Happy Saturday! Welcome back to Ask D'Mine, our weekly advice column hosted by veteran type 1, diabetes author and community educator Wil Dubois. For the first post of November, Wil puts his finger on a universal question for PWDs: Should we really poke our pinky finger with lancets? He also opines on the state of the market in comparing insulin pens versus syringes.

{Need help navigating life with diabetes? Email us at AskDMine@diabetesmine.com}

 

Claudia, type 2 from California, writes: I've just read your book "The Born-Again Diabetic" and, yes, I am now born-again and determined to stay "born" with the help of all the information you put out. On page 37, you say to avoid the little finger for fingerstick tests. Why is that? I have used all my fingers for sticks and the only thing I've noticed is that I usually get a much better blood flow whenever I use a little finger. It's a minor point, I'm sure; but, still, I'm curious to know the answer.

[I swear to God I did not pay her for that endorsement—WilD]

Wil@Ask D'Mine answers: True confession: I've never read my book. Well, not as a finished product, anyway. Writing a book is an exhausting task. That book actually started off hand-written in yellow legal-sized notebooks. Then I typed the first draft into a computer. Then there were many rounds of editing, tweaking, re-writing, reading, revising, re-reading, proofing, re-re-reading. I'm very proud of the final product, of course, but by the time it was done, I was sick to death of it. (And even with all that hard work there is a typo on the front cover.)

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Let's go back and see what I said....

Flip-flip-flip-flip...page 34, page 35, page 36... Ah ha! Page 37.

"The pad of the finger has more nerve endings than the sides or tippy-top. The tippy-top has more nerve endings than the sides. Ergo: if your fingers are sensitive, test along the side, parallel to the fingernail. Avoid the little finger, but otherwise don't play favorites. Hit a slightly different area on a different finger each time you test." [Note: the bold is added for today's discussion.]

Well, no wonder you're confused. I was as clear as mud about my reasons for avoiding the little finger. In fact, I didn't give a reason at all, and the truth is there is no valid medical reason whatsoever to avoid it. The capillary blood there is just as good as it is in any other finger, and as you yourself noted, blood flow from the little finger is no problem. But for most people, the pinky has the densest concentration of nerve endings of all the fingers. In plain English: poking the pinky hurts. Or at least is more likely to hurt than poking any of the other fingers.

Back then (the book was written during 2007 and 2008) I never used my pinkies at all. Now that my other eight fingers are more callused, worn out, and covered with little black badges of honor, I do find myself going to the pinky more, especially for nocturnal tests in low light—to make sure I have enough blood and don't waste one of my $1.30 iBG Star test strips like happened last night. Grrrrrrrrr....

I still caution my patients to avoid the pinky in general, but the reality is that you can use any finger that works. I think if you're still new to the party, or testing lightly, avoiding the little fingers is a good idea. But as you become a seasoned vet, and if you test a lot, pinky pokes become less bothersome. Of course another issue is how often you change the needle in your lancing device. The more you put it off, the harder it can be to get blood while at the same time, the more painful it can get. And, of course, some lancing devices are just plain better than others.

Oh, and thanks for the kind words, I'm glad you found the book helpful, and it was nice for me to revisit it. Kind of like bumping into an old friend you haven't seen for a while. You know, recently a doctor friend of mine, who was worried about my stress level, gave me his personal prescription: "Take some time off and read a good book you didn't write."

Maybe instead I'll sit back and re-read a good book I did write.

 

James, type 2 from Michigan, writes: I have used Lantus insulin for a period of time now, and am still using vials and syringes, but am constantly asked why I am not using the preloaded pens. I use between 2 and 3 syringes per week, but have been questioned as to why I do not use a new syringe at least daily. The pens are used over multiple injections, so I don't feel too bad about using my syringes more than once. Can you discuss the differences between the two systems and related costs? Our local pharmacy either can't or won't answer that question. I suspect that as things progress, the old system of vials and syringes may not always be available, thus becoming more expensive? As pens take over in the market place, they will probably become the method of choice and see a price reduction over time, but for now - how do the two systems stack up against each other for performance and cost?

Wil@Ask D'Mine answers: This is a very cool question, and one I happen to be well informed on at the moment. This summer I attended the Keystone Conference, a clinical education program for medical professionals, and the pens vs. syringes debate made the whole Dems vs. Republicans thing look like a side show. Fully 62% of Americans who use insulin still use syringes. The delegation from China couldn't believe their ears in their country, pen use stands at about 98%.

So why do Americans love their syringes so much? Actually, in general, American patients hate, hate, hate the venerable needle. It's insurance companies who love syringes, as in the vast majority of cases they're cheaper than pens.

Here's how the math works: A vial of insulin has 1,000 units of joy juice, while a pen comes pre-loaded with 300 units. Using your Lantus as an example, according to Epocrates on my iPod, the average retail price for a vial of Lantus is $118.99, while a box of five Solostar pens is $224.68. That means Lantus in vials costs about 12 cents per unit, while in pens it costs about 15 cents. (If you average all types of insulin, the per-unit cost for pens is 30% more.) The only time a pen is cheaper is when a patient uses little enough insulin that a significant part of a vial has to be thrown away unused at the end of the month when it "expires."

Wait a sec, you say, that's only a three-cent difference in cost! Why would a health plan care? Because pennies add up quickly. If you shot a typical type 2 dose of 80 units a day of Lantus at three cents a unit, your insurance company can save themselves $72 per month, or $864 per year, by making you use syringes rather than pens. When you consider how many people use insulin, these kinds of savings add up to a princely sum indeed. Millions of dollars. Fully a quarter of the 18.8 million diagnosed people with diabetes in the USA take some sort of insulin. Ka-ching!

Not that I'm accusing the health plans of being greedy or anything.

So, trust me, pens are in no danger of "taking over the marketplace" any time soon. The marketplaceis ruled by the laws of economics, not by what may or may not be best for patients. More on that in a minute. For what it's worth, the old system isn't so old anymore, either. There are technological advances happening in the old system, with syringe needles getting shorter and thinner with each passing year. The people who make syringes are quite confident that they will be in the game for years to come and are betting on it with their pocketbooks.

Actually, to be honest, I'm amazed that the price gap between vials and pens is as narrow as it is. First, think about what goes into a vial. It's a glass bottle. Pretty much a miniature version of the technology that's been around since they started bottling Coke back in 1894. Insulin vials have remained fundamentally unchanged for 95 years. It's a passive receptacle. A pen, even a disposable one, is a device. It's full of moving parts. It's a receptacle and a delivery system in one. It's a lot more complicated and expensive to make than a doll-sized Coke bottle.

But beyond cold, hard cash, there's something else that we need to think about. We Americans are big people. Both tall and, frankly, fat. American type 2s need a lot more insulin than Chinese type 2s. A Levemir pen can only deliver 60 units in a single shot. A Lantus pen can do 90, but can only do it three times before it's empty. Pens make a hell of a lot of sense for fast-acting meal insulin, or for people who need sparing amounts of basal; but they aren't necessarily the best choice for the typical type 2 using a boatload of basal insulin.

That pretty much covers cost. You also asked about performance. Several studies have shown that pens reduce dosing errors and increase compliance. And teaching someone to use a pen is a lot faster. If you remove the human factors (which, arguably, in this case you shouldn't) the two devices are equally accurate. Some will argue that with the hydraulic vs. mechanical nature of how they function, the syringe should trump the pen, but in reality, when used right they are much the same. For that matter, when used wrong consistently, it also really doesn't matter either. The dose is adjusted to a target. So long as you use your pen or syringe the same way each time, it really doesn't matter if you use it "right" or if you use it "wrong."

Lastly, about duration of use... In theory, the two platforms are actually the same. It isn't really fair to say that because preloaded pens are used for multiple injections that syringes should be treated the same way. That's because a pen has no needle. The business end of a pen is flat. You screw on, or snap on, a separate, disposable, allegedly one-shot-use pen needle on the tip of the pen for each injection. (Btw, back to pennies and sense, a pen needle and a syringe cost roughly the same.) And most modern insulin syringes do not have removable needles. So both platforms are intended for one-time use, and the people who make both tell you to use each one time and one time only. But of course, that's not what happens.

Personally, I couldn't care less if you use your syringes several times. I use a single pen needle on my Luxura all day long, taking on average 7 injections with it. My feeling is you should change the needle when it hurts.

In a perfect world, it should be left up to the PWD and their medical team to make the choice of pen vs. syringe. But that's not the way it is. The health insurance company makes the decision for most PWDs. Not the patient. Not their doctor.

I hear a lot of people lately wailing, rubbing their hands, and worrying about big government being in their healthcare. Doesn't it bother you that Wall Street is already there?

I'll take Capitol Street and Pennsylvania Avenue involved in my healthcare over Wall Street any day.

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

 
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