Patient Care Endocrinology & Cardiology - December 2007 - (Page 8)

I Basal insulins Drugs mentioned in this article the risk of nocturnal hypoglycemia.6 ed hemoglobin A1c (HbA1c) levels • Third, NPH insulin exhibits a sigare achieved in patients with type 2 Exenatide (Byetta) nificant degree of intersubject and diabetes.14 Patient preference and Insulin aspart (NovoLog) within-subject variability in its abindividual blood glucose patterns Insulin detemir (Levemir) sorption.7 The dissolution of NPH are also important factors. Thus, in Insulin glargine (Lantus) crystals in subcutaneous tissue is patients having the highest blood Insulin lispro (Humalog) one source of variation. In addition, glucose levels around dinner time, Neutral protamine Hagedorn NPH insulin must be shaken adeit is more appropriate to start glar(NPH) insulin (Humulin N, Novolin N) quately to create a suspension before gine in the morning. In patients Pioglitazone (Actos) injection. In fact, insufficient shaking who experience nocturnal hypoRosiglitazone (Avandia) of NPH insulin in pens before being glycemia while taking glargine at injected was shown to be associated bedtime, using glargine in the with substantial variability in blood glucose within the morning or at lunchtime may alleviate this problem. same patient.8 Efficacy and safety: Insulin glargine versus NPH INSULIN GLARGINE With few exceptions, a single daily injection of inTwo modifications have been introduced to the sulin glargine was shown to have similar effect on structure of human insulin to produce the soluble lowering HbA1c values compared with NPH insulin and long-acting insulin analogue glargine by recomgiven qd or bid.15 The most important study to evalbinant DNA technology. As a result, insulin glargine uate glargine in type 2 diabetes was the Treat-Tois less soluble than human insulin at the injection site Target Trial.11 This study randomized 756 patients and precipitates at the neutral pH of the subcutafailing 1 or 2 oral agents (72% were taking metneous tissue to form a depot from which insulin is formin plus a sulfonylurea [SU]) to receive insulin slowly released. The addition of zinc further extends glargine or NPH insulin qd at bedtime in addition to the action of insulin glargine. their prestudy medication aiming at a target fasting The effect of insulin glargine starts 2 to 4 hours blood glucose (FBG) of 100 mg/dL or less. After 24 1 after injection. The profile of insulin glargine is comweeks, mean levels of HbA1c decreased similarly in monly reported as peakless and lasting 24 hours, but both groups from a baseline of 8.6% to 7%. Howthis may not be the case in all patients. Clinical trials ever, the incidence of nocturnal hypoglycemia was in type 1 and type 2 diabetes suggest that hypo42% less with insulin glargine, while the frequency glycemia may occur within 5 to 15 hours after glarof hypoglycemia during the day did not differ begine injection, implying a peak effect occurring durtween the 2 insulin regimens. Trials in type 1 diaing that time range.9-11 Regarding its duration of betes in general reported similar results.16 action, there is trend of blood glucose to rise in the The data suggest that the main advantage of insulin few hours prior to the next glargine injection sugglargine over NPH insulin is the lower incidence of gesting that the action of glargine may be waning nocturnal hypoglycemia. Accordingly, the best candibefore 24 hours.9,10,12 Pharmacokinetic studies in date for insulin glargine is the patient in whom hypopatients with type 1 diabetes suggest that the mean glycemia is a concern or frequent or severe nocturnal 13 duration of action of glargine is about 20.5 hours. hypoglycemia has already developed on NPH insulin. There is no general agreement about the optimum An increasing number of clinicians prescribe insutiming of insulin glargine administration. However, lin glargine qd in conjunction with premeal rapid-actcompared with glargine injected at bedtime, limited ing insulin analog (lispro [Humalog] or aspart data suggest that glargine given in the morning may [NovoLog]) based on the assumption that the latter be associated with less nocturnal hypoglycemia in regimen is close to the physiologic pattern of insulin patients with type 1 diabetes.9 Slightly better glycatsecretion. This intensive regimen may be ideal for the 8 PATIENT CARE ENDOCRINOLOGY & CARDIOLOGY www.patientcareonline.com http://www.patientcareonline.com

Table of Contents Feed for the Digital Edition of Patient Care Endocrinology & Cardiology - December 2007

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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