A comparison of the use of premixed insulins in pen-injectors with conventional patient-mixed insulin treatment in children and adolescents with IDDM. Is there a decreased risk of night hypoglycemia?

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Healthcare professional and patient assessment of a new prefilled insulin pen versus two widely available prefilled insulin pens for ease of use, teaching and learning

OBJECTIVE

FlexTouch * (FT) is a new prefilled insulin pen with no push-button extension at any set dose and a low activation force that is designed to improve ease of use and insulin administration. This paper reports the results of two usability studies assessing perceptions of FT compared with KwikPen † (KP)and SoloStar ‡ (SS) among healthcare professionals (HCPs; both physicians and nurses) and people with diabetes (both insulin pen-experienced and insulin pen-naïve).

RESEARCH DESIGN AND METHODS

Participants were randomly assigned to start with FT or KP in one study and FT or SS in the other. Participants performed injections at different doses (20, 40 and 60 International Units [IU] in the FT vs. KP study or 20, 40 and 80 IU in the FT vs. SS study) into a foam cushion before answering questions on ease of use, teaching and learning, confidence and preference.

RESULTS

A total of 59 people with diabetes and 61 HCPs took part in the FT vs. SS study, and 79 people with diabetes and 81 HCPs took part in the FT vs. KP study. Considerably more patients and HCPs rated FT as very/fairly easy to inject with than KP or SS, particularly at the maximum dose (≥80% vs. ≤38% and ≤23%, respectively), and more were very/rather confident in the ability to manage daily insulin injections with FT than KP or SS. Overall, FT was rated significantly higher for ease of teaching and learning to use than KP or SS (all p < 0.001 vs. FT), and was preferred for teaching and learning compared with KP or SS (≥39% vs. ≤4% and ≤6%, respectively). More patients and HCPs would recommend FT (≥95%) than KP (≤72%) or SS (≤71%). The same pattern was generally seen across physicians, nurses, insulin pen-experienced and pen-naïve participants.

CONCLUSIONS

The findings suggest that devices such as FT are easy to use and can be prescribed with relatively few training needs, which may improve ease of insulin initiation, increase pen use, and ultimately improve treatment adherence. A limitation of the usability questionnaire used in this study is that it did not assess the factors that influence preference. Further analyses could be conducted to determine the factors that appeal to different users.

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

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

A review of 25 years' experience with the NovoPen family of insulin pens in the management of diabetes mellitus

NovoPen, the first insulin pen, was introduced in 1985. This review article is an update of a review paper published in 2006 on 20 years' use of the NovoPen family of insulin pens in the management of diabetes mellitus. The literature searches conducted in the earlier review article were updated with search results for new articles published since April 2005. This was followed by an iterative search of references cited in identified publications and by searches of abstracts from proceedings of major international diabetes conferences since 2005. Most of the original studies identified in the 2006 review showed that insulin regimens using the NovoPen family of insulin pens were at least as effective (and in some cases superior) in maintaining glycaemic control and were as safe (in terms of hypoglycaemia) as conventional insulin regimens employing vials and syringes. Most patients preferred the various NovoPen insulin pens over vials and syringes, with some evidence suggesting that the use of discreet devices, such as those of the NovoPen family, facilitates intensive insulin therapy regimens, thereby helping to improve lifestyle flexibility. The new search results showed that the current generation of the device for the adult population, NovoPen 4, retains these benefits and further meets patients' needs by improving ease of use, convenience and discretion, which may be particularly important for those with manual dexterity, visual or auditory impairments. There was also evidence that healthcare professionals would be more likely to recommend NovoPen 4 to their patients than other devices. The recently introduced NovoPen Echo, designed specifically for the paediatric population, combines half-increment dosing with a memory function that can be used to retrieve information about the time and amount of the last dose, potentially reducing the fear of double dosing or missing a dose. Evidence obtained from the new searches suggested that paediatric patients, their parents and healthcare professionals were highly satisfied with NovoPen Echo overall, with most paediatric patients rating it their favourite pen compared with other insulin pens. In conclusion, new data published over the last 5 years on the use of NovoPen devices add to the large body of published evidence supporting the patient-related benefits of durable insulin injection pens in the treatment of diabetes since the first such pen was introduced in 1985. Together, the benefits of NovoPen are considered likely to improve both patients' quality of life and their compliance with therapy.

Assessment of patient-reported outcomes of insulin pen devices versus conventional vial and syringe

Patient-reported outcomes (PROs) associated with insulin therapy are potentially important determinants of adherence to diabetes management programs. This article reviews published evidence of PROs over the past 3 decades in patients with type 1 diabetes (T1D) and/or type 2 diabetes (T2D) who used vial and syringe for insulin delivery compared to those who used insulin pens. Based on predetermined selection criteria, articles were identified through a search of primary sources published from January 1980 to February 2008. Two independent reviewers determined study eligibility and performed a detailed evaluation of the articles that met the selection criteria. Of the 124 articles screened, 41 met selection criteria. Approximately 75% of the selected articles were published between 1990 and 2008, and a majority (78%) of the research studies was conducted outside the United States. Most (>75%) of the studies evaluated male and female patients with T1D and/or T2D and mean ages around 45 years. Studies used varied comparative study designs with follow-up periods ranging from 2 weeks to 5 years. The PROs assessed in these articles included preference, acceptability, treatment satisfaction, ease of use, convenience, injection pain, handling, and dosing. Most articles (n = 36) showed more favorable PROs for insulin pen users compared to vial and syringe users. These findings have potential clinical and policy implications for patients, diabetes care providers, and/or payers to make evidence-based decisions regarding ways to facilitate initiation and management of insulin therapy.

United States patient preference and usability for the new disposable insulin device Solostar versus other disposable pens

The uptake of insulin pen use has been slow in the United States, despite their advantages over the vial/ syringe. We present results of a United States subset of 150 patients with type 1/type 2 diabetes, who were enrolled in an open-label study, that assessed usability, pen features, and patient preferences for four prefilled insulin pens: SoloSTAR, FlexPen, Lilly disposable pen, and a prototype, Pen X. Overall, the SoloSTAR and FlexPen were more user-friendly; 95 and 88% of patients, respectively, completed the steps correctly (without safety/attach-needle step-deemed independent of device) versus the Lilly disposable pen (60%) and Pen X (61%; all p < 0.05). The SoloSTAR was rated highest most frequently for pen feature comparisons. Results suggest that the SoloSTAR and FlexPen could potentially facilitate insulin use in the United States.

A Review of 20??Years??? Experience with the Novopen?? Family of Insulin Injection Devices

NovoPen, the first insulin pen injector, was introduced in 1985. This article reviews the published evidence over two decades of use of the NovoPen family of injection devices in diabetes management. A search for NovoPen publications from 1985 onwards was conducted in the following databases: MEDLINE/PubMed, Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, Database of Abstract Reviews and Effects, and Cochrane Controlled Trials Register. Publications were examined and underwent a selection process to identify studies of NovoPen devices (NovoPen [1], NovoPen 2, NovoPen 1.5 and NovoPen 3) in the diabetes/insulin therapy area that contained evidence of the effects of NovoPen in a variety of categories. Of the studies identified, most showed that insulin regimens using the NovoPen family of devices are at least as effective (and in some cases superior) in maintaining glycaemic control and are as safe (in terms of hypoglycaemia) as conventional insulin regimens employing syringes. The published evidence identified also showed that insulin administration via NovoPen devices was for most patients easier, more convenient and quicker than with conventional syringes and that most patients preferred the various NovoPen devices over syringes. There was also some evidence that the use of discreet devices, like those of the NovoPen family, facilitates adherence to intensive insulin therapy regimens, helps to improve lifestyle flexibility and reduces injection pain compared with conventional syringe-based regimens. Together these benefits of NovoPen devices are considered likely to improve both patients' quality of life and compliance with therapy. In conclusion, a large body of published evidence accumulated over the past two decades testifies to the patient-related benefits of the NovoPen family of insulin injection devices in the treatment of diabetes.

Emerging protein delivery methods

The efficient and safe delivery of therapeutic proteins is the key to commercial success and, in some cases, the demonstration of efficacy in current and future biotechnology products. Numerous delivery technologies and companies have evolved over the past year. To critically evaluate the available options, each method must be assessed in terms of how easily it can be manufactured, impact on protein quality, bioavailability, and toxicity. Recent advances in depot delivery systems have, for the most part, overcome all of these obstacles except for complex and costly manufacturing. On the other hand, pulmonary delivery usually involves efficient manufacturing, but low protein bioavailability resulting in higher doses compared with injections. Although recent advances in transdermal and oral delivery have been significant, both of these delivery routes require logarithmic increases in bioavailability to make them viable candidates for commercialization. In the next few years, protein delivery for commercial products will probably be limited to injection devices, depot systems and pulmonary administration.