Rising costs of commonly prescribed insulins have caused some people to ration their medications for financial reasons. One option is to change to older, and still cheaper, versions of insulin.
The first insulin was made from animal products. In the early 1980s, the initial human-based recombinant medications (NPH, regular and mixtures branded Humulin and Novolin) were released. By the late 1990s, the currently preferred analog insulins (AI), including lispro, aspart, glargine and others, became available.
The analogs took the recombinant insulin molecule and altered it so the effects would be seen quicker and be active for a shorter time when covering meals. For longer, basal coverage, their action was prolonged so they could be injected once a day and still control blood sugars overnight and between meals. This more closely mimics the way insulin works in the body.
“In a perfect world, all of my patients would be on analog insulin,” said Anne Peters, MD, professor of clinical medicine at the University of Southern California. “They are much easier to use. But with the increases in costs for these medications, I am finding more of my patients aren’t able to pay for them and need viable alternatives.”
One way is to return to the old standby, the recombinant forms of the medication.
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Shopping for insulin requires work
“For some patients without insurance or having high-deductible policies, the difference between the lowest-cost human insulin and the most expensive analog can be tenfold or more,” said Jing Luo, MD, a faculty member in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital in Boston. “You can get a vial of human insulin for around $25 a vial at Walmart. For a box of Lantus pens or another AI, it could be as high as $600.”
Shopping for the best price requires a bit of work. Call around to area pharmacies to see where the cost is the lowest. As noted above, Walmart and Costco are good places to start. Prescription aggregators such as goodrx.com offer coupons for similar prices at major chains such as CVS or Walgreens and can be cheaper than your insurance even for the analogs.
Recent developments from insulin manufacturers and health insurance companies also have the potential to reduce insulin costs for certain people. In April, heath insurance company Cigna and its pharmacy benefits manager, Express Scripts, announced a health insurance plan that will cap insulin costs at $25 monthly. The move could affect 70,000 people, reducing the cost of insulin from $40 a month on average (and much higher for some). And in May, drugmaker Eli Lilly announced that a lower-priced generic version of its rapid-acting insulin Humalog was on the market. The “authorized generic” version is sold as Insulin Lispro at half the current price.
Ask for prices both with and without insurance if you have a policy. It may cost more out of your pocket to have the insurance price than if they aren’t involved.
Transition can be tricky
If you are not able to afford AI formulations, changing to older human insulin can be a solution. After all, they were successfully used for over 20 years before the analogs. However, the transition can be tricky and needs to be made under the direction of an experienced health-care provider.
“The first thing you should do is ask your providers if it is clinically appropriate to make the switch,” said Dr. Luo. “If your provider has no problem, then you should feel comfortable, and even empowered, to do some comparison shopping. I don’t know why people feel they have to go to multiple car dealers looking for the best price but don’t do the same thing with their medications.”
Human insulin is available without a prescription in most states. You may decide to save a little extra money by not having a provider oversee the transition. However, since there are major differences in doses and length of actions between the two, you can’t just use the same dose as before.
Complicating your life
“You need to know going in that changing [to older insulin] is going to complicate your life,” said George Grunberger, MD, chairman of the Grunberger Diabetes Institute in Bloomfield Hills, Michigan. “When you are switched, you have to relearn and be retaught how to use the medicines.”
The longer-acting analogs are injected only once a day and hang around for 24 hours or more. In contrast, human insulin NPH peaks in a shorter time and is intermediate-acting instead of long-acting insulin. Instead of one shot that distributes an even amount of the medication all day, you have to get two shots, and there are more peaks and valleys. With older insulins, you can mix them in the same syringe, which may reduce the number of injections.
There are similar differences in the insulins you use to cover meals. The AI have a speedier onset and are out of the blood quicker. When you change, you have to give yourself insulin up to 45 minutes before eating instead of the 15 minutes you are used to for analogs.
New skill set for administering
There is also an entirely different skill set to be developed for administering the insulin. The newer medications are available in pens, and you get the proper dose by turning the dial on the side to the needed number of units.
“With human insulin, you are dealing with a vial, and you have to draw out the specific number of units instead of just twisting a dial on a pen,” said Dr. Grunberger. “It is an involved process. You have to inject air into the vial before you take out your medication. The longer-acting NPH insulin is a cloudy suspension, and you have to know how to resuspend it. If mixing NPH and regular insulin in the same syringe, you have draw them in the right order and the right amount.”
The different actions of the different insulins mean that you have to monitor your blood sugars more aggressively. You are more likely to have hypoglycemia overnight or before meals with the older formulations.
Other things to consider when switching to the older insulins include:
• Can you see the markings on the insulin syringe? If not, magnifiers are available.
• What are your glucose targets? You may need to raise these at first to get used to how the new insulin works and see if you are at increased risk of hypoglycemia.
It is important that you not only ask your doctor if you should change but also find out how much the doctor knows about using nonanalog insulin. There is as much of a learning curve for the physician as the patient.
Not all doctors experienced in using older insulins
“One problem that is not well appreciated is that there are generations of practitioners who don’t know how to use the older medications because they were brought up only with analogs,” said Dr. Grunberger. “You have a situation where doctors prescribing medications don’t know how to best use human insulin and don’t always understand the finer points of switching.”
The experts note that older practitioners are more likely to have hands-on experience in the use of nonanalog insulin. Ask directly about their background in the use of both analog and nonanalog medications. Find out how many, if any, of their patients have successfully made the transition.
“There is a huge cost saving between the two types of diabetes medications,” says Dr. Peters. “With the increases in the price of analog insulin, the patient and the provider will need to be ready to make the changes needed to keep the patient alive. Older recombinant insulin is better than no insulin.”
Want to learn more about how to save money on your insulin? Read “Insulin Prices: Four Ways to Pay Less.”