Insulin therapy in 2017: More options, but greater costs may limit use

Issue: November 2016

BOSTON — Several new insulin therapies are anticipated for patients with diabetes in 2017; however, for many, cost may put the latest options out of reach, according to a speaker at the Cardiometabolic Health Congress.

Perspective from Susan Cornell, PharmD, CDE, FAPhA, FAADE

Heading into 2017, eight basal insulins and six prandial insulins will be available, Irl B. Hirsch, MD, professor of medicine at the University of Washington School of Medicine in Seattle, Washington, said during a presentation. Clinicians and patients can expect a movement to improved basal insulins that further reduce nocturnal hypoglycemia, such as insulin degludec, as well as the arrival of at least one biosimilar glargine, he said.

Irl B. Hirsch

Availability of faster prandial insulins is also anticipated, which Hirsch said will be particularly helpful for patients on pump therapy and those who may potentially use the newly approved artificial pancreas system.

Fast-acting insulin aspart, a mealtime insulin, may also become an option in 2017, Hirsch said.

“We’re going to have 15 insulins available next year, and what is the reality for diabetes care for doctors, with all of these insulins available?” Hirsch asked. Patients, he said, are often forced to rely on cheaper insulins or forgo therapy entirely due to cost. Clinicians too, he said, are frustrated as they try to assist patients with resources they need.

Pricing issues

Research published this year in JAMA showed that insulin prices tripled between 2002 and 2013, whereas the cost of other diabetes drugs have fallen in price during that period, Hirsh said.

He cited a newspaper drug store ad from 1964, which advertised 40-unit NPH insulin for 99 cents; 80-unit NPH insulin cost $1.89.

Today, he noted, the picture is much bleaker. It is not uncommon for patients to tell him they had to make a choice between buying food or insulin, or that their monthly costs for insulin rivaled their mortgage payment, Hirsh said.

“The real losers here ... are patients,” Hirsch said. “And they are screaming.”

Comparing insulins around the world shows an even greater disparity, Hirsch said.

“A vial of regular insulin in India [costs] $2, whereas in the United Kingdom, it’s $11, whereas here [in the United States], on the day I happened to look it up, it was $136,” Hirsch said. “If you go to goodrx.com, it can change several times a day, depending on your zip code. It’s like gasoline.”

List prices for insulin, he said, are designed to be a “place to start confidential negotiations with middlemen” pharmacy benefit managers. Pharmacy benefit managers, he said, drive the insulin companies to maintain high profit margins.

“The system is out of control to maintain these high profit margins,” he said.

In addition, many patients on high deductible plans, those with high co-pays or the uninsured often end up paying the high list prices, he said.

‘ Going backward’

The issues of cost may result in many patients to go “backward” to human or NPH insulin in 2017, Hirsch said.

“For many, going backward to the human insulin ... the NPH and the regular at $25 per vial, is the only solution,” Hirsch said. “Next year at this time, that may be a much more common type of insulin that your patients are taking. So how much training do we give our med students, residents and even fellows about how to use these older insulins?

To change that, Hirsch said, the government will need to get involved to achieve better insulin access, particularly for patients with type 1 diabetes. Organizations like the American Diabetes Association, The Endocrine Society and American Association of Clinical Endocrinologists will need to be more active and visible regarding insulin access; in the meantime, there needs to be better professional and patient education regarding how to use NPH and regular insulins, he said.

“For patients who can’t afford their insulin, this is what they are going to be using,” Hirsch said. “Whether we like it or not.” – by Regina Schaffer

Reference:

Hirsch IB. Insulin Therapy Options: What’s in Store for 2017? Presented at: Cardiometabolic Health Congress; Oct. 5-8, 2016; Boston.

Disclosure: Hirsch reports receiving consultant fees from Abbott Diabetes Care, Intarcia and Roche Diagnostics.

Perspective

Susan Cornell, PharmD, CDE, FAPhA, FAADE

Since 1922, the evolution of insulin continues to advance. Over the past century, new insulin formations and delivery systems have improved the pharmacokinetics, pharmacodynamics and ease of use for patients. Cefalu and colleagues use the analogy of insulin as “the essential black dress,” referring to a standard clothing item in almost every woman’s closet (Cefalu WT, et al. Diabetes Care. 2015;doi.org/10.2337/dci15-0023). Similar to the little black dress, insulin will never be out of fashion, can go with almost anything (from a pharmacotherapy combination perspective), and with simple additions or modifications, it can be adapted for any occasion (type of diabetes) to help patients reach their treatment goals.

However, when the cost of a 1-month supply of insulin exceeds the cost of the designer black dress, patients lose.

The runaway drug-cost train stems from the growth of the “middlemen” in the drug distribution process. Historically, a pharmacy could purchase drugs directly from the manufacturer with no middleman at all. Then came the addition of the wholesale company, in an effort to provide the convenience of a one-stop shop for pharmacies to purchase all medications (prescription and over-the-counter). This was followed by the addition of another middleman, the pharmacy benefits manager groups, which also took control of deciding which drugs would and would not be covered by various insurance plans. As more and more middlemen enter the distribution and decision-making system, it is easy to see how the inflation of drug prices grew out of control, as each entity wants a piece of the money pie.

I completely agree that health care professionals who treat people with diabetes must be well-versed in the past, current and future insulin products, since we often need to know how to do the wrong thing, the right way. We need to understand that the over-the-counter insulins, which do not require a prescription (Humulin R and Humulin N, Lilly; Novolin R and Novolin N, Novo Nordisk), work differently than the prescription (analogue) insulin products. Therefore, it is crucial for us to educate patients on managing their diabetes under less-than-optimal circumstances to reduce diabetes-related conditions and complications.

Considering the nearly 95-year history of insulin, this treatment remains underutilized and is often used inefficiently. Much like the black dress, insulin remains a basic need in the diabetes pharmacotherapy armamentarium. Health care providers must realize that for many patients insulin is not the problem, but affording insulin is. Maybe instead of going backward with the type of insulin patients use, it would be better to revert to a time when there was no middleman in the drug-distribution process, allowing affordable drug therapy.

Susan Cornell, PharmD, CDE, FAPhA, FAADE

Associate Director, Experiential Education

Associate Professor, Dept. of Pharmacy Practice

Midwestern University Chicago College of Pharmacy

Downers Grove, Ill.

Disclosures: Cornell reports no relevant financial disclosures.