So
once you’ve been inducted into the insulin-appreciation society, the
all-important question is which method of delivery?
In order to keep you up-to-date, Reality Check has taken a
look at the available options, and some others that “will be available
in five years” (yeah right!)
Contents
of this article:
(Skip down by clicking the link)
Syringes
Insulin Pens
Insulin Pressure Injectors
Pumps
Inhalable Insulin
Insulin
Patch
Implantable Pumps
References
and Links
THOSE
IN STORES NOW
Most
people take their insulin by injection with either an insulin pen
or the traditional syringe.
SYRINGES
Using
traditional syringes and vials of insulin was the only method available
until the 1980s. The main advantages of sticking with syringes
is that very little can go wrong-you can see the insulin you are drawing
up and delivering, so you are unlikely to inject protaphane when you
meant to inject humalog and you can verify that you delivered the
full dose visually. The syringes are extremely unlikely to malfunction
or be damaged by being dropped or hit. In addition, you can “mix” insulins in a syringe
(just don’t change the order of the mix) that may mean fewer jabs.
The
downsides of syringes are that it can take longer to draw up the dose
and the needle is very visible-which can be scary for people with
needle-phobia.
PENS
Insulin
pens are recommended as a “more discrete” way to carry and inject
insulin. They are devices that
look like a cartridge pen, with a needle on the end.
Users turn a dial and then press a plunger that inserts the
needle under the skin and delivers the desired dose of insulin.
Being able to “dial-up” a dose is quicker than drawing up a
syringe, if you are self-concious or needle-phobic they look a bit
less intimidating than a syringe and you only have to carry one item
around (so long as you only need one type of insulin at a time) rather
than the syringe and vial.
Some
companies have brought out more sophisticated versions of the pen,
for example, the Innovo which remembers the amount and time of your
last dose.
“Being
a fraidy cat when it comes to needles I find the pens great…If I go
out for dinner it is easy to slip into your pocket…I think it is fantastic…”
(Neal, Humapen Roadtest, on www.realitycheck.org.au/insulin-pen_test.htm)
The
downside is that they can malfunction, they are slightly more expensive
than using syringes and they can actually be bulkier than a syringe
and vial.
Al
tells us he is disillusioned with pens:
“Although
I was assured that the pen would be easier to use in public, it is
not. First off it is twice
the size of a regular needle…I can’t scrunch it down into as small
a space as I can a needle and insulin cartridge….Finally I used to
be able to jab the needle into my leg, squirt in the insulin and that
was it. Now I have to jam this
dirty big thing into myself, at right angles, and hold it there for
ten seconds…”
Baz
tells us “They (pens) are much handier than syringes, but the things
just won’t work all of the time…Have been using Humapens for a while
and in the past twelve months have had about 4 or 5 failures… Surprises
me because if it was a watch or a computer people wouldn’t stand for
that… but medical equipment, that’s ok to fail every two months!!”
INSULIN
PRESSURE INJECTORS
To
the best of our knowledge, these devices are no longer marketed in
Australia,
but there are still a few around and they are supported by the company
that originally sold them. These
devices use a mechanical spring to push a microthin stream of insulin
through the skin. Steve told
us he has been using his for more than 10 years
“When
they work well injections are truly painless but when they work badly
you can get serious bruising and or insulin loss…I’ve stayed with
it because it doesn’t do the damage that needles do (bruising
aside? Ed) doesn’t generate disposable waste and has some benefits
in terms of improved insulin dispersal.” Melissa (Forum
February 6 2002) agrees that “when it was good it was incredible but when it was
bad it was amazingly painful…”
These
devices seem to be prone to the same if not greater malfunctions than
the pens and people seem to love ‘em or hate ‘em.
The fact that they are no longer distributed in Australia seems to indicate that the market determined more people hated them
than loved them.
INSULIN
PUMPS
Insulin
pumps deliver insulin constantly (basal rate) and on demand to cover
food or correct a high sugar (bolus) through narrow flexible tubing
that ends in a canula just under the skin. The pump is about the size of a deck of cards
and resembles a pager; it is clipped onto a belt, waistband or other
handy bit of clothing.
The
main advantages are that it delivers a constant (basal) dose of insulin
throughout the day, the rate of delivery
can be set to compensate for your needs, eg a lower rate to avoid
1am hypos and a higher rate to overcome the dawn phenomena. Only rapid acting insulin is used so it overcomes
the peaks and troughs of the long acting insulins. As it constantly delivers a basal rate of insulin,
flexibility in meal times, skipping meals, sleeping-in etc can be
achieved without sacrificing control.
“Since being on the pump my bsls have been the best ever
for the past 50 years.” Sue RC Forum
The
downsides are the cost, at the moment the pump itself is covered by
private health insurance (through your hospital cover as a prosthetic
device), if you don’t have private health
cover it would cost approximately $6,000. The consumables required to run the pump, did
for quite some time cost $200 a month but are now government-subsidised
through the National Diabetes Services Scheme (NDSS). Pumps remain
more expensive than syringes or pens but are now much more affordable.
Click here for more details
of registering as a pump user and getting subsidised consumables.
As
the pump delivers a constant stream of quick acting insulin, if the
pump malfunctions or you pull out the infusion site or run out of
insulin, you will very quickly run out of insulin completely and the
risk of developing ketoacidosis is high. To avoid this you must be prepared to monitor
your bsl frequently (about 6 times a day) and carry insulin with you,
so that you can inject some insulin if your pump stops delivering
insulin. Greg sums it up on pumpoz,
“If
considering a pump, be serious about it.
It requires more testing…You must learn to carry adequate supplies
to do a quick infuse in the field and as now there is no long-term
insulin aboard if you have a tube failure or an infusion set tear
out, without proper remedy. Bsl will climb quickly and almost uncontrollably.”
Also
potential pumpers need to be aware that changing over to pump involves
a lot of work as it is quite different to injections and despite the
many happy pumpers (myself included) who wax lyrical about its advantages-it
is still a long way from a cure and requires a lot of work and a fairly
serious commitment.
Being
attached to a pump constantly-having this “weird shite hanging
out of you” as one of our forum correspondents so eloquently stated
is a real downside. You have
to carry this thing around with you, sleep with it and be prepared
to answer those “what’s that”, “is that a pager” questions.
Carolyn
sums up how many pumpers feel about the pros and cons of pumping “Since
getting the pump my control has been so much better, my bsl more consistent
and I love the freedom…Yes the cost is a big deal but the freedom
and control it gives more than makes up for it…”
The
book, Pumping Insulin by John Walsh has been recommended
as an invaluable resource for pumpers old and new. If you decide to
buy it, here;s a link to Amazon - if you buy it via this link here,
a wee bit of Amazon's profits will come back to Reality Check. Thanks.
COMING
‘SOON’ TO A PHARMACY NEAR YOU
INHALABLE
INSULIN
The
drug companies are working furiously to provide a practical method
of providing insulin as a powder to be inhaled through the mouth,
passing into the lungs and then into the bloodstream. At this stage, a satisfactory method to control
the dosage has not been developed, and there have been insufficient
clincial trials to assess the long-term effect on the lungs. In addition the current device is about the
size of a flashlight and “phallic looking” (another comment
from our discussion forum)-not very discrete.
An
interview with Rebecca, a young adult with Type 1 diabetes who participated
in a trial of inhalable insulin can be read on the Reality Check website:
Click here.
Some
insulin inhalers currently in development:
INSULIN
PATCH
Apparantly
the insulin patch is being worked on, which would deliver a continuous
low dose of insulin, whilst to deliver a bolus before a meal, users
could pull of a tab on the patch to release extra insulin.
The main problem is that the insulin has trouble penetrating
the skin (that’d be why we use needles!!) and I would imagine it would
be difficult to achieve adequate control of dosage.
IMPLANTABLE
PUMPS
These
are being developed by pump companies. Implantable
pumps are surgically implanted and delivers a basal dose of
insulin and a remote control gets the pump to bolus for meals (wouldn’t
like to mix up the tv and pump remote…). The advantage of this method is that the insulin
can go directly to the liver (just like insulin from the pancreas)
so enhancing its effectiveness.
The
most exciting potential development in pumping is the “artificial
pancreas”. This would combine
continous blood glucose monitoring with insulin delivery-to automatically
control blood glucose levels. Companies such as Minimed proclaim that they
are well on the way to perfecting this technology.
MORE
INFO (and
references for this article)
www.minimed.com
www.insulinpen.com
www.zoomph.net/diabetes.world/medijector.htm
www.realitycheck.org.au
www.diabetesliving.com/manage/dvcs.htm - website no longer active
Thanks
to all the posters on the Reality Check Forum who shared
their views and opinions so enthusiastically.
Last
updated September 26, 2005
