100 years saving lives, but what next for insulin treatment?

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On 11th January 1922, 14-year-old Leonard Thompson received the first insulin injection as treatment for type 1 diabetes mellitus in a Toronto hospital, Canada. Frederick Banting and Charles Best, under the supervision of John Macleod and with the help of James Collip (instrumental in the purification process) developed the first insulin intended for human use in Toronto University almost exactly 100 years ago. This was a monumental development for the treatment of a chronic disease that currently affects approximately 415 million people worldwide, or what would be 1 in 11 adults, out of which 46% are thought to be undiagnosed.

Type 1 diabetes, commonly known as insulin-dependent diabetes, was the disease killing young Leonard. Food provides the body with both energy and building bricks for growth and restoration. Energy is mainly in the form of glucose and insulin is the key that allows glucose to enter the cells where it is used. No insulin and the organism starves, since energy cannot be used.

Type 1 patients died soon after diagnosis in a state of extreme malnutrition. This is what the first insulin (made from the purification of animal sources) solved.

Diabetes affects 1 in 11 adults, out of which 46% are thought to be undiagnosed

But diabetes is nowadays a word that, unbeknownst to many, comprises over 20 different diseases, all related by some sort of pancreatic malfunction. Type 1 (T1) diabetes is an autoimmune disease that occurs when the beta cells, which produce insulin in healthy bodies, stop working, meaning that the body no longer makes the hormone and the automatic regulation of blood sugar stops. T1 is mostly diagnosed in children, and there are many potential causes, none 100% dominant or identified.

Similarly, Type 2 (T2) occurs when the beta cells can still produce some insulin, but the body grows natural resistance to the hormone and cannot assimilate glucose at a rate that allows normal blood sugar levels. T2 diabetes, aside from being the most common type, is strongly related to genetic factors, and can also be influenced by some lifestyle choices. Although treatment for T2 is usually initially oral, insulin is also a viable treatment option. Importantly, insulin is also a lifesaving drug for many people with LADA (Latent Autoimmune Diabetes in Adults), MODY (Mature Onset Diabetes of the Young), gestational diabetes, brittle diabetes and many more.

Since its inception 100 years ago, however, insulin has improved dramatically. The protein is now modified to produce the actual drug we currently simply denominate insulin. The two most commonly known are fast- and long-acting. Fast-acting, or bolus insulin, otherwise known as lispro or aspart insulin, is used when eating, as it takes effect in 15-30 minutes and has an acting time of 3-5 hours, helping the glucose in food enter our cells.

The most well-known brand names for fast-acting insulin are Humalog and Novorapid/Novolog. Long-acting, otherwise known as basal insulin, on the other hand, is used to maintain stable levels of blood glucose throughout the day. There are several types (glargine, detemir, degludec), some lasting between 12-18 hours, others 24, and others even 42. The most well-known brand names for long-acting insulin are Levemir, Toujeo, Tresiba, Lantus, and Basalgar.

Most recently, even a super-fast type of insulin has been developed which takes effect in only 5-10 minutes. This has meant a lifestyle improvement for those diabetics with access to it, as the time between injection and actual eating is reduced, and sharp spikes in blood levels can be avoided. There’s even inhalable insulin now.

Developments in insulin and diabetes treatment technology don’t end there. We have moved from insulin vials and syringes to insulin pens with a myriad of needle lengths available. Delivery methods now no longer require several injections a day, even when using pens. The i-port, a cannula that sits in subcutaneous tissue and is held down by an adhesive with an injection site on top, helps prevent the lipohypertrophy (a deterioration of the subcutaneous tissue through an abnormal accumulation of fat) that can develop through regular injections. I-ports are changed every three days, reducing the number of injections over the same period of time from anywhere between 15-40 to just one.

And it just gets better. Insulin pump technology has evolved from being a machine the size of a microwave oven to a 4x5x1.45cm pod that adheres to the skin and delivers insulin via a cannula.

The world of insulin pumps is vast: you can go from tubed to tubeless, from Medtronic to Omnipod to Roche to Tandem, and then all the different models that exist within each brand.

In Syria, diabetes costs can amount to 75% of a person’s monthly salary

When coupled with the developments in glucose monitoring and linked devices, insulin pumps operate closed-loop systems, meaning that given the parameters of each individual diabetic’s treatment requirements (such as insulin to carb ratio and sensitivity factor), the pump will receive the blood glucose measurements and use the data to adjust basal patterns, give correction doses, and calculate bolus doses.

Even so, not everything is as rose-coloured as it seems. All of the advancements you have just read about, even including simple, basic insulin, is inaccessible to three out of every four diabetics in the world. Banting and Best sold the original patent of insulin for the symbolic price of CAD$1 to allow access to the drug for everyone who needed it. Now, only three insulin manufacturers; Eli Lilly, Novo Nordisk, and Sanofi, have a de facto monopoly over insulin production worldwide, marking up prices in a way that makes this life-saving drug increasingly inaccessible to millions. In the US, a Humalog vial containing 1000 units of insulin retails for approximately US$300.

Most diabetics on insulin therapy need more than one vial a month, and on top of that, there are costs for long-acting insulin, glucose monitoring, hypoglycemia treatments, and all other associated costs of living with diabetes. In Syria, on average, diabetes costs can amount to 75% of a person’s monthly salary. In many places in the world, even if you had the money to buy it, there simply is no insulin.

If you have diabetes and are lucky enough to live in a western state with fully subsidized healthcare, you are extremely privileged. If I hadn’t been born in Spain, maybe I wouldn’t still be alive today.

Diabetes is an extremely hard disease to live with that requires constant, 24/7 attention. The advancements in therapy, technology, and treatment that have been made over the past 100 years are incredible and life-changing, bringing us closer to a cure every day.

But the real question is — how much do these advancements really mean if barely anyone who needs treatment can access them?

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