Insulin Injection Technique

Husaini Umar

Celebes Nephro-Endo Metabolic Update

(CNEMU IV-31 Maret 2018)
AGENDA

• Insulin injection barrier, from phycisian and patients perspective

• Techniques on how do we overcome the barriers
• Insulin injection technique
• Conclusion
INJECTION BARRIERS
Discussion: Your experience
• Considering your patients uncontrolled on metformin, what
proportion would be open to consider an insulin treatment option?
• Why might some patients not consider an insulin therapy?
• What other barriers are there to choosing an insulin therapy?
Are phycisian and patient perceptions the same?
Overlap
between HCP Lose Other
and patient? independence barriers?

Injection is Needs
a last resort Injections are
Injection harder to use specialists/
means I’ve than OADs more
failed referrals
Social stigma/
embarrassment
at injecting in
public Needle Patients
phobia won’t
Pain comply

Fear of Weight
hypoglycaemia
gain Won’t improve
glycaemic
Takes too control
much time
to teach
• So what about the injection?

GAPP Survey: Global Attitudes of

Patients and Physicians in Insulin
Therapy for Type 2 Diabetes Mellitus
Patient responses GAPP – concerns before starting
insulin
Which, if any of the following were you concerned or afraid about when you were told you needed to start
insulin?
27%
Fear of injections First mention
40%
21%
Fear of low blood sugar events
53% Total mentions
15%
Lifestyle changes are required
42%
13%
Injections are painful
35%
9%
None/nothing/no problems
13%
8%
Too many injections to take
32%
4%
Fear of blood glucose testing
24%
3%
Other
3%
Global Attitudes of Patients and Physicians in Insulin Therapy (GAPP) survey results 2010; All UK patients n=205
Patient responses GAPP – responses from patients
who have started on taking insulin
What would you say are the biggest challenges you face in effectively managing you diabetes with insulin?

Total mentions

Controlling diet/working out what to eat 19%

Managing the sugar level 15%

Controlling weight 11%

Remembering to take insulin/compliance 8%

Travelling around/awkward when travelling 6%

Exercising/activity 5%

Fear of injections 4%

None/nothing/no problems 24%

Global Attitudes of Patients and Physicians in Insulin Therapy (GAPP) survey results 2010; All UK patients n=205
DAWN summit 2004
Patients often fear starting injection more than they fear injections themselves

Patient misconceptions (about insulin injection): HCP – attitudes to and misconceptions

• More demanding about insulin injections
• Hypoglycaemia • Use insulin as threat
• Mistaken concept (need to inject into vein) • Believe patients don’t want it
• Don’t believe it’s necessary • Injections are painful
• Fear loosing independence • Difficult to dose
• Employment concerns • Won’t improve diabetes control
• Suggests failure of self care to date • Patient needs more of my time
• BUT can learn to experiment/improve • Will need specialist referrals
• Not cost effective

Pearson, TL. Insulin therapy in patients with type 2 diabetes: overcoming patient and physician barriers.
(http://www.medscape.org/viewarticle/590729)
DAWN. Pract Diab Int 2004;21(5):201-208
Summary

Many patient barriers are based on myths and

fear of injection

HCP and patient perceptions not always aligned

AGENDA

• Insulin injection barrier, from phycisian and patients perspective

• Techniques on how do we overcome the barriers
• Insulin injection technique
• Conclusion
TECHNIQUES ON HOW TO
OVERCOME THE BARRIERS
Presenting and discussing information:
Setting patient expectations in type 2 diabetes care
Ideally – preparation for the move to injectable therapy
should start early following diagnosis
Consider each case individually, e.g. history of “failures”

Advise on progressive nature of the disease and the progressive nature of therapy

Diminish self-blame by explaining likely course at diagnosis

Consider showing patients injectable devices early – before they might need them

Pearson, TL. Insulin therapy in patients with type 2 diabetes: overcoming patient and physician barriers.
(http://www.medscape.org/viewarticle/590729)
Starting injectable treatment in adults with type 2 diabetes. RCN guidance for Nurses, 2012
Motivational interviewing: 5 key
principles
Principles
• Express empathy through active listening
• Roll with resistance
• Avoid arguing with the patient
• Resolve the patient’s ambivalence
• Support self-efficacy by emphasizing autonomy
Motivational interviewing: OARS
Open-ended questions
Letting patients tell their stories

Affirmations
Acknowledging the patient’s struggle

Reflections
Simple reflections – eg telling patients what you heard
them say without repeating their comments word for word

Summaries
Let you and the patient reflect on your discussion
and helps identify next steps

Mitchell SE. Motivational interviewing in the management of type 2 diabetes

Motivational interviewing: Some other
useful tips

• The “Readiness ruler”

• Ask questions about
importance of a behaviour
change
Probe
• Ensure they understand
the benefits of their
treatment
• Follow up
• “Change talk”
• Support patient in • Humans tend to
finding the solution
Overcome Encourage believe what they hear
on ways to themselves say rather
overcome barriers than simply taking
advice from others

Mitchell SE. Motivational interviewing in the management of type 2 diabetes

Take the reins....

....and help steer your patients to success

AGENDA

• Insulin injection barrier, from phycisian and patients perspective

• Techniques on how do we overcome the barriers
• Insulin injection technique
• Conclusion
Injection Site Rotation
Pen Injection Technique
Re-suspension required for Pre-mix and Intermediate acting
Insulin

Gulung Pena Insulin Gerakkan pena insulin

diantara kedua telapak keatas dan ke bawah
tangan sampai dengan 10 x sebanyak 10 x

&
Pen Injection Technique
Removing the Outer Cap
Pen Injection Technique
Ensure that no air bubbles are present in the pen
Pen Injection Technique
Adjust the Dose recommended by your Doctor
Pen Injection Technique
Injection Techniques
AGENDA

• Insulin injection barrier, from phycisian and patients perspective

• Techniques on how do we overcome the barriers
• Insulin injection technique
• Conclusion
Conclusion
• Many patient barriers are based on myths and fear of injection
• To overcome the barrier of injection, need more effort from doctor to
give patient motivation to encourage patients to achieve better
glycaemic control
• Insulin devices such as Flexpen® is a easy to use for patient with
diabetes
Patient Communication -
Role Play
 Bermain Peran:
1. Setiap kelompok akan bermain peran dengan waktu 3-5 menit
2. Kelompok yang bermain peran terdiri dari 1 orang berperan sebagai Dokter, 1
orang sebagai Pasien, yang lainnya sebagai Pengamat:
• Pasien akan mendapat kasus mengenai diabetes
• Dokter melakukan anamnesis singkat dan menjawab masalah utama pasien
• Pengamat membuat catatan kecil mengenai poin-poin komunikasi yang
disampaikan oleh Dokter
3. Fasilitator akan membahas bersama dan memberi masukan tekait poin-poin
komunikasi dari seluruh kelompok
 Kasus 1
• Anda seorang pasien berusia 57 tahun, terdiagnosis DMT2 sejak 5 tahun
yll.
• Pengobatan yang telah didapat selama ini:
– Glimepiride 4 mg/hari
– Metformin 2000 mg/hari
• Hasil Lab 1 tahun terakhir:
– HbA1C 9–10%
– GDP 180–230 mg/dL
• Jika Dokter Anda menyarankan untuk memulai menggunakan Insulin:
– Anda merasa kuatir bahwa dengan menggunakan Insulin berarti Anda sudah
di tahap terakhir penyakit diabetes
 Kasus 2
• Anda seorang pasien berusia 57 tahun, terdiagnosis DMT2 sejak 5 tahun
yll.
• Pengobatan yang telah didapat selama ini:
– Glimepiride 4 mg/hari
– Metformin 2000 mg/hari
• Hasil Lab 1 tahun terkahir:
– HbA1C 9–10%
– GDP 180–230 mg/dL
• Jika Dokter Anda menyarankan untuk memulai menggunakan Insulin:
– Anda merasa takut terhadap suntikan.
 Kasus 3
• Anda seorang pasien berusia 64 tahun, terdiagnosis DMT2 sejak 6 tahun
yll.
• Dokter memberikan obat:
– Glibenclamide 2 x 5 mg
– Metformin 3 x 500 mg
• Hasil Lab 3 bulan terkahir:
– HbA1C 8,9%
– GDP 182 mg/dL
• Jika Dokter Anda menyarankan untuk memulai menggunakan Insulin:
– Anda merasa gagal terhadap pengobatan selama ini.
 Kasus 4
• Anda seorang pasien berusia 64 tahun, terdiagnosis DMT2 sejak 6 tahun
yll.
• Dokter memberikan obat:
– Glibenclamide 2 x 5 mg
– Metformin 3 x 500 mg
• Hasil Lab 3 bulan terkahir:
– HbA1C 8,9%
– GDP 182 mg/dL
• Jika Dokter Anda menyarankan untuk memulai menggunakan Insulin:
– Menurut info yang pernah Anda dengar, Insulin akan menyebabkan
kecanduan
 Kasus 5
• Anda seorang pasien berusia 48 tahun, 9 bulan yll terdiagnosis DMT2.
• Anda telah melakukan apa yang telah Dokter sarankan:
– Olah raga, jalan kaki 30 menit 5 x seminggu
– Konsumsi Metformin 3 x 500 mg
• Hasil Lab terkahir:
– HbA1C 9,4%
– GDP 218 mg/dL
– GD2PP 302 mg/dL
• Jika Dokter Anda menyarankan untuk memulai menggunakan Insulin:
– Anda merasa tidak mampu untuk membeli Insulin tiap bulan
 Kasus 6
• Anda seorang pasien berusia 48 tahun, 9 bulan yll terdiagnosis DMT2.
• Anda telah melalukan apa yang telah Dokter sarankan:
– Olah raga, jalan kaki 30 menit 5 x seminggu
– Konsumsi Metformin 3 x 500 mg
• Hasil Lab terkahir:
– HbA1C 9,4%
– GDP 218 mg/dL
– GD2PP 302 mg/dL
• Jika Dokter Anda menyarankan untuk memulai menggunakan Insulin:
– Anda merasa malu saat menyuntikan Insulin, terutama jika orang lain tahu
bahwa Anda menyuntikan Insulin
 Kasus 7
• Anda seorang pasien berusia 64 tahun, terdiagnosis DMT2 sejak 6 tahun
yll.
• Dokter memberikan obat:
– Glibenclamide 2 x 5 mg
– Metformin 3 x 500 mg
• Hasil Lab 3 bulan terkahir:
– HbA1C 8,9%
– GDP 182 mg/dL
• Jika Dokter Anda menyarankan untuk memulai menggunakan Insulin:
– Anda ragu apakah mampu menyuntikan Insulin karena sehari-hari Anda
hidup sendiri karena menurut Anda, perlu bantuan saat penyuntikan
 Kasus 8
• Anda seorang pasien berusia 48 tahun, 9 bulan yll terdiagnosis DMT2.
• Anda telah melalukan apa yang telah Dokter sarankan:
– Olah raga, jalan kaki 30 menit 5 x seminggu
– Konsumsi Metformin 3 x 500 mg
• Hasil Lab terkahir:
– HbA1C 9,4%
– GDP 218 mg/dL
– GD2PP 302 mg/dL
• Jika Dokter Anda menyarankan untuk memulai menggunakan Insulin:
– Anda ingin mencoba daun insulin (herbal) terlebih dahulu.
Thank you for your attention