Glargine In Morning or Evening?
New study shows less nocturnal lows and
better control in Type 2’s who take in morning.
Morning insulin glargine appears to lower the
risk of nocturnal hypoglycemia in type 2 diabetics
who take the sulfonylurea drug glimepiride, compared
with bedtime insulin glargine or bedtime NPH insulin.
Therapy with oral antidiabetic drugs and bedtime
neutral protamine Hagedorn (NPH) insulin is as
effective as other, more complex insulin regimens
and is associated with less weight gain. However,
NPH insulin exhibits a peak of action 4 to 6 hours
after injection and is associated with an increased
risk of nocturnal hypoglycemia.
By comparison, insulin glargine, a newer human
insulin analogue, exhibits a 24-hour action profile
and may be more effective in achieving glycemic
control compared to NPH when combined with oral
antidiabetic drugs.
In their study, Andreas Fritsche, MD, with the
Eberhard-Karls-Universitat, Tubingen, Germany,
and colleagues conducted an open-label, randomized,
controlled trial of 695 patients with type 2 diabetes
whose diabetes was poorly controlled with oral
antidiabetic drugs alone. Patients were randomized
to treatment with morning insulin glargine, bedtime
NPH insulin, or bedtime insulin glargine for 24
weeks in addition to 3 mg of glimepiride.
Hemoglobin A(1c) improvement was more pronounced
with morning insulin glargine than with NPH insulin
(p = 0.001) or bedtime insulin glargine (p = 0.008).
Hemoglobin A(1c) levels improved by -1.24% with
morning insulin glargine, -0.96% with bedtime
insulin glargine, and by -0.84% with bedtime NPH
insulin.
Improvement in baseline to end-point fasting
blood glucose levels was similar in all three
groups, the researchers found. However, patients
receiving morning insulin glargine experienced
the least nocturnal hypoglycemia (17% with morning
insulin glargine versus 23% with bedtime insulin
glargine and 38% with NPH insulin, p < 0.001).
"Insulin glargine injected in the morning
resulted in better glycemic control than did bedtime
NPH insulin, " the researchers conclude.
"This can be explained by the longer action
profile of insulin glargine and, therefore, better
24-hour glycemic control."
However, the finding that insulin glargine results
in better glycemic control only when given in
the morning was "unexpected and is not easy
to explain," they point out. They speculate
that the reason for the better glycemic control
with morning insulin glargine is that the glucose-lowering
effect of insulin glargine given in the morning
together with glimepiride might be higher during
the first 12 hours after insulin glargine injection.
Ann Intern Med 2003;138:12:952-959
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