Practical Guidance on the Use of Premix Insulin Analogs in Initiating, Intensifying, or Switching Insulin Regimens in Type 2 Diabetes

Abstract

IntroductionPremix insulin analogs are a well-established treatment for type 2 diabetes (T2D). However, there is a lack of simple, clear guidance on some aspects of their use. These include choosing a regimen for insulin initiation, recognizing when patients need intensification of therapy, and switching from basal–bolus to a premix insulin analog when appropriate.MethodsAn independent expert panel formulated recommendations on the use in T2D of the premix insulin analog formulations widely available in Australasia, based on the available evidence and their own experience.ResultsResults from trials in both initiation and intensification of insulin show that no single insulin or regimen is best on all endpoints, and that improved glycemic control can be expected regardless of which regimen is used. Thus, individual patient factors and preferences become more important. Guidance is presented to help the clinician choose between a premix insulin analog or basal analog for insulin initiation, and to intensify insulin therapy using premix insulin analogs. Recommendations are made on dosing, titration, the concomitant use of non-insulin glucose-lowering drugs, and other practical issues, and on the special case of switching from basal–bolus to premix insulin analog therapy.ConclusionThis guidance is intended to help both general and specialist practitioners make informed choices and provide optimal care for patients with T2D. It emphasizes the importance of taking into account individual patient factors and preferences so that the choice of insulin regimen is individualized to the patient in the same way that glycemic targets are now individualized.FundingNovo Nordisk Region IO A/S.Electronic supplementary materialThe online version of this article (doi:10.1007/s13300-015-0116-0) contains supplementary material, which is available to authorized users.

Initiation and Intensification Strategies in Type 2 Diabetes Management: A Comparison of Basal Plus and Premix Regimens

“…Newer premix analogs such as insulin degludec/insulin aspart (Ryzodeg ® ; Novo Nordisk A/S, Bagsvaerd, Denmark) are also gaining popularity in clinical practice. It is thought that up to 40% of patients with T2D currently use premix insulin as part of their treatment, and a number of guidelines are now published for the use of premix insulin when initiating, intensifying, or switching insulin regimens [2, 9, 10]. …”

“…Broad advantages of premix insulin for patients diagnosed with T2D include convenience, improved PPG control compared with basal insulin alone, a single delivery device, and the ability to intensify treatment up to TID if needed [19]. One current practical guidance suggests that premix should be considered for, among other factors, initiation in patients who have a PPG increment of >3 mmol/L and predictable lifestyle and meal patterns [10]. For intensification, it is recommended that premix regimens should be considered in patients who prefer fewer injections, less frequent self-monitoring of blood glucose, and who may have a diminished ability to inject (e.g., poor manual dexterity) [10].…”

“…One current practical guidance suggests that premix should be considered for, among other factors, initiation in patients who have a PPG increment of >3 mmol/L and predictable lifestyle and meal patterns [10]. For intensification, it is recommended that premix regimens should be considered in patients who prefer fewer injections, less frequent self-monitoring of blood glucose, and who may have a diminished ability to inject (e.g., poor manual dexterity) [10]. …”

“…For example, it requires the patient to manage two different insulins and injecting devices, and the demands of variable dosing of the short-acting ‘plus’ component according to the carbohydrate content of meals. Nevertheless, the basal plus approach is now being used as a therapeutic alternative to premix BID regimens and is useful to prepare the patient for a full basal–bolus regimen, in those who are comfortable with more frequent injections and the need for increased self-monitoring [10, 11]. The next intensification step after basal failure (stepwise addition of prandial insulin from basal plus to TID), has shown non-inferiority to a full basal–bolus regimen for reducing HbA1c with similar, or lower, rates of hypoglycemia, and similar weight gain [21, 22].…”

Insulin lispro 25/75 and insulin lispro 50/50 as starter insulin in Japanese patients with type 2 diabetes: subanalysis of the CLASSIFY randomized trial

“…However, premixed insulins are more commonly used in Japan as starter insulin than in Western countries [6]. This is most likely related to benefits of premixed insulin compared with basal insulin, including improved overall and postprandial glycemic control [7][8][9], as well as greater ease of therapy associated with reduced regimen complexity and injection frequency [10,11]. The underlying need to take advantage of these benefits of premixed insulin in Japanese patients may relate to early deterioration of β-cell function leading to reduced insulin secretion [12,13].…”