Everything You Should Know About the New Insulins

By Peter Huynh, PHARM.D, CDE, Rhea Coquia Smith, Pharm.D.

Although many people can control their diabetes by eating well and exercising, medication is a necessity for others. Fortunately for these folks, there are more options than ever before to help control their blood sugar. And several new insulins have recently been added to the mix: Afrezza, Toujeo, Humalog U-200, Tresiba and Ryzodeg . Here we highlight these new weapons in the diabetes therapy arsenal.

Afrezza: Could this be the end of insulin injections?

A new insulin delivery system, Afrezza, was just approved by the FDA and is currently available. Afrezza is an inhaled, man-made insulin that is approved for adults with type 1 diabetes (the diabetes in which your own body produces antibodies against your insulin-producing cells) or type 2 diabetes (the type of diabetes where the insulin being produced does not work as it should combined with the body producing less insulin over time).

Afrezza is a meal-time insulin taken before eating. This new insulin therapy may be added when your blood sugars can no longer be controlled by pill medication alone or when long-acting insulin injection is not enough to manage your diabetes. It is currently available in a cartridge form which is loaded into a small device. Cartridges come in four, eight and twelve units. Prior to eating, you would inhale the dose of insulin prescribed by your clinician. Long-acting insulin administration is still required if you have type 1 diabetes.

Like other FDA-approved insulin products, Afrezza has potential side effects, such as low blood sugar. Also, the dosing is limited to four, eight, or twelve units or a combination of these units: for example, you cannot administer three units or 10 units with this insulin delivery system.

Insurance coverage issues as well as possible higher co-pays – and, therefore, affordability – might be additional challenges faced with this insulin delivery system. Also, lung function will need to be checked and monitored by your doctor, since long- term side effects on the lungs are not known. And this insulin is not recommended for those with any existing lung problem or if you smoke.

Toujeo and Humalog U-200: The new injectable insulins

Until recently, Lantus was the only type of concentrated insulin available in the U.S. market. This year, two other concentrated insulins were approved by the FDA: Toujeo and Humalog U-200. The main purpose of these insulins is to deliver the usual unit dose of insulin in less volume, which can potentially improve absorption of insulin and help decrease the frequency of having to change insulin pens.

Toujeo contains the same type of long-acting insulin glargine (Lantus), but delivers three times the concentration of the previous version; that is, each millimeter of liquid in Toujeo carries 300 units – U300 – of insulin versus 100 – U100 – for Lantus.

Similarly, Humalog U-200 contains short-acting insulin lispro (Humalog), but delivers two times the amount of insulin for every unit; therefore, it is twice the concentration of Humalog U-100. These two medications are only available in pre-filled pen forms designed to give the exact amount of insulin dose needed in less volume. Thus, it is not recommended they be drawn out of their original pen form. These medications can be particularly beneficial for those who require high doses of insulin.

How is the pen used?

Toujeo and Humalog U-200 come in pre-filled pen delivery systems. The same technique is used to administer and deliver the insulin dose as its less concentrated pen forms. One different technique to note is the amount of insulin used to prime (safety test) the pens. It is recommended that Toujeo be primed (flushed) using three units of insulin, while Humalog U-200 should be primed with two units of insulin. Priming should be performed before each injection. These two insulins should never be extracted from their pen forms as this will result in an overdose. Upon first use of Toujeo and Humalog U-200, it is best to review with your diabetes healthcare team the proper techniques used to inject insulin pens.

How are Toujeo or Humalog U-200 prescribed and started?

There is no difference in how Toujeo and Humalog U-200 are prescribed compared to other insulin pens. Your diabetes specialist will continue to recommend the exact amount of insulin you need and the frequency of use. No adjustment will be needed to accommodate the concentrated nature of these two insulins. It is important to make sure that you stop using insulins that might have similar action to the more concentrated Toujeo and Humalog U-200. Make sure you discuss with your diabetes specialist how to transition to the new insulins.

How are Toujeo and Humalog U-200 stored?

After first use, these two insulins can be kept at room temperature, but should be discarded after 28 days. Any unused pens should be stored in a refrigerator and discarded upon the expiration date indicated on the package.

What type of monitoring is involved when using Toujeo and Humalog U-200?

If you do start Toujeo or Humalog U-200, you should be monitoring your blood glucose (sugar) using a glucose meter as often as recommended by your diabetes healthcare team. Close monitoring is important to know if the insulin is doing its job, preventing high blood sugar as well as low blood sugar.

What is the cost of Toujeo and Humalog U-200?

Cost may vary depending on each insurance coverage and retailer price. You should check with your insurance company for coverage information or your local pharmacy for pricing.

Long-lasting Tresiba and Ryzodeg

Two more insulins were recently approved by the FDA. Insulin degludec (Tresiba) and a 70/30 mix of insulin degludec and short-acting insulin aspart (Ryzodeg) should be available in pharmacies shortly.

Tresiba is a long-acting insulin that is approved for use in adults with either type 1 or type 2 diabetes. The drug is given as an injection once daily at any time of day. In studies with this insulin, individuals with type 1 and type 2 diabetes who had inadequate glycemic control at the start of the study reached goal blood sugar control comparable to what has been seen with other previously approved long-acting insulins.

The second insulin, Ryzodeg 70/30, combines a long-acting insulin (insulin degludec) with a rapid-acting insulin (insulin aspart or Novolog) and is also indicated for improvement of blood sugar control in adults with diabetes. Study results with this insulin showed that in patients with type 1 and type 2 diabetes who had inadequate blood sugar control at study entry showed the same blood sugar control ability when using Ryzodeg 70/30 as previously available long-acting or pre-mixed insulin.

Hypoglycemia, allergic reactions, injection site reactions, pitting at the injection site, itching, rash, edema and weight gain were the most common adverse events associated with Tresiba and Ryzodeg in clinical trials.

So which insulin is the best for me?

Each person is different, so the best insulin for you is the one that works to control your blood sugars the best with little to no hypoglycemia (low blood sugar). Additional concerns are cost and what is covered by your insurance plan.

It is good practice for you to always bring your logbook or blood glucose meter to your appointments to help your diabetes team help you to best control diabetes blood sugar. And if you have any questions, please discuss them with your team- all questions are important and need attention!

Dr. Peter Huynh is a clinical pharmacist and Certified Diabetes Educator at the University of Washington Diabetes Care Center. He graduated from the University of Connecticut with his Doctor of Pharmacy degree and has completed a diabetes research fellowship at Washington State University. He is actively involved in direct patient care and plays and active role in the diabetes education program at the University of Washington, Diabetes Care Center.

Dr. Rhea C. Smith is a board-certified diabetes educator and a clinical pharmacist at University of Washington Medical Center Diabetes Care Center. Dr. Smith is actively involved in direct patient care as well as serving as a preceptor for students at University of Washington (UW) School of Pharmacy and UW Medicine Pharmacy residents.