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Anologue Basal Insulin

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Anologue Basal Insulin, Insulin Glargine, Glargine, Lantus, Levemir, Detemir, Toujeo, Insulin Degludec, Tresiba, Basaglar, Semglee

  • See Also
  1. Insulin
  • 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
  • Medications
  • U-100
  1. Insulin Glargine U-100 (Lantus, Basaglar, Semglee)
    1. Information below is based on Lantus
    2. Most closely matches 24 hour coverage
    3. Semglee (Insulin Glargine-yfgn U-100) is considered interchangeable biosimilar to Lantus as of 2021 in U.S.
      1. Allows pharmacists to auto-substitute Semglee (one third Lantus cost) for Lantus
      2. (2021) Presc Lett 28(9): 51
  2. Insulin Degludec (Tresiba)
    1. Ultra Long acting Insulin (lasts 42 hours)
    2. Onset of activity in 90 minutes
    3. Available as U-100 or U-200
  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 (twice daily may be preferred)
    6. Manufacturer discontinuing drug in U.S. in 2024 (for business reasons)
      1. Same total daily Detemir dose may be used when converting to other long acting agent
      2. May switch from Detemir total daily dose to any U-100 long acting Insulin (Lantus, Basaglar, Semglee)
      3. May also switch to the U-100 formulation of Insulin Degludec (Tresiba)
      4. Reduce total daily dose by 20% if patient at higher risk for Hypoglycemia
      5. (2024) Presc Lett 31(1): 4
  • Medications
  • U-300
  1. Insulin Glargine U-300 (Toujeo, Toujeo Max Solostar)
    1. Toujeo Solostar pen
      1. Toujeo contains 80 u/injection (450 u/pen)
      2. Toujeo Max contains 160 u/injection (900 u/pen)
      3. Both contain the same 3x Glargine Insulin concentration of Lantus)
    2. Released in 2015 (curiously as Lantus becomes generic)
      1. Promoted as a longer acting Lantus (closer to 24 hour duration)
      2. However, more expensive ($500/month if 60 u/day); contrast with NPH at 10% of cost
    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. (2018) Presc Lett 25(8)
      2. Riddle (2014) Diabetes Care 37(10):2755-62 +PMID:25078900 [PubMed]
  • Pharmacokinetics
  • Insulin Glargine (Lantus)
  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
  • Adverse effects
  1. Less nocturnal Hypoglycemia than other Insulins
  2. Lower post-prandial Glucose
  • Dosing
  • Insulin Glargine (Lantus)
  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 at bedtime
    2. Type II Diabetes: 10-14 Units at bedtime
  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. Typical adjustment is 1 to 2 units (or 5 to 10%) once to twice weekly
    2. 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
    3. 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
  • 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
  • References
  1. (2001) Med Lett Drugs Ther 43(1110):65-6 [PubMed]
  2. Riddle (2003) Diabetes Care 26:3080-6 [PubMed]