Originally published in HCPLive.com
by Anita Ramsetty, MD
We are very fortunate to have a number of newer insulins available for our patients.
For years we had animal insulins only. NPH and Regular, then we had Ultralente. The development of analog insulins marked the upswing in technology that we would sustain for a period of time. The most recent big blip in the radar came from Lantus insulin, which changed the landscape of diabetes treatment entirely.
Subsequently we had Levemir join the group of long-acting, “peakless” analog insulins, and a small group of super-fast acting insulins.
In my practice, I have new patients show up already having been started on these new insulins. In fact, I have not had a recent referred patient come to me on ANY older insulins. The big surprise? Many times I switch them back to an older insulin.
Please don’t get me wrong. I like the new kids on the block as much as anyone else. The analog insulins have truly revolutionized diabetes treatment. They are the closest we have to an insulin pump, which is, in turn, the closest we have to mimicking a real pancreas, aside from an islet cell transplant. In the right patient, and with the right dosing, a long-acting/short-acting insulin combination can be golden and really allow great flexibility for the patient while keeping their glucose levels under control.
That said, there have been more than a few instances when I switched back from this high powered combination to an older insulin, like NPH or 70/30 insulin, or sometimes even regular insulin.
Scenario 1 – the patient can’t handle the intensity of the long-acting/short-acting regimen. Face it, this regimen takes work. For anyone who eats three meals a day, it is at least four shots a day.
Scenario 2 – the patient doesn’t dose it correctly. The flat mealtime dosing doesn’t often work (who eats the same thing everyday?), so then we head either to a prandial scale based on pre-prandial blood glucose levels, or carb counting. What happens with incorrect dosing? Lows or highs sometimes.
Scenario 3 – cost issues. This is actually one of the most frequent reasons that I switch back to 70/30 or NPH regimen. There are no generic versions of Aspart, Levemir, or Lantus. None. They are all brand name and quite expensive without patient assistance or insurance coverage (and even then, it can still be costly).
Our patients need options, and that should include reconsideration of older insulins that do work. Their pharmacodynamics are not as impressive as the newer insulins, but they work well in many people.
So remember to give them a chance. They are still the good old guys.
Anita Ramsetty is an endocrinologist who blogs at The Hormone Zone.
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{ 1 comment… read it below or add one }
I agree that, especially in primary care, that split mixed is often better tolerated than basal bolus, and though basal bolus is more physiologic, there is limited data that says it is actually better. However, I find there is a big difference between old 70/30 and Humalog or Novalog 70/30 which contain the analogue insulin. Regular human insulin peaks too slow and stays around too long. I find I get better control and less hypoglycemia using these more expensive drugs. These insulins are always at a tier 2 status for patients with prescription coverage, so I would only use the generic insulins for patients who pay out of pocket, which is fortunately becomming more infrequent.
Finally, since Lantus has been shown to be potentially associated with cancer, I have avoided it’s use. Levemir is equally effective as Lantus and does not cause cancer.