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There is much public debate regarding the high cost of insulin. With 1-in-4 patients in the United States with type 1 diabetes reporting difficulties affording insulin, there is concern that some of these patients might look for cost savings on the internet, unaware that 96% of internet pharmacies are illegitimate. Patients who purchase insulin from illegitimate internet pharmacies remove themselves from traditional health care systems that ensure safe, quality-assured, and effective medication use.
This study aims to determine the accessibility of Humalog and NovoLog insulin from internet pharmacies and characterize how these sites approached patient safety, and priced as well as marketed their products.
From September to December 2019, we queried the phrases
We found that 59% (n=29) of the 49 internet pharmacies in our analysis were illegitimate, whereas only 14% (n=7) were legitimate and 27% (n=13) were unclassified. Across illegitimate internet pharmacies, Humalog and NovoLog insulin were 2 to 5 times cheaper as compared with both legitimate internet pharmacies and brick-and-mortar stores. Risks associated with the use of illegitimate internet pharmacies by American consumers were evident: 57% (8/14) did not require a prescription, 43% (6/14) did not display medication information or warnings, and only 21% (3/14) offered access to purported pharmacists. This included 9 rogue internet pharmacies that sold Humalog and NovoLog insulin within the United States, where 11% (1/9) required a prescription, 11% (1/9) placed quantity limits per purchase, and none offered pharmacist services. Rogue internet pharmacies often offered bulk discounts (11/18, 61%), assured privacy (14/18, 78%), and promoted other products alongside insulin (13/18, 72%). The marketing language of illegitimate internet pharmacies appealed more to quality, safety, and customer service as compared with legitimate sites.
The ease of access to low-cost insulin through illegitimate internet pharmacies calls for urgent attention. Illegitimate internet pharmacies place patients at risk of poor-quality medications and subpar pharmacy services, resulting in adverse events and poor diabetes control. A multifaceted approach is needed to close illegitimate internet pharmacies through legal and regulatory measures, develop better search engine filters, raise public awareness of the dangers of illegitimate internet pharmacies, and address the high costs of insulin.
For patients with type 1 or type 2 advanced diabetes, insulin is the cornerstone of therapy. Furthermore, 1 in 10 Americans (around 34.2 million people) have diabetes, with nearly 1.6 million living with type 1 diabetes [
Increasingly, rising costs unique to the US market have hindered access to insulin for patients [
Internet pharmacies are a popular destination for the purchase of prescription drugs, with 30,000 to 35,000 internet pharmacies accessible in 2016 [
Beyond concerns related to medication quality, there is also concern regarding the lack of services offered by illegitimate internet pharmacies [
The accessibility of rapid-acting insulins from illegitimate internet pharmacies could pose a threat to patient safety. We investigated the availability of Humalog and NovoLog insulin from internet pharmacies through common search engines and documented the website’s safety and marketing characteristics, as well as the costs of Humalog and NovoLog insulin.
Humalog and NovoLog were chosen for our analysis because of their relatively recent approval by the US Food and Drug Administration (FDA), high list prices, and their outsized role in the discussion of medication pricing in the United States [
The legitimacy of websites was assessed using LegitScript, which classifies pharmacies according to licensure or registration in affiliated jurisdictions, sale of controlled substances, previous discipline, requirement of valid prescription, protection of privacy, patient services offered, transparency, and domain name registration [
The average monthly traffic to website domains defined as unique visits from any country was obtained from SimilarWeb [
Costs of Humalog and NovoLog 100 IU/mL insulin at the most frequently sold dosage forms (ie, 1×10-mL vials, 5×3-mL pens, 5×3-mL cartridges) were collected from a subset of internet pharmacies offering to ship within the United States. Prices per mL of 100 IU/mL Humalog and NovoLog insulin for vials, pens, and cartridges were calculated. The shipping costs and bulk discounts were not considered in the cost calculations. Internet pharmacy prices were compared with prices offered through GoodRx, a drug coupon website. GoodRx prices are representative of out-of-pocket prices that uninsured US patients might pay at brick-and-mortar stores. Average prices at brick-and-mortar stores were obtained from GoodRx on April 30, 2020. Costs were averaged by legitimacy of internet pharmacies among websites selling Humalog and NovoLog pens that offered US shipping.
Marketing characteristics were selected based on previous literature, and the analysis focused on internet pharmacies classified by LegitScript [
We qualitatively analyzed the website marketing language by collecting texts from the homepages of all included internet pharmacies. After initially reading through the texts to identify the most common marketing language, we selected and defined 6 characteristics. Texts were then screened to assess whether these six characteristics were discussed: (1) quality, (2) safety, (3) customer service, (4) reputability, (5) affordability, and (6) convenience. Quotes representative of each characteristic were collected by legitimacy of internet pharmacies.
Safety characteristics were selected based on previous literature and focused on internet pharmacies classified by LegitScript [
We screened 300 websites and identified a total of 49 internet pharmacies that claimed to sell Humalog or NovoLog insulin. Of the internet pharmacies, LegitScript classified 59% (29/49) as illegitimate, including 37% (18/49) as rogue and 22% (11/49) as unapproved, whereas 14% (7/49) were legitimate and 27% (13/49) were unclassified. The listed locations of these internet pharmacies differed, with 41% (12/29, all rogue sites) of illegitimate internet pharmacies advertising no location. Of the 29 illegitimate internet pharmacies, 52% (15, 4 rogue and 11 unapproved sites) advertised a Canadian location. The remaining illegitimate internet pharmacies claimed to be located in Great Britain (1/29, 3%) or in Europe (1/29, 3%). No illegitimate internet pharmacies advertised a US location. For legitimate internet pharmacies, 43% (3/7) advertised locations in the United States, 29% (2/7) in Australia, 14% (1/7) in Canada, and 14% (1/7) in India. The majority (4/7, 57%) of legitimate internet pharmacies’ physical locations listed on their websites matched those of their server locations. In contrast, physical and server locations matched only 27% (3/11) of the time among unapproved internet pharmacies. None of the physical and server locations matched among the 18 rogue internet pharmacies.
Traffic to internet pharmacies, as determined by SimilarWeb [
The costs of Humalog and NovoLog insulin vials, pens, and cartridges were recorded only for internet pharmacies shipping within the United States (n=22). The most commonly sold volume and strength of the insulin vials were 10 mL at 100 IU/mL. Humalog and NovoLog insulin 3 mL pens and 3 mL cartridges were most often sold in packages containing a quantity of 5, which is in alignment with product packaging available from brick-and-mortar pharmacies. The cost per mL of 100 IU/mL insulin varied depending on the legitimacy of the internet pharmacies. For rogue internet pharmacies, the average costs of insulin varied depending on dosage forms: Humalog vials cost US $11.30 (n=1), Humalog pens cost US $7.84 (n=4), and Humalog cartridges cost US $10.04 (n=4), whereas NovoLog vials cost US $5.90 (n=2), NovoLog pens cost US $8.47 (n=7), and NovoLog cartridges cost US $8.00 (n=3). Costs were similarly low in unapproved and unclassified internet pharmacies.
For legitimate internet pharmacies, the average costs of insulin (without insurance) were two- to five-fold higher: Humalog vials cost US $31.51 (n=2) and Humalog pens cost US $38.89 (n=2), whereas Humalog cartridges were not available; meanwhile NovoLog vials cost US $32.77 (n=2), NovoLog pens cost US $40.77 (n=2), and NovoLog cartridges cost US $38.47 (n=2). Compared with illegitimate pharmacies, GoodRx costs—representative of average costs at brick-and-mortar pharmacies—were also approximately 2 to 5 times more expensive. However, compared with the cost of legitimate internet pharmacies for uninsured patients excluding shipping costs, GoodRx prices were marginally cheaper: Humalog vials cost US $17.22, Humalog pens cost US $21.83, and Humalog cartridges cost US $34.13, whereas NovoLog vials cost US $29.38, NovoLog pens cost US $37.31, and NovoLog cartridges cost US $35.90. The difference in costs per mL of Humalog and NovoLog insulin pens (the most common dosage form in our analysis) depending on the source is depicted in
Costs of Humalog and NovoLog insulin pens available in the United States on the internet and at brick-and-mortar stores.
The marketing characteristics of internet pharmacies selling Humalog and NovoLog insulin and classified by LegitScript (N=36) are described in
Marketing characteristics of internet pharmacies selling Humalog or NovoLoga.
Characteristics | Rogue (n=18), n (%) | Unapproved (n=11), n (%) | Legitimate (n=7), n (%) | ||||||||
|
Yes | No | Not reported | Yes | No | Not reported | Yes | No | Not reported | ||
US shipping of insulin | 9 (50) | 9 (50) | 0 (0) | 5 (45) | 6 (55) | 0 (0) | 3 (43) | 4 (57) | 0 (0) | ||
Bulk discounts | 11 (61) | 5 (28) | 2 (11) | 2 (18) | 8 (73) | 1 (9) | 2 (29) | 5 (71) | 0 (0) | ||
Coupons | 9 (50) | 8 (44) | 1 (6) | 2 (18) | 9 (82) | 0 (0) | 4 (57) | 3 (43) | 0 (0) | ||
Registration claims | 8 (44) | 10 (56) | 0 (0) | 10 (91) | 1 (9) | 0 (0) | 6 (86) | 1 (14) | 0 (0) | ||
Privacy assurances | 14 (78) | 4 (22) | 0 (0) | 8 (73) | 3 (27) | 0 (0) | 1 (14) | 6 (86) | 0 (0) | ||
Customer testimonies | 10 (56) | 8 (44) | 0 (0) | 7 (64) | 4 (36) | 0 (0) | 3 (43) | 4 (57) | 0 (0) | ||
Offer to speak with associate | 18 (100) | 0 (0) | 0 (0) | 9 (82) | 2 (18) | 0 (0) | 6 (86) | 1 (14) | 0 (0) | ||
Phone number | 7 (39) | 11 (61) | 0 (0) | 11 (100) | 0 (0) | 0 (0) | 7 (100) | 0 (0) | 0 (0) | ||
Insulin-specific advertisements | 0 (0) | 18 (100) | 0 (0) | 3 (27) | 8 (73) | 0 (0) | 0 (0) | 7 (100) | 0 (0) | ||
Advertisements for other products on page selling insulin | 13 (72) | 5 (28) | 0 (0) | 1 (9) | 10 (91) | 0 (0) | 4 (57) | 1 (14) | 2 (29) |
aIllustrates marketing characteristics of 36 websites selling Humalog or NovoLog. This table does not include 13 internet pharmacies selling Humalog or NovoLog insulin that were not classified by LegitScript.
Marketing language from website homepages differed according to the legitimacy of internet pharmacies, particularly for quality, safety, and customer service. Although 83% (24/29) of illegitimate internet pharmacies appealed to quality, only 29% (2/7) of legitimate internet pharmacies used language that suggest the quality of medication or services. Marketing language appealing to safety (19/29, 66% illegitimate vs 1/7, 14% legitimate) and customer service (24/29, 83% vs 4/7, 57%) were also more common among illegitimate internet pharmacies. The frequency of use of marketing language was similar among reputability (16/29, 55% vs 4/7, 57%), affordability (24/29, 83% vs 5/7, 71%), and convenience (22/29, 76% vs 5/7, 71%). Differences in marketing language are also demonstrated through the selection of quotes in
If you are looking to buy your prescription drugs in Canada, through a reputable international or online Canadian pharmacy, [our online pharmacy] provides you access to a trusted source of affordable and safe prescription drugs.
Types of marketing language used on the home pages of internet pharmacies.
Characteristics | Description | Illegitimate (n=29) | Legitimate (n=7) | ||
|
|
Values, n (%) | Selected quotea | Values, n (%) | Selected quote |
Quality | Language suggesting quality of medication or services | 24 (83) | “We guarantee that all [medications] for sale on this site are 100% genuine and extremely powerful.” | 2 (29) | “[We] offer you quality care...” |
Safety | Language explicitly referring to the safety of medication products, internet ordering platform, or other services | 19 (66) | “When it comes to your health, we know that safety is your number one concern. It’s ours too.” | 1 (14) | “Besides delivering medicines at your doorstep, we...help people use their medicines effectively and safely.” |
Customer service | Language suggesting availability of staff to answer questions or remedy problems | 24 (83) | “24/7 customer support (we are always at your disposal!).” | 4 (57) | “Customer service: get answers to your questions.” |
Reputability | Language suggesting renown in selling or accreditation to sell prescription drugs | 16 (55) | “[Our pharmacy] has a great reputation serving the community for 47 years and counting.” | 4 (57) | “Accredited and Certified in all 50 states.” |
Affordability | Language suggesting discounts or cheap prescription drugs | 24 (83) | “[We] provide the same insulin that’s available in the US except our prices are much lower, and we pass on the savings to you.” | 5 (71) | “At [our pharmacy], you can buy health products and medicines online at best discounts.” |
Convenience | Language suggesting ease of internet pharmacy use or prescription drug purchase; fast delivery or services that allow for time savings | 22 (76) | “The process of payment through Bitcoin is simple. You need to go through only a few steps to quickly confirm and complete your order.” | 5 (71) | “You get the convenience of online shopping combined with the support and guidance of our dedicated team.” |
aQuotes were taken directly from internet pharmacy websites.
The safety characteristics of internet pharmacies selling Humalog and NovoLog insulin within the United States and classified by LegitScript (N=17) are described in
Data were unavailable for one legitimate internet pharmacy regarding whether pharmacist services were offered (where member registration was required). Not all legitimate internet pharmacies were accredited through the NABP because of geography. However, legitimate internet pharmacies required or displayed characteristics consistent with best internet pharmacy communication practices, such as requiring pharmacists to offer individual, meaningful consultations [
Safety characteristics of internet pharmacies selling Humalog or NovoLog insulin in the United States.
Safety characteristics | Rogue (n=9), n (%) | Unapproved (n=5), n (%) | Legitimate (n=3), n (%) | ||||||||
|
Yes | No | Not reported | Yes | No | Not reported | Yes | No | Not reported | ||
Prescription required | 1 (11) | 8 (89) | 0 (0) | 5 (100) | 0 (0) | 0 (0) | 3 (100) | 0 (0) | 0 (0) | ||
Offer to speak with pharmacist | 0 (0) | 9 (100) | 0 (0) | 3 (60) | 2 (40) | 0 (0) | 2 (67) | 0 (0) | 1 (33)a | ||
Medication precautions on product page | 6 (67) | 3 (33) | 0 (0) | 2 (40) | 3 (60) | 0 (0) | 3 (100) | 0 (0) | 0 (0) | ||
Medication information on product page | 6 (67) | 3 (33) | 0 (0) | 2 (40) | 3 (60) | 0 (0) | 3 (100) | 0 (0) | 0 (0) | ||
Quantity control | 1 (11) | 8 (89) | 0 (0) | 5 (100) | 0 (0) | 0 (0) | 3 (100) | 0 (0) | 0 (0) | ||
Lists a physical location | 4 (44) | 5 (56) | 0 (0) | 5 (100) | 0 (0) | 0 (0) | 3 (100) | 0 (0) | 0 (0) | ||
Location listed on website and location of server match | 0 (0) | 9 (100) | 0 (0) | 2 (40) | 3 (60) | 0 (0) | 3 (100) | 0 (0) | 0 (0) |
aOne legitimate pharmacy required an account to gain access to services. Overall, 5 internet pharmacies selling Humalog or NovoLog insulin in the United States were not classified using LegitScript.
Our analysis demonstrates that both Humalog and NovoLog insulin are readily available from internet pharmacies that engage in illegal sales of prescription drugs. Illegitimate internet pharmacies were found to be abundant using common search engines, outnumbering legitimate internet pharmacies. Of the internet pharmacies included in our analysis, nearly 60% (29/49) were illegitimate, whereas only 14% (7/49) were legitimate (with the remainder unclassified). The widespread availability of illegitimate internet pharmacies poses a threat to unsuspecting consumers and provides easy access to those seeking insulin without a prescription [
In the United States, rising list prices on rapid-acting insulin analogs such as Humalog and NovoLog insulin have resulted in a substantial cost burden for patients with diabetes. Legislative initiatives to curb insulin costs include, among others, setting out-of-pocket maximums and allowing personal drug importation. However, these reforms have only been trialed in some states, and the legality of the personal importation of insulin remains contentious [
With financial pressure, some patients who need insulin to manage their diabetes have resorted to illegal activities such as borrowing insulin, importing insulin from lower-cost countries, or purchasing insulin from illegitimate internet pharmacies [
Although costs are lower for Humalog and NovoLog insulin from illegitimate internet pharmacies, they remain illegal because of the serious risks associated with their use. Humalog and NovoLog insulin are high-risk medications that require both therapeutic monitoring to ensure optimal short- and long-term outcomes and sufficient counseling for the prevention of adverse events such as hypoglycemia. Between 2007 and 2009, nearly 20% of emergency hospitalizations for the treatment of emergent adverse events were because of insulin [
Our analysis demonstrates that illegitimate internet pharmacies, particularly rogue internet pharmacies, do not offer pharmacy services that are on-par with those offered through legitimate internet pharmacies. The majority (8/9, 89%) of rogue internet pharmacies allowed the purchase of Humalog or NovoLog insulin in the United States without a prescription, precluding the involvement of health care professionals in patient care. Further preventing communication with health care professionals, no rogue internet pharmacies made the offer to speak with pharmacists. On illegitimate internet pharmacy websites, patients were often left without medication information and drug-related warnings and precautions. Illegitimate internet pharmacies, with rogue internet pharmacies being the worst offenders, allow patients to access Humalog and NovoLog insulin with minimal information, predisposing these patients to poor diabetes control and potential development of adverse events.
There is also concern as to whether the quality of insulin obtained from illegitimate internet pharmacies is comparable with that obtained from legitimate internet pharmacies. Low costs offered through illegitimate internet pharmacies could suggest less stringent cold chain shipping methods or lower-quality medications. Although our analysis did not collect information on the quality of Humalog and NovoLog insulin obtained from illegitimate internet pharmacies, substandard and falsified medicines are globally prevalent [
National organizations are combating the proliferation of illegitimate internet pharmacies. The FDA’s BeSafeRx campaign and the Alliance for Safe Online Pharmacies’
Regulatory and legal actions are ongoing against illegitimate internet pharmacies. Operation Pangea, an effort led by Interpol in conjunction with the FDA and US Department of Justice, has resulted in the removal of thousands of illegitimate internet pharmacies [
Given that patients with diabetes are frequently counseled on the management of their disease, health care providers such as physicians and pharmacists are uniquely positioned to lead the charge in making consumers aware of the risks of acquiring insulin from illegitimate internet pharmacies.
The limitations of our study include the small sample size and the cross-sectional design. However, our screening methods were consistent with what US consumers purchasing insulin on the internet might experience. An additional limitation is that we did not analyze the quality of products available from internet pharmacies, precluding conclusions pertaining to medication quality. We did not purchase medications from these websites because we questioned the ethical implications of financially supporting the operations of illegitimate internet pharmacies. Our analysis was conducted before the COVID-19 pandemic. We believe our results are even more relevant now as internet purchases have become commonplace in the United States [
The relatively low costs of Humalog and NovoLog insulin from easily accessible illegitimate internet pharmacies place patients at risk. Although the elimination of illegitimate internet pharmacies would be the gold standard way to reduce their risk to patients, illegitimate internet pharmacies are elusive. Governmental agencies should continue to pursue legal and regulatory measures with the intent of closing illegitimate internet pharmacies. Search engines should work to filter their results better, decreasing the visibility of illegitimate internet pharmacies. Finally, although public awareness campaigns and provider-to-patient efforts can bring attention to the dangers of illegitimate internet pharmacies, they do not address the reasons that patients may visit these sites. With patient safety in mind, US legislators and members of the pharmaceutical supply chain should work to lower the costs of insulin, thereby diminishing patients’ incentive to purchase from illegitimate internet pharmacies.
Food and Drug Administration
National Association of Boards of Pharmacy
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
The authors thank the directors and coordinators of the Research and Scholarship in Pharmacy (RASP) pathway at the UNC Eshelman School of Pharmacy for their guidance and support. The authors also thank Colleen Higgins on the Global Health Economics for Pharmacy (GHEP) team for her contributions.
BP was involved in the methodology, investigation, data curation, and writing of the original draft; LM was associated with methodology and writing, reviewing, and editing; HHC was involved with methodology, writing, reviewing, and editing; SE was involved with methodology, writing, reviewing, and editing; SO was associated with conceptualization, methodology, supervision, writing, reviewing, and editing.
None declared.