Insulin - So many slow pokes

Feb 18, 2020

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

Where is the fracking file! Keep your knickers on. I said fracking. I wrote it on my laptop in Winnipegosis. It was supposed to sync to DropBox and now be here on my home computer. It isn't. So, it also isn't on my phone. So, I can't record it at CKDM. What am I supposed to do, just ad lib a pharmacy feature about insulin? That'll so great! I'm sure I won't sound stupid at all. Wait a minute. Maybe I just saved it to the wrong folder. Okay. There it is. Now open. Just open. I said OPEN. Okay. Crisis averted. Blood pressure falling. Calming down. Deep breath. Focus. Okay, let's talk about insulin.

I was in the dispensary and a patient started asking about a slow acting insulin that I'd never heard of. Then I went to the fridge and found several slow acting insulins I'd never heard of. Time to do some reading.

Insulin is used to treat diabetes mellitus. The Latin translation of diabetes mellitus is "sweet tasting urine". It was diagnosed by "water tasters" who drank the urine of those suspected of having diabetes. The urine of people with diabetes mellitus was thought to be sweet-tasting. The Latin word for honey (referring to its sweetness), 'mellitus', is added to the term diabetes as a result. Doctors today should be very happy they have lab tests.

Fast forward to the 1920's and Canadians made a huge advance in the treatment of diabetes. Fredrick Banting and Charles Best found a substance called insulin inside the pancreas of dogs. It turned out that if you injected this "insulin" into people with the strange wasting disease called diabetes, it stopped them from dying.

We now think diabetes is when your body has trouble storing and using glucose. Glucose is a simple sugar that fuels many processes in the body. There are 3 types of diabetes: type 1, type 2, and gestational diabetes. Type 1 diabetes is when your pancreas doesn't produce insulin. You must inject insulin or you will die. In Type 2 diabetes, your body may produce normal, or even above normal amounts of insulin. However, other parts of the body like your muscle and fat cells aren't listening to the insulin signal. That means tissues like muscle and fat don't suck the glucose out of the blood and use it. Type 2 diabetes can be treated with diet, exercise, pills or insulin, or often a combination of these. Gestational diabetes only occurs in pregnancy.

There are many types of insulin. The simplest is called R or Toronto insulin (Did I mention Banting and Best worked out of the University of Toronto?). It is produced by microbes that have a tiny bit of human DNA implanted in them and is identical to the insulin that the human body produces (and you thought genetic engineering was in the future). It is a short acting insulin. Insulin has to be injected into the body because if it is taken orally, the stomach acid will destroy it.

Slow acting insulin start with Toronto or R insulin and get tweaked a little. But first, why would you want to use a slow acting insulin? When the pancreas is working properly it releases a small amount of insulin continuously all day. We call this the basal insulin level. The pancreas then releases a spike of insulin when you eat something with sugar in it. We call this bolus insulin. To mimic the basal or background insulin level we could hook a patient up to an insulin pump all day. Or if we had really long acting insulin we could inject the patient once or twice a day and it would slowly disperse insulin all day and mimic the basal insulin level.

The first long acting insulin I started dispensing was insulin glargine or Lantus. Lantus lasts for 24 hours in many patients, but it can vary from 11 to over 24 hours. Basaglar is another insulin glargine made by another company. It is essentially the same as Lantus. Toujeo is also insulin glargine. However, it is more concentrated that Lantus so people who need many units of insulin glargine can get them with having to inject less volume. Levemir is different than Lantus. Levemir is insulin detemir and it lasts from 6 to 24 hours. The way they are long acting is different.

Lantus is made by genetically engineered E.coli, a bacterium. Levemir is made by genetically engineered brewer's yeast. Lantus is made such that it stays in solution in the acidic environment of the Lantus pen, but precipitates out when it is injected into the neutral pH of the fatty tissue under the skin. The precipitated insulin glargine or Lantus then slowly leaks into the blood stream over the next day. Levemir is a neutral solution of insulin. It is designed to stick to itself when injected. It slowly leaks into the blood stream from its injection site. Then it binds to a protein in the blood called albumin. This is interesting since the insulin detemir or Levemir now has to detach slowly from the albumin to become active.

Which is better Lantus or Levemir? Hard to say. They both can be injected once or twice a day. Lantus might sting more at the injection site. Some studies have found Levemir to be more consistent than Lantus, but not all studies found that.

Tresiba is different again. It is insulin degludec and it is really long acting. It lasts 42 hours. It may cause less low blood sugars than Lantus. It works by a substance called hexadecanedioic acid, which allows the insulin to form soluble multi-hexamers once injected. These multi-hexamers result in a slower release of insulin than is possible with other insulin such as Levemir and Lantus.

I've got a million-dollar idea for a tech start up. But you've got to keep it very hush, hush okay? Tech that works better when I'm frustrated and angry. Hear me out. Maybe it's a phone that resets to its last working state when I throw it. Maybe it's a desktop that actually finds what I want when I kick it. Maybe it's a voice assistant like Siri or Alexa that knows when I curse at it, it is time to stop fracking around. Way easier to sell frustration tech than learning to control and manage my emotions in a crisis, right?

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.


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