Cost Comparison: Insulin Glargine vs Insulin Degludec
Insulin glargine is cheaper than insulin degludec, but degludec is not cost-effective at current pricing. According to the most recent cost-effectiveness analysis from the American College of Physicians, insulin degludec costs $192,000-$406,000 per quality-adjusted life-year (QALY) gained compared to glargine U-100, which far exceeds standard willingness-to-pay thresholds of $50,000-$150,000 per QALY 1.
Direct Cost-Effectiveness Evidence
The cost-effectiveness ratio strongly favors glargine over degludec:
- When used as basal insulin only, degludec costs $406,000 per QALY gained versus glargine 1
- When used as basal-plus-bolus therapy, degludec costs $192,000 per QALY gained versus glargine 1
- Neither scenario approaches acceptable cost-effectiveness thresholds used in U.S. healthcare decision-making 1
The American College of Physicians systematic review concluded that insulin degludec is probably of low value compared with insulin glargine when added to usual care (moderate certainty of evidence) 1.
Clinical Equivalence with Cost Disparity
Both insulins provide similar glycemic control, making the cost difference even more significant:
- Degludec and glargine achieve equivalent HbA1c reductions of approximately 1.1-1.2% 2, 3, 4
- Both reach similar mean HbA1c levels of 7.5% at 24 months 2
- Degludec provides modestly lower fasting plasma glucose (128 vs 136 mg/dL, P<0.001) 2
The primary clinical advantage of degludec is a lower rate of hypoglycemia, particularly nocturnal episodes 2, 3, 4, 5:
- Overall severe hypoglycemia: 4.9% with degludec vs 6.6% with glargine (rate ratio 0.60, P<0.001) 2
- Nocturnal confirmed hypoglycemia: 0.25 vs 0.39 episodes per patient-year with degludec vs glargine 3
- Nocturnal time below range reduced by 12.7 minutes/night with degludec 5
Practical Cost Considerations
For most patients with type 2 diabetes requiring basal insulin, glargine represents the more cost-effective choice:
- Human insulin (NPH) remains even more cost-effective than either analog for patients with relaxed A1C goals, low hypoglycemia rates, and cost concerns 1
- Generic versions and biosimilar insulin glargine products are now available, further reducing costs 1
- The American Diabetes Association recommends considering lower-cost medications including human insulin when financial barriers exist 1
Degludec may be justified in specific high-risk scenarios despite higher cost:
- Patients with recurrent severe or nocturnal hypoglycemia on glargine 2, 3
- Elderly patients at high hypoglycemia risk where the absolute risk reduction becomes clinically meaningful 2
- Patients requiring high-dose insulin (>100 units/day) where the 200 units/mL formulation reduces injection frequency 6
Cost-Effectiveness Context
The 2024 systematic review for the American College of Physicians emphasizes that large reductions in newer drug costs are key to improving type 2 diabetes care value 1. The threshold drug cost at which degludec would achieve high cost-effectiveness (<$50,000 per QALY) is far lower than current wholesale acquisition costs 1.
Common pitfall to avoid: Do not assume that modest clinical benefits (like reduced hypoglycemia) automatically justify substantially higher costs. The incremental benefit must be weighed against the incremental cost, particularly when both agents provide similar glycemic control 1.
Human NPH insulin remains the most cost-effective basal insulin option for appropriate patients, and clinicians should be familiar with its use 1.