Insulin detemir: a review

Patients with diabetes are at increased risk of mortality and morbidity from micro- and macrovascular complications. Landmark studies in type 1 and 2 diabetes have clearly shown that improved glycemic control leads to better outcomes. With the introduction of the General Medical Service contract, the England and Wales National Service Framework, and other schemes, there is a national drive to improve control in patients with diabetes. The treatment of diabetes was revolutionized shortly after the turn of the 20th century by the extraction and purification of insulin. Since methods to protract (i.e., prolong) the action of insulin were developed in the 1930s, little changed in this technology until the turn of this century. At this time there was renewed interest in the importance of basal insulin in controlling diabetes and thus preventing or delaying complications, and so technology advanced again. Two new basal insulin analogues have come to the market: insulin glargine, which has been widely used for some years now, and detemir. This review describes the novel method of protraction employed by insulin detemir, discusses the possible therapeutic benefits of this method of protraction, and describes the findings of studies comparing insulin detemir with other currently available basal insulin preparations. It is not the intention of this paper to be a review of all the currently available long-acting insulin analogues.

Insulin detemir: A review

Patients with diabetes are at increased risk of mortality and morbidity from micro- and macrovascular complications (1, 2). Landmark studies in type 1 and 2 diabetes have clearly shown that improved glycemic control leads to better outcomes (3-6). With the introduction of the General Medical Service contract, the England and Wales National Service Framework, and other schemes, there is a national drive to improve control in patients with diabetes. The treatment of diabetes was revolutionized shortly after the turn of the 20th century by the extraction and purification of insulin. Since methods to protract (i.e., prolong) the action of insulin were developed in the 1930s, little changed in this technology until the turn of this century. At this time there was renewed interest in the importance of basal insulin in controlling diabetes and thus preventing or delaying complications, and so technology advanced again. Two new basal insulin analogues have come to the market: insulin glargine, which has been widely used for some years now, and detemir. This review describes the novel method of protraction employed by insulin detemir, discusses the possible therapeutic benefits of this method of protraction, and describes the findings of studies comparing insulin detemir with other currently available basal insulin preparations. It is not the intention of this paper to be a review of all the currently available long-acting insulin analogues.

Insulin detemir, does a new century bring a better basal insulin?

The treatment of diabetes was revolutionised shortly after the turn of the twentieth century by the extraction and purification of insulin. Methods to protract (i.e. prolong) the action of insulin were developed in the 1930s; little changed in the technology of insulin protraction until the turn of this century when, with renewed interest in the importance of basal insulin in controlling diabetes and thus preventing or delaying complications, technology advanced again. Two new long-acting insulin analogues have come to the market; some may be familiar with insulin glargine, which has been widely used for some years now. This review attempts to describe the novel method of protraction that insulin detemir (launched last summer) employs by albumin binding, to discuss the possible therapeutic benefits of this method of protraction and to describe the findings of studies comparing insulin detemir with other currently available long-acting insulin preparations. The intention of this article is not to review all of the currently available long-acting insulin analogues.

Comparison of the effects on glucose and lipid metabolism of equipotent doses of insulin detemir and NPH insulin with a 16-h euglycaemic clamp

AIMS/HYPOTHESIS

The association of insulin detemir with non-esterified fatty acid binding sites on albumin may limit its transfer from the circulation into the extravascular extracellular space in adipose tissue and muscle, due to the capillary endothelial cell barrier. In the liver, the open sinusoids may expose hepatocytes to insulin detemir, enabling it to have a greater effect in the liver than in peripheral tissues.

METHODS

We investigated the effects of equipotent doses of insulin detemir and NPH insulin on hepatic glucose rate of appearance (Ra), peripheral glucose rate of disposal (Rd) and glycerol Ra (a measure of lipolysis) using stable isotope techniques. We also investigated the effects of these insulins on NEFA concentrations in seven healthy volunteers during a 16-h euglycaemic clamp. A higher dose of insulin detemir was also studied.

RESULTS

There was no difference in the glucose infusion profile between insulin detemir and NPH. Insulin detemir had a greater effect on mean suppression of glucose Ra (mean difference 0.24 mg kg(-1) min(-1); CI 0.09-0.39; p<0.01), and minimum glucose Ra, with minimum low dose detemir -0.10+/-0.15 mg.kg(-1).min(-1) and minimum NPH 0.17+/-0.10 mg.kg(-1).min(-1) (p<0.02). However, it had a lesser effect on mean suppression of NEFA concentrations (mean difference -0.10 mmol/l; CI -0.03 to -0.17; ANOVA, p<0.02) than NPH. The effect of insulin detemir on glucose Rd and glycerol Ra was not different from NPH. Following high-dose detemir, total glucose infused and maximum glucose Rd were higher (p<0.02, p<0.03) and plasma NEFA concentrations lower (p<0.01) than with low-dose determir.

CONCLUSIONS/INTERPRETATION

This study suggests that insulin detemir, when compared to NPH insulin, has a greater effect on the liver than on peripheral tissues and thus has the potential to restore the physiological insulin gradient.