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                           Insulin Pen FAQ

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Updated 07Aug96: Added instructions for refilling catridges 

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Latest news on the NovoPen 1.5 (thanks to Jim R.):

If you call Novo at 1-800-727-6500 and track through their automated 
phone message, you will eventually get to new product info on the 
NovoPen 1.5 and a real live human marketing rep. Novo will send you an 
info brochure with a coupon. 

With the coupon and the purchase of a box of cartridges and a box of pen 
needles, you get the pen free. The 1.5 is an excellent tool. I did not 
ask about the Novo III. I did ask and they are not selling the older 
longer pen needles any more. 
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1.  What is "the pen"?

    A pen-type insulin delivery suystem looks like an old-fashioned 
    fountain pen or cartridge pen, with two major differences: instead 
    of ink in the pen, there is insulin inside, and instead of a nib, a 
    needle attaches to the end.

2.  What pens are currently available in the United States?
   
    The insulin pens currently available in the U.S. are Novolin 
    Prefilled Pens, NovolinPen, and AutoPen.

3.  What pens are currently available in Canada?

    There are two brands of insulin pens in Canada. They are made by 
    Novo Nordisk Canada and Becton Dickinson.

    Novo has three pens on the market currently, the Novo Pen II, the 
    Novo Pen 1.5, and the Novo Pen 3.  

    The Pen II is the same as the one in the United states. It delivers 
    in 2-unit increments with a maximum dose of 36 units possible. It 
    takes the 150-unit cartridges and is free from any pharmacy (in 
    Canada) with a prescription and insulin purchase. This unit is 
    being phased out in Canada currently.

    The Pen 1.5 is a stainless steel unit that delivers in 1-unit 
    increments with a maximum dose of 40 units. It also takes the 150-
    unit cartridge and is free from any pharmacy (in Canada) with a 
    prescription and insulin purchase. The 1.5 is intended to replace 
    the Pen II.

    The Pen 3 looks just like the 1.5 but is slightly larger. It 
    delivers in 1-unit increments but can deliver up to a 70-unit dose.  
    It takes a larger 300-unit cartridge and is free from any pharmacy 
    (in Canada) with a prescription and insulin purchase.

    If you haven't caught on yet, the pens are given away by the drug 
    companies in Canada. They figure they will get the money from you 
    later with supplies.  :)  

    The BD pen comes in two styles, the BD Pen and the Designer BD Pen.  
    The only difference between the two is that the Designer is splashed 
    with bright colours to make it more attractive to kids. It delivers 
    insulin in single increments and delivers up to a 30-unit dose. It 
    takes the 150-unit cartridge and is free (in Canada), compliments of 
    Eli Lilly Canada (the guys that sell the insulin cartridges).

    (Thanks to Dave Griffith for this information.)

4.  What are the Novolin Prefilled Pens like? Are they disposable?

    The Novolin Prefilled Pens are disposable. You set the dose by 
    turning the top half of the pen in the opposite direction from the
    bottom half, while the cap is still on the pen. It clicks as you 
    turn, and you count up the dose by 2's. While you are counting up 
    the dose, the end of the pen opposite the needle end (where you 
    would push to extend or retract a ball-point pen) is coming out 
    slightly for each 2 units. When you have clicked up the correct 
    dose, you remove the cap, screw on a disposable needle, push the 
    needle through your skin, and inject by pressing the end of the pen. 
    You remove the needle, put the cap back on, and put your pen away. 
    When the pen is empty (each holds 150 units), you just throw it away 
    and start using a new one.

5.  What are the AutoPen and the NovolinPen like? Are they disposable?

    The non-disposable pen systems are the AutoPen and the NovolinPen.
    Both are loaded with insulin contained in a cartridge. The cartridge 
    is made of glass, about 2 1/4" long, 5/16" in diameter, and looks a 
    little like an ink cartridge for an old-fashioned cartridge pen. 
    Each cartridge holds 150 units, and they are sold in packages of 6, 
    usually for about the price of a vial of insulin. The end of the 
    cartridge where the needle is applied (when it's in the pen) has a 
    small metal ring and rubber stopper, just like a tiny insulin bottle 
    top. The other end is open and has a movable rubber stopper that 
    slides forward as insulin is dispensed from the cartridge. (Since 
    the space inside gets smaller when insulin is dispensed, you don't 
    have to inject air before each use.)

    The cartridge goes inside the pen, with the metal-ring end toward 
    the front of the pen, and a plunger inside the pen resting on the 
    movable rubber stopper in the back of the cartridge. You set the 
    dose by turning a ring on the end of the pen opposite the needle 
    end. This sets how far the plunger is going to move inside the pen. 
    With the AutoPen, you just turn one ring; with the NovolinPen, you 
    turn a ring to set the dose, then turn a different ring to lock the 
    dose in. Then you screw a disposable needle onto the end of the pen 
    and give your injection by pressing the end of the pen for the
    NovolinPen, or, with the AutoPen, a movable clip on the side. Then 
    you remove the needle, re-set the dose to 0, and put everything 
    away.

6.  What insulins are available for the pens?

    Both NovolinPen and the disposable Novolin Prefills are available
    in R, NPH, and 70/30. 

7.  The 2-unit increments aren't flexible enough for me. Can I still use
    a pen?

    Both the NovolinPen and the Novolin Prefills allow you to deliver 
    insulin in 2-unit increments only. If you take very small insulin 
    doses, you may need 1-unit increments. But, if 2-unit increments 
    work for you, both the non-disposable and the disposable 
    NovolinPens are excellent products.  

    NovoNordisk used to have a non-disposable pen that did 1-unit 
    increments, the NovoPen, which was sort of the Cadillac of pens -- 
    a sleek metal pen that looked like an executive's fountain pen. I 
    never used one myself but had several clients who were very happy 
    with it. If you can get one, take it. In 10 years it will be a 
    collectible. I have heard that NovoPen III, an update of the sleek 
    old NovoPen, is available in Canada and should be available in the 
    U.S. soon.
   
    The one pen currently on the market in the U.S. that allows you to
    deliver insulin in 1-unit increments is the AutoPen. There are two 
    models -- the 1-unit increment model and the 2-unit increment model, 
    so if you order one be sure to specify which one you want. I have 
    worked with these a little less than with the NovoNordisk products
    but have found them to be quite easy to use and reliable, in the 
    little experience I have had with them. 

8.  Where can I buy a pen?

    Any pharmacy or medical supply store that carries NovoNordisk 
    insulin should be able to get their insulin pens. To get the 
    AutoPen, contact Owen Mumford, 849 Pickens Industrial Drive, 
    Marrietta, GA, 30062; 1-800-421-6936. None of the medical suppliers 
    in my area are routinely carrying the AutoPen, so when someone wants 
    one we have to special order it. Owen Mumford does ship promptly 
    when an order has been placed.

9.  Where can I buy pen cartridges?

    Right now, only NovoNordisk sells pen cartridges, but I hear that
    Lilly will too, soon. It is rumored that in the near future BD and 
    Lilly will be releasing a pen that will be a joint venture. The 
    latest I heard was that this was due in late 1995. I have seen one 
    that was purchased in Canada but haven't been able to get any more 
    information about a release date in the U.S.

10. I am visually impaired. Is the pen a good idea for me?

    See section C under the next question.

11. Can I leave the needle on the pen between uses?
    
    You should remove the needle after each use. If the ambient 
    temperature changes, the insulin inside can expand and leak out or 
    contract and draw air in. It's a mess when insulin leaks (this I 
    have personal, and smelly, experience with), and you can run the 
    risk of injecting a bit of air if you have a large enough bubble in 
    the cartridge (this I have not done myself, but have seen a patient 
    of mine do). However, some people report that they successfully
    leave the needle on the pen.

12. Can I reuse the pen needles?

    You *can* recap the needle when you remove it, and reuse it, just
    as you can safely reuse syringes. If you reuse your syringes for 
    weeks, you can reuse a PenNeedle for weeks. I reuse about 5 times, 
    and then I start bruising at the injection site, so I change after 
    5 or 6 uses. (I use an NSAID for arthritis, and it makes my 
    platelets slippery, so I bruise easily.) 

13. Can I refill the cartridge with a syringe and insulin from a vial?

    I know people who do that, and I know of no reason it would be 
    unsafe, as long as you are really careful about not introducing 
    contaminants into the cartridge. I choose not to do this, because I 
    don't see any big advantage to it. (And, I hasten to add, I am not 
    endorsing this practice, meaning you can't sue me if you decide to 
    do it and something goes wrong. You are doing it at your own risk, 
    not mine.)

14. What are the advantages of pens?

    A. Convenience! It's easy to carry and to give pre-meal injections,
       much easier than carrying vials and  syringes.

    B. Inconspicuous. It's just not as obvious as vials and syringes,
       therefore much less embarrassing to use in public. I have often
       done injections with my pen (a NovolinPen) one-handed, under a
       restaurant table, counting the clicks to count my dose. My
       companions were completely unaware of the fact that I had just
       shot myself.

    C. For those who have visual impairment, or who have fluctuating
       vision, or vision that is unreliable when blood sugars are high:
       Many blind and visually impaired persons use insulin pens as 
       accurate, non-visual insulin measurement and administration
       devices. NovoNordisk includes a disclaimer in all their materials
       about the pens, saying that they were not designed for use by
       visually impaired people. This means that if you choose to use a
       NovoNordisk pen and something goes wrong, you can't sue them. If
       you decide that you, as an adult, are willing to assume 
       responsibility for your own safe use of a pen, you are free to do
       so. You should know that after a lot of use the clicks on the
       NovolinPen can become indistinct, making nonvisual use 
       unreliable; if this happens the manufacturer will replace it.

       [Please note: many other nonvisual insulin measurement devices 
       are available. For more information, contact Ann Williams, RN, 
       CDE, at aswilliams@igc.apc.org, or the National Federation of
       the Blind at 314-875-8911.]

15. What are the disadvantages of the pen?

    A. Insulin is slightly more expensive. But then, the needles are
       slightly less expensive than disposable syringes, so it sort of
       evens out.

    B. When you're traveling, you must be sure to take enough supplies 
       with you (a good idea in any case) because pen supplies are not 
       readily available in all areas. This may change as time goes on. 
       I hear pens are enormously popular in some European countries and 
       in Japan, to the point that it's hard to get standard vials in 
       some areas.

    C. Pen cartridges are not available in Lente or Ultralente.

    D. In the U.S., the only mixture currently available is 70/30. So if 
       you take another mixture, you'd need to take 2 injections. I use 
       vials and syringes at home, since I take Ultralente and also vary 
       my doses a lot. But I really like my pen for pre-meal boluses of 
       Regular when I'm away from home.

16. How can I see a pen without ordering one?

    If you have never seen any pens, you might either ask your diabetes 
    educator to show you some, or go to a medical supply store that 
    carries a lot of diabetes supplies and ask to see them.

17. Can I refill the pen cartridges?

    Here is one way to do it.

    1. With a clean syringe, take out all the insulin left over from 
       before. This should probably be discarded. Inspect the rubber 
       septum to be sure it's not damaged, and the glass to be sure it's 
       not cracked. If you like, you can wipe the top of the septum with 
       alcohol to disinfect it, but I don't, because I figure it has 
       only touched the sterile inside of the needle.

    2. Use a new 100u syringe to take insulin out of the vial you're 
       using. Try to get as little air as possible in it, and use the 
       usual techniques to rid it of air bubbles. 

    3. Inject the insulin into the pen cartridge. Each cartridge holds 
       150 units, so that would be 1 1/2 times with the 100u syringe. 
       There will probably be an air bubble in it (I've frequently seen 
       air bubbles in brand-new cartridges, too). If it's too large, you 
       can draw it out with the syringe by holding the cartridge RIGHT 
       SIDE UP, and sucking it out with the syringe. But for the most 
       part, air bubbles don't matter, because the pen is held 
       vertically to give your shot, and the air bubble floats to the 
       top, anyway.

    4. Keep the refilled cartridges in the refrigerator. You can save 
       the empty ones until you have enough to use up a complete bottle 
       of insulin (150 x 7 = 1050u, so you can plan on having 6 full and 
       one 2/3 full cartridges from one bottle). Then put them in a 
       baggie with the box from the vial, and you'll know when your 
       expiration date is. 

    5. If you're refilling the cartridges with a different kind of 
       insulin from what was already in there, you may have to be 
       careful -- a small amount of insulin from before may remain in 
       the cartridge. For me, it has never been enough to make a 
       difference, but your mileage may vary. You might consider 
       flushing out the cartridge with a small amount of the insulin you 
       will be putting in -- in other words, if you're going to put N in 
       an R cartridge, you might empty it as thoroughly as possible, and 
       then put in about 10u of N, swirl it around, take the fluid out 
       again, and discard it. Then fill it with N.