We asked Bzowyckyj, Dr. Isaacs, and Joshua D. Miller, MD, the medical director of diabetes care for Stony Brook Medicine, about the latest developments in insulin pen technology. Among the answers they shared were:
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Here’s a closer look at these developments.
“We’ve seen tremendous improvements in using pens to dose concentrated insulin,” says Miller, who is the medical director of diabetes care at Stony Brook Medicine in Stony Brook, New York. “The pharmaceutical industry has gotten better at packaging those insulins in a safer way to be able to dose the amount of insulin that the patient needs.”
Patients who require higher doses of insulin than the traditional U-100 concentration because they have obesity or have insulin resistance only had U-500 insulin to turn to until recently. U-500 insulin also was previously only available as a vial; now it’s available as a pen, further facilitating dose calculation. “At five times the concentration of traditional insulin, it’s very dangerous in an inappropriate amount and without accurate dosing,” he explains.
According to the aforementioned review in Therapeutics and Clinical Risk Management, newer pens on the market within the last few years contain varying concentrations of long-lasting (basal) insulin, such as a Tresiba FlexTouch pen with 3 mL of U-200 insulin degludec ($248 per pen, or $0.41 per unit); or a Toujeo Max SoloStar pen with 3 mL of U-300 insulin glargine ($315 per pen, or $0.35 per unit) — prices all according to GoodRx. “As a result of the wider availability of some of the concentrated long-lasting insulins, like U-200, patients are able to absorb the insulin in a much more predictable way, and their basal insulin requirements are met more reasonably, accurately, and effectively,” says Miller.
The ability to give half-unit doses is another exciting development, according to Bzowyckyj. Those who are especially sensitive to insulin (such as children and seniors, according to a review published in the Journal of Diabetes Science and Technology) and who use low amounts may be more prone to dosing errors. Half-unit functionality, such as that available in the Humalog Junior KwikPen ($129 per pen, or $0.34 per unit according to GoodRx) and the NovoPen Echo, makes it easier to deliver just the right amount of insulin.
“For me, the most exciting new development is the dose memory functionality, which keeps track of the doses and times of insulin doses that a person self-administered recently,” Bzowyckyj continues. “Oftentimes, it is easy for people to forget whether or not they administered their medications, especially with how hectic our lives can get. With traditional tablets and capsules, people can just check their pillbox to see if today’s space is empty, but unfortunately, that is not an option with insulin. The dose memory feature is a great way to prevent a person from double dosing their insulin.”
Among the smart pens with memory functionality is the NovoPen Echo 5. Its half-increment dosing uses 3 mL Penfill cartridges of Novo Nordisk insulins, such as 300 units of fast-acting NovoLog insulin aspart per cartridge ($130 per cartridge, or $0.47 per unit, according to GoodRx). The pen can cost as little as about $37 in some pharmacies but may be more expensive depending on your pharmacy, according to WellRx.
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Another example is Companion Medical’s InPen, which is compatible with Humalog and Novolog U-100 3 mL insulin cartridges. Prices vary by pharmacy, but the InPen for Humalog and the Novolog version can also cost around $37.
Isaacs’s patients use the InPen, which she prefers to the NovoPen Echo 5. “Currently, the Novo Echo has a dosing recorder but lacks the other advanced features of the InPen,” says Isaacs. For instance, with the InPen, “There is a dosing calculator embedded in it, which makes calculations much easier,” she says. “The calculator makes it much easier to add the insulin needed for a given amount of carbohydrates and a certain glucose level. It also may subtract active insulin from a previous dose that is still working in the body through an advanced calculation.” That last function is one that Miller points out as being especially useful for avoiding dosing errors.
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. The CGMs use a sensor wire inserted under the skin and a small, portable transmitter to send data to a receiver or smart device 24 hours a day. They are typically used by people with type 1 diabetes and are especially useful for those who are at risk for hypoglycemia and either don’t recognize the signs or experience them overnight, according to the National Institute of Diabetes and Digestive and Kidney Diseases, though doctors are seeing more people with type 2 diabetes who are starting to use CGMs.
Last year it was announced that Medtronic devices would integrate with future Novo Nordisk smart insulin pens beginning in 2020, and the Freestyle Libre would integrate with future insulin smart pens by Novo Nordisk and Sanofi (maker of the Lantus Solostar insulin glargine pen). Previously it was announced that the Dexcom G6 would integrate with upcoming Novo Nordisk smart insulin pens.
Despite all these developments, many insulin users aren’t even aware that smart pens exist, according to Isaacs. Miller doesn’t see growing awareness necessarily translating into wider adoption of smart pens at all. Instead, he predicts that over time those insulin users who are interested in technological improvement are more likely to move over to pump therapy rather than smart pens. “The patients I have who don’t want to go on a pump tell me that they want to stay on a [traditional] pen because the pens are simple. They are easier to use and they don’t have to think about numbers and data. They just dial the dosage, they take it, and they are done.”
He also sees affordability as another barrier to wider adoption. “Outside of rebate programs and coupons, company certificates and the like, I have not heard of robust insurance coverage from the managed-care and insurance companies to cover electronic pens over the cost of a traditional insulin pen.”
In 2019, Companion Medical announced a program to ensure that InPen users with commercial insurance will pay no more than $99 annually for the device, which is designed to last a year.
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