Injection Port Offers an Alternative for Insulin Delivery

February 1st, 2011

pin cushion

While most insulin dependent diabetics grow used to giving themselves multiple injections each day, there are many who would welcome an alternative insulin delivery system. An insulin pump is one such alternative, but some diabetics dismiss them as too expensive, too prone to malfunction, or just too complicated.

A less high tech (and thus less expensive) insulin delivery system is an injection port. An injection port, also called an indwelling catheter, is an FDA approved disposable medical device that is inserted just under the skin, providing a way to administer insulin injections without multiple skin punctures. The device is suitable for both type 1 and type 2 diabetics who take insulin.

An injection port contains a tiny, flexible plastic tube called a cannula, which is inserted into the skin's fatty tissue with one quick, firm push with an "introducer needle" - said to be equivalent to the prick of an insulin syringe. The introducer needle is then removed, leaving the port attached to the skin with an adhesive, and the cannula just under the skin in the fatty tissue. One manufacturer is about to release the i-port Advance, which combines a port with a built-in injector device to eliminate the need for manual insertion.

Once the port is in place, further insulin injections can be delivered with a syringe or an insulin pen directly into the port and through the cannula, eliminating the need to pierce the skin. The port can remain in place for up to 72 hours, and handle up to 75 injections. It can be worn while bathing, swimming and exercising. As the slogan forthe i-Port says, "It takes the shots for you."

Injection ports are popular with diabetics who are new to injecting insulin, those who are needle phobic, and those who are prone to bruising at the injection site. Diabetics struggling with these issues often skip meals to avoid having to take insulin injections, or skip a needed injection to avoid the discomfort or inconvenience. They are also popular with those who have to administer insulin injections to children.

Ports are small and discreet. They are usually worn on the abdomen, but can also be worn places like the arm, thigh or buttocks. One such port, insuflon, is inserted at a 20 to 45 degree angle and worn like an IV, making it ideal for people with little fatty tissue.

Drawbacks include the risk of infection at the insertion site, and the potential for poor medication delivery if the cannula becomes bent or crimped. The manufacturers suggest diabetics test their blood sugar levels two to four hours after each insulin injection to ensure that the device is working properly. The cost of an insulin port is covered by many insurance companies.

Lantus versus Levemir

February 2nd, 2011

insulin syringe

Choosing a long-acting insulin can be daunting, especially since both Lantus (insulin glargine) and Levemir (insulin detemir) are similar in many respects. There are a few key differences that will help you and your doctor make the decision about which insulin to use.

Both Lantus and Levemir are injected subcutaneously, either with a syringe or insulin pen, and both can be used with fast-acting insulin at meal times to aid with diabetes control. Neither forms of long-acting insulin should be diluted, or mixed with other insulin products. Lantus and Levemir have a 1:1 ratio, but will be accepted by the body differently from patient to patient; any changes to diabetes medication and dosage should always be discussed with a doctor.



Lantus

Lantus (insulin glargine) is marketed as a "peakless" insulin option, with an 18-26 hour action period. It is injected once a day, at the same time every day to maintain regularity. One of the biggest advantages of Lantus is that, due to its lack of peak, it decreases the risk of nocturnal hypoglycemia.

Some doctors suggest that Lantus be taken twice daily, even though it is approved to be taken once daily. Lantus may not be the best option for people with irregular schedules, as its long action time gives less control (it can take up to three days to complete its action). As with other long-acting insulin, Lantus can be used with fast-acting insulin at meal times.

Levemir

Levemir (insulin detemir) is a long-acting insulin with a 9-12 hour action period. It is injected twice a day, morning and night. Because one of its peak periods can occur at night, when glucose levels are often lower, it poses an increased risk of nocturnal hypoglycemia, and should not be used by patients with hypoglycemia.

Levemir has the advantage or greater diabetes control, because it is taken more frequently. And while patients using Levemir often use a higher insulin dosage, they often experience less weight gain than patients using Lantus.

Choosing a long-acting insulin comes down to what works best for the individual in question, taking into account the body's interaction with the insulin, as well as factors such as lifestyle and eating habits.Any decision involving diabetes medication should be made with the help of a doctor or other health-care provider.

Long-Acting Insulin Best at Controlling Blood Sugar

February 3rd, 2011

blood glucose testing

As type 2 diabetes progresses, oral diabetes medication doses typically need to be adjusted upwards over time, and a good many type 2 diabetics can expect to end up insulin dependent. There does not appear to be any clear consensus on how best to introduce insulin injections in addition to oral diabetes medications - three times a day with meals, twice daily injections, or a single daily long-acting insulin injection.

Professor Rury Holman, director of the Diabetes Trial Unit at Oxford University, was the principal investigator of a large scale study conducted to determine how best to introduce insulin to control blood sugar levels as type 2 diabetes progresses. "Type 2 diabetes is a progressive condition with the majority of patients eventually requiring insulin therapy," Holman explains.

Holman and his fellow researchers recruited over 700 type 2 diabetes patients whose current medications were not effectively controlling their blood sugar levels. The patients were divided randomly into three groups to compare the effectiveness of the different insulin dosing regimens, and monitored for three years. After the first year, those patients who were still not achieving the necessary blood glucose control were moved to a more complex insulin therapy.

At the end of the three years, the researchers concluded that once-a-day basal insulin and three-times-a-day mealtimes injections were both more effective at controlling blood sugar levels than twice-daily insulin injections. In addition, those who took the once-daily basal insulin had fewer incidents of low blood sugar than those taking three-times-a-day mealtime insulin.

As a result, the researchers advise those beginning insulin therapy to start with a basal insulin, and add a mealtime insulin if required for what they term "the best combination of effectiveness, safety, and treatment satisfaction". "This large scale study strengthens guidelines recommending adding a basal insulin to oral agents when glycemic targets are not met," says Holman.

Texas Researchers Hopeful They Can Eliminate the Need For Insulin Therapy

February 4th, 2011

dna strand

Research conducted at the University of Texas Southwestern Medical Center raises the exciting prospect of eliminating the need for insulin in type 1 diabetics by "turning off" the hormone glucagon, which plays a major role in blood sugar regulation.

Like insulin, glucagon is a hormone secreted by the pancreas. Glucagon has the opposite effect of insulin, increasing blood glucose levels rather than lowering them. The pancreas releases glucagon when blood sugar is low, causing the liver to release glucose into the blood stream, and stimulating the release of insulin.

Glucagon prevents low blood sugar in healthy people, but causes high blood sugar in people with type 1 diabetes, whose pancreas can't produce enough insulin to counteract its effect. A synthetic version of glucagon is used to treat severe low blood sugar, or hypoglycemia, in diabetics in emergency situations.

The UT Southwestern researchers genetically altered laboratory mice so that they lacked working glucagon receptors and couldn't react to glucagon. They then gave the mice the glucose tolerance test used to diagnose diabetes. Mice with normal insulin levels but non-working glucagon receptors responded normally to the test.

When their insulin-producing islet cells were destroyed and they lacked both insulin and the ability to use glucagon, they were still able to stabilize their blood sugar, again testing normally. Blocking the action of glucagon essentially made insulin unnecessary for the mice - despite the lack of both glucagon and insulin, the mice did not develop diabetes.

"We've all been brought up to think insulin is the all-powerful hormone without which life is impossible," says researcher and professor of internal medicine Dr. Roger Unger, "But that isn't the case. This doesn't mean that insulin is unimportant - it's essential for normal growth and development. But in adulthood, at least with respect to glucose metabolism, the role of insulin is to control glucagon. If you don't have glucagon, then you don't need insulin."

Insulin injections have been the treatment of choice for type 1 diabetes since its introduction in 1922. But insulin is a treatment, not a cure, and can't restore normal glucose tolerance as blocking the glucagon receptors did in the laboratory mice. It now appears that insulin's benefit results from its suppression of glucagon, and that the blocking of glucagon action restores glucose tolerance to normal.

In the next all-important step, the researchers will be studying the mechanism behind the results to determine how to turn off the glucagon receptors in humans. "If these latest findings were to work in humans, injected insulin would no longer be necessary for people with type 1 diabetes," states Dr. Unger, "If diabetes is defined as restoration of glucose homeostasis to normal, then this treatment can perhaps be considered very close to a cure."

Insulin Shock Therapy Once Used to Treat Schizophrenia

February 7th, 2011

electric shock

It's not widely known that large doses of insulin were commonly used in psychiatric institutions in the 1940s and 1950s to treat schizophrenia and other mental illness. Insulin shock therapy was regarded as the treatment of choice for schizophrenia for about twenty years, enjoying uncritical acceptance in Europe and America.

The "treatment" was considered a type of shock therapy. Patients were given regular insulin injections to produce five or six diabetic comas a week for weeks at a time. Insulin therapy continued until the patient improved, or until 50 to 60 comas had been induced.

The originator of insulin shock therapy, also known as insulin coma therapy, was Dr. Manfred Sakel. The Polish doctor stumbled upon the therapy accidentally while working in Vienna, when a patient in whom he'd provoked an insulin coma showed a remarkable improvement in her mental functioning.

Sakel practiced and popularized insulin therapy in Europe, and introduced it to the US after he emigrated from Austria to New York in 1936. The practice of insulin dosing continued into the 1960s in America, and for much longer in countries like China and the former Soviet Union.

Sakel believed that the seizures and unconsciousness experienced by psychiatric patients undergoing an insulin-induced hypoglycemic episode resulted in dramatic change in their mental state. In his own words: "My supposition was that some noxious agent weakened the resilience and the metabolism of the nerve cells-blocking the cell off with insulin will force it to conserve functional energy and store it to be available for the reinforcement of the cell."

Sakel claimed that close to ninety percent of his patients improved with insulin shock therapy, but his methods were later called into question and discredited as unscientific. In particular, Sakel was accused of "cherry picking" the patients most likely to improve using insulin therapy, and providing them with extra attention and support.

Patients were said to have been terrified of the procedure, which is now considered to be inhumane. Severe hypoglycemia such as that induced by Sakel can result in permanent brain damage and even death. Some of his insulin therapy patients did indeed suffer adverse effects, including fatalities. While today's antipsychotic medications are not without their side effects, thankfully they are much safer and more effective than anything available just a couple of decades ago.

Numerous Non-Invasive Glucose Monitors under Development

February 9th, 2011

Diabetics are still awaiting a reliable, non-invasive means of blood glucose monitoring - one that doesn't require breaking the skin or confirmation with a traditional monitoring method. The latest continuous glucose monitoring technology involves small sensors implanted in the skin that must be calibrated several times a day, and replaced every few days to a week to avoid infection. Because the blood sugar testers are implanted into the skin, the body sees the sensors as foreign objects, and frequently forms scar tissue around them.

The FDA approved one non-invasive monitor in the 2002 - the GlucoWatch Biographer. Worn on the wrist like a watch, the device used a small electric current to draw fluid through the skin, and a sensor to analyze the fluid's blood glucose levels. But at least half of the diabetics that used the product complained of skin irritation and sores, and the product was discontinued in 2007.

Despite the GlucoWatch disappointment, diabetics should not give up hope of being able to avoid multiple daily finger pricks to keep track of their blood sugar. Numerous non-invasive blood glucose monitors using different technologies are currently in development, including:

1) GlucoTrack - Integrity Application's GlucoTrack employs three different technologies: ultrasonic, conductivity and heat capacity. The device contains a main unit, a transmitter, a receiver and processor, and a sensor-containing ear clip. The main unit can support and store blood sugar readings for up to three users.

2) Symphony - Developed by Echo Therapeutics, Symphony is a biochemical sensor-based transdermal continuous glucose monitoring system with a wireless handheld device that reads the sensor's measurements.

3) Multisensor Glucose Monitoring System - Developed by Solianis Monitoring, this system delivers continuous information on glucose variations using impedance spectroscopy - a technology that uses frequencies to measure the effect of changes in blood glucose levels.

4) Portable blood glucose meter - Grove Instruments is working on miniaturizing a prototype blood glucose monitor which delivers a reading using Optical Bridge technology. The user simply inserts his or her finger into a port to obtain an optically assessed blood sugar test reading in less than 25 seconds.

5) Glucose Monitor Tattoo - Researchers at the Massachusetts Institute of Technology are testing a continuous glucose monitoring "tattoo" in which florescent nanoparticle ink is injected under the skin. The ink fluoresces in response to glucose when an infrared light is shone on it, telling a small monitor how much it detected.

6) Electronic thumb-pad sensor - Texas' Baylor University researchers are testing an electronic thumb-pad sensor which detects blood glucose by measuring changes when electromagnetic energy waves pass through the skin.

7) I-SugarX - Freedom Meditech is pioneering the I-SugarX, an ophthalmic medical device which monitors changes in the eye to determine glucose levels. The user gazes into a handheld device which shines a light on the eye for less than a second, and then displays a digital blood glucose reading.

8) Near infrared optical spectroscopy - Inlight Solutions is developing devices that use near infrared optical spectroscopy and multi-variate analysis to measure blood glucose levels. The technology employs a light source, an optical detector, and a spectrometer.

9) LighTouch Technology - Uses a glucose test technology that projects a specific color of light onto a patient's finger, and analyses the different colored light that is "re-projected" back from the finger to measure blood glucose levels.

Handling Fruit Can Result in Inaccurate Blood Glucose Test

February 15th, 2011

Japanese researchers are warning diabetics of the risk of "pseudohypergylcemia" when testing blood sugar after eating or handling fruit. A study published in the journal Diabetes Care demonstrated how fruit sugars can stay on the hands even after the fingers are swabbed with alcohol, causing an artificially high blood glucose test reading.

Researchers from the Juntendo University Graduate School of Medicine in Tokyo measured the blood sugar levels of ten non-diabetic volunteers, using a standard glucose monitor to test blood samples taken from a fingertip. They then asked the volunteers to peel oranges, grapes and kiwi fruit.

After the volunteers peeled the fruit, the researchers measured their blood glucose levels three more times - before they washed their hands, after they swabbed their hands with alcohol wipes, and after they washed their hands under running water.

Blood glucose levels taken before the volunteers handled the fruit were normal (an average 90 milligrams per deciliter (90 mg/dl). Glucose test results after they handled the fruit and before they cleaned their hands showed high blood sugar levels - around 360 mg/dl after peeling a grape, 180 mg/dl after peeling a kiwi, and 170 mg/dl after peeling an orange.

Even after they swabbed their hands with alcohol (the recommended practice for a diabetic before testing blood sugar), their blood sugar readings were higher than normal. Surprisingly, the volunteers were still receiving inaccurate blood sugar readings after swabbing five times. It was only after washing their hands under running water that their blood glucose readings returned to normal.

Diabetics rely on accurate blood glucose test results to determine how much diabetes medication to take. A diabetic who handled or ate fruit before conducting their blood sugar test could get an incorrect reading and give themselves an unneeded insulin injection, resulting in low blood sugar.

The take away message for diabetics - don't rely on alcohol swabs alone to clean your hands, and always wash them with soap and water before testing blood sugar. In the words of the study authors, "To avoid overestimation of blood glucose using portable monitors, their hands should be washed before monitoring capillary blood glucose, especially after fruit has been handled."

Travelling with Diabetes

February 15th, 2011

Diabetes control can be a trial, even when you are in a familiar location with all of your supplies at hand. Going to a foreign country, or even city, adds extra complications and can be daunting. With the proper planning, however, travel can be enjoyable and relaxing.

Before you go:

  • Get travel insurance
  • Check in with your health care provider to make sure that you are fit to travel, and get any vaccinations required for your destination
  • Fill any prescriptions you require (make sure you have twice what you need, just in case)
  • Bring copies of your prescriptions and a list of medications that you are taking
  • Research your destination for information on medical clinics and food options

En Route:

  • Check airline regulations concerning carry-on luggage
  • Keep prescriptions, diabetes medications and syringes on you at all times
  • Don't let your insulin or insulin pumps go through the x-ray talk to the security staff beforehand and ask for a manual search of your medical supplies
  • Make sure all insulin and supplies are properly marked with a professionally printed label from the manufacturer or pharmacy
  • Syringes must have needle guards and be kept with your insulin
  • Alert the security staff if you are wearing an insulin pump as they will need to check it in person
  • Take time to stretch or walk around

While There:

  • Remember to keep time differences in mind when you check your blood sugar level. Talk to your doctor, as you may need to adjust the dosage of your long-acting insulin, depending on how many hours you gain or lose in your travels.
  • Always bring extra water and snacks on outings
  • Keep your diabetes medication in two separate places, just in case anything gets lost or stolen
  • Never go on hikes or to remote places on your own, and make sure that your travel buddy is aware of your condition

Whether you are going away for a weekend or a month, to a new city or a new country, the proper preparation can ensure an enjoyable trip. Bring extras of all your supplies, keep snacks and bottled water with you at all times, and when in doubt, ask your health care provider.

Why Have Insulin Jet Injectors Never Really Caught On?

February 18th, 2011

An insulin jet injector sounds like a great idea. Intended to be a less painful way of delivering insulin than the traditional insulin syringes or insulin pens, they deliver a fine jet of insulin under such high pressure that it is able to penetrate the skin without a needle.

The first insulin jet injector, dubbed the "peace gun", was invented by a doctor in the 1940s for mass immunization of American troops. It was used right up until 1997, when it's use was discontinued because of concerns around cross-contamination from multiple users. According to all reports, the peace gun was efficient, but painful.

The jet injector was first offered for individual use in 1979. A modern insulin injector looks similar to an insulin pen, but larger. There are a number of different models, but the typical insulin injector consists of three pieces - a metal pen-like delivery device, a disposable plastic nozzle, and a disposable adapter to connect the injector to an insulin vial. The insulin injector has a dosing dial that allows individual users to select their correct dosage.

The metal injector is designed to last for years, and the detachable nozzle and adapter are intended for multiple uses before disposal. The air pressure is created by either a powerful spring device or a nitrogen or cartridge dioxide cartridge. The devices have adjustable pressure settings so users can select the one that is most effective while causing them the least discomfort.

There are some obvious benefits to a needle free jet injection system, the most apparent being the option for the needle phobic to avoid needles. Other advantages are the speed and ease of use, safety (no bent or broken needles, or "sharps" to dispose of ), less risk of contamination, a better spread of insulin into the subcutaneous tissue, no scar tissue build up at the injection site, and no need to keep buying syringes.

So why do so few diabetics use them? The number one reason seems to be pain. Although some people find a needleless injection quite tolerable, many find the pressure required to force the insulin through the skin most uncomfortable. It's not uncommon for the skin at the injection site to bleed, swell and/or bruise.

Another major factor is the initial cost (at least several hundred dollars) although this is offset by the fact that users don't have the ongoing expense of syringes. Not all insurance companies cover the cost of an insulin injector, and many of those that do require a letter from your doctor.

Jet injectors are also more cumbersome and less portable than insulin syringes or insulin pens, not just because they're larger and heavier, but also because users also need to carry an insulin vial (which requires refrigeration), the adapter and, with some models, the nozzle along with it.

It takes more time to set up an insulin injector than it does to fill a syringe. Unlike a syringe or insulin pen, an insulin injector requires maintenance, and has to be taken apart and sterilized on a regular basis. Some people are put off by the noise made by the compression system during use.

There are insulin injectors specially designed for use in children, and even one for dogs and cats, the Zoe Pet Jet. Those who have managed to find a comfortable setting on their jet insulin injector seem quite happy with the devices, and urge new users not to give up if they're not initially comfortable using one.

New Ultra Long Acting Insulin Could End the Need for Daily Injections

February 18th, 2011

insulin syringe

Danish pharmaceutical giant Novo Nordisk has completed clinical testing of a new generation of ultra long acting insulin, called insulin degludec. More than 10,000 type 1 and type 2 diabetics from 40 different countries participated in 17 different trials.

Trial results consistently showed Degludec to be as effective in lowering blood sugar as the current most widely used long acting insulin, Sanofi-Aventis' Lantus (insulin glargine), with no difference in adverse effects.

More importantly, trial participants given Degludec experienced significantly fewer episodes of hypoglycemia than those given Lantus, especially potentially dangerous night time hypoglycemia. Trials with type 2 diabetics saw a decrease in nighttime hypoglycemia of over 35 percent, and trials with type 1 diabetics of 40 percent.

Degludec is effective for up to 40 hours, roughly twice as long as insulin glargine. Lantus is said to be effective for 18 to 26 hours, although some users report a shorter efficacy. The only other long acting insulin on the market, Novo Nordisk's Levemir (insulin detemir), has a similar action period. Like Lantus and Levemir, Degludic's action is flat, without pronounced peaks in effectiveness.

The new insulin is released so slowly and steadily into the body that it may allow some diabetics to go from daily injections to just three injections a week. Degludic's long and steady action is attributable to the fact it forms a "depot" of soluble multi-hexamers when injected under the skin, from which the insulin is slowly and steadily absorbed into the body.

At the same time, Novo Nordisk is also developing Degludec Plus, the first combination of a long acting insulin (or basal insulin) with a rapid acting (or bolus) insulin, insulin aspart. Until now, it hasn't been possible to combine a basal insulin and a bolus insulin in one single injection.

Lantus (insulin glargine) currently leads the market, generating sales of almost $4 billion a year globally. Levemir (insulin detemir) lags far behind in sales. Now that the phase 3 trials have been completed, Novo Nordisk will be seeking FDA approval for both Degludec and Degludec Plus in 2011, and hopes to begin marketing the new diabetes medications in 2013. Degludec is expected to be marketed at a higher price than Lantus, because of its reduced incidence of hypoglycemia and potential need for less frequent insulin injections.

For more information on Degludec and Degludec Plus, click this Global Medical News video link.

Six Warning Signs of Diabetic Ketoacidosis

February 22nd, 2011

Ketoacidosis is a diabetic emergency which occurs as a result of a lack of insulin. Without insulin, the body is unable to use sugar for energy. Unable to use sugar, the body burns its fat stores for energy.

As the fat is broken down, byproducts called ketones are released, building up in the blood and urine. Ketones are acid waste products, and are dangerous at high levels. Blood sugar rises as the liver produces more glucose in an attempt to fuel the body, causing further acidity.

A diabetic who experiences two or more of the following warning signs, and has high glucose readings (over 300mg/dl) should contact their doctor or go to the hospital immediately:

  1. Breath that smells like fruit or nail polish remover
  2. Labored breathing (gasping)
  3. Pronounced thirst
  4. Stomach or abdominal pain
  5. Nausea and vomiting
  6. Flushed complexion

Diabetic ketoacidosis (DKA) usually develops slowly over 24 hours, starting with symptoms such as fatigue, mental stupor, decreased appetite, loss of appetite, headache, and fading consciousness. Often the symptoms of ketoacidosis lead to an initial diagnosis of type 1 diabetes.

Once the patient starts vomiting, their condition can deteriorate very quickly. If treatment is delayed, the diabetic can fall into a life threatening coma. Ketoacidosis is especially dangerous in the elderly.

Immediate treatment involves an insulin injection to reduce blood glucose levels, and the administration of fluids and electrolytes to combat the dehydration that accompanies DKA. The average adult DKA sufferer loses about one and a half gallons of fluid.

Ketoacidosis is a concern for insulin dependent type 1 diabetics, but occurs much less frequently in type 2 diabetics. Diabetics who are Hispanic or African American are more at risk of DKA. DKA is more common in children and adolescents, and, for unknown reasons, slightly more common in women.

DKA is often the result of an illness. Diabetic ketoacidosis can also result from:

  • A missed insulin dose
  • Incorrect insulin dosing
  • A malfunctioning insulin pump
  • An increased need for insulin (sometimes as a result of a growth spurt in children)
  • Infection
  • Surgery
  • Trauma
  • Heart attack
  • Use of cocaine

Diabetics can easily test their urine for ketones are using a test strip similar to a glucose test strip. Ketone testing should be done whenever the blood sugar is higher than 240 mg/dl, during an illness or health crisis such as a stroke, during pregnancy, and whenever a diabetic is experiencing nausea and/or vomiting. Diabetics who are ill should check their ketones every 4 to 6 hours to ensure adequate diabetes control.

DKA can largely be avoided with proper diet and self care when diabetics are ill or otherwise at risk, including adjusting insulin levels when needed. Before the introduction of insulin injections in the 1920's, DKA was almost always fatal. Since the 1950s, the mortality rate has, thankfully, been reduced to between one and ten percent.

Researchers Able to Decrease Insulin Resistance in Mice

February 25th, 2011

blue swirl
Science Daily reported today that a research team from La Jolla Institute has shed new light on the problem of insulin resistance, a discovery that may lead to new therapies to reduce the severity of type 2 diabetes.

Recently, type 2 diabetes has been linked to chronic low grade inflammation. The La Jolla team identified an immune system signaling molecule called adenosine that contributes to insulin resistance by triggering inflammation, and was able to decrease insulin resistance in mice by blocking the actions of the molecule.

Click here >Science Daily< to read the full article.