The analogue insulins were introduced into the United States in the late 1990s and early 2000s. They are called “analogue” insulins because their chemical structure is subtlety different than native human insulin, which gives them different, advantageous properties. Analogue insulins include the short acting insulins Humalog (insulin lispro) and Novolog (insulin aspart) and the long acting insulins Lantus (insulin glargine) and Levemir (insulin detemir).
Since their introduction, the insulin analogues have pretty much taken over the insulin market in the US. That is why I only mentioned human insulins in passing in the JailMedicine post “Insulin Dosing Made Simple.” It is unusual to see patients show up at the jail on any other insulin regimen than analogue insulins, usually Humalog and Lantus. And I have to admit; the analogue insulins are easier to use than human insulins. I like them.
But here is the problem: the analogue insulins have become insanely expensive! When they were first introduced, the price of Humalog and Lantus was around $20.00 per vial of 100 units. That compared to the price of human insulins like Humulin R and NPH of around $5.00 per vial. So the analogues were expensive, but doable. However, since around 2006, analogue insulins have dramatically increased in price—whereas the price for most other diabetic therapies has actually decreased over time. (You can read more about this price increase here)(In the graph above, notice the huge increase in insulin prices since 2006, while every other diabetic therapy price has actually fallen)
So where are we now? Using the Idaho Medicaid Actual Average Acquisition Cost as of August 29, 2017 (found here), here is the current price of one vial of each of the analogue insulins.
Lantus (insulin glargine) $242.29
Levemir (insulin detemir) $262.16
Humalog (insulin lispro) $267.67
Novolog (insulin aspart) $262.16
Let’s compare that to human insulins: After checking various sources, I found regular insulin and NPH available for between $15.00 to $50.00 a vial.
The reason that the analogue insulins continue to be used despite their hefty price tag is that they are perceived to be better than regular insulin and NPH. But is that true? And if they are better, are they ten times better?
Well, if we limit the discussion to Type 2 diabetics on insulin, the answer appears to be “Well . . . no.” Here, for example, is a study of Type 2 diabetics that compared those prescribed long acting analogue insulins with those prescribed NPH. It found “no consistent difference in long-term health outcomes when comparing use of long-acting insulin analogues and NPH insulin.” The study authors went on to say in their “Take-Away Points” summary:
“The higher cost of analogue insulin without demonstrable clinical benefit raises questions of its cost-effectiveness in the treatment of patients with diabetes.”
(Study abstract found here)
A recent JAMA editorial came to the same conclusion. It is titled “Human Insulin for Type 2 Diabetes: An Effective, Less-Expensive Option,” (It can be found here).
This editorial is so good that I think it should be required reading for all correctional practitioners, who are always under the gun to practice cost-effective medicine!
The authors begin by noting “Affordability of insulin has become a major issue for patients with diabetes in the united States.” Their estimate of the cost of analogue insulins, around $170.00, actually underestimates the actual cost by about $100.00 a vial! They rightly point out that the overall cost of analogue insulins is much higher for Type 2 diabetics compared to Type 1 diabetics because, since they are insulin resistant, Type 2 diabetics often require much higher insulin doses.
The article then makes the point that the analogue insulins do not improve glycemic control or reduce the risk of severe hypoglycemia in Type 2 diabetics when compared to human insulin.
After reviewing the physiologic differences in action between human insulin and analogue insulins, the article then states “Patients can safely switch from insulin analogues to human insulin.” Generally, they recommend that the total dosage of insulin be reduced by about 20% when making the switch.
I love it when the less expensive medication performs as well as the pricy option!
Thank you for this, Dr. Keller. What good info!
I find, also, that I must transition my patients from Humalog to Regular insulin when they arrive at jail. The Humalog just hits too fast and too hard, and is not safe in an environment in which there can be a delay in receiving meals for a multitude of reasons. Do others have this experience?
Yes we also use regular instead of Humalog for the same reason.
We use Humulin R sliding scale and Humulin N. When patients arrive on large quantities of Lantus/Levemir (50u QPM for example), we bridge to NPH 1:1. I split it up giving 2/3 in am, 1/3 in the pm . This seems to work best here.
Can anyone share their jail sliding scale for insulin? I think our jail sliding scale is a bit too aggressive.
Also, would like some thoughts on how you adjust insulin based on what they were taking in the community (verified by pharmacy) and what you start at the jail. We often start with half their long acting insulin and either do sliding scale or back off their short acting and watch accu checks. Many are either not taking as much insulin as prescribed (or not at all), not managing their diet and/or drinking..many do not need as much insulin as they do in the community with the diet and lifestyle changes that happen when they come to jail. We have some that bring their own insulin in that we often will use, while others don’t.. so it seems challenging to develop a “standard” way to manage.