Price Check! Are analogue insulins worth their hefty price?

Posted on September 14, 2017 by Jeffrey Keller MD

The analogue insulins were introduced into the United States in the late 1990s and early 2000s. They are called “analogue” insulins because their chemical structure is subtlety different than native human insulin, which gives them different, advantageous properties. Analogue insulins include the short acting insulins Humalog (insulin lispro) and Novolog (insulin aspart) and the long acting insulins Lantus (insulin glargine) and Levemir (insulin detemir).

Since their introduction, the insulin analogues have pretty much taken over the insulin market in the US. That is why I only mentioned human insulins in passing in the JailMedicine post “Insulin Dosing Made Simple.” It is unusual to see patients show up at the jail on any other insulin regimen than analogue insulins, usually Humalog and Lantus. And I have to admit; the analogue insulins are easier to use than human insulins. I like them.

But here is the problem: the analogue insulins have become insanely expensive! When they were first introduced, the price of Humalog and Lantus was around $20.00 per vial of 100 units. That compared to the price of human insulins like Humulin R and NPH of around $5.00 per vial. So the analogues were expensive, but doable. However, since around 2006, analogue insulins have dramatically increased in price—whereas the price for most other diabetic therapies has actually decreased over time. (You can read more about this price increase here)(In the graph above, notice the huge increase in insulin prices since 2006, while every other diabetic therapy price has actually fallen) Continue reading →

Diabetic Malingering, Part Two. Scams and Solutions!

Posted on October 10, 2012 by Jeffrey Keller MD

My last post introduced the subject of diabetic malingering. In this post, I present several patients I have encountered in my correctional medicine career and the various scams they have used to manipulate their blood sugars. Continue reading →

Thoughts on an Untreated Type 2 Diabetic

Posted on July 9, 2012 by Jeffrey Keller MD

Staged medical clinic at the Bonneville County Jail, Idaho Falls, Idaho. (The “patient” is actually one of the medical staff)

We recently had a 46-year-old male patient booked into our jail who reported a history of diabetes but who had not seen a physician or taken any medications for “years.” He said he used to take a medication for diabetes “a long time ago” but he could not remember the name. He also could not remember the name of the doctor he had once seen. He reported basically no other medical history. Continue reading →

Diabetic Case Studies–The Insulin Rules in Action!

Posted on March 9, 2012 by Jeffrey Keller MD

People come to jail taking the weirdest insulin regimens. Often times, I don’t know whether these insulin schems are the result of a practitioner who does not understand insulin dosing well, or whether the patient “tinker” with their insulin dosing, themselves. Here is a case from one my jails (I have changed some of the data and patient characteristics to protect patient privacy).

Banting and Best, Discoverers of insulin

A type 1 diabetic comes to jail taking Lantus 15 units in the morning and 40 units in the evening. He says he takes his Humalog on a sliding scale, but when asked to define exactly what the parameters of his sliding scale are, it becomes apparent that he basically decides his Humalog dose based on gut-feeling. He may take nothing; he may take up to 15 units. He certainly has no concept of counting carbs. He thinks his average Humalog dose is 6 units. His admission HbA1C is 12.8, or an average blood sugar of over 300. In other words, he is not doing a very good job of controlling his blood sugars on the outside.

Anyway, let’s apply the rules of insulin dosing to this patient: Continue reading →

Insulin Dosing Made Simple

Posted on February 26, 2012 by Jeffrey Keller MD

I have found, in my years of practicing correctional medicine, that few practitioners who come to corrections are comfortable with insulin dosing. In my experience, this is especially true for physician assistants and nurse practitioners, but many physicians have problems, too. Insulin dosing can be complicated and tricky at times, but for most patients, 10 simple rules will get you to where you need to be.

We first need to cover some groundwork and some terms. Insulin terminology can be confusing. First, it is very important to remember that this discussion applies to type 1 diabetics only. Type 2 diabetics sometimes use insulin, but that’s a “whole ‘nother ballgame.”

Continue reading →

Beware the Compliance Trap. It will catch the unwary . . .

Posted on February 15, 2012 by Jeffrey Keller MD

"I take 6 Dilantin caps a day."

I had yet another patient recently who demonstrated what I call the “Compliance Trap” of corrections. The Compliance Trap is simply this—on the outside of jail, in the real world, most people do not take their medications perfectly. They miss doses. They forget sometimes. Many studies have demonstrated this. But when these same people come to jail, they get their medications passed to them every dose—they do not miss doses. They are compliant with their medication dosing in a way they weren’t on the outside. And this can sometimes get them into trouble.

Take for example, the patient who came to my jail with a prescription for Dilantin 600mg a day. This is a huge dose! But he had a legitimate prescription for it and so it was continued at the same dose in jail. However, two weeks late, he began to have nausea, vomiting and dizziness. We checked his dilantin level and it was 32–he was toxic! Dilantin 600mg a day was, indeed, too big of a dose for this patient. In fact, after we had adjusted his dose and checked levels a couple of times, we found that the proper dose of Dilantin in this patient was a more modest 400mg a day.

So how did this happen? I did not interrogate this patient’s outside doctor, but I think I know what happened. He kept returning to the outside clinic with subtherapeutic blood levels of Dilantin and the doctor kept increasing to dose. However, the reason the patient had subtherapeutic blood levels was NOT that he was a super-rapid metabolizer of Dilantin; rather he just hadn’t been taking it every day. He had been missing doses.

But when he came to jail, the jail nurses made sure he did not miss any doses and quickly, he was toxic.

So that is the Compliance Trap. Outside of jail, many patients do not take their medications regularly or at all. When they come to jail, they don’t miss doses. Outside–not compliant. In jail–compliant. And sometimes this can make them sick.

The Compliance Trap–Examples