INSUMAN COMB 25 100 IU/ml INJECTABLE SUSPENSION IN A CARTRIDGE

Introduction

Package Leaflet: Information for the User

Insuman Comb 25 100 UI/ml injectable suspension in a cartridge

Human insulin

Read all of this leaflet carefully before you start using this medicine because it contains important information for you.

• Keep this leaflet, you may need to read it again.
• If you have any further questions, ask your doctor, pharmacist, or nurse.
• This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.
• If you get any side effects, talk to your doctor, pharmacist, or nurse. This includes any possible side effects not listed in this leaflet. See section 4.

Contents of the package leaflet:

1. What is Insuman Comb 25 and what is it used for
2. What you need to know before you use Insuman Comb 25
3. How to use Insuman Comb 25
4. Possible side effects
5. Storage of Insuman Comb 25
6. Contents of the pack and other information

1. What is Insuman Comb 25 and what is it used for

Insuman Comb 25 contains human insulin as the active substance, which is produced by a biotechnology process and is identical to the insulin produced by the human body.

Insuman Comb 25 is an insulin preparation with a gradual onset of action and a long duration of action.

Insuman Comb 25 is used to reduce high blood sugar levels in patients with diabetes mellitus who require insulin treatment. Diabetes mellitus is a disease in which the body does not produce enough insulin to control blood sugar levels.

2. What you need to know before you use Insuman Comb 25

Do not use Insuman Comb 25

If you are allergic to insulin or any of the other ingredients of this medicine (listed in section 6).

Warnings and precautions

Insuman Comb 25 in cartridges is only intended for subcutaneous injection using a reusable pen (see also section 3). Consult your doctor if you need to inject insulin by another method.

Consult your doctor, pharmacist, or nurse before starting treatment with Insuman Comb 25.

Follow strictly the instructions for dosage, monitoring (blood and urine tests), diet, and physical activity (physical work and exercise) that you have established with your doctor.

Consult your doctor if you are allergic to this medicine or to human insulins.

Special patient groups

If you have liver or kidney problems or if you are elderly, consult your doctor, as you may need a lower dose of insulin.

Changes in the skin at the injection site

The injection site should be rotated to avoid changes in the skin, such as lumps under the skin. Insulin may not work as well if it is injected into a lump (see How to use Insuman Comb 25). Contact your doctor if you are currently injecting into a lump, before starting to inject into a different area. Your doctor may advise you to check your blood sugar levels more closely and adjust your insulin or other antidiabetic medications.

Travel

Before traveling, consult your doctor. You may need to discuss:

• the availability of insulin in the country you are traveling to,
• insulin, needle, and other reserves,
• proper storage of insulin during travel,
• meal and insulin administration schedules during travel,
• possible effects of time zone changes,
• new health risks in the countries you will visit,
• what to do in emergency situations when you are ill or become sick.

Illnesses and injuries

Your diabetes management may require special care in the following situations:

• If you are ill or have a serious injury, your blood sugar level may rise (hyperglycemia).
• If you do not eat enough, your blood sugar level may drop too low (hypoglycemia).

In most cases, you will need a doctor. Make sure to consult a doctor immediately.

If you have type 1 diabetes (insulin-dependent diabetes mellitus), do not stop taking your insulin and follow a diet that provides sufficient carbohydrates. Always inform the people who care for you or treat you that you need insulin.

Some patients with long-standing type 2 diabetes mellitus and previous heart disease or stroke who were treated with pioglitazone and insulin developed heart failure. Inform your doctor as soon as possible if you experience symptoms of heart failure such as shortness of breath, rapid weight gain, or localized swelling (edema).

Other medicines and Insuman Comb 25

Some medicines can cause changes in blood sugar levels (a decrease, an increase, or both, depending on the situation). In each case, it may be necessary to adjust your insulin dose to avoid blood sugar levels that are too low or too high. Be careful when starting to take another medicine and also when stopping it.

Tell your doctor or pharmacist if you are using, have recently used, or might use any other medicines.

Ask your doctor before using a medicine if it can affect your blood sugar level and what measures you should take, if necessary.

Among the medicines that can cause a decrease in your blood sugar level (hypoglycemia) are:

• all other diabetes medicines,
• angiotensin-converting enzyme (ACE) inhibitors (used to treat certain heart diseases or high blood pressure),
• disopyramide (used to treat certain heart diseases),
• fluoxetine (used to treat depression),
• fibrates (used to lower blood lipid levels),
• monoamine oxidase inhibitors (MAOIs) (used to treat depression),
• pentoxifylline, propoxyphene, salicylates (such as aspirin, used to relieve pain and reduce fever),
• sulfonamide antibiotics.

Among the medicines that can cause an increase in your blood sugar level (hyperglycemia) are:

• corticosteroids (such as "cortisone", used to treat inflammation),
• danazol (a medicine that affects ovulation),
• diazoxide (used to treat high blood pressure),
• diuretics (used to treat high blood pressure or excess fluid retention),
• glucagon (a pancreatic hormone used to treat severe hypoglycemia),
• isoniazid (used to treat tuberculosis),
• estrogens and progestogens (such as birth control pills used for contraception),
• phenothiazine derivatives (used to treat psychiatric diseases),
• somatotropin (growth hormone),
• sympathomimetic medicines (such as epinephrine [adrenaline], salbutamol, terbutaline used to treat asthma),
• thyroid hormones (used to treat thyroid gland disorders),
• protease inhibitors (used to treat HIV),
• atypical antipsychotic medicines (such as clozapine, olanzapine).

Your blood sugar level may rise or fall if you use:

• beta-blockers (used to treat high blood pressure),
• clonidine (used to treat high blood pressure),
• lithium salts (used to treat psychiatric diseases).

Pentamidine (used to treat some parasitic infections) can cause hypoglycemia, which can sometimes be followed by hyperglycemia.

Beta-blockers, like other sympatholytic medicines (such as clonidine, guanethidine, and reserpine), can mask or completely suppress the early warning symptoms that could help you recognize hypoglycemia.

If you are not sure if you are using any of these medicines, ask your doctor or pharmacist.

Insuman Comb 25 with alcohol

Your blood sugar levels may rise or fall if you consume alcohol.

Pregnancy and breastfeeding

If you are pregnant or breastfeeding, or think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before using this medicine.

Tell your doctor if you are planning to become pregnant or if you are already pregnant. Your insulin administration regimen may need to be changed during pregnancy and after delivery. Very careful control of your diabetes and prevention of hypoglycemia are important for the health of your baby. However, there is no experience with the use of Insuman Comb 25 in pregnant women.

If you are breastfeeding, you may need to adjust your insulin dose and diet.

Driving and using machines

Your ability to concentrate or react may be reduced if:

• you have hypoglycemia (low blood sugar levels)
• you have hyperglycemia (high blood sugar levels)
• you have vision problems.

Be aware of this possible problem, considering all situations that may pose a risk to you or others (such as driving a vehicle or using machines). You should ask your doctor for advice on your ability to drive if:

• you have frequent episodes of hypoglycemia,
• the early warning symptoms of hypoglycemia have decreased or disappeared.

Important information about some of the ingredients of Insuman Comb 25

This medicine contains less than 23 mg of sodium per dose; this is essentially "sodium-free".

3. How to use Insuman Comb 25

Dose

Follow exactly the instructions for administration of this medicine given by your doctor or pharmacist. If you are not sure, consult your doctor or pharmacist again.

Based on your lifestyle and the results of your blood sugar (glucose) tests and previous insulin treatment, your doctor:

• will determine the dose of Insuman Comb 25 you need each day,
• will tell you when to check your blood sugar level and if you need to perform urine tests,
• will tell you when you may need to inject a higher or lower dose of Insuman Comb 25.

Many factors can influence your blood sugar level. You should know these factors so that you can react correctly to changes in your blood sugar level and avoid it becoming too high or too low. See the box at the end of this leaflet for more information.

Frequency of administration

Insuman Comb 25 is injected under the skin 30 to 45 minutes before a meal.

Method of administration

Insuman Comb 25 is a liquid (suspension) for injection under the skin.

Do not inject Insuman Comb 25 into a vein (blood vessel).

Your doctor will show you which area of the skin to inject Insuman Comb 25 into. With each injection, you should change the injection site within the specific area of skin you are using.

Do not use in insulin pumps or other infusion pumps. There are special insulin preparations for use in these devices.

How to handle the cartridges

Insuman Comb 25 in cartridges is only intended for subcutaneous injection using a reusable pen. Consult your doctor if you need to inject insulin by another method.

To ensure you get the exact dose, Insuman Comb 25 cartridges must only be used with the following pens:

• JuniorSTAR, which delivers doses in 0.5 unit increments
• ClikSTAR, Tactipen, Autopen 24, AllStar, or AllStar PRO, which deliver doses in 1 unit increments
• In your country, only some of these pens may be available.

The pen must be used as recommended in the manufacturer's instructions for the device. The manufacturer's instructions for the use of the pen must be followed carefully when loading the cartridge, inserting the needle for injection, and administering the insulin injection.

Keep the cartridge at room temperature for 1 to 2 hours before inserting it into the pen.

Mix the insulin well and check that it is well mixed before inserting it into the pen. Then, the insulin must be mixed well again immediately before each injection.

The best way to mix is to gently tilt the cartridge or the pen (with the cartridge inside) from side to side at least 10 times. To facilitate mixing, the cartridge contains 3 metal balls.

After mixing, the suspension should have a uniform white milky appearance. It should not be used if it remains transparent or, for example, there are lumps, flakes, flocculation, or similar aggregations in the suspension or on the sides or bottom of the cartridge. In such a case, another cartridge with a uniform suspension after mixing should be used.

Always use a new cartridge if you notice that your blood sugar control is worsening unexpectedly. This is because the insulin may have lost some of its effectiveness. If you think you may have a problem with your insulin, have it checked by your doctor or pharmacist.

Special precautions before injection

Before injection, remove all air bubbles (see pen user instructions). Make sure the insulin is not contaminated with alcohol or other disinfectants, or with other substances.

• Do not refill or reuse empty cartridges.
• Do not add any other insulin to the cartridge.
• Do not mix the insulin with any other medicine.

Problems with the pen?

Consult the manufacturer's instructions for the pen

If your insulin pen is damaged or does not work properly (due to mechanical problems), it must be discarded and a new insulin pen used.

If you use more Insuman Comb 25 than you should

• If you have injected too much Insuman Comb 25, your blood sugar level may become very low (hypoglycemia). Check your blood sugar level frequently. In general, to prevent hypoglycemia, you should eat more and monitor your blood sugar level. For more information on the treatment of hypoglycemia, see the box at the end of this leaflet.

If you forget to use Insuman Comb 25

• If you have forgotten a dose of Insuman Comb 25or if you have not injected enough insulin, your blood sugar level may rise too high (hyperglycemia). Check your blood sugar level frequently. For more information on the treatment of hyperglycemia, see the box at the end of this leaflet.
• Do not take a double dose to make up for forgotten doses.

If you stop treatment with Insuman Comb 25

This could lead to severe hyperglycemia (very high blood sugar levels) and ketoacidosis (increased acid in the blood because the body breaks down fat instead of sugar). Do not stop your treatment with Insuman Comb 25 without consulting a doctor; he will tell you what to do.

If you have any further questions on the use of this product, ask your doctor, pharmacist, or nurse.

Insulin confusion

Always check the insulin label before each injection to avoid confusion between Insuman Comb 25 and other insulins.

4. Possible Adverse Effects

Like all medicines, this medicine can cause adverse effects, although not all people suffer from them.

More serious adverse effects

Adverse effects reported with low frequency(may affect up to 1 in 100 people)

• Severe allergic reactions with low blood pressure(shock)

Adverse effects reported with unknown frequency(frequency cannot be estimated from available data)

• The most frequent adverse effect is hypoglycemia (low blood sugar levels). Severe hypoglycemia can cause brain damage and can be life-threatening. For more information on adverse effects due to low or high blood sugar levels, see the box at the end of this prospectus.

• Severe allergic reactions to insulinmay occur, which could be life-threatening. These reactions to insulin or excipients can cause large-scale skin reactions (rash and itching all over the body), severe swelling of the skin or mucous membranes (angioedema), difficulty breathing, a drop in blood pressure with rapid heartbeat, and sweating.

Other adverse effects

Adverse effects reported with frequency(may affect up to 1 in 10 people)

• Edema

Insulin treatment may cause temporary water retention in the body with swelling of the calves and ankles

• Injection site reactions

Adverse effects reported with low frequency

• Urticaria at the injection site (rash with itching)

Other adverse effects reported with unknown frequency

• Sodium retention
• Ocular reactions

A significant change (improvement or worsening) in the control of your blood sugar level can temporarily alter your vision. If you have proliferative retinopathy (an eye disease related to diabetes), severe hypoglycemic attacks can cause temporary vision loss.

• Changes in the skin at the injection site.

If insulin is injected too frequently in the same place, the fatty tissue can shrink (lipoatrophy) or become thicker (lipohypertrophy). Lumps under the skin can also occur due to the accumulation of a protein called amyloid (cutaneous amyloidosis). Insulin may not work very well if injected into a lumpy area. Change the injection site to help avoid these skin changes.

• Skin and allergic reactions

Moderate allergic reactions may occur at the injection site (such as redness, pain, especially intense when injecting, itching, urticaria, swelling, or inflammation). These reactions can also spread around the injection site. Most mild reactions to insulins usually resolve on their own in a few days or weeks.

• Antibodies to insulin

Insulin treatment may cause the body to produce antibodies to insulin (substances that act against insulin). However, this will only require modifying your insulin dose in rare cases.

Reporting of Adverse Effects

If you experience any type of adverse effect, consult your doctor, pharmacist, or nurse, even if it is a possible adverse effect that is not listed in this prospectus. You can also report them directly through the national reporting system included in Annex V.

By reporting adverse effects, you can contribute to providing more information on the safety of this medicine.

5. Storage of Insuman Comb 25

Keep this medicine out of the sight and reach of children.

Do not use this medicine after the expiration date stated on the packaging and on the cartridge label after "EXP". The expiration date is the last day of the month indicated.

Unopened cartridges

Store in a refrigerator (between 2°C and 8°C). Do not freeze. Do not place Insuman Comb 25 near the freezer compartment or next to a cold accumulator. Keep the cartridge in the outer packaging to protect it from light.

Cartridges in use

Cartridges in use (in the insulin pen) or carried as a spare can be stored for a maximum of 4 weeks in the outer packaging at a temperature not exceeding 25°C and protected from direct heat (e.g., next to a heating unit) or direct light (direct sunlight or next to a lamp). The cartridge in use should not be stored in a refrigerator. Do not use after this period.

Medicines should not be disposed of via wastewater or household waste. Ask your pharmacist how to dispose of the packaging and medicines you no longer need. This will help protect the environment.

6. Package Contents and Additional Information

Composition of Insuman Comb 25

• The active ingredient is human insulin. One ml of Insuman Comb 25 contains 100 IU (International Units) of the active ingredient human insulin. 25% of the insulin is dissolved in water; the remaining 75% is in the form of small crystals of insulin protamine.
• The other components are: protamine sulfate, metacresol, phenol, zinc chloride, sodium dihydrogen phosphate dihydrate, glycerol, sodium hydroxide (see section 2 on "Important information about some of the components of Insuman Comb 25"), hydrochloric acid (for pH adjustment), and water for injectable preparations.

Appearance of the Product and Package Size

After mixing, Insuman Comb 25 is a milky and uniform liquid (injectable suspension), without lumps, particles, or visible flocculation.

Insuman Comb 25 is presented in cartridges containing 3 ml of suspension (300 IU). It is presented in packages of 3, 4, 5, 6, 9, and 10 cartridges of 3 ml. Not all package sizes may be marketed.

Marketing Authorization Holder and Manufacturer

Sanofi-Aventis Deutschland GmbH

D‑65926 Frankfurt am Main

Germany

You can request more information about this medicine by contacting the local representative of the marketing authorization holder.

Date of the last revision of this prospectus:

Other sources of information

Detailed information about this medicine is available on the European Medicines Agency website: http://www.ema.europa.eu/

HYPERGLYCEMIA AND HYPOGLYCEMIA

Always carry something sweet with you (at least 20 grams)

Always carry some information that indicates you are diabetic

HYPERGLYCEMIA (high blood sugar levels)

If you have very high blood sugar levels (hyperglycemia),you may not have injected enough insulin.

Why do you have hyperglycemia?

Some examples are:

• you did not inject your insulin or did not inject enough, or if its effect has decreased, for example, due to incorrect storage,
• you are doing less exercise than usual, are under stress (emotional distress, nervousness), or are suffering from an injury, surgery, infection, or fever,
• you are using or have used certain medications (see section 2, "Other medicines and Insuman Comb 25").

Warning signs of hyperglycemia

Thirst, increased need to urinate, fatigue, dry skin, flushing of the face, loss of appetite, low blood pressure, rapid heartbeat, and the presence of glucose and ketone bodies in the urine. Abdominal pain, deep and rapid breathing, drowsiness, or even loss of consciousness can be signs of a serious condition (ketoacidosis) due to lack of insulin.

What should you do if you have hyperglycemia?

You should analyze your blood sugar level and acetone level in your urine as soon as you experience any of these symptoms.Hyperglycemia or severe ketoacidosis should always be treated by a doctor, usually in a hospital.

HYPOGLYCEMIA (low blood sugar levels)

If your blood sugar level drops too low, you can lose consciousness. Severe hypoglycemia can cause a heart attack or brain damage and can be life-threatening. Normally, you should be able to recognize when your blood sugar level is dropping too low to take the necessary measures.

Why do you have hypoglycemia?

Some examples are:

• you inject too much insulin,
• you miss meals or delay them,
• you do not eat enough, or eat foods that contain fewer carbohydrates than usual (sugars and substances similar to sugar are called carbohydrates; however, artificial sweeteners are NOT carbohydrates),
• you lose carbohydrates due to vomiting or diarrhea,
• you drink alcohol, especially if you are not eating much,
• you are doing more exercise than usual or a different type of physical activity,
• you are recovering from an injury, surgery, or other types of stress,
• you are recovering from an illness or fever,
• you are using or have used certain medications (see section 2, "Other medicines and Insuman Comb 25").

It is also more likely to have hypoglycemia if:

• you have just started insulin treatment or changed to another insulin preparation,
• your blood sugar levels are almost normal or are unstable,
• you change the skin site where you inject insulin (e.g., from the thigh to the upper arm),
• you have severe kidney or liver disease, or other conditions such as hypothyroidism.

Warning signs of hypoglycemia

• In your body

Examples of symptoms that indicate your blood sugar level is dropping too low or too quickly: sweating, moist and sticky skin, anxiety, rapid heartbeat, high blood pressure, palpitations, and irregular heartbeat. These symptoms often occur before the symptoms of low blood sugar in the brain appear.

• In your brain

Examples of symptoms that indicate there is a low blood sugar level in the brain: headaches, intense hunger, nausea, vomiting, fatigue, drowsiness, sleep disturbances, restlessness, aggressive behavior, concentration problems, altered reactions, depression, confusion, speech disorders (sometimes, complete loss of speech), visual disturbances, tremors, paralysis, tingling sensations (paresthesias), numbness and tingling sensations in the mouth area, dizziness, loss of self-control, feeling of helplessness, convulsions, loss of consciousness.

The first warning signs of hypoglycemia ("warning symptoms") may change, weaken, or be absent if

• you are an elderly person, have had diabetes for a long time, or suffer from a certain type of nerve disease (autonomic diabetic neuropathy),
• you have recently experienced a hypoglycemic episode (e.g., the day before) or if it develops gradually,
• you have almost normal or, at least, much improved blood sugar levels,
• you have recently changed from an animal insulin to a human insulin like Insuman,
• you are using or have used certain medications (see section 2, "Other medicines and Insuman Comb 25").

In this case, you may experience severe hypoglycemia (and even lose consciousness) before you realize the problem. Always be familiar with your warning symptoms. If necessary, more frequent blood sugar analysis can help identify mild hypoglycemic episodes that would otherwise go unnoticed. If you are not sure you can recognize your warning symptoms, avoid situations (such as driving a car) that could put you or others at risk due to hypoglycemia.

What should you do if you have hypoglycemia?

1. Do not inject insulin. Immediately ingest 10 to 20 grams of sugar, such as glucose, sugar cubes, or a sugary drink. Note: Artificial sweeteners and sugar-free products do not help treat hypoglycemia.
2. Afterward, eat something that will increase your blood sugar level in the long term (such as bread or pasta). Your doctor or nurse should have discussed this with you beforehand.
3. If hypoglycemia recurs, take another 10 to 20 grams of sugar.
4. Consult a doctor immediately if you are unable to control hypoglycemia or if it recurs.

Tell your family, friends, or people close to you:

If you are unable to swallow or lose consciousness, you will need an injection of glucose or glucagon (a medication that increases blood sugar levels). These injections are justified even if you are not sure you have hypoglycemia.

It is recommended to analyze your blood sugar level immediately after ingesting glucose to confirm that you actually have hypoglycemia.