Diabetes Center of Excellence, University of Massachusetts Medical School, Worcester, USA.
Curr Opin Endocrinol Diabetes Obes. 2019 Apr;26(2):77-83. doi: 10.1097/MED.0000000000000469.
Since its discovery almost a century ago, there have been numerous advancements in the formulations of insulin. The newer insulin analogs have structural modifications with the goal of altering pharmacokinetics to achieve either quick onset and offset of action (mealtime bolus analogs), or a prolonged steady action (basal analogs). These analogs offer many advantages over older human insulins but are several-fold more expensive. The aim of this review is to evaluate reasons for the exorbitant price of the newer insulins, to examine the evidence regarding their clinical advantages and to make value-based prescribing recommendations.
The higher cost of newer insulins cannot be justified based on drug development or manufacturing costs. Compared with older insulins, newer analogs do not offer significant advantage in achieving hemoglobin A1c targets, but they reduce risk of hypoglycemia. The reductions in hypoglycemia are relatively modest and most apparent in those with type 1 diabetes, possibly because these individuals are more prone to hypoglycemia.
When cost considerations are important, the older insulins (regular and NPH insulin) can be used safely and effectively for most individuals with type 2 diabetes who have a low risk of hypoglycemia.
自近一个世纪前发现以来，胰岛素的制剂已有了众多进展。新型胰岛素类似物进行了结构修饰，目的是改变药代动力学，从而实现快速起效和作用消退（餐时 bolus 类似物）或延长平稳作用（基础类似物）。这些类似物与较老的人胰岛素相比具有许多优势，但价格也高出数倍。本文的目的是评估新型胰岛素价格过高的原因，考察其临床优势的证据，并提出基于价值的处方建议。
新型胰岛素的高成本不能用药物开发或制造成本来解释。与较老的胰岛素相比，新型类似物在达到血红蛋白 A1c 目标方面没有明显优势，但它们降低了低血糖的风险。低血糖风险的降低相对较小，在 1 型糖尿病患者中最为明显，这可能是因为这些患者更容易发生低血糖。
当成本因素很重要时，对于低血糖风险低的大多数 2 型糖尿病患者，较老的胰岛素（常规和 NPH 胰岛素）可以安全有效地使用。
