After a patient had been using insulin syringes to administer insulin glargine rDNA origin (Lantus) from vials, his physician prescribed a Lantus SoloSTAR pen. When the patient picked up the pen at the pharmacy, he wasn't counseled on its use. This pen contains 300 units of Lantus. Proper use requires turning a dosage knob to set the dose and pressing an injection button once to administer it. The patient, who was supposed to inject 75 units of insulin, pressed the button three times and administered 225 units. He developed hypoglycemia and required treatment in the ED.

Unlike syringes and other pen devices, the Lantus SoloSTAR pen doesn't deliver the entire amount of insulin in the reservoir; the plunger moves only partially and a reservoir scale shows the remaining volume of Lantus. Expecting the plunger to move like a typical syringe, the patient didn't notice the subtle movement. After this event, he received proper instruction on how to use the pen.

If your patient is about to use any new product, provide education and hands-on training on its proper use. (An instructional video on using the Lantus SoloSTAR is available at http://www.ismp.org/sc?k=lantus.)