Insulin is way too expensive. California has a solution: Make its own

> Transit: The New York City Subway is the 3rd largest metro rail system on earth after London and Guangzhou

It’s also the worst large metro system, by timeliness and reliability, in the world, despite being very well funded.

People in the rest of the country aren’t exactly unaware of New York. But its transit, housing, and public school systems are a poster child for how government-run services are terrible, even when well funded. There’s a reason why New York has suffered net domestic outmigration for many years.

Look, if Stockholm was in America the American public would have a very different idea of what government-run services could be like. But we don’t have Swedes running our government services, we have Americans. It is what it is.

I dont mean to be dismissive or elitist. There is enough wrong with the medical system, that if somebody loses coverage and needs to see a doctor to get their prescription changed, that change alone becomes insurmountable, behavioral change not included.

My rub is that the conversation is dishonest. Saying "access to insulin is a right" and then changing the topic to modern delivery methods and such. Call a spade a spade, and have the direct honest conversation the first time. My pertubement goes beyond this topic into social justice/political correctness and just about anything. I may believe in the cause and the result, but be dismissive of how to get there by cheating and hacking peoples attention spans. It seems the only way to be an activist and get attention is to start with a lie, and now everybody is competing for the most inflammatory headline.

Everything you said is the conversation everybody should be having, instead of truncating it to "insulin is way too expensive."

My fiancée was close to death from a missed diagnosis of Type 1 diabetes. We were extremely lucky that she actually got a diagnosis; A nurse at the oncology ward had a hunch. (Overburdened medical personnel miss diagnoses.)

Her HbA1c long-term blood sugar measurement was literally off the charts. Off the chart on the wall on the hospital, right through the red “DANGER” section. She had lost 17% of her bodyweight and half of her hair.

We have learned the following:

You want a continuous glucose monitor (CGM), and an insulin pump, with rapid-acting insulin.

You do not want long-acting insulin. Especially not insulin glargine. It is a dangerous form of insulin: It is injected as a blob of insulin (“bolus”) under the skin. It’s supposed to stay in the place and slowly fritter and diffuse into the bloodstream. This effect is due to crystallization of the modified insulin amino acid chain in the pH level inside the body. It’s clever. However, if insulin glargine happens to go into a blood vessel, it works pretty much instantly. Then it is not long-acting at all. The subcutaneous environment is… living tissue. There are capillaries. It can and will go into directly into the bloodstream at some point. For some reason. At injection time, or due to bumps and jostles and physical pressure. Then there are no brakes on it. 24 hours’ worth of active insulin can go into the bloodstream. Then every cell in the body is signaled hard to pull glucose from the blood – all the flesh in the body rips the sugar out of your blood, leaving too little for the brain. People start losing consciousness in minutes, csn pass out, and may die.

Insulin degludec is another long-acting insulin, one which is acceptable in this regard. The bolus stays glommed together due to polymerization of the insulin so it’s more robust. It also has molecular brakes on it kind of – if it does go into the bloodstream, it attaches to albumin in blood plasma and doesn’t become active all at once.

However, using rapid-acting insulin in a pump is strictly better because this replicates the insulin oscillation of the pancreas. “[The pancreas’] basal insulin level is not stable. It oscillates with a regular period of 3-6 min. After a meal the amplitude of these oscillations increases but the periodicity remains constant. The oscillations are believed to be important for insulin sensitivity by preventing downregulation of insulin receptors in target cells. Such downregulation underlies insulin resistance, which is common in type 2 diabetes.”—https://en.wikipedia.org/wiki/Insulin_oscillation

The insulin pumps work this way. They pump the insulin with a rhythm. It’s easier to control the blood sugar and you need less insulin. It’s crucially different and much better for long-term health and quality of life.

The most important things are a good blood sugar sensor (continuous glucose meter or CGM), and a good pump with a good user interface. We haven’t tried one of the closed-loop automatically controlled pumps that reads from the sensor and autoadjusts, but it’s clear from the problems people have with badly designed pump that a good “semiautomatic” pump is better than a poor and unpredictable sensor-feedback-controlled automatic one. These have issues like sometimes cutting out without giving clear warning if blood sugar is high, and the blood sugar target range can’t be adjusted low enough (liability issues afaik) so people tend to stay at too high blood sugar levels which do long-term harm. I do assume that a good automatic pump is magic.

Also, glucose metabolism and inflammation are intimately related, which ties into the vascular system. There is a lot more actionable science out on this than most doctors are aware of. (Overburdened medical personnel are unable to keep abreast of scientific developments.)

Hi even the long acting insulin has been quoted to cost around $10 to manufacture (at scale)!

yes apologies glargine was approved in 2000. And I agree it does take a while for doctors to switch. Something interesting that I have recently learned is that it may even be hard to find clinical trial participants because doctors will be hesitant to take patients who have good reactions to their current insulin off of that insulin to be a part of a clinical trial.

I will also say that Pharmacy Benefit Managers (PBMs) also have a lot of power when it comes to influencing doctors to begin prescribing new drugs.