It’s unclear how many people are using OTC insulin because the meds aren’t tracked like prescription insulin, but an article published in February 2019 in the journal JAMA Internal Medicine suggested that people often buy ReliOn insulin and that Walmart sells up to 18,800 vials per day at its pharmacies in 49 states. “We were surprised that it was sold so frequently,” says study author Jennifer Goldstein, MD, assistant program director of internal medicine at Christiana Care Health System in Newark, Delaware. Walmart does not make its sales data public, so the researchers gathered this data by calling Walmart and other chain pharmacies to ask about daily sales. RELATED: Why Is Insulin So Expensive? (And What to Do if You Can’t Afford It) Despite the seemingly increasing use of OTC insulin, healthcare providers want people with diabetes to know that the injections aren’t one to one with prescription insulin. Thus, people interested in saving money by using this insulin option need to take certain steps before doing so.
Why People Sometimes Turn to OTC Insulin for Blood Sugar Control
Dr. Goldstein decided to research OTC insulin because she prescribes ReliOn brand insulin as the least expensive option for people without health insurance in her clinical practice. Insulin prices have risen dramatically in recent years, nearly tripling from 2002 to 2013 according to an article published in April 2016 in the Journal of the American Medical Association (JAMA). In March 2019, Eli Lilly announced it would sell a cheaper generic version of its Humalog 100 insulin for about $137 a vial, effectively cutting the price of the original in half. Other fixes include Cigna and Express Scripts offering a $25 cap on out-of-pocket insulin costs for its consumers in participating plans. Jennifer Trujillo, PharmD, CDE, associate professor at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences in Aurora, says she also has patients ask about cheaper options. “I think we have to accept the fact that some patients don’t have an option but to use the least expensive option available,” says Dr. Trujillo. “For some patients, this is the only alternative they have.” Besides people without health insurance, Trujillo says that people with high copays or high-deductible plans might be considering OTC insulin. People on Medicare in the “donut hole,” a coverage gap where patients are often pay more for drugs, might be paying more out-of-pocket for insulin and looking for relief. “The cost of insulin has increased so dramatically that many more patients are facing cost issues than ever before,” says Trujillo. For example, people with type 1 diabetes spent nearly double the yearly amount in 2012 versus 2016, according to the Health Care Cost Institute. How Exactly Does OTC Insulin Work and How Does It Differ From Newer Insulins? OTC insulin is also called synthetic human insulin. It’s different from newer insulins that are called insulin analogs. The three main types of over-the-counter insulin are regular insulin (short-acting), NPH (intermediate-acting), and a premixed combination of NPH and regular called 70-30, says Trujillo. Walmart sells all three types under the ReliOn brand umbrella for roughly $25 a vial. Chain pharmacies can also sell regular, NPH, and 70-30 insulin to patients over the counter, says Goldstein. She found that OTC insulin is more frequently sold at Walmart than other chain pharmacies, likely due to the considerably lower price point.
Differences Between Over-the-Counter Insulin and Newer Insulin
OTC insulins are inherently different than newer insulin analogs, and if you’re living with type 1 or type 2 diabetes, it’s key to know the difference. “The way in which they get into the system, how long they last, and when they peak are all different than the newer insulin products we have,” says Trujillo. For example, regular insulin takes longer to work in your body (30 to 60 minutes), so you may need to plan your meals up to an hour in advance, says Goldstein. This differs from newer insulins that you take right before you eat, she adds. Also, NPH insulin peaks at six hours, so you need to make sure you aren’t surprised by a low blood glucose episode at that time. This differs from newer insulins that don’t have a peak at all, says Goldstein. “These are not one-to-one substitutions,” says Goldstein. “They behave very differently. But if you know what to expect, then you can anticipate it and do fine.” She adds that for these reasons, education about these insulins is essential. “It’s really, really important to work hand-in-hand with a healthcare provider to help modify and adjust dosing and to understand how these insulins behave differently than other insulins they might have taken before,” says Goldstein. The way you give yourself over-the-counter insulin differs too. It’s sold in a vial that you use with a syringe. Many newer insulins come in pen devices. So you’ll want to make sure that you ask about how to use a syringe and vial, and how to store insulin vials. RELATED: 8 Essentials to Help You Manage Insulin Therapy
The Pros and Cons of Using OTC Insulin to Manage Diabetes
“Cost and access are the two big benefits of over-the-counter insulin,” says Trujillo. Safety in emergency situations is another pro. For example, OTC is a good option if you’re out of insulin in an emergency or while traveling, says Goldstein. In this case, contact your healthcare provider immediately about how to use these insulins. “They are safe and effective, when used properly with the correct supervision,” says Goldstein. An article published in July 2017 in JAMA pointed out that human insulin is an effective, less-expensive option for people with type 2 diabetes. On the other hand, people with diabetes, especially type 1 diabetes, may find older insulins more difficult and dangerous. Trujillo says that it can be more challenging to use older insulin to mimic what a normal, functioning pancreas does. For example, people with type 1 diabetes using older insulin have higher rates of low blood glucose, according to an article published in October 2014 in The BMJ. Low blood glucose is a serious issue, especially with repeated incidents over a lifetime, which can lead to seizures, cognitive impairment, loss of work productivity, and even a higher risk of early death, according to a review published in January 2019 in the journal Diabetology & Metabolic Syndrome. Elizabeth Pfiester, founder and executive director of T1International, an advocacy group for people with type 1 diabetes, says that many patients have told her organization that they are terrified of using older insulins, which have a different risk profile for low glucose compared with newer insulins. She says existing research about older versus newer insulin doesn’t reflect measures like quality of life. RELATED: The When, Why, and How of Injectable Insulin
Why It’s So Important to Consult Your Diabetes Care Team Before Taking OTC Insulin
“If somebody is struggling with being able to afford their insulin, they definitely need to have a conversation with their provider as soon as possible because we would never want somebody to ration or do without their insulin,” says Kellie Antinori-Lent, RN, CDE, a diabetes clinical nurse specialist at UPMC Shadyside Hospital in Pittsburgh. and president-elect of the American Association of Diabetes Educators. Schedule a phone call or an appointment to discuss your concerns. She says drug makers also provide assistance programs for insulin. Not taking your prescribed dose of insulin can make you extremely ill, and people have gone to the hospital and even died, says Antinori-Lent. Antinori-Lent, who works in a hospital setting rather than an outpatient clinic, says that sometimes patients may take newer insulin in the hospital, but then find out at discharge that they can’t afford it and they may need to switch to older insulin. Ideally, these discussions about cost can happen well before discharge so patients get the opportunity to learn how these insulins work and how to use them. Trujillo says: “The most important thing is to be honest and upfront about your situation. I think we have a lot of patients who are rationing their insulin or not taking it as prescribed because of cost issues.” One in four people with diabetes report having rationed or not used insulin because of cost, according to an article published in January 2019 in JAMA Internal Medicine. You can work with your provider to use these older insulins in a safe and effective way, says Trujillo. “But it’s a different approach for sure. And the patient and provider have to be on the same page,” she says.
