100 years after the discovery of insulin, the disparities persist

This November marks the centenary of the discovery of insulin, an event that transformed diabetes care “from a death sentence to a chronic disease,” says the Endocrine Society. And while progress has been made in access and distribution over the past century, a new review published in The Lancet details the current challenges facing children and adolescents with type 1 diabetes (T1D) in low- and middle-income countries (LMICs).

“Most types of insulin are still administered by subcutaneous injection and do not completely mimic the time profile of physiological insulin secretion over time,” the authors explained. But despite “improvements in new formulations of insulin and clinical development of biosimilar insulin in recent years, metabolic outcomes in diabetes have not changed dramatically,” they said.

Reports estimated that a total of 463 million people worldwide suffered from T1D in 2019, and one study found that the incidence of T1D in children and adolescents increased by an average of 2.8% between 1990 and 1999.

However, due to the paucity of representative population-based data, estimates likely underestimate the true cost and burden of T1D, a problem compounded by potential premature deaths before diagnosis. For example, in Africa few countries report data on relevant indicators, meaning that estimates may be based on an extrapolation from neighboring countries, the researchers said, leading to potential inaccuracies.

In addition, different regions report variability in the management of pediatric T1D. Data show the proportion of children with optimal glycemic control (glycated hemoglobin [A1C]

Global Health Observatory estimates indicate that less than half of countries in Central Asia, East Asia and West Sub-Saharan Africa have existing diabetes registries, availability of insulin, the existence of operational policies and facilities for diabetes screening in primary health care. level. “Only 20% of Central and South Asian countries have generally available insulin,” noted the authors.

A combination of these factors, in addition to inadequate infrastructure, diagnostic tools and personnel, lead to reduced and delayed T1D diagnoses in LMICs.

Since T1D involves the destruction of β cells, which can begin months or years before diagnosis, the process is often non-linear. Although several landmark studies have been published on risk factors for T1D, ethnic minorities and LMIC populations are often under-represented.

More inclusive analyzes are needed “to explore risk factors in various settings with varying risks, including those related to inbreeding,” the researchers noted.

In the treatment and management of T1D, the focus has shifted from symptomatic treatment to disease-modifying interventions. One development in this area is the development of teplizumab for people who are antibody positive and at high risk for T1D.

“Stage 3 prevention trials aim to preserve some of the β cell function to potentially delay complications of T1D and enroll children within 100 days of diagnosis of T1D,” said the authors. But the need to undertake similar studies among existing cohorts in LMICs remains crucial.

In a review of the literature published after 2015 on pediatric management of T1D, researchers found that the majority of evidence focused on interventions on health outcomes and quality of life came from studies in HICs; the data available from PRFIs were too scarce to draw meaningful conclusions.

While technological advances in insulin delivery, mainly implemented in HIC, have revolutionized the lives of people with T1D, these advances “do not take away from the reality of the differences and inequalities in access. to care, even in HICs like the United States, where price scams and the availability of insulin have negatively affected the care of children and youth with diabetes, ”the researchers wrote.

In recent years, the use of continuous glucose monitoring (CGM) in children and adolescents has grown, as parents can remotely monitor glucose levels and help reduce the risk of hospitalization due to diabetic ketoacidosis. Such promising results require the implementation of these interventions in children with LICs.

Over the past century, the life expectancy of pediatric patients with T1D has increased, although gains have been much slower in LMICs. Despite the lack of longitudinal studies on the long-term prognosis of T1D in LMICs, an analysis conducted in South Africa found that over 20 years, mortality in patients with T1D was 43%, renal failure , with hypoglycemia and ketoacidosis being the main causes of death. . Overall, “T1D patients in LMICs have high mortality rates and a high disease burden”, with poor administration of treatment largely due to the availability and cost of insulin.

According to the authors, an important step in overcoming these obstacles is the implementation of universal health coverage (UHC).

“Regardless of the path countries take to achieve UHC, there are few interventions more essential and life-saving than those for the management of T1D in children and adolescents, and it is crucial that these interventions, especially those for treatment, are available to people who are poor and are publicly funded, ”they said.

“For these goals to be achieved, countries must aim to achieve an 80% level of availability of essential drugs and technologies, as proposed in the WHO Global Plan of Action on Noncommunicable Diseases. “

It is estimated that among countries without public health system coverage for T1D, basic health care supplies for the disease have a median cost of 56% of the average annual income of individuals, or 153% in the highest income group. weak. Training physicians in LMICs in managing T1D and investing in community health workers could help alleviate some of the barriers to care.

To mitigate insulin costs, duties and taxes could be eliminated while price regulation and transparency could improve accessibility in the context of LMICs, the authors said.

“As the world rebuilds itself from the ravages of COVID-19, it is imperative that the needs of children and adolescents with T1D receive full attention,” they concluded.

Reference

Bhutta ZA, Salam RA, Gomber A, et al. A century after the discovery of insulin: Global progress and challenges for type 1 diabetes in children and adolescents in low- and middle-income countries. The Lancet. Published online November 13, 2021. doi: 10.1016 / S0140-6736 (21) 02247-9

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