Maximum Greed —  The EpiPen

This is the amazing success story of Heather Bresch, daughter of U.S. Sen. Joe Manchin. Bresch become a pharmaceutical CEO, quadrupled the price of her company’s lifesaving EpiPen and was then able to increase her salary by 671 percent to $18.9 million in eight years!

EpiPen is like a big plastic syringe. It is designed to easily administer epinephrine to treat anaphylaxis. The medication in an EpiPen is epinephrine, a generic drug available for less than $5 a dose. Anaphylaxis is a severe allergic reaction that usually starts with itching and swelling and untreated, can cause shock and death. Each year, approximately 1,500 people in the United States die from anaphylaxis. Anaphylaxis can be triggered by many substances including bee venom, peanuts and penicillin. Approximately three million people in the United States are prone to anaphylaxis.

The injector concept was originally developed by the military to deliver nerve gas antidote. The rights to the EpiPen were purchased by Mylan in 2007. At that time, the price per injection was about $50. By 2013, the company had raised the price to $127. As of September 2016 the price was $311 dollars. Mylan was able to get the largest market share partly by donating EpiPens to schools and partly by promoting EpiPen using news about children dying from anaphylaxis when epinephrine was not immediately injected. They were able to raise the price partly because a key competitor, Auvi-Q was recalled by the FDA.

Mylan has been criticized for price gouging. The current $311 dollar cost of an EpiPen is $65 more than a $246 a Waterman Carene Fountain pen with an 18k solid gold inlaid tip. Other companies sell injector pens for much less. A more complex reusable Novopen ECHO insulin pen which has an LCD screen on the top displaying the last dose sells for $80. Glargine insulin (Lantus brand) is sold in both vials and disposable pens. The pens have the same retail cost per unit of insulin as the vials.

Bresch has defended the large price increases and blamed the insurance companies for asking patients to pay more money for EpiPens after she raised the price. This ignores how high drug prices increase the already high cost of medical insurance. In Forbes, Frank David compared the cost of an EpiPen to the value of saving a life. This ignores that saving your life for $50 is a much better value than saving it for $300. Others have blamed the FDA and the high cost of regulation, as if this eliminates the responsibility the company has when setting prices.

A competing product, Adrenaclick, has largely escaped criticism.  However, it has raised its prices from $60 a shot in 2013 to the current price of $130. Impris Pharmaceuticals CEO Mark Baum plans to  market  a lower cost version. He defended Bresch, stating she would have been fired if she had not raised the price.

Pharmaceutical prices are continuing to rise faster than inflation. Unfortunately, corporate greed rather than corporate responsibility looks like the main priority among all of the pharmaceutical companies involved.

Editor’s Note: Mylan pharmaceuticals, maker of EpiPens, is trying to counter the negative publicity about its price hike by lobbying to get EpiPens added to the list of federal preventive medical services with no deductible and no co-pay, effectively shifting the high cost to all rate payers. The company has also lobbied to have EpiPens carried in all schools, hotels, restaurants and on commercial airlines. The New York State attorney general announced an investigation last month into the company for its non-compete contracts with schools. EpiPens are now sold in packets of two injections for $608, and the actual cost of the epinephrine medication less than $5 per dose.

Selected References

  1. Fred Hsieh. Anaphylaxis. December 2013. Cleveland Clinic Center for Continuing Education.
  2. Tamar Rubin, Jacqueline Clayton, Denise Adams, Hsing Jou, and Sunita Vohra: Systematic review of outcome measures in trials of pediatric anaphylaxis treatment.  BMC Pediatr. 2014; 14: 158.
  3. Rafi Mohammed : The Problem with Price Gouging Laws. July 23, 2013. Harvard Business Review.
  4. Frank David: Calculating The Value Of An EpiPen. Aug 29, 2016.
  5. Emily Willinghm, CEO of EpiPen Maker Sees 671 percent Compensation Increase in 8 Years. Aug 23, 2016. Forbes
  6. Matt Egan, EpiPen main ingredient costs ‘less than a Big Mac’ Aug. 30, 2016, The buzz.
  7. The Times Editorial Board. EpiPen price gouging demonstrates need for more competition in generic drugs. Aug. 26,, LA Times.
  8. Alexandra Rosenmann. Mylan CEO Heather Bresch Disastrously Defends EpiPen Price Hike and her Own 16M Pay Raise. Aug. 25, 2016. Alternet.
  9. Ben Popken, Mylan’s CEO’s Pay Rose Over 600 Percent as EpiPen Price Rose 400 Percent. Aug 23rd, 2016.     http”//



David Trachtenbarg, M.D.

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