4.5.2.0 Basal In­sulin

Basal in­sulin alone is the most con­ve­nient ini­tial in­sulin reg­i­men and can be added to met­formin and other oral agents. Start­ing doses can be es­ti­mat­ed based on body weight (e.g., 10 units a day or 0.1–0.2 units/‍kg/‍day) and the de­gree of hy­per­glycemia, with in­di­vid­u­al­ized titra­tion over days to weeks as need­ed. The prin­ci­pal ac­tion of basal in­sulin is to re­strain hep­at­ic glu­cose prod­uction, with a goal of main­taining eu­g­lycemia overnight and be­tween meals (59,60). Con­trol of fast­ing glu­cose can be achieved with human NPH in­sulin or with the use of a long-‍act­ing in­sulin ana­log. In clin­i­cal tri­als, long-‍act­ing basal ana­logs (U-100 glargine or de­temir) have been demon­strat­ed to re­duce the risk of symp­tomat­ic and noc­tur­nal hy­po­glycemia com­pared with NPH in­sulin (61-66), al­though these ad­van­tages are gen­er­ally mod­est and may not per­sist (67). Longer-‍act­ing basal ana­logs (U-300 glargine or degludec) may con­vey a lower hy­po­glycemia risk com­pared with U-100 glargine when used in com­bi­na­tion with oral agents (68-74). De­spite ev­i­dence for re­duced hy­po­glycemia with newer, longer-‍act­ing basal in­sulin ana­logs in clin­i­cal trial set­tings, in prac­tice they may not af­fect the de­vel­op­ment of hy­po­glycemia com­pared with NPH in­sulin (75).

The cost of in­sulin has been ris­ing steadi­ly, and at a pace sev­er­al fold that of other med­i­cal ex­pen­di­tures, over the past decade (76). This ex­pense con­tributes significant bur­den to the pa­tient as in­sulin has be­come a grow­ing “out-‍of-‍pocket” cost for peo­ple with di­a­betes, and di­rect pa­tient costs con­tribute to treat­ment non­ad­her­ence (76). There­fore, con­sid­er­a­tion of cost is an im­por­tant com­po­nent of ef­fec­tive man­age­ment. For many pa­tients with type 2 di­a­betes (e.g., in­di­vid­u­als with re­laxed A1C goals, low rates of hy­po­glycemia, and promi­nent in­sulin re­sis­tance, as well as those with cost con­cerns), human in­sulin (NPH and Reg­u­lar) may be the ap­pro­pri­ate choice of ther­a­py, and clin­i­cians should be fa­mil­iar with its use (77). Table 9.3 pro­vides AWP (52) and NADAC (53) in­for­ma­tion (cost per 1,000 units) for cur­rently avail­able in­sulin and in­sulin com­bi­na­tion prod­ucts in the U.S. As stat­ed for Table 9.2, AWP and NADAC prices list­ed do not ac­count for dis­counts, re­bates, or other price ad­justments that may af­fect the ac­tu­al cost to the pa­tient. For ex­am­ple, human reg­u­lar in­sulin, NPH, and 70/30 NPH/Reg­u­lar prod­ucts can be pur­chased for con­sid­erably less than the AWP and NADAC prices list­ed in Table 9.3 at se­lect phar­ma­cies.