Article on insulin pricing in today's Washington Post

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I never know whether to applaud them for the things they get right–it is soaring in cost and attention needs to be paid–or the things that seem half-right, wrong or nit-picky. This one is kind of a pet peeve:

“I don’t think it takes a cynic such as myself to see most of these drugs are being developed to preserve patent protection,” said David Nathan, a Harvard Medical School professor. “The truth is they are marginally different, and the clinical benefits of them over the older drugs have been zero.”

Given that, in the context, the “older drugs” are Humulin R/NPH I gotta say… GRRRR. Because “clinical benefits” and “quality of life” benefits are different things. Life on R/NPH is a very different proposition from life on Lantus-Novolog or the other modern MDI insulins (leaving aside pumps). I’d do just about anything not to have to go back to that stuff. Maybe “marginal” to him, but not to me!

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The “often suggested way” of using R+N just once a day, or R+N twice a day, was pretty poor. I did that for 5 years or so.

MDI using good old regular and good old NPH could be very effective. I did 4 shots a day of R+N in an MDI regime for 25 years and I was pretty good at it.

I now do 5 shots a day - 2 x Lantus, and 3 x Humalog - and feel it is at most a marginal improvement over MDI with R+N.

Once a day Lantus never worked well for me. Had to split into two.

Many times I am still surprised by how fast the Humalog kicks in and think it’d be nice to go back to R instead for my typical low-carb meals.

I do agree having Humalog kick in fast is very nice for corrections. Or for high-carb meals.

I think that the “older drugs” that are actually now digging in their heels to drag out their patent protection and inflated prices as long as possible are actually the first gen analogs like lantus (think-- toujeo) humalog and novolog.

R and NPH have been out of patent protection for a long long time, which is why they are $25/ vial now. It will be very very interesting to see what happens to lantus prices now that basglar is soon-to-be available and tresiba seems to be considered superior by the vast majority of those who’ve used it… but it’s not THAT superior like lantus was to NPH…

Basaglar could be an economic game changer in he ponzi scheme of insulin…

I was on R + NPH before I went on a pump three years after my diagnosis in 1984. I was taking NPH at bedtime and upon getting out of bed in the morning. I also took Regular for meals. When the morning NPH peaked, I often fell prey to what @DrBB terms “the eat now or die” syndrome. I had many lows at work since the NPH has a nominal peak of about six hours. It was a poor quality of life, especially for a younger adult trying to establish himself in a career. I had many lows bordering on the need to call 911 but I was able to treat well enough.

I never heard of a 4x/day R/NPH regimen. That was before internet days. I was going to some early adopter endocrinologists and it was never suggested to me. I was not as curious or engaged with my diabetes back then as I am now.

I reconnected with a T1 cousin of mine I hadn’t heard from for many years—

I was surprised to hear him say (since all the others I know are on this forum and pretty intense about it). That he still uses R and NPH because he actually prefers them… said he had tried lantus and novolog but never got comfortable with them so he went back to his old faithfuls…

One shot of mixed R/NPH per day for me, for twenty years. Ugh.

Didn’t mean to thread-jack this into a discussion of R/NPH–lots of interesting/irritating stuff in the article. But since we’re here, just about every point you made applied to me verbatim, especially:

^^^^
This!!! Yes, very much my experience too. “Could we meet at 12:00?” “Umm… okay but…” And I don’t know if it was purely subjective but those NPH lows seemed much more sudden and severe than anything I’ve experienced on Novolog or Humalog, and Lantus by itself didn’t produce any to speak of. The ability to delay or even skip lunch if necessary while working was so amazing to me. So liberating that was.

I did two shots a day of R+NPH for 5 years, back in the early 80’s, and I felt that was very mediocre control. In the mid-late-80’s, like 1987, I switched to a 4xdaily MDI regime using R+NPH and felt so much better.

In many ways I feel that 4xNPH made a better more constant basal than 1x or 2xLantus.

Doesn’t sound like it:

That’s how it starts… a generic comes in 15% cheaper and working just as good, if enough people switch to it the brands have to lower their price to stay competitive, then the generic had to further lower its price to stay competitive… competition with a lower priced product— something that’s been missing all along and the main reason why we’ve seen nothing but upward price pressure all along

Of course that model assumes a rational consumer, which it appears that PWD in the aggregate, unfortunately, are not… but we will see what happens. At least a generic gives me some glimmer of hope

An Express Scripts senior vice president is woefully ignorant of the actual benefits of the more modern analog insulin. This quote from the WaPo article makes insulin-using diabetes patients seem like market-manipulated dummies:

“In some ways you might want to put the [word] ‘improvements’ or ‘improved’ in quotes,” said Glen Stettin, a senior vice president at Express Scripts Holding, the largest pharmacy benefit manager. “For some people, some elements of convenience or how the insulin works for them may be different. But for most people, most of the time the improvements are not really improvements at all.”

I suspect that he knows little about how insulin works in a non-diabetic individual versus the crude approximation of subcutaneous delivered insulin in people with D. He probably knows little about the comparative onset, peak, and duration attributes of the old versus the new insulins. The more I read about pharmacy benefit managers, the more I think they are the primary reason many insulin formulations have risen 450% over inflation for the last 20 years.

The article missed an important point in showing how this wholesale theft is a US problem and that other first-world countries have been able to manage insulin price increases much better.

But we have the best system of medicine in the world! (Yeah, right!)

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Argh. This term “convenience” is a dog whistle term used by insurers to deny coverage. Using that word to describe any type of insulin usage is not right. That word struck a nerve with me because my insurer denied paying for a CGM because it was judged to be a “convenience”. The cynic in me says: Watch out for continuing press coverage of drug prices that stresses the “convenience” aspect. I think these bean counters all went to the same seminar.

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The insulin lispro (Humalog) patent expired in 2013.

Anyone know anything about why we don’t have a cheap generic?

While I am one of the few voices around here that defends the Health Care industry overall in terms of costs (the obscene profits just aren’t there), I am also solidly on the side of those that complain we are getting ripped off and abused with insulin pricing.

There’s no justification for raising the price of a vial of Humalog from $21 in the early 90s to $250+ today. While I do completely understand (and do not criticize) the financial model of recouping R&D costs during the patent life (20 years) of the drug, I do not agree there is any justification for “forward funding” new drug R&D by raising the price of current drugs beyond what it takes to recoup R&D for THAT drug.

This is something discussed in the article, and is cited as one of the reasons for price increases over the last decade or so.

I do not think it fair, or ethical, to hang the cost of someone else’s future treatment on the backs of those sick today with something else.

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Not sure why this is so, but price behavior like this indicates this is not a functioning competitive market.

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NPH lows packed a punch more powerful than a simple Regular low. I’ve learned over the last few years that basal lows are a different animal than bolus lows. During insulin basal adjustments on my pump, I’ve tweaked my basal rates too hot and found the lows incredibly persistent, often requiring two, three, or four low-BG glucose counter-measures. Then, when you finally raise up the low, it skyrockets through the target range and goes high for several hours. It’s not enough glucose, not enough glucose, not enough glucose, then quickly way too much glucose! It often happened while trying to sleep. Oh, the joys of the D-life!

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@DrBB and @Terry4, are you two going to write responses to the WP??

Thanks for the suggestion, @CatLady06. I’ve given up replying to major media story comment threads. I’ve seen too many devolve into fevered swamps of emotional invective. Do you think it would help?

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even on a script we are paying more for NPH
edit…I think it’s 5 vials, so forget what I said
http://www.chemistwarehouse.com.au/Buy/61441/Insulin-Humulin-NPH-100U-mL-10mL-5
Insulin Humulin NPH 100U/mL 10mL 5
IMPORTANT NOTE – A VALID AUSTRALIAN PRESCRIPTION IS REQUIRED BEFORE THIS ITEM CAN BE SHIPPED

Drug Name: insulin isophane human
Private Price $122.95
AU citizens
PBS $37.30
Concession $5.20
Safety Net $0.00