Carol H. Wysham, MD

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October 20, 2016

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When our patients with type 2 diabetes are ready to start insulin, there is great concern on the part of the provider as well as the patient as to the risk that this medication will pose for hypoglycemia. It turns out that these concerns about hypoglycemia not only prevent or postpone the initiation of insulin, but they also often prevent us from being able to titrate basal insulin up to help patients reach their glycemic targets.

Today we reported on the SWITCH 2 study,[1] which looks at insulin degludec. Patients with type 2 diabetes were randomized to receive either insulin glargine or insulin degludec and were titrated weekly to attempt to get the fasting glucose down to less than 90 mg/dL. The rate of hypoglycemia events was the primary endpoint.

Overall, hypoglycemia was reduced by 30% with insulin degludec compared with insulin glargine. Nocturnal hypoglycemia was reduced by 42%, and severe hypoglycemia, although it did not reach statistical significance, was 50% lower with insulin degludec.

What does this mean for clinical practice?

If all things were equal and this were available to our patients, I would recommend that we start one of the ultra-long-acting insulins as the basal insulin of choice. We do not have a comparison between degludec and U300, so we really are not in a position to say that one might be better than the other.

The lower hypoglycemia rate shown with ultra-long-acting insulins is important information for providers so that they may have more confidence in starting insulin in their patients. They are not going to have as many problems with hypoglycemia, and they can reassure patients that the rates of hypoglycemia are lower. Thank you.

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