Diabetes patients groan as high cost of insulin raises risk of blindness, amputation, kidney failure, stroke

Seventy-year-old Obiemeka Azikiwe has type 2 diabetes. He tested positive for diabetes 24 years ago, and since then, he has been on drugs and a special diet. Obiemeka also developed hypertension five years after diabetes. Despite Obiemeka’s efforts, he developed kidney problems and survived partial stroke at the age of 68. Obiemeka later succumbed to kidney failure.

Mrs. Abimbola Yahaya, aged 49, was unaware she had diabetes. She had a foot ulcer, which refused to heal and turned to gangrene. And to stop the gangrene from spreading, her foot was amputated. Abimbola was diagnosed late with diabetes. She lost her sight a year later and died of a stroke.

The 84-year-old Matthew Obasanjo was diagnosed with diabetes at the age of 45. And in the past 39 years, Matthew is still living well with the disease. He is yet to develop any of the complications associated with type 2 diabetes including blindness, kidney failure, heart attacks, stroke, and lower limb amputation.

Nine-year-old Divine Mark has type 1 diabetes. He was diagnosed with the disease at the age of six. Divine has been on daily doses of insulin injection to survive, which comes at a very high cost.

“In 2016, I had complications, I was admitted in the hospital and everyone thought it was malaria and typhoid, my regular sickness,” said Kaycee Lawrence.

Lawrence is a 50-year-old diabetic patient and has been living with and managing the condition for more than three years now.

Kaycee Lawrence

The 50-year-old said: “The ailment came with severe chest pains and pains all over my body. The doctors said they do not know what was wrong with me because I was not having malaria. They said the tests show no malaria just little typhoid. But they cannot understand why I am having consistent pain in my chest.”

Lawrence said that by the end of the three days he spent in the ward of the hospital, the doctors carried out some other tests and they discovered his blood sugar was high.

At this point, Lawrence said he felt very bad but was counselled by the hospital that also administered some drugs on him.

He continued: “So, I started using the drugs consistently, but whenever I use these drugs I feel upside down, my body is complete upside down, scattered and I do not feel comfortable, I feel very weak, I do not even have the strength to move around.

“Gradually I started to pick up. When you are having a sugar problem, you start having pains that you cannot describe, in the chest, arms, your body is not just it and I need not mention the level of substandard medications flooding the market.”

Lawrence after accepting his fate said he became determined to manage and control the ailment and decided to embrace a total lifestyle change.

He further stated: “I, then started to watch what I eat. I was told no more eating of rice, fufu, and other carbohydrate-rich foods. My favourite food then was fufu. I’ll take like two wraps and any day I miss it, I won’t feel good.

“Gradually, I started moving from high carbohydrate-rich foods to beans and unripe plantain. It was not easy for me to adjust to that type of diet but after some time of consistent eating of this food. I now discovered that it was not actually bad. Though, it took a lot of discipline.”

Lawrence said he adjusted to the food chain because he knew if he does not continue there will be an emergency, which might be difficult to manage.

Admitting that it has not been a smooth ride, he said he is on the road of recovery due to some lifestyle changes.

Reacting to the cost of managing, Lawrence said he was covered with health insurance stressing that it will be difficult for someone without insurance to survive the ailment. He urged the government to make healthcare accessible to all Nigerians regardless of class.

Obiemeka, Abimbola, Matthew, Divine, and Lawrence represent the estimated 15.3 million Nigerians living with diabetes.

Indeed, more Nigerians are developing diabetes and its concomitant complications, such as diabetic foot ulcer, blindness, erectile dysfunction, kidney failure, stroke, among others. Recent reports have shown that even more are dying because of poor funding from the government for treatment cocktails and non-compliance to treatment by patients. But medical experts are unanimous that a healthy diet especially balanced breakfast, regular physical activity, maintaining normal body weight, checking one’s blood glucose more often, and avoiding tobacco use can prevent or delay the onset of Type 2 diabetes.

According to the World Health Organisation (WHO), there are two main forms of the disease. People with type 1 diabetes typically make none of their own insulin and therefore require insulin injections for survival. People with type 2 diabetes, the form that comprises some 90 per cent of all cases, usually produce their own insulin, but not enough or they are unable to use it properly. People with type 2 diabetes are typically overweight and sedentary.
Burden/challenges

According to the Diabetes Association of Nigeria (DAN), the prevalence in Nigeria varies from 0.65 per cent in rural Mangu (North), 6.8 per cent in Port Harcourt to 11.0 per cent in urban Lagos, and it is associated with high morbidity and mortality.

Head of Department of Medicine College of Medicine, University of Lagos, Prof. Olufemi Fasanmade, said that diabetes is very common in Nigeria and from records; the country has the second-highest prevalence in sub-Saharan African.

He said there is inadequate awareness because only a few people are aware of it due to the fact that it is not something that attracts much attention.

The expert said that the prices of any drugs in Nigeria are not affordable especially if they are manufactured outside the country, because the company that makes them are not into charity, they do it for profit and when it gets to the border, customs add their own thereby making the drugs unaffordable.

He continued: “Some patients use N3, 000 to N10, 000 insulin monthly. There are different types of insulin and they all have different prices. The minimum amount a patient can require a month is between N3,000 to N4,000 for a patient who does not need much like a child. But somebody who is grown up and blood sugar difficult to control may need up to four or five times that amount.”

Fasanmade said that patients’ ignorance, low awareness, inadequate number of doctors and nurses and a lot of patients being misdiagnosed were challenges scuttling fight against the scourge.

He noted that smoking, obesity, lack of exercise, excessive alcohol intake, hypertension, and hereditary are the risk factors that predispose one to diabetes.

“Diabetes affects the whole family, one person is affected the whole family is affected because the financial burden affects everybody. If one person has it others in the family are at risk too.

“People should change their diet too and also avail themselves for screening at least once a year and people who have it should control their blood pressure very well,” the endocrinologist added.

Similarly, Senior Lecturer/Honorary Consultant Endocrinologist, Department of Medicine College of Medicine, University of Lagos/Lagos University Teaching Hospital, Dr. Ifedayo Odeniyi, said the International Diabetes Federation (IDF) released new figures that highlighted the alarming growth in the prevalence of diabetes around the world.

He noted that new findings show that there are now 463 million adults with diabetes worldwide who stated that the global prevalence of diabetes has reached 9.3 percent, with more than half (50.1per cent) of adults undiagnosed.

Odeniyi said that Type 2 diabetes accounts for around 90 per cent of all people with diabetes stressing that much can be done to reduce the impact of diabetes.

The consultant continued: “Evidence suggests that type 2 diabetes can often be prevented, while early diagnosis and access to appropriate care for all types of diabetes can avoid or delay complications in people living with the condition.

“IDF in collaboration with Stakeholders is encouraging everyone to learn about their risk of type 2 diabetes. The goal is to have at least 1 million people test their risk for type 2 diabetes by the end of November 2019,” the expert added.

Odeniyi stressed that the total number of people with diabetes is predicted to rise to 578 million by 2030 and to 700 million by 2,045 unless concerted efforts are put in place.

The endocrinologist continued: “374 million adults have impaired glucose tolerance, placing them at high risk of developing type 2 diabetes. Diabetes was responsible for an estimated $760 billion in health expenditure in 2019.

“Diabetes is among the top 10 causes of death, with almost half of deaths occurring in people under the age of 60 years.”

Indeed, the crisis now facing people with diabetes is equally dire.

The WHO’s chief of diabetes management guidelines, Dr. Gojka Roglic, said: “Over the last 35 years, the number of people in the world with diabetes has quadrupled to 400 million, said People with uncontrolled diabetes face premature death, blindness, strokes, foot amputations and other consequences of dangerously high blood sugar levels.”

The increase in diabetes is partly a result of population growth and rising life expectancy, but mostly it is driven by the obesity epidemic and lack of exercise, which contributes to Type 2 diabetes.

Type 1 diabetes — an autoimmune disease that typically begins in childhood and destroys the body’s ability to make insulin — has also increased by about three percent a year for unknown reasons.

Everyone with Type 1 — about 20 million people, the WHO estimates — needs regular injections of insulin. So do about one-fifth of those with Type 2, another 60 million people.

According to the WHO, even though insulin has been on the WHO’s essential medicines list for over 40 years, about half of those 80 million people cannot get the insulin they need, because they or their country’s health systems cannot afford it.

In the United States, where the price of a vial has risen to $275 from $35 over two decades, diabetics without good health insurance are forced to ration whatever they can afford or to buy insulin on the black market.

Drug companies making insulin for domestic use exist in India, China, Poland, Ukraine, United Arab Emirates, Brazil, Mexico, and Russia. Several have already expressed interest in entering the global market if they can win WHO-approval.

In a recent WHO survey of 24 countries, most of which were poor or middle-income, 40 percent of health care facilities had no insulin on hand. In some countries, the price of a vial in private pharmacies was 15 to 20 percent of a typical worker’s take-home pay.

Insulin was discovered almost 100 years ago. The drug itself is not patented, although different ways to make and deliver it are. In the United States, established pharmaceutical companies often file suits claiming patent violations to drive generic competitors out of the marketplace.

The WHO inspection and approval process currently takes about nine months.

Insulin, which is a hormone typically grown in Escherichia coli bacteria or yeast, is more complex to produce than, for example, Human Immuno-deficiency Virus (HIV) drugs, which are laboratory-synthesised chemicals.

According to a new modelling study published in The Lancet Diabetes & Endocrinology journal, the amount of insulin needed to effectively treat type 2 diabetes will rise by more than 20 per cent worldwide over the next 12 years, but without major improvements in access, insulin will be beyond the reach of around half of the 79 million adults with type 2 diabetes who will need it in 2030.

The findings are of particular concern for the African, Asian, and Oceania regions which the study predicts will have the largest unmet insulin need in 2030 if access remains at current levels.

The analysis underscores the importance of tackling barriers to the insulin market, particularly in Africa. The authors warn that strategies to make insulin more widely available and affordable will be critical to ensure that demand is met.

Insulin is essential for all people with type 1 diabetes and some people with type 2 diabetes to reduce the risk of complications such as blindness, amputation, kidney failure, and stroke.

As global rates of type 2 diabetes soar and people with type 2 diabetes live longer (which will increase insulin requirements), a comprehensive picture of global insulin need is required because insulin treatment is costly, and the international insulin market is presently dominated by only three major manufacturers.
Efforts

As part of activities to mark the World Diabetes Day (WDD) on November 14, and reduce the burden of the disease, experts have warned that over time, high blood sugars can endanger every major organ system in the body, causing heart attacks, strokes, kidney failure, blindness, impotence and infections that can lead to amputations.

They, however, said that if properly treated, the impact of diabetes could be minimised. Even people with type 1 diabetes can live long and healthy lives if they keep their blood sugars under tight control. WDD was created in 1991 by the International Diabetes Federation (IDF) as WHO’s response to growing concerns about the escalating health threat posed by diabetes.

WDD is the world’s largest diabetes awareness campaign with events organised in more than 100 countries in 2014 and dedicated advocacy activities around G7, United Nations (UN) General Assembly and G20. It unites the global diabetes community to produce a powerful voice for diabetes awareness and advocacy. WDD is a yearlong campaign to reflect the realities of dealing with a chronic condition.

To mark the WDD 2019, Fasanmade said awareness campaigns were held in the 36 states of Nigeria and the Federal Capital Territory.

“We have been having programmes and they are all awareness programme, media interview, community screening. These are most of the things we do to raise awareness and we do it all over the nation, the same day.

“The management of diabetes is unaffordable to people who do not have health insurance. If you have health insurance it will be a bit affordable. The role the government has to play is to waive all custom duty on insulin, and diabetes products,” he added.

However, the consultant said it is something the government will not want to do because if they do it for diabetes people treating hypertension and cancer will come for the same thing.

The HOD noted that the easiest thing the government can do is to ensure everyone is placed on health insurance instead of the five per cent that is covered now.

“If about 70 per cent of people are on insurance, then indirectly the government is making things easy for the patient. It is a role both government and people need to play. People need to enroll and the government needs to make it mandatory,” he added.

Meanwhile, the Federal Government has outlined six critical strategies to reduce the risk factors associated with diabetes and Non-Communicable Diseases (NCDs) in Nigeria. The ministry has adopted the global monitoring framework for NCDs, development of a National Diabetes Plan and Policy as some of the approaches to stemming the tide of diabetes in Nigeria. Others include increased monitoring and surveillance systems, engagement and right, improved access to care and sustainable financing for management of diabetes.

The Guardian learned the ministry had adopted the global framework, which focuses on strengthening data collection for the global burden of the disease. The Federal Ministry of Health (FMoH) has developed a National Policy and Strategic Plan of Action on NCD and a National Nutritional Guideline on NCD Prevention, Control and Management. The document lists the country’s local food items with glycaemic index, which provide Nigerians with information to make informed decision on food choices.

It is also believed that the Tobacco Control Act 2015 will further help in implementing stringent tobacco control measures given that tobacco use interferes with wound healing and blood vessel integrity vis-à-vis diabetes management.

Solutions
Fasanmade called on ministries departments and agencies (MDAs) and other government institutions to be part of the campaign and help in regulating the cross border marketing of foods with high saturated fats, trans-fatty acids, and free sugars. He also urged Nigerians to learn and identify the risk factors associated with diabetes and take a step to avoid them.

The endocrinologist advised that Nigerians should maintain a healthy weight, eat healthy food and remain physically active. He advised diabetic patients to adhere to the doctor’s advice and keep an appointment with their doctors.

Odeniyi highlighted the modalities of management which include lifestyle modification, diets, exercise, cutting down alcohol consumption, quitting smoking and also prescription drugs.

The endocrinologist said there is no cure for diabetes but it can be managed. He stated that a lot of people die due to the complications from diabetes urging the populace to present for the screening.

The consultant lamented that a lot of people out there do not even know they have diabetes and half of the people who know were not even getting to target treatment and among those who have got to target about half have complications.

Odeniyi said that prevention is the key against diabetes and also proper management for those who have it so as to reduce complications.

To drive down insulin prices, the WHO plans to certify generic versions. With insulin prices skyrocketing and substantial shortages developing in poorer countries, the WHO said to drive down product prices it would begin testing and approving generic versions of the drug.

Agency officials said they hoped to drive down insulin prices by encouraging makers of generic drugs to enter the market, increasing competition. At the moment, three companies — Eli Lilly, Novo Nordisk and Sanofi — dominate the world’s insulin market and they have steadily pushed up prices for two decades.

The WHO’s head of regulation of medicines and health technologies, Emer Cooke, said: “Four hundred million people are living with diabetes, the amount of insulin available is too low and the price is too high, so we really need to do something.”

The approval process, which the WHO calls “prequalification,” will permit United Nations agencies and medical charities like Doctors Without Borders to buy approved generic versions of insulin.

The process also will reassure countries without strong regulatory agencies that the approved drugs are safe for their health ministries to purchase.

The WHO aims to duplicate its success in widening global access to HIV drugs. Started in 2002, prequalification helped to rapidly lower the prices of these medications in poor and middle-income countries.

At that time, nearly 7,000 Africans were dying of Acquired Immune Deficiency Syndrome (AIDS) every day because they could not afford HIV medications, for which Western drug companies charged up to $15,000 a year.

Now the drugs are made in India, China and other countries with thriving generics industries, and they cost less than $75 a year. About 80 percent of the people in the world taking HIV drugs are taking inexpensive generics tested and approved by the WHO

Also, human insulin may be a lower-cost option for some people with diabetes.

According to recent news stories, people with diabetes have rationed insulin to save money, leading to illness and even death.

Analogue insulins have become the first choice when patients start insulin treatment because their action more closely matches the body’s own blood sugar patterns. Analogue varieties of insulin, introduced to the market in 1996, are designed to be slightly different from natural human insulin. Short-acting versions, such as Humalog, Novolog, or Apidra, are usually prescribed to be taken at meals, together with a once-daily, long-acting version such as Lantus, Levemir, or Tresiba.

Prior to analogue insulins, most people with diabetes were treated with synthetic human insulin, identical to the body’s natural insulin, which in turn replaced original animal-derived insulins in the 1980s.

Unfortunately, analogue insulins typically cost two to 10 times the price of human insulin.

In a recent JAMA study, researchers examined a cost-saving option: switching from analogue insulin to human insulin.

Overall, this study supports the idea that it is possible for certain older individuals with type 2 diabetes to safely change from expensive analogue insulin to more affordable human insulin. The findings should readily extend to some younger patients as well. However, there are many people, including most of those with type 1 diabetes, for whom this kind of change would not be appropriate and could destabilize blood glucose control.

Each person with diabetes has a unique medical situation, and good advice must be individualized after considering factors such as age, type, and duration of diabetes, blood glucose patterns, diet, concurrent medical issues and medications, lifestyle, and more.

For patients whose insulin costs have become intolerably high, switching from analogue to human insulin is one option to explore. As with any change in prescription medication, this option should be considered together in consultation with your diabetes care provider.