Your last shots

Doctors, dealing with a growing needle phobia among diabetes patients, have started recommending insulin shots as the last, rather than the first, line of treatment. Labonita Ghosh reports

Gauri Patel dreaded her daily insulin injection. But during her exams the teenager, who has Type 1 diabetes, flat-out refused to take them. She didn't want to add to her stress by rushing to a toilet during the break, just to stick a needle into herself. Her parents didn't help either. “They told her the injection had ruined her life, that it had ‘marked’ her, making her unsuitable for friends or even marriage,” says endocrinologist Vijay Negalur, who treated Patel, now 22. “It took a while to convince her that with Type 1, or insulin-dependent diabetes, there was just no avoiding the shot.”

Diabetologists often find themselves confronted by this needle phobia. Of an estimated 40 million diabetics in India, many of them require insulin injections, but almost all of refuse it initially, says Dr Rajiv Kovil, who runs the clinic Diabetes Care Centre in Andheri.

“Nobody wants to be pricked because they equate it with shots given by the family doctor,” he says. “But this is not just in India; It's a global problem.” Certainly among both Type 1 and Type 2 patients in Mumbai, who comprise two and nine per cent of the city's population, respectively. “Thanks to all the fear and myths around insulin injections, doctors now recommend them only as a last option, when in most cases, it should make up the first line of treatment,” said endocrinologist Shashank Joshi, at a conference.

According to Dr Kovil, some doctors even hold up the shots as a sort of bogey. “They tell patients, ‘You better take care of yourself, or I’ll have to put you on insulin injections’ when, in fact, that might be best for the patient.” Given that some diabetics have to inject themselves between one and three times a day, the needle phobia is understandable. A lesser inhibition relates to depending on someone else to do it, says endocrinologist HB Chandalia. “The fear is not relegated to a particular age group or profile,” he says.

“Kids with diabetes are much less anxious about shots than their parents, while those in their 50s and 60s are probably reluctant because of some bad experience in the past. The injections have become virtually painless today. The needles have become finer at 31-gauge (needle size) than the previous 29-gauge, but most people don’t know that.”

Julius Goveas didn’t. Diagnosed with Type II some years ago, last month his doctor decided to bolster the treatment with injections. “I was really wary — scared almost,” says the 50-year-old. “I realised I would have to watch out for so many things, like how, when and where to take the shots and clean up, it seemed like a big bother. But after a month of injections, I don’t feel it at all now.”

For people like Aparna Upasani, 53, it’s also about the money. Eight years ago she discovered she had Type II diabetes, but has been on injections only for four months. Upasani was first petrified, now she feels the pinch. “My doctor told me I had no choice but the shots,” she says. “But at Rs500 a month for the insulin ‘pen’, two needles, spirit and such, I spend a lot more than the Rs150 I spent on pills for a whole month.”

Sadly, there are few alternatives right now. Pumps that can be strapped onto the abdomen for a continuous flow of insulin, are usually required only by Type I. Besides, at Rs80,000 each, these are unaffordable to many. Pharma company Pfizer is primed to introduce its insulin inhaler, Exubera, into the Indian market soon, but doctors have concerns that there aren’t any long-term safety studies.

The inhaler has allegedly had a bad run in the US market for this reason, though American Diabetes Association president-elect John Buse said, at the Sanofi conference, that much post-marketing research is currently on. In Mumbai, some of those studies are being conducted by Dr Chandalia, who thinks Exubera may get the green light as soon as next month. However, the inhaler, like the insulin ‘patch’ sometimes used, is almost five times as expensive as injections. Oral insulin, currently in clinical trials in the country, is still a long way from coming into the market.

Doctors, meanwhile, have devised other ways of overcoming patients’ real or imagined fears. “We have to double up as counsellors,” says Dr Negalur, who runs the support group Association for Diabetes Care and Prevention in the city, to which patients bring their concerns several times a month. And yes, needle phobia often dominates conversations.

Dr Chandalia has tied up with SNDT University’s Food Sciences and Nutrition department for a six-month certificate course to train nurses, paramedics, dieticians, patient counsellors and other support staff to take care of diabetics’ problems. “The idea is to take a wholistic view of diabetes - even needle phobia - and nudge patients towards a solution,” says Dr Shobha Udipi, head of the department. If this can allay fears and set a patient on the path to speedy recovery, nothing could be better.