Sensitivity analyses conducted.

BackgroundLong-acting insulin analogues are the standard of care for Type 1 diabetes (T1D) in high-income countries but remain inaccessible in many low-resource settings. Cost-effectiveness is a key consideration for their adoption. This analysis evaluated the cost-effectiveness of biosimilar insulin glargine (IGlar) versus neutral protamine Hagedorn (NPH) insulin in youth with T1D in Tanzania and Bangladesh.MethodsData from the HumAn-1 trial informed a short-term economic model comparing NPH and IGlar over 12 months. The analysis, conducted from a health systems perspective, incorporated micro-costing data for insulin, injection supplies, blood glucose monitoring, and estimated hospitalization costs for complications. Effectiveness was based on a reduction in nocturnal hypoglycemia. In both countries, we calculated incremental cost-effectiveness ratios per quality-adjusted life year (QALY) gained in scenarios that compared IGlar against NPH across delivery devices (i.e., vials, cartridges, single-use pens).ResultsIGlar was cost-effective compared to NPH when provided in cartridges in Bangladesh at a threshold of three times gross domestic product per capita. Other delivery devices in Bangladesh and all options in Tanzania were not cost-effective at current prices. If offered, IGlar vials would be cost-effective in Tanzania and Bangladesh if the price introduced was no more than 32% or 134% higher, respectively, than the current prices of NPH vials. Annual per patient costs and other cost-effectiveness thresholds were explored.ConclusionIn low-resource settings, IGlar can be a cost-effective alternative to NPH, largely due to reduced nocturnal hypoglycemia, but the delivery device for the insulin has a major impact on the costs and cost-effectiveness comparisons.