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Topic Title: “ADAPT: Once-daily detemir was noninferior to twice-daily dosing in basal-bolus therapy”
Created On: 01/23/2009 03:42 PM
 01/27/2009 09:30 PM

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"but I know that both insulins do pretty well the same thing" - Levemir and Lantus do not do the same thing I'm afraid. I've used both extensively. Levemir is a much shorter acting product. It is the equivalent of Lente. Lantus is longer acting but at lower doses is no better than UltraLente.

Weight gain is primarily because people take so much insulin to extend the duration (to meet the marketing claims) and to cover for late digestion food that they wind up "eating to the insulin" and they have lows when they don't (eat enough to the quantity of insulin). They just don't need that many calories especially in the middle of the night. Honestly, at that point, they may as well take NPH at $20-30 a bottle instead of $85 - 130 for Lantus and Levemir.

There are a few articles on the Diabetes Health website I normally reference with regard to the fact that "there is no 24 hour insulin." But they try ... double those doses, it'll go longer!

I learned years ago, I don't attempt to satisfy my medical team. This is a disease of self- management. I'm a project manager by nature so I set goals, create a plan, analyze, assess and adjust. If I abided by a physician ... I'd be fat, have high A1Cs and a pile of complications from here to you in Montreal. Instead, I'm thin, have an A1C of 5.1 and my complications are all joint related - from years of not knowing what a normal blood sugar really is. That is my long term goal by the way, joint restoration. Short-term ... are based on small "micro" goals which are adjusted based on numbers and how I feel. Good thing I like project management!

 01/25/2009 08:47 PM

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I can't be as medically technical as you are on the subject of Lantus / Levimir (some of what you write is way beyond my comrehension - obviously my high school diploma education needs some dusting off or ??? <lol>) - but I know that both insulins do pretty well the same thing. I know the big plug for Levimir is that you do not gain weight with it - compared to say NPH. I am not sure if Lantus has the same claim - correct us here if you can. From discussions with other diabetics who MDI - and have switched from Levimir then to Lantus - they have varying reports of weight gain / loss with Lantus. Everyone is different. In the report you write about - I'm like you - think it's a plug for the product - sad to say. For those people who don't investigate further before using a product they've been prescribed - they may or may not know the difference - or really care - sad to say. Also, I found with Lantus - taking 2 shots a day worked better for me - then just one - as others have discovered with Levimir. Again, we're all different with the way we manage our diabetes - to satisfy both ourselves and our team that takes care of us.

BTW, wish I weighed what you do - but haven't been that since I think the age of ... having to think hard here - 13 or 14. I'm 5'4" and weigh in at around 160 lbs - but I blame it on my big watermelon head and bone structure!!!
 01/23/2009 03:42 PM

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“ADAPT: Once-daily detemir was noninferior to twice-daily dosing in basal-bolus therapy”

According to the this article in Endocrinetoday, researchers recently performed a study attempting to determine if once daily detemir (aka Levemir) is sufficient in patients upon initial diagnosis of type 1 diabetes (versus twice daily). Information was limited without purchasing a complete copy of the study.

The limited study details in the article:

• 512 participants randomly assigned to once or twice per day Levemir injection groups.
• Once daily injections were taken at bedtime. Twice daily injections were taken at bedtime and breakfast.
• Participants did not begin injections of rapid acting insulin until one-month post diagnosis.
• The rapid acting insulin used was “insulin apart” (aka Novolog).
• Injections of rapid acting insulin were limited to three times daily (assumption with meals). There was no mention of correction doses or snack dosing.
• Patients were followed for just three months before being given the option to switch regimens. Those who continued with the initial regimen were followed for an additional three months.

The variables missing from the study details are:

• Any mention of target blood sugar levels
• Any mention of glucose testing frequency
• Any mention of meal plans
• Any mention of training
• Any mention of residual insulin production
• Any mention of ongoing adjustments in basal or bolus calculations which traditionally occur
• Any mention of how a patient is to handle high blood sugar
• Any mention of exercise
• Any mention of insulin sensitivity
• Any mention of average weight
• Any mention of high basal insulin volume in order to extend the duration of the Levemir
• Any mention of low blood sugar incidences from increased insulin volume to extend duration of the Levemir
• Any mention of age of population. Were they all adult patients who likely still have residual insulin production or <18 (juvenile onset) who traditionally lose all insulin production much more rapidly.
• No consideration to the fact that Novolog may or may not be the best rapid acting product for the patient based on digestion speed, food plans and exercise habits. The wrong rapid acting for the job greatly affects blood sugar levels.

According to the results, at four months, the mean A1C levels for once-daily injections were 8.1% and 8.0% for twice-daily injections.

The articles states: “At month seven, patients originally assigned to once-daily detemir who switched to twice-daily administration experienced a decrease in HbA1c from 8.2% at four months to 8% at seven months in association with increased total insulin doses. However, HbA1c increased among patients who switched from twice-daily to once-daily detemir from 7.2% to 7.6% in association with decreased doses.”

That conclusion confuses me considering the stated A1C levels at four months in the previous paragraph. It did not mention 8.2% or 7.2%.

The article notes insulin volume averages as:

Once Daily Levemir Twice Daily Levemir
Levemir 29 TDD 39 TDD
Novolog 34 TDD 26 TDD

From personal experience, as an entirely insulin dependent diabetic (these are newly diagnosed and may easily have residual phase 2 insulin production) I take very small doses of Levemir 3 times per day (3, 2 ½ and 2 1/2 ) units. Therefore, I take 8 total units of Levemir without gaps and without peaks that require snacks.

I use a combination of rapid acting products but my total combination daily dosages are significantly lower than these studies. My total daily combined dosage varies from 19-25 units per day. I am 5’4” and 123 pounds. My carb to insulin ratio is 1:15 with a correction dose of 1:70/75 not inclusive of dawn phenomenon, adrenalin bursts, hormones …). My A1C is consistently 5.1.

The conclusion from the analysts is that once dose of Levemir, upon initial diagnosis, is sufficient. They also concluded that after some period of time, when the residual insulin production ceases, there is an improvement in A1C when increasing to two injections of Levemir per day.

I use this product. I like this product. I use it exactly the way I used the now obsolete Lente with exactly the same blood sugar results but at four times the cost.

My conclusion is that the study was geared towards a specific target. Perhaps, this target was driven by the pharmaceutical company’s continued attempts to market their product (a once-daily product to compete with Lantus). In addition, as I listed previously, many other variables can easily skew the results of the study that do not seem to have been considered. I ask that there be a more complete, less biased, less profit driven study to answer the same question so patients can make better informed, more accurate treatment decisions.

Doris J. Dickson

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