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Dr. Bill's Commentaries

The High Cost of Diabetes

Since the essay below was written (March 24, 2015), there has been another version of insulin glargine approved, called Basaglar, and Sanofi has introduced a revamped version of glargine, called Toujeo. But the increased choices hasn't resulted in decreased prices.

I recently received the following question:

I have type 2 diabetes, I'm on Medicare, and I take 80 units of insulin daily. Currently, I am taking Lantus [insulin glargine] and I need 10 pens per month. My current provider says that the insulin cost is over $700 per month, which means I will hit the doughnut hole in May - maybe earlier as I will get a couple of other medications on my Part D this year. I will then end up paying out of pocket costs for the insulin.

Am I missing something here? Is there any way or any strategy for getting my insulin at a lower cost? I have limited means, but not limited enough to qualify for assistance. Yet, the drug costs will have a negative impact on my life. I was just wondering if there is something else that Seniors can do to cut their insulin costs. As it is, I pay for all my other medications out of pocket because they are all generic and I can get a 3 month supply of all of them for $60 which is cheaper than going thru my Part D.

I know I can switch to mail order and I may do that, but I have concerns because I live in a very hot climate and worry about the insulin staying cold in shipping. I wouldn't always be home to retrieve the medicine right away.

My reply:

You are in a tough spot -- there aren't any insulins comparable to Lantus available in the US, although there might be cheap versions in other countries (there was one in India, but it was taken off their market). Clearly even if there are, the shipping problems would be just as bad as with mail-order insulin from the US (and I agree with you, it's problematic to ship any insulin in very hot/very cold climates).

Maybe in the future, when Lantus comes off patent, and when Sanofi's lawsuits with Lilly are resolved, the price of glargine will fall -- but that's probably a year or more in the future.

In the meantime, look closely at other alternative insurance plans. If you don't already have an insurance broker who can compare plans with you, ask one (their services are free to you as the consumer).

In the relatively unlikely event that you've considered using an insulin pump -- the insulin for pumps is covered under Part B -- no doughnut hole

Finally, consider writing your Congressional representatives and let your voice be heard. Let them know your thoughts on health care financing in your state and your thoughts on laws refusing to allow Medicare to bid competitively for drugs.

Follow-up:

After I wrote this reply, I found a new publication in the New England Journal of Medicine with the fascinating title Why Is There No Generic Insulin? Historical Origins of a Modern Problem. Sadly, neither the NEJM's abstract nor PubMed include any information on the author's answer to their question. I received a copy from co-author Dr. Jeremy Greene, and it really didn't give any answer to the pricing puzzle. Also, there are some commentaries on-line, including one from NPR that you can listen to, or you can read the NPR transcript. In it, Dr. Greene stated "There [is] no such thing as generic insulin in the United States in the year 2015... The older insulins, rather than remaining around on the market as cheaper, older alternatives to this newer and slightly better [human] insulin, disappear from the market."

Why didn't the older cheaper insulins remain available? The authors point out that "a series of incremental technological advances have maintained the patents on insulin," but that doesn't explain to me why the manufacturers chose to discontinue the cheaper products -- with only one logical explanation why: rather than having inexpensive generic insulins available, they want to force consumers and insurance companies to pay for newer and somewhat better products.

Let's give an example: Lantus versus the older NPH or Ultralente insulins as "basal" insulins when used in a basal-bolus insulin program. When Lantus (insulin glargine) hit the US market in 2001, sales took off like a skyrocket -- it clearly was better than the two existing "basal" insulins. It has longer duration of activity than NPH, and more predictable action than either NPH or UL, and frequently needs only a single injection per day whilst NPH needs two (or three) to establish a true basal action. But it's more expensive by far: the manufacturer states it had net sales of € 6,344,000,000 (that translates to $6,920,415,840 at present exchange rates) in 2014.

With profits like that, why would any rational pharmaceutical company want to continue to produce inexpensive insulin that would cut into the market for its expensive, newer, and somewhat better insulin?

The end result is that US citizens are stuck with expensive insulin.

Disclaimer: The author previously worked for Aventis and later Sanofi-Aventis, the manufacturer of Lantus, in the area of pharmacovigilance.

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