Concentrated Insulin Therapy in Advanced Type 2 Diabetes - Episode 7
Concentrated Insulin Options and Advantages
Dhiren Patel, PharmD; Jasmine D. Gonzalvo, PharmD; and Serge Jabbour, MD, provide an overview of the available concentrated insulin therapy options and their potential advantages for patients.
Dhiren Patel, PharmD: There has been a growth in the concentrated insulin market, and that’s primarily because of the increasing rates of obesity and the insulin resistance that we have here in the United States. Currently, when we look at concentrated insulins, we have formulations that are available as rapid-acting formulations, where we have U-200 insulin lispro.
We also have, on the other end of the continuum, basal insulin, such as Tresiba (insulin degludec) and Toujeo (insulin glargine). Toujeo is 300 units/ml, and so I try to avoid using “concentrated insulins” as a term. I like to call them “low-volume insulin,” because it helps in terms of understanding what that benefit is from the patient’s standpoint, as well as the pharmacist’s standpoint. They allow for one-third of the injection volume that they normally would be injecting, and the same holds true for the others.
For Tresiba, there’s a concentrated version of 200 units/ml and also 100 units/ml, which are both interchangeable when switching from one pen device to the other. And then, the last one is U-500 insulin, which was recently approved in a KwikPen to help with some of the conversions associated about concentrated insulins. Those are the 4 that currently exist on the market.
Jasmine D. Gonzalvo, PharmD: The benefits of concentrated insulin across the board tend to be that it’s just a smaller volume, a smaller amount. A lot of these concentrated insulins are a 1:1 conversion. It depends on which ones you’re talking about and patient individualization factors. But for the most part, we’re going to do a 1:1 conversion between U-100 insulin and the concentrated insulins. You’re getting a reduced volume. So, it’s a smaller amount for the patient to inject with the benefit of concentrated insulins.
But from there, you look at the specific concentrated insulins. For example, with U-200 degludec, you can actually inject a total of 160 units versus other insulins that would be comparable. Your maximum injection there would be about 80 units. So, for somebody on 100 or 120 units of a basal insulin, you could actually cut them down to 1 injection using the U-200 insulin degludec. That’s 1 example of a benefit of the concentrated insulins being able to decrease the number of injections that somebody would have to use.
Another one of the basal insulins is U-300 glargine, which actually has some evidence to show reduced nocturnal hypoglycemia. That’s a specific benefit of the basal insulin for that product, and it would be looked at as an advantage of one of the concentrated insulins. And then you have U-500, which is right now the most potent concentrated insulin. That insulin, the U-500, replaces all other insulins, and in most cases, it would result in a decreased number of injections. And so that is another benefit to a lot of patients. When I discuss being able to reduce the numbers of injections with my patients, that is usually a positive factor associated with switching to some of the concentrated insulin.
With concentrated insulin, I found that patients do tend to take the concentrated insulin just fine, and that really means as instructed. When we talk about adherence, I usually equate that with “as instructed.” When I tell my patients to take their concentrated insulins a certain way—a specific way—I’m finding that they are agreeable and do that pretty readily, the reasons being that they are potentially taking a reduced number of injections, which is a benefit, or perhaps that they find it more comfortable because they’re using a smaller amount. That oftentimes is a reflection of being more comfortable, as well. Those factors combined really contribute to a patient wanting to take the medications as written.
Serge Jabbour, MD: When we have patients on basal or mealtime insulin and they end up needing more and more insulin over time to get their sugars down to goal, sometimes patients end up on more than 200 units of insulin per day total. Based on the FDA label, in those patients, we can use insulin called R U-500. U-500 is indicted in those patients who have severe insulin resistance, and it’s given as 2 injections a day instead of at least 4 injections of the U-100 insulin. That can improve compliance, and based on studies where we switched patients from U-100 insulin to U-500, their A1C levels dropped by at least 1.2% over a 6-month period.
There’s 1 more insulin, which is called degludec. It comes in U-100 and also U-200. I’ll give you 1 quick example of how we can take advantage of the more concentrated insulin, degludec. When patients are injecting insulin, they might sometimes need higher and higher doses. With degludec, which is basal insulin, if you use the U-100 pen, you can dial up to 80 units at once with the insulin. If patients need more than 80 units, they have to inject it twice at the same time. That’s 1 more injection. But if they use the same insulin with U-200, they can inject up to 160 units in 1 single injection. So, that would improve compliance. That’s where we can think about these concentrated insulins, where compliance is so important.
What I’m most excited about with concentrated insulins being available for people with diabetes is that for the longest time, concentrated insulins haven’t been available. I’ve always wondered when they would become available, and here they are now. I think that we’re at an exciting time where more and more prescribers and providers are learning about how to effectively use the concentrated insulins. The more that becomes commonplace, the more options people with diabetes will have to help manage their diabetes effectively. So, it’s exciting to know that our patients with diabetes have more options to live healthier lives with improved blood sugars.