Recurrent diabetic ketoacidosis after changing pen devices for insulin injection

Objective: The purpose of this study is to examine risk factors for recurrence of diabetic ketoacidosis and determine interventions to prevent future admissions. Materials and methods: Review article. Results: Recurrent diabetic ketoacidosis is a serious and not uncommon health problem. Diabetic ketoacidosis is associated with severe morbidity and mortality and hospital admissions due to this problem constitute a serious economic burden on the healthcare system. Younger age at diabetic ketoacidosis onset, poor baseline glycemic control and elevated HbA1C, patient comorbidities, depression, alcohol or substance abuse, particularly active cocaine use, have been associated with recurrent diabetic ketoacidosis. In addition, socioeconomic factors (such as ethnic minority status, use of public health insurance and underinsurance), psychosocial, economic, and behavioral factors (including financial constraint, stretching a limited insulin supply, and homelessness) have been all reported to be associated with readmission among diabetic ketoacidosis patients. Conclusions: Identifying high-risk patients during the first diabetic ketoacidosis admission and performing relevant interventions (repeated instructions of insulin use, social help and involvement of family members in medical treatment, collaboration with the patient's primary care physician in order to establish a close and frequent follow up program) may help prevent future admissions. Further studies need to take place to determine whether early interventions with those factors prevent future admissions.

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“…and Bhardwaj and cols. : active use of cocaine and changing pen devices for insulin injection, respectively (20,21).…”

Section: Risk Factors and Causes Of Recurrent Dka Admissionmentioning

confidence: 99%

Recurrent diabetic ketoacidosis

Brandstaetter

Bartal

Sagy

et al. 2019

Archives of Endocrinology and Metabolism

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“…Some of them occurred in patients using reusable insulin pens, 4 -6 in which damage of the delivery mechanism could be more easily explainable by prolonged use, whereas mishandling of the pen or needles by incorrectly trained patients account for the rest of cases. 4,7 Although it is likely that our patient would had been aware of the pen malfunction if she had strictly followed the manufacturer's instructions (all major manufacturers recommend to prime pens before each injection), the present case illustrates that, albeit exceptionally, disposable insulin pens may bear grave structural defects that make them susceptible to putting the security of patients at risk. Therefore, the possibility of pen malfunction should be considered by both patients and health professionals involved in diabetes care in the presence of an unexplained impairment of metabolic control.…”

mentioning

confidence: 96%

Severe Deterioration of Metabolic Control Caused by Malfunction of a Disposable Insulin Pen Device

Boronat¹,

García-Delgado²,

Pérez-Martín³

et al. 2008

The Journal of the American Board of Family Medicine

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We communicate the case of a 68-yr-old woman diagnosed with type 2 diabetes with a severe metabolic deterioration caused by the use of a defective insulin pen device.Diabetes mellitus had been diagnosed 7 years ago and had been managed by her family physician with a combination of glymepiride and insulin glargine (48 units per day). Six weeks before presentation, the patient was switched to a twice-daily regimen of premixed aspart 70/30 (Novomix 30 Flexpen, Novo Nordisk)-36 units pre-breakfast and 18 units pre-dinner-to achieve further improvement of glycemic control. Three weeks later, she began with symptoms of hyperglycemia along with domiciliary blood glucose readings Ͼ300 mg/ dL. According to orders of her physician, the patient scaled insulin dose up to 45 units in the morning and 30 units in the evening. Nevertheless, during the previous week, she attended the hospital Emergency Unit 3 times because of malaise, dizziness, and capillary glucose levels Ͼ500 mg/dL.Formal diagnoses of diabetic ketoacidosis and hyperosmolar hyperglycemic nonketotic syndrome were ruled out by serum biochemistry and venous blood gases. The patient did not present symptoms or signs of an intercurrent infection. Leukocyte count, urinalysis, cardiac enzymes, electrocardiogram, and chest radiograph were normal. The patient was discharged after replenishment of fluids and normalization of plasma glucose with intravenous regular insulin infusion. An urgent appointment with our department was scheduled after the third discharge.The patient's weight was 83 kg and height was 162 cm. Physical stigmata of insulin resistance were lacking, and examination of insulin injection sites did not reveal lipohypertrophic areas. Simulated use of the insulin pen demonstrated that she knew proper handling of the device, and her injection technique was good, although she had been not trained to prime the pen before every injection. However, when she was required to show her currently used pen, it was obvious that it had a structural fault. The barb at the end of the piston rod was disengaged (Figure 1), so that the piston did not efficiently push to dispense insulin, even when the patient was able to fully depress the button and dose scale reset to zero after the procedure. Although the unworn pens remaining in the cartridge were in perfect condition, the patient refused to continue on the same type of insulin. She was offered a basal bolus regimen, using glargine at bedtime and insulin aspart pre-meals. Hyperglycaemia subsided in the following hours.Insulin pens devices have became the standard system for insulin delivery among diabetic patients in Europe. They are usually preferred by both patients and physicians over the traditional This article was externally peer reviewed.

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“…If a patient is switching from one type of insulin pen to another, it is important to check whether the procedure used for the previous pen also applies to the new pen. 50 …”

Section: How To Use An Insulin Penmentioning

confidence: 99%

Practical Aspects of Insulin Pen Devices

Pearson

2010

J Diabetes Sci Technol

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Insulin pen devices have several advantages over the traditional vial-and-syringe method of insulin delivery, including improved patient satisfaction and adherence, greater ease of use, superior accuracy for delivering small doses of insulin, greater social acceptability, and less reported injection pain. In recent years, pens have become increasingly user-friendly, and some models are highly intuitive to use, requiring little or no instruction. Despite this progress, uptake of these devices in the United States has not matched that in many other areas of the world. There is a need for improved awareness of the current characteristics of insulin pen devices among United States health care professionals. Knowledge of the design improvements that have been incorporated into pens, both to address patient needs and as a result of the improved technology behind the device mechanics, is essential to promoting the use of insulin pen devices. This review highlights some of the practical aspects of pen use and discusses the factors to be considered when selecting among different insulin pens.

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Recurrent diabetic ketoacidosis after changing pen devices for insulin injection

Cited by 14 publications

References 3 publications

Recurrent diabetic ketoacidosis

Recurrent diabetic ketoacidosis

Severe Deterioration of Metabolic Control Caused by Malfunction of a Disposable Insulin Pen Device

Practical Aspects of Insulin Pen Devices

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