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Rosenstock J, Bajaj HS, Lingvay I, Heller SR. Clinical perspectives on the frequency of hypoglycemia in treat-to-target randomized controlled trials comparing basal insulin analogs in type 2 diabetes: a narrative review. BMJ Open Diabetes Res Care 2024; 12:e003930. [PMID: 38749508 PMCID: PMC11097869 DOI: 10.1136/bmjdrc-2023-003930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/26/2024] [Indexed: 05/18/2024] Open
Abstract
The objective of this review was to comprehensively present and summarize trends in reported rates of hypoglycemia with one or two times per day basal insulin analogs in individuals with type 2 diabetes to help address and contextualize the emerging theoretical concern of increased hypoglycemic risk with once-weekly basal insulins.Hypoglycemia data were extracted from treat-to-target randomized clinical trials conducted during 2000-2022. Published articles were identified on PubMed or within the US Food and Drug Administration submission documents. Overall, 57 articles were identified: 44 assessed hypoglycemic outcomes in participants receiving basal-only therapy (33 in insulin-naive participants; 11 in insulin-experienced participants), 4 in a mixed population (insulin-naive and insulin-experienced participants) and 9 in participants receiving basal-bolus therapy. For the analysis, emphasis was placed on level 2 (blood glucose <3.0 mmol/L (<54 mg/dL)) and level 3 (or severe) hypoglycemia.Overall, event rates for level 2 or level 3 hypoglycemia across most studies ranged from 0.06 to 7.10 events/person-year of exposure (PYE) for participants receiving a basal-only insulin regimen; the rate for basal-bolus regimens ranged from 2.4 to 13.6 events/PYE. Rates were generally lower with second-generation basal insulins (insulin degludec or insulin glargine U300) than with neutral protamine Hagedorn insulin or first-generation basal insulins (insulin detemir or insulin glargine U100). Subgroup categorization by sulfonylurea usage, end-of-treatment insulin dose or glycated hemoglobin reduction did not show consistent trends on overall hypoglycemia rates. Hypoglycemia rates reported so far for once-weekly basal insulins are consistent with or lower than those reported for daily-administered basal insulin analogs.
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Affiliation(s)
| | | | - Ildiko Lingvay
- Endocrinology Division, Department of Internal Medicine and Peter O'Donnell School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Simon R Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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2
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 7. Diabetes Technology: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S126-S144. [PMID: 38078575 PMCID: PMC10725813 DOI: 10.2337/dc24-s007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
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.
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3
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De Mesmaeker G, Calles B, Smith JA. Analysis of Nurse and Patient Preferences for Pre-Filled Pen Devices for Self-Injection of Highly Purified Human Menopausal Gonadotropin (HP-hMG, MENOPUR ®). Patient Prefer Adherence 2023; 17:1281-1292. [PMID: 37220565 PMCID: PMC10200119 DOI: 10.2147/ppa.s385247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 05/02/2023] [Indexed: 05/25/2023] Open
Abstract
Purpose This study aimed to identify the most important attributes for a gonadotropin pen as perceived by assisted reproductive technology (ART) patients and fertility nurses, and to examine how well a prototype HP-hMG (MENOPUR®) pen reflects these preferences. Patients and Methods This market research study incorporated a two-part survey with respondents (N=221) from Poland, Spain and the UK. Respondents included patients (n=141) who consulted a fertility specialist in the previous 2 years, and fertility nurses (n=80) who assisted in at least 75 ART cycles/year. Patients were divided into two subgroups depending on their experience with ART (experienced and naïve). Key attributes for an injection pen, as perceived by patients and nurses, were assessed via an online survey and ranked by their relative importance using Anchored Maximum Difference Scaling. After performing a dummy injection, respondents compared the attributes of an unbranded prototype pen against the key attributes identified. Results Across all survey respondents, the ability to correct the dialed dose was considered to be the most important product attribute of a gonadotropin pen. Confidence in the patient's ability to inject correctly at home was also identified as a key attribute, considered by both nurses and naïve patients as extremely high. When considering the prototype pen device, almost all study respondents reported a positive experience (99%) with 72% rating it as "very good". The prototype pen was perceived to possess the key attributes considered important for a gonadotropin pen by patients and nurses, including correcting the dose, the ability to self-inject safely and correctly, ease of preparation and use, and an injection which appeared to be as painless as possible. Conclusion The prototype pen was found to perform well across all key attributes, especially those considered most important in gonadotropin pens, suggesting that it is a user-friendly option for patients undergoing ART.
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Affiliation(s)
- Guy De Mesmaeker
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
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Del Baldo F, Colajanni L, Corradini S, Palagiano P, Di Cunzolo A, Perissinotto L, Drudi I, Horspool L, Fracassi F. Owner preference for insulin delivery device and glycaemic control in diabetic dogs. J Small Anim Pract 2023; 64:255-264. [PMID: 36316285 DOI: 10.1111/jsap.13573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 08/26/2022] [Accepted: 09/06/2022] [Indexed: 04/12/2023]
Abstract
OBJECTIVES To assess treatment satisfaction and owner preference for two delivery devices (VetPen, MSD Animal Health, and U40 insulin syringes) and the effect on glycaemic control in diabetic dogs treated with porcine insulin zinc suspension. MATERIALS AND METHODS Randomised prospective cross-over study with two arms, each of 8 weeks. Twenty client-owned diabetic dogs on insulin treatment by U40 syringe were enrolled. Dogs were randomly assigned to receive insulin by syringe or pen injector for 2 months, followed by 2 months of the other injection method. Treatment satisfaction and owners' insulin delivery device preference were assessed using a questionnaire. Glycaemic control was assessed using a clinical score, serum fructosamine and glycated haemoglobin (HbA1c%) at the time of the enrolment (T0) and the end of each arm of treatment (T2 and T4). RESULTS Treatment satisfaction differed for the two types of the delivery device when the order that each device was used was taken into consideration. Owners who used the syringe first did not have a significant preference for an injection device. In contrast, owners who used the pen injector first expressed a significant preference for VetPen compared to syringes. No significant differences in the number of dogs of Groups 1 and 2 with good and poor glycaemic control at T2 and T4 were detected. CLINICAL SIGNIFICANCE Overall treatment satisfaction and preference for the two delivery methods were similar. However, VetPen was preferred by owners who were randomised to use this device first. Glycaemic control did not appear to be affected by the insulin delivery device used.
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Affiliation(s)
- F Del Baldo
- Department of Veterinary Medical Science, University of Bologna, Bologna, Italy
| | - L Colajanni
- Department of Veterinary Medical Science, University of Bologna, Bologna, Italy
| | - S Corradini
- Clinica Veterinaria dell'Orologio, Sasso Marconi, Italy
| | | | | | | | - I Drudi
- Department of Statistical Sciences, University of Bologna, Bologna, Italy
| | - L Horspool
- MSD Animal Health, Boxmeer, The Netherlands
| | - F Fracassi
- Department of Veterinary Medical Science, University of Bologna, Bologna, Italy
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5
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Kamrul-Hasan ABM, Hannan MA, Alam MS, Rahman MM, Asaduzzaman M, Mustari M, Paul AK, Kabir ML, Chowdhury SR, Talukder SK, Sarkar S, Hannan MA, Islam MR, Iftekhar MH, Robel MAB, Selim S. 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. BMC Endocr Disord 2023; 23:37. [PMID: 36782190 PMCID: PMC9926700 DOI: 10.1186/s12902-023-01292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 02/06/2023] [Indexed: 02/15/2023] Open
Abstract
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.
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Affiliation(s)
- A B M Kamrul-Hasan
- Department of Endocrinology, Mymensingh Medical College, Mymensingh, Bangladesh.
| | | | | | | | - Md Asaduzzaman
- Department of Endocrinology, Shaheed Sheikh Abu Naser Specialized Hospital, Khulna, Bangladesh
| | - Marufa Mustari
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Ajit Kumar Paul
- Department of Endocrinology, Mainamoti Medical College, Cumilla, Bangladesh
| | - Md Lutful Kabir
- Department of Endocrinology, Rangpur Medical College, Rangpur, Bangladesh
| | - Sumon Rahman Chowdhury
- Department of Diabetes, Endocrinology and Metabolism, Chittagong Diabetic General Hospital, Chattogram, Bangladesh
| | | | - Sourav Sarkar
- Department of Medicine, Boalkhali Upazila Health Complex, Chattogram, Bangladesh
| | | | | | | | | | - Shahjada Selim
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA. 7. Diabetes Technology: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S111-S127. [PMID: 36507635 PMCID: PMC9810474 DOI: 10.2337/dc23-s007] [Citation(s) in RCA: 116] [Impact Index Per Article: 116.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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7
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Langerman C, Forbes A, Robert G. The experiences of insulin use among older people with Type 2 diabetes mellitus: A thematic synthesis. Prim Care Diabetes 2022; 16:614-626. [PMID: 36089508 DOI: 10.1016/j.pcd.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Type 2 diabetes mellitus is common in older people. Managing diabetes in older people can be challenging due to comorbidities and age-related disabilities, particularly in the context of insulin therapy. The purpose of this review is to explore older people's experiences of insulin use and to consider how these experiences might inform healthcare delivery. REVIEW METHODS A systematic review with thematic synthesis was conducted and reported in accordance with the PRISMA and ENTREQ statements. MEDLINE, Embase, PsycInfo, CINAHL and Web of Science were searched from 1985 to September 2019 with subsequent updates in December 2019 and June 2022. Included studies were quality appraised, findings tabulated, and results used to inform an integrated thematic synthesis. RESULTS Fourteen studies that reported insulin experiences with 274 patients aged 60 years and over were included; nine of the studies were qualitative and five used questionnaires surveys. Seven themes emerged that were grouped into treatment-related factors (physical impact of insulin, physical capacity to administer insulin, insulin self-management behaviours) and person-centred factors (emotional factors, social factors, daily living, and personal knowledge/beliefs). Three analytical themes to guide clinical practice were derived from the data: addressing physical capacity and ability, supporting social and emotional issues and improving interactions with healthcare professionals. CONCLUSION The review indicates issues surrounding the technical aspects of insulin administration, side effects of treatment and reactions to insulin administration are common amongst older people. However, research evidence is limited, and there is an urgent need for empirical, participatory research with older insulin dependent adults with type 2 diabetes. IMPLICATIONS FOR PRACTICE Healthcare professionals need to ensure that older type 2 diabetes people on insulin are actively involved in their own care, to allow their insulin regimens to be personalised and aligned with their goals and expectations. Tailored educational interventions to reduce treatment hazards and promote physical and psychological wellbeing are also needed for this population.
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Affiliation(s)
- Chaya Langerman
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom.
| | - Angus Forbes
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom
| | - Glenn Robert
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom
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8
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Masierek M, Nabrdalik K, Janota O, Kwiendacz H, Macherski M, Gumprecht J. The Review of Insulin Pens-Past, Present, and Look to the Future. Front Endocrinol (Lausanne) 2022; 13:827484. [PMID: 35355552 PMCID: PMC8959107 DOI: 10.3389/fendo.2022.827484] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/02/2022] [Indexed: 12/17/2022] Open
Abstract
Currently, there are about 150-200 million diabetic patients treated with insulin globally. The year 2021 is special because the 100th anniversary of the insulin discovery is being celebrated. It is a good occasion to sum up the insulin pen technology invention and improvement which are nowadays the leading mode of an insulin delivery. Even though so many years have passed, insulin is still administered subcutaneously, that is why devices to deliver it are of great importance. Insulin pens have evolved only through the last decades (the reusable, durable pens, and the disposable, prefilled pens) and modern smart insulin pens have been developed in the last few years, and both types of the devices compared to traditional syringes and vials are more convenient, discrete in use, have better dosing accuracy, and improve adherence. In this review, we will focus on the history of insulin pens and their improvement over the previous decades.
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Affiliation(s)
- Małgorzata Masierek
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Nabrdalik
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- *Correspondence: Katarzyna Nabrdalik,
| | - Oliwia Janota
- Students’ Scientific Association by the Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Hanna Kwiendacz
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Maksymilian Macherski
- Students’ Scientific Association by the Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Janusz Gumprecht
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
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Abstract
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.
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10
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Malerba E, Fracassi F, Del Baldo F, Golinelli S, Ceccherini M, Barbarossa A. The accuracy and precision of insulin administration using human and veterinary pen-injectors and syringes for administration of insulin. J Vet Intern Med 2021; 35:1255-1264. [PMID: 33991138 PMCID: PMC8163132 DOI: 10.1111/jvim.16126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/28/2021] [Accepted: 04/01/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Many diabetic dogs and cats require small doses of insulin that must be administered accurately. OBJECTIVES To compare the accuracy and precision of insulin syringes and pen-injectors. ANIMALS None. METHODS To determine how accurately and precisely insulin doses are delivered, 0.5, 1, 2, 4, 8, and 16 U doses were dispensed 25 times from 5 SoloSTARs, 5 FlexPens, 5 KwikPens, 5 JuniorSTARs, 5 VetPens 0.5-8 U, 5 VetPens 1-16 U, and by 5 veterinarians using 30 U/0.3 mL and 40 U/mL insulin syringes. Each dose was weighed, using a precision balance, and the intended and delivered doses were compared. RESULTS All pen-injectors delivered less insulin than the intended dose, underdosage being inversely proportional to insulin dose. The differences between the intended and the delivered dose were not significant using JuniorSTAR and VetPen 0.5-8 U at insulin doses of 0.5, 1, 2, and 4 U, using the 30 U/0.3 mL insulin syringe at the 4 U dose and using the 40 U/mL insulin syringe at the 4, 8, and 16 U doses. With all the devices, precision increased with increasing doses of insulin. The coefficient of variation was <8% for all 6 pen-injectors. Conversely, using 30 U/0.3 mL and 40 U/mL syringes at an insulin dosage of 0.5 U the coefficients of variation were 12.08% and 9.39%, respectively. CONCLUSIONS AND CLINICAL IMPORTANCE JuniorSTAR and VetPen 0.5-8 U were more accurate than the other devices when delivering ≤2 U doses, while the delivery of 8 and 16 U doses was more accurate using 40 U/mL syringes.
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Affiliation(s)
- Eleonora Malerba
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Italy
| | - Federico Fracassi
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Italy
| | - Francesca Del Baldo
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Italy
| | - Stefania Golinelli
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Italy
| | - Martina Ceccherini
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Italy
| | - Andrea Barbarossa
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Italy
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Dubey SK, Alexander A, Pradhyut KS, Agrawal M, Jain R, Saha RN, Singhvi G, Saraf S, Saraf S. Recent Avenues in Novel Patient-Friendly Techniques for the Treatment of Diabetes. Curr Drug Deliv 2020; 17:3-14. [DOI: 10.2174/1567201816666191106102020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/14/2019] [Accepted: 10/15/2019] [Indexed: 12/26/2022]
Abstract
Background:
Diabetes is one of the most common chronic metabolic disorders which affect
the quality of human life worldwide. As per the WHO report, between 1980 to 2014, the number of
diabetes patients increases from 108 million to 422 million, with a global prevalence rate of 8.5% per
year. Diabetes is the prime reason behind various other diseases like kidney failure, stroke, heart disorders,
glaucoma, etc. It is recognized as the seventh leading cause of death throughout the world. The
available therapies are painful (insulin injections) and inconvenient due to higher dosing frequency.
Thus, to find out a promising and convenient treatment, extensive investigations are carried out globally
by combining novel carrier system (like microparticle, microneedle, nanocarrier, microbeads etc.) and
delivery devices (insulin pump, stimuli-responsive device, inhalation system, bioadhesive patch, insulin
pen etc.) for more precise diagnosis and painless or less invasive treatment of disease.
Objective:
The review article is made with an objective to compile information about various upcoming
and existing modern technologies developed to provide greater patient compliance and reduce the undesirable
side effect of the drug. These devices evade the necessity of daily insulin injection and offer a
rapid onset of action, which sustained for a prolonged duration of time to achieve a better therapeutic
effect.
Conclusion:
Despite numerous advantages, various commercialized approaches, like Afrezza (inhalation
insulin) have been a failure in recent years. Such results call for more potential work to develop a
promising system. The novel approaches range from the delivery of non-insulin blood glucose lowering
agents to insulin-based therapy with minimal invasion are highly desirable.
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Affiliation(s)
- Sunil Kumar Dubey
- Department of Pharmacy, Faculty of Pharmacy, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Pilani Campus, Rajasthan, India
| | - Amit Alexander
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER GUWAHATI), Ministry of Chemicals & Fertilizers, Govt. of India, NH 37, NITS Mirza, Kamrup- 781125, Guwahati (Assam), India
| | - K. Sai Pradhyut
- Department of Pharmacy, Faculty of Pharmacy, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Pilani Campus, Rajasthan, India
| | - Mukta Agrawal
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER GUWAHATI), Ministry of Chemicals & Fertilizers, Govt. of India, NH 37, NITS Mirza, Kamrup- 781125, Guwahati (Assam), India
| | - Rupesh Jain
- Department of Pharmacy, Faculty of Pharmacy, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Pilani Campus, Rajasthan, India
| | - Ranendra Narayana Saha
- Department of Biotechnology, Faculty of Biotechnology, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Dubai Campus, Dubai, United Arab Emirates
| | - Gautam Singhvi
- Department of Pharmacy, Faculty of Pharmacy, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Pilani Campus, Rajasthan, India
| | - Swarnlata Saraf
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, Chhattisgarh 492 010, India
| | - Shailendra Saraf
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, Chhattisgarh 492 010, India
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13
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Warren ML, Brod M, Håkan-Bloch J, Sparre T, Chaykin LB. 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. Curr Med Res Opin 2019; 35:1623-1629. [PMID: 30974973 DOI: 10.1080/03007995.2019.1605769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Thomas Sparre
- Medical & Science Devices & Titration, Novo Nordisk A/S, Søborg, Denmark
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Lohmeyer Q, Schneider A, Jordi C, Lange J, Meboldt M. Toward a new age of patient centricity? The application of eye-tracking to the development of connected self-injection systems. Expert Opin Drug Deliv 2019; 16:163-175. [PMID: 30577710 DOI: 10.1080/17425247.2019.1563070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Increasing interest in digitally enhanced drug delivery tools urges both industry and academia to rethink current approaches to product usability testing. This article introduces mobile eye-tracking, generating detailed contextual data about user engagement with connected self-injection systems as a new methodological approach to formative usability assessment. METHODS A longitudinal case study with a total of 35 injection-naïve participants was conducted. In three consecutive experiments, eye-tracking was applied to formative usability testing of a novel connected self-injection device. Three eye-tracking derived usability indicators were established to assess product effectiveness, efficiency, and ease of use. RESULTS Analysis of the data revealed events of user hesitation, process interruption and unintended action, and these occurrences could either be completely eliminated or significantly reduced throughout the process (product effectiveness). At the same time, the overall use duration decreased from 86.1 to 58.7 sec (product efficiency). Analysis revealed that product modifications successfully guided user attention to those interface elements most relevant during each task, thereby improving product ease-of-use. CONCLUSIONS The step-wise improvement in the usability indicators demonstrates that iteratively applying eye-tracking methods effectively supports the user-centered design of connected self-injection systems. The results highlight how eye-tracking can be employed to gain an in-depth understanding of patient engagement with novel healthcare technologies.
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Affiliation(s)
- Quentin Lohmeyer
- a Product Development Group Zurich, Department of Mechanical and Process Engineering , ETH Zurich , Zurich , Switzerland
| | | | | | | | - Mirko Meboldt
- a Product Development Group Zurich, Department of Mechanical and Process Engineering , ETH Zurich , Zurich , Switzerland
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Baghban Taraghdari Z, Imani R, Mohabatpour F. A Review on Bioengineering Approaches to Insulin Delivery: A Pharmaceutical and Engineering Perspective. Macromol Biosci 2019; 19:e1800458. [DOI: 10.1002/mabi.201800458] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Zahra Baghban Taraghdari
- Z. Baghban Taraghdari, Dr. R. Imani, F. MohabatpourDepartment of Biomedical EngineeringAmirkabir University of Technology Tehran 15875/4413 Iran
| | - Rana Imani
- Z. Baghban Taraghdari, Dr. R. Imani, F. MohabatpourDepartment of Biomedical EngineeringAmirkabir University of Technology Tehran 15875/4413 Iran
| | - Fatemeh Mohabatpour
- Z. Baghban Taraghdari, Dr. R. Imani, F. MohabatpourDepartment of Biomedical EngineeringAmirkabir University of Technology Tehran 15875/4413 Iran
- Division of Biomedical EngineeringUniversity of Saskatchewan Saskatoon S7N5A9 Canada
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Assessment of Insulin Injection Practice of Nurses Working in a Tertiary Healthcare Center of Nepal. Nurs Res Pract 2018; 2018:9375067. [PMID: 30155295 PMCID: PMC6093053 DOI: 10.1155/2018/9375067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/21/2018] [Accepted: 07/18/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction Sound knowledge and good practice on insulin injection technique are essential for nurses in order to administer insulin correctly and to educate patients or their relatives adequately. This study aimed to assess the insulin injection practice through the use of insulin pen among nurses working in a tertiary healthcare center of Nepal. Materials and Methods A cross-sectional descriptive study was conducted among 67 nurses working in one of the tertiary healthcare centers of Nepal. Demographic information and insulin injection practice of nurses through the use of insulin pen were assessed using self-administered questionnaire. Each correct practice was scored “1” and incorrect practice was scored “0.” Results. The median (IQR) insulin injection practice score of nurses was 11 (9-12) out of 16. Thirty-seven (55.2%) nurses store insulin pen filled with insulin cartridge at room temperature while 57 (85.1%) nurses store unopened cartridge at refrigerator (2-8°C). The practice of hand washing and injection site cleaning was mentioned by 92.5% and 82.1% of the nurses, respectively. However, just over half of the nurses mix the premix (cloudy) insulin and prime insulin pen before each injection. Thirty-four (50.7%) nurses do not lift skin during injection and more than half of the nurses keep needle beneath the skin for less than 5 seconds after completely injecting the required dose of insulin. One out of ten nurses massage injection site after injecting insulin. Most of the nurses (86.6%) use single needle more than once and the median (IQR) frequency of needle reuse was 6 (3-12). Similarly, systematic site rotation was performed by 59 (88.1%) nurses and twenty (29.9%) nurses claim that they use single insulin pen for two different cartridges. Conclusion The insulin injection practice of nurses assessed through the use of insulin pen was suboptimal and highlights the need for urgent educational intervention.
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Diabetes Mellitus with Poor Glycemic Control as a Consequence of Inappropriate Injection Technique. Case Rep Endocrinol 2018; 2018:7236452. [PMID: 29805817 PMCID: PMC5899865 DOI: 10.1155/2018/7236452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 02/16/2018] [Accepted: 02/25/2018] [Indexed: 01/12/2023] Open
Abstract
Majority of patients with diabetes mellitus (DM), who are on insulin therapy, use insulin pen for convenience, accuracy, and comfort. Some patients may require two different types of insulin preparations for better glycemic control. We have reported a case of poor glycemic control as a consequence of inappropriate insulin injection technique. A 57-year-old man with type 2 DM had been using premix insulin 30 : 70 for his glycemic control for the last 12 years. On follow-up visit, his blood sugar level (BSL) had increased; therefore the treating physician increased the dose of premix insulin and added basal insulin with the aim of controlling his blood sugar level. Despite these changes, his BSL was significantly higher than his previous level. On investigation, the cause of his poor glycemic control was found to be due to inadequate delivery of insulin (primarily premix) as a consequence of lack of priming and incompatibility of single insulin pen for two cartridges. His basal insulin was discontinued and the patient along with his grandson was instructed to administer insulin correctly. After correction of the errors, the patient had a better glycemic control.
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Schneider AE, Lange J. Pen devices for self-injection: contrasting measured injection force with users' perceived ease of injection. Expert Opin Drug Deliv 2017; 15:115-125. [PMID: 29226723 DOI: 10.1080/17425247.2018.1415884] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVES Past research has emphasized injection force as a clinically highly relevant technical attribute of pen devices. However, little work has been conducted to relate these results to in-use studies. This article explores whether and how differences in pen injection force profiles influence users' self-reported perceived ease of injection and preferences. METHODS Three different pen systems were subjected to measurements of injection force using an automated mechanical set-up followed by a simulated use study where users assessed perceived ease of injection. MAIN OUTCOMES MEASURE Outcomes were measured by fitting data of measured injection force and perceived ease of injection using a linear model. RESULTS Although mechanical testing revealed significant differences between the three pen's measured injection forces these differences were not directly perceived by users in simulated injection studies. CONCLUSION The article bridges literature on injection force measurement and simulated use. It reveals how users' perceived ease of injection is less sensitive to measured injection forces than prior research has assumed. Thus, future research should holistically integrate patient feedback in new device development. Key limitations of this work are the low number of participants in the simulated use study and the fact that the ease of injection was assessed indirectly.
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Affiliation(s)
- Luigi F Meneghini
- 1 Division of Endocrinology, UT Southwestern Medical Center , Dallas, Texas
- 2 Global Diabetes Program, Parkland Health & Hospital System , Dallas, Texas
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Guo X, Wang W. Challenges and recent advances in the subcutaneous delivery of insulin. Expert Opin Drug Deliv 2016; 14:727-734. [PMID: 27626885 DOI: 10.1080/17425247.2016.1232247] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Xiaohui Guo
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Wei Wang
- Department of Endocrinology, Peking University First Hospital, Beijing, China
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Lasalvia P, Barahona-Correa JE, Romero-Alvernia DM, Gil-Tamayo S, Castañeda-Cardona C, Bayona JG, Triana JJ, Laserna AF, Mejía-Torres M, Restrepo-Jimenez P, Jimenez-Zapata J, Rosselli D. Pen Devices for Insulin Self-Administration Compared With Needle and Vial: Systematic Review of the Literature and Meta-Analysis. J Diabetes Sci Technol 2016; 10:959-66. [PMID: 26920639 PMCID: PMC4928229 DOI: 10.1177/1932296816633721] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Pen devices offer advantages compared with vial and syringe (VaS). The purpose of this article was to evaluate efficacy of pen devices compared to VaS. METHODS A systematic review of literature was performed in 8 different databases. References were independently screened and selected. Primary observational or experimental studies comparing pen devices with VaS for insulin administrations were included. Studies on specific populations were excluded. Risk of bias was evaluated using appropriate tools. Data on glycosylated hemoglobin (HbA1c), hypoglycemia, adherence, persistence, patient preference, and quality of life (QOL) were collected. Meta-analysis was performed when appropriate. Heterogeneity and risk of publication bias were evaluated. Otherwise, descriptive analyses of the available data was done. RESULTS In all, 10 348 articles were screened. A total of 17 studies were finally selected: 7 experimental and 10 analytical. The populations of the included articles were mainly composed of adults with type 2 diabetes mellitus. Important risk of bias was found in all of the articles, particularly experimental studies. Meta-analyses were performed for HbA1c, hypoglycemia, adherence and persistence. Pen device showed better results in mean HbA1c change, patients with hypoglycemia, adherence and persistence compared to VaS. No difference was observed in number of patients achieving <7% HbA1c. Preference studies showed a tendency favoring pen devices, however nonvalidated tools were used. One QoL study showed improvements in some subscales of SF-36. CONCLUSIONS There is evidence that pen devices offer benefits in clinical and, less clearly, patient-reported outcomes compared to VaS for insulin administration. However, these results should be taken with caution.
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Affiliation(s)
| | | | | | | | - Camilo Castañeda-Cardona
- Pontificia Universidad Javeriana, Medical School, Bogota, Colombia NeuroEconomix SAS, Bogota, Colombia
| | | | - Juan José Triana
- Pontificia Universidad Javeriana, Medical School, Bogota, Colombia
| | | | | | | | | | - Diego Rosselli
- Pontificia Universidad Javeriana, Medical School, Bogota, Colombia
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Ball L, Davmor R, Leveritt M, Desbrow B, Ehrlich C, Chaboyer W. The nutrition care needs of patients newly diagnosed with type 2 diabetes: informing dietetic practice. J Hum Nutr Diet 2016; 29:487-94. [DOI: 10.1111/jhn.12357] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- L. Ball
- Centre for Health Practice Innovation; Menzies Health Institute Queensland; Griffith University; Gold Coast QLD Australia
| | - R. Davmor
- Centre for Health Practice Innovation; Menzies Health Institute Queensland; Griffith University; Gold Coast QLD Australia
| | - M. Leveritt
- School of Human Movement and Nutrition Sciences; The University of Queensland; Brisbane QLD Australia
| | - B. Desbrow
- Centre for Health Practice Innovation; Menzies Health Institute Queensland; Griffith University; Gold Coast QLD Australia
| | - C. Ehrlich
- Centre for Population and Social Health; Menzies Health Institute, Queensland; Griffith University; Gold Coast QLD Australia
| | - W. Chaboyer
- Centre for Health Practice Innovation; Menzies Health Institute Queensland; Griffith University; Gold Coast QLD Australia
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Gelhorn HL, Poon JL, Davies EW, Paczkowski R, Curtis SE, Boye KS. Evaluating preferences for profiles of GLP-1 receptor agonists among injection-naïve type 2 diabetes patients in the UK. Patient Prefer Adherence 2015; 9:1611-22. [PMID: 26635470 PMCID: PMC4646588 DOI: 10.2147/ppa.s90842] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To use a discrete choice experiment (DCE) to evaluate preferences for the actual treatment features and overall profiles of two injectable glucagon-like peptide-1 receptor agonists (dulaglutide and liraglutide) among patients with type 2 diabetes mellitus (T2DM) in the UK. METHODS In-person interviews were conducted in the UK to administer a DCE to patients with self-reported T2DM, naïve to treatment with injectable medications. The DCE examined six attributes of T2DM treatment each described by two levels: "dosing frequency," "hemoglobin A1c change," "weight change," "type of delivery system," "frequency of nausea," and "frequency of hypoglycemia." Part-worth utilities were estimated using random effects logit models and were used to calculate relative importance (RI) values for each attribute. A chi-square test was used to determine differences in preferences for dulaglutide versus liraglutide profiles. RESULTS A total of 243 participants [mean age: 60.5 (standard deviation 10.9) years; 76.1% male; mean body mass index: 29.8 (standard deviation 5.4) kg/m(2)] completed the study. RI values for the attributes in rank order were: "dosing frequency" (41.6%), "type of delivery system" (35.5%), "frequency of nausea" (10.4%), "weight change" (5.9%), "hemoglobin A1c change" (3.6%), and "frequency of hypoglycemia" (3.0%). Significantly more participants preferred the dulaglutide profile (83.1%) compared with the liraglutide profile (16.9%; P<0.0001). CONCLUSION This study elicited patients' preferences for attributes and levels representing the actual characteristics of two specific glucagon-like peptide-1 medications. In this context, dosing frequency and type of delivery system were most important, accounting for over 75% of the RI. While previous studies have identified efficacy as highly important in T2DM medication decisions, this study suggests that when differences in efficacy between medications are small, other treatment features (eg, dosing frequency and delivery system) are of much greater importance to patients.
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Affiliation(s)
| | | | | | - Rosirene Paczkowski
- Global Patient Outcomes and Real World Evidence, Eli Lilly and Company, Indianapolis, IN, USA
| | - Sarah E Curtis
- Global Patient Outcomes and Real World Evidence, Eli Lilly and Company, Indianapolis, IN, USA
| | - Kristina S Boye
- Global Patient Outcomes and Real World Evidence, Eli Lilly and Company, Indianapolis, IN, USA
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Perez-Nieves M, Jiang D, Eby E. Incidence, prevalence, and trend analysis of the use of insulin delivery systems in the United States (2005 to 2011). Curr Med Res Opin 2015; 31:891-9. [PMID: 25710707 DOI: 10.1185/03007995.2015.1020366] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Estimate the incidence and prevalence rates and assess overall trends among patients with diabetes using insulin vial/syringe and pens over time. METHODS A retrospective study was conducted using the Truven MarketScan database from 1 July 2004 to 31 December 2011. The database contained medical and pharmacy claims of >20 million US residents insured by commercial health plans. Patients with diabetes who utilized vial/syringe and pens were included. Incidence rate was defined as the proportion of patients initiating a new insulin type for the first time with vial/syringe and pens within each year from 2005 to 2011 among the total number of patients initiating that particular insulin type for the first time. Prevalence rate was defined as the proportion of patients using vial/syringe or pens among patients with diabetes using that insulin type within each year from 2005 to 2011. A linear trend over time was assessed by Cochran-Armitage Trend tests and Generalized Estimating Equations. RESULTS Incidence of patients initiating vial/syringe decreased from 2005 to 2011 (basal analog [90.5% to 31.3%]; mealtime analog [67.6% to 37.1%]), while patients initiating pens increased (basal analog [9.5% to 68.7%]; mealtime analog [32.4% to 62.9%]). There was a significant trend over time indicating increased usage of pens relative to vial/syringe; the number of pen users increased (all p < 0.0001 except mealtime human). Prevalence of patients using vial/syringe decreased from 2005 to 2011 (basal analog [93.8% to 41.2%]; mealtime analog [71.0% to 50.6%]), while patients using pens increased (basal analog [6.2% to 58.8%]; mealtime analog [29.0% to 49.4%]). From 2005 to 2011, patients were more likely to use pens than vial/syringe (all p < 0.0001 except for human mixtures and mealtime human). CONCLUSIONS The incidence and prevalence of patients using the traditional vial/syringe decreased over time, while the use of pens increased. Some patient populations may be under-represented, limiting generalizability of results.
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