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New Drug Reviews

Insulin Detemir (Levemir) for Diabetes Mellitus



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Am Fam Physician. 2006 Jul 15;74(2):323-324.

Insulin detemir (Levemir) joins insulin glargine (Lantus) as the only other long-acting insulin analogue approved as basal therapy for the treatment of diabetes mellitus. It is indicated for use in adults and children in combination with short-acting insulin for type 1 diabetes and with oral agents or short-acting insulin for adults with type 2 diabetes.

Name Starting dosage Dose form Approximate cost*

Insulin detemir (Levemir)

Type 1 or 2 diabetes on a basal-bolus regimen: convert unit to unit

10-mL vial and 3-mL prefilled pen

$82 (for 10-mL vial)

Type 2 diabetes new start: 10 units once or twice daily or 0.1 to 0.2 units per kg per day

$32 (for 3-mL prefilled pen)


*—Average wholesale cost, based on Red Book, Montvale, N.J.: Medical Economics Data, 2005.

Name Starting dosage Dose form Approximate cost*

Insulin detemir (Levemir)

Type 1 or 2 diabetes on a basal-bolus regimen: convert unit to unit

10-mL vial and 3-mL prefilled pen

$82 (for 10-mL vial)

Type 2 diabetes new start: 10 units once or twice daily or 0.1 to 0.2 units per kg per day

$32 (for 3-mL prefilled pen)


*—Average wholesale cost, based on Red Book, Montvale, N.J.: Medical Economics Data, 2005.

SAFETY

Insulin detemir has the same safety concerns as other insulins, with hypoglycemia being the most serious. Most safety trials compare insulin detemir with neutral protamine Hagedorn (NPH) insulin in patients with type 1 or 2 diabetes. When comparing patients with type 1 diabetes who are receiving mealtime insulin aspart with those receiving NPH insulin, insulin detemir caused slightly fewer episodes of minor hypoglycemia (i.e., approximately one fewer episode of nocturnal hypoglycemia every three months). There was no difference in the number of major hypoglycemic events.1,2 In another study,3 patients with type 2 diabetes receiving insulin detemir or NPH insulin had similar occurrences of minor and major hypoglycemic events.

Insulin detemir is pregnancy category C,4 as are insulins glargine, aspart, and aspart protamine/aspart. Other insulins are category B. The effect of insulin detemir on morbidity or mortality in patients with diabetes has not been evaluated.

TOLERABILITY

Insulin detemir is tolerated to the same degree as other insulins. Unlike NPH insulin, the use of insulin detemir has not been associated with weight gain in short-term studies.13

EFFECTIVENESS

Insulin detemir, as well as other long-acting insulins, is used to provide continuous low blood levels of insulin and is augmented with immediate-acting insulins to produce an insulin response more likely to mimic normal physiology. This approach has been attempted with older long-acting insulins. Detemir produces reductions in A1C levels similar to NPH insulin when both are used in combination with short-acting bolus insulin in patients with type 1 and 2 diabetes.13,5 There are no clinical trials comparing insulin detemir to insulin glargine.

PRICE

Insulin detemir is available in a vial and prefilled pen. The cost is $82 for a 10-mL vial and $32 for a 3–mL prefilled pen; this is more than the cost for NPH and insulin glargine. The cost of a 10–mL vial of NPH ranges from $31 to $32, and the 3–mL prefilled pen ranges from $14 to $20. The cost is $67 for a 10-mL vial of insulin glargine and $27 for a 3-mL prefilled pen.

SIMPLICITY

Insulin detemir is used as basal insulin in combination with short-acting insulin in patients with type 1 diabetes and in combination with oral medications with or without short-acting insulin in patients with type 2 diabetes. If preprandial glucose goals are not obtained, the total daily dose should be split and given every morning and evening. Mealtime insulin should be given in addition to insulin detemir to control postprandial hyperglycemia.4,6

When switching from another basal-bolus insulin regimen (i.e., insulin glargine) or once-daily NPH insulin, insulin detemir is given at the same dose and schedule as the previous insulin. Patients with type 2 diabetes may require a higher dose of detemir than NPH. For patients with type 2 diabetes who are naïve to insulin, detemir should be started at 10 units once or twice daily or 0.1 to 0.2 units per kg once daily. There is no stated starting dose for patients with type 1 diabetes who are naïve to insulin. Insulin detemir is a clear liquid that does not need resuspension before administration as NPH does. Insulin detemir cannot be mixed or diluted with any other insulin. Punctured vials or pens in use are stable for 42 days at room temperature.4,6

Bottom Line

Insulin detemir is suitable as basal insulin in a basal-bolus regimen. In limited research, it has been shown to cause slightly fewer episodes of minor hypoglycemia and no weight gain in patients with type 1 and 2 diabetes, which is a benefit that must be balanced against its higher price. Insulin detemir has been shown to provide similar glycemic control when compared with NPH insulin.

The Author

JENNIFER D. GOLDMAN-LEVINE, PHARM.D., C.D.E., is associate professor in the Department of Pharmacy Practice at the Massachusetts College of Pharmacy and Health Sciences School of Pharmacy, Boston, Mass., and a clinical pharmacy faculty member for the Tufts University Family Medicine Residency Program, Malden, Mass.

REFERENCES

1. Vague P, Selam JL, Skeie S, De Leeuw I, Elte JW, Haahr H, et al. Insulin detemir is associated with more predictable glycemic control and reduced risk of hypoglycemia than NPH insulin in patients with type 1 diabetes on a basal-bolus regimen with premeal insulin aspart. Diabetes Care. 2003;26:590–6.

2. Home P, Bartley P, Russel-Jones D, Hanaire-Broutin H, Heeg JE, Abrams P, et al. Insulin detemir offers improved glycemic control compared with NPH insulin in people with type 1 diabetes: a randomized clinical trial. Diabetes Care. 2004;27:1081–7.

3. Haak T, Tiengo A, Draeger E, Suntum M, Waldhausl W. Lower within-subject variability of fasting blood glucose and reduced weight gain with insulin detemir compared to NPH insulin in patients with type 2 diabetes. Diabetes, Obes Metab. 2005;7:56–64.

4. Levemir package insert. Novo Nordisk Inc. October 19, 2005. Accessed May 10, 2006, at: http://www.levemirus.com/prescribing_information.pdf.

5. Hermansen K, Madsbad S, Perrild H, Kristensen A, Axelsen M. Comparison of soluble basal insulin analog insulin detemir with NPH insulin: a randomized open crossover trial in type 1 diabetic subjects on basal-bolus therapy. Diabetes Care. 2001;24:296–301.

6. Levemir treatment guidelines. Accessed May 10, 2006, at: http://www.levemirus.com.

STEPS drug updates cover Safety, Tolerability, Effectiveness, Price, and Simplicity. Each update provides an independent review of a new medication by authors who have no financial association with the drug manufacturer.

The series coordinator is Allen F. Shaughnessy, Pharm.D., Tufts University Family Medicine Residency Program, Malden, Mass.



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