Utilization of Pen Devices Can Improve Diabetes Treatment for LTC Residents

Fri, 11/7/08 - 11:04am
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Author(s):

Barbara Resnick, PhD, CRNP, FAAN, FAANP

Author Affiliations:

Dr. Resnick is Professor, University of Maryland School of Nursing, Baltimore, MD.

__________________________

The prevalence of diabetes is increasing at an alarming rate worldwide, and, coupled with an aging population, it is expected that the number of persons with diabetes requiring long-term care will increase substantially over the next several decades. Therefore, it is imperative that optimal treatment is provided to reduce the associated health problems and improve the quality of life for those with the disease. Many of the barriers to adequate glycemic control can be overcome, and insulin therapy should be considered with the patient at the time of diagnosis. Traditional vial-and-syringe delivery is a valid insulin therapy option, but studies have demonstrated that some patients prefer pen devices over vial and syringe. Pen devices have also been associated with fewer hypoglycemic events and reduced emergency and physician visits. This delivery approach, therefore, may have a significant impact on patient quality of life. (Annals of Long-Term Care: Clinical Care and Aging 2008;16[11]:28-32)

Background

Diabetes mellitus is a chronic condition that requires lifelong treatment. By 2030, it is projected that the disease will affect nearly 4.4% of the worldwide population.1 In 2005, it was estimated that 7% of the U.S. population (approximately 20.8 million people) had diabetes that resulted in a $132 billion burden on the economy.2 The prevalence of diabetes is highest among the elderly. In 2004, 16.7% of persons age 65-74 years had been diagnosed with diabetes, which was approximately 12 times the rate of people aged younger than age 45 years (1.2%).1,3 Many of these elderly patients are admitted to nursing facilities for long-term custodial care, where the prevalence of diabetes is estimated to be between 8% and 25%.4

As life expectancies increase worldwide, the number of people who will require long-term care is expected to increase as well.5 When this demographic shift is coupled with the increasing prevalence rates of diabetes in the elderly, an even greater number of nursing care facility residents will require diabetes care. This will further increase the burden on the economy, and optimal LTC treatment are needed to reduce health problems and improve quality of life for those with the disease.

Management of Glycemic Control in LTC

Inadequate glycemic control is a major cause of diabetic complications such as cardiovascular disease, diabetic neuropathy, kidney disease, and nervous system damage.2,6,7 Intensive glycemic control, which is considered the critical marker of successful diabetes treatment, can prevent or delay the progression of these devastating complications.7-10 Glycemic control is defined by the American Diabetes Association as a glycosylated hemoglobin (A1c) value of less than 7% for patients in general, whereas the recommended A1c goal for individual patients is as close to normal as possible without significant hypoglycemia.11

However, not all individuals in LTC settings will benefit from strict glycemic control. In this setting, target A1c levels should be individualized, and a less-stringent target of 8% is more likely to be realistic and appropriate.12,13 In patients who are considered frail, have a life expectancy of less than 5 years, or present with any condition or comorbidity indicating that the risks of glycemic control would outweigh the benefits, quality-of-life considerations should take precedence over general guidelines.

References:

1. Wild S, Roglic G, Green A, et al. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27(5):1047-1053.
2. National Diabetes Fact Sheet: General information and national estimates on diabetes in the United States, 2005. Centers for Disease Control and Prevention Website. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf. Accessed August 8, 2008.
3. National Center for Chronic Disease Prevention and Health Promotion. Data and Trends. National Diabetes Surveillance System. Prevalence of diabetes. Prevalence of diagnosed diabetes by age, United States, 1980-2004. United States Department of Health and Human Services; 2005. Centers for Disease Control and Prevention Website. http://www.cdc.gov/Diabetes/statistics/prev/national/tablepersons.htm. Accessed August 8, 2008.
4. Fagot-Campagna A, Bourdel-Marchasson I, Simon D. Burden of diabetes in an aging population: Prevalence, incidence, mortality, characteristics and quality of care. Diabetes Metab 2005;31 Spec No 2:5S35-5S52.
5. Centers for Disease Control and Prevention (CDC). Trends in aging--United States and worldwide. MMWR Morb Mortal Wkly Rep 2003;52(6):101-104, 106.
6. Stratton IM, Adler AI, Neil HAW, et al. Association of glycaemia with macrovascular and microvascular
complications of type 2 diabetes (UKPDS 35): Prospective observational study. BMJ 2000;321(7258):405-412. 7. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993;329(14):977-986.
8. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care 1998;21(4):518-524.
9. Orchard TJ. From diagnosis and classification to complications and therapy. Diabetes Control and Complications Trial Part II. Diabetes Care 1994;17(4):326-338.
10. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33) [published correction appears in Lancet 1999;354(9178):602]. UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352(9131):837-853.
11. American Diabetes Association. Standards of medical care in diabetes-2007. Diabetes Care 2007;30(suppl 1):S4-S41.
12. American Medical Directors Association. Managing diabetes in the long-term care setting. Clinical Practice Guidelines. Columbia, MD: American Medical Directors Association; 2008.
13. Brown AF, Mangione CM, Saliba D, Sarkisian CA; California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc 2003;51(5 suppl):S265-S280.
14. Haas LB. Optimizing insulin use in type 2 diabetes: Role of basal and prandial insulin in long-term care facilities. J Am Med Dir Assoc 2007;8(8):502-510.
15. Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabetes. Diabetes Care 2003;26(6):1902-1912.
16. Currie CJ, Morgan CLI, Poole CD, et al. Multivariate models of health-related utility and the fear of hypoglycaemia in people with diabetes. Curr Med Res Opin 2006;22(8):1523-1534.
17. Svensson AM, McGuire DK, Abrahamsson P, Dellborg M. Association between hyper- and hypoglycaemia and 2 year all-cause mortality risk in diabetic patients with acute coronary events. Eur Heart J 2005;26(13):1255-1261.
18. Briscoe VJ, Davis SN. Hypoglycemia in type 1 and type 2 diabetes: Physiology, pathophysiology, and management. Clinical Diabetes 2006;24(3):115-121.
19. Chelliah A, Burge MR. Hypoglycaemia in elderly patients with diabetes mellitus: Causes and strategies for prevention. Drugs Aging 2004;21(8):511-530.
20. Shorr RI, Ray WA, Daugherty JR, Griffin MR. Incidence and risk factors for serious hypoglycemia in older persons using insulin or sulfonylureas. Arch Intern Med 1997;157(15):1681-1686.
21. Meneilly GS, Cheung E, Tuokko H. Counterregulatory hormone responses to hypoglycemia in the elderly patient with diabetes. Diabetes 1994;43(3):403-410.
22. Korytkowski M, Niskanen L, Asakura T. FlexPen: Addressing issues of confidence and convenience in insulin delivery. Clin Ther 2005;27(suppl B):S89-S100.
23. Bates D, Clark NG, Cook RI, et al; Writing Committee on Patient Safety and Medical System Errors in Diabetes and Endocrinology. American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology. Endocr Pract 2005;11(3):197-202.
24. Da Costa S, Brackenridge B, Hicks D. A comparison of insulin pen use in the United States and the United Kingdom. Diabetes Educ 2002;28(1):52-56, 59-60.
25. Kesson CM, Bailie GR. Do diabetic patients inject accurate doses of insulin? Diabetes Care 1981;4(2):333.
26. Hornquist JO, Wikby A, Andersson PO, Dufva AM. Insulin-pen treatment, quality of life and metabolic control: Retrospective intra-group evaluations. Diabetes Res Clin Pract 1990;10(3):221-230.
27. Houtzagers CM, Berntzen PA, van der SH, et al. Efficacy and acceptance of two intensified conventional insulin therapy regimens: A long-term cross-over comparison. Diabet Med 1989;6(5):416-421.
28. Gall MA, Mathiesen ER, Skott P, et al. Effect of multiple insulin injections with a pen injector on metabolic control and general well-being in insulin-dependent diabetes mellitus. Diabetes Res 1989;11(2):97-101.
29. Korytkowski M, Bell D, Jacobsen C, Suwannasari R; FlexPen® Study Team. A multicenter, randomized, open-label, comparative, two-period crossover trial of preference, efficacy, and safety profiles of a prefilled, disposable pen and conventional vial/syringe for insulin injection in patients with type 1 or 2 diabetes mellitus. Clin Ther 2003;25(11):2836-2848.
30. Puxty JA, Hunter DH, Burr WA. Accuracy of insulin injection in elderly patients. Br Med J (Clin Res Ed) 1983;287(6407):1762.
31. Rex J, Jensen KH, Lawton SA. A review of 20 years’ experience with the NovoPen family of insulin injection devices. Clin Drug Investig 2006;26(7):367-401.
32. Albano S; ORBITER Study Group. Assessment of quality of treatment in insulin-treated patients with diabetes using a pre-filled insulin pen. Acta Biomed 2004;75(1):34-39.
33. Niskanen L, Jensen LE, Råstam J, et al. Randomized, multinational, open-label, 2-period, crossover comparison of biphasic insulin aspart 30 and biphasic insulin lispro 25 and pen devices in adult patients with type 2 diabetes mellitus. Clin Ther 2004;26(4):531-540.
34. Rubin RR, Peyrot M. Quality of life, treatment satisfaction, and treatment preference associated with use of a pen device delivering a premixed 70/30 insulin aspart suspension (aspart protamine suspension/soluble aspart) versus alternative treatment strategies [published correction appears in Diabetes Care 2004;27(12):3032]. Diabetes Care 2004;27(10):2495-2497.
35. Sucic M, Galic E, Cabrijan T, et al. Patient acceptance and reliability of new Humulin®/Humalog® 3.0 ml prefilled insulin pen in ten Croatian diabetes centres. Med Sci Monit 2002;8(3):PI21-PI26.
36. Summers KH, Szeinbach SL, Lenox SM. Preference for insulin delivery systems among current insulin users and nonusers. Clin Ther 2004;26(9):1498-1505.
37. Szeinbach SL, Barnes JH, Summers KH, Lenox SM. Development of an instrument to assess expectations of and preference for an insulin injection pen compared with the vial and syringe. Clin Ther 2004;26(4):590-597.
38. Lee WC, Balu S, Cobden D, et al. Medication adherence and the associated health-economic impact among patients with type 2 diabetes mellitus converting to insulin pen therapy: an analysis of third-party managed care claims data [published correction appears in Clin Ther 2006;28(11):1968-1969]. Clin Ther 2006;28(10):1710-1725.
39. Pellissier G, Migueres B, Tarantola A, et al; The GERES Group. Risk of needlestick injuries by injection pens. J Hosp Infect 2006;63(1):60-64.
40. Edwards C, Metcalfe L, Allan J, Haynes A. Reducing the risk of injuries to staff from insulin pens. Nurs Times 2005;101(25):34-36.