Reusable and disposable insulin pens for the treatment of diabetes: understanding the global differences in user preference and an evaluation of inpatient insulin pen use

Transdermal Delivery of Insulin Using Combination of Iontophoresis and Deep Eutectic Solvents as Chemical Penetration Enhancers: In Vitro and in Vivo Evaluations

A serious challenge in transdermal iontophoresis (IP) delivery of insulin (INS) is the low permeability of the drug across the skin. In this paper, we introduced deep eutectic solvent (DESs) as novel chemical penetration enhancers (CPEs) for transdermal IP of INS across rat skin, both in vitro and in vivo. Three different DESs based on choline chloride (ChCl), namely, ChCl/UR (ChCl and urea), ChCl/GLY (ChCl and glycerol), and ChCl/EG (ChCl and ethylene glycol) in the 1:2 molar ratios have been prepared. To evaluate the capability of studied DESs as CPEs for IP delivery of INS, the rat skin sample was treated with each DES. The effects of different experimental parameters (current density, formulation pH, INS concentration, NaCl concentration, and treatment time) on the in vitro transdermal iontophoretic delivery of INS were investigated. The in vitro permeation studies exhibited that INS was easily delivered employing ChCl/EG, and ChCl/GLY treatments, compared with ChCl/UR: the cumulative amount of permeated INS at the end of the experiment (Q24h) was found to be 131.0, 89.4, and 29.6 µg cm-2 in the presence of ChCl/EG, ChCl/GLY, and ChCl/UR, respectively. The differences in Q24h values of INS are due to the different capabilities of the studied DESs to treat the epidermis layer of skin. In vivo experiments revealed that the blood glucose level in diabetic rats could be decreased using ChCl/EG, and ChCl/GLY as novel CPEs in the IP delivery of INS. The presented work will open new doors towards searching for novel CPEs in the development of transdermal IP of INS.

The Review of Insulin Pens-Past, Present, and Look to the Future

Currently, there are about 150-200 million diabetic patients treated with insulin globally. The year 2021 is special because the 100th anniversary of the insulin discovery is being celebrated. It is a good occasion to sum up the insulin pen technology invention and improvement which are nowadays the leading mode of an insulin delivery. Even though so many years have passed, insulin is still administered subcutaneously, that is why devices to deliver it are of great importance. Insulin pens have evolved only through the last decades (the reusable, durable pens, and the disposable, prefilled pens) and modern smart insulin pens have been developed in the last few years, and both types of the devices compared to traditional syringes and vials are more convenient, discrete in use, have better dosing accuracy, and improve adherence. In this review, we will focus on the history of insulin pens and their improvement over the previous decades.

A Multicenter, Prospective, Observational, Open-Label Study of the Safety and Comfort of Gensulin® Delivery Device Use in a Large Cohort of Adult and Elderly Patients with Type 2 Diabetes

Insulin treatment is necessary for many patients with type 2 diabetes, and its delivery must be safe and comfortable. This study evaluated patients' safety and comfort when using a Gensulin® delivery device, GensuPen (Bioton), a reusable insulin pen device for injecting Gensulin® insulin among adult and elderly patients with type 2 diabetes. This was a 4-week multicenter, prospective, observational, open-label study in patients with diabetes mellitus type 2 who have recently started using a GensuPen. Overall, 10,309 patients (mean age: 63 ± 12.0 years; 47.9% female) were analyzed in this study. Of these, 2.5% had used an insulin delivery device before, and for 97.5%, GensuPen was the first delivery device they had used. Most (87.8%) of the patients rated the GensuPen as very good in setting the dose, 92.0% in confirmation of successful insulin administration, 80.9% in trigger location, and 75.0% in force needed for injection. The overall safety of the GensuPen use was high since severe hypoglycemia occurred only in 0.2% of the studied patients. There were 0.6% adverse events, none of which were serious. This real-life observation data shows that the GensuPen was well accepted and safe in this large patient population of adult and elderly patients with type 2 diabetes.

Patient-reported outcomes from a randomized, crossover trial comparing a pen injector with insulin degludec versus a pen injector with insulin glargine U100 in patients with type 2 diabetes

Objective: Type 2 diabetes (T2D) is associated with insulin resistance and deteriorated glycemic control that can be restored with insulin injections. Choice of insulin pen injector may affect complexity, adherence, efficacy of treatment and health-related quality of life. We describe detailed patient-reported outcomes (PROs) on treatment impact and preference comparing insulin degludec (degludec) using FlexTouch¹ versus insulin glargine U100 (glargine U100) with SoloStar² pen injector.Methods: In this randomized, multicenter (USA), open-label, crossover, treat-to-target study (NCT01570751), patients with T2D using high-dose insulin (≥81 U/day from vials) were randomized (n = 145) 1:1 to 16 weeks of degludec U200 (3 mL FlexTouch) followed by 16 weeks of glargine U100 (3 mL SoloStar) or vice versa. PRO questionnaires assessed treatment impact and patient preference of pen injectors.Results: Significantly more patients (p < .01) considered FlexTouch "extremely easy" for learning (62.5 vs. 43.0%), maintaining (63.2 vs. 42.2%) and adjusting the dose (63.2 vs. 44.4%), and significantly more were "very" or "extremely confident" in using the device (60.3 vs. 36.3%) and in its accuracy (50.7 vs. 30.4%) versus SoloStar. Significantly more were "not at all bothered" by device discomfort (74.3 vs. 54.1%), whereas device size (83.8 vs. 80.0%) or public use (69.9 vs. 60.7%) were numerically in favor of FlexTouch. Significantly more patients preferred degludec treatment with FlexTouch (59 vs. 22%), preferred to continue (67 vs. 15%) and recommend (67 vs. 14%) use of FlexTouch compared with SoloStar with glargine U100.Conclusions: In this randomized, crossover trial, lower treatment impact and higher patient preference were reported for FlexTouch versus SoloStar pen injectors.

Predictors of Self-Efficacy in Administering Insulin Injection

This study aimed to identify the predictors of self-efficacy in administering insulin injection among patients with type 2 diabetes. Using a cross-sectional survey, data were collected via purposive sampling from a metabolic ward of a medical center in Southern Taiwan. Participants were 72 patients with type 2 diabetes, who had started using Lantus, Levemir, or Novomix pen injectors. Data were collected from October 2013 to August 2014, using the Diabetes and Insulin Injection Knowledge Scale, Self-Efficacy in Administering Insulin Injection Scale, and photographs illustrating insulin injection skills. The findings indicated that "knowledge of diabetes and insulin injection," "insulin injection skills," "senior high school or above education," and "diabetes duration" were predictors of self-efficacy in administering insulin injection, which explained 41% of the total variance in self-efficacy. Health care professionals can design relevant strategies for improving patient self-efficacy in administering insulin injection, thereby increasing patients' insulin self-injection abilities.

Development and Implementation of a Subcutaneous Insulin Pen Label Bar Code Scanning Protocol to Prevent Wrong-Patient Insulin Pen Errors

PROBLEM DEFINITION

Insulin, a high-alert medication, is regularly prescribed in the inpatient setting for hyperglycemia and diabetes mellitus. Although convenient, insulin pens carry a risk of blood-borne pathogens if the same pen is used on multiple patients. At the University of California, San Francisco (UCSF), a new nursing protocol for insulin pen administration was developed to ensure that insulin was quickly available and to identify and move to eliminate wrong-patient insulin pen errors. This protocol involved unit-based automated dispensing machines and an electronic health record (EHR)-integrated patient-specific bar code label work flow.

APPROACH

After piloting on three hospital units, this new patient-specific bar code label process was expanded hospitalwide. "Print Label For Insulin Pen" and "Scan Insulin Pen" buttons were programmed into the EHR to enable nurses to print patient-specific bar code labels. In addition, a "wrong-patient pen alert" was activated to prevent wrong-pen insulin pen administration.

OUTCOMES

For the 162,075 inpatient insulin pen administrations during the study period (April 2017-March 2018), monthly errors (rates) ranged from 13 (0.12%) to 36 (0.23%). In total, 296 near-miss events (0.18% of all insulin pen administrations) were observed and prevented.

CONCLUSION

Insulin pen work flow and EHR changes implemented at UCSF enable subcutaneous insulin to remain a time-critical medication and ensure patient safety. The wide adoption of EHRs offers an opportunity to integrate patient safety improvements directly into the electronic medication administration record systems to maximize patient safety.

Injecting without pressing a button: An exploratory study of a shield-triggered injection mechanism

AIMS

To evaluate the injection success and user perception of a shield-triggered pen-injector mechanism.

METHODS

The trial (ClinicalTrials.gov NCT02627287) was an exploratory, two-centre, one-visit, open-label, randomized controlled trial conducted in Germany in 150 injection-experienced individuals with type 1 or type 2 diabetes. Participants self-administered subcutaneous injections of a placebo solution using a prototype shield-triggered pen-injector, DV3316 (Novo Nordisk, Bagsvaerd, Denmark), and FlexPen (Novo Nordisk, Bagsvaerd, Denmark). Injection success was evaluated on a yes/no basis by the investigator. Participant confidence, leakage of fluid and pain were evaluated after each injection. Pain and device experience were assessed after completion of all injections with each pen-injector. Overall preference was assessed after completion of all injections with both pen-injectors.

RESULTS

Injection success was high with both pen-injectors (97.0%, DV3316 vs 99.7%, FlexPen). Participant confidence in dose delivery was similar for the two devices (88% of injections with DV3316 vs 81% with FlexPen were scored as "extremely confident"). The median injection pain score on a visual analogue scale (0-100) was 3 with DV3316 vs 4 with FlexPen after each injection, and 4 with DV3316 vs 5 with FlexPen after all injections with each device. After all injections were completed, 55% of participants reported an overall preference for DV3316 vs 21% for FlexPen.

CONCLUSION

This study demonstrates that injection-experienced individuals can achieve a high injection success rate with a shield-triggered pen-injector, with similar patient confidence and injection pain compared with FlexPen.

Dose Accuracy, Injection Force, and Usability Assessment of a New Half-Unit, Prefilled Insulin Pen

BACKGROUND

This study examines the utility of the first prefilled, rapid-acting insulin pen that can be dialed in half-unit increments. Dose accuracy and injection force were examined through a series of design-verification tests, and usability was established by human factors validation testing.

METHODS

Devices were tested for dose accuracy at 3 different doses and temperatures and under free fall, vibration, and cold storage conditioning. Injection force was measured at the maximum dose (30 units). Both experiments used the same semiautomated testing system. Usability was validated in a human factors simulated-use study that included 60 participants (patients with type 1 or type 2 diabetes [aged 10-79 years], adult caregivers, and health care providers).

RESULTS

The pen met the International Organization for Standardization (ISO) 11608-1:2014 requirements for dose accuracy at all settings and conditions tested. Furthermore, all individual results were within the ISO specification limits. Mean injection force across temperature settings ranged from 9.25 to 10.85 N at the highest dose. The usability validation study confirmed that use-related risks were reduced to the extent possible and that additional modifications were not likely to afford further reductions.

CONCLUSIONS

The results from these studies demonstrated accurate dosing over the dose range (0.5-30 units) at different temperatures and conditions with an injection force that should accommodate the intended users. Use safety and usability in patients with diabetes, caregivers, and health care professionals were validated. The added convenience of this new half-unit, prefilled pen may ease the burden of diabetes management for patients who require smaller incremental dosing.

Errors in the Administration Technique of Insulin Pen Devices: A Result of Insufficient Education

Insulin is a high-alert medication in both inpatient and outpatient settings. Insulin can cause significant harm when administered in error. Despite advancements in insulin pen technology, errors in the administration technique remain an issue. Although various factors can contribute to administration errors, lack of education on how to operate these devices is one of the most common reasons they occur. As such, the mechanical technique used by the patient needs to be continually assessed in order to reinforce education where needed. We describe three unique patient cases that depict incorrect administration techniques when using pen devices and the consequences that could have resulted from these errors. These cases involve the use of a syringe instead of a pen needle, injecting without removing the inner cap, and dialing the pen back down instead of pushing the plunger. Although pen devices are relatively simple to use, this article reinforces the need for continual assessment of and education about insulin administration. The teach-back method is an approach that can be used to assess a patient's technique and re-educate them at every available opportunity to reduce the risk of administration errors, which can result in complications and hospitalizations.

Behaviours, thoughts and perceptions around mealtime insulin usage and wastage among people with type 1 and type 2 diabetes mellitus: A cross-sectional survey study

AIMS

People with diabetes who use mealtime insulin (MTI) were surveyed about insulin wastage and injection habits when insufficient insulin remains in a disposable prefilled pen/cartridge to administer a full dose in a single injection.

METHODS

Cross-sectional, online, self-reported survey of MTI usage/wastage behaviour in 400 adults with type 1 (n=120) or type 2 (n=280) diabetes mellitus administering >20units/day of MTI via 100units/ml prefilled pens/cartridges for ⩾1month, conducted in France, Germany, Italy and UK.

RESULTS

Participants' mean±standard deviation age was 54.5±12.2years, body mass index was 29.9±7.2kg/m² and duration of MTI therapy was 8.6±7.8years. They administered 3.7±5.9 injections/day with meals, using 11.3±18.0 prefilled pens/cartridges per month. Overall, 63.5% split the dose across two prefilled pens/cartridges (i.e. administered two injections to obtain a full dose), 15.0% used just what remained in their current pen (i.e. took a lower-than-prescribed dose) and 36.3% discarded prefilled pens/cartridges still containing insulin (i.e. took full dose with new pen). The latter participants discarded a mean 5.5±8.2 prefilled pens/cartridges monthly still containing insulin, each containing 8.6±8.7 units of insulin. Participants who wasted insulin considered it frustrating, time-consuming and painful to inject twice.

CONCLUSIONS

Patients taking >20units/day MTI can find transitions between insulin pens challenging. This study highlights the need to identify ways of improving transitions between pens to make transitions easier for insulin users, which could potentially improve adherence to prescribed doses and reduce waste.

Administration of Biosimilar Insulin Analogs: Role of Devices

With the expiration of patent protection for several originator insulin analog molecules, the availability of insulin analog copies is set to increase. Many regulatory authorities have developed, and continue to refine, guidelines for the approval of biosimilar insulin analogs. Aspects such as the structure, pharmacokinetics and pharmacodynamics, efficacy, safety, and immunogenicity of biosimilar insulin analogs are extensively addressed in these guidelines, but how the biosimilar insulin analog is administered to people with diabetes is not usually a topic. The aim of this article is to highlight that the delivery device-drug combination is of particular importance. Regulatory, legal, and practical aspects of the delivery device, be it a syringe, pen, or pump, have to be considered in the context of biosimilar insulin analogs. Although the safety and efficacy of biosimilar insulin analogs per se are of primary importance for physicians and people with diabetes, functions and features of the devices used for administration also require attention from a practical point of view. Unfortunately, although there are several clinical studies investigating the technical aspects of and patient preference for the originator insulin analog pens, there are currently very little published data for nonoriginator or biosimilar insulin analog pens. In addition, it is not known if it is safe to assume that a biosimilar insulin analog cartridge is compatible with an existing originator insulin analog pen. We believe that there is a need for more discussion on the role of devices for administration of biosimilar insulin analogs.

Determining Current Insulin Pen Use Practices and Errors in the Inpatient Setting

BACKGROUND

The use of insulin pens in the inpatient setting has continued to be a controversial decision. Insulin pens provide several advantages, but given significant reports of medication errors, several organizations have issued alerts to caution users about safety concerns. A survey was conducted to assess the prevalence of insulin pen use and current utilization trends in the inpatient setting.

METHODS

The 31-question guided-logic survey was developed based on review of primary literature regarding insulin pen utilization and evaluated by a panel of medication safety experts from a variety of health care settings. The survey was sent electronically to subscribers of medication safety organizations.

RESULTS

The survey was completed by 474 respondents. Approximately three fourths of respondents indicated insulin pens were on formulary at their institution (n = 332; 74%). Of those who have had insulin pens on formulary, 15% (n = 49) are no longer using them. The most common reasons for not utilizing pens were cost and safety concerns. Pens were reported to be stored in the pharmacy prior to administration (n = 230; 78%) and in a patient's bin (n = 202; 69%) afterward. More than half of respondents use two patient identifiers on the pen and label with a bar code. Approximately 30% reported that an insulin pen has been used on more than one patient at least once in their institution, while 6% were not sure.

CONCLUSION

Insulin pens are widely being used in the inpatient setting. Various mitigation strategies are employed to reduce the risk of harm associated with insulin pen use. Health care professionals believe insulin pens are clinically useful and can be used safely in the inpatient setting. Many organizations and expert panels disseminate best practices in an effort to help ensure their safety. Further studies are needed to assess and validate the risk mitigation strategies identified through this research.

Examining Factors That Impact Inpatient Management of Diabetes and the Role of Insulin Pen Devices

Insulin administration in the acute care setting is an integral component of inpatient diabetes management. Although some institutions have moved to insulin pen devices, many acute care settings continue to employ the vial and syringe method of insulin administration. The aim of this study was to evaluate the impact of insulin pen implementation in the acute care setting on patients, healthcare workers and health resource utilization. A review of published literature, including guidelines, was conducted to identify how insulin pen devices in the acute care setting may impact inpatient diabetes management. Previously published studies have revealed that insulin pen devices have the potential to improve inpatient management through better glycemic control, increased adherence and improved self-management education. Furthermore, insulin pen devices may result in cost savings and improved safety for healthcare workers. There are benefits to the use of insulin pen devices in acute care and, as such, their implementation should be considered.

Improvement of Insulin Injection Technique: Examination of Current Issues and Recommendations

PURPOSE

Correct insulin injection technique is a crucial aspect of diabetes management. The purpose of this article is (1) to outline the medical literature, including patient-based studies and surveys, surrounding the type of issues and problems that patients encounter with injectable insulin therapy and the degree to which correct insulin technique is being applied and (2) to review the latest recommendations for insulin injection technique and discuss the key aspects that diabetes educators and other health care professionals should be communicating to their patients to ensure that injection technique is optimized.

CONCLUSIONS

Examination of the literature and multiple patient surveys demonstrates that patients continue to have many issues with insulin injection technique, highlighting the pressing need for effective patient education. In addition, many patients are not using insulin pen devices correctly. Widespread lack of injection site rotation and reuse of needles have resulted in high rates of lipohypertrophy. Lipohypertrophy has in turn been associated with significantly increased levels of unexplained hypoglycemia and glycemic variability and significantly increased insulin costs. By providing clear, evidence-based consensus recommendations, initiatives such as the Forum for Injection Technique are helping to address these issues but will be successful only if concerted efforts in patient education and reeducation are made to ensure that these recommendations are implemented consistently. This should involve all stakeholders in insulin therapy-particularly diabetes educators, who are at the forefront of patient education.

Determinants of nurse satisfaction using insulin pen devices with safety needles: an exploratory factor analysis

Background

A paucity of data exists to examine nurses’ satisfaction with the use of insulin pens with safety needles in hospitalized patients with diabetes. We investigated major determinants of nurses’ preference of the method of insulin administration in the context of a General Hospital in Northern Italy.

Methods

Consecutive patients admitted to three hospital units of different care intensity requiring insulin received insulin therapy through either the vial/syringe method (October to December 2012) or pen/safety needles with dual-ended protection method (January to March 2013). Before the implementation of insulin pens, floor nurses received a specific training program for proper insulin pen injection technique including individual testing of the devices (pen/safety needles). At the end of the study, nurses completed the Nursing Satisfaction Survey Questionnaire. Cronbach’s alpha was used to determine the internal consistency and reliability of the questionnaire. Major determinants of satisfaction were investigated through an exploratory factor analysis. The association between each retained factor and time spent to teach patients how to self-inject insulin with pen devices was also investigated.

Results

Fifty-three out of 60 nurses (mean age ± SD 36.2 ± 8.5 years, 85 % women, 57 % with 10+ years of working experience) returned the questionnaire. Internal consistency of the questionnaire was satisfactory (Cronbach’s alpha > 0.9). Three months after their introduction, about 92 % of nurses considered pen devices an “improvement” over the vial/syringe method. Two factors explained 85 % of nurses’ satisfaction, one related to convenience and ease of use, and the other to satisfaction/time spent for dose preparation and administration. The latter factor was inversely correlated with time spent on patients’ training tasks.

Conclusions

Nurses’ satisfaction with pen devices was higher than previously reported, possibly reinforced by safety needles with dual-ended protection. Perceived workload was a major determinant of nurse satisfaction using pen devices with safety needles. To facilitate the introduction of insulin pens in the hospital setting, it should be specifically addressed during training programs in the switch-over period.

Human factors engineering and design validation for the redesigned follitropin alfa pen injection device

OBJECTIVES

To demonstrate, using human factors engineering (HFE), that a redesigned, pre-filled, ready-to-use, pre-asembled follitropin alfa pen can be used to administer prescribed follitropin alfa doses safely and accurately.

METHODS

A failure modes and effects analysis identified hazards and harms potentially caused by use errors; risk-control measures were implemented to ensure acceptable device use risk management. Participants were women with infertility, their significant others, and fertility nurse (FN) professionals. Preliminary testing included 'Instructions for Use' (IFU) and pre-validation studies. Validation studies used simulated injections in a representative use environment; participants received prior training on pen use.

RESULTS

User performance in preliminary testing led to IFU revisions and a change to outer needle cap design to mitigate needle stick potential. In the first validation study (49 users, 343 simulated injections), in the FN group, one observed critical use error resulted in a device design modification and another in an IFU change. A second validation study tested the mitigation strategies; previously reported use errors were not repeated.

CONCLUSIONS

Through an iterative process involving a series of studies, modifications were made to the pen design and IFU. Simulated-use testing demonstrated that the redesigned pen can be used to administer follitropin alfa effectively and safely.

Dosing Accuracy of Two Disposable Insulin Pens According to New ISO 11608-1: 2012 Requirements

OBJECTIVE

The aim was to compare 2 disposable insulin pens, FlexTouch® (Novo Nordisk, insulin aspart) and SoloSTAR® (Sanofi, insulin glulisine), according to new ISO 11608-1:2012 requirements for dosing accuracy.

METHODS

Sixty pens of each type were tested at 1, 40, and 80 U doses. Following the new ISO requirements, each dose was delivered from the front, middle, and rear one-third of the pen. Statistical analysis was performed using Student's t test.

RESULTS

Both pens delivered all doses within ISO limits. The difference between the average measured dose and the target dose was significantly smaller for SoloSTAR than FlexTouch at 40 U (P = .009) and 80 U (P = .008), but not at 1 U (P = .417).

CONCLUSION

Both insulin pens fulfilled the dosing accuracy requirements defined by ISO 11608-1:2012 at all 3 dosage levels.

Biosimilar insulins: a European perspective

Biosimilar insulins are likely to enter clinical practice in Europe in the near future. It is important that clinicians are familiar with and understand the concept of biosimilarity and how a biosimilar drug may differ from its reference product. The present article provides an overview of biosimilars, the European regulatory requirements for biosimilars and safety issues. It also summarizes the current biosimilars approved in Europe and the key clinical issues associated with the use of biosimilar insulins.

Understanding sharps injuries in home healthcare: The Safe Home Care qualitative methods study to identify pathways for injury prevention

Background

Home healthcare is one of the fastest growing sectors in the United States. Percutaneous injuries from sharp medical devices (sharps) are a source of bloodborne pathogen infections among home healthcare workers and community members. Sharps use and disposal practices in the home are highly variable and there is no comprehensive analysis of the system of sharps procurement, use and disposal in home healthcare. This gap is a barrier to effective public health interventions. The objectives of this study were to i) identify the full range of pathways by which sharps enter and exit the home, stakeholders involved, and barriers for using sharps with injury prevention features; and ii) assess the leverage points for preventive interventions.

Methods

This study employed qualitative research methods to develop two systems maps of the use of sharps and prevention of sharps injuries in home healthcare. Twenty-six in-depth interview sessions were conducted including home healthcare agency clinicians, public health practitioners, sharps device manufacturers, injury prevention advocates, pharmacists and others. Interview transcripts were audio-recorded and analyzed thematically using NVIVO qualitative research analysis software. Analysis of supporting archival material also was conducted. All findings guided development of the two maps.

Results

Sharps enter the home via multiple complex pathways involving home healthcare providers and home users. The providers reported using sharps with injury prevention features. However, home users’ sharps seldom had injury prevention features and sharps were commonly re-used for convenience and cost-savings. Improperly discarded sharps present hazards to caregivers, waste handlers, and community members. The most effective intervention potential exists at the beginning of the sharps systems maps where interventions can eliminate or minimize sharps injuries, in particular with needleless treatment methods and sharps with injury prevention features. Manufacturers and insurance providers can improve safety with more affordable and accessible sharps with injury prevention features for home users. Sharps disposal campaigns, free-of-charge disposal containers, and convenient disposal options remain essential.

Conclusions

Sharps injuries are preventable through public health actions that promote needleless treatment methods, sharps with injury prevention features, and safe disposal practices. Communication about hazards regarding sharps is needed for all home healthcare stakeholders.

Initial experience and evaluation of reusable insulin pen devices among patients with diabetes in emerging countries

BACKGROUND

Many individuals with type 2 diabetes in emerging countries are transitioning from vial-and-syringe insulin delivery to that of insulin pens (disposable or reusable). As with all insulin delivery methods, patient preferences and comfort are of utmost importance to optimize adherence to treatment. Patient-preferred characteristics for reusable insulin pens and barriers to appropriate injection, particularly in these regions, have not been widely reported in the clinical literature, highlighting a key information gap for clinicians considering these methods as part of a comprehensive diabetes management approach.

METHODS

Face-to-face interviews were conducted with people with type 1/2 diabetes, including insulin-naïve and established insulin users. After moderator demonstration, participants were evaluated on their ability to perform a six-step process to inject a 10-unit dose into a pad with the AllStar(®) (AS; Sanofi, Mumbai, India), HumaPen Ergo II(®) (HE2; Eli Lilly, Indianapolis, USA), and NovoPen 4(®) (NP4; Novo Nordisk, Bagsværd, Denmark) pens. Local pens were also tested in India, China and Brazil.

RESULTS

A total of 503 people from India, Malaysia, Brazil, Egypt, and China participated. Participants completed the six-step process in an average, 2-3 min per pen. Participants ranked ease of overall use and ease of self-injection and dialing/reading dose as most important features for new insulin pens. When using the pens, the most difficult step was priming/safety testing, with 7-12% failing and 28-40% having difficulty; 6%, 18%, and 22% failed to hold the injection button down for the required period of time using AS, NP4, and HE2, respectively. Participants ranked AS significantly higher for nine of 12 ease-of-use features including three of the top four features considered the most important for reusable pens, while HE2 was ranked higher for two features. Local pens were ranked lowest.

CONCLUSIONS

Priming the pen and injecting the dose imparted most difficulty for people with diabetes in emerging countries. Most participants found AS easiest to use overall, with differences noted between pens for individual steps of dose delivery. Identifying characteristics most preferred by patients may assist in improving adherence to insulin therapy.

Achieving glycaemic targets with basal insulin in T2DM by individualizing treatment

Insulin therapy is an effective method for reducing blood glucose levels in patients with type 2 diabetes mellitus (T2DM), and most patients with T2DM eventually require insulin replacement to attain and preserve satisfactory glycaemic control. All patients with T2DM should be considered as potential candidates for intensive insulin treatment; however, there are certain considerations regarding replacement therapy for different types of people and special populations, such as patients with multiple comorbidities, adolescents, pregnant women and the elderly. Lowering HbA1c levels in isolation without assessing the patient as a whole is becoming redundant. HbA1c targets should be individualized to the specific patient, and insulin treatment ought to be customized accordingly. There are several questions that need to be taken into account when considering adding insulin therapy to other oral antidiabetic agents, for example, for whom and when insulin therapy is indicated and which basal insulin should be utilized. Potential barriers exist related to patients, providers and health-care systems that can delay the start of insulin therapy, and every effort should be made to identify and address these obstacles.

Comparing patient preferences and healthcare provider recommendations with the pen versus vial-and-syringe insulin delivery in patients with type 2 diabetes

OBJECTIVES

This study aimed to examine healthcare provider (HCP) recommendations and patient preferences for the insulin pen versus vial-and-syringe in patients with type 2 diabetes mellitus (T2DM) and to assess clinical end points and safety outcomes.

SUBJECTS AND METHODS

Using a randomized, open-label, crossover design, in total, 405 insulin-naive adults with T2DM from 60 centers received basal insulin glargine in one of two device treatment sequences (2 weeks of pen followed by 2 weeks of vial-and-syringe, or vice versa). The primary end point, patient device preference, was evaluated at Week 4 (end of the crossover period) using the Insulin Injection Preference Questionnaire. Patient preference and HCP recommendation were assessed with one global item and three subscale items (blood glucose control, reluctance to use insulin, and long-term insulin use) using a 5-point scale ranging from 1=not preferred or not recommended to 5=preferred or recommended. Patients were then re-randomized to either pen or vial-and-syringe for further observation (6, 10, and 30 weeks) to evaluate clinical end points (glycosylated hemoglobin [A1C] and fasting blood glucose levels) and safety outcomes (hypoglycemia and adverse events).

RESULTS

Patients reported a significant preference for pens over vial-and-syringe, and HCPs strongly recommended pens over vial-and-syringe (both P<0.001). Consistent response patterns were observed by HCPs and patients for the three subscale items. Fasting blood glucose, A1C levels, and the incidence of hypoglycemia were comparable in the two groups.

CONCLUSIONS

Patients preferred pens over vial-and-syringe, with the pen device also recommended by HCPs, when initiating basal insulin treatment in insulin-naive patients with T2DM.

Dose accuracy and injection force of different insulin glargine pens

BACKGROUND

Dose accuracy and injection force, representing key parameters of insulin pens, were determined for three pens delivering insulin glargine-based copies, Pen Royale (WR) and DispoPen (WD) for Glaritus® (Wockhardt) and GanLee Pen (GL) for Basalin® (Gan & Lee), compared with pens of the originator, ClikSTAR® (CS) and SoloSTAR® (SS) for Lantus® (Sanofi).

METHODS

Using the weighing procedure recommended by DIN EN ISO 11608-1:2000, dose accuracy was evaluated based on nonrandomized delivery of low (5 U), mid (30 U), and high (60 U) dosage levels. Injection force was measured by dispensing the maximum dose of insulin (60 U for the GL, WR, and WD; 80 U for the SS and CS) at dose speeds of 6 and 10 U/s.

RESULTS

All tested pens delivered comparable average doses within the DIN EN ISO 11608-1:2000 limits at all dosage levels. The GL revealed a higher coefficient of variation (CV) at 5 U, and the WR and WD had higher CVs at all dosage levels compared with the CS and SS. Injection force was higher for the WR, WD, and GL compared with the CS and SS at both dose speeds. In contrast to the CS and SS with an end-of-content feature, doses exceeding the remaining insulin could be dialed with the WR, GL, and WD and, apparently, dispensed with the WD.

CONCLUSIONS

All pens fulfilled the dose accuracy requirements defined by DIN EN ISO 11608-1:2000 standards at all three dosage levels, with the WR, WD, and GL showing higher dosage variability and injection force compared with the SS and CS. Thus, the devices that deliver insulin glargine copies show different performance characteristics compared with the originator.

Dosing accuracy and insulin flow rate characteristics of a new disposable insulin pen, FlexTouch, compared with SoloSTAR

BACKGROUND

The introduction of the FlexTouch® (FT; Novo Nordisk; insulin aspart), a prefilled insulin pen with a spring-loaded mechanism, has created more insulin pen options. The present study compared the dosing accuracy of the FT with that of the manually operated SoloSTAR® (SS; Sanofi; insulin glulisine). The volumetric flow rate of insulin delivery with the FT was also evaluated.

METHODS

Thirty unused pens from one batch of each pen type were used to test dosing accuracy at minimum (1 U), mid (40 U), and maximum dose (80 U). Statistical analysis was performed using Student's t-test. Insulin flow was determined with 20 FT pens ejecting 80 U three times per pen using a mass flow meter.

RESULTS

Both insulin pens revealed excellent dosing accuracy, delivering all doses within the limits set by ISO 11608-1:2000. The average relative deviation of the actual dose from the target dose was +6.86% and +3.87% at the minimum, -0.72% and -1.01% at the mid, and -0.68% and -1.06% at the maximum dose for the SS and FT, respectively. The difference at maximum dose was statistically significant (p = .006) in favor of the SS. The FT showed a mean maximum flow rate of 15.61 U/s, with 80.52% of the total dose delivered at an injection speed exceeding 10 U/s.

CONCLUSIONS

This study demonstrated excellent dosing accuracy for the SS and FT at all tested dosage levels. The average maximum injection speed of the FT was considerably higher than the usual range of 6-10 U/s assumed for a smooth and painless injection. Further investigations should confirm the clinical relevance.

A randomized, cross-over comparison of preference between two reusable insulin pen devices in pen-naïve adults with diabetes

OBJECTIVE

To evaluate final preference and ease-of-use attributes of two reusable pen injectors, HPS (HumaPen Savvio) and HPL (HumaPen Luxura), in adults with type 1 or type 2 diabetes.

RESEARCH DESIGN AND METHODS

This was a 1 day, randomized, two-period crossover, open-label, simulated-injection study in 203 pen-naïve subjects (mean age 58.4 years).

MAIN OUTCOME MEASURES

Functional and ease-of-use attributes of insulin pen injectors were evaluated using a 16-item survey (7 point scale) where higher scores reflected greater preference and equal scores reflected no preference. The primary objective was final pen preference, with statistical gate-keeping to the ease of detecting an insufficient remaining dose (IRD) of insulin upon dose selection.

RESULTS

For final overall pen preference, HPS was chosen by 150 of 203 subjects (73.9%, 95% confidence interval [CI] = 67.3%-79.8%). For the IRD item, 'It is easy to know when there is not enough insulin left in the cartridge for the dose I need before I inject', HPS was preferred by 94 of 107 subjects with a preference (87.9%, 95% CI = 80.1%-93.4%). In 14 of the remaining 15 survey items, 64.3% to 87.7% of subjects with a preference statistically significantly preferred HPS over HPL. To confirm the results, subjects with no preference for either pen, which ranged between 95 and 148, were included in a Bayesian analysis.

KEY LIMITATIONS

Injection simulation, use of an unvalidated survey, and office setting which did not allow for direct clinical experience with the devices.

CONCLUSIONS

The majority of pen-naïve subjects preferred HPS over HPL. For all ease-of-use attributes, the majority of subjects with a preference chose HPS over HPL. Some attributes of both pens were equally acceptable, as many subjects had no preference.

Usability and preference assessment of a new prefilled insulin pen versus vial and syringe in people with diabetes, physicians and nurses

OBJECTIVE

This multicenter, crossover study assessed the preference and usability of a new prefilled insulin pen, FlexTouch® (FT) versus vial and syringe (V&S).

RESEARCH DESIGN AND METHODS

People with type 1 or type 2 diabetes (n = 60), and physicians (n = 30) and nurses (n = 30) with experience of diabetes management performed test injections with FT and V&S, and then answered written questions on ease of use and preference.

MAIN OUTCOME MEASURES

The primary end point was preference for FT versus V&S. Secondary end points included perceptions of device handling.

RESULTS

Significantly more respondents preferred using FT (88%) to V&S (5%; p < 0.001; the remainder chose 'no preference'), found FT (91%) easier to use than V&S (6%; p < 0.001; the remainder chose 'no preference') and would recommend FT (91%) over V&S (3%; p < 0.001; the remainder chose 'no preference'). FT received better ratings than V&S for ease of use, holding the device stable when injecting, depressing the push-button/plunger and reading the dose scale (all p < 0.001). Ratings for confidence in correct insulin delivery and controlling blood sugar were also significantly better with FT (both p < 0.001).

CONCLUSIONS

FT was preferred to V&S for insulin delivery in this comparative analysis. The features of FT may improve the experience of insulin injection compared with V&S for a wide range of people with diabetes.

Analysis of comparison of patient preference for two insulin injection pen devices in relation to patient dexterity skills

Insulin therapy is the cornerstone of medical treatment for many patients with diabetes. Self-administration of this life-saving medication is no longer limited to the traditional vial and syringe. Instead, more and more patients worldwide are using prefilled insulin pen devices. Ease of use, convenience, confidence in dosing accuracy, and improved quality of life are just a few of their advantages. As with any medical technology, safe and proper use is vital. Many studies have examined pen device preference and usability. Until now, no study has included patients with both visual and dexterity impairments. To ensure safe and simple self-administration of insulin for all patients, it is time for the special needs of patients with diabetes to be considered not only during product development, but during postmarketing studies as well.

Preference for a new prefilled insulin pen compared with the original pen

BACKGROUND

The prevalence of diabetes is increasing in the United States and worldwide. Insulin injection pens are preferred over vial/syringe methods, and are designed to facilitate use, improve adherence, and provide accurate insulin delivery.

OBJECTIVE

This study compares the efficacy, safety profile, and patient preference of the new prefilled insulin pen FT* versus the original insulin pen FP.

METHODS

This randomized, multicenter, open-label, crossover study was conducted in insulin-treated pen-naïve patients with type 1 or type 2 diabetes mellitus (n = 242, mean age 58 years, mean body mass index (BMI) 31.4 kg/m(2), baseline glycosylated hemoglobin [HbA(1c)] 7.3%). Patients were randomized 1:1 to either FT or FP for 12 weeks and then switched to the alternate insulin device for 12 weeks, while the insulin regimen was kept the same. All subjects were on either insulin detemir alone or in combination with insulin aspart treatment during the trial. HbA(1c) was assessed at screening, randomization, cross-over period, and end of trial. The safety profile was evaluated based on adverse events (AEs), adverse device effects (ADEs), and hypoglycemic episodes. Patient-reported outcome (PRO) questionnaires assessed at randomization, crossover period, and end of trial were used to investigate the subjects' preference of the two prefilled devices.

RESULTS

A total of 400 subjects were screened, 242 subjects were randomized and exposed to the prefilled pen devices, and 222 subjects completed the trial. Twenty subjects discontinued the study. Four subjects discontinued due to adverse events. Subject default (withdrawal of consent and loss to follow up) was the most common reason for discontinuation (10 subjects), Glycemic control achieved with FT was comparable to that with FP (FT-FP: difference -0.047 [95% CI -0.127; 0.032%]). The majority of subjects (68%) indicated a preference for the FT device over FP. In addition, the majority of subjects found FT easier to use (64% [144/226]), easier to inject the insulin dose (65% [148/227]) and easier to push for injection (69% [155/226]). The Treatment Related Impact Measure-Diabetes (TRIM-D) ratings of FT were significantly higher for diabetes management facilitation (P < 0.001), and treatment burden (P < 0.001). The safety profiles were comparable for FT and FP.

CONCLUSIONS

FT was found to be comparable to FP with respect to the efficacy and safety profile. Significantly more subjects favored the FT device in terms of ease of use, insulin injection, diabetes management, and overall preference. A limitation of the present study was its open-label design because the pen devices used to administer the insulin were distinctively different and the use of a double-dummy design was precluded by the absence of placebo pen devices. The questionnaires about treatment were related to the use of the device and therefore a blinded study was not possible.

Needle with a novel attachment versus conventional screw-thread needles: a preference and ease-of-use test among children and adolescents with diabetes

BACKGROUND

This usability test investigated the overall preference and usability of the novel NovoTwist® insulin pen needle versus conventional screw-thread needles, when used with Next Generation FlexPen®, in children and adolescents with diabetes.

METHODS

This was an open-label, randomized, crossover usability test in children and adolescents with type 1 diabetes who administered insulin with an insulin pen. Test needles were NovoTwist and the participant's current screw-thread needle (or NovoFine® needle). Following instruction, participants attached the needle to Next Generation FlexPen, made an injection into a foam cushion, and detached the needle. This procedure was conducted three times with both needles in a random order. Responses to 13 questions on user experience with each needle (including overall preference, ease of attachment/detachment of needle/cap, handling, learning, confidence in attachment, and convenience of use) were subsequently recorded on a six-point rating scale (1 = very difficult; 6 = very easy).

RESULTS

Fifteen children aged ≥ 6 to ≤ 12 years and 15 adolescents aged ≥ 13 to ≤ 17 years participated in the test. A significantly higher proportion of children and adolescents (77%) indicated that they would prefer to use NovoTwist compared with screw-thread needles (p = .005). NovoTwist was preferred by most children and adolescents for overall ease of use (77%; p = .005), for ease of attachment (87%; p < .001) and detachment (83%; p < .001), and as the most appropriate needle to handle for daily injections (73%; p = .016). The mean rating for confidence in correct needle attachment was not significantly different between the two needle types. Seven out of eight parents of children who required assistance for their daily insulin injections stated that they would be "very likely" to allow their child to attach NovoTwist.

CONCLUSIONS

These factors may promote confidence in this needle, and thus in self-injecting, among younger patients and their parents.

What can we learn from patient-reported outcomes of insulin pen devices?

Although a variety of effective treatment options are available for patients with type 1 or type 2 diabetes, many patients in the United States have difficulty reaching their glycemic goals. Patient adherence to insulin therapy, which often involves self-administered subcutaneous injections of insulin using either a vial and syringe or an insulin pen device, is often poor. Various factors associated with the type of injection device have been shown to influence the rate of patient adherence to insulin therapy. This article reviews patient-reported outcome (PRO) evidence from pediatric and adult studies that compared insulin pen devices with vial and syringe use. In a majority of these cases, patients preferred the pen devices over vial and syringe, stating advantages such as ease of use, convenience, greater confidence in their ability to properly administer the drug, and a greater perceived social acceptance. The pens were considered less painful than syringes and were associated with less needle fear. In addition, PRO evidence has directed pen technology design, leading to development of more advanced insulin pen devices. By appreciating the correlation between adherence to insulin regimens and a patient's device preference, clinicians can make improved treatment recommendations to facilitate achievement and maintenance of glycemic targets.

Analysis of the NovoTwist pen needle in comparison with conventional screw-thread needles

Administration of insulin via a pen device may be advantageous over a vial and syringe system. Hofman and colleagues introduce a new insulin pen needle, the NovoTwist, to simplify injections to a small group of children and adolescents. Their overall preferences and evaluation of the handling of the needle are reported in the study. This new needle has the potential to ease administration of insulin via a pen device that may increase both the use of a pen device and adherence to insulin therapy.

Dose accuracy of the ClikSTAR, NovoPen 4, and Luxura insulin pens: results of laboratory and field studies

BACKGROUND

A high dosing accuracy is needed to maintain normal glycemia in patients with diabetes. This study investigated the dose accuracy of the commonly used reusable insulin pens ClikSTAR®, NovoPen® 4, and Luxura®.

METHODS

Pens were tested in a laboratory setting by one trained technician who delivered four doses of 30 U from each of 15 pens per pen model (a total of 60 doses from each pen model). Pens were also tested in a simulated clinical setting by 48 people with diabetes. Each participant delivered 27 doses: three doses of 30 U from each of three pens per pen model. Overall, the technician delivered 180 doses and the participants 1296 doses.

RESULTS

All pens met the tolerance limits defined by the German edition of the International Standardization Organization (ISO) 11608-1:2000 standard [30 ± 1.5 U (28.5-31.5 U)]. All doses were delivered within the limits proposed by the ISO, except for two doses with Luxura in the clinical setting. In laboratory testing, the mean dose delivered by ClikSTAR (29.69 U) or Luxura (29.89 U) was less than the expected 30 U and significantly less than the mean dose delivered by NovoPen 4 (30.04 U; p < .001 for both comparisons). Similar results were observed in the simulated clinical setting. NovoPen 4 had the greatest variance in laboratory testing but the least in the simulated clinical setting.

CONCLUSIONS

This study demonstrates comparable dose accuracy and variability of the ClikSTAR, Luxura, and NovoPen 4 insulin pens. The slight differences in mean doses between pens are unlikely to be clinically significant.

Analysis of patient satisfaction with a prefilled insulin injection device in patients with type 1 and type 2 diabetes

In this issue of Journal of Diabetes Science and Technology, Hancu and colleagues present an observational 6-8-week Pan-European and Canadian prospective survey on patient satisfaction with a prefilled insulin injection device, the SoloSTAR pen device, in patients with type 1 and 2 diabetes (n = 6542). The SoloSTAR pen is one of several up-to-date insulin pens of high quality and characteristics that fit many of our patients with diabetes. The mainly excellent-good votes of the participants for the SoloSTAR are not surprising, as we have seen continuous improvements with prefilled pens, such as the SoloSTAR device. Several years ago, patients as well as health care providers found considerable differences between the available pen options. Nowadays, as almost all pen providers have clearly improved their products, the differences are much smaller; we are closer to a "perfect" prefilled pen device. Nevertheless, there is a need for more randomized controlled trials, ideally sponsored not by just one manufacturer, to be able to make clear statements toward different pen device aspects (e.g., accuracy of dosing, adherence to therapy, ease of use, and patient satisfaction). An additional handicap is the difficulty to get blinded study designs.

Analysis and perspective: A randomized, open-label, comparative crossover handling trial between two durable pens in patients with type 1 or 2 diabetes mellitus

Insulin pen therapy is superior to vial and syringe with regard to more accurate insulin delivery, patient preference, adherence, and favorable health economics. In this issue of Journal of Diabetes Science and Technology, Sommavilla and Pietranera compare two generations of NovoPen, showing significant improvements in selecting and injecting the insulin dose as well as superior overall satisfaction with the newer versus older generation insulin pen among both experienced pen users and insulin-naïve patients. There are other potentially useful features that might be implemented and better-studied in future pen devices. These include insulin dose tracking, insulin error mitigation, and insulin dosing advice. Caring more effectively for the multitude of people impacted by the diabetes epidemic requires a new approach that will require "smarter," more "connected" devices.

Injection force of reusable insulin pens: Novopen 4, Lilly Luxura, Berlipen, and ClikSTAR

BACKGROUND

Insulin pen devices are used by approximately half of insulin users worldwide. The injection force of insulin pens is a key element in their design. This study aimed to demonstrate that the sanofi-aventis reusable ClikSTAR® (CS) pen has an improved injection force over existing insulin pens.

METHODS

The injection force of four reusable insulin pens--Novopen® 4 (NP4; Novo Nordisk), Luxura® (LL; Eli Lilly and Co.), Berlipen® (BP; Haselmeier GmbH), and CS (sanofi-aventis)--was tested in a laboratory setting. Injection force was tested using two methods: six dispense rates between 6 and 24.66 U/s (constant volume flow rate) and constant button speeds of 4 and 8 mm/s.

RESULTS

The CS required a lower mean injection force versus NP4, LL, and BP at both doses and all dispense rates. Mean injection force was 45%, 126%, and 60% higher for NP4, LL, and BP versus CS, respectively (p < .05 for each of the comparisons), for a flow rate of 6 U/s at 60 U dose. Mean injection force in all pens increased with the dispense rate, but the injection force remained significantly lower for CS versus all other pens (p < .05). The injection force for CS was significantly lower for 60 U at 10 and 17.03 U/s than for 80 U.

CONCLUSIONS

The study demonstrated that CS pens require a lower injection force at a wide range of different injection speeds than other reusable insulin pens. This is an important benefit for patients with diabetes, especially those with limited dexterity.

Coverage of insulin delivery devices and basal insulin analogs by US managed care organizations

OBJECTIVE

The perception in the US is that insulin formulations prescribed for type 1 and type 2 diabetes and delivered via insulin pens are more costly to patients than the same or similar products provided in vials, and that basal insulin analogs offered either in pens or vials are likewise more costly to patients than human insulin formulations. This study compares levels of coverage and copays by private and Medicare Part D plans for insulin pens and vials containing basal insulin analogs and for NPH formulations in vials.

METHODS

A commercially available formulary database (Access Point, Pinsonault Associates; updated quarterly) was analyzed as of January 2010 for private insurance plans and as of March 2010 for Medicare Part D plans. Analyses were performed for Tier-level coverage and copays per prescription for basal insulin analogs in pens and vials, and NPH in vials.

RESULTS

Basal insulin analogs in pens were covered by >91% of private and Part D plans. NPH coverage was reported by >92% of private plans and 69-95% of Part D plans, depending on brand. Irrespective of delivery mode, copays in the majority of private plans for basal insulin analogs and NPH were in the >$10-35 range. Copays were higher in Part D plans, with the majority of plans and subscribers in a >$35-50 range. Prior authorization was required by <10% of insurance plans for insulin analog pen prescriptions, and <3% of plans for insulin analog or NPH prescriptions in vials.

LIMITATIONS

This analysis was descriptive, copay stratification was not based on a statistical model but on copay ranges typically used by the plans, and there were no direct correlations performed on the numbers of subscribers per plan vs copay or Tier level.

CONCLUSION

These results counter the widely held perception that insurance coverage is less extensive for insulin pens vs vials. Medicare Part D plans often had higher copay requirements than private plans for the same product at the same copay Tier.

Insulin pen use for type 2 diabetes--a clinical perspective

While insulin delivery technology continues to progress, its adoption in the clinic lags behind, particularly in people with type 2 diabetes. In this article the authors present their clinical perspective regarding insulin pen therapy in this population.