Patient Care Endocrinology & Cardiology - December 2007 - (Page 10)

I Basal insulins TABLE 1 Comparison of basal insulins Type of insulin Advantages Disadvantages NPH (Humulin N, Novolin N) Cost, $38.44 for a 10-mL vial; can be mixed with short-acting types of insulin More frequent hypoglycemia compared with glargine and detemir; marked within-subject and intersubject variability; duration of action, 24 h* Cost, $83.54 for a 10-mL vial; cannot be mixed with short-acting insulins Cost, $84.15 for a 10-mL vial; duration of action, 24 h in commonly used dosages;* cannot be mixed with shortacting insulins Glargine (Lantus) Duration of action, close to 24 h; less frequent nocturnal hypoglycemia compared with NPH Less frequent hypoglycemia compared with NPH; weight gain is slightly less pronounced compared with NPH; less blood glucose variability compared with NPH Detemir (Levemir) Key: NPH, neutral protamine Hagedorn. *Duration of action generally increases with increasing dosages. Source for drug costs, http://www.drugstore.com, accessed December 5, 2007. Costs may differ according to contracts that medical institutions may have with manufacturers. reducing HbA1c in type 2 diabetes, with comparable blood glucose variability and risk of hypoglycemia.22 Yet, weight gain was slightly less pronounced with insulin detemir compared with insulin glargine. OPTIONS FOR PATIENTS FAILING METFORMIN AND A SULFONYLUREA A commonly encountered situation in clinical practice is the patient whose type 2 diabetes is no longer controlled with metformin plus an SU. For these patients, several options may be available. One is to add either a thiazolidinedione (TZD) or insulin. The latter is commonly started in this setting in the form of qd basal insulin. In this respect, trials suggest that making the choice of adding a TZD versus adding a basal insulin regimen should include several factors:23,24 • First, consider the baseline glycemic control as reflected by levels of HbA1c and FBG. Thus, in patients with HbA1c values more than 8.5% to 9% or an FBG consistently more than 180 mg/dL, it would be more appropriate to add basal insulin rather than adding a TZD because a TZD is unlikely to reduce HbA1c by more than 2% or FBG by more than 50 mg/dL. Conversely, there is no maximum dose of insulin beyond which a therapeutic effect will not occur.25 Indeed, the major factor that prevents increasing insulin doses is hypoglycemia. • Second, consider the risk of hypoglycemia. If hypoglycemia is a major concern, the addition of a third oral agent may be preferred since the risk of hypoglycemia is clearly less than with insulin. • Third, consider nonglycemic factors. For instance, concerns about edema and cost favor the use of insulin. With respect to the effect on body weight, it is hard to make a choice based on this factor alone because both insulin and TZD cause weight gain, and the available comparative data regarding the extent of weight gain is insufficient. • Finally, it should be emphasized that the use of rosiglitazone (Avandia) may be associated with increased risk of MI (by about 30% to 40%), and the use of both rosiglitazone and pioglitazone increase the risk of heart failure.26,27 Add a basal insulin or an exenatide? An option that recently became available is to add the incretin analog exenatide (Byetta). In one trial of patients uncontrolled on metformin and an SU, the addition of exenatide or insulin glargine was similarly effective in decreasing mean HbA1c values by approximately 1%.28 Patients randomized to exenatide lost an average weight of 2.3 kg compared to a weight gain of 1.8 kg in the glargine group, but more patients receiving exenatide withdrew from the trial 10 PATIENT CARE ENDOCRINOLOGY & CARDIOLOGY www.patientcareonline.com http://www.drugstore.com http://www.patientcareonline.com

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Patient Care Endocrinology & Cardiology - December 2007 Research Digest Contents Medicine in the News Options for Managing Diabetes: Three Types of Basal Insulin Therapy Using the New AHA Guidelines for Preventing Coronary Heart Disease in Women Cardiovascular and Metabolic Implications of Polycystic Ovary Syndrome Case & Comment Classified Advertising Clinical Clips

Patient Care Endocrinology & Cardiology - December 2007

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