II. Precautions

  1. Insulin Dosing in the U.S. has become unconscionably expensive
    1. Consider NPH Insulin (still $25 per vial at Walmart as of 2016) for basal control instead
  2. Basal Insulin does not cover meal times
  3. Use in combination with agents to cover meals
    1. Rapid acting Insulin (e.g. Lispro)
    2. Oral agents (Sulfonylureas, Metformin, Glitazone) or
      1. Switch to basal/bolus when Glargine >0.5 units/kg

III. Preparations

  1. Insulin Glargine U-100 (Lantus, Basaglar)
    1. Information below is based on Lantus
    2. Most closely matches 24 hour coverage
    3. Less expensive than Lantus
  2. Insulin Glargine U-300 (Toujeo)
    1. Toujeo Solostar pen (80 u/pen, with 3x the concentration of Lantus)
      1. Released in 2015 (curiously as Lantus becomes generic)
    2. Promoted as a longer acting Lantus (closer to 24 hour duration)
    3. Do not adjust Toujeo dose more often than every 3-4 days
    4. Transitioning from other agents
      1. From Lantus, Basaglar daily
        1. Dose Toujeo at 110% of Lantus dose
      2. From Lantus twice daily
        1. Dose Toujeo at 100% of the Lantus dose
      3. From Detemir or NPH twice daily
        1. Dose Toujeo at 80% of total daily basal Insulin dose
    5. Transitioning to other agents
      1. To Lantus or Basaglar
        1. Dose Lantus or Basaglar at 80% of Toujeo dose to start, then titrate up
    6. References
      1. Riddle (2014) Diabetes Care 37(10):2755-62 +PMID:25078900 [PubMed]
  3. Detemir U-100 (Levemir)
    1. Similar pharmacokinetics as Lantus
    2. Less burning on injection compared with Lantus
    3. Binds and released from circulating albumin
    4. Most consistent basal Insulin day to day
    5. Duration varies by dose (bid may be preferred)
  4. Insulin Degludec (Tresiba)
    1. Ultra Long acting Insulin (lasts 42 hours) available as U-100 or U-200

IV. Pharmacokinetics

  1. Onset: 1 hour
  2. Duration: 21 to 24 hours
    1. May require divided dosing bid to maintain basal rate
  3. Peak: No peak
    1. Flat action profile throughout duration
    2. Mimics continuous Insulin Infusion

V. Adverse effects

  1. Less nocturnal Hypoglycemia than other Insulins
  2. Lower post-prandial Glucose

VI. Dosing

  1. Starting dose (no prior Insulin)
    1. Hemoglobin A1C <8%: 0.1 units/kg
    2. Hemoglobin A1C >8-10%: 0.2 units/kg
    3. Hemoglobin A1C >10%: 0.3 units/kg
  2. Old regimen for starting dose (use units/kg as above instead)
    1. Type I Diabetes: 10 Units qhs
    2. Type II Diabetes: 10-14 Units qhs
  3. Conversion from other long-acting Insulin
    1. NPH/ultralente qhs: start Lantus at same dose
      1. Consider starting Lantus at 80% of prior NPH dose
    2. NPH bid: Start Lantus at 80% of total daily NPH dose
  4. Adjustment based on Fasting plasma Glucose (FPG)
    1. Protocol 1
      1. FPG <70 mg/dl for 3 days: Decrease Lantus 1-2 units
      2. FPG 140-250 for 3 days: Increase Lantus 2-4 units
      3. FPG >250 for 3 days: Increase Lantus 4-8 units
    2. Protocol 2
      1. FPG <80 for 3 days: Decrease Lantus by 2 units
      2. FPG 100-120 for 3 days: Increase Lantus by 2 units
      3. FPG 120-140 for 3 days: Increase Lantus by 4 units
      4. FPG 140-180 for 3 days: Increase Lantus by 6 units
      5. FPG >180 for 3 days: Increase Lantus by 8 units
  5. Timing of dose for Lantus
    1. Studies gave Lantus at bedtime to avoid confusion
    2. Lantus is most effective if given in the morning

VII. Preparations: Delivery Devices - OptiClik Pen

  1. Pens are free from Aventis
    1. Phone: 800-207-8049
  2. Pens ease Insulin delivery
  3. Lantus in cartridges costs 2 cents/unit more than vial
  4. (2005) Prescriber's Letter 12:32

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Cost: Medications

lantus (on 6/22/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
LANTUS 100 UNITS/ML VIAL $23.93 per ml
LANTUS SOLOSTAR 100 UNITS/ML $24.06 per ml
levemir (on 6/22/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
LEVEMIR 100 UNITS/ML VIAL $26.07 per ml
LEVEMIR FLEXPEN 100 UNITS/ML $26.08 per ml
LEVEMIR FLEXTOUCH 100 UNITS/ML $26.08 per ml
toujeo (on 5/18/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
TOUJEO SOLOSTAR 300 UNITS/ML $72.08 per ml
tresiba (on 5/18/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
TRESIBA FLEXTOUCH 100 UNITS/ML $28.68 per ml
TRESIBA FLEXTOUCH 200 UNITS/ML $56.86 per ml

Ontology: insulin detemir (C0537270)

Definition (NCI) A long-lasting, recombinant version of human insulin. It is an insulin analogue with myristic acid bound to the lysine at position B29 and a deletion of B30.
Concepts Amino Acid, Peptide, or Protein (T116) , Pharmacologic Substance (T121) , Hormone (T125)
MSH C105111
SnomedCT 414518007, 414515005
English 12C-Lys(B29)-DB30I, B29-tetradecanoyl-Lys-B30-des-Ala-insulin, des-(B30)-insulin, Lys(B29)-tetradecanoyl-, insulin, tetradecanoyllysyl(B29)-desalanyl(B30)-, Insulin Detemir, INSULIN DETEMIR, basal insulin detemir, insulin detemir (medication), Insulin detemir (substance), Insulin detemir product (product), Insulin detemir product, Insulin detemir, insulin detemir, insulin, tetradecanoyl-Lys(B29)-des-Ala(B30)-
Spanish insulina detemir (producto), producto con insulina detemir (producto), producto con insulina detemir, insulina detemir (sustancia), insulina detemir

Ontology: Basal insulin (C0650607)

Concepts Amino Acid, Peptide, or Protein (T116) , Pharmacologic Substance (T121)
SnomedCT 416303005
English Basal insulin (product), Basal insulin
Spanish insulina basal (producto), insulina basal

Ontology: Lantus (C0876064)

Concepts Pharmacologic Substance (T121) , Amino Acid, Peptide, or Protein (T116)
MSH C106526
English Lantus, lantus

Ontology: Insulin Glargine (C0907402)

Definition (NCI) A recombinant human insulin analog with long-acting, blood glucose-lowering activity. Insulin glargine, like regular types of human insulin, regulates glucose metabolism by binding to insulin receptors on muscle and fat cells, thereby facilitating the cellular uptake of glucose. This lowers blood glucose levels. At the same time, insulin glargine inhibits the liver's conversion of stored glycogen into glucose, which also contributes to lower blood glucose levels. Insulin glargine also inhibits lipolysis in adipose tissue, inhibits proteolysis, and enhances protein synthesis. (NCI05)
Definition (NCI_NCI-GLOSS) A drug used to control the amount of sugar in the blood of patients with diabetes. It is a form of the hormone insulin that is made in the laboratory. Insulin glargine controls blood sugar longer than insulin does. It is a type of therapeutic insulin.
Concepts Pharmacologic Substance (T121) , Amino Acid, Peptide, or Protein (T116) , Hormone (T125)
MSH C106526
SnomedCT 126212009, 126207008, 411529005
English A21-Gly-B31-Arg-B32-Arg-insulin, Insulin Glargine,Hum.Rec.Anlog, insulin, Gly(A21)-Arg(B31,B32)-, insulin, glycyl(A21)-arginyl(B31,B32)-, insulin glargine, Insulin Glargine, Insulin glargine preparation, Insulin Glargine Recombinant, INSULIN GLARGINE, glargine [Chemical/Ingredient], glargine insulin, insulin glargine human, glargine, Insulin glargine (product), insulin glargine recombinant, Insulin glargine product (product), Insulin glargine product, Insulin glargine preparation (substance), Insulin glargine, Insulin glargine (substance), INSULIN,GLARGINE,HUMAN/rDNA
Spanish insulina glargina (producto), preparado de glargina insulínica (producto), preparado de glargina insulínica, glargina insulínica (producto), glargina insulínica, glargina insulínica (sustancia), preparado de glargina insulínica (sustancia), insulina glargina (sustancia), insulina glargina

Ontology: Levemir (C1314782)

Concepts Amino Acid, Peptide, or Protein (T116) , Hormone (T125) , Pharmacologic Substance (T121)
MSH C105111
English Levemir, levemir