DIABETES MELLITUS

FLEXPEN
SOLOSTAR
ALLSTAR
NOVOPEN

PRESENTERS:
MUHAMAD FAIZ
REBECCA CHWEE CHIEN PUI
TAN GUI ZHI
TEE YEE LEE
 DIABETES MELLITUS
Diabetes is a chronic disease in which the body cannot regulate the
amount of sugar in the blood .
People with diabetes have high blood sugar because their body
cannot move sugar from the blood into muscle and fat cells to be
burned or stored for energy, and because their liver makes too
much glucose and releases it into the blood. [1]
Diabetes can be caused by :
too little insulin i.e. the pancreas does not make enough insulin
resistance to insulin i.e. the cells do not respond to insulin
normally
Both of the above

1. MedlinePlus;
http://www.nlm.nih.gov/medlineplus/ency/article/001214.htm
 STATISTICS OF DM IN MALAYSIA
From the National Diabetes Registry Report in 2013, between 2009 to end of 2012,
there were a total of 657,839 patients enrolled in the registry. Nearly all the patients
enrolled, 653,326 (99.314%) were diagnosed with T2DM.[2]
Distribution of T2DM patients by age at diagnosis:

2. Feisul MI, Azmi S. (Eds).National Diabetes Registry Report, Volume 1, 2009-2012. Kuala Lumpur;
Ministry of Health Malaysia; 2013 Jul.
 The prevalence of diabetes in Malaysia has increased
by 31.0% in the space of just 5 years, from 11.6% in
2006 to 15.2% in 2011[3]
This means that there are currently about 2.6 million
adults age 18 years and above living with diabetes. [2]

2. Feisul MI, Azmi S. (Eds).National Diabetes Registry Report, Volume 1, 2009-2012. Kuala Lumpur;
Ministry of Health Malaysia; 2013 Jul.
 About 80% of patients diagnosed with diabetes seek
treatment at public health care facilities (Figure 2),
while the rest are treated by private general
practitioners, or take complementary and alternative
medicines .[3]

3. Institute for Public Health (IPH) 2011. National Health and Morbidity Survey 2011 (NHMS 2011). Vol.
II: Non- Communicable Diseases.
TYPES OF DIABETES MELLITUS

(source: "About Diabetes - Bermuda Diabetes Association." About Diabetes - Bermuda Diabetes
Association. Web. 30 Mar. 2015. <http://www.bermudadiabetes.org/diabetes.htm)
PATHOPHYSIOLOGY OF DIABETES MELLITUS
(1)TYPE 1 DIABETES MELLITUS

Risk factors including:

a.Family history
b.Genetics
c.Exposure to certain viruses
d.Diet--Early exposure of cows milk
low vitamin D consumption

autoimmune pancreatic -cell destruction

(2) TYPE 2 DIABETES MELLITUS
Type 2 diabetes characterized by impaired insulin secretion and
resistance to insulin action.
 PATHOPHYSIOLOGY OF DIABETES
MELLITUS

Source: What is Diabetes Mellitus? (n.d.). Retrieved April 4, 2015, from http://www.wisegeekhealth.com/what-is-diabetes-
mellitus.htm
(3) GESTATIONAL DIABETES MELLITUS
Pregnancy hormones are thought to interfere with the action of
insulin as it binds to the insulin receptor.

Insulin resistance prevents glucose from entering the cells

properly. As a result, glucose remains in the bloodstream, where
glucose levels rise.
Source: Big babies: High birthweight may signal later health risks. (n.d.). Retrieved April 4,
2015, from https://www.sciencenews.org/article/big-babies-high-birthweight-may-signal-later-
health-risks
TARGET BLOOD GLUCOSE LEVEL

Target level Before meal 2 hours after meal

(pre prandial) (post prandial)
Pregnant woman below 5.9 mmol/L below 7.8 mmol/L

HBA1c should be less than

6.5%
 HYPOGLYCEMIA
DEFINITION:
Characterized by a reduction in plasma glucose
concentration to a level ( 3.9 mmol/L) that may
induce symptoms or signs such as altered
mental status and/or sympathetic nervous
system stimulation.
This condition typically arises from abnormalities
in the mechanisms involved in glucose
homeostasis.

Osama Hamdy, MD, PhD is a member of the following medical societies: American Association of Clinical
Endocrinologists and American Diabetes Association
 HYPOGLYCEMIA
CAUSES:
Medication overdose, inject too much insulin
Excessive exercise
Missed a meal
Drink too much alcohol

Osama Hamdy, MD, PhD is a member of the following medical societies: American Association of Clinical
Endocrinologists and American Diabetes Association
 HYPOGLYCEMIA
SYMPTOMS:
1) Neurogenic (sympathoadrenal activation)
Sweating
Tremor
Tachycardia
Anxiety
Sensation of hunger
2) Neuroglycopenic
Weakness, tiredness, or dizziness
Inappropriate behavior
Difficulty with concentration
Confusion
Blurred vision

Osama Hamdy, MD, PhD is a member of the following medical societies: American Association of
Clinical Endocrinologists and American Diabetes Association
 HYPOGLYCEMIA
MANAGEMENT:
Diet therapy
Take 2 cubes of sugar or take 10 raisins
Drink a glass of milk (240ml)
Drink 1/2 glass of fruit juice (120ml)
Glucose supplements (eg, dextrose)
Glucose-elevating agents (eg, glucagon)
Inhibitors of insulin secretion (eg, diazoxide,
octreotide)
 HYPOGLYCEMIA
HOW TO AVOID:
Take correct medication and dosage
Eat regular meals on time
Test blood glucose levels regularly
Eat before exercise
Always carry something sweet
 HYPERGLYCEMIA
DEFINITION:
A condition of an abnormal high blood glucose level
(14.5mmol/L) seen especially in patients with diabetes
mellitus.
There are two main kinds:
1) Fasting hyperglycemia
This is blood sugar that's higher than 7.2 mmol/L, after not
eating or drinking for at least 8 hours.
2) Postprandial hyperglycemia
This is blood sugar that's higher than 10 mmol/L, 2 hours
after you eat.

Joseph Michael Gonzalez-Campoy, MD, PhD, FACE is a member of the following medical societies:American
Association of Clinical Endocrinologists, Association of Clinical Researchers and Educators (ACRE),
and Minnesota Medical Association
 HYPERGLYCEMIA
CAUSES:
Low compliance to medication (insulin or
oral glucose-lowering agents)
Uncontrolled intake of food high in glucose
Inactivity or lack of exercise
 HYPERGLYCEMIA
SYMPTOMS:
Polyphagia (Increased appetite)
Polyuria (Frequent urination)
Polydipsia (Increased thirst)
Headache
Blurred vision
Fatigue
 HYPERGLYCEMIA
COMPLICATIONS:
Proteinuria
Gangrene/Amputation
Stroke
Neuropathy
Blindness
Myocardial Infarction
 HYPERGLYCEMIA
MANAGEMENT:
Medication adjustment
Proper diet
Limit intake of sugar and carbohydrates
Limit use of alcohol
Eating a diet rich in vegetables, fruit and
whole grains.
Regular exercise
 Colourle
ss

Cloudy
Yellow,
colourles
s

Green,
Colourle
cloudy
ss
 Onset, Peak and Duration of Insulin

Insulin Chart. 2015.Insulin Chart. [ONLINE] Available at:

http://www.dlife.com/diabetes/insulin/about_insulin/insulin-chart. [Accessed 04 April 2015].
 Plasma Insulin Levels vs. Time

More benefit in the treatment of diabetes from modern insulin. 2015.More benefit in the treatment of
diabetes from modern insulin. [ONLINE] Available at:
http://archive.thedailystar.net/newDesign/news-details.php?nid=9179. [Accessed 04 April 2015].
Sliding Scale Therapy :: Diabetes Education Online. 2015.Sliding Scale Therapy :: Diabetes Education Online.
[ONLINE] Available at:
http://dtc.ucsf.edu/types-of-diabetes/type2/treatment-of-type-2-diabetes/medications-and-therapies/type-2-insuli
n-rx/sliding-scale-therapy/
SITE OF INSULIN INJECTION
 SITES TO AVOID
Avoid the 2 inch circle around the navel
Avoid injecting too close to the bony area above the
knee
Avoid forearm and only use outer back area of the
upper arm
Always rotate the injection site for each injection
Never force the needle.
This can hurt
May damage the needle
Too much force may affect the amount of insulin injected
Never inject into the muscle
Never rub the injection spot after an injection
 STORAGE
Store the insulin in the refrigerator. Do not store the new insulin cartridge at
the door side of the fridge.
Do not store the insulin near extreme heat or extreme cold.
Never store the insulin in the freezer, under direct sunlight or in the glove
department of a car.
Check the expiry date before using.
Examine the bottle of insulin for particles or discolouration before each
use.
Once opened, the vial of insulin could be kept at room temperature and
should be used within 30 days.

Insulin Storage and Syringe Safety: American Diabetes Association. 2015.Insulin Storage and Syringe
Safety: American Diabetes Association. [ONLINE] Available at:
http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/insulin/insulin-storage-and-syrin
ge-safety.html
 SMBG (SELF-MONITORING
BLOOD GLUCOSE)
Allows patients to evaluate their response to lifestyle,
meals and therapy and to access whether glycaemic
targets are being achieved.
Should be carried out 3-4 times per day.
Omit the insulin injection if blood glucose level is below
4.0 mmol/L.
Factors to be considered to assure the accuracy of home
glucose-monitoring:
a) Test strips within expiry date
b) Blood is applied correctly to cover all of test strip
c) Blood glucose level is carefully recorded and showed to the
doctor on the next appointment.
 SPECIAL SITUATIONS
Sick days Potential problems:

Always take diabetes

pills unless patient has Hyperglycemia

vomiting. Continued release of glucose from

liver and insulin resistance secondary
Always take insulin
to infection. E.g. viral and bacterial
injection. The dose illnesses.
may be increased or
decreased.
Hypoglycemia
What to do? Gastroenteritis (vomiting & diarrhea)
Treat underlying illness often cause decreased appetite and
More frequent SMBG the food intake is not well absorbed.
Maintain positive fluid balance and
adequate nutrition
 SPECIAL SITUATIONS
Travel c)
Find out the types, formulations and
strengths of insulin which are d)
available in the area of destination.
e)
Preparation:
a)Take twice as much insulin,
syringes or pens, needles or tablets
as will be needed f)
b)If travelling with others, split the
amount between each passenger in
case one of the bags is lost
Bring a cool bag for insulin
storage
Bring blood glucose monitoring
equipment
Bring carbohydrate (glucose
tablets, snacks etc.) to cover
any travelling delays in case of
hypoglycemia
A diabetes identity card or
medic alert bracelet
FLEXPEN
 STEP 1: PREPARATION
Wash your hands.
Then pull of the pen cap and wipe the rubber stopper with an alcohol swab.

Roll Flexpen back and forth in the palm for 10 times. Then move it up and
down 10 times. Check and ensure the insulin is uniformly white and cloudy.
If not, repeat the previous 2 steps.
 STEP 2: ATTACH THE NEEDLE
Remove the protective tab from the
disposable needle.

Then screw the needle tightly onto the

Flexpen. Ensure that the needle is put on
straight.

Pull of the big outer needle cap. Then pull

of the inner needle cap.
 STEP 3: THE AIR SHOT
Before each injection, perform an air shot to avoid
injecting air and to ensure proper dosing.

Dial 2 units. Then hold the Flexpen with the needle

pointing up. Tap the cartridge gently with your finger
few times to make any air bubbles collect at the top of
the cartridge.

Keep the needle pointing upwards and press the push

button all the way in. The dose selector will then return
to zero. A drop of insulin should appear at the needle
tip. If not, change the needle and repeat the procedure
no more than 6 times.

If you do not see a drop of insulin after 6 times, do not

use the Flexpen.
 STEP 4: INJECTION
Wipe the skin with an alcohol swab.

Make sure that the dose selector is set at zero. Then, turn the dose selector
to number of units needed.

Insert the needle into the skin. Inject the dose by pressing the push button
all the way in until the zero lines up with the pointer.

Keep the needle in the skin for at least 6 seconds.

Discard the needle and put on the pen cap.

Reference: Product insert

Solopen Insulin
SoloSTAR
 SOLOPEN INSULIN
SoloSTAR is a new, disposable insulin injection
pen device to administer long-acting insulin to:
Type 2 DM for adult
Type 1 DM for adult and pediatric ( 6 y.o.)
The SoloSTAR device has a lower injection force
compared with other marketed pen devices.
It should be taken once a day at the same time
each day to lower blood glucose level.
Studies have shown that the SoloSTAR device is
more accurate, easier to use and is preferred by
patients over other pens on the market. [4]
4. Bode A. (2009 Jan). Development of the SoloSTAR insulin pen device: design verification and
validation. Expert Opin Drug Deliv;6(1):103-12.
 STEP 1 : GET READY

Check the exp. Date

Wait 1 to 2 hour until pen warms up to room temperature if
the pen stored in the refrigerator before.
Remove the cap with clean hands
Check the reservoir, make sure the insulin is clear,
colourless, and no particles if not, use another pen.
STEP 2 : ATTACH THE NEEDLE
Wipe the pen tip (rubber seal)with alcohol swab
Remove the protective seal from the new
needle, line the needle upstraight with the pen,
and screw the needle on.
Do not screw too tight.
After attached, take off the outer needle cap and
save it (you will need it to remove the needle
after injection).
Remove the inner needle cap and throw it away
STEP 3 : PERFORM A SAFETY TEST
Dial a test dose of 2 unit

Hold the pen with needle pointing up and lightly tap

the insulin reservoir so that the air bubble rise to

the top of the needle.

Press the inj. button all the way in and check to

see the insulin come out from the needle.

If no insulin come out, repeat the test. If there is still

no insulin coming out, use a new needle and do the

safety test again.

If no insulin coming out after second needle, do not

use the pen.

STEP 4 : SELECT THE DOSE
Make sure the window shows 0, then select the dose.

Dial back up or down if you dialed the wrong amount.

If you cant dial the dose, check the insulin in the reservoir. It may be

because you dont have enough insulin left.

You cant dial more than 80 units because the pen has a safety stop. If

the dose is more than 80, redial the dose for the second injection.

Never force the dose selector and never set the dose to half unit. This

may jam the pen.

STEP 5 : INJECT YOUR DOSE
Clean the injection site with alcohol swab.
Keep the pen straight (90), insert the needle into your
skin.
Using your thumb, press the
injection button all the way
down. Slowly count to 10
before removing the needle.
Release the button and
remove the needle from the
skin.
STEP 6 : REMOVE THE NEEDLE
Always remove the needle after injecting to prevent
contamination and leakage.
Put the outer needle cap back on the needle and
unscrew the needle from the pen.
Throw the needle in a sharps container.
Put the pen cap back on the pen and store in a safe
place at room temperature.
ALLSTAR REUSEABLE INSULIN
INJECTION PEN
STEP 1: INSERTING THE INSULIN
CARTRIDGE
Roll the cartridge between
palms. Then, insert the
cartridge, narrow end first into
the cartridge holder.

Screw the cartridge holder

firmly back onto the pen body
until it clicks into the place.

CHECK
The alignment marks on the
cartridge holder and the pen
body must line up as shown.
 STEP 2: CHECK INSULIN BEFORE
EVERY INJECTION
Ensure that you have the correct insulin.

Check the appearance of the insulin.

A) Clear insulins
(e.g. Lantus, Apidra or Insuman Rapid)
Check the appearance of your insulin.
Do not use the cartridge if the insulin is cloudy, coloured or
has particles.

B) Suspension insulins
(e.g. Insuman Basal, Insuman Comb 25/75 or
Insuman Comb 50/50)
Turn the pen gently up and down at least 10 times to mix
the insulin.
After mixing, check your insulin. Insulin suspensions must
have an even milky-white appearance.
STEP 3: ATTACH A NEW NEEDLE
BEFORE EVERY INJECTION
Line up the needle with the
pen and keep it straight as
you screw it into the cartridge
holder.

Pull out the outer needle cap

and keep it safe to unscrew
the needle after the injection.

Pull off the inner needle cap

and discard it.
STEP 4: PERFORM THE SAFETY TEST
BEFORE EVERY INJECTION
Select a dose of 2 units by
turning the dose button.

Holding the pen with the

needle pointing upwards, tap
the cartridge holder so that
any air bubbles rise up
towards the needle.

Press the dose button all the

way in and hold it in for 10
seconds.
STEP 5: SELECT DOSE
Select required dose by
turning the dose button.

After cleaning the injection

site with alcohol swab, insert
the needle into the skin.

Inject dose by pressing the

dose button slowly, all the
way in. Keep the dose
button pressed in for 10
seconds.
STEP 6: REMOVAL OF NEEDLE

Remove needle form

the skin.

CHECK
Full dose is received only if dose
window shows 0.

Carefully put the outer

needle cap back on the
needle.

Unscrew , pull out and

dispose the needle.
STEP 7: STORE ALLSTAR PEN

Replace the pen cap

back on AllStar pen
after use.
Store pen safely until
next injection.
NOVOPEN

Insulatard Cartridge

Actrapid
Cartridge
Mixtard
Cartridge
 ADVANTAGES OF NOVOPEN
Improved safety
Dose scale is easier to read and 3 times larger
Improved ergonomics
Injection force has been decreased by 50%
Shorter push button
Improved convenience
Each injection ends with a click for your convenience
You are able to correct a dose setting without losing insulin by
simply dialling back
The cartridge holder can be twisted off in one quick turn
motion
The piston rod is returned by simply pushing it back until it
stops and locks into place
 ADVANTAGES OF INSULIN
PEN OVER VIAL AND
SYRINGE
1. More convenient and easier to transport than
traditional vial and syringe
2. Repeatedly more accurate dosages
3. Easier to use for those with visual or fine motor
skills impairments
4. Less injection pain (as polished and coated
needles are not dulled by insertion into a vial of
insulin before a second insertion into the skin)
 DISADVANTAGES OF
INSULIN PEN OVER VIAL
AND SYRINGE
1. Two different insulins cannot be mixed by the
user in an insulin pen
2. Using pens and pen needles is usually more
expensive than using the traditional vial and
syringe method
INSULIN WITH A VIAL AND SYRINGE

Choose a syringe [1]

1) 0.3 ml insulin syringes
Graduated in 1-unit intervals.
Ideal for doses under 30 units because of
their discrete size.

1. Becton Dickinson and Company.(2005) Getting started with Insulin Injections.

Franklin Lakes, NJ 07417
INSULIN WITH A VIAL AND SYRINGE

Choose a syringe
2) 0.5 ml insulin syringes
Graduated in 1-unit intervals.
Ideal for doses between 30 units and 50
units.
INSULIN WITH A VIAL AND SYRINGE

Choose a syringe
3) 1 ml insulin syringes
Graduated in 2-unit intervals.
Ideal for doses over 50 units.
 STEP 1
Wash your hand
Gently roll vial of cloudy
insulin (premixed,
intermediate- or long-acting
insulin) between your hands
20 times to mix evenly. Never
shake.
Check the label on
the insulin vial for
any special
instructions and the
expiry date.
1. Becton Dickinson and Company.(2005) Getting
started with Insulin Injections. Franklin Lakes, NJ
 STEP 2
If you are using new vial,
remove the protective cap.
Do not remove the stopper.

Sterilize the top of the vial

by wipe it with an alcohol
swab. [2]

2. Lantus.(2014) Injecting Lantus With a Vial and a Syringe; Sanofi

US
 STEP 3
Remove the white cap
covering the plunger,
then carefully twist and
remove the orange
needle cap without
touching the needle.
Draw air into the
syringe equal to
the number of
units of insulin
needed.
 STEP 4
With the vial standing
upright, insert the needle
straight through the centre
of the rubber cap of the
insulin vial and push the
plunger down.
This injects air into the
vial, making it easier for
you to draw out the
insulin.
 STEP 5
Hold the vial and syringe
upside down. Make sure that
the point of the needle inside
the vial is well beneath the
surface of the insulin.
Slowly pull the plunger,
drawing the correct
amount of insulin, plus a
little extra, into the
syringe.
 STEP 6
Check for bubbles. Tap syringe.
Expel any bubbles and the extra
insulin. Check that you have the
correct amount for your dose.

Although air bubbles are not

dangerous if injected, they
may affect the accuracy of
your insulin dose.

If air bubbles remain, inject all

of the insulin back into the vial
and start again.
 STEP 7
Remove the needle from the
vial. Do not let the needle
touch anything.

You are now ready to inject.

 STEP 8
Choose an injection site (see
injection site slide).

Lifting your skin into a fold before

injecting with an 8 mm or 12.7 mm
needle will help you avoid delivering
insulin into your muscle by
accident.
Use only the thumb, index and
middle finger to perform a
correct lifted skin fold.
 STEP 9
Insert the needle into the skin
(90). Slowly push in the plunger
all the way in. leave the needle in
the skin for 10 seconds.
Pull the needle straight out and
gently press the injection spot for
several seconds. Do not rub.
Safely dispose of your needle and
syringe using the right technique.
 DISPOSAL OF SYRINGE
Never throw used syringes, syringe
needles, or needles needles in the regular
garbage.
Put your used syringes and needles into a
sharps container or a hard plastic or metal
container with a screw-on lid.
When the container is full, seal the lid
securely and dispose of it.
Keep this container away from children.
1. Becton Dickinson and Company.(2005) Getting started with Insulin Injections.
Franklin Lakes, NJ 07417
 ADVANTAGES OF USING INSULIN WITH
A VIAL AND SYRINGE
1. Simplicity. They are easy to learn to use
2. Choice. They come in such a variety that you
can usually find one to suit you.
3. Reliability. There is not much that can go wrong
in a syringe - it has very few moving parts
4. Flexibility. They allow you to use one type of
insulin or to combine 2 types of insulin within a
single syringe if needed.

3. Diabetes Explained. (2013 Apr). Insulin Syringes. retrieved from

http://www.diabetesexplained.com/insulin-syringe.html
 DISADVANTAGES OF USING INSULIN
WITH A VIAL AND SYRINGE
1. Less patients adherence and increase
hypoglycemic events compared to insulin
pen.
2. Overall health care costs were either
unchanged or improved in insulin pen users
as compared with those using insulin vials
and syringes
3. Patients tend to prefer insulin pen use
based on patient satisfaction and ease of
use compared to insulin vials and syringes
4. Bastian MD, Wolters NE, Bright DR.(2011 Jun). Insulin pens vs. vials and syringes: differences
in clinical and economic outcomes. Consult Pharm;26(6):426-9. doi: 10.4140/TCP.n.2011.426.
 REFERENCES
1. MedlinePlus: Diabetes;
http://www.nlm.nih.gov/medlineplus/ency/article/00121
4.htm
2. Feisul MI, Azmi S. (Eds).National Diabetes Registry
Report, Volume 1, 2009-2012. Kuala Lumpur; Ministry
of Health Malaysia; 2013 Jul.
3. Institute for Public Health (IPH) 2011. National
Health and Morbidity Survey 2011 (NHMS 2011). Vol.
II: Non- Communicable Diseases.
4. Bode A. (2009 Jan). Development of the SoloSTAR
insulin pen device: design verification and validation.
Expert Opin Drug Deliv;6(1):103-12.
5. Lantus SoloSTAR; http://www.lantussolostar.com