Insulin delivery: Needles get competition from pens, pumps, patches, and sprays

Key Points

Insulin injections are here to stay. That's the blunt warning from Jerry Meece, pharmacist, certified diabetes educator, and director of clinical services at Plaza Pharmacy and Wellness Center in Gainesville, Texas. But just because Exubera (inhaled insulin, Pfizer), the first non-injected insulin on the U.S. market, was killed for lack of sales, it does not mean that there are no alternatives to syringes and vials.

Wall Street was not wowed by inhaled insulin either, Leerink Swann diabetes analyst Jonas Alsensas said. Exubera's only strength was novelty. "Exubera didn't offer significant clinical advantage since it used regular insulin," he said. "And the device was unfortunate. There was no reason to carry around a fire extinguisher-sized gadget when there are more portable alternatives."

Those more portable alternatives use needles, usually in an insulin pen. According to a 2008 market study by information analysis company RNCOS, pens deliver 94 percent of all insulin units in Japan, 86 percent in Europe, and 14 percent in the United States. "We got a late start with pens," John Buse, MD, PhD, American Diabetes Association president for medicine and science, said. "Lilly didn't have the best pens years ago. Sanofi launched a pen that met with a good deal of resistance. Now all the manufacturers have great products. And they're starting to tell prescribers about them more effectively."

Meece said that more effective marketing is key to converting patients. In Europe and Japan, patients with diabetes are commonly treated by care teams that include endocrinologists and pharmacists. Both groups are familiar with delivery options. In the United States, diabetes is usually treated by primary care physicians who are more familiar with drugs than delivery. "Next to pumps, the most accurate and economic delivery route we have is the insulin pen," Meece said. "Pharmacists know that, endocrinologists know that. Primary care docs are just starting to see that message."

Cost is another key factor. Payors outside the United States have long covered pens because they are more cost-effective than syringe and vial delivery.

Pumps and patches

Dr. Buse said insulin pumps are another hot delivery technology. Once the insulin delivery schedule is set, administration is precise, and no drug is wasted. The ultimate goal of pump delivery is closed-loop glucose monitoring/sensing and insulin delivery. A 24/7 closed-loop system is still years in the future, he said, but patients can expect automated overnight monitoring and delivery in the very near future.

For now, Dr. Buse said, size remains the most important factor. Smaller is better. One of the smallest is a patch pump called OmniPod. Pump, reservoir, and cannula sit on an adhesive patch (1.6 inches by 2.4 inches by 0.7 inches) stuck to the skin. A wireless PDA-sized control unit is carried in pocket or purse. "The companies that don't have patch pumps are working on them," he added.