Clinical Briefs
April 15, 2016 3 minutes read
Misadministration of Insulin: How Much of a Problem?
SOURCE: Trief PM, et al. Incorrect insulin administration: A problem that warrants attention. Clin Diabetes 2016;34:25-33.
According to data reported by the CDC in 2015, insulin is a component of the glycemic control regimen of approximately one-third of all diabetics. Because hypoglycemia is responsible for a significant number of emergency care visits, misadministration of insulin (e.g., incorrect dosing, missing meals, inappropriate dose escalation, inappropriate injection administration, or rotation) is often a cause.
To clarify the role of insulin misadministration among experienced users, Trief et al contacted 60 adults who had self-administered insulin for at least 2 years (mean = 15 years). The authors asked these individuals to demonstrate their insulin injection technique. More than 90% of participants reported they were moderately-very confident in their ability to properly inject insulin.
Investigators found that syringe users made fewer errors in preparation and drawing insulin than insulin pen users. About 20% of the time, users drew an incorrect dose. Over 25% of subjects did not consistently rotate injection sites. More than 10% of participants acknowledged using expired insulin.
These experienced insulin users were highly confident in the correctness of their insulin administration. The authors suggested that the insights provided by this study should prompt providers to ask for a demonstration of insulin administration technique, even in highly experienced users.
Comparing Smoking Cessation Pharmacotherapies
SOURCE: Baker TB, et al. Effects of nicotine patch vs varenicline vs combination nicotine replacement therapy on smoking cessation at 26 weeks: A randomized clinical trial. JAMA 2016;315:371-379.
Pharmacotherapy for smoking cessation is only modestly effective. Clinicians often want to intensify smoking cessation pharmacotherapy in an effort to enhance cessation rates. Does it make a difference?
Baker et al randomized adult smokers (n = 1086) to one of three regimens: varenicline alone (VAR), nicotine replacement therapy patch (NRT-P) alone, or NRT-P plus nicotine replacement therapy lozenge (NRT-L) combined (NRT-P + NRT-L). Subjects were treated for 12 weeks.
Outcomes were measured at 26 weeks and again at 52 weeks. At both endpoint measurement times, there was no significant difference among the three treatment arms: Abstinence rates hovered closely around the 20% mark for each of the interventions at both points in time.
Since the two monotherapy arms were as effective as intensified nicotine treatment (NRT-P + NRT-L), the additional expense and complexity of the latter treatment does not appear to be justified.
Ambulatory BP Monitoring to Diagnose Hypertension
SOURCE: Bloch MJ, Basile JN. Ambulatory blood pressure monitoring to diagnose hypertension — an idea whose time has come. J Am Soc Hypertens 2016;10:89-91.
The United Kingdom Guidelines on Hypertension issued by the National Institute for Clinical Excellence and Health recommended use of ambulatory blood pressure monitoring (ABPM) as early as 2011. By their calculations, requiring the country’s general practitioners to routinely confirm blood pressure (BP) elevations through ABPM would lead to significant annual financial savings. Why? Because as many as one-third of patients originally diagnosed as hypertensive based on office BP measurement turn out to have white-coat hypertension and do not require treatment at all; hence, inexpensive ABPM makes sense.
Even the United States Preventive Services Task Force in its 2015 recommendations designated a level “A” recommendation to out-of-office BP monitoring to establish the diagnosis of hypertension, preferably ABPM, but home BP monitoring if ABPM is not available.
ABPM is an inexpensive (generally in the range of $125-$150), noninvasive tool that reduces the treatment of patients with office BP elevations, which do not merit treatment. In addition to this benefit, it has been recognized for more than a decade that BP elevation as defined by ABPM is a much stronger predictor of cardiovascular outcomes than office BP measurement. We should follow the lead of our U.K. colleagues and perform ABPM (or at least home BPM) on a much more routine basis.
In this section: the insulin misadministration problem; comparing smoking cessation pharmacotherapies; more support for ambulatory BP monitoring.
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