Living with diabetes in the new age

Dr Monashis Sahu, Fellow, American College of Endocrinology elaborates on insulin therapy and the various ways of administering it to manage diabetes effectively

Kavitha, a 52-year-old teacher was prescribed insulin for her uncontrolled diabetes. It made her feel angry as well as disturbed. Fear of insulin injections and feeling of guilt overwhelmed her. Like Kavitha, there are many people who fear insulin and try to avoid it at the cost of their health. It was not surprising to me as 50 per cent of my patients are reluctant to start insulin in the beginning. In fact, data from several studies indicate that 27 per cent to 73 per cent people with type 2 diabetes are reluctant to start insulin at beginning.

Insulin is a natural hormone produced by our body, lack of which in body causes diabetes. It is vital for the treatment for many people with diabetes. Relatively, a large percentage of world population, around 425 million people (IDF- 2017), is affected by diabetes mellitus. Out of which approximately 5-10 per cent are with type 1 diabetes while the remaining 90 per cent are with Type 2. For people diagnosed with type 1 diabetes, insulin is essential for life as body does not produce insulin at all. In case of Type 2 diabetes where there is a progressive destruction of the insulin-producing beta cells, most people eventually require insulin to attain their blood glucose levels in target range.

Research has shown that there is definitely benefit of early insulinisation in preventing complications and providing a better quality of life for people with diabetes. However, many people with type 2 diabetes like Kavitha are reluctant to start insulin even when it is utmost essential, for a number of reasons including fear of injections.

This is where the role of education, awareness and counselling comes in.Insulin as a medicine cannot be taken by oral route as pills as it gets destroyed in the gastrointestinal tract, although research is going on for this option on a rapid pace. The traditional and most predictable method for taking insulin is by subcutaneous injections, in layer of fat between the skin and the muscle. Historically, people with diabetes injected insulin using glass syringes with detachable needles. These needles were large, and injections were painful. However now a days, if one’s diabetes treatment plan includes insulin therapy, one can choose between various insulin delivery devices.  For increased compliance and comfort of people with diabetes many insulin delivery devices have been developed, including insulin pens and pumps.

Insulin Injections: Today, insulin injection syringes available in the market are derived from plastics, are light in weight, disposable and have fixed micro fine needles. These syringes increase patient comfort and offer convenience, still many people find syringes daunting and not very convenient.

Insulin pen injectors: These are a convenient way of administering insulin. The first insulin pen (Novo Pen) was introduced by Novo Nordisk in 1987. Many pens are available since then in a variety of types and shapes. Pens offer not only, comfort and accuracy but also convenience to use and carry since they combine the insulin container and the syringe into a single unit. The pens are discreet and popular as one can carry them along with them without anybody noticing. There are two main types of pens, one that is reusable and the other a prefilled device. In the former case, the patient must load an insulin cartridge prior to use. Reusable insulin pens offer a wide range of advantages such as their durability, cost effectiveness and eliminating the need of cartridge refrigeration and flexibility in carrying three to five-day supply. The prefilled insulin pens are smaller in size and lighter in weight. Prefilled pens are ready to use, eliminating the step of loading insulin into the delivery device.  Pen causes minimal pain due to the finest and shortest disposable insulin needles. The needles for pens are available in varying lengths (from 4 mm to 8 mm) and varying gauges (from 29- to 32-gauge; the larger the gauge number, the smaller the diameter of the needle bore).

External insulin pumps: These are small devices the size of a pager that can be attached to your belt or placed in pocket. An insulin pump delivers infusions of insulin through a catheter placed in the layer of fat under the skin of abdomen. The catheter needs to be changed every two to three days.  Pump is programmed to deliver a continuous (basal) dose of insulin and supplemental (bolus) doses before meals. Although insulin pumps provide accuracy and greater flexibility in insulin delivery for patients according to their individual requirements, one needs to check his/her blood sugar level every three to four hours to determine how much insulin one need. Pump is advantageous for people who do not like injections as it is only necessary to insert a needle once every three to four days. insulin patches, insulin sprays, either for the nose or mouth, and oral insulin (insulin pills) are methods of insulin delivery that continue to be investigated. These options along with stem cell transplant represent long-term possibilities for insulin delivery, as difficulties in obtaining adequate amounts of insulin in the bloodstream are yet to be overcome.

Education about all aspects of managing diabetes and counseling about living with the disease is essential. It is important that patients are given the opportunity to handle the types of devices available and choose the one that best suits their need for better compliance. Most trials indicate that insulin pens are a widely accepted, economical and accurate device for taking insulin. Users just need to turn a dial to select the desired dose of insulin and press a plunger on the end to deliver the insulin just under the skin.   Thus, insulin pens can be called as a new bottle for old elixir.

When taking insulin is essential, insulin delivery devices like pens play the role of a friend for people with diabetes. Kavitha also accepted the pen and by taking proper doses of insulin along with diet and exercise management, she felt that her own self was back with more energy and happiness, she felt more healthy as well. It is very essential for management of chronic diseases like diabetes; one must accept the situation and many wonderful solutions are here to assist the person.