Insulin: Newer vs. Cheaper

As we discussed last week[1] here at Diabetes Flashpoints, the cost of medications for people with diabetes has been rising steadily for years. Part of the reason for this escalation is that newer, more expensive drugs — mostly for Type 2 diabetes[2] — have entered the market in recent years. But newer drugs alone don’t explain the increase in drug spending. Certain drugs that have been on the market for years — particularly insulin[3] — are getting significantly more expensive.

A recent opinion article[4] in the Journal of the American Medical Association outlines just how much more expensive certain insulins have become. Between 2000 and 2010, for example, the price of a vial of insulin lispro (brand name Humalog) rose from $35 to $234 — a 585% increase — and the price of a vial of human insulin (Humulin, Novolin, and others) rose from $20 to $131, a 555% increase. By comparison, the national inflation rate during this period was 33.7%. The most expensive insulins, both now and 15 years ago, are known as insulin analogs[5]. These insulins resemble natural insulin produced by the pancreas, but have had their molecular structure altered to achieve a desired effect — such as a very rapid or a long, sustained course of action in the body. The authors of the JAMA article argue that in many cases, doctors should prescribe older, less expensive varieties of insulin to lower the cost for their patients.

A Medscape Medical News article about the opinion piece[6] summarizes the arguments made by the authors, both of whom are doctors at the University of Washington School of Medicine in Seattle. The authors note that even as prices rose dramatically, the use of insulin analogs increased from 19% of the insulin market in 2000 to 96% of the market in 2010. This increase, they argue, happened because of the added convenience promised by these newer varieties — such as the ability to inject fewer times each day — rather than any demonstrated clinical benefit — such as a lower HbA1c[7] level (a measure of long-term blood glucose control) — at least when it comes to Type 2 diabetes. Therefore, say the authors, it makes sense to prescribe older, cheaper insulins to some patients, particularly those with high deductibles and copays in their health insurance plans.

The authors go on to describe how a doctor might safely switch a patient from an insulin analog to an older insulin variety. For example, insulin glargine (Lantus) — an analog — provides steady coverage over a full day with just one injection, while NPH insulin (Humulin N, Novolin N, and others) must be injected twice a day and can cause nighttime hypoglycemia[8] (low blood glucose). To minimize this risk, doctors can instruct patients to take one-third of their daily dose at bedtime and the remaining two-thirds in the morning.

Despite this kind of guidance, it’s unclear how many doctors are willing to undergo the trouble of switching patients to a different insulin just to save money, rather than improve their diabetes control or quality of life. In fact, the extra attention that older insulins may require may make them off-putting to some people with diabetes — and possibly jeopardize their blood glucose control, if they don’t stick to their new treatment regimen. And given that 96% of insulin prescriptions are for analogs, it’s unclear if many doctors even know enough about how older insulins work to feel comfortable prescribing them.

What’s your take on older, cheaper versus newer, more convenient insulins — have you tried both categories? Have you found that newer insulin analogs make your life easier or improve your blood glucose control? Has your doctor ever asked you how well you’re able to handle the cost of your insulin, or other diabetes drugs? Have you ever been offered, or would you appreciate, a choice between older and newer varieties of insulin? Leave a comment below!

  1. discussed last week:
  2. Type 2 diabetes:
  3. insulin:
  4. recent opinion article:
  5. insulin analogs:
  6. article about the opinion piece:
  7. HbA1c:
  8. hypoglycemia:

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