Disclosures: Miller-Owen reports no relevant financial disclosures. Weiner reports she is a clinical adviser to Livongo Health.
October 05, 2020
3 min read
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Smart insulin pens address challenges of multiple daily injection therapy

Disclosures: Miller-Owen reports no relevant financial disclosures. Weiner reports she is a clinical adviser to Livongo Health.
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In this issue, Susan Weiner, MS, RDN, CDN, CDCES, FADCES, talks with nurse practitioner and diabetes care and education specialist Colleen Miller-Owen, MSN, APRN, CDCES, about the benefits of smart insulin pens for multiple daily injections.

How many Americans use insulin therapy and rely on injections for insulin delivery today?

Susan Weiner
Colleen Miller-Owen

Miller-Owen: Close to 8 million U.S. residents with diabetes are on insulin therapy, and the clear majority use injections. Less than 1% of people with type 2 diabetes and less than 30% with type 1 diabetes use insulin pumps. Multiple factors influence the choice to continue using injections instead of an insulin pump, including cost, insurance coverage, complexity of pump use and desire to avoid having a device attached to the body. Smart insulin pens have some of features of insulin pumps — assisting with dose calculation, recording time and amount of insulin — but come without the cost and other assumed barriers to an insulin pump.

Source: Adobe Stock

What are some of the challenges multiple daily injection therapy poses?

Miller-Owen: Teaching people to adjust mealtime doses using an insulin-to-carbohydrate ratio and insulin sensitivity factor is time-consuming, and two-thirds of people with diabetes have difficulty accurately calculating insulin doses. More than 60% of insulin doses are given with some insulin still on board from previous doses, which can lead to insulin stacking and increase hypoglycemia risk. Missing doses of mealtime insulin, even twice per week, can lead to HbA1c increases of 0.3% to 0.4%. Insulin doses can be missed for multiple reasons, such as simply forgetting, inconvenience of injections, dose complexity or concerns regarding cost of insulin and potential rationing. Also, lack of objective data on dose and timing of injections can limit clinicians and people with diabetes in optimizing dosing. Manually recording data can be time-consuming and may be inaccurate, so devices to ease this burden can potentially lead to improved glucose levels.

How can smart insulin pens address these challenges?

Miller-Owen: Smart insulin pens can assist with reducing and recording doses. Smart pens with bolus calculators can assist with accuracy of dose calculations. Carbohydrate ratios and sensitivity factors can be programmed, and then a dose calculated based on blood glucose reading and carbohydrate amounts, reducing potential manual calculation errors. The ability of smart pens to keep track of the insulin on board and deduct a correction amount, if appropriate, helps prevent insulin stacking and thus can reduce the risk for hypoglycemia. Some smart pens can even deliver in half-units, which is beneficial if someone is very sensitive to insulin.

Most smart insulin pens keep track of time and previous dose amount. This memory can prevent accidently taking a duplicate dose or send reminders if a dose window has been missed. Finally, the ability to accurately review blood glucose, timing and insulin dose data can help to optimize dosing. Recording data is time-consuming and often not available at office visits, which can prevent a health care provider from getting a true picture of insulin dosing. Smart insulin pens can easily transmit data for the provider to review via blue tooth connectivity, fax or email. This has become more apparent with the increase of virtual visits due to the COVID19 pandemic.

What role can the diabetes care team play in helping people get started with smart insulin pens?

Miller-Owen: Choosing a method of insulin delivery is a very personal decision. The diabetes care team can help the person with diabetes review the pros and cons of all the available options and help them determine a good choice. Then they can assist with training on the pen to make sure settings are optimized and individualized to the user’s unique carbohydrate ratios and sensitivity. The Inpen (Companion Medical), for example, allows for three types of bolus dosing: fixed doses, meal estimates and carbohydrate counting. Many people with diabetes are unable or unwilling to count carbohydrates, so these choices allow them to use the protective features of the corrections based on sensitivity while meeting them where they are with regard to carb counting. This can lead to recognition that more education or more sophisticated carb counting is needed for optimizing therapy. The care team can also assist with a plan for sharing and reviewing data. This can help with optimizing dosing, reducing risk for hypoglycemia and empowering the person with diabetes in their care.

What effect have you seen on glucose levels?

Miller-Owen: Use of automated bolus calculators can help people with diabetes lower their HbA1c by 0.7% to 1%. I always am curious whether research outcomes can be replicated in the real world. My experience in outpatient community clinics has shown that most have had an improvement in HbA1c after starting a smart insulin pen. Also, if the person with diabetes is using a continuous glucose monitor, the time in range has generally increased and the percent of time below range decreased. Since most people with diabetes who are injecting insulin use syringes or pens, there is a huge opportunity to improve HbA1c. Smart insulin pens are one option.

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For more information:

Colleen Miller-Owen, MSN, APRN, CDCES, is an endocrinology nurse practitioner at the Tampa General Medical Group. She can be reached at cmillerowen@tgh.org.

Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is co-author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com; Twitter: @susangweiner.