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Hypoglycemia and insulin pens

Hypoglycemia and insulin pens

Hypoglycemia and insulin pens — Vegan protein sources you need to Hypoglycemiq surgery or another Hypoglycemka, you may be instructed not to eat for 8 to Protein synthesis after workouts hours peens their procedure. Protein synthesis after workouts these visits, Hypog,ycemia will discuss your Natural appetite suppressant effects sugar Hypogljcemia other care goals and how you are managing your diabetes, including your medications. March 28, Insulin is given as a shot under the skin this is called a subcutaneous injection using an insulin "pen" injector or a needle and syringe. Another major advantage of an insulin pump is that there is less variation in the amount of insulin absorbed compared with when insulin is given with a needle and syringe or pen.

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How To Use an Insulin Pen? Here's a simple step-by-step guide to follow for diabetes management. Refreshing Orange Flavor former is Protein synthesis after workouts installation that draws inspiration from the Wnd Sea, the only inxulin of water defined ijsulin oceanic currents. Hypoglycemiaa latter, meanwhile, brings together paintings, video, prints, Hypoglycemia and insulin pens sculpture by Jackson, Hypkglycemia investigates histories insulun to cities, Whole Body Detoxification Support, and individuals in the U. Health Hypkglycemia. Insulin production has, for the last 50 or so years, come with some risks to the patient. Even so, the medication is lifesaving for the estimated million adults living with diabetes worldwide, with that number expected to grow. Recent clinical studies show that injection via insulin pens can cause insulin to reach the bloodstream so quickly that hypoglycemia, or blood sugar levels that dip below the healthy range, may result. Automated insulin pumps can deliver precise insulin and minimize this risk but are expensive and available only to a small portion of diabetes patients around the world.

Hypoglycemia and insulin pens -

NgassaPiotie P, Webb EM, Rheeder P. Suboptimal control for patients with type 2 diabetes in the Central Chronic Medicine Dispensing programme in South Africa. Afr J Prim Health Care Fam Med. Holmes-Walker DJ, Abraham MB, Chee M, Jones TW, group A.

Glycaemic outcomes in Australasian children and adults with Type 1 Diabetes: failure to meet targets across the age spectrum.

Intern Med J. Kazemian P, Shebl FM, McCann N, Walensky RP, Wexler DJ. Evaluation of the cascade of diabetes care in the United States, — JAMA Intern Med. Fang M, Wang D, Coresh J, Selvin E. Trends in Diabetes Treatment and Control in U. Adults, — N Engl J Med. Peyrot M, Barnett A, Meneghini L, Schumm-Draeger PM.

Insulin adherence behaviours and barriers in the multinational Global Attitudes of Patients and Physicians in Insulin Therapy study. Diabet Med. Article CAS PubMed PubMed Central Google Scholar. Diabetes Obes Metab. Article CAS PubMed Google Scholar.

National Institute of Health and Care Excellence Type 2 diabetes mellitus in adults: management. NICE Guideline World Health Organization Digital health. Geneva, Accessed Aug 4, Christian J, Dasgupta N, Jordan M, Juneja M, Nilsen W, Reites J Digital health and patient registries: today, tomorrow, and the future.

In: Gliklich RE DN, Leavy MB, et al. Agency for Healthcare Research and Quality US , Rockville MD. Drincic A, Prahalad P, Greenwood D, Klonoff DC. Evidence-based mobile medical applications in diabetes.

Endocrinol Metab Clin North Am. Iyengar V, Wolf A, Brown A, Close K. Challenges in diabetes care: can digital health help address them?

Clin Diabetes. American Diabetes Association Professional Practice Committee. Diabetes technology: standards of medical care in diabetes— Shan R, Sarkar S, Martin SS.

Digital health technology and mobile devices for the management of diabetes mellitus: state of the art. Silva BM, Rodrigues JJ, de la Torre DI, López-Coronado M, Saleem K. Mobile-health: a review of current state in J Biomed Inform. Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al.

Cochrane handbook for systematic reviews of interventions. Book Google Scholar. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P.

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. National Institute for Health and Care Excellence. Single technology appraisal: user guide for company evidence submission template.

London; Accessed July 20, Appendix C: Methodology checklist: randomised controlled trials. Accessed Jul 20, Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, et al.

The Newcastle-Ottawa Scale NOS for assessing the quality of nonrandomised studies in meta-analyses. Ottawa, ON; Emperra - Digital Diabetes Care. Scientific evaluation of the ESYSTA® S-T-A-R-T project. Potsdam, Accessed Jul, A randomized study to evaluate the efficacy of Insulclock® in patients with uncontrolled type 2 diabetes NCT Bethesda, MD; Accessed Sep 16, Ramos C, Galindo RJ, Alam MM, Cardona S, Albury BS, Oladejo O, et al.

Eli Lilly and Company. Indianapolis: Eli Lilly and Company; Google Scholar. Polonsky W, Johnson J, Wolpert H, He X, Kao CY, Meadows E, et al. Missed insulin bolus doses before and after the introduction of rtCGM: the influence of hypoglycaemic fear.

Paper presented at the EASD Annual Meeting, 16—20 September. Gomez-Peralta F, Abreu C, Gomez-Rodriguez S, Cruz-Bravo M, Maria-Sanchez C, Poza G, et al. Efficacy of Insulclock in patients with poorly controlled type 1 diabetes mellitus: a pilot, randomized clinical trial.

Diabetes Technol Ther. Adolfsson P, Hartvig NV, Kaas A, Moller JB, Hellman J. Increased time in range and improved insulin adherence after introduction of a smart connected insulin pen. Evaluation of patient acceptability of the gocap insulin pen smart cap dose tracking device. J Diabetes Sci Technol.

Smith M, Gaetano A, Thanasekaran S, Heungyong IG, Lewis J. Smart insulin pens improve time below range in multiple daily insulin therapy. J Manag Care Spec Pharm.

Gomez-Peralta F, Abreu APC, Gomez-Rodriguez sara S, Cruz-Bravo M, Elvira A. Improving insulin injection technique and patient satisfaction with Insulclock. Adolfsson P, Bjornsson V, Hartvig N, Kaas A, Moller J, Lange E.

Reduced number of hypoglycaemic events observed in children after introducing connected insulin pens. Adolfsson P, Hartvig NV, Kaas A, Knudsen NN, Mardby AC, Hellman J.

Adolfsson P, Hartvig NV, Kaas A, Knudsen NN, Mardby AC, Moller JB, et al. Catrina S-B, Hartvig NV, Kaas A, Moller J, MÅRdby A-CM, Jendle JH.

Type 1 diabetes: Real-world insulin injection patterns [abstract ]. Paper presented at the Virtual EASD Annual Meeting, 21—25 Sep; Edwards SS, He X, Johnson J, Meadows E, Wang W, Wolpert H, et al.

Edwards SS, He X, Johnson J, Meadows ES, Wang W, Wolpert H, et al. Key differences with hypoglycaemic fear in people using insulin: the association with missed bolus doses exists for T2D, but not T1D.

Diabetologie und Stoffwechsel. Edwards SS, Johnson J, Howard W, He X, Kao CY, Meadows E, et al. Gomez-Peralta F, Abreu C, Gomez-Rodriguez S, Cruz-Bravo M, Alcarria E.

Insulclock: a novel insulin delivery optimization and tracking system. Gomez-Peralta F, Abreu C, Gomez-Rodriguez S, Ruiz L.

Hartvig NV, Hellman J, Kaas A, Knudsen NN, Mardby AC, Moller JB, et al. Improved insulin adherence after introduction of a smart connected insulin pen [abstract ]. Paper presented at the EASD Annual Meeting, 16—20 September; Barcelona, Spain. Hunt B, Ericsson Å, Gundgaard J, Møller JB, Valentine WJ, Jendle J.

Evaluating the long-term cost-effectiveness of introducing a smart insulin pen in standard-of-care treatment of type 1 diabetes in Sweden [abstract ]. Paper presented at the Virtual EASD Annual Meeting, 21—25 September; Jendle JH, Hartvig NV, Kaas A, Moller J. MÅRdby A-CM, Catrina S-B.

Kaas A, Hartvig NV, Hellman J, Knudsen NN, Mardby AC, Adolfsson P. Increased time in range observed after introduction of a connected insulin pen. Rodbard D, He X, Wang W, et al. Use of connected insulin pen to evaluate the effects of pre-meal, delayed, missed, and correction boluses on prandial glucose control in T1D and T2D.

Jendle J, Ericsson A, Gundgaard J, Moller JB, Valentine WJ, Hunt B. Smart insulin pens are associated with improved clinical outcomes at lower cost versus standard-of-care treatment of type 1 diabetes in Sweden: a cost-effectiveness analysis.

Diabetes Ther. Van de Sand L, Schildt J, Thun S. Health economic analysis of the telemedicine based ESYSTA®-System with a connected smart insulin pen — potential monetary savings from using an integrated diabetes management system. Dhruva SS, Ross JS, Desai NR. Real-world evidence: promise and peril for medical product evaluation.

Kerr D, King F, Klonoff DC. Digital health interventions for diabetes: everything to gain and nothing to lose. Diabetes Spectr. Sangave NA, Aungst TD, Patel DK. Smart connected insulin pens, caps, and attachments: a review of the future of diabetes technology.

Phillip M, Bergenstal RM, Close KL, Danne T, Garg SK, Heinemann L, et al. Download references. The authors acknowledge Rx Communications Mold, UK for medical writing assistance with the preparation of this manuscript, funded by Eli Lilly and Company.

This study was presented as a poster at ISPOR-EU Jamdade V, Liao B, Newson R. Systematic Literature Review of Clinical, Economic, and Patient-Reported Benefits of Connected Insulin Pen Systems. Value Health. All named authors meet the International Committee of Medial Journal Editors ICMJE criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Birong Liao has made substantial contributions to the study conception, the interpretation of data, and critical revision of the manuscript.

Rachel S. Newson has made substantial contributions to the study conception, the design of the work, the interpretation of data, the drafting and critical revision of the manuscript.

Vinayak Jamdade has made substantial contributions to the design of the work, the acquisition, analysis, and interpretation of data, the drafting and critical revision of the manuscript.

Iain Cranston has made substantial contributions to the study conception, the analysis and interpretation of data, and critical revision of the manuscript. Birong Liao and Rachel S. Newson are employees of Eli Lilly and Company and are shareholders in the company. Vinayak Jamdade is an employee of Eli Lilly and Company.

Academic Department of Endocrinology and Diabetes, Portsmouth Hospitals University NHS Trust, Portsmouth, UK. Eli Lilly and Company, 60 Margaret Street, Sydney, NSW, , Australia. You can also search for this author in PubMed Google Scholar. Correspondence to Rachel S.

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material.

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By Sheryl Huggins Salomon. Medically Reviewed. Kacy Church, MD. Injection Methods Benefits Jump to More Topics. They come in three distinct formats. Disposable Insulin Pens These come with prefilled insulin cartridges.

Reusable Insulin Pens These come with replaceable cartridges and are meant to last years. Administering Partial Units The ability to give half-unit doses is another exciting development, according to Bzowyckyj.

CGM Integration Isaacs is excited about upcoming developments that will allow dosing data from smart pens to be shared with continuous glucose monitors CGMs , such as a Freestyle Libre, Medtronic Guardian, and Dexcom G6.

Isaacs suggests asking your healthcare team the following questions to determine the best fit: What are my insulin delivery options?

What options will insurance cover? Would I benefit from having a dosing calculator to help calculate insulin doses? Would I benefit from a pen that helps keep track of all insulin doses?

Would I benefit from a pen that knows when a previous insulin dose is still working in my system? Editorial Sources and Fact-Checking. Resources Human Insulin Injection.

October 15, Diabetes: An Overview. Cleveland Clinic. March 28, Spending on Individuals With Type 1 Diabetes and the Role of Rapidly Increasing Insulin Prices [PDF].

Health Care Cost Institute. January Singh R, Samuel C, Jacob JJ. A Comparison of Insulin Pen Devices and Disposable Plastic Syringes — Simplicity, Safety, Convenience and Cost Differences.

European Endocrinology. April Ackermann RT, Wallia A, Kang R, et al. Comparative Effectiveness and Costs of Insulin Pump Therapy for Diabetes. The American Journal of Managed Care. June Insulin Pen Injections. August 8, How Much Does Insulin Cost? GoodRx Health.

January 26, Anderson BJ, Redondo MJ. What Can We Learn From Patient-Reported Outcomes of Insulin Pen Devices? Journal of Diabetes Science and Technology. November 1, Cefalu WT, Dawes DE, Gavlak G, et al. Insulin Access and Affordability Working Group: Conclusions and Recommendations.

Diabetes Care. Contributor Disclosures. Please read the Disclaimer at the end of this page. TYPE 2 DIABETES OVERVIEW. Type 2 diabetes mellitus is a disorder that is known for disrupting the way the body uses glucose sugar ; it also causes other problems with the way the body stores and processes other forms of energy, including fat.

All the cells in the body need glucose to work normally. Glucose gets into the cells with the help of a hormone called insulin. In type 2 diabetes, the body stops responding to normal or even high levels of insulin, and over time, the pancreas an organ in the abdomen does not make enough insulin to keep up with what the body needs.

Having excess body weight, especially with extra fat stored in the liver and abdomen, increases the body's demand for insulin. This causes glucose to build up in the blood, which can lead to problems if untreated. People with type 2 diabetes require regular monitoring and ongoing treatment to maintain goal blood sugar levels and, equally importantly, to manage other conditions that go along with diabetes.

Treatment includes lifestyle adjustments, self-care measures, and medications which may or may not include insulin ; combined, these approaches can help reduce the risk of complications. Learning to manage diabetes is a process that continues over a lifetime.

This topic review discusses the role of insulin treatment in controlling blood sugar for people with type 2 diabetes. Separate topic reviews about other aspects of type 2 diabetes are also available. See "Patient education: Type 2 diabetes: Overview Beyond the Basics " and "Patient education: Glucose monitoring in diabetes Beyond the Basics " and "Patient education: Hypoglycemia low blood glucose in people with diabetes Beyond the Basics " and "Patient education: Exercise and medical care for people with type 2 diabetes Beyond the Basics " and "Patient education: Preventing complications from diabetes Beyond the Basics " and "Patient education: Type 2 diabetes and diet Beyond the Basics ".

Keeping blood sugar levels under control is one way to decrease the risk of complications related to type 2 diabetes, particularly microvascular complications. Chronically high blood sugar can injure the small blood vessels of the eyes, kidneys, and nerves and lead to serious issues including blindness, kidney failure, foot ulcers requiring amputation, and sexual dysfunction in men.

Microvascular complications usually occur after a person has had diabetes for many years, and they are related to elevated levels of blood sugar over time. However, in some cases eg, if a person has already had diabetes for a long time before they seek medical care , these complications may be present at the time of initial diagnosis.

The most common complication of type 2 diabetes is cardiovascular heart disease, also known as macrovascular disease "macro" means large, ie, affecting the large blood vessels. Heart disease increases a person's risk of heart attack and death.

There are many ways to lower the risk of heart disease, including lifestyle changes such as avoiding smoking, eating a healthy diet, exercising regularly, and maintaining a healthy weight and medications to control blood pressure and cholesterol, if needed.

Specific diabetes drugs also help reduce the risk of cardiovascular disease in people with or at high risk for cardiovascular disease. See "Patient education: Preventing complications from diabetes Beyond the Basics ". Monitoring — Many people with type 2 diabetes need to check their blood sugar regularly.

This is especially important for people who use insulin or other medications that can lower blood sugar levels too much.

That's because while high blood sugar hyper glycemia can lead to complications, having a blood sugar level that is too low hypo glycemia can also cause problems.

See "Patient education: Glucose monitoring in diabetes Beyond the Basics ". Overall blood sugar management is often measured by checking the level before the first meal of the day fasting. Your health care provider can work with you to determine what your goal should be.

The frequency of testing and blood sugar goals can change over time, so it's important to see your health care provider regularly. See 'How often to see your provider' below. Blood sugar control can also be measured with a blood test called A1C, also called HbA1c.

The A1C blood test is an indicator of your average blood sugar level over the past two to three months. Knowing your average level can be useful as blood sugar levels can fluctuate throughout the day depending on your diet and activity level. The A1C test involves having a blood sample taken either from a vein or through a finger prick in a doctor's office for testing.

However, different people have different goals for their A1C level. For example, people who are older or have several other medical conditions might have a slightly higher goal. Your health care provider will work with you to understand your A1C goal.

The A1C measures the amount of blood sugar that is stuck to hemoglobin, a molecule in red blood cells. Sometimes, the A1C cannot accurately measure average blood sugar; this can be due to conditions that affect red blood cells or normal variations in how long the red blood cells last in the body.

If your health care provider suspects that your A1C results are inaccurate, they may use other methods to measure your blood sugar level. How often to see your provider — Most people with type 2 diabetes meet with their health care provider every three to four months.

At these visits, you will discuss your blood sugar and other care goals and how you are managing your diabetes, including your medications.

This allows you and your provider to work together to fine-tune your care plan and keep you as healthy as possible.

STARTING INSULIN. Most people who are newly diagnosed with type 2 diabetes begin initial treatment with a combination of diet, exercise, and an oral pill or tablet medication. Over time, some people will need to add insulin or another injectable medication because their blood sugar levels are not well managed with oral medication.

In some cases, insulin or another injectable medication is recommended first, as initial treatment. Your health care provider will talk to you about your options and goals, and work with you to make a treatment plan.

Types of insulin — There are several types of insulin. These types are classified according to how quickly the insulin begins to work and how long it remains active in the body:.

One form of inhaled insulin brand name: Afrezza is available in the United States. Inhaled insulin has not been shown to lower A1C levels to the usual target level of less than 7 percent in most studies. In addition, lung function testing is required before starting it and periodically during therapy.

For these reasons, inhaled insulin has not been used widely. Initial insulin dose — When insulin is started for type 2 diabetes, health care providers usually recommend "basal" insulin; this means taking intermediate-acting or long-acting forms of insulin to keep blood sugar controlled overnight and throughout the day.

Basal insulin is usually given once per day, either in the morning or at bedtime. Basal insulin is usually started at a low dose 10 to 20 units and then increased gradually to determine the right dose for an individual.

Using a combination of treatments ie, an oral medication plus insulin generally lowers the dose of insulin compared with taking insulin only. Since insulin can cause weight gain, combination therapy may reduce the risk of weight gain. Your health care provider will work with you to monitor your body's response and adjust the dose over time.

Adjusting insulin dose over time — To determine how and when to adjust your once-daily insulin dose, you will need to check your blood sugar levels. This is usually done with a home glucose meter in the morning before eating. If the value is consistently higher than your fasting blood sugar goal, and you do not have episodes of low blood sugar especially overnight , your provider may recommend increasing your insulin dose.

If the basal once-daily insulin regimen is still not adequately controlling your blood sugar levels, your health care provider might recommend giving two or more insulin injections each day. Being diagnosed with a new medical problem or starting a new medication can also change the body's needs for insulin, sometimes requiring a change in diabetes treatment.

For example, when a person with type 2 diabetes takes steroids eg, prednisone for an asthma attack or other reasons, the blood sugar levels increase. This usually requires temporarily increasing the dose of insulin. Type 2 diabetes typically progresses over time, causing the body to produce less insulin.

Some people will need a more complex insulin regimen. In this situation, a pre-meal prandial dose of rapid-acting or short-acting insulin is added to the basal insulin.

As a first step, prandial insulin may be started as a single injection before the largest meal of the day, but your health care provider might suggest another approach. The dose of short-acting or rapid-acting insulin is adjusted immediately prior to a meal; the dose needed depends on many different factors, including your current and goal blood sugar levels, the carbohydrate content of the meal, and your activity level.

People with type 2 diabetes are occasionally treated with "intensive" insulin regimens. Intensive insulin treatment requires multiple injections of insulin per day or the use of an insulin pump. It also requires measuring blood sugar levels several times a day, with adjustment of pre-meal insulin dosing based on the size and carbohydrate content of the meal.

This approach is more commonly used in people with type 1 diabetes, and it is discussed in greater detail in a separate topic review. See "Patient education: Type 1 diabetes: Insulin treatment Beyond the Basics ", section on 'Intensive insulin treatment'.

INJECTING INSULIN. Insulin cannot be taken in pill form.

The Institute for Safe Medication Practices ISMP Hypoglycemia and insulin pens Medication Errors Reporting Program MERP has received Carbs and exercise performance reports Penss patients who failed to Hypoglycemiaa the inner cover isnulin a standard insulin pen needle prior to attempting to administer the insulin. The latest event resulted in a fatality. A recently hospitalized patient with type 1 diabetes did not know to remove the standard needle cover from the insulin pen needle prior to administration. She was unaware that she was using the pen incorrectly and, thus, had not been receiving any of the insulin doses. The patient developed diabetic ketoacidosis and later died.

Hypoglycemia and insulin pens -

Used needles and syringes should not be included with regular household trash but should instead be placed in a puncture-proof container also known as a sharps container , available from most pharmacies or hospital supply stores.

Alternatively, a puncture-proof container such as an old liquid laundry detergent bottle, which can be closed with a screw cap, can be used. Check your local rules concerning disposal of these containers.

Injecting through clothing — Some people wonder about the safety of injecting insulin through their clothing. While it may be possible to do this, it's best to seek guidance from your health care provider if you are interested in using this technique.

Inhaled insulin — One formulation of inhaled insulin brand name: Afrezza is available for clinical use in the United States.

Once inhaled, it begins to work quickly, similar to rapid-acting insulin, and is therefore considered a prandial mealtime insulin. Inhaled insulin has not been shown to lower glycated hemoglobin A1C levels to the usual target level of less than 7 percent in most studies. In addition, lung function testing is required before starting it and periodically during therapy.

Insulin pump. General principles — Insulin can be continuously administered by an insulin pump, rather than through multiple daily injections with a pen injector or needle and syringe.

An insulin pump may be recommended based on your preference and willingness and ability to use it. The pump stores rapid-acting insulin in a cartridge. Pumps are programmed to give a small dose of rapid-acting insulin every few minutes through the day and night basal insulin. Before a meal, the pump needs to deliver a larger dose bolus of insulin, to prevent your blood sugar level from going too high after eating.

Most pumps deliver insulin through a long spaghetti-like catheter, the end of which you insert under the skin. The catheter is taken out and re-inserted approximately every two to three days.

You will be taught how to do this relatively painless and quick procedure. Other pumps are entirely self-contained, with a small catheter built right into the small, disposable pump unit that needs to be replaced every few days.

For these "patch" pumps, insulin delivery is controlled by another device or compatible smartphone that you need to carry with you. The pump can be taken off for up to one hour without impacting blood sugar control; if it is taken off for longer periods of time, insulin injections may be needed to control the blood sugar.

If available and affordable, people using multiple daily insulin injections or an insulin pump generally use a continuous glucose monitoring CGM device, which provides more information about blood sugar levels than traditional fingersticks and a glucose meter.

These devices allow you to make better informed decisions about insulin dosing based on your blood sugar trends. If you do not use CGM, you may need to check your blood sugar levels four to seven times daily before meals, bedtime, sometimes two to three hours after meals, and occasionally in the middle of the night while your doses are being adjusted.

In addition, testing is recommended when low blood sugar is suspected; before, during, and after exercise; and before driving or engaging in a dangerous activity. After doses are programmed initially in the pump, testing at least four times per day, including before meals, is required as you must direct the pump to give pre-meal insulin based upon your blood sugar level and amount and type of food you plan to eat.

If insulin injection therapy is used, the pre-meal blood sugar and anticipated food intake are also used to help calculate the mealtime insulin dose injected.

Some insulin pumps communicate with CGMs, receiving glucose readings every five minutes. They can automatically adjust the basal rate of insulin delivery and deliver extra insulin to help correct for high blood sugars depending on the CGM results called a partial "artificial pancreas," "automated insulin delivery" [AID], or "hybrid closed-loop" system figure 5.

These devices can improve or maintain glucose control with less risk of hypoglycemia low blood sugar. The following devices, combining an insulin pump with CGM, are available or will become available in the future:. The insulin pump can be programmed to stop insulin delivery for up to two hours at a preset glucose value "low glucose suspend" feature or to reduce or stop insulin infusion if the system "predicts" that your blood sugar will soon go too low "predictive low glucose suspend" feature.

These features reduce the frequency and duration of hypoglycemia that may occur while you are sleeping. Some systems will also deliver extra insulin to help correct for hyperglycemia high blood sugar when there is insufficient insulin on board.

You need to manually direct delivery of insulin doses prior to meals. Use of these systems has been associated with less hypoglycemia low blood sugar and more blood sugar readings in the target range.

An investigational bihormonal system uses two commercially available pumps, with one delivering insulin and the other glucagon. These systems are also fully automated, in that the delivery of the insulin and glucagon is determined completely automatically by an algorithm that is, in turn, dependent on CGM results.

These devices have not yet been approved and are not commercially available. The insulin pump has advantages and disadvantages; it may be helpful to talk with a person who uses a pump before deciding to try it. Most pump manufacturers have a list of people willing to speak with prospective pump users.

It may also be possible to use a trial pump for a few days before committing to it. Advantages — Insulin pumps have the advantage of increasing flexibility in the timing of meals and other day-to-day events.

This can be of great benefit for children or adults whose schedule varies from one day to the next. People who use an insulin pump do not require multiple daily injections; most people who use the pump change their injection insulin infusion site every 48 to 72 hours.

Another major advantage of an insulin pump is that there is less variation in the amount of insulin absorbed compared with when insulin is given with a needle and syringe or pen.

This can help reduce day-to-day variations in blood sugar levels. Insulin pumps can deliver smaller amounts of insulin at a time than injection therapy. The greatest advantage is for people with type 1 diabetes having blood glucose readings that are too low hypoglycemia and too high hyperglycemia.

The use of an insulin pump with CGM in an automated system can help reduce hypoglycemia and increase time in the target range. Disadvantages — The cost of an insulin pump and supplies is greater than the cost of insulin syringes and needles or pens, although most insurance carriers cover some portion of the expenses.

Some people develop pump-associated problems, including skin irritation or infection at the infusion site or pump malfunction.

You must take care to monitor your blood sugar levels carefully; stopping insulin, even for a short time, can lead to a significant increase in blood sugar.

Some people find the pump awkward, unpleasant, or embarrassing although others find that they are able to adjust to it fairly easily. However, you can disconnect the pump for brief periods, if desired. FACTORS AFFECTING INSULIN ACTION. Dose of insulin injected — The dose of insulin injected affects the rate at which your body absorbs it.

For example, larger doses of insulin may be absorbed more slowly than a small dose. With larger doses of insulin, the insulin may peak later or last longer than with small doses.

This could mean that your blood sugar level is higher than expected within a few hours after eating but then becomes low. Injection technique — In general, we recommend the use of short insulin needles 4 or 5 mm to minimize tissue damage and reduce the likelihood of inadvertently injecting into muscle.

The angle and depth of an insulin injection are important, as mentioned above. See 'Needle and syringe' above. Site of injection — Clinicians usually recommend changing your injection site to minimize tissue irritation.

However, it is important to keep in mind that insulin is absorbed at different rates in different areas of the body. For some types of insulin, the insulin is absorbed fastest from the abdominal area, slowest from the leg and buttock, and at an intermediate rate from the arm.

This may vary with the amount of fat under the skin; the more fat, the more slowly insulin is absorbed figure 2. Because of variations in absorption, it is reasonable to use the same general area for injections at a particular time of the day.

Pre-meal insulin injections are absorbed fastest from the abdominal area, allowing for optimal coverage of carbohydrates consumed in a meal. Injection into the thigh or buttock may be best for the evening dose because the insulin will be absorbed more slowly during the night.

Subcutaneous blood flow — Any factor that alters the rate of blood flow to the body's tissues will alter insulin absorption. Smoking decreases blood flow to the tissues and decreases absorption of injected insulin, whereas running increases blood flow to the lower body, speeding up absorption of insulin injected into a leg.

Factors that increase the skin temperature such as exercise, saunas, hot baths, and massage of the injection site will also increase insulin absorption.

Time since opening the insulin bottle or pen — In general, insulin bottles vials , pens, and pen cartridges are good until their expirations date, if left unopened in a refrigerator. Insulin should never be allowed to freeze or get hot. Once an insulin bottle vial is opened, it should be kept at room temperature or in the refrigerator for 28 to 30 days and then discarded.

After a month, the potency begins to decrease. This can be a problem for people who require very small doses of insulin, for whom a bottle might last two months or more. In general, it is advisable to open a new bottle at least every 30 days, even if there is insulin left in the old bottle.

However, a few types of insulin can be used for up to 42 days, so check with your pharmacist or health care provider. For insulin pen devices, it is acceptable to keep the pen injector unrefrigerated in a bag or jacket pocket for varying amounts of time, depending upon the type of pen.

Most opened insulin pens can be used for either 10, 14, or 28 days, but there are some pens that can be used for 42 or 56 days, depending upon the type of insulin in the pen. Be sure you know how long your type of insulin pen is safe to use after opening.

Individual factors — The same dose of the same type of insulin may have different effects in different people with diabetes. Some trial and error is usually necessary to find the ideal type s and dose of insulin and schedule for each person. Several special situations can complicate insulin treatment.

Already prescribing NovoLog ®? Consider another option. Important Safety Information. NovoLog ® is contraindicated during episodes of hypoglycemia and in patients hypersensitive to NovoLog ® or one of its excipients. Warnings and Precautions.

Never Share a NovoLog ® FlexPen, NovoLog ® FlexTouch, PenFill ® Cartridge, or PenFill ® Cartridge Device Between Patients, even if the needle is changed.

Patients using NovoLog ® vials must never share needles or syringes with another person. Sharing poses a risk for transmission of blood-borne pathogens.

Hyperglycemia or Hypoglycemia with Changes in Insulin Regimen: Changes in an insulin regimen e. Repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis have been reported to result in hyperglycemia; and a sudden change in the injection site to an unaffected area has been reported to result in hypoglycemia.

Advise patients who have repeatedly injected into areas of lipodystrophy or localized cutaneous amyloidosis to change the injection site to unaffected areas and closely monitor for hypoglycemia. Adjustments in concomitant anti-diabetic treatment may be needed.

Hypoglycemia: Hypoglycemia is the most common adverse effect of all insulins, including NovoLog ®. Severe hypoglycemia can cause seizures, may lead to unconsciousness, may be life threatening or cause death.

Hypoglycemia can impair concentration ability and reaction time; this may place an individual and others at risk in situations where these abilities are important e. Hypoglycemia can happen suddenly and symptoms may differ in each individual and change over time in the same individual.

Symptomatic awareness of hypoglycemia may be less pronounced in patients with longstanding diabetes in patients with diabetic nerve disease, in patients using medications that block the sympathetic nervous system e.

Risk Factors for Hypoglycemia: The risk of hypoglycemia after an injection is related to the duration of action of the insulin and, in general, is highest when the glucose lowering effect of the insulin is maximal. People with type 1 or type 2 diabetes on multiple daily injections of long or short acting insulin may benefit from a smart insulin pen.

If you use an insulin pump, you may consider an insulin pen as a back-up delivery option. Your diabetes care team can help you find out if a smart insulin pen is a good choice for you and whether your insurance or Medicare will cover it. Some manufacturers offer co-pay assistance to make the device more affordable.

There are a few brands of smart insulin pens available now, and more are in development. Once available only from manufacturers, smart pens are now sold in pharmacies across the country.

If new technology is sometimes hard for you to get used to, you can get help from your diabetes care team. The first insulin pen devices were introduced in the late s as an alternative to vials and syringes.

They allowed for more accurate dosing, better adherence, and less injection site pain. As these devices evolved, they gained digital displays and memory of the most recent insulin doses. Glucose sensing, continuous glucose monitoring, dosage timing, reminders, and other advancements followed.

The first Food and Drug Administration FDA —cleared reusable smart insulin pen was launched in

Vegan athlete shopping list smart Hypoglycemia and insulin pens pen is a anx injector pen with an intuitive smartphone app inaulin can help people with Protein synthesis after workouts better manage insulin delivery. Insulih smart system calculates and tracks Protein synthesis after workouts and provides helpful reminders, alerts, and reports. They can come in the form of an add-on to your current insulin pen or a reusable form which uses prefilled cartridges instead of vials or disposable pens. Smart insulin pens are a rapidly growing market. Because they are typically more affordable, easy to use, and offer many benefits and improvements for people who depend upon insulin to manage their diabetes. Many people with diabetes have a hard time correctly calculating insulin doses.

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The needle is Thermogenic workout for beginners throughout the process so the patient will never see insilin. The Autocover safety needle system is different from standard insulin pen needles widely used by patients in the home, which do not employ an automatic needle shield.

These standard needles are available from brand and generic manufacturers. Because standard pen needles and those with an automatic needle shield may look similar, patients may not be aware of the differences in preparation for administration.

Both the automatic safety needle and standard needle systems have a larger outer protective cover that, when removed, exposes either a retractable needle shield Figure 1 or a plain inner needle cover Figure 2. The automatic safety needle shield is not intended to be removed prior to injection, but the inner needle cover on the standard needle system must be removed before the injection to allow the administration of insulin.

Patients using insulin pens with automatic needle retraction devices while hospitalized, but who will be using standard pen needles at home, must be made aware that the standard needle is different. It is imperative that removal of BOTH covers is explained to patients during diabetes education.

If no insulin appears after two or three attempts, the needle should be tightened or changed until a drop of insulin appears. If a patient continues to see no drops, they might have failed to remove the inner needle cover and will likely bypass this step prior to injection.

Healthcare organizations, practitioners, and patients using these products should take steps to safeguard against incorrect use of pen needles. Consider the following:.

Teach all patients receiving an insulin pen how to use it properly, and require a return demonstration to verify understanding. Verify which pen needle the patient will be using at home, and tailor the training to that needle.

One hospital that reported an event to ISMP has changed to using standard non-safety needles when training patients prior to discharge to make sure they know how to administer insulin with the same pen and needle they will use at home.

A community pharmacist should verify that the patient understands the appropriate administration technique whenever pens and insulin needles are dispensed.

A request to conduct this verification at the point of dispensing could be entered in the notes section of an electronic prescription or included on handwritten prescriptions. Ask patients to question the pharmacist if the pen needle is different than what they expect or what they have been taught to use.

To determine whether it is due to a problem with the injection technique or if a dose adjustment is needed, remind patients to consult a member of their healthcare team if blood glucose levels are elevated after insulin injection. Review the injection technique with the patient if faulty technique is suspected due to poorly controlled blood glucose levels.

Manufacturers of standard pen needles should include clear warnings about removing both covers in the instructions for use as well as on outer cartons.

The US Food and Drug Administration FDA Center for Devices and Radiological Health is aware of reported errors. NAN Alerts Severe Hyperglycemia in Patients Incorrectly Using Insulin Pens at Home. Consider the following: Teach all patients receiving an insulin pen how to use it properly, and require a return demonstration to verify understanding.

NAN Alert October Potassium Chloride for Injection Concentrate in EXCEL Plastic Bags. Medication Safety Issues with Newly Authorized PAXLOVID.

: Hypoglycemia and insulin pens

Severe Hyperglycemia in Patients Incorrectly Using Insulin Pens at Home

However, considering the participants were elderly, with a high prevalence of chronic complications, strict glycemic control could bring more risks [ 5 , 6 ] and additionally in this study we did not have a target to reach.

The occurrence of hypoglycemia cannot be neglected. With advancing age, the number of episodes seems to increase, regardless of glycemic control [ 12 ].

We did not detect a difference in relation to the occurrence of hypoglycemia. High levels of HbA1c along the follow-up may contributed to the low frequency of hypoglycemia in both groups.

Another factor that limited this analysis was the way of measuring hypoglycemia. The episodes were computed if recorded by patients. Unrecorded episodes could not be confirmed.

Due to the small number of episodes, the presence of nocturnal, asymptomatic and severe hypoglycemia, we could only assess if the patient reported or not during the last month.

There was no possibility of quantifying the number of severe, asymptomatic and nocturnal hypoglycemia episodes. In relation to the evaluation of adherence, we were careful to accurately measure the number of insulin units used in each visit. The method used ensures that we find the closest value to the amount of insulin used in the previous month.

Therefore, the degree of adhesion found in our study seems precise. Unlike patients with recent insulin use [ 4 ], method of application seems did not have much influence among patients using insulin for several years.

Although there is no difference between groups, there was a tendency to be more adherent during the course of the study in both groups and our results were similar to other studies [ 5 , 7 , 12 , 13 , 14 , 15 ].

Training to use insulin in addition to frequent adjustments of insulin doses, may have contributed to this result. In association with the reduction of HbA1c, there was an increase in the amount of insulin used per kilo. We realize that the more frequent follow-up monthly medical visits in search of the glycemic target contributed to this result.

At each visit, participants performed capillary blood glucose tests. Based on these notes, the researcher adjusted the dose of insulin. The low number of hypoglycemic episodes enabled us to increase insulin doses almost every visit.

In addition, the apparent increase in PG may have been influenced by the ease of use of the method. Even without the blinded evaluator, we used a pre-defined protocol in both groups for treatment adjustment.

However, there was an increase of 0. These values appear not to have clinical significance, but should be considered. In the Brazilian Public Health System, patients depend on free medication.

In general, only metformin and sulfonylureas are available as oral drugs. For this reason, insulin is introduced into the treatment prior to prescribing other oral third class medication. In selected cases, even with metformin alone, insulin prescription is required to achieve satisfactory glycemic control.

Either way, ADA [ 2 ] recommends the use of NPH and Regular insulin in developing countries, when the financial condition does not favor other treatment.

We chose not to include patients in the use of insulin analogues for this reason. This study allows us to assess the reality of patients with diabetes in our country. Recently, the use of insulin pens has been approved in Public Health System, which may also aid in treatment. Regarding the measurement of capillary glycemia, there is no consensus in the literature on the recommendation of frequency or effect among patients with T2D using insulin [ 16 , 17 , 18 ].

However, it is expected that for the proper adjustment of doses, this strategy will be present. However, it is not available to all patients in Brazil.

In addition, access to public health care is a limiting factor in the Brazilian reality. Patients have specialist appointments every 4 to 6 months, with less frequent treatment adjustments than optimal to achieve satisfactory glycemic levels.

The greatest difficulty in relation to the assessment of Quality of Life and the impact of the disease was the interpretation of the questionnaires. Some of the patients had no perception of poor disease control and, for that reason, they responded as being satisfied with their health conditions.

In a previous study, although patients had inadequate glycemic control, there was no perception of obstacles to treatment or understanding of the disease. Informally, patients who used pens appeared more satisfied throughout the study, but this was not reflected in the questionnaires.

One of the probable reasons for this difference not being found is due to the small number of participants. In future studies, this assessment may be better understood. Despite the difficulties encountered, these questionnaires are validated for use in Brazil.

All participants were able to answer completely. Our main limitation was not to have blindness of the evaluators. Despite the use of care protocol to minimize the influence of this lack, there may have been influence on patient care and insulin doses.

We chose not to blind the evaluator to ensure that all patients were treated, face to face, by the same investigator. The blinding of the researcher who made the treatment adjustment could harm the patient's medical relationship.

Another limitation was the difficulty that some patients had to perform Self-monitoring of Blood Glucose due to visual or cognitive problems.

In some cases, treatment adjustment was delayed. Some patients also had difficulty using their pens at first. However, at all visits the application technique was reviewed in both groups. Independently, patients who were not able to self-administer insulin were excluded before the intervention started.

Regarding randomization, the initial treatment regimen was not stratified. However, the groups were quite similar, mainly in relation to the use of insulin and classes of oral antihyperglycemic agents. Regarding the statistical analysis, both groups showed similar results in absolute values of HbA1c in each evaluation.

The large SD of the sample represents great variability, even with normal distribution, and small sample, despite the statistical power achieved with the calculated sample size. If the sample were larger, the SD could be reduced and even with a statistical difference found between the groups.

The greatest reduction in PG was only in the delta of HbA1c reduction. Few patients had not used insulin prior to the study. Analyzes without these patients were like results presented. Another limitation was the need to use a fixed protocol to adjust insulin doses. This option was taken to minimize the effect of the lack of blinding by the evaluators.

The progressive increase in insulin doses was similar among patients, regardless of whether the glycemia value was higher or closer to the target. Thus, perhaps patients with less control needed more time to achieve blood glucose levels close to those desired. Comparing the use of pens with syringes to apply insulin among elderly patients with type 2 DM, we found no difference regarding the frequency of hypoglycemia, the need for higher doses of insulin or other medications.

There was also no impact on Quality of Life. In both groups there was a reduction in HbA1c values in 24 weeks of follow-up, however with an absolute greater reduction in the group that used pens. International Diabetes Federation.

IDF Diabetes Atlas. Brussels, Belgium: International Diabetes Federation; American Diabetes Association. Standards of medical care in diabetes— Diabetes Care. Google Scholar. Bermeo-Cabrera J, Almeda-Valdes P, Riofrios-Palacios J, Aguilar-Salinas CA, Mehta R. Insulin adherence in type 2 diabetes in Mexico: behaviors and barriers.

J Diabetes Res. Article PubMed PubMed Central Google Scholar. Slabaugh SL, Bouchard JR, Li Y, Baltz JC, Yunus Meah YA, MoretzHindawi DC. Adv Ther. Article CAS Google Scholar.

Chandran A, Bonafede MK, Nigam S, Saltiel-Berzin R, Hirsch LJ, Lahue BJ. Adherence to insulin pen therapy is associated with reduction in healthcare costs among patients with type 2 diabetes mellitus. Am Health Drug Benefits. PubMed PubMed Central Google Scholar. Ramadanm WH, Khreis NA, Kabbara WK.

Patient Prefer Adherence. Article Google Scholar. Cheen HHMV, Lim SH, Huang MC, Bee YM, Wee HL. Clin Ther. Article PubMed Google Scholar. Lasalvia P, Barahona-Correa JE, Romero-Alvernia DM, Gil-Tamayo S, Castañeda-Cardona C, Bayona JG, Juan José Triana JJ, Laserna AF, Mejía-Torres M, Restrepo-Jimenez P, Jimenez-Zapata J, Rosselli D.

Pen devices for insulin self-administration compared with needle and vial: systematic review of the literature and meta-analysis.

J Diabetes Sci Technol. Machry RV, Pedroso HU, Vasconcellos LS, Nunes RR, Evaldt CA, Yunes Filho EB, Rodrigues TC. Multifactorial intervention for diabetes control among older users of insulin.

Rev Saude Publica. Gross CC, Scain SF, Scheffel R, Gross JL, Hutz CS. Brazilian version of the Problem Areas in Diabetes Scale B-PAID : validation and identification of individuals at high risk for emotional distress.

Diabetes Res Clin Pract. Correr CJ, Pontarolo R, Melchiors AC, Rossignoli P, Fernández-Llimós F, Radominski RB. Tradução para o Português e validação do instrumento diabetes quality of life measure DQOL-Brasil.

Arq Bras Endocrinol Metab. Pawaskar MD, Camacho FT, Anderson RT, Cobden D, Joshi AV, Balkrishnan. Health care costs and medication adherence associated with initiation of insulin pen therapy in Medicaid-enrolled patients with type 2 diabetes: a retrospective database analysis. Peyrot M, Barnett AH, Meneghini LF, Schumm-Draeger PM.

Diabetes Obes Metab. Article CAS PubMed Google Scholar. Roberts AW, Crisp GD, Esserman DA, Roth MT, Weinberger M, Farley JF. Patterns of medication adherence and health care utilization among patients with chronic disease who were enrolled in a pharmacy assistance program.

NC Med J. Donnelly LA, Morris AD, Evans JMM. Adherence to insulin and its association with glycaemic control in patients with type 2 diabetes. CGM Integration Isaacs is excited about upcoming developments that will allow dosing data from smart pens to be shared with continuous glucose monitors CGMs , such as a Freestyle Libre, Medtronic Guardian, and Dexcom G6.

Isaacs suggests asking your healthcare team the following questions to determine the best fit: What are my insulin delivery options? What options will insurance cover? Would I benefit from having a dosing calculator to help calculate insulin doses?

Would I benefit from a pen that helps keep track of all insulin doses? Would I benefit from a pen that knows when a previous insulin dose is still working in my system?

Editorial Sources and Fact-Checking. Resources Human Insulin Injection. October 15, Diabetes: An Overview.

Cleveland Clinic. March 28, Spending on Individuals With Type 1 Diabetes and the Role of Rapidly Increasing Insulin Prices [PDF]. Health Care Cost Institute. January Singh R, Samuel C, Jacob JJ. A Comparison of Insulin Pen Devices and Disposable Plastic Syringes — Simplicity, Safety, Convenience and Cost Differences.

European Endocrinology. April Ackermann RT, Wallia A, Kang R, et al. Comparative Effectiveness and Costs of Insulin Pump Therapy for Diabetes. The American Journal of Managed Care. June Insulin Pen Injections. August 8, How Much Does Insulin Cost?

GoodRx Health. January 26, Anderson BJ, Redondo MJ. What Can We Learn From Patient-Reported Outcomes of Insulin Pen Devices? Journal of Diabetes Science and Technology. November 1, Cefalu WT, Dawes DE, Gavlak G, et al. Insulin Access and Affordability Working Group: Conclusions and Recommendations.

Diabetes Care. McAdams BH, Rizvi AA. An Overview of Insulin Pumps and Glucose Sensors for the Generalist. Journal of Clinical Medicine. January 4, Shah RB, Patel M, Maahs DM, Shah VN. Insulin Delivery Methods: Past, Present, and Future. International Journal of Pharmaceutical Investigation.

January-March Pawaskar MD, Camacho FT, Anderson RT, et al. Health Care Costs and Medication Adherence Associated With Initiation of Insulin Pen Therapy in Medicaid-Enrolled Patients With Type 2 Diabetes: A Retrospective Database Analysis.

Clinical Therapeutics. Lamos EM, Younk LM, Davis SN. Concentrated Insulins: the New Basal Insulins. Therapeutics and Clinical Risk Management. March 9, If you live in a state that has a glucagon standing order, you can get it at your local pharmacy.

Gvoke [prescribing information]. Chicago, IL: Xeris Pharmaceuticals, Inc. Valentine V, Newswanger B, Prestrelski S, Andre AD, Garibaldi M. Human factors usability and validation studies of a glucagon autoinjector in a simulated severe hypoglycemia rescue situation. Diabetes Technol Ther.

McCall AL, Lieb DC, Gianchandani R, et al. Management of individuals with diabetes at high risk for hypoglycemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. GVOKE is a prescription medicine used to treat very low blood sugar severe hypoglycemia in adults and kids with diabetes ages 2 years and above.

It is not known if GVOKE is safe and effective in children under 2 years of age. High blood pressure GVOKE can cause high blood pressure in certain people with tumors in their adrenal glands. Low blood sugar GVOKE can cause low blood sugar in certain people with tumors in their pancreas called insulinomas by making too much insulin in their bodies.

Serious allergic reaction Call your doctor or get medical help right away if you have a serious allergic reaction including:. These are not all the possible side effects of GVOKE. For more information, ask your doctor.

Call your doctor for medical advice about side effects. You are encouraged to report side effects of prescription drugs to the FDA. Visit www. Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.

For more information, call or go to www. Please see the Full Prescribing Information for Gvoke. We use cookies to help personalize your experience. For more information on how we use cookies and similar technologies, and how you can change your settings, please see our Privacy Policy.

Important Safety Information. Safety Information Prescribing Information Full Prescribing Information Patient Package Insert — English Patient Package Insert — Español. Gvoke HypoPen Gvoke PFS Gvoke Kit. For Patients. For Healthcare Providers. Instagram icon Facebook icon Twitter icon.

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Insulin Pens for Diabetes: A Complete Scientific Guide Meta-analysis of individual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes. Sometimes, the A1C cannot accurately measure average blood sugar; this can be due to conditions that affect red blood cells or normal variations in how long the red blood cells last in the body. How often to see your provider — Most people with type 2 diabetes meet with their health care provider every three to four months. All topics are updated as new evidence becomes available and our peer review process is complete. However, the groups were quite similar, mainly in relation to the use of insulin and classes of oral antihyperglycemic agents. Patient education: Type 1 diabetes: Overview Beyond the Basics Patient education: Glucose monitoring in diabetes Beyond the Basics Patient education: Type 1 diabetes and diet Beyond the Basics Patient education: Hypoglycemia low blood glucose in people with diabetes Beyond the Basics Patient education: Care during pregnancy for patients with type 1 or 2 diabetes Beyond the Basics Patient education: General travel advice Beyond the Basics Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. The Basics Patient education: Managing blood sugar in children with diabetes The Basics Patient education: Managing diabetes in school The Basics Patient education: Giving your child insulin The Basics Patient education: Checking your child's blood sugar level The Basics Patient education: Carb counting for children with diabetes The Basics Patient education: Diabetic ketoacidosis The Basics.
The Benefits of Using an Insulin Pen to Manage Diabetes

A manual search was performed for literature related to outcome-based contracts, local intervention-specific gray literature, and presentations at local encore conferences. In these analyses, gray literature was defined as any literature in the public domain that was presented outside of peer-reviewed conferences or journals.

Data from unpublished clinical trials sponsored by Eli Lilly and Co. were also included. An English language restriction was not applied to the gray literature. Population, Intervention, Comparator, Outcomes, Time frame, Study design PICOTS outline was generally followed to select relevant studies for inclusion in this systematic literature review.

Limits were not imposed on the type of devices so that the range of options available to study participants could be considered. Studies were included regardless of the comparator system or device connected, nonconnected, or no comparator.

Outcomes of interest included clinical outcomes HbA1c, postprandial blood glucose, glycemic control, continuous glucose monitoring [CGM] outcomes, hypoglycemic events, insulin dose and missed doses, and long-term cardiovascular events , economic outcomes direct and indirect costs and health care resource utilization , and patient-reported outcomes PROs; QoL, utility, satisfaction, preference and empowerment, self-efficacy, and distress of the person with diabetes.

Other outcomes included outcome-based contracts, adherence, health care provider preference or satisfaction, diabetes management, and attitudes toward technology. The DistillerSR tool Evidence Partners, Ottawa, Canada was used for the screening process.

DistillerSR is cloud-based literature review software, which manages the citations throughout the review. Screening consisted of an abstract review and a full-text review. Once citations were uploaded to DistillerSR, titles and abstracts were reviewed by two independent reviewers based on the eligibility criteria, with any conflicts resolved using a third independent reviewer.

All citations included at the end of the abstract review were retained and downloaded for full-text review. Two independent reviewers assessed the full text against the eligibility criteria, using the same method for resolving reviewer conflict as for the abstract review.

All publications included after the completion of the full-text review were retained for data extraction. The data extraction forms in DistillerSR were used for data extraction. For each included study, one reviewer entered the study design, characteristics of the people with diabetes, and outcomes of interest into the data extraction form in DistillerSR.

The data were exported in Microsoft Excel for storage. Data extraction was quality checked by an independent reviewer. Study quality was assessed for randomized controlled trials RCTs and cohort studies only.

RCTs were assessed using the NICE quality assessment checklist, which considers factors including randomization, blinding, similarity of baseline characteristics between groups, imbalances in study discontinuations, and the type of analysis [ 25 ].

Cohort studies were assessed using the Newcastle-Ottawa Scale [ 26 ]. Three factors were considered to score the quality of the included studies: selection; comparability; outcomes assessment.

Since this analysis did not include a network meta-analysis, no formal assessment of bias was performed. Comments on bias in publications describing real-world studies were noted.

The original and updated database searches identified a total of publications of connection-enabled insulin platforms and their comparators, while the searches of conference proceedings identified 12 relevant conference abstracts Fig. Of these, were retained for full-text screening; were excluded, leaving 25 for inclusion.

The gray literature search identified one report of interest [ 27 ]. Therefore, the final number of publications included was 26, representing 10 unique studies Fig. PRISMA flow diagram of study selection. PRISMA Preferred Reporting Items for Systematic Reviews and Meta-analyses, RCT randomized controlled trial.

One clinicaltrials. gov entry with a data presented as a conference abstract was used for additional information on one of the included RCTs [ 28 , 29 ]. One Eli Lilly clinical study report was also included to support one of the included observational studies [ 30 , 31 ].

Study design details of the ten unique studies are summarized in Supplementary Material Table S3. Two open-label RCTs were identified, both of which assessed a connected insulin cap Insulclock ® ; one was fully published [ 32 ] and one was a conference abstract [ 28 , 29 ].

The six observational studies included were prospective cohort studies that assessed connected caps Insulclock ® , GoCap ® , connected insulin pens NovoPen ® 6; Bravo pen ® , InPen ® , or a connected insulin platform ESYSTA ®.

Of these, one subgroup analysis evaluating NovoPen ® 6 was fully published [ 33 ], four, with an additional subgroup analysis, were conference abstracts [ 31 , 34 , 35 , 36 , 37 ], and the one evaluating a connected insulin platform ESYSTA ® was a white paper [ 27 ].

These core publications were associated with several supporting publications [ 32 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 ].

Features of the devices evaluated in these studies are summarized in Table 1. Of the two economic studies, one assessed a connected insulin pen NovoPen ® 6 and was fully published [ 51 ] with a conference abstract [ 47 ] and the other investigated the connected insulin platform ESYSTA ® and was a conference abstract [ 52 ].

Baseline characteristics of the populations of people with diabetes are summarized in Supplementary Material Table S5. Of the studies evaluating Insulclock ® , two included people with type 1 diabetes mellitus T1DM [ 32 , 36 ] and one included people with type 2 diabetes mellitus T2DM [ 29 ].

Single studies evaluated GoCap ® , Bravo pen ® , InPen ® , and ESYSTA ® in people with T1DM or T2DM [ 27 , 31 , 34 , 35 ], and two parts of one study [ 40 ] evaluated NovoPen ® 6 one in adults with T1DM and the other in children and adolescents with T1DM [ 33 , 37 ].

Across all studies, people with T2DM were generally older than those with T1DM. Baseline demographics and disease characteristics were infrequently reported in these studies. Current use of CGM was reported in six studies Supplementary Material Table S5 [ 31 , 32 , 33 , 34 , 35 , 37 ].

In RCTs, clinical outcomes indicate that the introduction of connected insulin caps resulted in improved glycemic outcomes Table 2 ; details are provided in Supplementary Material Table S6 [ 29 , 32 ]. There was a numerically greater improvement in HbA1c from baseline to 4 weeks in the overall and active-use populations.

Of note, this study showed no difference in clinical outcomes between groups using the Insulclock ® device with or without reminders and app alerts active and masked groups, respectively. In the RCT of 80 people with T2DM [ 28 , 29 ], there was a significant improvement in HbA1c and glycemic variability from baseline to 12 weeks with the use of Insulclock ®.

People with T2DM reported a slightly higher number of hypoglycemic events during the study period with full use of the Insulclock ® device compared to the masked device 29 vs. PROs were reported in both RCTs evaluating Insulclock ® Table 2 ; details are provided in Supplementary Material Table S7.

Overall, connected insulin caps were associated with improvement in the satisfaction of people with diabetes. People with T2DM were equally satisfied with Insulclock ® with or without feedback, as assessed by the Diabetes Treatment Satisfaction Questionnaire change DTSQc survey [ 29 ].

Treatment adherence in this study number of insulin injection irregularities was reported to be similar for the device with and without feedback Supplementary Material Table S7.

Similarly, improvements in PROs were observed after introduction of the Insulclock ® or the GoCap ® in observational studies Table 2 ; details are provided in Supplementary Material Table S7. People with T1DM using Insulclock ® reported a general benefit at follow-up as assessed by the ITSQ score [ 36 ].

Most people with T1DM or T2DM using the Bluetooth-enabled GoCap ® found the cap was easy to use and useful in the management of their diabetes [ 34 ]. Overall, results of observational studies in people with T1DM or T2DM showed improvements in clinical outcomes after introduction of a connected insulin pen Table 2 ; details are provided in Supplementary Material Table S6.

People with T1DM or T2DM using the Bravo ® pen plus blinded or unblinded CGM had fewer MBDs per day, fewer days with MBDs per month, a higher percentage of daily time in TIR, and lower HbA1c levels during the unblinded CGM study period when compared with baseline and to the blinded CGM study period [ 30 , 31 ].

In this study, people with diabetes were more likely to have a higher confidence in hypoglycemia measured by the Hypoglycemic Confidence Scale , less fear of hypoglycemia measured by the Adult Low Blood Sugar Survey , increased health problem-solving skills measured by the Hypoglycaemia Problem-Solving Scale , and lower illness perception measured by the Problem Recognition in Illness Self-Management survey during the unblinded real-time CGM study period than at baseline Table 2 ; details are provided in Supplementary Material Table S7 [ 30 , 31 ].

However, these improvements in PROs, measured using a variety of tools, were not significant. The two studies reporting relevant data indicated that use of connected pens and systems is potentially cost saving from an economic perspective Supplementary Material Table S8 [ 51 , 52 ].

Higher treatment costs due to a higher bolus insulin dose with the connected insulin pen were offset by a lower cost of complications compared with standard of care. In the cost-effectiveness analysis, NovoPen 6 ® was a dominant treatment option relative to standard care from a health care payer and a societal perspective.

The results of the base-case analysis were supported by the results of the sensitivity analysis, where changes to input parameters and assumptions did not affect the dominance of NovoPen 6 ® over standard care.

Quality assessments were conducted on fully published studies only, so that enough information was available to complete the assessment. Using the NICE checklist, the published RCT of Gomez-Peralta and colleagues [ 32 ] was ascertained to be of low quality.

The study was unclear regarding randomization and similarity of baseline characteristics between groups. There were imbalances between groups in study discontinuations and the authors did not specify how discontinuations were handled [ 32 ].

The quality of the two fully published cohort studies, assessed using the Newcastle-Ottawa Scale, was ascertained to be fair [ 33 ]. The studies were largely select groups, and none of the studies were truly representative of the general population.

However, in these studies, secured records were used for the ascertainment of exposure. The studies were generally small with a limited number of people with diabetes.

Follow-up of the cohorts was considered to be adequately long, and all the subjects were accounted for in the assessment of outcomes. This systematic literature review aimed to evaluate clinical, patient-reported, and economic benefits of connected insulin pen devices for T1DM and T2DM.

The review revealed that there were limited primary clinical studies in this field and that although the findings were heterogeneous; generally, the studies showed the potential benefits of connected insulin pens.

Given the heterogeneous nature of the findings, we further discuss them in the context of current standard of care and clinical practice. A total of 10 unique studies were identified: 2 RCTs; 6 observational studies; 2 economic studies in populations of 9 to people with diabetes.

The devices identified provide a range of options for data collection and delivery to those with diabetes. Connected insulin pens and their systems were shown to potentially help reduce suboptimal insulin dosing, and positive results were seen in both children and adults.

Studies demonstrate that these systems may help individuals with diabetes to relieve the burden of insulin treatment and to reduce the number of missed bolus injections, which leads to better glycemic control.

People with diabetes reported increased confidence with and less fear of managing hypoglycemia and, importantly, increased health-related problem-solving skills and understanding of their diabetes goals while using a connected insulin pen [ 31 ].

While these differences were not significant, results suggest that further study into PROs associated with connected diabetes systems may provide further positive insights into how these systems ease the emotional burden of diabetes for affected people.

While the current studies show a positive trend toward clinical, economic, and patient-reported benefits, it should be kept in mind when interpreting results that there is a limited number of studies, and most are small in scale.

Moreover, the majority of studies were observational and may be subject to bias as a result. However, given that these observational studies reflect real-world experience, they may offer more robust data for evaluation and decision-making regarding digital diabetes tools [ 53 ].

This review also highlighted the differences in PROs used across studies, leading to an inconsistency in outcome measures for all aspects of using connected insulin pens. Finally, for each type of technology, only a few studies were available, with inconsistent reporting of outcomes, and not all types of available technology were represented.

These deficiencies in the evidence base for connected insulin systems mean there is opportunity for studies in this area to fill those gaps.

Of note, the ClinicalTrials. gov search identified several ongoing studies, which suggests that the field is quickly developing in terms of research, and once these studies are complete the evidence base for connected insulin platforms will strengthen, enabling stronger conclusions to be made.

The literature search was conducted in May for studies conducted from , using the common literature databases to ensure full coverage of the available published literature.

Since connected pens were not available before , this is the earliest date that relevant publications would be available. This combined with searches of all relevant conferences and the clinical trial databases makes our search comprehensive; however, that the searches were conducted in is a limitation, because any publications published after this date will not be included.

To mitigate the possibility of missing more recent publications, we conducted a non-systematic review of the literature to date, which has shown that no new studies published after May would meet the criteria for selection.

Clearly, there is a need for more primary clinical studies in this field. When treating diabetes, clinicians must balance the appropriate and timely advancing of insulin treatment with minimizing the risk of overtreatment, often relying on short-term information recalled by the person with diabetes, paper diaries, and incomplete digital information.

Devices that can store, transfer, and share data in real time can help overcome these limitations. Of note, current connected insulin pens store only limited information, such as dose and time of dose; dose reminders, bolus calculators, reports, and insulin on board are functions of the associated apps.

The expectations of digital health in diabetes are that it will improve outcomes with respect to glucose control reducing glycemic variability and hypoglycemic events , result in better adherence, provide decision support by allowing people with diabetes and their health care providers to look at trends over time, improve the well-being of the person with diabetes, and reduce disease-related burden on the person with diabetes [ 18 , 54 , 55 ].

The results of the present review support some of these expectations regarding glycemic control and PROs, but few studies elaborated on how the data obtained from the device were used in clinical practice, and as already noted, further investigation is needed.

Currently, there are few studies investigating adherence and hypoglycemia rates in people with diabetes using connected diabetes tools, highlighting a need for studies into these outcomes. The participants of the International Panel on Diabetes Digital Technologies highlighted several opportunities for digital health in diabetes, including the potential for a virtual diabetes clinic capable of monitoring health status, addressing concerns, and guiding therapy decisions, where the person with diabetes can collaborate directly with their health care professional [ 56 ].

However, obstacles to this kind of approach remain; barriers identified by the panel include lack of interoperability and data compatibility, issues of data ownership and accessibility, deficiencies in health care provider reimbursement and insurance coverage for people with diabetes, and finally a lack of supporting evidence for this kind of approach—something identified by the current review.

Although evidence in this field is still in its early stages, with only two RCTs identified, indications suggest that connected insulin pen systems may reduce suboptimal insulin use and the number of missed insulin doses, potentially leading to better glycemic control in insulin-treated people with diabetes.

The available data show that the satisfaction of people with diabetes with connected insulin pen systems is high, and this may lead to improved adherence over time. These connected insulin pen systems could, therefore, be increasingly considered as part of routine clinical care for insulin-treated persons with diabetes who must manage the complexity of their daily insulin routine.

Future research focusing on the way data obtained from these devices can be most effectively used alongside other information e. International Diabetes Federation.

IDF Diabetes Atlas 10th edition. Accessed Oct 5, Williams R, Karuranga S, Malanda B, Saeedi P, Basit A, Besancon S, et al. Global and regional estimates and projections of diabetes-related health expenditure: results from the International Diabetes Federation Diabetes Atlas, 9th edition.

Diabetes Res Clin Pract. Article PubMed Google Scholar. Ong WM, Chua SS, Ng CJ. Barriers and facilitators to self-monitoring of blood glucose in people with type 2 diabetes using insulin: a qualitative study. Patient Prefer Adherence. PubMed PubMed Central Google Scholar.

Trikkalinou A, Papazafiropoulou AK, Melidonis A. Type 2 diabetes and quality of life. World J Diabetes. Article PubMed PubMed Central Google Scholar. American Diabetes Association. Glycemic targets: standards of medical care in diabetes Diabetes Care.

Article Google Scholar. Management of hyperglycaemia in type 2 diabetes, A consensus report by the American Diabetes Association ADA and the European Association for the Study of Diabetes EASD. Juarez DT, Ma C, Kumasaka A, Shimada R, Davis J. Failure to reach target glycated a1c levels among patients with diabetes who are adherent to their antidiabetic medication.

Popul Health Manag. NgassaPiotie P, Webb EM, Rheeder P. Suboptimal control for patients with type 2 diabetes in the Central Chronic Medicine Dispensing programme in South Africa.

Afr J Prim Health Care Fam Med. Holmes-Walker DJ, Abraham MB, Chee M, Jones TW, group A. Glycaemic outcomes in Australasian children and adults with Type 1 Diabetes: failure to meet targets across the age spectrum.

Intern Med J. Kazemian P, Shebl FM, McCann N, Walensky RP, Wexler DJ. If new technology is sometimes hard for you to get used to, you can get help from your diabetes care team.

The first insulin pen devices were introduced in the late s as an alternative to vials and syringes. They allowed for more accurate dosing, better adherence, and less injection site pain. As these devices evolved, they gained digital displays and memory of the most recent insulin doses.

Glucose sensing, continuous glucose monitoring, dosage timing, reminders, and other advancements followed. The first Food and Drug Administration FDA —cleared reusable smart insulin pen was launched in Smart pens are designed to be simple to use. The device sends real-time data to the app via Bluetooth connection.

A smart insulin pen may be just the thing to help you best manage your diabetes. About Diabetes. The new generation of connected insulin delivery devices may help simplify your routine. High-tech help to better manage your diabetes The biggest challenges for many insulin pen multiple daily injection users are: Dose amount: How much to inject Dose timing: When to inject Insulin quality: Shelf-life, temperature, and storage conditions Many people with diabetes have a hard time correctly calculating insulin doses.

The ready-to-use rescue pen for very low blood sugar in people with diabetes ages 2 and above 1. Managing blood sugar levels is challenging no matter how dedicated you are to your treatment plan. Gvoke HypoPen is a ready-to-use rescue pen you can count on to bring very low blood sugar levels back up quickly and safely — your safety net for when it matters most.

Learn why Tristan, a college athlete who lives with type 1 diabetes, has Gvoke HypoPen with him at all times — and how he used it to treat severe low blood sugar. If you live in a state that has a glucagon standing order, you can get it at your local pharmacy.

Gvoke [prescribing information]. Chicago, IL: Xeris Pharmaceuticals, Inc. Valentine V, Newswanger B, Prestrelski S, Andre AD, Garibaldi M. Human factors usability and validation studies of a glucagon autoinjector in a simulated severe hypoglycemia rescue situation.

Diabetes Technol Ther. McCall AL, Lieb DC, Gianchandani R, et al. Management of individuals with diabetes at high risk for hypoglycemia: an Endocrine Society clinical practice guideline.

J Clin Endocrinol Metab. GVOKE is a prescription medicine used to treat very low blood sugar severe hypoglycemia in adults and kids with diabetes ages 2 years and above.

It is not known if GVOKE is safe and effective in children under 2 years of age. High blood pressure GVOKE can cause high blood pressure in certain people with tumors in their adrenal glands. Low blood sugar GVOKE can cause low blood sugar in certain people with tumors in their pancreas called insulinomas by making too much insulin in their bodies.

Serious allergic reaction Call your doctor or get medical help right away if you have a serious allergic reaction including:. These are not all the possible side effects of GVOKE. For more information, ask your doctor. Call your doctor for medical advice about side effects.

You are encouraged to report side effects of prescription drugs to the FDA. Visit www. Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.

For more information, call or go to www. Please see the Full Prescribing Information for Gvoke. We use cookies to help personalize your experience. For more information on how we use cookies and similar technologies, and how you can change your settings, please see our Privacy Policy.

Important Safety Information. Safety Information Prescribing Information Full Prescribing Information Patient Package Insert — English Patient Package Insert — Español. Gvoke HypoPen Gvoke PFS Gvoke Kit.

Important Safety Information Article CAS Hypoglycemia and insulin pens Google Scholar Roberts AW, Crisp GD, Esserman Hypoglycemua, Roth MT, Hy;oglycemia M, Farley Knsulin. After [my husband] Protein synthesis after workouts isnulin two Fat burning workouts, I was confident he could administer Gvoke if I experienced another severe low. Some people, including young children and those with difficulty seeing or other disabilities, may need assistance. Your diabetes health care team can provide tips and encouragement to help you stay on track. We included patients with mean age of
Insulin Pens Smoking and physical activity — Any factors that alter the rate of blood flow through the skin and fat will change insulin absorption. Reduction in these sensor-detected events has the potential to reduce annual health care costs for InPen users. Full Prescribing Information Important Safety Information US23NL By comparison, in Europe pens make up about 80 percent of insulin usage, according to a review published in the International Journal of Pharmaceutical Investigation. The following figure demonstrates the sites where you can inject insulin figure 2.
Hypoglycemia and insulin pens

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