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Tata Laksana Diabetes

Dengan Terapi Insulin


Dr. Taufik Hidayat
Novo Nordisk Indonesia
Pengelolaan Diabetes Tipe 2
Gaya Hidup Sehat • Jika HbA1C>9%
• Ada Gejala Diabetes
•Jika GD
tidak
terkontrol Obat Anti Diabetes
• Pemakaian Insulin
bukan berarti gagal.
•Jika sudah 1 - 2
OAD, namun GD • Diabetes tipe 2 adalah
tidak terkontrol Insulin penyakit progresif.
± Obat Lain • Insulin dapat menunda
Dapat ditambahkan dan menghambat
komplikasi jika
diberikan lebih awal.

Diadaptasi dari PERKENI 2015. Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia.
American Diabetes Association. 2007. Insulin Myths and Facts
LEVEMIR®
Insulin Detemir
• Levemir® is a soluble, basal insulin analogue with a prolonged duration of
effect (up to 24 hours).

• Each pre-filled Levemir® pen contains 300 U of insulin detemir in 3 ml


solution for injection.
Levemir® is for subcutaneous administration only. (abdominal wall, the
thigh, upper arm, deltoid and gluteal region)

• Indication : Treatment of diabetes mellitus

• Can be used in pregnant women and children ≥ 2 years

• Contraindication : Hypersensitivity to the active substance or to any of the


excipients
Levemir®. Indonesia Prescribing Information. 2017
• Storage : Store in refrigerator (2˚-8˚C). Keep away from the cooling
element. Do not freeze. Keep the pen cap on FlexPen® in order to protect
from light. Levemir® must be protected from excessive heat and light. After
first opening or carried as a spare: Do not refrigerate. Store below 30°C.
The in-use shelf life is 6 weeks.

Levemir®. Indonesia Prescribing Information. 2017


How to Titrate Basal Insulin
Levemir® Dose Titration Guidelines:
3-0-3 Algorithm

Simple Dose titration with Levemir ®


Mean 3-day FPG (mg/dL)

Start with Levemir® 10 U or 0.1-0.2 U per Kg body weight


FPG>110 mg/dL +3U

FPG 80-110 mg/dL 0

FPG <80 mg/dL -3U

Patients who experienced hypoglycemia reduced their daily dose by 3 units

Blonde L et al. Diabetes Obes Metab. 2009; 11(6):623-631.


Levemir Indonesia Prescribing Information 2017
Summary of A1chieve study in Indonesia
Insulin naïve participants initiated on IDet (Indonesia)

Efficacy Safety Other


Baseline
HbA1c Δ HbA1c Δ FPG Δ PPG Hypoglycaemia Weight

↓101 ↓115 1.0*


IDet 9.5% ↓2.2% mg/dL mg/dL

Significant improvement
(p<0.001)

*p<0.001

Soewondo P, et al. Clinical experience with insulin detemir: Results from the Indonesian cohort of the international A1chieve study.
Diabetes Research and Clinical Practice 2013; 100(S1): S47–S53
NovoRapid®
Insulin Aspart
• NovoRapid® is a rapid-acting insulin analogue.

• Each pre-filled NovoRapid® pen contains 300 U of insulin Aspart in 3 ml


solution for injection.
NovoRapid® is for subcutaneous administration (abdominal wall, the
thigh, upper arm, deltoid and gluteal region), insulin infusion and
intravenously

• Indication : Treatment of diabetes mellitus


• Can be used in Adult T1DM, Adult T2DM, Children ≥ 2 years old, Pregnancy
& lactation

• Contraindication : Hypoglycaemia. Hypersensitivity to the active substance


or to any of the excipients
NovoRapid®. Indonesia Prescribing Information. 2016
• Special population : Elderly patients, Patients with renal/ hepatic
impairment

• Storage
• Before opening: Store in a refrigerator (2°C – 8°C). Keep away from the
cooling element.
• During use or when carried as a spare: Do not refrigerate. Store below
30°C. Use within 4 weeks.
• Do not freeze.
• Keep the pen cap on NovoRapid® FlexPen® in order to protect from
light.
• NovoRapid® must be protected from excessive heat and light.

NovoRapid®. Indonesia Prescribing Information. 2016


NovoRapid® is approved in various population

Children Pregnancy Elderly Patients using Patients with Hospitalised


Adult T1DM Adult T2DM
≥ 2 years & lactation patients insulin pump renal/ hepatic patients
old impairment

NovoRapid. Indonesia Prescribing Information. 2016


Strategies for dose intensification
Straight to three bolus doses Sequential addition of bolus doses

Fix the FPG first using basal insulin (dose optimisation) Fix the FPG first using basal insulin (dose optimisation)
Goal: FPG 70-130 mg/dl (3.9-7.2 mmol/l) Goal: FPG 70-130 mg/dl (3.9-7.2 mmol/l)
Consider adding bolus insulin when : Consider adding bolus insulin when :
A1C>7% and FPG at goal or basal insulin dose > 0.5 U/kg A1C>7% and FPG at goal or basal insulin dose > 0.5 U/kg

Add bolus 2U at each meal Add bolus 4U at largest meal


Titrate to next pre-prandial goals ( and bedtime) daily Titrate to next pre-prandial (or bedtime) goal daily

If subsequent pre-meal sugars are: If subsequent pre-meal sugars are:


<70mg/dl -1U <70mg/dl -1U
70-130mg/dl 0 70-130mg/dl 0
>130mg/dl +1U >130mg/dl +1U
Discontinue SU on addition of bolus insulin Discontinue SU on addition of bolus insulin
Patients need to monitor up to 4x per day Patients may need monitor up to 4x per day

Id A1C>7% after 3 months despite titrating bolus dose, Id A1C>7% after 3 months despite titrating bolus dose, or
or bolus dose s are more than 30 U per meal : bolus dose is more than 30 U per meal :
Resume titration of basal insulin and/or consider performing Add 2nd bolus of 4U at 2nd largest meal and titrate as before.
a 7 point profile Repeat for 3rd bolus dose at final meal of the day

Pfutzner A, Forst T. Intensification with prandial insulin. Int J Clin Pract 2009; 63 (Suppl. 164): 11–14
NovoMix® 30
Biphasic Insulin Aspart 30
• NovoMix®30 dosing is individual and determined in accordance with the
needs of the patient.

Each pre-filled NovoMix®30 pen contains 300 U of insulin Aspart


/protamine-crystallised insulin aspart in 3 ml solution for injection.
NovoMix®30 is for subcutaneous administration only. (abdominal wall,
the thigh, upper arm, deltoid and gluteal region)

• Indication : Treatment of diabetes mellitus


• Contraindication : Hypersensitivity to the active substance or to any of the
excipients. During episodes of hypoglycaemia.

NovoMix®. Indonesia Prescribing Information. 2016


• Special population : Elderly, Renal and hepatic impairment, and children
and adolescents ≥ 10yrs

• Storage
• NovoMix® 30 FlexPen® that is being used or carried as a spare is not to
be kept in the refrigerator. It can be kept at room temperature (below
30°C) for up to 4 weeks.
• Keep the pen cap on FlexPen® in order to protect from light.

NovoMix®. Indonesia Prescribing Information. 2016


Switching from basal insulin OD or BID to
BIAsp 30 BID
• 1:1 total dose transfer to BIAsp 30
• Split the dose 50:50 pre-breakfast and
pre-dinner

• Titrate the dose preferably once a week


• Discontinue sulphonylureas
• Continue metformin
• Consider discontinuing TZDs as per local guidelines and
practice

• Administer BIAsp 30 just before meals

BIAsp, biphasic insulin aspart; BID, twice daily; OD, once daily; TZDs, thiazolidinediones
Unnikrishnan et al. Int J Clin Pract 2009;63:1571–7
Teknik Injeksi
Insulin
Materi presentasi

• Pengenalan FlexPen®
• Jarum NovoTwist®
• Teknik Injeksi Insulin
Bagian Flexpen® device
Flexpen® Device

 1 pen : 3 ml ~ 300 U
 Warna yang kontras, mudah dibedakan
 Tactile pada push button
 1 klik = 1 Unit
 Pen sekali pakai, praktis untuk pasien
 Dosis yang lebih akurat dibanding pen
insulin lainnya1

1. Asakura T et al.2008. Cur. Med. Res. and Opin. 2008;24(5):1429-34


Materi presentasi

• Pengenalan FlexPen®
• Jarum NovoTwist®
• Teknik Injeksi Insulin
 Pasien berhak mendapat jarum yang baik pada saat
inisiasi insulin

 Dokter setuju bahwa yang paling penting dari jarum


adalah kenyamanannya

NovoTwist®
Didesain untuk kemudahan

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NovoTwist® portfolio

Panjang Diameter
5 mm 32G (0.32 mm)

No Reg : AKL 20902412159


Tersedia dalam kemasan dus isi 100 buah

Jarum insulin sekali pakai


Kompatibel digunakan dengan Levemir®, NovoRapid®, NovoMix®
FlexPen® dan pena Victoza®

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Kelebihan NovoTwist® – Just Twist

Lebih mudah – Pemasangan jarum yang lebih sederhana menjadikan penyuntikkan


lebih mudah

Nyeri yang minimal – Jarum yang tipis seperti NovoTwist® meminimalkan rasa
nyeri saat penyuntikan

References:
2. Arendt-Nielsen L et al. Pain following controlled cutaneous insertion of needles with different diameters. Somatosensory and Motor Research 2006; 23 (1-2); 37-43.

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Jarum Insulin Sekali Pakai

• Single use, Selalu gunakan jarum baru


• Penggunaan individual
• Risiko penggunaan jarum berkali-kali:
1. Kontaminasi yang menyebabkan infeksi
area penyuntikan
2. Jarum menjadi tumpul sehingga timbul
nyeri saat penyuntikan
3. Jarum mengalami penyumbatan, dosis
5 mm, 32G
menjadi tidak akurat
4. Jarum mudah patah, risiko tertinggal di
area penyuntikan
NovoTwist® – untuk semua kebutuhan Ingat! Selalu
gunakan
jarum baru

Jarum NovoTwist® cocok untuk semua usia dan ukuran tubuh

DEWASA DEWASA ANAK-ANAK


Cara mencubit
Kurus Normal dan Kurus, normal, kulit:
Obesitas obesitas Cubit kulit
dengan jempol
Jarum 32G

dan telunjuk.
5 mm

Tahan selama
5-10 detik
setelah
menyuntik dan
Kulit dicubit Kulit dicubit
sebelum
mencabut jarum

Gitte Ehlers, Diabetes Nurse, Kalundborg Hospital, Denmark. April 2007.


Materi presentasi

• Pengenalan FlexPen®
• Jarum NovoTwist®
• Teknik Injeksi Insulin
Area Penyuntikan dan Rotasinya

Keterangan

A1&A2: Lengan atas


B : Perut
C : Bokong
D : Paha atas
Teknik Injeksi dengan Flexpen®
Bentuk Sediaan :
- Premix : Suspensi (Keruh)
- Insulin Basal dan Prandial : Solusio (Jernih)

Gulung Pena Insulin diantara kedua Gerakkan pena insulin keatas


telapak tangan sampai dengan 10 x dan ke bawah sebanyak 10 x
(posisi horizontal)

&
Teknik Injeksi dengan Flexpen®
Teknik Injeksi dengan Flexpen®
Teknik Injeksi dengan Flexpen®

Putar dosis sesuai rekomendasi dokter


Teknik Injeksi dengan Flexpen®

• Posisi tegak lurus 90°, tekan sampai kembali ke


angka 0
• Setelah disuntikkan, tahan hingga hitungan 10
Penyimpanan

 Insulin yang belum digunakan harus disimpan dalam suhu 20 –


80 C

 Insulin akan stabil sampai dengan masa kadaluarsa yang


tercantum pada FlexPen®

 Insulin yang sudah digunakan dapat disimpan pada suhu


kamar (< 300 C) dan akan stabil sampai dengan 6 minggu
(Levemir®) sedangkan NovoMix® dan NovoRapid® 4 minggu.
Berlaku untuk Flexpen® maupun vial.

 Hindari terpapar cahaya matahari langsung

Referensi: Novo Nordisk FlexPen. Indonesia Package Insert


THANK YOU