Three bites into my enchilada my mother asks me, "Did you take your insulin?"

My first response is to glare at her. I'm 50 years old fer' God's sake. I don't need to be reminded to take my insulin. My second response is to realize that I'm not sure whether or not I did take my insulin. After all, five to six shots a day, 365 days a year, adds up to something well over 2,000 shots annually. They blend together, one pretty much like the last, and each pretty much like the next.

In the past, I'd wrack my brain to remember. But until my blood sugar either shot up or stayed where it belonged, there was no way to know for sure whether or not I'd forgotten my insulin.NovoPen

Now, thanks to a sleek new sleek royal-red insulin pen that hit the market in January, with a swift flick of my thumb have the answer: I took 2.5 units of Novolog minutes ago.

It's not an app. It's not a pump. It's a super-pen from Novo Nordisk called the NovoPen Echo, one of which I've been test-driving lately. It's the world's first half-unit dosing pen with a memory. Echo is not unique in delivering half-unit drips of insulin; Lilly makes a half-unit re-fillable pen called the HumaPen Luxura HD, and Novo themselves have made the NovoPen Junior, another half-unit re-fillable pen, for years. A pen with a memory is not a new idea either. Lilly at one time offered the HumaPen Memoir that stored dosing info. But combining half-unit with memory is something entirely new.

The Echo is billed as a tool for kids, but there are plenty of adult type 1s like me who take fast-acting insulin from a pen. Why wouldn't we want to be more accurate about it too?

{Note: Echo is only new to the USA, it's been use in the rest of the civilized world since 2010.}

NovoPen Echo Photo from Wil

Quick additional background: Refillable pens have been around since 1985. They are mechanical devices that hold a pre-filled glass cartridge of insulin called a penfill, use pen needles for delivery, and delivery is set by dialing up a dose on the non-business end of the pen. While eclipsed by their disposable brethren in recent years, the traditional pen is more landfill-friendly, may be cheaper over time depending on your health insurance, and is considered more accurate by some experts. And, of course, if you want half-unit delivery in a pen, there's no disposable alternative.

Novo has also launched a full-unit dosing pen with a similar memory feature called the NovoPen 5, which I haven't tried (or even seen yet), but I would assume it is similar to the Echo in overall design and operation.

So how does the new Echo compare to other half-unit pens? And how does it compare to other memory pens of the past?

First Impressions

Size-wise, the Echo is nearly identical in length and diameter to the Novo disposable Flexpen—no mean feat, given the added technology. This makes it both shorter and substantially thinner than the competing Luxura. Of course, the Echo weighs more than its plastic doppelganger, because the Echo has a sturdy metal barrel and cap. But even with a full load of insulin, it's no heavier than a good quality fountain pen. In both appearance and handling, it exudes quality.

Novo coated its new hot-rod of a pen in a hot-rod metallic burnt orange-red with deep ash-grey accents. Their previous half-unit pen had daisies on it, under the assumption, I suppose, that only kiddos need half-unit dosing. I'll wear a pink shirt and I'm not afraid to eat quiche, but I will not take insulin from a pen covered in daises. A man has to put his foot down somewhere.

To my eye, the Echo has pretty sexy lines. It looks and feels classy, modern, and well-built. Someone clearly spent some time on the cosmetic design, as well as on the internal features.

On the rest of the planet, theNovoPen Echo Color Skins Echo also comes in blue, so you can put your basal insulin in one color and your fast-acting in another to avoid killing yourself by mixing them up. Here in the USA, Novo doesn't sell its Levemir basal insulin in penfills so I guess that helped make the choice to import the Echo in only one color, the redish-orange. Pity, the blue would have matched my wardrobe better.

You can also get pen skins to personalize the pen. They are called (groan) Echo®Skins. No kidding. Globally there are 24 to choose from, but currently in the USA we're limited to a dozen and you can get two each year for free if you join their also-free support program called NovoLog®Reach, which also includes all kinds of other cool free stuff for members.

Some of the skins are very kid-like. We're talking yellow Teddy bears and pink elephants here. But there are also sports-themed skins, a USA flag skin, a solid orange skin, some teen-girl style skins, and a pretty cool piano keys skin. But no plain blue.


The pen holds a 300-unit pre-filled glass "penfill" cartridge of Novolog, and in case you were wondering, the Lilly and Novo penfills aren't compatible so you can't put Humalog in the new Echo.

Getting the Echo ready for action is easy. In a departure from the traditional screw-off holder (the top half of a refillable pen), the Echo uses a bayonet connection like many camera lenses. You un-bayonet the holder, slip in a penfill, re-attach the holder, then advance the plunger. Once you've got it loaded you leave it alone until it's empty: However long it takes you to use up 300 units, or one month, whichever comes first. After you've used up a penfill and removed it, returning the plunger into the base is a simple push instead of the endless cranking of the piston rod required on most refillable pens.

To shoot up, slip the cap off the pen and screw on a pen needle. Of course, Novo tells you not to reuse the pen needle, and of course I do anyway, so I was glad the engineers made the Echo's cap long enough that you can re-cap the pen with a needle in place. Next, with Echo, you need to do an "airshot" to prime the needle. I've never done this with any pen in the past, but the Novo literature emphasized it on nearly every page of the 28-page manual for this pen. So the first few times I used the pen, I did do airshots, and to my surprise, many times a half-unit or one-unit airshot left me with a dry needle tip (with a 4mm BD Nano, no less), so there must be something unique about the design of the pen that requires the priming.

Next you spin the rotating dial at the base of the pen to set the dose, slideNovoPen Echo Comparisons the needle into your skin, and depress the butt of the pen in a single smooth click. Unlike all of the mechanical re-fillable pens I've used in the past, there's no downward "ratcheting" action to inject. It's way cool-simple and smooth, doesn't take too little or too much pressure, and is reassuringly syringe-like.

You can set the Echo's dose up to 30 units, and even at a full 30 units, the pen's base extends outward from the body by only hair under half an inch. A 30-unit push on a Novolog disposable flexpen, by comparison, extends about three-quarters of an inch. Each half-unit makes a satisfying click as you spin the dial, but the literature from Novo cautions the user not to use the clicks to set the dose, but rather to always use the scale window to view the dose. This is at odds with their other pens, where the clicking sounds are bragging points on the utility of their pens for the vision-impaired.

Oh, and in an improvement over the competing Luxura: As you run low on insulin, the Echo will not let you dial up more insulin than is left in the pen. The counter freezes at the remaining volume once it drops below 30 units.

Of course, as with all pens, during the injection process, you need to hold the needle in your skin for about six seconds. If you don't believe me, take a pen, hold it at eye level (the lawyers say I have to remind you to point it down, not towards your eyes) and inject. You'll be surprised by how long the stream of insulin lasts after your thumb has rammed the plunger button home.

But in what might be the most important improvement over the NovoPen Junior, the Echo is accurate at just a half-unit. That is, the older pen was only accurate at half-units beyond the first full unit. I don't know about the rest of you, but there are plenty of times when a half-unit is just what I need.

So the Echo is as accurate as the Luxura, while being thinner, lighter, and sexier. But Echo raises the bar even higher by sporting a memory function.

About That Memory

The Echo has a very liNovoPen Echo Capmited memory, but it might just be better than mine. The pen only remembers the very last thing it did. So it's only purpose in life is to tell you what you need to know when you are three bites into an enchilada and can't remember if you've taken your insulin or not.

To activate the Echo's memory, you "flick" the dose button on the base up and down, turning on an LCD screen at the butt end of the dial. The screen shows how many full and half units you last took. A clock-like graphic surrounds the volume readout to indicate how many hours ago the shot was taken, up to 12 hours. If your last shot was more than 12 hours previously, the display just shows it as 12 hours. The display stays on for ten seconds. It's a bit small for my trifocal-assisted eyes, but it's pretty slick. I wish it had a backlight, but I guess that would gobble up the batteries too quickly. Oh, speaking of batteries, you can't change them. Novo says they'll last for 4-5 years. According to the manual, when they start to run low, the pen will warn you.


The manufacturer's suggested retail price for the Echo is $54.00, but I'm told many pharmacies are selling them for more. Co-pays vary with each health plan -- yada, yada.


I like the Echo a lot, but it does have some negatives. First, having to give the damn thing an airshot before each injection is a pain in the ass. I'm also not too keen about the design of the carry-clip. Like the NovoPen Junior, Echo has a plastic clip that I refer to as the Echo®Clip (OK, I made that one up, but Novo is really trying to elevate the registered trade mark symbol to a bonafide punctuation mark with the status of a hyphen). I carry my pen in the right front pocket of my jeans and the sturdy metal clip on the Luxura has never let me down. I worried for day one that Echo's plastic clip might break. It has not done so yet, but has twice failed me by coming loose.

Recently, after stopping in at the local pharmacy to pick up some meds, I found my pen lying on the ground next to my car. Several days later, while I was walking across a parking lot, the Echo worked its way loose and again fell out of my pocket. This time I heard it clatter to the ground, but if I had been walking over softer turf it would have been lost forever.

Another thing that concerns me is that in the period of a week, the pen has used 50 units more insulin than my RapidCalc tracking app says I've used. Now some of that is due to the airshots. And some of it might be due to the fact that the pen has a better memory than I have. Who's to say how many times I forgot to log my dose in my iPod app? Still, all of that combined doesn't really add up to that much insulin. I haven't had any out-of-the norm lows, so I'm not worried about delivery accuracy, but it's looking like I'm on track to use up a penfill in half the time I'm used to, which makes me wonder if the pen doesn't leak in some way I haven't figured out yet.

Despite all of that, at least until I lose the damn thing, I will keep using it. I like the memory. I like the action. And I really like the slimmer size.

But I still want a blue one.

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