August 7, 2019
ReliOn insulin dangerous for type 1 diabetes
ReliOn insulin - or any human insulin - is not a solution or even a stopgap for people living with type 1 diabetes.
By Elizabeth Snouffer
Walmart’s ReliOn insulin has been called out as the cheaper insulin that one young man used to save his life, but failed. Mainstream news all over the US and abroad are reporting about the death of Josh Wilkerson, age 27 years. Josh, who lived with type 1 diabetes, had aged out of his parents insurance at 26 and struggled to pay for his insulin. Josh turned to ReliOn insulin, Walmart’s version of Novo Nordisk’s Human insulin, which sells for about $25. Josh used a combination of regular and NPH insulins, or a pre-mixed version (Humulin 70/30), which was used in the 1980s and early 90’s to try and maintain daily insulin profiles.
Achieving near normal blood glucose for the person with type 1 diabetes is impossible. How do I know so much about Human insulin? I took it in the early 1980’s in high school then in college. Blood sugars in the 200s and 300s mgdL (11 - 17 mmol/L) for a type 1 were not uncommon, and neither was DKA.
Josh’s death is one of many tragic losses of people with type 1 diabetes rationing insulin in the recent past. Modern analogue insulin prices have nearly tripled since 2002, and cost as much as $1200 per month. Many people with type 1 diabetes in the US are opting for cheaper insulins as an affordable solution.
ReliOn insulin – or any human insulin – is not a solution or even a stopgap for people living with type 1 diabetes.
1. Unpredictable – Human insulins have very different peak times and duration of action times from analogue insulins and do not offer the same coverage.
They are unpredictable and that’s a scary scenario for a person injecting the hormone. Humulin R doesn’t quite cover meal excursions and can lead to hypos. NPH doesn’t last long enough, especially if a person is hoping for 24 hour coverage from an intermediate insulin. People with type 1 diabetes require full-on coverage. Without any insulin production, we require 24 hour insulin coverage with or without food. In addition, it’s hard to calculate insulin sensitivity with human insulin. One unit of a modern analogue fast-acting insulin can easily equate to 15 to 20 grams of carbohydrate. Counting carbohydrates is so important for basal-bolus therapy – the backbone of good care. This is not exactly what’s at play here with human insulins. Imagine taking the 70/30 mix at least 30 minutes before a meal – like breakfast. You’d need to time the meal just right and chances are that R may or may not cover your food. It’s hard to know. Trial and error and eating the same thing every day would help. Intermediate acting NPH won’t cover you for 24 hours. It will cover for a basic 12 hours more likely, but this isn’t what it says on the pack.
You certainly can’t correct with this kind of insulin if you are high, and targets literally go out the window. Achieving near normal blood glucose for the person with type 1 diabetes is impossible. How do I know so much about Human insulin? I took it in the early 1980’s in high school then in college. Blood sugars in the 200s and 300s mgdL (11 – 17 mmoL) for a type 1 were not uncommon, and neither was DKA. I lost a friend to DKA who was just 18. Hypoglycemic episodes were dangerously unpredictable. Doctors were frustrated by outcomes and their patients were more or less blamed. Truly a no-win game. What’s even harder to fathom in our modern world is how most people with type 1 diabetes in developing countries must depend on these human insulins for life. It shouldn’t be surprising that this is one of the primary reasons complications like kidney disease, and early death are common.
If you really don’t think ReliOn is a problem, just consider for one moment why longer duration (basal) and shorter peaks (bolus) became our modern analogues today. Go even further and consider why 24-7 insulin infusion from a pump became so important – especially for youth with type 1 diabetes – in the 1990s. It was a way to save and improve complication-free and longer healthier lives. I know it’s saved me.
2. Good doctors don’t like them (plus, good doctors in the US cost more than analogues).
It’s really a slap in the face when people not exactly in the know suggest calling or visiting a doctor for assistance when switching down the bad medicine ladder for human insulin. No ethical doctor is going to help any person with type 1 diabetes try and work with these risky, outdated insulins. Additionally, seeking a doctor’s care is unaffordable without insurance on a low to moderate income. A visit to a proper endocrinologist (who cares for the rarer type 1 diabetes) in the US can range from $400-1000 depending on the length of the visit and services provided. Blood labs for a person with type 1 diabetes are usually billed at $1500-2000 US. This includes labs to check kidney function, HbA1c, CBC, Metabolic panel and more.
3. Recommended for people with type 2 diabetes (not type 1 diabetes).
Many people with type 2 diabetes don’t need insulin because they can manage blood glucose issues with a healthy diet and exercise. Often people with type 2 need to incorporate insulin at mealtimes or long-acting insulins to achieve targets. People with type 2 diabetes have an advantage – they produce insulin. In fact, many people produce a lot of insulin with type 2 diabetes, but the insulin can’t do the job. Eventually people with type 2 diabetes may become insulin dependent, but most doctors will do anything and everything to prevent this from happening. The upshot here? When JAMA reported that human insulin worked just as good as analogues in people with type 2 diabetes that’s exactly what they meant! They did not include people with type 1 diabetes, because for people who produce zero insulin – older insulins like NPH, Humulin R and Humulin N are dangerous.
Rationing and misinformation on how to manage blood glucose with older insulin has got to stop to help prevent the early deaths of young adults with type 1 diabetes. Access to affordable modern insulin is a human right.
Elizabeth is Editor of Diabetes Voice. She nearly lost her life to DKA diagnosed 42 years ago with a blood glucose value greater than 1600 mg/dL (89 mmol/L).