Insulin administration

Use of continuous glucose monitoring when initiating glucagon-like peptide-1 receptor agonist therapy in insulin-treated diabetes

Glucagon-like peptide-1 receptor agonist (GLP-1RA) medications have been shown to be effective in achieving optimal glucose control and reducing all-cause death, cardiovascular death, nonfatal myocardial infarction, hospitalization for heart failure, and end-stage kidney disease in individuals with type 1 (T1D) and type 2 diabetes (T2D). However, use of these medications has been associated with increased hypoglycaemia risk in patients treated with concomitant antihyperglycaemic medications. The risk is particularly high in patients with T1D due to their loss of glucagon counter-regulatory response. This article reviews the effect of GLP-1RA formulations on the development of hypoglycaemia in individuals with T1D and T2D treated with insulin therapy, discusses the benefits of continuous glucose monitoring with GLP-1RA treatment, and presents strategies for safely initiating GLP-1RA therapy in these individuals.

Are People With Type 1 Diabetes Mellitus Appropriately Following Insulin Injection Technique Practices: A Review of Literature

People with type 1 diabetes mellitus (T1DM) need to take multiple doses of insulin injections daily throughout their lives. However, a notable portion of people with diabetes mellitus (DM) show suboptimal insulin injection technique practices. They are supposed to follow the recommended insulin injection technique guidelines. Our explorative literature search, including studies from the past 30 years, is expected to identify the deficiencies of self-injection insulin techniques and the associated complications in people with T1DM, where we have summarised the overall incidence of complications that have occurred due to nonadherence of the prescribed guidelines, along with their associated risk factors. We have attempted to include multiple systematic reviews, meta-analyses, literature reviews, case reports, and original articles from the search engines and databases like PubMed, Scopus, ScienceDirect, Cochrane Library, Google Scholar, and BioMed Central, and studies with only human participants were included in this search. The knowledge sharing from this research may be utilised for enhancing the structured education diabetes programme and implementing the population-based corrective measures, including the thrust areas in future multi-centre longitudinal research studies and recommendations, which can prevent unnecessary complications and enhance their quality of life. Correct insulin administration technique, abstaining from administration of injection at the areas with lipohypertrophy, rotation of injection sites, and ultrasound scanning can be used as a complimentary method to detect the lipohypertrophy at an early stage. Liposuction is beneficial in reducing the extensive lipohypertrophic tissues but helps achieve only cosmetically satisfactory outcome; thus, empowering people to follow insulin injection technique guidelines is one of the best strategies to reduce the high prevalence of lipohypertrophy. To conclude, education among the people with DM, especially T1DM who have to take insulin regularly, needs to be carried out consistently in the clinical settings, to prevent the severe complications caused due to inappropriate insulin injection techniques.

Reducing potential errors associated with insulin administration: An integrative review

RATIONALE, AIMS, OBJECTIVES

Around one-third of medication errors resulting in death within 48 h involve insulin therapy. Despite a growing number of interventional strategies that have been published over the past decade, it remains unclear which of these interventions is effective in reducing insulin errors. Therefore, the study aimed to synthesize interventions to reduce the frequency of insulin errors in either home or health care settings.

METHODS

This integrative review was conducted based on Whittemore and Knafl's four steps, which includes problem identification, literature search, data analysis and presentation. Six databases including Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Scopus, PsychInfo and Cochrane were searched from January 2010 through July 2021. The level of evidence quality was assessed according to the Johns Hopkins Nursing Evidence-Based Practice grading scale.

RESULTS

Sixteen studies meeting inclusion criteria were reviewed. The results provide strong support for teaching patients how to use automated bolus calculators and educating patients to self-administer insulin to prevent insulin errors in the home setting. Computerized protocols, education and double-checking procedures were also found to be effective strategies for minimizing insulin errors in healthcare settings.

CONCLUSION

While the strategies might be effective in reducing insulin administration errors in the home settings, computerized protocols, continuing education and the manual validation of insulin products appear to be the most effective strategies for reducing such insulin errors in healthcare settings. Understanding these findings may help clinicians and patients to decrease the number of insulin errors administration.

Flash glucose monitoring in gestational diabetes mellitus: study protocol for a randomised controlled trial

INTRODUCTION

Gestational diabetes mellitus (GDM) is a glucose intolerance occurring in 3%-10% of pregnant women and being a risk factor for multiple maternal and fetal complications. The risk of perinatal complications is proportional to the level of maternal hyperglycaemia. Proper glycaemic control is therefore one of the key elements of GDM therapy. Until recently, determination of blood glucose concentration was performed using glucose meters, which involved multiple fingerpricks. Nowadays, due to the flash glucose monitoring (FGM) availability, it is possible to collect measurements at any time without routine puncturing. The aim of the presented study is to assess the impact of FGM on the efficacy of treatment in population of patients diagnosed with GDM.

METHODS AND ANALYSIS

This is a prospective, randomised study, that will recruit 100 women at 24-28 weeks of gestation at the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Poland. Women diagnosed with GDM, who will meet the inclusion criteria, will be individually randomised to the FGM or self-monitoring of blood glucose groups. Further on, clinical and laboratory results of the mother and their newborns will be collected for analysis during the course of pregnancy. Primary outcome is mean glycaemia result in each group after 1 month analysis and percentage of results in the target glycaemic range. The secondary objectives will be to compare the two groups for maternal and neonatal outcomes in conjunction with long-term glycaemic control using blood glycated haemoglobin and fructosamine serum concentrations.

ETHICS AND DISSEMINATION

The study is exempt from regional ethics review due to its nature of quality improvement in patient care. The study has been approved by the Bioethics Committee at the Medical University of Warsaw and the patient privacy protection boards governing over the recruitment sites. Results of the study will be presented in peer-reviewed journals and at conferences.

TRIAL REGISTRATION NUMBER

NCT04422821.

Knowledge, attitude and practice towards insulin self-administration and associated factors among diabetic patients at Zewditu Memorial Hospital, Ethiopia

BACKGROUND

Diabetes mellitus is a common health problem worldwide. Proper insulin administration plays an important role in long term optimal blood sugar control. Adequate knowledge and attitude about insulin self-administration could also improve the management of diabetes and eventually improve the quality of life. This study aimed to assess knowledge, attitude and practice towards insulin self-administration and associated factors among diabetic patients at Zewditu Memorial Hospital (ZMH), Ethiopia.

METHODS

An institution-based cross-sectional study was conducted among 245 diabetic patients who were selected by systematic random sampling during follow-up at ZMH. The data was collected using an interviewer-administered structured questionnaire and analyzed by SPSS v.20. Binary logistic regression was used to identify associated factors of patients' knowledge and P < 0.05 was used to declare the association.

RESULTS

Among 245 patients enrolled, 53.9% were male with a mean age of 53.26 ±13.43 years and more than 84% of the patients can read and write. The overall patients' knowledge was 63.4%. Better knowledge was observed concerning timing (78.4%) and site of insulin injection (89.4%), while knowledge on the angle of inclination during insulin administration (43.3%) and complications of insulin therapy (49%) were low. Patients who were male gender, never married, government or NGO employees, urban residents, who completed elementary and higher education had a higher knowledge than their comparators. The majority (62%) of the study patients had a favorable attitude on insulin self-administration. Although the majority 177(72.2%) of the study patients have administered insulin themselves, only 120(49.0%) of the patients injected insulin appropriately at 450. Frequent repetition of the injection site was practiced among 176(71.8%) patients and 139(56.7%) injected insulin before or immediately after food intake.

CONCLUSION

Patients' knowledge and attitude seem suboptimal and malpractice of insulin self-administration was reported. Therefore, the gaps should be addressed through patient education and demonstration of insulin injection during each hospital visit.

Artificial Pancreas Control Strategies Used for Type 1 Diabetes Control and Treatment: A Comprehensive Analysis

This paper presents a comprehensive survey about the fundamental components of the artificial pancreas (AP) system including insulin administration and delivery, glucose measurement (GM), and control strategies/algorithms used for type 1 diabetes mellitus (T1DM) treatment and control. Our main focus is on the T1DM that emerges due to pancreas’s failure to produce sufficient insulin due to the loss of beta cells (β-cells). We discuss various insulin administration and delivery methods including physiological methods, open-loop, and closed-loop schemes. Furthermore, we report several factors such as hyperglycemia, hypoglycemia, and many other physical factors that need to be considered while infusing insulin in human body via AP systems. We discuss three prominent control algorithms including proportional-integral- derivative (PID), fuzzy logic, and model predictive, which have been clinically evaluated and have all shown promising results. In addition, linear and non-linear insulin infusion control schemes have been formally discussed. To the best of our knowledge, this is the first work which systematically covers recent developments in the AP components with a solid foundation for future studies in the T1DM field.

Penetration force and cannula sliding profiles of different pen needles: the PICASSO study

Purpose

Pen needles used for insulin injections can have different characteristics that affect a patient’s injection experience. The aim of the study was to investigate in a standardized laboratory setting the penetration force and sliding force of different 31/32/33/34 gauge pen needles available in 3.5/4/5/8 mm length and 3/5 bevel tips for subcutaneous injection through pen needles and injection pens.

Methods

Eight different commercially available pen needles were tested in this experimental study. The needle was inserted into a polyurethane substrate at a specific constant speed and the force for insertion was recorded as a function of penetration depth. A load cell was utilized to measure force during the different stages of insertion.

Results

Maximum load was lower with the PiC G32×4 when compared with the G32×4 5-bevel needle (p<0.0001), while it was not significantly lower with the PiC G32×4 when compared to the G32×4 3-bevel needle (p=0.064). The comparison of G33×4 PiC and G34×3.5 PiC needles with G32 needles demonstrated significantly lower maximum loads with G33 and G34 (p<0.0001). No difference between needles emerged for sliding results.

Conclusion

Newer pen needles represent a significant improvement in insulin delivery, reducing the amount of force required to penetrate tissues. Needle tip sharpness and other factors that can reduce the force of insertion such as lubrication are important parameters that can be optimized to increase patient acceptance.

Adherence to antidiabetic medication and factors associated with non-adherence among patients with type-2 diabetes mellitus in two regional hospitals in Cameroon

BACKGROUND

Diabetes mellitus is a growing cause of disease burden globally. Its management is multifaceted, and adherence to pharmacotherapy is known to play a significant role in glycaemic control. Data on medication adherence among affected patients is unknown in Cameroon. In this study, the level of adherence and factors influencing non-adherence to antidiabetic medication among patients with type-2 diabetes was assessed.

METHODS

A hospital-based cross-sectional study among adult patients receiving care in the diabetic clinics of the Limbe and Bamenda Regional Hospitals in Cameroon was conducted. Medication adherence was assessed using the Medication Compliance Questionnaire (MCQ). Factors associated with non-adherence to medication were determined using basic and adjusted multivariable logistic regression models.

RESULTS

A total of 195 patients with type 2 diabetes were recruited. The prevalence of non-adherence to medication was 54.4% [95% confidence interval (CI): 47.1-61.5%]. In multivariable analysis, age > 60 years (aO.R. = 0.48, 95% CI: 0.25-0.94), alcohol consumption (aO.R. = 2.13, 95% CI: 1.10-4.14) and insulin alone therapy (aO.R. = 2.85, 95% CI: 1.01-8.08) were associated with non-adherence. Patients attributed their non-adherence to forgetfulness (55.6%), lack of finances (38.2%) and disappearance of symptoms (14.2%).

CONCLUSIONS

Adherence to anti-diabetic medication is poor in this study with more than half of participants being non-adherent. Urgent interventions are required to tackle this problem in combined efforts to stem this looming diabetes epidemic.

EADSG Guidelines: Insulin Storage and Optimisation of Injection Technique in Diabetes Management

To date, insulin therapy remains the cornerstone of diabetes management; but the art of injecting insulin is still poorly understood in many health facilities. To address this gap, the Forum for Injection Technique and Therapy Expert Recommendations (FITTER) published recommendations on injection technique after a workshop held in Rome, Italy in 2015. These recommendations are generally applicable to the majority of patients on insulin therapy, athough they do not explore alternative details that may be suitable for low- and middle-income countries. The East Africa Diabetes Study Group sought to address this gap, and furthermore to seek consensus on some of the contextual issues pertaining to insulin therapy within the East African region, specifically focusing on scarcity of resources and its adverse effect on the quality of care. A meeting of health care professionals, experts in diabetes management and patients using insulin, was convened in Kigali, Rwanda on 11 March 2018, and the following recommendations were made: (1) insulin should be transported safely, without undue shaking and exposure to high (> 32 °C) temperature environments. (2) Insulin should not be transported below 0 °C. (3) If insulin is to be stored at home for over 2 months, it should be stored at the recommended temperature of 2-8 °C. (4) Appropriate instructions should be given to patients while dispensing insulin. (5) Insulin in use should be kept at room temperature and should never be kept immersed under water. Immersing insulin under water after the vial has been pierced carries a high risk of contamination, leading to loss of potency and likelihood of causing injection abscesses. (6) The shortest available needles (4 mm for pen and 6 mm for insulin syringe) should be preferred for all patients. (7) In routine care, intramuscular injections should be avoided, especially with long-acting insulins, as it may result in severe hypoglycaemia. (8) The practice of slanting the needle excessively should be avoided as it results in sub-epidermal injection of insulin which leads to poor absorption and may cause "tattooing" of the skin and scarring. (9) In patients presenting in a wasted state, with "paper-like skin", injections should, if possible, be initiated with pen injection devices, so as to utilise the 4-mm needle without lifting a skin fold (pinching the skin); otherwise lifting of a skin fold is required, if longer needles are utilised. (10) Reuse of needles and syringes is not recommended. However, as the reuse of syringes and needles is practiced for various reasons, and by many patients, individuals should not be given alarming messages; and usage should be limited to discarding when injections become more painful; but at any rate not to exceed reusing a needle more than 5 times.

In-Hospital Administration of Insulin by Nurses in Northern Greece: An Observational Study

OBJECTIVE

The purpose of this study is to explore current practice regarding insulin administration by nurses in a Greek public hospital.

DESIGN AND METHODS

A mixed-methods qualitative data collection design was used with ad hoc nonparticipant observation and post hoc interviews with the staff involved. Insulin management and administration was observed and compared to international guidelines. A sample of 20 nurses from two medical wards was assessed on 100 occasions of insulin administration, and 8 nurses were subsequently interviewed.

RESULTS

Inter-rater agreement was found to be satisfactory (average κ 0.840). In 61% of all instances, nurses washed their hands before administering insulin, and, in 70%, they donned gloves before injections. In 64.5% of all instances, the nurses did not clean the insulin bottle before inserting the needle, and in 42.7% of instances, they did not check for air bubbles in the syringe. In 89.1% of instances, nurses did not check the injection site for appropriateness or other possible complications. However, in 90.9%, they cleaned the skin at the injection site with an alcohol swab. In 70.9% of all instances, the needle was placed vertically to the skin but without a skinfold. In 89.1% of instances, post-injection care was rated as poor.

CONCLUSION

Overall, compliance with international guidelines regarding insulin administration techniques, as observed in these sample wards, is not satisfactory. Nurses in this Greek hospital tend to administer subcutaneous injections in ways not reflected in current research findings, practice guidelines, or evidence-based care recommendations. Evidently, Greek nurses in this sample require updating on current evidence-based practice, clinical guidelines, and protocols of care regarding routine insulin administration.

Delay discounting and parental monitoring in adolescents with poorly controlled type 1 diabetes

In a sample of adolescents with poorly controlled type 1 diabetes, this study examined if delay discounting, the extent to which individuals prefer immediate over delayed rewards, was associated with severity of non-adherence and poor glycemic control, and if parental monitoring of diabetes management moderated those associations. Sixty-one adolescents (M _age = 15.08 years, SD 1.43) with poorly controlled type 1 diabetes completed a delayed discounting task and an HbA1c blood test. Adherence was assessed via self-monitoring of blood glucose (SMBG) data from adolescents' glucometers. Parents completed a parental monitoring questionnaire. Greater delay discounting was associated with higher HbA1c, but not SMBG. Direct parent observation of diabetes tasks, but not indirect parental monitoring, moderated the link between greater delay discounting and higher HbA1c, with higher direct parent observation buffering the link between greater discounting and poorer glycemic control. Delay discounting may be a target for future interventions to improve HbA1c in youth with type 1 diabetes.

Analysis of glycaemic control and weight change in patients initiated with human or analog insulin in an US ambulatory care setting

BACKGROUND

Insulin is a mainstay in the treatment of type 1 diabetes and is a recommended option in patients with type 2 diabetes who fail to maintain glycaemic control on other non-insulin therapies. The purpose of this study was to describe patient characteristics and evaluate changes in glycaemic control and weight in patients treated with insulin in an ambulatory care setting.

METHODS

Patients with diabetes were identified from the General Electric electronic medical record (EMR) database (1 September 2004 to 30 April 2008). Patients were > or =18 years, insulin naive, newly treated with monoinsulin therapy (index date). Baseline characteristics were identified overall and stratified by insulin type (basal, mixed, and rapid). Basal insulins were described by human versus analog and for insulin detemir and insulin glargine. Change in haemoglobin A1C (HbA1C) and weight from baseline (45 days pre- to 15 days postindex date) to 6 months (+/-90 days) were compared. Regression analyses were used to evaluate HbA1C outcomes across insulins and for the likelihood of gaining 0.9 kg (2 lbs) for detemir versus glargine controlling for baseline characteristics.

RESULTS

A total of 12 136 patients were included. A majority were initiated on a basal insulin (64.7%) followed by mixed (20.8%) and rapid (14.4%). Basal users had significantly higher mean body weight and lower mean baseline HbA1C than mixed users (p < 0.001 for all), and were significantly older, had higher baseline HbA1C and higher baseline body mass index (BMI) than rapid insulin users (p < 0.001 for all). Glargine patients had a significantly higher mean baseline HbA1C (p = 0.003) than detemir patients. The adjusted reduction in HbA1C was greater for rapid insulin than for mixed or basal insulin (p < or = 0.05). The adjusted differences in HbA1C between basal human and basal analog insulins and between detemir and glargine were not statistically significant (p > 0.05). Patients using detemir were 30% less likely to gain 0.9 kg or more than glargine users (p < 0.05).

CONCLUSIONS

HbA1C outcomes in the ambulatory care setting were generally not different between insulin classes. The likelihood of weight gain was less with insulin detemir than with insulin glargine. Thus, real-world weight outcomes for basal analog insulin may differ by specific product.

A comparison of preprandial insulin glulisine versus insulin lispro in people with Type 2 diabetes over a 12-h period

A comparison of the plasma glucose and insulin day profiles between two prandial rapid-acting insulin analogues, insulin glulisine (glulisine) and insulin lispro (lispro), in 18 obese subjects with Type 2 diabetes. Subjects (body mass index: males, 36.7 [33.2-43.8] kg/m(2); females, 40.0 [35.7-46.5] kg/m(2)) received subcutaneous glulisine or lispro (0.15 U/kg) at 4-h intervals immediately (within 2 min) before three standard test meals during each of two 12-h, randomised, open-label, crossover studies (7+/-2-day interval between each). Overall, preprandial-subtracted glucose concentrations (area under the curve) were similar on the glulisine and lispro study days. However, the mean of the three maximal preprandial subtracted plasma glucose concentrations (DeltaGLU(max)) were lower with glulisine versus lispro (12%; p<0.01). Mean concentrations of insulin analogue were significantly higher post-meal with glulisine (p<0.01 for all). Post hoc analysis showed a significantly faster absorption rate for glulisine versus lispro in the first 30 min post-meal (estimated difference 0.48 microU/min; p<0.0001). Only two cases of hypoglycaemia were reported; both from one subject during the lispro day. When glulisine is injected immediately before a meal in obese patients with Type 2 diabetes, glulisine achieves significantly lower glucose excursions over lispro. Significantly faster absorption with higher and sustained post-meal levels of insulin analogue was achieved at every meal with glulisine versus lispro.

Insulin: a model system for nanomedicine?

One of the predominant aims of insulin therapy for diabetes is to appropriately mimic physiological insulin secretion levels and their correlation with glucose concentration in healthy individuals. This report outlines current methods and their limitations in glycemic control and their possible relationship to insufficient knowledge about the structure and dynamics of the insulin hormone itself. Based on recent experimental and computational work, a possible approach to less-invasive insulin administration is sketched.

Advantage of premeal-injected insulin glulisine compared with regular human insulin in subjects with type 1 diabetes

OBJECTIVE

Insulin glulisine, a rapid-acting insulin analog, provides prandial insulin replacement. In this study, we compared postprandial blood glucose control after pre- and postmeal insulin glulisine with regular human insulin (RHI).

RESEARCH DESIGN AND METHODS

In a single-dose, randomized, four-way complete cross-over study, subjects received standardized, 15-min meals, covered by subcutaneous injections of either insulin glulisine (immediately premeal or 15 min postmeal; 0.15 unit/kg per injection) or RHI (30 min or immediately premeal; 0.15 unit/kg per injection). Twenty-one patients with type 1 diabetes (mean age 36.4 years; mean BMI 26.0 kg/m(2)) were enrolled; 20 patients completed the study. Postprandial baseline-subtracted blood glucose exposure, maximum excursion, maximum and minimum blood glucose concentrations, and time to the maximum excursion and minimum concentration were assessed, along with serum insulin concentrations.

RESULTS

Lower maximum blood glucose excursion (65 vs. 89 mg/dl), total blood glucose exposure within 2 h (279 vs. 334 mg . h/dl, maximum blood glucose concentration (180 vs. 209 mg/dl), and less time to maximum blood glucose excursion (48 vs. 70 min) were seen with immediately premeal insulin glulisine versus immediately premeal RHI. The maximum serum concentration of insulin glulisine was almost double that of RHI (82 vs. 45 microU/ml), achieved in approximately half the time (55 vs. 97 min). Conversely, insulin glulisine (15 min postmeal) versus RHI (immediately premeal) and RHI (30 min premeal) versus insulin glulisine (immediately premeal) resulted in comparable blood glucose control.

CONCLUSIONS

Insulin glulisine renders postprandial glucose disposal closer to physiologic requirements compared with RHI and enables appropriate timing of prandial insulin administration.

Characteristics of basal insulin requirements by age and gender in Type-1 diabetes patients using insulin pump therapy

Establishment of appropriate basal insulin levels is an essential component of intensive insulin therapy. While the existence of a "dawn phenomenon" is widely recognized, the present study sought to establish whether diurnal basal insulin patterns exist in Type-1 diabetes, and whether these patterns vary by age and gender. Participant data was drawn from 322 Type-1 insulin pump users treated at a private diabetes education practice in suburban Philadelphia. All participants completed a battery of fasting tests designed to match basal insulin levels to endogenous glucose production and insulin sensitivity. Analysis of resultant basal patterns revealed significant differences between juvenile (age < or =20) and adult (age >20) basal insulin patterns. The younger group exhibited a more pronounced and sustained night-time peak; the older group exhibiting a briefer and less pronounced early-morning peak. Lower overall basal insulin requirements were found in the youngest (age < or =10) and oldest (age >60) groups. No noteworthy gender differences were found. Results can serve as a guide for clinicians when initiating and fine-tuning patients who utilize basal/bolus insulin therapy.

Using insulin pen needles up to five times does not affect needle tip shape nor increase pain intensity

AIMS

Reusing insulin pen needles could help to reduce the increasing economic burden of diabetes. We tested the hypothesis that reusing insulin pen needles leads to needle tip deformity and increased pain.

METHODS

Three blinded reviewers assessed 123 electron microscope pictures analyzing needle tip deformity of insulin pen needles used up to four times by diabetic subjects and up to five times by blinded non-diabetic volunteers. The estimated frequency of needle use was correlated to the actual number of needle use. Pain intensity and unpleasantness of each injection were measured by a visual analogue scale and their differences analyzed by Kruskal-Wallis analysis of variance.

RESULTS

Unused needles could be differentiated visually from used needles. However, there was no correlation between the actual and guessed number of times a needle was used (r = 0.07, P = 0.2). Evaluating all 270 injections, neither pain intensity nor unpleasantness increased with repeated injections of the same needles in people with diabetes (P = 0.1 and 0.96) and in the volunteers (P = 0.63 and 0.92).

CONCLUSIONS

Using pen needles four to five times does not lead to progressive needle tip deformity and does not increase pain intensity or unpleasantness, but could increase convenience and lead to substantial financial savings in Europe of around EUR 100 million/year.