Not long ago, I wrote an entry about the extraordinarily high costs of insulin. What I didn’t do in that entry was to provide an approach to therapy that could tame much of the costs. I actually didn’t think about this until the other day, when a friend who is a pediatrician came by to visit, and she mentioned how difficult it has become to find ways for her patients with insulin-dependent diabetes (almost all of her patients have type 1 diabetes) to afford their insulin.
What is Insulin-Dependent Diabetes?
The nomenclature for the various types of diabetes mellitus has gone through an evolution of sorts. At first it was just juvenile-onset diabetes (JOD) and maturity-onset diabetes (MOD), then it was insulin-dependent diabetes (IDDM) and non-insulin-dependent diabetes (NIDDM). Finally, we decided to name the types of diabetes based on what we knew about etiology; now we call them type 1 (T1DM), type 2 T2DM), and basically, other (such as monogenic, secondary to drugs, post-traumatic, etc.) Most T1DM has onset in childhood and is caused by auto-immune destruction of the pancreatic beta-cells. Most T2DM is associated with obesity and depending on the genetic basis, is characterized mostly by insulin resistance, but also some beta-cell secretory defect. In quite a number of patients with T2DM, the condition progresses to become insulin-dependent; that is, satisfactory blood glucose control cannot be achieved without insulin therapy (with or without oral medications). Here I want to focus on patients who are insulin-dependent, regardless of etiology.
A Brief Historical Perspective on Insulin
When I first started out seeing patients with diabetes in 1965, the only insulins widely available were produced from cows and pigs. There were the Humulin brands of Regular (R) and NPH or N (the “NPH” stands for neutral, protamine, and Hagedorn: neutral pH; trout protein used to tie-up regular insulin and lead to slow release; and discovered by Hans Christian Hagedorn, a Danish scientist). There were also the Lente brands which consisted of zinc insulin crystals of various sizes: Semi-Lente (SL), which was like R; Lente (L), which was like N; and Ultralente (UL), which was like a longer-acting form of N. Most patients with IDDM were treated with one or 2 injections of either N and R or L and SL (or SL and UL). Then, in the early 1980s, recombinant DNA techniques brought us human N and R. In 1996, ultra-fast-acting lyspro (Humalog brand) was FDA- approved (insulin aspart, Novolog brand) made the scene in 2001. Then in 2000, insulin glargine (Lantus brand), an ultra-long-acting insulin was FDA-approved. Since then quite a number of new insulins have been FDA-approved, but in my opinion, they are only “me too” insulins with no important new properties with respect to pharmacokinetics, safety, etc.
So, when the famous Diabetes Control and Complications Trial (DCCT) started in 1983 (the study that first proved glycemic control matters), the Intensive Treatment Group (IT) was treated with either an insulin infusion pump containing R insulin, or three daily injections of R insulin and one bedtime injections of N. The Conventional Treatment Group (CT) was treated with one or two daily injections of N and R insulins. Both IT groups showed far better glycemic control than the CT study volunteers. Now days, most endocrinologists treat patients using a form of intensive therapy, either an insulin infusion pump containing an ultra-fast-acting insulin or a multiple daily insulin injection regimen (MDI), using an ultra-fact-acting insulin before meals, and insulin glargine once daily. As I discussed in an earlier entry, all of these newer insulins are incredibly expensive and for no particular reason. Patients without health insurance cannot possibly afford these insulins unless they are very rich. So, what to do?
The Budget Fix
I told my friend that she should tell her patients who cannot afford their insulins to go “retro” and rediscover the beauty of R and N insulins. They can be purchased at Wal-Mart for less than $25 a bottle. So, for a pump it is R insulin and for MDI it is R before each meal and N at bedtime. It is very important to understand how these insulins differ from lyspro, insulin aspart, and insulin glargine (and the copy-cats). R insulin needs to be taken about 30 minutes before meals and it is important to have small snacks about 2-3 hours after the R insulin injections. It is very important to understand that R insulin does not peak until about 3-4 hours after an injection or a pump bolus, and can last 8-12 hours. So,the R insulin has both bolus and basal effects. The N insulin is all about having a reasonable morning blood glucose reading, nothing more and nothing less. That is it. Not very complicated, is it? Oh yes. what about insulin pumps. It is important to note that since R insulin has a longer time-course of action than either insulin lispro or insulin aspart, using R in a pump usually means that the day-time basal rate is lower than the night-time rate, just the opposite of what we do with the insulin lyspro and insulin aspart. So does this really save money? Just for fun, if we figure a person requires about 2.5 bottles of insulin (10 ml/bottle= 1000 units) each month, the cost to someone is about $800 per year for the N and R (or just R if the person is using an insulin pump) versus about $9000 per year. It’s not chump change.
One last thing. If you are a patient with diabetes, please do not try out this regimen without first talking to your health provider. If you are a health care provider and need some guidance, I suggest you contact one of the DCCT docs, since they will all surely know how to do these old-fashioned insulin regimens.