Friday, November 12, 2021

A Century of Insulin

 2021 marks 100 years since the discovery of insulin. Before 1921 the diagnosis of diabetes was a death sentence, with an average life expectancy of fewer than 2 years in young people, who were only kept alive by a starvation regimen that reduced them to walking skeletons.  The discovery of insulin in 1921 was transformative and many patients with diabetes went on to live full and productive lives. Insulin treatment was a ground-breaking scientific and clinical achievement that transformed diabetes care

Banting, Best, and Collip sold their patent rights to insulin for the sum of one dollar to guarantee access for anyone who needed insulin. But despite the altruistic sentiments of the discoverers—Banting, Best, Collip, and Macleod—that “insulin belongs to the world”, the lack of access to insulin over the past 100 years reflects an appalling policy and implementation failure when it comes to insulin provision in low-income and middle-income countries.

 537 million adults now live with type 1 or type 2 diabetes worldwide, an increase of 16% or 74 million people. Globally, an estimated 76% of children with type 1 diabetes are unable to stay within the recommended glycaemic ranges, putting them at risk of life-threatening short-term and long-term complications. More than 50% of patients with type 2 diabetes are unable to receive the insulin they need.  Early deaths from type 1 and type 2 diabetes globally have increased by 5% since 2000, in stark contrast to premature deaths from other non-communicable diseases, which have been decreasing. In one 20-year study from Soweto, South Africa, the mortality rate for people with type 1 diabetes was 43%. Globally, around 80% of patients living with diabetes live in low-income and middle-income countries, yet most interested parties continue to pursue a research agenda driven by high-income needs. 

Global production and supply of insulin are dominated by three companies—Novo Nordisk, Eli Lilly, and Sanofi.  Insulin remains unaffordable for many people. In the USA, a quarter of the 7 million patients taking insulin have reported difficulties in affordability. Documents show a century of controversial pricing practices, including price-fixing, that has led to repeated market failures and continued unnecessary deaths in the USA.  Policy and regulatory processes work to the benefit of a few greedy drug companies rather than serving the needs of people who require insulin. 

Structural racism complicates insulin access pricing for racially marginalised Americans, who are both more likely to be prescribed insulin and more likely to be from low-income, uninsured, or underinsured populations that are unable to pay for it. Racial and ethnic minorities have a higher burden of disease from diabetes, in terms of prevalence, poor glycaemic control, comorbid conditions, diabetes-related complications, and diabetes-related mortality. 

Along with difficulty in getting insulin, many patients do not have access to basic blood glucose monitoring, diagnosis continues to be a problem. In high-income countries advanced technologies, such as insulin analogues, insulin pumps, continuous glucose monitoring, and hybrid closed-loop devices, have become firmly established for diabetes management and treatment. Many believe that closed-loop devices, which adjust insulin infusion largely automatically according to changing glucose values, will soon enable people with type 1 diabetes to lead lives without the continual demands of self-management. 

 In many low-income and middle-income countries, few patients can afford modern insulin analogues let alone devices to record glucose continuously or adjust insulin automatically. The provision of free medicines and glucose monitoring would make a major difference. 

Insulin needs to be stored at 2–8°C, making it difficult to treat many patients.
“The majority of families in low- and middle-income countries do not have refrigeration facilities in their homes, or electricity power and, therefore, diverse methods of safely storing insulin should be devised”, explained Naby Baldé, vice-president of International Diabetes Federation (IDF).

100 years of insulin: a technical success but an access failure - The Lancet

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