Diabetes (whichever type of diabetes you may have) is an expensive condition to live with, pretty much anywhere in the world. We ran a poll on our Facebook community, in which 49% of people told us they spend between Rs 6,000 to Rs 10,000 per month on diabetes medication. Managing diabetes is a full time task which requires resources like money & diabetes education. Not only is there an obvious financial burden but there is also a mental health impact on families and people living with different types of diabetes. Here's a screenshot from a discussion we had on diabetes related expenses-

In India, there is no coverage for day to day medical supplies and expenses (unless you are a State or Central Government employee or dependent family member or your employer has agreed to cover some expenses. Read this post on our Facebook community Diabetes Support Network India to learn the experience of a family with a child with type 1 diabetes where the (private) employer of one of the parents agreed to cover recurring expenses associated with an insulin pump, including the cost of the pump.

Several state government hospitals provide free insulins (the older ones, R, NPH and/or mixed insulins) so you could visit your local government hospital to find out (and please update us too on Diabetes Support Network India so others can benefit as well). It's great to see that some state governments (such as Goa and Uttarakhand) also provide free analogue insulins (the newer, faster, more expensive ones) such as Novorapid & Tresiba too. Apart from this various online pharmacies offer convenience of home deliveries & roughly 5-20% off the MRP (Maximum Retail Price).

While there might be a certain degree of uncertainty associated with getting insulin & related diabetes supplies for free, there is a definitely a solid option for getting inexpensive generic insulins and medicines and that's something we will attempt to unpack in this article.

What are generic medicines?

Generic drugs are marketed under a non proprietary name rather than a brand name. That does NOT make them less effective - they are equally effective, in fact since they are generic they are much cheaper than their branded counterparts. For example, Regular is the generic version of Actrapid (made by Novo Nordisk) & Glargine is the generic version of Lantus (made by Sanofi).

Generics & Biosimilars

Generic & biosimilar drugs including insulin are similar in the way that both are inexpensive & safe options however here's a simple overview to understand how they are different from one another-

Jan Aushadhi Kendras

Pradhan Mantri Bhartiya Jan Aushadhi Pariyojana (PMBJP) is a campaign launched by the Department of Pharmaceuticals in association with Central Pharma Public Sector Undertakings to provide quality medicines at affordable prices to the masses through dedicated pharmacies called Pradhan Mantri Bhartiya Janaushadhi Kendras. The potency of these inexpensive, generic medicines are the same as compared to expensive, branded medicines available in the market.

An official representative from Pradhan Mantri Bhartiya Jan Aushadhi Pariyojana (PMBJP) told Blue Circle Diabetes Foundation that awareness about Jan Aushadhi Kendras is slowly increasing and in May 2022 for the first time sales crossed 100 crore, thereby saving 600 crore for citizens & minimising their out of pocket expenditure. The government plans to open 10,000 kendras by 2025. Regarding diabetes related medication they also mentioned that as and when drugs go off patent, their generics are included; for example in the last quarter of 2021, Sitagliptin and Vildagliptin used for type 2 diabetes were included as generics since they went off patent.

Pricing

Generic medicines are undoubtedly cheaper than the branded medicines (upto 50-90%) & that is their biggest USP in a price sensitive market such as India, where all expenses are out of pocket for people living with diabetes.

Want to know more about insurance & diabetes in India? Watch our Facebook Live.

Efficacy, is it safe?

Absolutely. In the case of insulins as long as the cold chain is maintained there should not be a problem. We tend to assume expensive things come with higher quality even if there is no evidence to prove it. It makes sense to question, seek answers, compare compositions & then decide.

The official representative from Pradhan Mantri Bhartiya Jan Aushadhi Pariyojana (PMBJP) reassured Blue Circle Diabetes Foundation that all medicines are dual tested and WHO-GMP & NABL certified. If any manufacturer doesn't follow the stringent process, they are de-barred.

Availability

There are over 8600 Jan Aushadhi Kendras spread across India so you shouldn't have much trouble finding one in your city/town. A simple google search will show you the Jan Aushadhi Kendras near you (you could also check on the Jan Aushadhi Sugam mobile app). The product basket comprises 1616 drugs and 250 surgical equipments.

Our friends with type 2 diabetes & anyone who uses oral medication for diabetes can also explore the different options available. In fact our community members living with type 2 diabetes also gave us positive feedback for generic medicines such as Glimperide, Metformin & cholesterol meds.

These are the insulins available at the kendras. You will have to visit a kendra near you to confirm the actual availability of specific insulins.

Packaging

Glargine is available only in cartridges. Regular 40 iu insulin is available in vials as are the mixed insulins. All medicines & glucometers are clearly labelled & come with standard user manuals & package inserts.

Incidentally, Glargine available at the kendras is manufactured by Biocon. An official representative from global biopharmaceutical Biocon, which is an Indian company working in 120 countries, told Blue Circle Diabetes Foundation that the company is working on life saving drugs that are also cost saving for people with various medical conditions & that they have served 1.7 million people with diabetes in India & 5.5 million people globally through their biosimilars. They mentioned they develop one global quality product & not separate products for India and the rest of the world.

In 2021 Biocon received marketing authorisation approval from the European Commission to launch an aspart biosimilar in the EU & the European Economic Area countries, Iceland, Liechtenstein and Norway. While this insulin also got approval in India, the recent controversy is likely to extend our wait for this affordable rapid acting insulin.

Nupur's experience

I have been wanting to try generic insulins before suggesting them to friends and our larger community. I've been type 1 diabetic since the past 27 years. At the time of publishing this article, I have used generic insulin for almost 9 months (on syringes) and my latest A1c has been 5.6 (largely thanks to low carb) so it definitely hasn't negatively impacted my sugars. I am sharing this because I know the effectiveness of generic insulins is of concern to a lot of people.

I have used an insulin pump for some years and now I'm on MDI (Multiple Daily Injections) through syringes which I find pretty convenient (I have actually never used an insulin pen yet!). I have been using Glargine (as basal) with the 100 iu syringes and have not had any issues yet. I haven't yet found Regular insulin 100iu in the 2 Jan Aushadhi Kendras I checked out, they only stocked Regular 40iu, so I haven't been able to try any other generic insulin yet.

Incidentally, Regular insulin works beautifully with low carb foods. Click here to read about myths associated with low carb & click here to read a lot more articles about low carb, including recipes. You can also find recipes on the Blue Circle Diabetes mobile app under 'Recipes' (download on Android & iOS) & by using the search function on our Facebook community too. Low carb and low cost can be a winning combination, here's some proof-

PSA- 40iu and 100iu are different potencies and must be used with different syringes. 40iu insulin is compatible with the red cap 40iu syringe and 100iu insulin is compatible with the orange cap 100iu syringe. This is super important to know because if you use insulin with the wrong syringe, you could essentially be giving yourself 2.5 times more or less insulin, both of which can be a disaster!

Interested in knowing why some prefer MDI over insulin pumps? Read Sunil's experience of why their family made the choice for their daughter with type 1 diabetes.

One of the drawbacks (not complaining, but..) is that there is no home delivery of course. In the past, I have used services like Dunzo to have my meds delivered home.

My experience with the Jan Aushadhi Kendra glucometer was that it is easy to use & affordable. The meter comes in a hard plastic container, with 25 lancets (which will last me a lifetime!), control solution, a lancing device and a battery which you need to put into the meter before using it. The carton also comes with a User Manual (only in English, no other languages) & a warranty card that you can fill and return to avail a lifetime replacement! It would be nice if the bottle of strips fit into the white case too. It would also be convenient to be able to buy 100 strips without having to buy 4 bottles of 25 but hey I'm not complaining because the price remains the same. I bought the glucometer for Rs 525 & got 25 strips free. The cost for 25 strips is Rs 225 which works out to Rs 9 per strip. Perhaps they could consider selling 50 or 100 strips for a cheaper price.

Diabetes makes us all 'scientists' & I excitedly ran a little experiment/comparison with every glucometer/sensor I owned to see how the new glucometer fares & I think it did okay. I haven't used it long enough to make more observations yet.

Snehal's experience

I have being living with type 1 diabetes since 20 years now. I am on MDI (Multiple Daily Injections) & I use 3 types of insulin on everyday basis- Actrapid (bolus) with syringe, Novorapid (bolus) with pen and Lantus (basal) with pen.

I went to the nearest Jan Aushadhi Kendra here in Mumbai which I easily found on Google. I chatted with the lady on the counter about diabetes related things & she seemed pretty interested in how I manage my sugars, overall a good experience! I bought the 40iu Regular insulin vials (which is same as Actrapid) & 100iu Glargine insulin cartridges (which is same as Lantus) & I have been using them since almost 8 months now. Both these insulins have worked wonderfully well & my latest HbA1c was 6.2, so I know they are as effective as the branded insulins.

I really went all out when I was testing the generic insulins- the action start time & the impact on blood sugars with different food items and exercises. I found that the generic insulins worked exactly the same as the branded ones. In fact, I noticed that the generic Regular insulin started working in about 30 mins after injecting whereas Actrapid took anywhere between 45mins to 1 hour to start acting in my body. This means less waiting time so that's a big yess!! Glargine worked same as Lantus. I tested this by doing basal testing & my blood sugars stayed in range. The 40iu Regular insulin vials don't come with the outer box as you get with Actrapid so you have to be little careful while carrying them.

FAQs

• Is it effective? Yes, please read the sections above. Also, this is a very common question on our Facebook community, Diabetes Support Network India. Use the search function on the top right of the Facebook page to search 'Jan Aushadhi' or 'generic' medicines and read other people's experiences too.
• Which generic insulins are available at Jan Aushadhi Kendras? Glargine, Regular, NPH & mixed insulins.
• Is there a generic available for Novorapid, Apidra, Humalog, Fiasp etc? No, not yet. There are no generics available yet for analogue insulins. Once their patents expire (likely in 2023 for aspart), generic manufacturing will start.
• Is Glargine available in vials or cartridges? Cartridges only but you can use them with pens and syringes both. See this video to know how to save insulin when your insulin pen seems like it's over.
• Can I use the Lantus Solostar pen with the generic Glargine cartridge? It has worked fine for some of our friends, you can try too.

Pros

• Inexpensive
• Fairly large number of kendras (and growing)
• As effective as branded medication

Cons

• Less awareness about these facilities among the public
• Availability issues for certain medicines
• Myths about generic medicines being less effective

Video review

Lesser priced glucometers

Another common question on our Facebook community is about inexpensive and reliable glucometers. We did some glucometer reviews & comparisons which you can read here (for Dr Morepen, Freestyle Optium Neo H & Ypsomed Pura X glucometers) here (for Accu Chek Active & Alere G1 glucometers) and here (BeatO).

What matters is the (recurring) cost of strips, not the cost of the glucometer

Here's a non-exhaustive list of glucometers in random order, where the strips are priced between Rs 7 to Rs 9 per strip (look on different online platforms to find the best price, prices are dynamic for some) -

• Jan Aushadhi Kendra glucometers (available in the physical kendras only)
• Alere G1
• Dr Morepen
• Freestyle Optium Neo H

If you want to know personal experiences, recommendations etc use the search function on the top right on Diabetes Support Network India.

Here are some video tutorials in multiple languages to learn how to use a glucometer- see in English, Hindi, Marathi, Gujarati, Kannada, Punjabi, Tamil, Malayalam, Sindhi, Bengali, even Swahili - there's no reason to not test your sugars!

Lesser priced CGMs

Continuous Glucose Monitors (CGMs) are medical devices which are injected onto the body and show your blood sugars (pretty much) in real time, every few minutes. They don't completely replace glucometers but are an excellent tool to closely monitor blood sugar levels, trends and understand the impact of various foods, exercise, hormones, etc to be able to self manage any type of diabetes effectively.

In India, there are 3 types of CGMs/FGMs (Flash Glucose Monitors) apart from those that come along with some insulin pumps-

• Freestyle Libre Pro (FGM)- least priced- read the blog & watch the video
• Freestyle Libre (FGM)- the only one available OTC, on Amazon etc- read the blog & watch the video
• Medtronic Guardian Connect (CGM)- read the blog & watch the video

Apart from the Libre, all other options are available through your physician and or company representative. Click here to see all of the CGM (& transmitter) related information in one place. The visual below explains the difference between Libre & Libre Pro. If you want to know personal experiences, recommendations etc use the search function on the top right on Diabetes Support Network India -

Financial burdens & Mental Health

There is no easy way to say this but living with or caring for someone with any type of diabetes is not easy. You must balance trying to stay alive & thrive between the hypo and hyper lines and you must find a way to live normally, while paying for all your medications, insulin, CGMs etc and all of this obviously takes a toll on one's mental health.

If you are depressed, distressed or just want to vent to someone who 'gets it', please do not hesitate to schedule a call our Buddy Project Helpline, which is a diabetes + mental health, multilingual, app based, psychosocial helpline run by trained volunteers living with different types of diabetes. These are our amazing buddies-

How to call the Buddy Project helpline

The Buddy Project Helpline started during Covid-19 and continues to be a diabetes & mental health support system & helpline, free of cost and open to anyone with any type of diabetes & their caregivers. Mental health support in no way replaces the financial burden of diabetes but we hope our helpline makes it a little better for you.

Open the Blue Circle Diabetes app > Buddy Project > Schedule tab > pick a buddy of your choice > Schedule a call (once you schedule you'll see it under the 'Meetings' tab > 10 minutes prior to the call, you'll receive an app notification/reminder > To join the call, open the app, go to Buddy Project & under the 'Meetings' tab, press the 'Join' button (video is off by default, can switch on as per preference). Please note, the calendar availability of buddies is currently in IST (Indian time) only, so if you are not located in India you need to manually consider the time difference or temporarily switch your phone time in Settings to IST to schedule a buddy call.

100 years on..

In 1923, Banting, Best & Collip sold the patent for insulin to the University of Toronto for $1 each, hoping that insulin would be accessible to everyone. Hundred years on, people are being forced to ration insulin & are dying from its unavailability due to not only the high prices but also the lack of knowledge about effective & inexpensive options. Knowledge is power & being able to make an informed choice about one's own healthcare can be life-changing. Effectively involving patients in their own care has known to improve health outcomes, cut costs & even benefit clinicians!

This article hopes to explore diabetes on a budget in India, tried & tested!

Banting is famously known to have said-

Insulin belongs to the world, not to me

As patient advocates & people living with various types of diabetes, we appeal for Universal Health Coverage and Health for All! Everyone deserves the right to affordable & accessible healthcare.

*Disclaimer : Speak to your healthcare provider before making any changes to your insulin regime. The authors live with type 1 diabetes themselves & are Certified Diabetes Educators sharing their personal experience, not be taken as medical advice.