2. Before you use Levemir
Do not use Levemir
- If you are allergic (hypersensitive) to insulin detemir, or any of the other ingredients in Levemir (see section 6, Further information).
- If you suspect hypoglycaemia (low blood sugar) is starting (see Other effects from diabetes in section 4).
- In insulin infusion pumps.
- If FlexPen is dropped, damaged or crushed.
- If it has not been stored correctly or if it has been frozen (see section 5, How to store Levemir).
- If the insulin does not appear water clear and colourless.
If any of these applies, do not use Levemir. Talk with your doctor, nurse or pharmacist for advice.
Before using Levemir
- Check the label to make sure it is the right type of insulin.
- Always use a new needle for each injection to prevent contamination.
- Needles and Levemir FlexPen must not be shared.
Take special care with Levemir
Some conditions and activities can affect your need for insulin. These include:
- If you have trouble with your kidneys or liver, or with your adrenal, pituitary or thyroid glands.
- If you exercise more than usual or if you want to change your usual diet, as this may affect your blood sugar level.
- If you are ill, carry on taking your insulin and consult your doctor.
- If you are going abroad, travelling over time zones may affect your insulin needs and the timing of your injections. Consult your doctor if you are planning such travelling.
- If you have very low albumin you need to carefully monitor your blood sugar level. Discuss this with your doctor.
Using other medicines
Tell your doctor, nurse or pharmacist if you are taking or have recently taken any other medicines, including medicines obtained without a prescription. Some medicines affect the way blood sugar works in your body and this may influence your insulin dose. Listed below are the most common medicines which may affect your insulin treatment.
Your blood sugar level may fall (hypoglycaemia) if you take:
- Other medicines for the treatment of diabetes
- Monoamine oxidase inhibitors (MAOI) (used to treat depression)
- Beta-blockers (used to treat high blood pressure)
- Angiotensin converting enzyme (ACE) inhibitors (used to treat certain heart conditions or high blood pressure)
- Salicylates (used to relieve pain and lower fever)
- Anabolic steroids (such as testosterone)
- Sulphonamides (used to treat infections).
Your blood sugar level may rise (hyperglycaemia) if you take:
- Oral contraceptives (birth control pills)
- Thiazides (used to treat high blood pressure or excessive fluid retention)
- Glucocorticoids (such as ‘cortisone’ used to treat inflammation)
- Thyroid hormones (used to treat thyroid gland disorders)
- Sympathomimetics (such as epinephrine [adrenaline], or salbutamol, terbutaline used to treat asthma)
- Growth hormone (medicine for stimulation of skeletal and somatic growth and pronounced influence on the body’s metabolic processes)
- Danazol (medicine acting on ovulation).
Octreotide and lanreotide (used for treatment of acromegaly, a rare hormonal disorder that usually occurs in middle-aged adults, caused by the pituitary gland producing excess growth hormone) may either increase or decrease your blood sugar level.
Beta-blockers (used to treat high blood pressure) may weaken or suppress entirely the first warning symptoms which help you to recognise low blood sugar.
Pioglitazone (tablets used for the treatment of type 2 diabetes)
Some patients with long-standing type 2 diabetes and heart disease or previous stroke who were treated with pioglitazone and insulin experienced the development of heart failure. Inform your doctor as soon as possible if you experience signs of heart failure such as unusual shortness of breath or rapid increase in weight or localised swelling (oedema).
If you have taken any of the medicines listed here, tell your doctor, nurse or pharmacist.
Drinking alcohol and taking Levemir
- If you drink alcohol, your need for insulin may change as your blood sugar level may either rise or fall. Careful monitoring is recommended.
Pregnancy and breast-feeding
- If you are pregnant or planning a pregnancy please contact your doctor for advice. Your insulin dose may need to be changed during pregnancy and after delivery. Careful control of your diabetes, and prevention of hypoglycaemia, is important for the health of your baby.
- If you are breast-feeding consult your doctor as you may require adjustments in your insulin doses.
Ask your doctor or pharmacist for advice before taking any medicine while pregnant or breast-feeding.
Driving and using machines
- Please ask your doctor whether you can drive a car or operate a machine:
- If you have frequent hypoglycaemia.
- If you find it hard to recognise hypoglycaemia.
If your blood sugar is low or high, your concentration and ability to react might be affected and therefore also your ability to drive or operate a machine. Bear in mind that you could endanger yourself or others.
Important information about some of the ingredients in Levemir
Levemir contains less than 1 mmol sodium (23 mg) per dose, i.e. Levemir is essentially ‘sodium-free’.
3. How to use Levemir
Dose and when to take your insulin
Always use your insulin as prescribed by your doctor and follow the doctors advice carefully.
Levemir may be used in combination with tablets for diabetes or as add-on therapy to liraglutide (Victoza), which is used to treat type 2 diabetes in adults. Levemir can also be used with meal-related rapid acting insulin medicines.
If your doctor has switched you from one type or brand of insulin to another, your dose may have to be adjusted by your doctor. Do not change your insulin unless your doctor tells you to.
Use in children
Levemir can be used in adolescents and children aged 2 years and above.
There is no experience with the use of Levemir in children below the age of 2 years.
Use in special patient groups
If you have reduced kidney or liver function, or if you are above 65 years of age, you need to check your blood sugar more regularly and discuss changes in your insulin dose with your doctor.
How often to inject
When Levemir is used in combination with tablets for diabetes or as add-on therapy to liraglutide, Levemir should be administered once a day. When Levemir is used as part of a basal-bolus insulin regimen Levemir should be administered once or twice daily depending on patients’ needs. Dose of Levemir should be adjusted individually. The injection can be given at any time during the day, but at the same time each day. For patients who require twice daily dosing to optimise blood sugar control, the evening dose can be administered in the evening or at bedtime.
How and where to inject
Levemir is for injection under the skin (subcutaneously). Never inject your insulin directly into a vein (intravenously) or muscle (intramuscularly).
With each injection, change the injection site within the particular area of skin that you use. This may reduce the risk of developing lumps or skin pitting (see section 4, Possible side effects). The best places to give yourself an injection are: the front of your thighs, the front of your waist (abdomen), or the upper arm. You should always measure your blood sugar regularly.
How to handle Levemir FlexPen
Levemir FlexPen is a pre-filled, colour-coded, disposable pen containing insulin detemir.
Read carefully the instructions for use included in this package leaflet. You must use the pen as described in the Instructions for use.
Always ensure you use the correct pen before you inject your insulin.
If you take more insulin than you should
If you take too much insulin your blood sugar gets too low this is called hypoglycaemia. See Other effects from diabetes in section 4.
If you forget to take your insulin
If you forget to take your insulin your blood sugar may get too high this is called hyperglycaemia. See Other effects from diabetes in section 4.
If you stop taking your insulin
Do not stop taking your insulin without speaking with a doctor, who will tell you what needs to be done. This could lead to very high blood sugar (severe hyperglycaemia) and ketoacidosis. See Other effects from diabetes in section 4.
If you have any further questions on the use of this medicine, ask your doctor or pharmacist.
4. Possible side effects
Like all medicines, Levemir can cause side effects, although not everybody gets them.
Very common side effects
Affecting more than 1 in every 10 people.
Low blood sugar (hypoglycaemia): See details in Other effects from diabetes, below.
Common side effects
Affecting less than 1 in every 10 people.
Injection site reactions (pain, redness, hives, inflammation, bruising, swelling and itching): These usually disappear after a few weeks of taking your insulin. If they do not disappear see your doctor. If you have serious or continuing reactions, you may need to stop using Levemir and use another insulin.
Uncommon side effects
Affecting less than 1 in every 100 people.
Signs of allergy: Hives and rash may occur.
Seek medical advice immediately:
- If the above signs of allergy appear, or
- If you suddenly feel unwell, and you: start sweating; start being sick (vomiting); have difficulty in breathing; have a rapid heart beat; feel dizzy.
- If you notice any of these, get medical advice immediately.
Vision problems: When you first start your insulin treatment, it may disturb your vision, but the disturbance is usually temporary.
Changes at the injection site (lipodystrophy): The fatty tissue under the skin at the injection site may shrink (lipoatrophy) or thicken (lipohypertrophy). Changing the site with each injection may help to reduce the risk of developing such skin changes. If you notice your skin pitting or thickening at the injection site, tell your doctor or nurse. These reactions can become more severe, or they may change the absorption of your insulin, if you inject in such a site.
Swollen joints: When you start taking insulin, water retention may cause swelling around your ankles and other joints. Normally this soon disappears.
Diabetic retinopathy (an eye disease related to diabetes which can lead to loss of vision): If you have diabetic retinopathy and your blood sugar level improves very fast, the retinopathy may get worse. Ask your doctor about this.
Rare side effects
Affecting less than 1 in every 1,000 people.
Painful neuropathy (pain due to nerve damage): If your blood sugar level improves very fast, you may get nerve related pain, this is called acute painful neuropathy and is usually transient.
Very rare side effects
Affecting less than 1 in every 10,000 people.
Serious allergic reaction to Levemir or one of its ingredients (called a systemic allergic reaction). See also the warning in section 2, Before you use Levemir.
- If any of the side effects listed gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor, nurse or pharmacist.
Other effects from diabetes
Low blood sugar (hypoglycaemia)
Low blood sugar may occur if you:
- Inject too much insulin.
- Eat too little or miss a meal.
- Exercise more than usual.
- Drink alcohol (See Drinking alcohol and taking Levemir in section 2).
Warning signs of low blood sugar:
The warning signs may come on suddenly and can include: Cold sweat; cool pale skin; headache; rapid heart beat; feeling sick; feeling very hungry; temporary changes in vision; drowsiness; unusual tiredness and weakness; nervousness or tremor; feeling anxious; feeling confused; difficulty in concentrating.
What to do if you experience low blood sugar:
- If you experience low blood sugar, eat glucose tablets or another high sugar snack (sweets, biscuits, fruit juice). Measure your blood sugar if possible and rest. Always carry glucose tablets, sweets, biscuits or fruit juice with you, just in case.
When symptoms of low blood sugar have disappeared or when your blood sugar level is stabilised, continue insulin treatment as usual.
- Tell relevant people that you have diabetes and what the consequences may be, including the risk of passing out (become unconscious) due to low blood sugar. Let them know that if you pass out, they must turn you on your side and get medical help straight away. They must not give you any food or drink due to risk of suffocation.
You may recover more quickly from unconsciousness with an injection of the hormone glucagon by someone who knows how to use it. If you are given glucagon you will need glucose or a sugary snack as soon as you are conscious. If you do not respond to glucagon treatment, you will have to be treated in a hospital.
- If prolonged severe low blood sugar is not treated, it can cause brain damage (temporary or permanent) and even death.
- If you have such a low blood sugar that you pass out, if you have had need for injection of glucagon, or if you have experienced many incidents of low blood sugar, talk with a doctor. The amount or timing of insulin, food or exercise may need to be adjusted.
High blood sugar (hyperglycaemia)
High blood sugar may occur if you:
- Have not injected enough insulin.
- Forget to take your insulin or stop taking insulin.
- Repeatedly take less insulin than you need.
- Get an infection and/or a fever.
- Eat more than usual.
- Exercise less than usual.
Warning signs of high blood sugar:
The warning signs appear gradually. They include: increased urination; feeling thirsty; losing your appetite; feeling sick (nausea or vomiting); feeling drowsy or tired; flushed; dry skin; dry mouth and a fruity (acetone) smell of the breath.
What to do if you experience high blood sugar:
- If you get any of above signs: test your blood sugar level, test your urine for ketones if you can, then seek medical advice immediately.
- These may be signs of a very serious condition called diabetic ketoacidosis (build-up of acid in the blood because the body is breaking down fat instead of sugar). If you do not treat it, this could lead to diabetic coma and eventually death.
5. How to store Levemir
Keep out of the reach and sight of children.
Do not use Levemir after the expiry date which is stated on the FlexPen label and carton after ‘EXP.’ The expiry date refers to the last day of that month.
Before opening: Levemir FlexPen that is not being used is to be stored in the refrigerator at 2°C to 8°C, away from the cooling element. Do not freeze.
During use or when carried as a spare: Levemir FlexPen that is being used or carried as a spare is not to be kept in the refrigerator. You can carry it with you and keep it at room temperature (below 30°C) for up to 6 weeks.
Always keep the pen cap on your FlexPen when you are not using it in order to protect it from light. Levemir must be protected from excessive heat and light.
Medicines should not be disposed of via wastewater or household waste. Ask your pharmacist how to dispose of medicines no longer required. These measures will help to protect the environment.
Detailed information on this medicine is available on the website of the European Medicines Agency http://www.ema.europa.eu.
LEVEMIR solution for injection in a pre-filled pen. FlexPen. INSTRUCTIONS FOR USE
Please read the following instructions carefully before using your Levemir FlexPen.
Your FlexPen is a unique dial-a-dose insulin pen.
- You can select doses from 1 to 60 units in increments of 1 unit.
- FlexPen is designed to be used with NovoFine or NovoTwist disposable needles up to a length of 8 mm.
- As a precuationary measure, always carry a spare insulin delivery device in case your FlexPen is lost or damaged.
- Your FlexPen is designed to work accurately and safely. It must be handled with care. If it is dropped or crushed, there is a risk of damage and leakage of insulin.
- You can clean the exterior of your FlexPen by wiping it with a medicinal swab. Do not soak it, wash or lubricate it as it may damage the pen.
- Do not refill your FlexPen.
Preparing your Levemir FlexPen
Check the label to make sure that your FlexPen contains the correct type of insulin.
Pull off the pen cap.
Take a new needle and tear off the paper tab.
Screw the needle straight and tightly onto your FlexPen.
Pull off the big outer needle cap and keep it for later.
Pull off the inner needle cap and dispose of it.
- Always use a new needle for each injection to prevent contamination.
- Be careful not to bend or damage the needle before use.
- To reduce the risk of unexpected needle sticks, never put the inner needle cap back on when you have removed it from the needle.
Checking the insulin flow
Prior to each injection small amounts of air may collect in the cartridge during normal use. To avoid injection of air and ensure proper dosing:
Turn the dose selector to select 2 units.
Hold your FlexPen with the needle pointing upwards and tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge.
Keeping the needle upwards, press the push-button all the way in. The dose selector returns to 0.
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 a drop of insulin still does not appear, the pen is defective, and you must use a new one.
Selecting your dose
Check that the dose selector is set at 0.
Turn the dose selector to select the number of units you need to inject.
The dose can be corrected either up or down by turning the dose selector in either direction until the correct dose lines up with the pointer. When turning the dose selector be careful not to push the push-button as insulin will come out.
You cannot select a dose larger than the number of units left in the cartridge.
- Do not use the residual scale to measure your dose of insulin.
Making the injection
Insert the needle into your skin. Use the injection technique shown by your doctor or nurse.
Inject the dose by pressing the push-button all the way in until 0 lines up with the pointer. Be careful only to push the push-button when injecting.
Turning the dose selector will not inject insulin.
- Keep the push-button fully depressed and let the needle remain under the skin for at least 6 seconds. This will make sure you get the full dose.
- Withdraw the needle from the skin then release the pressure on the push-button.
Lead the needle into the big outer needle cap without touching it. When the needle is covered, carefully push the big outer needle cap completely on and then unscrew the needle.
Dispose of it carefully and put the pen cap back on.
- Always remove the needle after each injection and store your FlexPen without the needle attached. Otherwise the liquid may leak out which can cause inaccurate dosing.
- Caregivers should be most careful when handling used needles to avoid needle sticks.
- Dispose of the used FlexPen carefully without the needle attached.
- Needles and Levemir FlexPen must not be shared.