NPH insulin may be as good as analogs in type 2 diabetes
medwireNews: Patients with type 2 diabetes in clinical practice have similar outcomes regardless of whether they use long-acting insulin analogs or the cheaper human neutral protamine Hagedorn (NPH) insulin, say researchers.
The 25,489 study participants, identified in the Kaiser Permanente of Northern California diabetes registry, had a similar likelihood for hospital visits for hypoglycemia and had no significant differences in glycemic control, irrespective of which basal insulin they used.
The rate of emergency department visits and hospital admissions for hypoglycemia was 8.8 per 1000 person–years among the 92% of patients who started on NPH insulin and 11.9 per 1000 person–years among the 8% who started on insulin analogs, giving a nonsignificant difference of 3.1 events per 1000 person–years.
This difference remained nonsignificant in an analysis of 4428 patients in which users of NPH insulin and insulin analogs were matched for the propensity to receive insulin analogs and the findings were adjusted for factors including previous hypoglycemia-related hospital visits.
During the first year of use, glycated hemoglobin levels fell by an average 1.48 and 1.26 percentage points in users of NPH insulin and insulin analogs, respectively. Kasia Lipska (Yale University School of Medicine, New Haven, Connecticut, USA) and co-researchers say the difference between the groups was statistically but not clinically significant.
The findings are published in JAMA, in which the authors of an accompanying editorial, Matthew Crowley and Matthew Maciejewski (both from Duke University Medical Center, Durham, North Carolina, USA) note the use of insulin analogs was relatively low within this healthcare system, and that clinicians’ high familiarity with NPH insulin may have helped to ensure equivalent outcomes relative to insulin analogs.
They also stress the need to consider events such as “nocturnal hypoglycemia, which basal insulin analogs reduce relative to NPH insulin in clinical trials, and other symptomatic hypoglycemic events, which are clinically meaningful to patients.”
However, they note the substantially lower cost of NPH insulin; the median co-payment in the study was around US$ 20 (€ 17.2) for insulin analogs versus $ 10 (€ 8.6) for NPH insulin.
Crowley and Maciejewski therefore highlight the importance of determining whether there are specific subgroups of patients who will do better on certain types of insulin. “Identifying moderating factors would allow clinicians to tailor insulin recommendations to maximize clinical benefits while minimizing costs,” they say.
But they add: “In this era of high costs of diabetes care, questions of value in insulin prescribing are unlikely to be resolved anytime soon. Newer, even higher-priced basal insulin analogs are now being promoted despite their minor absolute benefits vs current widely used analog options, so questions about value will remain pressing into the foreseeable future.”
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