Can I use NPH (Neutral Protamine Hagedorn) insulin and glargine (insulin glargine) together?

From the Guidelines

Yes, NPH insulin and insulin glargine can be used together as part of a basal-bolus insulin regimen, but this should be done with caution and under medical supervision to avoid hypoglycemia and ensure optimal blood glucose control. This combination is sometimes prescribed to provide more comprehensive blood glucose control throughout the day. NPH is an intermediate-acting insulin that typically peaks 4-10 hours after injection and lasts 10-16 hours, while glargine is a long-acting insulin that provides relatively peakless coverage for approximately 24 hours. When used together, NPH might be administered twice daily (morning and evening) to provide daytime and overnight coverage with some peak effect, while glargine might be given once daily to provide steady baseline insulin.

Key Considerations

• The most recent and highest quality study, 1, suggests that basal insulin alone is the most convenient initial insulin regimen and can be added to metformin and other oral agents, with long-acting basal analogs like glargine reducing the risk of symptomatic and nocturnal hypoglycemia compared with NPH insulin.
• However, the study also notes that the advantages of long-acting basal analogs may be modest and may not persist, highlighting the need for individualized titration and careful monitoring.
• Another study, 1, also supports the use of long-acting insulin analogs like glargine for controlling fasting glucose, but emphasizes the importance of considering the degree of hyperglycemia and individualizing the starting doses based on body weight.

Clinical Implications

• Using two basal insulins requires careful blood glucose monitoring to avoid overlapping effects that could cause hypoglycemia.
• The specific dosing schedule should be determined by your healthcare provider based on your individual glucose patterns, lifestyle, and insulin sensitivity.
• Any adjustment to your insulin regimen should only be made under medical supervision, taking into account the potential risks and benefits of combining NPH insulin and insulin glargine, as noted in studies like 1 and 1.

From the FDA Drug Label

In clinical studies in adult patients, there was a higher incidence of injection site pain in insulin glargine-treated patients (2.7%) compared to NPH insulin-treated patients (0. 7%). The reports of pain at the injection site did not result in discontinuation of therapy. In clinical studies of insulin glargine, increases in titers of antibodies to insulin were observed in NPH insulin and insulin glargine treatment groups with similar incidences.

The FDA drug label does not answer the question.

From the Research

Using NPH and Glargine Together

• The provided studies do not directly address the use of NPH (Neutral Protamine Hagedorn) insulin and glargine (insulin glargine) together 2, 3, 4, 5, 6.
• However, the studies compare the effects of long-term treatment with (ultra-)long-acting insulin analogues, such as insulin glargine, to NPH insulin in adults with type 2 diabetes mellitus 2.
• Insulin glargine has been shown to result in fewer participants experiencing hypoglycaemia when compared with NPH insulin 2, 4, 6.
• The incidence of severe hypoglycaemia was lower with insulin glargine compared to NPH insulin in some studies 4, 5, 6.
• There is no clear evidence to suggest that using NPH and glargine together would be beneficial or harmful, as the studies focus on comparing the two insulins separately 2, 3, 4, 5, 6.

Key Findings

• Insulin glargine reduces the risk of severe hypoglycemia compared to NPH insulin 2, 4, 6.
• Insulin detemir also reduces the risk of severe hypoglycemia compared to NPH insulin 3, 5.
• The use of insulin glargine compared to NPH insulin appears to reduce the risk of nocturnal and severe hypoglycemia by 40% to 60% 6.
• There is no clear difference between insulin analogues and NPH insulin in terms of weight gain or adverse events 2, 3.

Considerations

• The studies suggest that insulin glargine and insulin detemir may be preferable to NPH insulin in terms of reducing the risk of hypoglycemia 2, 3, 4, 5, 6.
• However, the decision to use NPH and glargine together should be based on individual patient needs and medical history, as the studies do not provide direct evidence for this specific combination 2, 3, 4, 5, 6.