1. 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.

2. 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

3. 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

4. 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

5. Insulin devices and patient choice
Section subhead copy here if needed or section presenter info

6. 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: (accessed )

7. 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: (accessed )

8. 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: (accessed )

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

10. 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

11. 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

12. 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

13. 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.

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

15. 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: (accessed )

16. 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: (accessed )

17. 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: (accessed )

18. 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: (accessed )

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

20. 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: (accessed )

21. 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. (accessed )

22. 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. (accessed )

23. 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.

24. 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.

25. 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.

26. Your chance to try out the pens
Section subhead copy here if needed or section presenter info

27. Lilly patient and healthcare professional support materials
Section subhead copy here if needed or section presenter info

28. 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.

29. 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

30. 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

31. Lilly insulin device support for patients
Lilly device helpline:
Printed device guides
Online resources at
KwikPenTM: user guide PDF
HumaPen® SavvioTM: user guide PDF and video guide in 10 languages

32. 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

33. Chair’s summary key points
Section subhead copy here if needed or section presenter info

34. 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
SIGN. Management of diabetes March
Riddle MC et al (2003) Diabetes Care 26: 3080–6
Philis-Tsimikas A et al (2006) Clinical Therapeutics 28: 1569–81

35. UKDBT01519d September 2013