Missed and Mistimed Insulin Doses in People with Diabetes: A Systematic Literature Review

Background: Development of coordinated management approaches is important to facilitate self-care in people with diabetes (PwD). Gaining a better understanding of suboptimal insulin use is key in this endeavor. This review aimed, for the first time, to systematically identify and narratively summarize real-world evidence on the extent of suboptimal insulin use (missed and mistimed insulin) in PwD. Methods: A systematic literature search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews identified studies reporting on missed and mistimed insulin dosing. Results: From 3305 studies, 37 publications reporting on 30 unique studies that involved 58,617 PwD were included. Studies were conducted across 12 different countries and most employed cross-sectional surveys. Observations regarding missed and mistimed insulin doses were reported in 25 and 10 studies, respectively. PwD reported missing insulin doses, but rates varied due to differences in reporting methods, participant populations, and insulin regimens. The association between missed dosing and glycemic control was evaluated in ten studies in which the authors reported lower glycated hemoglobin (HbA1c) levels in PwD who did not omit insulin. The proportion of PwD reporting mistiming of insulin was in the range of 20-45%, depending on the study; this was associated with higher rates of hypoglycemia and higher HbA1c as reported by study authors. Reasons for suboptimal insulin use were multifactorial, occurring due to disrupted daily routines, social situations, and hypoglycemia avoidance. Conclusions: This review suggests that suboptimal insulin use is widespread and that PwD using insulin may still be struggling with disease management. There is an unmet need for better integrated support in managing the complexities of insulin therapy and for the development of systems (e.g. digital solutions) that empower people to take control of insulin-treated diabetes.