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Company Confidential © 2012 Eli Lilly and Company
Getting people started with human insulin: A hands-on session
Speaker name and affiliation
Prescribing information is available on the last slide.UKDBT01519d September 2013
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
This session will cover:
Insulin devices and patient choice Considerations when selecting a device Demonstrations of pre-filled and durable pen devices from Lilly Support materials and resources available to guide the
healthcare professional and the person with diabetes
2
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Initiating insulin therapy in type 2 diabetes (1)
It is important that the responsible healthcare professional is aware that:– There are various insulins and insulin regimens available– There are various injection device options available– Patient education is complex, and patient understanding is critical– There may be varying dosing and timing issues for different
patients due to the different durations of action of the various insulins prescribed
– Appropriate management of hypoglycaemia is essential– The impact of insulin treatment on weight should be discussed with
the patient
3
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Initiating insulin therapy in type 2 diabetes (2)
It is important that the person with type 2 diabetes understands:– That there are various injection devices available– The meaning of the term “dose titration”
i.e. an increase or decrease in insulin dose to achieve an agreed blood glucose target
– How to deal with hypoglycaemia i.e. prevention, recognition and treatment
– That weight gain is a potential side-effect of insulin treatment, but that it can be managed
– The key rules associated with insulin use e.g. sick day rules, driving restrictions
4
Insulin devices and patient choice
Section subhead copy here if needed or section presenter info
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
The importance of patient choice
“Choice is integral to empowerment.
People with diabetes who have always been
‘told what to do’ may find any choice difficult to make, but the
experience of real choice enables ever greater confidence and
personal control of health in daily life.”
6
Diabetes UK (2005) What does choice mean to people with diabetes? Available at: www.diabetes.org.uk/Documents/Reports/Patient_choice.pdf (accessed 27.03.2013)
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Information provision and choice
7
1. Diabetes UK (2005) What does choice mean to people with diabetes? Available at: www.diabetes.org.uk/Documents/Reports/Patient_choice.pdf (accessed 27.03.2013)
To exercise effective choice regarding insulins, pen devices and regimens, people with diabetes ideally require:
– Provision of the full range of information1
– Information that is open and honest1
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
The possible benefits of a patient choosing his or her insulin pen at the start of treatment
8
1. Diabetes UK (2005) What does choice mean to people with diabetes? Available at: www.diabetes.org.uk/Documents/Reports/Patient_choice.pdf (accessed 27.03.2013)
The person feels in control from the beginning The injection experience may be easier There is a recognition that the responsibility is theirs
This may lead to greater engagement of the patient with their own self-care
Choosing the most appropriate injection device
Section subhead copy here if needed or section presenter info
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Key factors to consider when choosing the most appropriate injection device
10
Ease of use– Injection pressure– Device “reach” at high doses, i.e. is the end of the injection button
within thumb reach with the dose dialled up?– Changing cartridges in durable devices
Handling– Size, shape, weight
Patient device preference– Durable vs. pre-filled
The maximum amount of insulin that can be injected at one time
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Dispensing human insulin in pre-filled pen devices
11
KwikPen™ devices for Humulin® I and Humulin® M3
Human insulins available in pre-filled devices Humulin® I (isophane human insulin [prb]) Humulin® M3 (human insulin [prb] 30% soluble insulin 70% isophane insulin) Insulatard® (isophane human insulin) Insuman® Basal (isophane human insulin) Insuman® Comb 25 (biphasic human insulin; 25% dissolved insulin and
75% crystalline protamine insulin)
Complete Summaries of Product Characteristics are available at http://www.medicines.org.uk/emc/
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Dispensing human insulin in durable pen devices
12
Human insulins compatible with durable devices Humulin® I (isophane human insulin [prb]) Humulin® M3 (human insulin [prb] 30% soluble insulin 70% isophane insulin) Humulin® S (human insulin [prb]) Insulatard® (isophane insulin) Insuman® Basal (isophane human insulin) Insuman® Comb 15; Comb 25 and Comb 50 (biphasic human insulin) Insuman® Rapid (human insulin)
HumaPen® SavvioTM devices for Humulin® I, Humulin® M3 and Humulin® S
Complete Summaries of Product Characteristics are available at http://www.medicines.org.uk/emc/
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Questions to discuss in groups
13
Which groups of patients might a pre-filled pen suit best?
Which groups of patients might a durable pen suit best?
Preparing and administering injections
Section subhead copy here if needed or section presenter info
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Mixing cloudy insulin preparations
15
Current advice from the Forum for Injection Technique recommends that cloudy insulin preparations should be:
– “gently rolled ten times and inverted ten times (not shaken) until the crystals go back into suspension and the solution becomes milky white”
Forum for Injection Technique (2011) Diabetes Care in the UK. The First UK Injection Technique recommendations 2nd Edition.Available at: http://www.fit4diabetes.com/files/2613/3102/3031/FIT_Recommendations_Document.pdf (accessed 28.03.2013)
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Injection sites: Diabetes UK guidance (1)
16
Diabetes UK (2009) About injecting. Available at: www.diabetes.org.uk (accessed 21.03.2013)
There are three main areas where insulin is injected:
– Stomach– Buttocks– Thighs
Sometimes other areas are appropriate, such as the upper arms
It is important to remember that insulin absorption rates differ between areas
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Injection sites: Diabetes UK guidance (2)
17
Diabetes UK (2009) About injecting. Available at: www.diabetes.org.uk (accessed 21.03.2013)
It is important to vary or rotate injection sites within these areas
Lipohypertrophy may lead to erratic absorption of the insulin, which
will affect control of blood glucose levels
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Lifted skin folds: Forum for Injection Technique guidance
18
Forum for Injection Technique (2011) Diabetes Care in the UK. The First UK Injection Technique recommendations 2nd Edition.Available at: http://www.fit4diabetes.com/files/2613/3102/3031/FIT_Recommendations_Document.pdf (accessed 28.03.2013)
People with diabetes/carers should be taught the correct technique for lifting a skin fold from the onset of injectable therapy
The lifted skin fold should not be squeezed so tightly that it causes blanching or pain
The correct angle of injection when lifting a skin fold is 90°
Hands-on experience with Lilly devices for administering human insulinsSection subhead copy here if needed or section presenter info
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
KwikPenTM demonstration (1): Pen parts
20
Eli Lilly and Company Limited (2012) Humulin KwikPen user manual.Available at: http://www.medicines.org.uk/emc/pdfviewer.aspx?isAttachment=true&documentid=23663 (accessed 04.04.2013)
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
KwikPenTM demonstration (2): Preparing the pen
21
Eli Lilly and Company Limited (2011) KwikPenTM Kwik Guide. https://www.lillypro.co.uk/diabetes/hcps/downloads/Lilly%20KwikPen%20User%20Guide.pdf (accessed 04.04.2013)
If the insulin is cloudy, the pen should be gently rolled and turned 10 times to mix it
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
KwikPenTM demonstration (3): Priming and injecting
22
Eli Lilly and Company Limited (2011) KwikPenTM Kwik Guide. https://www.lillypro.co.uk/diabetes/hcps/downloads/Lilly%20KwikPen%20User%20Guide.pdf (accessed 04.04.2013)
Attach a new needle for every injection
To prime, dial 2 units, point the needle end of the pen upwards and press the dose knob in until a “0” appears in the dose window and hold for a full 5 seconds
Repeat this step until a stream of insulin appears
Dial required dose Insert needle into skin, depress
knob until a “0” appears, then hold for a further 5 seconds before removing needle from skin
Remove needle and dispose
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
HumaPen® SavvioTM demonstration (1): Pen parts
23
Eli Lilly and Company Ltd (2012) HumaPen® SavvioTM Insulin delivery device user guide.
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
HumaPen® SavvioTM demonstration (2): Preparing the pen
24
Eli Lilly and Company Ltd (2012) HumaPen® SavvioTM Insulin delivery device user guide.
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
HumaPen® SavvioTM demonstration (3): Priming and injecting
25
The pen should be primed to a stream of insulin before every injection– Dial up to 2 units of insulin– Push the injection button and look for a stream of insulin– The pen is NOT properly primed if you only see a few drops of insulin
Injecting a dose– Dial the required dose– Insert needle, push firmly on injection button, hold for
5 seconds– Remove needle slowly, check dose reads “0”– Replace outer cap on needle and dispose of needle
Eli Lilly and Company Ltd (2012) HumaPen® SavvioTM Insulin delivery device user guide.
Your chance to try out the pens
Section subhead copy here if needed or section presenter info
Lilly patient and healthcare professional support materials
Section subhead copy here if needed or section presenter info
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
In order to identify a suitable insulin regimen, consider using discovery sheets
28
Eli Lilly and Company Ltd (2012) HumaPen® SavvioTM Insulin delivery device user guide.
These help the patient and the healthcare professional identify patterns in blood glucose readings and meal patterns across the day
The sheet may also aid in the adjustment and optimisation of an insulin regimen
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Lilly human insulin patient support materials
29
Consider patient packs for initiation:• Booklets to introduce patients to their
insulin regimen:• Time action profile• Dose for injection and when to inject• Information on injection sites
• Booklets on other aspects of diabetes care e.g. travel, driving
• Device guides• Diaries for blood glucose monitoring• Insulin identification cards: To meet the
NPSA (National Patient Safety Agency) insulin safety requirements for insulin passports
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Lilly human insulin patient support materials
30
Consider patient packs for initiation:• Booklets to introduce patients to their
insulin regimen:• Time action profile• Dose for injection and when to inject• Information on injection sites
• Booklets on other aspects of diabetes care e.g. travel, driving
• Device guides• Diaries for blood glucose monitoring• Insulin identification cards: To meet the
NPSA (National Patient Safety Agency) insulin safety requirements for insulin passports
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Lilly insulin device support for patients
31
Lilly device helpline: 0800 783 6764
Printed device guides
Online resources at www.lillydiabetes.co.uk:
– KwikPenTM: user guide PDF– HumaPen® SavvioTM: user guide
PDF and video guide in 10 languages
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Session 4 summary
32
It is important to offer people with diabetes choice regarding insulin and insulin pen devices
Humulin® I and Humulin® M3 are available in the KwikPenTM pre-filled pen device
All Lilly human insulins can be used with durable pen devices, such as the HumaPen® SavvioTM
Lilly provides both patient and healthcare professional support for its human insulin range
For further information– Contact your local Lilly representative– Visit www.lillydiabetes.co.uk
Chair’s summarykey points
Section subhead copy here if needed or section presenter info
Company Confidential © 2012 Eli Lilly and Company© 2013 Eli Lilly and Company
Summary
34
Basal insulin (either human NPH insulin or a long-acting analogue) is often used when starting insulin therapy in type 2 diabetes, followed by the addition of mealtime insulin if glycaemic targets are not met
National guidelines recommend initiating insulin for people with type 2 diabetes by using human NPH insulin1,2
Human NPH insulin and analogue basal insulins give comparable reductions in HbA1c and with no significant difference in the occurrence of severe hypoglycaemia3,4
A range of support materials and resources regarding the initiation, titration and on-going management of human NPH insulin are available for both the healthcare professional and the person with type 2 diabetes
NPH=neutral protamine Hagedorn1. NICE. Type 2 diabetes: newer agents for blood glucose control in type 2 diabetes. CG87. London: NICE; May 2009. www.nice.org.uk 2. SIGN. Management of diabetes. 116. March 2010. www.sign.ac.uk 3. Riddle MC et al (2003) Diabetes Care 26: 3080–64. Philis-Tsimikas A et al (2006) Clinical Therapeutics 28: 1569–81
UKDBT01519d September 2013