The greater ease, compared to older insulins, in the implementation of basal/bolus regimens, is appealing. According to this meta-analysis, though, the benefits in terms of HbA1C levels were modest and of questionable clinical significance.
This analysis in the same issue of CMAJ looked at cost effectiveness and found that among short and long acting insulin analogues for type 1 and type 2 diabetes only the short acting analogues for type 1 diabetes were cost effective.
A related editorial made these key points:
· The improved glycemic control, reduced risk of hypoglycemia and improved quality of life achieved with insulin analogues versus conventional insulins are at best minor and of clinically debatable relevance.
· Insulin analogues should be reserved for use in selected patients, such as those with nocturnal hypoglycemia.
· Efforts should be focused on offering structured educational programs to help patients manage their diabetes and improve glycemic control.
Many patients receive their initial diagnosis of diabetes during hospitalization. Basal/bolus regimens are started in such patients in order to maintain inpatient glycemic control. Protocols and order sets for glycemic control tend to favor insulin analogues. Newly diagnosed diabetics are often discharged on insulin analogues as a continuation of their hospital regimens, and because basal/bolus treatment is easier to understand and teach using analogues. The down side is that for patients with limited financial resources such a regimen may be a recipe for “noncompliance.”
These papers will cause me to rethink my discharge planning for newly diagnosed diabetics, particularly those with limited finances.