Levemir

insulin detemir

(in-su-lin de-te-mir) ,

Levemir

(trade name) Pregnancy Category: B

Indications

Action

Pharmacokinetics

Time/action profile ( hypoglycemic effect)

ROUTE	ONSET	PEAK	DURATION
Subcut	3–4 hr	3–14 hr†	6–24 hr‡

†Small amounts of insulin detemir are slowly released resulting in a relatively constant effect over time.‡Duration is dose dependent; duration increases as dose increases.

Contraindications/Precautions

Adverse Reactions/Side Effects

Endocrinologic

• hypoglycemia (life-threatening)

Local

• lipodystrophy
• pruritis
• erythema
• swelling

Miscellaneous

• allergic reactions including anaphylaxis (life-threatening)

Interactions

Drug-Drug interaction

Beta blockers, clonidine, and reserpine may mask some of the signs and symptoms of hypoglycemia.Corticosteroids, thyroid supplements, estrogens, isoniazid, niacin,phenothiazines,, and rifampin may ↑ insulin requirements.Alcohol, ACE inhibitors, MAO inhibitors, octreotide, oral hypoglycemic agents, and salicylates, may ↓ insulin requirements.Concurrent use with pioglitazone or rosiglitazone may ↑ risk of fluid retention and worsening HF.Glucosamine may worsen blood glucose control.Fenugreek, chromium, and coenzyme Q-10 may produce additive hypoglycemic effects.

Route/Dosage

Dose depends on blood glucose, response, and many other factors.

Availability

Nursing implications

Nursing assessment

• Assess patient for signs and symptoms of hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait) and hyperglycemia (confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; nausea; vomiting; unusual thirst) periodically during therapy.
• Monitor body weight periodically. Changes in weight may necessitate changes in insulin dose.
• Lab Test Considerations: Monitor blood glucose every 6 hr during therapy, more frequently in ketoacidosis and times of stress. Hemoglobin A_1C may be monitored every 3–6 mo to determine effectiveness.
Overdose is manifested by symptoms of hypoglycemia. Mild hypoglycemia may be treated by ingestion of oral glucose. Severe hypoglycemia is a life-threatening emergency; treatment consists of IV glucose, glucagon, or epinephrine. Recovery from hypoglycemia may be delayed due to the prolonged effect of subcut insulin detemir.

Potential Nursing Diagnoses

Noncompliance (Patient/Family Teaching)

Implementation

• high alert: Insulin-related medication errors have resulted in patient harm and death. Clarify ambiguous orders; do not accept orders using the abbreviation “u” for units, (can be misread as a zero or the numeral 4; has resulted in tenfold overdoses). Insulins are available in different types, strengths. Check type, dose, and expiration date with another licensed nurse. Do not interchange insulins without consulting physician or other health care professional.
• Do not confuse Levemir (insulin detemir) with Lovenox (enoxaparin).
• Use only insulin syringes to draw up dose. The unit markings on the insulin syringe must match the insulin’s units/mL. Special syringes for doses <50 units are available. Prior to withdrawing dose, rotate vial between palms to ensure uniform solution; do not shake.
  • high alert: Do not mix insulin detemir with any other insulin or solution, or use syringes containing any other medicinal product or residue. If giving with a short acting insulin, use separate syringes and different injection sites. Solution should be clear and colorless with no particulate matter.
  • Do not use if cloudy, discolored, or unusually viscous. Store unopened vials and cartridges of insulin detemir in the refrigerator; do not freeze. After initial use vials of insulin detemir cartridges (PenFill) or a prefilled syringe may be stored in a cool place for 42 days. Do not store in-use cartridges and pre-filled syringes in refrigerator or with needle in place. Keep away from direct heat and sunlight.
• Subcutaneous: Rotate injection sites.
  • Administer daily insulin detemir with evening meal or at bedtime. Administer twice daily insulin detemir evening dose with evening meal, at bedtime, or 12 hrs after morning dose.
• Not for IV administration or use with insulin pumps.

Patient/Family Teaching

• Instruct patient on proper technique for administration. Include type of insulin, equipment (syringe, cartridge pens, alcohol swabs), storage, and place to discard syringes. Discuss the importance of not changing brands of insulin or syringes, selection and rotation of injection sites, and compliance with therapeutic regimen. Patients taking insulin detemir should be given the Patient Information circular for this product.
• Explain to patient that this medication controls hyperglycemia but does not cure diabetes. Therapy is long term.
• Instruct patient in proper testing of serum glucose and ketones. These tests should be closely monitored during periods of stress or illness and health care professional notified of significant changes.
• Emphasize the importance of compliance with nutritional guidelines and regular exercise as directed by health care professional.
• Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other Rx, OTC, herbal products, or alcohol.
• Advise patient to notify health care professional of medication regimen prior to treatment or surgery.
• Advise patient to notify health care professional if nausea, vomiting, or fever develops, if unable to eat regular diet, or if blood glucose levels are not controlled.
• Instruct patient on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur.
• Patients with diabetes mellitus should carry a source of sugar (candy, glucose gel) and identification describing their disease and treatment regimen at all times.
• Advise patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding or planning to breastfeed.
• Emphasize the importance of regular follow-up, especially during first few weeks of therapy.

Evaluation/Desired Outcomes

• Control of blood glucose levels in diabetic patients without the appearance of hypoglycemic or hyperglycemic episodes.