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While the EpiPen’s price increase has been thoroughly documented, the skyrocketing cost of insulin — another life-saving drug — has gone largely unnoticed.

With some 26 million Americans diagnosed with a type of diabetes, and another 360 million worldwide also living with diabetes, insulin remains a high-demand drug that a significant number of people depend on to live. However, much like Martin Shkreli’s 5,000 percent price increase for AIDS treatment drug Daraprim, and Mylan Pharmaceuticals’ 461 percent price increase for the EpiPen, the patent for insulin has been cornered by three pharmaceutical giants who are relentlessly jacking up the price of insulin, almost exclusively for customers in the United States.

As Yale School of Medicine endocrinologist Kasia Lipska wrote in the New York Times, the patent for rapid-acting insulin has been monopolized by “The Big Three” pharmaceutical companies — Eli Lilly, Sanofi, and Novo Nordisk — and the price for the insulin products made by those manufacturers has risen astronomically over the last decade. Earlier this year, PBS reported that the cost of insulin tripled between 2002 and 2013, going from $231 per patient each year to $736.

In March of this year, T1 International conducted a survey on insulin use from diabetic patients in a variety of countries on several continents. Their findings confirmed that patients in the United States pay an exorbitant price for rapid-acting insulin products in comparison to patients in Africa, Asia, Australia, Europe, and South America. When examining the per-milliliter price patients pay for Apidra, which is made by Sanofi, the drug is virtually free in every country where data is available, while the same drug costs $6 per milliliter in the United States.

Eli Lilly’s product, Humalog, varies slightly in cost, though the insulin product still costs less than $1 per milliliter in France, Italy, Lithuania, Portugal, and Rwanda. Patients in the United States pay four times as much for Humalog than in Canada.

Data for patients using Novorapid/Novolog, which is manufactured by Novo Nordisk, is available in 20 different countries. In 15 of those countries, the drug costs less than $1 per milliliter. Novorapid/Novolog customers in the United States pay $9.20 per milliliter. The only country where the cost of the product comes remotely is Singapore, where patients pay less than half that amount.
However, the difference between the Daraprim and EpiPen price hike, and the insulin price hike is huge. While cheaper, generic alternatives exist for both the life-saving AIDS treatment drug and the emergency epinephrine injector, insulin currently has no generic competitor. The way the Big Three have managed to avoid competition with generics is the fault of a process known as “evergreening.”

The companies that own the patent to insulin — which has been around since 1923 — continue to maintain rights to the drug by offering slightly improved versions periodically. Each new version comes with its own patent, meaning the shelf life of the patent is extended as a result. As VICE reported, this results in doctors continuing to prescribe the latest version of the drug to diabetic patients, as it stands to reason the newer version is better than the older version.

“People are suffering a lot,” college student and type 1 diabetes patient Allison Bailey told CBS News. “There are no generics. We have to go through these big companies, and they charge so much.”

In order to get around the problem of pharmaceutical companies gouging patients for life-saving drugs, a group of biohackers is attempting to create an open-source insulin product so low-income diabetics can afford the drug. According to TechDirt, the crowd-sourcing initiative, which has been dubbed “The Open Insulin Project,” aims to create a generic alternative to insulin by putting generic insulin research and development into the public sphere. However, the biohackers admit that in order to mass-distribute the generic insulin, an angel investor will need to step forward with a significant amount of money to get the product approved by the FDA and onto drugstore shelves nationwide.

“The real hurdles are getting the drug approved by the FDA (and since insulin is a biologic drug, it requires a lot more original data than an application for a small-molecule generic would), and then upfront manufacturing costs (because making a biologic drug is different, so it requires different equipment),” Open Insulin Project spokesman Kevin Riggs told Popular Science.

Pharmaceutical Research and Manufacturers of America (PhRMA), the chief lobbying arm of the pharmaceutical industry, told PBS that the price increases don’t represent reality, as rebates are often provided to companies, unions, and government agencies, which lowers the net price of prescription drugs.

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