Better vs Best Choices in Basal Insulin Therapy: Improving Injection Comfort with Concentrated Basal Insulin Analogues
One of the great strengths of insulin therapy is that the doses are individualized. Patients with T2DM who are treated with basal insulin can require widely varying total daily doses to reach their glycemic goals. For example, in the large-scale ORIGIN trial, insulin glargine was titrated to achieve a fasting plasma glucose goal of less than 95 mg/dL, and, after 1 year, the median dose was 0.31 U/kg, with an interquartile range of 0.19 to 0.46 U/kg (approximately 16-38 U/d, based on a mean weight of 83 kg).10 Patients who are insulin resistant may require very large doses of insulin to maintain glycemic control.74 Among patients with T2DM, some of the more common etiologies of insulin resistance include obesity and nonalcoholic fatty liver disease.75 Concomitant medications for comorbid diseases can also increase insulin resistance.76 Corticosteroids—used to manage inflammatory conditions including asthma, rheumatoid arthritis, and inflammatory bowel disease—are commonly recognized as agents that increase insulin resistance and raise blood glucose levels.76
Large insulin doses required by some patients with T2DM may exceed the amount of insulin that can be delivered in a single injection using a pen injector device. U-100 insulin pens contain 3 mL of insulin, or 300 U/pen, but the devices can administer only 60 to 80 U in a single injection.15 Patients who require larger doses of basal insulin face the inconvenience of splitting the dose between 2 (or more) injections. However, another option is to use a concentrated basal insulin (Table 1). An important advantage of concentrated insulins is that they permit the dose of insulin to be ad-ministered with a smaller volume of injectate than the same dose of a U-100 basal insulin. This is especially advantageous for patients who require large doses of insulin, as large injectate volumes may be uncomfortable to inject.77 For many years, the only concentrated insulin available in the United States was U-500 regular human insulin.15 This highly concentrated insulin is recommended for patients who need greater than 200 U/d.15,74 U-500 regular human insulin has both prandial and basal characteristics: it has the rapid onset time of short-acting regular human insulin (<15 min) but a much longer duration of action (13-24 hours) than short-acting regular human insulin (Table 1).15The total daily dose of U-500 regular human insulin is split between 2 or 3 daily injections and administered at intervals throughout the day.15 New additions to the concentrated insulin armamentarium are the basal insulin analogues U-200 degludec and U-300 glargine, which are administered only once-daily.15 The duration of action of each of these insulins is longer than for U-500 regular human insulin (Table 1).15
All concentrated insulins sold in the United States are available in pens.15 With pens, the dose (in units) is simply dialed up regardless of the concentration of the insulin inside.
Going Flat Out for Glycemic Control: The Role of New Basal Insulins in Patient-Centered T2DM Management
This activity is intended for NPs, PAs, and other health care professionals (HCPs) with a particular interest in the clinical diagnosis and treatment of common metabolic and endocrine diseases, especially those who provide care for or manage adult patients with T2DM.
Supported by an educational grant from:
Sanofi US
Activity Information
Expired
Activity Release Date: December 1, 2018
Expiration Date: November 30, 2019
Expired
PLEASE NOTE:
There are pre-assessment questions associated with the content of this program that should be accessed at www.caringfordiabetes.com/CRinsulin prior to participating in this activity.
This activity is provided by the Institute for Medical and Nursing Education, Inc.
ACTIVITY OVERVIEW
Current type 2 diabetes mellitus (T2DM) guidelines emphasize individualizing care and prioritizing treatment regimens that minimize hypoglycemia and weight gain. Several new insulins have recently been approved, some of which are available in concentrations not previously available in the United States. Among these are next generation longer-acting (ultralong-acting) basal insulin analogues, which are associated with a lower risk of hypoglycemia than previous long- acting basal insulin analogues. With the availability of new basal insulins, there is a need to educate nurse practitioners (NPs) and physician assistants (PAs) about initiating, titrating, and individualizing insulin therapy.
This activity will review current evidence and best practices for individualizing and intensifying antihyperglycemic therapy using current basal insulin options to achieve patient-centered goals in individuals with T2DM. Additionally, participants in this activity will learn about the rationale for and role of different basal insulins for the treatment of patients with T2DM. To enhance the written information, embedded QR codes will feature video clips of patient cases and audio clips of faculty discussion, offering realistic insight regarding the personal and professional experiences of participants and expert opinions of program faculty in providing optimal diabetes care in patients with T2DM.
LEARNING OBJECTIVES
- Explain the role and appropriate use of next-generation longer-acting (ultralong-acting) basal insulins for addressing the underlying pathophysiology of T2DM
- Compare next-generation longer-acting (ultralong-acting) and other basal insulins regarding therapeutic characteristics, including pharmacokinetic/pharmacodynamic profiles, efficacy, safety, and dosing
- Develop patient-centered treatment regimens that include next-generation longer-acting (ultralong-acting) insulins to minimize barriers to successful use of basal insulin therapy
CME AND CE ACCREDITATION AND CREDIT DESIGNATION STATEMENTS
For Physicians
The Institute for Medical and Nursing Education, Inc. (IMNE), is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
IMNE designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits™.
Physicians should claim only the credit commensurate with the extent of their participation in the activity.
For Physician AssistantsThe American Academy of Physician Assistants (AAPA) has determined that AMA PRA Category 1 Credit(s)™ is acceptable to meet AAPA CME requirements for PAs.
For Nurse Practitioners and Nurses
IMNE is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s (ANCC’s) Commission on Accreditation.
This educational program provides 1.5 contact hours of continuing education credit.
IMNE has determined the 1.25 hours of this program will satisfy ANCC’s pharmacotherapeutics contact hour requirement for ANCC certified Clinical Nurse Specialists and Nurse Practitioners. The CEU certificate will reflect this credit.
For Certified Diabetes Educators
ANCC-accredited providers have been approved by the National Certification Board for Diabetes Educators (NCBDE) as providers of continuing education (CE). Individuals seek-ing recertification from the NCBDE can use the CE contact hours received through their participation in this activity.
METHOD OF PARTICIPATION
To receive a maximum of 1.5 AMA PRA Category 1 Credits™ or ANCC continuing nursing education credit, participants should:
- Complete the preassessment questions at www.caringfordiabetes.com/CRinsulin
- Read the entire activity
- Complete the activity posttest and evaluation at http://www.cvent.com/d/pbqrw7/7E
- A CME/CE certificate will be emailed or mailed to you upon achieving a score of 80%.
CME/CE CREDIT QUESTIONS
For questions about the content or obtaining CME/CE credit, please contact IMNE:
Steve Weinman RN, CHCP
Email: [email protected]
Phone: 1-609-936-7015
Activity Release Date: December 1, 2018
Expiration Date: November 30, 2019
DISCLOSURES
It is the policy of IMNE to ensure fair balance, independence, objectivity, and scientific rigor in all programming. All individuals involved in planning (eg, faculty, CME/CE provider staff, and educational partner staff) are expected to disclose any significant financial relationships with commercial interests over the past 12 months. It is also required that faculty identify and reference off-label product or investigational uses of pharmaceutical agents and medical devices.
Resolutions of conflict of interest have been made in the form of external peer review.
The following disclosures have been made:
Faculty
Vanita Aroda, MD
Consultant: Novo Nordisk; Sanofi
Research Grants: AstraZeneca/Bristol-Myers Squibb; Calibra; Eisai; Janssen; Novo Nordisk; Sanofi; Theracos
Davida Kruger, MSN, APN-BC, BC-ADM
Advisory Board: Abbott; Dexcom; Eli Lilly; Intarcia; Janssen; Novo Nordisk; Sanofi
Speakers’ Bureau: Abbott; AstraZeneca; Boehringer Ingelheim; Dexcom; Eli Lilly; Insulet; Janssen; Novo Nordisk; Valeritas
Research Grants: AstraZeneca; Dexcom; Eli Lilly; The Leona M. and Harry B. Helmsley Charitable Trust; Lexicon; Novo Nordisk
Stock: Dexcom
IMNE Staff
All staff of IMNE in a position to influence content have filed statements of disclosure with the continuing education provider. Any conflicts of interest were identified and resolved prior to their involvement in planning this activity. These disclosures are available for review by contacting Steve Weinman at 1-609-936-7015 or [email protected].
Amy Carbonara
Vice President
Ms. Carbonara has nothing to disclose.
Margery Tamas, HBSE, MPH
Editorial Manager
Ms. Tamas has nothing to disclose.
Steve Weinman, RN, CHCP
Director of Accreditation
Mr. Weinman has nothing to disclose.
External CME/CE Reviewers
Martin Quan, MD
Dr. Quan has nothing to disclose.
Darilyn Paul, APRN
Ms. Paul has nothing to disclose.
DISCLAIMER
This activity is designed for HCPs for educational purposes. Information and opinions offered by the faculty/presenters represent their own viewpoints. Conclusions drawn by the participants should be derived from careful consideration of all available scientific information. While IMNE makes every effort to have accurate information presented, no warranty, expressed or implied, is offered. The participant should use his/her clinical judgment, knowledge, experience, and diagnostic decision-making before applying any information, whether provided here or by others, for any professional use.
COMMERCIAL SUPPORT ACKNOWLEDGMENT
This activity is supported by an educational grant from Sanofi US.