Living with Diabetes update

So - here we are in Tampico, Tamaulipas Mexico. Not a place you'd want to be, as it turns out! I've already talked about the difficulties of getting hold of Glucagon and given my views on the underlying reasons. Living with Diabetes (Type 1 anyway) in this part of Mexico continues to get more problematic. Especially if, as my spouse, you follow the tight control regime using the 24 hour ultra-slow acting analog insulin, Lantus, once a day and the ultra-fast acting analog insulin, NovoRapid (or NovoLog in the States), before every meal. Very few, if any, Mexican Type 1 Diabetics can be on this regime. Why do I say this? Well, read below.

As most Type Ones on the tight control regime know, trying to keep blood sugar levels within the normal person's range of 70-100 mg/dl means frequent hypoglycemic episodes of varying degrees of intensity. In the US that fragility means high additional costs occasioned by the need for treatment from Emergency Services or from third party administered Glucagon or, at less extreme times, from self or assisted dosing with glucose jelly or tablets. Therefore, the problem for diabetics in the US is not the unavailability of the treatments - it is their cost. And that can be prohibitive if or when the diabetic is not covered by health insurance. The lack of government controls on drug pricing alone appears to mean that everyone involved in selling the vital products is out to make a fortune. Nevertheless the paramedical services, Glucagon and glucose jelly are available. Not so readily so once you step outside of the first world (not just the USA!), where if products are on shop shelves this week, they may well not be ever afterwards.

So: here in Mexico, there is the Glucagon Problem and its attendant costly Paramedical-Hospital visit Dextrose replacement Set Up difficulty. Avoiding the high expenses entailed in all but compulsory use of the hospital following the administration of Dextrose solution by paramedics necessarily means avoiding hypos altogether; and that means keeping the Blood Glucose levels higher than is good over the long term. No tight control regimen here!

Now you see, now you don't! About a month ago, the locally made glucose tablets that we had discovered disappeared from the pharmacy shelves of two US chain grocery stores in town. It took us a while to find them and they were more expensive and lower in carbohydrate values than their US counterparts - but they had existed. For about two months. As we bought them during our weekly shopping trips, we watched the numbers of their boxed bottles dwindle away to None-at-All.

As for glucose (dextrose) jelly - Ha Ha!! You must be Joking! (I mentioned its never presence in third world countries in an earlier post.)

Now we have just (almost, nearly...) hit another Block in Living with Diabetes in Mexico. The sudden disappearance from pharmacies (here in Tampico, at least) of NovoRapid (Novolog)! My spouse has just enough left for about 12 days! We had bought a box of cartridges three weeks ago from the closest branch of Mexico's largest chain pharmacy: Benavides. Now they no longer stock the insulin - not in either its cartridge or disposable pen form. We already knew that one of the US chain stores here did not stock either it or Lantus. So we took a taxi over to the other to see if their pharmacy stocked it. There was none readily available, and the best that could be offered was that the pharmacist would find out if it could be got for us!

Living without glucose tablets or jelly or even Glucagon can be and is edgy. But without the insulin - that, my friends, cannot be done.

But why not go back to using regular fast-acting insulin? Surely that would be available. Maybe, maybe not. However, long past experience tells us that that course is no option at all without ready access to Glucagon and glucose jelly. Before his doctor put him on these two insulins, my spouse had frequent comas, most of which I dealt with by using the Glucagon. For the equally frequent near comas, I used the jelly. We cannot go back to the dangers inherent in using regular fast-acting at mealtimes in a country where we do not have access to these two items. And living with high blood glucose levels is not an option, either.

So we wait until Monday, when we go again to the Texas chain store pharmacy to find out whether or not the insulin will be available to us.

Living with Diabetes in the third world is riddled with uncertainties and the vagaries of market capitalism. Quite probably the pharmacies here see no profit - literally - in stocking an insulin that has a market of only one. Let him use another! Let him eat cake!

The Travails of Glucagon

As those of you who are living with type one diabetes already know, Glucagon in its emergency kit form is nothing short of a LifeSaver. It allows others, usually nearest and dearest others, to give you that quick fix for a hypoglycemic coma which reduces the need for calling in the emergency services and a trip to hospital. It is cheaper by far for all concerned than either of the former. So you would imagine that a Glucagon kit would be readily available for a reasonable price. You could be wrong on either count, depending on where you lived.

On our summer vacation in California my spouse went into a coma (travelling is frequently dodgy for diabetics). We had brought four kits with us from Turkey because our travel insurance did not cover ordinary chronic disease needs and in California calling out the emergency services is costly. The Glucagon in one kit was not good, so I had to use another from our precious lode. Some time later that week we thought to try to replace at least one of these kits; but what would it cost, leaving aside the cost of seeing a doctor for the necessary prescription? Effectively, we were without insurance for the kit; but I had once checked into the cost of a kit from Eli Lilly and seemed to recall that it was in the region of $130. Exorbitant, yes, but it is a LifeSaver. Imagine our shock-horror to find that without insurance coverage (when it costs about $35) pharmacies were more than willing to think of a number, double it and then charge more! Prices in excess of $300 were quoted at supposedly reputable chain pharmacies. My spouse said no way. We managed throughout the rest of the stay on glucose jelly and hope. We needed at least a couple of Glucagon kits to get us to Mexico, to where we were moving, so did our best to avoid using the rest of the stache.

Before we set out for Mexico we checked into the availability of Glucagon; and we also tried to find out from Walmart whether or not their glucose jelly and tablets were available in their stores with pharmacies. Walmart never responded to our email enquiries (at least here in Tampico Walmart does NOT stock either glucose jelly or its own glucose tablets; nor does it stock its own glucometer and test strips). As for the Glucagon, or Glucagen (Novo Nordisk's brand) we found out that it was available. We felt somewhat more secure.

Within a few days of our arrival in Tampico, Mexico, my spouse had another coma, during the day at work. I was able to give him some glucose jelly, tiny spot by tiny spot rubbed into the inside of his cheek; by the time the ambulance had arrived he could almost communicate. Rather than give him the intravenous dextrose there on the spot, the paramedics carried him on a stretcher to the ambulance and closed the doors, refusing me entry. (There was a doctor there in charge of using the intravenous needle, I suppose.) Normally, my spouse refuses point blank to be taken to hospital, and he was protesting strongly against it this time; but his refusals were ignored. So he, and I, were taken to a private hospital where he was kept hooked up to one fluid or another (more dextrose then saline) for a couple of hours. While waiting agitatedly for our release, we asked about Glucagon. The thought of another episode like this one was not appealing - and would undoubtedly be expensive (his workplace paid this time). Glucagon? Who uses that? Here diabetics, we were informed, are maintained so as not to go into comas! Tight Control regimens do not appear to exist in Mexico.

Undaunted with this news we sought information from Eli Lilly here in Mexico via email. Glucagon is available here - on prescription (unlike syringes which can be bought over the counter) of course. The cost, without insurance? About $68. Of course we have yet to go to a doctor and ask for a prescription. That will be the acid test of its "availability". Private hospitals here clearly have a stake in Glucagon not being readily available. The cost to type one diabetics here may well be much greater over the long term, however. The only way to avoid hypoglycemic comas in type one diabetes is to maintain a higher than optimal blood glucose. With a generally high blood glucose comes the likelihood, if not the certainty, of cardio-vascular disease, kidney disease, ophthalmic ailments and polyneuropathy, with its attendant greater risk of injury induced gangrene. Of course, one avoids the possibility of earlier death by hypoglycemic coma.

In the sum of things, perhaps there is not that much difference between the US and Mexican systems: the making of profit out of illness and disease rather than doing everything to provide a vital service at the least cost to all.