Insulin Options Longer-Lasting and Stronger than Lantus
Insulin degludec (U-200) and insulin glargine U-300 (Toujeo) are longer-lasting and stronger than standard insulin glargine (Lantus), with insulin glargine U-300 having a more stable and prolonged pharmacokinetic profile exceeding 24 hours. 1
Comparison of Long-Acting Insulin Options
Insulin Glargine U-300 (Toujeo)
- Three times more concentrated than standard Lantus (glargine U-100)
- More stable and prolonged pharmacokinetic/pharmacodynamic profile 1
- Duration of glucose-lowering activity exceeding 24 hours
- Flatter and more consistent insulin levels with less variability 2
- Lower risk of nocturnal hypoglycemia in insulin-experienced patients with type 2 diabetes 1
- Requires slightly higher daily insulin doses compared to Lantus 2
Insulin Degludec (U-200)
- Twice as concentrated as standard insulin formulations
- Longer duration of action than U-100 formulations 3
- Allows higher doses of basal insulin administration per volume used
- When combined with liraglutide (IDegLira), provides potent glucose-lowering with less weight gain and hypoglycemia 3
Clinical Considerations When Switching
When transitioning from Lantus (insulin glargine U-100) to a more concentrated insulin:
- Expect to adjust dosing - insulin requirements may be slightly higher with glargine U-300 2
- Reinforce blood glucose monitoring during transition period 2
- Both U-300 glargine and U-200 degludec are available only in prefilled pens to minimize dosing errors 3
- Consider cost implications, as newer formulations may be more expensive 3
Dosing Guidelines
- Starting dose when switching from Lantus may need adjustment
- For insulin-naïve patients, typical starting dose is 0.1-0.2 units/kg/day 3
- Titrate by increasing dose by 10-15% or 2-4 units once or twice weekly until fasting blood glucose target is met 3
- For high doses (>0.5 units/kg/day), consider combination therapy with GLP-1 receptor agonists 3
Advantages of Newer Formulations
- Less within-day variability and higher day-to-day reproducibility 4
- Potentially better flexibility in timing of injection 2
- Lower risk of hypoglycemia, especially nocturnal hypoglycemia 1, 2
- Higher concentration allows for smaller injection volumes for patients requiring large insulin doses 3
Important Caveats
- These concentrated insulins may be more expensive than standard formulations 3
- The efficacy in terms of A1C reduction is generally comparable to Lantus 1
- The main advantage is in the pharmacokinetic profile and reduced hypoglycemia risk rather than improved glycemic control 4
- Insulin glargine should not be mixed with other insulins due to its acidic pH 5
For patients requiring longer and more stable insulin coverage than Lantus can provide, insulin glargine U-300 (Toujeo) offers the most evidence for extended duration with a more stable profile, while insulin degludec U-200 provides similar benefits with potentially fewer injections.