https://orcid.org/0000-0002-8186-3697
Several intervention and follow up studies have demonstrated the significant role of optimum glycemic control to prevent the chronic complications of diabetesCitation1–3. Despite improvement in the care of patients with type 1 diabetes (T1D), the majority of these patients do not achieve the recommended target HbA1cCitation4. Adolescents and young adults in particular have greater challenges in maintaining good glycemic control. There is a need for intensifying treatment and individualizing therapy as large observational studies in T1D have revealed that mean HbA1c level in 13–17 year olds is 9.0% and target Hba1c was achieved in only 29% of 13−18 year olds and 19% of 19−25 year oldsCitation5,Citation6.
For intensifying insulin therapy, a basal–bolus multiple daily injection (MDI) is an effective regimen to improve glycemic control. It mimics the physiologic insulin secretion and allows flexibility with respect to mealtimes and carbohydrate intake. However in people with T1D, intensive insulin therapy has been associated with increased frequency of severe hypoglycemic episodesCitation7. Dosing errors are common in young children and the elderly as they have lower insulin requirements. Due to their greater insulin sensitivity and lower body weight, young children usually need small insulin doses. Frequent hypoglycemia observed in these age groups may result from error in injecting small amounts of insulin when using a vial and syringe. In this population it has been seen that increasing the insulin dose by 1 unit (U) may not be sufficient, whereas a 2 U increment result in hypoglycemia. Hence accurate and precise dosing is extremely important in the management of children and elderly patient with diabetesCitation8,Citation9.
Insulin may be administered through a syringe that is filled from a vial, an insulin pen or an insulin pump – continuous subcutaneous insulin infusion (CSII). Syringes are inexpensive, but they can be inconvenient, indiscreet and have a greater risk of inaccuracy. Syringes also pose a barrier to appropriate and accurate dosing in patients with visual or physical impairmentCitation8. On the other hand, insulin pens have been designed to overcome these barriers in insulin therapyCitation10–12. Most of the available pens in the market deliver insulin in 1 U increments, a few deliver in half-units (0.5 U). Half-unit pens (HUPs), compared to 1 U pens, can further improve the accuracy and precision in insulin therapyCitation13. Young people and elderly, who need very small insulin dosages, are much benefited by the use of HUPs. Carbohydrate counting improves glycemic control and reduces glycemic variability. Half unit insulin delivery can more effectively match the insulin to carbohydrate ratio in people using carbohydrate counting to calculate insulin doseCitation9,Citation13. The main purpose of HUPs is to provide accurate insulin administration to an insulin-sensitive patient. HUPs improve treatment adherence leading to better clinical outcome and quality of lifeCitation13. HUPs that are available in the market are HumaPen Luxura HDFootnotei, NovoPen EchoFootnoteii, JuniorSTARFootnoteiii, Humalog Junior KwikpenFootnoteiv, and InPenFootnotev,Citation9.
While the use of HUPs may lead to improved clinical outcomes in young people with diabetes, more studies are needed to determine the merits and demerits of HUPs. In this issue of the journal, Carolina Piras de Oliveira et al. have presented the findings from a cross-sectional observational study on the patient perspectives on the use of HUPs by people with T1D. Three hundred participants were divided into two groups based on the following criteria: those who have ever used a half-unit pen (EVER user) or have never used a half-unit pen (NEVER user); 56% were EVER users and 44% were NEVER users of a half-unit pen. EVER users reported a shorter duration of T1D diagnosis and a numerically lower average HbA1c (6.0% ± 0.7% vs. 6.6% ± 1.1%) than NEVER users. The most common reasons for using HUPs by EVER users were preventing hyperglycemia, preventing hypoglycemia and reducing anxiety or worry. The majority of the EVER users found HUPs convenient and easy to use. Improvement in insulin pen technology may impact quality of life in the majority of diabetes patients not using insulin pumps, including pediatric patientsCitation14. The next-generation pens by improving dose accuracy with fine dosing increments will likely make diabetes management more effectiveCitation15.
The current study reiterates the utility of HUPs in people with T1D in achieving optimal glycemic control and better quality of life by reducing hypoglycemic episodes and allaying worry and anxiety. Insulin pens with half-unit dose may be useful across the diabetes spectrum particularly for the young and elderly people with increased insulin sensitivity who need individualized therapy and small insulin doses. These pens can deliver accurate and precise doses that are needed for tight glycemic control. HUPs provide easy usability, greater patient satisfaction, treatment adherence and better quality of life. However, larger studies are needed to determine whether refined dosing and easy operability of HUP translates into better glycemic control, reduced hypoglycemia and fewer missed doses. Further studies are needed to determine whether switching to expensive HUPs leads to reduction in health care costs associated with hypoglycemia and reduced insulin wastage.
Transparency
Declaration of funding
No funds were received for this editorial.
Declaration of financial/other relationships
No potential conflict of interest was reported by the authors. CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
Notes
i HumaPen is a registered trademark and Luxura HD is a trademark of Eli Lilly and Company, Indianapolis, IN, USA.
ii NovoPen Echo is a registered trademark of Novo Nordisk, Bagsværd, Denmark.
iii JuniorSTAR is a registered trademark of Sanofi, Paris, France.
iv Humalog Junior Kwikpen is a registered trademark of Eli Lilly and Company, Indianapolis, IN, USA.
v InPen is a trademark of Companion Medical, San Diego, CA, USA.
References
- Nathan DM, Genuth S, Lachin J, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977–986.
- Nathan DM, Cleary PA, Backlund JY, et al. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005;353:2643–2653.
- Nordwall M, Arnqvist HJ, Bojestig M, et al. Good glycemic control remains crucial in prevention of late diabetic complications – the Linköping Diabetes Complications Study. Pediatr Diabetes. 2009;10(3):168–176.
- McKnight JA, Wild SH, Lamb MJ, et al. Glycaemic control of type 1 diabetes in clinical practice early in the 21st century: an international comparison. Diabet Med. 2015;32(8):1036–1050.
- Miller KM, Foster NC, Beck RW, et al. Current state of type 1 diabetes treatment in the U.S.: updated data from the T1D Exchange clinic registry. Dia Care. 2015;38(6):971–978.
- Laffel L, Domenger C, Dain MP, et al. Global assessment of factors associated with target glycemic control in youth with type 1 diabetes (T1D): the TEENs study. Diabetes. 2014;63:A9.
- Diabetes Control and Complications Trial Research Group. Epidemiology of severe hypoglycemia in the diabetes control and complications trial. Am J Med. 1991;90:450–459.
- McCoy EK, Wright BM. A review of insulin pen devices. Postgrad Med. 2010;122(3):81–88.
- Aanstoot HJ, Rodriguez H, Weinzimer S, et al. Precision dosing of rapid-acting insulin matters. Diabetes Technol Ther. 2020;22(5):346–351. Epub 2020 Mar 3. PMID: 32125891.
- Asakura T, Seino H, Jensen KH. Patient acceptance and issues of education of two durable insulin pen devices. Diabetes Technol Ther. 2008;10(4):299–304.
- Tschiedel B, Almeida O, Redfearn J, et al. Initial experience and evaluation of reusable insulin pen devices among patients with diabetes in emerging countries. Diabetes Ther. 2014;5(2):545–555.
- Baruah MP. Insulin pens: the modern delivery devices. J Assoc Phys India. 2011;59(suppl):38–40.
- Klonoff DC, Nayberg I, Stauder U, et al. Half-unit insulin pens: disease management in patients with diabetes who are sensitive to insulin. J Diabetes Sci Technol. 2017;11(3):623–630.
- Sherr JL, Hermann JM, Campbell F, et al. Use of insulin pump therapy in children and adolescents with type 1 diabetes and its impact on metabolic control: comparison of results from three large, transatlantic paediatric registries. Diabetologia. 2016;59(1):87–91.
- Aronson R, Bailey T, Hirsch L, et al. Advances in insulin injection research influences patient adherence. US Endocrinol. 2013;9(2):114–118.