NAPLEX Question of the Week: Transitions in Care

An insulin substitution is the subject of our question of the week.
NAPLEX Question of the Week: Transitions in Care

 JM is a 59-year-old female with a past medical history significant for hypertension and type 2 diabetes mellitus. She comes into your ambulatory care clinic requesting a Toujeo SoloStar insulin pen to help with convenience. She has recently gotten insurance and had previously been well controlled using over-the-counter 70/30 insulin, 50 units injected subcutaneously twice daily.  If she is only going to be injecting the Toujeo once daily, how many units of the Toujeo would you recommend? 

A. 48 units

B. 56 units

C. 70 units

D. 80 units

E. 100 units

Answer with rationale:

The correct answer is B.

Brand/generics covered: Insulin glargine - Toujeo/Lantus, insulin detemir - Levemir, insulin degludec - Tresiba

Most insulin conversions are 1:1, but switching from NPH that is dosed twice daily to insulin glargine once daily is an exception where you should use 80% of the NPH dose if the patient is well controlled. With 70/30, the 70 is the NPH long-acting component, and this is a unique scenario where you should give 80% of the NPH component as Toujeo once daily to minimize the risk of hypoglycemia. Our patient’s total dose is 100 units of 70/30 daily. This is 0.7 * 100 units or 70 units of NPH daily. This should then be reduced to 80% of the NPH dose: 0.8* 70 units = 56 units daily of Toujeo, making answer choice B correct.  The patient should also be given 30% of each premixed (70/30) insulin dose as prandial insulin if desired. In this case, that could be 15 units (30% of the 50 unit injection) of insulin aspart before the meals where the 70/30 was taken previously. Toujeo SoloStar is a concentrated insulin glargine pen that comes in a U-300 formulation, meaning it is 300 units per 1 mL. Toujeo comes in 1.5 and 3 mL pen sizes. Remember, all insulin pens are multi-dose, and pen needles need to be dispensed with every prescription for insulin pens unless the patient has some already.

NAPLEX Competencies covered:

2.2 – Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied

3.4 – Drug dosing or dosing adjustments; duration of therapy

4.4 – Dose conversions

Hope everyone is having a great summer!

Dr. B

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