Application of Premixed Insulin NovoMix®30 and NovoRapid® as Multiple Daily Injections

Managing type-1 or type-2 diabetes

Managing type-1 or type-2 diabetes by insulin is one of the best techniques, especially for type-2 diabetics after oral hypoglycemic agents (OHAs) failure. Multiple daily injections (MDI) or basal bolus methodology is an ideal regimen for type-1 diabetics. However, it is a difficult option for type-2 diabetic patients, especially older age groups. Most of the type 2 diabetics usually prefer two injections per day, in the morning and evening. Analog premixed biphasic insulins include NovoMix® 30, Humalog Mix® 25 and Humalog Mix® 50. These insulin analogs are also recommended because of their safety and efficacy as compared to older or traditional insulins (Human Regular Insulin such as Humulin® R and Actrapid®, neutral protamine Hagedorn or NPH and their mixtures of premixed human insulin 30/70), which are associated with more frequent hypoglycemia. Safety and efficacy of insulin analogs have also been demonstrated during Ramadan fasting. Basal insulin analogs include glargine (Lantus®), detemir (Levemir®) and degludec (Tresiba®); bolus or mealtime insulins analogs, also called rapid-acting insulin analogs (RAIs), are Aspart (NovoRapid®), Lispro (Humalog®) and glulisine (Apidra®). Furthermore, basal-bolus insulin regimen is ideal and best fits for type-1 diabetics and should be prescribed to them.

Premixed insulin

In the last decades, there has been increasing preference for Premixed Biphasic Insulin Analogs. However, also it has been observed that physicians are now prescribing premixed insulin three times a day (after failure to achieve glycemic targets twice daily injections). Some of the limited trials were also conducted to demonstrate that premixed biphasic insulin analogs and NovoMix® 30 three times as day achieved a good glycemic control. It should be mentioned here that such technique is not a standard one, however. This technique will be applicable to the limited number of patients. Patients with advanced age, erratic meal pattern, compromised renal failure, chronic renal disease (CRD) or advanced renal disease/end stage renal disease (ESRD) will not benefit from such insulin regimen and can experience severe hypoglycemia. According to our last ten years of clinical practice, 30-40% of such patients usually experience hypoglycemia, especially in the evening or late night. We have also recently published such cases, where three injections of premixed insulin analogs (Humalog® Mix 25 and Humalog® Mix 50) were associated with evening or late night hypoglycemia and described a new method of prescribing premixed insulin analogs in the morning and evening (before the breakfast and dinner) and giving a third injection of RAIs at lunch, instead of prescribing premixed insulin three times a day. Hence, in this way, Premixed or biphasic insulin analogs can be used in basal-bolus format, when basal-bolus insulin regimen itself becomes difficult (4-5 injections per day) for type-2 diabetic patients, especially elderly subjects.

Premixed Insulin
Insulin for all

Managing diabetes by insulin injections

In this paper, we are also presenting a new regimen of managing diabetes by insulin injections, and case series, where premixed biphasic insulin analogs with one injection of RAIs at lunch can manage uncontrolled diabetes successfully. We selected 35 patients who were difficult to control, with High HbA1c, demonstrating frequent hypoglycemia and fasting hyperglycemia. This was approved by the research committee of Aseer Diabetes Center and the study protocols were according to Declaration of Helsinki (DoH). Table-1 shows characteristics of 35 patients which were uncontrolled on three injections of NovoMix® 30, and these patients were experiencing hypoglycemia, especially evening time, after dinner or late night. Self-monitoring of blood glucose was given to such patients to detect hypoglycemia severity and it’s timings. In spite of hypoglycemia, their HbA1c was high (because of hypoglycemia and overeating). Increase weight was an additional finding. Additionally, all of these patients presented with fasting hyperglycemia, an observation explained by Somogyi effect/phenomenon.

To read full article visit  International Journal of Diabetology & Vascular Disease Research.  published by SciDocPublishers

 

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