A Review of Insulins

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Insulin has evolved since it was first developed to treat diabetes.

Unlike the limited selection of insulins Dr. Elliott P. Joslin had to work with, today we have a range of alternatives to choose from. Instead of coming from pigs or cows, most of our insulin is made in the laboratory using recombinant DNA.(As an interesting aside, the insulins used  for our pets with diabetes usually still come from the pancreas of animals) .

The insulins we have today fit into one of three broad categories: basal, bolus, and mixed basal-bolus insulin. Basal insulins after being injected, dissociate slowly in the fatty tissue to provide a constant stream of insulin into the circulation throughout the day. They help reduce the amount of glucose secreted by the liver, thereby keeping glucose levels steady. The new basal insulins last approximately 24 hours and are given once or twice a day.

Currently we have three basal insulins available in the United States: Lantus®, Levemir® and NPH. (Lantus® and Levemir® are brand names, NPH is a generic) Lantus® and Levemir® are categorized as long-acting insulins because they can be given once- a -day to cover a 24-hour period. (In people with type 1 diabetes, Levemir® and sometimes Lantus® is given twice per day to avoid reduction in efficacy in the waning hours before the next dose is due) Both are flat, peakless insulins. Peakless insulin works with the same intensity throughout the life of the dose. This has some advantages for people with diabetes because they can calculate approximately how much basal is working per hour by simply dividing their dose by 24. The advent of peakless basal insulins freed people from having to have fixed-snack times that match the insulin peak.

Today most people use Lantus® or Levemir ®as their basal insulin. However, there are still some people who continue to use NPH. NPH, although used as basal insulin, is not truly long-acting. It lasts between 14 and 16 hours. It has been in existence much longer than the other two. Because it does have a peak, NPH is the favored insulin for people who have strong DAWN effects – very high blood glucose in the morning hours- such as women with gestational diabetes.

Bolus insulins are used to cover the rise in blood glucose following a meal or to “correct” a high blood glucose reading back to normal.  Today we have the option of using regular insulin which is short-acting insulin or a trio of fast-acting insulins: Novolog®, Humalog® or Apidra®. Regular takes longer to get going than the fast-acting insulins so it isn’t as convenient to use. However it can be a bonus for people who eat high fat meals on a regular basis or for those who have gastroparesis (nerve damage to the gastrointestinal tract) because it lasts for a longer time than fasting acting insulin. Fast acting insulins work for about four hours whereas regular lasts up to eight hours.

Mixed dose insulins combine basal insulin (an analog of NPH) with fasting acting insulin. This incorporates the features of bolus and basal insulin in one injection. They are usually given twice per day at breakfast and dinner. Although more convenient than dosing basal and bolus insulin separately, they do not allow patients as much flexibility. Since they come in fixed amounts of bolus to basal, dosing isn’t as precise. Mixed dose insulin is often used in the elderly or with people who do not wish to take more than two injections per day.

7 Responses to A Review of Insulins

  1. Doris Dickson says:

    1) They are hardly peakless especially in the high doses most doctors prescribe.
    2) They do not last as long as big pharma claims though in high doses, they durations are longer and less predictable just like NPH was.
    3) Levemir is far more useful, predictable, safe and “peakless” in three small doses (see Dr. Richard Bernstein’s material). Otherwise there are gaps.
    4) Lantus … ya, I wouldn’t give that to my least favorite person much less in the high doses most doctors prescribe which causes lows, eating to the insulin and weight gain.

    There are articles in Diabetes Health and in other publications written by Dr. Richard Bernstein (e.g. There is no 24 hour insulin) for those who wish to read details.

    • Nora Nutrition Manager says:

      Dear Ms. Dickson:
      You are correct; any insulin’s properties begin to distort at very high doses. However, for many people both Lantus and Levemir come as close as is currently available to a peakless insulin.

  2. can you please clarify me..why insulin is last choice over the oral anti diabetic drugs in the diabetes patient.
    why doctor use primarily insulin in diabetes patients…on the besis of science…can you please help me with the strong reason..

    • Here is a response from Nora Saul, Manager of Nutrition Services at Joslin:
      “Insulin is often used as a last resort for patients with type 2 diabetes because it can cause weight gain, which is problematic for many people with type 2. It can also cause hypoglycemia and it requires an injection, which many people do not like. However, if a patient wants to start insulin instead of orals there is no reason they couldn’t do it. Patients with type 1 diabetes have to start on insulin right away, as there aren’t any other options.”

  3. Saeed says:

    Thanks alot can you please tell me is it possible to use mixtard twice aday with lantus once aday in diabetic patient

    • Here is a response from Nora Saul, Manager of Nutrition Services at Joslin
      “Lantus can be used with NPH insulin (an NPH analog is used in mixed dose insulin). However, it isn’t used very often as you would essentially be using two basal insulins which do the same thing.”

  4. “However, for many people both Lantus and Levemir come as close as is currently available to a peakless insulin.”

    I think this is a really, really important point. There is a big difference between “as close as is currently available to peakless” and “peakless”. .Back in the old days pre-Lantus and Levimir, everybody was on NPH and we were never told how peaky and unreliably peaky at that it was. Many, many diabetics were led to believe it was something wrong with them and assumptions made about “non-compliance” when type 1s struggled with highs and lows, partticularly the 1am hypos brought about by NPH (or protaphane as we say in Australia).

    THere’s no doubt that Lantus and Levemir are much more basal, peakless insulins than NPH but please let’s reduce the hyperbole about peakless and also 24hr insulin because it just makes diabetes even harder to manage for those whose non-paid, second job it is to manage their diabetes 24/7.

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