Company Confidential © 2012 Eli Lilly and Company Getting people started with human insulin: A hands-on session Speaker name and affiliation Prescribing

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


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


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


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)

http://www.diabetes.org.uk/Documents/Reports/Patient_choice.pdf


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



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



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


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/


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/


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



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)

http://www.fit4diabetes.com/files/2613/3102/3031/FIT_Recommendations_Document.pdf


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


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


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°

http://www.fit4diabetes.com/files/2613/3102/3031/FIT_Recommendations_Document.pdf

Hands-on experience with Lilly devices for administering human insulinsSection subhead copy here if needed or section presenter info


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)

http://www.medicines.org.uk/emc/pdfviewer.aspx?isAttachment=true&documentid=23663


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

https://www.lillypro.co.uk/diabetes/hcps/downloads/Lilly%20KwikPen%20User%20Guide.pdf



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




HumaPen® SavvioTM demonstration (1): Pen parts

23

Eli Lilly and Company Ltd (2012) HumaPen® SavvioTM Insulin delivery device user guide.


HumaPen® SavvioTM demonstration (2): Preparing the pen

24



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


Your chance to try out the pens


Lilly patient and healthcare professional support materials



In order to identify a suitable insulin regimen, consider using discovery sheets

28


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


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


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


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


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



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

http://www.nice.org.uk/

http://www.sign.ac.uk/

UKDBT01519d September 2013