Jay H. Shubrook, DO; Leonard R. Bertheau, DO


April 03, 2017

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Jay H. Shubrook, DO: Hi. I am Jay Shubrook, family physician and diabetologist at Touro University California College of Osteopathic Medicine, in Vallejo, California. I am happy to continue our series on practical insulin use in primary care. Today our guest is Dr Leonard Bertheau, family physician and fellowship-trained diabetologist, who is going to talk about switching to human insulins. Insulins are expensive today, and the cost of insulins has become a major barrier to healthcare planning for patients. How has this affected your practice?

Leonard R. Bertheau, DO: The cost of the new insulins has made it very challenging to take care of patients. In particular, it can be quite difficult for my patients to get access to the branded basal insulins. This has forced them to change insulins, and sometimes that transition is not simple, especially if they want to save money.

The Switch Between Branded Basal Insulins

Dr Shubrook: This is also the case for my patients. Sometimes the insurance company prefers one basal analog over another. Is this a switch you are comfortable with? How do you accomplish that?

Dr Bertheau: The transitions are usually smooth when switching from one branded basal insulin to another. The duration and actions are not too dissimilar among these insulins. Usually the dosages are also fairly similar. Sometimes you do have to reduce or slowly increase the dose over time, but typically I can easily walk my patients through that transition.

It becomes more difficult when a patient cannot afford the branded basal insulins; insurance plans have placed all of those branded insulins at a higher tier now. Even the copays are quite high. Some patients have deductibles that have to be met before their insurance will cover the cost of prescription medications. Other patients are covered by Medicare, and these high-cost basal insulins push them into the Medicare "gap" sooner. At that point, patients are responsible for 100% of the cost of their insulins, at least for a time.

Switching to Lower-Cost Insulin

Dr Shubrook: What options are available for patients who cannot pay these high costs?

Dr Bertheau: The cheapest alternative is ReliOn NPH insulin in a vial. When that is prescribed, some patients have to learn how to draw up the insulin dose from the vial and inject with a syringe. The transition from the branded basal insulins to NPH is not simple, so we hope patients are reaching out to get instructions from us on how to do this.

Dr Shubrook: What are the steps for a switch from a branded basal insulin to ReliOn NPH?

Dr Bertheau: The switch is not as simple as switching between branded insulins. Typically, I divide the patient's total basal insulin dose and prescribe the NPH at one third of the basal insulin dose at bedtime and two thirds of it in the morning. Knowing that the morning dose will kick in at lunchtime, I will stop the patient's prelunch bolus or fast-acting insulin. Typically, I have to titrate the dose up from there, but I feel that it is safest to start there and then teach the patient how to work their way up.

Dr Shubrook: Two thirds in the morning, one third at bedtime. Why bedtime?

Dr Bertheau: The NPH insulin is replacing the patient's basal needs at this point, and thus it is best to give some at bedtime so that it can work overnight and help the patient wake up with the best blood sugars in the morning.

Cost Is the Key

Dr Shubrook: This could be a bit more complex for the patients. Now they are dosing twice a day, they have to take lunch into account, and they have to pay more attention to spacing out their meals. But it may be a necessary change based on cost.

Dr Bertheau: Yes. Cost is the key. The patient should be paying no more than $25 per 1000-U vial. This is substantially cheaper than the branded basal insulins. If a patient is paying more than $25 a vial for NPH insulin, I encourage them not to use their insurance. When patients just pay cash, they can usually get a generic version for $25 a vial.

Dr Shubrook: That makes a big difference. My experience is that most of these insulins cost more than $100 otherwise.

Dr Bertheau: That is correct. It make no sense, but if a patient pays for the insulin out of pocket, it is much cheaper than if they go through the insurance plan and often pay more than the vial is worth.

Dr Shubrook: It sounds as though insurance has made this decision-making more complicated. If you were going to switch between basal insulin analogs, you could do a unit-to-unit switch, but we may see a growing number of patients who have to use NPH because of cost. In this case, you have to change the dosing based on the NPH peaks of action, so the patient takes more in the morning and less at bedtime. Do you ever prescribe NPH to be given three times a day?

Dr Bertheau: During my fellowship, you taught me that it can be given three times a day. In that case, you are using a lower dose more frequently, and it does behave more like basal insulin. Until now, I liked the basal insulins, and I have been using them almost exclusively. But lately I have been faced with this dilemma of transitioning from basal insulin to NPH. Can you share some of your experiences with using NPH insulin three times a day?

Dr Shubrook: I believe that NPH can be effective as basal insulin. The three-times-a-day dose schedule may be helpful for someone who eats throughout the day rather than just at mealtimes. For most people, it is quite hard to keep up with more than twice-a-day dosing. I believe that your suggestions are quite good. We already have enough complexity in diabetes care that we want to try to make it as easy as possible for the patient. I like your two thirds at breakfast and one third at bedtime.

Dr Bertheau: To dovetail on your statement about trying to make it simpler, sometimes I do use this as an opportunity to make it very simple for the patient. If the patient is forced to switch to NPH anyway, often I will suggest another, easier alternative. We can switch to 70/30, a generic insulin that is available for $25 per vial. That way, the patient gets all of the insulin, the long-acting and the short-acting. The trade-off to that is that patients must be very consistent with mealtimes and the carbs they eat at each meal. With dosing, 70/30 is a lot simpler, but with eating, for some patients, it is more difficult. For those patients who are already sticking to a regimented schedule, this is an easy, smooth transition for them. That has been beneficial.

Dr Shubrook: Lee, you shared some very important insights today. This is a very complex issue, and we appreciate your time and expertise.

Dr Bertheau: Thank you so much for having me.


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