Individuals who teach patients how to use insulin pens need to be aware of what can happen when patients become familiar with the NovoFine Autocover disposable safety needle system that is used for education in many hospitals. With this needle system, the user holds the outer cover of the needle system while it is screwed onto the insulin pen. The outer cover is then removed, exposing a plastic needle shield that covers the needle. As the device is held against the skin, the needle shield slides back, allowing the skin to be punctured, and the insulin is injected once the button is pressed. After the injection is complete, the shield slides back over the needle as it is removed from the skin and locks in place so the needle cannot be used again.
The Autocover safety needle is quite different than standard insulin pen needles that patients purchase at their pharmacy. Insulin pen needles for home use are not safety needles and do not employ a needle shield. However, these two needle systems look similar, and patients may not recognize the difference. Both the Autocover safety needles and standard needle systems have an outer cover that, when removed, exposes either a retractable needle shield (Figure 1) or a needle cap (Figure 2). The Autocover needle shield is not intended to be removed prior to injection, but the needle cap on the standard needle must be removed before the injection to allow administration of insulin.
A hospitalized patient was receiving new insulin therapy with a NovoFine Autocover safety needle attached to the pen. Prior to being discharged, the patient was taught how to use the insulin pen at home using the safety needle. Home visits were made after discharge, and the patient reported elevated blood glucose levels to the nurse. When the nurse investigated, she realized the patient was not removing the cap from the pen needle because she thought it was the same safety needle used during her hospitalization. Consequently, the needle never punctured the skin.
Patients who use Autocover safety needles in the hospital and are then switched to standard pen needles at home must be advised that there are two types of needle systems for pens. If they are using standard needles, they need to know to remove both caps. The hospital that reported the latest event has changed to nonsafety needles when training patients to make sure they know how to administer insulin with the pen and needle they will use at home. Home care nurses should verify which needle the patient used in the hospital and tailor the training.
Tresiba U-200 won't allow odd number dosing of insulin units. With the introduction of the TRESIBA (insulin degludec) U-200 pens comes a chance for dosing errors. A pharmacist reported that a physician prescribed 25 units daily of Tresiba U-200. This product is only available in the Novo Nordisk FlexTouch insulin pen. An odd numbered dose is not possible with U-200 because the pen only allows dosing increments in even numbers, from 2 units to 160 units. In this case, a patient tried to dial 25 units by estimating the proper position between 24 units (marked on the pen) and a notch or score that represents 26 units (Figure 3). Due to the design of the pen, the insulin will not be administered unless the pen is set to an even dose-24 or 26 units in this case. Be aware of the difference between U-100 pens and the U-200 Tresiba pen. Although the U-200 pen will allow doses from 2 to 160 units (in even numbers only), prescribers should consider providing a U-100 pen when smaller or odd numbered doses must be administered.
"Ellipta"-it's not a drug. A pharmacist misread a prescription for INCRUSE ELLIPTA (umeclidinium), which was a new prescription for a patient upon discharge from a hospital, as "Increase Ellipta." The pharmacist was only familiar with BREO ELLIPTA (fluticasone and vilanterol) and had never filled a prescription for Incruse Ellipta prior to this incident. Because the patient had not been taking an "Ellipta" inhaler previously, the pharmacist called the prescriber's office to clarify the dose. The prescriber confirmed the dose for Breo Ellipta as 100/25 mcg per inhalation, evidently overlooking the fact that he had prescribed Incruse Ellipta for this patient. When the patient was readmitted to the hospital several weeks later for an unrelated diagnosis, a pharmacist discovered the error and investigating why the patient was taking both ADVAIR (fluticasone propionate and salmeterol) and Breo Ellipta.
GlaxoSmithKline has marketed several inhalers for asthma or chronic obstructive pulmonary disease (COPD) using the "Ellipta" trademark to identify the inhalation delivery device. Breo Ellipta, was the first, becoming available in 2013. Since then, several other "Ellipta" products have been marketed, including ANORO ELLIPTA (umeclidinium and vilanterol) and Incruse Ellipta (umeclidinium), both for COPD, and ARNUITY ELLIPTA (fluticasone furoate), for asthma. We have received reports about "Ellipta," the inhaler delivery system trademark, contributing to confusion and errors when patients or healthcare professionals refer to these products only by that name and not the associated drug brand name. This increases the risk of an incorrect medication being added to the patient's medication history. Do not refer to these new inhalers by the name "Ellipta."
Does ClariSpray look familiar? CLARISPRAY is fluticasone propionate, a corticosteroid nasal spray that is generically equivalent to FLONASE ALLERGY RELIEF. In the upper right-hand corner of the ClariSpray package label (Figure 4), Bayer, the distributor of the product, notes that it is "from the Makers of Claritin." CLARITIN is loratadine, an antihistamine. With this product association, the similar package colors and graphics, and because each name starts with "CLARI-," it's possible that some patients may think that ClariSpray is a spray form of loratadine. Consumers and pharmacists need to be aware of the differences between these products.