Jet injectors that deliver insulin without needles have been around for years, and that could be the problem.
‘Nobody likes needles.’
"Maybe people hesitate with the technology because they are thinking about the big injectors that the military used to give them immunizations," speculates Dr. Naomi Neufeld, clinical professor of pediatrics at UCLA School of Medicine and attending physician at Cedars-Sinai Medical Center. "Those injectors hurt and that would terrify anybody. They don't realize that this is a simple hand-held device that is smaller than a VCR's remote control."
Jet injectors, which release a tiny stream of insulin forced through the skin under high pressure, now are also much less expensive than earlier models, she says. Furthermore, manufacturers say that they have become easier to use, simpler, smaller, less painful, and more reliable.
Paradoxically, however, jet injectors are losing U.S. market share. About 3.2 million Americans with diabetes take insulin daily, according to National Institutes of Health data. Most use syringes, with few using jet injectors, insulin pens, or pumps.
In 1997 jet injectors accounted for only 1 percent of Americans using these insulin delivery systems, according to Joon Kim, research analyst for the Frost & Sullivan market research firm. That's down from the 1.5 percent share reported in the company's 1994-95 study, he says.
Three companies sell jet injectors. Medi-Ject Corporation had two-thirds of this market in 1994-95, Mr. Kim says. Moore Industries (now called Health-Mor Personal Care Corporation) had about 30 percent, and Vitajet Corporation had less than 5 percent. No more recent data is available, he says.
Dr. Neufeld prescribes Health-Mor jet injectors in her practice in part because "they get in better with the insurance companies than some of the other devices," she says. Since she works with children, who often need only small doses of insulin, Health-Mor injectors also have the advantage of being able to deliver as little as 0.5 units. Medi-Ject's and VitaJet's injectors deliver 2 or more units.
Getting insurance coverage is often difficult for people who use jet injectors. "Our big struggle right now is getting medical insurance to pay," Dr. Neufeld says.
Because federal and state insurance plans often have given her patients a hard time, she compared how well Health-Mor's GentleJet and syringes delivered low doses of insulin. "At doses of insulin commonly used in the youngest patients, we found that the GentleJet injector was uniformly more consistent in delivering a given dose of insulin than currently available low-dose syringes," she concluded in an article accepted for publication in Diabetes Educator.
Aside from insurance difficulties, "Jet injectors are not suitable for everybody," says Vitajet President Sergio Landau. He says that people who are very thin often can't use it. He also doesn't recommend them for people who would have difficulty winding the coil spring power pack or who are visually impaired.
"One way or another 20 to 25 percent of the people will come to the conclusion that for them it is no better than a standard syringe," Mr. Landau admits. "It might cause bruising. Some people cannot use the system because of the speed and pressure."
A Medi-Ject Web page mentions others who should not use a jet injector. People taking anti-coagulant medicine, those with hemophilia and those on dialysis are among those who should avoid using a jet injector as it could cause a bleeding problem.
A Medi-Ject spokesperson would not divulge its return rate. "We don't release that information," says Chief Financial Officer Mark Derus.
Health-Mor's return rate is 7 percent, says Todd Garcia, senior director of sales for North America. He attributes this low rate to individualized training by diabetes educators. At the customer's choice, the training will be in the person's home, in a facility, or by phone, he says.
And even visually impaired people can use Health-Mor's jet injectors, Mr. Garcia says. Its models have tactile detents.
Bruising and Pain
Bruising and pain is a common complaint that users mention in messages on Internet newsgroups. Jonathan Mills, associate professor of computer science at Indiana University and the leading on-line proponent of jet injectors, says that he initially had some bruising. He attributes it mainly to using too light a setting.
Jeff Hitchcock, who runs the "Children with Diabetes" Web page found "absolutely no pain" when he tested it on himself. His test of three adults and two children showed that only one user—who happened to be his daughter Marissa—found it too painful.
Because jet injectors are more precise in delivering the desired dose of insulin, as Dr. Neufeld's study demonstrates, they offer the opportunity for tighter control. And it is precisely tight control that means fewer complications, according to the 1993 Diabetes Care and Complications Trial.
"The kids who use jet injectors tend to have better control of their blood sugars than kids who use syringes," Dr. Neufeld says. "Also, people have reported that they need far less insulin, although I haven't seen it personally in my practice."
Frequent injections also means tighter control. "In terms of enhancing compliance I don't mind recommending four injections a day, because they aren't getting stuck with a needle," she says. "Nobody likes needles."
Other advantages of jet injectors, as enumerated by Front Line Strategic Management Consulting, include eliminating the need for sharps disposal and the risk of cross contamination. Different settings also allow adjustment for different skin types. Plus, they are portable enough so they can be used discretely when away from home.
While jet injectors seem to be expensive, they are also less expense than syringes, Mr. Garcia points out. You don't regularly have to buy boxes of syringes.
Stainless Steel v. Disposable Nozzles
Compared with Medi-Ject's and Vitajet's jet injectors, however, Health-Mor's are initially more expensive. But because its stainless steel nozzles don't require regular replacement as do their competitors' disposable plastic nozzles, he maintains that within a year, "Users of the other two systems will spend just as much money on the injector and supplies as they do on the AdvantaJet. The one big difference is that after that year you still have to buy those disposable chambers."
For now, Medi-Ject also continues to offer a model with a stainless steel nozzle. "We are still selling it on a very limited basis," Mr. Derus says. "But it's probably not a long-term product for us."
Gas Spring Cartridges
The most exciting development for jet injectors on the horizon is the development of a new power source, the gas spring. Medi-Ject has patented a permanently charged gas cylinder that is smaller than the current coil spring. It will be less expensive, smaller, and easier to use, and may result in more comfortable injections, Mr. Derus says. He expects to ship the product, which is now in clinical testing, in late 1998.
Becton Dickinson, which has exclusive rights to the device, will market this pen-size injector, says investment analyst Dennis Nielsen of R.J. Steichen & Company. He predicts that it will carry a retail price of $200.
This article appeared as "The Jet Injector Paradox" in Diabetes Wellness Letter, February 1998, pages 1-3.
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