Rapid-Acting Insulin Analogue Cost-Effectiveness in Type 1 Diabetes: What the Evidence Shows

Insulin analogue cost-effectiveness studies for adults with type 1 diabetes mostly point the same way: the newer products usually come out ahead of human insulin. A new systematic review says that headline rests on thinner ground than it looks. The paper, by Shiwa Yaghoubi Bina, Steve Njokuocha and the T1D Economic Evidence Synthesis Group, has been accepted for Value in Health. The version available now is a pre-proof, so figures could still change at copyediting. The World Health Organization funded the work, which is meant to feed into its international guideline on type 1 diabetes management.

Insulin analogue cost-effectiveness: what the review covered

The authors searched MEDLINE, Embase, Web of Science, WHO Global Index Medicus and the HTA database on 17 March 2025, with no language restrictions. They included full economic evaluations of insulin regimens for adults with type 1 diabetes and found 35 studies, reporting 50 insulin comparisons across 19 countries, most of them in Europe. Thirty-one of the 35 studies came from high-income countries, and 27 were set in Europe. Nearly all (34 of 35) were model-based.

Ratios were converted to 2024 US dollars using purchasing power parity. Cost-effectiveness judgements were made against the threshold each original study used. Quality was assessed with the Swedish SBU checklists and the 2022 CHEERS reporting standard.

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Rapid-acting analogues look the most consistent

The clearest signal is for rapid-acting insulins. Lispro and aspart were cost-effective or dominant against regular human insulin in every study identified. That held across high- and upper-middle-income settings, and in both industry-funded and independently funded work. For background on how these insulins are used in practice, see Syenza News’s overview of diabetes management in the Arab region.

Probabilistic sensitivity analysis is less reassuring. Probabilities of cost-effectiveness above 50% were reported for lispro and aspart against regular insulin. Across the whole set, though, a probabilistic analysis appeared in only 23 of the 35 studies.

Long-acting analogues and the uncertainty around them

For long-acting analogues compared with NPH insulin, the direction is consistent but the certainty is not. Glargine was cost-effective against NPH in four studies and dominant in two. One of those analyses put the probability of cost-effectiveness as low as 42.5%. Detemir was cost-effective against NPH in at least one model specification in eleven studies, but probabilities in the studies that reported them ran from 15% to 89.5%.

The least secure comparisons are analogue against analogue. Degludec against glargine was favourable in eleven of twelve studies, and all eleven were funded by the manufacturer of degludec. The only independently funded study found degludec not cost-effective. Single studies also reported icodec dominant against degludec and detemir dominant against glargine. Each of those rests on one study, and the icodec result carried a 40% probability of cost-effectiveness.

Industry funding and the direction of results

Most of the evidence is industry-funded. Thirty of the 35 studies (86%) were sponsored by a manufacturer of one of the insulins being evaluated, and 24 (69%) by a single company, Novo Nordisk. In all 30 manufacturer-funded studies, the sponsor’s product was cost-effective or dominant in at least one specification. Every unfavourable conclusion in the set came from an independently funded study: 2 of 5 independent studies versus 0 of 30 industry-funded ones (Fisher’s exact test, p = 0.017). The authors call this exploratory, because independent studies are few and funding is tangled up with setting, model type and publication period.

Thirteen of the studies share one proprietary model, the CORE Diabetes Model, whose structure cannot be fully reported. That makes independent replication of those results impossible for now.

Who is missing from the evidence

No study came from a low- or lower-middle-income country. Four came from upper-middle-income countries: Brazil, Colombia, Iran and Serbia. The search included the WHO Global Index Medicus and had no language restrictions, so the gap is not from a narrow search. The authors argue that costs do not transfer between settings. The incremental cost of an analogue depends on local prices, procurement and biosimilar availability, while the savings from avoided hypoglycaemia admissions are far lower in absolute terms where resources are scarce. The hypoglycaemia effects that drive most favourable results were also estimated in settings with structured education, self-monitoring and emergency care.

What this means for HTA and guideline makers

The review concludes that analogues are reported as cost-effective in most of the 35 evaluations, but the certainty of that finding is limited. Three practical points follow. A result that rests only on a deterministic analysis is low certainty, and 12 of the 35 studies had no probabilistic analysis. A probability near or below 50% means the evidence is indeterminate at the assumed price and threshold, so any recommendation built on it should be conditional and time-limited. Price-threshold analysis is more useful to a global guideline than a ratio transferred from another country. The authors call for context-specific thresholds. A Syenza News piece on implementing HTA in Oman covers one country’s work on developing its own cost-effectiveness thresholds.

On reporting, only three of the 35 studies (9%) were published after the 2022 CHEERS statement. The authors read the checklist as a measure of reporting against current standards, not a judgement of quality. Engagement with people living with type 1 diabetes was among the least completely reported items, and none of the studies involved patients in defining the decision problem, choosing outcomes or valuing health states.

The authors conclude that independent, locally parameterised evaluations reporting price-threshold results are needed before these findings can inform decisions in lower-income settings.

Source: Bina SY, Njokuocha S, and the T1D Economic Evidence Synthesis Group. Cost-effectiveness of insulin regimens and insulin types for adults with type 1 diabetes: a systematic review. Value in Health (2026), pre-proof. https://doi.org/10.1016/j.jval.2026.09.3127