Smart Pens and Pen Caps for Managing Patients With Diabetes
In this podcast, Diana Isaacs, PharmD, CDCES, talks about smart insulin pens and pen caps and how they can help patients with diabetes manage their insulin. Dr Isaacs discusses the benefits of using this technology, important education points for clinicians when implementing their use in care, and more.
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TRANSCRIPTION:
Jessica Ganga: Hello everyone and welcome to another installment of Podcasts360, your go-to resource for medical education and clinical updates. I’m your moderator, Jessica Ganga with Consultant360, a multidisciplinary medical information network.
Dr Diana Isaacs is joining us today to talk about smart insulin pens and pen caps for managing patients with diabetes. Thank you for joining us, Dr. Isaacs. Please introduce yourself to our audience.
Diana Isaacs: Hello, everyone. I am Diana Isaacs. I'm an endocrine clinical pharmacist, also a certified diabetes care and education specialist, and I'm the director of education and training in diabetes technology at Cleveland Clinic in Cleveland, Ohio.
Jessica Ganga: Thank you so much, Dr Isaacs for joining us today. For the first question, can you please talk about what smart pens and pen caps are, and how are they used for the management of diabetes in patients?
Dr Isaacs: Yeah, so smart pens and pen caps are definitely an up-and-coming diabetes technology, so they have a lot of things that they can help people do that are taking insulin. They can help with dose calculations. So just to put it in perspective, they're typically paired up with a mobile application on someone's smartphone. And then they're able to track insulin doses that are taken and they're able to help a person calculate how much to take. So for example, we can put inputs in there like what their carbohydrate ratio is for someone that is counting carbohydrates. Some people have set doses that we can program in there. We can program things like a correction factor, how much one unit of insulin is expected to lower glucose levels, and people can use that then to calculate how much to give if they have a high glucose level.
And then also these devices can be paired with continuous glucose monitors or with blood glucose monitors, which can help with that tracking as well as how much insulin to take and then they even can do things like having dose reminders of when to take insulin.
Jessica Ganga: How has this technology improved the way the disease is managed in patients and what are some benefits for patients with using this technology?
Dr Isaacs: Yeah, so on the simplest level it can remind people to take their insulin and that can be really helpful because when you're doing something all the time it can be easy to forget whether that's at meal times or that's a daily long-acting insulin. Some people have the issue of, “Gosh did I take my insulin or didn't I take it. I don't remember.” And then they come into this challenge of risking double dosing or just missing the dose all together.
So all of them allow the ability to kind of look back and see, “Oh did I take my insulin. Oh, I didn't, so I better go ahead and take it." Also, some of the benefits in terms of the data aggregation. So for the health care team, it's just beautiful because when someone is taking insulin and we have, let's say a continuous glucose monitor report. Yes, that is nice, but we often have questions, "Well, did you take your insulin here? How much did you take?” And it can be challenging for a person to even remember what they took.
And so it then becomes challenging for us to know how to help them to how to adjust their doses. And so by having this data, we can see exactly how much a person took. We can see if they took the recommended amount, if they took more, if they took less. And so that really helps with the discussion. We also can see the number of percentage of missed doses and then even get things like the breakdown of basal versus bolus. So that would be like, for example, the background or the long-acting insulin versus mealtime insulin. And that's very helpful just in terms of adjusting the insulin regimen with the ultimate goal of helping someone increase their time in range and get to their A1C target.
Jessica Ganga: So you mentioned the benefits for patients. Who are the ideal candidates for the use of this technology?
Dr Isaacs: Definitely you want people that are taking insulin. So, it's definitely meant for insulin users. They all do work with mobile apps, so ideally you want someone that has a smartphone and has a connected app. Although I have had some situations where someone maybe didn't have their own smartphone or mobile app, but had someone in their family or a caregiver that did so that's not necessarily a total deal breaker, but you do need to be able to use that associated mobile app.
Even though these devices could be used just with a long-acting insulin, at least to track it and remind someone to take it, I think that people definitely get the most benefit that are on some type of mealtime insulin. And so that could be people, certainly with type 1 diabetes, all of them are going to need mealtime insulin. Many people with type 2 diabetes end up needing mealtime insulin. And so those can be great candidates. The one caveat I'll say is that we also have insulin pump technology, which is fantastic. So, for type 1 diabetes, typically the gold standard is we want to offer people automated insulin delivery with an insulin pump and continuous glucose monitor. Now, there's many reasons not everyone wants to be on that technology. And when you look at the statistics, only about 40% of people with type 1 are even using that technology. And we can talk, there's many barriers, costs, certainly complexity, just wearing something all the time so not everyone wants to be on that and I think for those that don't want to be on it with type 1 diabetes this is a great, great option. Also for those that just want to take an insulin pump break sometimes people just get tired of wearing something all the time and they want to break or their pump malfunctions it's great to have a backup. Now with type 2 diabetes, the insulin pump recommendations, they're still very useful tools, but the recommendations aren't just strong and we have more people with type 2 diabetes that are utilizing insulin pens.
And so I truly believe we're going to get to a time where everyone that's on insulin pens uses a connected pen because they offer everything that regular insulin pens do with all these additional advantages. So that's kind of my long winded answer for that.
Jessica Ganga: You mentioned in the beginning of the interview that this is an up-and-coming technology for patients with diabetes. For clinicians, what are important education points when initiating this technology?
Dr Isaacs: Yeah, so, well, we want to make sure that a person has the compatible pieces and parts. So, making sure they understand what app would be needed for what specific product that they're prescribed. I think that this is a space that's going to continue to grow, but with our current products, there can be certain limitations. Like for example, there's one where you need to have cartridges—it's a reusable pen—and so you need to have cartridges that are prescribed. And so making sure a person has those cartridges and understands how to use them.
There are other products that may only work with certain types of insulin or certain types of insulin pens. And so, it's just important to make sure the person knows that and has the correct insulin to utilize with their device. And then additional things would just be setting up an education and training. These are generally not very long education sessions. Most of them are pretty, fortunately, pretty easy to get started and many of the companies also offer education if there's not someone in the office, for example, that can help the person set it up. And then generally, you're going to need to know the inputs to put in and this will be a little bit device specific.But for example, if someone's going to be calculating their mealtime insulin doses, you would need to put in some of the inputs similar to what we would put in with an insulin pump. And those would be things like the carbohydrate ratio, if a person is counting carbohydrates. Some have the option where you could do set doses or do meal estimates, regardless though, those would be things that would need to be put it into the mobile app of the device.
And then the most heavy option to put in what's called that correction factor, how much we expect that unit of insulin is going to lower glucose, as well as like what the target would be as well. So making sure the person has these settings, helping them put it in, and then once these settings are put in, it's generally the actual use of it is really straightforward. Either it's paired directly with the glucose monitor or a person would have to input their glucose and input their carbohydrates or what meal they're eating, and then the device will tell them exactly how much insulin to take.
One other thing would just be with glucose monitors, understanding what's compatible with the device. You don't have to use one that's compatible. You could have two separate devices, but it is nice when they directly talk to each other and then they're in the same work together, all that data. So, understanding that and making sure a person has access to that can be really helpful.
Jessica Ganga: In terms of barriers, does this technology help patients overcome them when managing their diabetes?
Dr Isaacs: I think there's several barriers that this helps people to overcome. One is certainly the forgetting to take insulin. This can help a lot with the reminders and being able to track and everything and if there are patterns of forgetting certain doses, coming up with strategies. And then also just with the dose calculations, it is really common in practice that we give people the simplified correction scales or sometimes they call them sliding scales. And it'll be things like, “Oh, take two units if your blood sugar is between 150 and 200 and take four if it's 200 to 250,” and so on. And while that seems kind of straightforward and simple, what I find is I'm putting that in people's after visit summary, then they may take a picture of it or they might put it on the refrigerator at home. But when I ask a person, well, how much insulin do you take when your blood sugar is, let's say, 205? They're like, “Oh, I have to go find that sheet. I have no idea.” And if they're not at home by the refrigerator where the thing is posted, then they really don't know how much to take and so this is just such an easier way of knowing how much to take.
And one other thing I'll add to it is we have a real problem with what's called stacking insulin and that is where let's say someone's blood sugar is running high. Let's say they ate a couple hours ago they gave themselves insulin it's running really high. Well, it's really common that we'll say you know wait four hours because that other insulin is still working in your system, we don't want you to dip too low. And we do that out of safety. But the reality is that two hours later, if it's still going up, like that can be frustrating for a person to just have to sit and wait another two hours. And so, these devices actually keep track of active insulin. And so, it can take how much insulin is working into consideration and recommend a safe amount to take. So, a person does not need to wait that full four hours. So, I think that's a huge benefit as well.
And ultimately through doing all of this, again, it's going to increase that time and range and hopefully help a person get to their A1C targets and just feel better overall.
Jessica Ganga: Looking towards the future, what are the next steps in research on this topic?
Dr Isaacs: Yeah, so I think in terms of, with this, there's tons of benefits that we know and that we've seen, anecdotally. Honestly though, there's not a ton of data out there, so the gold standard is really our randomized control trials. And we certainly have those for insulin pumps and automated insulin delivery systems and even CGM. There's less data out there on these connected pens. And so I would like to see us continue to build that data. I'd also like to see more compatibility with different devices and just more devices in general. So outside of the US, there's actually a lot more connected pen and pen cap options. But one of the things we see happening is that they may only work with one type of insulin or even one type of continuous glucose monitor. And so my hope is, and this is similar to what we're seeing in the insulin pump space, is that we will see more CGMs working with more of these connected devices and also working with more different types of insulin to really give people the most choice and also just make it easier to get the supplies that they need and everything.
Jessica Ganga: Well, thank you again, Dr Isaacs. Is there anything else you would like to add?
Dr Isaacs: Just that, I think this is a really exciting space. Also, one thing I didn't mention is there's a lot of other mobile apps that can even collect this type of data and work with them. And so, se have the ability to potentially do other things, like really, for example, taking pictures of meals and showcasing those and how they aggregate with how much insulin was taken and the rise in glucose and all of those things. And also, I think artificial intelligence is another thing to keep our eyes on and how that will ultimately pair with this data. So I think it's really neat. It's just an exciting field and I encourage people to just stay in the know about it, keep their eyes open because we're likely to see more and more options in the future for people with diabetes.
Jessica Ganga: As you said, this is an exciting time for diabetes technology. So thank you so much for speaking with us today about the smart pens and the pen caps. We appreciate your time.
Dr Isaacs: You're very welcome. Thank you so much for having me.