Patient Care Endocrinology & Cardiology - December 2007 - (Page 9)

Basal insulins I motivated patient who is willing to take 4 injections daily (insulin glargine cannot be mixed with other types of insulin). Trials are needed to compare the intensive therapy of glargine plus premeal short-acting insulin analogs with the traditional regimen consisting of NPH insulin mixed with regular insulin given bid. INSULIN DETEMIR The action of insulin detemir starts after 1.6 to 2 hours, and its duration of action is dose-dependent, increasing as the dosage increases from 5.7, to 12.1, to 19.9, to 22.7, to 23.2 hours for 0.1, 0.2, 0.4, 0.8, and 1.6 U/kg, respectively.17 The time-action profile of insulin detemir exhibits a peak effect at dosages higher than 0.4 U/kg.17 However, with dosages commonly used in clinical practice (0.4 U/kg and lower), the profile is rather flat. Another advantage of insulin detemir compared to other basal insulins is its high reproducibility. One report has shown that insulin detemir had less withinsubject variability compared with NPH insulin and insulin glargine in patients with type 1 diabetes.18 Thus, the within-subject variances, expressed as the coefficients of variation of the 24-hour glucose lowering effect of insulin detemir, NPH insulin, and insulin glargine were 27%, 77%, and 66%, respectively.18 Moreover, pharmacodynamic studies suggest that the between-subject variability may be less with insulin detemir compared with NPH insulin.17 the mean weight gain was less pronounced with insulin detemir compared with NPH insulin—1.2 and 2.8 kg, respectively. The within-subject variation, expressed as standard deviation in predinner blood glucose, was approximately 10% less with insulin detemir compared with NPH insulin. The Treating to Target in Type 2 Diabetes (4-T) Study Group compared insulin detemir to biphasic insulin aspart (a premixed combination of 70% NPH insulin and 30% insulin aspart) bid and tid premeal (prandial) insulin aspart as additional therapy in patients with type 2 diabetes not optimally controlled on metformin plus SUs (baseline HbA1c, 8.5%).20 After 1 year of follow-up, mean HbA1c values were similar in the biphasic group (7.3%) and the prandial group (7.2%) but higher in the insulin detemir group (7.6%). Meanwhile, insulin detemir was associated with the lowest risk of hypoglycemia and weight gain. Thus, mean numbers of hypoglycemic events (defined as blood glucose 56 mg/dL) per patient per year were 5.7, 12, and 2.3 in the biphasic, prandial, and detemir groups, respectively. Corresponding mean weight gains were 4.7, 5.7, and 1.9 kg. It can be concluded that insulin detemir may be appropriate for the patient with frequent hypoglycemia, wide fluctuations, and unpredictable blood glucose values, and when weight gain is a major concern. Efficacy and safety: Insulin detemir versus NPH Clinical trials have generally shown that the use of insulin detemir was associated with less hypoglycemia, less blood glucose variability, and lower weight gain compared with NPH insulin. In the Levemir Treat-to-Target Study, 476 patients with type 2 diabetes uncontrolled on oral agents (baseline HbA1c, 8.5%) were randomized to receive insulin detemir or NPH insulin bid before breakfast and at dinner time aiming at prebreakfast and predinner blood glucose levels of 108 mg/dL or less.19 After 26 weeks, the reduction in HbA1c values was similar, approximately 1.8%. Yet, the risk for all hypoglycemia was reduced by 47%, and nocturnal hypoglycemia by 55% with insulin detemir. In addition, Insulin detemir versus insulin glargine Few head-to-head trials comparing the efficacy and safety of insulin detemir and glargine are available. One recent trial showed that insulin detemir given bid was equally effective to qd insulin glargine in decreasing HbA1c values (from approximately 8.7% to 8.2%) in patients with type 1 diabetes taking premeal insulin aspart.21 However, while the overall risk of hypoglycemia was comparable, major hypoglycemic and nocturnal hypoglycemic events were 72% and 32% lower, respectively, with insulin detemir compared to insulin glargine. Weight gain was 0.52 and 0.96 kg with insulin detemir and glargine, respectively, which is not statistically different.21 A preliminary report suggested that both insulin detemir and insulin glargine were equally effective in DECEMBER 2007 PATIENT CARE ENDOCRINOLOGY & CARDIOLOGY 9

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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