Toddlers' diabetes: the lost insulin drop and SemiPens vs. DeciPen

Abstract

Background: While childhood diabetes incidence is rising, especially in toddlers, once or twice-daily toddler-friendly insulin mixtures were withdrawn, imposing four to five miniscule injections, on needle-phobic toddlers. Although more injections may mean more needle-dribbling, such potential dose-loss is unstudied.Objective: Study insulin loss in toddlers' dose range if one-drop dribbled during injection from half-unit pens (SemiPens). Drop-loss is assessed relative to current insulin dose adjustment, and if significant, propose solutions.Methods: The SemiPens, New HumaPen Luxura HD® (HumaPen) and NovoPen Junior® (NovoPen), with 31G-5mm BD-MicroFine needles were used to study drop size or dose-fraction lost if one drop dribbled in dose range 0.5-10 units.Results: HumaPen and NovoPen produced sizable drops mean standard deviation (SD) 0.30 (0.05) and 0.36 (0.06) units/drop (p<0.001). This constituted progressively increasing proportion of the toddlers' doses, 10-fold higher percentage from 6 to 60% or 7.2 to 72%, as the dose gets smaller from 5 to 0.5 units.Discussion: Insulin dose-adjustments are usually done therapeutically within 5-20% dose-changes, while one-step reduction by >20% is hardly required.Therefore, the unintentional dosing change if a drop dribbles is clinically important particularly on using multiple doses below 6 units, compared with fewer larger daily injections. We propose using U20 insulin in disposable SemiPens to make DeciPen, with fivefold-reduction in insulin loss if a drop is lost through dribbling or skin-leak.Conclusion: The one-drop insulin loss is statistically significant, clinically important, and potentiates glycemic variability. Disposable DeciPen may minimize insulin dribbling and leaking and fivefold improve dose accuracy and precision; and ensure reproducibility without prolonging injection time.

Multiple daily injection of insulin regimen for a 10-month-old infant with type 1 diabetes mellitus and diabetic ketoacidosis

“…In the past, infants and toddlers with diabetes were treated with 1 to 2 daily injections of 10% or 20% rapid/intermediate insulin mixture. More recently, due to the difficulties with the fluctuations of the serum glucose level at this age, the use of basal-bolus therapy with long-acting insulin analogs and multiple premeal injections of rapid-acting analogs are increasing 7 8) .…”

Precision Dosing of Rapid-Acting Insulin Matters

“…They are most susceptible to insulin dosing errors as a small volume error translates to a higher proportional change in the administered insulin dose. 14,22 To be successful in their glucose regulation, many people on intensive basal-bolus (MDI) insulin therapy utilize carbohydrate counting, which involves measuring the carbohydrate content of the meal to calculate the exact insulin dose needed to maintain postprandial glycemic control. In addition, correction doses of insulin for hyperglycemia may be required.…”

Which people with diabetes are treated with a disposable, half‐unit insulin pen? A real‐world, retrospective, database study in Spain

“…Glycemic targets are particularly challenging to attain for adolescents and young adults 6–8 as well as for elderly patients 9 . Young children typically require smaller insulin doses because of their lower body weight and greater sensitivity to insulin, while elderly patients with diabetes are generally at a notably higher risk for severe hypoglycemia and its complications because of age, duration of diabetes and greater prevalence of hypoglycemia unawareness 10–13 . This risk increases when cognitive and/or physical impairments and other comorbidities are present, as they affect insulin requirements and reduce insulin clearance, which result in increased insulin sensitivity.…”

“…This risk increases when cognitive and/or physical impairments and other comorbidities are present, as they affect insulin requirements and reduce insulin clearance, which result in increased insulin sensitivity. Precision dosing is especially critical for these patients, as they are most susceptible to insulin dosing mismatch 10,14 . Pregnant women with diabetes are also a subpopulation with stringent glucose targets because of pregnancy‐related complications 15 .…”