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Do Away With Multiple Daily Insulin Injections For Diabetes

Aug 21, 2010 2:46:46 PM - thesundayleader.lk

Written by Dr Harold Gunatillake – Health Writer

An article written by Kalyan Ray (New Delhi) on the subject of,”No more multiple insulin jabs, for diabetics” was circulated through the internet recently, and the text in full is given below for your perusal, followed by my comments on the subject.
He states, “In what may open up a new management technique for millions of diabetics, a Bangalore-based scientist has discovered a novel way to do away with multiple insulin injections for scores of patients. Instead, one injection of a new pro-drug every 10 days – maybe once a month – would be good enough to take care of the patient’s need for insulin, a pancreatic hormone, for those many days, said Bangalore-based Indian Institute of Science professor Avadesh Surolia who, along with his students, developed the new insulin-delivery molecule.

They call it a pro-drug or a supra-molecular insulin assembly (SIA).  It’s like a big blob in which many insulin molecules are grouped together in a specific folding pattern. In its experimental stage, when injected in mice, it released small amounts of insulin continuously for 120 days. For humans, the scientists first plan to develop an SIA that can release the insulin for 10 days. Its capacity will then be enhanced for 30 days.

“It means, once realised, SIA will do away with multiple daily insulin injections.  The patient requires taking insulin injection once in a month,” Surolia, who currently heads the National Institute of Immunology here, told Deccan Herald over phone. In a multi-million dollar deal the technology was transferred to San Diego based firm, Life sciences Pharmaceuticals, that will further develop the molecule for human applications and carry out the clinical trials. However, it is still many years away from the market.

Discovered almost 100 years ago, insulin is still one of the trusted and most-used medicines to keep the blood glucose level within a limit. But the fear of pricking oneself multiple times a day generally leads to low patient compliance. Since insulin is generally taken after meals, its effect weathers away late in the night, sometimes creating problems for patients early in the morning. “On one hand, SIA reduces the number of injections and can take care of fasting hyperglycemia,” Surolia said.

The SIA is stable inside the body and does not show any side-effects in animal models.  The trick behind sustained release of insulin comes from packing up insulin molecules in a way so that they are slowly released in the blood. For rats, 200 micrograms were released daily for four months. The human dosage could be tailored accordingly.

The insulin assembly can be folded in three specific ways. While SIA-I is meant for bulk release of the drug in a short period, SIA-III releases even tinier amount of the drug over a very long period. It is the SIA-II that has potential for human use. The findings on SIA will soon be published in the prestigious Proceedings of the National Academy of Sciences”.

My Comments

Research done by the Bangalore-based Indian Institute of Science professor Avadesh Surolia, along with his students, in developing the new insulin-delivery molecule is another step  in the progress of management of diabetic patients and should be congratulated. There are a few problems in treating diabetic patients with   prolong acting insulin having a sustained effect for 10 days or longer. The glucose level in the blood fluctuates every second due to the influence of many factors.

•    Exercise
•    Type of food (low GI or high GI or a mixture, and gastric load).
•    Absorption of glucose  depends on whether they are from simple or complex carbohydrates, processed or unprocessed foods, and the presence of fat as with biriyani and other cooked foods
•    Stress factors
•    social life and alcohol consumption
•    Sudden lifestyle changes, as going on vacation
•    And many unknown factors

Presently, with the daily insulin injections, one could adjust the dose according to daily requirements assessing on your gluco-meter readings. The quick acting insulin (Actrapid) which acts for 4-6 hours given three times a day can be adjusted according to the meals taken and the blood glucose level can be fairly well controlled. Lente types (novomix 30/70) given every 12 hours may be adjusted according to the food eaten during the day. Lantus can be taken once a day dose which works for 24 hrs. So the pleasure of enjoying food is not restricted, though one has to be careful with the diet by adhering to low glycaemic index (GI) foods.

Today, insulin is available in pen form; one could carry in your shirt pocket and could be self-injected even in public. Unfortunately, the price prohibits most of our diabetic patients in using it, though so convenient. Psychologically you feel better and more confident regulating your blood glucose level daily and taking insulin as required on a daily basis..

There is no advantage in checking your glucose levels daily with your glucometer when you are managed on slow release molecule insulin acting for over 10 days, (still experimental) and may help  save on test strips (not cheap in Sri Lanka).
Insulin pump

This is a device used for the administration of insulin in the treatment of diabetes mellitus with a continuous under the skin (subcutaneous) insulin infusion therapy.

This is composed of
•    The pump itself
•    Disposable reservoir for insulin
•    Disposable infusion set including a cannula for insertion under the skin
•    Can be uploaded to a computer and graphed for trend analysis.
Neuropathy is a troublesome complication of diabetes resistant to usual treatment. There are reports of alleviation or even total disappearance of resistant neuropathic pain with the use of insulin pumps.

The pump allows the replacement of slow acting insulin for basal needs with infusion of rapid acting insulin during the time of eating.  The advantage of the pump is that the user can give a bolus dose before the meal to cover the glucose level resulting from the meal. These pump users feel that bolus injections from the pump is more convenient and discreet than the regular injections (pen types).

•    Many modern “smart” pumps have a “bolus wizard” that calculates how much bolus insulin you need taking into account your expected carbohydrate intake, blood sugar level, and still-active insulin.
•    Insulin pumps can provide an accurate record of insulin usage through their history menus. On many insulin pumps, this history
•    Recent studies of use of insulin pumps in Type 2 diabetes have shown profound improvements in HbA1c, sexual performance, and neuropathy pain.

•    In case of malfunction you need to revert back to the injections.
•    If the pump fails without your knowing an episode of diabetic ketosis may occur. This can happen if the battery fails without your knowing
•    Pumps cost over $ 8000.00 in Australia. More details you could get from your diabetic specialist.
•    Can be  bothersome since you are attached to the pump which is placed invariable round your hip.
•    You need to be trained and require stay in hospital.
•    Insulin levels need constant adjustment manually with this pump device.

I think the bottom line is that it is best that the diabetic patient takes full responsibility for daily injection of insulin intelligently as required, and not depend on high technology equipment and assemblies, for the control of diabetes.  The ideal apparatus would be a pump which infuses the insulin in minute doses automatically maintaining an optimal blood glucose level (glucose sensor), controlled by an affordable computerised device.

Artificial Pancreas- for type 1 diabetics

Encouraging research raises new hopes that a long awaited “artificial pancreas” to treat with type 1 diabetes (not type 2, adult onset) could be available in the U.S. within the next few years. This device is an insulin pump with a continuous glucose sensor to achieve control of the blood sugar continuously without taking insulin injections. Bergenstal is executive director of the International Diabetes Center at Park Nicollet as well as president for medicine and science with the American Diabetes Association.

“We were able to get blood sugar down into the range where we can prevent long-term complications and we did it without causing it to drop too low,” he tells WebMD. “These are probably the best results in terms of balancing the two of any study done to date.” Study researcher Richard M. Bergenstal, MD, says the new study proves that combining an insulin pump and sensor can help patients achieve optimal blood sugar control even without the automatic insulin delivery.

Advantages of Insulin Pump-Sensor Improved Diabetes Control

Poorly controlled diabetes with fluctuating blood sugar levels may lead to long-term complications of diabetes, including possible blindness, amputation, and kidney failure. Glucose sensor controlled pump could well prevent such complications due to the control of blood sugar level as for a non-diabetic.

Hypo-glycaemia or low blood sugar levels will be a word of the past with this device. Normal haemoglobin A1c will be achieved as with non-diabetics ranging from 4%-6%. With daily insulin injections it is with difficulty one could achieve hbA1c within that range.

Let’s hopefully wait for this device which will be marketed soon.