Trends in Insulin Pen Priming for Patients with Type 1 Diabetes

JUNE 26, 2018
Matt Hoffman
Grenye O'Malley, MD, from the Icahn School of Medicine at Mount Sinai, talked with MD Mag at the American Diabetes Association's 78th Annual Scientific Sessions in Orlando, Florida, about her study data on insulin pen priming for patients with type 1 diabetes that require multiple daily injections (MDIs). 

In her interim analysis, 16,135 pen records from 25 different patients were examined. It was found that the percent of injections with a prime was 80% overall, but had a massive range of 2% to 99%. Additionally, the number of primes varied and did not correlate to hemoglobin A1C. The percentage of missed primes also did not correlate with hemoglobin A1C but appeared to have a relation with men and younger patients. In cases were the patients primed until insulin could be seen, 74% of the primes did not necessitate ≥2 units. The frequencies of priming—defined as low if <25%, variable if 25‐75%, and consistent if >75%—were not evenly distributed. Patients either primed their injections the majority of the time or totally infrequently.

She also talked about the need to improve communication with these patients to better meet their needs and relieve them of burden. As it requires multiple fingersticks per day to check blood glucose levels and multiple doses of insulin, it adds to the number of needles patients need to endure each day. And while some products, such as the insulin pen, make it easier to administer insulin, these patients remained burdened by the discomfort and work involved with condition management.


Grenye O'Malley, MD, from the Icahn School of Medicine at Mount Sinai:
There is very little known about patients who use multiple daily injections, especially [those with type 1 diabetes] because, historically, they have their pens at home and they're doing their own thing. We have very few ways to get a lot of information about how they're actually doing anything. There have been a few studies, that are just questionnaires, that are [have] a lot of bias, or they’re [doing] recall or testing [patients] and then they're trying to do well on a test. It's not a lot about what they actually do at home.

In this study—the larger study is a study with type 0, on a decision support system, to facilitate more information and advice for patients using MDI for type 1. Basically, what we're trying to do is give them some of the benefits that the patients using pumps or closed-loop systems get, but we can't just take that system and just stick it on MDI users because there are different people. There's a reason why they're using MDI, there are things that they like about it.

Within this study, that's still ongoing, we were able, with the smartpens from Novo Nordisk, to get a lot more information about what they're actually doing at home. My poster is about how often patients actually prime their pens, and then also how much. What we found was that—and this was patients who had just been taught to prime, and we had reinforced that, [because] a lot of them had forgotten what that was—the majority of patients did prime. Overall, 80% of the injections I looked at, and I looked at about 16,000 injections, were primed. But when you looked at the patients, they weren't distributed on how often they primed. They were either priming almost all the time or very little, and what we found was the patients were kind of what we would expect. The patients were younger, they were all men, and they primed a lot less. But we didn't find any correlation to their baseline hemoglobin a1c.

The findings on the priming were kind of where I asked would have guessed people would have been priming. Not all the time—I don't think anyone really was perfect in our study. But, I think what was overall most interesting is how, from an engineering perspective, [the question was] can we just take a fiber close loop for a pump and then just stick it on for MDI? You can't do that, they're different people. They have different needs, they've had a lot of control over what they've been doing, and they're not used to having to interact with all these different steps. I think that's been the most surprising thing in the development of it. Just how little we know and how much more we need to know about this population in order to [help them].

The majority of people type 1 diabetics use multiple daily injections, and it's a huge area that we just don't know of anything about. I think that was probably the most surprising thing to me going through the study.

That's what this really allows us to do with these pens, that now are getting more information, is to really know. When we're teaching them, we don't really know how often patients are priming. We don't know how much we really need to emphasize this. I know that since doing this study, now I've been emphasizing in a different way than I might have previously because a lot of us assume that the patients were priming. We were just reminding them and going through our steps. But actually, maybe, we should be emphasizing it.

It's something that, since we don't know what they're doing, we've never really emphasized it in their whole history. We don't usually see them doing it, we don't usually interact with that part of it, so I think having more information about what patients are really doing at home is going to allow more of an interaction on what the patients really care about, what they're doing day-to-day, instead of our checklists of things we want to tell them.

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