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Guide: Use of IDegAsp in T2D

Many people with type 2 diabetes (T2D) will require insulin at some point to reach glycaemic targets. However, insulin initiation and intensification is often delayed, resulting in prolonged hyperglycaemia, which can increase the risk of micro and macrovascular complications.1 Contributing factors to this delay include the perception that insulin therapy is complex, fear of hypoglycaemia, and lack of adequate guidance regarding when treatment intensification is required.1

Insulin degludec/insulin aspart (IDegAsp) is the first insulin coformulation with insulin degludec – an ultra-long acting basal insulin – and insulin aspart, which is a rapid-acting prandial insulin.1,2 IDegAsp offers a number of practical advantages compared with premixed or basal-bolus insulin regimens including a reduced injection burden, flexibility in the timing of insulin administration (so long as it is dosed with the main meal), and a lower risk of hypoglycaemia, especially nocturnal hypoglycaemia.1

This guide summarises a recently published Australian consensus statement providing guidance for the use of IDegAsp for T2D in primary care.1

Where and how to use IDegAsp

IDegAsp can be used in both insulin initiation and insulin intensification, as shown below.1

BID: twice daily; GLP-1 RA: glucagon-like peptide-1 receptor agonist; OAD: oral antidiabetic drug; OD: once daily;
TID: three times daily.
Adapted from: Glastras, et al, 2020.1

A. Insulin initiation1

Who
  • Can be used as first-line therapy for people with T2D who are insulin-naïve
Why
  • Need treatment intensification and prandial glucose control is required
How
  • 10 units IDegAsp administered OD before the most carbohydrate-heavy meal of the day

Note: In individuals with poor glycaemic control, a higher starting dose may be appropriate. Twice-daily dosing may be used if there is unacceptable post-prandial hyperglycaemia at two or more mealtimes.

B. Insulin intensification from basal insulin to IDegAsp1

Who
  • People with T2D receiving basal insulin
Why
  • Need treatment intensification
How
  • Unit-to-unit replacement of basal insulin with IDegAsp

Note: If switching from high-dose basal insulin, consider lowering IDegAsp starting dose by 20% to reduce the risk of hypoglycaemia. Dose can be given OD or split BID into equal or unequal doses.

C. Switching from basal-plus or basal-bolus to IDegAsp1

Who
  • People with T2D receiving basal-plus or basal-bolus
Why
  • Need treatment intensification or regimen simplification
How
  • Basal-plus: start with IDegAsp OD at dose matched to basal insulin*
  • Basal-bolus: start with IDegAsp BID at the two largest meals, initially at dose matched to basal insulin split BID*

*Note: Individualise according to glycaemic profile.

D and E. Switching from premixed insulin to IDegAsp1

Who
  • People with T2D receiving premixed insulin
Why
  • Need treatment intensification or regimen simplification
How
  • Start with same IDegAsp unit dose and injection schedule as current premixed therapy; reduce dose by 10–20% in some cases (at clinician’s discretion)

Note: IDegAsp should only be used either OD or BID dosing; avoid TID dosing.

Algorithm for weekly titration of IDegAsp

FPG: fasting plasma glucose.

Dosing

IDegAsp can be dosed once daily or twice daily with the main meal.1,2

BID: twice daily; OD: once daily; TID: three times daily.

IDegAsp in special T2D populations

T2D population Considerations
Older people
  • IDegAsp can be used in older people with T2D1,2
  • The dosing flexibility (as long as dosed with the main meal) may suit those who rely on home visits to receive their injections1
People on a very-low-calorie, reduced-carbohydrate or erratic diet
  • The dosing flexibility with IDegAsp may be useful in these situations as long as IDegAsp is administered with a carbohydrate-containing meal1
People with hepatic or renal impairment
  • IDegAsp can be used in people with hepatic impairment or renal impairment, with close glucose monitoring and individualised dosing1,2
Pregnant women
  • Not recommended in pregnancy (Category B3) due to the lack of clinical experience1,2

IDegAsp may be useful in the following people with T2D:1

  • those who struggle with injection burden or with adherence to a more complex regimen
  • those who need flexibility in the timing of insulin administration (so long as IDegAsp is dosed with the main meal)
  • those with postprandial glucose spikes despite optimising basal or premixed insulins
  • those at increased risk of hypoglycaemia

Key resource

References

  1. 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.
  2. Ryzodeg 70/30 Product Information.

This activity is sponsored by Novo Nordisk.