Under Dosing Insulin to Cut Costs
The high cost of insulin is causing some people to use less than prescribed amounts to make the drug affordable. A recent study at Yale University reported that 25% of people with type 1 or 2 diabetes are reducing their insulin doses to make it last longer because of high costs. The study, published in JAMA Internal Medicine also states that over 33% of those people have not discussed the “cost-related underuse” with their doctors. It’s a significant public health concern: the American Diabetes Association says more than 30 million Americans have diabetes and approximately 7.4 million depend on insulin.
TV news, editorials and general publications have reported this phenomenon, which has resulted in severe medical complications, emergency room visits and even death.
The Yale study
Although small, the survey queried 200 people in the New Haven area who use the Yale Diabetes Center, about their insulin usage.1 Questions covered topics such as:
- Trying to stretch out one’s prescribed insulin
- Taking smaller doses of insulin than prescribed
- Stopping the use of insulin
- Not filling an insulin prescription
- Not starting insulin use
Insulin underuse generally results in poor glycemic control, that is difficulty keeping blood sugar levels in the normal range. Treatment and management of diabetes depends on managing blood sugar levels. Insulin was discovered in 1921, and its inventors won a Nobel Prize in 1923. The original patent holders, at the University of Toronto, sold the patent to the university for $1. They wanted to ensure that “when the details of the method of preparation are published anyone would be free to prepare the extract, but no one could secure a profitable monopoly."1
Insulin is a life-sustaining hormone for those whose pancreas produces insufficient or limited amounts of natural insulin. The majority of insulin produced today is by 3 large drug companies, not a monopoly, but a cause for concern around access.
Income and age
People in lower income brackets were more likely to engage in cost-related underuse, and they also had difficulty affording diabetes management equipment such as insulin pumps, blood sugar meters and continuous glucose monitors.1 They report rationing and using other friends or family members’ insulin. This problem doesn’t just affect the poor. People reporting incomes of up to $100,000 indicated that rising prices make it difficult to pay for insulin.4
Insulin rationing appears to be largely age-neutral: 32 percent of diabetes patients ages 18 and 44 reported underusing insulin, as did 24 percent of those 44 to 64 years old. 21 percent of those over 64 also underused insulin due to cost.4
Insulin has nearly tripled in cost since 2002, reports the American Diabetes Association. High prices, complicated pharmacy insurance rules, and expensive copays make it difficult for many diabetics to get the insulin they need to stay healthy. For those without insurance at all, costs can be prohibitive. Physicians should discuss insulin cost issues with all of their patients. If this becomes part of the general practice pattern, it will reduce stigma, and allow costs to be part of the prescribing consideration.
Advocacy and resources
The detrimental effects of improper insulin dosing result in elevated blood sugar, which can cause severe medical complications including ketoacidosis (a buildup of acid in the blood). That, in turn, causes cells to dehydrate, leading the body to stop functioning. It can lead to kidney failure, blindness, and amputation of limbs, heart attacks and death.6
Insulin cannot be safely rationed.4 According to the Yale study authors, for type 1 diabetics, insulin is a lifesaving drug; without it, people can die within days. Of those with type 2 diabetes, roughly 20% require insulin to prevent complications. Because it is so dangerous to run out of insulin, all diabetics should have an emergency supply on hand. Note that insurance rules and dispensing parameters can create obstacles for diabetics seeking to keep an extra supply for emergencies. Discuss with your doctor if issues arise.
The American Diabetes Association says more than 30 million Americans have diabetes and approximately 7.4 million depend on insulin. The American Diabetes Association has established a platform at MakeInsulinAffordable.org to broaden communications and ensure that insulin is affordable and accessible. It focuses on efforts to promote pricing transparency and increasing competition.2
Do you live with any sleep disorders (eg. insomnia, sleep apnea, RLS) in addition to your diabetes?