The Price Is Right?

A pressure to reduce overall drug costs had to come as part of the government drive to reduce overall spending.  It is hardly surprising that one of the pressures should come in the field of insulin when the annual spend on the substance is getting up towards £400,000,000 a year.

It is interesting to look at insulin a bit more closely.  Human basal insulins have been available since about 1980 and currently cost about 1.27p per unit of insulin.  Analogue insulins have been available since the late 1990’s and currently cost an average of 2.25p per unit of insulin although there is quite a big difference between the shorter acting analogue cost (1.9p per unit) and the longer acting analogue cost (2.8p per unit).

Bolus analogue insulins are more convenient for the patient because their rapid onset of action means they can be taken immediately with, during or even just after eating rather than 20 to 30 minutes beforehand and there may also be a reduced hypo risk if snacks are not eaten between meals but in some a soluble may still be acceptable.

So the BIG question is:  Are basal analogue insulins twice as effective as isophane insulins?

NICE says “No” (they suggest tight restrictions of those who need analogue insulins).

Popular Medical Opinion says “Yes” (over 85% of the annual spend on insulin is on analogue insulins).

On a cost basis this translates to nearly four times as many patients being prescribed basal analogue as opposed to human basal insulins.

So who is right?

NICE is government financed.  One would therefore expect them to have cost in mind when making recommendations.  However, in this case, their recommendations are backed by firm evidence. These show that:

    Isophane                                                    Basal Analogue

No difference

Hypos     More                                                                   Less
Severe Hypos

No difference


No difference

Weight Gain     Slightly more                                                      Slightly less

On the basis of these findings, NICE recommend that basal analogues may be considered (rather than isophane) in patients:

  1. Who require assistance with injecting insulin
  2. Who cannot use the device needed to inject isophane
  3. Whose lifestyle is significantly restricted by recurring hypos
  4. Who would otherwise need twice daily basal insulin injections in combination with oral antidiabetic drugs

The first two recommendations are a little odd.  The devices used to inject basal analogue insulins are generally similar to those used for isophane although the NovoNordisk FlexPen is not available for isophane (one wonders why) so 1] and 2] are difficult to interpret.

The Bottom Line

It will be difficult for practitioners to resist pressure from on high to change from basal analogue to isophane insulins for routine use.  So far the manufacturers of the newer drugs have failed to demonstrate any major advantage of the new drugs.  There is a lot of pressure from them for us to regard isophane as old-fashioned.  Isophane has been around for a while but it is still an excellent insulin.


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