Health economics and compliance of vials/syringes versus pen devices: a review of the evidence

7. Diabetes Technology: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Emicizumab prophylaxis for people with hemophilia A: Waste estimation and the Brazilian perspective

Costs of hemophilia A treatment are increasing. Waste of clotting products should be avoided. To estimate the first-year waste of emicizumab prophylaxis for people with hemophilia A and inhibitors (PwHAi) who failed immune tolerance induction (ITI), in Brazil. We evaluated the manufacturer and the Brazilian Ministry of Health (MoH) protocol-recommended regimens in a budget impact model. The loading dose consisted of 3.0 mg/kg/Q1W for 4 weeks, for both recommendations. The manufacturer maintenance regimens comprised 1.5 mg/kg/Q1W, 3.0 mg/kg/Q2W, and 6.0 mg/kg/Q4W. The MoH protocol maintenance regimen encompassed a hybrid Q1W/Q2W administration, depending on the body weight. The Q4W regimen was not recommended by the MoH protocol. Analyses were performed to estimate waste given its expense based on the World Health Organization body weight range (percentiles [P] 15, 50, and 85). The first-year emicizumab waste was estimated individually and for the disclosed PwHAi who failed ITI (n = 114). The highest emicizumab waste was estimated for the lowest body weights and the Q1W regimen. The Q4W regimen resulted in the lowest emicizumab waste, followed by the MoH protocol regimen. The total reconstituted costs estimated for the PwHAi who failed ITI according to the hybrid MoH protocol ranged from US$32,858,777 (P15) to US$47,186,858 (P85), with emicizumab waste ranging from 7.9 % (US$2,594,515) to 3.7 % (US$1,738,750), respectively. Lost resources due to current protocols for emicizumab prophylaxis for PwHAi who failed ITI in Brazil are considerable. Waste was more pronounced due to lower body weight and shorter administration intervals.

Insulin Therapy in Small Animals, Part 1: General Principles

Understanding the pharmacology of insulin and how it relates to the pathophysiology of diabetes can lead to better clinical outcomes. No insulin formulation should be considered "best" by default. Insulin suspensions (NPH, NPH/regular mixes, lente, and PZI) as well as insulin glargine U100 and detemir are intermediate-acting formulations that are administered twice daily. For a formulation to be an effective and safe basal insulin, its action should be roughly the same every hour of the day. Currently, only insulin glargine U300 and insulin degludec meet this standard in dogs, whereas in cats, insulin glargine U300 is the closest option.

Factors Affecting Performance of Insulin Pen Injector Technology: A Narrative Review

BACKGROUND

Insulin treatment is an essential hormone replacement therapy for the survival of people with type 1 diabetes and is often used for treatment in type 2 diabetes, particularly as the disease progresses. Advances in insulin therapy have been made since its discovery, including production of human insulin and development of insulin analogs with improved efficacy and safety profiles. The different types of available insulin formulations allow health care professionals to personalize treatment to an individual's needs. Generally, insulin requires parenteral administration via subcutaneous injection owing to very low oral bioavailability.

METHODS

This article reviews the human, technological, economical, and regulatory factors affecting the performance of insulin pens and the relationship between them. Opportunities and challenges that insulin pen injections may encounter in the future are also considered.

RESULTS

Insulin delivery devices, together with other factors, influence dose accuracy, convenience, and quality of life, contributing to easier medication administration with high efficacy and safety. For patients, ease of use, fast and accurate drug delivery, and painless injection are the most valuable features of an insulin injection device. For manufacturers, technological feasibility and economic viability also need to be considered when developing injection devices.

CONCLUSION

Insulin pen injectors are generally preferred over vial and syringe, although access may be limited in some health care systems. Insulin pen injectors can adapt to different insulin regimens and formulations and have the potential to acquire dosing data in real time.

Comparison of simplicity, convenience, safety, and cost-effectiveness between use of insulin pen devices and disposable plastic syringes by patients with type 2 diabetes mellitus: a cross-sectional study from Bangladesh

INTRODUCTION

Insulin pen devices and disposable plastic insulin syringes are two common tools for insulin administration. This study aims to compare the simplicity, convenience, safety, and cost-effectiveness of insulin pens versus syringe devices in patients with type 2 diabetes mellitus (T2DM).

METHODS

A cross-sectional study was conducted at 14 diabetes clinics throughout Bangladesh from November 2021 to April 2022 among adults with T2DM injecting insulin by pen devices or disposable insulin syringes at least once a day for at least one year by purposive sampling. The simplicity, convenience, and safety of insulin devices were assessed using a structured questionnaire, and the study subjects were scored based on their answers; higher scores indicated a poorer response. Total scores for simplicity, convenience, and safety were obtained by adding the scores for relevant components. Their average monthly medical expense and cost of insulin therapy were recorded. The median values of the total scores and monthly expenses were compared between pen devices and disposable syringe users.

RESULTS

737 subjects were evaluated; 406 were pen users, and 331 were vial syringe users. The pen users had lower median scores for simplicity [6.0 (5.0-8.0) vs. 7.0 (5.0-9.0), p = 0.002], convenience [4.0 (3.0-6.0) vs. 5.0 (4.0-6.0), p < 0.001], and safety [7.0 (6.0-8.0) vs. 7.0 (6.0-9.0), p = 0.008] than vial syringe users. Pen devices were more expensive than vial syringes in terms of average medical expense per month [BDT 5000 (3500-7000) vs. 3000 (2000-5000), p < 0.001], the total cost of insulin therapy per month [BDT 2000 (1500-3000) vs. 1200 (800-1700), p < 0.001] and cost per unit of insulin used [BDT 2.08 (1.39-2.78) vs. 0.96 (0.64-1.39), p < 0.001]. Non-significant differences in favor of pens were observed in HbA1c levels [8.7 (7.8-10) vs. 8.9 (7.9-10)%, p = 0.607] and proportions of subjects having HbA1c < 7% (6.9 vs. 6.3%, p = 0.991).

CONCLUSION

Insulin pens are simpler, more convenient, and safe but more expensive than vial syringes. Glycemic control is comparable between pen and syringe users. Long-term follow-up studies are needed to determine the clinical and economic impacts of such benefits of insulin pens.

7. Diabetes Technology: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Trends in U.S. Insulin Use and Glucose Monitoring for People with Diabetes: 2009-2018

BACKGROUND

The delivery and administration of insulin has undergone many changes over the years. This research examines U.S. trends in insulin use among people with type 1 diabetes (T1D) or type 2 diabetes (T2D) in the U.S. from 2009 to 2018.

METHODS

The IBM^® MarketScan^® Commercial and Medicare databases were used to identify trends in insulin use over 10 years. The study included people with T1D or T2D who filled a prescription for insulin in any calendar year from 2009 to 2018. The analyses examined insulin regimen and delivery and the use of glucose monitoring systems. Generalized estimating equations were used to test whether trends were statistically significant.

RESULTS

Individuals with T1D were most commonly prescribed a basal and bolus insulin regimen or short/rapid insulin only, while for people with T2D the use of basal-only insulin increased significantly over the study period. In both groups there was a significant decline in the use of premix insulin from 2009 to 2018. Insulin pump use increased for individuals with T1D, while disposable pen use increased for people in both cohorts. In both cohorts, there was a statistically significant increase in the use of continuous glucose monitoring, although this increase was more pronounced and occurred earlier among individuals with T1D.

CONCLUSIONS

Results indicate significant changes in insulin regimens and delivery and glucose monitoring from 2009 to 2018. These findings suggest that insulin prescribing continues to change in response to the development of new therapeutics, advances in insulin delivery technology, and glucose monitoring systems.

Enabling faster subcutaneous delivery of larger volume, high viscosity fluids

OBJECTIVES

Many current subcutaneous (SC) biologic therapies may require >1 mL volume or have increased viscosity, necessitating new delivery system approaches. This study evaluated 2-mL large-volume autoinjector (LVAI) delivery performance across varying solution viscosities and design inputs to assess the design space and identify configurations that produce practical injection times.

METHODS

Investigational LVAI delivery duration and volume, depot location, and tissue effects were examined in both air and in vivo models across various pre-filled syringe (PFS) cannula types (27 G Ultra-thin wall [UTW], 27 G special thin wall [STW], or 29 G thin-wall [TW]), drive spring forces (SF_LOW or SF_HIGH), and Newtonian solutions (2.3-50 centipoise [cP]).

RESULTS

Within each design configuration, increasing PFS internal diameters and spring forces reduced delivery times, while increasing viscosity increased times. The 27 G UTW PFS/SF_HIGH combination achieved shorter delivery times across all injection conditions, with 2 mL in vivo durations <15 seconds at ≤31 cP and routinely <20 seconds at 39 and 51 cP, with nominal and transitory tissue effects.

CONCLUSION

PFS cannula and spring force combinations can be tailored to achieve various injection durations across viscosities, while UTW PFS enables faster rates to potentially better accommodate human factors during LVAI injection, especially at high viscosity.

One hundred years of insulin: Is it time for smart?

Smarter understanding of diabetes pathophysiology and pharmacology of insulin therapy can lead to better clinical outcomes. Rather than looking for an insulin formulation that is considered "best" for a general population, it could be appropriate to seek the "smart" insulin choice, tailored to the specific clinical situation. Different treatment goals should be considered, with pros and cons to each. Ideally, insulin therapy in most diabetic dogs should mimic a "basal-bolus" pattern. The "intermediate"-acting insulin formulations might provide better "bolus" treatment in dogs than the rapid-acting formulations used in people. In patients with some residual beta cell function such as many diabetic cats, administering only a "basal" insulin might lead to complete normalisation of blood glucose concentrations. Insulin suspensions (neutral protamine Hagedorn, neutral protamine Hagedorn/regular mixes, lente and protamine zinc insulin) as well as insulin glargine U100 and detemir are "intermediate"-acting formulations that are administered twice daily. For a formulation to be an effective and safe "basal" insulin, its action should be roughly the same every hour of the day. Currently, only insulin glargine U300 and insulin degludec meet this standard in dogs, whereas in cats, insulin glargine U300 is the closest option.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Assessment of basal insulin adherence using 2 methodologies among Texas Medicaid enrollees with type 2 diabetes

BACKGROUND: Basal insulin is often recommended as the initial therapy for patients with type 2 diabetes who require insulin treatment. Adequate adherence is critical to diabetes management, yet suboptimal insulin adherence has been reported. Second-generation long-acting (SGLA) insulin has higher dosing flexibility and lower hypoglycemia risk and may improve adherence. However, little is known regarding adherence to SGLA insulin and how adherence to SGLA insulin compares with intermediate-acting neutral protamine Hagedorn (NPH) and first-generation long-acting (FGLA) insulin. Measurement of insulin adherence is challenging because of the inaccuracies of recorded days supply of insulin, and traditional medication possession ratio (MPR) may be negatively affected. Adjusted MPR (aMPR) has been developed in an effort to address this issue. OBJECTIVE: To examine the unadjusted and adjusted associations between basal insulin type and adherence to basal insulin using MPR and aMPR. METHODS: This retrospective database study used Texas Medicaid prescription claims from January 1, 2014, through June 30, 2017. The index date was the date of the first basal insulin prescription without the same prescription 6 months before (pre-index), and all patients were followed for 12 months (post-index). Patients aged 18-63 years with ≥ 1 pre-index prescription of an oral hypoglycemia agent (OHA) or a glucagon-like peptide-1 receptor agonist (GLP-1 RA), without any post-index prescription of premixed insulin or a basal insulin different from index insulin, and with continuous enrollment throughout the pre- and post-index periods, were included. The dependent variable was basal insulin adherence over 12 months, measured using MPR and aMPR. Unadjusted and adjusted adherence comparisons were conducted by basal (background) insulin type (NPH, FGLA, and SGLA). Covariates included age, gender, baseline use of basal insulins and comorbid medications, total number of medications, OHA adherence, post-index number of OHAs, and use of bolus insulins and GLP-1 RAs. Analysis of variance, chi-square tests, and multiple logistic regression analyses were performed. RESULTS: Of the 5,034 patients included, NPH, FGLA, and SGLA insulin users accounted for 3.7%, 89.8%, and 6.5%, respectively. The overall mean (SD) age was 50.9 (9.9) years, and 65.9% were female. In the unadjusted bivariate analyses, SGLA insulin users had significantly higher adherence, using either MPR (SGLA 0.68 [0.25] vs. FGLA 0.59 [0.27] vs. NPH 0.55 [0.27]; P < 0.0001) or aMPR (0.83 [0.23] vs. 0.78 [0.26] vs. 0.73 [0.28]; P = 0.0001). After controlling for covariates, insulin type was not significantly associated with the likelihood of being adherent (MPR or aMPR ≥ 0.8) using either measure. CONCLUSIONS: Adherence to SGLA insulin was not different from adherence to other basal insulins after controlling for patient characteristics. Yet, MPR and aMPR have limitations and warrant further confirmation of the study findings. Before new adherence measures for insulin therapy are developed, MPR and aMPR should be used with caution. DISCLOSURES: No specific funding was received for this manuscript. The authors report no potential conflicts of interest. Part of the data from this study was presented as posters at the American Pharmacists Association 2020 Annual Meeting & Exposition, March 20-23, 2020, in National Harbor, MD, and at the International Society for Pharmacoeconomics and Outcomes Research 2020 Conference, May 16-20, 2020, in Orlando, FL.

The diffusion of innovative diabetes technologies as a fundamental cause of social inequalities in health. The Nord-Trøndelag Health Study, Norway

This study investigates patterns of adoption and diffusion of innovative health technologies by socioeconomic status (SES) in order to assess the extent to which these technologies may be a fundamental cause of health-related inequalities. Quantitative analyses examined SES-based inequalities in the adoption and diffusion of diabetes technologies. Diabetes data from three panels of the Nord-Trøndelag Health Study (HUNT), Norway, were combined with income and education data. Cross-sectional and longitudinal regression analyses were used to examine relevant inequalities. Cross-sectional analyses suggest often present SES-based gradients in the adoption of diabetes technologies, favouring high-SES groups. Statistically significant differences (p ≤ 0.05) were most often present when technologies were new. In a cohort followed from 1984 to 1997, high SES individuals were more likely to adopt insulin injection technologies but, due to modest sample sizes, these inequalities were not statistically significant after adjusting for age, gender, and duration of illness. Moreover, compared to low SES individuals, high SES individuals are more active users of diabetes technologies. Results suggest that SES-based variations in access and use of innovative health technologies could act as a mechanism through which inequalities are reproduced. This study provides a discussion of mechanisms and a methodological foundation for further investigation.

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.

Randomized controlled evaluation of an insulin pen storage policy

PURPOSE

Results of a quality-improvement project to enhance safeguards against "wrong-pen-to-patient" insulin pen errors by permitting secure bedside storage of insulin pens are reported.

METHODS

A cluster-randomized controlled evaluation was conducted at an academic medical center to assess adherence with institutional policy on insulin pen storage before and after implementation of a revised policy allowing pen storage in locking boxes in patient rooms. In phase 1 of the study, baseline data on policy adherence were captured for 8 patient care units (4 designated as intervention units and 4 designated as control units). In phase 2, policy adherence was assessed through direct observation during weekly audits after lock boxes were installed on intervention units and education on proper insulin pen storage was provided to nurses in all 8 units.

RESULTS

Phase 1 rates of adherence to insulin pen storage policy were 59% in the intervention units and 49% in the control units (p = 0.56). During phase 2, there was no significant change from baseline in control unit adherence (67%, p = 0.26), but adherence in intervention units improved significantly, to 89% (p = 0.005). Common types of observed nonadherence included pens being unsecured in patient rooms or nurses' pockets or left in patient-specific medication drawers after patient discharge.

CONCLUSION

An institutional policy change permitting secure storage of insulin pens close to the point of care, paired with nurse education, increased adherence more than education alone.

Effects of Sting Plant Extracts as Penetration Enhancers on Transdermal Delivery of Hypoglycemic Compounds

Background and objectives: The percutaneous route is an interesting and inventive investigation field of drug delivery. However, it is challenging for drug molecules to pass through the skins surface, which is a characterized by its permeability barrier. The purpose of this study is to look at the effect of some penetration enhancers on in vivo permeation of insulin and insulin sensitizers (curcumin and rutin) through diabetes-induced mouse skin. Materials and Methods: Sting crude extracts of Dendrocnide meyeniana, Urtica thunbergiana Sieb. and Zucc, and Alocasia odora (Lodd.) Spach were used as the penetration enhancers. Mouse skin irritation was tested by smearing the enhancers for the measurements at different time points and the cell viability of the HaCaT human skin keratinocytes, which was determined by Trypan blue exclusion and MTT assays to evaluate human biosafety for these extracts after the mouse skin permeation experiments. Results: All enhancers induced a slight erythema without edema on the mouse skin that completely recovered after 6 h from the enhancer smears as compared with normal mouse skin. Furthermore, no damaged cells were found in the HaCaT keratinocytes under sting crude extract treatments. The blood sugar level in the diabetic mice treated with the insulin or insulin sensitizers, decreased significantly (p < 0.05) in the presence of enhancers. The area under the curve (AUC) values of transdermal drug delivery (TDD) ranged from 42,000 ± 5000 mg/dL x min without enhancers, to 30,000 ± 2000 mg/dL x min in the presence of enhancers. Conclusions: This study exhibited that natural plant extracts could be preferred over the chemically synthesized molecules and are safe and potent penetration enhancers for stimulating the transdermal absorption of drugs.

Bridging the Gap Between Self-Reported and Claims-Derived Adherence Measures for Basal Insulin Among Patients with Type 2 Diabetes Mellitus

Introduction

Complex or personalized insulin regimens challenge traditional adherence measures. Our objective was to develop an improved basal insulin (BI) adherence measure using both patient-reported and administrative claims data, resulting in a more complete measure.

Methods

Patients’ self-reported BI utilization over the previous 12 months was linked with their claims data for the same period. Hybrid medication possession ratio (MPR) was derived by calculating expected days of insulin supply [total dispensed insulin units from claims over 12 months divided by self-reported total daily dose (TDD)]. The hybrid MPR was compared against traditional claims-based MPR, adjusted claims-based MPR, and patient-reported MPR. For all MPR measures, the adherence threshold was ≥ 0.8. A logistic model was used to predict non-adherence per hybrid MPR. The predicted model-based MPR was compared with existing measures in a larger cohort.

Results

The study sample consisted of 296 patients. TDD derived from claims was higher than self-reported TDD [77.9 (71.8) vs. 57.7 (38.3)], implying average dispensed insulin would last longer than claims-based days supply. Correspondingly, hybrid and MPRs adjusted for package size (56% and 71%, respectively) were higher than claims-based MPR (50%). Age, total claims-based days supply, retinopathy, adjusted MPR-based adherence, and non-insulin injectable use were key predictors of hybrid MPR-based adherence. Applying the claims-based prediction model to a larger cohort to test validity showed high correlations with predicted and adjusted MPR-based adherence.

Conclusions

Traditional claims-based MPR underestimated adherence while adjusted MPR overestimated adherence when self-reported total daily dose was taken as benchmark insulin dose. The predicted model may help identify patients with poor basal insulin adherence. More research is needed to further confirm the findings.

Funding

Eli Lilly and Company, Indianapolis, IN, USA.

Electronic supplementary material

The online version of this article (10.1007/s12325-018-0828-4) contains supplementary material, which is available to authorized users.

Strategies for implementing effective mealtime insulin therapy in type 2 diabetes

BACKGROUND

Type 2 diabetes mellitus (T2D) is a growing global epidemic. Due to the progressive nature of the disease, many people with T2D require insulin at some point, most commonly a long-acting (basal) insulin to assist with 24-h control of glucose levels.

OBJECTIVE

This opinion paper provides an overview of considerations for primary care providers (PCPs) in intensifying the treatment regimen when basal insulin therapy is inadequate.

RESULTS

Control of mealtime hyperglycemia, in addition to fasting hyperglycemia, has been shown to be crucial in reaching A1c goals of <7.0%. However, initiating and optimizing mealtime insulin therapy can be challenging for both people with T2D and PCPs, due to a perceived lack of efficacy and burden of insulin treatment, causing "psychological insulin resistance" in people with T2D and clinical inertia among PCPs. Successful implementation of mealtime insulin therapy requires not only choosing appropriate treatment strategies, but also addressing patient-related behavioral and emotional barriers. Simplified treatment algorithms, combined with the use of advanced technology (devices such as insulin pens, pumps, and patches), and collaborative decision-making can help decrease barriers to effective mealtime insulin therapy.

CONCLUSIONS

It is possible to implement an effective basal-bolus insulin regimen in people with T2D in a way that improves glucose control while minimizing negative effects on quality-of-life, treatment satisfaction, and psychological well-being.

Practical Considerations for the Use of Subcutaneous Treatment in the Management of Dyslipidaemia

Suboptimal drug adherence represents a major challenge to effective primary and secondary prevention of cardiovascular disease. While adherence is influenced by multiple considerations, polypharmacy and dosing frequency appear to be rate-limiting factors in patient satisfaction and subsequent adherence. The cardiovascular and metabolic therapeutic areas have recently benefited from a number of advances in drug therapy, in particular protease proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and incretin-based therapies, respectively. These drugs are administered subcutaneously and offer efficacious treatment options with reduced dosing frequency. Whilst patients with diabetes and diabetologists are well initiated to injectable therapies, the cardiovascular therapeutic arena has traditionally been dominated by oral agents. It is therefore important to examine the practical aspects of treating patients with these new lipid-lowering agents, to ensure they are optimally deployed in everyday clinical practice.

Forum for Injection Technique and Therapy Expert Recommendations, India: The Indian Recommendations for Best Practice in Insulin Injection Technique, 2017

Health-care professionals in India frequently manage injection or infusion therapies in persons with diabetes (PWD). Patients taking insulin should know the importance of proper needle size, correct injection process, complication avoidance, and all other aspects of injection technique from the first visit onward. To assist health-care practitioners in their clinical practice, Forum for Injection Technique and Therapy Expert Recommendations, India, has updated the practical advice and made it more comprehensive evidence-based best practice information. Adherence to these updated recommendations, learning, and translating them into clinical practice should lead to effective therapies, improved outcomes, and lower costs for PWD.

A Systematic Review of Patients' Perspectives on the Subcutaneous Route of Medication Administration

BACKGROUND

Subcutaneous injections allow for self-administration, but consideration of patients' perspectives on treatment choice is important to ensure adherence. Previous systematic reviews have been limited in their scope for assessing preferences in relation to other routes of administration.

OBJECTIVE

Our objective was to examine patients' perspectives on subcutaneously administered self-injectable medications when compared with other routes or methods of administration for the same medicines.

METHODS

Nine electronic databases were searched for publications since 2000 using terms pertaining to methods of administration, choice behavior, and adverse effects. Eligibility for inclusion was determined through reference to specific criteria by two independent reviewers. Results were described narratively.

RESULTS

Of the 1726 papers screened, 85 met the inclusion criteria. Studies were focused mainly on methods of insulin administration for diabetes but also included treatments for pediatric growth disorders, multiple sclerosis, HIV, and migraine. Pen devices and autoinjectors were favored over administration with needle and syringe, particularly with respect to ergonomics, convenience, and portability. Inhalation appeared to be more acceptable than subcutaneous injection (in the case of insulin), but how subcutaneous infusion, intramuscular injection, and needle-free injection devices compare with subcutaneous injections in terms of patient preference is less certain.

CONCLUSIONS

The review identified a number of studies showing the importance of the methods and routes of drug delivery on patient choice. However, studies were prone to bias, and further robust evidence based on methodologically sound approaches is required to demonstrate how patient choice might translate to improved adherence.

A real-world study of treatment patterns and outcomes in US managed-care patients with type 2 Diabetes initiating injectable therapies

AIMS

Examine real-world outcomes in patients with type 2 diabetes mellitus (T2DM) initiating injectable therapy as part of the Initiation of New Injectable Treatment Introduced after Antidiabetic Therapy with Oral-only Regimens (INITIATOR) study.

MATERIALS AND METHODS

Linked insurance claims and medical record data were collected from 2 large US health insurers (April 1, 2010 to March 31, 2012) of T2DM adults initiating treatment with glargine (GLA) or liraglutide (LIRA). Baseline characteristics were examined and changes in 12-month follow-up outcomes were described for both treatment groups: HbA1c, weight change, hypoglycaemia, persistence, healthcare utilisation and costs.

RESULTS

A total of 4490 patients were included (GLA, 2116; LIRA, 2374). At baseline, GLA patients had significantly higher HbA1c vs LIRA patients (9.72% vs 8.19%; P < .001), lower likelihood of having HbA1c < 7% (7.1% vs 23.8%; P < .001), lower bodyweight (100.9 kg vs 110.9 kg, P < .001), higher Charlson Comorbidity Index score (0.88 vs 0.63; P < .001), and higher diabetes-related costs ($3492 vs $2089; P < .001), respectively. During 12-months of follow-up, treatment persistence was 64%, mean HbA1c reduction was -1.24% and weight change was + 1.17 among GLA patients, and was 49%, -0.51% and -2.74 kg, respectively, among LIRA patients. Diabetes-related costs increased significantly from baseline to follow-up for LIRA patients ($2089 vs $3258, P < .001) but not for GLA patients ($3492 vs $3550, P = .890).

CONCLUSIONS

There were clinically relevant baseline differences in both groups, suggesting that GLA and LIRA are prescribed for different patient groups, and highlighting that efficacy results from clinical trials do not always translate into real-world practice. Significant increases in healthcare costs were observed in the LIRA group, warranting further cost-effectiveness analysis.

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.

NovoPen Echo(®) insulin delivery device

The introduction of insulin pen devices has provided easier, well-tolerated, and more convenient treatment regimens for patients with diabetes mellitus. When compared with vial and syringe regimens, insulin pens offer a greater clinical efficacy, improved quality of life, and increased dosing accuracy, particularly at low doses. The portable and discreet nature of pen devices reduces the burden on the patient, facilitates adherence, and subsequently contributes to the improvement in glycemic control. NovoPen Echo^® is one of the latest members of the NovoPen^® family that has been specifically designed for the pediatric population and is the first to combine half-unit increment (=0.5 U of insulin) dosing with a simple memory function. The half-unit increment dosing amendments and accurate injection of 0.5 U of insulin are particularly beneficial for children (and insulin-sensitive adults/elders), who often require small insulin doses. The memory function can be used to record the time and amount of the last dose, reducing the fear of double dosing or missing a dose. The memory function also provides parents with extra confidence and security that their child is taking insulin at the correct doses and times. NovoPen Echo is a lightweight, durable insulin delivery pen; it is available in two different colors, which may help to distinguish between different types of insulin, providing more confidence for both users and caregivers. Studies have demonstrated a high level of patient satisfaction, with 80% of users preferring NovoPen Echo to other pediatric insulin pens.

Characteristics Relating to Adherence and Persistence to Basal Insulin Regimens Among Elderly Insulin-Naïve Patients with Type 2 Diabetes: Pre-Filled Pens versus Vials/Syringes

Introduction

Previous studies have found higher rates of adherence in patients with type 2 diabetes mellitus (T2DM) using insulin pens compared to vial and syringe administration; however, little evidence is available to support this observation in elderly patients.

Methods

This was a retrospective claims database analysis of a predominantly elderly Medicare Advantage with Prescription Drug (MAPD) insurance population consisting of 3172 insulin-naïve patients with T2DM who initiated basal insulin using pre-filled pens or vial and syringe (‘vial’). The index date was defined by the first pharmacy claim for basal insulin. Adherence, measured as proportion of days covered (PDC) and medication possession ratio (MPR), and persistence were evaluated in a 12-month follow-up period using an adjusted days’ supply. Multivariate regression analyses and a Cox proportional hazards model were used to identify characteristics associated with adherence and non-persistence, respectively, and compare findings between the pen and vial groups.

Results

The pen cohort was slightly younger than the vial cohort (69.4 vs. 70.1 years, respectively; P = 0.0338). Similar proportions of male patients (53.3% vs. 56.8%; P = 0.0529) occurred in both cohorts, and lower Deyo–Charlson Comorbidity Index (4.4 vs. 5.0; P < 0.0001) was found for the pen cohort. Adjusted mean PDC was significantly higher in the pen cohort than the vial cohort (0.67 vs. 0.50; P < 0.001), as was mean MPR (0.75 vs. 0.57; P < 0.0001). Adjusted odds for adherence (PDC ≥ 80%) showed a positive association with use of an insulin pen (odds ratio = 2.19, 95% CI: 1.86–2.59). The adjusted risk of non-persistence (discontinuation) was significantly lower (58%) in the pen cohort relative to the vial cohort (hazard ratio = 0.42, 95% CI: 0.38–0.45). Key limitations include assumptions related to accuracy and comprehensiveness of claims data, and specifically days’ supply data used to measure insulin adherence.

Conclusion

These findings suggest that pen devices improved insulin therapy adherence in a primarily elderly MAPD population with T2DM.

Funding

Novo Nordisk Pharmaceuticals, Inc.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-015-0266-5) contains supplementary material, which is available to authorized users.

Accuracy and Injection Force of the Gla-300 Injection Device Compared With Other Commercialized Disposable Insulin Pens

BACKGROUND

To deliver insulin glargine 300 U/mL (Gla-300), the widely used SoloSTAR(®) pen has been modified to allow for accurate and precise delivery of required insulin units in one-third of the volume compared with insulin glargine 100 U/mL, while improving usability. Here we compare the accuracy and injection force of 3 disposable insulin pens: Gla-300 SoloSTAR(®), FlexPen(®), and KwikPen™.

METHODS

For the accuracy assessment, 60 of each of the 3 tested devices were used for the delivery of 3 different doses (1 U, half-maximal dose, and maximal dose), which were measured gravimetrically. For the injection force assessment, 20 pens of each of the 3 types were tested twice at half-maximal and once at maximal dose, at an injection speed of 6 U/s.

RESULTS

All tested pens met the International Organization for Standardization (ISO) requirements for dosing accuracy, with Gla-300 SoloSTAR showing the lowest between-dose variation (greatest reproducibility) at all dose levels. Mean injection force was significantly lower for Gla-300 SoloSTAR than for the other 2 pens at both half maximal and maximal doses (P < .0271).

CONCLUSION

All tested pens were accurate according to ISO criteria, and the Gla-300 SoloSTAR pen displayed the greatest reproducibility and lowest injection force of any of the 3 tested devices.

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.

Health economic evaluation of type 2 diabetes mellitus: a clinical practice focused review

Type 2 diabetes mellitus (T2D) is a growing healthcare burden primarily due to long-term complications. Strict glycemic control helps in preventing complications, and early introduction of insulin may be more cost-effective than maintaining patients on multiple oral agents. This is an expert opinion review based on English peer-reviewed articles (2000–2012) to discuss the health economic consequences of T2D treatment intensification. T2D costs are driven by inpatient care for treatment of diabetes complications (40%–60% of total cost), with drug therapy for glycemic control representing 18% of the total cost. Insulin therapy provides the most improved glycemic control and reduction of complications, although hypoglycemia and weight gain may occur. Early treatment intensification with insulin analogs in patients with poor glycemic control appears to be cost-effective and improves clinical outcomes.

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.

Transdermal delivery of insulin by amidated pectin hydrogel matrix patch in streptozotocin-induced diabetic rats: effects on some selected metabolic parameters

PURPOSE

Studies in our laboratory are concerned with developing optional insulin delivery routes based on amidated pectin hydrogel matrix gel. We therefore investigated whether the application of pectin insulin (PI)-containing dermal patches of different insulin concentrations sustain controlled release of insulin into the bloodstream of streptozotocin (STZ)-induced diabetic rats with concomitant alleviation of diabetic symptoms in target tissues, most importantly, muscle and liver.

METHODS

Oral glucose test (OGT) responses to PI dermal matrix patches (2.47, 3.99, 9.57, 16.80 µg/kg) prepared by dissolving pectin/insulin in deionised water and solidified with CaCl2 were monitored in diabetic rats given a glucose load after an 18-h fast. Short-term (5 weeks) metabolic effects were assessed in animals treated thrice daily with PI patches 8 hours apart. Animals treated with drug-free pectin and insulin (175 µg/kg, s.c.) acted as untreated and treated positive controls, respectively. Blood, muscle and liver samples were collected for measurements of selected biochemical parameters.

RESULTS

After 5 weeks, untreated diabetic rats exhibited hyperglycaemia and depleted hepatic and muscle glycogen concentrations. Compared to untreated STZ-induced diabetic animals, OGT responses of diabetic rats transdermally applied PI patches exhibited lower blood glucose levels whilst short-term treatments restored hepatic and muscle glycogen concentrations. Plasma insulin concentrations of untreated diabetic rats were low compared with control non-diabetic rats. All PI treatments elevated plasma insulin concentrations of diabetic rats although the levels induced by high doses (9.57 and 16.80 µg/kg) were greater than those caused by low doses (2.47 and 3.99 µg/kg) but comparable to those in sc insulin treated animals.

CONCLUSIONS

The data suggest that the PI hydrogel matrix patch can deliver physiologically relevant amounts of pharmacologically active insulin.

NOVELTY OF THE WORK

A new method to administer insulin into the bloodstream via a skin patch which could have potential future applications in diabetes management is reported.

Adherence to premixed insulin in a prefilled pen compared with a vial/syringe in people with diabetes in Singapore

BACKGROUND

The real-world clinical effectiveness of exogenous insulin is limited by nonadherence. Various insulin delivery systems have been developed to help improve adherence, with prefilled pens gaining popularity among adult Singaporeans with diabetes. However, adherence to insulin in people with diabetes in Singapore and most of Asia has not been studied.

OBJECTIVES

This study aimed to compare adherence to premixed insulin formulated in a prefilled pen versus a vial/syringe and to identify predictors of adherence in 955 patients managed at the outpatient clinics of the largest acute care hospital in Singapore.

METHODS

In this retrospective longitudinal study, electronic medical and pharmacy refill records were used to determine adherence to insulin over 24 months, measured in terms of compliance and persistence. Compliance is expressed as the medication possession ratio (used as continuous and categorical variables), and persistence is reported as a dichotomous variable with a permissible refill gap of 30 days before discontinuation of therapy is considered. Multivariate linear or logistic regression analysis was used to identify predictors of adherence.

RESULTS

Compared with prefilled pen users, vial/syringe users were older (mean [SD] age, 64.1 [10.6] vs 62.4 [11.9] years; P = 0.032), and more were undergoing polypharmacy (69.6% vs 54.1%; P < 0.001). The mean (SD) medication possession ratio was comparable in vial/syringe versus prefilled pen users (83.8% [26.9%] vs 86.0% [23.2%]; P = 0.266). Prefilled pen users were more persistent with therapy compared with vial/syringe users (odds ratio = 1.36; 95% CI, 1.01-1.86) after adjusting for sociodemographic and clinical covariates. Median time to discontinuation of therapy was comparable (vial/syringe vs prefilled pen: 409 vs 532 days; P = 0.076). Being managed by an endocrinologist and not receiving government subsidies were significant predictors of persistence.

CONCLUSIONS

Compared with other studies that found strong associations between adherence and insulin devices, the findings of this study suggest that persistence but not compliance varies by insulin device. The willingness to pay for health care, in addition to affordability, may affect insulin therapy adherence. Patients with uncontrolled diabetes due to suspected nonadherence may benefit from referral to a multidisciplinary care team comprising endocrinologists, diabetes nurse educators, dietitians, and allied health professionals. These findings are applicable to outpatients with similar demographic features managed at other acute care hospitals in Singapore. The impact of insulin devices on glycemic control needs to be investigated in future larger studies.

Does Device Make Any Difference? A Real-world Retrospective Study of Insulin Treatment Among Elderly Patients With Type 2 Diabetes

We compared real-world clinical and economic outcomes for insulin glargine treatment administered by disposable pen and traditional vial-and-syringe injections among elderly patients with type 2 diabetes mellitus (T2DM). Using a large database of US retirees, this retrospective longitudinal study examined 1-year follow-up outcomes in patients with T2DM aged 65 years or older who were either insulin naïve and initiated insulin glargine via disposable pen (pen initiators [PI]) or vial (vial initiators [VI]) or were already insulin glargine users but either continued with a vial (vial continuers [VC]) or switched to a disposable pen (pen switchers [PS]). There were 7856 propensity-score-matched patients, including 2930 each in the PI and VI cohorts, and 998 each in the VC and PS cohorts. Compared with vial-and-syringe users, the disposable pen users had significantly greater treatment persistence (P < .0001 for both comparisons), duration of persistence (P < .0001 for both), and adherence (P < .01 for both) and lower insulin daily average consumption (P < .05 for both). Compared with the VI cohort, the PI cohort had significantly fewer hypoglycemia-related events (P = .0164). Total health care costs were comparable for the respective matched cohorts. In elderly patients with T2DM receiving insulin glargine therapy, initiating or switching to a disposable pen was associated with better treatment persistence and adherence than initiating or continuing with vial-and-syringe, without increased total health care costs. Among insulin-naïve patients, initiating insulin glargine by disposable pen was also associated with significantly reduced risk of hypoglycemia compared with vial-and-syringe patients.

The INITIATOR study: pilot data on real-world clinical and economic outcomes in US patients with type 2 diabetes initiating injectable therapy

Introduction

Type 2 diabetes mellitus (T2DM) progression often results in treatment intensification with injectable therapy to maintain glycemic control. Using pilot data from the Initiation of New Injectable Treatment Introduced after Anti-diabetic Therapy with Oral-only Regimens study, real-world treatment patterns among T2DM patients initiating injectable therapy with insulin glargine or liraglutide were assessed.

Methods

This was a retrospective analysis of claims from the OptumInsight™ (OI; January 1, 2010 to July 30, 2010) and HealthCore^® (HC; January 1, 2010 to June 1, 2010) health insurance databases. Baseline characteristics, health care resource utilization, and costs were compared between adults with T2DM initiating injectable therapy with insulin glargine pen versus liraglutide. Follow-up outcomes, including glycated hemoglobin A_1c (A1C), hypoglycemia, health care utilization, and costs, were assessed.

Results

At baseline, almost one in three liraglutide patients (OI, n = 363; HC, n = 521) had A1C <7.0%, while insulin glargine patients (OI, n = 498; HC, n = 1,188) had poorer health status, higher A1C (insulin glargine: 9.8% and 9.1% versus liraglutide: 7.9% and 7.7%, OI and HC, respectively, both P < 0.001), and were less likely to be obese (insulin glargine: 10.8% and 9.2% versus liraglutide: 17.4% and 18.8%, OI and HC, respectively, both P < 0.01). The percentage of patients experiencing a hypoglycemic event was numerically higher for insulin pen use for both cohorts (OI 4.4% versus 3.0%; HC 6.2% versus 2.3%). During follow-up, in the insulin glargine cohort, annualized diabetes-related costs remained unchanged ($8,344 versus $7,749 OI, and $7,094 versus $7,731 HC), despite a significant increase in pharmacy costs, due to non-significant decreases in medical costs, while the liraglutide cohort had a significant increase in annualized diabetes-related costs ($4,510 versus $7,731 OI, and $4,136 versus $7,111 HC; both P < 0.001) due to a non-significant increase in medical costs coupled with a significant increase in pharmacy costs.

Conclusion

These descriptive data identified differences in demographic and baseline clinical characteristics among patients initiating injectable therapies. The different health care utilization and cost patterns warrant further cost-effectiveness analysis.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-013-0074-8) contains supplementary material, which is available to authorized users.

Differences in rates of hypoglycemia and health care costs in patients treated with insulin aspart in pens versus vials

OBJECTIVES

To study whether initiation of insulin aspart therapy with a pen vs. a vial/syringe has an impact on the risk of subsequent hypoglycemic episodes and health care costs.

METHODS

This was a longitudinal, retrospective analysis of the MarketScan and IMS LifeLink health plan claims databases for patients with type 1 or type 2 diabetes who initiated insulin aspart with a pen or a vial/syringe. Included were adults (≥18 years) who had received no short-acting insulin for the 6 months prior to their index date (date of first claim for either treatment) and who initiated treatment with insulin aspart with a pen or with a conventional vial/syringe during the period from January 1, 2004, through December 31, 2007, based on outpatient pharmacy claims data. Patients were excluded if they did not have at least two claims for the index treatment during the 12 month post-index period. Hypoglycemic episodes were identified by any claim containing a diagnosis code for hypoglycemia.

RESULTS

Analyses include 6065 patients in the pen group and 5523 patients in the vial/syringe group in the MarketScan database and 4512 patients in the pen group and 3782 patients in the vial/syringe group in the LifeLink database. Vial/syringe use was associated with 35% greater odds of at least one hypoglycemic episode than pen use in the MarketScan database (P < 0.001) and 44% greater odds in the LifeLink database (P < 0.001). Use of vials/syringes was associated with 89% and 62.7% greater health care costs for hypoglycemic events than use of pens, respectively (P < 0.001 for both databases). Patient groups were subject to selection bias as they did not have random assignment to treatment groups.

CONCLUSIONS

In two independent claims databases, initiation of insulin aspart treatment with pen was associated with fewer hypoglycemic events and lower diabetes-related health care costs than initiation with vial/syringe.

The association between use of mealtime insulin pens versus vials and healthcare charges and resource utilization in patients with type 2 diabetes: a retrospective cohort study

OBJECTIVE

To compare all-cause and diabetes-related resource utilization and healthcare charges among adults with type 2 diabetes mellitus who initiated therapy with mealtime insulin disposable pens or vials.

METHODS

Data were obtained from the Innovus inVision database from January 1, 2006 through June 30, 2010. Generalized linear models with a gamma distribution and log link estimated the association between medical charges and use of mealtime insulin pens vs vials in the 1 year post-index date, while generalized linear models with a negative binomial distribution estimated resource utilization.

RESULTS

Controlling for patient characteristics, general health, and patient copayments, insulin therapy initiation with disposable pens, compared to vials, was associated with significantly fewer all-cause hospitalizations (1.45 vs. 1.66; p < 0.0001) as well as a significantly shorter hospital length of stay (2.16 days vs. 3.53 days; p < 0.0001). Pen use, compared to vials, was also associated with significantly fewer diabetes-related hospitalizations (1.36 vs. 1.47; p < 0.0001), and shorter hospital length of stay (1.12 days vs. 1.72 days; p < 0.0001). Despite higher diabetes-related drug charges ($3593 vs. $2755; p < 0.0001) associated with the use of pens, results showed significantly lower all-cause total healthcare charges ($42,150 vs. $53,340; p < 0.0001) and significantly lower diabetes-related total healthcare charges ($12,722 vs. $14,540; p < 0.0001) for patients who initiated therapy on mealtime insulin with pens compared to vials.

LIMITATIONS

Data were drawn from administrative claims and included only patients with medical and outpatient prescription drug benefit coverage. Hence, the results may not be generalizable. The retrospective analyses relied on diagnostic codes to identify patients, assess patient general health, and determine other values, rather than formal, clinical assessments. The analyses did not include indirect healthcare costs.

CONCLUSIONS

The administration of mealtime insulin via disposable pens, compared to vials, was associated with a significant reduction in all-cause and diabetes-related resource utilization and total healthcare charges.

Faster pharmacokinetics and increased patient acceptance of intradermal insulin delivery using a single hollow microneedle in children and adolescents with type 1 diabetes

OBJECTIVE

In an effort to improve compliance with insulin therapy and to accelerate insulin pharmacokinetics, we tested the hypothesis that intradermal insulin delivery using a hollow microneedle causes less pain and leads to faster onset and offset of insulin pharmacokinetics in children and adolescents with type 1 diabetes (T1DM) compared with a subcutaneous, insulin pump catheter.

RESEARCH DESIGN AND METHODS

In this repeated measures study, 16 children and adolescents with T1DM received Lispro insulin by microneedle and subcutaneous administration on separate days. Subjects rated the pain of insertion and infusion using a visual analog scale. Blood specimens were collected over 4 h to determine insulin and glucose concentrations.

RESULTS

Microneedle insertion pain was significantly lower compared with insertion of the subcutaneous catheter (p = 0.005). Insulin onset time was 22 min faster (p = 0.0004) and offset time was 34 min faster (p = 0.017) after hollow microneedle delivery compared with subcutaneous delivery.

CONCLUSIONS

In this study, intradermal insulin delivery using a single, hollow microneedle device resulted in less insertion pain and faster insulin onset and offset in children and adolescents with T1DM. A reduction in pain might improve compliance with insulin delivery. The faster onset and offset times of insulin action may enable closed-loop insulin therapy.

Breaking down patient and physician barriers to optimize glycemic control in type 2 diabetes

Approximately half of patients with type 2 diabetes (T2D) do not achieve globally recognized blood glucose targets, despite the availability of a wide range of effective glucose-lowering therapies. Failure to maintain good glycemic control increases the risk of diabetes-related complications and long-term health care costs. Patients must be brought under glycemic control to improve treatment outcomes, but existing barriers to optimizing glycemic control must first be overcome, including patient nonadherence to treatment, the failure of physicians to intensify therapy in a timely manner, and inadequacies in the health care system itself. The reasons for such barriers include treatment side effects, complex treatment regimens, needle anxiety, poor patient education, and the absence of an adequate patient care plan; however, newer therapies and devices, combined with comprehensive care plans involving adequate patient education, can help to minimize barriers and improve treatment outcomes.

Clinical and economic outcomes among patients with diabetes mellitus initiating insulin glargine pen versus vial

BACKGROUND

Insulin pens may help patients reach glycated hemoglobin (HbA1c) target levels, but a substantial proportion of patients continue to use insulin vials/syringes. The objective of the current study was to evaluate real-world clinical and economic outcomes of patients with type 2 diabetes mellitus (T2DM) initiating insulin glargine via pen delivery (pen) or vial/syringe (vial) within a large managed-care population in the United States.

METHODS

This retrospective administrative claims study used data on adult, insulin-naïve patients with T2DM treated with ≥ 1 oral antidiabetic or glucagon-like peptide-1 receptor agonist at baseline. The index date was the earliest pen or vial prescription date. Propensity score matching (1:1) of patients in the pen and vial cohorts was used when comparing 1-year outcomes, including treatment persistence and adherence, HbA1c levels, hypoglycemia rates, and all-cause and diabetes-related health care costs (computed as paid amounts on claims).

RESULTS

Patients in the matched cohorts (n = 733 per cohort) were well balanced with regard to demographics (mean age 52 years; 43% women), clinical measures (mean HbA1c level, 9.4%; mean Quan-Modified Charlson Comorbidity Index score, 0.9), and health care utilization at baseline. Following initiation of insulin glargine, pen patients were more persistent (60.6% vs 50.1%; P < 0.001) and adherent (medication possession ratio, 0.73 vs 0.57; P < 0.001), with lower HbA1c levels during follow-up (mean adjusted change, -1.05 vs -0.73; P < 0.001), compared with vial patients. Hypoglycemic events occurred at similar rates across pen and vial cohorts (3.8% vs 5.2%, respectively; P = 0.21). Study drug costs were higher among pen users ($1164 vs $762, respectively; P < 0.001), but this did not translate into higher total all-cause or diabetes-related costs.

CONCLUSION

For patients with diabetes newly initiating insulin glargine, using an insulin pen device was associated with increased therapy persistence and adherence, and lower HbA1c levels relative to vial/syringe, without increasing total all-cause or diabetes-related costs.

Accuracy and preference assessment of prefilled insulin pen versus vial and syringe with diabetes patients, caregivers, and healthcare professionals

OBJECTIVES

The primary objective of this study was to investigate the dosing accuracy of the new prefilled FlexTouch insulin pen (FT) in comparison to conventional vial and syringe (V&S) when used by patients (Pts), caregivers (CG) and healthcare professionals (HCPs).

METHODS

A total of 120 subjects participated in the trial (40 diabetes patients aged 61 ± 11 [mean ± SD] yrs, 20 caregivers [parents and other relatives], 20 physicians, and 40 nurses/certified diabetes educators). The participants were introduced to the devices in randomized order and were asked to perform injections of 5, 25, 43 and 79 IU doses into laboratory tubes. Dosing accuracy was analyzed by weighing the tubes on a pharmaceutical balance and calculating the mean absolute deviation (MAD) from the intended doses. After completing a device assessment questionnaire, Patient Perception Questionnaire (PPQ), with questions regarding device design and performance, the procedure was repeated for the other device, and the patients were finally asked to complete a device preference questionnaire (DPQ).

RESULTS

Dosing accuracy was significantly better for FT when used by any of the cohorts at all doses. (MAD ± SD for FT/V&S; 5 IU: 0.4 ± 0.4/0.6 ± 0.6 IU; 25 IU: 0.3 ± 0.4/0.7 ± 0.9 IU; 43 IU: 0.4 ± 0.4/0.9 ± 1.2 IU; 79 IU: 0.5 ± 0.5/1.7 ± 1.6 IU, p < 0.005 for all doses). Dosing accuracy with FT for all three subgroups was comparable (patients: 0.35-0.59 IU; HCP&CG: 0.29-0.54 IU; n.s.). Dosing accuracy with V&S for all three subgroups was not comparable: HCP and CG performed much better with V&S than patients and delivered the doses with significantly higher accuracy (range of mean MAD; patients: 0.81-2.54 IU; HCP&CG: 0.51-1.30 IU, p < 0.005 at all doses). FT was ranked superior to V&S for all aspects of the PPQ. In the DPQ, 93% of the patients voted for FT (neutral: 5%, V&S: 2%), (CG: 100%/0%/0%; HCPs: 85%/2%/13%; p < 0.001 in all cases).

CONCLUSION

FT, compared to V&S, was more accurate at all tested doses and was used with similar accuracy by patients, HCPs, and CGs. Using questionnaires only, and without dexterity assessment, study participants rated FT higher than V&S in every component of the PPQ and the vast majority of them preferred FT. These findings may point to a better alternative for dosing accuracy and improved adherence when using the new prefilled insulin pen compared to V&S for insulin delivery in patients with diabetes.

Evaluation of preference for a novel durable insulin pen with memory function among patients with diabetes and health care professionals

BACKGROUND

Improving adherence to insulin treatment for better glycemic control remains a challenge in the management of diabetes. New technological aids are required to help support adherence. This study evaluated preference for the NovoPen(®) 5 (NP5), a durable insulin pen with memory function, compared with the HumaPen Luxura(®) (HPL) among patients with diabetes and health care professionals.

METHODS

This crossover, multicenter usability study included insulin pen-experienced patients with diabetes and health care professionals treating patients with diabetes in Canada, China, and Germany. Participants evaluated NP5 and HPL in a randomized order by performing handling tasks in a usability test related to everyday use during a face-to-face interview. Tasks, pens, and preferences were assessed by completing a questionnaire comprised of rating and open-ended questions relating to confidence in everyday diabetes management.

RESULTS

Overall, 300 patients with diabetes and 150 health care professionals participated in the study. Significantly more participants preferred NP5 (81%) to HPL (18%) (P < 0.001). Also, 82% of patients with diabetes had more confidence in NP5 for managing their daily injections versus 11% with HPL (P < 0.001), and 7% had no preference. Memory function was most helpful in giving patients with diabetes confidence about when they last injected (63%), how much insulin they last injected (62%) and improving diabetes management (55%). Participants gave higher ratings to NP5 than to HPL on all parameters relating to performing an injection (ease of handling, satisfaction when using the pen, convenience of using the pen day-to-day, quality of the pen, and the extent to which the pen meets their needs; P < 0.05 for all comparisons).

CONCLUSION

NP5 was preferred to HPL by most participants. Significantly more patients with diabetes had more confidence for managing daily insulin injections when using NP5, the pen with a memory function.

Does pen help? A real-world outcomes study of switching from vial to disposable pen among insulin glargine-treated patients with type 2 diabetes mellitus

OBJECTIVE

The study was designed to evaluate real-world data on clinical and economic outcome differences between patients with type 2 diabetes mellitus (T2DM) who use insulin glargine with vial-and-syringe delivery and those who switch to pen administration.

SUBJECTS AND METHODS

This retrospective study analyzed medical and pharmacy claims information from the national managed-care IMPACT(®) database (Ingenix Inc., Salt Lake City, UT). Adults with T2DM treated with insulin glargine were evaluated. Clinical and economic outcomes over 1 year were compared between individuals who had converted from administering glargine via vial-and-syringe to the SoloSTAR(®) (sanofi-aventis U.S., Bridgewater, NJ) pen (Switchers) and patients who continued to use vial-and-syringe administration (Continuers). Patients from each cohort were matched using propensity score matching for a comparison sample.

RESULTS

In total, 3,893 eligible patients were identified (665 Switchers and 3,228 Continuers), with a matched cohort with 603 patients in each group. Baseline characteristics were similar between groups. One-year treatment persistence was significantly higher with Switchers versus Continuers (65.3% vs. 49.8%; P<0.0001). Medication possession ratio was also significantly higher among Switchers (0.79 vs. 0.76; P=0.0173). Insulin use and glycemic control were similar between groups. Healthcare utilization and total costs were also similar between groups. Higher prescription costs among Switchers were offset by lower overall and diabetes-related outpatient and inpatient costs.

CONCLUSIONS

Switching from insulin glargine vial-and-syringe administration to pen delivery resulted in improved treatment adherence and persistence, with comparable clinical and economic outcomes.

Empowering people with diabetes: improving perceptions and outcomes with technical advances in insulin pens

For people with diabetes treated with insulin, the development of insulin pens has led to important advantages compared with the use of vials and syringes. Insulin pens are associated with improved ease of use, user confidence, treatment satisfaction, and quality of life compared with vials and syringes. Continual improvements to insulin pen designs to further enhance usability and improve patient perceptions may help to lower patients' resistance to initiating insulin therapy and further improve treatment adherence. This article reviews recent developments in prefilled insulin pens that may assist health care professionals when considering insulin-delivery devices to recommend to their patients.

Comparison of the effects of a new 32-gauge × 4-mm pen needle and a 32-gauge × 6-mm pen needle on glycemic control, safety, and patient ratings in Japanese adults with diabetes

BACKGROUND

This study was designed to evaluate two pen needles (PNs) with the same diameter but different lengths (4 mm and 6 mm) and different needle tip shapes (straight and tapered) to compare their effects on glycemic control, perceived pain, safety, patients' ease of use and preferences, and visual impression.

SUBJECTS AND METHODS

In this prospective, open-label, controlled crossover study, 41 insulin-treated patients with type 1 or type 2 diabetes were randomized into either Group 1 (the 32-gauge × 4-mm PN was used during Study Period 1, then the 32-gauge × 6-mm PN was used during Study Period 2) or Group 2 (the order for using the PNs was reversed).

RESULTS

The 32-gauge × 4-mm PN provided an equivalent glycemic control in diabetes patients as the 32-gauge × 6-mm PN, with an equivalent occurrence rate of adverse events. The 32-gauge × 4-mm PN was perceived as significantly less painful and rated as significantly more favorable than the 32-gauge × 6-mm PN according to the survey results on patients' ease of use and preferences and on their visual impressions.

CONCLUSIONS

The 32-gauge × 4-mm PN was not only as safe and efficacious as the 32-gauge × 6-mm PN, but also was perceived as less painful, easier to use, and more favorable to Japanese adult patients with diabetes.