Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: PHARMACOLOGICAL THERAPIES | 6-72

Insulin detemir (Levemir ® ) Insulin detemir is made by the removal of the B30 amino acid and the addition of a 14-carbon fatty acid chain added; the addition of the fatty acid chain allows detemir to bind to albumin in blood (about 98% is albumin-bound) and results in a prolonged duration of action. Insulin detemir is approved for once and twice-daily insulin administration. Insulin detemir cannot be mixed with other insulins or solutions (168). There is no variability in absorption patterns based on injection site (170). Detemir achieves a steady state in two to three days. When switching insulins, dose adjustments with detemir are not necessary for individuals on a once-daily N/NPH regimen; however, it is recommended that the dose be decreased by 20% when transitioning from a twice-daily N/NPH regimen. The dose can be titrated by 10% (2 units) every two to four days until glycemic targets have been achieved (159). Glargine and detemir versus NPH Head-to-head clinical trials comparing the efficacy of glargine and detemir with once or twice- daily N/NPH in people with type 1 and type 2 diabetes have demonstrated treatment with glargine or detemir is associated with: • No statistically significant difference in A1C levels (171,172) but lower FBG levels (173). • Lower rates of hypoglycemia and nocturnal hypoglycemia (vs N/NPH). o Glargine is associated with an 11 to 21% reduction in the frequency of hypoglycemic events (p=0.0006), a 42% reduction in the rate of nocturnal hypoglycemia (p<0.001), a 59% reduction in the severe nocturnal hypoglycemia (p=0.0231) and a 46% reduction in severe hypoglycemia (p=0.0442) (167,172,174,175). • A Cochrane review of long-acting basal analogues compared to NPH showed: o Relative risk reduction in hypoglycemia of 16% for glargine (p=0.005) and 18% for detemir (p<0.001) o Relative risk reduction of 34% for nocturnal hypoglycemia for glargine (p<0.0001) and 37% for detemir (p<0.00001) (176). o Detemir is associated with an overall 47% reduction in the frequency of hypoglycemic events and a 55% reduction in the rate of nocturnal hypoglycemia (p=0.001) (176). o Glargine has weight gain similar to that of N/NPH; detemir has been shown to be weight-neutral or associated with weight loss (166).