LINDA A. JOHNSON AP Business Writer Diabetics are increasingly risking life and limb by cutting back on — or even going without — doctor visits, insulin, medicines and blood-sugar testing as they lose income and health insurance in the recession, an Associated Press analysis has found. Doctors have seen a drop in regular appointments with diabetic patients, if they come back at all. Patients more often seek tax-subsidized or charity care. And they end up in emergency rooms more often, patients and physicians said in interviews. Sales of top-selling drugs and other products used to treat and monitor the disease have dropped since the economic crisis accelerated last fall, the AP analysis found. There are even signs that some patients are choosing less-expensive insulin injections over pricier pills to save money. Meanwhile, the number of people with the disease keeps growing — another 1.6 million Americans were diagnosed in 2007 alone. People with other health problems also are cutting back on care amid the recession, but diabetics who don't closely monitor and control the chronic disease risk particularly dire complications: amputations, vision loss, stroke — even death. Patients' frugality comes at a tremendous cost to the already-strained health care system. The typical monthly bill to treat diabetes runs $350 to $900 for those without insurance, a price tag that's risen as newer, more expensive medicines have hit the market. Emergency care and a short hospitalization can easily top $10,000, and long-term complications can cost far more. M. Eileen Collins, 48, of Indianapolis, tried to scrimp on her medication last fall after her husband lost his job and with it their insurance. Without money for insulin, test supplies and other medicines, she asked for free samples and also got a few drugs through $4-a-month generic programs. But she stopped taking most of her drugs and cut her insulin doses in half to stretch her budget. "I truly did not think I was putting my life in danger," Collins said. "I thought if I was just real careful with what I ate ... I'd be all right." By Thanksgiving eve, Collins was vomiting blood and rushed to a hospital. Doctors diagnosed her as malnourished, anemic and in diabetic ketoacidosis, a life-threatening condition caused by lack of insulin and sky-high blood sugar. She spent a week in the hospital. Her story is hardly unique. Dr. Steven Edelman, a University of California, San Diego endocrinologist who runs a free clinic staffed by medical students, has seen a 30 percent surge the past six months in patients seeking free diabetes medicines and supplies, which the clinic has to ration. Many had been solidly middle class, but the recession took their jobs, insurance and even some homes. "A third to a half of these people haven't been taking their meds at all," said Edelman, who also founded the advocacy group Taking Control of Your Diabetes. Diabetes occurs when the body doesn't make enough insulin or doesn't efficiently use the hormone, which helps turn sugar from food into energy. The disease can be kept under control by monitoring blood sugar as well as exercising, improved diet, medications, testing and regular checkups. Uncontrolled diabetes can cause fatigue, blurry vision, excessive urination, gum problems, infections and wounds that don't heal. Damage to the kidneys, liver, heart and eyes follow. Often, much of that damage isn't apparent until a stroke or heart attack strikes. Sales of diabetes testing supplies and drugs indicate how many Americans have moved beyond scrimping and are cutting vital expenses. Several doctors said they began noticing a shift in August or September, when the financial markets melted down and layoffs accelerated. Sales have dipped for pricey brand-name diabetes pills, blood glucose monitors and even test strips, based on industry sales figures and interviews with the top two makers of testing supplies. The strips generally cost $1 or more each; patients using insulin are supposed to test at least two to four times a day to be sure their blood sugar is in a safe range. Most diabetics typically can control the disease for a few years with diet, exercise and pills available as cheap generics. But eventually, those pills stop working well, and patients switch to more advanced — and more expensive — medicines. Sales of the most widely used pill, $4-a-month metformin, are up 7 percent since June, according to the AP analysis of figures from health data firm IMS Health Inc. Brand-name versions of the same drug, costing 10 times as much, are down 9 percent, on average, since then. By February, sales for nearly every other category of diabetes pills and insulins were down from a year earlier, most by double digits, IMS figures show. The only exceptions were a heavily promoted new type of diabetes pill, Januvia, and advanced insulins that tightly control blood sugar levels. The sales declines come even as the number of diabetes cases grows, fueled by the rise in obesity. According to the American Diabetes Association, more than 24 million Americans have diabetes. Even as sales of expensive pills have fallen, sales of advanced insulin injections are up 9 percent since summer. That could mean some patients would rather face a needle to save money, according to Brian Lasky, a research analyst at IMS Health. "By December, people were making decisions in terms of, 'Do I fill this prescription or ... buy Christmas presents for my kids?'" Lasky added.Johnson & Johnson, a maker of top-selling OneTouch blood sugar meters, testing strips and insulin pumps, reported a 2 percent fourth-quarter drop in U.S. sales for the category compared with the same period a year earlier, a large drop considering quarterly sales up to then had been rising at around 10 percent. "We're seeing some signs that consumers and patients are becoming more frugal," J&J Chief Executive Bill Weldon told analysts in January. Getting patients to stick to their treatment has long been tough. But rising unemployment has made things worse. At a family clinic in impoverished Newark, N.J., so many patients simply stopped showing up after losing health insurance that doctors posted notices asking clients with financial troubles to speak up so staff can try to help. "Sometimes you don't see (diabetes) patients for several months," said Dr. Cynthia Paige, medical director of the New Jersey Family Practice Center. They "don't understand what a nightmare uncontrolled diabetes is and how it's ravaging your body," she said. April Bumpus, 31, of Woodstock, Ga., was laid off from her job in medical sales last spring while recovering from surgery, and her health insurance was canceled. By September, she had to switch from two advanced insulins that tightly controlled her blood sugar to cheaper, older ones that cause surges and drops. The advanced insulin would have cost $360 a month, the older insulin only $100. "It makes you really feel like you have the flu" at least once a week, said Bumpus, who's more worried about the long-term consequences. "That does scare me. I can have a heart attack, I can have a stroke, I can go blind." Emergency rooms increasingly are treating diabetics who haven't been taking medicines, according to doctors at several hospitals nationwide and the professional group for ER doctors. Many of the patients have blood sugar so high they are hospitalized for days. Free clinics also are getting a surge of diabetes patients desperate for help. "There's an increase in just overall consequences of diabetes: losing a foot, losing a kidney, bad eyesight. At least six people come to mind over the last six months ... most because of the recession," said Dr. Nicholas Vasquez, who works in one of the country's biggest ERs, at St. Joseph's Hospital in Phoenix. Vasquez and his colleagues view the desperate patients in their ER as harbingers of what's to come if the recession deepens. "What we're seeing mostly is the first steps of people not taking care of their diabetes and starting to have consequences," he said.