Insulin delivery using pen devices. Simple-to-use tools may help young and old alike

Emicizumab prophylaxis for people with hemophilia A: Waste estimation and the Brazilian perspective

Costs of hemophilia A treatment are increasing. Waste of clotting products should be avoided. To estimate the first-year waste of emicizumab prophylaxis for people with hemophilia A and inhibitors (PwHAi) who failed immune tolerance induction (ITI), in Brazil. We evaluated the manufacturer and the Brazilian Ministry of Health (MoH) protocol-recommended regimens in a budget impact model. The loading dose consisted of 3.0 mg/kg/Q1W for 4 weeks, for both recommendations. The manufacturer maintenance regimens comprised 1.5 mg/kg/Q1W, 3.0 mg/kg/Q2W, and 6.0 mg/kg/Q4W. The MoH protocol maintenance regimen encompassed a hybrid Q1W/Q2W administration, depending on the body weight. The Q4W regimen was not recommended by the MoH protocol. Analyses were performed to estimate waste given its expense based on the World Health Organization body weight range (percentiles [P] 15, 50, and 85). The first-year emicizumab waste was estimated individually and for the disclosed PwHAi who failed ITI (n = 114). The highest emicizumab waste was estimated for the lowest body weights and the Q1W regimen. The Q4W regimen resulted in the lowest emicizumab waste, followed by the MoH protocol regimen. The total reconstituted costs estimated for the PwHAi who failed ITI according to the hybrid MoH protocol ranged from US$32,858,777 (P15) to US$47,186,858 (P85), with emicizumab waste ranging from 7.9 % (US$2,594,515) to 3.7 % (US$1,738,750), respectively. Lost resources due to current protocols for emicizumab prophylaxis for PwHAi who failed ITI in Brazil are considerable. Waste was more pronounced due to lower body weight and shorter administration intervals.

Needle Technology for Insulin Administration: A Century of Innovation

Innovations in syringe and pen needle (PN) technology over the last 100 years have led to important advances in insulin delivery for people with diabetes, paralleling the strides made in developing recombinant DNA human insulin and insulin analogs with varying onset and duration of action. In this review, the history of advances in insulin delivery is described, focusing on progress in syringe, needle, and PN technologies. The early glass and metal syringes that required sterilization by boiling have been replaced by disposable, single-use syringes or pens with clear labeling for precise insulin dosing. The early needles ranging in length from 19 to 26 mm that required manual sharpening against a whetstone have been replaced by syringe needles of 6 mm and PNs of 4 mm in length as slender as 34 gauge. Imaging studies using ultrasound and computed tomography measured the thickness of skin and subcutaneous tissue layers to show feasibility of targeted insulin administration with shorter needles. These developments, coupled with innovations in needle/PN wall and tip structure, have led to improved injection experience for people with diabetes. It is also important to acknowledge the role of injection technique education, together with these advances in injection technology, for improving clinical outcomes and patient satisfaction. With continued projected growth of diabetes prevalence, particularly in developing countries where expensive and complex insulin delivery systems may not be practical, insulin syringes and pens will continue to serve as reliable and cost-effective means of insulin delivery for people with diabetes.

Medical Device-related Counseling Practice and Barriers among Sudanese Pharmacists: A Questionnaire-Based Study

Objective:

The aim of the present study was to assess medical devices-related counseling practice and barriers among pharmacists.

Methods:

This was a cross-sectional study conducted using a convenient sample of Sudanese pharmacists. An online-version survey was used to collect data.

Findings:

One hundred and thirty pharmacists responded to the online survey. Most pharmacists in this sample were master or Ph.D. degree holders (62.3% and 12.3%, respectively), having a clinical training experience (70%) and substantial proportion are board-certified (30%). Medical devices reported to be commonly inquired by patients were blood glucose monitors, nebulizers, blood pressure monitors, dry powder inhalers, and insulin pens. Devices most frequently requiring counselling were blood glucose monitors, blood pressure monitors, syringes, thermometers, nebulizers, dry powder inhalers, insulin, and weighing scales. The most frequently supplied devices reported were syringes, blood glucose monitors, insulin pens, blood pressure monitors, thermometers, nebulizers, and dry powder inhalers. Devices least frequently requiring counselling were implanted devices, respirometers, and stethoscopes. The least frequently supplied devices were respirometers, implanted devices, and heart rate monitors.

Conclusion:

Medical devices reported to be commonly inquired by patients were most frequently requiring counseling, and most frequently supplied. Findings reflect the availability of devices in the market and pharmacists' response to the needs of their patients. Pharmacists should maintain adequate knowledge about the proper use of medical devices because this is a common patient inquiry.

Quality of care to institutionalized patients with diabetes in Italy: a national survey

PURPOSE

To evaluate the epidemiology of diabetes and quality of care of institutionalized patients with diabetes in Italian nursing homes. More specifically, to evaluate the adherence to the national/international guidelines for the management of older people with diabetes.

METHODS

Data related to the epidemiology of diabetes and the quality of care were collected from questionnaires sent to 41 nursing homes. Data were extracted from papers, electronic medical records and validated operating protocols regulating the management of patients with diabetes in various homes. Completed questionnaires were returned in electronic format and centrally processed.

RESULTS

Out of 4692 residents, 906 (19.3%) had diabetes. Among these residents, excluding patients undergoing diet treatment, more than half were on insulin treatment (alone or in combination with oral antidiabetic agents). The critical findings can be summarized as follows: a lack of shared diagnostic-therapeutic protocols, specifically related to evaluation of frailty; the preparation of nutritional and physical activity plans; the clarification of the objectives of the treatment; the timing of insulin administration (frequent use of sliding scale); the frequency and timing of capillary blood glucose; metabolic control methods; hypoglycemia and hyperglycemia treatment; and the scant use of new drugs that do not cause hypoglycemia.

CONCLUSION

Our data revealed substantial heterogeneity in the treatment of nursing home residents with diabetes in Italy with many discrepancies between what is recommended in the guidelines and real-world practice. The implementation of local diagnostic-therapeutic protocols shared by all caregivers should be encouraged and properly funded to overcome communication problems between doctors and nurses and eventually improve the quality of care for institutionalized patients with diabetes.

Analysis of "Dose Accuracy, Injection Force, and Usability Assessment of a New Half-Unit, Prefilled Insulin Pen"

Half-unit insulin pens (HUPs) offer finer gradation of insulin dosing than their integer-unit counterparts, tackling the inaccuracies of dose rounding that make it difficult for insulin-sensitive populations to achieve tight glycemic control. This article analyzes the first prefilled HUP, the Humalog Junior KwikPen, in the context of other, similar devices and the developing landscape of smart insulin pens. The Junior KwikPen's suitability for pediatric patients is assessed in reference to a recent study surveying its accuracy and usability under varying conditions intended to simulate real-world use.

Impact of Pharmacist Intervention on Appropriate Insulin Pen Use in Older Patients with Type 2 Diabetes Mellitus in a Rural Area in Iran

OBJECTIVE

The aim of this study was to evaluate the impact of pharmacist-conducted educational intervention on reducing errors related to inappropriate insulin pen use.

METHODS

This was a prospective, before-after study with an educational intervention component. The study was conducted on 122 elderly diabetic patients. Data were collected through interviews using researcher-administered questionnaires as well as patients' medical records. Patients were asked about the preparation, injection, and storage techniques, they followed when using insulin pens. Blood glucose parameters were extracted from laboratory records. After the detection of errors, patients and their caregivers were instructed about the insulin pen use by the pharmacist. Patients were reevaluated after 12 weeks.

FINDINGS

Patients' mean age was 67.2 ± 3.5 with male: female ratio of 71:51. Mean diabetes duration was 7.1 ± 2.8 years. Fifty-four patients (44.2%) stated that they had received instructions for insulin pen use previously. The majority of this group (24 cases, 44.4%) reported that the instructions were given by a pharmacist. The mean number of errors decreased from 3.99 ± 0.22 errors per patient to 1.49 ± 0.13 errors (odds ratio: 0.28, 95% confidence interval: 0.23-0.33,P < 0.05). Of eleven evaluated insulin pen-related medication error items, nine items experienced a significant decrease after patient education. Fasting plasma glucose (FPG) levels decreased significantly from 161.7 ± 12.5 to 147.3 ± 13.1 mg/dL (P < 0.05). However, glycated hemoglobin levels did not change significantly after 3 months (P = 0.18). Controlled FPG had a significant rise from 45% before education to 63.9% postintervention (P < 0.05).

CONCLUSION

Pharmacists can play an important role in safe and efficient use of insulin pen in elderly diabetic patients by minimizing the likelihood of medication errors associated with insulin pen use.

New Insulin Delivery Recommendations

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

Insulin Delivery Devices

More than 6million Americans require daily injections of insulin. Insulin therapy, using the vial and syringe method, can be complicated and time consuming. Insulin pens were introduced in the United States in 1987 and have simplified insulin administration for many patients. Continuous Subcutaneous Insulin Infusion (insulin pumps or CSII) is being utilized to achieve and maintain tight glycemic control for personswith Diabetes Mellitus (DM). CSII therapy has existed since the 1960s. These insulin delivery devices provide improvements in flexibility, convenience, and freedom for patients-with diabetes. These devices may also help promote dosing accuracy and often improve compliance. CSII uses only rapid acting insulin, which has more reliable and predictable absorption. Gone are the days of sliding scales and feeding times to match the insulin delivery systems. This article focuses on insulin pen therapy and other alternative methods of delivering insulin including insulin pump therapy.

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.

MS, Mithal A, Modi S, Pitale S, Sahay R, Shukla R, Sundaram A, Unnikrishnan AG, Wangnoo SK. Forum for Injection Technique (FIT), India: The Indian recommendations 2.0, for best practice in Insulin Injection Technique, 2015

As injectable therapies such as human insulin, insulin analogs, and glucagon-like peptide-1 receptor agonists are used to manage diabetes, correct injection technique is vital for the achievement of glycemic control. The forum for injection technique India acknowledged this need for the first time in India and worked to develop evidence-based recommendations on insulin injection technique, to assist healthcare practitioners in their clinical practice.

Effect of adherence and insulin delivery system on clinical and economic outcomes among patients with type 2 diabetes initiating insulin treatment

BACKGROUND

Adherence to insulin affects real-world health outcomes and may itself be affected by the choice of insulin delivery device (pen or vial/syringe). The choice of insulin delivery device may also have direct effects on effectiveness.

OBJECTIVE

This study aimed to estimate the effects of insulin adherence and delivery device on real-world health outcomes.

METHODS

This study included adults with type 2 diabetes mellitus initiating insulin, with continuous health plan insurance for 6 or more months before initiation (baseline) and 1 or more year after. Measured outcomes included glycosylated hemoglobin (Hb A1c) reduction, hospitalization rate, total health care costs, and pharmacy costs over 1 year of follow-up. Adherence (defined as having insulin fills sufficient for the entire quarter), pen or vial/syringe use, and disease-related patient characteristics were assessed in each quarter. To account for the time-varying relationship between adherence, patient characteristics, and outcomes, marginal structural generalized linear models were used to estimate the effect of adherence and device use. Mean outcomes were predicted for different combinations of adherence and device choice.

RESULTS

Among the 13,428 patients (mean age 54 years; 46% women; baseline Hb A1c 9.3%), adherent pen users had greater reductions in Hb A1c (-0.35%; P = 0.045), lower hospitalization rates (-0.36; P < 0.01), and higher pharmacy costs ($2923; P < 0.01) than did nonadherent vial users, and similar total health care costs ($3906 lower; P = 0.1). Pen use and adherent vial use decreased hospitalization rate and increased pharmacy but not total costs.

CONCLUSIONS

Adherence and pen use have beneficial effects on patients' real-world outcomes, with the most favorable effects attributable to adherent pen use.

Do insulin cartridges really provide a lower risk of potential diabetes complications than traditional vials?

SCOPE

Recently, many publicly funded healthcare organizations suffered from an economical crisis. This forced some organizations to utilize less costly alternatives where possible. Insulin cartridges and vials are examples. Many patients are questioning the difference between the two alternatives as they contain the same active ingredient.

OBJECTIVE

To find out if insulin cartridges really provide a lower risk of potential diabetes complications than traditional vials.

METHOD

A questionnaire was used to ask two random samples of diabetic patients about the development of some diabetes complications. The first sample (n = 41) consisted of patients using cartridges; the second sample (n = 40) consisted of patients using vials. Patients were randomly selected from the endocrine clinic and the out-patient pharmacy in Al-Hussein Hospital in King Hussein Medical Center in Amman- Jordan.

RESULTS

44% of respondents in the first sample did not suffer from any complication; on the other hand, the percentage was only 15% of respondents in the second sample. All respondents (100%) in the first sample suffered from only 2 complications or less; however, 25% of the respondents in the second sample suffered from 3 or more complications. Nephropathy complications, were slightly higher in the first sample; 22% compared to 15% in the second sample. On the other hand, all complications reported in the second sample were higher; 30% for neuropathy, 65% for retinopathy complications and 42.5% for extremities damage compared to only 9.7%, 7.3% and 26.8% respectively in the first sample.

CONCLUSION

In general, respondents who were using cartridges reported a lesser incidence of diabetes complications. Although many organizations suffered from an economical crisis, the cost-effectiveness aspect should be taken into consideration when purchasing medical alternatives. This will provide higher quality of life for patients and eventually lower hidden and future costs for the organizations.

Comparative Assessment of Lixisenatide, Exenatide, and Liraglutide Pen Devices: A Pilot User-Based Study

BACKGROUND

Glucagon-like peptide-1 (GLP-1) receptor agonists are a relatively recent addition to the treatment options for type 2 diabetes mellitus (T2DM) and are administered using prefilled pen devices.

METHOD

In this open-label task and interview-based pilot study, 3 GLP-1 receptor agonist pen devices-exenatide (Byetta^®, Bristol-Myers Squibb/AstraZeneca), liraglutide (Victoza^®, Novo Nordisk), and lixisenatide (Lyxumia^®, Sanofi-Aventis)-were comparatively assessed in a randomized order in 30 participants with T2DM for ease of use, using a series of key performance measures (time taken to complete a series of tasks, number of user errors [successful performance], and user satisfaction rating). Linear and logistic regression analysis was conducted for the lixisenatide and liraglutide pens versus the exenatide pen. Participants' mean age was 60 years; 27% and 20% of the participants had visual impairments and reduced manual dexterity, respectively.

RESULTS

Tasks were completed faster (P < .001) and with higher successful performance (P = .001) with the lixisenatide pen than with the exenatide pen, whereas the liraglutide pen was not statistically significant versus the exenatide pen on these parameters. Overall, user satisfaction was statistically higher for the lixisenatide and liraglutide pens versus the exenatide pen (P < .001 for both).

CONCLUSIONS

Lixisenatide and liraglutide pens are associated with higher user satisfaction compared with the exenatide pen. In addition, the lixisenatide pen is faster and results in fewer errors than its comparator (exenatide). The lixisenatide pen may therefore be a suitable choice for patients with T2DM, including older and pen device-naïve patients, and those with visual impairments and reduced manual dexterity.

Evaluation of a new durable insulin pen with memory function among people with diabetes and healthcare professionals

OBJECTIVES

The aim of the study was to evaluate durable insulin pens among people with diabetes (PwD) and healthcare professionals (HCPs), by comparing two durable insulin pens with memory function: NovoPen® 5 (NP5) and HumaPen® Memoir™ (HPM), and two durable insulin pens without memory function: HumaPen Luxura® (HPL) and ClikSTAR® (CS).

RESEARCH DESIGN AND METHODS

This cross-over, multicentre usability test was conducted in China, Germany and the UK. Participants evaluated all four pens in randomised order by performing handling and usability tasks related to everyday use during a face-to-face interview. Tasks, pens and preferences were rated by completing a questionnaire comprising of rating and open-ended questions.

RESULTS

NP5 was preferred by 51% of participants compared with HPM (22%, p < 0.01), HPL (12%, p < 0.01) and CS (15%, p < 0.01). Participants preferred the design of NP5 (in particular, appearance, length and robustness). Memory function for the two pens was rated equally by participants, but 54% of PwD rated NP5 as 'very easy' to learn to use versus 22% for HPM and significantly more HCPs found it 'very easy' to teach patients to use NP5 versus HPM (6-point rating scale; difference in mean score, p < 0.01). Substantially, more PwD would be confident in using NP5 (64%) compared with HPM (43%), HPL (49%) and CS (45%) (6-point rating scale; difference in mean score, p < 0.01).

CONCLUSIONS

NP5 was preferred by > 50% of PwD and HCPs. NP5 was more highly rated for design, memory function and ease of learning/teaching compared with HPM. Most PwD would be confident in using NP5 for administering daily insulin injections.

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.

A questionnaire-based survey to assess patient satisfaction, ease-of-learning, ease-of-use, injection site pain and overall patient satisfaction of the follitropin-alpha (Gonal-f) filled-by-mass (FbM) prefilled pen compared with other systems of gonadotrophin administration

BACKGROUND

Gonadotrophins are used routinely for follicular stimulation during ovarian induction and assisted reproduction techniques. Developments in recombinant follicle-stimulating hormone preparations and their injection devices have improved patient quality of life by enabling patients to self-administer treatment at home. The objective of this study was to investigate patient experiences of learning to use and overall satisfaction with the follitropin-alpha (Gonal-f) filled-by-mass (FbM) prefilled pen.

METHODS

This questionnaire-based survey study was conducted in 23 fertility centres in Japan over a period of 14 months. Patients who were receiving fertility treatment with the follitropin-alpha (FbM) prefilled pen were asked to complete a questionnaire to assess their satisfaction, ease of learning and use, and injection site pain following treatment.

RESULTS

A total of 663 women participated in the study. The majority of patients found the instructions for administering follitropin-alpha with the prefilled pen easy to understand (83.0%; n = 546/658) and patients found that a hands-on demonstration by a nurse or doctor was the most useful tool for learning to use the follitropin-alpha (FbM) prefilled pen (80.0%; n = 497/621). Forty-eight percent (n = 318) of patients in the study had previous experience with different types of fertility medications and the majority of these patients found the follitropin-alpha (FbM) prefilled pen easier to use (75.1%; n = 232/309) and less painful (89.0%; n = 347/390) than their previous medication. The majority (80.2%; n = 521/650) of patients reported overall satisfaction with the follitropin-alpha (FbM) prefilled pen.

CONCLUSIONS

The follitropin-alpha (FbM) prefilled pen is an easy-to-use injection device according to this questionnaire-based survey. Patients who had experience of different types of fertility medication preferred the follitropin-alpha (FbM) prefilled pen to other injection devices.

Forum for injection techniques, India: the first Indian recommendations for best practice in insulin injection technique

Advances in the treatment of diabetes have led to an increase in the number of injectable therapies, such as human insulin, insulin analogues, and glucagon-like peptide-1 analogues. The efficacy of injection therapy in diabetes depends on correct injection technique, among many other factors. Good injection technique is vital in achieving glycemic control and thus preventing complications of diabetes. From the patients' and health-care providers' perspective, it is essential to have guidelines to understand injections and injection techniques. The abridged version of the First Indian Insulin Injection technique guidelines developed by the Forum for Injection Technique (FIT) India presented here acknowledge good insulin injection techniques and provide evidence-based recommendations to assist diabetes care providers in improving their clinical practice.

Safety and patient perception of an insulin pen with simple memory function for children and adolescents with type 1 diabetes--the REMIND study

OBJECTIVES

NovoPen Echo * is a durable pediatric insulin pen incorporating half-unit dosing starting at 0.5 units and a last-dose memory function. The REMIND † (Rating the Effects of Memory function in pediatric INsulin Devices) study primarily examined the safety of this new device by collecting data on technical complaints (TCs) related to adverse reactions (ARs) during use in a clinical setting.

METHODS

REMIND was an observational, multicenter study involving patients with type 1 diabetes on injection therapy, aged 2-18 years, from Canada, Finland, Israel and Sweden. Questionnaires and case report forms were completed at baseline and after using NovoPen Echo for 12-18 weeks.

RESULTS

In total, 358 patients participated and 315 completed. No serious ARs were reported. Three ARs related to TCs were reported, equated to one every 29 patient-years. Most patients found it 'easy' or 'somewhat easy' to read amount (99%) and hours lapsed (95%) since last dose using the memory function. The proportion of children self-injecting was significantly higher (71%) compared with those on previous device (66%, p=0.006). 80% of physicians answers reported they could train users in ≤10 minutes.

CONCLUSIONS

Only three device safety events were reported for NovoPen Echo. Physicians found it easy and quick to educate users. Patients/caregivers missed fewer injections and reported greater confidence in managing their insulin injections. As this was an observational study without controls or centralized laboratory testing, caution should be used in interpreting outcomes in glycemic control. Further studies are required to examine the effects of features such as memory function and half-unit dosing on HbA1c and hypoglycemia over a longer time period.

Insulin vials vs. insulin cartridges: Further cost considerations

SCOPE

Many studies have provided evidence that favor the use of insulin pens over traditional insulin vials due to lower overall costs. The cost of insulin in the Royal Medical Services in Jordan is subject to other considerations due to the favorable tender prices and the process of dispensing of insulin within the Royal Medical Services.

OBJECTIVE

To highlight further cost considerations associated with the wastage in the use of insulin vials and cartridges in the Jordanian Royal Medical Services.

METHODS

Two random samples were selected from prescriptions dispensed for diabetic patients using insulin in January 2012 from the outpatient pharmacy in Al-Hussein Hospital, King Hussein Medical Center, Amman, Jordan. First sample was selected from prescriptions of patients using vials; second sample was selected from prescriptions of patients using pens and cartridges. Average costs for insulin and wastage were calculated per patient from the Royal Medical Services perspective.

RESULTS

The average direct cost per patient using vials was JD 5.197 and for those using cartridges was JD 22.135. The average wasted quantity per patient in the first sample was more than ten times that of the second sample. The cost of the average wasted quantity per patient in the first sample (1.022 JD) was more than the double that in the second sample (0.441 JD).

CONCLUSION

Although, the direct cost of insulin per patient by using vials was lower than cartridges, there was a substantial reduction in the cost of wastage by using the cartridges in the Jordanian Royal Medical Services outpatients.

Patient device assessment evaluation of two insulin injection devices in a mixed cohort of insulin-treated patients with type 1 or type 2 diabetes mellitus

OBJECTIVE

FT (FlexTouch*) is a new disposable insulin injection pen device for use in insulin-treated patients with diabetes mellitus. The aim of this study was to evaluate patient perception of FT versus IL (InnoLet†) with respect to the ease of use and patient preference in a mixed patient cohort with different kinds and degrees of visual or dexterity impairments.

METHODS

Ninety patients were included into this investigation (54 male/36 female, age [mean ± SD]: 62 ± 8 yrs, disease duration: 18 ± 11 yrs, HbA1c: 7.2 ± 1.0%). After assessment of visual acuity and dexterity skills (by Jebsen-Taylor Hand Function Test), the patients were introduced to the two pen devices in random order, and were asked to perform mock injections with 10 IU, 30 IU and 50 IU doses before completing a 41 item standardized device assessment questionnaire. The questions asked were covering five topics of pen use (confidence in delivering a correct dose, dose setting, performance of the injection, general handling, and others) and could be answered with a rank scale from '1 = very easy' to '5 = very difficult'.

RESULTS

FT was ranked superior to IL with respect to the injection procedure (FT: 1.2 ± 0.1 vs. IL: 2.1 ± 0.4, p < 0.001) and general handling (1.3 ± 0.2 vs. 2.3 ± 0.7, p < 0.001), and numerically better with respect to confidence in correct dosing (1.4 ± 0.2 vs. 2.1 ± 0.9, n.s.). The two devices were ranked equally for ease of dose setting (1.6 ± 0.3 vs. 1.7 ± 0.4, n.s.). When ranked individually, FT use was recommended by 92.2% of the patients (IL: 30.0%).

KEY LIMITATIONS

Patients of this investigation were from one local area (San Jose, CA, USA) only. The subgroups may be considered small for the performed analysis.

CONCLUSIONS

In summary, FT was perceived to be easier to use than IL in this investigation.

Analysis of comparison of patient preference for two insulin injection pen devices in relation to patient dexterity skills

Insulin therapy is the cornerstone of medical treatment for many patients with diabetes. Self-administration of this life-saving medication is no longer limited to the traditional vial and syringe. Instead, more and more patients worldwide are using prefilled insulin pen devices. Ease of use, convenience, confidence in dosing accuracy, and improved quality of life are just a few of their advantages. As with any medical technology, safe and proper use is vital. Many studies have examined pen device preference and usability. Until now, no study has included patients with both visual and dexterity impairments. To ensure safe and simple self-administration of insulin for all patients, it is time for the special needs of patients with diabetes to be considered not only during product development, but during postmarketing studies as well.

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

Insulin injection pens have improved the ease and convenience of administering insulin for people with diabetes. This article reviews the data on a new prefilled insulin pen, FlexTouch®. FlexTouch has a novel injection mechanism with no push-button extension and a lower injection force than other prefilled pens, and other features including an end-of-dose click; a large dose display; color-coded pens to distinguish different insulin types; an ergonomic design; and compatibility with both NovoTwist® needles and most screw-thread needles. FlexTouch has been demonstrated to deliver insulin consistently and accurately at minimum, half-maximum and maximum doses. In usability studies recruiting patients and healthcare professionals, FlexTouch was easier to use and instilled more confidence than other prefilled pens, and was preferred to other prefilled pens. FlexTouch was also found to be easier to use and was preferred for learning and teaching to use.

Comparison of follitropin β administered by a pen device with follitropin β administered by a conventional syringe in patients undergoing IVF-ET

Objective

To compare the effectiveness and convenience of a pen device for the self-administration of follitropin β with a conventional syringe delivering follitropin β solution in patients undergoing IVF-ET.

Methods

GnRH agonist long protocol was used for controlled ovarian stimulation (COS) in all subjects. A total of 100 patients were randomized into the pen device group or the conventional syringe group on the first day of COS. Local tolerance reactions were assessed within 5 minutes, at 1 hour and at 3 hours after each injection. On the day of hCG injection, patients were asked to rate their overall pain and convenience experienced with self-injection on a visual anlaogue scale (VAS).

Results

There were no differences in patients' characteristics between the two groups. The duration of COS was significantly shorter in the pen device group than in the conventional syringe group. Patients included in the pen device group needed a significantly smaller amount of follitropin β. However, no differences between the two groups were found in IVF results and pregnancy outcome. The incidence of local pain within 5 minutes, at 1 hour and at 3 hours after the injection was significantly lower in the pen device group. VAS scores indicated that injections using the pen device were significantly less painful and more convenient.

Conclusion

The pen device for self-administration of follitropin β is less painful, safer and more convenient for the patients, and can be more effective because of the shorter duration and smaller dose of follitropin β when compared with the conventional syringe.

Patient preferences for characteristics differentiating ovarian stimulation treatments

BACKGROUND

Little is known concerning patient preferences for IVF treatments. The objective of this study was to elicit patient preferences for characteristics differentiating ovarian stimulation treatments.

METHODS

Women undergoing IVF were recruited from six clinics in Sweden between May 2010 and December 2010. Included patients completed a study questionnaire consisting of one contingent valuation (CV) question (with six different bids) and 16 conjoint analysis (CA) questions formulated as discrete choices between two hypothetical ovarian stimulation treatments (defined in terms of manufacturing method, method of administration, time required for administration, dose variability and hypothetical price). Patient preferences were derived using multinomial logit modelling.

RESULTS

The final study population consisted of 294 women (mean age of 35). Respondents were willing to pay €360 [95% confidence interval (CI): €340-€390] to receive FSH derived from DNA technology instead of highly purified extract from urine from post-menopausal women, €300 (95% CI: €280-€320) to administer the FSH using a prefilled injection pen instead of a conventional syringe, €30 (95% CI: €20-€40) per saved minute required for administration and €530 (95% CI: €500-€570) to reduce the dose variability from 10-20% to 1-2% (P< 0.001 for all estimates). The result from the CV was similar to the CA.

CONCLUSIONS

Women undergoing IVF place significant value on characteristics differentiating ovarian stimulation treatments. Product-specific aspects should be taken into account by decision-makers when discriminating between commercial gonadotrophins in clinical practice to align health-care decision-making with patient preferences and potentially improve the effectiveness of IVF interventions through enhanced patient satisfaction and treatment compliance. Preferences for treatment characteristics should also be considered in evaluations of ovarian stimulation products to capture their true value from a patient perspective.

FlexTouch: a prefilled insulin pen with a novel injection mechanism with consistent high accuracy at low- (1 U), medium- (40 U), and high- (80 U) dose settings

BACKGROUND

FlexTouch® is the only prefilled insulin pen that utilizes an easy touch button that does not extend at any dose in place of a push-button extension. Rigorous testing has shown that the new FlexTouch pen accurately and consistently delivers insulin doses.

METHODS

This study assessed dose accuracy of FlexTouch, KwikPen®, and SoloSTAR®. Dose accuracy for minimum, medium, and maximum doses of each pen type (1, 40, and 80 U for FlexTouch and SoloSTAR and 1, 30, and 60 U for KwikPen) was assessed.

RESULTS

FlexTouch delivered all doses consistently, as demonstrated by low standard deviations. FlexTouch showed similar accuracy to KwikPen at 1 U and to SoloSTAR at 40 and 80 U. However, FlexTouch was significantly more accurate at delivering 1 U of insulin than SoloSTAR (p < .0001).

CONCLUSIONS

This study demonstrates that FlexTouch, a new prefilled pen, delivers insulin accurately and consistently at low, medium, and high doses. In addition, FlexTouch is currently the only prefilled pen that has a push button that does not extend at any dose, making FlexTouch easier to use than other pens.

Comparison of clinically relevant technical attributes of five insulin injection pens

BACKGROUND

Insulin injection pens are the predominant devices for insulin delivery in Europe and Japan because of their ease of use and convenience. This study compared clinically relevant technical attributes of durable insulin pens that are important to people with diabetes, specifically functions relating to cartridge-fitting, dose-setting, and dose-delivery on NovoPen® 4, ClikStar®, HumaPen Luxura®, Itango®, and Biosulin® Pen.

METHODS

Frequency components and duration of audible clicks on dose setting and injection were measured using audio equipment when setting and delivering 20 IU of insulin. To assess cartridge-fitting torque, each pen was attached to a torque gauge via the attached needle, and torque was measured with each 180° turn as the cartridge was screwed into the body of the pen. Rotary torque of the dose-setting dial was measured when setting the dose to the maximum dose unit of the pen. Injection force was measured when delivering 20 IU at 5 mm/s in a vertical position and at a tilt of 14.7° from vertical.

RESULTS

Audible clicks on dose-setting and dose-delivery were most distinguishable on NovoPen 4, while NovoPen 4 and ClikStar had generally lower cartridge-fitting torque and injection (both vertical and angled) force values.

CONCLUSION

Overall, the results showed that durable insulin pens such as NovoPen 4 have useful features related to assembly, dose-setting, and injection, which may facilitate ease of use for diabetes patients, particularly elderly patients and those with visual and/or manual dexterity impairments.

Insulin delivery by injection in children and adolescents with diabetes

Type 1 diabetes is treated with insulin, which has traditionally been delivered by vial and syringe. However, for many patients, dosing inaccuracy, pain, anxiety, inconvenience, and social acceptability present barriers to this method of administration (1-5). This has contributed to the increased popularity of alternative insulin delivery systems, including pen delivery devices (4, 6). Evidence suggests that discreet devices, such as insulin pens, facilitate adherence to intensive insulin therapy regimens, help improve lifestyle flexibility, and reduce injection pain compared with the conventional syringe-based regimens, as shown in studies in adults and adolescents (7). In addition, compared with the vial and syringe method of insulin administration, pens may provide more accurate dosing - which is particularly important in children - thereby improving short-term blood glucose control and potentially improving long-term outcomes (5, 8). Children, in particular, may benefit from insulin pens that are simple to use as adherence issues may be more evident in this patient group (9). Pens for insulin delivery in children with type 1 diabetes have been used for a long time in Europe, and have recently gained in popularity in many other places around the world (4, 10). Furthermore, the conventional vial and syringe method of insulin delivery is beginning to be considered as obsolete (11). Moreover, there is a continued drive to improve insulin pen technology, to refine and enhance the functionality and usability of these pens. However, despite recent advances in pen design and function, the selection of pens available especially for children is limited.

The redesigned follitropin α pen injector for infertility treatment

INTRODUCTION

Treatment for infertility may require multiple drugs and complex dosing schedules. Available injection devices for patients who require regular injections during treatment are reviewed in this article, focusing on pen injectors used to self-administer recombinant human follicle-stimulating hormone (follitropin α). Following the introduction of the first and second follitropin α pen injectors in the last decade, a third pen injector with improved design for the administration of follitropin α has been developed for use in fertility treatment cycles.

AREAS COVERED

This paper presents the results of the dose accuracy testing with this pen injector that was performed in accordance with international standards (EN ISO 11608-1:2000). This overview also provides an understanding of the key features of the redesigned pen injector that are of interest to healthcare professionals.

EXPERT OPINION

The availability of an improved injection device for the delivery of follitropin α used during infertility treatment cycles of ovulation induction and assisted reproductive technology offers patients and healthcare professionals new treatment administration options. As fertility treatment cycles involve the use of several injectable gonadotropins, a standard device that could be used for all such treatments would simplify both the administration and the teaching of administration considerably.

Needle with a novel attachment versus conventional screw-thread needles: a preference and usability test among adults with diabetes and impaired manual dexterity

BACKGROUND

NovoTwist(®) (Novo Nordisk A/S, Bagsværd, Denmark) is an insulin pen needle that features a novel attachment and detachment system. The aim of this test was to assess overall preference and handling of NovoTwist compared with conventional screw-thread needles in people with type 1 or type 2 diabetes.

METHODS

One hundred twenty adults with type 1 or type 2 diabetes and manual dexterity dysfunction who were currently self-injecting with an insulin pen were included in this open-label, randomized, crossover test. Participants were stratified according to the impact that manual dexterity problems had on their ability to inject insulin (1 = no effect at all; 4 = a lot), and those rated as 1 were excluded from subanalyses because of low numbers. Following instruction, participants attached the needle to Next Generation FlexPen(®) (Novo Nordisk A/S), made an injection into a foam cushion, and detached the needle; this process was repeated three times with NovoTwist and the participant's current screw-thread needle (or NovoFine(®) [Novo Nordisk A/S]) in a random order. Responses to questions on user experience with each needle were subsequently recorded on a 6-point rating scale (1 = very difficult; 6 = very easy).

RESULTS

Significantly more respondents had a preference for NovoTwist (79%) compared with the conventional screw-thread needles (21%, P < 0.001). Significantly more respondents preferred NovoTwist for both ease of attachment (80%, P < 0.001) and ease of detachment (74%, P < 0.001). Most respondents found NovoTwist the most appropriate needle for performing everyday injections (71%, P < 0.001).

CONCLUSIONS

Such preference by patients has a positive impact on the treatment of diabetes as NovoTwist may alleviate the burden of performing everyday injections through its ease of use.

The Third Injection Technique Workshop in Athens (TITAN)

The first Injection Technique workshop brought together endocrinologists and injection experts from around the world in Strasbourg in 1997. From its work came groundbreaking recommendations which advanced best practices in areas such as the use of a skin fold when injecting. The second Injection Technique workshop, with an expanded format including nurses and diabetes educators, took place in Barcelona in 2000. The initial stimulus to use shorter injecting needles can be said to date from this meeting. The third Injection Technique workshop was held in Athens in September 2009 and involved 127 experts from across the globe. After a comprehensive review of all publications since 2000 as well as several unpublished studies, the attendees divided into smaller groups to debate and draft new injecting recommendations based on the new data and their collective experience. This paper summarizes all the formal presentations given at this practical consensus workshop.

New injection recommendations for patients with diabetes

AIM

Injections administered by patients are one of the mainstays of diabetes management. Proper injection technique is vital to avoiding intramuscular injections, ensuring appropriate delivery to the subcutaneous tissues and avoiding common complications such as lipohypertrophy. Yet few formal guidelines have been published summarizing all that is known about best practice. We propose new injection guidelines which are thoroughly evidence-based, written and vetted by a large group of international injection experts.

METHODS

A systematic literature study was conducted for all peer-reviewed studies and publications which bear on injections in diabetes. An international group of experts met regularly over a two-year period to review this literature and draft the recommendations. These were then presented for review and revision to 127 experts from 27 countries at the TITAN workshop in September, 2009.

RESULTS

Of 292 articles reviewed, 157 were found to meet the criteria of relevance to the recommendations. Each recommendation was graded by the weight it should have in daily practice and by its degree of support in the medical literature. The topics covered include The Role of the Professional, Psychological Challenges, Education, Site Care, Storage, Suspension and Priming, Injecting Process, Proper Use of Pens and Syringes, Insulin analogues, Human and Pre-mixed Insulins, GLP-1 analogs, Needle Length, Skin Folds, Lipohypertrophy, Rotation, Bleeding and Bruising, Pregnancy, Safety and Disposal.

CONCLUSION

These injecting recommendations provide practical guidance and fill an important gap in diabetes management. If followed, they should help ensure comfortable, effective and largely complication-free injections.

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.

Patient evaluation of the use of follitropin alfa in a prefilled ready-to-use injection pen in assisted reproductive technology: an observational study

BACKGROUND

Self-administration of recombinant human follicle-stimulating hormone (r-hFSH) can be performed using injection pen devices by women undergoing assisted reproductive technology procedures. The objective of this study was to explore the use of the prefilled follitropin alfa pen in routine assisted reproductive technology procedures in Germany.

METHODS

This prospective, observational study was conducted across 43 German IVF centres over a period of 1.75 years. Patients who had used the prefilled follitropin alfa pen in the current or a previous cycle of controlled ovarian stimulation completed a questionnaire to assess their opinions of the device.

RESULTS

A total of 5328 patients were included in the study. Of these, 2888 reported that they had previous experience of daily FSH injections. Significantly more patients reported that less training was required to use the prefilled follitropin alfa pen than a syringe and lyophilized powder (1997/3081 [64.8%]; p < 0.001 'less' versus 'more' training). Significantly more patients rated the prefilled follitropin alfa pen as easier in terms of use (2321/3206, 72.4%; p < 0.001 'much more easy' versus 'less easy') and daily injection (2384/3262, 73.1%; p < 0.001 'much more easy' versus 'less easy') than existing injection methods. Approximately one third of respondents rated the prefilled follitropin alfa pen as easier to use than the follitropin beta pen with reloadable cartridges. The majority (3378/4024, 83.9%) of patients had a general preference for the prefilled follitropin alfa pen over other injection methods.

CONCLUSIONS

In this questionnaire-based survey, routine use of the prefilled follitropin alfa pen was well accepted and associated with favourable patient perceptions. Users of the pen found it easier to initially learn how to use, and subsequently use, than other injection methods. In general, the prefilled follitropin alfa pen was the preferred method for self-administration of gonadotrophins. Together with previous findings, the results here indicate a high level of patient satisfaction among users of the prefilled follitropin alfa pen for daily self-administration of r-hFSH.

Ease of use and patient preference injection simulation study comparing two prefilled insulin pens

OBJECTIVES

To determine patient ease of use and preference for the Humalog KwikPen* (prefilled insulin lispro [Humalog dagger] pen, Eli Lilly and Company, Indianapolis, IN, USA) (insulin lispro pen) versus the Next Generation FlexPen double dagger (prefilled insulin aspart [NovoRapid section sign ] pen, Novo Nordisk A/S, Bagsvaerd, Denmark) (insulin aspart pen).

RESEARCH DESIGN AND METHODS

This was a randomized, open-label, 2-period, 8-sequence crossover study in insulin pen-naïve patients with diabetes. Randomized patients (N = 367) received device training, then simulated low- (15 U) and high- (60 U) dose insulin injections with an appliance. Patients rated pens using an ease of use questionnaire and were asked separately for final pen preferences.

MAIN OUTCOME MEASURES

The Insulin Device 'Ease of Use' Battery is a 10-item questionnaire with a 7-point scale (higher scores reflect greater ease of use). The primary objective was to determine pen preference for 'easy to press to inject my dose' (by comparing composite scores [low- plus high-dose]). Secondary objectives were to determine pen preference on select questionnaire items (from composite scores), final pen preference, and summary responses for all questionnaire items.

RESULTS

On the primary endpoint, 'easy to press to inject my dose,' a statistically significant majority of patients with a preference chose the insulin lispro pen over the insulin aspart pen (68.4%, 95% CI = 62.7-73.6%). Statistically significant majorities of patients with a preference also favored the insulin lispro pen on secondary items: 'easy to hold in my hand when I inject' (64.9%, 95% CI = 58.8-70.7%), 'easy to use when I am in a public place' (67.5%, 95% CI = 61.0-73.6%), and 'overall easy to use' (69.9%, 95% CI = 63.9-75.4%). A statistically significant majority of patients had a final preference for the insulin lispro pen (67.3%, 95% CI = 62.2-72.1%).

CONCLUSIONS

Among pen-naïve patients with diabetes who had a preference, the majority preferred the insulin lispro pen over the insulin aspart pen with regard to ease of use. Study limitations included open-label design and injection simulation, use of an unvalidated questionnaire, and enrollment of mostly insulin-naïve patients.

Self-injection of insulin using appropriate supportive devices in handicapped subjects with diabetes

BACKGROUND

To self-inject insulin, individuals with diabetes must be able to attach the needle to the injector, recognize the appropriate insulin dosage, detach the needle from the injector, and perform a series of operations necessary for the actual injection. These tasks require a grip strength that is strong enough to hold the necessary devices, eyesight, the use of both hands, and at least a minimum intellectual capacity. Subjects who are unable to grasp or handle the devices required for insulin injection often have difficulties with the self-injection of insulin.

METHODS

We treated four diabetes patients who had trouble grasping objects and using both hands. One patient had lost five fingers in an accident, two patients had suffered from ischemic cerebral infarction resulting in complete one-sided hemiplegia with no movement in one arm, and one patient had limited muscular power in an arm as a result of spinal cord disease. The plasma glucose control was poor, and the initiation of insulin therapy was necessary in each of these patients. In three cases, we used a commercially available self-injection device (HumaHelper; Eli Lilly Japan K.K., Kobe, Japan) to enable self-injection; in the fourth case, we used a newly manufactured device similar to HumaHelper.

RESULTS

All the patients were able to inject insulin by themselves using the appropriate supplementary devices. The blood glucose control of all the patients subsequently improved.

CONCLUSION

Existing or newly manufactured supportive devices can enable handicapped subjects to self-inject insulin.

Comparative device assessments: Humalog KwikPen compared with vial and syringe and FlexPen

PURPOSE

The purpose of this study was to compare pen device-naïve patients' preferences for Humalog KwikPen (insulin lispro injection) (Eli Lilly and Company, Indianapolis, IN) to use of a vial and syringe and FlexPen(R) (insulin aspart injection) (Novo Nordisk A/S, Bagsvaerd, Denmark).

METHODS

This open-label, randomized, crossover 1-day study tested the hypotheses that KwikPen was preferred to vial and syringe, and if this was found to be a significant preference, that KwikPen was preferred to FlexPen. Accuracy of doses prepared, ease of use via insulin device assessment battery, and preference via insulin device preference battery were administered following each pen evaluation, and a final preference question administered following the evaluation of both pens. Clinical measures were not included as subjects injected into an appliance to simulate the injection experience. Primary outcome variables were evaluated by Question 13 of the insulin device preference battery and the final preference question.

RESULTS

Among 232 enrolled patients randomized to 1 of 4 sequences (n = 58), Humalog KwikPen was significantly preferred over vial and syringe and over FlexPen. After patients were asked to assess Humalog KwikPen or FlexPen versus V&S by choosing "strongly agreed" or "agreed" to the following attributes: easy to use, easy to hold in their hands when injecting, and easy to press the injection button, the results exhibited significant differences in patient responses. Humalog KwikPen was significantly more accurate and was preferred to vial and syringe in appearance, quality, discretion, convenience, public use, easy to learn, easy to use, reliability, dose confidence, following insulin regimen, overall satisfaction, and recommendation to others.

CONCLUSIONS

Humalog KwikPen was significantly preferred over vial and syringe and FlexPen. When compared with vial and syringe, Humalog KwikPen and FlexPen were easier to use and operate, demonstrated superior accuracy of doses prepared, and preferred by pen-naïve users.

Usability, participant acceptance, and safety of a prefilled insulin injection device in a 3-month observational survey in everyday clinical practice in Australia

BACKGROUND

SoloSTAR (SOL; sanofi-aventis, Paris, France) is a prefilled insulin pen device for the injection of insulin glargine and insulin glulisine. This is the first Australian survey to determine its usability, participant acceptance, and safety in clinical practice.

METHODS

A 3-month, nonrandomized, noncomparative, observational survey in Australia was conducted in individuals with diabetes. Participants were given SOL pens containing glargine, the instruction leaflet, and a toll-free helpline number. Training was offered to all participants. Safety data, including product technical complaints (PTCs), were gathered from ongoing feedback given by the participant or health care professional (HCP) and by independent interviews conducted 6-10 weeks after study start.

RESULTS

Some 2674 people consented to take part across 93 sites (150 HCPs), and 2029 participated in interviews. Of these, 52.6% had type 1 diabetes, 16.3% had manual dexterity problems, and 15.5% had poor eyesight not corrected by glasses. At the time of interview, 96.8% of participants were still using SOL. None of the eight PTCs reported were due to technical defects; most were related to handling errors. Some 62 participants reported 77 adverse events; none were related to a PTC. The vast majority of participants (95.4%) were "very satisfied" or "satisfied" with using SOL, and 89.7% of the participants had no questions or concerns using SOL on a daily basis. Similar positive findings were reported by participants with manual or dexterity impairments.

CONCLUSIONS

In this survey of everyday clinical practice, SOL had a good safety profile and was very well accepted by participants.

A comparison of injection force and dosage scale size between NovoPen 3 and NovoPen 4

BACKGROUND

Easy-to-use insulin devices are an important tool in the treatment of diabetes. In this study, injection force requirements and dosage scale displays were evaluated for NovoPen 3 and NovoPen 4 (both from Novo Nordisk A/S, Copenhagen, Denmark).

METHODS

To simulate 5 years of expected lifetime usage, 5,475 injections were performed automatically. Before and after lifetime testing, the force required to expel 60 U of insulin from NovoPen 3 and NovoPen 4 with 30-gauge or 31-gauge needles was measured. To compare dosage scale displays, digital images of multiple settings were made, and the total inked areas of digits were converted to mm(2).

RESULTS

At baseline, the mean +/- SD injection force of NovoPen 4 was 9.14 +/- 0.87 N and 16.55 +/- 1.17 N, which was significantly lower (P < 0.001) than for NovoPen 3, at 18.36 +/- 1.06 N and 29.81 +/- 1.26 N, with the 30-gauge and 31-gauge needle, respectively. After simulated lifetime testing, mean +/- SD injection force was 10.93 +/- 0.77 N and 17.77 +/- 1.14 N for NovoPen 4, which was significantly lower than the injection force of 18.54 +/- 0.94 N and 31.69 +/- 1.98 N for NovoPen 3 (P < 0.001). The mean dosage scale digit size was 1.63 mm(2) for NovoPen 3 and 7.82 mm(2) for NovoPen 4, with a mean difference of 6.19 mm(2). The display for NovoPen 4 was 4.74 times larger (P < 0.001).

CONCLUSIONS

The mean injection force required to operate NovoPen 4 was reduced up to 50% compared with NovoPen 3 (P < 0.001), and the mean dosage display for NovoPen 4 was over four times larger than for NovoPen 3 (P < 0.001). Based on these findings, patients with diabetes who have manual or visual impairment should find it easier to dose insulin with NovoPen 4.

Comparison of the dose accuracy of prefilled insulin pens

BACKGROUND

Prefilled insulin pens have become a convenient and accurate way for diabetes patients to inject insulin. Their ease of use has helped to reduce the resistance of patients with type 1 diabetes and type 2 diabetes in the United States and Europe toward initiation of insulin therapy. This study compared the dosing accuracy of two prefilled insulin pens (the SoloStar((R)) from Sanofi Aventis, Berlin, Germany, and the Next Generation [NG] FlexPen((R)) from Novo Nordisk, Mainz, Germany).

METHODS

The dosing accuracy was tested for both pens with x 24 10 international units of insulin (IU) and 9 x 30 IU injection volumes to investigate whether the pens comply within the acceptable International Organization for Standardization (ISO) limits of 10% (±1 IU) for 10 IU and 5% (±1.5 IU) for 30 IU. The doses were applied each with a new needle strictly according to the instructions for use of the pen manufacturers. A sensitive pharmaceutical balance was used for the assessment of the applied volumes, and the results were corrected for the specific density of the insulin formulations. We used 18 insulin pens (from two different production lots each) for the two volumes, respectively, resulting in a total of 432 doses per pen with 10 IU and 162 doses per pen with 30 IU.

RESULTS

Both pens showed a very good performance, which was better for the 10 IU dose than in comparative previous studies. The NG FlexPen (mean absolute percent deviation 10 IU/30 IU: 1.63 ± 0.84%/1.23 ± 0.76%) was even more accurate than the SoloStar (2.11 ± 0.92%/1.54 ± 0.84%, p < .001/p < .05 versus the NG FlexPen). Only 0.2% of the doses were outside the ISO limit at 10 IU, with the NG FlexPen (0.6% at 30 IU). The corresponding figures for the SoloStar were 0.4% and 1.8%, respectively.

CONCLUSIONS

A direct head-to-head comparison of the two prefilled insulin pens with a standardized protocol resulted in a more stable dosing accuracy of both pens as compared to previous investigations. In this investigation, the NG FlexPen was more accurate than the SoloStar at both tested doses.

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.

Lessons in initiating insulin in clinical practice

Insulin therapy in type 2 diabetes (T2DM) can produce greater improvements in fasting plasma glucose (FPG) and glycated haemoglobin (HbA1c) than oral antidiabetic drugs (OADs). There is a growing trend to recommend initiation of insulin in T2DM patients sooner in the course of the disease, and good results have been achieved in insulin-naïve patients during randomised, controlled trials, often using aggressive dose titration algorithms. The Physicians' Routine Evaluation of Safety & Efficacy NovoMix((R)) 30 Therapy (PRESENT) study was a 6-month observational study of the safety and efficacy of biphasic insulin aspart 30 (BIAsp 30) as monotherapy or in combination with OADs in inadequately controlled patients with T2DM. This review article compares results from those patients who entered the study insulin-naïve (either with or without previous OAD treatment), with results from randomised, controlled trials of BIAsp 30 in insulin-naïve T2DM patients. It aims to provide guidance on the initiation of insulin in patients with T2DM, focusing on the efficacy of BIAsp 30 when used for this purpose, and highlighting both the low risk of hypoglycaemia associated with therapy, and the availability of delivery devices that can minimise injection site discomfort and help to overcome psychological insulin resistance.

Initiating insulin therapy in type 2 diabetes: benefits of insulin analogs and insulin pens

Despite the development of alternative therapies in recent years, insulin injections remain essential treatment for type 2 diabetes once oral therapy alone becomes inadequate. However, neither patients nor physicians are proactive enough with regard to starting insulin, despite the well-known benefits of early insulin initiation and aggressive dose titration. Barriers to starting insulin therapy are being overcome by developments in insulin and delivery device technology and are the subject of this review. A literature search spanning the last 25 years was carried out to identify publications addressing issues of insulin initiation, how insulin analogs can help overcome barriers to initiation, and the advantages of pen-type insulin delivery systems. Seventy-five publications were identified. These references illustrate that the drawbacks associated with regular exogenous human insulins (soluble and NPH) are improved with modern insulin analogs. The more rapid absorption of prandial insulin analogs compared with human insulin eliminates the need for an injection-meal-interval, increasing convenience, while basal analogs have no discernible peak in activity. Modern insulin delivery devices also have advantages over the traditional vial and syringe. Currently available insulin pens are either durable (insulin cartridge is replaceable; e.g., HumaPen, Eli Lilly [Indianapolis, IN]; NovoPen series, Novo Nordisk [Bagsvaerd, Denmark]) or disposable (prefilled; e.g., FlexPen, Novo Nordisk; SoloSTAR, sanofi-aventis [Paris, France]), with features to aid ease-of-use. These include a large dose selector, dial-up and dial-down facility, and audible clicks when selecting the dose. The potential for dosing errors is thus reduced with pen-type devices, with other benefits including a discreet appearance, ease of learning, and greater user confidence. Collectively, these features contribute to overwhelming patient preference when compared with vials and syringes. Despite the greater cost of insulin pens relative to vials and syringes, improvements in treatment adherence with pens-and hence glycemic control-may offset these costs in the long term.

Comparison of follitropin-beta administered by a pen device with conventional syringe in an ART programme - a retrospective study

OBJECTIVES

This study compares the efficacy and patient tolerance of follitropin-beta (recagon) administered using a pen device with conventional syringe in infertile couples undergoing in vitro fertilization/intracytoplasmic sperm injection treatment.

METHODS

Data for 481 patients were retrieved retrospectively for the analysis. Conventional syringe group constituted 204 patients with 217 cycles and 265 patients with 294 cycles in the pen-device group. Down-regulation was achieved with GnRH agonist.

RESULTS

Comparison of follitropin-beta administered with pen and syringe showed the following data, respectively. A total dose of 1909.38/2100.65 IU (P < 0.001), duration of stimulation, 9.70/10.47 days (P < 0.05), oestradiol levels on the day of human chorionic gonadotropin, 1488.34/1067.63 pg/ml, number of follicles reaching >16-mm size, 9.75/7.34 (P < 0.05), number of oocytes retrieved, 13.84/9.55 (P < 0.001) and number of embryos available for freezing, 4.56/1.30 (P < 0.05), the above data were observed in pen/conventional syringe groups, respectively. The live birth rates per cycle were 28.85% and 30.95% in the conventional syringe/pen-device groups, respectively. Patient tolerance with respect to pain at injection site was better with the pen device (P < 0.025).

CONCLUSION

The data show that follitropin-beta administered with pen device is well tolerated and more efficacious with respect to ovarian stimulation outcome compared with the conventional syringe.