A multicenter, randomized, open-label, comparative, two-period crossover trial of preference, efficacy, and safety profiles of a prefilled, disposable pen and conventional vial/syringe for insulin injection in patients with type 1 or 2 diabetes mellitus

7. Diabetes Technology: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Owner preference for insulin delivery device and glycaemic control in diabetic dogs

OBJECTIVES

To assess treatment satisfaction and owner preference for two delivery devices (VetPen, MSD Animal Health, and U40 insulin syringes) and the effect on glycaemic control in diabetic dogs treated with porcine insulin zinc suspension.

MATERIALS AND METHODS

Randomised prospective cross-over study with two arms, each of 8 weeks. Twenty client-owned diabetic dogs on insulin treatment by U40 syringe were enrolled. Dogs were randomly assigned to receive insulin by syringe or pen injector for 2 months, followed by 2 months of the other injection method. Treatment satisfaction and owners' insulin delivery device preference were assessed using a questionnaire. Glycaemic control was assessed using a clinical score, serum fructosamine and glycated haemoglobin (HbA1c%) at the time of the enrolment (T0) and the end of each arm of treatment (T2 and T4).

RESULTS

Treatment satisfaction differed for the two types of the delivery device when the order that each device was used was taken into consideration. Owners who used the syringe first did not have a significant preference for an injection device. In contrast, owners who used the pen injector first expressed a significant preference for VetPen compared to syringes. No significant differences in the number of dogs of Groups 1 and 2 with good and poor glycaemic control at T2 and T4 were detected.

CLINICAL SIGNIFICANCE

Overall treatment satisfaction and preference for the two delivery methods were similar. However, VetPen was preferred by owners who were randomised to use this device first. Glycaemic control did not appear to be affected by the insulin delivery device used.

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.

Patient preference for second- and third-line therapies in type 2 diabetes: a prespecified secondary endpoint of the TriMaster study

Patient preference is very important for medication selection in chronic medical conditions, like type 2 diabetes, where there are many different drugs available. Patient preference balances potential efficacy with potential side effects. As both aspects of drug response can vary markedly between individuals, this decision could be informed by the patient personally experiencing the alternative medications, as occurs in a crossover trial. In the TriMaster (NCT02653209, ISRCTN12039221), randomized double-blind, three-way crossover trial patients received three different second- or third-line once-daily type 2 diabetes glucose-lowering drugs (pioglitazone 30 mg, sitagliptin 100 mg and canagliflozin 100 mg). As part of a prespecified secondary endpoint, we examined patients' drug preference after they had tried all three drugs. In total, 448 participants were treated with all three drugs which overall showed similar glycemic control (HbA1c on pioglitazone 59.5 sitagliptin 59.9, canagliflozin 60.5 mmol mol^-1, P = 0.19). In total, 115 patients (25%) preferred pioglitazone, 158 patients (35%) sitagliptin and 175 patients (38%) canagliflozin. The drug preferred by individual patients was associated with a lower HbA1c (mean: 4.6; 95% CI: 3.9, 5.3) mmol mol^-1 lower versus nonpreferred) and fewer side effects (mean: 0.50; 95% CI: 0.35, 0.64) fewer side effects versus nonpreferred). Allocating therapy based on the individually preferred drugs, rather than allocating all patients the overall most preferred drug (canagliflozin), would result in more patients achieving the lowest HbA1c for them (70% versus 30%) and the fewest side effects (67% versus 50%). When precision approaches do not predict a clear optimal therapy for an individual, allowing patients to try potential suitable medications before they choose long-term therapy could be a practical alternative to optimizing treatment for type 2 diabetes.

Ease of Use of the iGlarLixi SoloStar Pen from the LixiLan ONE CAN Pen Sub-Study: Questionnaire Findings from People Living with Type 2 Diabetes and Their HealthCare Providers

INTRODUCTION

For people with type 2 diabetes mellitus who do not achieve glycated hemoglobin A1C targets after treatment with basal insulin therapies, additional therapy with a glucagon-like peptide-1 receptor agonist (GLP-1 RA) may be required. One option is to use a once-daily fixed-ratio combination (FRC) of basal insulin and a GLP-1 RA such as iGlarLixi (which is composed of insulin glargine 100 U/ml and lixisenatide). However, the ease of transitioning from basal insulin to an FRC has not been studied.

METHODS

This sub-study of the LixiLan ONE CAN trial (NCT03767543) was conducted to assess the ease of transitioning from insulin glargine 100 U/ml to the FRC, iGlarLixi, using the iGlarLixi SoloStar^® pen. Patients completed a validated, ten-item questionnaire, and healthcare professionals (HCPs) completed a five-item questionnaire. Both questionnaires used either five-point Likert scales or yes/no answers as appropriate, and both were completed after 4 weeks of using the iGlarLixi SoloStar pen.

RESULTS

Overall, 95.1% of patients reported that the iGlarLixi Solostar pen was "easy" or "very easy" to use. Similarly, 100% of HCPs reported that it was "easy" or "very easy" to train people to use the pen. Nearly all participants (97.5% of patients and 94% of HCPs) responded that they would recommend the iGlarLixi Solostar pen to others.

CONCLUSIONS

These results suggest that during the transition from insulin glargine 100 U/ml to iGlarLixi, there were no difficulties associated with using the iGlarLixi SoloStar pen injector regarding instruction for use by HCPs or actual use by the majority of patients. The results indicate a broad consensus between patients and HCPs on the relative simplicity of transitioning from self-administration of insulin glargine 100 U/ml to iGlarLixi.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03767543; Date of registration: December 6, 2018; Retrospectively registered.

7. Diabetes Technology: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

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

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

The Role of Human-Centered Design in Insulin Pen Innovation and the Future of Insulin Delivery

Insulin pens have made a dramatic impact on diabetes care, with evidence suggesting that they promote performance of self-care and reduce negative health outcomes for people with diabetes. Human-centered design (HCD), practiced by IDEO for over 40 years and together with Eli Lilly for over 15 years, has helped to design insulin pens that evolved with the needs of people with diabetes. HCD employs unique methods that help to uncover people's needs and design with them in mind. The future of diabetes care is bright with the ongoing application of HCD methodology in this space.

Compatibility of PiC Insupen Needles with a Broad Range of Pens for the Injection of Subcutaneously Administered Drugs for Diabetes

Purpose

To test the compatibility of PiC Insupen needles with a broad range of pens produced by different manufacturers for the injection of subcutaneously administered drugs.

Patients and Methods

The “extreme” products in PiC pen needles range were considered (G33x4 mm and G29x12 mm), to verify that the compatibility was not affected by the cannula diameter and length. Following the launch of the G34x3.5mm needle, additional tests were performed comparing G33x4 and G34x3.5 pen needles. A test medium with viscosity similar to insulin was used. Additional tests were performed with a liquid with a much higher viscosity. All the requirements of the technical standard ISO 11608-2 were satisfied, and the differences between G29, G33 and G34 were negligible. Therefore, the PiC Insupen needle G33x4mm was chosen as representative of the PiC pen needles. Dose accuracy and needle hub torque were assessed, according to the ISO 11608-2:2012 norms. For pens with variable volume, two different volumes were tested (Vlow and Vhigh) in random order, testing 60 needles with Vlow and 60 with Vhigh.

Results

Overall, 50 different pens were tested. Dose accuracy acceptance criteria were met for all the pens tested, with the only exception of Vhigh for Berlipen Precision pen. The removal torque was adequate for all pens, with the only exception of Berlipen 301 and Berlipen 302 pens.

Conclusion

We documented that Pikdare needles are compatible with a large array of different pens for the injection of insulin and other drugs administered subcutaneously.

The Review of Insulin Pens-Past, Present, and Look to the Future

Currently, there are about 150-200 million diabetic patients treated with insulin globally. The year 2021 is special because the 100th anniversary of the insulin discovery is being celebrated. It is a good occasion to sum up the insulin pen technology invention and improvement which are nowadays the leading mode of an insulin delivery. Even though so many years have passed, insulin is still administered subcutaneously, that is why devices to deliver it are of great importance. Insulin pens have evolved only through the last decades (the reusable, durable pens, and the disposable, prefilled pens) and modern smart insulin pens have been developed in the last few years, and both types of the devices compared to traditional syringes and vials are more convenient, discrete in use, have better dosing accuracy, and improve adherence. In this review, we will focus on the history of insulin pens and their improvement over the previous decades.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

100 years on: the impact of the discovery of insulin on clinical outcomes

Throughout history, up to the early part of the 20th century, diabetes has been a devastating disorder, particularly when diagnosed in childhood when it was usually fatal. Consequently, the successful pancreatic extraction of insulin in 1921 was a miraculous, life-changing advance. In this review, the truly transformative effect that insulin has had on the lives of people with type 1 diabetes and on those with type 2 diabetes who are also dependent on insulin is described, from the time of its first successful use to the present day. We have highlighted in turn how each of the many facets of improvements over the last century, from advancements in the properties of insulin and its formulations to the evolution of different methods of delivery, have led to continued improvement in clinical outcomes, through the use of illustrative stories from history and from our own clinical experiences. This review concludes with a brief look at the current challenges and where the next century of technological innovation in insulin therapy may take us.

Understanding Patients' Willingness to Pay for Biphasic Insulin Aspart 30/70 in a Pen Device for Type 2 Diabetes Treatment in an Out-of-Pocket Payment Market

OBJECTIVE

Our objective was to investigate willingness to pay (WTP) for biphasic insulin aspart 30/70 (BIAsp 30) in patients with type 2 diabetes mellitus (T2DM) in India.

METHODS

A multicenter, prospective, non-interventional, preference study was conducted that assessed WTP for BIAsp 30 in an insulin pen (FlexPen^® or Penfill^® device) in patients in India with T2DM previously treated with biphasic human insulin (BHI) in vials and believed to be able to pay for treatment. The primary endpoint was the proportion of patients willing to continue to pay for BIAsp 30 after 12 weeks' treatment. Secondary endpoints included the change from baseline in treatment and device satisfaction and patient preferences for treatment attributes as assessed by a nested discrete-choice experiment.

RESULTS

Overall, 54.9% (n = 277/505) of participants were male; the mean age was 56.4 years; diabetes duration was 10.9 years; 63.8% had a body mass index ≥ 25 kg/m²; > 75% had an annual household income > 150,000 Indian rupees (INR). After 12 weeks' treatment, 96.4% of patients were willing to pay for BIAsp 30. Mean treatment and device satisfaction significantly improved from baseline (p < 0.0001). Patients were willing to pay INR3576 (95% confidence interval [CI] 2755-4398) for improved glycemic control, INR688 (95% CI 383-994) for a device upgrade (vial/syringe to an insulin pen), or INR327 (95% CI 95-560) to avoid major hypoglycemia. Patients would need to be compensated INR44 (95% CI 56-32) per minor hypoglycemic event.

CONCLUSIONS

In India, patients with T2DM previously treated with BHI were willing to pay for BIAsp 30 in an insulin pen. Furthermore, treatment and device satisfaction improved after this therapeutic switch.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03374774.

The accuracy and precision of insulin administration using human and veterinary pen-injectors and syringes for administration of insulin

BACKGROUND

Many diabetic dogs and cats require small doses of insulin that must be administered accurately.

OBJECTIVES

To compare the accuracy and precision of insulin syringes and pen-injectors.

ANIMALS

None.

METHODS

To determine how accurately and precisely insulin doses are delivered, 0.5, 1, 2, 4, 8, and 16 U doses were dispensed 25 times from 5 SoloSTARs, 5 FlexPens, 5 KwikPens, 5 JuniorSTARs, 5 VetPens 0.5-8 U, 5 VetPens 1-16 U, and by 5 veterinarians using 30 U/0.3 mL and 40 U/mL insulin syringes. Each dose was weighed, using a precision balance, and the intended and delivered doses were compared.

RESULTS

All pen-injectors delivered less insulin than the intended dose, underdosage being inversely proportional to insulin dose. The differences between the intended and the delivered dose were not significant using JuniorSTAR and VetPen 0.5-8 U at insulin doses of 0.5, 1, 2, and 4 U, using the 30 U/0.3 mL insulin syringe at the 4 U dose and using the 40 U/mL insulin syringe at the 4, 8, and 16 U doses. With all the devices, precision increased with increasing doses of insulin. The coefficient of variation was <8% for all 6 pen-injectors. Conversely, using 30 U/0.3 mL and 40 U/mL syringes at an insulin dosage of 0.5 U the coefficients of variation were 12.08% and 9.39%, respectively.

CONCLUSIONS AND CLINICAL IMPORTANCE

JuniorSTAR and VetPen 0.5-8 U were more accurate than the other devices when delivering ≤2 U doses, while the delivery of 8 and 16 U doses was more accurate using 40 U/mL syringes.

Hypoglycemia frequency and treatment satisfaction in patients receiving insulin analogues for treatment of type 1 diabetes mellitus

Objective

The aim of this study was to evaluate the frequency of hypoglycemia and the treatment satisfaction in patients with type 1 diabetes (T1D) using insulin analogues.

Methods

This observational retrospective study included 516 adult patients with T1D from 38 cities in Southern Brazil. Demographics and clinical data were collected using a self-report questionnaire. Hypoglycemia was defined as an event based on either symptoms or self-monitored blood glucose < 70 mg/dL. Treatment satisfaction was evaluated using the Diabetes Treatment Satisfaction Questionnaire status version (DTSQs) and with a specific question with scores ranging from 0-10. Common mental disorders were assessed using the General Health Questionnaire (GHQ-12).

Results

Overall, the mean age was 38 ± 14 years and 52% of the participants were women. The median diabetes duration was 18 years. The scores for insulin analogue treatment satisfaction were higher than those for previous treatments. DTSQ scores had a median value of 32 (interquartile range 29-35) and remained unchanged over time. The percentage of patients with hypoglycemia (including severe and nocturnal) was comparable across groups divided according to duration of use of insulin analogues. Most patients (n=395, 77%) screened positive for common mental disorders.

Conclusion

Patient satisfaction with insulin analogue treatment was high and remained unchanged with time. Episodes of hypoglycemia also remained unchanged over time among patients using insulin analogues.

User experiences with second-generation 32-gauge × 4 mm vs. thinner comparator pen needles: prospective randomized trial

OBJECTIVE

Two similarly designed studies compared user experiences with a second-generation extra-thin-wall, 5-bevel 32 G × 4 mm pen needle (PN) with redesigned hub versus four thinner commercially available PNs.

METHODS

Adults (18-75 years old) with type 1 or type 2 diabetes and ≥3 months of experience with pen injectors qualified for single-visit, single-blinded randomized studies. The investigational 32 G PN was compared with three 33-34 G × 3.5-4 mm PNs in Study 1 and one 34 G × 4 mm PN in Study 2. Participants completed 12 abdominal injections of 0.3 mL sterile saline using insulin pens in 6 pairs, each comprising one investigational 32 G PN and one comparator PN in random order. After each injection pair, participants compared injection pain via relative 150 mm visual analog scale (VAS) and perceived dose delivery force via relative 5 point Likert scale. Adjusted models tested injection pain scores (primary endpoint) for noninferiority and, if met, then for superiority. ClinicalTrials.gov identifiers: NCT03878758 and NCT03878745.

RESULTS

The investigational 32 G PN met noninferiority as well as superiority criteria for less injection pain vs. each comparator (p < .01), with adjusted mean relative VAS scores 9.1-17.6 in Study 1 (n = 154) and 7.3 in Study 2 (n = 55). The investigational 32 G PN was also superior vs. each comparator PN in requiring less relative perceived force to deliver the dose (p < .01).

CONCLUSIONS

The investigational 32 G PN was associated with less participant-reported injection pain and less perceived dose delivery force compared with four thinner PNs, suggesting no additional pain reduction or force reduction benefit conferred by the thinner PNs.

A narrative literature review on traditional medicine options for treatment of corona virus disease 2019 (COVID-19)

Coronavirus disease 2019 (COVID-19) as a life-threatening disease is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that is accounted as global public health concern. Treatment of COVID-19 is primarily supportive and the role of antiviral agents is yet to be established. However, there are no specific anti-COVID-19 drugs and vaccine until now. This review focuses on traditional medicine such as medicinal plant extracts as promising approaches against COVID-19. Chinese, Indian and Iranian traditional medicine, suggests some herbs for prevention, treatment and rehabilitation of the diseases including COVID-19. Although, inhibition of viral replication is considered as general mechanism of herbal extracts, however some studies demonstrated that traditional herbal extracts can interact with key viral proteins which are associated with virus virulence. Chinese, Indian and Iranian traditional medicine, suggests some herbs for prevention, treatment and rehabilitation of the diseases including COVID-19. However the beneficial effects of these traditional medicines and their clinical trials remained to be known. Herein, we reviewed the latest updates on traditional medicines proposed for treatment of COVID-19.

Evaluation of Antidiabetic Injectable Technique: Is There an Association between Accuracy and Health Literacy or Duration of Diabetes?

Introduction:

Effective diabetes pharmacotherapy often involves injectable medications, which if used inappropriately represents a type of unintentional medication nonadherence that leads to poor outcomes.

Objectives:

The primary objective of this study was to assess the percent of patients who accurately prepared, administered, stored, and disposed of their injectable diabetes medication. Secondary objectives included comparing the accuracy of injectable use among those with diabetes <5 years vs. ≥ 5 years duration and those with limited vs. proficient health literacy.

Methods:

This was a prospective analysis conducted on a convenience sample of patients who received a pilot pharmacist-led, quality improvement service at an urban, ambulatory care clinic. The service components included health literacy screening, using the Rapid Assessment of Adult Literacy in Medicine – Short Form (REALM-SF) tool, evaluation of injectable technique by use of a standardized questionnaire, and provision of medication education. Duration of diabetes was determined by patient self-report. Chi-square and Fisher’s exact tests were utilized to assess accuracy of injectable technique in two group comparisons: (1) patients with limited vs. proficient health literacy and (2) patients with diabetes <5 years vs. ≥5 years.

Results:

Thirty-five patients were included in the analysis. Despite the majority (71.4%) of patients reporting prior education on injectable use, 54.3% reported at least one error in product use. Significant findings noted were that those with limited health literacy had higher rates of accurately using the skin-fold technique and appropriate angle for injection vs. those with proficient health literacy (p<0.05 for both comparisons). Likewise, more patients in the cohort of diabetes duration ≥5 years accurately rotated the injection site vs. those with a duration <5 years (p=0.001).

Conclusion:

Errors in injectable technique were common in this study and spanned across health literacy levels and duration of diabetes. Patients prescribed injectable diabetes medications should be routinely educated on proper technique for use.

Adherence to subcutaneous anti-TNFα agents in patients with rheumatoid arthritis is largely influenced by pain and skin sensations at the injection site

AIM

The aims of this prospective study were to determine the dimension of adherence in rheumatoid arthritis (RA) patients receiving subcutaneously administered anti-tumor necrosis factor-α (anti-TNFα) agents and to evaluate the influence of injection site pain and skin perceptions following subcutaneous administration of anti-TNFα drugs on patients' adherence.

METHOD

An inception cohort of patients starting subcutaneously administered anti-TNFα treatment was enrolled. Injection site pain perception was assessed through the Self-Injection Assessment Pain Questionnaire (SIAPQ), and adherence to treatment was ascertained by the Compliance Questionnaire for Rheumatology (CQR5). Associations between beliefs and non-adherence, and the influence of demographic (age, disease duration, educational level), clinical (body mass index, patient global assessment, physician global assessment, Numerical Rating Scale of pain, Health Assessment Questionnaire-Disability Index, Simplified Disease Activity Index, and comorbidities measured by the modified Rheumatic Disease Comorbidty Index), and radiographic (Simple Erosion Narrowing Score) variables were assessed using logistic regression models.

RESULTS

Adherence data over a 12-month interval were available for 193 patients. Of these, 21.7% reported non-adherence to anti-TNFα therapy. No difference (P = .383) was found for anti-TNFα drugs (adalimumab, etanercept, certolizumab pegol and golimumab). In the logistic model, age (P = .0029), higher disease activity (P = .020), low numbers of comorbidity conditions (P = .0004), injection site pain and skin perception (P = .0008), were significantly associated with increased likelihood of medication adherence.

CONCLUSION

Adherence is influenced by both demographic characteristics (age) and clinical factors (disease activity, comorbidity burden and injection site pain and skin perception) in RA patients.

Correct performance of subcutaneous injections in plaque psoriasis: comparison of trained and untrained patients with different application systems in routine clinical care

BACKGROUND

Moderate-to-severe plaque psoriasis can be treated very successfully with systemic therapies. Often the therapeutics must be injected subcutaneously. This prospective observational study aimed to compare the correct preparation and performance of subcutaneous injections in trained and untrained patients with plaque psoriasis.

MATERIALS AND METHODS

We asked 110 patients (29.1% women, 70.9% men, injection system: 75.5% prefilled syringe, 24.5% autoinjector) to what extent they were trained for self-injection. While participants injected a sham injection with their current system, we evaluated the preparation, execution, and follow-up using a newly developed scoring system.

RESULTS

87.3% (n = 96) of the participants declared that they had been trained for self-injection. No statistically significant difference was observed between the trained and untrained participants in performing the injection correctly (p = .458). The most common mistakes were the wrong preparation and follow-up of the injection. A bifactorial rank-variance analysis showed a negative influence of the factor injection system (prefilled syringe) on the total score (p = .005).

CONCLUSION

We can indicate that patients with plaque psoriasis are well prepared for subcutaneous self-injection. Self-injection of systemic therapies is easy to perform, especially with patient-friendly systems, and does not require specialized training.

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

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

Insulin pen use and diabetes treatment goals: A study from Iran STEPS 2016 survey

Background

Frequency of insulin pen use, despite its higher costs, is increasing to substitute the traditional use of insulin vials. This study aims to report insulin pen use frequency and its associated factors among participants of the STEPS survey 2016 in Iran, which was conducted based on the World Health Organization (WHO) STEPS methodology.

Methods

In this cross-sectional study, 19,503 (mean age of 46.03±0.13) out of 30,541 participants of the Iran STEPS survey were included (Inclusion criteria: aged >25 years old and availability of their demographic, clinical, and laboratory results for serum glucose, HbA1c, and lipid profile). Clinical and demographic characteristics, a frequency of use of each diabetes mellitus treatment type, and the association of insulin pen use with health outcomes are reported using descriptive analysis and propensity score modeling.

Results

There were 1,999(10.85%) individuals diagnosed with diabetes in the population, while 1,160(56.87%) cases were taking antihyperglycemic treatments. In this subset, 240(21.14%) individuals administered insulin with or without using oral agents at the same time. 52.28% of participants who were under insulin therapy used insulin pens. None of the socioeconomic determinants, including gender (p-value = 0.11), type of residential areas (p-value = 0.52), years of schooling (p-value = 0.27), wealth index (p-value = 0.19), marital status (p-value = 0.37), and insurance types (p-value = 0.72) were significantly different among groups using insulin pens and insulin vials. Moreover, in the propensity score modeling, pen usage was not associated with a lower heart attack and ischemic stroke histories, systolic blood pressure, serum lipid profile, blood glucose, or HbA1c levels.

Conclusion

Results showed that the use of the higher-costing insulin pens compared to traditional vials and syringes is not associated with improved glycemic control and better lipid profile in our sample. Future studies are needed to confirm these findings and to compare other aspects of insulin pen use, including adherence to treatment and cost-effectiveness.

Burden of insulin injection-related needlestick injuries in mainland China-prevalence, incidence, and healthcare costs

OBJECTIVE

To estimate the prevalence and incidence of needlestick injuries associated with insulin injection among nurses working in hospitals in China and to quantify the direct healthcare costs associated with insulin injection-related needlestick injuries.

METHODS

We conducted a large online survey among hospital nurses from 31 provinces, municipal cities, and autonomous regions in China from October 2016 to February 2017. The survey covered a wide range of questions, including geographical location, years of experience, insulin injection practice, number of insulin injection-related needlestick injuries in the past 12 months, interventions for needlestick injuries, and treatment costs. We developed a cost estimate model and categorized costs into two major components: infection prevention and treatment of infections.

RESULTS

We received a total of 10,447 questionnaires, of which 9873 were complete and validated. 39.1% of the nurses reported at least one needlestick injury while administering diabetic injections at some point in the past. The incidence of needlestick injuries involving injection pens was 139.5 per 1000 nurses per year and, with adjustment for exposure, 10.2 needlestick injuries per 100,000 injections. Among the respondents, 3.2% reported of having hepatitis B virus infection and 0.9% having hepatitis C virus infection as a result of needlestick injuries. The total costs of one insulin injection-related needlestick injury was estimated to range from ¥1,884 - ¥2,389.

CONCLUSIONS

Insulin injection-related needlestick injuries were common in nurses working in hospitals in China and imposed a significant economic burden. More resources should be allocated for preventive efforts for needlestick injuries, including adoption of injection devices with advanced safety features.

Evaluating the User Performance and Experience with a Re-Engineered 4 mm × 32G Pen Needle: A Randomized Trial with Similar Length/Gauge Needles

INTRODUCTION

Since insulin pens were first introduced in 1985, many advances have been made in pen needles (PNs). In this study we evaluated patient-reported outcomes of an investigational newly re-engineered 4 mm × 32G PN, the BD Nano™ 2nd Gen (also known by its "PRO" brand extension in many markets outside of the USA). In place of a conventional cylindrical posted hub, the investigational PN's hub is contoured with an expanded surface area. The investigational PN also includes a redesigned inner shield that includes tactile ridges and a remodeled outer cover with improved proportions and attachment grips.

METHODS

This was a multi-site, prospective, open-label, two-period crossover trial. Individuals with type 1 and type 2 diabetes using 32G PNs of ≤ 6 mm in length for ≥ 4 months were eligible. Subjects using     31G PNs of a similar length were eligible after a 2-week wash-in period. Subjects were assigned to one of four groups, with each group using a commercially available PN to which the investigational PN was compared. Each of the two study periods were 15 days: one with the investigational PN and the other with a comparator PN. After completing both study periods, subjects compared experiences between the two PN types. A 150-mm comparative visual analog scale (VAS) was used to evaluate overall preference (primary endpoint) and several secondary endpoints, including overall comfort, injection pain, and ease of use. Data from the four PN groups were combined after poolability was verified. Subgroup analyses were also conducted on each PN group. For VAS responses, a two-sided 95% confidence interval (CI) was calculated for average rating. Threshold for non-inferiority or superiority was established at the lower bound CI of >  - 10 mm or > 0 mm, respectively.

RESULTS

At baseline, average age of subjects was 55.6 years; 51.6% were female; and 85.1% has type 2 diabetes mellitus. Average diabetes duration was 14.2 years, and average duration of injecting was 7.8 years. The investigational PN demonstrated superiority for all outcomes, both primary and secondary, for all groups combined (p < 0.05).

CONCLUSIONS

The investigational PN was rated as being overall preferred, more comfortable, less painful, and easier to use when compared to comparator PNs of similar gauge and length, in all groups combined.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov (NCT03267264).

FUNDING

BD (Becton, Dickinson, and Company).

Development and Implementation of a Subcutaneous Insulin Pen Label Bar Code Scanning Protocol to Prevent Wrong-Patient Insulin Pen Errors

PROBLEM DEFINITION

Insulin, a high-alert medication, is regularly prescribed in the inpatient setting for hyperglycemia and diabetes mellitus. Although convenient, insulin pens carry a risk of blood-borne pathogens if the same pen is used on multiple patients. At the University of California, San Francisco (UCSF), a new nursing protocol for insulin pen administration was developed to ensure that insulin was quickly available and to identify and move to eliminate wrong-patient insulin pen errors. This protocol involved unit-based automated dispensing machines and an electronic health record (EHR)-integrated patient-specific bar code label work flow.

APPROACH

After piloting on three hospital units, this new patient-specific bar code label process was expanded hospitalwide. "Print Label For Insulin Pen" and "Scan Insulin Pen" buttons were programmed into the EHR to enable nurses to print patient-specific bar code labels. In addition, a "wrong-patient pen alert" was activated to prevent wrong-pen insulin pen administration.

OUTCOMES

For the 162,075 inpatient insulin pen administrations during the study period (April 2017-March 2018), monthly errors (rates) ranged from 13 (0.12%) to 36 (0.23%). In total, 296 near-miss events (0.18% of all insulin pen administrations) were observed and prevented.

CONCLUSION

Insulin pen work flow and EHR changes implemented at UCSF enable subcutaneous insulin to remain a time-critical medication and ensure patient safety. The wide adoption of EHRs offers an opportunity to integrate patient safety improvements directly into the electronic medication administration record systems to maximize patient safety.

Efficacy, safety and acceptability of the new pen needle 34G × 3.5 mm: a crossover randomized non-inferiority trial; AGO 02 study

OBJECTIVE

Insulin injection aspects, such as fear of injection and pain, directly affect glycemic control, patient adherence and quality of life. Use of thinner and shorter needles could increase acceptance of injections. The aim of the study is to evaluate the non-inferiority of the new 34G × 3.5 mm needle compared to a 32G × 4 mm in patients with diabetes treated with insulin.

METHODS

This is an open, randomized, two-period crossover, non-inferiority trial. Every treatment period lasted 3 weeks. Patients with type 1 or type 2 diabetes, treated with multiple daily insulin injections, were randomly assigned to receive a 34G × 3.5 mm or a 32G × 4 mm pen needle. The primary endpoint was the non-inferiority of the 34G × 3.5 mm in comparison with the 32G × 4 mm pen needle in terms of percentage absolute change of blood fructosamine (% |ΔFru|), using a non-inferiority margin of 20%.

RESULTS

Overall 77 patients were randomized and 73 completed the study. Patients characteristics were: 52% male, 80.5% affected by type 1 diabetes, mean age 52 years (±14.6), mean BMI 24.5 kg/m² (±5.6), HbA1c 8% (±1.1) and baseline fructosamine level 350 µmol/l (±84). Mean fructosamine levels increased by 0.56 µmol/l with the 34G needle, while a reduction of 7.29 μmol/l was documented with the 32G needle. The difference between the two groups (7.84 μmol/l) was not statistically significant (p = .27). The % |ΔFru| between the two groups was 7.55% (95% CI 5.67-9.44), meeting the non-inferiority criterion. Glycemic variability, expressed as standard deviation of fasting blood glucose and post-prandial glucose, was not different between the two treatment groups (p = .63 and p = .77, respectively).

CONCLUSIONS

The 34G × 3.5 mm needle was non-inferior to the 32G × 4 mm needle regarding fructosamine levels and glycemic variability supporting the suitability of the 34G × 3.5 mm needle for insulin injection in patients with diabetes.

CLINICAL TRIAL REGISTRATION

NCT02690467.

Injecting without pressing a button: An exploratory study of a shield-triggered injection mechanism

AIMS

To evaluate the injection success and user perception of a shield-triggered pen-injector mechanism.

METHODS

The trial (ClinicalTrials.gov NCT02627287) was an exploratory, two-centre, one-visit, open-label, randomized controlled trial conducted in Germany in 150 injection-experienced individuals with type 1 or type 2 diabetes. Participants self-administered subcutaneous injections of a placebo solution using a prototype shield-triggered pen-injector, DV3316 (Novo Nordisk, Bagsvaerd, Denmark), and FlexPen (Novo Nordisk, Bagsvaerd, Denmark). Injection success was evaluated on a yes/no basis by the investigator. Participant confidence, leakage of fluid and pain were evaluated after each injection. Pain and device experience were assessed after completion of all injections with each pen-injector. Overall preference was assessed after completion of all injections with both pen-injectors.

RESULTS

Injection success was high with both pen-injectors (97.0%, DV3316 vs 99.7%, FlexPen). Participant confidence in dose delivery was similar for the two devices (88% of injections with DV3316 vs 81% with FlexPen were scored as "extremely confident"). The median injection pain score on a visual analogue scale (0-100) was 3 with DV3316 vs 4 with FlexPen after each injection, and 4 with DV3316 vs 5 with FlexPen after all injections with each device. After all injections were completed, 55% of participants reported an overall preference for DV3316 vs 21% for FlexPen.

CONCLUSION

This study demonstrates that injection-experienced individuals can achieve a high injection success rate with a shield-triggered pen-injector, with similar patient confidence and injection pain compared with FlexPen.

A Comparison of Insulin Pen Devices and Disposable Plastic Syringes - Simplicity, Safety, Convenience and Cost Differences

Context: Managing diabetes efficiently demands a simple, safe, convenient and economical therapy. This study was done to understand the simplicity, safety, convenience and cost effectiveness of using pen versus syringe devices in patients on long-term insulin therapy. Design: This prospective observational study was conducted at the endocrine outpatient department of a universityaffiliated teaching hospital in North India. The investigator interviewed patients using a self-made questionnaire after obtaining consent; patients were scored based on their answers. A high score represented a poor response. A total of 90 completed questionnaires (45 from each group) were obtained. Results: Mean simplicity, safety and convenience score among the pen users was 5.31 ± 0.51, 5.4 ± 0.89 and 4.13 ± 1.04 respectively, as compared to 9.78 ± 1.43, 8.09 ± 2.02 and 8.67 ± 0.56 in syringe users respectively. The difference in these scores was statistically significant (p=0.0001). All patients felt that treatment using pen device was costlier when compared to using syringes, with pen users spending Rs1,756 per month on their insulin therapy, as compared to syringe users, who spent Rs590 per month. Among insulin pen users, 22.2% had optimal glycated haemoglobin levels (6-7.5%) as compared to 2.2% among syringe users, and this difference was statistically significant (p=0.007). Conclusions: An insulin pen is simple, safe and convenient to use, and may provide better glycaemic control. Treatment with a pen device is costlier, which may be due to the higher use of analogue insulin among pen users.

Practical considerations in clinical strategy to support the development of injectable drug-device combination products for biologics

The development of an injectable drug-device combination (DDC) product for biologics is an intricate and evolving process that requires substantial investments of time and money. Consequently, the commercial dosage form(s) or presentation(s) are often not ready when pivotal trials commence, and it is common to have drug product changes (manufacturing process or presentation) during clinical development. A scientifically sound and robust bridging strategy is required in order to introduce these changes into the clinic safely. There is currently no single developmental paradigm, but a risk-based hierarchical approach has been well accepted. The rigor required of a bridging package depends on the level of risk associated with the changes. Clinical pharmacokinetic/pharmacodynamic comparability or outcome studies are only required when important changes occur at a late stage. Moreover, an injectable DDC needs to be user-centric, and usability assessment in real-world clinical settings may be required to support the approval of a DDC. In this review, we discuss the common issues during the manufacturing process and presentation development of an injectable DDC and practical considerations in establishing a clinical strategy to address these issues, including key elements of clinical studies. We also analyze the current practice in the industry and review relevant and status of regulatory guidance in the DDC field.

Preference for a prefilled syringe or an auto-injection device for delivering golimumab in patients with moderate-to-severe ulcerative colitis: a randomized crossover study

PURPOSE

Simponi^® (golimumab, MSD) is a fully human monoclonal antibody against tumor necrosis factor alpha administered subcutaneously using an autoinjector or a prefilled syringe. This study examined preference for administration of golimumab by autoinjector or prefilled syringe in patients with moderate-to-severe ulcerative colitis (UC).

PATIENTS AND METHODS

This was a multicenter, open-label, randomized crossover trial (EudraCT no 2014-000656-29). Patients with moderate-to-severe UC were randomized 1:1 to receive 2 subcutaneous injections of 50 mg golimumab with the autoinjector followed by 2 injections of 50 mg with the prefilled syringe or the same 4 injections administered in the opposite order. Patients assessed preference, ease of use, and discomfort immediately after the injections and 2 weeks later.

RESULTS

Ninety-one patients were included (median age=42.7 years [range, 19.7-93.7]; 58% male). The autoinjector was preferred by 76.9% of patients immediately after injections and by 71.4% 2 weeks later. The autoinjector was more often considered extremely easy or easy to use (94.5%) than the prefilled syringe (73.6%). Moderate discomfort or worse was reported by more patients when using the prefilled syringe (20.9%) than when using the autoinjector (5.5%), and severe discomfort or discomfort preventing injection of future doses was reported by 8.8% for the pre-filled syringe but not at all when using the autoinjector. A favorable or extremely favorable overall impression was reported by 89.0% for the autoinjector and 72.5% for the prefilled syringe.

CONCLUSION

Most patients with moderate-to-severe UC preferred to self-administer golimumab with the autoinjector over a prefilled syringe.

Health state utilities associated with attributes of weekly injection devices for treatment of type 2 diabetes

Background

Glucagon-like peptide-1 (GLP-1) receptor agonists are often recommended as part of combination therapy for type 2 diabetes when oral medication does not result in sufficient glycemic control. Several GLP-1 receptor agonists are available as weekly injections. These medications vary in their injection delivery systems, and these differences could impact quality of life and treatment preference. The purpose of this study was to estimate utilities associated with attributes of injection delivery systems for weekly GLP-1 therapies.

Methods

Participants with type 2 diabetes in the UK valued health states in time trade-off interviews. The health states (drafted based on literature, device instructions for use, and clinician interviews) had identical descriptions of type 2 diabetes, but differed in description of the treatment process. One health state described oral treatment, while six others described oral treatment plus a weekly injection. The injection health states varied in three aspects of the treatment administration process: requirements for reconstituting the medication (i.e., mixing the medication prior to the injection), waiting during medication preparation, and needle handling. Every participant valued all seven health states.

Results

A total of 209 participants completed interviews (57.4% male; mean age = 60.4y). The mean utility of the oral treatment health state was 0.89. All injection health states had significantly (p < 0.01) lower utilities ranging from 0.86 to 0.88. Differences among health state utilities suggest that each administration requirement had a small but measureable disutility: -0.004 (reconstitution), -0.004 (needle handling), -0.010 (reconstitution, needle handling), and -0.020 (reconstitution, waiting, needle handling).

Conclusions

Findings suggest it is feasible to use the TTO method to quantify preferences among injection treatment processes. It may be useful to incorporate these utility differences into cost-utility models comparing weekly injectable treatments for patients with type 2 diabetes.

FlexTouch: An Insulin Pen-Injector with a Low Activation Force Across Different Insulin Formulations, Needle Technologies, and Temperature Conditions

FlexTouch® (Novo Nordisk A/S, Bagsvaerd, Denmark) is a pen-injector with a torque spring mechanism requiring a low activation force. This laboratory-based study compared the activation force of FlexTouch during the injection of insulin with different needles and at temperature conditions within the range at which the device is recommended for use. Using a tensile tester, activation force was measured at maximum dose settings for insulin detemir (100 U/mL) and insulin degludec (100 and 200 U/mL) at standard (23°C ± 5°C), cool (5°C ± 3°C), and warm (30°C ± 2°C) conditions. Activation force was measured with two 32-gauge needles differing in internal diameter at standard conditions. At standard, cool, and warm conditions, estimated mean activation forces with 95% confidence interval were 5.71 newtons (N) (5.63-5.79), 5.94 N (5.83-6.06), and 5.69 N (5.58-5.80) with insulin detemir, 5.53 N (5.45-5.62), 5.56 N (5.44-5.67), and 5.33 N (5.22-5.44) with 100 U/mL insulin degludec, and 5.53 N (5.45-5.61), 5.83 N (5.71-5.94), and 5.56 N (5.45-5.68) with 200 U/mL insulin degludec, respectively. Mean activation forces were observed to be low with very small variability between measurements; however, the differences between insulins and temperature conditions were statistically significant. The activation force required by FlexTouch remained low across all situations tested. The differences between activation force needed with different insulins and temperature conditions were small and unlikely to be clinically meaningful.

Forum for Injection Technique and Therapy Expert Recommendations, India: The Indian Recommendations for Best Practice in Insulin Injection Technique, 2017

Health-care professionals in India frequently manage injection or infusion therapies in persons with diabetes (PWD). Patients taking insulin should know the importance of proper needle size, correct injection process, complication avoidance, and all other aspects of injection technique from the first visit onward. To assist health-care practitioners in their clinical practice, Forum for Injection Technique and Therapy Expert Recommendations, India, has updated the practical advice and made it more comprehensive evidence-based best practice information. Adherence to these updated recommendations, learning, and translating them into clinical practice should lead to effective therapies, improved outcomes, and lower costs for PWD.

The impact of insurance coverage and the family on pediatric diabetes management

BACKGROUND/OBJECTIVE

The impact of family composition on glycemic control in children with type 1 diabetes remains unclear. We sought to evaluate the relationship between health insurance coverage, family composition, and insulin management, and assess their impact on glycemic control in a pediatric type 1 diabetes population.

METHODS

A retrospective chart review was completed for patients seen in the Pediatric Endocrinology Clinic at the University of Louisville in 2012.

RESULTS

The analysis included 729 patients with type 1 diabetes; 268 (37%) had public insurance while 461(63%) had private insurance. Compared with publicly insured patients, privately insured patients had higher rates of intensive insulin management with multiple daily injections (MDI) plans or pump devices (88 vs. 83.2%, p = 0.066) and lower HbA1c levels [8.57 vs. 9.39% (70 vs. 79 mmol/mol), p < 0.001]. Of the 729 patients, 243 were in single-adult homes (33%). Single-adult homes had higher HbA1c levels than two-adult homes, [9.3 vs. 8.6% (78 vs. 70 mmol/mol), p < 0.001]. Among publicly insured, there was no difference in HbA1c levels for single-adult vs. two-adult homes [9.4 (79 mmol/mol), p = 0.868]. For privately insured, patients in single-adult homes had higher HbA1c levels than peers in two-adult homes [9.2 vs. 8.4% (77 vs. 68), p < 0.001].

CONCLUSION

Insurance type and family composition have significant associative effects on glycemic control and insulin management that may be mitigated by insulin pump therapy. Identifying and addressing factors such as availability of resources, family education, and adult support and supervision, may help improve glycemic control in high-risk pediatric diabetes patients.

Errors in the Administration Technique of Insulin Pen Devices: A Result of Insufficient Education

Insulin is a high-alert medication in both inpatient and outpatient settings. Insulin can cause significant harm when administered in error. Despite advancements in insulin pen technology, errors in the administration technique remain an issue. Although various factors can contribute to administration errors, lack of education on how to operate these devices is one of the most common reasons they occur. As such, the mechanical technique used by the patient needs to be continually assessed in order to reinforce education where needed. We describe three unique patient cases that depict incorrect administration techniques when using pen devices and the consequences that could have resulted from these errors. These cases involve the use of a syringe instead of a pen needle, injecting without removing the inner cap, and dialing the pen back down instead of pushing the plunger. Although pen devices are relatively simple to use, this article reinforces the need for continual assessment of and education about insulin administration. The teach-back method is an approach that can be used to assess a patient's technique and re-educate them at every available opportunity to reduce the risk of administration errors, which can result in complications and hospitalizations.

A Systematic Review of Patients' Perspectives on the Subcutaneous Route of Medication Administration

BACKGROUND

Subcutaneous injections allow for self-administration, but consideration of patients' perspectives on treatment choice is important to ensure adherence. Previous systematic reviews have been limited in their scope for assessing preferences in relation to other routes of administration.

OBJECTIVE

Our objective was to examine patients' perspectives on subcutaneously administered self-injectable medications when compared with other routes or methods of administration for the same medicines.

METHODS

Nine electronic databases were searched for publications since 2000 using terms pertaining to methods of administration, choice behavior, and adverse effects. Eligibility for inclusion was determined through reference to specific criteria by two independent reviewers. Results were described narratively.

RESULTS

Of the 1726 papers screened, 85 met the inclusion criteria. Studies were focused mainly on methods of insulin administration for diabetes but also included treatments for pediatric growth disorders, multiple sclerosis, HIV, and migraine. Pen devices and autoinjectors were favored over administration with needle and syringe, particularly with respect to ergonomics, convenience, and portability. Inhalation appeared to be more acceptable than subcutaneous injection (in the case of insulin), but how subcutaneous infusion, intramuscular injection, and needle-free injection devices compare with subcutaneous injections in terms of patient preference is less certain.

CONCLUSIONS

The review identified a number of studies showing the importance of the methods and routes of drug delivery on patient choice. However, studies were prone to bias, and further robust evidence based on methodologically sound approaches is required to demonstrate how patient choice might translate to improved adherence.

Improving drug-like properties of insulin and GLP-1 via molecule design and formulation and improving diabetes management with device & drug delivery

There is an increased incidence of diabetes worldwide. The discovery of insulin revolutionized the management of diabetes, the revelation of glucagon-like peptide-1 (GLP-1) and introduction of GLP-1 receptor agonists to clinical practice was another breakthrough. Continued translational research resulted in better understanding of diabetes, which, in combination with cutting-edge biology, chemistry, and pharmaceutical tools, have allowed for the development of safer, more effective and convenient insulins and GLP-1. Advances in self-administration of insulin and GLP-1 receptor agonist therapies with use of drug-device combination products have further improved the outcomes of diabetes management and quality of life for diabetic patients. The synergies of insulin and GLP-1 receptor agonist actions have led to development of devices that can deliver both molecules simultaneously. New chimeric GLP-1-incretins and insulin-GLP-1-incretin molecules are also being developed. The objective of this review is to summarize molecular designs to improve the drug-like properties of insulin and GLP-1 and to highlight the continued advancement of drug-device combination products to improve diabetes management.

Determining Current Insulin Pen Use Practices and Errors in the Inpatient Setting

BACKGROUND

The use of insulin pens in the inpatient setting has continued to be a controversial decision. Insulin pens provide several advantages, but given significant reports of medication errors, several organizations have issued alerts to caution users about safety concerns. A survey was conducted to assess the prevalence of insulin pen use and current utilization trends in the inpatient setting.

METHODS

The 31-question guided-logic survey was developed based on review of primary literature regarding insulin pen utilization and evaluated by a panel of medication safety experts from a variety of health care settings. The survey was sent electronically to subscribers of medication safety organizations.

RESULTS

The survey was completed by 474 respondents. Approximately three fourths of respondents indicated insulin pens were on formulary at their institution (n = 332; 74%). Of those who have had insulin pens on formulary, 15% (n = 49) are no longer using them. The most common reasons for not utilizing pens were cost and safety concerns. Pens were reported to be stored in the pharmacy prior to administration (n = 230; 78%) and in a patient's bin (n = 202; 69%) afterward. More than half of respondents use two patient identifiers on the pen and label with a bar code. Approximately 30% reported that an insulin pen has been used on more than one patient at least once in their institution, while 6% were not sure.

CONCLUSION

Insulin pens are widely being used in the inpatient setting. Various mitigation strategies are employed to reduce the risk of harm associated with insulin pen use. Health care professionals believe insulin pens are clinically useful and can be used safely in the inpatient setting. Many organizations and expert panels disseminate best practices in an effort to help ensure their safety. Further studies are needed to assess and validate the risk mitigation strategies identified through this research.

Comparative usability study for a certolizumab pegol autoinjection device in patients with rheumatoid arthritis

OBJECTIVES

To compare the usability of a new certolizumab pegol (CZP) autoinjector with the adalimumab, etanercept, and golimumab devices in patients with rheumatoid arthritis.

METHODS

Two identical studies were performed in 2013 and 2016; patients performed a simulated self-injection with the CZP autoinjector and the most up-to-date device versions at the time in a randomized, consecutive sequence. The primary end point was the ranking of the four autoinjectors in order of preference. Device usability and intuitiveness were assessed across a range of secondary and exploratory end points.

RESULTS

The 2013 and 2016 study populations included 76 patients each; a significant majority (2013: 67%; 2016: 59%) ranked the CZP autoinjector as their most preferred device (p < 0.001). Most patients agreed that the CZP autoinjector was easier to use, start, and manipulate, and were more willing to use it than the comparator devices (p < 0.001 for all pairwise comparisons with CZP). Likert score differences also favored the CZP autoinjector regarding how easy it was to determine injection completion. The CZP autoinjector was associated with a low rate of use error.

CONCLUSIONS

In both studies, the CZP autoinjector was the preferred choice compared to the alternative devices and was associated with a high level of patient satisfaction.

Real-world therapeutic benefits of patients on insulin glargine versus NPH insulin

AIMS

The addition of a single injection of insulin to the oral drugs (basal supported oral therapy; BOT) has been shown to greatly reduce blood glucose levels. The intermediate-acting NPH insulin (NPH) and the long-acting insulin glargine (Lantus(®)) have been compared for use in BOT in numerous clinical trials; however, their efficacy and safety in a real-life setting have not been described.

METHODS

TIP (therapeutic benefits of patients on insulin glargine vs. NPH insulin being poorly controlled on prior short-time basal-insulin supported therapy with NPH insulin or insulin glargine) is a non-interventional, multicentre, observational study over 24 weeks. A total of 2629 patients were enrolled and 1931 were fully evaluable (1614 insulin glargine, 303 NPH insulin). Propensity scoring (PSM) was used to match 570 patients into 2 similar cohorts of 285 patients.

RESULTS

In the PSM cohort, a slightly greater reduction in FBG and HbA1c levels was seen in the insulin glargine group compared to the NPH group. A weight loss, which was slightly more pronounced in insulin glargine patients despite receiving a lower insulin dose relative to the NPH group, was seen in both the groups. Additionally, hypoglycaemia, including nocturnal and severe events, was more prevalent in the patients receiving BOT with NPH. The occurrence of new micro- or macro-vascular complications and adverse events was low for both groups. A large proportion of patients changed from NPH therapy to insulin glargine therapy during the study, which was mainly attributable to insufficient glucose modulation. Improvements in quality of life and treatment satisfaction were found for both types of insulin.

CONCLUSIONS

This observational study provides evidence from a real-life setting that BOT with insulin glargine provides slightly greater reductions in weight, FBG and HbA1c levels, with a lower risk of hypoglycaemia than patients receiving NPH. This conclusion indicates that insulin glargine may be preferable to NPH insulin for BOT.

Facilitating the safe use of insulin pens in hospitals through a mentored quality-improvement program

PURPOSE

Results of the MENTORED QUALITY IMPROVEMENT IMPACT PROGRAM℠ (MQIIP) on Ensuring Insulin Pen Safety in Hospitals, which was part of an ASHP educational initiative aimed at ensuring the safe use of insulin pens in hospitals, are described.

METHODS

During this ASHP initiative, which also included continuing-education activities and Web-based resources, distance mentoring by pharmacists with expertise in the safe use of insulin pens was provided to interprofessional teams at 14 hospitals between September 2014 and May 2015. The results of baseline assessments of nursing staff knowledge of insulin pen use, insulin pen storage and labeling audits, and insulin pen injection observations conducted in September and October 2014 were the basis for insulin pen quality-improvement plans. Postintervention data were collected in April and May 2015.

RESULTS

Compared with the baseline period, significant improvements in nurses' knowledge of insulin pen use, insulin pen labeling and storage, and insulin pen administration were observed in the postintervention period despite the relatively short time frame for implementation of quality-improvement plans. Program participants are committed to sustaining and building on improvements achieved during the program. The outcome measures described in this report could be adapted by other health systems to identify opportunities to improve the safety of insulin pen use.

CONCLUSION

Focused attention on insulin pen safety through an interprofessional team approach during the MQIIP enabled participating sites to detect potential safety issues based on collected data, develop targeted process changes, document improvements, and identify areas requiring further intervention. A sustained organizational commitment is required to ensure the safe use of insulin pen devices in hospitals.

Examining Factors That Impact Inpatient Management of Diabetes and the Role of Insulin Pen Devices

Insulin administration in the acute care setting is an integral component of inpatient diabetes management. Although some institutions have moved to insulin pen devices, many acute care settings continue to employ the vial and syringe method of insulin administration. The aim of this study was to evaluate the impact of insulin pen implementation in the acute care setting on patients, healthcare workers and health resource utilization. A review of published literature, including guidelines, was conducted to identify how insulin pen devices in the acute care setting may impact inpatient diabetes management. Previously published studies have revealed that insulin pen devices have the potential to improve inpatient management through better glycemic control, increased adherence and improved self-management education. Furthermore, insulin pen devices may result in cost savings and improved safety for healthcare workers. There are benefits to the use of insulin pen devices in acute care and, as such, their implementation should be considered.

Effect of glargine insulin delivery method (pen device versus vial/syringe) on glycemic control and patient preferences in patients with type 1 and type 2 diabetes

OBJECTIVE

To evaluate the effects of two different glargine insulin delivery methods (pen device vs. vial/syringe) on glycemic control and patient preferences in a randomized, open-label, crossover, comparative effectiveness study.

METHODS

Thirty-one patients discharged from the hospital were recruited for this study. In the hospital, all patients were treated with a basal-bolus insulin regimen. Upon discharge, 21 patients received glargine by pen device for 3 months and were then switched to vial/syringe for the next 3 months (group 1). Group 2 consisted of 10 patients discharged on vial/syringe and converted to pen device after 3 months. Hemoglobin A1c (HbA1c) was measured at enrollment and at 3 and 6 months. A questionnaire assessing patient preference was administered at 3 and 6 months.

RESULTS

Groups 1 and 2 had similar baseline HbA1c (10.7 ± 2.2% and 11.2 ± 2.5%, respectively) and similar reduction in HbA1c at 3 months (7.8 ± 1.7% and 7.3 ± 1.4%, respectively; P<.001 vs. baseline). However, after crossover, the changes in HbA1c from 3 to 6 months were significantly different between groups. HbA1c increased to 8.5 ± 2.0% at 6 months in group 1 after switching to the vial/syringe but remained unchanged (7.1 ± 1.6%) in group 2 after switching to a pen device (P<.01, group 1 vs. group 2). Patient questionnaires after each phase of the trial revealed that patients found the pen device more convenient and were more likely to recommend this insulin delivery method to someone else.

CONCLUSION

Patients switching to a glargine pen device achieved lower HbA1c at the 6-month follow-up. Patients in both groups overwhelmingly preferred glargine pens over vials/syringes.

Pen Devices for Insulin Self-Administration Compared With Needle and Vial: Systematic Review of the Literature and Meta-Analysis

OBJECTIVES

Pen devices offer advantages compared with vial and syringe (VaS). The purpose of this article was to evaluate efficacy of pen devices compared to VaS.

METHODS

A systematic review of literature was performed in 8 different databases. References were independently screened and selected. Primary observational or experimental studies comparing pen devices with VaS for insulin administrations were included. Studies on specific populations were excluded. Risk of bias was evaluated using appropriate tools. Data on glycosylated hemoglobin (HbA1c), hypoglycemia, adherence, persistence, patient preference, and quality of life (QOL) were collected. Meta-analysis was performed when appropriate. Heterogeneity and risk of publication bias were evaluated. Otherwise, descriptive analyses of the available data was done.

RESULTS

In all, 10 348 articles were screened. A total of 17 studies were finally selected: 7 experimental and 10 analytical. The populations of the included articles were mainly composed of adults with type 2 diabetes mellitus. Important risk of bias was found in all of the articles, particularly experimental studies. Meta-analyses were performed for HbA1c, hypoglycemia, adherence and persistence. Pen device showed better results in mean HbA1c change, patients with hypoglycemia, adherence and persistence compared to VaS. No difference was observed in number of patients achieving <7% HbA1c. Preference studies showed a tendency favoring pen devices, however nonvalidated tools were used. One QoL study showed improvements in some subscales of SF-36.

CONCLUSIONS

There is evidence that pen devices offer benefits in clinical and, less clearly, patient-reported outcomes compared to VaS for insulin administration. However, these results should be taken with caution.

Improvement of Insulin Injection Technique: Examination of Current Issues and Recommendations

PURPOSE

Correct insulin injection technique is a crucial aspect of diabetes management. The purpose of this article is (1) to outline the medical literature, including patient-based studies and surveys, surrounding the type of issues and problems that patients encounter with injectable insulin therapy and the degree to which correct insulin technique is being applied and (2) to review the latest recommendations for insulin injection technique and discuss the key aspects that diabetes educators and other health care professionals should be communicating to their patients to ensure that injection technique is optimized.

CONCLUSIONS

Examination of the literature and multiple patient surveys demonstrates that patients continue to have many issues with insulin injection technique, highlighting the pressing need for effective patient education. In addition, many patients are not using insulin pen devices correctly. Widespread lack of injection site rotation and reuse of needles have resulted in high rates of lipohypertrophy. Lipohypertrophy has in turn been associated with significantly increased levels of unexplained hypoglycemia and glycemic variability and significantly increased insulin costs. By providing clear, evidence-based consensus recommendations, initiatives such as the Forum for Injection Technique are helping to address these issues but will be successful only if concerted efforts in patient education and reeducation are made to ensure that these recommendations are implemented consistently. This should involve all stakeholders in insulin therapy-particularly diabetes educators, who are at the forefront of patient education.

Quality Improvement Initiative and Safety of Insulin Pen Usage in a Small Hospital

Background

The Institute for Safe Medication Practices (ISMP) has stressed the need for hospitals to re-evaluate their methods of insulin delivery in an effort to minimize complications of insulin pen use. Improper use of insulin pens can lead to adverse effects, such as hypoglycemia or blood-borne infections.

Objective

This study was an American Society of Health-System Pharmacists (ASHP) quality improvement activity focused on insulin pen safety in the hospital. The objective of this study was to improve insulin pen delivery and patient health and to reduce adverse effects related to insulin pen use. The purpose of the impact activity was to utilize pharmacist experts to evaluate processes related to the use of insulin pens within the hospital and then implement quality improvement efforts to address potential safety concerns.

Methods

Baseline and postintervention questionnaires were administered to all nursing personnel ( N = 400) to assess their analytical and procedural knowledge regarding insulin pen use and administration. Insulin administration observations and insulin pen storage and labeling audits were also conducted at the same time points in 3 patient care areas where insulin administration was common. Process improvements were made after the baseline data were collected.

Results

An overall improvement in insulin pen use was determined after implementation of the quality improvement plan. The greatest improvements were seen for insulin pen administration. The proper storage of insulin pens had 69% compliance at baseline that rose to 98% compliance post intervention, an improvement of 29% ( P < .01). Similarly, compliance with the return of insulin pens to proper storage areas increased by 16%, from 78% at baseline to 94% post intervention ( P < .05).

Conclusion

An improvement in insulin pen usage was promoted by a quality initiative in a small hospital setting. Periodic education about safety procedures along with yearly reviews for all nurses will improve the ongoing safety of insulin pen usage within the hospital.