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To Color or Not to Color Insulin With Vitamin B-12? Our "Help Us Avoid Fatal Mistakes!" Discussion Continues

Apr 28, 2008

Editor’s Note: Intrigued by the responses to our recent article, “Readers Challenge Insulin Manufacturers: Help Us Avoid Near-Fatal Mistakes!” Editor-in-Chief Scott King asked our board member, R. Keith Campbell, RPh, CDE, to respond to some questions about coloring insulin with vitamin B-12.

The discussion continues on safe and effective ways users can mark the difference between slow and fast-acting insulin.

Hi, Keith,
One of our most popular articles right now is about the many, many folks who accidentally mix up their insulin bottles and take a huge dose of fast-acting insulin by mistake, thinking they are taking long-acting.  (See the article and the 22 reader comments here.)

In a recent “Letter of the Week,” a woman asked about coloring the insulin itself to avoid mix-ups.  I remember in the early nineties, some folks mixed vitamin B-12 with their insulin and put it in their insulin pumps. I also remember my mom getting shots of B-12 in the early seventies, but thought this practice had fallen off. So I responded to the reader with this comment:  I have heard of folks putting bright orange injectable vitamin B-12 into their insulin. I also recall that doctors used to give shots of B-12 to folks who were tired or B-12 deficient.”

To which I received this response: Mr. King, answer this one: If they only used to give B-12 shots, then why in Hades do I get a monthly 3,000 mcg shot of B-12 (upped from 1,500 mcg monthly)?

I need to know how to reply to this comment. I wasn’t aware that B-12 shots are still a common practice. So, my questions to you are:

1. How do doctors know who needs B-12?  Is there a test for B-12 deficiency?  I remember that in the past, if you felt tired, the doctor might just say, “Bend over, you’re getting a shot of B-12.”  Is this still the case?

2. What's involved in adding B-12 to your bottle of insulin?   Would it hurt the action of the insulin? Is it OK with regular insulin but not with the analogs? Or is it OK to mix it with Novolog or Humalog?

3. Is B-12 a prescription item? Is 3,000 mcg of B-12 a lot or a little?  And how much would you need to color (darken) a bottle of insulin?

Any light you can shine on this issue would be great!

Yours, Scott

Keith’s Answer:

Hi, Scott, 

Where should I begin?  First of all, what is wrong with reading the labels on all of the medications you take before using them?  That would seem the smartest and easiest thing to do. In my 59 years of practice, I have seen only one patient who messed up his doses. He worked a night shift, went home one morning, and injected regular insulin in place of NPH. He called me, and I advised him to test his blood glucose frequently and to handle it by eating.  

I am not sure that color-coding will prevent people from using the wrong insulin, but it is a reasonable solution to try to avoid this relatively rare problem.  When Lantus and Levemir came out, it was predicted that there would be confusion because they are long-acting insulins that are clear.  Before Lantus, the only clear insulins were short-acting, like regular, or rapid-acting, like Humalog or Novolog and, now, Apidra.

With reference to B-12 as a coloring agent, however, it is a vitamin that is injected intramuscularly to treat people who are anemic.  Insulin is administered subcutaneously. Adding B-12 to insulin, therefore, would not provide B-12 in a useable manner for anemia. 

There are no published studies that show the effect of adding B-12 to either Lantus or Novolog.  Furthermore, it would become difficult to measure the correct amount of insulin if people started adding other ingredients to their bottles of insulin.

Please note that the vast majority of people who used to get B-12 shots were given them mainly for a placebo effect, to make them feel less tired.  It was also a good way to pad doctors’ incomes. In fact, I stopped seeing one doctor who insisted that all of his patients get B-2 shots to “prevent anemia.” 

If your letter writer is getting B-12 monthly, then I guess we should assume that he has been diagnosed as anemic or that his healthcare provider thinks it is doing some good.  Why his dose was increased is a mystery, given the info we have available. 

I hope this helps. Read the friggin’ label! is my best advice. One other trick is to put a smear of red fingernail polish on the rapid-acting insulin.

Keith

Read the letter that inspired Keith and Scott’s correspondence here.


Categories: Blood Glucose, Diabetes, Diabetes, Insulin, Insulin Pumps, Lantus, Letters to the Editor, Type 1 Issues



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Comments

Posted by Anonymous on 30 April 2008

in practice for 8yrs in internal medicine, I have had at least 1 patient die from this this type of error and have had multiple other near misses. This is a relatively frequent problem in patient care. Most patients are told clear and cloudy insulin as ways to distinguish this. I think that color coding might be better.

Posted by Anonymous on 1 May 2008

"Only had one patient in many years of practice" means you're not paying attention. After all, taking 6 shots of insulin is 2000 a year so you only have to make a mistake one in 2000 times to have a bad episode once a year. And no matter how careful you are, slipping up once every 1000 or 2000 times you do something is not only possible, it's highly likely. So my guess is A) you never ask your patients if they hav problems like this AND B) your patients who are used to slogging through the many difficulties and pains of dealing with their diabetes just don't mention these episodes becaues they figure it's just par for the course. And if they do tell you about, you blow them off with something unhelpful like "Be Sure to Read the Bottle" which they are obviously did the 999 times they got it right. So how likely are they to bother to mention something like this to you next time? I'm sorry if that sounds harsh but I find it amazing how easily doctors dismiss legitimate, serious medical concerns with a flip answer or a quick dash out the door.

Posted by Anonymous on 1 May 2008

What a tone-deaf comment from Keith! I am guessing this mix up is quite a bit more common than what he has seen in his 59 years. Possibly input from an endocrinologist who has taken calls from those of us who have screwed up our doses would be helpful. I have made this mistake before (late night, took humalog rather than lantus) and have other type 1 friends who have as well. It's the change from cloudy longer-acting insulins (that we even had to roll to mix) to clear solutions for both long- and short-acting. Why not make the differentiation between insulin life clear through adding color? I recall Target receiving design awards when they redesigned their prescription bottles. Simply putting different color caps on bottles doesn't help enough. Thanks for highlighting this issue and potential solution!

Posted by Anonymous on 2 May 2008

Here's a good reason why my Dad can't read the label, he's vision impaired, legally and functionally blind.

It seems not enough people (MDs and big pharma included) think how Diabetic Retinopathy can make managing much more difficult. How do you know how many ccs you're drawing if you can hardly see the syringe!? There simply aren't many options for the vision impaired who also need to manage insulin. Even digital read outs on pumps/CGM are difficult to read.

Does anyone know of any solutions for the blind diabetic?

Posted by Anonymous on 3 May 2008

My B12 SHOT (I am the 3000mcg IM monthly person). is due to PERNICIOUS anemia and there IS a blood test that can determine your B12 level.
Your body REQUIRES B12 for proper functioning nervous system and for red blood cell formations.
Lack of B12 aka pernicious anemia is a megaloblastic anemia.
I have a autoimmune issue, that has caused my immune system to attack the INTRINSIC FACTOR (IF) producing cells of the stomach, therefore I do not absorb the B12 from the diet.
This website is from National Heart Lung and Blood institute, which is a office of the NIH (thats National Institute of Heatlh a US Federal Health agency).
http://www.nhlbi.nih.gov/health/dci/Diseases/prnanmia/prnanmia_what.html

What caused my doctor to TEST my B12 level is due to having numbness at first in 1 finger, then 2, then 3 fingers, then up to elbow, and only on one side, then the shoulder, extream fatigue, and the fact that I am of scandinavian heritage (which is common in both the Finnish part and the Dutch part), and also she asked to see my tongue, which according to her was not normal. Well she ordered a blood draw. I got my normal copy of the labs in the mail (I get ALL .. copies of labs, copies of radiology, ect). The labs normal veriance was 312-999, my B12 level was 72.
Ever since I started to do B12, I am not as exreamly pale as I used to, I have energy, I still have nerve damage to my right arm due to the pernicious anemia, but it is slowly going away.

Posted by Anonymous on 5 May 2008

As an RD,CDE, I can certainly appreciate the advice to read the label. But as a human being, I can understand how someone who doe the same thing, day after day, sometimes several times per day might feel confident enough in their routine to make an accidental mistake. In addition, I work with an elderly, sometimes visually impaired population so mistakes can be even more of an issue. I think the bright red fingernail polish is a great idea, and I also think companies ought to make a clear label difference too. Anything that can be done to make mistakes less likely.

Posted by whimsy2 on 6 May 2008

I've been diabetic for 10 years, type 1 LADA and last night I had my first bottle mix-up mistake. I'm a pretty careful person, and I never expected to make this mistake, but I did. At the very moment I injected, I noticed the empty box (where I keep my insulins, in the refrigerator) and realized I'd just shot 9 units of Lantus instead of my dinner dose of 9 Humalog. So what did I do? I skipped the dinner dose of Humalog, and checked BG a few extra times, including at 2:30 a.m. Came out of it okay. But it was definitely a "whew!" moment. And any doc who thinks this doesn't happen isn't living in the real world.

Posted by Anonymous on 15 May 2008

I am a diabetic that has also been diagnosed with pernicious anemia. I believe there are alot of diabetics out there that are too. It is an autoimmune issue like diabetes. I was extremely tired for years and had numbing in my feet but thought this was the progression of neuropathy due to the diabetes. My aunt, a type 1 diabetic (not blood related) almost died of b12 anemia. When I found out her symtoms, I asked my doctor to check my b12. My b12 level was 52. My doctor allows me to give myself b12 shots once a month. I feel alot better. Why hasn't this been uncovered before and why don't endocrinologists check for this. I feel like for the past 31yrs. of having diabetes I've had to pretty much self diagnose. It is too bad that I could have been feeling better for years and not had the neuropathy to such an extent.

Posted by davisxa on 13 June 2008

"Read the friggin label" is Mr. Campbell's advice? That's the kind of apathetic attitude that many diabetics have come to expect from the medical community ... which in turn factors into things like "diabetes burnout" and depression. Here's my advice to Mr. Campbell: read the friggin medical journals' studies on deaths from hypoglycemia.

He should be kicked off the board.

Posted by Anonymous on 6 October 2008

good news! a colored insulin product is soon to hit the market! multipal colors.. keep your eys open


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