1. Tamas Ungar, MD; Mayur Rali, MD FAAFP
A COMPARISON OF DIABETIC TREATMENT OUTCOME BASED ON VARIATIONS IN INSULIN REGIMENS AND PATIENT INSURANCE STATUS
Tamas Ungar, MD; Mayur Rali, MD FAAFP
Hofstra North Shore-LIJ School of Medicine, Dept. of Family Medicine at Southside Hospital
Introduction:
Methods:
Results:
Graph 3:
Since the invention on Insulin, several regimen options have become available. Among the regimens, efficacy, the risk of hypoglycemia and financial aspects must be taken into consideration.
We sorted 40 insulin dependent Type II Diabetics into four groups based on their insulin regimens as follows:
The rate of meaningful A1C reduction were 30% in the NPH groups, 70% in the Split-Mixed, 40% in the Basal, and 70% in the Basal-Bolus groups (Graph1).
NPH
Lantus
Alone
“Split-Mixed” regimen
Patients in on basal insulin had no reported episodes of hypoglycemia (Graph 3).
Graph 1: .
Conclusions:
3. Alone as “Basal”
4.“Basal-Bolus” regimen
The uninsured seemed to have worse glycemic control. Those with government-funded access to Lantus seem to have worse control than patients on a Split-Mixed NPH regimen. It is unclear if these trends are attributable to the choice of insulin or other patient-related factors.
Our study confirmed previous findings (2,3) showing a similar efficacy among the Basal and NPH insulins.
The lack of reported episodes of hypoglycemia in the Lantus group might be an important consideration in selected patients.
A 1% decrease A1C has been found to result in a 24.7% reduction of all-cause mortality at 20 years (1).
Comparing the basal analogue and NPH regimens, a modest difference in treatment outcome was found (2). Other studies showed that Lantus achieved the best A1C reduction among the regimens under comparison, with fewer episodes of hypoglycemia (3).
Since Lantus tends to be the more costly regimen (4), uninsured patients may opt for the less costly regimens that utilize NPH insulin.
The average reduction in HbA1C over a 12 month period after initiation of insulin was calculated for each patient using a systematic chart review.
A 1% or greater reduction in HbA1C was considered meaningful, and the percentage of those achieving this cutoff were compared across the four groups.
Patients were then categorized based on insurance status, and likewise compared based on the percentage achieving a meaningful HbA1C reduction.
Table 1: The uninsured were 90% in the NPH and 80% in both the Split-mixed and Basal groups. All of the patients in the Basal-Bolus group had insurance.
Insulin Regimen
Percent of patients with no insurance
NPH 90
Split-Mixed 80
Basal
80*
Basal-Bolus
* Access to Lantus with assistance program.
Graph 2:
The un-insured group was 23% less likely to achieve meaningful reductions in glycemic control (Graph 2).
Bibliography:
Main Outcome Measures:
The Writing Team for the DCCT/EDIC research group Effect of intensive therapy on the micro-vascular complications of Type I Diabetes Mellitus. JAMA 2002; 287;   
K. Horvath et. al., Cochrane Review – long acting analogues versus NPH Insulin in Type II Diabetes, Cochrane Database of Systematic Reviews, April 2007, Issue 2. 
J. Gordon et. al, A comparison of intermediate and long-acting insulins in people with type 2 diabetes starting insulin: an observational database study, International Journal of Clinical Practice 2010 Nov;64(12):1609.
Jensen et. al., Rx Files Drug Comparison Charts, 9th Edition, Saskatoon Health Region (SHR), 2013.
Objectives:
% of patients with meaningful reduction in HbA1C after initiation of insulin
% of patients reporting complications of hypoglycemia
To conduct a comparative study of reduction of HbA1C using various insulin regimens, in relation to the insurance status of diabetic patients.