Mail-Order Insulins Can Go Bad

Many people with diabetes suspect that the insulin they get by mail sometimes has lost its effectiveness. Now, a study has proven their suspicions are probably true, causing the medical community to question mail-order pharmacies and bring people back to their community pharmacies, where face-to-face treatment delivers to them the best care possible.

In 1997, a study published by the United States Pharmacopeia demonstrated that medicines sent through the mail, especially in the summertime, are routinely exposed to temperature conditions far exceeding the manufacturers’ recommendations. Two manufacturers of insulin, Eli Lilly & Co. and Novo Nordisk, recommend that their insulin be stored at temperatures less than 85 degrees Fahrenheit. The study showed that nearly 92 percent of the medicines delivered by mail are exposed to extreme temperature conditions, which can affect their potency.

“We sent some insulin through the mail with a special thermometer just to see how hot it would become during transit,” reported Maryann Sheeley, RPh, CDE, of Kingston, New York. “We found temperature ranges greater than 110 degrees Fahrenheit.”

Liz Holst, RN, CDE, CPT, works with patients as an insulin pump trainer in New Jersey.

“Unfortunately, I have had patients whose blood sugars seem to go out of control for no apparent reason,” says Holst. “When I have them purchase replacement insulin at local pharmacies, often their control returns. The insulin they replace is the insulin that comes through the mail with no special packaging to keep it cool. In fact, three times I have had to send patients to the hospital because their blood sugars were dangerously high. The common thread between these patients was that their insulin arrived by mail during the summer months.”

Cold weather can also affect the potency of some medications.

“We had a report of a woman in Schenectady, New York, whose insulin was left in the mailbox on a cold day,” reports Craig Burridge, executive director of the Pharmacy Society of the State of New York. “When she went to use the insulin, she found particulate matter in the vial because it had frozen. How long would this patient have used the vial with subpotent insulin if she had had poor vision? She ended up buying new insulin at a local pharmacy, since she could not wait for more to come through the mail.”

The heat in a metal mailbox on a summer day, or the cold of a winter day, have the potential to decrease the potency of drugs.

“Community pharmacies would have to destroy their medications if they were subjected to these conditions,” states Burridge.

This is not limited to just diabetes drugs, as other patients, suffering from chronic diseases such as high blood pressure, heart disease and high blood fats, experience similar problems.

Many consumers are being asked to make a decision that can have serious consequences to their health. They are being asked, often coerced, by their employers or insurance plans to purchase their diabetes medication through the mail.

Todd Dankmyer, senior vice president of communication of the National Association of Community Pharmacies, adds that “state boards of pharmacy are not doing enough to protect patients from the hazards of mail order.”

The local pharmacist ideally has a complete record of patients’ medicines and all the physicians’ writings for these medications. If a patient is receiving medication from different pharmacies, then the opportunity to catch dangerous drug interactions is lost (current guides list over 700 different drug interactions). The potential for harm looms high if the interactions are not caught.

“We have concerns about patients being serviced by mail-order pharmacies because of the lack of face-to-face interactions,” warns Dankmyer. “Patients with diabetes see pharmacists more than any other patient population. They require the professional expertise and consultation of a pharmacist.”

Dankmyer reminds us that “Ten years in a row, pharmacists have been voted in a Gallup poll as the most trusted profession in America.” Behind this confidence is the pharmacists’ accessibility, their knowledge and the trust that pharmacists have the people’s best interests at heart. Community pharmacists know their patients, keep their records of medications, are available to answer a question or offer helpful comments, and give professional guidance to the individuals based on previous medication history.

Marty Irons, RPh, CDE

Insulin potency is a major concern throughout the diabetes supply industry. Everyone knows that insulin exposed to extremes of temperature can degrade, and that the stability rates of insulin vary, with Regular being the most stable and Ultralente the one most susceptible to extreme temperatures.

The issue is not how customers purchase insulin, but the care the insulin provider takes to maintain the product’s potency. From the manufacturer, to the distributor, then to a mail-order company or a local pharmacy, the shipping procedure is the same. There is no guarantee that the insulin didn’t sit out on a loading dock of a pharmacy, any more than it did at a mail-order facility.

When a customer orders insulin through my company, it is shipped by two-day air. If the order comes in on a Thursday or Friday, it is sent by overnight mail. Our shipping policy meets the criteria established by the major insulin manufacturers, Eli Lilly and Novo Nordisk.

Mail-order pharmacies and supply companies provide a very valuable service. Hundreds of thousands of people, many of them senior citizens, live in small towns and out-of-the-way places without pharmacies. We receive thousands of letters from customers who tell us that the nearest pharmacy is 30 or more miles away. Without a mail-order provider, how is someone old and sick, who is unable to drive or arrange transportation, going to get to town to pick up his or her supplies?

Although it is comforting to believe that pharmacists provide face-to-face counseling to people with diabetes, the reality for many is that they do not. Often there is only one pharmacist on duty with a dozen customers waiting in line. It is not realistic in today’s bottom-line-oriented health care industry to say customers get a high degree of personal attention. It would be nice, but it’s just not so.

Mr. Irons seems genuinely concerned about the well-being of his patients with diabetes and the limits placed on them by their insurance companies. His anger should be directed at the insurance, managed care and health maintenance organizations that make obtaining insulin and other medications difficult for his patients.

The problem is not with the mail-order supply industry. It is with the company that supplies a bad product. Consumers should always buy from a company that has a reputation for quality, service and reliability, whether it is a local pharmacy or a major mail-order supplier.

Mark Libratore
Liberty Medical Supply

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