Commentary: Politics of affordable insulin

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d5675 (Published 14 September 2011) Cite this as: BMJ 2011;343:d5675
  1. Edwin A M Gale, emeritus professor of diabetic medicine1,
  2. John S Yudkin, emeritus professor of medicine2
  1. 1University of Bristol, Bristol, UK
  2. 2University College London, London, UK
  1. Correspondence to: E A M Gale Edwin.Gale{at}bristol.ac.uk

The diabetes pandemic increasingly affects low and middle income countries, where most of those affected have type 2 diabetes. Cheap generic versions of current first line treatments, metformin and sulfonylureas, are widely available so why does this not apply to insulin?

Human insulin is off patent, is relatively simple to manufacture, and WHO recently included it in its list of essential medicines in preference to analogue insulin.1 Generic biosynthetic human insulin would bring down the price of insulin, and several companies have the capacity to produce it, but progress has been confounded by claims that branded analogue insulins—which are typically two to four times the cost of branded human insulin—are better treatment.

This claim does not relate to biological action, for the analogues are simply delivery systems designed to speed or smooth the rate at which insulin reaches its receptor from the injection site. Although these properties are valuable in some situations, Cochrane type reviews of the use of human and analogue insulins have found limited evidence of benefit in type 2 diabetes 2 3 and NICE has reaffirmed that human insulin should be considered first line therapy in this condition.2 Only one study, on people with type 1 diabetes, has compared analogue and human insulin in double blind fashion. This found no change in haemoglobin A1c and a small reduction in nocturnal hypoglycaemia. The participants were unable to tell the insulins apart at the end of the study and …

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