Hypoglycaemia is a known adverse reaction to insulin products. Severe hypoglycaemia may also be caused by medication errors, e.g. due to a mix-up of insulins with a different onset of action or different duration of action. An insulin product mix-up may be a differential diagnosis that should be considered in cases of severe hypoglycaemia.
Risk of product mix-up with various insulin products
Incident data |
Description |
|---|---|
Case (year): 2024 Age group: Elderly Sex: Male Medicinal product: Apidra Active substance: Insulin glulisin Indication: Diabetes mellitus ADRs: Severe hypoglycaemia; hypoglycaemic coma; product mix-up; medication error. Outcome: Recovered |
During the hospitalisation of an elderly male patient with Diabetes mellitus, there was a mix-up of different insulin products. Instead of administering “Lantus long acting” (long-acting insulin), a healthcare professional administered 26 IU of “Apidra rapid” (rapid-acting insulin) in error. This led to severe, life-threatening hypoglycaemia with hypoglycaemic coma. The patient fully recovered after immediate treatment in the intensive care unit, including glucose IV. |
Summary and recommendation
Mixing up insulin products with different onset of action or different duration of action can have life-threatening consequences.
The Information for healthcare professionals for the medicinal products listed in the example report warns of severe hypoglycaemia. It indicates that switching to another insulin product may only be done under careful medical supervision and instruction.
Hypoglycaemia is also listed as a possible adverse drug reaction.
Apidra (very common): Hypoglycaemia
Recommendation: The possibility of a product mix-up should be considered as a differential diagnosis for new occurrences of (severe) hypoglycaemia with a temporal relationship to an insulin product.
Suspected cases should be reported in order to obtain better information on the possible causes of mix-ups of insulin products.
Swiss information for healthcare professionals (www.swissmedicinfo.ch)
Statutory duty of healthcare professionals to report adverse drug reactions (ADRs)
In Switzerland, healthcare professionals who are authorised to dispense or administer medicinal products are obligated to report severe and/or previously unknown side effects. Reports to Swissmedic can be entered and sent in the Electronic Vigilance Reporting Portal “ElViS” (ElViS login).
Supplementary information
Swiss information for healthcare professionals
(www.swissmedicinfo.ch)
Reporting adverse drug reactions
Electronic reports via the ElVis portal