Shoot Up or Put Up

According to the BBC, everyone’s favourite pharmaceutical company Novo Nordisk is withdrawing its insulin products – including Levemir & NovoRapid – from Greece after the Greek government ordered a 25% price cut in all medicines due to their current financial difficulties. You can read Aunty Beeb’s full article here: http://news.bbc.co.uk/1/hi/world/europe/10189367.stm

Being evil, I always like to stick up for the capitalist overlord – after all Big Pharma is a huge business, it’s not a lovely, fluffy, ickle-wickle charity. But if I were a Greek diabetic I would find this move by Novo Nordisk somewhat unnerving. It’s unlikely that we’ll see pancreatically-challenged hoards dying the streets – there are other insulins available after all and I expect grey imports of Novo Nordisk products into Greece will flourish – but it does represent a reduction in choice of the insulins that are available. This is obviously not good.

It remains to be seen whether the other members of Big Pharma will follow suit and, if so, it’s rather disconcerting for all of us with broken pancreases. I don’t know about you but I find the thought of my insulin being withdrawn from sale somewhat unpleasant – after all we do all rely on it to live and I, personally, quite like living.

So it’s something I think we should all watch closely. And immediately start stocking up on our life-giving insulin! And keeping our stashes under (refrigerated) lock and key; and nailing rough pieces of timber over our doors and windows; guarding our supplies while clutching – sweaty, watchful and paranoid – a loaded shotgun!

However, it’s not all bad for Greek diabetics – there is a ray of sunshine amongst these gloomy clouds; the BBC reports that Novo Nordisk is making glucagen available for free. Which will be really very useful in bringing those high blood sugar levels down. Mmmm.

BBC article – http://news.bbc.co.uk/1/hi/world/europe/10189367.stm

I recently did an interview for a diabetes magazine (yes, another magazine – we’re getting really big now in diabetes celebrity circles; such as they are). And I was asked what single development would make life easier for me as a member of the pancreatically-challenged hoard.

I did think about a new pancreas grown from stem cells, but I just don’t think science is advanced enough to come up with a proper cure for diabetes in my lifetime (or what I expect my lifetime to be – obviously even I don’t know how long I’m going to live). When you think about it, science has had 90-odd years since Banting & Best successfully stopped killing dogs and discovered insulin to come up with a complete cure. Although there have been leaps and bounds forward since then, science hasn’t even yet managed to come up with a long acting insulin that actually delivers consistently and smoothly for a full 24 hours (yes, we’re talking about you lantus). So I’m afraid that I think cures are still a long way off.

So I side-stepped the question by answering that incremental improvements to existing systems actually make life a lot easier for people with wonky pancreases. Take for example blood glucose meters. I’m a huge fan of Abbott’s FreeStyle Lite as it uses a tiny sample, is stupidly quick to process your result and is just generally well designed and thought out.

When you compare this to the medieval instruments of torture that were used not that long ago for measuring BG you can see that the world has moved on enormously and checking your BG is now ludicrously easy and relatively pain free. Given that a Good Diabetic will check their BG 4, 5 or 6 (or more) times a day such seemingly small changes to meters make a huge difference to the quality of our lives.

Similarly, faster acting insulins would be hugely beneficial. Humalog is pretty good stuff, but I still have to stick it in about 20 minutes before breakfast to avoid a massive post-port and pheasant peak (there’s nothing like a good, well-matured roast pheasant and a flagon of port for a good start to the day. The sort of breakfast empires were built upon, God be my witness!).

Anyway, so that’s what I’m hoping for the future – not a cure – but lots of little incremental improvements. Each one might not be wildly noticeable by itself, but cumulatively they’ll make a huge difference to our everyday, mundane, shuffling lives.

I’ve been reviewing my insulin history over the last 26 years and it appears that while I’m able to sustain a reasonably long relationship with an insulin brand, I have been a bit of an insulin tart over the years swapping to the latest thing when it’s caught my eye.

When I was diagnosed, back in the dark ages, Eli Lilly were the big thing in insulin. They’d just brought out this new stuff called human insulin. In the dark ages most people used animal insulin, produced by boiling up dead cows and pigs, running the resultant broth through an insulin extraction machine then bottling it. (Here, I must admit that the finer details of this description may be a little inaccurate and I acknowledge the process was probably a little more refined than this, likely using microscopes and stuff.)

Anyway, human insulin was the next big thing and my consultant was very excited that Lilly’s Soluble and Isophane human insulins were on his prescription pad. At the time they seemed fine, they kept me alive which was better than my own body could manage so they were a good thing. Looking back, they were pretty crude. The long acting liked to peak and fall like a rollercoaster and the short acting needed to be injected six weeks in advance of you thinking about eating.

It was the best we could find though, so we stuck with it. My promiscuity started early when aged 9 I jumped ship and moved to NovoNordisk. They’d brought out a marvellous new invention – the NovoPen. Instead of using a syringe twice a day, you could now use a super sexy metal pen to inject with four times a day – it came with Actrapid, a faster, shorter acting insulin you injected just 2 weeks before your anticipated meal. This was intergalactic type progress!

Actrapid’s long acting partner was Ultratard, still with plenty of ups and downs but it also had the additional quirk of only lasting about 18 hours when you actually needed it for 24. Nice.

About 10 years ago the world really changed. A new thing called insulin glargine arrived. And being the insulin tart that I am, I went for it. Sanofi-Aventis became my new best friends with their 24 hour lasting, flat as a pancake Lantus. Marvellous stuff, so much better than that nasty Ultratard although personally the no peaks/no dips thing didn’t really work for me, I found it liked to rocket about 6 hours after I’d injected it, but perhaps that was just me.

The best thing was still to come though. A properly fast acting insulin. Despite my long term relationships with other drug companies, it seems I still held a torch for my first love, Lilly. That smouldering torch was ignited again when they brought out Humalog. You could inject and then eat pretty much straight away (well 20-30 mins but who’s counting?). And it didn’t last for hours on end causing hypos 5 hours after meals like some of it’s predecessors.

I’ve used Humalog for at least 6 years now and we get on just fine. But am I being complacent in this relationship, have I just got all comfy with Humalog and taken myself off the insulin dating scene because we’re lazily snuggled up on the sofa together? There’s plenty more fish in the sea, should I be setting up a date with the slightly newer Apidra or NovoRapid/Novolog? They claim to work a little bit faster and possibly for a shorter duration, but is it enough to be worth the hassle of getting to know a new insulin?

At the moment I think I’m settled in front of the fire in my slippers with my Humalog, not because it’s earth-shatteringly fabulous, but because it’s doing what I need it to do.

Are there any Apridra/NovoRapid/Novolog lovers out there who can convince me it’s worth getting back on the dating scene?

Anyone who has read an account of Banting and Best’s discovery of insulin will know that they worked their guts out to come up with a cure for us diabetic hoards. Many dogs gave their lives for diabetic research – having their pancreases ligated allowing their pancreases to atrophy – leading to their untimely and grisly deaths.

James Collip worked himself almost to madness to purify the secretions Banting and Best made, while at the same time JJR Macleod laboured tirelessly with the research laboratories at Eli Lilly to make insulin available on a scale that made it commercially viable and available to grateful diabetics the world around. For their efforts Banting and Macleod won the Nobel Prize for Medicine in 1923.

Since then researchers and pharmaceutical companies have poured millions of pounds and countless hours of work into new insulin analogs, so creating wondrous new insulins including technically advanced biosynthetic human recombinant analogues and shifted isoelectric point insulins.

Modern insulin – the culmination of years of research and labour and sweat and tears – is now available in plentiful supply at a reasonably affordable price throughout most of the world.

So what do we do with it when we get it?

Yes, that’s right, shove it in the fridge in an old cheese box next to a jar of mouldy pickled onions and some posh French mustard.

Poor old Banting must be turning in his grave.

Some pickled onions. And some insulin in Tim

I think a unit of insulin is a huge amount. One too many is the difference between me waking up and going to work, or waking up drenched in sweat jibbering complete rubbish and scaring the husband.

Equally, a unit less than I needed for dinner is the difference between a very pleasant evening with friends and an evening spent with my tongue stuck to the roof of my mouth and a fuzzy headache while I battle to get my blood sugar down from the ceiling.

In my world a unit of insulin is a big thing, it’s massive. A unit of insulin to me looks like a biscuit, half an apple, a small yoghurt or 5 fruit pastilles.

I generally use between 50 and 60 units a day (although I get really stroppy when ignorant travel insurance companies ask me how many units I use a day as if the answer will give them any meaningful information, but I digress).  Do you know what 50 units of insulin looks like? Its nothing. Tiny, miniscule, I take at least twice as much medicine to sooth an irritating cough several times a day.

My daily elixir of life boils down to this – less than a teaspoon full!