What is the most appropriate insulin for a 22-year-old patient with Diabetes Mellitus Type 1 (DM1) to use three times a day for mealtime coverage?

From the Guidelines

Rapid-acting insulin analogs such as insulin lispro (Humalog), insulin aspart (NovoLog), or insulin glulisine (Apidra) are the most appropriate choice for mealtime coverage in a 22-year-old patient with type 1 diabetes. These insulins should be administered approximately 15 minutes before meals, three times daily, as they work quickly (onset within 15 minutes), peak in 1-2 hours, and have a relatively short duration of action (3-4 hours), making them ideal for controlling post-meal blood glucose spikes 1. The typical starting dose is calculated based on body weight, usually 0.3-0.5 units/kg/day, with about 50-60% allocated to mealtime insulin divided among three meals.

Key Considerations

• The patient should also be educated on carbohydrate counting to adjust mealtime insulin doses based on food intake and pre-meal blood glucose levels, using an insulin-to-carbohydrate ratio and correction factor personalized to their needs.
• This mealtime insulin regimen must be complemented with a once or twice-daily long-acting insulin (such as insulin glargine or insulin detemir) to provide basal coverage.
• The ideal time to administer premeal insulin varies with the type of insulin used, measured blood glucose level, timing of meals, and carbohydrate consumption, and therefore should be individualized 1.
• Rapid-acting and long-acting insulin analogues are associated with less hypoglycemia in type 1 diabetes and match the HbA1c improvements obtained with human insulins 1.

From the FDA Drug Label

CLINICAL STUDIES The efficacy and safety of LEVEMIR given once-daily at bedtime or twice-daily (before breakfast and at bedtime, before breakfast and with the evening meal, or at 12-hour intervals) was compared to that of once-daily or twice-daily NPH human insulin or once-daily insulin glargine in non-blinded, randomized, parallel studies of 6004 patients with diabetes (3724 with type 1, and 2280 with type 2). Type 1 Diabetes – Adult In one non-blinded clinical study (Study A, n=409), adult patients with type 1 diabetes were randomized to treatment with either LEVEMIR at 12-hour intervals, LEVEMIR morning and bedtime or NPH human insulin morning and bedtime. Insulin aspart was also administered before each meal

The most appropriate insulin for a 22-year-old patient with diabetes type 1 who wishes to use insulin 3 times a day for mealtime coverage is insulin aspart.

• Key points:
  • The patient's profile matches the study population in Study A.
  • Insulin aspart was administered before each meal in the studies.
  • The studies compared LEVEMIR (insulin detemir) to NPH human insulin, but insulin aspart was used for mealtime coverage in both arms.
  • There is no direct information in the label to support the use of LEVEMIR three times a day for mealtime coverage 2.

From the Research

Insulin Options for Type 1 Diabetes

The patient's requirement for insulin three times a day for mealtime coverage can be met with rapid-acting insulin analogues.

• Rapid-acting insulin analogues, such as insulin lispro, insulin aspart, and insulin glulisine, provide better postprandial glucose coverage than human regular insulin 3.
• These analogues have a faster onset of action and a shorter duration of action compared to human regular insulin, making them suitable for mealtime coverage.

Comparison of Rapid-Acting Insulin Analogues

• Insulin aspart and insulin lispro have been shown to be equivalent in terms of blood glucose excursions and pharmacokinetic profiles in patients with type 1 diabetes 4.
• Insulin glulisine has been compared to lispro and aspart in patients with type 1 diabetes using continuous subcutaneous insulin infusion, and has been found to have comparable glucose control 5.

Basal Insulin Options

• Insulin detemir is a long-acting insulin analogue that can be used as basal insulin therapy in patients with type 1 diabetes 6.
• It has been shown to have a beneficial effect on glycaemic control and less within-patient variability in glucose-lowering effect compared to NPH insulin.

Suitable Insulin Regimen

• A suitable insulin regimen for the patient could be a combination of rapid-acting insulin analogue (such as insulin lispro or insulin aspart) for mealtime coverage and a long-acting insulin analogue (such as insulin detemir) for basal coverage 3, 6.
• The use of insulin glargine or insulin detemir with a rapid-acting insulin analogue at meals is an effective and reasonable alternative to insulin pump therapy 3.