In 1998, Eli Lilly & Co.’s rapid-acting insulin analogue lispro (Humalog) appeared on the U.S. market, followed in 2000 by Novo Nordisk’s rapid-acting counterpart aspart (NovoLog). Joined now by sanofi-aventis’ glulisine (Apidra), these rapid-acting insulins offer both convenience and improved blood glucose control to your patients who require bolus insulin.
Sanofi-aventis’ glargine (Lantus), the first commercial long-acting insulin analogue, has facilitated better basal insulin coverage for millions of patients with both type 1 and type 2 diabetes since its introduction in 2000. And now Novo Nordisk’s insulin detemir (Levemir) presents another new option for basal insulin therapy.
As insulin analogues are moving from the cutting edge to the mainstream, what are endocrinologists and primary care physicians to do?
“The challenge for the prescribing physician is to recognize the state of diabetes and whether the patient can respond to a basal insulin alone, or whether the patient needs both a basal insulin and a bolus component,” says Alan Moses, MD, medical director for Novo Nordisk Pharmaceuticals. “Clinical trial data suggest that when the A1C is above 8.5%-9%, it is more likely that the patient will respond better to basal-bolus treatment, although the primary goal is to get the blood glucose levels down to as low as can be achieved safely.”
The Three Rapid-Acting Insulin Analogues
Humalog, NovoLog and Apidra begin working within about 15 minutes of bolus, peak 60 to 90 minutes later and have a duration of therapeutic activity of approximately four hours. Rapid-acting analogues are essentially equal in terms of pharmacodynamics and pharmacokinetics.
Your patients on multiple daily injections (MDI) of insulin may prefer one analogue over another in part because of the corresponding injection pen. Sanofi-aventis’ recently revamped OptiClik injection pen can be used with Apidra, which may pique the interest of patients already accustomed to using the device to inject Lantus.
“The Apidra cartridge for use in OptiClik is an important addition to the sanofi-aventis portfolio of diabetes treatments,” says Poul Strange, vice president of medical affairs, diabetes at sanofi-aventis. “We can now offer physicians and patients both the number-one prescribed insulin, the once-daily 24-hour basal insulin Lantus, as well as Apidra—a novel mealtime insulin developed for flexible use. When taken together, these two products will provide a complementary approach to overall glucose control.”
All three rapid-acting analogues are approved for use in insulin pumps.
Intermediate-Acting vs. Long-Acting Analogues
Levemir is an exciting addition to our arsenal of basal insulin options for patients who take insulin. Today most clinical researchers well versed in the insulins commonly used for basal coverage would argue that NPH is not an appropriate basal insulin; its variable intrapatient absorption rate (10 to 55 percent from injection to injection), its pronounced peak and its dose-dependent duration make it a very fearsome beast to tame. It is especially difficult for patients taking NPH to achieve euglycemia overnight, when they are prone to hypoglycemia because of naturally greater insulin sensitivity at night and because a delayed hypo resulting from physical activity or alcohol consumption during the evening may coincide with the “peaking” of the evening NPH dose.
Lantus is currently the most-prescribed prescription insulin product that is a once-daily, 24-hour, long-acting basal insulin with no pronounced peak. Levemir may help many of your patients who have not achieved optimal control on Lantus and for whom insulin pump therapy is not indicated.
Find the Right Regimen for Your Insulin-Using Patient
Ultimately, the right insulin regimen for your patient with diabetes is the one that is tailored to the patient’s lifestyle and preferences. Insulin analogues can bring flexibility and convenience to diabetes management as well as reduced hyper- and hypoglycemia. After generations of altering their lifestyles to fit their diabetes care regimen, today’s insulin users and their care teams can design regimens that enable patients to reach their career, academic, fitness and personal goals without sacrificing the pursuit of euglycemia.
How does the availability of fast-acting and basal insulins affect how an endo and PCP manage their patients?
For patients who use a basal-bolus regimen, rapid-acting analogs like Humalog provide mealtime flexibility with the benefit of improved postprandial glucose control, an important part of A1C reduction. Pre-mixed insulins, such as Lilly’s new Humalog Mix 50/50, take postprandial control a step farther by offering the same mealtime control and flexibility, but with the added between-meal glucose control benefit of an intermediate-acting insulin. Both options provide the physician with a number of approaches that can be tailored to a patient’s lifestyle and specific treatment needs.
—Ron Hoven, insulin brand leader, Eli Lilly and Company