Trends in Insulin Types and Devices Used by Adults With Type 2 Diabetes in the United States, 2016 to 2020

Real world evidence of insulin and biosimilar insulin therapy-Opportunities to improve adherence, outcomes and cost-effectiveness

Insulin has been discovered for more than a century; however, its benefits to people with diabetes are yet to be fully realized due to barriers related to access, quality of care and costs. Insulin therapy remains the cornerstone of diabetes management. The multicausality of diabetes and its subtypes calls for comprehensive phenotyping and use of biomarkers to ensure timely use of insulin to achieve early glycaemic control for long-term benefits. Biosimilar insulins are biologic products that closely resemble originator insulins without significant differences in safety or efficacy. The lower investment costs needed for research and development make biosimilar insulin more affordable to improve access. While the efficacy of insulin products is proven in controlled settings, real world evidence (RWE) from real world data (RWD) plays a crucial role in assessing the safety, efficacy, cost-effectiveness, adherence to and impacts of different insulin products, including biosimilars, on clinical outcomes. In this narrative review, we summarized the trends of insulin use and patterns of biosimilar insulin utilization in real world practice across different regions. We reviewed RWE on clinical safety, efficacy and cost-effectiveness of biosimilar insulin, as well as therapeutic inertia and non-adherence with insulin therapy. We also highlighted barriers to insulin adherence and enablers for persistence, along with potential solutions to promote the use of insulin and technologies for optimizing glycaemic control in different subtypes of diabetes. During our extensive literature review, we identified data gaps in the usage of biosimilar insulin in real world practice. We advocate for implementing a diabetes register designed fit-for-purpose, managed by a trained doctor-nurse team with system support, to generate RWE. By setting up registers with structured data collection, we can generate high quality data for integrative analysis with electronic health records (EHR) and health claims to evaluate the impacts of insulin products and other diabetes programmes on clinical outcomes, quality of life and healthcare costs to inform practice and policies. PLAIN LANGUAGE SUMMARY: Diabetes affects approximately 10.5% of the global population and insulin is a vital treatment for diabetes management. Insulin was discovered more than a century ago, although its benefits to people with diabetes are yet to be fully realized due to barriers related to access, quality of care, and costs. Real-world evidence from real-world data plays a crucial role in assessing the safety, efficacy, cost-effectiveness, adherence to, and impacts of different insulin products, including biosimilars, on clinical outcomes. In this publication, the authors provided a detailed review of the patterns of use and cost-effectiveness of biosimilar insulin, and identified major data gaps. The authors explained the methodology, utility, and limitations of generating real-world evidence based on real-world data from sources such as registers, electronic health records and health claims for assessing treatment effectiveness and safety. The authors proposed the implementation of a purpose-built diabetes register with structured data collection, managed by a trained doctor-nurse team with system support. These high-quality data can be integrated with electronic health records and health claims for evaluation of interventions, including insulin on outcomes, quality of life, and costs to inform practice and policy. Based on these premises and available data, the authors summarized trends in insulin use including biosimilar insulin, and reviewed real-world evidence on the safety, efficacy, and cost-effectiveness of these products. They also identified barriers like therapeutic inertia and non-adherence, discussed enablers for persistence, and proposed solutions to evaluate the impacts of insulin products and other diabetes programs on clinical outcomes, quality of life, and healthcare costs to inform practice and policies.

Type 2 Diabetes Mellitus: A Comprehensive Review of Pathophysiology, Comorbidities, and Emerging Therapies

Humans are perhaps evolutionarily engineered to get deeply addicted to sugar, as it not only provides energy but also helps in storing fats, which helps in survival during starvation. Additionally, sugars (glucose and fructose) stimulate the feel-good factor, as they trigger the secretion of serotonin and dopamine in the brain, associated with the reward sensation, uplifting the mood in general. However, when consumed in excess, it contributes to energy imbalance, weight gain, and obesity, leading to the onset of a complex metabolic disorder, generally referred to as diabetes. Type 2 diabetes mellitus (T2DM) is one of the most prevalent forms of diabetes, nearly affecting all age groups. T2DM is clinically diagnosed with a cardinal sign of chronic hyperglycemia (excessive sugar in the blood). Chronic hyperglycemia, coupled with dysfunctions of pancreatic β-cells, insulin resistance, and immune inflammation, further exacerbate the pathology of T2DM. Uncontrolled T2DM, a major public health concern, also contributes significantly toward the onset and progression of several micro- and macrovascular diseases, such as diabetic retinopathy, nephropathy, neuropathy, atherosclerosis, and cardiovascular diseases, including cancer. The current review discusses the epidemiology, causative factors, pathophysiology, and associated comorbidities, including the existing and emerging therapies related to T2DM. It also provides a future roadmap for alternative drug discovery for the management of T2DM.

Differential insulin response characteristics of graphene oxide-gold nanoparticle composites under varied synthesis conditions

The structural alterations in the constituent materials of nanocomposites such as graphene nanocomposites typically induce changes in their properties including mechanical, electrical, and optical properties. Therefore, by altering the preparation conditions of nanocomposites and investigating their responsiveness to basic biomolecules (such as proteins), it is possible to explore the application potentials of the composites and guide development of new nanocomposite preparation. In this study, different composites of graphene oxide and gold nanoparticles (AuNPs/GO) were obtained by varying the volumes of reducing agents used in the one-pot hydrothermal method. Insulin was chosen as a basic protein to study the response characteristics of AuNPs/GO under different preparation conditions. Optical responses of these composites to pure insulin and various commercial insulin types were all explored for the first time. The results indicated that AuNPs/GO could optically respond to insulin, including pure insulin and various types of commercial insulin, and changes in the preparation conditions could really influence this response. Moreover, optimal preparation conditions could be determined by an optical method for the largest responses of the nanocomposites to insulin. Based on previous research and the results of this study, it is speculated that the responses of AuNPs/GO to insulin may attribute to glutamic acids, asparagines, and glutamines on insulin, which may interact with AuNPs/GO, particularly with the AuNPs in the composites. Besides, the AuNPs/GO could exhibit relatively stable responses to various commercial insulin types and detect the concentration of specific branded commercial insulin with smaller errors. In summary, this study demonstrated the application potential of AuNPs/GO in areas such as drug testing and production, while also furnishing an experimental foundation and direction for further applications of AuNPs/GO in biosensing and biomolecule detection.

Level of Satisfaction Among Patients Using Insulin Administered by Pen vs Vial/Syringe. An Observational Prospective Study

Purpose

To determine the satisfaction of patients with diabetes mellitus who used subcutaneous insulin application devices in Colombia.

Patients and Methods

An observational prospective study of patients with diabetes mellitus receiving insulin treatment in Colombia. Sociodemographic, comorbidity and pharmacological data were taken from a drug dispensing database. Through telephone calls, satisfaction with application devices was evaluated with Diabetes Treatment Satisfaction Questionnaire status version (DTSQ-s). Satisfaction was considered high at a score ≥30 points. The change in the type of insulin delivery device (ie, from pen to vial/syringe, and from vial/syringe to pen) was evaluated during a 1-year follow-up.

Results

A total of 382 patients from 75 cities were selected, with a median age of 66.0 years, and 56.3% were women, and 65.2% were treated with long-acting insulins. The mean DTSQ-s score was 26.6±5.3 points, and 38.7% presented high satisfaction, without statistically significant differences between pen and vial/syringe. A total of 18.8% changed the administration device, mainly those that came from Bogotá-Cundinamarca (OR:2.19; 95% CI:1.01-4.75), in concomitant treatment with other antidiabetic drugs (OR:2.28; 95% CI:1.00-5.22) and those who previously used insulin in vial/syringe (OR:33.90; 95% CI:11.88-96.74).

Conclusion

The participants had low satisfaction with the insulin delivery device. No statistically significant differences were found in satisfaction between those who received pen vs vial/syringe insulin, and patients using the latter had a high probability of switching to insulin pen.

Causality between insulin use and malignant tumors of the digestive system: a two-sample mendelian randomized study

BACKGROUND

Existing cohort studies show no association between insulin use and cancers of the digestive system, while numerous meta-analyses suggest that insulin use increases the risk of digestive system tumours. This study uses two-sample Mendelian randomization (MR) to further investigate the causal relationship between the two.

METHODS

We selected single nucleotide polymorphisms (SNPs) strongly associated with insulin use as instrumental variables and used aggregated statistics on digestive system neoplasms as the outcome event. The primary method of analysis was inverse variance weighting (IVW), supplemented by weighted median, MR-Egger regression, weighted mode and simple mode methods. The reliability of the study was assessed by heterogeneity testing, pleiotropy analysis and sensitivity analysis.

RESULT

A total of 8 SNPs associated with insulin use were included as instrumental variables. Random-effects IVW analysis showed an association between insulin use and increased risk of colorectal cancer (OR = 1.1037, 95%CI = 1.0183-1.1962, P = 0.016). No statistically significant association was found between insulin use and the development of other digestive system tumours. The results were unaffected by pleiotropy and heterogeneity, and the reliability of the findings was confirmed by sensitivity analysis.

CONCLUSION

Our Mendelian randomization study suggests an association between insulin use and an increased risk of CRC, with no clear association observed for other digestive system tumours. However, further MR studies with larger sample sizes from genome-wide association study (GWAS) data are needed to verify this association.

Microfluidic-based systems for the management of diabetes

Diabetes currently affects approximately 500 million people worldwide and is one of the most common causes of mortality in the United States. To diagnose and monitor diabetes, finger-prick blood glucose testing has long been used as the clinical gold standard. For diabetes treatment, insulin is typically delivered subcutaneously through cannula-based syringes, pens, or pumps in almost all type 1 diabetic (T1D) patients and some type 2 diabetic (T2D) patients. These painful, invasive approaches can cause non-adherence to glucose testing and insulin therapy. To address these problems, researchers have developed miniaturized blood glucose testing devices as well as microfluidic platforms for non-invasive glucose testing through other body fluids. In addition, glycated hemoglobin (HbA1c), insulin levels, and cellular biomechanics-related metrics have also been considered for microfluidic-based diabetes diagnosis. For the treatment of diabetes, insulin has been delivered transdermally through microdevices, mostly through microneedle array-based, minimally invasive injections. Researchers have also developed microfluidic platforms for oral, intraperitoneal, and inhalation-based delivery of insulin. For T2D patients, metformin, glucagon-like peptide 1 (GLP-1), and GLP-1 receptor agonists have also been delivered using microfluidic technologies. Thus far, clinical studies have been widely performed on microfluidic-based diabetes monitoring, especially glucose sensing, yet technologies for the delivery of insulin and other drugs to diabetic patients with microfluidics are still mostly in the preclinical stage. This article provides a concise review of the role of microfluidic devices in the diagnosis and monitoring of diabetes, as well as the delivery of pharmaceuticals to treat diabetes using microfluidic technologies in the recent literature.

The Rate of Insulin use and Suboptimal Glycemic Control among Egyptian Patients with T2DM: Cohort Analysis of Eighth Wave of the International Diabetes Management Practices Study (IDMPS)

AIMS

The International Diabetes Management Practices Study (IDMPS) is an international annual survey aiming to study and characterize the current standards of care for managing DM in developing countries.

BACKGROUND

In Egypt, DM represents a substantial burden on the healthcare system, with an estimated 10.9 million patients, ranking it 10th amongst countries with the highest prevalence of DM. Previous studies showed that to maintain safety and achieve treatment goals among diabetic patients, optimal insulin therapy should be selected individually based on the patient's needs. We reported the proportion of Egyptian T2DM patients on insulin therapy who participated in the eighth wave of the IDMPS.

METHODS

The 2018 IDMPS wave consisted of cross-sectional and longitudinal phases and aimed to evaluate the proportion of T2DM who were on insulin therapy in 13 countries from four regions. In Egypt, 17 physicians agreed to participate in the present study and were required to include at least one patient.

RESULTS

A total of 180 T2DM patients were included in the cross-section phase. At the end of the ninth month of follow-up, data from 170 T2DM patients were available. A total of 39 T2DM patients (21.7%) were on insulin therapy, with a mean duration of 32.4 ± 36.6 months. More than half of the patients (n = 22; 56.4%) were on basal insulin, mainly long-acting (n = 20; 90.9%). The mean basal insulin daily dose was 0.3 ± 0.1 IU/Kg. Notably, 28.2% of the patients received insulin via vials, and 46.2% stated that they were adjusting the insulin dose by themselves. On the other hand, 60.2% of the study population was on oral antidiabetic drugs at the cross-sectional phase. Nearly 17.4% and 27% of the patients in the cross-sectional phase achieved the glycemic target per recommendations of international guidelines and the treating physicians, respectively. At the end of the longitudinal phase, the percentage of T2DM patients who achieved glycemic targets increased to 38.4% and 77.4% as per recommendations of international guidelines and the treating physicians, respectively. Overall, 38.3% of T2DM patients received diabetes education, and 28.9% were involved in an educational program provided by the physician or their clinical staff. Besides, 85.5% of T2DM patients followed their diabetes medication dosage and frequency strictly as prescribed.

CONCLUSION

The proportion of insulin use in patients with T2DM aligned with the previous studies from different countries; however, it is still inadequate to achieve the targeted glycemic control. Nearly one-third of Egyptian patients received diabetes education, highlighting the need for adopting a national educational program. Nonetheless, the level of adherence among T2DM from Egypt appears to be high.

Patents and regulatory exclusivities on FDA-approved insulin products: A longitudinal database study, 1986-2019

BACKGROUND

Insulin is the primary treatment for type 1 and some type 2 diabetes but remains costly in the United States, even though it was discovered more than a century ago. High prices can lead to nonadherence and are often sustained by patents and regulatory exclusivities that limit competition on brand-name products. We sought to examine how manufacturers have used patents and regulatory exclusivities on insulin products approved from 1986 to 2019 to extend periods of market exclusivity.

METHODS AND FINDINGS

We used the publicly available Food and Drug Administration (FDA) Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book) to identify all approved biosynthetic insulin products. Individual products approved under the same New Drug Application (NDA)-e.g., a vial and pen-were considered as separate products for the purposes of analysis. We recorded all patents and regulatory exclusivities listed in the Orange Book on each product and used Google Patents to extract the timing of patent application and whether patents were obtained on delivery devices or others aspects of the product. The primary outcome was the duration of expected protection, which was determined by subtracting the FDA approval date for each product from its last-to-expire patent or regulatory exclusivity (whichever occurred later). We performed a secondary analysis that considered overall protection on insulin lines-defined as groups of products approved under the same NDA with the same active ingredients manufactured by the same company. We also examined competition from follow-on insulin products-defined as products approved with the same active ingredients as originators but manufactured by different companies (approved via a specific drug approval pathway under section 505(b)(2) of the Food, Drug, and Cosmetic Act). During the study period, the FDA approved 56 individual products across 25 different insulin lines and 5 follow-ons across 3 different insulin lines. Thirty-three (59%) of the 56 products were drug-device combinations. Manufacturers of 9 products approved during the study period obtained patents filed after FDA approval that extended their duration of expected protection (by a median of 6 years). Approximately 63% of all patents on drug-device combinations approved during the study period were related to delivery devices. The median duration of expected protection on insulin products was 16.0 years, and the median protection on insulin lines was 17.6 years. An important limitation of our analysis is that manufacturers may continue to add patents on existing insulin products while competitors may challenge patents; therefore, periods of protection may change over time.

CONCLUSIONS

Among several strategies that insulin manufacturers have employed to extend periods of market exclusivity on brand-name insulin products are filing patents after FDA approval and obtaining a large number of patents on delivery devices. Policy reforms are needed to promote timely competition in the pharmaceutical market and ensure that patients have access to low-cost drugs.

Overcoming barriers to patient adherence: the case for developing innovative drug delivery systems

Poor medication adherence is a pervasive issue with considerable health and socioeconomic consequences. Although the underlying reasons are generally understood, traditional intervention strategies rooted in patient-centric education and empowerment have proved to be prohibitively complex and/or ineffective. Formulating a pharmaceutical in a drug delivery system (DDS) is a promising alternative that can directly mitigate many common impediments to adherence, including frequent dosing, adverse effects and a delayed onset of action. Existing DDSs have already positively influenced patient acceptability and improved rates of adherence across various disease and intervention types. The next generation of systems have the potential to instate an even more radical paradigm shift by, for example, permitting oral delivery of biomacromolecules, allowing for autonomous dose regulation and enabling several doses to be mimicked with a single administration. Their success, however, is contingent on their ability to address the problems that have made DDSs unsuccessful in the past.

The Association Between Insulin Use and Asthma: An Epidemiological Observational Analysis and Mendelian Randomization Study

BACKGROUND

Asthma is a common respiratory disease caused by genetic and environmental factors, but the contribution of insulin use to the risk of asthma remains unclear. This study aimed to investigate the association between insulin use and asthma in a large population-based cohort, and further explore their causal relationship by Mendelian randomization (MR) analysis.

METHODS

An epidemiological study including 85,887 participants from the National Health and Nutrition Examination Survey (NHANES) 2001-2018 was performed to evaluate the association between insulin use and asthma. Based on the inverse-variance weighted approach, MR analysis were conducted to estimate the causal effect of insulin use on asthma from the UKB and FinnGen datasets, respectively.

RESULTS

In the NHANES cohort, we found that insulin use was associated with an increased risk of asthma [odd ratio (OR) 1.38; 95% CI 1.16-1.64; p < 0.001]. For the MR analysis, we found a causal relationship between insulin use and a higher risk of asthma in both Finn (OR 1.10; p < 0.001) and UK Biobank cohorts (OR 1.18; p < 0.001). Meanwhile, there was no causal association between diabetes and asthma. After multivariable adjustment for diabetes in UKB cohort, the insulin use remained significantly associated with an increased risk of asthma (OR 1.17, p < 0.001).

CONCLUSIONS

An association between insulin use and an increased risk of asthma was found via the real-world data from the NHANES. In addition, the current study identified a causal effect and provided a genetic evidence of insulin use and asthma. More studies are needed to elucidate the mechanisms underlying the association between insulin use and asthma.

Efficacy and safety of empagliflozin in combination with insulin in Chinese patients with type 2 diabetes and insufficient glycaemic control: A phase III, randomized, double-blind, placebo-controlled, parallel study

AIM

To evaluate the efficacy and safety of empagliflozin in combination with insulin ± oral antidiabetic drugs (OADs) over 24 weeks, in Chinese patients with type 2 diabetes (T2D) who had insufficient glycaemic control.

MATERIALS AND METHODS

This was a randomized, double-blind, placebo-controlled, parallel group, multicentre phase III study. Adult patients with T2D and insufficient glycaemic control who received insulin ± up to two OADs were randomized (1:1:1) to receive empagliflozin 10 or 25 mg, or placebo for 24 weeks. The primary endpoint was change from baseline in HbA1c at week 24.

RESULTS

Of 219 randomized patients, 73 patients were in each treatment group; baseline characteristics were comparable among the groups. There was a significantly larger decrease from baseline in HbA1c (adjusted mean treatment difference -0.99 and -0.98 for in the empagliflozin 10 and 25 mg groups, respectively; P < .0001) with both doses of empagliflozin than with placebo. There were also significantly larger decreases from baseline in fasting plasma glucose, 2-hour postprandial glucose and body weight with both empagliflozin doses than with placebo. Among patients in the empagliflozin 10 mg, 25 mg and placebo groups, 17.8%, 9.6% and 11.0% reported confirmed hypoglycaemic events, respectively (nominal P = .2422 and .7661 in the empagliflozin 10 and 25 mg groups, respectively), and no Clinical Events Committee-confirmed diabetic ketoacidosis events were reported.

CONCLUSIONS

In Chinese patients with T2D, empagliflozin combined with insulin ± OADs improved glycaemic control and was well tolerated, without an increased risk of hypoglycaemia.

Insulin Fact Sheet in Type 1 and 2 Diabetes Mellitus and Trends of Antidiabetic Medication Use in Insulin Users with Type 2 Diabetes Mellitus: 2002 to 2019

BACKGROUND

This study investigated the trends of insulin use among Korean patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). Changes in prescription of antidiabetic medications in T2DM patients taking insulin therapy were evaluated.

METHODS

We analyzed data from the National Health Insurance Service database in Korea to evaluate the prevalence of insulin users and trends of insulin use in T1DM and T2DM patients from January 2002 to December 2019. We also investigated numbers and types of antidiabetic medications in insulin users with T2DM.

RESULTS

The overall total number of insulin users increased from 2002 to 2019, reaching 348,254 for T2DM and 20,287 for T1DM in 2019 compared with 109,974 for T2DM and 34,972 for T1DM in 2002. The proportion of patients using basal analogs and short acting analogs have increased and those using human insulin, premixed insulin, or biphasic human insulin have decreased (rapid acting analogs: 71.85% and 24.12% in T1DM and T2DM, respectively, in 2019; basal analogs: 76.75% and 75.09% in T1DM and T2DM, respectively, in 2019). The use of other antidiabetic medication in addition to insulin increased for T2DM, especially in dual therapy, reaching up to 52.35% in 2019 compared with 16.72% in 2002.

CONCLUSION

The proportion of the patients using basal or rapid acting analogs increased among all insulin users in both T1DM and T2DM patients. Among patients with T2DM, the proportion of patients using antidiabetic medications in addition to insulin was significantly increased compared to those who used insulin alone.

Factors Affecting Performance of Insulin Pen Injector Technology: A Narrative Review

BACKGROUND

Insulin treatment is an essential hormone replacement therapy for the survival of people with type 1 diabetes and is often used for treatment in type 2 diabetes, particularly as the disease progresses. Advances in insulin therapy have been made since its discovery, including production of human insulin and development of insulin analogs with improved efficacy and safety profiles. The different types of available insulin formulations allow health care professionals to personalize treatment to an individual's needs. Generally, insulin requires parenteral administration via subcutaneous injection owing to very low oral bioavailability.

METHODS

This article reviews the human, technological, economical, and regulatory factors affecting the performance of insulin pens and the relationship between them. Opportunities and challenges that insulin pen injections may encounter in the future are also considered.

RESULTS

Insulin delivery devices, together with other factors, influence dose accuracy, convenience, and quality of life, contributing to easier medication administration with high efficacy and safety. For patients, ease of use, fast and accurate drug delivery, and painless injection are the most valuable features of an insulin injection device. For manufacturers, technological feasibility and economic viability also need to be considered when developing injection devices.

CONCLUSION

Insulin pen injectors are generally preferred over vial and syringe, although access may be limited in some health care systems. Insulin pen injectors can adapt to different insulin regimens and formulations and have the potential to acquire dosing data in real time.

Comparison of simplicity, convenience, safety, and cost-effectiveness between use of insulin pen devices and disposable plastic syringes by patients with type 2 diabetes mellitus: a cross-sectional study from Bangladesh

INTRODUCTION

Insulin pen devices and disposable plastic insulin syringes are two common tools for insulin administration. This study aims to compare the simplicity, convenience, safety, and cost-effectiveness of insulin pens versus syringe devices in patients with type 2 diabetes mellitus (T2DM).

METHODS

A cross-sectional study was conducted at 14 diabetes clinics throughout Bangladesh from November 2021 to April 2022 among adults with T2DM injecting insulin by pen devices or disposable insulin syringes at least once a day for at least one year by purposive sampling. The simplicity, convenience, and safety of insulin devices were assessed using a structured questionnaire, and the study subjects were scored based on their answers; higher scores indicated a poorer response. Total scores for simplicity, convenience, and safety were obtained by adding the scores for relevant components. Their average monthly medical expense and cost of insulin therapy were recorded. The median values of the total scores and monthly expenses were compared between pen devices and disposable syringe users.

RESULTS

737 subjects were evaluated; 406 were pen users, and 331 were vial syringe users. The pen users had lower median scores for simplicity [6.0 (5.0-8.0) vs. 7.0 (5.0-9.0), p = 0.002], convenience [4.0 (3.0-6.0) vs. 5.0 (4.0-6.0), p < 0.001], and safety [7.0 (6.0-8.0) vs. 7.0 (6.0-9.0), p = 0.008] than vial syringe users. Pen devices were more expensive than vial syringes in terms of average medical expense per month [BDT 5000 (3500-7000) vs. 3000 (2000-5000), p < 0.001], the total cost of insulin therapy per month [BDT 2000 (1500-3000) vs. 1200 (800-1700), p < 0.001] and cost per unit of insulin used [BDT 2.08 (1.39-2.78) vs. 0.96 (0.64-1.39), p < 0.001]. Non-significant differences in favor of pens were observed in HbA1c levels [8.7 (7.8-10) vs. 8.9 (7.9-10)%, p = 0.607] and proportions of subjects having HbA1c < 7% (6.9 vs. 6.3%, p = 0.991).

CONCLUSION

Insulin pens are simpler, more convenient, and safe but more expensive than vial syringes. Glycemic control is comparable between pen and syringe users. Long-term follow-up studies are needed to determine the clinical and economic impacts of such benefits of insulin pens.

A Survey Snapshot Measuring Insulin Underuse in a Primary Care Clinic

The rising cost of insulin has created problems for physicians in the management of diabetes. The objective of our study was to determine the prevalence of cost-related insulin underuse in a primary care environment. We administered surveys to adult respondents diagnosed with diabetes who were prescribed insulin in the last 12 months. The primary outcome measured was the frequency of cost-related underuse of insulin within the last year. Ninety respondents completed the survey with results indicating 44% experienced cost-related suboptimal therapy. Prevalence of insulin underuse remains high in primary care and prescribers should regularly assess medication cost barriers with all patients.

Non-adherence to guideline recommendations for insulins: a qualitative study amongst primary care practitioners

Background

Guideline adherence is generally high in Dutch general practices. However, the prescription of insulins to type 2 diabetes mellitus patients is often not in line with the guideline, which recommends NPH insulin as first choice and discourages newer insulins. This qualitative study aimed to identify the reasons why primary care healthcare professionals prescribe insulins that are not recommended in guidelines.

Methods

Digital focus groups with primary care practitioners were organised. A topic list was developed, based on reasons for preferred insulins obtained from literature and a priori expert discussions. The discussions were video and audio-recorded, transcribed verbatim and coded with a combination of inductive and deductive codes. Codes were categorized into an existing knowledge, attitudes and behaviour model for guideline non-adherence.

Results

Four focus groups with eleven general practitioners, twelve practice nurses, six pharmacists, four diabetes nurses and two nurse practitioners were organised. The prescription of non-recommended insulins was largely driven by argumentation in the domain of attitudes. Lack of agreement with the guideline was the most prominent category. Most of those perspectives did not reflect disagreement with the guideline recommendations in general, but were about advantages of non-recommended insulins, which led, according to the healthcare professionals, to better applicability of those insulins to specific patients. The belief that guideline-recommended insulins were less effective, positive experience with other insulins and marketing from pharmaceutical companies were also identified as attitude-related barriers to prescribe guideline-recommended insulins. One additional category in the domain of attitudes was identified, namely the lack of uniformity in policy between healthcare professionals in the same practice. Only a small number of external barriers were identified, focusing on patient characteristics that prevented the use of recommended insulins, the availability of contradictory guidelines and other, mostly secondary care, healthcare providers initiating non-recommended insulins. No knowledge-related barriers were identified.

Conclusions

The prescription of non-recommended insulins in primary care is mostly driven by lack of agreement with the guideline recommendations and different interpretation of evidence. These insights can be used for the development of interventions to stimulate primary care practitioners to prescribe guideline-recommended insulins.

Patient Perceptions of Satisfaction and Quality of Life Regarding Use of a Novel Insulin Delivery Device

Advances in insulin delivery technologies have led to the development of tubeless "patch" systems; however, these devices still involve a level of complexity. We surveyed individuals with type 1 or type 2 diabetes to explore their attitudes and satisfaction after using the CeQur Simplicity insulin patch (SIP) for 2 months. Transition to the SIP yielded significant increases in respondents' overall treatment satisfaction, less diabetes burden, and improvements in psychological well-being compared with respondents' prior insulin delivery method.