This year marked the 100th anniversary of insulin’s discovery in 1921, and professional societies and stakeholders have highlighted advances in formulations and delivery. Yet today, global insulin access and affordability issues persist.

A century after the discovery of insulin, the therapy is still widely unavailable to many people who need it. The WHO Global Report on Diabetes, issued in 2016, states, “People with diabetes who depend on lifesaving insulin pay the ultimate price when access to affordable insulin is lacking.” Globally, one in two people needing insulin lack access.

Healio spoke with Henry Anhalt, DO, a pediatric endocrinologist and vice president and global head of medical and clinical affairs for BD Diabetes Care, the developer of the first insulin syringe, about the evolution of insulin delivery, the future of decision-support tools and meeting the challenge of insulin access globally.

Healio: Looking back since the initial discovery of insulin, how far have we come over 100 years?

Anhalt: It all depends on how progress is defined. For thousands of years, we had no understanding or documented evidence of what diabetes was. People who lost weight and were observed to have ants attracted to their urine led to the term “sugar cream urine.” Over the last 100 years, there has been an explosion of diabetes innovation. First, we had insulin, and then insulin syringes and urine tests, and later, blood glucose monitors. And then we had insulin pumps, continuous glucose monitoring, artificial pancreas, closed-loop systems and decision support, all happening in a short period of time. If we go back to the days of Elliott P. Joslin, MD, when the only treatment for diabetes was starvation, we have come a long way. However, we do have a long way to go.

Healio: What is the global burden of diabetes today, and how does that affect insulin access?

Anhalt: Data from the International Diabetes Federation show more than half a billion people across the globe have diabetes. Approximately 1.2 million people have type 1 diabetes. By 2045, we are going to be looking at about three-quarters of a billion people with diabetes. That is incredible. It is mind-blowing to see the exponential growth in cases. Diabetes is not only a burden on the health care system, but on each person, with respect to access to care, insulin and supplies.

However, when we say “burden,” we must think about what those individuals living with diabetes experience, and the chasm that exists between those that have access and those that do not.

A number of years ago, I chaired a panel for the International Society for Pediatric and Adolescent Diabetes (ISPAD) on insulin analogues and innovation. On the panel was a doctor from Honduras, a doctor from Germany and a doctor from India. I opened it up to general comments. The doctor from Germany said, “We need better data systems to centralize collection so we can look at outcomes and quality improvement to develop best practices.” The doctor from Honduras said, “We finally have access to insulin analogues, the government just approved it.” The doctor from India said, “We need insulin.” We need insulin. We need to think about that when we talk about access.

Healio: People often look at insulin in a box by itself. What is the unmet need for diabetes supplies, like syringes, especially in low-resource settings?

Anhalt: About 100 years ago, we did not have a way to reliably administer insulin. BD basically invented the first dedicated insulin syringe, a glass syringe. I hear from some colleagues how patients who are alive today remember the days of boiling and sharpening syringes and needles. And of course, not everyone had access to needles.

When I was an intern, I accidentally stuck myself with needles, because safety needles were not available. Syringes and pen needles have come a long way. There are now safety needles and greater access. Yet today, there are places in the world where children with diabetes are dying, where people are reusing syringes day after day. That is not just a problem for the developing world. Sometimes I’ll ask my patients, “When did you last change your needle?” And they respond, “You’re supposed to change your needle?” There often is a disconnect we have as practitioners in appreciating how people with diabetes use their supplies in the real world.

It can also be a statement around cost of diabetes supplies. One of the things we think about at BD is that you cannot give insulin without a syringe. As part of the 100-year commemoration of insulin, we are donating millions of syringes across the globe to lower resourced countries to deal with that challenge, through the Life for a Child program. I am most proud of how we are trying to, in the way that we can, deal with some of the access challenges.

Healio: What does the future of insulin and insulin delivery look like?

Anhalt: A long time ago, we realized that delivering insulin as physiologically as we can is important, either by changing the characteristics of insulin or delivering it as closely as you can using insulin delivery systems, like continuous infusion pumps. Now we live in a world of half a billion people who have diabetes, many of whom rely on insulin. How can we administer insulin in the best way possible? I believe in delivering insulin either through continuous infusion or other ways closer to physiologic delivery. Most importantly, diabetes decision-making is a never-ending war, trying to integrate data with varying degrees of literacy and numeracy. How can people make better decisions about their insulin dosing? There is no other disease that requires so much input from the patient. The patient makes the decisions; the patient takes the drug. In other disease states, patients may be very sick but are passive when receiving therapy. In this disease state, we must lift the burden that patients bear. I believe utilizing technology for insulin delivery combined with decision support makes the burden lighter for patients. That is where the frontier is.

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