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Switch from analogue to human insulin safe, cost-effective in older adults with type 2 diabetes
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Older adults with type 2 diabetes who switched from analogue to human insulin as part of a managed care intervention experienced a small increase in HbA1c over 12 months but no increase in serious hypoglycemia or hyperglycemia when compared with baseline outcomes, according to findings published in JAMA.
“This was a real-world, pragmatic study of a health plan intervention switching 14,000 older adults with type 2 diabetes from analogue to human insulin,” Jing Luo, MD, MPH, an instructor of medicine in the division of pharmacoepidemiology and pharmacoeconomics at Brigham and Women’s Hospital and Harvard Medical School, told Endocrine Today. “We found that the switch intervention was not associated with substantially worsened glycemic control or increased risk of serious hypoglycemia but was associated with cost-savings and reduced risk of reaching the Medicare Part D coverage gap.”
Goals of insulin switch
In a retrospective study, Luo and colleagues analyzed member data from CareMore, a managed accountable care organization and Medicare Advantage plan based in Cerritos, California, serving members in Arizona, California, Nevada and Virginia. Members filled at least one insulin prescription from 2014 to 2016 (mean age, 73 years; 51% women; 93% with type 2 diabetes). In 2015, the organization piloted an intervention to switch members from analogue to human insulin, with a preference for regimens containing fewer daily injections, according to the study background. Goals of the intervention, according to researchers, were to reduce daily injection burden and delay or avoid the Medicare Part D coverage gap for members with insufficient coverage. Researchers evaluated the association between the intervention and outcomes, including change in mean HbA1c estimated for three 12-month periods: preintervention (baseline) in 2014, intervention in 2015 and postintervention in 2016. Secondary outcomes included rates of serious hypoglycemia and hyperglycemia, as well as the proportion of members who reached the Medicare Part D coverage gap and total spending on insulin products.
Glycemic changes
Over 3 years, 14,635 members filled 221,866 insulin prescriptions (median follow-up time, 729 days). Mean HbA1c was 8.46% at baseline and decreased at a mean rate of –0.02% per month in the year before the intervention (2014).
Researchers observed an association between the start of the intervention and an overall mean HbA1c increase of 0.14% (95% CI, 0.05-0.23) and a slope change of 0.02% (95% CI, 0.01-0.03). However, at the completion of the intervention, researchers did not observe any between-group differences in HbA1c (0.08%; 95% CI, –0.01 to 0.17) or in slope of mean HbA1c (< 0.001%; 95% CI, –0.008 to 0.01) when compared with the intervention period.
The intervention was not associated with changes in rates of serious hypoglycemia or hyperglycemia.
Economic outcomes
Researchers found that total monthly expenditures for analogue insulin increased from $2,226,389 in January 2014 to a high of $3,214,437 by December 2014. By December 2015, monthly expenditures for analogue insulins decreased to $1,372,942, and fell to $515,875 by December 2016. The percentage of members who reached the Medicare Part D coverage gap fell from 20.6% in 2014 to 11.1% in 2016.
“It may be clinically appropriate and cost-saving to switch many older adults with type 2 diabetes from analogue to human insulins,” Luo said. “Follow-up studies should examine patient adherence after switching to human insulin, persistence and satisfaction with the human insulin regimens, as well as provide more detailed economic analyses.” – by Regina Schaffer
Disclosures: Luo reports he consults for the nonprofit groups Alosa Health and Health Action International.
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Luo J, et al. JAMA. 2019;doi:10.1001/jama.2018.21364.
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