Insulin: How To Restore A Tarnished Miracle

by james s. hirsch

It was hailed as a “miracle cure,” restoring life to the “erstwhile dead” and delivering not just health but “salvation.” Discovered in 1922, insulin did not live up to its initial euphoria – it didn’t cure anything – but the life-saving elixir has stood as one of the greatest breakthroughs in medical history.

But a funny thing happened to insulin’s halo. It’s been replaced by an albatross. Though the product is purer and better than ever before, insulin is often underused by type 1 diabetics and frequently avoided by type 2 patients – even with A1cs at 8, 9, 10, or higher - who would benefit from taking it. Insulin is often feared, reviled, misunderstood, poorly taught, used incorrectly, or neglected. At the recent ADA Postgrad meeting in New York, Dr. Arturo Rollo of Harvard Medical School said that delaying insulin therapy for type 2 patients was the greatest disaster in primary care.

Even when insulin is used properly, sometimes it has to be called a different name. Dr. Lois Jovanovic, the director of research and chief scientific officer of Sansum Diabetes Research Institute in Santa Barbara, California, realized that many of her Mexican-American patients feared insulin because they recalled that it had been given to an aging diabetic ancestor long after it could do much good. Insulin seemed like a precursor to death. “The word was terrifying, because it’s the drug that killed everyone in the family,” said Dr. Jovanovic, who has type 1 herself. To convince these patients to accept insulin therapy, she uses insulin pens, calling them las plumas.

Ironically, the need for insulin has never been greater. Type 1 patients, of course, whose numbers are growing, need the injected hormone to live. But the real epidemic is occurring in type 2 diabetes – and that’s where insulin’s underuse is most glaring. It is estimated by the Centers for Disease Control (CDC) that under 30 percent of type 2 patients take insulin, but Dr. David M. Nathan, director of the Diabetes Center of Massachusetts General Hospital, believes that about 60 percent need it to achieve near-normal blood sugars.

What makes insulin’s fall from grace so jarring is that it was once the very symbol of modern science defeating an ancient disease. After its discovery, widely published photographs demonstrated insulin’s miraculous power to literally restore flesh to bones. “A Boon to the Human Race,” shouted an early ad from Eli Lilly, which was the first company to mass produce insulin. Another ad by Eli Lilly showed a beautiful bride kissing her beaming father, the happy groom in the background, with the tagline: “Our favorite picture of insulin.”

To be sure, many patients remain grateful for this “miracle,” and I for one remain in awe. When I took injections (I now use a pump), I would sometimes paraphrase Shakespeare with the words, “Insulin, do thy deed.” Which was, keep me alive for another day. And when my young son took his first shot, the heartbreak of his diagnosis was leavened by the knowledge that insulin would save him from death.

So how did insulin lose its groove?

Some concerns are longstanding. Insulin sometimes causes weight gain because patients now retain their nutrients, and excessive insulin can cause hypoglycemia, which itself can be a killer. (Nietzsche said, “That which does not kill me, makes me stronger.” With insulin, the inverse is true: “That which makes me stronger, can also kill me.”)

The more pressing issue is with type 2 diabetics. It was long assumed that they avoided insulin because they feared the injections, but the extraordinary success of Byetta, an injectable drug for type 2 patients, has undermined that argument. The real problem with insulin is that it is equated with failure or punishment: according to this view, type 2 patients who can’t maintain good control with diet, exercise, and oral agents must suffer the consequences with insulin. Some doctors reinforce this perception by threatening their patients that they will have to start shots unless they lose weight. Insulin can also represent the needs of a body in its final throes, so avoiding it is a form of denial.

“There is a fear of insulin in that it represents the final stage,” said Dr. Paul S. Jellinger, president of the American College of Endocrinology. “The connotation is that you’re about to lose a leg, or whatever.”

This view is both shortsighted and wrong. Type 2 diabetes is a “progressive” disease, which means beta cells become increasingly impaired over time. If a type 2 patient lives long enough, that individual will essentially have the same beta cell function – little or none – as a type 1 patient. Thus, the goal of every type 2 patient should be to live long enough to require insulin.

Health care providers also shoulder some of the blame. Initiating insulin therapy for any patient is time consuming, so doctors who receive no extra compensation for good care may prefer to delay the burdens (their own) of insulin. (Some doctors also delay type 2 oral agents because they then have to deal with patients’ adverse side effects.) Doctors also underprescribe insulin for type 1 patients because they fear getting sued over a severe hypoglycemic incident, or perhaps they just don’t want to be bothered with late-night phone calls. “Hyperglycemia is considered the patient’s fault; hypoglycemia, the doctor’s fault,” said Dr. John Holcombe, Medical Fellow at Eli Lilly.

To restore insulin’s luster, at minimum health care providers need to be taught how to use it. Many in training don’t even know what it looks like. My brother, Dr. Irl Hirsch, runs a diabetes clinic for the University of Washington in Seattle, and when students or residents assist him, he has to show them what a vial of insulin looks like. “Even the fellows are clueless,” he said.

Patients must also be convinced about the indispensability of the product, particularly in the high-tech age of insulin analogs: rapid-acting, peakless, inhaled, and formulations we’ve not yet envisioned. I would love to see the principal manufacturers – Novo Nordisk, Eli Lilly, Aventis – sponsor a marketing campaign that reminds patients that insulin is not a sign of weakness or failure but a product with a glorious history and marvelous future. I would put a tall vial next to a precious child, with the tagline: “Insulin. The Miracle Keeps Getting Better.”