Today’s post centers around a discussion that one of my friends had with a nurse educator. It centers around the right to choose and who is making that choice. Be prepared as we cue the sound of
Thunderbolts and Lightening – this story is quiet frightening!
Diabetes and Your Choice of Care
This article comes about after a friend of mine asked this simple question of a diabetes nurse educator:
How do you go about showing new innovations to patients so that they get to choose options that best suit their lifestyle?
The response shocked both him and I
Oh, they don’t get to choose, I choose for them, and then decide if they need to see any new items
Patients deserve more! You deserve more. So here in a few paragraphs, I am going to outline some of what I know to be available for your care. If you don’t know about them, then you know your care team is choosing for you which they have no right to do. I doubt that same educator would go to a shoe store, allow the girl to go out back and choose the color and type of shoe, along with the size, so why does she think this approach is okay for our outcomes?
The list below is not comprehensive, does not allow for individual country differences and is only what I know of. I did not include meters as there is simply too many to mention so would advise asking a pharmacist to show you some alternatives. I also tried to focus on the newer items to market as there are way too many “other” choices, that have been surpassed through newer technologies.
For those of you reading this list, who have seen other innovations, feel free to share them in the comments. That way as patients, we get to own our disease, and to choose what works for us and not have a nurse not even living with the disease, making choices for us without us even knowing!
BD 4mm needle & BD 6mm needle
BD makes several different sizes, but their claim to fame is the 4mm nano needle which fits all pens. The needle may be a little too small for some, but definitely worth asking for a sample to try.
Novotwist 5mm needle (32 gauge): This needle fits only Novo Nordisk products but saves that annoying, screwing on of a needle. Basically, one twist and its on. On top of that, the base is flat so that it spreads the force out over the skin better. The length being 5mm, means you hardly feel it. Definitely worth trying!
Novofine 6mm needle (32 gauge). This needle is similar to bd’s 6mm with the only difference being its slightly larger interior diameter which might make it easier to give the injection (less force required). Once again, request a sample to try and use the one you like. This needle fits all brands of insulin
Pen delivery systems
Novopen 4: Not available in every country, but this pen is durable, made in Germany, and easy to use and hold. The piston rod is easy to reset and the numbers are clear and easy to read when dialing up.
Humapen: Different in shape to the pen 4, most people using this non disposable pen also like it. It is definitely one of those “try it and see” as some people find the shape and weight a little awkward.
Echo pen: This pen remembers the last dose given. It is the same as the Novopen 4 except that it comes in half units. It’s strength is that it is a simple concept, to help people remember if they took their insulin, its weakness is that it only remembers the last dose given so it is not so great when trying to work out if what your insulin requirements are over a couple of days.
Memoir: Lilly’s memory pen offers more memory of results storing up to 16 and includes time and date given. The only down side is that it is a little more difficult to set and it also remembers the priming dose given. The average techie could work it out in minutes. Once again, the only way you are going to know is if you have an option to try it.
Clickstar: Synofi’s pen is okay. This non disposable version does not have many bells or whistles and quite frankly resembles something made in a sweat shop, but if it works for you,then who cares what I think. It’s the insulin that makes the difference and if that is working for you, and you don’t mind the pen, then it doesn’t matter.
Kwikpen: To be honest I am not a big fan of this pen simply because it gives no tactile feedback on when the dose is finished. As you get closer to zero, it is harder to depress the plunger. However, if you want to have the “strongest thumbs in west” then this will definitely give you those. However, options are what we are after, and once again if you like disposables for convenience, then this is lilly’s offering.
Flexpen: Novo’s offering in the disposable market is much like the other pens, but at least is color coded so that it is hard to mix up your insulins (something that I think is very important, having injected 30 units of bolus by accident once).
Flextouch: Having played with this pen (and used it, along with all the others), this pen is pretty cool. It’s plunger doesn’t come out and you can deliver the insulin by pressing the button with your little finger! I think it is only available in some markets (I am not sure if the U.S. has it yet), but worth enquiring about once it is, even if you are on other products!
Insulins Long Acting
When it comes to insulins, they all have their pros and cons. There is next to no difference between N or NPH so if you are wanting to try a different pen, then demand to try it. Lantus and Levemir have different benefits. Lantus claims it lasts once a day but often doesn’t in type 1′s. It definitely has 2-4 hours longer duration (respective monographs and Hiese 2004). Levemir, however, is shown to be more predictable and less likely to cause hypos in type 1′s (Pieber 2005).
Insulins Short Acting
If you are on toronto or R, I would seriously suggest finding another health team. These insulins are from the 50′s, need to be taken 30mins before a meal (who knows how much they want to eat 30 minutes before eating?) and have a 4 hour duration. Forget it!
The other rapid acting insulins outside a pump have not much difference between them. What it comes down is what pen do you like to use. Often you won’t be shown them, which is why I provided a complete list. Ask to see them all, hold them in your hands, take them apart (if they are non disposable). Have fun with the decision making. It should feel like shopping for shoes or a new iPod! without having to bring a credit card.
The only advantage that novorapid/novolog has over all of them is in the pump where by it is less likely to occlude and have less unexplained highs. Apart from that, they are much of a muchness.(Kerr 2008)
Pumps are a very individual choice and all have pros and cons. I wrote an article on my thoughts of some of the ones listed below, but the point is to make sure you see all the options, so you know which is best for you.
If you knew of these innovations, then you truly have a great team of health professionals looking after you. If you didn’t, next time you are with your team, a conversation around seeing the latest innovations, irrespective of who makes them, may be warranted. Options allow for your care to be individualized to you, be sure to demand options so that choices and ultimately your outcomes are not being made by others.
Now go forth and choose!