Jose Gomez-Marquez asks ‘So why can’t we use the orange one [older insulins]?’ I originally posted this as a long @juliaboss5 Twitter thread on 10/27/16; I’ve edited it here to improve readability.
To evaluate the use of newer vs. older insulins, you must factor in the social value added by newer, especially faster-acting, insulins. Within a strictly medical model, it’s possible to set up a trial where a person on an “orange one” insulin (e.g. NPH) follows a strict regimen of meals timed to peaks of insulin action and attains good A1c results. But it’s also important to consider the social model: how each insulin works in the real world, where T1Ds live among other people who are used to living with a pancreas that works on demand.
Modern work/school schedules and especially worker availability expectations do not mesh easily, if at all, with older insulin regimens. Our modern economy — at least as we experience that economy in the U.S. — constructs job performance expectations according to employers’ scheduling needs, not employees’ scheduling needs. Consider the following: your (older, orange line) insulin, dosed an hour or more prior, peaks at 2 p.m., and you must eat then to match the peak or else suffer a dangerous low. But you are a lawyer or PR agent; your most important client calls with a breaking crisis at 1:55. How will your client respond if you delay the call? Or you’re a grocery store clerk whose meal break time depends on the goodwill/discretion of a supervisor who doesn’t understand diabetes. How will your supervisor respond if you say you must eat immediately?
In theory, older insulins with big peaks could work in institutional settings (e.g. elder care) if meals were carefully scheduled accordingly. In practice, insulin operation varies considerably, so older insulins can lead to dangerous lows even in a predictable institutional context. Incrementally improved (your “blue line”) insulins allow T1Ds to function well in the real world while requesting fewer employer or school accommodations. On blue-line insulins, T1Ds and insulin-dependent T2Ds can more easily manage rigid or ever-changing employer/school schedules because modern basal insulin regimens (whether pump or MDI) have reduced/eliminated built-in peaks, and fast-acting insulins allow one to manage meals by dosing and then eating almost immediately.
Recall that U.S. T1Ds and T2Ds live in a world where an employee can be fired for treating a low on the job. Yes, that’s illegal, but it does happen; legal challenges can be costly and can affect future employment prospects. Lows, especially severe lows, can also be a crisis in a school setting. Many students with T1D attend schools where there is no school nurse, or only a part-time school nurse, and school staff in many U.S. states are not required or are otherwise restricted from giving emergency care (#glucagon) in case of severe hypoglycemia.
A return to older insulins would increase both risk and the social burden involved in negotiating accommodations with employers and schools. A return to older insulins would very likely lead to more on-the-job or at-school lows/highs, impacting performance and even potentially causing loss of life.
The social benefit of faster-acting “incrementally improved” insulins (blue) vs. older (orange) insulins is undeniable. The problem comes from framing the social benefit of newer insulins as a private value that people with diabetes should pay individually in the form of higher insulin prices. Incrementally improved insulins allow T1Ds and T2Ds to perform more effectively in the larger economy, reduce other costs (e.g. hospitalizations). “Newer insulin as private good” is especially problematic because those most likely to be on older insulins for cost reasons are precisely the people who have least control over their own schedules (e.g. shift workers, incarcerated, low-income elder care).
None of this social benefit argument is intended to validate the huge price increases for fast-acting insulins that we’ve seen in the U.S. Though the social value of those newer insulins does partly explain why insulin companies feel they can increase prices on new insulins without significantly impacting demand, these “new” insulins were in fact delivering the identical social benefit 10 years ago at a fraction of the price. Fast-acting, pump-compatible biosimilars, especially with lower prices, would obviously have comparable social value to current brand name options. But the social value explanation does, I hope, clarify why “just use the orange one” is not a real solution to the insulin pricing crisis.