What are alternative long-acting insulins to Lantus (insulin glargine) if it's not covered by insurance?

Alternative Long-Acting Insulins to Glargine

If insulin glargine is not covered by insurance, the best alternatives are insulin degludec or NPH insulin, with degludec preferred for patients at high risk of hypoglycemia and NPH insulin as the most cost-effective option when hypoglycemia risk is lower. 1

Primary Alternative Options

Insulin Degludec (Preferred Long-Acting Analog)

• Insulin degludec conveys a lower nocturnal hypoglycemia risk compared to U-100 glargine and provides ultra-long duration of action exceeding 24 hours with highly consistent day-to-day absorption. 1, 2
• Degludec is noninferior to glargine for achieving A1C targets while significantly reducing nocturnal hypoglycemia episodes in both type 1 and type 2 diabetes. 3
• When switching from glargine to degludec, doses can typically be converted unit-for-unit with subsequent adjustment based on glucose monitoring. 1
• For patients previously on twice-daily glargine, the conversion equation is: degludec dose = 0.44 + (0.69 × prior basal insulin dose), though unit-for-unit conversion with monitoring is simpler in practice. 4

NPH Insulin (Most Cost-Effective Alternative)

• NPH insulin achieves equivalent glycemic control to glargine and costs approximately $133-165 per 1,000 units compared to $272-340 for branded glargine. 1
• Long-acting basal analogs like glargine reduce the risk of level 2 hypoglycemia and nocturnal hypoglycemia compared with NPH insulin, though these advantages may be modest in real-world practice. 1
• NPH insulin requires more careful timing and may need twice-daily dosing to provide adequate 24-hour coverage. 1
• The World Health Organization suggests human insulin (including NPH) as first-line insulin therapy, with long-acting analogs reserved for those experiencing frequent severe hypoglycemia. 5

Insulin Detemir (If Available)

• Insulin detemir is another long-acting analog that demonstrated reduced hypoglycemia risk compared to NPH insulin in clinical trials. 1
• Note that insulin detemir has been removed from the market in some regions, so availability should be confirmed before prescribing. 1
• Detemir often requires twice-daily dosing and when switching from detemir to another insulin, an initial dose reduction of 10-20% is typically needed. 1

Conversion Guidelines When Switching

General Conversion Principles

• Doses can often be converted unit-for-unit between basal insulins with subsequent adjustment based on glucose monitoring. 1
• An initial dose reduction of 10-20% should be used for individuals in very tight glycemic management or at high risk for hypoglycemia. 1
• This dose reduction is typically needed when switching from insulin detemir or U-300 glargine to another insulin. 1

Monitoring After Conversion

• Close blood glucose monitoring is essential when initiating or changing insulin regimens, with dose adjustments based on glucose patterns. 5
• Titration should be based on home glucose monitoring or A1C levels, with doses adjusted by 10-15% or 2-4 units once or twice weekly until fasting blood glucose target is met. 5

Cost Considerations for Decision-Making

Relative Cost Comparison

• Glargine follow-on products (biosimilars) cost approximately $190 per 1,000 units compared to $340 for branded glargine, making biosimilar glargine another cost-effective alternative if covered. 1
• Long-acting insulin analogs may be of low value compared to NPH insulin when added to metformin plus sulfonylureas, being similarly effective but more expensive. 1
• NPH insulin is available at some retail pharmacies for approximately $25 per vial, representing the most affordable basal insulin option. 1

Clinical Scenarios for Choosing Alternatives

When to Prioritize Degludec Over NPH

• Patients with frequent nocturnal hypoglycemia on previous insulin regimens should receive degludec rather than NPH. 1, 3
• Patients with unpredictable schedules who need flexible dosing timing benefit from degludec's ultra-long duration of action. 2
• Patients requiring very consistent basal insulin levels with minimal day-to-day variability should receive degludec. 3

When NPH is Acceptable

• Patients without significant hypoglycemia history can safely use NPH insulin with appropriate education about timing and twice-daily dosing if needed. 1
• Cost-constrained situations where hypoglycemia risk is not elevated make NPH the most practical choice. 1
• Patients who can adhere to strict dosing schedules and accept potential for twice-daily injections are appropriate for NPH. 1

Important Caveats

Avoiding Overbasalization

• Clinical signals that should prompt evaluation include basal dose greater than 0.5 units/kg/day, high bedtime-to-morning glucose differential (≥50 mg/dL), hypoglycemia, and high glucose variability. 1
• If basal insulin dose exceeds 0.5 units/kg/day and A1C remains above target, advance to combination injectable therapy with GLP-1 receptor agonists or add prandial insulin rather than continuing to escalate basal insulin. 5

Administration Differences

• NPH insulin must be resuspended by rolling the vial or pen before each injection, unlike clear insulin analogs. 1
• Glargine should not be diluted or mixed with other insulins due to its low pH, though this restriction does not apply to NPH. 5
• All basal insulins should be administered at consistent times each day for optimal efficacy, though degludec tolerates more variation in timing than other options. 5, 2