Insulin at 90
This year marks the 90th anniversary of the introduction of insulin into human use. Its discovery and availability for treatment of type 1 diabetes was one of the true medical miracles of the 20th century. No longer was the diagnosis of diabetes a sentence of certain death; with insulin, people with diabetes could lead normal lives, go to work, go to school, play sports, raise families. Above all else, insulin offered hope.
However, insulin use today is often viewed with a mix of fear and misunderstanding, both by people with diabetes and by physicians who care for them. Instead of insulin being the treatment of choice after a diagnosis of type 2 diabetes, it is all too often regarded as the option of last resort, years after diagnosis and far too late for it to be of any value in preventing complications.
Why the resistance to using insulin? After all, it has been used for 90 years in millions of patients. Major technological breakthroughs have given us biosynthetically pure human insulin and insulin analogs that mimic normal human insulin secretion. New devices have increased the safety and comfort of giving oneself insulin.
There are many reasons why insulin use is delayed and avoided. The emergence of eight different classes of oral diabetes medications over the past 60 years has served to replace or delay the use of insulin for treating type 2 in many cases. Oral agents have been very effective, but none reduce A1C more than an average of 0.5 to 2 percentage points, while insulin is the most potent treatment available for A1C reduction.
The risk of hypoglycemia (low blood glucose) is often cited as a reason for avoiding insulin use. Yet many oral medications for diabetes also can cause hypoglycemia. What's more, this preoccupation with hypoglycemia overshadows any discussion of the effect of prolonged high blood glucose levels: insidious and progressive organ damage caused by years of unacceptable, yet tolerated, hyperglycemia.
Early use of insulin has been shown to help sustain the limited amount of beta cell activity left in a person's pancreas at the time of diagnosis. Insulin in combination with oral diabetes medications could also serve to reduce the confusing and often ineffective combinations of three or more oral diabetes medications, some of which may no longer have any therapeutic benefit.
After 90 years, it's time to reassess insulin's unique role in the treatment of diabetes. It's time to openly question why there is still fear and reluctance to use such a valuable tool earlier in the course of the disease. It's time to recognize that, after all that has followed it in the treatment of diabetes, there is still no better ally than insulin.