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Practical Diabetes Care: How Do I Order That?

Mizuho Morrison, DO, Neda Frayha, MD, and Rana Malek MD
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Ever struggled with how to prescribe lancets, test strips, or insulin pen needles? Or wondered which syringe length or gauge to order? In this mind-blowingly practical, helpful segment, endocrinologist and clinician educator Dr. Rana Malek teaches Miz and Neda the basics of what to order for our diabetic patients, along with tips for injection techniques, common prescribing pitfalls to avoid, attention to insulin pricing, and the new continuous glucose monitor that primary care providers will be prescribing. This segment will change your practice.

Pearls:

  • Starting and maintaining a patient on insulin can be complicated. Dr. Malek (endocrinologist) breaks down all the important components. Don’t memorize it: store the information somewhere so you can reference the tips and tricks below!

 

  • What a patient needs when starting insulin?

    • 1. Glucometer - tests the blood sugar level

    • 2. Lancing Device - device that pricks their finger to test blood sugar level

    • 3. Lancets - small needle that is loaded into the lancing device

    • 4. Test strips - holds the blood and plugs into the glucometer to get a reading of the blood sugar

    • 5. Alcohol wipes - better to use than alcohol solution/sanitizer because that can artificially raise the blood sugar level

    • 6. Insulin delivery mechanism - may be a preloaded pen or syringes

    • 7. Ketostix - may test ketones in the urine

    • 8. Glucagon - used if hypoglycemia is an issue for patients

  • How to know what is covered by insurances?

    • www.formularylookup.com

    • Know there are options outside of insurance:

      • Example - Walmart has test strips 50 for $9 whereas any other brand device it may cost $35-50 for the same amount

  • How do you order supplies?

    • Generally order them as individual units as opposed to 1 box, 2 boxes, etc.

      • Example -cheaper things come in boxes of 100 while more expensive ones come in boxes of 50  like glucose test strips.

    • Syringes needs to be ordered by:

      • Volume (ml): 30, 50, 100

      • Length (in): ½, 3/16, 5/16 or  6mm/8mm

        • Most patients 4mm is enough because you just want subcutaneous tissue

        • Patients who get burning with insulin, they have may try a longer needle

      • Gauge: 29, 31

    • Lancets:

      • Each is matched to the particular lancing device

      • Some are single use and others are a drum that contain multiple needles

      • Also come in different gauges → larger gauge for those who have been using for a long time and have scarred over their finger

    • Insulin pen needle:

      • Length

        • Nano = 4mm

        • Mini = 5mm

        • Short = 8mm

        • Original = 12mm

    • Insulin:

      • U100 insulin = 1ml has 100U of insulin → 10mls = 1000U of insulin

        • One pen usually holds about 3mls of insulin = 300U, one box of insulin pens usually has 5 pens

      • U200 insulin is double the concentration of U100 insulin

        • One pen of 3mls of U200 insulin = 600U of insulin. One box of these pens usually has 2-3 pens

      • U300 and U500 insulin are also out there

  • Medicare requirements:

    • Type II diabetes ICD-10 code

    • Indicate whether or not you are using insulin

    • Indicate if going by Medicare principles of testing:

      • Oral medications = once a day

      • Insulin = 3 times a day

      • If going over these limits, you have to indicate a reason (ie: “hypoglycemia”)

  • Continuous glucose monitoring:

    • Used to be limited to type I diabetes and endocrinologists; however, a newer system (FreeStyle Libre) is a much more affordable/accessible option:

      • Worn on the arm, continuously reading blood sugar levels, no calibration, no fingersticks

      • Medicare covers for anyone testing their blood sugar level 3 times per day

      • Each sensor costs about $30, lasts for 10 days → pretty equivalent price-wise to test strips

      • Handheld device costs $70-90

 

References:

https://formularylookup.com   

http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/?loc=lwd-slabnav

http://www.diabetes.org/living-with-diabetes/health-insurance/medicare.html

 

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This Mailbag is About to Rupture! Full episode audio for MD edition 191:34 min - 90 MB - M4APrimary Care RAP - May 2019 Written Summary 601 KB - PDF

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