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Diabetes in Older Adults and Its Management
Published in K. Rao Poduri, Geriatric Rehabilitation, 2017
Susanne U. Miedlich, Steven D. Wittlin
Insulin degludec was approved by the FDA in 2015. It contains an added hexadecanoic acid at LysB29 using a linker of glutamic acid. As a result, it is injected as a dihexamer containing phenol and zinc. These hexamers combine to form multihexamers in the depot as phenol is removed. Finally, in the subcutaneous space, as zinc is removed, the multihexamers break up into absorbable dimers and eventually monomers. The result is a very protracted duration of action of insulin degludec, more predictable absorption, with less hypoglycemia (156–158). As opposed to glargine, whose acid pH makes combining it with other preparations difficult, insulin degludec has been formulated with insulin aspart (see below) and liraglutide. It is injected once daily.
Anti-Diabetic Drugs
Published in Awanish Kumar, Ashwini Kumar, Diabetes, 2020
The first recombinant human insulin was made by the pharmaceutical giant Eli Lilly in 1982, and was named Humulin®, with Humulin R as the short-acting and Humulin N as the intermediate-acting formulations. Now as per the physiological action, the insulin secretion is classified into basal and bolus. The small continuous insulin secretion throughout the day is known as basal, while the insulin amount released during or after a meal is known as bolus. Therefore, the recombinant human insulin was prepared and formulated in a way that it could provide glucose management throughout the day in a basal–bolus way [1]. Therefore, according to the action pattern, the commercial insulin formulations are available as bolus, prandial and pre-mixed. Secondly, commercial insulin is either human insulin or insulin analogues as per their structure. Insulin analogues are the insulin molecules that have a slight structural variation, mostly in terms of change of amino acid residue(s) or change in their position or both. In terms of their duration of action, insulin formulations are classified as rapid acting (action starts 15 minutes after administration), short acting (action starts 30 minutes after injection), intermediate acting (reaches systemic circulation 2–4 hours after administration), long acting (action starts over 24 hours) and ultra-long acting (action starts for up to 40 hours). Insulin glulisine (Apidra®), insulin lispro (Humalog®) and insulin aspart (Novolog®) are a few of the popular commercial rapid-acting analogues. Short-acting analogues include Humulin R and Novolin R. Humulin N and Novolin N are the popular intermediate-acting insulin analogues, while insulin detemir (Levemir®) and insulin glargine (Lantus) are the most popular commercial long-acting insulin analogues. Currently, insulin degludec is the only commercially available ultra-long acting insulin analogue. Pre-mixed insulin formulations available are 70/30 Humulin or Novolin (70% NPH insulin and 30% regular insulin), 50/50 Humulin (50% NPH insulin and 50% regular), 75/25 Humalog (75% protamine lispro and 25% lispro), 50/50 Humalog (50% protamine lispro and 50% lispro), 70/30 Novolog Neutral (70% protamine aspart and 30% aspart) and Ryzodeg 70/30 (70% degludec and 30% aspart). The pre-mixed formulations are basically a mixture of basal and prandial insulin/analogues and are considered better and safer as they reduce the mixing of insulin by the patients which may increase the chance of error. They are also better in mimicking the physiological basal–bolus insulin action. They are more convenient and are aimed at reducing the number of insulin injections per day [1,4]. More details about insulin and analogues can be found in the References section (reference 1 and reference 4).
Practical guidance on the initiation, titration, and switching of basal insulins: a narrative review for primary care
Published in Annals of Medicine, 2021
Roopa Mehta, Ronald Goldenberg, Daniel Katselnik, Louis Kuritzky
Advice regarding missed or double doses depends on the pharmacologic characteristics of each basal insulin product (Table 1) [20,25–29]. In general, if the patient thinks they have missed a dose, they should test their FPG and contact their care team. Again, the flexibility and stable glucose-lowering action of long-acting insulin analogs help in this regard. For insulin degludec, for example, patients who realize they have missed a dose can inject it during waking hours the same day, as long as they ensure at least 8 h between consecutive injections [27]. If a double dose is taken, we suggest that patients should test their blood sugar frequently during the day, eat a snack and, in the night, wake up every 2–3 h to test glucose (with an extra snack if the reading is <126 mg/dL).
Treatment satisfaction, safety, and effectiveness of biosimilar insulin glargine is comparable in patients with type 2 diabetes mellitus after switching from insulin glargine or insulin degludec: a post-marketing safety study
Published in Current Medical Research and Opinion, 2020
Kentaro Taki, Momoha Koyanagi, Soshi Nagaoka, Tomotaka Shingaki
Insulin is recommended for patients with advanced T2DM in order to prevent or delay the development of long-term complications associated with diabetes.7–8 Guidelines recommend commencing therapy with a basal insulin9 such as insulin glargine or insulin degludec, both long-acting basal insulin analogs indicated to improve glycemic control and commonly prescribed for patients with T2DM. Insulin degludec was designed to achieve a highly stable pharmacodynamic profile and has demonstrated lower daily glucose variability in comparison to insulin glargine.10 For various reasons, patients may be required to switch to an alternate insulin. In addition, there is considerable interest in the use of biosimilar insulins, a biological copy of an original insulin. Health care providers recognize that psychosocial issues play a pivotal role in how effectively patients manage their diabetes. It is, therefore, important to assess patient treatment satisfaction using real-world survey-data in order to understand patient perspectives such as potential treatment differences, needs, and grievances in patients who switch insulin therapies. Understanding these factors may improve the therapeutic effects of insulin by reducing treatment barriers such as adherence, thereby leading to medically stable disease.
Real-world cost-effectiveness of insulin degludec in type 1 and type 2 diabetes mellitus from a Swedish 1-year and long-term perspective
Published in Journal of Medical Economics, 2020
Johan Jendle, Åsa Ericsson, Bertil Ekman, Stefan Sjöberg, Jens Gundgaard, João da Rocha Fernandes, Ann-Charlotte Mårdby, Barnaby Hunt, Samuel J. P. Malkin, Maria Thunander
Insulin degludec is a once-daily, long-acting basal insulin with a duration of action of more than 42 h, approved for the treatment of people with T1D and T2D15. Insulin degludec has been associated with lower rates of hypoglycemia versus other basal insulins in several clinical trials16–18. Recently, insulin degludec was assessed in a real-world setting in the prospective, observational, single-arm ReFLeCT study. ReFLeCT examined the impact of switching from non-degludec basal insulin therapy (with or without bolus insulin) to insulin degludec (with or without bolus insulin) in people with T1D and T2D19. This study showed that insulin degludec was associated with significantly fewer hypoglycemic events than previous insulin therapy, as well as significant reductions in HbA1c, in people with T1D and T2D, and lower insulin doses and slight increases in body weight in people with T1D.