Insulin degludec

Insulin degludec (INN/USAN) is an ultralong-acting basal insulin analogue that was developed by Novo Nordisk under the brand name Tresiba.[1] It is administered via subcutaneous injection once daily to help control the blood sugar level of those with diabetes. It has a duration of action that lasts up to 42 hours (compared to 18 to 26 hours provided by other marketed long-acting insulins such as insulin glargine and insulin detemir), making it a once-daily basal insulin,[2][3][4] that is one that provides a base insulin level, as opposed to the fast- and short-acting bolus insulins.

Insulin degludec
Clinical data
Trade namesTresiba
AHFS/Drugs.comUK Drug Information
License data
Routes of
administration		Subcutaneous
ATC code
Legal status
Legal status
  • In general: ℞ (Prescription only)
Identifiers
CAS Number
PubChem SID
ChemSpider
  • none
UNII
KEGG
Chemical and physical data
FormulaC274H411N65O81S6
Molar mass6104.04 g·mol−1
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Insulin degludec is a modified insulin that has one single amino acid deleted in comparison to human insulin, and is conjugated to hexadecanedioic acid via gamma-L-glutamyl spacer at the amino acid lysine at position B29.

In 2017, it was the 265th most commonly prescribed medication in the United States, with more than one million prescriptions.[5][6]

Side effects

A significant side effect of insulin therapy is hypoglycemia. A meta-analysis of clinical trials published in July 2012 found 39 to 47.9 events of hypoglycemia (defined as blood glucose <56 mg/dL) per patient year, with higher rates in the more concentrated degludec formulation. Rates of nocturnal hypoglycemia ranged from 3.7 to 5.1 events per patient year.[7]

Pharmacology

Mechanism of action

Insulin degludec is an ultra-long acting insulin that, unlike insulin glargine, is active at a physiologic pH. The addition of hexadecanedioic acid to lysine at the B29 position allows for the formation of multi-hexamers in subcutaneous tissues.[8] This allows for the formation of a subcutaneous depot that results in slow insulin release into the systemic circulation.[9]

Pharmacokinetics

Insulin degludec has an onset of action of 30–90 minutes (similar to insulin glargine and insulin detemir). There is no peak in activity, due to the slow release into systemic circulation. The duration of action of insulin degludec is reported as being longer than 24 hours.[8][7]

When taken at the same time of day, this long (but under 48 hour) duration can result in an overlap from one dose to the next, resulting in greater insulin action then. if the overlap should be during sleep, there is a risk of lower blood sugar, so it is important to dose in the morning so that the overlap will be when users are eating and otherwise checking their blood sugar. The dose should be titrated during this overlap period as well.

Effectiveness profile

Studies have shown that patients taking insulin degludec needed to take significantly smaller doses of basal insulin than those taking insulin glargine U100, while achieving similar blood glucose levels. Insulin degludec also has the ability to be mixed with other insulins, thereby improving glycemic control. This cannot be done using current long-acting insulins.[10][11] A physician involved in the trials was quoted as saying,

This allows the creation of a novel formulation that retains the smooth control of a long-acting basal with rapid-acting mealtime control from insulin aspart. This 2-component insulin retains the ultralow risk characteristics of degludec with simultaneous mealtime coverage.[12]

History

Insulin degludec has been filed for registration in the United States.[13] Novo Nordisk hopes to begin marketing the insulin analog in 2015 or 2016 after the completion of additional cardiac safety studies requested by the U.S. Food and Drug Administration (FDA) in February 2013.[14] Insulin degludec received FDA approval 25 September 2015[15] and marketing began on 26 January 2016.[16]

Clinical trial data

Type 1 diabetes mellitus

Insulin degludec was studied as an alternative to insulin glargine as part of a basal-bolus regimen in the BEGIN Basal-Bolus Type 1 trial. 629 patients with type 1 diabetes were randomized in a 3:1 ratio to either insulin degludec (n=472) or insulin glargine (n=157) in addition to mealtime insulin aspart. Patients in the degludec treatment arm were switched from their basal insulin to insulin degludec in a 1:1 ratio, with a 20-30% dose reduction in patients receiving multiple basal doses per day. After 52 weeks, patients treated with insulin degludec produced a similar reduction in HbA1c (0.40% vs. 0.39%) meeting the criteria for noninferiority. Adverse events were similar in the two treatment arms; however, rates of nocturnal hypoglycemia (between midnight and 6am) were 27% lower in patients treated with insulin degludec (3.91 vs. 5.22%,p=0.024). The reduction in the incidence of hypoglycemia was seen as a therapeutic benefit, as hypoglycemia is often a dose limiting toxicity in insulin therapy.[17]

Type 2 diabetes mellitus

In the BEGIN Basal-Bolus Type 2 trial, insulin degludec was studied as an alternative to insulin glargine in patients with type 2 diabetes mellitus. 995 patients were randomized to receive either insulin degludec (n=755) or insulin glargine (n=251), in addition to either mealtime insulin aspart, metformin, and/or pioglitazone. Patients in this trial had an average HbA1c of 8.3–8.4%, and 49–50% were on a regimen consisting of basal-bolus insulin plus oral antidiabetic medications. After 52 weeks, insulin degludec was found to be noninferior to insulin glargine, providing a similar HbA1c lowering effect (−1.10 vs. −1.18%). Overall rates of hypoglycemia were significantly lower with insulin degludec (11.09 vs. 13.63%/yr, p=0.0359), including cases of nocturnal hypoglycemia (1.39 vs. 1.84%/yr, p=0.0399).[18]

Pharmacoeconomics

Given the treat-to-target nature of the BEGIN trial program, much of the health economic analysis of insulin degludec has focussed on short-term cost-effectiveness based on differences in insulin dosing and hypoglycemic event incidence rather than differences in glycemic control.[19] The first cost-effectiveness analysis of this nature was conducted from a societal perspective in the Swedish setting in 2013, finding that insulin degludec would be cost-effective relative to insulin glargine in the treatment of type 1 diabetes, and type 2 diabetes as part of either a basal or basal-insulin regimen.[19]

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References
  1. CHMP (October 18, 2012), "Summary of opinion 1 (initial authorisation): Tresiba" (PDF), Pending EC decisions (PDF), EMA, retrieved November 6, 2012
  2. Klein O, Lynge J, Endahl L, Damholt B, Nosek L, Heise T (May 2007). "Albumin-bound basal insulin analogues (insulin detemir and NN344): comparable time-action profiles but less variability than insulin glargine in type 2 diabetes". Diabetes, Obesity & Metabolism. 9 (3): 290–9. doi:10.1111/j.1463-1326.2006.00685.x. PMID 17391154.
  3. Haahr H, Heise T (September 2014). "A review of the pharmacological properties of insulin degludec and their clinical relevance". Clinical Pharmacokinetics. 53 (9): 787–800. doi:10.1007/s40262-014-0165-y. PMC 4156782. PMID 25179915.
  4. "Tresiba Summary of product characteristics" (PDF). European Medicines Agency.
  5. "The Top 300 of 2020". ClinCalc. Retrieved 11 April 2020.
  6. "Insulin Degludec - Drug Usage Statistics". ClinCalc. Retrieved 11 April 2020.
  7. Wang F, Surh J, Kaur M (2012). "Insulin degludec as an ultralong-acting basal insulin once a day: a systematic review". Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 5: 191–204. doi:10.2147/DMSO.S21979. PMC 3402007. PMID 22826637.
  8. Nasrallah SN, Reynolds LR (2012). "Insulin Degludec, The New Generation Basal Insulin or Just another Basal Insulin?". Clinical Medicine Insights. Endocrinology and Diabetes. 5: 31–7. doi:10.4137/CMED.S9494. PMC 3411522. PMID 22879797.
  9. Robinson JD, Neumiller JJ, Campbell RK (December 2012). "Can a new ultra-long-acting insulin analogue improve patient care? Investigating the potential role of insulin degludec". Drugs. 72 (18): 2319–25. doi:10.2165/11642240-000000000-00000. PMID 23145524.
  10. "Monograph - Insulin Glargine: Dosage & Administration". American Society of Health-System Pharmacists, Inc. Retrieved 2010-11-07.
  11. Ringstrom A (2010-06-26). "Novo says degludec has potential to lower blood sugar". Reuters. Retrieved 2010-11-07.
  12. Lowry F. "Novel Ultralong-Acting Insulin as Effective as Insulin Glargine". Medscape. Retrieved 2010-11-07.
  13. "R&D Pipeline". Novo Nordisk. Retrieved 2012-01-27.
  14. Hirschler B (2010-10-27). "New Novo insulin fails to knock out rival Sanofi". Reuters. Retrieved 2010-11-07.
  15. "FDA approves two new drug treatments for diabetes mellitus". U.S. Food and Drug Administration. Archived from the original on 16 January 2016.
  16. "Novo Nordisk Launches Tresiba® (insulin degludec injection 200 Units/mL) in the United States". novonordisk-us.com.
  17. Heller S, Buse J, Fisher M, Garg S, Marre M, Merker L, et al. (April 2012). "Insulin degludec, an ultra-longacting basal insulin, versus insulin glargine in basal-bolus treatment with mealtime insulin aspart in type 1 diabetes (BEGIN Basal-Bolus Type 1): a phase 3, randomised, open-label, treat-to-target non-inferiority trial". Lancet. 379 (9825): 1489–97. doi:10.1016/S0140-6736(12)60204-9. PMID 22521071.
  18. Garber AJ, King AB, Del Prato S, Sreenan S, Balci MK, Muñoz-Torres M, et al. (April 2012). "Insulin degludec, an ultra-longacting basal insulin, versus insulin glargine in basal-bolus treatment with mealtime insulin aspart in type 2 diabetes (BEGIN Basal-Bolus Type 2): a phase 3, randomised, open-label, treat-to-target non-inferiority trial". Lancet. 379 (9825): 1498–507. doi:10.1016/S0140-6736(12)60205-0. PMID 22521072.
  19. Ericsson, Å.; Pollock, R. F.; Hunt, B.; Valentine, W. J. (2013). "Evaluation of the cost-utility of insulin degludec vs insulin glargine in Sweden". Journal of Medical Economics. 16 (12): 1442–1452. doi:10.3111/13696998.2013.852099. ISSN 1369-6998.
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