Recently published consensus statement: Practical guidance for the use of IDegAsp in type 2 diabetes
Dr Sarah Glastras provides practical advice on the usage of the insulin degludec/insulin aspart coformulation, and outlines its role in insulin initiation and intensification in light of the recently released consensus statement.
Type 2 diabetes is a progressive disease with an established risk of complications related to long-term hyperglycaemia.1,2
Although guidelines recommend the escalation of therapy in a timely manner when glycaemic targets are not met, insulin initiation and intensification are often delayed in clinical practice.1,2 Contributing factors to clinician clinical inertia include the perception that insulin therapy is complex, fear of hypoglycaemia, and lack of adequate guidance regarding when treatment intensification is required.1
A range of insulins are available to individualise treatment regimens.1 Approaches to insulin initiation may consist of a basal-only insulin (intermediate or long-acting insulin), or a basal-containing coformulation or premixed insulin.2
IDegAsp is a coformulation of insulin degludec – an ultra-long acting basal insulin – and insulin aspart, which is a rapid-acting prandial insulin.1 The half-life of insulin degludec is about twice as long as that of insulin glargine (25.4 vs 12.1 hours) with steady state achieved in 2 to 3 days.1,3 Insulin degludec has been shown to have a lower variability in its glucose-lowering effect versus insulin glargine, as well as a relatively lower risk of hypoglycaemia.1 Indeed, IDegAsp has been shown to have a lower rate of hypoglycaemia than premix, basal plus or basal-bolus regimens.1
Therefore, the use of IDegAsp should be considered in individuals with an increased risk of hypoglycaemia, especially nocturnal hypoglycaemia.1 IDegAsp can also be considered in those with postprandial glucose spikes despite optimising basal or premixed insulins.1
IDegAsp offers flexibility in the timing of insulin administration, so long as it is dosed with the main meal(s).4 This dosing flexibility may suit shift workers, people travelling across time zones, and those who rely on home visits to receive their injections.1 The simplicity of dose regimen can also benefit those who struggle with injection burden or with adherence to a more complex regimen.1
IDegAsp can be used in both insulin initiation and insulin intensification, as shown below.
BID: twice daily; GLP-1 RA: glucagon-like peptide-1 receptor agonist; OAD: oral antidiabetic drug; OD: once daily; TID: three times daily.
Source: Glastras, et al, 2020.1
In insulin initiation, IDegAsp is preferable to basal insulin alone when prandial glucose control is needed.1 The advantage of using IDegAsp as the first-line insulin therapy is not having to add a prandial insulin or switching insulins further down the track when treatment intensification is required.
The recommended total daily starting dose of IDegAsp is 10 units administered before the most carbohydrate-heavy meal of the day.1,4 The dose can then be titrated weekly to achieve the target fasting plasma glucose level.1 In individuals with poor glycaemic control, a higher starting dose may be appropriate.1 Twice-daily dosing may be used if there is unacceptable post-prandial hyperglycaemia at two or more mealtimes.1
Individuals on a once-daily basal insulin who need treatment intensification may be switched unit-to-unit to IDegAsp once daily.1
Individuals on premixed insulins who need treatment intensification may switch to IDegAsp, with the possible advantage of lowering the risk of hypoglycaemia.1 Those on a once-daily premixed insulin may be switched unit-to-unit to IDegAsp once daily; those on a twice-daily or thrice-daily premixed insulin may be switched to IDegAsp twice daily at the same total daily insulin dose.1 However, clinicians may choose to reduce the IDegAsp starting dose by 10–20% in some cases.1
Individuals on basal-plus or basal-bolus regimens who need treatment intensification or regimen simplification may be switched to IDegAsp based on individual needs.1 Generally, a person on basal-plus therapy may be switched to IDegAsp once daily while a person on basal-bolus regimen may be switched to IDegAsp twice daily at the two largest meals, using the same dosage as the basal insulin.1
In summary, IDegAsp is an option as first-line insulin therapy or when treatment intensification is required for individuals on a range of insulin regimens.
- Glastras SJ, Cohen N, et al. The clinical role of insulin degludec/insulin aspart in type 2 diabetes: An empirical perspective from experience in Australia. Journal of Clinical Medicine. 2020;9(4):1091.
- The Royal Australian College of General Practitioners. Management of type 2 diabetes: A handbook for general practice. East Melbourne, Vic: RACGP, 2020.
- Heise T, Hovelmann U, et al. Comparison of the pharmacokinetic and pharmacodynamic profiles of insulin degludec and insulin glargine. Expert Opin Drug Metab Toxicol. 2015;11:1193–201.
- Ryzodeg 70/30 Product Information.
Dr Sarah Glastras is a clinician researcher who works as a Staff Specialist in Endocrinology at the Royal North Shore Hospital, Sydney and holds a conjoint appointment as an academic Senior Lecturer at the University of Sydney. She also consults in a busy private endocrinology practice in St Leonards. Dr Glastras completed her PhD studies in 2016 at the Kolling Institute of Medical Research, University of Sydney on the role of maternal obesity in predisposing offspring towards chronic disease and continues foetal programming research as a NHMRC Early Career Fellow. In addition to her basic science research, she is involved in many clinical studies in the areas of diabetes and obesity, with a special interest in pregnancy. She is leading a clinical study investigating the role of biomarkers in predicting preeclampsia in women with type 1 diabetes in pregnancy, funded by a JDRF Mentored Clinician Researcher Fellowship and supported by Diabetes Australia. She chairs the Complex Medical Management in Pregnancy Working Group and the Diabetes Group within the Northern Sydney Local Health District.
This blog is sponsored by Novo Nordisk.