NPH has similarly low risk of clinically meaningful hypoglycemia as more expensive basal insulin analogs in patients with type II diabetes, and may be more effective for lowering HbA1c

EBM Focus - Volume 13, Issue 28

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Reference: JAMA 2018 Jul 3;320(1):53 (level 2 [mid-level] evidence)

When the first basal insulin analog was approved for treatment of type II diabetes in 2000, prescribing of neutral protamine hagedorn (NPH) fell sharply in comparison. Basal insulin analogs are often touted for their once daily dosing and reduced risk of asymptomatic nocturnal hypoglycemia. NPH does have a slightly shorter half-life, but can be dosed once or twice daily and is ½ to 1/10 of the cost. A recently published large retrospective cohort analysis evaluated clinically meaningful hypoglycemia in patients treated with NPH compared to basal insulin analogs (JAMA 2018). The trial measured time to a hypoglycemia-related ED visit or hospital admission in 25,489 patients with type II diabetes who initiated insulin therapy with either NPH or basal analog over a mean 1.7 years. The notably smaller cohort receiving basal analog insulin (1,928 compared to 23,561 in NPH cohort) were more likely to have a greater number of comorbid conditions and more ED or hospital visits in the prior year. In order to minimize the effect of these covariates, the authors performed a propensity score matched analysis that took into account the relevant baseline characteristics.

There was no significant difference in hypoglycemia-related ED visits or hospital admissions comparing patients initiated on basal insulin analog or NPH in the primary analysis or after propensity score matching. There was a statistically significant reduction in HbA1C in those patients treated with NPH (1.48 percentage points) compared to basal insulin analogs (1.26 percentage points), though this difference is unlikely to be clinically meaningful.

Focus Point: When choosing between NPH and basal insulin analogs for your type II diabetic patients, perhaps the only meaningful difference between the two is cost.

For more information, see the topic Insulin for type 2 diabetes with suboptimal glycemic control in DynaMed Plus. DynaMed users click here.