Debbie Hinnen APN, BC-ADM, CDCES, FAAN joins The Huddle to share her expertise and experiences starting patients with type 2 diabetes on injectable, non-insulin therapies. We will cover topics like how to have a conversation with someone who may have concerns about starting a patient on an injectable, setting realistic expectations, storage and side effects. Disclosures: Speaker/Consultant for Eli Lilly and Company, Boehringer Ingelheim, Novo Nordisk, Intuity This podcast was developed in partnership with Eli Lilly and Company. Resources: Download a patient-focused tipsheet that complements the topics covered in this podcast. https://www.adces.org/docs/default-source/handouts/cvd/60-23_tipsheet-startstaynoninsulininjectable-9.pdf?sfvrsn=7f11759_5 1. https://pi.lilly.com/us/trulicity-uspi.pdf 2. https://www.bydureon.com/bydureon-bcise.html 3. https://www.novo-pi.com/victoza.pdf 4. https://www.novo-pi.com/ozempic.pdf 5. https://www.novo-pi.com/rybelsus.pdf 6. https://pi.lilly.com/us/mounjaro-uspi.pdf?s=pi 7. Triplitt & Solis-Herrera. The Diabetes Educator. 2015;41:S22 8. De Block et al., DOM. 2023;25:3 9. Frias et al., Lancet Diabetes Endocrinol. 2021;9:563 10. Jendle et al., Diabetes Metab Res Rev. 2016;32:776 11. El Sayed et al., Diabetes Care. 2023;46:S140
Debbie Hinnen APN, BC-ADM, CDCES, FAAN joins The Huddle to share her expertise and experiences starting patients with type 2 diabetes on injectable, non-insulin therapies. We will cover topics like how to have a conversation with someone who may have concerns about starting a patient on an injectable, setting realistic expectations, storage and side effects.
Disclosures: Speaker/Consultant for Eli Lilly and Company, Boehringer Ingelheim, Novo Nordisk, Intuity
This podcast was developed in partnership with Eli Lilly and Company.
Resources:
Download a patient-focused tipsheet that complements the topics covered in this podcast. https://www.adces.org/docs/default-source/handouts/cvd/60-23_tipsheet-startstaynoninsulininjectable-9.pdf?sfvrsn=7f11759_5
1. https://pi.lilly.com/us/trulicity-uspi.pdf
2. https://www.bydureon.com/bydureon-bcise.html
3. https://www.novo-pi.com/victoza.pdf
4. https://www.novo-pi.com/ozempic.pdf
5. https://www.novo-pi.com/rybelsus.pdf
6. https://pi.lilly.com/us/mounjaro-uspi.pdf?s=pi
7. Triplitt & Solis-Herrera. The Diabetes Educator. 2015;41:S22
8. De Block et al., DOM. 2023;25:3
9. Frias et al., Lancet Diabetes Endocrinol. 2021;9:563
10. Jendle et al., Diabetes Metab Res Rev. 2016;32:776
11. El Sayed et al., Diabetes Care. 2023;46:S140
Jodi:
Hello and welcome to ADCES's podcast, The Huddle, Conversations with the Diabetes Care Team. In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues, and updates that elevate your role, inform your practice, and ignite your passion. I'm Jodi Lavin-Tomkins, Director of Accreditation and Content Development at the Association of Diabetes Care and Education Specialists. My guest today is Debbie Hinnen, a nurse practitioner, certified diabetes care and education specialist, and board certified in advanced diabetes management. She practices at the University of Colorado Health.
I also wanted to thank Eli Lilly for their partnership on this episode in which we will be discussing some of the practicalities of using long-acting injectable, incretin therapies for type 2 diabetes, and some tips for facilitating patient success. There is also a complementary tip sheet that can be found in the resources section of this podcast that covers much of the same content we'll discuss today.
Debbie, welcome to The Huddle.
Debbie:
Thank you.
Jodi:
Before we get into today's discussion, could you tell our audience a bit more about yourself and your work as it relates to today's topic?
Debbie:
Well, thank you, Jodi. I have been able to provide clinical care and education for people with diabetes for decades, starting with kids at diabetes camp. But related to this topic, this class of medication was approved for our use going on almost 20 years, and I was on call when the very first medication came out, and I was on my way home. My pager went off, and when I called in, I got ahold of the patient. They said, "Debbie, I'm full." And I said, "Well, stop eating." And the patient said to me, "No, no, you don't understand the dietitian said that I could have this much, and I'm only half done." I said, "That's great. That's what that medication is supposed to do. Stop eating." So we have seen great changes since that point when people took that incretin several times a day. Now we're seeing, of course, once a week as a very common frequency for the newer incretins.
Jodi:
Well, you did give us a little bit of insight into what you say to patients, but what advice do you have for starting a conversation with someone with type 2 diabetes who's naive to injections? So specifically, how do you anticipate their questions and make them feel more comfortable with the idea of an injection and explain how the medication is different from insulin?
Debbie:
Those are great questions, and[JP1] if we're following ADA guidelines, this should be the first injection before insulin. And so I like to ask how they feel about giving an injection. Have you been around people before who have given injections? And then you pause, and people have usually been around someone who takes insulin. And surprisingly, they're not always afraid of the needle. It may be weight gain or something totally unrelated to what you're thinking. So let your patient explain any concerns they have, and then you walk them through that and talk to them about whatever it was that they expressed to you. But explaining the medication is very important, and this is a non-insulin injectable.
And the long-acting injectables, as we said, are used quite commonly today, but they do a number of different things. They don't just have one action. They're glucose-activated therapies. And so when people eat is when they are beginning to be triggered, and they improve first and second phase insulin secretion. They[JP2] help reduce the glucagon levels. They[JP3] help improve insulin sensitivity. And as we discussed earlier, they help people feel[JP4] full. So that is five of the metabolic defects that we know are happening very commonly in type 2 diabetes. They can take the injection any time of the day, with or without food. That's quite different from other diabetes medications.
And that kind of information is very reassuring for people. It's also helpful to talk about and demonstrate the injection with your patient. The medication is a sub-q injection, so that's under the skin in the stomach, away from the umbilicus, the upper part of the thigh, the arm, any of those places. It could be a sub-q fatty tissue injection. And it's important, of course, to encourage your patients to rotate their injection sites and be sure that if they have multiple injections that they're using different sites.
And of course, if you have a demo pen on hand, you should pull that out and offer to show that to the person with diabetes and have them practice. Because there's just a few simple steps to perform this injection. And the pens are slightly different. If it's a single dose, meaning that the dose you've been prescribed is what you'll be delivered in that particular pen, or there will be pens that you will adjust the dial to get the right dose. So you can encourage patients to bring this in for their first injection into the clinic. And then after they give that injection, there's multiple ways to confirm the delivery. And they're slightly different. So you want to be sure you review that with patients as well. They may need to hold the dose knob against their skin, the device against their skin, 5, 6, 10 seconds, or hold down the dose knob. And then they may listen for a second click that would let them know that the medication has been injected and the needle retracted.
Jodi:
Well, thank you, Deb, for walking us through that. And now I want to move into the expectations around glucose management and weight management while on the injectable medication. Can you talk about that for our audience?
Debbie:
I can. And I think that's very important. Because as these medications become more well known, people come in with some big requests. And we want to be realistic. But the blood glucose may actually begin to improve, after the first injection. Now, it may take several weeks or even months to get to a dose that gets the patient's very best response, though. And now, if your patients are on sulfonylureas or insulin, they may need a proactive dose reduction. Since this combination of anti-hyperglycemic medications, namely the SU and the insulin, can increase the risk of hypos. So for patients on SU or insulin, it may be worthwhile to encourage your patient to do some baseline glucose levels before they start on their medication. And then test again before and sometimes after meals in those first few weeks. That gives some data to them to share with their clinician so they'll know how they may need to adjust the insulin doses.
Now, depending on the response, I've actually had patients that have been able to stop their insulin or their sulfonylurea therapy. And let me tell you, you are at the top of your patient's list, if that happens.
Now, weight, it's important to know that the weight reductions with people with type 2 diabetes may also begin within the first week or two. And the weight reduction may be as little as five or even up to 25 pounds in some instances more than that. Of course, it depends on the medication and the dose and how the person with diabetes is responding to that. And of course, there may be some people that don't lose weight, but thinking about that possible five to 25 pounds of weight loss, let me put that in perspective. That may be 1 to 2 percent or up to 10 to 15 percent of their starting body weight.
Jodi:
Well, Deb, I'm sure you have some best practices to share with our audience on how to help people with diabetes have success to start, not only start, but to stay on the medication. So can you share those?
Debbie:
Absolutely. And boy, is that important. We want people to stay on this medication. So helping them get a good start is really our most important beginning point. And that first injection, if that can happen in the office or the clinic, and it may not be the clinician, it could be someone else in the office who helps with that. It's just very reasonable to have the patient ask the pharmacist if the clinic isn't available to help them with that as well.
And, you know, we have patients who've already figured this out before they start. They may come into clinic asking us for this medication. So they may have found the resources, the medication guide, the tutorials, pharmacy websites, product websites, or even YouTube. And we've created a tip sheet as part of this whole process that you can download for your patients. And that may also be a great help. But you know if your patient needs your help with that first injection. So if you've got samples available, that's another way that you can help that patient give that first injection in the clinic. If samples aren't available or you're not able to take samples in your clinic, you may ask the patient to pick up the prescription and bring that medication, that new device, back with them to the office for your support.
Another important point is the dose escalation time frame. So review the dose escalation procedure with your patient and tell them that you expect to follow up with them, usually within a few weeks after they begin that initial injection. You want to check on tolerability. You want to check on glucose levels. And in some cases, you may be able to adjust the escalation depending on your patient's response.
Explain that they will start low and go slow and that will increase as needed to allow their body to get used to the medication. And then to get to the best dose for their optimum outcome.
Okay, so moving on. Cost expectations are very important for our patients and they need to know the out-of-pocket expected amount. Now, if they have commercial insurance, the copay cards will be available for them to use. And you, of course, will be sure that you're checking formulary preference, depending on affordability options. This may drive the medication choice. But don't be surprised if you've got some prior-auths, maybe more than you're used to. Now, here's a tip. For prior-auths, I find it helpful to quote the ADA Standards of Care. The recommendation is that patients with type 2 diabetes at high risk for cardiovascular disease should be started on a GLP or an SGLT2 inhibitor regardless of metformin or A1c level.
So I think this gives a little more power to your request that the insurance company approved this. Make sure you set up a specific follow-up plan and give clear directions on when and what to call for. You don't want your patients to stop this medication and then you find out a month later.
Jodi:
Well, Deb, you've addressed a lot of the questions I think our audience may have had, but I'm sure there's some other advice that you may give that we want to hear about, especially around scheduling the dose and maybe storing the medication. What advice would you give around those kinds of things?
Debbie:
Yes, a very important topic as well. So scheduling, that injection day can be changed. So if you help your patient give their injection on a Thursday in the clinic and they want to give it on the weekend, they may be able to change it two or three days. There's slight differences in the medication, so be sure you review that as part of the initial consultation visit. And then some patients need a reminder system. I know we're focused today on long acting and they're once a week, but some people need some help remembering that until they get into the habit.
And also talk about what to do in case they miss a dose.
Now storage, typically these are kept in the refrigerator until the day of the injection. So they may set it out for a while before they give the injection, but the single dose pens need to be disposed of after that use, that first injection.
The multiple dose pens, be sure the patient takes off the needle and then they put it back in the refrigerator or they keep it at room temperature for 30 or 56 days, depending on the pen that they have. When the device is kept in the fridge, make sure it's not in an area that's likely to freeze.
Now travel, I'm so glad you asked about that. There's slight differences in how long each med can be left out of the refrigerator, but review that as well because patients are able to travel without an ice chest potentially. Encourage your patient to double check how long it can be kept at room temperature and how long it can stay out of the fridge after first use. For example, if your patient is driving cross country, whether it's in the summer or the winter, keep in mind the medication shouldn't be left in the car. It may freeze or it may get way too hot.
Jodi:
Yeah, these are some good points that you make, Deb.You know, with any medication, if you're starting a new medication, you want to know about side effects probably. So how do you coach the person with diabetes about minimizing the possible GI issues? And I think we want to hear if anti-nausea or anti-diarrheal medications can help the person during this adjustment period.
Debbie:
That is very important. And people hear all kinds of things. They read all kinds of things and they need to hear from their clinician what is factual. So those expectations around side effects early on are important and that they will know that when they initiate the medication and when they escalate the dose, those are the times that they are most at risk for GI side effects. And so the kind of coaching I give my patients is because those first few days after the injection is when they're most at risk. Eat half of what you normally eat or snack for those first few days and avoid high fat and spicy foods, of course. And I used to say eat slowly and stop eating when you're full. And of course, that's still good advice, but it's not quite as actionable as snack or eat half of what you normally would.
And be sure that you've explained to your patients what GI side effects are. We know it as nausea, vomiting, indigestion, diarrhea, decreased appetite, constipation, stomach pain, but be sure you do kind of walk through those. I say queasy because it, I think, softens that list a little bit. But don't take for granted that everybody knows what GI side effects would mean.
Now, the slower titration up on your dose is your clinical decision. So that reminder to you is another thing you want to keep in the back of your mind. Now, Jodi, you asked about anti-diarrheal and anti-emetic or anti-diarrheal medications may be beneficial for side effects. A nurse practitioner that I talked to this week said she has patients with constipation. So she tells them at the initial consult if they're having any problem, be sure they increase their fluid, be sure they increase their fiber. So she's coaching them ahead of time on that.
And it's also important to remind our type 2 patients with pre-existing renal dysfunction, if they have nausea, vomiting, electrolyte imbalance, dehydration, that they should be very well hydrated while they're taking this drug.
Jodi:
Those are all good points, Debbie. And I think we're at a point in the conversation where I want to recognize all the great information you've provided in this kind of deep dive into this topic. And I want to know if you have any other closing thoughts or tips for our listeners.
Debbie:
When writing the prescription, be sure you've thought about what else the patient may need. For example, if they're taking some of the once a day medications, they'll need pen needles.
Once a week, they won't need that, of course. They may need a sharps container. I think it's very encouraging for people to track their progress. We know that we are hoping for good glucose improvement, for weight reduction. And people may want to track that before they start the medication, and then in the first few weeks after. And if they're on insulin or sulfonylureas, this is very important to help titrate those doses down. If they're not on those medications, of course, it's not as critical that they check blood sugars. It's just for their sort of biofeedback information about their progress. Now, if patients do have GI issues, remember that the data shows that most are mild to moderate, and they usually go away after a few weeks.
Jodi:
Well, Debbie, thank you so much for taking the time to join us for this episode of The Huddle, and for sharing your knowledge and experience with our audience. As a diabetes care and education specialist, I know how useful this information is for practice, so I'm sure our listeners really appreciate hearing your firsthand experience.
Debbie:
This has been great fun, and I really hope there's some pearls that may be helpful for our colleagues.
Jodi:
Absolutely. And thank you all for listening to this week's episode of The Huddle. I also want to thank Eli Lilly for partnering on this episode. Make sure to download the resources discussed in today's episode. You can find them linked in the show notes at diabeteseducator.org forward slash podcast. And remember, ADCES membership gets you free access to resources, education, and networking that can improve your practice and optimize outcomes for your clients. Learn more about what ADCES can do for you at diabeteseducator.org forward slash join. The information in this podcast is for informational purposes only, and may not be appropriate or applicable to your individual circumstances. This podcast does not provide medical or professional advice, and is not a substitute for consultation with a health care professional. Please consult your health care professional for any medical questions.
[JP1]New content from approved speaker notes. ADA Pharmacologic Guidelines 2023 Figure 9.4
[JP2]See Triplitt-Solis-Herrera, S33 (pg 2 of 15)
AND
Holst JJ, The physiology of glucagon-like peptide 1. Physiol Rev 2007:87(4):1409-39 doi: 10.1152/physrev.00034.2006.
[JP4]See tirzepatide USPI Section 12.2 and Holst The Physiology of Glucagon-like Peptide 1. Physiological Reviews. 2007;87(4);1409-1439 https://doi.org/10.1152/physrev.00034.2006 Section "Effects on Appetite and Food Intake"