Losing Lyumjev: how the system failed patients

As MiniMed, Insulet, Tandem and CamDiab work to bring fully closed loop, a system that needs no meal boluses at all, into wider use, the system that decides which insulins people are offered has conspired to take away a key part of that equation: the fastest-absorbed subcutaneous mealtime insulin available. This is a story of inertia, ineptitude and indifference.

In March 2026 a pump user in Switzerland went to order more Lyumjev and was told it could not be ordered. “There’s no press release, pharmacy just says they can’t order it anymore due to being discontinued,” they wrote on Reddit. Lilly had told Swiss specialists the previous autumn. It had not told the national patient organisation, which found out from a copy passed to it unofficially.

Norway lost two Lyumjev pens in October 2025, but Switzerland was the first country to lose its vial, cartridges and standard pen together. In March 2026 Lilly announced that it would stop selling selected presentations of its insulins in selected European countries before 2027, and Lyumjev, its ultra rapid insulin lispro, is on the list. The formal reason is “commercial”. Closer to the ground, the reason given is that not many people used it.

So Europe is losing presentations of its fastest-absorbed subcutaneous insulin after years of surprisingly low and uneven use. The UK dispensing and formulary data in this article show that access policy is strongly associated with that use, and that for most of the period the price of the insulin explains very little of it. It cannot prove what drove Lilly’s commercial decisions. But it raises an uncomfortable question: did health systems help create the low-demand market that the manufacturer is now retreating from? I think the answer is largely yes, and the rest of this article sets out why, and where the evidence stops.

Personally, I have used the fastest subcutaneous mealtime insulin available since each one reached the UK, some of the time on private prescription, because I read the pharmacology and the trials and decided that an insulin which starts working sooner was worth having. I have talked about it openly on this website. I built Boost, the open-source automated insulin delivery algorithm I develop, around the pharmacology of Lyumjev, and with it my own time in range (3.9 to 10 mmol/L) was about 83% between 1 April and 31 August 2026, without announcing meals or bolusing for them (calculation; the personal CGM data behind it are not published). This is a major reason for my concern.

What is being lost

Neither Lyumjev nor Fiasp, Novo Nordisk’s faster aspart, has lost its EU licence. Their presentations (the delivery mechanism or brand name) are disappearing country by country. Lyumjev cartridges have gone in France and Belgium, its 200 unit and Junior KwikPens in Norway, and its vial, cartridges and standard KwikPen in Switzerland. Germany has kept Lyumjev but dropped its five-pen packs. The Lyumjev Tempo Pen was removed from the EU licence in July 2026. On the Novo Nordisk side, the Fiasp PumpCart, a prefilled cartridge for the YpsoPump, is being withdrawn across the whole EU by the end of 2026.

The official statements are brief. The European Medicines Agency says Lilly “decided to stop marketing some of its insulin medicines for commercial reasons”, and that the decision “is not related to a quality defect or safety issue”. Lilly’s template letter to European clinicians says the decision followed “careful consideration and a thorough market assessment”. In France, Lilly said it was rationalising its insulin range worldwide to “maintain a continuous and reliable supply of the insulins most commonly used by patients”.

Digging deeper, the reason becomes specific. Norway’s diabetes association, reporting the loss of the two Lyumjev pens there, wrote that Lilly “points out that these are variants that are little used”. In Switzerland, the patient organisation diabetesschweiz complained, and in March 2026, in an email reply that the recipient later posted publicly, passed on what it had been told, which it was careful to call unofficial: that very few people in Switzerland had stayed on Lyumjev long term, partly because of pain or burning at injection, and that specialist prescribing had been very low.

The UK has not seen any announcement. The NHS medicines dictionary marks only the Lyumjev Tempo Pen as discontinued, and Lilly’s March notice covers the EU and EEA. The UK’s share of Lyumjev is the same as France’s, which has already lost the cartridges, and Lilly has not said what it plans here.

Why Lyumjev matters

Every injected rapid-acting insulin has the same problem. Food starts raising glucose within minutes, and an injected insulin takes a good deal longer to get going. That is why we are told to inject 15 to 20 minutes before eating and many choose to do so considerably earlier than that. In practice many people do not wait. A Spanish study using connected pen caps recorded 775 evenings from 49 people, and in 52.6% of them (408 evenings) the dinner insulin went in up to 45 minutes after the start of the meal, as detected from the glucose trace.

The ultra-rapid insulins change the first half hour. Fiasp appears in the blood about five minutes earlier than NovoRapid. Lyumjev adds citrate and treprostinil to lispro, which open up the local blood vessels, and has several times Humalog’s exposure in the first quarter of an hour and is typically faster still than Fiasp. In the meal test of PRONTO-T1D, the rise in glucose an hour after eating was 1.55 mmol/L lower with Lyumjev than with Humalog, and a meta-analysis pooled reductions of 0.94 mmol/L in type 1 diabetes and 0.56 mmol/L in type 2, with little difference in HbA1c.

Lyumjev is the faster of the two. In a crossover study of all four insulins, it reached half its early peak concentration six minutes before Fiasp, though its lower glucose after the meal against Fiasp, about 0.4 mmol/L at two hours, was numerical and not statistically significant. In closed-loop systems the gains from both are modest and depend on the algorithm. In the Cambridge CamAPS FX system, Fiasp added no time in range over standard aspart (though it reduced time below range), while Lyumjev added 2.5 percentage points over standard lispro, and a pooled analysis of meals found Lyumjev improved the four hours after breakfast where Fiasp made no measurable difference. In Medtronic systems, Fiasp added about 1.8 to 1.9 percentage points of time in range in two studies (670G, advanced hybrid closed loop).

What people value is not having to wait. “Lyumjev is faster for me, I don’t pre-bolus now and I just feel much more confident with it,” wrote a Diabetes UK forum member in 2021. A Swiss pump user wrote in 2026 that “Lyumjev worked extremely well with Control-IQ because of the faster pharmacokinetics. It noticeably improved post-meal spikes compared with standard lispro.”

It does not suit everyone. Site pain is a common complaint, especially on pumps. In the Lyumjev pump trial, infusion-site reactions occurred in 19.1% of people against 6.9% on Humalog, and of 29 people whose earlier public accounts I collected to illustrate experience, not to measure it, nine described pain or site reactions, seven of them with Lyumjev. “Burning, painful infusion sites that left lumps several days after,” one t:slim user wrote in March 2026. That is a reason to offer a choice: Lyumjev suits some people and hurts others.

Low prescribing rates

The figures that follow are shares of insulin units dispensed in the community, from England’s open prescribing data and the equivalents for Scotland, Wales and Northern Ireland. They count insulin supplied. They do not count people, and they cannot show who was offered what. I suspect that far fewer people have ever been offered Lyumjev because I suspect that many clinicians don’t know enough about it. I have taken the data for the UK as an example because it is freely available and extremely detailed, where other countries are less so. I suspect the same arguments apply across national boundaries.

The UK was always going to struggle with this, as by far the most frequently prescribed rapid acting insulin comes from Novo (even though pricing for Novo and Lilly products has historically been similar) so it would have required a major marketing push to get Lyumjev in front of prescribers. In the year to July 2026, Lyumjev was 3.7% of the rapid-acting analogue insulin units dispensed in English primary care, six years after it arrived. Its share of lispro has grown every year, to 24% in 2026. Fiasp adds 13.9%, so the two ultra-rapid insulins together are 17.5% of units. It’s notable that Fiasp is still a larger share than Humalog. Other European markets split differently. In France in 2025 Humalog was 27.3% of rapid-acting analogue units and Fiasp 11.1%; in Denmark, Novo Nordisk’s home market, Fiasp was 11.0% and Humalog 1.1%. Standard-speed products make up the other 82.5% of units in English primary care, about 2.74 million prescription items a year.

The share varies widely by paying entity (the integrated care boards). Between English integrated care boards it ranges from 3.2% in Birmingham and Solihull to 30.0% in Leicester, Leicestershire and Rutland. Across the UK nations it is 14.7% in Scotland, 17.4% in England, 26.4% in Northern Ireland and 32.8% in Wales, and in one Welsh health board, Cwm Taf Morgannwg, it is 56.3%. Lyumjev alone is 6.0% of units in both Wales and Northern Ireland, against 3.7% in England and 3.4% in Scotland.

England is not unusual internationally. France was at 14.3% in the year to June 2026 and Denmark at 11.0% in 2025; both rose faster than England at first and then levelled off at around 11% to 15%. The spread inside the UK is wider than the spread between countries, which points to local factors.

The system’s part

The trials and the guidelines

The phase 3 treat-to-target trials that supported licensing, such as onset 1 and PRONTO-T1D, used HbA1c non-inferiority as their main efficacy outcome. They all met it, and the post-meal benefit appeared as a secondary result. Other studies have used post-meal glucose or time in range as their main outcome, but it is the licensing programmes that guidance and formulary committees lean on, and their headline is “no different on HbA1c”. HbA1c is also what audits and incentive schemes look at, so that headline gave a busy clinician little prompt to switch anyone.

NICE’s guidance for adults with type 1 diabetes recommends rapid-acting analogues as a class and names no product. Its wording on mealtime insulin dates from 2015; NICE reviewed the guideline in January 2026 and decided not to update it. The guidance does say that if someone has a strong preference for an alternative mealtime insulin, clinicians should respect it and offer it, which gives anyone who asks a route. It does not tell prescribers that the faster insulins are worth raising with people who do not ask about them.

Formularies

Each area has a formulary that sets which insulins are first choice. I went through the entries for Lyumjev in 38 areas across the UK: 17 English integrated care boards, 13 Scottish health boards, all seven Welsh health boards and Northern Ireland. Lyumjev was open to any prescriber in five of them. In eight it needed a specialist or set clinical criteria. In twelve it was placed behind another insulin, as a second or third choice or only after the standard insulin had failed. In thirteen it was not on the formulary at all, including eight of the thirteen Scottish boards and Northern Ireland.

Some of those gaps were made by the process. From October 2020 the Scottish Medicines Consortium stopped requiring a submission for “an alternative formulation of an established medicine … which costs the same per patient or less”, which Lyumjev is, so there is no Scottish advice on it at all. The All Wales Medicines Strategy Group excluded Lyumjev from appraisal on the same grounds, as it had Fiasp. Northern Ireland adopts NICE decisions first, then the Scottish Consortium’s, then the Welsh group’s, and none of them had made one, so there was no recommendation for Northern Ireland to adopt through its usual sequence. Clinicians there can still prescribe outside the formulary or ask for an addition. A rule meant to spare same-priced medicines unnecessary paperwork left one with no decision anywhere, and no public record shows anyone, Lilly included, trying to close the gap.

Formulary restriction is associated with lower use. In England, where formularies left both ultra-rapid insulins open, the median ultra-rapid share was 26.8%; where they were second line, restricted to pregnancy or not listed, it was 9.5%. Birmingham and Solihull, the lowest in England, allows Fiasp only in pregnancy “after other insulins have been tried and failed” and does not list Lyumjev. Scotland shows the same direction: the two boards using the Highland Formulary, which lists both products without restriction, are at 26.2% and 23.5%, while the rest have a median of 5.2%. Across the 16 English integrated care boards, the rank correlation between how restrictive the formulary is and ultra-rapid use was -0.72 (95% interval -0.91 to -0.35; permutation p = 0.002), and across Scotland’s 13 boards -0.51, or in plain English, the more restrictive it is, the less likely ultra-rapid insulin will be used.

Taken on its own, Lyumjev tells a narrower story. Setting its formulary position against its share of lispro, the same thing happens and the more restrictive the formulary is about Lyumjev, the less of it is used, in England and across the UK (figures). Almost all of that comes from being left off. Where Lyumjev is not listed, its median share of lispro is 5.2% in England and 2.9% in Scotland; wherever English formularies list it, under any restriction, the median is 27% to 31%, with no clear gradient between the restrictions. Leaving it off the formulary goes with very low use.

This is an association between areas, does not demonstrate cause, but it is highly coincidental. The open group in England is composed of only two integrated care boards; I reviewed the formularies after seeing the uptake figures; many formulary pages carry no date, so current wording is being compared with past prescribing; and none of it is adjusted for how many people use pumps, the reach of specialist centres, the local population or past habit. Wales goes the other way: its boards that require a specialist have higher uptake than its open ones (rank correlation +0.63), so formulary position explains part of the pattern in England and Scotland and plainly not in Wales. Northern Ireland dispenses Lyumjev at 1.6 times the English rate without listing it. Local specialist practice clearly matters as well. But a formulary that leaves an insulin off, or puts it behind the one most people are already on, makes it harder to prescribe.

The insulin that got through

Tresiba (insulin degludec), Novo Nordisk’s ultra-long-acting insulin, is a useful comparison: a newer insulin that the same formularies did make room for. It also costs more than the insulins it would replace: £3.11 per 100 units at list price in English primary care in the year to July 2026, against £2.32 for Lantus and £2.00 for Semglee, the cheapest glargine biosimilar, which has been dispensed in England since 2019 (prices). Formularies made room for Tresiba with a cheaper long-acting insulin to protect. The ultra-rapid insulins were in that position only after Trurapi arrived in 2021, and before then they cost no more than the insulins they would replace.

I read the same 38 formularies for Tresiba, using the same documents and the same four categories as for Lyumjev. Tresiba is on 37 of them and Lyumjev on 25. Of the 13 areas that leave Lyumjev off, 12 list Tresiba, Northern Ireland and seven Scottish boards among them. Tresiba is the less restricted of the two in 20 areas and Lyumjev in 3; in the other 15 they are treated alike (table). Tresiba is seldom open to any prescriber either. Most formularies tie it to a specialist or to named uses, such as night-time hypoglycaemia or a carer giving the injection. What it has, almost everywhere, is a written place.

Part of the difference is process. As a new molecule, Tresiba had to be appraised. The Scottish Medicines Consortium accepted it for use in NHS Scotland in August 2016, and the All Wales Medicines Strategy Group recommended it in 2016 and again in 2022, so every board had a decision to adopt. Lyumjev, as a same-priced version of an existing insulin, was spared appraisal and was given no decision at all.

Part is the kind of evidence each had. Tresiba was tested in trials whose main outcome was hypoglycaemia: in SWITCH 1, people with type 1 diabetes had fewer episodes on degludec than on glargine. When NICE revised its type 1 guidance on long-acting insulin in 2021, it named degludec for people with “a particular concern about nocturnal hypoglycaemia”. Its mealtime recommendations still date from 2015 and name no product. A committee could point to a problem Tresiba addressed and a group of people to give it to. For the ultra-rapid insulins the headline was no difference in HbA1c, and the problem they address, waiting before a meal, is not one formularies record.

The dispensing follows a similar course. Counted from launch, Tresiba was taken up in England no faster than Fiasp for five years: 7.8% of long-acting analogue units at five years, against 7.9% of rapid-acting units for Fiasp. They separated after the 2017 hypoglycaemia trials, and at nine years Tresiba was at 19.6% and Fiasp at 13.9%. Areas that use more Tresiba and Toujeo also tend to use more ultra-rapid insulin (Spearman 0.49, 95% interval 0.25 to 0.67, across 59 UK areas), so local habit plays a part. Tresiba still reached places the faster mealtime insulins did not. Most long-acting insulin in primary care goes to people with type 2 diabetes, so these are not the same patients, and the timing fits the trials without showing that they caused the rise.

Outside the UK, the route differs, and appraisal can shut a door as well as open one. France’s assessment committee re-rated Tresiba in 2019 as a minor improvement over glargine (ASMR IV) for people at high risk of hypoglycaemia, on the strength of those trials, while it rated Fiasp and Lyumjev as no improvement (ASMR V). In Germany every benefit assessment of degludec found no added benefit, and Novo Nordisk took Tresiba off the market from January 2016 until December 2018. Australia’s PBAC rejected it in 2013, and it was subsidised only from July 2026, while Fiasp was listed there by the end of 2019 at the same price as NovoRapid. Outside Australia, wherever both can be measured, Tresiba now takes a larger share of long-acting insulin than the ultra-rapid insulins take of rapid-acting: 22% against 15% in France in 2025, 41% against 11% in Denmark, and 20% against 9% in the US Medicare drug programme in 2024 (figures). Price parity for the faster insulins was also a mostly British arrangement. In France Fiasp is listed at €2.09 per 100 units against €1.48 for NovoRapid, and in Denmark at 32.1 kroner against 16.7. Denmark’s reimbursement committee counted Fiasp among “de dyrere lægemidler” (the more expensive medicines) in 2019, and since 2022 it has been reimbursed only for people whose after-meal glucose is not managed on another rapid insulin.

Cost before biosimilars

For much of the period, the price of the insulin offers little explanation. Lyumjev has cost English primary care the same per unit as Humalog in every year since it arrived. Its list price per box is the same as Humalog’s. Fiasp was the same against NovoRapid. For the 52 months between Fiasp’s arrival in February 2017 and the first biosimilar, Trurapi, in June 2021, English primary care paid £1.68 per 100 units of Fiasp against £1.76 for NovoRapid. There was little or no acquisition-cost premium for choosing the faster formulation. That is not the same as no cost to the system: switching takes clinic time and training, and pumps and pens have to be compatible. Those costs are not measured here.

In those 52 months, 10.1 million prescription items for standard-speed rapid-acting insulin were dispensed in England, more than 97 of every 100 rapid-acting analogue items. Some of that was formulary committees keeping the faster insulins out. North Central London recorded Fiasp as “Not approved for: Adults with Type 1 diabetes” in November 2018. Birmingham and Solihull restricted it to pregnancy in June 2019. South East London made it a second-line option in January 2020. None of those decisions could have rested on the acquisition price.

It was not only committees. In June 2017, four months after Fiasp arrived, people on the diabetes.co.uk forum were describing what happened when they asked for it. One was given “a straight ‘No'” by a diabetes consultant: “Apparently I am too well controlled to change anything!” A pump user was told “no your a1c is low enough as it is, we don’t want it going any lower!!” and got it only after arguing. Another had been told by a consultant and a specialist nurse that Fiasp “is still undergoing trials, and is not available on their formulary”, and after three or four attempts had got nowhere. A specialist nurse told another that their clinic would move only NovoRapid users across, because “they don’t think there is much difference between Humalog and Fiasp”. I wrote in the same thread at the time that “Many HCPs will not prescribe it until they see the outcome of this trial because they don’t want to get in to trouble for prescribing something they don’t have details of.”

People told me at the time that some consultants in England went further and said they did not believe a faster insulin offered any benefit, and would not therefore prescribe Fiasp. These were clinical judgements made against the trials’ own meal-test results and against what the people asking for it were saying. At around the same time, the feedback received at a major diabetes conference from one of the manufacturer reps was that the prescribing committee doesn’t want anyone on novel insulins because they can’t easily transition them to biosimilars.

These data cannot show how often anyone was offered a faster insulin and declined it, perhaps because of site pain. As I’ve already mentioned, I’m reasonably sure that large swathes of the population simply weren’t offered it. Among the small number of hospital prescriptions dispensed in the community, 0.13% of rapid-acting units, the ultra-rapid share is about twice the GP figure (35.6% against 17.6% on the same six-brand basis), yet most of it is still standard-speed. The much larger supply issued inside hospitals cannot be split by brand. What the data do show is that, through the years when the faster insulins carried little or no price premium, they stayed at under 6% of the rapid-acting insulin dispensed in England.

Cost after biosimilars

From 2021 there was a cheaper insulin to protect. Trurapi and the other biosimilars are about 30% cheaper than NovoRapid and work at the same speed. Norfolk and Waveney estimated that moving 80% of people from NovoRapid to Trurapi would save about £340,000 a year, and Cheshire and Merseyside about £1 million. Each is about an eighth of what the area now spends on rapid-acting analogues at list price. NHS Dorset’s 2026/27 prescribing incentive scheme asks primary care networks to make biosimilar aspart at least half of all aspart prescribing. Those documents exclude Fiasp from the switch, but once Trurapi is first choice an ultra-rapid insulin becomes a second step, and the trial evidence gives that step little to stand on. Trurapi reached 7.5% of units within five years. Lyumjev, after six, is at 3.7%.

Outside England, biosimilars don’t explain the low use of the faster insulins. In Denmark and Germany they were about 5% of rapid-acting analogue insulin in 2025, and in France 2.9%. The discount on NovoRapid in France and Denmark is only 4 to 5%, and in each country the faster insulins held at 11% to 15%. In the US Medicare drug programme Admelog costs the same as Humalog. England is where that could change. Trurapi lists at 21% less than NovoRapid overall and 30% less for pens. Its share of rapid-acting units rose from 0.3% in 2022 to 6.0% in 2025, pushed by incentive schemes such as Dorset’s and by formularies such as North West London’s that send every new start to it. Within the UK, the two nations with the most ultra-rapid use, Wales at 30.9% and Northern Ireland at 23.9%, dispensed almost no biosimilar: 2.1% in Wales and none at all in Northern Ireland. The concern is that once England makes the cheaper standard-speed insulin the default for new starters, the people who might have done better on a faster insulin are never offered one, and the gap with Wales grows (figures).

Where the savings should come from

The biosimilar effort has been pointed at the wrong insulin. In the year to July 2026, at list price and device for device, Fiasp cost English primary care exactly what NovoRapid cost, and Lyumjev exactly what Humalog cost. Moving someone from either older insulin to its faster version adds no acquisition cost at published list prices for the same device; the clinic time a switch takes is a separate cost. The only money at stake is the saving given up by not moving them to Trurapi, which is £0.47 per 100 units cheaper than Fiasp. Lispro has no cheaper alternative left to protect, since Sanofi is withdrawing Admelog.

Long-acting insulin is where a switch does not mean accepting a slower insulin, though it is still a shared decision and a new pen to learn. Semglee, the cheapest glargine, lists at £2.00 per 100 units against £2.32 for Lantus and £2.35 for Abasaglar, the older biosimilar, and it is the same molecule with the same profile of action. Yet it is 4.8% of the glargine 100 dispensed in England. Moving 80% of Lantus and Abasaglar pens to it would save about £5.5 million a year. That is enough to pay for 14.5% of all the rapid-acting insulin dispensed in England to be Fiasp in place of Trurapi, and close to the £5.8 million, at most, that bringing England up to Wales’s ultra-rapid share would forgo (figures).

North West London shows the blunt version. Its formulary says “All new initiations should be the lower cost biosimilar, Trurapi, instead of NovoRapid”. It leaves Fiasp off and makes Lyumjev a second-line choice for specialists to start. For long-acting insulin it lists Lantus, Abasaglar and Semglee side by side, with no preference for the cheapest. Its ultra-rapid share is 10.1%, the 12th lowest of 106 areas in England. Even the biosimilar push has gone slowly there: Trurapi is 9.2% of its standard aspart and Semglee 5.1% of its glargine. Moving 80% of its glargine pens to Semglee would save about £300,000 a year, more than the £270,000 it would give up in reaching Wales’s ultra-rapid share. A more granular policy, pressing the biosimilar where speed is not at stake and leaving the faster mealtime insulins open to anyone who wants them, would have saved money and widened choice at the same time.

These are list prices, which leave out confidential discounts, and they keep everyone on the same kind of device. Semglee is sold only as a pen, so the 230 million units of Lantus and Abasaglar in cartridges are left out.

Lilly’s part

Lilly’s role in this needs to be questioned too. On the public record, it did the formal work each country required, and I found little public evidence of a sustained campaign in the UK beyond it.

In France, Lilly applied for reimbursement and, according to the assessment committee’s transcript, claimed no added benefit over Humalog (“pas d’ASMR”), presenting the trials’ comparable HbA1c and better post-meal glucose. The committee rated Lyumjev ASMR V, no improvement over Humalog, noting no demonstrated advantage in efficacy, tolerance or quality of life. In Germany Lilly agreed rebate contracts covering Humalog, Lyumjev and Abasaglar for “nearly all” people with statutory insurance.

When Fiasp reached the UK in April 2017, it was reported as “made available to the NHS at no additional cost compared to NovoRapid”. I found no comparable UK announcement for Lyumjev in 2020, in the diabetes press or from Lilly. Lilly was a named collaborator on Tandem and Medtronic trials that led to US clearances of Lyumjev with Tandem’s t:slim X2 in 2025 and with Medtronic’s MiniMed 780G in December 2025; every site in both trials was in the United States. In the UK, Medtronic’s 780G page still lists “Humalog and NovoRapid” only, and Omnipod 5 lists neither ultra-rapid insulin. Tandem’s UK and European t:slim X2 guide does list Lyumjev.

Lilly priced Lyumjev the same as Humalog, which removed the most obvious barrier, and several of the obstacles above applied to Novo Nordisk’s Fiasp just the same. Lilly’s field activity, medical education and dealings with payers are not public, so I cannot say how much it did. What I can say is that I found little public sign of a case being made for Lyumjev in the UK, and that in Norway Lilly has described the presentations it is withdrawing as little used.

What “commercial reasons” means in money

These are what payers spent at list or reimbursement prices, and they give a sense of scale. In England, primary care spent £5.6 million on Lyumjev in the year to July 2026, against £18.3 million on Humalog. In France it was €6.4 million against €49.3 million. In the US Medicare drug programme Lyumjev took $90 million in 2024, against $664 million for Humalog. Lyumjev is between a tenth and a quarter of what payers spent on Lilly’s rapid-acting insulins in each of these markets (figures).

Pricing every market at the NHS list price, the figure the BNF prints, puts them on one scale. On that basis the UK’s rapid-acting analogue market came to £174 million over the latest twelve months: £143 million in England, £16 million in Scotland, £9.1 million in Wales and £6.0 million in Northern Ireland. Lyumjev was £7.1 million of it (4.1%) and Fiasp £24.6 million. France’s 2025 community dispensing would cost £170 million at the same prices, with Lyumjev £6.1 million of it. Germany’s statutory-insurance market would cost £218 million, and there Lyumjev is pooled with Liprolog in a line worth £34 million. Local prices differ from the NHS’s, so these are volumes priced in pounds and say nothing about what each country paid (figures).

For context, Lilly’s total revenue in the first three months of 2026 was $19.8 billion, $12.8 billion of it from Mounjaro and Zepbound, which in 2025 accounted for 56% of its revenue. That contrast does not show that Lilly moved money or attention from insulin to its newer products; the European Medicines Agency records only that the reasons were commercial. It does show how small a line Lyumjev is in each European market.

What the community is saying

I collected 31 public posts from people with diabetes across Europe, and 11 statements from companies, regulators and patient groups, from 2025 and 2026. The posts were gathered to show the range of reactions. They are not a sample, so they say nothing about how common any view is.

The sharpest reaction is from Switzerland, where Lyumjev’s main presentations went first. “Not cool that the best insulin for tslim gets discontinued by the manufacturer – also without any sort of proper announcement” (Reddit, Switzerland, March 2026). “Why was my favorite insulin (Lyumjev) pulled from the Swiss market?” (Reddit, Switzerland, April 2026). “I am from Switzerland and currently use my very last Lyumjev pen” (Reddit, July 2026).

Some suspect insulin is being sidelined for weight-loss drugs, which is speculation the evidence above can’t confirm: “Lyumjev is handsdown the best insulin on the market at this time, its a shame Eli Lilly wants to take it away from many people so they can focus on more profitable endeavours such as Mounjaro” (Reddit, May 2026). Another person wrote: “It’s such a quality of life issue” (Reddit, September 2026). In the UK the mood is uncertainty: “Doesn’t look like they’ve said anything about withdrawing Lyumjev in the UK, just EU/EEA, so hopefully they keep it here, but does seem worrying” (Reddit, UK, July 2026).

Not everyone is sorry. The site pain comes up again, and Norway’s diabetes association quoted a professor saying there are good alternatives to every insulin being withdrawn there. In the Czech Republic, where Lilly said supplies were continuing, the national regulator reported in July 2025 that Lyumjev deliveries had risen by 20% in a year, driven by pump users including children.

What comes next?

As algorithms are asked to handle meals without being told about them, the speed of the insulin matters more. A fully closed loop has to catch a meal from the glucose rise alone, and the faster its insulin acts the less of the rise it misses. The manufacturers are moving that way. In May 2026 Insulet enrolled the first participant in EVOLVE, a pivotal randomised trial of up to 350 adults at 40 US sites, of a fully closed-loop system for type 2 diabetes that it says eliminates “user interactions for bolusing and mealtime announcements”. In June 2026 MiniMed said it was about halfway through enrolling a pivotal trial of an algorithm, for type 1 as well as type 2 diabetes, that “would remove the need for pre-meal insulin doses”; in its early testing, people spent 82% of the time in range when they announced meals and about 74% when they did not. Neither company has said which insulin its system is designed around.

Fully closed loop works with the insulins already available. Cambridge’s CamAPS HX has run it with Fiasp in adults with type 2 diabetes and in adolescents with type 1 diabetes, and with Lyumjev in adults with type 1 diabetes. The one trial comparing Lyumjev with standard lispro in fully closed loop with unannounced meals found time in range of 49.3% against 39.9% in 17 people, over 8-hour inpatient sessions with one unannounced meal, a difference that did not reach statistical significance (p = 0.072). Its authors concluded that “Further advancements in faster-acting insulins are needed to alleviate the burden of pre-meal bolusing and enhance fully closed-loop performance in the future.” As one person put it in September 2026: “every minute counts with a system working on a time offset.”

So fully closed loop does not depend on Lyumjev. The 9.4-point difference in that trial would matter to someone living with it, but it came from a small, short study and was too imprecisely estimated to reach statistical significance. Insulin speed is still one of the few ways of reducing the delay these systems have to work around, and in Europe the fastest-absorbed subcutaneous insulin is being withdrawn country by country, with low use given as the reason by Lilly in Norway and, in the patient organisation’s unofficial account, in Switzerland. Pump users can still fill reservoirs from Fiasp vials, as the German Diabetes Society has pointed out, but the options are narrowing as the systems that would benefit most arrive. The UK still has every Lyumjev presentation except the Tempo Pen.

Where do we go from here?

None of the reasons Lyumjev was so little used rests on evidence that the older insulins are better. They have, by default, been left in place: licensing trials built around equivalence on the measure everyone watches, guidance that names no product, formularies that left Lyumjev off altogether in a third of the UK areas I read, cost programmes that made a cheaper standard-speed insulin first choice once there was one, and a manufacturer that made little visible case for it.

The part I find hardest to accept is the years before biosimilars. The faster insulins carried little or no price premium over the ones they would have replaced, and they stayed at under 6% of the rapid-acting insulin dispensed in England. Some people who asked for them in that period were refused. I cannot measure from these data how many others might have chosen them if offered, but the quality-of-life case was there from the start and the system did not act on it. The low use that followed is now part of the background to the withdrawals.

Wales shows it did not have to go this way. Across a whole nation a third of rapid-acting insulin dispensed is ultra-rapid, and in one health board more than half.

What I want to see now is the diabetes charities and patient organisations of Europe standing up and being counted, and so far they have barely made a sound. Diabetes UK’s page on insulin supply lists ten discontinuations and shortages and does not mention Lyumjev or the withdrawals across Europe, and Breakthrough T1D UK’s site mentions Lyumjev only in its guide to connected pens. In France, which has already lost the cartridges, the last thing I can find on Lyumjev from the national federation of people with diabetes is a 2023 note about a temporary shortage. Germany’s diabetesDE has nothing on it, and the German Diabetes Society’s statement was practical advice on pump cartridge shortages (search record). Norway’s diabetes association reported the withdrawals and quoted a professor reassuring readers that there were good alternatives to every insulin going. diabetesschweiz complained to Lilly, then passed on its own unofficial account of what it had been told: that hardly anyone used it. Reporting a withdrawal and relaying the manufacturer’s reasons is the least an organisation can do, and these organisations exist to speak for the people who use these insulins. They should be demanding that the faster insulins stay on the market, that they are part of the fully closed-loop systems now in trials, that formularies stop parking them behind the insulin people are already on, and that clinicians offer them to everyone who might benefit and let each person decide for themselves whether to turn them down. When they stay quiet, the manufacturer’s account of low demand is the only one anyone hears.

Is this a failure of the system? Yes, at every level, and nobody escapes the blame. The licensing trials were built to show the new insulins were no worse on HbA1c, and that was read as showing they were no better. NICE left its mealtime insulin advice as it stood in 2015, looked at it again in January 2026 and left it there. The Scottish and Welsh appraisal bodies wrote rules that left Lyumjev without a decision in either country, and Northern Ireland, which depends on them, inherited the gap. Formulary committees left it off in 13 of 38 areas, which is where its use is lowest, while finding a written place for Tresiba, which costs a third more than Lantus. Consultants told people who asked for a faster insulin that they were too well controlled to need one. Lilly priced Lyumjev the same as Humalog and then, as far as the public record shows, did almost nothing to make the case for it in the UK, and did not even tell the Swiss patient organisation that it was going. The charities, whose whole purpose is to make noise about exactly this, have barely raised their voices.

The cost of it all falls on people with diabetes who had less chance to make that choice. These data cannot show who was offered what, but they make it very hard to believe the pattern arose because almost everyone preferred the older insulins.

---

The method, the code, the formulary wording area by area and the outputs behind every number are at https://github.com/tim2000s/rapid-insulin-prescribing. The sources follow.

Sources

Sources for “Losing Lyumjev: how the system let its patients down”, in approximately the order the article draws on them.

1. NHS Business Services Authority. English Prescribing Dataset and English Prescribing Dataset with SNOMED code; Hospital prescribing dispensed in the community; Secondary Care Medicines Data with indicative price (finalised). https://opendata.nhsbsa.net (accessed 30 September 2026)
2. Public Health Scotland. Prescriptions in the community. https://www.opendata.nhs.scot/dataset/prescriptions-in-the-community; Business Services Organisation Northern Ireland. GP prescribing data. https://www.opendatani.gov.uk/@business-services-organisation/gp-prescribing-data; NHS Wales Shared Services Partnership. General practice prescribing data extract. https://nwssp.nhs.wales (all accessed 30 September 2026)
3. Assurance Maladie. Open Medic: base complète sur les dépenses de médicaments interrégimes; Medic’AM. https://open-data-assurance-maladie.ameli.fr/medicaments/ (accessed 30 September 2026)
4. Sundhedsdatastyrelsen. medstat.dk: data download. https://medstat.dk/en/download (accessed 30 September 2026)
5. GKV-Spitzenverband. GKV-Arzneimittel-Schnellinformation (GAmSi), Bundesberichte 2020 to 2026. https://www.gkv-gamsi.de (accessed 30 September 2026)
6. Australian Government Department of Health. PBS date of supply data. https://www.pbs.gov.au/info/statistics/dos-and-dop/dos-and-dop (accessed 30 September 2026)
7. Centers for Medicare and Medicaid Services. Medicare Part D spending by drug; Medicare Part D prescribers by geography and drug. https://data.cms.gov (accessed 30 September 2026)
8. Centers for Medicare and Medicaid Services. State Drug Utilization Data. https://data.medicaid.gov (accessed 30 September 2026)
9. NHS Business Services Authority. Dictionary of medicines and devices browser: actual medicinal product packs for Fiasp, NovoRapid, Lyumjev, Humalog, Trurapi and Admelog. https://dmd-browser.nhsbsa.nhs.uk (data as of 24 September 2026, accessed 30 September 2026)
10. European Medicines Agency. Eli Lilly insulin (various forms): supply shortage. First published 23 March 2026; and medicine shortage communication on the marketing cessation of selected presentations of Lilly insulins, adopted 16 March 2026. https://www.ema.europa.eu/en/medicines/human/shortages/eli-lilly-insulin-various-forms-supply-shortage (accessed 1 October 2026)
11. European Medicines Agency. Fiasp PumpCart (insulin aspart): supply shortage. First published 12 May 2025. https://www.ema.europa.eu/en/medicines/human/shortages/fiasp-pumpcart-insulin-aspart (accessed 1 October 2026)
12. European Medicines Agency. Lyumjev: procedural steps taken and scientific information after authorisation (variation deleting the Tempo Pen presentations from the Humalog, Lyumjev and Abasaglar marketing authorisations). https://www.ema.europa.eu/en/documents/procedural-steps-after/lyumjev-epar-procedural-steps-taken-scientific-information-after-authorisation_en.pdf (accessed 1 October 2026)
13. Vidal. Insulines Lilly en cartouche et flacon: des arrêts de commercialisation à venir. https://www.vidal.fr/actualites/31598-insulines-lilly-en-cartouche-et-flacon-des-arrets-de-commercialisation-a-venir.html (accessed 1 October 2026)
14. Diabetesforbundet. Faser ut noen typer insulin. 9 September 2025. https://www.diabetes.no/mer/nyheter-om-diabetes/nyheter-2025/faser-ut-noen-typer-insulin/ (accessed 1 October 2026)
15. Den norske legeforening. Brev til fastleger om utfasing av insulin, april 2026. https://www.legeforeningen.no/contentassets/007bc46ac76641fd8a8cdca2753f298b/brev-til-fastleger-om-utfasing-av-insulin-april-2026_endelig.pdf; Direktoratet for medisinske produkter. Diabeteslegemidler avregistreres. https://www.dmp.no/forsyningssikkerhet/legemiddelmangel/nyheter/Diabeteslegemidler-avregistreres (both accessed 1 October 2026)
16. Belgian Federal Agency for Medicines and Health Products. PharmaStatus notifications. https://pharmastatus.be; drugshortage.ch. Ausser Handel. https://www.drugshortage.ch/index.php/ausser-handel-2/ (both accessed 1 October 2026)
17. Arzneimittelkommission der Deutschen Apotheker. AMK-Nachricht 18/26: Informationsschreiben zu diversen Insulin-haltigen Arzneimitteln der Lilly Deutschland GmbH, Einstellung des Vertriebs. 24 April 2026. https://www.abda.de/fuer-apotheker/arzneimittelkommission/amk-nachrichten/detail/18-26-information-der-hersteller-informationsschreiben-zu-diversen-insulin-haltigen-arzneimitteln-der-lilly-deutschland-gmbh/ (accessed 1 October 2026)
18. Deutsche Gesellschaft für Endokrinologie. Ältere Insulinpräparate von Novo Nordisk nicht mehr verfügbar. 10 March 2025. https://blog.endokrinologie.net/aeltere-insulinpraeparate-novo-nordisk-nicht-mehr-verfuegbar-5765/ (accessed 1 October 2026)
19. Vitalia.cz. Problémy s inzulinem do pump: Lyumjev chybí v lékárnách. 24 July 2025. https://www.vitalia.cz/clanky/problemy-s-inzulinem-do-pump-lyumjev-chybi-v-lekarnach/ (accessed 1 October 2026)
20. diabetesschweiz. Email reply to a member of the public about the withdrawal of Lyumjev, 10 March 2026, published by the recipient; copy held with the paper’s sources.
21. Heise T, Pieber TR, Danne T, Erichsen L, Haahr H. A Pooled Analysis of Clinical Pharmacology Trials Investigating the Pharmacokinetic and Pharmacodynamic Characteristics of Fast-Acting Insulin Aspart in Adults with Type 1 Diabetes. Clin Pharmacokinet 2017;56(5):551-559. https://doi.org/10.1007/s40262-017-0514-8
22. Leohr J, Dellva MA, Carter K, LaBell E, Linnebjerg H. Ultra Rapid Lispro (URLi) Accelerates Insulin Lispro Absorption and Insulin Action vs Humalog Consistently Across Study Populations: A Pooled Analysis of Pharmacokinetic and Glucodynamic Data. Clin Pharmacokinet 2021;60(11):1423-1434. https://doi.org/10.1007/s40262-021-01030-0
23. Heise T, Linnebjerg H, Coutant D, LaBell E, Zijlstra E, Kapitza C, et al. Ultra rapid lispro lowers postprandial glucose and more closely matches normal physiological glucose response compared to other rapid insulin analogues: A phase 1 randomized, crossover study. Diabetes Obes Metab 2020;22(10):1789-1798. https://doi.org/10.1111/dom.14094
24. Russell-Jones D, Bode BW, De Block C, Franek E, Heller SR, Mathieu C, et al. Fast-Acting Insulin Aspart Improves Glycemic Control in Basal-Bolus Treatment for Type 1 Diabetes: Results of a 26-Week Multicenter, Active-Controlled, Treat-to-Target, Randomized, Parallel-Group Trial (onset 1). Diabetes Care 2017;40(7):943-950. https://doi.org/10.2337/dc16-1771
25. Klaff L, Cao D, Dellva MA, Tobian J, Miura J, Dahl D, et al. Ultra rapid lispro improves postprandial glucose control compared with lispro in patients with type 1 diabetes: Results from the 26-week PRONTO-T1D study. Diabetes Obes Metab 2020;22(10):1799-1807. https://doi.org/10.1111/dom.14100
26. Warren M, Bode B, Cho JI, Liu R, Tobian J, Hardy T, et al. Improved postprandial glucose control with ultra rapid lispro versus lispro with continuous subcutaneous insulin infusion in type 1 diabetes: PRONTO-Pump-2. Diabetes Obes Metab 2021;23(7):1552-1561. https://doi.org/10.1111/dom.14368
27. Avgerinos I, Papanastasiou G, Karagiannis T, Michailidis T, Liakos A, Mainou M, et al. Ultra-rapid-acting insulins for adults with diabetes: A systematic review and meta-analysis. Diabetes Obes Metab 2021;23(10):2395-2401. https://doi.org/10.1111/dom.14461
28. Oktavian P, Kencono Wungu CD, Mudjanarko SW, Amin IM. A comparison of ultra-rapid and rapid insulin in automated insulin delivery for type 1 diabetes: A systematic review and meta-analysis of randomized controlled trials. Diabetes Obes Metab 2025;27(5):2658-2669. https://doi.org/10.1111/dom.16268
29. Boughton CK, Hartnell S, Thabit H, Poettler T, Herzig D, Wilinska ME, et al. Hybrid closed-loop glucose control with faster insulin aspart compared with standard insulin aspart in adults with type 1 diabetes: A double-blind, multicentre, multinational, randomized, crossover study. Diabetes Obes Metab 2021;23(6):1389-1396. https://doi.org/10.1111/dom.14355
30. Nwokolo M, Lakshman R, Hartnell S, Alwan H, Ware J, Allen JM, et al. CamAPS FX Hybrid Closed-Loop with Ultra-Rapid Lispro Compared with Standard Lispro in Adults with Type 1 Diabetes: A Double-Blind, Randomized, Crossover Study. Diabetes Technol Ther 2023;25(12):856-863. https://doi.org/10.1089/dia.2023.0262
31. Haliloglu B, Boughton CK, Lakshman R, Ware J, Nwokolo M, Thabit H, et al. Postprandial Glucose Excursions with Ultra-Rapid Insulin Analogs in Hybrid Closed-Loop Therapy for Adults with Type 1 Diabetes. Diabetes Technol Ther 2024;26(7):449-456. https://doi.org/10.1089/dia.2023.0509
32. Thabit H, Lim J, Willinska ME, Fullwood C, Hovorka R, Leelarathna L. Fully closed-loop control with ultra-rapid versus standard insulin lispro: A randomised crossover study simulating missed meal boluses. Diabet Med 2025;42(10):e70122. https://doi.org/10.1111/dme.70122
33. Kadiyala N, Lakshman R, Allen J, Ware J, Boughton CK, Wilinska ME, et al. Fully Closed-Loop Improves Glycemic Control Compared with Pump with CGM in Adolescents with Type 1 Diabetes and HbA1c Above Target: A Two-Center, Randomized Crossover Study. Diabetes Technol Ther 2025;27(9):719-727. https://doi.org/10.1089/dia.2025.0062
34. Lakshman R, Hartnell S, Ware J, Allen JM, Wilinska ME, Nwokolo M, et al. Lived Experience of Fully Closed-Loop Insulin Delivery in Adults with Type 1 Diabetes. Diabetes Technol Ther 2024;26(4):211-221. https://doi.org/10.1089/dia.2023.0394
35. Gómez-Peralta F, Valledor X, Abreu C, Fernández-Rubio E, Cotovad L, Pujante P, et al. Nocturnal Glucose Profile According to Timing of Dinner Rapid Insulin and Basal and Rapid Insulin Type: An Insulclock(®) Connected Insulin Cap-Based Real-World Study. Biomedicines 2024;12(7):. https://doi.org/10.3390/biomedicines12071600
36. Novo Nordisk. Fiasp 100 units/mL solution for injection in vial: Summary of Product Characteristics. electronic medicines compendium. https://www.medicines.org.uk/emc/product/8109/smpc (accessed 30 September 2026)
37. Eli Lilly. Lyumjev 100 units/mL solution for injection in vial: Summary of Product Characteristics. electronic medicines compendium. https://www.medicines.org.uk/emc/product/11533/smpc (accessed 30 September 2026)
38. National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management (NG17), recommendations 1.7.10 to 1.7.12. Published 26 August 2015, last updated 17 August 2022. https://www.nice.org.uk/guidance/ng17
39. Norfolk and Waveney Therapeutics Advisory Group. Biosimilar insulin aspart (Trurapi) guidance, version 1.1. September 2025; review date July 2027. https://nwknowledgenow.nhs.uk/wp-content/uploads/2025/09/Trurapi-2025-Guidance-v1.1-Sept-2025.pdf (accessed 2 October 2026)
40. NHS Cheshire and Merseyside. Biosimilar insulin aspart (Trurapi) position statement, version 1.0. ICB approval 19 September 2024; review date September 2026. https://www.cheshireandmerseysideformulary.nhs.uk/docs/files/trurapi_position.pdf (accessed 2 October 2026)
41. NHS Dorset Medicines Optimisation. Insulin aspart biosimilar switch (prescribing incentive scheme 2026/27, PINH 2627). 31 March 2026. https://nhsdorset.nhs.uk/medicines/value/insulin-aspart/ (accessed 2 October 2026)
42. Diabetes Forum (diabetes.co.uk). Fiasp experiences, thread, June 2017. https://www.diabetes.co.uk/forum/threads/fiasp-experiences.121804/
43. Diabetes.co.uk. New faster-acting insulin Fiasp now available in the UK. 11 April 2017. https://www.diabetes.co.uk/news/2017/apr/new-faster-acting-insulin-fiasp-now-available-in-the-uk-97369705.html
44. Scottish Medicines Consortium. Guidance on medicines outwith SMC remit. Updated October 2020. https://www.scottishmedicines.org.uk/media/5429/guidance-on-medicines-outwith-smc-remit-october-2020.pdf
45. All Wales Therapeutics and Toxicology Centre. Insulin lispro (Liumjev), reference 3703, 22 April 2020. https://awttc.nhs.wales/accessing-medicines/medicine-recommendations/insulin-lispro-liumjev/; AWMSG exclusion criteria, June 2019.
46. Northern Ireland Formulary. Managed entry: policy context. https://niformulary.hscni.net/managed-entry/policy-context/
47. Haute Autorité de Santé. Commission de la Transparence, Lyumjev, transcription of the session of 3 June 2020 (CT-18474). https://www.has-sante.fr/upload/docs/application/pdf/2020-07/lyumjev_03062020_transcription_ct18474.pdf
48. Gemeinsamer Bundesausschuss. Zusammenfassende Dokumentation, AM-RL Paragraf 40c, 4 December 2025. https://www.g-ba.de/downloads/40-268-12140/2025-12-04_AM-RL_Paragraf-40-c_Austausch-Biologika-Apotheke_ZD.pdf
49. Eli Lilly and Company. Annual report 2020 and Form 10-K 2025. https://www.annualreports.com/HostedData/AnnualReportArchive/e/NYSE_LLY_2020.pdf; https://www.annualreports.com/HostedData/AnnualReports/PDF/NYSE_LLY_2025.pdf
50. Eli Lilly and Company. Form 10-Q for the quarter ended 31 March 2026. https://www.sec.gov/Archives/edgar/data/0000059478/000005947826000045/lly-20260331.htm
51. US Food and Drug Administration. PMA P160017/S125, MiniMed 780G compatible insulins, 11 December 2025; Medtronic Diabetes press release, 2 February 2026. https://www.prnewswire.com/news-releases/medtronic-diabetes-expands-access-to-full-stack-insulin-delivery-solutions-with-medicare-access-and-new-fda-clearances-302676383.html
52. Medtronic Diabetes UK. MiniMed 780G system. https://www.medtronic-diabetes.co.uk/insulin-pump-therapy/minimed-780g-system
53. Insulet Corporation. Insulet initiates EVOLVE pivotal study to advance fully closed-loop automated insulin delivery system for type 2 diabetes. 4 May 2026. https://investors.insulet.com/news/news-details/2026/Insulet-Initiates-EVOLVE-Pivotal-Study-to-Advance-Fully-Closed-Loop-Automated-Insulin-Delivery-System-for-Type-2-Diabetes/default.aspx
54. Reuter E. MiniMed is in the lead as diabetes tech firms focus on fully closed loop systems, exec says. MedTech Dive, 9 June 2026. https://www.medtechdive.com/news/minimed-is-in-the-lead-as-diabetes-tech-firms-focus-on-fully-closed-loop/822446/
55. Analysis code, data extracts, formulary coding, withdrawal register and statements: https://github.com/tim2000s/rapid-insulin-prescribing. Community posts quoted are held with the author and are available on request.
56. Scottish Medicines Consortium. Insulin degludec (Tresiba), resubmission, advice 856/13. 8 August 2016. https://www.scottishmedicines.org.uk/medicines-advice/insulin-degludec-tresiba-resubmission-85613/
57. All Wales Medicines Strategy Group. Insulin degludec (Tresiba), advice 1822 (4 October 2022), replacing advice of October 2016; as quoted on the Cwm Taf Morgannwg formulary entry. https://formulary.wales.nhs.uk/indexNew.aspx?prefixUrl=cttformulary (accessed 2 October 2026)
58. Lane W, Bailey TS, Gerety G, et al. Effect of insulin degludec vs insulin glargine U100 on hypoglycemia in patients with type 1 diabetes: the SWITCH 1 randomized clinical trial. JAMA. 2017;318(1):33-44. https://doi.org/10.1001/jama.2017.7115
59. National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management (NG17), recommendations 1.7.3 and 1.7.4 on basal insulin [2021]. https://www.nice.org.uk/guidance/ng17
60. Formulary positions of insulin degludec in 38 UK areas, read 2 October 2026, with captured pages: https://github.com/tim2000s/rapid-insulin-prescribing/tree/master/formulary_basal
61. Haute Autorité de Santé, Commission de la Transparence. Tresiba, avis CT-17265 (re-evaluation, ASMR IV in adults at high risk of hypoglycaemia), 6 February 2019; Fiasp, avis CT-16059 (ASMR V), 19 July 2017; Lyumjev, avis CT-18474 (ASMR V), 10 June 2020. https://www.has-sante.fr/jcms/c_2906439 ; https://www.has-sante.fr/jcms/c_2788573 ; https://www.has-sante.fr/jcms/p_3190312
62. Gemeinsamer Bundesausschuss. Insulin degludec, Nutzenbewertung nach § 35a SGB V, procedures 109, 121, 162, 168 and 415 (2014 to 2019), each “Ein Zusatznutzen ist nicht belegt”; Deutsche Apotheker Zeitung, Endgültiges Aus für Tresiba, 16 December 2015; arznei-telegramm 2019;50:17 on the return from December 2018. https://www.g-ba.de/bewertungsverfahren/nutzenbewertung/415/ ; https://www.deutsche-apotheker-zeitung.de/news/artikel/2015/12/16/endgultiges-aus-fur-tresiba
63. Pharmaceutical Benefits Advisory Committee. Insulin degludec, Public Summary Document, March 2013 and July 2025; Fiasp, Public Summary Document, November 2018; PBS Medicine Status, insulin degludec, listed 1 July 2026. https://www.pbs.gov.au/industry/pbac/psd/2013/03/insulin-psd-032013.pdf ; https://www.pbs.gov.au/industry/pbac/psd/2018/11/insulin-aspart-psd-november-2018.pdf ; https://www.pbs.gov.au/medicinestatus/document/1406
64. Lægemiddelstyrelsen. Ny tilskudsstatus for insuliner, decision of 14 March 2022 (Fiasp: generelt klausuleret tilskud); Tresiba får generelt tilskud, 16 April 2026; medicinpriser.dk prices read 2 October 2026. https://www.medicinpriser.dk
65. Long-acting insulin by country, prices and appraisal records for degludec, glargine 300, Fiasp and Lyumjev in France, Denmark, Norway, Germany, Australia and the US: https://github.com/tim2000s/rapid-insulin-prescribing/tree/master/international/scoping (each country’s basal folder); combined in international/output/BASAL_INTL.md
66. Deutsche Diabetes Gesellschaft. Stellungnahme DDG zu möglichen Engpässen der Insuline NovoRapid PumpCart und Fiasp PumpCart sowie anderer Insuline. July 2025. https://www.ddg.info/politik/stellungnahmen/stellungnahme-ddg-zu-moeglichen-engpaessen-der-insuline-novorapid-pumpcartr-und-fiasppumpcartr-sowie-anderer-insuline
67. Diabetes UK. What you need to know about insulin supply issues in the UK, updated 14 November 2025, read 3 October 2026 (including the Medicine Supply Notification of 18 September 2025 for the discontinuation of Admelog); and the searches of Breakthrough T1D UK, Fédération Française des Diabétiques, diabetesDE, diabetesschweiz and the Belgian associations recorded at https://github.com/tim2000s/rapid-insulin-prescribing/blob/master/withdrawals_eu/charities/SEARCH_LOG.md
68. North West London Integrated Formulary, version 64, last updated 3 September 2026, section 6.1.1 (insulins). Captured in https://github.com/tim2000s/rapid-insulin-prescribing/tree/master/formulary_basal/raw (nwl_integrated_formulary)
69. List prices by device and the biosimilar scenarios for England and North West London, August 2025 to July 2026: https://github.com/tim2000s/rapid-insulin-prescribing/blob/master/output/biosimilar/SUMMARY.md
70. Biosimilar rapid-acting insulin by country and year, with prices against the originator: https://github.com/tim2000s/rapid-insulin-prescribing/blob/master/international/output/RAPID_BIOSIMILAR_INTL.md
71. Ozer K, Cooper AM, Ahn LP, Waggonner CR, Blevins TC. Fast Acting Insulin Aspart Compared with Insulin Aspart in the Medtronic 670G Hybrid Closed Loop System in Type 1 Diabetes: An Open Label Crossover Study. Diabetes Technol Ther 2021;23(4):286-292. https://doi.org/10.1089/dia.2020.0500
72. Lee MH, Paldus B, Vogrin S, Morrison D, Zaharieva DP, Lu J, et al. Fast-Acting Insulin Aspart Versus Insulin Aspart Using a Second-Generation Hybrid Closed-Loop System in Adults With Type 1 Diabetes: A Randomized, Open-Label, Crossover Trial. Diabetes Care 2021;44(10):2371-2378. https://doi.org/10.2337/dc21-0814
73. National Institute for Health and Care Excellence. Type 1 diabetes in adults (NG17): surveillance review of 30 January 2026, decision not to update; recommendations 1.7.10 to 1.7.12 on mealtime insulin unchanged from 2015. https://www.nice.org.uk/guidance/ng17
74. Tandem Diabetes Care. t:slim X2 insulin pump with Control-IQ technology, technical user guide outside the US (AW-1020085, 2 September 2026), listing Lyumjev as a compatible insulin. https://assets.ctfassets.net/k5s5iz8jouwn/74Y30BhsHQ7oR0nVR5PvF/4e023ed1c21d1fdcb14d34d6546db030/technical-user-guide-tslimx2-control-iq-7-10-4-en-ous-AW1020085.pdf ; Insulet. Omnipod 5 UK important safety information. https://www.omnipod.com/en-gb/safety (both accessed 1 October 2026)
75. diabetesschweiz. Email reply of 10 March 2026 as posted publicly by its recipient on Reddit (r/diabetes). https://www.reddit.com/r/diabetes/comments/1rlmdui/lyumjev_apparently_discontinued_ausser_handel_in/o9nkdrx/ (accessed 1 October 2026)
76. Haute Autorité de Santé. Commission de la Transparence, session of 3 June 2020, Lyumjev (CT-18474): “Le laboratoire demandait un SMR important, pas d’ASMR”. https://www.has-sante.fr/upload/docs/application/pdf/2020-07/lyumjev_03062020_transcription_ct18474.pdf
77. Formulary position and uptake: ultra-rapid analysis (England and UK) and Lyumjev-specific analysis, with the author’s time-in-range calculation: https://github.com/tim2000s/rapid-insulin-prescribing/blob/master/output/formulary/UK_SUMMARY.md ; https://github.com/tim2000s/rapid-insulin-prescribing/blob/master/output/formulary/LYUMJEV_SUMMARY.md ; https://github.com/tim2000s/rapid-insulin-prescribing/blob/master/author_tir/RESULT.md