Can insulin pumps control blood sugar better minus the pricks?

However, technological advances in the field of insulin delivery have made the process far more efficient and convenient. When I started my career (in the 1980s), injecting insulin meant glass syringes and long needles, which had to be boiled and reused. Since then, we have come a long way. Insulin syringes are disposable, have become sleeker, needles finer, reducing the pain associated with injections drastically. The development of prefilled insulin pens has been a game changer. Pens are easy to carry and ensure virtually pain-free injections. The psychological impact of seeing a syringe, filling it with insulin and injecting oneself is gone. Administering insulin has literally become child’s play. Children between eight and nine years of age (or even younger), routinely self-administer insulin with the help of an insulin pen.

Insulin pump, a technology to continuously administer insulin, represents a paradigm shift in insulin administration and is one of the most important technological advances of recent times. The idea of continuously infusing insulin emerged in the 1960s. Dr Arnold Kadish from the United States developed a pump which was the size of a backpack and administered insulin based on the data from continuous glucose monitoring. This probably was the first ‘artificial pancreas’ device.

Another computer-controlled device, called “Biostator,” was developed in the 1970s. Both these devices were bulky and complicated. Pumps, which were practical enough to be used on a day-to-day basis, became available in the 1990s. Since then, pump technology has evolved rapidly with newer pumps being sleeker, accurate and safer than older pumps.

EASE OF OPERATION

The modern insulin pump is a battery-operated device, smaller than a typical smartphone which delivers insulin through a small Teflon or a steel cannula under the skin. It administers insulin continuously at pre-programmed rates. In addition, pump users take insulin doses for their meals and snacks by pushing a button, without pricking. This reduces the number of pricks, from several times a day to once in two to three days and provides greater flexibility in lifestyle.

Some of the latest insulin pumps are tubeless, and some can interact with the glucose data obtained from a continuous glucose monitor to adjust insulin doses automatically.

Insulin pump is currently the most physiological option for insulin replacement. It is most suitable for people with Type 1 diabetes, diabetes in pregnancy and some people with Type 2 diabetes requiring multiple shots of insulin. In addition to the reduced number of pricks, pumps offer the advantage of better adjustments of insulin for different time periods of day and night, exercise, sickness, menstruation, exams and different day to day situations. Use of insulin pumps reduces episodes of low blood glucose (hypoglycemia), improves overall control (HbA1c) and reduces day-to-day variation in glucose values.

WHAT STOPS THEIR USAGE?

Despite its advantages, in India the uptake of insulin pumps continues to be poor. Less than 10 per cent people with Type 1 diabetes (in metros) opt for this technology. Compare this with pump usage of 50-70 per cent among those with Type 1 diabetes in more developed countries. The most important and obvious reason for this is the high cost (Rs 2 to 5 lakhs upfront).

However, cost is not the only barrier for insulin pump use. Some do not like to wear the pump since it is a constant reminder of their condition. Others, particularly teenagers, do not like to reveal the device as they consider it a stigma. Since the pump patch has to be secured using adhesive tapes, there can be skin reactions. People who are very thin or sweat profusely sometimes face cannula related challenges. Insulin pump therapy also demands some additional effort on the part of the user. This includes carbohydrate counting, frequent glucose testing and dose adjustment, which may seem cumbersome initially.

Often people have unrealistic expectations from the pump, thinking of it as a magic wand. Hence careful selection of candidates is very important to achieve success with insulin pump therapy. A common mistake is initiating pump therapy in patients who are ill-prepared for it. Substantial effort is required on the part of the treating team to inform, educate and convince a patient about optimal insulin pump usage. On its part, the treating team has to be trained and skilled in pump usage and technology.

Use of artificial intelligence is likely to advance this field further. We might soon see a day when an insulin pump truly functions like the human pancreas and requires very few manual adjustments and interventions.

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(With inputs from Dr Ganesh Jevalikar, Pediatric Endocrinologist, Max Healthcare)