The insulin racket

In much of Europe, the cost of insulin is about a sixth of what it is here. That’s because the government negotiates prices directly with the drug manufacturers. In this country an invisible group of businesses, called pharmacy benefit managers (PBMs), do the negotiating. Supposedly they are negotiating for lower drug prices on behalf of insurers, such as employer plans and Medicare Part D. The problem is that PBMs are money-making enterprises: they get “rebates” (kickbacks) from drug manufacturers whose products get the okay from insurers. Though they're supposed to be driving down costs, how can they resist choosing the products with the largest rebates? They don’t resist. They make big bucks: the three biggest PBMs—Express Scripts, CVS Health, and OptumRx—bring in more than $200 billion a year in revenue. Industry analysts estimate that these payments, and other back-room deals, amount to as much as 50 percent of the list price of insulin.

Added to the problem is the fact that, even though insulin has been around for almost a century, there is no generic form available in the US. Just three pharmaceutical companies hold patents for insulin: Eli Lilly, Sanofi, and Nordisk. Together, these companies made more than $12 billion in profits in 2014, a big portion of which is from insulin sales. What's more, they’re able to extend their patents by making little tweaks to the molecules, effectively making them “new” drugs. (After patents run out on older drugs, companies usually stop making them.) Not only that, the three manufacturers keep raising their prices. For example, the price of Humulin RU-500 rose by 325 percent from 2010 to 2115. A racket indeed.

Some smart consumers are fighting back. Anthony Di Franco, who has had diabetes for ten years, set out to learn whether insulin could be home-brewed on a small scale. (Don’t try this at home.) After some research, he concludes; “We can do it, and we can do it now. All of the tools already exist.” Last year, the Open Insulin project raised $16,656 to demonstrate the technological feasibility of manufacturing insulin (it involves injecting certain genes into bacteria). As their website explains, “Industrial protocols for insulin production don't support generic production. They're complex, decades-old, and often encumbered by patents. Ours will be simple and open. All protocols we develop and discoveries generated by our research will be freely available in the public domain.”  Hooray for them!

I keep saying I will stop ranting about pharmaceutical companies. I seem unable to do this. Sorry.

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Vertigo: A do-it-yourself remedy

I've had vertigo two or three times. It’s frightening. My first bout happened when I got out of bed in the morning. The room was spinning and I could hardly stand up straight. I can’t remember if I laid back down or kept walking around. At any rate, it went away after about five minutes.

At least I didn’t call 911 as one man did. He was afraid he was having a stroke. He spent a day and a night in the hospital undergoing thousands of dollars' worth of tests. They found nothing. He later found out (as I did) that he had a common malady called benign paroxysmal positional vertigo. What happens is that the little rocks (calcium carbonate crystals) that live in your inner ear loosen and migrate into one of the fluid-filled semicircular canals where they’re not supposed to be. In this location they send false signals to the brain. The little rocks are part of the elaborate balancing mechanism located in our inner ears.

Apparently vertigo occurs more frequently in older people because the protein coating that covers the crystals weakens with age, making the crystals more apt to move out of place. In my case, in addition to the time I got it when getting out of bed, I also got it while standing at the kitchen counter. I simply moved my head a certain way and got dizzy (I swear that the square patterns in the counter tiles contributed to it). In my case, the episodes always resolved on their own within a few minutes. 

If your vertigo doesn't go away, you can try a couple of maneuvers, one of which is new. The most commonly used one, which has been used for about 20 years, is called the Epley maneuver. It involves turning your head in several positions, first while sitting and then while lying on your side. The newer maneuver is called the half somersault [!], which you do from a kneeling position.

Here are links to videos demonstrating how to do both maneuvers:   

https://www.youtube.com/watch?v=llvUbxEoadQ   (This is just one; there are many more to chose from.)

https://www.youtube.com/watch?v=_8ucpWIIC3g (I think this is the best one. It’s by the doctor who came up with the somersault maneuver and explains the inner ear business. It’s not a real somersault, by the way, and looks quite simple.)

I haven’t had vertigo for a long time. I kind of wish I would so I could try the somersault.

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Super Bowl drug ad: Need something for opioid-induced constipation?

We watched the Super Bowl this year. I don’t remember much about it except for an ad, titled “Envy” aimed at people with “opioid-induced constipation.” I was flabbergasted! (The ad showed an ordinary-looking guy looking enviously at those who do not have this problem, such as a dog “goes” effortlessly.)

What was odd about this ad, besides the wacky subject matter, is that it never mentioned a specific drug. That’s because, by omitting the name of the drug, the pharmaceutical company—in this case AstraZeneca—is not required to mention the unfortunate side effects. I looked these up. My favorite is “vomiting of material that looks like coffee grounds, severe and continuing.” At any rate, you don’t need to know the name of the drug, all you have to do, as the ad tells us is “Have a conversation with the doctor…and ask about prescription treatment options.”

Because the ad is shown during the Super Bowl, you might think there must be a big market for drugs that treat opioid-induced constipation. (I have no idea. Is there?) As a rule, these ads are aimed at a niche market: people with good insurance or those who can pay out of pocket for pricey drugs. And the drugs advertised on the Super Bowl show are indeed pricey: for example, Xifaxin for irritable bowel syndrome costs $1,800 a month; Jublia for toenail fungus costs thousands of dollars for a full course of treatment (cure rates, by the way are under 20 percent after 48 weeks of use). By comparison, the drug for opioid induced constipation seems cheap: “only’ $280 to $350 a month. Still, I guess it’s enough to justify spending those advertising dollars, which by the way, amount to $4.8 billion a year for the pharmaceutical industry.

Pricey new patented drugs are usually no better than old generic drugs that have gone off patent, but the older drugs, with their lower prices, don’t merit spending the big advertising bucks. Speaking of which: have you noticed that you never see ads for Lipitor nowadays? It used to be the most heavily advertised medication in the US. Its patent expired in 2012 and its price dropped as a result of generic competition. Now the advertising money is funneled to more profitable drugs. (Incidentally, the US and New Zealand are the only two countries that allow consumer advertising for drugs.)

I’m sorry if you suffer from opioid-induced constipation. I suppose you've already tried prunes.

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Saturated fat: nothing to worry about

The notion that saturated fat is bad for you is a myth that was debunked long ago by reputable scientists. For example, doctors representing the National Heart and Lung Institute in London concluded: “The commonly-held belief that the best diet for the prevention of coronary heart disease is one that is low in saturated fat and cholesterol is not supported by the available evidence from clinical trials…such diets do not reduce the risk of myocardial infarction or coronary or all-cause mortality.” Many other studies come to the same conclusions. Saturated fats do not clog arteries. They are either burned for fuel or stored in your fat cells. Dr. George Mann, former Director of the Framingham Heart Program calls the belief that heart disease is caused by eating saturated fats and cholesterol “the greatest biomedical error of the twentieth century.” It’s a medical reversal, yet the myth refuses to go away.

Saturated fat generally refers to fats, such as butter and animal fats, that are firm when refrigerated. Unfortunately the word “saturated” seems to imply that the fat is somehow ‘”fattier” than other types of fat. But the term simply describes the composition of the fat molecule: each carbon atom in the chain is linked to two hydrogen atoms such that the carbon is “saturated” with hydrogen atoms.

Actually, there is no such thing as a fat that is purely saturated. If there were, it would be as hard as candle wax. In fact, all fats are mixtures of saturated, monounsaturated, and polyunsaturated fats. For example, the fat component of a porterhouse steak is 51 percent monounsaturated (like olive oil), with only 45 percent saturated. (The remaining four percent is polyunsaturated.) Likewise, lard is only 40 percent saturated fat. Olive oil is 13.7 percent saturated fat, which is why it turns cloudy when refrigerated.

Seeing saturated fats demonized in print is tiresome and annoying—not to mention wrong. What also annoys me is that labels on food products show the amount of saturated fat but not the amounts of monounsaturated or polyunsaturated fats, implying that you must be on the lookout for saturated fats but need not worry about the others. The only fat you need worry about are trans-fats, which are man-made.

So grab that bacon from the supermarket shelves and live a little!

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.