Please don’t start reading until you have some idea of what insulin costs these days. It’s scary and sad, and realizing how much of your household income will go to this necessity can send you into shock. Or a panic attack. I’m not kidding. It sucks, but it’s not the end of the world. You have a child (or other loved one) who will not die before the end of the week because pharmaceutical insulin exists.

You can do your own research, but list price for 3 milliliters of a modern insulin in a delivery pen runs about $100. This is U-100 concentration, so that’s 300 units. My son is 155 lbs with no insulin resistance and uses about 60 units per day, so, if we were paying cash, with no insurance write-off and no out-of-pocket limit, that would be $7300 per year. What if I told you that there was an insulin that was just $25 per 1000 units, or just $550 per year? There is such an insulin. And you don’t want it.

Elsewhere on this site you’ll read how modern insulins have been engineered to make the body’s uptake of an injection as close as possible to the body’s uptake of natural pancreatic insulin. This allows one to consume normal amounts of normal food without an inordinate amount of time between dosing and eating. Prior to the development of these insulins, regular human insulin was all we had, with both a longer uptake time and a longer duration of action. The chart here tells the story. The black line is the way normal people access insulin. The blue line is regular human insulin, but injected  rather than delivered to the liver by the pancreas. The yellow line is Novo Nordisk’s modern “fast” insulin. A real modern miracle.

So – there are serious trade-offs to using this cheap insulin. Without deliberate management, you’d suffer a blood glucose high as the carbs hit and before the insulin kicks in. Then, a low is more likely as insulin remains in the system long after digestion. Neither of these is healthy. Obviously those with diabetes managed for decades on “old” insulin, though, and some older diabetics prefer this medium-acting, so called “rapid” insulin, claiming headaches and other effects from the “fast” kind.

Before I go further, let me emphasize that there are programs out there to provide modern, superior insulins at affordable prices to those who are truly financially needy. Some companies offer year-long discounting to urge you to switch. Others offer programs that seem to be simply humanitarian in nature. There are also non-profits prepared to connect you to insulin in some economical way. DO NOT ECONOMIZE BY TAKING TOO LITTLE INSULIN!!!

All that said, how do you get this stuff for $25? Believe it or not, in most states it’s over-the-counter…without a prescription…from WalMart. They re-package it under their ReliOn brand. As of this writing the insulin itself is Novolin, but in the past it’s been Humulin. They basically play Eli Lilly and Novo Nordisk off against one another to keep that $24.88 price.  At this price point Wal-Mart offers regular human insulin – Novolin R, they offer delayed reaction insulin, Novolin N, and they offer a 70/30 mix that creates an extended reaction similar to the extra post-meal bump seen in normal blood insulin levels. (Editor’s note, similarly re-branded Novolin formulations are now available for $25 at CVS, and see our posts elsewhere about pricing from GoodRx.)

As I’ve said elsewhere on Type1News, no ethical physician would prescribe regular insulin these days. However, for some patients, the uptake curve of ReliOn N makes for a reasonable basal dose (if directed by a physician!) injected every 12 hours rather than once per day. We personally know diabetics dosing like this. Most intriguing is the notion of using regular insulin (Novolin R)in a pump, for basal dosing, at least.  One could imagine a dual-reservoir pump with a supply of cheap insulin for the less-time-critical basal dose and a separate supply of the latest insulin for well-controlled mealtime dosing. Obviously the increased complexity would cancel out much of the savings, but it would be nice to only pay for the fast insulin that you need to be fast!

Here’s the insidious thing: The best we can figure, it costs no more to manufacture these modern insulins than it does to manufacture old-fashioned regular. Both are made in that recombinant DNA process…they just use just different bacteria engineered to produce a slightly different insulin. The extraction, processing, packaging and shipping are all the same! So, although one can think of constructive ways to use cheap insulin, its cheapness is politico-economic, not chemical. It would be “easier” to make effective insulin cheap than to make cheap insulin effective.

Still, isn’t it good to know that if you’re in a strange city and lose your insulin…and they don’t have your pharmacy but it’s a state that allows this over-the-counter sales…you can keep body and soul together for a couple of days. Likewise, it’s good to know if you had an insurance disruption but didn’t yet qualify for assistance, there is an option available. We recommend considering this information carefully so you’re ready to make use of it in the worst of times.

As I type this Eli Lilly is just days from releasing Basaglar, their version of the same insulin in Lantus. If I understand correctly, they’re producing an insulin composed of the same amino acid chain as Lantus, but they’re producing it by their own technique so it’s not under Sanofi’s patent.

Just having another player in the insurance market should be beneficial to patients and insurance companies. Your insurance company may, for instance, negotiate better with Lilly than other pharma companies, and this may be the first time this so-called insulin glargine is available on your formulary…at least at the most economical tier. Sadly the introduction of Basaglar is not expected to create a lot of new competition in the overall marketplace. It’s been suggested that all long-acting basal insulins may eventually come down only 20% or so in reaction to the new player.

This type of insulin is described as a 24-hour insulin, compared to Novo Nordisk’s Levemir, which is described some places as a 20-hour insulin. My son really did seem to have superior results with the 24-hour stuff before it was taken away by insurance. Although he’s on a pump, now, and not using all-day insulin, it would be nice to have access to this superior formulation. Therefore, we welcome Lilly’s innovation.

By now you may be aware that a common insulin regimen is to take one type of insulin for mealtime (bolus) dosing and another for baseline, all-day insulin needs (basal). The communications professional in me says that before taking another step forward, the industry should adopt a new name for at least one of these to avoid confusion. For the sake of teachers and other caregivers we should be using a more universally-meaningful term than “bolus” for the mealtime dose. I don’t have a suggestion, I just hope that those already in the field are communicating effectively.

In our experience the daily basal dose of long lasting insulin is about twice the bolus, mealtime dose. This creates a dangerous situation, particularly if you use “pen” injectors that have a “dial” to scale the dose. Simply put, if you pick up the bolus insulin pen and give yourself the volume of insulin prescribed for your basal dose, it could be fatal. Folks experienced with diabetes usually catch themselves as their blood glucose falls to dangerous levels, but if the dose was a bedtime dose, you may not be conscious-enough to be sensitive to the low.

In describing this situation to others, they propose pens that are color-coded. This is a great step, and I’d like to see standards for this coloring. The people who propose mere color-coding, however are not as absent-minded as I can be. I have another concrete suggestion.

Not all of the liquid one injects is insulin. Most of it is a suspension solution, and the insulin itself tends to be available in so-called U-100, U-200 and U-500 concentrations, My suggestion is that rather than take twice the volume of the basal insulin, it be simply prescribed at twice the concentration, and the pen dial labeled arbitrarily rather than by actual units of insulin. The goal would be for each of the the pens to be dialed up to a much more similar number each time one injects, and giving yourself the numerical volume of either insulin in the other’s dosage isn’t nearly so dangerous. Alternately, one class of pens could be labeled in numbers and the other in letters, or some other way so that the prescribed dose of one pen simply can’t be fulfilled by the mechanism of the other. Judging by how much pricier pens are than vials, much of the prescription price must be going toward the patented mechanism, itself, so there should be plenty of motivation to improve the situation by some means! I’d be glad to hear your thoughts, as well. In the mean time, be careful!