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Clinical Question
Do long-acting insulin analogs, such as glargine (Lantus) or detemir (Levemir), reduce the risk of clinically significant hypoglycemia compared with NPH insulin?
Bottom line
This study found that, compared with expensive long-acting insulin analogs costing 2 to 10 times as much, human neutral protamine Hagedorn (NPH) insulin results in a similar number, if not fewer, episodes of severe hypoglycemia that result in emergency department visits and hospitalizations. NPH insulin also improves glycemic control as well, if not better, than insulin analogs. In a previous report (Singh SR, et al. CMAJ 2009;180(4):385-96), overall quality of life was also similar with NPH insulin or insulin analogs. Compared with long-acting insulin analogs, NPH insulin is as Safe if not safer, equally Tolerated, equally or more Effective, and at a much lower Price (STEP). One in 4 adults with diabetes either stop or cut back significantly on their insulin because they can't afford it. 2b-
Reference
Study design: Cohort (retrospective)
Funding: Government
Setting: Population-based
Synopsis
Marketing efforts have convinced most clinicians that long-acting insulin analogs, such as glargine and detemir, reduce the risk of hypoglycemia and are thus safer than traditional NPH insulin. These investigators analyzed data from 2006 and 2015 from multiple patient and prescription registries with the Kaiser Permanente of Northern California. Outcomes of interest included pharmacy use; laboratory results; and outpatient, emergency department, and hospitalization diagnoses of diabetes and related complications. The inception cohort consisted of 25,489 adults, 19 years or older, with type 2 diabetes who were initiating basal insulin therapy without any insulin prescription fills during the prior 12 months. Results were analyzed after controlling for multiple potential confounders, including demographics, index year, clinician specialty, comorbidity index, chronic kidney and/or liver disease, visual impairment, history of depression, glycemic control, history of severe hypoglycemia episodes requiring third-party intervention, and medication nonadherence. The risk of a subsequent severe hypoglycemic episode resulting in an emergency department visit or hospital admission was nonsignificantly lower in patients who initiated NPH insulin at baseline compared with those initiating insulin analogs (8.8 vs 11.9 events per 1000 person-years, respectively). In addition, glycemic control was significantly more improved in patients using NPH insulin versus insulin analogs (difference in HbA1C -0.22%; 95% CI -0.09% to -0.37%).
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Comments
The new is not necessarily more effective than the old, and the new may very well be less efficient than the old- quite possibly a STEP backward.
Good poem
Useful for my back pocket. I have had conversations with patients whose compliance with using analog insulin is poor because of cost issues. Although I don't prescribe insulin at least I
now have a tool to advise patients about talking to their diabetes doctor about switching to NPH. Hopefully they will listen.
seems like a lot of confounders? What happened to all the studies showing less hypoglycemia events with long acting analogue's given at HS. NPH will usually need to be given BID to get similar effect
This would also be a cost saving for the patient which will be very helpful for her.
Seems to go against what we've previously been told about long acting insulin analogs