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Patient: I can’t afford the insulin you prescribed for me.

Me: It’s a pretty standard long acting insulin

Patient: My insurance says it’ll cost $350 a month to use it, is there something less expensive?

Insulin is a magic drug. Discovered in 1921, it was first administered to humans in 1922. Although there were a long line of discoveries that made the discovery possible, Drs. Banting and Best at the University of Toronto were the first to identify the source (the pancreas) and to extract insulin for use. Even more amazing, the University made the discovery “open source,” allowing the manufacture and distribution without royalty.

The discovery was not without its problems. Although human insulin was synthesized in the lab, it was difficult to make for many years. Insulin taken from cows and pigs was commonly used clinically. Unfortunately, in one of the Creator’s little jokes, these insulins vary from human insulin by a couple of amino acids. Not enough to make them unusable as extracted but enough so that over time the diabetic patient developed antibodies and was unable to use the insulin, leading to his or her premature death.

In 1982 Richard diMarche and Eli Lilly obtained a patent for human insulin made from recombinant DNA. Originally sold as Humalog, this was the first medication manufactured in this manner and it was a game changer. No longer were we putting a foreign body into people to lower their blood sugar temporarily. We were putting human insulin into people and keeping people alive longer and keeping people healthier.

Which brings us to today. Drug companies developed pens, different types of insulins, and different delivery methods. They have also jealously guarded their patents, preventing cheaper generics from being developed. To quote the New England Journal:

“But whether each incremental innovation is worth the price we pay, in a world where insulin remains unaffordable to many patients with diabetes, is less certain.”

Reasons used for the high cost might include the need to ship the medication in liquid form as well as the different delivery mechanisms. The bulk of the cost of the drug, however, is in R&D. These drugs have been developed for years and there are no more R&D costs. Their investment has been recouped. It is becoming clear that a major reason is good old-fashioned “profit taking”:

Between 2005 and 2015 the cost of a lispro vial went up 264 percent, while a vial of insulin glargine went up 348 percent, and a vial of NPH went up 364 percent. That’s a lot, but other insulins went up even more.

The cost of an aspart pen rose in this 10-year period by 389 percent. And the cost of a vial of U-500 regular insulin jumped a staggering 508 percent.,

 

So, in America in 2016 we have people choosing between insulin and food. People that weren’t having to do that in 2006. The speculation is that this profit taking is in advance of the loss of the patent as well as the lack of “blockbuster” drugs on the horizon. Perhaps generics will be developed soon.

What did I do for my patient? There is one type of intermediate acting insulin that is $27 a vial at Wal-mart. No special pen, has to take it twice a day. For now, it turns out that diabetes in now a two-tiered disease, easy for the rich to handle but increasingly difficult to manage if you are poor.

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