Do long-acting insulin analogs, such as glargine (Lantus) or detemir (Levemir), reduce the risk of clinically significant hypoglycemia compared with NPH insulin?

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. (LOE = 2b-)

Lipska KJ, Parker MM, Moffet HH, Huang ES, Karter AJ. Association of initiation of basal insulin analogs vs neutral protamine Hagedorn insulin with hypoglycemia-related emergency department visits or hospital admissions and with glycemic control in patients with type 2 diabetes. JAMA 2018;320(1):53-62.  [PMID:29936529]

Cohort (retrospective)

Government

Population-based

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%).