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Minimally invasive procedure may free Type 2 diabetics from insulin

A small study suggests that a new procedure that treats part of the intestine just beyond the stomach may allow people with type 2 diabetes to safely stop taking insulin.

The procedure — which resurfaces the duodenum — was combined with a popular kind of diabetes medication called GLP-1 receptor agonists — such as Victoza, Trulicity, Ozempic — and counseling on lifestyle factors, such as nutrition and physical activity.

Six months after treatments began, three-quarters of participants taking insulin no longer needed it. The amount of fat stored in their livers dropped from 8% to less than 5%.

“The duodenum harbors a broad potential for the treatment of type 2 diabetes and this combination treatment could be a game-changing approach in the treatment of type 2 diabetes and the metabolic syndrome,” said lead researcher Dr. Suzanne Meiring, of Amsterdam University Medical Center in the Netherlands.

This preliminary study included 16 patients, all of whom underwent Duodenal Mucosal Resurfacing, or DMR. There was no placebo group or medication-only group for comparison. The study was funded by Fractyl Laboratories, which developed the procedure.

DMR is a minimally invasive procedure that relies on an endoscope — a narrow, flexible tube containing a light and video camera that lets your doctor see inside the body. The endoscope may also carry special tools for treatment. The tube is threaded down the throat into the digestive system.

In DMR, the endoscope is guided to the duodenum, where doctors then resurface, or ablate, its lining. Meiring said it’s not yet clear why the procedure works.

“We think the effects result from a combination of changes that occur when the duodenal mucosa is ablated and rejuvenated,” she said. “We think that changes in hormonal signaling, including the gut hormone GLP-1, bile acid compositions and the microbiome play an important role.”

The 16 participants had type 2 diabetes for an average 11 years. On average, they had been on insulin just under three years. None had taken a GLP-1 receptor agonist before the study.

At the outset, their average A1C levels — an estimate of blood sugar levels over two to three months — were under 8%. After 12 months, the average fell to 6.7%. For most adults, the American Diabetes Association recommends aiming for an A1C below 7%.

After the DMR procedure, patients were given a specific diet for two weeks. After that, they began taking the GLP-1 receptor agonist medication.

Meiring said researchers added the drug because it also targets the duodenum. They hoped it would boost the effects of DMR, “possibly even causing a synergistic effect,” she said.

She said she doesn’t think the positive effects in this study stem from just the drug treatment. Other studies have shown that about 10% of people who start GLP-1 therapy are able to get off insulin, Meiring said. In this study, 75% of those taking insulin were able to stop.

Participants who weren’t insulin-free after 12 months needed only about half the insulin they required before the procedure.

Insulin Copay Caps Fall Short

Editor’s note: Find the latest COVID-19 news and guidance in Medscape’s Coronavirus Resource Center.


After losing her health insurance earlier this year, D.j. Mattern, who has Type 1 diabetes, turned to a growing underground network of people with diabetes who share extra insulin free of charge when they have it.

D.j. Mattern had her type 1 diabetes under control until COVID’s economic upheaval cost her husband his hotel maintenance job and their health coverage. The 42-year-old Denver woman suddenly faced insulin’s exorbitant list price — anywhere from $125 to $450 per vial — just as their household income shrank.

She scrounged extra insulin from friends, and her doctor gave her a couple of samples. But as she rationed her supplies, her blood sugar rose so high her glucose monitor couldn’t even register a number. In June, she was hospitalized.

“My blood was too acidic. My system was shutting down. My digestive tract was paralyzed,” Mattern said, after 3 weeks in the hospital. “I was almost near death.”

So she turned to a growing underground network of people with diabetes who share extra insulin when they have it, free of charge. It wasn’t supposed to be this way, many thought, after Colorado last year was the first of 12 states to implement a cap on the copayments that some insurers can charge consumers for insulin. But as the COVID pandemic has caused people to lose jobs and health insurance, demand for insulin sharing has skyrocketed. Many patients who once had good insurance are now realizing the $100 cap is only a partial solution, applying just to state-regulated health plans.

Colorado’s cap does nothing for the majority of people with employer-sponsored plans or those without insurance coverage. According to the state chapter of Type 1 International, an insulin access advocacy group, only 3% of patients with type 1 diabetes under 65 could benefit from the cap.

Such laws, often backed by pharmaceutical companies, give the impression that things are improving, said Colorado chapter leader Martha Bierut. “But the reality is, we have a much longer road ahead of us.”

The struggle to afford insulin has forced many people into that underground network. Through social media and word-of-mouth, those in need of insulin connect with counterparts who have a supply to spare. Insurers typically allow patients a set amount of insulin per month, but patients use varying amounts to control their blood sugar levels depending on factors such as their diet and activity that day.



After D.j. Mattern’s husband lost his job during the coronavirus pandemic, the couple lost their health insurance. Mattern, who has type 1 diabetes, was suddenly faced with buying insulin at list price, which ranges anywhere from $125 to $450 per vial.

Though it’s illegal to share a prescription medication, those involved say they simply don’t care: They’re out to save lives. They bristle at the suggestion that the exchanges resemble back-alley drug deals. The supplies are given freely, and no money changes hands.

For those who can’t afford

Trump says insulin is now so cheap, it’s ‘like water.’ It isn’t

President Trump made a number of claims about lowering drug prices during his debate with Democratic challenger Joe Biden. Most were untrue. <span class="copyright">(Arkasha Stevenson / Los Angeles Times)</span>
President Trump made a number of claims about lowering drug prices during his debate with Democratic challenger Joe Biden. Most were untrue. (Arkasha Stevenson / Los Angeles Times)

There was much to dislike in this week’s presidential debate — the lies, the rudeness, the inability of the White House incumbent to rise above the level of a cranky kindergartner.

For me, the low point came not when President Trump refused to condemn white supremacy, and not when he tore into the sons of Democratic candidate Joe Biden, but when he once again sought to convince the American people that he had single-handedly lowered the cost of prescription drugs.

Trump claimed that drug prices “will be coming down 80% or 90%” thanks to him.

He claimed that a series of executive orders have forced pharmaceutical companies to slash prices.

And the one that floored me: Trump claimed that the cost of insulin is now so low, it’s practically free.

“I’m getting it for so cheap, it’s like water,” he said. “You want to know the truth? So cheap.”

Like water.

“Saying that insulin is as cheap as water is a complete disconnect from reality,” said Vivian Ho, a healthcare economist at Rice University.

“For the overwhelming majority of the millions of Americans with diabetes who depend on insulin, the prices are outrageous,” she told me. “People have been dying because they can’t afford insulin.”

I don’t want to make this about me. This is about a country saddled with a former game-show host who believes he can say anything to advance his personal and political interests.

But as someone with Type 1 diabetes, who relies on daily insulin doses to stay alive, I found Trump’s remarks particularly offensive, even for him.

It may take some effort for many Americans to fact-check Trump’s claims that Mexico is paying for his border wall or that he’s accomplished more than all other presidents.

The high price of drugs — no ambiguity there. Stratospheric drug costs hit nearly every American family where they live.

Spending on prescription meds soared from $354 billion in 2009 to about $535 billion in 2018, according to the Department of Health and Human Services.

This is an increase of 50% compared with 17% inflation over the same period. Drug spending is expected to approach $600 billion this year.

As for insulin, well, Trump is taking a modest improvement for a relatively small number of people with diabetes and presenting it as a political triumph for all.

What he was apparently referring to with that comment about insulin now being “like water” was an announcement in May from the Centers for Medicare and Medicaid Services that some (but not all) Medicare plans would cap monthly insulin co-payments by seniors at $35.

This won’t begin until next year. It also will affect fewer than half the estimated 7.4 million Americans with diabetes who use insulin, leaving everyone else to continue paying as much as $300 per vial, which in many

Diabetic Americans dispute Trump’s claim he made insulin so cheap ‘it’s like water’

That came as a shock to the Americans who shell out hundreds of dollars a month on insulin, a number of whom posted triple-digit pharmacy bills to social media immediately after the president’s assertion.

“I looked at my husband and slapped my leg and said, ‘Can you believe that!’ ” said Tiffany Garrioch, 36, a public health nurse and educator in Minnesota with Type 1 diabetes, who watched the debate with her family.

“We’re already an underserved and highly vulnerable population,” she said. “To hear the president say it costs as much as water makes us look like we’re crybabies or liars.”

Insulin costs her $36.76 a day, she said. In 2008, it was $9.81.

Insulin prices have ballooned over two decades, including during the Trump administration. A subset of people enrolled in Medicare drug plans that cap payments at $35 a month are insulated from those costs. Otherwise a patient with diabetes can spend hundreds of dollars on a monthly insulin supply.

A few decades ago, people could pay about $20 per month for insulin, said Jeremy Greene, a primary care physician and medical historian at Johns Hopkins University. “Insulin prices have been a travesty of American pharmaceutical policy.”

The only way Trump’s statement could not be anything but an “out-and-out fabrication,” Greene said, is if insulin were compared to some of the priciest bottled water on Earth — such as the liquid harvested twice a year from melting Arctic polar ice that the doctor once spotted for sale in a Norway airport.

“The cost of insulin is still high for the majority of Americans who need it to survive,” said Laura Friedman, vice president for federal payment policy at the American Diabetes Association, which supports insurance co-pay caps and Medicaid expansion to help people with diabetes afford the drug.

“The ADA and the millions who are living with diabetes look forward to the day when insulin is affordable so that people can stop suffering from the consequences of dangerous practices like rationing insulin due to exorbitant costs,” she said in a statement.

About 1 in 4 patients with diabetes report underusing insulin because of financial pressure, which “effectively means that they are trying to make their insulin stretch, or having difficulty buying groceries or paying utility bills,” said physician Jing Luo, a professor at the University of Pittsburgh’s Center for Pharmaceutical Policy and Prescribing.

Switching to cheaper but less effective forms of insulin, or rationing it, can be devastating. People with diabetes can suffer strokes, kidney failure or death without sufficient insulin.

“The consequence of the untenable price of insulin can be measured in body counts,” Greene said.

Three companies — Eli Lilly, Novo Nordisk and Sanofi — dominate the market for insulin.

Insulin sold by Novo Nordisk, under the brand name NovoLog, was priced at $40 per vial in 2001 and rose to $289 in 2018, as The Washington Post reported last year. Eli Lilly’s Humalog insulin was $275 a vial as of last year, up from