Alan Moses, MD, is the medical director for Novo Nordisk Pharmaceuticals
With the new basal-bolus insulin landscape, what is the most important thing that endocrinologists and primary care physicians need to know so that their insulin-using patients can follow the best possible regimen?
It is extremely important that, by concentrating on the specific needs of the patient through diabetes education and by prescribing the “right” insulin for the “right” patient, the majority of patients can safely get to target glucose control individualized for that patient. Clinical trial data supporting the approval of Levemir as the newest addition to Novo Nordisk’s insulin analogue portfolio, and experience generated over the last year in Europe and other parts of the world, demonstrate the value of Levemir as a basal insulin in combination with oral anti-diabetes agents in type 2 diabetes, and in combination with rapid-acting analogues for both type 2 and type 1 diabetes.
The challenge for the prescribing physician is to recognize the state of diabetes and whether the patient can respond to a basal insulin alone (in combination with oral agents), or whether the patient needs both a basal insulin and a bolus (pre-meal) component, either in the form of Levemir plus NovoLog or NovoLog Mix 70/30. 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. Rapid-acting insulin analogues such as NovoLog add a convenience factor for mealtime administration and provide better post-meal glucose control than regular human insulin. In addition, new once-a-day basal insulin analogues such as Levemir provide glucose control with no additional risk of hypoglycemia and low weight gain.
When should an endocrinologist or primary care physician entertain the idea of putting a type 2 patient on an insulin regimen?
We know from a number of important studies, such as the UKPDS [United Kingdom Prospective Diabetes Study] and the Kumamoto study, that patients with type 2 diabetes can suffer all of the same adverse complications of diabetes as patients with type 1 diabetes. Thus, good glucose control is a very important part of their overall management. Yet in the United States, there has been a hesitancy to use insulin early in the course of diabetes because of the perception that it is complicated and not safe. Too many patients are exposed to excessive glucose levels for too long without being afforded the advantages of good glucose control with insulin. Starting insulin early with a basal insulin like Levemir before beta cell function deteriorates completely not only can achieve good glucose control safely, but may preserve beta cell function longer, and thus make it easier to achieve good control for a longer time with a simple insulin treatment schedule.
What precautions should endos and PCPs take when starting a patient on an insulin regimen?
The key to starting insulin in any patient is to ensure that patients understand how to administer the insulin, when to measure their blood glucose and how to moderate their diet and exercise patterns to take account of the time (for short-acting insulins) when insulin has its peak action. Thus, patient education is key to successful insulin administration. It also is imperative that patients are taught how to monitor their own progress so that they can adjust insulin doses themselves to accommodate changes in their glucose control. Insulin delivery devices like FlexPen make it easier to teach patients how to use insulin and increase their confidence in their insulin treatment program. Physicians should start insulin doses at a low to moderate level so that patients do not experience episodes of hypoglycemia early in their treatment, as that discourages patients from achieving good levels of glucose control.
How will Levemir change the way patients take insulin?
As a basal insulin lasting up to 24 hours and providing smooth absorption with excellent efficacy and safety, Levemir provides patients with an insulin that can reliably lower blood glucose with a decreased risk of hypoglycemia and with less weight gain. The label supports its use in both type 1 and type 2 diabetes and in combination with rapid-acting insulin before meals and with oral diabetes agents in patients with type 2 diabetes who still have some residual insulin secretion to cover meals. FlexPen provides an accurate, safe, easy-to-teach, easy-to-learn and easy-to-use means of administering Levemir. Importantly, the extended “in use” time of 42 days compared to 28 for other insulins is a real advantage to patients.
What should endos and PCPs know about the future of insulin therapy?
The future of insulin therapy increasingly will depend on better analogue insulins like Levemir, which can more closely reproduce physiologic blood insulin profiles. In addition, with the advent of accurate and affordable continuous glucose-monitoring systems, it is likely that more patients can be treated aggressively to achieve target levels of glucose control that will reduce the risk of long-term diabetes complications, while at the same time avoiding short-term complications such as hypoglycemia and weight gain. We are likely to see increased emphasis on alternative routes of insulin administration, such as pulmonary insulin, which are convenient for patients, but it still will be necessary to demonstrate that this convenience can be translated into better glucose control. Novo Nordisk is committed to continuing to improve both the insulins and the delivery systems that will allow patients to achieve the very best diabetes control.Click Here To View Or Post Comments