NEW ORLEANS — Use of older, recombinant insulin may be a reasonable alternative to managing diabetes when patients cannot afford contemporary insulin analog therapy, according to a poster presentation at the American Association of Nurse Practitioners 2015 meeting.
Current insulin treatments cost $120 to $400 without insurance and co-pays for insulin have increased 20% to 40%. Newer agents, such as dipeptidyl peptidase 4 inhibitors, glucagon-like peptide-1 receptor agonists, and sodium-glucose co-transport 2 inhibitors are also prohibitively expensive.
With no generic insulin available, patients with diabetes who are uninsured or unable to pay for insulin face poor glycemic control, increased risk of hospitalization, and greater risk of complications.
After seeing many patients in this predicament, Mary Boyle, FNP-BC, CDE, a nurse practitioner with Mayo Clinic in Scottsdale, Arizona, came up with an alternative to care for these patients and presented an example case of a 72-year-old man with type 2 diabetes complicated by coronary artery disease, hypertension, hyperlipidemia, neuropathy, nephropathy, and sleep apnea.
His medical history was notable for 15 myocardial infarctions and multiple percutaneous transluminal coronary angioplasty procedures. His co-pay for Lantus vials and Novolog pens was $574 with a deductible of $1,500, and he could no longer afford it.
The solution, according to Ms. Boyle, is a return to the use of recombinant human insulin, such as neutral protamine hagedorn (NPH; i.e., Novolin N and R) at 2 to 3 injections/day or regular insulin at 3 injections/day.
Novolin N and R are available at less than $25 per vial. She also suggested considering reintroducing oral agents, such as metformin, sulfonylurea, or thiazolidinedione (e.g., Actos). A 3-month supply of either metformin or Actos can be purchased for $10.
Considering the patient in her case had high insulin resistance and no history of congestive heart failure or bladder cancer, Ms. Boyle switched him to 40 units of Novolin N twice daily and 20 units of Novolin R twice daily, adding 500 mg of metformin twice daily at first and then 15 mg of Actos daily.
Emphasizing the need for careful monitoring, Boyle said her patient’s diabetes was managed well on this regimen. In monitoring the patient, she asked him to weigh himself daily and call her if there was a gain of 2 lbs in one day and to measure abdominal circumference and call if there was an increase of 1 inch. In addition, she monitored him for hypoglycemia, lower extremity edema, shortness of breath, and cough. A urinalysis was performed yearly.
Adverse events, which include heart failure, fluid overload, increase in abdominal girth, and bladder cancer, are a concern with Actos, Boyle noted. “Actos would not have been my first choice in this patient, especially since he’s had so many myocardial infarctions, but I needed a very strong insulin sensitizer,” she said. “He could not tolerate the 500 mg of metformin at the time, so I thought if I place him on Actos, partner with his cardiologist, internist, and endocrinologist, and carefully monitor him, we may be able to effectively manage the risk and his diabetes.”
In discussing the case, Boyle said this patient fits the profile of someone who would benefit from this particular regimen, adding that she has used it with success in patients who are not as resistant to insulin as him. She emphasized that providers should make sure to lower the insulin when the drug starts working or the patient will gain weight.
Boyle M. “Treatment strategies when your patients can no longer afford insulin analogs.” Presented at: AANP 2015. June 9-14; New Orleans, Louisiana.