Concentrated long-acting insulin analogues in type 2 diabetes

Leszek Czupryniak, MD, PhD, is head of the Department of Diabetology and Internal Medicine at the Medical University of Warsaw, Poland.

What is the place of long-acting insulin analogues with higher than standard concentrations (200 IU/mL and 300 IU/mL) in the treatment of type 2 diabetes? In which patients should we expect the benefits to justify recommending the drug despite the higher cost to the patient?

Insulin preparations with greater concentration, which is 200 IU/mL or 300 IU/mL... The classical standard, introduced over 2 decades ago by the World Health Organization (WHO), is 100 IU/mL of insulin preparation, but some companies decided to introduce more concentrated insulins. The reason for that was twofold. One was completely business oriented. The patent of insulin was going off and the companies wanted to maintain their monopoly with a given preparation, so they simply introduced different concentrations to keep up… to have this insulin, but only in the preparation produced by this original producer. This is something we’re not interested in.

But the second reason—and this is justified by evidence—is that those more concentrated insulins are usually safer. The classic comparison: glargine—we have glargine 100 IU/mL and 300 IU/mL—and there is strong evidence showing that those more concentrated insulins, glargine-300, as we say, are… the use of it is associated with significantly lower risk of hypoglycemia, particularly nighttime hypoglycemia. So it makes sense to use these insulins.

The second benefit for the patient could be that if a patient is taking high doses of insulin: 80 IU, 100 IU, 150 IU in one injection—it happens with long-acting analogues in type 2 diabetes—if he or she uses more concentrated insulin, then the volume of a fluid given subcutaneously is smaller and—we know it also from the patients—the pain caused by the injection and by this volume of the fluid given is smaller.

The second reason we switch patients to more concentrated insulins are the situations when the patient is requiring higher doses of insulin. I would say these are the 2 benefits, (1) lower risk of hypoglycemia—that is very important and that actually applies to all patients taking insulin, whether type 1, or type 2, or any other type of insulin, and (2) in patients [treated with] high doses, this may make using insulin simply more comfortable.