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Wal-Mart has announced they will be selling a generic version of human insulin for a quarter of the brand-name price. It’s about time somebody undercut the drug manufacturers.

2021-07-04

Wal-Mart has announced that they will be selling a generic version of analog insulin, sourced from Novo-Nordisk, for $73 a vial, considerably less than the more than $300 a vial normally charged at regular pharmacies. This news appeared in the Los Angeles Times on June 30, 2021, and I read it on the iPhone news reader application. You can also find this information through a google search.

An article in WebMD notes that “advocates complain the price is still too high.” They are comparing the current price to the fact that the patent for the discovery of insulin was sold for a dollar almost a hundred years ago. The price of human insulin in 2001, shortly after it was introduced, was $30-$40 a vial– so it has gone up by ten times in the last twenty years. By comparison, in other countries, human and analog insulin is much cheaper.

Analog insulin is an advance on human insulin; the corresponding human insulins sell for $25 a vial at WalMart.

The motivation for WalMart to sell cheap insulin is complex. They may reason that, once you come to a WalMart pharmacy for one of your drugs, you are likely to transfer all your prescriptions. People with diabetes often taken a dozen different medications. In addition, nowadays both doctors and pharmacies encourage you to get all your prescriptions filled at one place (for several good reasons, too many to detail here.)

Thus, WalMart could be offering cheap insulin as a “loss leader” and accepting a smaller profit from it in anticipation of capturing more business overall. This retail business technique is well over a hundred years old. While the discount is a good thing for consumers, WalMart is likely not doing it out of deep human concern.

We can only speculate what effect WalMart’s move will have on brand name drug manufacturers. A lot depends on whether WalMart will add other drugs to this discounted sales platform. Unless they do, most drug manufacturers are unlikely to feel much pressure to reduce their prices– particularly when many patients are partially insulated by their insurance plans from price competition.

The price of insulin is certainly too high in the United States, leading impecunious diabetics to try to ration their supplies. This problem has been widely documented in the news media and doctors are all too aware of it. Not taking enough insulin is deadly in the long run– chronic high blood sugar causes major complications sooner or later.

People with severe type I diabetes can die in a day or two without insulin, but people with moderate disease can get by for a few months on inadequate doses. Emergency room visits for high blood sugar or its acute complications– diabetic ketoacidosis– are extremely common, especially among patients without insurance or with inadequate insurance.

Depending on your dosage, a vial of insulin will last from a couple of days to more than a month. Doses vary from perhaps 20 units a day to more than 100 units multiple times a day, depending on your needs and level of insulin resistance.

Human insulin is a great advance over the old type of insulin (which has been sourced from the pancreases of cows and pigs for nearly a hundred years.) Human insulin is better because many people develop antibodies to insulin from other animal species, which gradually reduces the hormone’s effectiveness, sometimes dramatically. The old form of insulin, porcine or bovine insulin, is still available for low prices, but it is a poor substitute for human insulin because antibody formation is extremely common.

So, be happy that (relatively) cheap human insulin is available. Be angry that brand-name drug companies are making a killing off of Americans, with insurance or without. Beware of WalMart– their low prices are the result of an employment model that forces employees to take food stamps and other government aid despite having full-time jobs, while their owners are multi-billionaires.

The rest of this post is background information for the average reader about diabetes and its treatment:

What is Diabetes Mellitus? What is Insulin? What is a pancreas? Please comment if you don’t want to know.

Insulin is, of course, a hormone, produced by specialized cells in the pancreas. This organ, an irregularly shaped solid that resembles a lumpy, curved sweet potato (if you are so inclined to look at it that way), produces insulin, glucagon (which has the opposite effect to insulin), digestive hormones, and other hormones which were unknown when I was in medical school 45 years ago.

The pancreas sits on the lower spine, behind the stomach and duodenum, and disgorges its secretions into the upper duodenum as well as into the blood. It is traversed by the bile duct, which delivers additional digestive secretions from the liver and gall bladder and disgorges into the common bile duct. This duct opens into the duodenum through a hole called the papilla of Vater, which has a muscular coat that opens and closes it.

By the way, the gall bladder serves as a storage sac for secretions from the liver. It contracts when you eat a heavy, fatty meal, and sends its contents down through the pancreas into the duodenum. The gall bladder is not an essential organ, and it can become a trap for stones which form when the liver’s secretions become too concentrated to remain in solution.

The pancreas, on the other hand, is an essential organ, without which you cannot digest your food. Even with insulin administration, people without pancreases rapidly become malnourished. “Liver pills” are not a good substitute for bile from the liver because the essential digestive hormones are destroyed by acid in the stomach and never reach the duodenum– which is where the real digestion starts.

Diabetes– the two major types

People develop diabetes through one of two general mechanisms. The first, and most immediately dangerous, is known as Type I or “insulin-dependent” diabetes. In this condition, often with onset in childhood, the pancreas’ ability to secrete insulin is destroyed by an auto-immune reaction following an infection (usually with a virus.) In Type I diabetes, the patient will die in days or weeks if they do not receive injections of insulin. Multiple types of insulin are often given, with short and long onsets and durations of action.

Most people with Type I diabetes receive insulin through a pump or by self-injecting with a syringe (pictured above; the apple is for decorative purposes and is often used to demonstrate injection techniques.) They must vary the dose depending on the blood sugar, their levels of activity, and what they have eaten or are about to eat.

Blood sugar is measured (since the early 70’s) with a device that accepts a small amount of blood obtained by a finger-prick. The new method of following blood sugar is with a disc glued to the skin that accesses blood continuously and sends a wireless signal to your smartphone every five minutes. This device is obviously far superior to pricking your finger (which does hurt) up to four times a day. The device is replaced once a week.

The second major type of diabetes, Type II (previously called “adult onset”) is far more common, representing 90% or more of all cases. The CDC (Centers for Disease Control) says that over 34 million Americans have diabetes– potentially a huge market for WalMart.

As the old name suggests, it usually presents in mature individuals. Unlike insulin-dependent diabetes, however, the Type II diabetic does not respond well to exogenously administered insulin. It appears that the body in these patients has developed a resistance to insulin.

Usually, especially at onset, Type II diabetics are obese and inactive. Their metabolisms are disordered in other ways as well. Type II diabetics often have high levels of cholesterol and lipids (fats) in their blood. They also have a tendency to high blood pressure and “hardening” of the arteries. Patients with Type II diabetes usually have normal or even high levels of insulin, but their muscles don’t respond well to it.

Type II diabetes is ideally managed by significant (>20%) weight loss through dieting and increased activity. When active, the muscles are able to draw glucose (sugar) from the bloodstream without the help of insulin. At rest, muscles require insulin to use glucose.

In the absence of weight loss and activity, a number of drugs help to reduce blood sugar, although they are not very effective. The problem with increased blood sugar in the presence of adequate insulin is that the blood vessels develop deposits of cholesterol within their walls that eventually narrow and stiffen (“harden”) them. In addition, arteries that normally expand when increased blood flow is needed are unable to do so, resulting in impaired circulation and exercise intolerance.

Treatment of the most common form of diabetes– it’s not insulin.

When you give insulin to a Type II diabetic, it does reduce blood sugar, but it requires much larger doses, and patients often gain weight as a result– rather than losing weight as you would wish. Giving insulin to a Type II diabetic person is, or should be, a last resort, when all other methods have failed and the blood sugar is still way too high.

When the blood sugar is high enough, the kidneys are unable to retain sugar in the blood and instead release much of it into the urine. In severe Type II diabetes, this loss of sugar into the urine may result in unintended weight loss. Frequent urination may be the only symptom of Type II diabetes, as the loss of sugar forces the kidneys to release more water to go with it.

One new type of pill for treatment of Type II diabetes lowers the kidney’s threshold for releasing sugar into the urine. Impairment of glucose retention results in high levels of sugar in the urine, even with relatively mild high blood sugar. Only if the blood sugar is perfectly normal is the kidney able to retain all of the blood sugar.

This pill is surprisingly popular although its potential side-effects can be devastating. The most common side effect, unintended weight loss, may be welcomed, but it indicates a significant imbalance in nutritional status. Chronic sugar in the urine often causes yeast infections of the vagina, penis, and genital skin.

Bacterial infection of the perineum (skin of the area around the genitals) is said to be rare, but is vanishingly unknown except during treatment with this type of drug. The perineal infection, while rare, is deadly, and is known as “Fournier’s gangrene.” (any disease with “gangrene” in the name has got to be bad.)

The kidneys also develop thickening of their filtering membranes with high blood sugar, which impairs filtering ability. It appears that deposits of glucose-altered proteins cause this thickening. Blood sugar gradually attaches itself to body proteins, and when sugar levels are high, this occurs more rapidly.

Proteins normally have a few sugars attached to them in precise places. However, with high blood sugar, the attachments are random and chaotic. With extra sugar attached to it, a protein cannot function as well and eventually must be replaced through repair mechanisms that the body normally uses to replace damaged molecules and tissues.

There are other metabolic consequences of high blood sugar, too numerous to mention in a popular blog post like this one. I will limit myself to saying that high blood sugar damages many organs faster than usual, and the body’s normal repair processes cannot keep up with the damages– which results in accelerated aging.

The eyes are another vital organ which is damaged, worse with time and higher sugar levels. One’s vision is altered by high levels of blood sugar, so that spectacle’s corrective factors change. This is noticeable to diabetics, who find their eyeglasses don’t work the same when their sugar is high.

In Type II diabetics, the most dangerous thing is that there are no symptoms to tell you that your sugar is high until it gets so high that you become drowsy. In Type I diabetes, the most dangerous thing is that your sugar could get too low if you take too much insulin, causing you to become hungry, shaky, and then pass out.

photo courtesy of “Meine Reise geht hier leider zu Ende. Märchen beginnen mit” and pixabay

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