BootCamp for Betics

Note: BootCamp for Betics is not a medical center. Anything you read on this site should not be considered medical advice, and is for educational purposes only. Always consult with a physician or a diabetes nurse educator before starting or changing insulin doses.

Did you know that all type 1 diabetics and some type 2 diabetics need injectable insulin in order to live?

Put another way, if a diabetic needs insulin in order to live, and the diabetic does not get insulin, the diabetic will die. 

Diabetic death from Diabetic Ketoacidosis is a grisly process, during which acid starts running through your bloodstream, searing your vessels and organs while your body shrivels up in dehydration as it tries to push the acid out of your body through your urine and lungs, and, left untreated, the condition shuts down your organs one by one until you are dead. If you're lucky, your brain will be the first thing to swell itself into a coma and you'll be unconscious for the remainder of the organ failures. 

In some cases, this grisly diabetic death can take a few days or weeks to complete its process. Or, if you're one of the luckier less-resistant insulin-dependent type 2 diabetics, you may actually get away with staying alive for quite a few years and suffer only some heart disease, stroke, kidney damage/failure, neuropathy, limb amputations and blindness.

(my intent in describing how lack of insulin leads to death is not to cause fear in people with diabetes or their loved ones; rather, my intent is to make clear the reality that injectable insulin is absolutely vital to diabetics who depend on injectable insulin to live)

While I'd love to go off on a political rant about how insulin should be a basic human right for all insulin-dependent diabetics (and why the hell isn't it?), that's not the purpose of this article.

This article is about how to stay alive when you are insulin-dependent and you can't afford your Humalog, Novolog, Apidra, Lantus or Levemir.

There are actually a few reasons why insulin dependent diabetics can't get access to insulin:

1. They don't have a healthcare plan
2. Their healthcare plan offers very poor insulin/diabetes supply coverage
3. They can't afford a co-pay
4. They can't afford to pay out-of-pocket for insulin
5. They are in between insurances and need to stay alive until the new insurance starts

You might be wondering what the cash price is for insulin these days. Well, if you want to check for yourself, feel free to visit http://www.goodrx.com and run a search.

Or you can just read on...

The most common (and most effective) types of insulin on the market are Humalog, Novolog, Apidra, Lantus, and Levemir. Most insulin-dependent diabetics need at least 2-3 bottles of insulin per month in order to survive. Some insulin-dependent diabetics need even more. Insulin comes in various forms, such as vials, cartridges and pens, but the per-vial price is by FAR the cheapest, so that's what we're using for our price list below. Here's the cash price per bottle of insulin by type:

Humalog: $254
Novolog: $255
Apidra: $241
Lantus: $283
Levemir: $277

Sometimes, if you pay cash in a pharmacy, you can get a coupon for a 2%-7% discount off the cash price. Sometimes.

So, if the average price of a bottle of insulin is $262 and an insulin-dependent diabetic needs at least 2-3 bottles of insulin per month (to be clear, some people need MORE than this!), that's, at a minimum, $524 - $786 per month for insulin just to keep an insulin-dependent diabetic alive.

Then there's all these other pesky supplies insulin-dependent diabetics need, such as needles (to inject the insulin) - $43.95 per month, and that figure assumes you re-use your needles multiple times each (we're actually against reusing needles, because this causes lipohypertrophy, but the reality is, there's only so much one can afford when diabetic and we have to make sacrifices, and lipohypertrophy is definitely better than dying). And there's also glucose test strips (~$143.96 per month for the cheapest brand-name strips) and if you're really really lucky and have an insulin pump and/or a continuous glucose monitor, there's a few extra thousand dollars per month on top of the insulin. Oh, and there are oral meds and non-insulin injectables, too. I don't have time to list the prices of those right now, but I hope you believe that they are also quite expensive.

Insulin-dependent diabetics who have decent health insurance can get away with paying only a fraction of these prices because their health plan covers a good portion of the cost.

But what if you don't have insurance or a health plan? Or, what if your insurance coverage for diabetes is so crappy, you simply can't afford even the co-pays or co-insurance?

Well, there are various websites that offer information about getting insulin and test strips at a reduced price (or even free, for those who qualify). If you haven't tried to get help from these organizations, you should really do that. There are numerous articles available that can help you find such programs. 

This is no such article. THIS article is your last resort. So if you haven't tried to find a program that can help you get your insulin at a reduced price (or free), go do that first. When that fails, come back here.

If you're insulin-dependent and you've exhausted all other opportunities only to discover that you're just not going to get your hands on a bottle of Humalog, Novolog, Apidra, Lantus or Levemir anytime in the foreseeable future, then you have another option for your life-saving insulin. It's not free. But it's gobs cheaper than paying out-of-pocket for the good stuff, and it may cause some of you to stay alive just a little bit longer. And that option is to buy the old-school Reli-on brand insulins at Wal-Mart.

A long time ago (pre-1995), Humalog, Novolog, Apidra, Lantus and Levemir didn't exist. In order to stay alive, insulin-dependent diabetics had to make do using other types of insulin: Regular insulin, NPH insulin, and a few others, too. 

To be clear, an insulin-dependent diabetic's BEST chance of staying healthy is to take one or two of the five majorly expensive insulins listed above. But, drug companies are STILL making that old-school pre-1995 insulin! An insulin-dependent diabetic can still survive, albeit with increased level of difficulty, using a few of the old-school, pre-1995 insulins. Lilly and Novo-Nordisk still make these old-school insulins, and insulin-dependent diabetics can pay cash for these old-school insulins in most states withOUT a prescription. 

These insulins are called Regular insulin and NPH insulin (there's also a less-popular combo called 70/30).

The brand-name versions of these insulins from Lilly and Novo-Nordisk cost about $130 per bottle.

But guess what. Wal-Mart has its own Reli-on brand version of the same old-school insulins, and Wal-Mart's Reli-on insulin is the EXACT SAME as the old-school insulins still made by Novo-Nordisk. Do you know how I know this? I know this because Novo-Nordisk actually makes the Reli-on insulins that are sold at Wal-Mart.

These old-school insulins have a cash price of roughly $26.00 per vial at Wal-Mart stores and these insulins do not, in most states, require a doctor's prescription. If I can't afford one of the five really awesome insulins that most diabetics are taking, it's possible that I can't afford to see a doctor, either. So it is nice news that most states don't require a prescription for Regular and NPH.

So, if I can't afford my Humalog, Novolog, Apidra, Lantus or Levemir, I am still going to have to suck it up and find SOME way to get my hands on some of the Wal-Mart branded insulin. I wouldn't necessarily say that $26 per vial is cheap, but at roughly 10% of the price of the other insulins, purchasing it may become more manageable for some people.

Now, to those who might read this article and think, "Wow, treating the diabetes epidemic would be so much cheaper if people would stop using the expensive insulin and use the cheap insulin instead," well, that is completely wrong and you should stop thinking those thoughts immediately. This old-school cheap insulin will certainly prevent immediate death, but it is unlikely to result in optimal long-term intensive blood sugar management outcomes that the newer types of insulin support. So, it is still in the best interest of all insulin-dependent diabetics (and it's in the best interest of insurance companies and the community at large) to use the newer types of insulin. But. When you're stuck, you're stuck. And sometimes, you're stuck with old-school insulin.

So, if I were completely stuck (and of course, I'm talking only about what I would do in this situation, because I'm not a doctor and can't give YOU medical advice, so please know that everything listed below is just something that I would do as a diabetic individual), I would figure out which type(s) of insulin I needed from Wal-Mart by reading the comparison charts below, and then I would match my current insulin needs to one or more of the specific circumstances listed below, and then follow the instructions, making sure I'm testing my blood sugar a LOT for the first few days/weeks I'm on the new insulin to make sure I stay safe.

​Insulin Comparison Charts:

Humalog/Novolog/Apidra                 vs                  Reli-on Regular
Starts working in 10-20 minutes                             Starts working in 30-45 minutes
Peaks at 1.5-2.5 hours                                              Peaks at 2-3.5 hours
Stops working at 4-6 hours                                      Stops working at 5-8 hours
Can be mixed in same syringe with NPH               Can be mixed in same syringe with NPH

Lantus/Levemir                                   vs                  Reli-on NPH
Starts working in 1-2 hours                                       Starts working at 1-3 hours
Peaks slightly at 8-10 hours                                     Peaks significantly at 4-9 hours
Stops working at 18-26 hours                                   Stops working at 14-20 hours
DO NOT MIX in same syringe with anything          Can mix with Humalog, Novolog, Apidra, Regular

Novolog 70/30                                    vs                  Reli-on Novolin 70/30 (gah! what similar names!)
~ 70% NPH and 30% Novolog mix                          ~ 70% NPH and 30% Regular mix

WHAT TO BUY AT WAL-MART

If I was taking Humalog, Novolog or Apidra, I should buy a bottle of Reli-on Regular ($26) as its replacement. It is NOT the same as what I was taking, but I can use it (carefully) as a substitute.

If I was taking Lantus or Levemir, I should buy a bottle of Reli-on NPH ($26)  as its replacement. 
It is NOT the same as what I was taking, but I can use it (carefully) as a substitute.

If I was taking Novolog 70/30 (or even Humalog 75/25), I should buy a bottle of Reli-on Novolin 70/30 ($26) as its replacement. It is NOT the same as what I was taking, but I can use it (carefully) as a substitute.

I would also get a Wal-Mart Reli-on Prime meter ($16.24) and 200 strips ($39.96). 

And I would buy a box of syringes ($43.95). Probably 50 unit syringes with a regular (not SHORT) needle. Only because short needles don't always work as well.

Two bottles of insulin plus the other stuff would set me back about $133 dollars total. If I didn't have the money, I'd beg someone for it or borrow it. Or maybe I'd sell my iphone or my clothes or something.

Then, I'd read on to understand what the heck to do with all this stuff depending on my circumstance(s):

Circumstance #1: Switching from Long Acting (Lantus or Levemir) to Wal-Mart Reli-on NPH

First, I'd get myself some NPH. Then, I'd try to remember what my TOTAL DAILY LEVEMIR/LANTUS DOSE is. Let's say I was taking 24 units of Levemir/Lantus per day. I could have been taking 12 units in the morning and 12 units in the evening, or I could have taken all 24 units once a day. That part doesn't matter. All I care about right now is the total daily dose of Lantus/Levemir.

The Lantus/Levemir gets replaced with NPH but it has to be split into two doses, 12 hours apart. To figure out my initial total daily NPH dose as a replacement for Levemir/Lantus, here's what I'd do.

Multiply my total daily Lantus/Levemir dose by .85 (yes, there is a decimal point before the 85) which will calculate a SAFE total daily dose of NPH for me. When you multiply something by .85, it's the same as subtracting 15%. So what I'm really doing here is reducing my total daily dose of Levemir/Lantus by 15% to come up with a SAFE total daily dose of NPH.

In my case, I'd multiply 24 units x .85 = 20.4 units

My new INITIAL and safe dose of NPH is 20.4 units per day.

Then, I'd split that total dose in half, taking half in the morning and half in the evening (every 12 hours).

So in my case, I'd take 10.2 units of NPH around 8 in the morning, because that is when I wake up (I'm a late sleeper) and then I'd take 10.2 units of NPH around 8 in the evening (12 hours later). But, since it's impossible to measure 10.2 units in a syringe, I'd reduce the dose to 10 units.

If I was nervous about going low in the middle of the night due to this new dosing, I could, instead of splitting the dose in half, take 2/3 of the total daily dose in the morning (13.5 units in my case) and 1/3 of the total daily dose in the evening (6.75 units, rounded up to 7, in my case).

My blood sugars might run HIGH initially because of the reduction in total daily basal dose, but running a bit HIGH temporarily is safer than having a dangerous LOW. The only way to know how safe I am with my new insulin is to check my blood sugar frequently as I'm getting accustomed to the new insulin. After 2-3 days, I'd start to gradually increase and/or decrease my NPH doses depending on how my blood sugars were behaving throughout the day. Of course, I would dutifully record all blood sugars using a pen and paper so that I could do a better job analyzing how well the insulin is working. It may become the case that I need to take MORE NPH in the evening than in the morning, or vice versa. Only careful experimentation (via increase/decrease of 5-10% for each dose adjustment every 2-3 days) and frequent blood sugar testing would tell me for sure.

***I MIGHT discover that I don't need any short acting insulin at lunchtime, because the NPH peaks so significantly at that time that I MUST eat in order to prevent a low blood sugar.

***I MIGHT discover that I DO need short acting insulin at lunchtime, but that around 3PM, I need an extra snack because the NPH and the short acting insulin are peaking together.

***I MIGHT discover that I need a morning snack to prevent a mid-morning low blood sugar, because maybe the NPH peaks a little sooner in my body than it does in others'.

***I MIGHT discover that my blood sugar goes a bit low during the night when the NPH is peaking, so I should probably have a bedtime snack that contains carbs and either some protein or fat to help prevent a nighttime low.

***IN FACT, I might just start eating a morning, afternoon and evening snack every day just to be on the safe side.

Circumstance #2: Switching from Rapid Acting (Humalog, Novolog or Apidra) to Reli-on Regular
As I learned by reading the insulin comparison charts above, Regular insulin takes longer to start working in my body than the newer rapid acting insulins. Also, Regular insulin hangs out in my body longer than the newer rapid acting insulins. But fortunately, the amount of Regular I'll need is pretty similar to the amount of newer, rapid acting insulin I used to take.

I use rapid acting insulin (Humalog, Novolog or Apidra) for two reasons. One reason is to take a MEAL BOLUS. In other words, if I eat carbs, then I need to take some amount of insulin for those carbs. I might have a carb ratio, or I might be using a sliding scale. Whatever the method, I (as do most diabetics on mealtime insulin) have some way to figure out how much insulin to take for each meal. Another reason I take rapid acting insulin is to take a CORRECTION BOLUS (extra insulin that I take when my blood sugar is too high).

If I switch to Regular from Humalog, Novolog or Apidra, I can use Regular for MEAL BOLUSES and CORRECTION BOLUSES, but I just need to be extra careful about it, because the way Regular behaves is different from the way Humalog, Novolog and Apidra behave.

The good news about Regular insulin is that I can take the same amount of Regular as I would take of Humalog, Novolog or Apidra for any given meal or correction bolus (except bedtime corrections). BUT. I need to plan this really well. 

For a meal bolus, I need to know exactly how much I'm going to eat at least 30 minutes prior to the time I actually eat, and I need to bolus with the Regular insulin 15-30 minutes before I even start eating. Then, I need to make sure I eat exactly what I bolused for.

If I'm going to use Regular insulin to take a correction bolus (when my blood sugar is too high), I need to be extra careful. First, I need to know exactly how long ago my last shot of Regular was. Because if I take a correction bolus for a high blood sugar but there's still a bunch of Regular insulin left in my body (remember, Regular insulin can hang out in your body for up to 7 or 8 hours), then I'm doing something called "stacking insulin," the results of which (read: my blood sugar) could come crashing down hours after I took the shot(s). So before each correction, I would need to ask myself, "Do I really need to correct this blood sugar? Or is there still active insulin in my body right now, just taking its sweet-ass time to work?" I would have to have a lot of patience.

***I MIGHT discover that I cannot safely bolus for high blood sugars without going low many hours later, and that sometimes, I may have to patiently "wait out" my high blood sugar events.

***I MIGHT discover that instead of taking an extra dose of Regular insulin to treat a high blood sugar, I can just wait for my blood sugar to come down as a result of my NPH peaking.

***I MIGHT discover that it's a BAD idea to take a full high blood sugar correction of Regular at bedtime, because if I'm also taking NPH, the combination of those two insulins could result in a nighttime low blood sugar event. Gah!

***I SHOULD really just make sure I have a snack at bedtime if I'm going to be taking new insulin(s), at least until I can figure out how to manage the doses to eliminate the bedtime snack need.

Circumstance #3: Switching from an insulin pump to Reli-on Regular and Reli-on NPH
First, I would figure out what my NPH dose needs to be. In order to do this, I need to look at my pump to figure out my TOTAL DAILY DOSE of BASAL insulin. In my case, the total daily dose of basal insulin is 30 units.

Then, I need to multiple the total daily dose of basal insulin by .85 (there is a decimal point before the 85), which basically "reduces" my "total daily dose of basal insulin" number by fifteen percent.

30 units of total daily basal insulin in the pump x .85 = 25.5 units of NPH per day (initially).

This number (in my example, it's 25.5) is the total daily dose of NPH I'll need, but I'll need to split this dose, taking half of it in the morning, and the other half in the evening, or 12 hours later. So in my case, 15% off my total daily basal dose is 25.5 units. So if I divide 25.5 by 2, that tells me that I need 12.75 units of NPH in the morning, and 12.75 units of NPH in the evening (or 12 hours later). I might round up to 13. Or, if I was nervous about going low at night, I'd move some of that nighttime dose to the morning (maybe take 16 in the morning and 10 at night? I dunno. I'd have to mess around with it in order to figure it out).

At this point, I would definitely pay close attention to Circumstance #1 above to learn more about the features of taking NPH insulin!

Next, I would definitely closely read Circumstance #2 above to figure out how much Regular insulin I need in order to cover meals and high blood sugar corrections (hint: I would use the same carb ratios and ISFs that are in my pump, possibly slightly decreasing any correction boluses at nighttime just to be safe).

Circumstance #4: Staying on the insulin pump (until it stops working) using Reli-on Regular
Yes, I can put regular insulin in my pump. It's not great, but it'll get the job done (kind of). I'll still experience some blood sugar peaks, and it'll take much longer to correct a high blood sugar, but Regular is fine for use with a pump. In fact, pumps were invented before Humalog was invented, so Regular insulin was used in pumps for quite some time (back in the day). 

In order to use Regular insulin in my pump, I'll need to set the active insulin time in the pump to 6 or 7 or 8 hours, depending on how long I think the Regular insulin will stay in my body. 

Then, I'll need to make sure I bolus for meals 15-30 minutes before I eat them.

Finally, I'll need to try REALLY hard to not rage-bolus when I have a high blood sugar. It's just going to take longer for high blood sugars to come down now that I'm no longer taking that awesome (and expensive) rapid-acting insulin.

Circumstance #5: Switching from Novolog 70/30 to Reli-on Novolin 70/30
This is a unit-for-unit replacement. It's easy. The only thing to remember is that instead of taking my Novolog 70/30 WITH a meal, I now have to take my Novolin 70/30 15 - 30 minutes PRIOR to a meal. Also, I would eat a bedtime snack for the first few nights. At least until I can decide that I'm not in danger of overnight lows while I'm on this insulin. I may discover, after a few days, that it's necessary to slightly increase or decrease my doses depending on how my blood sugar reacts.

Circumstance #6: Starting with Reli-on NPH when I have never been on insulin before
If I've never taken insulin before, it's probably not a good idea to start taking it without checking with a doctor. But as long as I'm over 18 and weight over 100 pounds (which I am and I do), I can probably start taking NPH using a VERY conservative dose, increasing by a small amount every few days until I reach optimal blood sugar outcomes.

NPH Starting dose for type 1s: .4 (yes, there is a decimal point in front of the 4) units per kilogram of body weight per day, 1/3 of which is given at bedtime, and 2/3 of which is given in the morning. Increase gradually until optimal blood sugar results are achieved.

Kilograms = # of pounds x .45
Example: 200 pounds x .45 = 90 kilograms. This means that 200 pounds = 90 kilograms
Example 90 kilograms x .4 = 36 total units of NPH PER DAY. Roughly 12 units of NPH at night and 24 units of NPH in the morning for a 200 pound type 1 diabetic.

NPH Starting dose for type 2s: .2 (yes, definitely a decimal point in front of the 2) units per kilogram of body weight per day, 1/3 of which is given at bedtime and 2/3 of which is given in the morning.

I would adjust the morning and evening doses every few days in order to achieve optimal blood sugar results.

Of course, I would never start taking insulin for the very first time ever without first consulting with a doctor. Like, ever.

Circumstance #7: Starting with Reli-on Regular and Reli-on NPH when I have never been on insulin before
Seriously, I would go see a doctor before doing this.


Other tricks to reduce my insulin needs (which will, in turn, require me to buy less insulin in all of the above mentioned situations):

1. Exercise more - this helps my cells accept insulin more readily, so I'll need less insulin if I exercise regularly (I would definitely watch out for hypoglycemia events if I started exercising, though)
2. Reduce carbohydrate intake (Reducing my carbohydrate intake to between 100 and 180 carbs can reduce my insulin needs)
3. Take Metformin (requires a doctor's prescription, so I may be SOL here if I don't have access to a doctor). If I could find a way to get my hands on Metformin, that would lower my baseline/basal insulin needs, because Metformin reduces the amount of glucose released by my liver on a daily basis. Metformin was created for type 2 diabetics, but type 1 diabetics can take Metformin, too, and it will reduce a type 1 diabetic's insulin needs (so I would definitely lower my basal insulin dose, and possibly even my bolus doses, if I were going to start Metformin).