Affordable Insulin, Traffic in Sight

Many of my insulin-dependent diabetic pilot friends and relatives received an early Christmas gift on March 1, 2023. The price of insulin dropped like a Piper Warrior on the final approach after taking out power. I aim to find ways pilots can continue to fly without paying too much money for their chronic prescriptions. 

The pancreas of a diabetes mellitus type 1 (DM1) patient does not produce insulin. Insulin is needed to deliver the glucose in the blood to the body’s cells. The cells utilize glucose for energy. There is a feedback mechanism where insulin signals the liver to store glucose. Glucose goes into the cells, and plasma glucose levels decrease. The DM1 patient must inject insulin to maintain normal glucose levels. High glucose levels, called hyperglycemia, are a high-risk concern to the DM1 patient.

Diabetic patients, due to uncontrolled glucose, run the risk of nephropathy, neuropathy, and retinopathy. Nephropathy is kidney failure, which, if not stopped, may lead to the patient needing hemodialysis. Hemodialysis is necessary to rid the blood of toxins that accumulate due to little or no kidney function. Neuropathy is nerve damage outside of the brain and spinal cord. People with diabetes will not feel pain in their extremities. These individuals may also have foot and leg ulcers with no pain sensation. If the ulcers are not taken care of, they may get infected and cause tissue damage. The damage to the leg and foot may be so severe that an amputation may be necessary. Retinopathy is damage to the retina. Retinopathy can cause loss of sight over time and eventually may cause blindness. DM1 patients must visit their primary healthcare professional regularly, an ophthalmologist yearly, and they may need a neurologist if their neuropathy gets out of control.

The diabetic patient is also at a high risk for cardiovascular disease, which includes myocardial infarction (heart attack) and a chance of stroke. Neuropathy can cause damage to the circulation of the diabetic. They have brittle veins and peripheral vascular disease, all due to hyperglycemia. Insulin is the game changer.

In 1921, Dr. Frederick Banting and a medical student, Charles Best, in Toronto, Canada, removed dog pancreases to study the pathophysiology of diabetes. Later, the dogs showed symptoms of diabetes. They ground up the pancreas and manufactured an injectable dog insulin extract. They gave this injection several times daily, and the dogs regained their health. In other words, the dog’s hyperglycemia became controlled. In 1922, the pharmaceutical company Eli Lilly became the first to manufacture insulin. Drs. Banting and Best, in 1923, won the Nobel Prize in Medicine for their discovery of insulin.

The pharmaceutical manufacturing process used pork and cow pancreas as injectable insulin sources. The pharmaceutical company Novo Nordisk entered the insulin-producing market competition in 1950 and, in 1985, added the insulin pen as a unique way for patients to inject insulin. In 1982, synthetic human insulin was discovered and manufactured. Biotechnology began synthesizing better insulin products that were more compatible with injection into patients. The beef and pork insulin did cause more allergic reactions post-injection. In 1996, Eli Lilly genetically modified the amino acid sequence of their synthetic human insulin to increase the absorption, distribution, metabolism, and excretion. The pharmaceutical manufacturing and marketing process for these insulin innovations comes with a cost to the patients.

There are multiple reasons for insulin costs to have been allowed to increase dramatically. Insulin is a life-saving medication for these patients. They will pay whatever the market will bear to procure their insulin. Unfortunately, many people with diabetes cannot afford their insulin. The cost of producing insulin by the three big pharmaceutical companies has not risen. The pharmaceutical company will set a price for their insulin and send it to the wholesaler. The wholesaler may also increase the price of insulin and then sell it to retail pharmacies. The burden of cost is on the patient. Do I pay for food, cut my use or dose of insulin, or do I pay for my insulin and not eat?

It is challenging for new pharmaceutical companies to jump through the regulatory hoops of the FDA to produce cheaper or generic forms of insulin. Three pharmaceutical companies control the insulin market, Eli Lilly, Novo Nordisk, and Sanofi. Historically, prices have risen, and each company has followed the other’s lead. Prices of insulin are based on the cost per unit of insulin. For instance, short-acting insulin (insulin lispro) comes in a 10 ml vial with 100 units/ml. The recommendation for insulin vials is to discard them after 28 days of use.

There are three types of insulin, short-acting, intermediate-acting, and long-acting. The preferred method is to give short-acting insulin before meals in addition to one or two doses per day of long-acting insulin. This method of insulin injection is called “basal/bolus dosing.” Recently, new generic brands of short- and long-acting insulins have dramatically decreased patients’ insulin costs. The most commonly used short-acting insulin is called insulin lispro. It is administered before each meal to lower glucose levels and prevent hyperglycemia.

In 1999, a vial of lispro cost $21, and in 2019, $332, reflecting a 1,000% increase in cost. I am so happy to tell you that as of May 1, 2023, per Eli Lilly & Company, a vial of insulin lispro will cost $25. Long-acting insulin glargine is administered once daily and controls the blood glucose levels over 24 hours. It will cover all the daily stressors that manifest into a glucose spike in the blood. Insulin glargine costs were over $700 per vial up to July 2021. The generic brand of insulin glargine costs $129 per vial. The decrease in prices of the two insulins is an 87% decrease per month for the patient.

I am sharing Eli Lilly and Company’s plans to decrease prices significantly on all their other insulin products. Human insulin cost per vial will be cut by 70% as of the fourth quarter of 2023. Eli Lilly will launch a biosimilar insulin that is interchangeable with insulin glargine. The insulin glargine comes in an injectable pen and will cost $92 for a pack of five, a 78% decrease in price versus brand-name insulin glargine. The product will come to market on April 1, 2023. All Eli Lilly insulins will be capped at $35 if the patient has commercial insurance. For people with diabetes without insurance, there is an insulin affordability website. Once registered, all insulins will cost the patient $35.

Diabetic pilots and the general diabetic patient population have been working through the challenges of their disease complications and the costs of maintaining normal blood sugar levels. Just like I save money for my flight students, I also make it a point to save money for my diabetic friends to live the happiest and healthiest lives possible. “No bucks, no Buck Rogers” for diabetic patients is unacceptable. My mission is affordable insulin to fly like Buck Rogers. Be well and fly safely.

Larry M. Diamond, PharmD, CFII
Larry Diamond has a Doctor of Pharmacy Degree and has been a pharmacist for 37 years. Larry’s pharmacy practice has been as a Clinical Pharmacy Specialist in Cardiology, Orthopedic Surgery Specialist and most recently Clinical Pharmacy Coordinator. He is a CFII, a pilot for 33 years and has been an AOPA member since 1984.

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