Analog insulins and Cancer?

There was a recent scare that associated the use of Lantus insulin (insulin glargine) with an increased rate of cancer. This report was based on a German health insurance database. The journal that reported it also was careful to include comparable studies from other countries where Lantus is used. The results from these other nations were less compelling. In fact one study showed no significant association between Lantus and higher rates of cancer. None of these studies looked at Levemir (insulin detemir), the other long acting basal insulin. The makers of Levemir are quick to point out that the chemical structure of Levemir is different from Lantus. This is relevant because insulin analogs (which is what both Lantus and Levemir are), also may cross react with receptors for growth factors on the surface of certain cells. The term for the cell growth promoting effect of any insulin molecule is its mitogenic effect. This is different from the blood sugar lowering effect of insulin.

It’s believed that human insulin itself does not cause cancer. However, it might be possible for an analog of insulin (like the two insulins being discussed) could drive the growth of abnormal cells that may have arisen by a separate process. For a body cell to become cancerous, it is thought that at least 6 different things (i.e., cellular “checks and balances”) must be breached in order for that cell to grow out of control (a primary trait of any cancer). It might be possible that some analog insulins could play a role in driving the rapid growth of existing abnormal cells. But the analog itself probably had nothing to do with the formation of the cancer in the first place. It may surprise some of you to know that cancerous and precancerous cells exist in many healthy people. These abnormal tissues may remain in check somehow until an outside force or substance drives the tissue to grow out of control. No one can say with any certainty that any analog insulin (including Lantus) doesn’t cause existing or hidden cancer cells to grow.

So, the bottom line is: keep using Lantus. There is no credible evidence any insulin (human or analog) causes cancer. But, without question Lantus and Levemir should both be carefully studied for any effects that might not have been apparent in the first few years of use, and not only cancer.

Don’t forget to check back later for tonight’s Diabetes Challenge Question!

Gotten enough”D” lately?

Thinking about a very essential vitamin has undergone a renaissance in the past few years. It was highlighted by a 2009 report from the Joslin Diabetes Center in Boston which found that up to 70% of all children and teens with type 1 diabetes were insufficient or deficient in vitamin D. The reason for this may be less sun exposure or effective use of sunscreen, which blocks most of the vitamin D producing rays of the sun.

Dietary reasons for low vitamin D include less fortified milk consumption (soda pop reigns!) or other sources of vitamin D (oily fish, fortified cereals, eggs).

I have seen this problem in my patients with both forms of diabetes. So, why is there such a fuss about this vitamin? Well as it turns out, vitamin D is necessary for a healthy immune system. But low vitamin D levels are known to be associated with a list of serious diseases, include both types of diabetes, high blood pressure, heart disease, some cancers, Alzheimer’s disease, Parkinson disease, and Multiple sclerosis to name just a few. Our blood vessels are richly lined with receptors for vitamin D. The current recommendations for daily vitamin D intake are probably too low. On top of that, the current vitamin D intake of most Americans is quite poor. 400 IU is the official RDA for vitamin D, but it may be better to move that value closer to 1000 IU. There have been over 3,000 papers on vitamin D in just the past year. This is a white hot diabetes topic and will remain so for a long time to come. I strongly suggest getting your child with diabetes checked for their 25-hydroxy-vitamin D level at the next office visit. You may be surprised at the result. Personally, I take 1000 mg vitamin D3 daily and have so for over a year.

Link to the story to see a video of a day in Daisy's and her family's lives

Unless We Make Some Changes…

Read this story from the BBC for yourself. We’ve seen this dramatic increase in type 1 already starting about a year ago in the diabetes centers that we work with in the USA. Basically, the new cases of kids with type 1 diabetes have doubled!

Historically, the statistics on type 1 in kids is roughly 1 in 400 or 1 in 600 depending on the source. So let’s say 1 in 500. With doubling, that number will soon begin to approach 1 in 250 over time. In the USA, there are approximately 200,000 school age kids with type 1. Another source I read in the past states that there are approximately 30,000 new cases of type 1 each year in the USA and that approximately half of those are school aged kids. Based on this story and recent discussion, it’s safe to say that there are 30,000 new onset cases of type 1 in school aged kids. It used to be that a typical age for new onset (the mode) was around 8 to 11 years. Based on discussions with endocrinologists and educators along with the information in the story, the age of new onset is clearly moving to younger and younger kids. That means more diabetes supplies over more years and more risk of trips to the Emergency Department not to mention more time at risk for complications like cardiovascular disease in the teen years.

My experience has shown me that each endocrinologist working with diabetic patients handles approximately 200 to 400 patients. There are only 200 pediatric endocrinologists in the US and very few docs coming out of med school are attracted to the relatively low pay (vs other specialist alternatives), unbilled hours for telephone consults and logbook review, and lack of control (behavior change is the required skillset vs. diagnosing to prescribe pills/dose change to fix the condition).

While there are something like 14,000 diabetes educators in the US, most of them are trained and experienced on how to work with adults with type 2 diabetes - a very different scenario than working with a kid with type 1 who may also come from a broken home or other family issues.

If each patient requires 6 hours per year (30 minutes per office visit 4 times per year plus 20 minutes per month on average for another hour over the course of a year) and there are 700 trained providers, then there are a total of 1,380,000 hours of skilled care required at a minimum since this assumes no complications. If each provider is available for 30 hours per week of patient facing time, then the current skilled pediatric labor pool is able to provide 1,050,000 hours of patient directed care. Not enough providers to deliver standard care especially when you factor in the doubling effect of new onset. The numbers I use here are only rough assumptions to illustrate the gap in the current health care delivery model for type 1 diabetes. At some point there is a scary reality and a breaking point that nobody is aware of.

Sadly, until the economics are changed to incent providers to work with type 1 kids, I don’t believe we’ll get sufficient trained people to help us with this avalanche of new patients. That leaves us with having to develop new models of care that increase the efficiency, effectiveness and reach of the trained providers we already have as well as making patients better at self-care in the absence of their diabetes coaches. A little technology will go a long way if done right and adopted (embraced) by providers. I’m reminded of a slogan we adopted a year or two ago which is now posted at the top of Diabetech’s home page on the Web, “We’re dragging Diabetes Technology ‘kicking and screaming’ into the 21st Century”. With recent successes made on the payer front, we’re soon going to need to swap out the word ‘Technology’ for ‘Providers’.

My reason for making this post is to raise the awareness that the perfect storm is upon us. Who is doing the study to prove that we need to make changes now - based on irrefutable proof that maintaining the status quo is like using a syringe to bail out a sinking ship?