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Clinician’s Corner: Basal Insulin

The human body spends about 12 hours in the fasting state, and the other 12 hours in the “fed state”. In April 2000, the biggest change in diabetes therapy since the introduction of human insulin in the early 1980’s occurred.  Lantus (insulin glargine) came to the market. NPH insulin was the mainstay of diabetes management since its introduction in the late 1940’s.  By rearranging the amino acid sequence of human insulin, they were able to make a 24-hour insulin. After injection into the fatty tissue, the acidic solution (pH=4) becomes neutralized, leading to formation of tiny “clumps” from which small amounts of insulin are slowly released.  The low pH is responsible for the “stinging” patients experience upon injection.

Insulin Glargine

  • Lantus ®  U-100 (insulin glargine)  by Sanofi-Aventis
  • Basaglar® U-100 (biosimilar insulin glargine) by Eli Lilly
  • Toujeo ® (insulin glargine) by Aventis is a U-300 insulin.  May substitute unit for unit with Lantus. Some patients may need a dosage adjustment.

Glargine has an onset of 1.1 hours, and a duration of 24 hours. It has no pronounce peak.  Because of the low pH, other insulins should not be mixed in the same syringe with glargine. Glargine is usually dosed in the evening; can be dosed in the morning if morning hypoglycemia is a problem (especially with the elderly).  Glargine has an expiration date of 28 days after first use of either a pen or vial.

Insulin Detemir

Levemir® (detemir) by Novo Nordisk became available to mount a challenge to Lantus in 2005.

Like Lantus it has a one-hour onset, and is peak less, but that is where the similarities end.  Levemir has a duration of 16-20 hours.  Very few patients get the “up to 24 hours” of coverage. If converting from glargine, it is NOT unit for unit and may require 1.5 to 2x increase in units. Most patients require twice daily dosing. Detemir has an expiration date of 42 days from first use of a vial or pen.

Insulin Degludec

Tresiba (Degludec) by Novo Nordisk, released in 2015, was another attempt to unseat glargine from its hold on the basal insulin market. Degludec has an onset and peak similar to glargine and detemir BUT has a duration of action of 42 hours which allows for more flexible dosing. A subcutaneous depot is formed that results in slow insulin release into the systemic circulation.

Tresiba® is available in 2 concentrations: 200 units/mL and 100 units/mL, available only in pens, and carries an expiration date of 56 days.

Your Thompson Pharmacist is a great resource for managing your blood sugars.  Your morning fingerstick reading is the one that governs the dose of the long acting insulin.  Whether your insurance company insists on Basaglar or Lantus, you should always insist in Thompson Pharmacy for ALL of your diabetic needs.  Go Ahead and AS… at Thompson Pharmacy it’s all for YOU!