COMMENTARY

'Whatever It Takes': Helping Patients Afford Insulin

Anne L. Peters, MD; Irl B. Hirsch, MD

Disclosures

July 13, 2018

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Anne L. Peters, MD: Hi. I am Dr Anne Peters and I am here today with my dear friend, Dr Irl Hirsch, from the University of Washington in Seattle. We are going to talk about something that he and I are incredibly passionate about: the high cost of insulin and how to help our patients manage these costs.

Irl, it is so good to have you here. Would you set the playing field? We know that insulin can be incredibly expensive. How do you handle this in your patients?

Irl Hirsch, MD: The cost of insulin is a sensitive topic. Some patients are embarrassed when they canʹt afford their medications. I am honest with them. I ask patients whether they can afford their insulin, and if not, we try to come up with some solutions.

As with many of the personal issues we discuss with our patients, this is quite important. For the majority of my patients, the most expensive medication they take is insulin.

I try to take the embarrassment fences down.

Peters: And for many, insulin is absolutely life-sustaining. Without it, those with type 1 diabetes will die, and those with type 2 will go out of control. Asking about and looking at this issue is extremely important.

How do you ascertain whether your patients are taking their insulin?

Hirsch: The most direct way, of course, is simply to ask them. We also have a very complete medical record. Based on the last visit, I can see if they are refilling all of their medications appropriately. Are they taking their statin? Are they taking their ACE inhibitor and refilling it? That takes a fraction of a second.

If I see that they are refilling the generic tablets, but not their insulin, I know they are withholding it. Again, they may be embarrassed about it. I try to take the embarrassment fences down.

Peters: That is comforting and good for your patients, and it is quite important. I have patients I have seen for years who are embarrassed to tell me that they cannot afford their insulin. It's something that people do not want to talk about.

Yet, we do have other options. If someone cannot afford analog insulin, what do you do? How do you approach it?

Hirsch: With outpatients, we look to see if a cheaper analog option is available through their particular insurance. Often there is; sometimes there is not. But for some of the covered insulins, the copays are also unaffordable. That is a big problem.

In the worst-case scenario, we go back to human insulin—NPH and regular. NPH and regular insulin work well and you can get both quite cheaply under the trade name ReliOn at Walmart. They cost about $25 per vial, whereas at a regular pharmacy, the cost for the same insulin is closer to $140 or $150 a vial. So we do have affordable insulin in this country, but many people do not know that.

I will use whatever it takes to get a patient to where they need to be.

Peters: That is something I teach all the time. But human insulin requires a vial and a syringe, so you have to be good at teaching your patients about how to use them. It is a bit different from a pen, a bit more cumbersome, but a zillion times cheaper, so it is a very good option.

How do you approach this with inpatients?

Hirsch: We started a new approach about 2 years ago. A typical patient comes in with pneumonia, or a fractured hip, or whatever. And we learn that this patient has type 2 diabetes and needs to be on insulin. Typically, these people have A1c levels above 10%.

We start them on human NPH or regular insulin in the hospital. Previously, when we sent them home on analog insulin, many of these patients got to the pharmacy and found that they could not afford it. Then they would see their primary care providers (PCP) at follow-up and they werenʹt taking the insulin they had been prescribed. By starting out with human NPH or regular insulin, patients could afford to get human insulin after discharge, and then the PCP can figure out what is the best insulin for the patient in the long term.

The data are clear that with the lower A1c levels in patients with type 2 diabetes, NPH is associated with a bit more hypoglycemia than analog insulin. There are no data showing that regular insulin is associated with more hypoglycemia than analog insulin in patients with type 2 diabetes. I explain that to the patients if they are concerned about it. For the most part, I think our little experiment has worked very well.

Peters: Iʹm not afraid to mix and match. I will use whatever it takes to get a patient to where they need to be. If patients do not mind using a vial and syringe to administer NPH, but during the day they want a pen, I will do whatever it takes to make this work.

I wish these insulins were not so expensive. Given that they are expensive, we all have to be flexible and realize that there is no single way to accomplish this. The only way that is wrong is to have patients run out of insulin or not take the insulin they need. If we can work with them and make this happen, I believe that we are successful.

Hirsch: To your point of "whatever it takes," my practice is close to the Canadian border, so our patients will go to Canada if necessary. The cost difference for retail insulin is amazing. A vial of almost any insulin costs about $30 Canadian. You do not need a prescription. For a box of five pens, the cost is between $45 and $50 Canadian. About 20% of our patients obtain insulin in Canada. The folks at Passport Control know this. They have no problem with it as long as people are not bringing back such a large amount that it looks like they are selling to other people in a black-market situation. To my knowledge, that is not happening.

The point is that people do what they have to do. This is more common for patients with type 1 diabetes, where the analogs really do make a difference.

Peters: That is good advice for people who live close to the border. I wish it were otherwise, but this is what people need to do to make sure they can get the insulin they need. It is heartbreaking. Irl, thank you very much for being here with me to discuss this important topic.

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