Insulated From Reality

IN THREE DECADES of treating people with diabetes, I have not come across a single patient who jumped with joy at the idea of being prescribed insulin. In fact, the joke among endocrinologists is that if you want to put an end to the conversation with an exceptionally demanding patient, advise insulin treatment. The next minute the consultation ends and the patient walks out, often never to return.

Why do patients react so strongly at the very mention of insulin? The overpowering sentiment is the fear of injections, despite the fact that modern day insulin administration is remarkably simple and virtually pain free. Other cited reasons for avoiding insulin are the perception that it is the last ‘stage’ of diabetes, or an admittance of failure. There is also a myth that complications of diabetes are related to insulin and not to diabetes per se. In reality, the only established side effects of insulin are low blood sugar reactions and some weight gain, effects which can be seen with several other anti-diabetic medications as well.

It is not without reason that doctors spend considerable time in convincing patients to take insulin. Every major study ever carried out has shown that controlling glucose level reduces complications. A healthy lifestyle is the key to good control. However, with passage of time it becomes impossible for lifestyle alone to control diabetes. Two decades ago the landmark United Kingdom Diabetes Prospective study (UKPDS) showed that medication is necessary for most patients, and it needs escalation every few years to sustain good control. In late stages of diabetes, pancreatic function declines to such an extent that insulin administration becomes unavoidable. Delayed insulin initiation is one of the big challenges in diabetes management and a major contributor to poor outcomes. Some studies suggest that early use of insulin protects the pancreas from further damage, and may at times allow discontinuation of medicines for many years.

Every scientific society in the world places insulin high on the list of anti-diabetes medications. This is only natural since insulin deficiency is one of the primary defects in diabetes. Countries like India with huge economic disparities and vast differences in access to medical care have made attempts to control insulin prices to make it more accessible. It came as a surprise, therefore, when I recently read the headline in a reputed newspaper (Economic Times, November 20th, 2016) which said, ‘Pushing diabetics to take insulin is a medical scam’. My surprise turned to dismay when I realised that the statement was apparently made by the editor of the well-known British journal, the BMJ. It is difficult to believe that such a statement could come from someone who should be well versed with the facts. I quote further: ‘I think it is a scam, an industry scam. I think we need to speak out against the pressure to put people on insulin [in India].’ This, rather strong statement, needs close scrutiny. Is insulin use in India excessive? Is it being given to patients who do not need it? Does expensive, foreign manufactured insulin comprise the bulk of insulin used in India? Let us look at the facts. At a conservative estimate, India is estimated to have 70 million people with diabetes. IMS September 2016 data suggests that about 4.2 million patients (6.1 per cent) in India use insulin. Compare this with data from the US and UK where 30- 50 per cent of the diabetes population uses insulin. Over 80 per cent of insulin used in India is human insulin, and much of it is manufactured within India itself. The pricing of human insulin vials is tightly controlled by the Government. Some of the newer, higher priced insulins (analogs), are designed by structural modification of the insulin molecule and have unique properties, giving them subtle advantages over the conventional kind. Such insulins, however, comprise less than 20 per cent of the total insulin used in India. Thus, the newspaper that published the interview has done a great disservice to the Indian diabetes community—it could potentially drive away patients from insulin, adversely impacting their care.

What should someone with diabetes do? Start insulin if your doctor asks you to, learn the technique (it’s easy), clarify all doubts at the time of initiation, and do not stop insulin on your own. If you come across information in the media, take a doctor’s help to separate the truth from the myth. Ultimately it will be self-destructive to avoid or discontinue insulin if you need it. Remember what the British comedian Jasper Carrott says: “Laughter is the best medicine—unless you’re diabetic, then insulin comes pretty high on the list”.

About The Author

Dr Ambrish Mithal

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