This company would be happy to have fewer customers

The longtime head of international operations of Novo Nordisk, the huge maker of insulin for diabetes patients, came to Israel to see progress in treatment.

By JUDY SIEGEL-ITZKOVICH
Giving a vaccination injection shot 370 (R) (photo credit: Chaiwat Subprasom / Reuters)
Giving a vaccination injection shot 370 (R)
(photo credit: Chaiwat Subprasom / Reuters)
Novo Nordisk, the 90-year-old, Denmark-based pharmaceutical firm that specializes in diabetes care, is rather an odd kind of company: its executives and employees would be ecstatic if education about lifestyles, exercise and proper diet would meant hundreds of millions never need their products.
But once people join the ranks of the estimated 330 million (including over 400,000 Israelis and 21 million Americans) who contract type-2 and type-1 diabetes, the company is doing its utmost to help patients live a full and long life. It began with the two small Danish companies, Nordisk Insulinlaboratorium and Novo Terapeutisk Laboratorium, founded in 1923 and 1925, respectively. The two companies started the production of the revolutionary new drug insulin that had just been discovered by two Canadian scientists, Dr. Frederick Banting and Dr. Charles Best.
Diabetes is a worldwide phenomenon, not only in the well-fed Western world. By 2025, 80 percent of all diabetics will live in low and middle-income countries. It is estimated that today’s 330 million diabetics will grow to 560 million in 2030, and the worldwide annual cost of treating them is likely to jump to an astronomical $390 billion. If diabetes is not prevented and the blood sugar of diabetics is not well controlled, complications threaten to topple health systems around the world because they can’t spend the huge amounts for treatment that this will require.
More people are dying of overeating today than from starvation. The world is eating itself into a slow tsunami, and with the aging of the population, the world will reach a crisis.
Tens of millions of patients don’t get any treatment at all.
Diabetes is a metabolic condition that leads to excessively high levels of sugar in the blood. Chronic exposure of various key organs and tissues – the eyes, blood vessels, kidneys, nerves, feet, heart and gums – to superfluous sugar has several serious consequences on health. In type 1 diabetes, which constitutes only about five percent to 10% of cases, the body’s immune system, charged with protecting the body from invasion by pathogens, mistakenly identifies the insulin-producing beta cells in the pancreas as an “enemy,” destroys them, usually quite quickly, and the body does not produce any insulin.
Excessive thirst and frequent urination are the most obvious signs. A combination of heredity and environmental factors, many as yet unknown, trigger the autoimmune process. Complications and death will occur quickly unless the victim receives insulin by injection (via syringes or a pump worn on the body) several times a day.
Type-2 diabetes, a lifestyle disease with some genetic and even high-stress influences, develops gradually, usually without being noticed. Lack of exercise, overweight, a diet of junk food – especially simple carbohydrates such as sugars rather than whole grains and vegetables – can cause metabolic syndrome (pre-diabetes), which means higher- than-normal blood sugar levels along with high cholesterol and triglyceride levels in the blood and high blood pressure.
If lifestyle changes are not made, this will develop into full-fledged type-2 diabetes. As symptoms are not always as clear as in type 1, people should go for lab tests on a regular basis, especially after the age of 40 and earlier if they are at high risk. Patients are prescribed various oral drugs (such as metformin, first put on the market in 1958) that reduce insulin resistance and increase insulin production by the remaining active beta cells. They are also put on a strict diet, ordered to lose weight and placed on a daily exercise regimen.
THE USE of insulin began in 1922 when August Krogh, a Dane who won the Nobel Prize in physiology, and his wife Marie, a type 2 diabetic, traveled to Canada to visit researchers Banting and Best, who a year before had begun to extract insulin from the pancreas of cows. The Kroghs returned to Denmark and in 1924, August Krogh established the Nordisk Insulin Laboratorium to produce the precious hormone for treating diabetics. Due to differences in views, one of the company’s first staffers, Harald Pedersen, set up a competing insulin factory in 1925 that he called Novo Therapeutisk Laboratorium.
In 1989, after competing with each other for more than six decades, the two Danish companies decided to cooperate and merge to become Novo Nordisk A/S. The new entity dedicated itself to developing new diabetes products, conquering world markets and, ultimately, to further the cure of diabetes.
A public corporation that aims at making a profit, Novo Nordisk set up a foundation that has invested huge sums in research to improve its projects and help discover a cure, as well as instituted a social agenda and a firm policy to protect the environment.
It also established the International Diabetes Federation, which promotes research, education and political action to fight the disease. The company also has leading products in hemophilia care, growth hormone therapy and hormone replacement therapy.
Today, Novo Nordisk employs some 35,000 employees in 75 countries and markets its products in more than 180.
The global company has a branch in Kfar Saba, with 100 employees conducting research and dealing with the distribution of products in Israel. Jesper Hoiland, an economist and Novo Nordisk’s senior vice president for international operations visited Israel last week to update himself on how our health system copes with diabetic care and to consult with local employees, including general manager Larry Adelson.
“I like to come here every two or three years,” Hoiland, who on August 1 will take up a new job in charge of North American operations, told The Jerusalem Post in an interview.
“This is my third visit. Israel is really in the forefront of primary care for diabetes in its health fund clinics. Fifty percent of patients here have their blood sugar in control. There is a very sophisticated healthcare model in Israel. You have one of best [healthcare systems] in the world and incredibly good insight [into] patients. By checking health indicators and computerization of medical records, health professionals can easily tell how groups of patients are doing,” Hoiland continued. “The costs of treating patients is coming down.”
The needs are different around the world.
“They are not the same in the developed world as in the Third World, but in the poorer countries, the diabetes threat is rising due to poor diets.”
Novo Nordisk is a corporation and thus must make a profit, but only 30% is on the stock market. Fully 70% of the shares are owned by the original foundation that gives it an altruistic bent. The foundation is a trust that aims at helping people, and it has donated large sums of money on roving vans to inform people about diagnosis and perform blood-sugar tests and many other projects. The firm contributes new wings to hospitals in various parts of the world, insists that companies it deals with give equal rights to women and do not use child labor and encourages employees to participate volunteer projects such as repainting school buildings.
“I have worked for the company for 26 years,” said the Danish-born Hoiland.
“When I retire and look back at my career, I’m not going to tell my grandchildren that I just sold insulin. I want to tell them that people in the world had better life because of what company does and what I did. I will be immensely proud to say so.”
Just as it wants the general public to be healthier, Novo Nordisk has a mission to keep its tens of thousands of employees healthy.
“In the cafeteria, we serve no cola or other soft drinks – not even fresh juice. We prefer water. We also subsidize health clubs for them. “I usually climb 12 floors at work, rather than take the elevator,” concludes the very-fit Hoiland. “I exercise every morning before work. We encourage employees to avoid diabetes by riding bicycles and doing other exercise.
INSULIN IS generic, Hoiland said, “and we have competitors, but nobody can make it in the quantity we can. Our company is fortunate in having the right people, who care for patients and make a difference. The second thing is the company’s heritage.
Nobody else has been around for 90 years.
We and our products are very well known.
That makes a difference.”
Insulin is comprised of huge chains of 51 amino acids, explained Hoiland. “Originally, it was made from pigs and cows. Now it can be manufactured in E coli bacteria, but now we use baker’s yeast as a raw material.
It manufactures itself in a huge tank, but is identical to the human form of insulin. It’s very safe.”
In more recent years, Novo Nordisk researchers changed the molecule, which naturally clots together. “We’ve been able to separate the chains, resulting in much faster absorption by the body. This means that diabetics who need to inject insulin and go to a restaurant, for example, can do it more easily before eating. Before, they had to inject it considerably longer before eating,” making its use more complicated.
In the 1980s, the company invested in developing insulin pumps that can be worn on the body like a beeper and that steadily monitor blood sugar via a needle inserted into the skin. More young children with type-1 diabetes and some adults are using them.
Constantly wearing the catheter may cause infections and other complications. Novo Nordisk decided to focus on insulin pens and leave the insulin pump market to other companies. “I know that many patients think insulin use is only relegated to more advanced stages of the disease. They regard going from oral drugs to insulin as a major disaster and the beginning of the end. But it isn’t true. Our development of longer-lasting and more flexible insulins will change the attitudes of patients and make insulin management much more simple.”
Insulin cartridges are stored in the refrigerator, but can be carried around for days without refrigeration. Only the tiny needle at one end of the pen, said Hoiland, needs to be changed daily and does not need to be disinfected.
Today, he continued, “the most painful part of diabetes care is taking a blood sample from the tip of a finger to measure glucose to determine needed dosage. It needs to be done four to six or seven times a day.
But Israelis are working on a new technology – an infrared device to monitor blood sugar without being invasive.”
Monitoring is important to prevent hypoglycemia – too much insulin and a too-low level of sugar can result in confusion, abnormal visual disturbances, shakiness, sweating, anxiety, heart palpitations, sweating and other symptoms and should be avoided.
An international study a year ago showed that 80% of diabetics dependent on insulin suffer from hypoglycemia at least some of the time, and that 55% of the incidents occur during sleep, when the patient is not always aware of the symptoms. An Israeli startup company named NightSense has developed a non-invasive device that monitors physiological parameters during sleep to sound the alarm in event of too-low blood sugar.
A new but promising approach to treating patients newly diagnosed with type-2 diabetes uses intensive insulin treatment instead of pills to “shock and restart” the islet cells in the pancreas to function more normally. Argentina-born endocrinologist Dr. Mariela Glandt, who works at a private diabetes center in north Tel Aviv, said that a month of fixed-dose injections several times a day can improve the situation for a year or more. But she has not yet conducted a formal study of this non-patented technique.
Novo Nordisk itself is working on the development of an oral insulin tablet – as is the Israeli company Oramed. “We thought insulin could be delivered to the bloodstream by inhaling it, and we almost put it on the market, but we found it was not feasible.
Only 4% to 8% of the insulin actually entered the bloodstream, and it was not very accurate,” revealed Hoiland. “Maybe insulin in tablet form will work in eight or 10 years, but I don’t think it will completely replace the need for insulin pens,” he said.