Diabetes Care in My Part of the World — Rural America

By Anne Leddy, MD, FACE

I officially entered retirement on December 31, 2012 at 11:59 p.m., when I closed my medical office. Having practiced endocrinology for over 40 years, I felt a bit peculiar not heading off to my office every morning. Within a short time, however, I found a new place to do what I have always loved, serving as an endocrinologist at the Gloucester-Mathews Care Clinic in my rural county in Virginia.

One characteristic shared by the patients seen at our clinic is that they have all had very bad luck. They are not eligible for Medicaid in our state and cannot afford health insurance. Eligibility for care is based on income, and patients are rechecked for eligibility every six months.

More than 90 percent of my clinic patients have diabetes. Many have co-existing conditions such as obesity, hypertension, heart disease, stroke and complications of long-standing high blood glucose (blood sugar): nerve, kidney and eye damage.

Because of their circumstances, many of the people I see live on “the edge” of serious illness. Hearing stories such as them losing their job because of illness or an accident and then losing health insurance is common. Before finding their way to our clinic, some of our patients with diabetes have not had adequate insulin or other medication for diabetes in over a year. Their blood sugar control is often reflected in their hemoglobin A1C (a measure that reports a person’s average blood sugar in the past three months) of eight or nine or higher when they first come to the clinic for medical treatment; a person with no diabetes would typically show a value of under six. (The American Association of Clinical Endocrinologists considers an A1C level of ≤ 6.5 percent as optimal if it can be achieved in a safe and affordable manner, but higher targets may be appropriate for certain individuals.)

Keeping Patients Healthy by Managing Costs Creatively

The clinic staff works to lower drug costs for our patients through the pharmaceutical industry’s patient assistance programs, so with a lead time of about six weeks we can obtain many drugs still on patent. The clinic policy is to provide the people we see with as many glucose meter test strips as needed for appropriate testing. This is a great expense for the clinic, but is recognized as a priority.

The clinic is part of what is considered a “safety net” of medical care. Although the administrator of the clinic is skilled in securing grant support for clinic operations, there are still limitations on who can be seen as a patient. A patient may become disqualified from continued clinic eligibility because of even a slight increase in income; for example, a painter who gets a few more jobs during the summer or a house cleaner who adds another customer.

To help with insulin costs, we have had to reacquaint ourselves with NPH (neutral protamine Hagedorn) insulin and regular insulin. These insulin preparations first became available in the 1980s and represented a great advance at that time. Made synthetically, they are much less likely to cause an allergic reaction than insulins derived from the pancreas glands of animals. In my state, NPH and regular insulins can be purchased at pharmacies without a prescription. And although not cheap, their price ranges from $25 to $100 a vial, while newer types of insulin are priced much higher, from about $250 to over $500 for a vial (an average month’s supply).

NPH insulin has an “intermediate” duration of action. It begins to take effect at about two hours and builds to peak activity between four and eight hours. The effect then wears off by 12 to 18 hours. If continuous 24-hour action is required, then two injections of NPH insulin are used, one in the morning (usually before breakfast), and one in the vening at dinnertime or before bedtime. Many diabetes specialists prefer giving the second injection at bedtime to focus the peak effect of the medication on the following morning at breakfast time. This lessens the possibility of a hypoglycemia (low blood sugar) episode during the night when the person is sleeping, which can be very dangerous.

Regular insulin has a “short” duration of action. It is used to manage the glucose increase that occurs at mealtimes and to correct when the glucose is over target. Because the onset of action is in 30 minutes to two hours, regular insulin should be injected 20 to 30 minutes before eating. Peak action occurs at about four hours after injection, and the effect wears off over the next two to four hours. Regular insulin can be mixed in a syringe with NPH insulin. This must be injected immediately after mixing to avoid loss of insulin potency. Our clinic diabetes educators teach our patients how to mix NPH and regular insulin. No other insulin preparations can be mixed.

NPH and regular insulins are also available in a premixed form, 70/30, i.e., 70 percent NPH and 30 percent regular at a price per vial similar to a vial of NPH or regular alone. There is also a premixed 50/50 combination, i.e., 50 percent NPH and 50 percent regular. 50/50 is more expensive than the 70/30 combination.

Two combined injections of NPH and regular insulin can provide 24-hour coverage with insulin action peaks at breakfast, lunch and dinner. One needs to follow a consistent meal schedule to avoid hypoglycemia. This is different than what occurs with the long-acting insulins, such as glargine (Lantus®) and detemir (Levemir®), which do not have a peak action time. When using the long-acting insulins, there is relative freedom to eat at convenient times, covering the nutritional glucose rise with an injection of rapid-acting insulin at mealtime. However, these patients can’t afford to buy any of the long-acting insulins. And when a patient no longer qualifies, I teach them how to make the transition to more affordable insulin before their last visit.

Safety First

The dosage requirements of different insulin preparations are not the same for all people, so it is important to get the advice of your diabetes medical professional when making the change from the newer, and more expensive, insulin preparations to NPH and regular insulin. A larger dose of NPH insulin might be needed to replace one of the long-acting insulins. As with all diabetes care, each person with diabetes needs a personalized care plan. No two people with diabetes have the same requirement for treatment.

Doing well with diabetes requires more than medication alone. We emphasize a healthy lifestyle for all our clinic patients: proper nutrition, regular exercise, weight control and no smoking. Diabetes education and nutritional counseling is provided at our community hospital.

It has given me enormous pleasure to work at the Care Clinic and help patients return to good glucose control and good health. It is a privilege to participate in the care of this deserving and very appreciative group of neighbors with diabetes.