Give the Old Guys a Chance: Remembering Older Insulins

We are very fortunate to have a number of newer insulin’s available for our patients. For years we had animal insulins only. NPH and Regular, then we had Ultralente. The development of analog insulin’s marked the upswing in technology that we would sustain for a period of time. The most recent big blip in the radar came from Lantus insulin, which changed the landscape of diabetes treatment entirely. Subsequently we had Levemir join the group of long-acting, “peakless” analog insulin’s, and a small group of super-fast acting insulin’s.

In my practice I have new patients show up already having been started on these new insulins. I in fact have not had a recent referred patient come to me on ANY older insulin’s. The big surprise? Many times I switch them back to an older insulin.

Please don’t get me wrong. I like the new kids on the block as much as anyone else. The analog insulin’s have truly revolutionized insulin treatment. They are the closest we have to an insulin pump, which is in turn the closet we have to mimicking a real pancreas aside from islet cell transplant. In the right patient, and with the right dosing, a long-acting/short-acting insulin combination can be golden and really allow great flexibility for the patient while keeping their glucose levels under control. That said, there have been more than a few instances when I switched back from this high powered combination to an older insulin like NPH or 70/30 insulin, sometimes even regular insulin.

Scenario 1—the patient can’t handle the intensity of the long-acting/short-acting regimen. Face it, this regimen takes work. For anyone who eats three meals a day, it is at least four shots a day.

Scenario 2—the patient doesn’t dose it correctly. The flat mealtime dosing doesn’t often work (who eats the same thing everyday?), so then we head either to a prandial scale based on pre-prandial blood glucose levels, or carb counting. What happens with incorrect dosing? Lows or highs sometimes-ugly ones.

Scenario 3—cost issues. This is actually one of the most frequent reasons that I switch back to 70/30 or NPH regimen. Right now there are no generic versions of Aspart, Levemir, lantus etc, none. They are all brand name and quite expensive without patient assistance or insurance coverage (and even then, it can still be costly).

Our patients need options, and that should include reconsideration of older insulin’s that DO WORK. Agreed, their pharmacodynamics are not as impressive as the newer insulin’s, But they do work, and work great in many people. So remember to given them a chance. They are still the good old guys.