BootCamp for Betics

Hey Friends,

This video is a bit long, and I can't quite decide whether it's a rant or a plea. I'm feeling proud that I managed to keep my $--t together until the final minute or two.

Our people are dying, senators. We must do something quickly.

Below are 60 of the 3,445 Google searches from the last month that resulted in traffic to my article about how to take matters into your own hands when you can't afford insulin.

​It's reckless. It's dangerous. And unfortunately, it's necessary to prevent death due to lack of insulin.

Here's what more than one hundred people per day are searching for:

Please forward this to anyone who might be able to help.

ALERT (November 12, 2016): THIS POST HAS BEEN UPDATED TO:

1. REFLECT A RECENT ANNOUNCEMENT BY TRUMP
2. MORE THOROUGHLY DESCRIBE THE HISTORY AND POTENTIAL IMPACT OF USING HIGH RISK POOLS TO COVER PEOPLE WITH PRE-EXISTING CONDITIONS

Today is Friday, November 11 and the sticky, sweaty shit storm of election dust has not yet settled, but, I’m going to chill the heck out for a few minutes here so that I can share what the reversal and replacement of Obamacare might mean for people with diabetes.

Despite the fact that Donald Trump has said that he wants to continue to cover people with pre-existing conditions, his policy makers, according to his website, have decided to make it extremely difficult for people with pre-existing conditions to get insurance coverage if they've had a gap in coverage. Here's what's on Trump's website as of November 11, 2016:

The Administration also will work with both Congress and the States to re-establish high-risk pools – a proven approach to ensuring access to health insurance coverage for individuals who have significant medical expenses and who have not maintained continuous coverage.

Now, the way this is written, to the untrained eye, it sounds kind of good, right? Sounds like Trumpcare is going to cover people with pre-existing conditions.

But, to the well-trained eye, this statement is a half-assed squirt of Febreze on a rug saturated with cat piss.

To be clear, as a policy, BootCamp for Betics doesn’t argue ideology or have political opinions except as it directly relates to people and communities affected by diabetes.

And boy, does this ever.

The imminent repeal and replacement of the ACA could affect your diabetes care and coverage in a very undesirable way. So listen up, folks.

The first thing I'm going to do is translate Trump's website's policy statement for you to make sure you understand what it really says:

The Administration also will work with both Congress and the States to re-establish high-risk pools. A high risk pool is a group of sick people who need more medical care than other, regular, healthy people, and these sick people cost insurance companies a lot of money. So, with the new Trumpcare plan, people with pre-existing conditions will be taken OUT of the regular group and put into a high risk group. This means that regular people who aren't sick can pay less for their insurance premiums, while people with pre-existing conditions will either have to pay for a private plan at a much higher rate than regular, healthy people OR that people with pre-existing conditions can apply for insurance through their state risk pool.  - a proven approach to ensuring access to health insurance coverage for individuals who have significant medical expenses  Sounds great, right? If you can't afford the jacked up private insurance rate for your pre-existing condition, just sign up through the high risk pool! Wait. Wait. Let's talk more about that. Risk pools, back in the day (before Obamacare), were largely run by the states and they operated at a loss. Funding came from various sources, some state, some federal. Often, there wasn't enough money in the high risk fund to subsidize everyone, so people with pre-existing conditions had to go on a waiting list. So, your ability under Trumpcare to procure an insurance plan from a state high risk pool may be limited depending on what state you live in, what type of care you need, and whether or not the state pool even has the money to subsidize you. This creates risk and uncertainty. The truth is, we have no idea exactly how Trumpcare plans to cover people with pre-existing conditions. and who have not maintained continuous coverage There just isn't a way to actually pay for pre-existing conditions for people who've had a gap in insurance. That's what's missing from Trump's plan.

Ok, let's move on.

The next thing I'd like to do is provide encouragement to our president-elect, and to congressional leaders, to continue to find a way to provide affordable, and not prohibitively expensive, healthcare coverage for people with diabetes (and for other sick people) as they work through the imminent reversal and replacement of Obamacare (or whatever Trump & congressional republicans decide to do).

​Do you want to write your senator or representative? Scroll down to download and print my letter templates.

Finally, I'd like to help those of us with Diabetes hedge against insurance loss so that you don't get totally fucked. Read on, my friends.

Here's what you need to do to hedge against potential insurance loss:

1. If you don't have it, get insurance NOW. If you and your spouse both have jobs, and if you can afford it, consider getting double-insured. This may seem excessive, but the truth is, we just don't know what's going to happen and I am very risk-averse when it comes to healthcare. I've been screwed too many times. If you have insurance through your employer, you are in the best possible position right now. Don't quit your job. If you don't have insurance through your employer, go to healthcare.gov and enroll. If you don't currently have health insurance, your opportunity will be lost when open enrollment closes unless you experience a qualifying event. Let me put this another way.  If you don't have 2017 insurance coverage by January 31, 2017 you could be in trouble whenever Trumpcare takes effect (probably 2018). Listen. If you already have insurance coverage when the new healthcare law takes effect, it will be more difficult (though not impossible) for your insurance company to jack up your rates and/or deny your diabetes coverage. If you can't afford insurance, sell your clothes, ask your family members for money, or stop grocery shopping and start eating peanut butter sandwiches.

2. Call, email or write your senators and your representative (you can download a template below) to see if they'll reconsider their position on pre-existing conditions. Do it now, because they are already working on the ACA's replacement.

3. Start saving money.

4. Do what you can to get your blood sugars into target range as often as possible. The sooner you do this, the better. A lower A1C means fewer health problems, and if you're on your own next year without insurance, you'll need to do everything you possibly can to keep yourself healthy so that you can continue to stay alive.

To be clear, NONE of this is certain. No one knows what is going to happen. It's the level of risk and uncertainty regarding pre-existing conditions that I'm uncomfortable with.

Obamacare has its problems, but it also has some features that support the lives of people with diabetes.

I’d like to encourage congress, in its effort to repeal and replace Obamacare, to consider continuing to support healthcare coverage for people with diabetes.

Love,
Kara Stiles

This is all I have to say to you today.

Love,
​Me

Hell yes, insulin prices are skyrocketing. And the trajectory is so much steeper than we thought. Last week's news made a really amazing effort to shed light on the insane costs of being diabetic, and, as a result of last week's reports, a bunch of change.org petitions to lower insulin prices popped up and got passed around on Facebook and other social media.


Which is awesome. It’s really nice to see people caring about insulin prices.


The JAMA study's data from which the news reports got their numbers is entirely correct and you should definitely read it if you get an opportunity (It's a study about type 2 diabetics. It didn't include type 1s). But I am concerned that the news reports have not clearly explained the meaning of JAMA's figures in a way that is relevant to the diabetics who actually take insulin (and their loved ones). So I'd like to set the record straight and help clarify the figures.


Why?


Well, I figure if you're gonna be pissed off on behalf of the diabetic(s) you love, I want you to be pissed off based on a more clear interpretation of the data.


The actual average price of insulin per insulin-dependent type 2 diabetic in 2013 was $2661.52, not $736.09, as many believe based on last week's news reports.
​

Wait, WHAT? Why am I saying the average yearly price of insulin in 2013 was $2661.52 and all the other news articles are saying it was $736.09?


Let me explain.


This JAMA study tells us that insulin cost an average of $736.09 per type 2 diabetic per year in 2013, This average cost is distributed across ALL diabetics, whether they’re taking insulin or not! But, only 29.2% of Type 2 diabetics actually take insulin. Do you know what this means? 


It means that 29.2% of type 2 diabetics are absorbing 100% of the insulin cost.


Look, if you're an insulin-dependent type 2 diabetic with a kick-ass health plan, your insurance company might absorb a good portion of this cost on your behalf. But, if you don't have a health plan, or if you have a high deductible before drug coverage kicks in, or if you pay a high coinsurance percentage, or if you're stuck in the donut hole, you might become desperate enough to start thinking about other less healthful options, such as rationing insulin by skipping doses (yes, this is actually happening, and it really shouldn't be) or using the cheaper but less effective insulins.


So sure, the study had numbers in it. And the numbers were correct. But the study didn't calculate the values that are most relevant to people who are going broke thanks to their insulin bill (which wasn't the purpose of the study anyway, so don't be mad at the researchers. They didn't do anything wrong).


So, here’s what’s actually relevant to us: The average cost of insulin for an insulin-dependent type 2 diabetic increased from $742.14 in 2002 to $2661.52 in 2013.


And guess what else. Prices have increased a LOT since 2013. Based on the published cash prices for insulin on GoodRX.com and using the JAMA study’s average figures for yearly insulin consumption in mL, an insulin-dependent diabetic on analog insulin (the good stuff that actually works) can expect their “average” insulin costs in 2016 to be anywhere between $2662 and $5459 or more per year. If you don't have a good health plan to cover these costs, you are screwed.


Here’s some extra math, for those of you who like math:
​

The JAMA study indicates that in 2002, the average price of insulin was $4.34 per mL, and that in 2013, the average price of insulin was $12.92 per mL. The study also indicates that in 2002, insulin-dependent type 2 diabetics took an average of 171mL  per year and in 2013, insulin-dependent type 2 diabetics took an average of 206 mL per year.


So, if you care about a diabetic, and if you've been getting all pissed off about the price of insulin increasing but you haven't yet fully grasped how ridiculous the price increases are, just do the math yourself using the figures above, and then join me in my full blown rage, or cry, or shout expletives, or call someone and cry, or whatever.

​
And, if you haven't done so yet, go sign one of those change.org petitions! Because for pete's sake, we 'betics can't afford these disgusting insulin price shenanigans.

Dear Betics,
​
Nothing makes me madder than having to arduously fight the insurance bureaucracy to stay alive. And the NPR report I read today has my heart racing with indignant rage on behalf of diabetics everywhere who KNOW what a struggle it is to cry, beg and plead with the insurance company in an effort to coerce them into doing the very thing they’re charged with doing: keeping you alive and well.

If you have diabetes, you probably (like me) burst into tears at least three times per year after ending a call with a customer service representative who insists your life-saving diabetes treatment isn’t covered by insurance. Before you continue reading, get your game face on, because this is going to piss you off.

In 2017, diabetics who get their meds through CVS Caremark or Express Scripts are in for some blood boiling adjustments to diabetes (and other) drug coverage.

NPR’s got the full story, and you can read it here. For my part, I’ll summarize the CVS diabetes drug denial list for 2017 (because it’s bigger than the Express Scripts list), and discuss why denying people the drugs they need to stay alive is so awful.

Both companies are choosing to remove brand name drugs from their formulary and instead are choosing to cover generic versions. Fine. We’re all accustomed to that. That isn’t news. Substituting generic for brand name happens ALL the time. I’m not upset about that.

Here’s what I AM upset about: the prescription insurers are choosing to replace some of your current meds with biosimilar medications (this happens from time to time with all insurers, but not to this degree). Replacing a drug with a biosimilar is NOT the same thing as replacing a brand name drug with a generic drug that has the exact same ingredients. In this particular context, biosimilar means, “Drugs that are designed to do the same thing, mostly, but each drug is actually different from the other, and they each have their own interesting side effects, and there are some people who can tolerate a certain drug but CAN’T tolerate its biosimilar competitor drug(s).”

To see the full list of formulary changes for CVS Caremark and Express Scripts, visit these sites:
​(Consider taking a xanax before you click, though. Oh, wait. That isn't covered.)
​
CVS Caremark Full List of Formulary Changes
Express Scripts Full List of Formulary Changes
​
For the purpose of this article, I’m going to use CVS Caremark as my example. Below is a table of CVS Caremark’s diabetes treatment changes and what should have been considered (see notes/comments) before implementing the restrictions.

(In a relatedly dickish move, United Healthcare decided to stop covering all insulin pumps except the Medtronic pump, which is *really* going to destroy some people’s lives. More on that in another article.)

Look, I see biosimilars as treatment options, and I hope I will always be able to get my hands on the best drugs & treatments that will help me, as an individual, control my diabetes. I want options. I NEED options. And so does every other diabetic.

Unfortunately, the insurers see biosimilars as an opportunity to negotiate lower drug prices, which I can certainly understand (diabetes meds are hella expensive), and I *know* there are factors involved in these decisions that I’m not privy to, but, as a patient on the receiving end of these new restrictions, I feel like I’m being stuffed into a regimented care plan box, which will inevitably result in an uncomfortable and less healthful life. I need the freedom to use the treatment options my doctor and I decide will keep me alive for as long as possible. I don’t know how to solve the myriad of problems insurers face with regard to ever increasing drug prices. But I want prescription insurers to realize that what they’ve devised as a viable solution to THEIR problem has created a BIG problem for ME. And I implore prescription insurers to actually care about this.

Look, you guys. It’s an obnoxious battle to try and keep my blood sugar in target range every single hour of every single day, especially when I’m trying to eat healthy, exercise regularly and still maintain a flat baseline. I use three different pieces of medical equipment to stay alive. I use the test strips and insulin that work best for me, as an individual. And I *really* depend on this stuff to stay healthy. It’s difficult, but I’m not gonna complain, because at least I’m lucky enough to be alive. But. I can’t understand why I constantly have to fight my insurance company for the stuff that keeps me alive. This shit wears me down. Makes a diabetic want to just hold up her hands and say, “I give up.”

So, to CVS Caremark and Express Scripts, for restricting diabetes treatment options, and to United Healthcare, for restricting insulin pump options, and to the drug companies who charge way more for drugs in the US than they charge anyone else, I have a challenge for you. I’d like to invite you to spend a few days with me (or better yet, sign up for my Diabetes Education Course) so that you can better understand how potentially devastating your new 2017 restrictions are.

With as much diabetic love as I can muster in this dire situation,
Kara

Did you know there are two types of carbs, only one of which diabetics should be eating? Watch the video below to find out more.

Note: This is my first attempt at a vlog post (a video blog). I promise to improve the sound quality when I make the next one. :)

With Diabetic Love,
Kara

Once you learn that someone you know has diabetes, you probably want to say and do things that are helpful and supportive. ​Your desire to help and support actually means a lot to those of us who have diabetes, and we appreciate it! I've heard it can be challenging and sometimes even awkward to interact with someone who has diabetes, because it's hard to know what to say in certain situations. Sometimes your efforts to be helpful and supportive can come off as insensitive and foolish, which, typically, is the exact opposite of your intentions. To assist you in your efforts to be helpful, I've listed below some situational phrases that you can use to ensure you're being supportive of (and not accidentally hurtful toward) your local diabetic.

Situation:
-Someone tells you that they have diabetes
Don't say this:
-Oh wow, that's awful. My grandmother died from diabetes.
-So, that means you can't have any sugar, right?
-I see. Are you sure you're supposed to be eating that?
-Did you get diabetes from eating too much sugar?
-Well, at least it's not cancer!
-My Aunt Tilly is in kidney failure because she never took care of her diabetes.
​-Huh. I thought only fat people got diabetes. You're not fat.
-I've heard that cinnamon/chromium/okra can cure diabetes. Have you tried it?
Say this instead:
-Thanks for telling me. Please let me know if there's ever anything I can do.
-That's good to know. Please let me know if there's ever anything I can do.
​-I've always wanted to learn more about diabetes. Please let me know if there's ever anything I can do.


Situation:
-You witness a diabetic eating or drinking something that you've heard is "against the rules" for diabetics (the generally accepted belief that there are hard and fast rules for all diabetics is a myth, by the way).
Don't say this:
-Are you allowed to eat that?
-You can't have that, can you?
-Isn't that bad for you?
-You need to take better care of your diabetes.
-Is this going to put you into a coma?
-My aunt ate cake all the time and had to have her foot amputated
Say this instead:
-<nothing>


Situation:
You have deep knowledge about how another friend/family member cares for their diabetes, and you witness someone else managing their diabetes in a way that is different from what you've observed in the past.
Don't say this:
-I'm pretty sure you're not supposed to be doing that.
-My friend/family member manages their diabetes by <enter treatment method here>. Have you tried that?
Say this instead:
-<nothing>


Situation:
You witness a diabetic checking their blood sugar and/or taking insulin. You are squeamish and HATE needles.
Don't say this:
-Oh wow, I would just DIE if I had to prick myself like that every day!
-That's disgusting.
-Can you please go into the bathroom if you're going to do that?
-Can you not do that in front of me?
-You must have the bad kind of diabetes.
-Your diabetes must be really bad.
Say this instead:
-<nothing>


Situation:
You learn that your friend/family member's blood sugar is, at this very moment in time, too high or too low (This occasionally happens to all diabetics. Blood sugars will never be perfect 100% of the time).
Don't say this:
-Wow, isn't that bad?
-Wow, why is it so bad?
-OMG that's really low/high isn't it?
-Is this because you ate something you shouldn't have eaten?
-You need to take better care of yourself.
-But you don't look sick.
Say this instead:
-Let me know if there's anything you need.
-How can I help?
​-What can I do to help?
-What can I get you?


Situation:
You say, "what's that?" and the diabetic responds with "It's an insulin pump" or "It's a glucose monitor."
Don't say this:
-OhMyGosh I'm SO sorry, I shouldn't have asked!
-Wow, your diabetes must be really bad.
-Are you a brittle diabetic?
-My friend was a bad diabetic so that's why they put him on insulin.
-Oh, you have diabetes? I know someone who died from that.
​-I heard insulin makes you fat.
Say this instead:
-Cool!
-That is awesome technology!
-Oh neat! That is so fascinating. Mind if I ask some questions about how it works?

Situation:
A diabetic you know is unconscious or having a seizure (uncommon, but possible)
Do this:
-If you're trained in blood sugar testing/treatment and/or glucagon administration, follow protocol.
-If you're not trained in blood sugar testing and glucagon administration, call 911.


​Diabetes (all types) is a very difficult and confusing disease to manage. Diabetes behaves in extremely inconsistent ways from day to day. Most diabetics are doing the best they can! Things don't always work out perfectly. I understand that most of our supporters really just want to help, especially when they believe a diabetic is struggling. But. Unless you are a diabetes educator or an endocrinologist, it's unlikely that any suggestions you make will add value to a diabetic's life. Always remember that there is a very fine line between curiosity and perceived criticism. When in doubt, just say this: How can I help? If there's a way for you to help, we'll let you know! And, in case we forget to tell you, thank you for caring so much about us.

With Diabetic Love,
​Kara

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).