Should Patients Be Switched to Another Insulin If There Is No Clear Advantage?

The International Diabetes Federation (IDF), in its March 2005 position statement, stated that “All insulins have slightly different properties, and patients should not be changed from one to another insulin type unless there is a clear advantage.”

The IDF went on to say, “No insulin type will suit every patient, and it is important that variety is maintained in order to find the insulin that suits each patient best.”

We asked our experts what they thought about the IDF position statement.

“That pretty much makes sense. I took every one of my patients off NPH and switched them to Ultralente because there was a clear advantage. The only times I ever switch a person from Regular to Humalog is if during a correction they wanted to get their BG down fast; if their prediction of when they were going to eat a meal was uncertain; and if they had the type of job where they never know when they are going to eat. Those are all clear advantages. If something is working, you don’t mess with it unless there is an advantage.”

—Richard K. Bernstein, MD, FACE, FACN, FACCWS

“They should not be changed if it is going to create a problem. Sometimes you don’t know if there is an advantage for that patient until you do the switch. Lantus is an advantage for most patients as a basal, but you don’t know that until you make the switch.”

—Nancy Bohannon, MD, FACP, FACE

“An excellent statement! In the United States, insurance companies ignore this all the time, and not just for insulin, but for blood pressure medications, thyroid preparations, lipid medications, antidepressants. Cost is the major factor for Medicare, Medicaid and all other healthcare in the United States. I suspect that this is similar in other parts of the world, although rationing decisions are rarely discussed openly.”

—Stuart Brink, MD

“A clear advantage was created with studies that were specifically designed to make Lantus look far superior to Ultralente. The problem with these studies, when you read the fine print hidden within the research, was that Lantus was used in appropriate ways and then contrasted to inappropriately used Ultralente (and NPH). It is unfortunate that within the clinical and medical education setting, very few physicians or their patients were ever given an opportunity to understand and see how well Ultralente can work when it is used appropriately. Contrary to the opinions continually propagated as truth because of these poorly run studies, when Ultralente is used appropriately, it is a very predictable and stable basal insulin. For the diabetic trying to make sense of seemingly contradictory information, everything becomes more and more confusing. For the companies who are forcing changes, confusion has a secondary effect of neutralizing the motivation needed to initiate action against them. In context of the many long-term safety unknowns with the new synthetic “insulin analogues,” the loss of the only other stable basal insulin is tragic. Outside of the confusion game, the effects of the impending forced insulin changes will in actuality be a clear disadvantage for many diabetics.”

—Steven Gordon, ND

“The IDF statement is coming too late. What is the point of issuing that statement now, after the insulin companies have made decisions to remove first the animal insulins and now Lente and Ultralente? I can’t help asking: Why didn’t they make this statement five years ago?”

—Jenny Hirst

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