Timing Of Insulin Administration Research Articles

Improving the insulin therapy for diabetic patients using optimal impulsive disturbance rejection: Continuous time approach

The paper proposes a new model-based optimization approach to improve the clinical efficiency of compensatory insulin bolus treatment in diabetic patients, aiming to mitigate the consequences of diabetes. The most important contribution of this paper is a novel methodology for determining the optimal parameters of insulin treatment, namely the size and timing of insulin boluses, to effectively compensate for carbohydrate intake. This concept can be seen as the so-called optimal model-based bolus calculator. The presented theoretical framework deals with the problem of optimal disturbance rejection in impulsive systems by minimizing an integral quadratic cost function. The methodology considers a personalized empirical transfer function model with static gains and time constants as the only parameters assumed to be known, making the bolus calculator more straightforward to implement in clinical practice. Contrary to other techniques, the proposed methodology considers impulsive insulin administration in the form of boluses, which is more feasible than continuous infusion. In contrast to the conventional bolus calculator, the proposed algorithm allows for maximizing therapy performance by optimizing the relative time of insulin bolus administration with respect to carbohydrate intake. Another feature to highlight is that the solution of the optimization problem can be obtained analytically, hence no numerical iterative solvers are required. Additionally, the continuous-time domain approach allows for a much finer adjustments of the insulin administration timing compared to discrete-time models. The proposed approach was validated in an in-silico study, which demonstrated the importance of systematically determined insulin–carbohydrate ratio and the relative delay between disturbance and its compensation. The results showed that the proposed optimal bolus calculator outperforms the traditional suboptimal formula.

Dominican Adolescents’ Preferences for Content, Design, and Functionality of a Mobile Application for Type 1 Diabetes Mellitus Self-management

ObjectiveThe purpose of this interdisciplinary study was to determine Dominican adolescents’ preferences for the content, functionality (i.e. food’s glycemic index list, and amount of insulin based on foods’ carbohydrate count), and design of a culturally and linguistically relevant mobile application (app) for type 1 diabetes mellitus (T1DM) self-management. The app would facilitate T1DM self-management education and support by addressing providers’ challenges in monitoring patients’ disease progression and promoting patient adherence to recommended lifestyle changes. Findings inform an app development process that considers the linguistic and cultural values, norms, and structures of people with T1DM and their providers in the Dominican Republic. MethodsPhone interviews were conducted with 23 adolescents (14 to 18 years of age), using a semistructured questionnaire. The research team conducted the data analysis using NVivo through a deductive and inductive approach. ResultsThe findings suggest that, regardless of the context, adolescents with T1DM desire similar features and functionalities in a self-management app. Overall, participants preferred an app with a graphic format that has accessible information, a straightforward design, and instructional videos. Participants also desired that an app provide information and reminders about proper eating and insulin administration timing and be a vehicle to access a social network to foster mutual support and encouragement. ConclusionsOur study highlights adolescents’ perspectives on components for inclusion in an app for T1DM self-management. Participants' recommendations for the app’s potential usability, contents, and design features will be used to guide the development of a new app to promote engagement and foster better health outcomes.

Improving the Timing of Insulin Administration in Adult Acute Care Patients

Background: The correct timing of insulin administration in diabetic patients admitted to the hospital is important for the prevention of transient and serious glycemic deviations that could lead to negative patient outcomes. In November 2021, a South Florida Hospital identified an area of opportunity for quality improvement related to the process of subcutaneous insulin administration. In addition to bar code scanning, manual verification of the insulin dose by the primary nurse and another nurse was required prior to administration. Patients were experiencing delays in the timing of their insulin dose and nurses were reporting frustration with the process. Methods: The project followed the Plan-Do-Study-Act (PDSA) cycle for performance improvement. Results: The change in medication administration workflow resulted in achievement of administering insulin within 30 minutes of the scheduled time. Ninety percent of the nurses surveyed reported improvement in their workflow when giving subcutaneous insulin to their patients (n=112). Conclusion: Interdisciplinary collaboration, innovation in education of the nursing staff, monitoring adherence to the process, and sustaining engagement among stakeholders contributed to the success of this initiative, resulting in improved workflow in subcutaneous insulin administration.

Management of Type 1 Diabetes in Children in the Outpatient Setting.

Management of Type 1 Diabetes in Children in the Outpatient Setting.

Pemberian Nutrisi Enteral sebagai Kontrol Glikemik pada Pasien Kritis di Unit Perawatan Intensif

This study aims to determine how to provide nutrition that effectively maintains the balance of blood glucose levels and glycemic control. This study uses a narrative literature review method by entering keywords into the Pubmed, Science Direct, CINAHL, Wiley, and ProQuest databases. The results showed that from the search results of 569 articles and obtained ten relevant and qualified pieces, then extracted using the DSVIA method. Provision of nutrition with the continuous method can lower the average blood glucose or reduce the incidence of hyperglycemia. Then the intermittent process significantly reduces hypoglycemia during the meal period, prevents hypoglycemia during the fasting period, and can reduce insulin requirements. In conclusion, enteral nutrition needs to be modified so that nutrition and insulin administration time can be practical and effective in controlling critical sugar levels.
 
 Keywords: Bolus Feeding, Continuous Feeding, Blood Glucose, Intermittent Feeding, Enteral Nutrition

C-Peptide as a Therapy for Type 1 Diabetes Mellitus.

Diabetes mellitus (DM) is a complex metabolic disease affecting one-third of the United States population. It is characterized by hyperglycemia, where the hormone insulin is either not produced sufficiently or where there is a resistance to insulin. Patients with Type 1 DM (T1DM), in which the insulin-producing beta cells are destroyed by autoimmune mechanisms, have a significantly increased risk of developing life-threatening cardiovascular complications, even when exogenous insulin is administered. In fact, due to various factors such as limited blood glucose measurements and timing of insulin administration, only 37% of T1DM adults achieve normoglycemia. Furthermore, T1DM patients do not produce C-peptide, a cleavage product from insulin processing. C-peptide has potential therapeutic effects in vitro and in vivo on many complications of T1DM, such as peripheral neuropathy, atherosclerosis, and inflammation. Thus, delivery of C-peptide in conjunction with insulin through a pump, pancreatic islet transplantation, or genetically engineered Sertoli cells (an immune privileged cell type) may ameliorate many of the cardiovascular and vascular complications afflicting T1DM patients.

Insulin Bolus Calculator: Lessons Learned from Institutional Experience.

Insulin bolus calculators have proven effective in improving glycemia and patient safety. Insulin calculators are increasingly being implemented for inpatient hospital care. Multidisciplinary teams are often involved in the design and review of the efficacy and utilization for these calculators. At times, unintended consequences and benefits of utilization are found on review. Integration of our insulin calculator into our electronic health record system was a multidisciplinary effort. During implementation, several obstacles to effective care were identified and are discussed in the following manuscript. We describe the barriers to utilization and potential pitfalls in clinical integration. We further describe benefits in patient education, time of insulin administration versus meal delivery, variations in insulin bolus for ketone correction, variation in care, and maximum bolus administration. Sharing lessons learned from experiences using electronic insulin calculator order sets will further our goals of improved patient care in the hospital setting.

Quality of care to institutionalized patients with diabetes in Italy: a national survey.

To evaluate the epidemiology of diabetes and quality of care of institutionalized patients with diabetes in Italian nursing homes. More specifically, to evaluate the adherence to the national/international guidelines for the management of older people with diabetes. Data related to the epidemiology of diabetes and the quality of care were collected from questionnaires sent to 41 nursing homes. Data were extracted from papers, electronic medical records and validated operating protocols regulating the management of patients with diabetes in various homes. Completed questionnaires were returned in electronic format and centrally processed. Out of 4692 residents, 906 (19.3%) had diabetes. Among these residents, excluding patients undergoing diet treatment, more than half were on insulin treatment (alone or in combination with oral antidiabetic agents). The critical findings can be summarized as follows: a lack of shared diagnostic-therapeutic protocols, specifically related to evaluation of frailty; the preparation of nutritional and physical activity plans; the clarification of the objectives of the treatment; the timing of insulin administration (frequent use of sliding scale); the frequency and timing of capillary blood glucose; metabolic control methods; hypoglycemia and hyperglycemia treatment; and the scant use of new drugs that do not cause hypoglycemia. Our data revealed substantial heterogeneity in the treatment of nursing home residents with diabetes in Italy with many discrepancies between what is recommended in the guidelines and real-world practice. The implementation of local diagnostic-therapeutic protocols shared by all caregivers should be encouraged and properly funded to overcome communication problems between doctors and nurses and eventually improve the quality of care for institutionalized patients with diabetes.

MON-663 Prandial Insulin Dosing Based on Carbohydrate Content Does Not Significantly Improve Glycemic Control in Hospitalized Patients with Diabetes

Introduction: Diabetes mellitus (DM) is a highly prevalent concern in hospital medicine. In-hospital hyperglycemia and hypoglycemia are common. Hospitalized patients have variable and unpredictable amounts of carbohydrate content in their meals. We hypothesized that order sets that allow for flexible dosing of prandial insulin using an insulin to carbohydrate ratio (ICR) would provide superior blood glucose control in the complex hospital environment. Methods: We performed a retrospective review of electronic medical records from a single university hospital. The hospital implemented new order sets allowing prandial insulin dosing based on an ICR and inpatient nursing staff received necessary training. We compared glucose levels over the first three days after admission in hospitalized patients prescribed prandial insulin either as a fixed dose or based on an ICR. Patients on fixed dose insulin were selected from a time 3 months prior to the implementation of ICR order sets, to avoid any bias in patient selection. Patients on ICR dosing were selected from 3 months after implementation of ICR order sets, to allow adequate time for initial implementation. Our inclusion criteria included patients admitted to both medicine and surgery services, with Type 1 or Type 2 DM, age between 18-80. Exclusion criteria included transplant patients, patients on insulin infusion, pregnancy, steroid use and dialysis. 65 patients were included in each group. Outcome measures included average blood glucose over 72 hours, fasting and postprandial hypoglycemia (<70 mg/dL) and hyperglycemia incidence (>180 mg/dL). Results: Average glucose over 3 days was 167 +/- 39 mg/dL and 162 +/- 33 mg/dL and did not differ between groups. However, a higher percentage of glucose values were in target range (70-180 mg/dL) in the fixed dosing group (67.9%) compared to ICR (62.5%, p=0.018). The incidence of hypoglycemia was low and did not differ between groups (1.2% in both). However, patients had more overall hyperglycemia with ICR dosing (36% vs 31%, p=0.018), particularly pre-lunch hyperglycemia (52% vs. 38%, p=0.007). Fasting glucose was similar between groups. Conclusions: In conclusion, our study demonstrated that prandial insulin administered based on ICR did not improve overall glycemic control or reduce incidence of hypoglycemia in hospitalized patients with diabetes. In fact, overall and post-meal rates of hyperglycemia were generally higher with ICR dosing. This could be related to inaccurate counting of carbohydrates or delayed timing of insulin administration as it was given after the food was consumed. Additional studies are needed to further evaluate the effectiveness of flexible meal dosing and the impact on patient satisfaction and staff workload.

Examining the Relationship Between Pre- and Postprandial Glucose Levels and Insulin Bolus Timing Using Bluetooth-Enabled Insulin Pen Cap Technology and Continuous Glucose Monitoring.

Background: Timing of insulin administration in persons using multiple daily injections (MDI) is self-reported. New technology enabling tracking and logging of insulin doses, combined with continuous glucose monitoring (CGM), may provide insight into the relationship between insulin administration and glucose levels. Methods: We performed a prospective observational study using Bluetooth-enabled pen caps, along with CGM, in participants with type 1 diabetes (T1D) on MDI to objectively assess the relationship between the timing of insulin administration and its impact on pre- and postprandial glucose levels for a 2-week period. Results: We evaluated 50 participants (age 40.3 ± 19 years; A1c 8.2% ± 1.5%, duration of T1D 20 ± 15 years). Thirty-seven percent of total boluses resulted in persistent hyperglycemia (glucose >180 mg/dL 3 h postprandially), while 10% resulted in clinically significant hypoglycemia (glucose <55 mg/dL 3 h postprandially) on CGM. Preprandial glucose levels at the time of the bolus did not correlate with postprandial glucose levels. Late boluses, defined as a rise in glucose of ≥50 mg/dL before a bolus, were seen two times/patient/week. Missed boluses, defined as a rise in glucose of ≥50 mg/dL without a bolus within 2 h, occurred 17 times/patient/week. Late and missed boluses were associated with worse glycemic control (A1c; R2 = 0.1, P = 0.02; R2 = 0.1, P = 0.02). Conclusions: The use of Bluetooth-enabled pen caps, with CGM, in persons with T1D on MDI can illustrate the relationship between insulin bolus timing and postprandial glucose. These data may help clinicians and patients understand the impact of timing of insulin doses on glucose levels and glycemic control.

Assessment of optimal insulin administration timing for standard carbohydrates-rich meals using continuous glucose monitoring in children with type1 diabetes: A cross-over randomized study.

Aims/IntroductionThe present study was an assessment of postprandial glucose concentration after carbohydrates‐rich meals using continuous glucose monitoring in 30 children with type 1 diabetes treated using continuous subcutaneous insulin infusion with a rapid‐acting insulin analog.Materials and MethodsOver a period of 3 days, participants administered simple boluses with different delay times between insulin administration and the beginning of carbohydrates‐rich meal consumption (meal no. 1 containing 197 kcal, no. 2 containing 247 kcal and meal no. 3 containing 323 kcal; containing practically no protein and fat). In the present cross‐over randomized study, we analyzed the average glucose concentration profiles in 5‐min intervals, mean glucose at insulin administration, mean glucose after 120 and 180 min, mean and peak glucose, glucose peak time, areas under the glucose and glucose increase curves, and time period lengths with glucose <50, 70 mg/dL, and >140 and 200 mg/dL.ResultsFor test meals at 20‐min versus 0‐min delay time, the study exposed a longer median time period to reach peak glucose (95 vs 65 min, P = 0.01) after meals. A tendency to the lowest peak and mean glucose, and the longest time with glucose within a normal range was observed in patients who administered bolus insulin 20 min before a meal.ConclusionsFor carbohydrates‐rich meals, administration of a proper dose of a rapid‐acting insulin analog is crucial. The influence of rapid‐acting insulin analog administration timing seems to be of minor importance in comparison with correct insulin dose adjustment; however, a tendency to achieve more balanced glucose profiles was found in a group who administered insulin 20 min before a meal.

Internal Experts Collaborate to Reduce Critical Hypoglycemia and Insulin Errors and Improve Insulin Administration Timing.

IN BRIEF “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a project aimed at reducing inpatient critical hypoglycemia episodes in a community hospital setting.

Evaluating an Order Set for Improvement of Quality Outcomes in Diabetic Ketoacidosis.

The timely management of diabetic ketoacidosis (DKA) is essential to avoid lengthy hospitalizations and poor clinical outcomes. There is often an absence of ownership for glycemic management in hospitalized patients, most notably in those with a diagnosis other than diabetes. Evidence supports the use of evidence-based DKA protocols. The purpose of this project was to determine whether utilization of an evidence-based order set versus an individualized provider approach for the treatment and management of DKA decreases resolution time and occurrences of hypoglycemia and improves clinical outcomes. Preintervention and postintervention retrospective reviews of the electronic medical record of 150 nonpregnant adult patients diagnosed with DKA allowed retrieval of relevant outcome data. Multiple events provided an intensive orientation and development of health care professionals for a systems approach to utilization of the evidence-based order set. Implementation of the institutionally approved evidence-based order set affirmed anticipated outcomes. Results showed improvements in the (a) total length of stay, (b) arrival to intravenous fluid time, (c) intravenous insulin initiation to discontinuation (resolution) time, (d) arrival to subcutaneous insulin administration time, (e) time from initial to sequential laboratory testing, (f) use of a basal, prandial, and correction insulin approach (physiological mimic), and (g) the incidence of hypoglycemia. Outcomes substantiate the importance and need for maintaining an evidence-based and systems approach for the management of DKA.

Evaluating insulin information provided on discharge summaries in a secondary care hospital in the United Kingdom

BackgroundPrescribing errors at the time of hospital discharge are common and could potentially lead to avoidable patient harm, especially when they involve insulin, a high-risk medicine widely used for the treatment of diabetes mellitus. When information regarding insulin therapy is not sufficiently communicated to a patient’s primary care provider, continuity of care for patients with diabetes may be compromised. The objectives of this study were to investigate the nature and prevalence of insulin-related medication discrepancies contained in hospital discharge summaries for patients with diabetes. A further objective was to examine the timeliness and completeness of relevant information regarding insulin therapy provided on discharge summaries.MethodsThe study was undertaken at a large foundation trust hospital in the North of England, UK. A retrospective analysis of discharge summaries of all patients who were being treated with insulin and were included in the 2016 National Inpatient Diabetes Audit was conducted. Insulin regimen information provided on discharge summaries was scrutinised in light of available medical records pertaining to the admission and current national recommendations.ResultsThirty-three (79%) out of the 42 patients included in the study had changes made to their insulin regimen during hospital admission. Eighteen (43%) patients were identified as having an error or discrepancy relating to insulin on their discharge summary. A total of 27 insulin errors or discrepancies were identified on discharge, most commonly involving non-communication of an insulin dose change (n = 8) and wrong insulin device (n = 7). Seventeen issues relating to completeness of insulin information were identified, including the omission of the prescribed time of insulin administration (n = 10) and unexplained insulin dose change (n = 4). Two patients who had insulin-related errors identified on their discharge summaries were readmitted to hospital within 30 days of discharge due to poor diabetic control.ConclusionsThis small-scale study demonstrates that errors and discrepancies regarding insulin therapy on discharge persist despite current insulin safety initiatives. Poorly communicated information regarding insulin therapy may jeopardise optimal glycaemic control and continuity of patient care. Insulin-related information should be comprehensively documented at the point of discharge. This is to improve communication across the interface and to minimise risks to patient safety.

Insulin preconditioning elevates p-Akt and cardiac contractility after reperfusion in the isolated ischemic rat heart.

Insulin induces cardioprotection partly via an antiapoptotic effect. However, the optimal timing of insulin administration for the best quality cardioprotection remains unclear. We tested the hypothesis that insulin administered prior to ischemia provides better cardioprotection than insulin administration after ischemia. Isolated rat hearts were prepared using Langendorff method and divided into three groups. The Pre-Ins group (Pre-Ins) received 0.5 U/L insulin prior to 15 min no-flow ischemia for 20 min followed by 20 min of reperfusion. The Post-Ins group (Post-Ins) received 0.5 U/L insulin during the reperfusion period only. The control group (Control) was perfused with KH buffer throughout. The maximum of left ventricular derivative of pressure development (dP/dt(max)) was recorded continuously. Measurements of TNF-α and p-Akt in each time point were assayed by ELISA. After reperfusion, dP/dt(max) in Pre-Ins was elevated, compared with Post-Ins at 10 minutes after reperfusion and Control at all-time points. TNF-α levels at 5 minutes after reperfusion in the Pre-Ins were lower than the others. After 5 minutes of reperfusion, p-Akt was elevated in Pre-Ins compared with the other groups. Insulin administration prior to ischemia provides better cardioprotection than insulin administration only at reperfusion. TNF-α suppression is possibly mediated via p-Akt leading to a reduction in contractile myocardial dysfunction.

A Prospective, Randomized, Open-Label Study Comparing the Efficacy and Safety of Preprandial and Prandial Insulin in Combination with Acarbose in Elderly, Insulin-Requiring Patients with Type 2 Diabetes Mellitus

By delaying absorption of carbohydrates, acarbose can reduce preprandial hyperglycemia and delay the emergence of postprandial hyperglycemia. To evaluate whether acarbose can shorten the desirable time interval between insulin injection and meals, 60 elderly (≥60 years) patients with unsatisfactorily controlled type 2 diabetes mellitus despite insulin use were enrolled in a randomized, open-label study of 16 weeks' duration. Two groups (n=20 each) were randomized to receive isophane protamine biosynthetic human insulin 70/30 injections twice daily 30 min before meals plus acarbose 50 mg once daily (Group A) or three times daily (Group B) before meals, whereas the third group (n=20) received isophane protamine biosynthetic human insulin 70/30 injections twice daily immediately before meals plus acarbose 50 mg three times daily before meals (Group C). The required insulin dosage at study end was significantly less in Groups B and C than in Group A. Both continuous glucose monitoring data and the patients' self-monitoring data indicated that blood glucose variability parameters were significantly improved in Groups B and C in comparison with Group A, but there were no significant differences between Groups B and C. The incidence of hypoglycemia was low in all three groups. The absence of a significant difference in glucose variability between Groups B and C suggests that the addition of acarbose permitted adjustment of the insulin administration time from 30 min before meals to immediately before meals-which may be more convenient for patients-without affecting glycemic control.

Insulin degludec: a novel ultra-long-acting basal insulin for use in Type 1 and 2 diabetes

The prevalence of diabetes, a chronic disease that currently poses a significant health burden in both developed and developing countries, is expected to increase significantly over the foreseeable future. In Type 1 diabetes, insulin replacement is absolutely imperative; in Type 2 diabetes, many patients will eventually require insulin replacement therapy to compensate for progressive β-cell failure and maintain blood glucose control. Even though currently available insulin analog preparations more closely mimic physiologic insulin needs when compared with neutral protamine Hagedorn insulin, many patients with diabetes still experience unacceptable glycemic control, in part owing to limitations in insulin therapy, such as hypoglycemia risk, weight gain and the need for patients to adjust their lifestyle to their insulin therapy. Insulin degludec, appropriately labeled as an ultra-long-acting basal insulin, promises to achieve similar blood glucose control to currently available preparations (glargine and detemir insulin), with a reduced risk of hypoglycemia and greater flexibility in the day-to-day timing of insulin administration. Greater flexibility in basal insulin administration and/or reducing hypoglycemia risk in insulin-requiring patients with Type 1 or 2 diabetes may facilitate insulin management for patients and physicians.

Timing of Insulin Therapy Affects the Inflammatory Response in Endotoxemic Rats

The aim of the present study was to determine whether timing of insulin administration influences the hepatic and serum proinflammatory and anti-inflammatory cytokines during endotoxemia stimulated by lipopolysaccharide (LPS). Eighty-one male Sprague-Dawley rats were divided into different time groups and insulin was given 30min pre-LPS administration or hour0, 1, 3, 6, 12, 24 after the induction of endotoxemia, respectively. Hepatic and serum proinflammatory cytokines IL-1β, IL-6, and TNF-α, and anti-inflammatory cytokine IL-10 were detected 24 and 48h after the induction of endotoxemia. Compared with sham control rats, serum concentrations of proinflammatory cytokines IL-1β, IL-6, and TNF-α and anti-inflammatory cytokine IL-10 significantly increased on 24 and 48h after induction of endotoxemia. Similarly, LPS administration also significantly increased the hepatic IL-1β, TNF-α, IL-6, and IL-10 protein concentration 48h after LPS injection. Compared with levels in positive LPS controls animals receiving saline, on 24 and 48h after LPS injection, insulin administrated ahead of 6h after LPS injection significantly decreased the serum IL-1β, IL-6, and TNF-a concentration (P < 0.05), and significantly increased anti-inflammatory cytokine IL-10 concentration (P < 0.05); hepatic IL-1β and IL-6 expression were (P < 0.05) significantly decreased compared with levels in positive LPS controls. But, the significant decrease of hepatic TNF-a expression and significant increase of hepatic IL-10 were only seen in the animals in which insulin was administrated at 30min pre-LPS or coadministrated with LPS. Insulin administrated 6h after LPS injection lost the ability to significantly reduce serum or hepatic IL-1β, TNF-α, and IL-6 concentrations. Insulin has a protective role in systemic inflammatory response syndrome related to sepsis, such as downregulation of proinflammatory cytokines and upregulation of anti-inflammatory cytokine production. However, timing of insulin administrated may change its effect of inflammatory response in endotoxemic rats. Insulin administrated 6h after LPS injection weaken the ability to protect inflammatory response related to sepsis.

Home-based subcutaneous continuous glucose monitoring in 10 diabetic dogs

A subcutaneous continuous glucose monitoring system (GlucoDay; Menarini Diagnostics) based on microdialysis was investigated for its clinical applicability in veterinary medicine. Ten diabetic dogs, referred as clinically stable, were equipped...

Insulin Pens vs. Vials and Syringes: The Pharmacist's Role in Individualizing Therapy

As pharmacists strive for tighter glucose control in their patients, several considerations exist including the selection of insulin delivery administration methods. Traditionally, insulin administration using vials and syringes has been common, but insulin pens are also a viable option. Insulin pens have been shown to increase patient autonomy, which may impact adherence. Elderly patients, who may suffer from dexterity and visual impairment, have been shown to prefer insulin pens because they are easier to use. Although insulin pens are more expensive per mL, some patients may find an economic advantage with insulin pens based on copays and beyond-use dating. In long-term care settings, the additional cost of insulin pens may be offset by the reduced insulin-administration time. Pharmacists are well suited to advocate for their patients and to help select the insulin administration method that considers individual limitations and fiscal realities, and will best support the patient's disease management.