Missing insulin doses linked to lower time in range for adults with diabetes
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Key takeaways:
- Adults with diabetes receiving both basal and bolus insulin through a smart pen miss about six doses every 14 days.
- Each missed basal or bolus insulin dose is tied to a reduction in time in range.
Adults with diabetes who use a smart pen for both basal and bolus insulin delivery have a reduction in time in range with each injection they miss over a 14-day period, according to data published in Diabetes Care.
In an analysis of data from 3,945 adults with diabetes receiving basal insulin degludec (Tresiba, Novo Nordisk) and either bolus insulin aspart or fast-acting insulin aspart, participants missed a mean 0.19 doses of basal insulin and six doses of bolus insulin per 14-day period. The study revealed the challenges and consequences adults with diabetes face with when they do not adhere to insulin therapy, according to Thomas Danne, MD, PhD, professor at Hannover Medical School in Germany.
“We found it intriguing that missing only two basal insulin doses or four bolus insulin doses over a 14-day period would be associated with a clinically relevant change of continuous glucose measurement results,” Danne told Healio. “This clinically relevant change was defined as a 5 percentage point decrease in time in range.”
Danne and colleagues conducted a retrospective real-world study of adults with diabetes who were using the NovoPen 6 (Novo Nordisk) or NovoPen Echo Plus (Novo Nordisk) along with a continuous glucose monitor to administer basal and bolus insulin. Researchers collected data from the smart insulin pen and CGM through each participant’s mobile app. Data were compiled into nonoverlapping 14-day periods. Adherence to insulin therapy was measured through the number of missed basal insulin doses and missed bolus insulin doses during each 14-day period.
Participants missed an average of 0.19 basal insulin doses during each 14-day period. The estimated probability of missing at least one basal insulin dose during each 14-day period was 17.6%. Adults missed a mean six doses of bolus insulin every 14 days. The estimated probability of missing at least one bolus insulin dose during each 14-day period was 99.1%. The researchers said there was large variation among the number of missed bolus doses in the study group, with some participants missing more than 20 doses on average during each 14-day period.
Each missed basal insulin dose was associated with a 2.76 percentage point reduction in time in range with glucose between 70 mg/dL and 180 mg/dL, and a 2.9 percentage point increase in time above range with a glucose level of more than 180 mg/dL (P < .0001 for both). Missing one bolus insulin dose was linked to a 1.73 percentage point decrease in time in range, a 1.8 percentage point increase for time above range, and 0.07 percentage point decrease in time below range with glucose of less than 70 mg/dL (P < .0001 for all). Each daily bolus insulin injection increased time in range by 1.55 percentage points and decreased time above range by 1.71 percentage points (P < .0001 for both). Time below range increased by 0.16 percentage points with each daily bolus injection (P < .0001).
Adults uploaded data to their mobile app a mean 4.8 days during each 14-day period. Each day data were uploaded to the app was associated with an increase in time in range of 0.47 percentage points and reductions in time above range by 0.41 percentage points and time below range by 0.06 percentage points (P < .0001 for all).
Danne said future studies need to investigate how providers can use data from smart insulin pens and CGM to improve insulin adherence and treatment outcomes.
“Combining a smart insulin pen with additional support, such as app-based training, education or artificial intelligence-derived insulin dosing suggestions, may further improve glycemic control and help bridge the gap observed between individuals treated with multiple-daily injection therapy and those treated with automated systems,” Danne said.
For more information:
Thomas Danne, MD, PhD, can be reached at danne@hka.de.
Perspective
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How important is adherence and engagement in the management of insulin requiring diabetes? This large data analysis from Danne and colleagues, attempts to answer this question for adults using smart pens to deliver insulin.
In a world where the use of automated insulin delivery systems has been a focus of research and clinical use, smart pens have emerged as an important option for many patients.
This multinational real-world analysis revealed that even small oversights in providing consistent insulin injections resulted in significant reductions in time in range. This report confirms that adherence and engagement positively correlated with clinical outcomes. It also suggests that almost all patients missed at least one dose of insulin during the observed 14-day time periods.
Taken in aggregate, these data provide several important lessons as well as unanswered questions. Treating this disease has a small margin for error. It also suggests that we have more work to do. But how much vigilance is too much? Helping our patients find an appropriate balance is part of providing personalized medicine. Next steps are to evaluate the changes in time in range as they relate to clinical outcomes, such as complications, and patient-related outcomes, such as quality of life, and patient preferences.
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