Table 19.

Types of Insulin

	Onset	Peak	Duration
Basal insulins
Intermediate-acting human (cloudy)
Neutral Protamine Hagedorn (human)	1–3 h	5–8 h	Up to 18 h
Long-acting (clear) analogs
Detemir	1.5 h	near peakless	16–24 h
Glargine U100a	1.5–2 h	near peakless	24 h
Glargine U300	6 h	peakless	>30 h
Degludec U100	1 h	peakless	42 h
Degludec U200	1 h	peakless	42 h
Prandial insulins
Short-acting human
Regular	30–60 min	2–4 h	5–8 h
Rapid-acting analogs
Aspart	15 min	1–1.5 h	3–5 h
Glulisine	12–30 min	1–1.5 h	3.5–5 h
Lisprob (U100 and U200)	15–30 min	1–2 h	3–4.75 h
Faster-acting analogs
Faster aspart	4 min	0.5–1.5 h	3–5 h
Lispro aabc	15–17 min	≈ 2 h	4.6–7.3 h
Inhaled technosphere insulin	≈ 12 min	0.5–1 h	1.5–3 h
Premixed Insulins (cloudy)
70/30 NPH/Regular	These insulins contain a fixed ratio of intermediate-acting insulin and short- or rapid-acting insulin. These suspensions must be resuspended uniformly for more consistent glucose lowering. The timing and adjustment of these insulins depend on glucose levels and the individual kinetics of the insulin components.
70/30, 60/40, 50/50 N/R
70/30 aspart protamine/aspart
75/25 lispro protamine/lispro
50/50 lispro protamine/lispro

Biosimilars are follow-on biologics which have been approved via the Public Health Service Act. Biosimilar designation allows the drugs to be interchangeable with the reference drug and are approved by the US Food and Drug Administration (FDA) to allow pharmacists to substitute without the need for an authorized prescription.

Clinicians should refer to the FDAdapproved prescribing information for the most current official product information on any of the insulins.

Degludec

Flexible dosing with at least 8 to 40 hours between injections was not associated with increased hypo- or hyperglycemia. Source: Mathieu C, Hollander P, Miranda-Palma B, et al. NN1250–3770 (BEGIN: Flex T1) Trial Investigators. Efficacy and safety of insulin degludec in a flexible dosing regimen vs insulin glargine in patients with type 1 diabetes (BEGIN: Flex T1): a 26-week randomized, treat-to-target trial with a 26-week extension. J Clin Endocrinol Metab. 2013;98(3):1154–1162 [EL 1; RCT].

Similar glycemic variability parameters, but better continuous glucose monitoring metrics (time in range, time above range, time below range) compared with glargine U300.¹¹⁴⁸

Detemir

Up to 40% to 50% of persons may require twice daily dosing (with 12 hours after the morning dose). Sources: Dornhorst A, Lüddeke HJ, Sreenan S, Koenen C, Hansen JB, Tsur A, Landstedt-Hallin L, et al. Safety and efficacy of insulin detemir in clinical practice: 14-week follow-up data from type 1 and type 2 diabetes patients in the PREDICTIVE European cohort. Int J Clin Pract. 2007;61(3):523–528 [EL 2; PCS]; and Heller S, Koenen C, Bode B, et al. Comparison of insulin detemir and insulin glargine in a basal-bolus regimen, with insulin aspart as the mealtime insulin, in patients with type 1 diabetes: a 52-week, multinational, randomized, open-label, parallel-group, treat-to-target noninferiority trial. Clin Ther. 2009;31(10):2086–2097 [EL 1; RCT].

Glargine U300

Persons with type 1 diabetes may require ~15% to 30% higher dose compared with glargine U100. Source: Porcellati F, Bolli GB, Fanelli CG. Pharmacokinetics and pharmacodynamics of basal insulins. Diabetes Technol Ther. 2011;13 Suppl 1:S15–S24 [EL 4; NE].

Prandial insulins

Based on onset of action, insulin should be taken at appropriate time to match the postprandial glucose absorption. All can be used in insulin pumps with preference given to rapid-acting insulins. Source: Bode B, Weinstein R, Bell D, McGill J, Nadeau D, Raskin P, Davidson J, Henry R, Huang WC, Reinhardt RR. Comparison of insulin aspart with buffered regular insulin and insulin lispro in continuous subcutaneous insulin infusion: A randomized study in type 1 diabetes. Diabetes Care. 2002;25(3):439–444 [EL 1; RCT].

^aGlargine available as branded, U100 biosimilar (2 preparations) or U100 follow-on biologic (single preparation)

^bLispro available as branded, or a follow-on biologic (U-100)