I recently attended a local update for practice nurses who initiate insulin in general practice. One of the many good things about attending this update was that there was group of six or seven of us, so we could all participate. The two diabetes specialist nurses (DSNs) who led the afternoon were great, and allowed time to get answers to questions we had, and deal with difficult patient scenarios we were trying to manage within our own practices.
One very helpful discussion was centred on the use of neutral protamine hagedorn (NPH) insulin versus the newer analogues. Several of us shared how our original training in initiating insulin therapy had been sponsored by one or two drug companies and as a result, we had quickly become familiar with their insulin products. Of course, it was no surprise that they were two of the newer analogues, and we admitted that we had experienced a lack of confidence in using other types of insulin to begin with. With increasing experience, a few of us felt confident now to use human insulin for starting patients on insulin therapy.
We were reminded of the reason for returning to older human insulin more frequently now, and the big reason is of course cost. The difference in cost is enormous, and for what gain for the individual? We are not achieving any superior level of control with the analogues over the human insulin. For some patients, there will be other reasons that they end up with an analogue, but it should no longer be first-line and we must think very carefully before switching our patients to analogues.
Figures published by the Independent Diabetes Trust show us that enormous amounts of taxpayers’ money has been spent on these much more expensive insulin analogues. In 2010, if all the patients prescribed insulin analogues and been prescribed human insulin, £625 million could have been saved. You can read more here.
We all know the NHS is running out of money. As a proportion of the whole, diabetes spend is huge, and only set to increase with the current obesity epidemic and subsequent type 2 diabetes epidemic. If we are not familiar with human insulin, we need to seek out our local experts to teach us and guide us in their use, as this type of expenditure cannot be sustained.
How many of you have heard about insulin Degludec, which has an apparent capacity to provide long acting background insulin for approximately 42-48 hours? Have you seen any patients on this new insulin? Currently it is only licensed for initiation by secondary care, and it is hugely expensive, way beyond even the current analogues.
It is worth considering the use of Xenical when we have patients who desperately need to lose weight. While the GLP1 group of drugs can assist with this, they are much more expensive, and Xenical would be much more cost-effective if used as licensed. Yes, there are side effects to its use, but if taken as prescribed with a very low-fat diet, there are immense benefits in weight loss. What we must remember when using GLP1s is to have an up-to-date weight, body mass index (BMI) and HbA1c for our patients before commencing the drugs - and at three and six months we should be reassessing both weight and HbA1c. If these drugs have not produced the results they were prescribed for, then we should not continue to prescribe them.
We do not need to become obsessed with cost, because ultimately we are concerned with providing our patients with quality of care - however we certainly do need to factor it in whenever we are considering adding in new therapies to assist our patients in managing their diabetes.
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