insulin detemir (Rx)

Brand and Other Names:Levemir, Levemir FlexTouch
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

injectable solution

  • 100 units/mL (10mL vial)

prefilled syringe

  • 100 units/mL (3mL FlexTouch)
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Type I or II Diabetes Mellitus

Once daily dosage: Administer SC with evening meal or at bedtime

Twice daily dosage: Administer SC with morning meal and either with evening meal, at bedtime, or 12 hr after the morning dose

Initial dose

  • Type 1 diabetes: Approximately one third of the total daily insulin requirements SC; rapid-acting or short-acting, premeal insulin should be used to satisfy the remainder of the daily insulin requirements; usual daily maintenance range is 0.5-1 unit/kg/day in divided doses; nonobese may require 0.4-0.6 unit/kg/day; obese may require 0.6-1.2 units/kg/day
  • Type 2 diabetes inadequately controlled on oral medication: 10 units/day SC (or 0.1-0.2 unit/kg/day) in evening or divided q12hr
  • Type 2 diabetes inadequately controlled on GLP-1 receptor agonist: 10 units/day SC given once daily in evening
  • Subsequently adjust dose based on blood glucose measurements

Conversion from other insulins

  • If converting from insulin glargine: Change can be accomplished on a unit-to-unit basis
  • If converting from NPH insulin: Change can be accomplished on a unit-to-unit basis; however, some patients with type 2 diabetes may require more insulin detemir than NPH insulin
  • Closely monitor blood glucose during transition and in the initial weeks thereafter; concurrent rapid-acting or short-acting insulins or other concomitant antidiabetic treatment may require dose adjustment

Dosing Considerations

Dosage of human insulin, which is always expressed in USP units, must be based on the results of blood and urine glucose tests and must be carefully individualized to optimal effect

Dose adjustments should be based on regular blood glucose testing

Adjust to achieve appropriate glucose control

Dose adjustments

  • Look for consistent pattern in blood sugars for >3 days
  • Same time each day: Compare blood glucose level with previous levels that occurred at that time of day
  • For each time of day: Calculate blood glucose range
  • Calculate median blood glucose
  • Consider eating and activity patterns during the day

Rate of dose adjustments

  • Adjust only 1 insulin dose at a time
  • Correct hypoglycemia first
  • Correct highest blood sugars next
  • If all blood sugars are high (within 2.75 mmol/L [50 mg/dL]): Correct morning fasting blood glucose first
  • Change insulin doses in small increments: Type 1 diabetes (1-2 U change); type 2 diabetes (resistant to diet, exercise; 2-3 U change)

Sliding scales

  • Many sliding scales exist to determine exact insulin dose based on frequent blood glucose monitoring
  • Commonly written for q4hr blood glucose test
  • Sliding scale coverage usually begins after blood glucose >11 mmol/L (200 mg/dL)
  • If coverage is needed q4hr for 24 hr, then base insulin dose is adjusted first; sliding scale doses may be adjusted upwards as well

Dosage Forms & Strengths

injectable solution

  • 100 units/mL (10mL vial)

prefilled syringe

  • 100 units/mL (3mL FlexTouch)
more...

Type 1 Diabetes Mellitus

<2 years: Safety and efficacy not established

≥2 years: Approximately one-third of the total daily insulin requirements SC; rapid-acting or short-acting, premeal insulin should be used to satisfy the remainder of the daily insulin requirements; usual daily maintenance range in adolescents is ≤1.2 units/kg/day during growth spurts

Dosing Considerations

Dosage of human insulin, which is always expressed in USP units, must be based on the results of blood and urine glucose tests and must be carefully individualized to optimal effect

Conversion from other insulins

  • Change from basal insulin to insulin detemir can be done on a unit-to-unit basis (then adjust to achieve glycemic targets)
  • Monitor closely during growth spurts and adjust dose accordingly
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Interactions

Interaction Checker

and insulin detemir

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            Adverse Effects

            Frequency Not Defined

            Hypoglycemia

            Headache

            Influenza-like symptoms

            Pallor

            Palpitation

            Tachycardia

            Mental confusion

            Redness

            Urticaria

            Weakness

            Blurred vision

            Itching

            Hunger

            Nausea

            Lipodystrophy

            Lipohypertrophy

            Local allergic reaction

            Hypokalemia

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            Warnings

            Contraindications

            Systemic allergic reactions

            During episodes of hypoglycemia

            Cautions

            Never share pen between patients even if needle is changed

            Long-acting insulin; do not use for circumstances that require rapid-acting insulin

            Use with caution in patients with decreased insulin requirements, including those with diarrhea, nausea/vomiting, malabsorption, hypothyroidism, renal impairment, or hepatic impairment

            Rapid changes in serum glucose may induce symptoms of hypoglycemia

            Frequent glucose monitoring and insulin dose reduction may be required with renal or hepatic impairment; not recommended during periods of rapidly declining renal or hepatic function, because of risk for prolonged hypoglycemia

            May cause a shift in potassium from extracellular to intracellular space, possibly leading to hypokalemia; caution when coadministered with potassium-lowering drugs or conditions that may decrease potassium  

            Use with caution in patients with increased insulin requirements, including those with fever, hyperthyroidism, trauma, or infection or who have undergone surgery

            Pregnancy, lactation

            Lower dose when used in combination with a GLP-1 receptor agonist to minimize the risk of hypoglycemia

            Thiazolidinediones are peroxisome proliferator-activated receptor (PPAR)-gamma agonists and can cause dose-related fluid retention, particularly when used in combination with insulin; fluid retention may lead to or exacerbate heart failure; monitor for signs and symptoms of heart failure, treat accordingly, and consider discontinuing thiazolidinediones

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            Pregnancy & Lactation

            Pregnancy category: B; randomized, controlled trial (n=310) observed insulin detemir reduced Hgb A1C similarly to insulin NPH in pregnant women; no differences observed in fetuses and newborns

            Lactation: Safe

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            Regulates glucose metabolism

            Insulin and its analogues lower blood glucose by stimulating peripheral glucose uptake, especially by skeletal muscle and fat, and by inhibiting hepatic glucose production; insulin inhibits lipolysis and proteolysis and enhances protein synthesis; targets include skeletal muscle, liver, and adipose tissue

            Absorption

            Bioavailability: 60% SC; well absorbed

            Onset: 3-4 hr

            Peak onset: 6-8 hr (not pronounced; released at constant rate over 24 hr)

            Duration: Up to 24 hr (range 5.7-23.2 hr)

            Distribution

            Protein bound: 98% bound to albumin

            Vd: 0.1 L/kg

            Elimination

            Half-life elimination: 5-7 hr (dose dependent)

            Excretion: Urine

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            Formulary

            FormularyPatient Discounts

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
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            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
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            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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