The thought of self-injecting a medicine will worry most patients, so having strategies on hand for managing their move to an injectable is helpful.
There appears to be little published literature on cultural considerations relating to injectable medicines in the New Zealand context. Using a respectful approach helps. Invite patients and their whānau to share their feelings, memories and stories, acknowledge these, and offer choices and understanding around the process.
At the start of the diabetes journey
Most people with type 2 diabetes will require an injectable therapy at some stage, so prepare your patient for this throughout the whole of their diabetes journey. How you prepare them and their whānau over the long term, and not just at the time they need an injectable therapy, will have a big impact on the whole family’s acceptance of these therapies when the time comes.
Present injectables positively
Talk positively and pragmatically about injectable therapies. Mention them when you talk through future medication options.
There are many tools in your toolkit or kete to help you manage your diabetes well. A range of medications are here when you need them: tablets, insulin, newer medications. They are developing and improving all the time.
Avoid using injectables as a threat
“If you don’t do...you may have to go onto insulin/an injectable.”
Using these treatments as a threat will contribute to your patient feeling they have failed when one of these medicines is needed, and may impair or delay their engagement with them.
Allow your patient time to express any negative feelings
Exploring patient/whānau beliefs and perceptions of a new treatment helps improve acceptability. People often have fearful memories from a time when someone they knew was on insulin. Allow them to express their feelings about this, then validate their feelings so they feel heard. You can then ask simple questions that will help them to start re-framing those memories and moving beyond them.
For example, if your patient says: “I could never go onto insulin or inject myself”, ask: “How do you feel about needing insulin/or an injectable?” or “Tell me about any past experience you have of others being on insulin.”
Whatever they say validate the feeling behind it: “Yes, I can see how that felt/feels scary for you.”
Allow a space in the consult to accommodate their feelings or the consequences of those feelings – it will often be tears or sadness.
Once the time is right, you can then invite them to reframe their feelings: “Have you thought about how this could be different for you?” or “That was your mother’s experience of insulin. Your experience doesn’t have to be the same. We can help you with this.”
Offer the injectable as a choice or a trial
Some people perceive needing insulin as “the end of the line”. Others believe that once you are on insulin you can never come off it. However, in type 2 diabetes a person’s need for insulin can vary over time, particularly if their weight and activity levels change.
There may be a time when you might need to stop this medication – especially if your level of activity increases or your body weight drops.
You can try this for three months, then you and your whānau can decide if it is right for you.
When your patient needs an injectable
Helping a patient commence on insulin is a more complex process than helping them commence on dulaglutide. For more on commencing a patient on insulin, work through the free online NZSSD Diabetes Knowledge Programme and partner with a local diabetes clinical nurse specialist to support your learning.
Commencing a patient on dulaglutide
Before starting a patient on dulaglutide (Trulicity), you need to prepare yourself:
- Get a demonstration Trulicity pen from your local Eli Lilly representative. Learn how it operates through your pharmaceutical representative or an online video.
- If your patient is on insulin or a sulfonylurea, dose reduction of these agents may be needed – visit NZSSD for guidance.6
- Vildagliptin should be stopped when starting dulaglutide as both these agents work via a similar pathway.6
- Have an instruction guide on hand to supply to your patient.
You will also need to prepare your patient:
- If your patient is taking insulin or a sulfonylurea, they should check their blood glucose levels regularly while taking dulaglutide. Their need for insulin and a sulfonylurea may change initially and over the long term. You and they will be able to gauge this through their blood glucose levels.
- Ask them to show you their blood glucose testing equipment and assess their skill in using it. Are their blood glucose testing strips in date? Provide them with a blood glucose record book if needed.
- Revise hypoglycaemia management with them – visit NZSSD6 for information on this.
- Provide them with a link to a Trulicity delivery video, if possible.
- Talk through the possibility they will experience some nausea in the first weeks of treatment.
- Supply them with the prescription for Trulicity and ask them to bring the pen to their next appointment. They will not need needles prescribed as they are pre-attached to the device.
- Advise them to store their Trulicity pen in the refrigerator and well away from the freezer compartment.
- If on vildagliptin, advise them to stop it on the day of the first Trulicity injection and provide them with guidance as to any insulin or sulfonylurea reduction needed on the day of their first injection – supply this as a written plan.
- Set up a 20 or 30-minute appointment for the first injection and invite them to bring a whānau member as support.
On the first injection day
If possible, have the patient give their injection at the beginning of this consult. They will be anxious before they have administered their first injection and won’t retain details when in this state. Once they've done the injection, they will be relieved and more open to receiving information.
Guide the patient through their first injection:
- Use your demonstration pen to show how the device works.
- Help the patient to choose a preferred injection site. If possible, this should be in the abdomen – avoiding the umbilicus and scars – or the outer aspect of the thighs.
- Hand the patient their dulaglutide pen and be there while they give their first injection. Don’t be tempted to “help” them: it is important they manage this first step independently.
- Remind them to wait for the second click before removing the pen.
- Congratulate your patient!
Once they have completed their first injection and they are feeling more relaxed, offer the following guidance:
- Advise them to use a fresh injection site each week.
- If they are also on insulin, advise them to use widely separated injection sites for each medicine.
- Advise them to dispose of the pen in a sharps container.
- If appropriate, remind them of reductions needed to their insulin or sulfonylurea.
- If they have been taking vildagliptin, ensure they have stopped this.
- Provide written guidance on how often to inject dulaglutide (once per week, unrelated to food).
- Discuss a possible reduction in appetite and that they may want to eat smaller portions or smaller, more regular meals.
- Offer an appointment for the second injection, if needed.
- Book a follow-up for 2–4 weeks’ time to review.