STICK IT TO DIABETES:INSULIN PEN INCORPORATION AND ADHERENCE

Brad Wright, PharmD, BCPSAssistant Clinical Professor of Pharmacy Practice

Auburn University Harrison School of Pharmacy

Adjunct Assistant Clinical Professor of Internal Medicine

University of South Alabama College of Medicine

Objectives

Identify currently available insulin pen devices.

Discuss the advantages and disadvantages of insulin pen devices with vial and syringes, especially within the elderly population.

Describe the use of insulin pen devices in the inpatient, long-term care, and outpatient settings.

Disclosure

Nothing to disclose

Diabetes Mellitus

Diabetes Mellitus (DM) affects 25.8 million people in the United States

Seventh leading cause of death in the US in 2007 Overall, the risk for death among diabetics is

about twice that of people without diabetes Associated with numerous micro- and

macrovascular complications Medical expenses diabetics are more than two

times higher than for people without diabetes

www.cdc.gov

Diabetes Treatment 50% of patients with T2DM will require

multiple therapies within 3 years of diagnosis More than 5 million Americans use insulin

Insulin has an unlimited ability to decrease A1C levels

Clinicians often delay initiation of insulin More patients will require insulin

Prevalence of T2DM increases Increase in obesity Increase in Elderly Earlier initiation of Insulin

Insulin

1921 – Banting and Best discover Insulin1930s – NPH insulin1961 – Single-use syringe1973 – U100 Insulin1980s – Human Insulin1984 – First pen device1990s – Insulin analogues2006 – Inhaled insulin

Types of Insulin Rapid-acting

Glulisine, Lispro, Asparte

Short-Acting Regular

Intermediate-acting NPH

Long-Acting Detemir, Glargine

Defined by: Onset Peak Duration of Action

Insulin Delivery Syringe and vial

Insulin Pen Device

Barriers to Use of Insulin Patient and Provider barriers

Fear of hypoglycemia Complicated and time consuming

Psychosocial barriers Needle anxiety Fear of injection pain Concern over inconvenience Social embarrassment Perception of failure

Barriers to Use of Insulin Physical barriers

Visual impairment Reduced manual dexterity Peripheral neuropathy

These barriers make it more difficult for patients to accurately draw up and inject an insulin dose

Barriers to Use of Insulin

Age-related factors

Children and Adolescents Often require smaller doses of insulin More at risk for hypoglycemia Increased percentage of error associated

with injecting small doses of insulin with vial and syringe

Barriers to Use of Insulin Age-related Factors

Elderly Insulin is a high-alert medication in the

elderly Elderly are more likely to experience

hypoglycemia More likely to experience inaccurate dosing

Vision Manual dexterity

Insulin Adherence

Physical barriers lead to non-adherence Patients often have poor information,

perceptions, and/or education regarding insulin therapy

Negative perceptions can reduce adherence Adherence with insulin injections may range

from 20-90% Non-adherence leads to increased hospital

admissions and health-care costs Fear of non-adherence leads to delay in

insulin therapyClin Ther 2006;28:1712-1725,Clin Ther 2007;29:1294-1305

Insulin Pens First devices introduced in the U.S. in the

mid to late 1980’s (Novo Nordisk)

Many changes have been made to optimize use

In Europe 80-90% of patients use insulin pen devices

In the US only about 15% of patients use insulin pen devices

Medscape J Med. 2008; 10(5): 120.

Insulin Pens Designed to provide an easy and convenient

means of insulin administration Often resemble a writing pen Contains either an insulin cartridge or

reservoir Insulin is stored in the device

Patient only needs to screw on a small pen needle

More portable and helps the patient keep insulin and subsequent administration discreet

Insulin Pens

Many of the insulin formulations currently available today are offered in both vials and pens All insulin types other than Regular are

available in Pens Novolin N (NPH) and Novolin 70/30 are not

available in a pen device Humulin N and Humulin 70/30 are available

Generally cost more than vials 1500 units per box

1 box = 5 pens or cartridges

Postgrad Med 2010;122

Types of Insulin Pens Durable Pens

Prefilled pen devices

Durable Pens Combines the reusable insulin

container with disposable insulin cartridges and pen needles

Designed to be reused by the patient Sturdy design Refilled by obtaining cartridges of insulin to be loaded into the device May be used for several years

Durable Pens Hold 3ml cartridge – 300 units of insulin Many pens are designed with special

features Deliver insulin in 0.5 -, 1-, 2- unit

increments Maximum 80 units

Many manufacturers are beginning to move away from durable pens

Durable Pens

HumaPen® Luxura HD® (Humalog) Discreet design for pediatric and adult

patients Sturdy metal design Delivers insulin in 0.5 unit increments

Autopen® Classic (Humalog) Side mounted release button Less force and distance to deliver the dose

https://www.mylillypen.com/lilly_insulin_pens.aspx; http://www.owenmumford.com/en/range/6/autopen.html

Durable Pens

NovoPen® 3 (Novolog, Levemir) Discreet looking with sturdy metal design Can be used with the Penmate® device Available in different colors

Novopen® Jr (Novolog, Levemir) Metal construction with an attractive modern

design and different colors Designed for children and teenagers Delivers insulin in 0.5 unit increments

www.novonordisk.com

Penmate®

Automatic needle insertion accessory Hides the needle during the entire

process Specifically designed for patients with

needle phobia Reduces pain perception compared to

manual needle insertion

www.novonordisk.com

Prefilled Pen Devices

Designed with a built-in, prefilled insulin reservoir

Loaded with 3ml (300 units) of insulin

Once empty, the device is to be discarded and the patient must use another prefilled device

Easier to use and more convenient because there is no need to install a cartridge

Audible clicks to help with dosing

Prefilled Pen Devices

Solostar®

Lantus Apidra

Humalog KwikPen™ Humalog®

Humalog® Mix 75/25 and 50/50

Humulin KwikPen™ Humulin® N Humulin 70/30

www.lantus.com, www.mylillypen.com

Prefilled Pen Devices

FlexPen®

Novolog®

Novolog Mix® 70/30 Levemir®

Counseling Tips

Once insulin has been injected, keep device in place for 5-10 seconds

Insulin suspensions – Roll or tip the pen to mix

Pens must be primed before each injection, and the needle removed immediately after each use

Keep unused pens/cartridges in the refrigerator and open pens at room temperature

Pens vs. Vials Advantages of Pen Devices

More convenient for patients More compact and portable Eliminate the need to draw up the insulin

from a vial More discreet in social situations

Less pain 50% of patients reported experiencing less

pain when using insulin pen devices Less degree of injection anxiety Reduction in needle phobia

Pens vs. Vials Advantages of Pen Devices

Greater accuracy and reliability with dosing Shown to provide a more accurate dose

than vial-and-syringe method Particularly important for elderly and

children Easy-dial mechanism Sensory and auditory feedback – “Clicks”

and display Important for patients with impairments in

vision and manual dexterity

Pens vs. Vials Advantages of Pen Devices

Other advantages Easier to handle, dose, and use

Decrease in hypoglycemia

Increased confidence and treatment satisfaction

Improved attitude toward insulin therapy

Greater improvements in quality of life

More patients willing to continue therapy

Pens vs. Vials Advantages of Pen Devices - Elderly

Pen devices offer special features that may improve the use of insulin in the elderly

Audible clicks and large dosing windows Help patients with visual impairments

Convenience, size, and overall ease of use Help patients with dexterity impairments

Pen devices have been found to be safe, efficacious, and more accurate in the elderly populationClinical Medicine Insights: Endocrinology and Diabetes 2010;3:53-63

Pens vs. Vials Disadvantages of Pen devices

More costly Take longer amount of time to inject

Needle must remain in SQ tissue for 5-10 seconds Difficult to determine if full dose has been given

Not every type of insulin is available in a pen device Fewer choices

Contamination – air and biologic materials May lead to under dosing

Potential for malfunction

Pens vs. Vials Advantages of Pen Devices

Studies have shown an increase in: Patient preference and acceptability Convenience and ease of use Dosing accuracy Satisfaction

Increased adherence

Decreased cost

Clin Ther 2006;28:1712-1725,

Insulin Pens – Inpatient Use

In 2008 a reported 30% of hospitals had switched to using insulin pen devices

Many proposed advantages including initiating in new diabetics and transitioning patients for outpatient use

ISMP recognizes several risks associated with inpatient use of insulin pens

Insulin Pens - Inpatient Use

Advantages of pen use for inpatients Individuals pens are labeled by the manufacturer Each pen is labeled with an individual patient’s

name Insulin is provided in form ready for administration Decreases nursing preparation and administration

time Increased dosing accuracy Reduces potential for overdose Reduces medication waste Reduce costs – Average cost savings of $36 per

patient per hospital staywww.ismp.org

Insulin Pens – Inpatient Use

Potential problems associated with inpatient use Needlestick injuries

Poor visualization during injection User technique errors

Wide variety of pens available Risk of contamination

Using pen as a multi-dose vial Using a pen for multiple patients

Dispensing and administration errors

www.ismp.org

Insulin Pens – Inpatient Use

Inpatient switch to pens has resulted in: Reduction in needle-stick injuries Reduction in cost Patients may be more willing self-inject as well

as to continue insulin as an outpatient Increase in nurse satisfaction

More convenient, simple and easy to use For successful conversion to pens it is

important to consider a multi-disciplinary approach, addressing education of the staff and safety concerns

Insulin Pens – LTC

While pens are more expensive, overall costs may decrease in the long-term care (LTC) setting Less waste Fewer vial breaks Decreased nursing time Lower level of care for some self-administering

patients Greater consistency and accuracy of dosing Increase in nurse satisfaction Increase in patient satisfactionConsult Pharm 2011;26:495-97

Summary

Consideration should be given to method of insulin delivery to ensure patient and provider satisfaction

Insulin pens are easier, more convenient, and less painful than vial-and-syringes

Pens are associated with greater patient satisfaction, preference, and social acceptability

Insulin pens have the potential to improve patient medication adherence in the outpatient setting

Insulin pens may reduce errors, nursing time, and costs in the inpatient or LTC setting

References Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and

general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.

Institute of Safe Medication Practices. Considering insulin pens for routine hospital use? Consider this… www.ismp.org (Accessed 8/26/2011)

Ward LG, Aton SS. Impact of an interchange program to support use of insulin pens. Am J Health-Syst Pharm. 2011;68:1349-1352

Honebrin AN, Peters CR, Bright DR. Insulin pens vs. vials and syringes: The pharamacists role in individualizing therapy. Consult Pharm 2011;26:495-97

Lee WC, Balu S, Cobden D, et al. Medication adherence and the associated health-economic impact among patients with type 2 diabetes mellitus converting to insulin pen therapy: An analysis of third-party managed care claims data. Clin Ther 2006;28:1712-1725

Pawaskar MD, Camacho FT, Anderson RT, et al. Health care costs and medicattion adherence associated with initiation of insulin pen therapy in medicaid-enrolled patients with Type 2 diabetes: A retrospective database analysis. Clin Ther 2007;29:1294-1305

Wright BM, Bellone JM, McCoy EK. A review of insulin pen devices and use in the elderly diabetic population.. Clinical Medicine Insights: Endocrinology and Diabetes 2010;3:53-63

McCoy Ek, Wright BM. A review of insulin pen devices. Postgrad Med;2010:1-8. Asamoah E. Insulin pen – The “ipod” for insulin delivery. J Diabetes Sci Technol 2008;2:292-296 Brunton S. Insulin delivery systems: Reducing barriers to insulin therapy and advancing diabetes

mellitus treatment. Am J Med 2008;121:S35-41

STICK IT TO DIABETES:INSULIN PEN INCORPORATION AND ADHERENCE

Brad Wright, PharmD, BCPSAssistant Clinical Professor of Pharmacy Practice

Auburn University Harrison School of Pharmacy

Adjunct Assistant Clinical Professor of Internal Medicine

University of South Alabama College of Medicine