FlexTouch® for the delivery of insulin: technical attributes and perception among patients and healthcare professionals

Development of an Insulin Pen is a Patient-Centric Multidisciplinary Undertaking: A Commentary

The goal of human-centered insulin pen design is to relieve the treatment burden of a chronic condition and help affected individuals to feel free of disease. The patient as well as their entire ecosystem should be considered. At Novo Nordisk A/S, we believe that embedding human-centered design at the heart of our development processes is best achieved with multidisciplinary experts in-house to work alongside product development teams and, importantly, the end user. Novo Nordisk introduced the first commercially available insulin pen in 1985 and has continued to develop reusable/durable and prefilled insulin pens to meet different patient needs, through to the latest NovoPen 6 and NovoPen Echo Plus with SMART technology. Human-centered design is essential for delivering meaningful and practical solutions for individuals with diabetes.

User-Centric Approach to Specifying Technical Attributes of Drug Delivery Devices: Empirical Study of Autoinjector-Cap Removal Forces

PURPOSE

The subcutaneous delivery of biologics using pre-filled autoinjector devices continues to attract broad scholarly interests. However, research still lacks a detailed understanding of user perceptions as the basis for specifying the clinically relevant technical attributes of a device, such as the cap-removal force. Therefore, this article studies the ability of users to remove the autoinjector cap, as well as the effects of the cap-removal force and user characteristics on the perceived ease of decapping.

PATIENTS AND METHODS

Forty-two participants among patients, caregivers, and healthcare professionals removed the protective cap using non-functional devices with different target cap-removal forces between 25 N and 55 N. Data were collected on the ability of the users to effectively decap the device and their perceived ease of decapping. Linear regression was then applied to quantify the impact of the decapping force and patient characteristics on the perceived ease of decapping.

RESULTS

The participants of the study effectively decapped all autoinjector devices irrespective of age, sex, and dexterity impairments. Moreover, the study reveals that the perceived ease of decapping decreases significantly with increasing decapping force and participants' dexterity impairments.

CONCLUSION

The study provides initial empirical evidence on the ability of users to decap autoinjector devices and shows how increasing the cap-removal force and dexterity impairments reduce the perceived ease of decapping.

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

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

Achieving Glycaemic Control with Concentrated Insulin in Patients with Type 2 Diabetes

The recent introduction of the second-generation long-acting analogue insulins degludec and insulin glargine U300 have increased the choice of basal insulin therapy for patients with type 2 diabetes. The pharmacokinetic and pharmacodynamic properties of these insulins result in a flatter profile that lasts over 24 h and provides an increased window of administration of 6 h once daily. Large-scale multicentre randomised clinical trial programmes (BEGIN for degludec U100 and U200 and EDITION for glargine U300) evaluating these insulin therapies against glargine U100 have demonstrated that they are either non-inferior or superior for glycaemic efficacy and safety, but less likely to result in severe or nocturnal hypoglycaemia than glargine U100. The disposable pen devices for these insulins have been designed with patient satisfaction and convenience in mind. No concerns have arisen with adverse events with insulin analogues or cardiovascular safety from the ORIGIN and DEVOTE trials. As they demonstrate equivalent glycaemic efficacy to other basal insulins, they should be considered more in selected patient groups including those with recurrent or increased risk of hypoglycaemia, especially severe or nocturnal episodes, in the elderly or those living alone, and in patients with multiple co-morbidities such as cardiovascular or renal disease.

How to prevent medication errors: a multidimensional scaling study to investigate the distinguishability between self-injection platform device variants

Background: The importance of subcutaneous drug delivery using self-injection devices based on common device platforms continues to grow. The resulting broad adoption of potentially look-alike or similar devices, however, raises concerns over limited device distinguishability and ensuing risk of medication errors. The objective of the study is thus to understand whether and how users effectively distinguish between self-injection device variants. Methods: Seventy-four patients, caregivers, and healthcare professionals were asked to pairwise rate the similarity of eight platform autoinjector variants. Multidimensional scaling was then used to convert individual ratings into spatial configurations and thereby identify the attributes that influence device distinguishability. Results: Five different device attributes driving distinguishability were identified. Three of the attributes corresponded to single design features (the label color, device size and device shape). Two device attributes (the aspect ratio and chromaticity) combined distinct yet interrelated design features. Conclusions: The study provides initial empirical evidence that users are able to distinguish between device variants and as to what device attributes drive distinguishability. Furthermore, the results highlight patterns in how various user groups distinguish between device variants. These patterns relate with the user group characteristics (e.g. age, sight or dexterity) and the context of device usage (e.g. healthcare professionals).

Toward a new age of patient centricity? The application of eye-tracking to the development of connected self-injection systems

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.

The value of fast-acting insulin aspart compared with insulin aspart for patients with diabetes mellitus treated with bolus insulin from a UK health care system perspective

BACKGROUND

Fast-acting insulin aspart is a new formulation of the rapid-acting insulin analogue insulin aspart and represents an advancement over current rapid-acting insulin analogues in terms of onset of action and postprandial glucose control. The objective of the current analysis was to demonstrate the cost impact of prescribing fast-acting insulin aspart instead of insulin aspart, to highlight the value of fast-acting insulin aspart for the treatment of people with diabetes requiring mealtime insulin.

METHODS

A cost-impact analysis was conducted from the perspective of the UK National Health Service (NHS). The analysis excluded patients' out-of-pocket expenses, carers' costs and lost productivity. The time horizon of the analysis was 1 year, and no discounting was therefore applied.

RESULTS

The displacement of insulin aspart with fast-acting insulin aspart is cost neutral for the UK NHS. Fast-acting insulin aspart is at price parity to insulin aspart in terms of the vial and Penfill® cartridge and is available in the FlexTouch® pen at the same price as the insulin aspart FlexPen® (and thus cheaper than the insulin aspart FlexTouch® pen). Patients using the insulin aspart FlexPen® will be upgraded to the FlexTouch® pen device, which is preferred by patients and healthcare professionals, on switching to fast-acting insulin aspart, at no additional cost.

CONCLUSIONS

Fast-acting insulin aspart offers additional clinical benefit but at no additional cost when compared with insulin aspart, and thus provides value to the UK NHS.

Nurse evaluation of the redesigned fertility pen injector: a questionnaire-based observational survey

BACKGROUND

Owing to the wide-ranging role nurses have in supporting patients undergoing fertility treatment, we recorded the learning/teaching expectations and experiences of nurses using a redesigned fertility pen injector.

METHODS

This was a multicentre, simulated-use study, using unbranded placebo-filled pens. Before teaching patients, nurses were given free choice to rank the importance of the device attributes and predict the level of patient anxiety. Nurses taught 2-5 patients how to prepare the device, inject the dose and complete an incomplete dose. They rated the teaching experience on a 5-point scale during a questionnaire interview.

RESULTS

Thirty nurses were enrolled across four countries. All nurses found the redesigned fertility pen injector easy to use and teach. 90% found the overall administration process easy to learn and teach. More than 80% (range 83%-100%) found each of the steps easy (score 4 or 5), and most found the steps easier to teach than expected (score 4 or 5; range 57%-90%). 97% would recommend the redesigned fertility pen injector to a colleague.

CONCLUSIONS

Nurses rated the redesigned fertility pen injector easy to learn and use and easier to teach than expected. Most would recommend the device to a colleague.

Pen devices for self-injection: contrasting measured injection force with users' perceived ease of injection

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.

NovoPen Echo(®) insulin delivery device

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

Usability of the Novel Liraglutide 3.0 mg Pen Injector Among Overweight or Obese Adult Patients With or Without Prior Injection Experience

BACKGROUND

Obesity is associated with multiple comorbidities and increased mortality, making it an important target for treatment. However, achieving and maintaining weight loss by diet and physical activity remains challenging, and may often require pharmacotherapy. Liraglutide 3.0 mg has recently been approved for weight management in the United States, Canada, and EU. The current analysis used a summative usability test to assess safety and effectiveness, ease of use, and training requirements for the novel liraglutide 3.0 mg pen injector.

METHODS

Of the 234 participants, half received instructions for use and video-based training and/or opportunity to handle the device. All participants (excluding pharmacists) performed 6 tasks followed by post- task interviews on task difficulty, device ease of use, and any use errors, close calls, and operational difficulties. Tasks included differentiation of correct box and pen injector, medication clarity assessment, normal, dose reversal, and end-of-content injection. Number/type of use errors, close calls, and operational difficulties were evaluated.

RESULTS

All assessed participants interpreted the instructions for use correctly. No potentially serious use errors, and low numbers of nonserious errors, were reported. Overall, participants committed 105 use errors related to handling, with no potential for harm. A total of 25 close calls and 44 operational difficulties were reported without any pattern indicative of a design flaw. Marked differences in the incidence of events were observed for trained versus untrained participants regardless of prior injection experience. Participants rated ease of use as 6.4/7.

CONCLUSIONS

The liraglutide 3.0 mg pen injector is safe and easy to use for liraglutide administration. New device features allow for safe use after brief training.

Insulin degludec once-daily in type 2 diabetes: simple or step-wise titration (BEGIN: once simple use)

INTRODUCTION

Insulin degludec (IDeg) is a new basal insulin in development with a flat, ultra-long action profile that may permit dosing using a simplified titration algorithm with less frequent self-measured blood glucose (SMBG) measurements and more simplified titration steps than currently available basal insulins.

METHODS

This 26-week, multi-center, open-label, randomized, treat-to-target study compared the efficacy and safety of IDeg administered once-daily in combination with metformin in insulin-naïve subjects with type 2 diabetes using two different patient-driven titration algorithms: a "Simple" algorithm, with dose adjustments based on one pre-breakfast SMBG measurement (n = 111) versus a "Step-wise" algorithm, with adjustments based on three consecutive pre-breakfast SMBG values (n = 111). IDeg was administered using the FlexTouch® insulin pen (Novo Nordisk A/S, Bagsværd, Denmark), with once-weekly dose titration in both groups.

RESULTS

Glycosylated hemoglobin (HbA1c) decreased from baseline to week 26 in both groups (-1.09%, IDegSimple; -0.93%, IDegStep-wise). IDegSimple was non-inferior to IDegStep-wise in lowering HbA1c [estimated treatment difference (IDegSimple - IDegStep-wise): -0.16% points (-0.39; 0.07)95% CI]. Fasting plasma glucose was reduced (-3.27 mmol/L, IDegSimple; -2.68 mmol/L, IDegStep-wise) with no significant difference between groups. Rates of confirmed hypoglycemia [1.60, IDegSimple; 1.17, IDegStep-wise events/patient year of exposure (PYE)] and nocturnal confirmed hypoglycemia (0.21, IDegSimple; 0.10, IDegStep-wise events/PYE) were low, with no significant differences between groups. Daily insulin dose after 26 weeks was 0.61 U/kg (IDegSimple) and 0.50 U/kg (IDegStep-wise). No significant difference in weight change was seen between groups by week 26 (+1.6 kg, IDegSimple; +1.1 kg, IDegStep-wise), and there were no clinically relevant differences in adverse event profiles.

CONCLUSION

IDeg was effective and well tolerated using either the Simple or Step-wise titration algorithm. While selection of an algorithm must be based on individual patient characteristics and goals, the ability to attain good glycemic control using a simplified titration algorithm may enable patient empowerment through self-titration, improved convenience, and reduced costs.

Transjecting growth hormone: continuous nightmare or controlled nuisance? Evaluation of a new needle-free device

BACKGROUND

Administering growth-hormone therapy (GHT) is a long-term treatment, associated with avoidance and phobic behaviors in the children involved. The current study examined GHT users' perceptions of a new needle-free device (ZomaJet Vision X [10 mg/mL]) with a lower injection volume compared to the traditional device.

METHODS

A total of 73 persons participated (mean age ± standard deviation, 10.10 ± 3.60 years) in a longitudinal design. Users' views were studied 4 weeks after having applied both the old and the new device for a period of at least 4 weeks. Satisfaction, ease and frequency of restitution, local sensations, bruises during administering GHT, affective response to local sensations, and subject preference were assessed on the basis of the users' responses.

RESULTS

Subjects' satisfaction with the new device was equal compared with the previous device for the total group of 73 children. However, the subgroup of 59 children who proved tolerant to meta-cresol (new preservative for Vision X only) reported a significantly higher satisfaction rating with the new device compared to the old device (7.7 vs 6.6, P=0.0002). Vision X was evaluated as better on ease and frequency of restitution and the number of bruises. Pain sensations did not differ meaningfully between the two devices. The new device was favored over the previous one in a majority of respondents. Vision X allows easy reconstitution of the solution, which was reflected in the percentage of young children able to prepare transjections themselves being more than doubled, illustrating the greater sense of empowerment in these users. Self-reported adherence to the therapy was good (less than 10% of injections missed) with both devices.

CONCLUSION

The new device ZomaJet Vision X appears to be evaluated more positively than the previous version on criteria that refect users' preferences.