the insulin clumps break apart and are utilized by the cells. This is why even if blood sugar rises after eating, there is only a certain amount of (long-acting) insulin acting at any given point. If we know how an insulin works in the body, it's much easier to understand the clinical implications.

We have to learn so much about antibiotics in micro, it's a shame we don't get any training about the insulins. Seriously, in what nursing setting do you never encounter a diabetic?

[CHESCCRP]

Have you thought about asking your manager to contact your rep for Lantus and have that person drop by some education sheets for your patients? As part of an internship, I educated patients on starting basal insulin, and I remember that the Lantus rep gave me patient education materials that helped the patients get started. The reps are pretty good about providing educational materials as they relate to the disease and especially adoption of a new drug regimen.

This sounds like I'm advocating for a particular drug, but the decision to put the patient on Lantus was already made by the doctor. Please don't flame me for suggesting items provided by the drug reps.

[BrandonLPN, LPN]

I think I'd still feel uncomfortable giving lantus or levemir to a pt whose blood sugar was in the 50's. I get that the lantus won't have any immediate effect on his blood sugar level, but what if he doesn't eat? Won't the lantus just push it down further? And if you have a pt who is vomiting and not eating, shouldn't you hold the lantus until the situation resolves?

[nctamelanurse]

I received almost no education and I now wonder about what damage I may have done to my body because of the "education" I got. I am very disturbed but this is somewhat the norm for my area.....

[TheCommuter, BSN, RN]

I think I'd still feel uncomfortable giving lantus or levemir to a pt whose blood sugar was in the 50's. I get that the lantus won't have any immediate effect on his blood sugar level, but what if he doesn't eat? Won't the lantus just push it down further? And if you have a pt who is vomiting and not eating, shouldn't you hold the lantus until the situation resolves?

The pancreas of the nondiabetic person who does not eat is still producing a low-level supply of basal insulin at all times. However, (s)he will not become hypoglycemic because the liver is constantly producing glucose to cover any basal insulin that is being secreted.

The diabetic also needs this low-level supply of basal insulin. The Lantus will not push the blood glucose level down; rather, it will keep it steady, even if the patient does not eat. The liver of the diabetic patient is also producing glucose continually.

If one of my patients has a blood glucometer reading in the 50s, I'll call the doctor prior to giving anything. For instance, if the patient usually takes 30 units of Lantus at bedtime, the doctor will usually instruct me to give 15 units tonight instead of the usual 30 units. I have never been told to hold the Lantus, even if the blood sugar is low.

If the patient consistently tests at 50mg/dL at a certain time of day or night, we need to inform the doctor so they can initiate a permanent reduction in the dose of Lantus. Instead of 30 units nightly, the order might be changed to 20 units nightly or titrated downward until the consistent low blood glucose levels disappear.

However, if you hold the Lantus altogether, the same patient's blood sugars may run sky high the next day, and nobody can figure out what is going on. The nurse who completely holds the Lantus has just deprived the patient of their much-needed supply of basal insulin.

[BrandonLPN, LPN]

Ok, thanks for clarifying that. I've never held lantus, because I was told never to do so without a doctors order, unlike novolog which obviously has parameters. Now I understand better why.