Insulin delivery devices represent technological advances in drug delivery systems that have offered diabetes patients with alternatives to the syringe. When one in every eight adult Indian is a diabetic. sedentary lifestyle and unhealthy diet contribute to an increasing number of Indians falling into the diabetic trap. Most of the people with diabetes will require insulin over a period of time for better management of blood sugar and quality of life.

Insulin is the most effective therapy for better glucose control and is a vital treatment for people with diabetes. However large population studies from India have shown that majority of people with type 2 diabetes (the most widely prevalent form of diabetes) require insulin and nearly 70% of such people do not take insulin because of fear hypoglycemia (low blood glucose), inconvenient injection timing with complex regimens and fear of injection.

When a patient is advised by the physician to get onto insulin therapy, the patient can prefer either the durable (reusable) devices or disposable pre-filled (use-and-throw) devices. Durable devices come as a sturdy and safe pen for longer use. The disposable pre-filled devices, are much the easier to use and are the best way to initiate insulin injections.

Historically, patients injected insulin using glass syringes with detachable needles. They had to boil the syringes and needles between injections and store them soaked in alcohol to keep them sterile. These needles were large, and injections were painful. The advent of the disposable plastic 'diabetic syringes' with a fixed needle represented a considerable advance and injections were less painful. They did, however, have a number of disadvantages, and doses and administration practices were often inaccurate.

This was partly because of the range of insulins available and the need to mix each dose of short- and longer-acting insulin in the same syringe at the time of injection. The advent of biphasic insulin made drawing up insulin doses easier and less confusing for patients.

The last five years have seen an increase in the range of insulin delivery devices. These devices have revolutionized insulin self-care. One of the most significant advances has been the production of short, fine needles as they considerably reduce injection pain. In practice, patients report that blood glucose testing is more painful than insulin injections.

There are various studies which have reiterated the benefits of early insulin initiation. Such studies involving hundreds of doctors and thousands of patients have helped us understand the perceptual barriers to insulin initiation among healthcare providers and patients. One of them, the iSTART (Indian Initiative: Start Therapy at the Right Time) is the largest study conducted countrywide by Novo Nordisk. The study had over 200 doctors and 17,000 patients across India participating.

The outcome of this study has further reinforced the belief that early insulin initiation can remarkably improve diabetes state in people with type 2 diabetes. This study also showed that 93 per cent of the patient population has accepted the disposable pre-filled device which proves that early insulin initiation is no longer a subject of debate but in fact becoming a norm or routine practice.

Choosing an appropriate insulin device

Education about all aspects of managing diabetes and counselling about living with the disease are essential and should include the patient's family and others who may be involved in the patient's care. Diabetes educators have an important role in teaching people to use insulin delivery devices.

The newest insulin delivery device available in India is a disposable pre-filled device which has improved the ease-of-use over all the earlier available devices. Presently, insulin analogue devices too are easily available in the Indian market. Surveys among the health care providers in Europe have shown that insulin analogue devices are the most preferred device among all insulin delivery mechanisms.

It is important that patients are given the opportunity to handle the types of devices available and choose the one that best suits their needs.

Issues to consider are
- Vision and ability to see the dose indicator numbers. Most devices, other than syringes, have an audible click for each one or two units of insulin dialed up. This can help people with impaired vision maintain their independence. Magnification aids are available with some insulin devices..
- Ability to perform the fine motor skills required to load insulin cartridges into the device and dial up a dose.
- Ability to manage the device. This includes loading and checking the accuracy of the dose, cleaning and maintaining the device, and recognising the signs of malfunction and knowing what to do about them.
- Ability to give the injection correctly. Most clinical trials indicate that insulin pens are accurate, provided the patient is educated appropriately and their technique and the performance of the device are monitored regularly.
- Preference for short, fine needles. Short, fine needles (7 - 8 mm long and 29 - 31 gauge) look less menacing and most people prefer to use them. They also avoid inadvertent intramuscular injection. People who continually take intramuscular injections may be more prone to wide swings in blood glucose because insulin is more rapidly absorbed from muscle than from subcutaneous tissues. Shorter needles significantly reduce this risk especially if patients are taught to pinch up and inject into a fold of skin.

Diabetes (diabetes mellitus) is a chronic condition that can be associated with significant ill health especially if it is poorly controlled. Diabetes occurs when the body does not make enough insulin, and/or the body becomes resistant to the action of insulin. Produced in the pancreas, insulin is a hormone that regulates the amount of glucose in the blood (blood sugar). Blood sugar is the fuel required by cells to function. When it remains high over many years, the blood vessels and nerves become damaged, causing severe complications. Diabetes is a common cause of blindness, kidney failure, poor cardiovascular health and erectile dysfunction (impotence). The number of people with diabetes in India has increased by more than 300 per cent within the past 20 years. Over one million India have diabetes; although up to half remain undiagnosed.

Monitoring treatment

Regular visits to the doctor as also screening for complications of diabetes to monitor eye health, and supervise other aspects of diabetes care, such as heart, kidney health, foot and skin care is essential. The role of a physician in convincing the patient to start insulin therapy is very important. Diabetes educators and dietitians are also heavily involved in educating patients in various aspects of diabetes management.

- (The author is Regional Medical Director, Novo Nordisk India Pvt. Ltd.)