Getting people started with human insulin: A hands-on session Speaker name and affiliation UKDBT01519d September 2013 Prescribing information is available on the last slide.

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

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

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

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.” 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)

Information provision and choice 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 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 possible benefits of a patient choosing his or her insulin pen at the start of treatment 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 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)

Choosing the most appropriate injection device Section subhead copy here if needed or section presenter info

Key factors to consider when choosing the most appropriate injection device 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 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) KwikPen™ devices for Humulin® I and Humulin® M3 Complete Summaries of Product Characteristics are available at http://www.medicines.org.uk/emc/

Dispensing human insulin in durable pen devices 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 Which groups of patients might a pre-filled pen suit best? Which groups of patients might a durable pen suit best? These questions aim to stimulate discussion amongst the delegates.

Preparing and administering injections Section subhead copy here if needed or section presenter info

Mixing cloudy insulin preparations 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)

Injection sites: Diabetes UK guidance (1) 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 Diabetes UK (2009) About injecting. Available at: www.diabetes.org.uk (accessed 21.03.2013)

Injection sites: Diabetes UK guidance (2) 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 Diabetes UK (2009) About injecting. Available at: www.diabetes.org.uk (accessed 21.03.2013)

Lifted skin folds: Forum for Injection Technique guidance 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° 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)

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

KwikPenTM demonstration (1): Pen parts At this part of the presentation, the presenter will demonstrate how to use the KwikPen. 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)

KwikPenTM demonstration (2): Preparing the pen If the insulin is cloudy, the pen should be gently rolled and turned 10 times to mix it 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)

KwikPenTM demonstration (3): Priming and injecting 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 At this part of the presentation, the presenter will demonstrate how to use the KwikPen. 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)

HumaPen® SavvioTM demonstration (1): Pen parts At this part of the presentation, the presenter will demonstrate how to use the HumaPen Savvio. Eli Lilly and Company Ltd (2012) HumaPen® SavvioTM Insulin delivery device user guide.

HumaPen® SavvioTM demonstration (2): Preparing the pen At this part of the presentation, the presenter will demonstrate how to use the HumaPen Savvio. Eli Lilly and Company Ltd (2012) HumaPen® SavvioTM Insulin delivery device user guide.

HumaPen® SavvioTM demonstration (3): Priming and injecting 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 At this part of the presentation, the presenter will demonstrate how to use the HumaPen Savvio. 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

In order to identify a suitable insulin regimen, consider using discovery sheets 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 At this part of the presentation, the presenter will demonstrate how to use the HumaPen Savvio. Eli Lilly and Company Ltd (2012) HumaPen® SavvioTM Insulin delivery device user guide.

Lilly human insulin patient support materials 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 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 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 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 summary key points Section subhead copy here if needed or section presenter info

Summary 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 Hagedorn NICE. Type 2 diabetes: newer agents for blood glucose control in type 2 diabetes. CG87. London: NICE; May 2009. www.nice.org.uk SIGN. Management of diabetes. 116. March 2010. www.sign.ac.uk Riddle MC et al (2003) Diabetes Care 26: 3080–6 Philis-Tsimikas A et al (2006) Clinical Therapeutics 28: 1569–81

UKDBT01519d September 2013