Dr. Irl Hirsch’s Annual DT&T Rant: “Difficult to Conclude Our System Has Improved for Our Patients or for Us” – February 1, 2018

Dr. Irl Hirsch provided his ever-insightful annual rant on the state of diabetes care with trademark passion and humor. Published in Diabetes Technology & Therapeutics, this year’s alarming two-page editorial focuses on the rising costs of insulin and other critical diabetes medications. In one particularly compelling example, Dr. Hirsch noted that eight of the 14 insulin-treated patients he saw on the last clinic day of 2017 were saving money by using human insulin or insulin purchased from Canada to save costs – a year ago, only a few of Dr. Hirsch’s patients in total had to resort to such measures. (He wrote a highly viewed piece in JAMA last year on using human insulin.) Dr. Hirsch acknowledged that new and improved drugs can minimize insulin use, but that these medications are simply not financially feasible for many. Ultimately, he argues that despite advancements in diabetes drugs, glycemic control has not improved, suggesting insulin is still under-utilized.

Dr. Hirsch also commented on the rising costs of other medications like digoxin, conjugated estrogen, and colchicine, which are now too expensive for his low- or middle-income patients. In fact, he notes, average wholesale price for 90 tablets of generic atorvastatin is now a whopping $519. Dr. Hirsch adds that the cost increases are even more upsetting following political promises to prioritize drug price control. Despite congressional pressure from the ADA and others, plus a letter to the Department of Justice and the Federal Trade Commission penned by Senator Bernie Sanders and Congressman Elijah Cummings, there has been no public follow-up.

Beyond cost, Dr. Hirsch expressed concern regarding insulin potency – as we covered at DTM, 18 vials of human insulin purchased from five US pharmacies were found to have insulin concentrations ranging from 13.9 U/mL to 94.2 U/mL; no vial met the minimum standard of 95 U/mL. As Dr. Hirsch put it: “this is beyond alarming.” The editorial also detailed the serious administrative headaches associated with obtaining diabetes supplies for those without diabetes (see below for a particularly infuriating example) and acquiring medications known to reduce cardiovascular events and mortality for type 2 patients. Dr. Hirsch’s rant is well worth the read in its entirety, but for some of our favorite quotes, see below.

  • “Our local bureaucracy has become almost comical. I’ve decided not to ventilate about the juvenile treatment from our administrators as that would be disrespectful to children.”
  • “The time when physicians practiced until they were admitted directly to the nursing home to have their secretions suctioned does not exist any longer. We should all agree that the practice of medicine, and even more so the practice of diabetes and endocrinology should be enjoyable. I will always enjoy my face-to-face time with patients despite the dysfunctional system and world I work and live in.”
  • I was volunteering at a low-income community clinic where I met a 29-year-old woman with type 1 diabetes since she was 11 years old. Her last insulin injection was 48 hours prior to her clinic visit. She knew she was just a few hours away from an intensive care unit admission for ketoacidosis. Unfortunately, this is a common scenario for some in the US.
  • “Overall, it is difficult to conclude our system has improved for our patients or for us. I am still hopeful that some aspects of our system will someday improve, and colleagues my age (and younger) don’t continue to retire early simply because the system has become intolerable.”
  • “I have a patient who has unprovoked hypoglycemia from nesidioblastosis, a known complication from Roux-en-Y gastric bypass surgery. We were able to prevent hypoglycemic coma and seizures only with continuous glucose monitoring (CGM) as she was able to defend against low blood glucose with eating when required (the story is much more complicated as she also had a partial pancreatectomy). We learned late in 2016 the new insurance company wouldn’t approve [CGM]. I had written several letters, my staff had spent many hours on the phone, and I had spoken to a ‘‘peer’’ but was told CGM is ‘‘experimental’’ for nesidioblastosis as there is no randomized controlled trial (RCT) showing it improved outcomes. WTF? An RCT for a condition so rare most physicians will never see it?


-- by Maeve Serino, Brian Levine, Adam Brown, and Kelly Close