Fridays and Snacking Bad for Smart Insulin Pen Adherence

MADRID — Day of the week, age, snacking, and being more engaged with smart insulin pens are important factors that affect adherence to injecting bolus insulin in people living with diabetes (PLWD), according to a study using real-world connected insulin pen data.

Sunday and Monday were found to be the best days for adherence to bolus insulin injections, while Friday showed the poorest, reported Francisco Ampudia-Blasco, MD, endocrinologist, Hospital Clínico Universitario de Valencia, Valencia, Spain, who presented findings of the study here at the European Association for the Study of Diabetes (EASD) 2024 Annual Meeting.

Snacking was found to be associated with missing a bolus insulin dose.

“It is well known that adherence with injections is challenging for people living with diabetes,” said Ampudia-Blasco. “By using connected insulin pens, it may be possible to identify different patient behaviors and then plan and conduct targeted interventions for people living with diabetes who have difficulty achieving glycemic control.”

Smart, also known as connected, pens store data on insulin use as well as the time of its administering. By pairing with an app, data from the connected insulin pen can be linked to data from blood glucose meters as well as flash and continuous glucose monitors (CGMs).

“Connected insulin pens may be a useful tool in clinical practice to improve
adherence, glycemic control, and clinical outcomes in people living with diabetes,” said Ampudia-Blasco.

“Managing multiple daily insulin injections around the demands of daily life can be challenging and burdensome for people living with diabetes,” said Ampudia-Blasco. “Results of a recent real-world study in Sweden found that, in adults with type 1 diabetes who used continuous glucose monitors and connected insulin pen injections, the estimated probability that a patient missed at least one basal insulin dose over any 2-week period was 22% (95% CI, 10%-40%).”

This poor adherence to insulin injections can lead to inadequate glycemic control, he added. “The Swedish study found that missed basal dosing was associated with a drop-in time-in-range by 2.63% and an increase in mean glucose of 0.44 mmol/L and GMI [glucose management indicator] of 0.19, the latter two measures having most statistical significance.”

Study Setup

The study by Ampudia-Blasco and colleagues used real-world connected insulin pen data from PLWD (type 1 and type 2) to gain insight into treatment adherence and investigated which behavioral and lifestyle-related factors may influence the probability of missing bolus insulin injections.

A missed bolus dose was defined as a meal detected by the glucose rate increase detector algorithm when there is no bolus dose detected within the bolus window (−15 to +60 minutes from meal onset).

The researchers collected data from adults with type 1 or type 2 diabetes across 21 countries who were using CGM and a connected insulin pen (NovoPen 6 or NovoPen EchoPlus) to deliver the bolus insulin dose. All available days with data containing at least one registered bolus insulin injection and at least 70% CGM coverage were included in the analysis, and the mean number of data uploads from the pen to a partner application every 2 weeks was used as a proxy measure of engagement with the connected insulin pen. Using these data, the probability of having a day with at least one missed bolus dose was estimated.

“We were particularly interested in analyzing the impact of age, country of residence, main number of daily injections, day of the week, and month of the year [on the probability of missing bolus insulin injections],” explained Ampudia-Blasco.

The mean participant age was 43 years, 55% were men, 93% had type 1 diabetes, and 4.4% had type 2 diabetes. Data from 22,964 participants were included. This comprised around 2.5 million injection days from 29 countries — mostly from the United Kingdom, Spain, France, and Sweden. Partner apps that provided data were largely made by Abbott at 83% but also Glooko, while some used multiple platforms, said Ampudia-Blasco. Connected insulin pens mainly contained faster insulin aspart and insulin aspart (35% and 34%).

Factors Affecting Missed Bolus Insulin Dose

“In people living with diabetes, the mean probability of having a day with at least one missed bolus dose was 44.5% (95% CI, 44.1%-45.0%) over a 2-week period,” reported Ampudia-Blasco, adding that “the probability of missing at least one bolus insulin dose decreased with increasing connected insulin pen engagement and with increasing age.”

“It’s clear that it’s important to download information from the connected insulin pen to the app because those people who have higher engagement [use the app more] have less probability of missing a bolus dose once every 2 weeks,” he said.

He added that younger people, approximately aged under 40, had the highest probability of missing a bolus dose once every 2 weeks.

“Furthermore, the probability of a day with a missed bolus dose varied according to the day of the week. The estimated probability of having a day with at least one missed bolus dose increased toward the end of the week, with higher probabilities on Fridays and Saturdays than on Sundays and Mondays. Friday had the highest probability of a missed bolus dose at 46% compared with Sunday at 43%.

On any given day, the probability of missing at least one bolus dose was higher for those who ate snacks than for the consumption of breakfast, lunch, or dinner, respectively. “It’s a clear difference in patient behavior in that people don’t inject insulin when they snack between meals.”

Co-moderator, Leszek Czupryniak, MD, specialist in medicine and diabetology and head of the Department of Diabetology and Internal Diseases at the Medical University of Warsaw, Warsaw, Poland, said, “This is an eye-opener of a study. We ask patients if they take their boluses, and now we suddenly see that they don’t always do so.”

“It also confirms my long-term conviction that, ideally, the whole week should consist of Sundays. All the other days are unnecessary,” he remarked on a lighter note. “But I do wonder if we should send reminders on Fridays to young people because that’s when they’re out partying and forgetting.”

Reflecting on the study bias, Czupryniak added, “I wonder if there was some selection bias because there were some countries that had a very low percentage of people with these smart pens, and, given they comprise quite new technology, I wonder if these people are those who are very comfortable with technology. If you covered larger numbers of people in more countries, the results would be worse.”

Ampudia-Blasco has served as a consultant/adviser and/or speaker for, and/or received grant support from, several companies including Abbott Diabetes Care, AstraZeneca, Boehringer Ingelheim, Eli Lilly, GlaxoSmithKline, LifeScan, Mankind Co., Medtronic, Menarini, Merck, Novartis, Novo Nordisk, and Sanofi.

Ampudia-Blasco’s study was sponsored by Novo Nordisk.

Professor Czupryniak has received honoraria for being an advisory board member and/or a speaker from AstraZeneca, Adamed, Boehringer Ingelheim, Egis, Eli Lilly, KRKA, Novo Nordisk, Polpharma, Sanofi, Servier, and Vifarm.