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babyjakes · 3 years ago

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forever and a day | 7. something important to save.

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summary | a story in which america’s favorite captain gives a new life and family to a five-year-old girl who has suffered well beyond her years at the hands of hydra.

characters | dad!steve rogers, girl/willa rogers (original character)

warnings | AU similar enough to OU to include spoilers to many Marvel movies (Age of Ultron and beyond). mature themes related to child abuse/neglect. mentions of past CSA. medical abuse. ptsd/trauma symptoms in a child (developmental discrepancies, de-humanized behavior, detachment, extreme fears). medical treatment of CSM. somewhat evil!Tony Stark (eventually)

[Steve]

Girl’s teeth begin to chatter as we stand in front of the closed elevator doors, waiting for it to drop back down to our level. Eyeing the lit-up button on the panel in front of her, the little one tilts her head, not seeming to understand. “We’re just waiting for the elevator,” I explain, “it’ll take us up to the place where we live.”

The Avengers tower is a monster, totaling in at an impressive fifty floors, though I’ve honestly never been on most of them. We only use the top few levels; that’s where our living quarters are. We have access to a training facility, too, and Tony and Bruce have a floor designated to lab work.

“We live all the way up on the fiftieth floor!” Peter tells the little girl enthusiastically. Her eyes grow wide at his comment, and I can’t tell if she’s intrigued by it or just more anxious now than she was before.

As soon as the elevator bell rings, the large metal doors slide open in front of us, revealing the car that’s thankfully empty. We all pile in, and I take to rubbing Girl’s back gently as the doors close. Someone scans their hand and presses the button for the top floor, and I feel Girl beginning to tremble slightly against me. Looking down at her, her eyes meet mine, glittering with tears. “You’re alright, bub,” I promise her, “we won’t have to be in here for too long at all.”

As we shoot up through the shaft, the whole group is strangely quiet. After the normal two minutes or so, the bell sounds again, and the doors open. I’m the first to walk out, straight into the living area. Looking around sheepishly, the little girl in my arms seems to be fascinated by the sight before her.

“Welcome home, Girl,” Natasha says gently as she pauses beside us. The others are quick to settle themselves in; Tony, Bruce, Thor, and Clint all settle in on the large sectional in front of the television, while Wanda takes an armchair, along with Peter. The exhaustion from the mission and the travel is clear on everyone’s faces, though I’m not surprised since it tends to be like this whenever we come back from big assignments.

“You know, some of us are gonna have to go take care of the cargo we still have on the ship,” Bruce comments.

“Nose goes,” Tony says, quickly bringing his finger to his nose.

“Quit being a baby,” Nat teases back at him, “no one else is gonna-”

“I-I’m doing it, Mr. Stark,” Peter chirps up nervously, shooting up his hand to copy his mentor. As Tony gives Peter an air-five, a few of the grumpy faces around the room form into smiles.

“I can go back down. Thor, Wanda. How about you guys come too? It can’t take more than the three of us,” Clint offers.

“But I want pizza!” Thor complains, causing me to roll my eyes at the six-foot-something-man-child.

“We can order pizza while you’re down there. We’ll let you know as soon as it gets here,” I reason with him, feeling like I’m trying to sate a toddler. Sighing, the god nods, standing. Clint and Wanda rise as well, and together they head back towards the elevator. Looking down at Girl who’s still resting quietly in my arms, I ask, “You wanna find somewhere to sit in here?” The child looks around warily before dropping her gaze to the ground, clearly not knowing what to say. I offer her a kind smile and glance around as well, trying to see if there’s anywhere that might be nice for her to settle in.

“I had Peter and Wanda fix up the spare room at the end of the hallway,” Tony says to me, and I give him a nod. “Obviously we can, um… decorate, and stuff, too. I just figured we would want to have the basics covered.”

“We should probably get her in a bed,” Bruce adds. “We can bring her down to medbay, or I guess we could probably accommodate her in the room Peter and Wanda worked on, too.”

“The latter sounds like a better idea,” I decide, not wanting her to become frightened by being brought into a place that looks like what Hydra might have had in their labs.

“Sure. Why don’t you bring her down there, and I’ll grab some stuff from downstairs for monitoring her,” Bruce agrees, rising to his feet. I nod, offering a small wave to everyone in the room before walking over to the archway that leads to the hall.

“This is where all of our rooms are,” I tell her as we walk down the long hallway. When we finally reach the end, I point to the door that’s cracked slightly open. “This was our spare room. But now it belongs to you,” I explain. “This one next to it is mine. And the one here, across from it, is Tony’s.” She nods as I point, seeming perplexed.

Reaching out, I swing the door open, revealing the simple bedroom. It’s got nothing more than the basics, but it’s definitely an upgrade from what the poor thing had in Hydra’s care. There’s a real bed, with big fluffy pillows and light yellow blankets. There are a nightstand and a dresser as well, along with a small desk by the window. There are two doors, one on either side of the bed. One leads to a bathroom, the other to a closet. I notice that the bed itself is new. There used to be just a queen-sized mattress on the floor, but it’s now been replaced by a much more appropriate twin-sized bed, complete with a bed frame, sheets, pillows, and blankets. On the desk, there are some books, and a new lamp has been placed on the nightstand.

Looking around, Girl seems to be completely taken aback by what she sees. “This is your room, Girl. What do you think?” I ask as I carry her over to the bed, pulling back the blankets and setting her down on the soft mattress. As gently as I can, I lift the covers back up and tuck them in just below her arms, letting them rest on top of the pastel yellow. The child looks at me with wide eyes as I take a seat next to her on the mattress, smiling at her. “This’ll be a much nicer place for you to live, don’t you think?” Clearly at a loss for words, Girl simply nods.

Soon, there’s a knock on the door, followed by it swinging back open to reveal Bruce who’s brought a metal cart along with him equipped various medical supplies. Girl lets out a soft whimper and cowers noticeably, causing Bruce’s expression to soften almost immediately. “Hey, I’ve got some things we can use for stabilization,” he tells us, rolling the cart over to the side of the bed. Pulling out a strange wire contraption, the doctor hooks it over the headboard of the bed, grabbing a bag of fluids and twisting it into place. As she watches him attach the tubing to the bag and prepare the needle, Girl’s big eyes fill with tears.

But just as I’m about to offer her some words of comfort, the door swings open yet again to reveal Peter, carrying a whole bunch of stuffed animals in a big cloth sack. I smile warmly at him as he enters the room, barely able to see us above all the little plushies he’s got in his arms. “Hey guys!” he greets happily, “I brought some stuffed animals for you, Girl! I didn’t know which would be your favorite, so I sort of just brought the whole bag!” Walking over, he swings the bag up onto the bed beyond Girl’s feet. I look back to see that the child is now fixated on the sack, peering curiously over at it.

“Do you have a favorite animal, sweetheart?” I ask her, wondering if she would even know many varieties of animals at all. She frowns slightly, only offering a silent shrug.

“Well lucky for you, I have a whole bunch of different kinds!” Peter says happily, walking around the bed and sitting on the other edge across from me. Reaching in, the teen begins to pull some out, one at a time. “Here’s a lion, and a dog, and a hippo, and a bunny, and oh, here’s a teddy bear,” he says. At his words, Girl’s eyes lock on the bear and Peter senses her interest, gently handing it over to her. She flinches, but takes it anyway, holding it out in front of her by its arms and looking at it carefully. “He’s a really soft one, too. You can have him, if you like. I bet he would love to be friends with you.”

But as Peter rambles on, I can tell that the child before us isn’t even listening to what he’s saying. As she stares at the bear with such intense longing, so strong that it almost hurts to watch, Girl’s head tilts slightly, her bottom lip falling open. It’s incredibly heartbreaking and humbling to see, such an innocent creature being given one of the many simple yet important things she was deprived of all her life. Slowly, she brings the bear in close to her, pressing her face up against its light brown tummy. Closing her eyes, she takes a deep breath in through her nose. Looking to both sides, I see that both Bruce and Peter have stopped what they were doing just to witness the little girl receiving the comfort of the bear as well.

After several more inhales into the bear’s stomach, Girl lowers it gently into her lap, holding onto it for dear life. She then looks up at Peter, and I can tell that she’s too frightened to speak, but the look in her eyes says “thank you”, and Peter understands, smiling at her brightly.

“Alright kiddo, we gotta get you back onto the fluid cycle,” Bruce’s soft voice cuts through the peaceful silence softly. To my disappointment, the calmness falls from her face immediately, her body cowers away from him, shaking.

“Hey, it won’t hurt you, remember?” I remind her, reaching out and tucking a section of hair behind her ear that’s fallen into her face.

“No poke, please no poke,” the poor thing whimpers, tears streaming down her cheeks before I can do anything more to stop them.

“Oh no- hey, i-it’s okay, Girl,” Peter intervenes quickly, clearly upset by the sight of his new friend crying. “I-I don’t like needles either, but Bruce is really good at them, and it’ll barely last a moment!”

Taking the girl’s little arm in his hand, Bruce wipes the underside of her wrist with an alcohol pad, and causing her breathing to become rapid. “I promise it’ll be real quick,” the man says says, his guilt written all over his face. Popping the cap off, he holds her arm still as she closes her eyes, her body curling up slightly. “Three, two, one, there.” Girl whimpers loudly when the needle is inserted, but Bruce quickly positions the catheter in her vein and pulls the needle back out, securing the tubing down and beginning the drip.

“See, sweetheart? That wasn’t so bad,” I try to soothe the little one gently, but she only frowns at me in response, looking down at her arm sadly.

Before anything more can be said, a knock on the door causes all of us to look up. As it opens slowly, Tony walks in slowly, looking like he’s worried he might be interrupting something. “Hey guys, the pizza’s on its way. Think I could talk with Spangles and Girl for a moment?” he asks.

“Alright, I just set her back up on fluids so she should be fine for now. I’ll come back in and take her vitals when you guys are done, or after dinner,” Bruce agrees. Peter stands, and the two of them make their way out of the room without another word. Nodding, Tony closes the door behind them, walking over and taking a seat where Peter was.

“Hey there, how’re you feeling?” he asks the little girl. Girl looks down at her hands, not saying anything. Sighing, I can tell that she’s still pretty scared of everyone. But she seems to be specifically wary of Tony, along with Thor, and maybe even Clint. “Looks like Peter brought you some friends! That’s fun; who’ve you got there?”

At the man’s question, Girl clings the bear closer to her body, looking up at Tony with watery eyes. His face drops instantly as she begins to beg, “Please don’t take it, p-please don’t.”

“Of course I won’t,” he tells her gently, shaking his head., “you can keep him. He seems pretty happy with you- hey. Oh, don’t cry,” he tries quickly, but he’s too late; the tears are now falling freely down Girl’s cheeks, her head lowered, little droplets falling into her lap. “Oh honey, I’m sorry. I won’t take your bear; I promise I won’t.” As I watch the heartbreaking scene play out before me, I realize that I’ve never seen Tony Stark looking this sad in my entire life.

“Does your little bear have a name?” I ask the small girl softly, hoping to change the focus slightly to something more positive.

Girl’s eyes flicker up at me, her mouth remaining closed as she fails to come up with an answer.. “I named my bear Teddy when I was little,” Tony says, catching onto my strategy. “Not too original of a name, but it fit nicely.”

“T-Teddy,” Girl repeats softly, causing Tony to smile at her with a nod.

“Yep, Teddy,” he breathes. “They’re called Teddy Bears, you know. I think they’re named after a president or something. But anyway, that’s why I named him Teddy. It’s a cute name, too. Very simple.”

“Teddy,” Girl says again, looking to her bear, then back up at us. Nodding, I offer her a warm smile.

“I think that’s a wonderful name,” I tell her. Seeming content with the decision, the child smiles a bit back at me.

After a few minutes of comfortable silence, Tony speaks up again. “Anyway, I wanted to talk to you guys about that thing I was working on earlier, you know- the thing Clint was ‘supervising.’” I nod, though Girl doesn’t seem to be catching on quite yet. “So, Girl, because you’re transitioning into being an American citizen, you have to have some people commit to looking after and caring for you. I talked with Child Services, and they said that if you stay here, you’ll need at least one legal guardian to claim you as their dependent, though their recommendation was that you have at least two. Cap, I just assumed naturally that you would be the first. You seem to have the closest bond to her.”

I nod, not taking even a moment to think twice about the decision. There’s no need for me to. I’ve already made my choice; I made as soon as those big green eyes met mine for the first time all the way back in Seoul and I realized the poor thing had no other person on the planet to call her own.

“And I… I know that this might sound crazy, but I talked with the others about it, and I think… I think I want to sign as the second one.”

I look at him, blinking.

Tony Stark? Wants to claim legal guardianship? Of a five year old little girl?

The first thing that comes to my mind is that, why yes. That does sound crazy. Not crazy, even. No. It’s much more than that. It’s just absolutely absurd.

But after the shock, my mind clears, and I think back to the look on his face when he first met Girl. And the way he was so heartbroken on the ship when she first was brought into the infirmary. And the way he looked so lovingly at her, the way he seemed absolutely destroyed when she got scared he would take away her bear. And I realize that though I never would have thought he would have the capacity to, Tony already seems to feel the same love and protectiveness over Girl as I do.

Taking a deep breath, I look into my friend’s eyes. “I think… there’s no one I’d rather do the job with,” I say finally. Tony’s expression fills with gratitude, and he smiles at me, a real, genuine smile, before turning back to Girl.

“What do you think?” he asks her.

Looking back and forth between the two of us a few times, Girl’s eyebrows furrow, and I can tell that she doesn’t quite understand everything that’s been presented to her.

“How do you feel about living here with us, Girl,” I ask her, “about having me and Tony to look after you?”

Taking another look at each of us, the little girl gulps. “S-scary,” she whimpers after a few moments, and my heart sinks. Looking over, I see that Tony’s absolutely crushed as well, but I have to remind myself that anyone offering to take her in would be terrifying.

“I know, sweetie, but I promise, it’ll get less scary over time. You can have a brand new life here, Girl. We just wanna give you a safe home, a-”

“A family,” Tony finishes for me.

“Not hurt Girl?” the child asks skeptically.

“Never, we would never hurt you,” I tell her.

“No one’s ever going to hurt you again, Girl. Not if we have any say in it,” Tony adds.

“Don’t shift Girl, please don’t.”

“No, we won’t do that, either,” Tony says. “Your powers are something that none of us truly understand, but we aren’t going to do what Hydra did to you. No one wants to hurt you here, kiddo. This is a safe place.”

Reaching out, Tony tries to touch the girl’s cheek, but she instinctively cowers, raising an arm above her head to shield her face. The devastation is clear as day on Tony’s face as she pleads weakly, “Don’t hit Girl, please don’t-”

“Hey, hey, easy,” the flustered man coos, setting a gentle hand on her arm, causing her to flinch. “It’s okay, Girl. You don’t have to hide. I’m not going to hit you; we don’t hit people here.”

“Honey, can you listen for a moment?” I try to reason. “I know this is scary for you, sweetheart, but please. Give us a chance. We only want what’s best for you, and this is the safest place in the world you could possibly be. It’s okay to be scared. It’s okay, really. We understand. Just please, please. Let us help you,” I beg.

Lowering her arms slowly, Girl looks at me with doubt in her eyes. But deep beneath the uncertainty, I can just barely pick out tiny glimmers of yearning. Longing. Hope. She opens her mouth to talk, but says nothing. After a few moments of silence, the little one just nods. Sighing in relief, I look her in the eyes.

“This is going to be a change for all of us, doll. We’ll go slow, make sure everything feels comfortable and safe, alright?” I promise her.

“We’re the Avengers,” Tony says with a small smile. “How hard could this possibly be? We save the world for a living.”

“Yeah,” I murmur, reaching out and brushing Girl’s rosy cheek as she sits before me. “But now, we have something even more important to save.”

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lashaygeoghegan-blog · 5 years ago

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freeyoutubelikesendo691-blog · 5 years ago

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type2diabetestreatments-blog · 8 years ago

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If you don’t take your multivitamin every day, it’s not the end of the world. But if you skip your insulin, you put your health at risk. Unfortunately, as the price of insulin rises, some people are forced to ask an impossible question: Do I make ends meet or buy the insulin I need?

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Switching from pricey analogs to the older, lower-priced human formulas may be an option for some people with diabetes. But does the lower price of human insulin offset potential drawbacks?

Human Era

To understand the term “human insulin,” you have to consider the history of insulin production, says Evan Sisson, PharmD, MSHA, CDE, FAADE, an associate professor at Virginia Commonwealth University School of Pharmacy and a spokesman for the American Association of Diabetes Educators. “When insulin was first purified to be used in humans, it was actually coming from animal products,” he says. As cows and pigs were slaughtered, workers would save the pancreases. Once two tons of pig parts were collected, they would crush them and eventually extract 8 ounces of purified insulin.

In the 1970s, researchers discovered how to program bacteria in the lab to manufacture human insulin, and in 1982, regular human insulin became the first “recombinant DNA” drug product. “It’s a very pure, clean product, and it’s exactly what we as humans make,” Sisson says. Human insulin is now available as short-acting “regular” (or “R”) insulin, which is used at mealtimes, and intermediate-acting NPH (or “N”) insulin, which is used as a basal insulin. A big difference between the two? NPH insulin needs to be mixed, at which point it becomes cloudy due to insulin-protein microcrystals. Those teeny crystals slowly dissolve at the injection site and prolong the release of insulin into the bloodstream.

Analog debut

While the development of human insulin was a major advancement, it wasn’t perfect. Regular insulin didn’t hit the bloodstream quick enough to cover the rapid absorption of carbohydrates after meals, and it stuck around too long after meals, causing hypoglycemia. In 1996, Eli Lilly introduced the first rapid-acting insulin analog to the market: insulin lispro (Humalog). Insulin aspart (Novo Nordisk’s Novolog) and insulin glulisine (Sanofi’s Apidra) quickly followed. With rapid-acting insulin analogs, onset occurs 10 to 20 minutes after injection, instead of the 30 to 60 minutes it takes for regular human insulin to take effect. This allows people to inject their insulin right before a meal, rather than having to dose 30 minutes or more before eating.

But scientists, and people with diabetes, were still eager for more long-acting insulin options—versions that wouldn’t have NPH’s peak (which can cause hypoglycemia hours after injecting) or fairly short duration. They modified the insulin molecule to be absorbed more slowly and consistently from the insulin injection site. The result: long-acting analogs such as insulin glargine (Lantus), insulin detemir (Levemir), and last year, Basaglar, which is a newer form of insulin glargine by a different manufacturer. These newer, long-acting insulins work in the body for 20 to 26 hours and typically permit once-daily dosing. Newer ultra-long-acting insulins—degludec (Tresiba) and glargine (Toujeo)—last even longer.

Insulin Comparisons

With all of these insulins on the market, it’s hard to know which is best. Studies have shown that analogs have some advantages over human insulins, but not all experts agree they’re the best choice for everyone. Three experts weigh in on important factors to consider when prescribing types of insulin:

Hypoglycemia

Deliver a dose of NPH insulin, and it’ll reach its peak about six to eight hours later. This means your insulin may peak while you’re sleeping, posing a serious danger if you don’t wake up to treat. Long-acting analogs, on the other hand, don’t peak, resulting in more-stable blood glucose levels and fewer unexpected highs or lows. In fact, one study showed that long-acting analog insulin glargine reduced overnight bouts of hypoglycemia by up to 48 percent compared with NPH. In another study, detemir reduced nighttime hypoglycemia by 34 percent. This is especially beneficial for people with type 1, who need to be much more precise about matching insulin dosages with their insulin needs to avoid nighttime lows, says Sisson.

But for people with type 2 diabetes who are capable of some degree of insulin production, it’s less clear whether the benefits of analog insulin warrant the higher price, says Mayer Davidson, MD, professor of medicine in the Department of Internal Medicine at Charles R. Drew University in Los Angeles. According to the American Diabetes Association 2017 Standards of Medical Care in Diabetes, people with type 2, and without a history of hypoglycemia, may use NPH as basal insulin safely and at a much lower price than analogs. Davidson also says that people taking human insulin can potentially avoid overnight hypoglycemia by eating a bedtime snack, such as an apple with a tablespoon of peanut butter, something he strongly recommends to his patients.

Inject regular insulin at mealtime, and it’ll stick around longer after eating, upping your risk for delayed lows, says Grunberger. Because regular insulin peaks two to four hours after injection, people with type 1 who take it have to be careful about activity a few hours after meals. If you decide to take a long walk two hours after dinner, you may end up having a low in the middle of your walk. Injections of regular insulin for your evening meal can also increase the risk of overnight hypoglycemia.

The 2017 Standards of Medical Care recommends that most people with type 1 use rapid-acting insulin analogs (which leave the body in about four hours) to reduce hypoglycemia risk. However, for people with type 2 who are still able to produce insulin, this isn’t as much of an issue. “What you do is consistently under-dose them a little bit so that their pancreas makes up the difference,” says Sisson.

Weight Gain

The peak and duration of human insulin may create a need for more snacking during the day to prevent lows, says Grunberger. This can increase caloric intake and cause weight gain. Davidson suggests this workaround: Eat fewer calories at meals to offset calories from snacks during the day.

Convenience

When it comes to meals, regular insulin requires a bit of planning. It needs to be injected 30 to 45 minutes before you eat, says Grunberger. Rapid-acting analogs, on the other hand, allow you to inject right before eating, offering more flexibility in your schedule. You can even inject the analogs after a meal, adjusting the dose to cover what you ate, although blood glucose will be slightly higher after the meal using this approach.

Effectiveness

All types of insulin lower blood glucose effectively. From a user perspective, the logistics of analogs are much simpler: You can inject your mealtime insulin immediately before the meal, and you generally have one daily basal insulin injection. (Glargine and, more often, detemir sometimes have to be given twice daily for maximum efficacy.) There are other benefits to analogs over human insulins—namely less hypoglycemia. Rapid-acting analogs also lead to slightly lower after-meal glucose levels. Even so, good control of blood glucose levels can be attained with human insulins in most cases.

Those benefits, however, do not necessarily translate to a better A1C (a measure of how well your diabetes is controlled over a period of time), says Davidson. “The right insulin depends on when you want the insulin to peak, how long you want it to last, and, honestly, what insurance company you have and how you are going to pay for this stuff,” Sisson says.

The Cost Conundrum

Rising insulin prices have caused many people to question what necessities they’ll do without to be able to pay for their meds. “No one in need of lifesaving insulin should ever go without it due to prohibitive costs,” says Desmond Schatz, MD, immediate past president of medicine and science at the American Diabetes Association. In November 2016, the Association issued a resolution and launched a petition calling for access to affordable insulin.

Worldwide, the analogs are 2½ times more expensive than human insulins, says Davidson, who has been tracking the wholesale cost of insulin for six years. From 2011 to 2015, the average wholesale price of a box of five disposable insulin glargine pens (300 units each) went from $234 to $447, a 91 percent increase. A 10-milliliter vial (1,000 units) of the same insulin rose from $121 to $298—a 146 percent price hike. Some of the rapid-acting analogs jumped by as much as 88 percent, raising the cost to more than $500 for a box of disposable pens (300 units each) in 2015.

Human insulin is rapidly increasing in price, too. Regular and NPH jumped from about $66 for a 10-milliliter (1,000-unit) vial to $144.72 between 2011 and 2015—a 118 percent jump. Human insulin is considerably cheaper because the price started out much lower, says Davidson.

Also, while human insulin may have a lower wholesale price tag than analogs, insurance coverage will ultimately dictate the cost to the consumer. Some drug companies have suggested that many people pay less than wholesale prices due to rebates that are privately negotiated between the pharmaceutical companies, pharmacies, and pharmacy benefit managers—middlemen who work for commercial and government-run health plans to negotiate drug prices—and payers such as insurance companies, Medicare, and Medicaid.

Advocates, however, say that is not always the case. Whether you have a high-deductible insurance plan, a gap in Medicare drug coverage (called the donut hole), or pricey drug co-pays, people with diabetes are increasingly feeling squeezed by these price hikes. “Insulin has become obscenely expensive,” says Grunberger. “The longer they’ve been on the market, the more expensive they become,” he says.

All three insulin companies—Eli Lilly, Novo Nordisk, and Sanofi—have raised their prices in lockstep every year. When one company increases the price, the other two follow suit with a similar increase. The price hikes have become so excessive that in November, Sen. Bernie Sanders (I-Vt.) and Rep. Elijah Cummings (D-Md.) called on the Department of Justice and the Federal Trade Commission to investigate possible collusion among the insulin companies.

Making the Switch

Many providers are switching patients from analog to human insulin due to its lower cost, and the cheapest options are the regular and NPH products, which retail at Walmart for $25 per 1,000-unit vial. You can find it under the names ReliOn Novolin R, ReliOn Novolin N, and ReliOn Novolin 70/30 (70 percent NPH/30 percent regular). Brand-name human insulin is available from other pharmacies, though the cost varies and is typically higher.

James MacDonald, 51, switched from insulin glargine to branded 70/30 human insulin because he could no longer get insulin glargine through the patient assistance program at Sisson’s clinic. The swap worked well for MacDonald, who has type 2, but his financial struggles were just beginning. He lost Medicaid eligibility, which meant he had to buy his own insurance. He went from paying nothing for his insulin to shelling out over $700 a month with his new policy. “It would cost $120 a vial, and I need six vials a month to live,” he says. He has since discovered the ReliOn brand and has kept his A1C at 6.5 percent.

In most states, human insulin requires no prescription, says Grunberger. If you take a large daily dose of insulin and have insurance, check to see if it covers ReliOn insulin, or if your out-of-pocket expenses for ReliOn would be lower than your co-pay for branded insulin.

Beware: If you’re buying your insulin out of pocket from a pharmacy like Walmart, some insurers may no longer cover your test strips because you’re no longer getting insulin through insurance. Instead, you’ll be covered as someone with type 2 who’s not on insulin therapy. Private insurers and Medicare typically pay for only one test strip per day for those not on insulin therapy. Work with your doctor to get what you need.

Competitive Boost

Researchers say people with diabetes can expect more follow-on biologics—the equivalent of a generic for drugs that are made from living material, like insulin; Basaglar is one example—for insulin to enter the marketplace in the near future. That would result in greater competition among brand-name insulins, potentially helping to bring down costs and lessen the financial burden for many families.

Check out the wholesale price of insulins.

Go to care.diabetesjournals.org/insulin_cost.

Find out more about the rising cost of insulin.

Stand Up for Affordable Insulin

Join more than 150,000 others and sign the American Diabetes Association’s petition at makeinsulinaffordable.org. You’ll also find resources to help you pay for insulin, a place to share your story, and more.

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type2diabetestreatments-blog · 8 years ago

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Making Your Provider Your Health Ally

New Post has been published on http://type2diabetestreatment.net/diabetes-news/making-your-provider-your-health-ally/

Making Your Provider Your Health Ally

How to team up with your provider to enhance your care

By Kimberly Goad March 2017

Spending a day at the pool or riding her BMX bike shouldn’t have been cause for concern after Victoria Bryson was diagnosed with type 1 diabetes in 2013. But the 8-year-old was repeatedly missing the warning signs of hypoglycemia in the hours following physical activity, a condition known as hypoglycemia unawareness.

When Victoria’s endocrinologist, Susan Phillips, MD, recommended she start using a continuous glucose monitor (CGM) in addition to a pump, Victoria’s mother didn’t need to be convinced. The benefits of the device, which records and displays glucose readings in real time, were obvious. “To really fine-tune my daughter’s diabetes management, it made sense to have a CGM as an additional tool to monitor the lows and the highs,” says Polina Bryson, who lives with her husband and two children in San Diego. “We could improve control and quality of life.”

But before Victoria could get the device, Bryson needed to clear an enormous hurdle: cost. The particular CGM recommended by Phillips was a few months shy of being approved for pediatric use by the Food and Drug Administration. That meant Phillips would be prescribing the device for off-label use, possibly hindering insurance coverage. And the Brysons couldn’t afford to buy a CGM out of pocket.

The obstacles seemed insurmountable, Bryson says, until she teamed up with Phillips, who wrote what’s known as a “letter of medical necessity” to the insurance company. Phillips detailed how Victoria Bryson could benefit from using a CGM, citing research studies and including Victoria’s blood glucose logs, which showed that she was having lows and that they were pervasive.

“You have to make a case for using whatever device, documenting the safety and efficacy of it, and explaining in detail the risk that the patient is suffering due to the lack of intervention,” says Phillips, a pediatric endocrinologist at Rady Children’s Hospital–San Diego and an assistant professor of pediatrics at the University of California–San Diego School of Medicine.

The strategy paid off: Not only was the CGM covered by insurance, saving the Brysons thousands of dollars, but it happened in a timely fashion. “Our endocrinologist knew what to do,” says Bryson. “She knew what language to use, what data to include in the request to document medical necessity.”

Joining forces with your primary care provider or specialist can lead to improved diabetes management. But some people, particularly those newly diagnosed, may not realize the power of partnering with a provider to boost their quality of care.

“Your physician is there to collaborate and be your partner because you’re the one who—day in and day out—is making the decisions and figuring out what’s working and what’s not,” says Martha Funnell, MS, RN, CDE, FAADE, associate research scientist in the Department of Learning Health Sciences at the University of Michigan Medical School. “Having a provider who’s open to that type of relationship is absolutely critical because this is a long-term chronic disease.”

Forming that relationship begins with listening, says Phillips. “If you do that enough, patients believe you and trust that you’re going to help them the next time something comes up,” she says.

Keep reading to see how your provider can help you get the treatment you need when you find yourself in challenging situations.

Situation: Your doctor recommends a pump to help with better blood glucose management. You’re familiar with the basics, but you’re not entirely comfortable using the device.

Strategy: Your doctor might not have the time or the detailed knowledge needed to help you learn about all aspects of self-care. That’s why it’s important to work with someone who can refer you to another provider without delay. “Diabetes is a team sport,” says Funnell. “There are lots of other people you need to be working with: the educator, the dietitian, the community pharmacist. Part of making your provider your ally is about saying, ‘I understand you’ve only got 10 minutes, but I want to learn about this. Who else can I talk to?’ ”

Situation: Your doctor suggests a CGM to help you manage your diabetes. But you’re on Medicare, which generally doesn’t cover the device. (Medicare recently announced it would cover one brand of FDA-approved CGM for making treatment decisions; however, it’s not yet clear when coverage will begin.)

Strategy: “Continuous glucose monitoring has evidence-based benefits for people with diabetes, and yet access to these technologies is limited for many people,” says David Kerr, MD, FRCPE, director of research and innovation at the William Sansum Diabetes Center in Santa Barbara, California. His advice: Don’t take “no” for an answer. If your insurance plan doesn’t cover a CGM, ask your provider to write a letter of medical necessity to your insurance company explaining why you need the device. If you’re denied, ask your provider to appeal the decision with what’s known as a “peer-to-peer review”—typically a phone conversation between your physician and a physician at your insurance company.

If that still doesn’t do the trick, craft a letter of your own. “I can make the case, but it can be much more powerful coming from the patient,” says Veronica Brady, PhD, MSN, FNP-BC, BC-ADM, CDE, a nurse practitioner at the University of Nevada–Reno. Ask your provider for a copy of the original letter sent on your behalf so you can address yours to the same person and include any peer-reviewed studies it mentions. Add a copy of your blood glucose logs to prove your case. Then personalize your letter with details from your own experience.

Situation: Your doctor recently prescribed insulin to help you manage your type 2 diabetes, but you skip doses on more occasions than you care to admit. You’re afraid you’ll gain weight, or perhaps it’s the injections that scare you, so you’re less than honest with your doctor.

Strategy: Fudging about any aspect of your treatment doesn’t do you or your provider any good. If you’re not able to stay on track, it’s important to be honest so you can reassess your goals.

“Patients worry you’ll be upset that they didn’t take their medicine or didn’t stick with whatever plan you set as a goal,” says Neil Skolnik, MD, professor of family and consumer medicine at Temple University School of Medicine and member of the American Diabetes Association’s primary care advisory group. “Whenever you put two people together—and this is true whether they’re longtime friends, or doctors and patients—there’s value in saying, ‘What are we trying to accomplish together?’ Once you clarify the goals, it’s easier to move forward.” Your doctor isn’t there to judge you, but to help you find solutions.

Another thing to remember: Honesty is a two-way street. For your provider to be your ally, he or she will need to deliver the cold, hard truth. “You want a provider who will hold up the mirror and say, ‘This is what’s going on. I’m going to give you the information. What choice are you going to make?’ ” says Morrison.

Take Harold Young. He weighed 465 pounds when he was diagnosed with type 2 diabetes at age 27. But it wasn’t until he began seeing a new primary care doctor five years later that he fully realized he needed to do something about his weight. “He didn’t sugarcoat anything,” says Young, manager of team development at the American Diabetes Association. “At that first appointment, he said, ‘You’re going to die earlier than you need to if you don’t get a handle on your weight.’ ”

Young spent the next few years trying to shed pounds and improve his blood glucose levels through diet and exercise, but with limited success. Finally, his doctor recommended bariatric surgery. By then, doctor and patient had developed enough trust for Young to confide his misgivings. “My fear was that I’d go through this major surgery—then what?” says Young, now 41. He was also worried about pain. His doctor referred him to a surgeon who alleviated his fears with straight talk. “He said, ‘Initially, I’ll give you pain meds, but then you’ll have to learn to deal with it,’ ” recalls Young.

Now, four years later, Young has lost more than 200 pounds and he’s met his A1C goals. The lesson? “You are the steward of your own health, but you have to trust your doctor,” he says.

Situation: You’re curious about a new treatment you’ve heard of, but you leave your doctor’s office without getting around to asking about it.

Strategy: “Go in with an agenda,” says Tyree Morrison, CRNP, CDE, a nurse practitioner with Frederick Primary Care Associates in Frederick, Maryland. That’s how Susette Langston approaches her doctor visits. Diagnosed with type 1 diabetes 14 years ago, she arrives for appointments armed with a small notebook detailing her blood glucose readings, blood pressure and other test results, as well as a file of things she wants to discuss with her doctor, such as magazine articles related to some aspect of diabetes she’s unclear about.

“I don’t want to forget anything that’s important to me,” says Langston, who lives in Rochester, New York. “I jot down questions as they occur to me and keep them with my blood glucose readings so I will have them handy for my doctor visit.” She tries to save time early in a visit so she can spend it asking questions later. “While you are waiting for your doctor to come into the exam room, take off your shoes and socks so you’re ready to have your feet examined, as they should be at each visit,” she says. (For more tips, see “Make The Most of Your Doctor Visit,” below.)

Situation: You’re having trouble paying for your insulin. Or maybe you’re curious about a new drug you’ve seen advertised on TV but you’re worried about the cost.

Strategy: Let your doctor know you’re having trouble financially. He or she may be able to revise your prescriptions by suggesting an equally effective but less expensive medication, or recommend coupons and assistance programs to help you cover the expense. Also ask your pharmacist for information that you can share with your doctor, whether that’s about cost or medication facts.

Make the Most of Your Doctor Visit

Fifteen minutes. That’s how much time you’re typically allotted with your health care provider. Here’s howto make the most of it.

Prep for Your Visit

Bring a detailed blood glucose log; a list of your medications—not just the names, but also dosages and time of day you take each; and any other health forms or documents. Make a note of when you last had your eyes, feet, and blood pressure screened. If you cover the basics and your urgent needs quickly, you’ll have more time for an open conversation.

Ask Questions

“Between visits, write down the things that are of concern to you,” says Veronica Brady, PhD, MSN, FNP-BC, BC-ADM, CDE, a nurse practitioner at the University of Nevada–Reno. Put a star next to the questions you feel are the most pressing, such as: Should I be concerned about the tingling or numbness in my feet?

Recap

Review everything that was covered in your exam, as well as next steps. “If your doctor is referring you to another [provider], ask for a copy of any correspondence so you’ll have a record of what’s being said about you,” suggests David Kerr, MD, FRCPE, director of research and innovation at the William Sansum Diabetes Center in Santa Barbara, California. “It will move the clinician to use language that’s understandable.”

Find a Diabetes Educator

Visit diabetes.org/findaprogram.

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type2diabetestreatments-blog · 8 years ago

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Human vs. Analog Insulin

New Post has been published on http://type2diabetestreatment.net/diabetes-news/human-vs-analog-insulin/

Human vs. Analog Insulin

The cost of switching from analog to human insulin

By Allison Tsai March 2017

Switching from pricey analogs to the older, lower-priced human formulas may be an option for some people with diabetes. But does the lower price of human insulin offset potential drawbacks?

Human Era

Analog debut

Insulin Comparisons

Hypoglycemia

Weight Gain

Convenience

Effectiveness

The Cost Conundrum

Making the Switch

Competitive Boost

Check out the wholesale price of insulins.

Go to care.diabetesjournals.org/insulin_cost.

Find out more about the rising cost of insulin.

Stand Up for Affordable Insulin

Type 2 Diabetes Treatment Type 2 Diabetes Diet Diabetes Destroyer Reviews Original Article

0 notes