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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.


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Patient on hospital bed

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.

Here’s why:

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).


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4 Comments
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  • stefanos

    August 12, 2019 at 6:31 pm

    Hi Elizabeth. Let me start by saying I absolutely agree that ALL diabetics should have access to affordable insulin of their choosing, and both doctors and diabetics should be educated on how to use these insulins.

    I think vilifying R insulin is NOT the right answer. R insulin has it’s place, and when used in conjunction with a low carb diet (along with proper timing of injections) it gave me the best control of my life (Type 1 diabetic for 29 years).

    Most doctors do not like R because they do not understand that it can be used well to cover protein meals in a low carb diet. The current “eat whatever you want and cover it with fast-acting insulin” approach didn’t work for me. It sent me on the rollercoaster of highs and lows that is VERY dangerous (and all too familiar to many diabetics).

    I was using R as my main bolus insulin (and using it as a basal in my pump as well) with almost NO lows (below 75) in conjunction with a low carb diet. My A1c was 5.3 with lows below 5% of the time. (In range 75-140 80% of the time)

    I still used Humalog pens to correct highs. It is absolutely correct that the analog insulin’s (humalog, Novolin, Fiasp, etc) are great for correcting highs, where R is not fast-acting enough. This is why I agree that diabetics and doctors should have access to ALL insulins equally, and the education on how to best use these insulins in conjunction with the diet and lifestyle that works best for them.

    Again, I believe diabetics should have financial access to whatever insulin works best for them, HOWEVER, we should also have access to the information so that we can make informed choices.

    Vilifying R and NPH may result in making it more difficult to get access to these insulins, and they have a place in the treatment and therapy.

    These deaths are a tragedy. The complications that come from years of uncontrolled blood sugars are a tragedy.

    Education and access are the answer, not vilifying one type of insulin in preference to another.

    • Lorenzo Piemonte

      August 13, 2019 at 10:29 pm

      There is no vilifying human insulin from me. It’s just an old and outdated exogenous insulin that should only be used when analogue insulin is NOT available, like in poorly resourced nations, and even then, it’s too bad because we have the data and people on human insulins do not fare as well. For information on why here are some papers to look at –I’m certain there are many more… https://care.diabetesjournals.org/content/37/6/1767 “treatment with analog insulin is associated with decreased incidence of long-term diabetes complications, improved quality-adjusted life expectancy, than human insulin–based regimen (NPH + regular).” I have lived with diabetes now for 43 years – I don’t think I would have been complication free at my age were it not for insulin pumping and analogs (you can’t pump with Human R). And here: “Because analogue insulins better mimic pancreatic basal and bolus insulin replacement as injection therapy (although less well than insulin pumps), they play an increasingly important role in successful physiologic insulin replacement strategies and thereby reduce hypoglycemic risk with intensive therapy.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265808/ I appreciate your anecdotal advice/evidence, and I don’t doubt you have made it work, but that certainly doesn’t mean that human insulins aren’t safe, and I stand behind my statement. There are many endocrinologists (including paediatric) who work with people who live with type 1 diabetes who would never consider successfully prescribing human insulins therapeutically in 2019. -Elizabeth

  • lori

    August 11, 2019 at 11:41 pm

    I was also on N and R for about 20-25 years. Most of those times I was not under an Endocrinologists care. I didn’t even know they existed. I did my own thing, which was eat/drink what I wanted and take my insulin when ever I felt like it, and only check my sugar if I felt high/low. Little did I know that I am both hyper and hypo unaware. But, for the last few years I was on N and R, I had started seeing an Endocrinologist I started to understand the ramifications of allowing my blood sugars to fly like I had been. My A1c for that entire time was in the low to mid teens I would say, as my first ever known A1c was a 13.1 about 8 years ago. Once I realized I needed to take care of myself, even on N and R, I was able to do this. I still dealt with the peaks and delays of the insulin but I was able to bring my sugars under much better control. It’s not dangerous to me because I know how to use it, I know of the delays and peaks, and of the explicitly rigid meal schedule you must adhere to.
    It’s those who think they can just swing by Walmart and grab a vial of N and R and move on like they’re still on Lantus and Novolog. That is where the issues and likely all of the N and R related deaths are coming from.

    • Lorenzo Piemonte

      August 13, 2019 at 10:30 pm

      See above comment to Stefanos. Thanks!