1. Stick it to Diabetes: Insulin Pen Incorporation and Adherence
Brad Wright, PharmD, BCPS
Assistant 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

2. 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.

3. Disclosure
Nothing to disclose

4. 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
8.3% of the population

6. 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
Combination of orals and insulin
More than half of healthcare provideres avoid using insulin in T2DM until it is absolutely necessary. Owing to this “clinical”inertia, patients have often had diabetes for more than 10 years, have a long history of poor glycemic control, and have had already developed complications before insulin is initiated

8. Insulin
1921 – Banting and Best discover Insulin 1930s – NPH insulin 1961 – Single-use syringe 1973 – U100 Insulin 1980s – Human Insulin 1984 – First pen device 1990s – Insulin analogues 2006 – Inhaled insulin

9. Types of Insulin Rapid-acting Defined by: Short-Acting
Glulisine, Lispro, Asparte
Onset
Short-Acting
Peak
Regular
Duration of Action
Intermediate-acting
NPH
Long-Acting
Detemir, Glargine

10. Insulin Delivery
Syringe and vial
Insulin Pen Device

11. 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
Negative perceptions

12. 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
Diabetes is the leading cause of blindness
in those aged 20 to 74 years, and diabetic retinopathy causes
to new cases of blindness annually.1,5 Glaucoma,
cataracts, and other ocular disorders all occur earlier
and more frequently in patients with diabetes,5 and visual
impairment is estimated to affect at least 16% and 27% of the
patients at ages 65 years and 75 years, respectively.17 Limited
joint mobility and symptomatic peripheral neuropathy are
also prevalent in 25% to 50% of patients with diabetes

13. 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

14. 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
May result from difficulty achieving consistent reproducibility of insulin administration with a vial and syringe

15. 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 %
Non-adherence leads to increased hospital admissions and health-care costs
Fear of non-adherence leads to delay in insulin therapy
Clin Ther 2006;28: ,
Clin Ther 2007;29:

16. 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.

17. 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

18. 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

19. Postgrad Med 2010;122

20. Types of Insulin Pens
Durable Pens
Prefilled pen devices

21. 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

22. 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

23. Durable Pens HumaPen® Luxura HD® (Humalog) Autopen® Classic (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
Autopen 24 (Sanofi) only available in Canada

24. 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

25. 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

26. 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

27. Prefilled Pen Devices Solostar® Humalog KwikPen™ Humulin KwikPen™
Lantus
Apidra
Humalog KwikPen™
Humalog®
Humalog® Mix 75/25 and 50/50
Humulin KwikPen™
Humulin® N
Humulin 70/30
Solostar requires less injection force

28. Prefilled Pen Devices
FlexPen®
Novolog®
Novolog Mix® 70/30
Levemir®

29. 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

30. 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
– easier to carry in pocket or purse

31. 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
Elderly and kids - Higher rates of hypoglycemia due to dosing errors

32. 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

33. 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 population
Clinical Medicine Insights: Endocrinology and Diabetes 2010;3:53-63

34. 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

35. 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: ,

36. 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

37. 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 stay
30% of hospitals in 2008

38. 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

39. 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

40. 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 satisfaction
Average nursing home dose = 20 units
Decreases nursing time by 6-8 minutes
Consult Pharm 2011;26:495-97

41. 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

42. References
Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 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… (Accessed 8/26/2011)
Ward LG, Aton SS. Impact of an interchange program to support use of insulin pens. Am J Health-Syst Pharm ;68:
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:
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:
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:
Brunton S. Insulin delivery systems: Reducing barriers to insulin therapy and advancing diabetes mellitus treatment. Am J Med 2008;121:S35-41

43. Stick it to Diabetes: Insulin Pen Incorporation and Adherence
Brad Wright, PharmD, BCPS
Assistant 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