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Reading a couple of topics on here recently, I thought I'd try and shed some light on why Detemir (Levemir) is recommended as a twice daily injection model when using MDI in the NICE guidelines due to cost and one of the guy indicators is a reduction in nocturnal hypoglycaemic events. Firstly, the chart below is very useful in understanding this, and secondly, the trial data that NICE uses reflects the chart below.
But what am I talking about?
The key is to look at the peaks in the chart, the effects on the body and then the costs. Of the "Modern", non-NPH insulins, Insulin Detemir is one of the cheapest, (as the NICE guidelines 2015 were written before the availability of the new Biosimilar glargines), and that plays an important part in the evaluation.
The next point is to look at this chart and the shape of the curve. The dose units are important. For a 90kg person, 0.2u/KG works out at a dose of 18units. For a 70kg person, it's 14u (predictably!).
At these low doses, the action of the insulin is quite benign. It takes about an hour to kick in, has a low peak and is mostly having little to no effect after 8-12 hours.
If you take it once per day, you need 0.5u/kg or more to effectively get coverage for that period of time (45u for that 90kg person) and even then, the last few hours have very little active insulin in the body. Once you get to this level, you see a much more pronounced peak at around 8-12 hours. If this insulin is taken in the evening, this would occur during the night and could induce a night-time hypo. If taken in the morning, the insulin may be running out by the end of the night, and could cause blood glucose levels to rise, especially in tandem with the dawn phenomenon, which is not what is really wanted.
By splitting the dose into two shots (not necessarily taken exactly 12 hours apart) it is possible to generate a much less peaky basal insulin profile, reducing the risk of nocturnal hypo events (as evidenced in the NICE guidelines) that has a full 24 hour duration.
Further, when the dose is split, to me it makes sense to take a larger dose in the morning, so that any effects of larger peaks occur when you are conscious, with a smaller dose overnight to reduce the size of any peak insulin action that may occur and reduce the risk of nocturnal hypos.
I hope that this helps people understand why there is often advocacy on the forum regarding splitting Levemir into two doses.
But what am I talking about?
The key is to look at the peaks in the chart, the effects on the body and then the costs. Of the "Modern", non-NPH insulins, Insulin Detemir is one of the cheapest, (as the NICE guidelines 2015 were written before the availability of the new Biosimilar glargines), and that plays an important part in the evaluation.
The next point is to look at this chart and the shape of the curve. The dose units are important. For a 90kg person, 0.2u/KG works out at a dose of 18units. For a 70kg person, it's 14u (predictably!).
At these low doses, the action of the insulin is quite benign. It takes about an hour to kick in, has a low peak and is mostly having little to no effect after 8-12 hours.
If you take it once per day, you need 0.5u/kg or more to effectively get coverage for that period of time (45u for that 90kg person) and even then, the last few hours have very little active insulin in the body. Once you get to this level, you see a much more pronounced peak at around 8-12 hours. If this insulin is taken in the evening, this would occur during the night and could induce a night-time hypo. If taken in the morning, the insulin may be running out by the end of the night, and could cause blood glucose levels to rise, especially in tandem with the dawn phenomenon, which is not what is really wanted.
By splitting the dose into two shots (not necessarily taken exactly 12 hours apart) it is possible to generate a much less peaky basal insulin profile, reducing the risk of nocturnal hypo events (as evidenced in the NICE guidelines) that has a full 24 hour duration.
Further, when the dose is split, to me it makes sense to take a larger dose in the morning, so that any effects of larger peaks occur when you are conscious, with a smaller dose overnight to reduce the size of any peak insulin action that may occur and reduce the risk of nocturnal hypos.
I hope that this helps people understand why there is often advocacy on the forum regarding splitting Levemir into two doses.
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