Drs Goldman and Meece discuss factors surrounding insulin administration.
Jerry Meece, RPh, CDCES, FACA, FADCES: Let’s move on to a more specific medication. In spite of all the new drug entities that we’ve developed over the past few years, a lot of our patients with type 2 diabetes and all of our patients with type 1 diabetes are going to start using insulin. They need insulin to survive. In educating patients on insulin use, what factors do we need to consider that impact the rate of absorption? How is that absorption affected if I go too deep and do an IM [intramuscular injection] instead of subcutaneous? Talk to us a little about insulin use and how we’re going to work with getting the right needle into the right patient.
Jennifer D. Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP: One thing we know is that skin thickness is basically the same in all patients. Regardless of their BMI [body mass index], race, gender, or age, it’s less than 3 mm in virtually everyone at all injection sites. If you use the shortest needle—4 mm for a pen—at 90 degrees, straight in without a pinch, you’ll get a subcutaneous injection almost 100% of the time. You would avoid an IM injection. If you use longer needles, you don’t pinch, and you go in 90 degrees, then you could end up with an IM. That can cause erratic absorption.
[Many patients are] still using 8-mm or 12.7-mm pen needles because things keep getting refilled. They keep refilling the same prescription and didn’t change it. Pharmacists are in the perfect place to make an intervention there and get a shorter needle. If they’re using vials, the shortest needle that patients can get is a 6-mm needle on a syringe. That’s the shortest that you can go and still be able to get the insulin out of the vial to penetrate deep enough. But you definitely want to make sure you get into that subcutaneous space to have predictable absorption vs an IM injection.
Jerry Meece, RPh, CDCES, FACA, FADCES: Maybe we can advise pharmacists that when your patient is selecting needles, if they’ve been using a certain needle length for a given time, it’s a good idea to contact their doctor and suggest switching to a shorter needle. Let everybody be on the same page. Because sometimes just to experience what they’re doing with that longer needle, switching to a shorter needle could change the absorption—probably for the better—but they could need to change their dose during that time.
I was fortunate enough to be in a workshop a few years ago. It was such a sea change in that room when they threw the slide up that showed the thickness of a skin of a 250-lb person vs a 150-lb person. Everybody from the ultrasound study showed that it’s still a 2.5-mm to just over 3-mm thickness regardless of obesity, and that 4-mm needle works, and 6 mm is enough to take care of everything. That’s great advice, and it keeps those IM injections.
When our patients are injecting and something weird happens and they go low, I’ve heard physicians say, “That’s just diabetes.” Sometimes it’s getting down to asking the right questions. “What syringe are you using? What needle are you using?” You and I both remember when insulin pens weren’t nearly as common as they are now. We remember it being 90% syringe vials and 10% pens, and Europe was using 90% pens. We were saying, “What do they know that we don’t?” Now we know. We’re finally catching up. Do you think we’re now using more pens than vials and syringes? It’s more than fifty-fifty. Maybe we’re climbing on a regular basis. It’s getting more common to use pens rather than vials and syringes. What’s your opinion on recommending a pen for a patient vs a vial and syringe? What goes into choosing one over the other?
Jennifer D. Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP: I just had a flashback from decades ago of fighting with insurance companies and doing prior authorizations to get pens for people. We could get them only if someone had dexterity issues or vision issues. I’ve been in my practice for almost 11 years, and I haven’t written a prescription for a vial in 11 years. It’s common now. Most people can have a pen, and most insurance companies cover a pen.
Will there be times when we might use a vial? Possibly. But I try to look at every patient and ask myself how I would want to be treated and how I would want my family members to be treated. I want to make sure they’re offered a pen. Why? Because it’s easier. It isn’t as complicated. It’s easy to dial. It’s easy to see. It’s easier to administer. There are lots of data that show that adherence is improved and that patients prefer a pen. I would definitely move to a pen instantly. I don’t even think about vials anymore.
Jerry Meece, RPh, CDCES, FACA, FADCES: I still remember when insurance companies would pay for the insulin pens but not the needles.
Transcript edited for clarity.