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Early Insulin Therapy Makes an Impact

Improved glycemic control can reduce A1c, medical costs and complications…

According to a new study, early introduction of insulin could save money, help more patients reach A1c goals and decrease diabetes-related complications and mortality.

Currently, insulin therapy for persons with type 2 diabetes is traditionally added to an anti-hyperglycemic regimen at the time when the disease progresses to where these oral agents can no longer control HbA1c. This results in complex treatment regimens that have become more expensive to maintain the cost of oral agents and non-insulin injectable. Therefore, the question must be asked, could adding insulin earlier in treatment help reduce cost and produce clinical benefits?

The researchers used a microsimulation model to estimate T2DM complications, mortality, costs and newly diagnosed patients who reached a target A1c of less than 7.0%. They used the results from randomized controlled clinical trials to estimate treatment efficacy. They followed current standard of care guidelines in initiation of metformin first, followed by the addition of a sulfonylurea, then addition of a DPP-4 inhibitor, a thiazolidinedione or non-insulin injectable, followed by initiating basal insulin and removed the sulfonylurea, and finally adding bolus insulin.

Using a time frame of 5 years, the researchers analyzed two categories of treatment: two-stage insulin (basal with oral anti-diabetics followed by biphasic insulin plus metformin) and one-stage insulin (biphasic with metformin).

Compared to standard of care the results showed:

  • Target A1c: Reached by 0.10% to 1.79% more patients with the two-stage approach, and 0.50% to 2.63% more patients with the one-stage approach
  • Major diabetes complications: decreased by 0.38% to 17.46% with the two-stage approach, and 0.72% to 25.92% with the one-stage approach.
  • Severe hypoglycemia: Increased by 17.97% to 60.43% with the two-stage approach and 6.44% to 68.87% with the one-stage approach.
  • Incremental costs: Ranged from $95 to $3,267 with the two-stage approach, and from $1642 to $1177 with the one-stage approach
  • The cost savings for the one-stage approach may have been related to lower pharmacy costs and reductions in T2DM complications
  • Both approaches were linked to reaching target A1c earlier, fewer diabetes complications, and reduced mortality.

When considering earlier initiation of insulin, Smolen and colleagues recommend that clinicians consider the patient’s ability to regularly self-monitor glucose and make appropriate insulin adjustments. Clinicians should also consider whether the patient will maintain consistent interaction with healthcare providers.

The results indicate that medical cost savings from improved glycemic control can potentially offset increased treatment costs in certain cases. Smolen states, “We do not contradict current practice, but reinforce the need for patients and treating physicians to engage more actively in treatment evaluation and modification.” Smolen added, “The purpose of the study is not to apportion blame for this delay in treatment of T2DM patients, but about helping clinician make rational decisions based on sound evidence.”

Practice Pearls:

  • Study set out to determine if early introduction of insulin could save money, help more patients reach A1c goals and decrease diabetes-related complications and mortality.
  • Results showed both approaches evaluated were linked to reaching target A1c earlier, with fewer diabetes complications and reduced mortality.
  • This reinforces the idea that patients and treating physicians to engage more actively in treatment evaluation and modification.

Smolen HJ, Murphy DR, Gahn JC, Yu X, Curtis BH. The evaluation of clinical and cost outcomes associated with earlier initiation of insulin in patients with type 2 diabetes mellitus. J Manag Care Pharm. 2014;20:968-984.