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The real problem with inhaled insulin lies in the cost

From Dr David Taylor

Birmingham

I feel Professor Kirby is being a little disingenuous when he argues that inhaled insulin's 'ground-breaking technology' should be available for patients to choose (Letters, 18 May).

It seems it is excluded in smokers (and we are told that passive smoking is ever more dangerous), poorly controlled asthmatics and poor COPD. It causes coughs and more hypoglycaemic attacks. It seems more work may just prevent another thalidomide, benoxyprofen, troglitazone or rofecoxib.

He argues that the poor control, while people put off insulin, will cause 'subsequent complications'. (And with it the implication that this will cost the NHS 'billions of pounds' ­ there I'm being disingenuous!)

I have always read the UKPDS study to show that while good glucose control reduces microvascular complications by a small amount, we are better to concentrate on BP. I'm not alone in that1. The DCCT trial is similarly underwhelming.

But the real problem to me lies in the cost. At more than £1,000 a year it will cost considerably more than injected insulin. How long can individuals continue to claim the moral high ground of 'autonomy' while that autonomy denies another their access to care? Who is going to balance the books in Professor Kirby's PCT?

1 BMJ 2000;320:1720-1723 ( 24 June ). Seeing what you want to see in randomised controlled trials: versions and perversions of UKPDS data. J McCormack, T Greenhalgh

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