COMMENTARY

Basal Insulins: 'We've Come a Long Way'

Aaron R. Chidakel, MD

Disclosures

April 25, 2017

Editorial Collaboration

Medscape &

Hello. My name is Aaron Chidakel, and I am an endocrinologist at New York University. I am here at the 2017 Endocrine Society Annual Meeting, where I have been to a number of great talks.

We've come a long way in the treatment of diabetes, particularly with basal insulin management. We want to mimic the insulin normally secreted by the pancreas, so ideally, basal insulin should have very low variability, a low risk for hypoglycemia, and be a once-daily injection.

The first insulins did not replicate pancreas activity very well. A newer generation of synthetic insulin analogues (eg, glargine and detemir) came out that were better than the traditional insulins, but they still had a bit of a peak and some variability, and tended to cause some hypoglycemia.

We now have a newer generation of basal insulins. The first was glargine U300—the same molecule as glargine U100 but just more concentrated. We also have degludec, which comes in two concentrations: U100 and U200. These insulins are more similar to that made by the pancreas; they have less variability, less of a peak, and less hypoglycemia.

Tips and Trends in Insulin Dosing

I went to a presentation by Dr Carol Wysham,[1] which was one of the most interesting and concise talks I have seen since I have been here. She spoke about topics pertaining to the newer basal insulins, and these are some of her main points.

Dr Wysham discussed techniques that can help transition patients on earlier analogues of glargine or detemir to the newer analogues glargine U300 and degludec U100 and U200.[2]

Because it has flexible dosing, degludec is ideal for someone who is a shift worker, such as a night nurse, a flight attendant, or even a college student. It is good to take it once a day, but it could be taken as much as 48 hours between dosing. A good idea is to tie it to something the person does on a daily basis, such as brushing teeth, so that they remember to take it consistently.

As the A1c approaches normal (elevated, but not super-elevated), we always thought about adding a prandial insulin three times a day to bring the A1c to goal, rather than having the basal insulin be the biggest factor in reducing A1c. But we know this can be very difficult for patients.

Sometimes it is beneficial to have them take the prandial insulin once a day at their heavier meal. Or, a newer glucagon-like peptide 1 (GLP1) receptor agonist or even a sodium/glucose cotransporter 2 (SGLT2) inhibitor could be added,[3] which may lead to less weight gain (or possibly weight loss) and less hypoglycemia—things we worry about with insulin. These alternatives may improve patient adherence.

In a sense, U500 insulin is not really a pure basal or bolus insulin, but a combination thereof. In certain patients, dosing two or three times a day might be a very good option.

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