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Use of correct insulin crucial in diabetes treatment

“Diabetes is an increasing problem in Asia, particularly in the Philippines. The number of people with diabetes will double in 15 or 20 years’ time,” said Professor Peter Tong of the Department of Medicine and Therapeutics of the Chinese University of Hong Kong, in symposium organized by Sanofi Aventis held recently.

According to Professor Tong, there is also a significant delay in the introduction of insulin therapy. “Brown et al. in their 2004 study published in Diabetes Care reported that a patient is already with diabetes for 10 years and his or her HbA1c level is already 9.6 percent before insulin therapy is even considered.”

There are, however, several limitations with insulin use as a clinical treatment for diabetes. These include fear of hypoglycemia.

This is perhaps the single most important reason why diabetic patients refuse insulin treatment, said Professor Tong. “Insulin can cause dangerously low levels of blood sugar that can cause cardiac arrhythmias and impaired cognitive function.”

“Clinicians need to understand the profound effect of hypoglycemia to patients and to understand why they don’t like experiencing hypoglycemia,” Professor Tong said. “The ADA and EASD in their diabetes treatment algorithm highlighted the importance of using insulin therapy early during treatment; however, it is equally important to choose the correct type of insulin that will not cause hypoglycemia.”

Professor Tong enumerated three ways to initiate insulin therapy. “The first one is the use of basal insulin once daily. Examples of basal insulin are insulin glargine, insulin detemir, and NPH insulin. The second way is the use of twice-daily premixed insulin (biphasic insulin), particularly among patients with higher HbA1c. Finally, there’s the multiple daily injections (meal-time and basal insulin) where blood glucose control is suboptimal on other regimens.”

“The next question probably is should we use basal or premixed insulin?” Professor Tong furthered. He cited the study of Fritsche et al., where an intensified basal-bolus regimen using insulin glargine/ glulisine resulted in more patients attaining superior glycemic control compared to those who received premixed therapy.

The 371-patient LAPTOP study, which compared the efficacy and safety of insulin glargine plus oral antidiabetic drug versus two premixed injections in uncontrolled type 2 diabetes, found that the frequency of hypoglycemia is much lower in the insulin glargine group compared to the premixed insulin group.

“Long-acting insulin has demonstrated lower rates of hypoglycemia than premixed insulin,” said Professor Tong. For instance, the results of a randomized, 28-week study in 233 insulin-naïve patients with type 2 diabetes treated with biphasic insulin aspart 70/30 twice daily or 10-12 units insulin glargine at bedtime titrated to target blood glucose, found that rates of minor hypoglycemia were significantly lower with insulin glargine.

Furthermore, in the Lantus Versus Levemir Treat-To-Target study, insulin glargine and insulin detemir, in terms of efficacy, provided similar efficacy in 964 insulin-naïve patients.

“However, the same study found that significantly lower doses of insulin glargine are needed to achieve good glycemic control compared to insulin detemir,” Professor Tong furthered. “Indeed, to achieve the same mean glycemic control, insulin detemir patients needed to receive 76 percent units more in average than insulin glargine patients. The take-home message here is that we, as clinicians, should be able to pick the correct insulin that patients will be able to comply with. Otherwise, insulin therapy will not improve glycemic control.”

Insulin glargine (Lantus, Sanofi Aventis) is a recombinant human insulin analogue for once-daily subcutaneous administration. It is indicated for the treatment of adult and pediatric patients with type 1 diabetes or adult patients with type 2 diabetes who require basal insulin for the control of hyperglycemia.

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