The role of comfort and discomfort in insulin therapy

Relevance of Adalimumab Product Attributes to Patient Experience in the Biosimilar Era: A Narrative Review

Adalimumab (ADL, Humira®, reference product), an anti-TNF-α biologic, has transformed the treatment of chronic, immune-mediated inflammatory diseases. However, the high cost of ADL therapy has driven the development of more affordable ADL biosimilars, agents with no clinically meaningful differences from the reference product. This review summarizes the product attributes of reference ADL and the nine ADL biosimilars approved and available in the USA in relation to patient experience of injection-site pain (ISP). Product formulation, delivery volume and device features (e.g., type and needle gauge size) influence patient experience of ISP with potential clinical consequences. Citrate-free formulations generally cause less ISP; injection volumes of > 1.5 ml may be associated with increased ISP. Reference ADL and all ADL biosimilars offer a citrate-free formulation, and reference ADL and four ADL biosimilars offer a high-concentration solution that allows a smaller injection volume. All available ADL products are injected subcutaneously using either a pre-filled pen (PFP) or pre-filled syringe (PFS). Patients prefer the PFP, but the PFS permits better control over the speed and duration of injection. Smaller (29-gauge) needle outer diameter is associated with less ISP; reference ADL and seven ADL biosimilars offer a device with a 29-gauge needle. In the USA, an approved biosimilar can be designated "interchangeable," allowing pharmacy-level substitution, where state law permits. In the USA, two ADL biosimilars have received interchangeability designation; others are seeking interchangeability designation from the Food and Drug Administration (n = 2), are being evaluated in clinical studies to support interchangeability (n = 2), or do not have/are not seeking interchangeability designation (n = 3). Product-related attributes influence patient experience of ISP caused by subcutaneous ADL injection. Reference ADL and ADL biosimilar products differ in their attributes, so discussion with patients about treatment options is essential to optimize adherence and outcomes.

Impact of the Number of Needle Tip Bevels on the Exerted Forces and Energy in Insulin Pen Injections

Patients affected with type 1 diabetes and a non-negligible number of patients with type 2 diabetes are insulin dependent. Both the injection technique and the choice of the most suitable needle are fundamental for allowing them to have a good injection experience. The needles may differ in several parameters, from the length and diameter, up to the forces required to perform the injection and to some geometrical parameters of the needle tip (e.g., number of facets or bevels). The aim of the research is to investigate whether an increased number of bevels could decrease forces and energy involved in the insertion-extraction cycle, thus potentially allowing patients to experience lower pain. Two needle variants, namely, 31 G × 5 mm and 32 G × 4 mm, are considered, and experimental tests are carried out to compare 3-bevels with 5-bevels needles for both the variants. The analysis of the forces and energy for both variants show that the needles with 5 bevels require a statistically significant lower drag or sliding force (p-value = 0.040 for the 31 G × 5 mm needle and p-value < 0.001 for 32 G × 4 mm), extraction force (p-value < 0.001 for both variants), and energy (p-value < 0.001 for both variants) during the insertion-extraction cycle. As a result, 3-bevels needles do not have the same functionality of 5-bevels needles, show lower capacity of drag and extraction, and can potentially be related to more painful injection experience for patients.

Novel Robust Needle Tip Design Enables Needle Reuse and Reduced Skin Trauma in Combination With Autoinjector Needle Shields

BACKGROUND

Pen needles and autoinjectors are necessary for millions of patients needing injectable drug treatment but pose economic and environmental burdens. A durable device with a multiuse needle could reduce cost and improve user experience. This study explores a novel robust needle tip (EXP) designed for multiple uses and durability against hooking.

METHOD

Needle robustness was investigated through a structural analysis. Furthermore, EXP and control needles (NF30, NF28) were evaluated in an in-vivo porcine model as pen needles or embedded in autoinjectors to study the resulting increase in skin blood perfusion (SBP). The SBP was assessed by laser speckle contrast analysis (LASCA) of 192 randomized and blinded needle insertions.

RESULTS

Forming a 33 µm hook against a hard surface requires 0.92 N for the NF30 control needle and 5.38 N for EXP. The EXP did not induce more tissue trauma than the NF30. There was a positive relation between needle diameter and SBP (P < .05). Furthermore, the presence of an autoinjector shield and applied force of 10 N was found to significantly reduce SBP for worn EXP needles (P < .05) compared to insertions without autoinjector shield.

CONCLUSIONS

The investigated robust needle EXP is on par with the single-use needle NF30 in terms of tissue trauma, which is further reduced by combining the needle with a needle shield. These results should encourage the innovation and development of durable, reusable injection systems with pharmacoeconomic and environmental value and a simplified and enhanced user experience for patients.

Design Development of the SMARTCLIC®/CLICWISE® Injection Device for Self-Administered Subcutaneous Therapies: Findings from Usability and Human Factor Studies

INTRODUCTION

An easy-to-use, multiuse, single-patient, electromechanical autoinjector, the SMARTCLIC®/CLICWISE® injection device, was recently developed to improve the self-administration options available to patients with chronic inflammatory disease treated with biologic agents. An extensive series of studies were conducted to guide the design and development of this device and to ensure its safety and effectiveness.

METHODS

Participants in two user preference studies and three formative human factor (HF) studies evaluated evolving iterations of the autoinjector device, dose dispenser cartridge, graphical user interface, and informational materials; participants in a summative HF test subsequently assessed the final proposed commercially representative product. In the user preference studies, rheumatologists and patients with chronic inflammatory disease, interviewed online and in-person, provided feedback on the design and functionality of four prototypes. In the HF studies, the safety, effectiveness, and usability of adapted prototypes were assessed under simulated-use conditions by patients with chronic inflammatory disease, caregivers, and healthcare professionals (HCPs). The safety and effectiveness of the final refined device and system were confirmed in a summative HF test by patients and HCPs in simulated-use scenarios.

RESULTS

Rheumatologists (n = 204) and patients (n = 39) interviewed in the two user preference studies provided feedback on the device size, feature ergonomics, and usability that guided prototype development in the subsequent formative HF studies. Observations from patients, caregivers, and HCPs (n = 55) participating in the latter studies yielded additional critical design revisions that culminated in development of the final device and system. Of 106 injection simulations conducted in the summative HF test, all resulted in successful medication delivery, and no potential harms were associated with injection-related use events.

CONCLUSION

Findings from this research facilitated development of the SmartClic/ClicWise autoinjector device and demonstrated that it could be used safely and effectively by participants representative of the intended-use population of patients, lay caregivers, and HCPs.

Experimental and computational analysis of the injection-induced mechanical changes in the skin microenvironment during subcutaneous injection of biologics

Subcutaneous (SQ) injection is an effective delivery route for various biologics, including proteins, antibodies, and vaccines. However, pain and discomfort induced during SQ injection pose a notable challenge for the broader and routine use of biologics. Understanding the underlying mechanism and quantification of injection-induced pain and discomfort (IPD) are urgently needed. A crucial knowledge gap is what changes in the skin tissue microenvironment are induced by the SQ injection, which may ultimately cause the IPD. In this study, thus, a hypothesis is postulated that the injection of biologics solution through the skin tissue microenvironment induces spatiotemporal mechanical changes. Specifically, the injection leads to tissue swelling and subsequent increases in the interstitial fluid pressure (IFP) and matrix stress around the injection site, which ultimately causes the IPD. To test this hypothesis, an engineered SQ injection model is developed capable of measuring tissue swelling during SQ injection. The injection model consists of a skin equivalent with quantum dot-labeled fibroblasts, which enables the measurement of injection-induced spatiotemporal deformation. The IFP and matrix stress are further estimated by computational analysis approximating the skin equivalent as a nonlinear poroelastic material. The result confirms significant injection-induced tissue swelling and increases in IFP and matrix stress. The extent of deformation is correlated to the injection rate. The results also suggest that the size of biologics particulates significantly affects the pattern and extent of the deformation. The results are further discussed to propose a quantitative understanding of the injection-induced changes in the skin microenvironment.

Current Development of Chemical Penetration Enhancers for Transdermal Insulin Delivery

The use of the transdermal delivery system has recently gained ample recognition due to the ability to deliver drug molecules across the skin membrane, serving as an alternative to conventional oral or injectable routes. Subcutaneous insulin injection is the mainstay treatment for diabetes mellitus which often leads to non-compliance among patients, especially in younger patients. Apart from its invasiveness, the long-term consequences of insulin injection cause the development of physical trauma, which includes lipohypertrophy at the site of administration, scarring, infection, and sometimes nerve damage. Hence, there is a quest for a better alternative to drug delivery that is non-invasive and easily adaptable. One of the potential solutions is the transdermal delivery method. However, the stratum corneum (the top layer of skin) is the greatest barrier in transporting large molecules like insulin. Therefore, various chemical enhancers have been proposed to promote stratum corneum permeability, or they are designed to increase the permeability of the full epidermis, such as the use of ionic liquid, peptides, chemical pre-treatment as well as packaging insulin with carriers or nanoparticles. In this review, the recent progress in the development of chemical enhancers for transdermal insulin delivery is discussed along with the possible mechanistic of action and the potential outlook on the proposed permeation approaches in comparison to other therapeutical drugs

The Efficacy of Treatment Intensification by Quadruple Oral Therapy Compared to GLP-1RA Therapy in Poorly Controlled Type 2 Diabetes Mellitus Patients: A Real-world Data Study

We compared the glycemic efficacy of treatment intensification between quadruple oral antidiabetic drug therapy and once-weekly glucagon-like peptide-1 receptor agonist (GLP-1RA)-based triple therapy in patients with poorly controlled type 2 diabetes mellitus refractory to triple oral therapy. For 24 weeks, changes in glycosylated hemoglobin (HbA1c) from baseline were compared between the two treatment groups. Of all 96 patients, 50 patients were treated with quadruple therapy, and 46 were treated with GLP-1RA therapy. Reductions in HbA1c for 24 weeks were comparable (in both, 1.1% reduction from baseline; P=0.59). Meanwhile, lower C-peptide level was associated with a lower glucose-lowering response of GLP-1RA therapy (R=0.3, P=0.04) but not with quadruple therapy (R=-0.13, P=0.40). HbA1c reduction by GLP-1RA therapy was inferior to that by quadruple therapy in the low C-peptide subgroup (mean, -0.1% vs. -1.3%; P=0.04). Treatment intensification by switching to quadruple oral therapy showed similar glucose-lowering efficacy to weekly GLP-1RA-based triple therapy. Meanwhile, the therapeutic response was affected by C-peptide levels in the GLP-1RA therapy group but not in the quadruple therapy group.

Barrier Factors of Adherence to Dupilumab Self-Injection for Severe Allergic Disease: A Non-Interventional Open-Label Study

PURPOSE

The status of dupilumab self-injection at home is not well understood. We therefore aimed to identify the barriers to adherence to dupilumab self-injection.

PATIENTS AND METHODS

This non-interventional open-label study was conducted between March 2021 and July 2021. Patients with atopic dermatitis, bronchial asthma, and chronic rhinosinusitis with nasal polyps receiving dupilumab, from 15 sites, were requested to complete a self-administered questionnaire regarding the frequency and effectiveness of dosing as well as their use and satisfaction with dupilumab. Barriers to adherence were assessed using the Adherence Starts with Knowledge-12.

RESULTS

We included 331 patients who used dupilumab for atopic dermatitis (n = 164), chronic rhinosinusitis with nasal polyps (n = 102), and bronchial asthma (n = 65). The median efficacy of dupilumab scored 9.3 on the visual analog scale. Overall, 85.5% of the patients self-injected dupilumab, and 70.7% perfectly complied with the established injection dates. The pre-filled pen was significantly superior to the conventional syringe in terms of usability, operability, ease of pushing the plunger, and patient satisfaction. However, the pre-filled pen caused more pain during self-injection than did the syringe. Multivariate logistic regression analysis showed that adherence decreased with longer dupilumab treatment duration (p = 0.017) and was not associated with age, sex, underlying disease, or device type. There was a difference in responses related to "inconvenience/forgetfulness" between the good and poor adherence groups.

CONCLUSION

The pre-filled dupilumab pen was superior to the syringe in terms of usability, operability, ease of pushing the plunger, and satisfaction. Repetitive instructions are recommended for preventing poor adherence to dupilumab self-injection.

RoboCap: Robotic mucus-clearing capsule for enhanced drug delivery in the gastrointestinal tract

Oral drug delivery of proteins is limited by the degradative environment of the gastrointestinal tract and poor absorption, requiring parenteral administration of these drugs. Luminal mucus represents the initial steric and dynamic barrier to absorption. To overcome this barrier, we report the development of the RoboCap, an orally ingestible, robotic drug delivery capsule that locally clears the mucus layer, enhances luminal mixing, and topically deposits the drug payload in the small intestine to enhance drug absorption. RoboCap's mucus-clearing and churning movements are facilitated by an internal motor and by surface features that interact with small intestinal plicae circulares, villi, and mucus. Vancomycin (1.4 kilodaltons of glycopeptide) and insulin (5.8 kilodaltons of peptide) delivery mediated by RoboCap resulted in enhanced bioavailability 20- to 40-fold greater in ex vivo and in vivo swine models when compared with standard oral delivery (P < 0.05). Further, insulin delivery via the RoboCap resulted in therapeutic hypoglycemia, supporting its potential to facilitate oral delivery of drugs that are normally precluded by absorption limitations.

Injection site microflora in persons with diabetes: why needle reuse is not associated with increased infections?

Needle reuse is a common practice and primary cause of customer compliance issues such as pain, bruising, clogging, injection site reactions (ISR), and associated lipodystrophy. This study aimed to characterize skin microflora at injection sites and establish microbial contamination of used pen injectors and needles. The second objective was to evaluate the risk of infections during typical and repeated subcutaneous injections. 50 participants with diabetes and 50 controls (n = 100) were sampled through tape strips and skin swabs on the abdomen and thigh for skin microflora. Used pen injectors and needles were collected after in‐home use and from the hospital after drug administration by health care professionals (HCPs). Samples were analyzed by conventional culture, matrix‐assisted laser desorption/ionization‐time of flight (MALDI‐TOF), mass spectrometry (MS), confocal laser scanning microscopy (CLSM), and 16S/ITS high throughput sequencing (HTS). A mathematical model simulated the risk of needle contamination during injections. Injection site populations were in 10² cells/cm² order, with increased viable bacteria and anaerobic bacteria on the skin in persons with diabetes (p = 0.05). Interpersonal variation dominated other factors such as sex or location. A higher prevalence of Staphylococcus aureus on abdominal skin was found in persons with diabetes than control skin (p ≤ 0.05). Most needles and cartridges (95% and 86%) contained no biological signal. The location of the device collection (hospital vs home‐use) and use regimen did not affect contamination. CLSM revealed scarcely populated skin microflora scattered in aggregates, diplo, or single cells. Our mathematical model demonstrated that penetrating bacteria colonies during subcutaneous injection is unlikely. These findings clarify the lack of documented skin infections from subcutaneous insulin injections in research. Furthermore, these results can motivate the innovation and development of durable, reusable injection systems with pharmacoeconomic value and a simplified and enhanced user experience for patients.

J. Schreiber L, Wallace EJ, Wylie R, O'Sullivan J, Dolan EB, Duffy GP. Medical devices, smart drug delivery, wearables and technology for the treatment of Diabetes Mellitus

Diabetes mellitus refers to a group of metabolic disorders which affect how the body uses glucose impacting approximately 9% of the population worldwide. This review covers the most recent technological advances envisioned to control and/or reverse Type 1 diabetes mellitus (T1DM), many of which will also prove effective in treating the other forms of diabetes mellitus. Current standard therapy for T1DM involves multiple daily glucose measurements and insulin injections. Advances in glucose monitors, hormone delivery systems, and control algorithms generate more autonomous and personalised treatments through hybrid and fully automated closed-loop systems, which significantly reduce hypo- and hyperglycaemic episodes and their subsequent complications. Bi-hormonal systems that co-deliver glucagon or amylin with insulin aim to reduce hypoglycaemic events or increase time spent in target glycaemic range, respectively. Stimuli responsive materials for the controlled delivery of insulin or glucagon are a promising alternative to glucose monitors and insulin pumps. By their self-regulated mechanism, these "smart" drugs modulate their potency, pharmacokinetics and dosing depending on patients' glucose levels. Islet transplantation is a potential cure for T1DM as it restores endogenous insulin and glucagon production, but its use is not yet widespread due to limited islet sources and risks of chronic immunosuppression. New encapsulation strategies that promote angiogenesis and oxygen delivery while protecting islets from recipients' immune response may overcome current limiting factors.

Non-invasive ways of administering insulin

BACKGROUND AND AIMS

Insulin is crucial in the management of diabetes. However, requires injection which itself comes with some challenges. Alternative delivery routes have been investigated that are needle-free, with enhanced absorption and bioavailability. This review presents novel non-invasive insulin administration approaches that overcome some hurdles, as well as delineating their advantages and disadvantages.

METHODS

Information was primarily gathered by employing various PubMed scholarly articles for real-world examples in addition to data extraction from supplementary manuscripts. Articles were evaluated between 1958 and 2022. An introductive approach was used to identify matters related to the concept of different ways of administering insulin.

RESULTS

Approaches aim to administer insulin in a safe, stable, and easy to use form, whether via oral, buccal, intranasal, oral inhalation, transdermal, ocular, rectal, or vaginal routes. Some have been shown to clinically improve blood glucose levels, while others are still in the investigational stage.

CONCLUSION

Many approaches have been taken in an attempt to overcome physical barriers of insulin delivery. Some of these systems discussed may reach the market in the future and assist the millions of people who currently take subcutaneous injections of insulin.

Engineering a Rapid Insulin Release System Controlled By Oral Drug Administration

Rapid insulin release plays an essential role in maintaining blood-glucose homeostasis in mammalians. Patients diagnosed with type-I diabetes mellitus experience chronic and remarkably high blood-sugar levels, and require lifelong insulin injection therapy, so there is a need for more convenient and less invasive insulin delivery systems to increase patients' compliance and also to enhance their quality of life. Here, an endoplasmic-reticulum-localized split sec-tobacco etch virus protease (TEVp)-based rapamycin-actuated protein-induction device (RAPID) is engineered, which is composed of the rapamycin-inducible dimerization domains FK506 binding protein (FKBP) and FKBP-rapamycin binding protein fused with modified split sec-TEVp components. Insulin accumulation inside the endoplasmic reticulum (ER) is achieved through tagging its C-terminus with KDEL, an ER-retention signal, spaced by a TEVp cleavage site. In the presence of rapamycin, the split sec-TEVp-based RAPID components dimerize, regain their proteolytic activity, and remove the KDEL retention signal from insulin. This leads to rapid secretion of accumulated insulin from cells within few minutes. Using liver hydrodynamic transfection methodology, it is shown that RAPID quickly restores glucose homeostasis in type-1-diabetic (T1DM) mice treated with an oral dose of clinically licensed rapamycin. This rapid-release technology may become the foundation for other cell-based therapies requiring instantaneous biopharmaceutical availability.

Impact of OMNIPOD® on the quality of life of adolescents with type 1 diabetes

INTRODUCTION

Several pediatric studies have demonstrated that therapy using a conventional insulin pump improves glycemic control and quality of life. At the beginning of this study, a new tubeless insulin pump, Omnipod®, had recently been marketed in France.

OBJECTIVES

Analyze the response of adolescents treated with multiple injections to the proposal to use this new medical device and compare both the quality of life and the glycemic control of adolescents according to their choice.

MATERIAL AND METHODS

This was a prospective, observational study of adolescents aged 10-17 years who had type 1 diabetes for more than 1 year, all treated with multi-injection insulin delivery according to a basal-bolus regimen. They were separated into three groups: group A choosing to use the Omnipod® system, group B taking the time to think before making a decision, and group C choosing to keep their multi-injection therapy. The three groups were compared according to their quality of life with validated tools and glycemic control.

RESULTS

Groups were formed with 30 (25%) patients in group A, 55 patients (45%) in group B, and 36 patients (30%) in group C. As to the WHO Well-Being Index, no significant difference appeared in the study for the patients in the three groups. An increased treatment satisfaction score was found, evolving from 3.79 ± 0.68 to 4.36 ± 0.56, p = 0.002 (group A) and from 3.87 ± 0.7 to 4.16 ± 0.7, p = 0.032 (group B), with no significant change for group C (from 4.39 ± 0.6 to 4.31 ± 0.62, p = 0.582). The wish to change treatment score improved for group A (from 4.14 ± 0.88 to 1.68 ± 0.9; p < 0.001) and group B (from 3.51 ± 1.05 to 1.84 ± 1; p < 0.001), with no significant change for group C (from 1.81 ± 0 0.98 to 1.61 ± 0.8; p = 0.432). There was no significant difference regarding HbA1c rates in the three groups.

CONCLUSION

There was no significant difference in quality-of-life scores between adolescents who chose to switch from multiple injection to the tubeless patch pump and those who retained multi-injection treatment, but increased satisfaction was observed in the former group.

Multi-Electrode Array of Sensory Neurons as an In Vitro Platform to Identify the Nociceptive Response to Pharmaceutical Buffer Systems of Injectable Biologics

PURPOSE

Pharmaceutical buffer systems, especially for injectable biologics such as monoclonal antibodies, are an important component of successful FDA-approved medications. Clinical studies indicate that buffer components may be contributing factors for increased injection site pain.

METHODS

To determine the potential nociceptive effects of clinically relevant buffer systems, we developed an in vitro multi-electrode array (MEA) based recording system of rodent dorsal root ganglia (DRG) sensory neuron cell culture. This system monitors sensory neuron activity/firing as a surrogate of nociception when challenged with buffer components used in formulating monoclonal antibodies and other injectable biologics.

RESULTS

We show that citrate salt and citrate mannitol buffer systems cause an increase in mean firing rate, burst frequency, and burst duration in DRG sensory neurons, unlike histidine or saline buffer systems at the same pH value. Lowering the concentration of citrate leads to a lower firing intensity of DRG sensory neurons.

CONCLUSION

Increased activity/firing of DRG sensory neurons has been suggested as a key feature underlying nociception. Our results support the utility of an in vitro MEA assay with cultured DRG sensory neurons to probe the nociceptive potential of clinically relevant buffer components used in injectable biologics.

Use of a Flexible Catheter for the Administration of Subcutaneous Insulin in Diabetic Ketoacidosis: A Feasibility Controlled Clinical Trial

BACKGROUND

Although intravenous insulin administration is the standard of care in diabetic ketoacidosis (DKA), subcutaneous insulin administration could be a suitable alternative in resource-limited settings, but pain caused by hourly insulin applications are limiting factors for using it, especially in children. We aimed to assess whether the use of a flexible subcutaneous catheter improves comfort in patients with DKA compared with the usual hourly injections' treatment. We also compared the evolution of metabolic variables in patients with DKA using both insulin administration systems.

METHODS

Randomized feasibility controlled open trial, comparing 2 ways (flexible catheter and steel needle) for the initial insulin administration in children with DKA, who were randomly selected to receive subcutaneous insulin by a flexible catheter or using standard needles. The main outcome was pain, assessed hourly and secondary outcome time to achieve ketoacidosis resolution.

RESULTS

Twenty subjects were included (10 by group). There were no differences between groups in baseline lab values (glycemia, urea, sodium, bicarbonate and pH). Pain assessment at first insulin administration was significantly lower in the intervention group (4.5 vs 0 points; P = 0.001). Similar differences between both treatment arms were observed in every pain assessment. There were no differences between groups regarding the time elapsed to achieve ketoacidosis resolution. (11.4±4.3 vs 16±8.4; P = 0.12). No adverse events or DKA complications were observed.

CONCLUSIONS

The use of a flexible catheter reduced the pain associated with subcutaneous insulin administration in nonsevere DKA. The flexible subcutaneous catheter could be a safe alternative for the treatment of uncomplicated DKA in resource-limited settings.

Needle Gauge Influences Pain Perception During Intrapulpal Anaesthesia - A Randomized Clinical Trial

OBJECTIVE

The purpose of this randomized trial was to assess the pain perception during intrapulpal anesthesia (IP) using thinner gauge needles and syringes with or without topical anaesthesia as an adjunct.

METHODS

One hundred patients, on whom the inferior alveolar nerve block and intraligamentary injections failed, were recruited for the trial. Block randomization was performed and the patients were allocated into 4 groups based on the needle gauge and topical application of anaesthesia prior to IP injection. In two groups (27GN, 31GN) the patients received IP injection with 27 gauge or 31 gauge needles. The patients of other two groups received topical lignocaine-prilocaine mixture prior to the IP injection with 27 or 31 gauge needles, respectively (27GT, 31GT). The visual analogue scale (VAS) was used to assess the pain immediately after IP injection and after cleaning and shaping by a blinded outcome assessor. The Kruskal-Wallis test for overall comparisons followed by the post-hoc analysis using the Conover's test (P<0.05) was done. Chi-square and Fischer exact test was used to assess the proportion of patients who were comfortable during IP anaesthesia.

RESULTS

The intensity of pain during IP administration with 31GN and 31GT (3.7 and 2.3 respectively) was significantly less in comparison to 27GN and 27GT (5.6 and 5.7 respectively). The proportion of patients who were significantly comfortable with IP injections in the groups 31GN and 31GT (52% and 80% respectively) were more (VAS<4) when compared to 27GN and 27GT (12% and 8% respectively). Topical application of lignocaine-prilocaine reduced the pain on IP injection significantly when used as an adjunct with 31 gauge needles. The anaesthetic success of IP anaesthesia was comparable and 100% (VAS scoring <4) in all the groups.

CONCLUSION

Thinner gauge needles (31 gauge) significantly reduce pain perceived during IP anaesthesia. Topical anaesthesia with lignocaine-prilocaine acts as an effective adjunct only with 31gauge needle.

Dose-dependent effects of necrostatin-1 supplementation to tissue culture media of young porcine islets

Previous studies have shown that necrostatin-1 (Nec-1) supplementation improved the viability of murine islets following exposure to nitric oxide, increased the survival of human islets during hypoxic culture, and augmented the maturation of pre-weaned porcine islets (PPIs) after 7 days of tissue culture. A limitation of these studies is that only one concentration of Nec-1 was used, and no studies have determined the optimal dose of Nec-1 for PPIs. Thus, the present study examined the effects of Nec-1 on PPIs at four different doses—0, 25, 50, 100, and 200 μM—after 7 days of tissue culture when supplemented on day 3. PPIs were isolated from pancreata of pre-weaned Yorkshire piglets (8–15 days old) and cultured in a specific islet maturation media added with Nec-1 on day 3 of tissue culture at 4 different doses—0, 25, 50, 100, and 200 μM (n = 6 for each dose). After 7 days of tissue culture, islets were assessed for recovery, viability, endocrine cellular content, GLUT2 expression in beta cells, and insulin secretion after glucose challenge. Nec-1 did not affect the viability of both intact islets and dissociated islets cells during tissue culture regardless of doses. Islets cultured in media supplemented with Nec-1 at 100 μM, but not 25, 50, or 200 μM, had a significantly higher recovery, composition of endocrine cells, GLUT2 expression in beta cells, and insulin secretion capacity than control islets cultured in media without Nec-1 supplementation. Moreover, culturing islets in 200 μM Nec-1 supplemented media not only failed to improve the insulin release but resulted in a lower glucose-induced insulin stimulation index compared to islets cultured in media added with 100 μM Nec-1. Xenotransplantation using porcine islets continues to demonstrate scientific advances to justify this area of research. Our findings indicate that Nec-1 supplementation at 100 μM was most effective to enhance the in vitro maturation of PPIs during tissue culture.

User experiences with second-generation 32-gauge × 4 mm vs. thinner comparator pen needles: prospective randomized trial

OBJECTIVE

Two similarly designed studies compared user experiences with a second-generation extra-thin-wall, 5-bevel 32 G × 4 mm pen needle (PN) with redesigned hub versus four thinner commercially available PNs.

METHODS

Adults (18-75 years old) with type 1 or type 2 diabetes and ≥3 months of experience with pen injectors qualified for single-visit, single-blinded randomized studies. The investigational 32 G PN was compared with three 33-34 G × 3.5-4 mm PNs in Study 1 and one 34 G × 4 mm PN in Study 2. Participants completed 12 abdominal injections of 0.3 mL sterile saline using insulin pens in 6 pairs, each comprising one investigational 32 G PN and one comparator PN in random order. After each injection pair, participants compared injection pain via relative 150 mm visual analog scale (VAS) and perceived dose delivery force via relative 5 point Likert scale. Adjusted models tested injection pain scores (primary endpoint) for noninferiority and, if met, then for superiority. ClinicalTrials.gov identifiers: NCT03878758 and NCT03878745.

RESULTS

The investigational 32 G PN met noninferiority as well as superiority criteria for less injection pain vs. each comparator (p < .01), with adjusted mean relative VAS scores 9.1-17.6 in Study 1 (n = 154) and 7.3 in Study 2 (n = 55). The investigational 32 G PN was also superior vs. each comparator PN in requiring less relative perceived force to deliver the dose (p < .01).

CONCLUSIONS

The investigational 32 G PN was associated with less participant-reported injection pain and less perceived dose delivery force compared with four thinner PNs, suggesting no additional pain reduction or force reduction benefit conferred by the thinner PNs.

Consensus on Choice of Insulin Pen Devices in Routine Clinical Practice in India

Although insulin delivery devices are widely used by the patients, there is a paucity of published guidelines to help professionals manage their patients in insulin therapies. To provide simple and easily implementable guidelines to health care physicians on the choice of insulin delivery devices in routine clinical practice, experts in diabetes gathered together and discussed the recommendations at the National insulin Summit 2018. An ideal insulin delivery device should accurately deliver the prescribed dose of insulin and be easy to use. Recommendations are: (1) insulin should be initiated by using an insulin device if the patient seems to discontinue insulin therapy. (2) Pen devices offer accurate dosing than a syringe and vial and are associated with cost savings in the long term. (3) Switching over from syringes and vial to disposable pen devices improves adherence. (4) FlexPen^® offers better accuracy, and it requires lower dose force and injection force than SoloStar^® and KwikPen^® (5). Durable delivery pens such as NovoPen^® 4 maintain accuracy and low dose force compared with vials and syringes. (6) One pen should be used by only one patient. (7) Regular counseling on the proper use of the pen device is required regularly. This consensus-based recommendation is a useful reference tool for health care practitioners to initiate insulin therapy in patients with diabetes by using the appropriate insulin pen device.

Comparison of glucose variability in patients with type 2 diabetes administrated glargine with needle-free jet injector and conventional insulin pen

Background: The effects of insulin delivered by needle-free jet injector on glycemic variations (GV) in patients with type 2 diabetes (T2D) which remains largely unknown.Research design and methods: We aimed to compare the glucose variability in Chinese T2D patients administrated glargine 100 U/mL (Gla-100) with a needle-free jet injector and conventional insulin pen. This was a self-comparative, observational study of 26 patients who were subjected to a flash glucose monitoring system (FGM) for 14 consecutive days. During the study period, all subjects received Gla-100 daily before breakfast using a conventional insulin pen, with the exception of day 3 and day 7, when insulin was delivered by needle-free jet injection. We analyzed FGM data of day 3, day 5, day 7, and day 9 at the endpoint.Results: There were no differences in the glycemic variability between the jet injector group and the conventional pen group. However, patients with needle-free jet injection had a lower 24 hr mean glucose (MG) and lower incremental area under the curve (AUC) of 1 hr, 12 hr, and 24 hr, compared to the conventional pen group (p = 0.001).Conclusions: Gla-100 delivered by needle-free jet injection potentially lowered MG in patients with T2D in the Chinese population.

Treatment satisfaction correlated with glycaemic control and burden of diabetes in Swedish adolescents with type 1 diabetes

AIM

To assess treatment satisfaction and perceived discomfort or pain from the treatment, and potential associations with glycaemic control, type of treatment, perceived burden of diabetes, sex and age, in adolescents with type 1 diabetes.

METHODS

A cross-sectional study was performed at one paediatric and at one adult diabetes clinic in Sweden, preceded by a translation of 'Diabetes Treatment Satisfaction Questionnaire (DTSQ) Teen'. Adolescents with type 1 diabetes (15-20 years) participated. The questionnaires 'DTSQ Teen' and 'Check your health' were used. Data on glycosylated haemoglobin (HbA1c), type of treatment, sex and age were collected.

RESULTS

One hundred and thirty-eight adolescents (70 females, mean age 17.3, mean HbA1c 64.0 mmol/mol) participated. Treatment satisfaction correlated inversely with HbA1c (r = -.352, P < .001) and with all types of burden of diabetes (r = -.342 to -0.467, P < .001), but did not differ with type of treatment, sex and age. Perceived pain correlated inversely with burden on physical health (r = -.265, P = .002), mental health (r = -.237, P = .006) and quality of life (r = -.246, P = .004) but not with HbA1c, age or burden on social relations. Females perceived more discomfort or pain.

CONCLUSION

In Swedish adolescents with type 1 diabetes, treatment satisfaction correlated with both glycaemic control and perceived burden of diabetes.

How Much Do We Know about the Biopsychosocial Predictors of Glycaemic Control? Age and Clinical Factors Predict Glycaemic Control, but Psychological Factors Do Not

OBJECTIVE

Diabetes mellitus is one of the most common noncommunicable diseases in Malaysia. It is associated with significant complications and a high cost of treatment, especially when glycaemic control is poor. Despite its negative impact on health, data is still lacking on the possible biopsychosocial predictors of poor glycaemic control among the diabetic population. This study is aimed at determining the prevalence of poor glycaemic control as well as its association with biopsychosocial factors such as personality traits, psychiatric factors, and quality of life (QOL) among Malaysian patients with diabetes.

METHODS

A cross-sectional study was conducted at the Universiti Kebangsaan Malaysia Medical Centre (UKMMC) using outpatient population diabetic patients. Demographic data on social and clinical characteristics were collected from participants. Several questionnaires were administered, including the Beck Depression Inventory-II (BDI-II) to measure depressive symptoms, the Generalized Anxiety Disorder-7 (GAD-7) to assess anxiety symptoms, the Big Five Inventory (BFI) to evaluate personality traits, and the WHO Quality of Life-BREF (WHOQOL-BREF) to assess QOL. Multivariate binary logistic regression was performed to determine the predictors of poor glycaemic control.

RESULTS

300 patients with diabetes mellitus were recruited, with the majority (90%) having type 2 diabetes. In this population, the prevalence of poor glycaemic control (HbA_1C ≥ 7.0%) was 69%, with a median HbA_1C of 7.6% (IQR = 2.7). Longer duration of diabetes mellitus and a greater number of days of missed medications predicted poor glycaemic control, while older age and overall self-perception of QOL protected against poor glycaemic control. No psychological factors were associated with poor glycaemic control.

CONCLUSION

This study emphasizes the importance of considering the various factors that contribute to poor glycaemic control, such as duration of diabetes, medication adherence, age, and QOL. These findings should be used by clinicians, particularly when planning a multidisciplinary approach to the management of diabetes.

Evaluating the Impact of Human Factors and Pen Needle Design on Insulin Pen Injection

BACKGROUND

Limited published data exists quantifying the influence of human factors (HF) and pen needle (PN) design on delivery outcomes of pen injection systems. This preclinical in vivo study examines the impact of PN hub design and applied force against the skin during injection on needle penetration depth (NPD).

METHOD

To precisely locate injection depth, PN injections (20 µl; 2 IU, U-100 volume equivalent) of iodinated contrast agent were administered to the flank of Yorkshire swine across a range of clinically relevant application forces against the skin (0.25, 0.75, 1.25, and 2.0 lbf). The NPD, representing in vivo needle tip depth in SC tissue, from four 32 G × 4 mm PN devices (BD Nano^™ 2nd Gen and three commercial posted-hub PN devices; n = 75/device/force, 1200 total) was measured by fluoroscopic imaging of the resulting depot.

RESULTS

The reengineered hub design more closely achieved the 4 mm target NPD with significantly less variability ( P = .006) than commercial posted-hub PN devices across the range of applied injection forces. Calculations of IM (intramuscular) injection risk completed through in silico probability model, using NPD and average human tissue thickness measurements, displayed a commensurate reduction (~2-8x) compared to conventional PN hub designs.

CONCLUSIONS

Quantifiable differences in injection depth were observed between identical labeled length PN devices indicating that hub design features, coupled with aspects of variable injection technique, may influence injection depth accuracy and consistency. The reengineered hub design may reduce the impact of unintended individual technique differences by improving target injection depth consistency and reducing IM injection potential.

Conceptual framework for designing video games for children with type 1 diabetes

OBJECTIVE

to present a theoretically based conceptual framework for designing video games for children with type 1 diabetes mellitus.

METHODS

this was a methodological study that developed a conceptual framework with nine steps in view of health behavior change theories and the user-centered design approach as theoretical and methodological frameworks, respectively. Twenty-one children, aged 7 to 12 years, participated by expressing their needs and preferences related to diabetes and video games. Data were analysed following content analysis guidelines. Then, a choice of appropriate health behavioral change theories and their determinants that should be capable of influencing children's behaviors and preferences.

RESULTS

the conceptual framework proposes a video game that consists of six phases, each addressing one stage of behavioral change and specific determinants, aligned with the needs and preferences identified by the participating children. This study shows the applicability of this framework in view of each proposed phase presenting examples and the children's ideas.

CONCLUSION

the results of this study contribute to advance the discussion on how behavioral theories and their determinants should be related to the design of creative and funny video games considering the profile of the target population as well as its needs and preferences.

Sodium Glucose Co-transporter-2 Inhibitor: Benefits beyond Glycemic Control

Type 2 diabetes mellitus (T2DM) is a family of metabolic disorders characterized by hyperglycemia as a consequence of abnormalities in insulin secretion and insulin sensitivity. It affects hundreds of millions of people worldwide and leads to increased morbidity, compromised quality of life, higher mortality sodium glucose co-transporter 2 (SGLT2) inhibitors, a new class of oral antidiabetic drugs, have garnered considerable attention in the recent past and are considered potential first-line candidates for the management of T2DM. This review outlines the evidence-based therapeutic efficacy, safety, limitations, and advantages of SGLT2 inhibitors in the management of T2DM. SGLT2 inhibitors work by preventing the kidneys from reabsorbing glucose back into the blood, leading to increase in excretion of glucose through urine, thereby lowering hyperglycemia. Treatment with SGLT2 inhibitors improves A1C levels, reduces blood pressure and body weight, and is overall well tolerated by patients with T2DM. However, additional data on long-term cardiovascular safety are still needed. Characteristic adverse events include mild genital - urinary tract infection more commonly seen in women than in men, but serious infection is uncommon. Their use should be exercised with extra caution in patients suffering from renal impairment. Further, advancing to dual/triple combinational therapies with SGLT2 inhibitors and existing oral antidiabetic options may prove to be a breakthrough in the management of T2DM.

Ultra-structural evaluation of needles and their role for comfort during subcutaneous drug administration

Objective To evaluate the morphology of hypodermic needle bevels after drug aspiration, and the perception of comfort caused by the change or not of needles between preparation and subcutaneous drug administration. Method Experimental research carried out in two moments. Initially, hypodermic needles were analyzed by scanning electron microscopy, and then a pilot trial was conducted with the participants, which indicated the level of comfort perceived at the time of needle bevel penetration during subcutaneous administration. Results Forty-one adult inpatients participated in the study. Although the needles presented a slight to significant morphological alteration when evaluated by ultramicroscopy, the participants in this study were not able to report significant sensory changes during their penetration in the two techniques used. Conclusions The standardization of fixed needle syringes, or the use of a single needle for both the preparation and the subcutaneous drug administration should be considered as strategies to reduce the production of sharp-perforating residues, to decrease the cost per procedure, and to limit the risk of contamination of critical devices.

Impact of Injection Speed, Volume, and Site on Pain Sensation

BACKGROUND

Painful subcutaneous insulin injections may decrease treatment compliance. Improving injection comfort therefore represents a particular area of technological research in which steady progress has been made since the introduction of the insulin pen in 1985. Injection pain can be influenced by many variables, but relatively little is known about their impact. This study investigated the impact of injection volume (range 0-2250 µL), speed (range 0-800 µL/sec), and site (abdomen vs thigh) on pain sensation.

METHOD

In random order, patients (n = 80) with type 1 or type 2 diabetes received 24 saline injections subcutaneously through a 27G ultra-thin-wall needle. Injections were performed in the abdomen (n = 19) and thigh (n = 5) with predefined speed-volume combinations. For each injected speed-volume combination, patients scored their pain sensation on a 100 mm visual analog scale (VAS).

RESULTS

The mean pain scores for speed-volume combinations were all in the lower part (<20 mm) of the VAS, indicating zero to mild pain. Pain sensation was statistically higher ( P < .05) with the 2250 µL volume compared to other injection volumes (range 4.3-5.1 mm) and with thigh compared to abdomen injections (2.1 mm). Pain sensation did not change with increasing injection speed. Patient acceptance of the injection pain was high for all injections (range 93.7-98.7%).

CONCLUSIONS

In summary, large volume and thigh injections are rated more painful, but the clinical impact of these findings is likely marginal considering the low absolute pain levels and high patient acceptance rates. Injection speed does not influence pain sensation.

The Application of One-Hour Static Qigong Program to Decrease Needle Pain of Korean Adolescents With Type 1 Diabetes: A Randomized Crossover Design

The aim of this study was to describe application of a static Qigong program to decrease needle pain in Korean adolescents with type 1 diabetes and its pilot test results. The pilot study was a randomized crossover design including 26 adolescents randomized to Qigong or rest group. Participants received a 60-minute Qigong program consisted of warm up, deep breathing, imaginary, and a closing warm up. After 24-hour washout period, treatment assignments were switched. We collected before and after intervention using a self-administered questionnaire, which included the faces pain scale to assess expected and perceived pain during blood sugar testing and insulin injection and the Positive and Negative Affect Schedule. Only expected pain on insulin injection was significantly lower after intervention (P = .025). The results suggested that the devised static Qigong program was feasible intervention to decrease at least expected pain on insulin injection of adolescents with type 1 diabetes.

Fear of Self-Injecting and Self-Testing and the Related Risk Factors in Adolescents with Type 1 Diabetes: A Cross-Sectional Study

INTRODUCTION

This study was conducted to investigate the fear of self-injecting and self-testing and its related risk factors among adolescents with type 1 diabetes mellitus (T1DM).

METHODS

From December 2015 to April 2016, a cross-sectional study was performed at the Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia on 142 registered T1DM patients between 13 and 19 years of age. Selection of the respondents was done deliberately and carefully, and the suitable patients were given specific identification numbers. A trained interviewer administered the short Diabetes Fear of Injecting and Self-testing Questionnaire to each patient. It included two subscales estimating the fear of self-injection (FSI) and fear of self-testing (FST). Each patient's age, gender, weight, height, adjusted body mass index (BMI), duration of the diabetic condition, treatment modality, insulin dosage, and glycosylated hemoglobin (HbA1c) were recorded.

RESULTS

The study found that the overall mean score of FSI was 2.44 ± 0.96, whereas that of FST was 2.25 ± 1.04. Adolescents above 16 years of age, treated with multiple daily insulin (MDI), on higher insulin doses, having poor glycemic control, and fewer finger pricks were observed to show significant risk factors for fear of self-injection of insulin, whereas in those patients having a long duration of T1DM, MDI treated, on higher insulin doses, with poor glycemic control, and fewer finger pricks showed significant risk factors for fear of self-testing of blood glucose. From the regression analysis it was evident that the variables of higher age, MDI treatment, and fewer finger pricks were independent risk factors for fear of self-injection of the insulin, whereas a fewer number of finger pricks was an independent risk factor for fear of self-testing the blood glucose.

CONCLUSION

Fear of self-injecting and fear of self-testing are common among adolescents with T1DM. Therefore, it is essential to ensure comprehensive multidisciplinary diabetes education to lower the risk factor of fear of injections.

Efficacy of oral versus insulin therapy for newly diagnosed diabetes in low-income settings

BACKGROUND

There are conflicting recommendations and highly variable practices regarding the level of A1c to initiate insulin for individuals with newly diagnosed diabetes. This is complicated in low-income settings where adverse reactions or negative perceptions of insulin are often magnified.

OBJECTIVES

Compare the clinical outcomes of insulin and Oral Agents (OAs) in low-income settings in the United States.

METHODS

We conducted a retrospective chart review in community clinics serving low -income individuals with newly diagnosed type 2 diabetes who were initiated on insulin or OAs. The primary outcome was change of hemoglobin A1c (A1c) from baseline to 12 months. Secondary outcomes consisted of other clinical measures including Emergency Department (ED) visits.

RESULTS

A total of 18% (88/489) of patients were started on insulin. The adjusted average decrease of A1c from baseline was greater in the OA group (insulin: -1.97% vs. OA: -2.52%; p<0.001). In a subset analysis of individuals with A1cs >11%, significantly more patients were started on OAs (insulin: n=51, OA: n=93; p<0.001) and A1c improvements were similar at 12 months (insulin: -5.06% [12.94% to 7.88%] OA: -4.62% [12.57% to 7.96%]; p=0.846). Baseline A1c predicted insulin initiation (p<0.001): For every one-unit increase in baseline A1c, the odds of insulin initiation increased by 47.5%. Individuals in the insulin group had more ED visits per year (0.169 vs. 0.0025; p<0.005).

CONCLUSIONS

Given the positive clinical outcomes of OAs even with markedly elevated A1c levels in addition to the healthcare system benefits, they are a promising initial therapy for low-income adults with newly diagnosed type 2 diabetes.

The role of insulin pump therapy for type 2 diabetes mellitus

Many patients with type 2 diabetes fail to achieve adequate glucose control despite escalation of treatment and combinations of multiple therapies including insulin. Patients with long-standing type 2 diabetes often suffer from the combination of severe insulin deficiency in addition to insulin resistance, thereby requiring high doses of insulin delivered in multiple injections to attain adequate glycemic control. Insulin-pump therapy was first introduced in the 1970s as an approach to mimic physiological insulin delivery and attain normal glucose in patients with type 1 diabetes. The recent years have seen an increase in the use of this technology for patients with type 2 diabetes. This article summarizes the clinical studies evaluating insulin pump use in patients with type 2 diabetes and discusses the benefits and shortcomings of pump therapy in this population. Copyright © 2016 John Wiley & Sons, Ltd.

New Insulin Delivery Recommendations

Many primary care professionals manage injection or infusion therapies in patients with diabetes. Few published guidelines have been available to help such professionals and their patients manage these therapies. Herein, we present new, practical, and comprehensive recommendations for diabetes injections and infusions. These recommendations were informed by a large international survey of current practice and were written and vetted by 183 diabetes experts from 54 countries at the Forum for Injection Technique and Therapy: Expert Recommendations (FITTER) workshop held in Rome, Italy, in 2015. Recommendations are organized around the themes of anatomy, physiology, pathology, psychology, and technology. Key among the recommendations are that the shortest needles (currently the 4-mm pen and 6-mm syringe needles) are safe, effective, and less painful and should be the first-line choice in all patient categories; intramuscular injections should be avoided, especially with long-acting insulins, because severe hypoglycemia may result; lipohypertrophy is a frequent complication of therapy that distorts insulin absorption, and, therefore, injections and infusions should not be given into these lesions and correct site rotation will help prevent them; effective long-term therapy with insulin is critically dependent on addressing psychological hurdles upstream, even before insulin has been started; inappropriate disposal of used sharps poses a risk of infection with blood-borne pathogens; and mitigation is possible with proper training, effective disposal strategies, and the use of safety devices. Adherence to these new recommendations should lead to more effective therapies, improved outcomes, and lower costs for patients with diabetes.

Non-stick syringe needles: Beneficial effects of thin film metallic glass coating

This paper reports on the use of Zr-based (Zr₅₃Cu₃₃Al₉Ta₅) thin film metallic glass (TFMG) for the coating of syringe needles and compares the results with those obtained using titanium nitride and pure titanium coatings. TFMG coatings were shown to reduce insertion forces by ∼66% and retraction forces by ∼72%, when tested using polyurethane rubber block. The benefits of TFMG-coated needles were also observed when tested using muscle tissue from pigs. In nano-scratch tests, the TFMG coatings achieved a coefficient of friction (COF) of just ∼0.05, which is about one order of magnitude lower than those of other coatings. Finite-element modeling also indicates a significant reduction in injection and retraction forces. The COF can be attributed to the absence of grain boundaries in the TFMG coating as well as a smooth surface morphology and low surface free energy.

Attributes Influencing Insulin Pen Preference Among Caregivers and Patients With Diabetes Who Require Greater Than 20 Units of Mealtime Insulin

BACKGROUND

This study compared patient preference for Humalog® KwikPen™ 200 units/mL (insulin lispro; hereafter, IL 200 pen; Eli Lilly and Company, Indianapolis, IN) versus the Humalog KwikPen 100 units/mL (insulin lispro; hereafter, IL 100 pen; Eli Lilly and Company, Indianapolis, IN) in patients with diabetes requiring >20 units of mealtime insulin and diabetes caregivers. This study also determined which attributes had the greatest influence on pen preference selection.

METHODS

In this 2-period, crossover, simulated-use study, 106 participants were randomized to 1 of 8 sequences that varied the pen order (IL 100 pen or IL 200 pen) and dosing order (15 units = low dose or 50 units = high dose) for a total of 4 simulated injections. Participants then completed a self-administered questionnaire to select their overall preference between the 2 pens and then rated the importance of 11 pen attributes in contributing to their overall preference.

RESULTS

Of the 90 participants expressing an overall preference, significantly more preferred the IL 200 pen to the IL 100 pen (IL 200 pen: 80 respondents; IL 100 pen: 10 respondents; 95% confidence interval [0.81, 0.94], P < .0001). The total amount of insulin in the pen, the ease in pressing the injection button, and the amount of fluid injected were key attributes influencing IL 200 pen preference.

CONCLUSIONS

Based on these key attributes, the IL 200 pen was significantly preferred over the IL 100 pen by patients with diabetes who require >20 daily mealtime insulin units or diabetes caregivers and may improve the injection experience for these patients.

Effects of Axial Vibration on Needle Insertion into the Tail Veins of Rats and Subsequent Serial Blood Corticosterone Levels

Blood collection is commonplace in biomedical research. Obtaining sufficient sample while minimizing animal stress requires significant skill and practice. Repeated needle punctures can cause discomfort and lead to variable release of stress hormones, potentially confounding analysis. We designed a handheld device to reduce the force necessary for needle insertion by using low-frequency, axial (forward and backward) micromotions (that is, vibration) delivered to the needle during venipuncture. Tests with cadaver rat-tail segments (n = 18) confirmed that peak insertion forces were reduced by 73% on average with needle vibration. A serial blood-sampling study was then conducted by using Sprague-Dawley rats divided into 2 groups based on needle condition used to cause bleeds: vibration on (n = 10) and vibration off (n = 9). On 3 days (1 wk apart), 3 tail-vein blood collections were performed in each subject at 1-h intervals. To evaluate associated stress levels, plasma corticosterone concentration was quantified by radioimmunoassay and behavior (that is, movement and vocalization) was scored by blinded review of blood-sampling videos. After the initial trial, average corticosterone was lower (46% difference), the mean intrasubject variance trended lower (72%), and behavioral indications of stress were rated lower for the vibration-on group compared with the vibration-off group. Adding controlled vibrations to needles during insertion may decrease the stress associated with blood sampling from rats--an important methodologic advance for investigators studying and assessing stress processes and a refinement over current blood sampling techniques.

Impact of telephonic interviews on persistence and daily adherence to insulin treatment in insulin-naïve type 2 diabetes patients: dropout study

OBJECTIVE

The objective of this study is to evaluate the impact of sequential telephonic interviews on treatment persistence and daily adherence to insulin injections among insulin-naïve type 2 diabetes patients initiated on different insulin regimens in a 3-month period.

METHODS

A total of 1,456 insulin-naïve patients with type 2 diabetes (mean [standard deviation, SD] age: 56.0 [12.0] years, 49.1% were females) initiated on insulin therapy and consecutively randomized to sequential (n=733) and single (n=723) telephonic interview groups were included. Data on insulin treatment and self-reported blood glucose values were obtained via telephone interview. Logistic regression analysis was performed for factors predicting increased likelihood of persistence and skipping an injection.

RESULTS

Overall, 76.8% patients (83.2% in sequential vs 70.3% in single interview group, (P<0.001) remained on insulin treatment at the third month. Significantly higher rate for skipping doses was noted in basal bolus than in other regimens (27.0% vs 15.0% for premixed and 15.8% basal insulin, respectively, P<0.0001). Logistic regression analysis revealed sequential telephonic interview (odds ratio [OR], 1.531; 95% confidence interval [CI], 1.093-2.143; P=0.013), higher hemoglobin A1c levels (OR, 1.090; 95% CI, 0.999-1.189; P=0.049), and less negative appraisal of insulin therapy as significant predictors of higher persistence. Basal bolus regimen (OR, 1.583; 95% CI, 1.011-2.479; P=0.045) and higher hemoglobin A1c levels (OR, 1.114; 95% CI, 1.028-1.207; P=0.008) were the significant predictors of increased likelihood of skipping an injection.

CONCLUSION

Our findings revealed positive influence of sequential telephonic interview, although including no intervention in treatment, on achieving better treatment persistence in type 2 diabetes patients initiating insulin.

Adherence to insulin treatment in insulin-naïve type 2 diabetic patients initiated on different insulin regimens

OBJECTIVE

We aimed to evaluate adherence to insulin treatment in terms of treatment persistence and daily adherence to insulin injections among insulin-naïve type 2 diabetic patients initiating insulin therapy with basal (long acting), basal-bolus, and premixed insulin regimens in a tertiary endocrinology outpatient clinic.

METHODS

A total of 433 (mean age of 55.5±13.0 years; 52.4% females) insulin-naïve type 2 diabetic patients initiated on insulin therapy were included in this questionnaire-based phone interview survey at the sixth month of therapy. Via the telephone interview questions, patients were required to provide information about persistence to insulin treatment, self-reported blood glucose values, and side effects; data on demographics and diabetes characteristics were obtained from medical records.

RESULTS

Self-reported treatment withdrawal occurred in 20.1% patients, while 20.3% patients were nonadherent to daily insulin. Negative beliefs about insulin therapy (24.1%) and forgetting injections (40.9%) were the most common reasons for treatment withdrawal and dose skipping, respectively. Younger age (49.5±15.0 vs 56.4±12.0 years) (P=0.001) and shorter duration of diabetes (4.8±4.3 vs 8.8±6.3 years) (P=0.0008) and treatment duration (5.2±2.4 vs 10.7±2.4 months) (P=0.0001) were noted, respectively, in discontinuers vs continuers. Basal bolus was the most commonly prescribed insulin regimen (51.0%), while associated with higher likelihood of skipping a dose than regular use (61.3% vs. 46.0%, P=0.04).

CONCLUSIONS

Persistence to insulin therapy was poorer than anticipated but appeared to be higher in patients with the basal bolus regimen. Negative perceptions about insulin therapy seemed to be the main cause for poor adherence in our cohort.

Challenges associated with insulin therapy in type 2 diabetes mellitus

Despite advances in treatment for type 2 diabetes in recent decades, many patients are failing to achieve adequate glycemic control. Poor glycemic control has been shown to have a detrimental effect on patients' health and well-being, and to have significant negative financial implications for both patients and healthcare systems. Insulin therapy has been proven to significantly reduce glycated hemoglobin levels; however, both patients and physicians can be reluctant to initiate insulin therapy. Research shows that both patient and provider factors contribute to a delay in initiation of insulin therapy. This review discusses the most common barriers contributing to this delay with potential solutions to overcome them.

Impact of injection speed and volume on perceived pain during subcutaneous injections into the abdomen and thigh: a single-centre, randomized controlled trial

AIM

The aim of this study was to assess pain associated with subcutaneous injection into the abdomen and thigh of different combinations of injection speeds and volumes.

METHODS

The study was a single-centre, one-visit, double-blinded, randomized controlled trial in 82 adults with type 1 or type 2 diabetes receiving daily injections of insulin or glucagon-like peptide-1 (GLP-1) agonists. Participants received 17 subcutaneous injections (12 in abdomen, 5 in thigh) of saline at different injection speeds (150, 300 and 450 µl/s), with different volumes (400, 800, 1200 and 1600 µl), and two needle insertions without any injection. Pain was evaluated on a 100-mm visual analogue scale (VAS) (0 mm no pain, 100 mm worst pain) and on a yes/no scale for pain acceptability.

RESULTS

Injection speed had no impact on injection pain (p = 0.833). Injection of larger volumes caused significantly more pain [VAS least square mean differences 1600 vs. 400 µl, 7 · 2 mm (95% confidence interval - CI; 4.6-9.7; p < 0.0001); 1600 vs. 800 µl, 7.2 mm (4.4-10.0; p < 0.0001); 1200 vs. 400 µl, 3.5 mm (0.4-6.6; p = 0.025) and 1200 vs. 800 µl, 3.6 mm (0.4-6.7; p = 0.027)]. Significantly more pain occurred in the thigh versus the abdomen [9.0 mm (6.7-11.3; p < 0.0001)].

CONCLUSIONS

Injection speed had no effect on injection pain, whereas higher injection volumes caused more pain. The results of this study may be of value for guiding patients to use the appropriate injection site and technique to reduce their injection pain. Furthermore, these findings may have important implications for the development of new injection devices and drug formulations for clinical practice.

OpT2mise: a randomized controlled trial to compare insulin pump therapy with multiple daily injections in the treatment of type 2 diabetes-research design and methods

BACKGROUND

In insulin-requiring type 2 diabetes patients, current insulin therapy approaches such as basal-alone or basal-bolus multiple daily injections (MDI) have not consistently provided achievement of optimal glycemic control. Previous studies have suggested a potential benefit of continuous subcutaneous insulin infusion (CSII) in these patients. The OpT2mise study is a multicenter, randomized, trial comparing CSII with MDI in a large cohort of subjects with evidence of persistent hyperglycemia despite previous MDI therapy.

SUBJECTS AND METHODS

Subjects were enrolled into a run-in period for optimization of their MDI insulin regimen. Subjects showing persistent hyperglycemia (glycated hemoglobin [HbA1c] ≥8% and ≤12%) were then randomly assigned to CSII or continuing an MDI regimen for a 6-month phase followed by a single crossover of the MDI arm, switching to CSII. The primary end point is the between-group difference in mean change in HbA1c from baseline to 6 months. Secondary end points include change in mean 24-h glucose values, area under the curve and time spent in hypoglycemia and hyperglycemia, measures of glycemic excursions, change in postprandial hyperglycemia, and evaluation of treatment satisfaction. Safety end points include hypoglycemia, hospital admissions, and emergency room visits.

RESULTS

When subject enrollment was completed in May 2013, 495 subjects had been enrolled in the study. The study completion for the primary end point is expected in January 2014.

CONCLUSIONS

OpT2mise will represent the largest studied homogeneous cohort of type 2 diabetes patients with persistent hyperglycemia despite optimized MDI therapy. OpT2mise will help define the role of CSII in insulin intensification and define its safety, rate of hypoglycemia, patient adherence, and patient satisfaction.

Skin blood perfusion and cellular response to insertion of insulin pen needles with different diameters

Today most research on pen needle design revolves around pain perception statements through clinical trials, but these are both costly, timely, and require high sample sizes. The purpose of this study was to test if tissue damage, caused by different types of needles, can be assessed by evaluating skin blood perfusion response around needle insertion sites. Three common sized pen needles of 28G, 30G, and 32G as well as hooked 32G needles, were inserted into the neck skin of pigs and then removed. Laser Speckle Contrast Analysis was used to measure skin blood perfusion for 20 minutes after the insertions. Seven pigs were included in the study and a total of 118 randomized needle insertions were conducted. Histology was made of tissue samples inserted with 18G, 28G, and 32G needles, and stained to quantify red and white blood cell response. Based on area under curve, calculated for each individual blood perfusion recording and grouped according to needle type, skin blood perfusion response relates to needle diameter. The response was significantly higher after insertions with 28G and hooked 32G needles than with 30G (P < .05) and 32G (P < .01) needles. Histology results were not significant, but there was a trend of an increased response with increasing needle diameter. Skin blood perfusion response to pen needle insertions rank according to needle diameter, and the tissue response caused by hooked 32G needles corresponds to that of 28G needles. The relation between needle diameter and trauma when analyzing histology was also suggested.