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Medical Forum / Diseases and Disorders / Diabetes / March 2007

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Lantus (Glargine)/ Levemir (Detemir) ?

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Kumar - 09 Mar 2007 04:25 GMT
Hello,

Many benefits are indicated specific/uniquue to Lantus (Glargine)/
Levemir (Detemir) insulins;

"http://medweb.bham.ac.uk/easdec/prevention/lantusnotes.htm"

"Insulin glargine, sold under the name Lantus, is a long-acting basal
insulin analogue, usually given once or twice daily to help control
the blood sugar level of those with diabetes. Its theoretical
advantage is that it has a 24 hour duration of action, with a
"peakless" profile. Thus, it more closely resembles the basal insulin
secretion of the normal pancreatic beta cells..
The peakless profile of Lantus also enables the dose to be relatively
higher than standard NPH insulin. Because standard NPH is normally
administered at night, its peak of action tends to coincide with the
lower serum glucose levels associated with nocturnal metabolism. This
can induce nocturnal hypoglycaemia. Lantus offers the benefit of a
more consistent pharmacological dynamic without nocturnal
hypoglycaemia.

Lantus is formulated at pH4, whereby it is completely soluble. Upon
injection, it is neutralized leading to the release small
precipitates. This ensures that small amount of Lantus is released
into the body continuously, giving a peakless profile
http://en.wikipedia.org/wiki/Lantus "

"Key Benefits

No pronounced peak.

Only insulin analog used once a day, proven to lower basal glucose
levels for a full 24 hours.

Can be used with oral diabetes medications and/or short-acting insulin
to control diabetes.
http://chinese-school.netfirms.com/diabetes-insulin-lantus.html "

In view of above quotes, I want to unerstand:-

1. How lantus is different/unique in  its availabilty in view of that
it precipitate and crystalize after injected due changes in its low
pH=4 to 7 whereas other long acting may be injected in already
precipitated/crystalized state due to higher pH (7.0)?

2. How it is diffetrent from other long acting insulins which may also
be having 24hrs effects?

3. How lantus can be claimed to have "no pronounced peak"?

4. With claimed "no pronounced peak and steady availability during 24
hrs.", will it be better suited to diabetics2 with persisting chronic
hyperglycemia (persistance of this take care persistance of higher
glucose levels)?

5. In view of claimed "no pronounced peak and steady availability
during 24 hrs", can it result lesser hunger (if insulin is a cause to
getting hunger) hat other insulins with pronounced peaks?

6. How lantus's considerable low pH=4 than body's injected sites pH(I
think 7 appx.) can damage/effect locally and systemically?

I think, above questions are need to be looked into seriously, so pls
contribute?

Best wishes.
Kumar - 09 Mar 2007 04:28 GMT
> Hello,
>
[quoted text clipped - 60 lines]
>
> Best wishes.

Sorry, other related groups also to contrinute to this topic, so
added.
Andrew B. Chung, MD/PhD - 13 Mar 2007 23:46 GMT
Lantus is really not indicated in someone with the usual type-2
diabetes.

Indeed, type-2 diabetics using Lantus will likely run a higher risk of
becoming hypoglycemic when trying to eat less to lose the visceral
adipose tissue (VAT) that is killing them.

Andrew <><
--
Andrew B. Chung, MD/PhD
http://EmoryCardiology.com

> > Hello,
> >
[quoted text clipped - 63 lines]
> Sorry, other related groups also to contrinute to this topic, so
> added.
Kumar - 14 Mar 2007 08:19 GMT
> Lantus is really not indicated in someone with the usual type-2
> diabetes.
>
> Indeed, type-2 diabetics using Lantus will likely run a higher risk of
> becoming hypoglycemic when trying to eat less to lose the visceral
> adipose tissue (VAT) that is killing them.
Thanks and welcome. How Lantus is specific to above effect?

Pls also tell about other questions.
> Andrew <><
> --
[quoted text clipped - 68 lines]
> > Sorry, other related groups also to contrinute to this topic, so
> > added.
Andrew B. Chung, MD/PhD - 16 Mar 2007 01:04 GMT
> Andrew, in the Holy Spirit, boldly wrote:
>
[quoted text clipped - 6 lines]
>
> Thanks and welcome. How Lantus is specific to above effect?

Lantus has an extremely long duration of action which will make it
less forgiving for someone who has chosen to eat considerably less.

> Pls also tell about other questions.
> > Andrew <><
[quoted text clipped - 44 lines]
> > > > pH=4 to 7 whereas other long acting may be injected in already
> > > > precipitated/crystalized state due to higher pH (7.0)?

It is a different insulin analogue.

> > > > 2. How it is diffetrent from other long acting insulins which may also
> > > > be having 24hrs effects?

Again, it is a different insulin analogue.

> > > > 3. How lantus can be claimed to have "no pronounced peak"?

That is what is observed.

> > > > 4. With claimed "no pronounced peak and steady availability during 24
> > > > hrs.", will it be better suited to diabetics2 with persisting chronic
> > > > hyperglycemia (persistance of this take care persistance of higher
> > > > glucose levels)?

It is for lowering the basal glucose level.

> > > > 5. In view of claimed "no pronounced peak and steady availability
> > > > during 24 hrs", can it result lesser hunger (if insulin is a cause to
> > > > getting hunger) hat other insulins with pronounced peaks?

When beneficial, it will increase hunger.

> > > > 6. How lantus's considerable low pH=4 than body's injected sites pH(I
> > > > think 7 appx.) can damage/effect locally and systemically?

The pH is brought up by the body's buffering system at the site of
injection.

Andrew <><
--
Andrew B. Chung, MD/PhD
http://EmoryCardiology.com
Kumar - 16 Mar 2007 09:54 GMT
> > Andrew, in the Holy Spirit, boldly wrote:
> >
[quoted text clipped - 9 lines]
> Lantus has an extremely long duration of action which will make it
> less forgiving for someone who has chosen to eat considerably less.
But it is claimed to has steady and lesser hypoglycemic giving
effects. Is it better suited to diabetics who have persisting
hyperglycemia and need continual/occasional insulin's exposure during
24hrs?

In view of its claimed "peakless effect", can it cause lesser cravings
due to steady(not peak) exposure?

Can there be some adversities due to its low pH and its continual and
prolonged exposure on increased synthesis and decreased breakdown of
energy stores due to indicated actions of insulin?
> > Pls also tell about other questions.
> > > Andrew <><
[quoted text clipped - 79 lines]
> Andrew B. Chung, MD/PhD
> http://EmoryCardiology.com
Andrew B. Chung, MD/PhD - 17 Mar 2007 08:56 GMT
> Andrew, in the Holy Spirit, boldly wrote:
> > > Andrew, in the Holy Spirit, boldly wrote:
[quoted text clipped - 13 lines]
> But it is claimed to has steady and lesser hypoglycemic giving
> effects.

For someone who is not purposefully eating less to lose his/her
visceral adipose tissue (VAT).

> Is it better suited to diabetics who have persisting
> hyperglycemia and need continual/occasional insulin's exposure during
> 24hrs?

This would not describe someone who is purposefully eating less and is
thus consequently losing his/her VAT and overcoming his/her insulin
resistance.

> In view of its claimed "peakless effect", can it cause lesser cravings
> due to steady(not peak) exposure?

If it is beneficial, a person will be hungrier.

> Can there be some adversities due to its low pH and its continual and
> prolonged exposure on increased synthesis and decreased breakdown of
> energy stores due to indicated actions of insulin?

Local irritation at the site of injection.

Andrew <><
--
Andrew B. Chung, MD/PhD
http://EmoryCardiology.com
Kumar - 17 Mar 2007 14:57 GMT
On Mar 17, 12:56 pm, "Andrew B. Chung, MD/PhD" <lov...@thetruth.com>
wrote:
> > Andrew, in the Holy Spirit, boldly wrote:
> > > > Andrew, in the Holy Spirit, boldly wrote:
[quoted text clipped - 16 lines]
> For someone who is not purposefully eating less to lose his/her
> visceral adipose tissue (VAT).

How such steady any additional long term effect become possible? Is it
different in polymerization into crystals/precipitation after
injection than other long acting insulin?
> > Is it better suited to diabetics who have persisting
> > hyperglycemia and need continual/occasional insulin's exposure during
[quoted text clipped - 3 lines]
> thus consequently losing his/her VAT and overcoming his/her insulin
> resistance.
Yes, but what about to them who are not overcoming his/her insulin
resistance and having persisting hyperglycemia?

> > In view of its claimed "peakless effect", can it cause lesser cravings
> > due to steady(not peak) exposure?
>
> If it is beneficial, a person will be hungrier.
How steady and peakless insulin's exposure can effect irregular eating
habits?
> > Can there be some adversities due to its low pH and its continual and
> > prolonged exposure on increased synthesis and decreased breakdown of
> > energy stores due to indicated actions of insulin?
>
> Local irritation at the site of injection.
Can it cause comparetively more and irreversible tissue damges due to
its lower pH than other insulins with higher pH?
> Andrew <><
> --
> Andrew B. Chung, MD/PhDhttp://EmoryCardiology.com- Hide quoted text -
>
> - Show quoted text -
Andrew B. Chung, MD/PhD - 18 Mar 2007 19:51 GMT
> Andrew, in the Holy Spirit, boldly wrote:
> > > Andrew, in the Holy Spirit, boldly wrote:
[quoted text clipped - 21 lines]
> different in polymerization into crystals/precipitation after
> injection than other long acting insulin?

It is precipitation from decreased solubility at neutral pH compared
to other insulin analogues.

> > > Is it better suited to diabetics who have persisting
> > > hyperglycemia and need continual/occasional insulin's exposure during
[quoted text clipped - 6 lines]
> Yes, but what about to them who are not overcoming his/her insulin
> resistance and having persisting hyperglycemia?

All can overcome their insulin resistance by eating less.

> > > In view of its claimed "peakless effect", can it cause lesser cravings
> > > due to steady(not peak) exposure?
[quoted text clipped - 3 lines]
> How steady and peakless insulin's exposure can effect irregular eating
> habits?

Insulin does not affect irregular eating habits.

> > > Can there be some adversities due to its low pH and its continual and
> > > prolonged exposure on increased synthesis and decreased breakdown of
[quoted text clipped - 4 lines]
> Can it cause comparetively more and irreversible tissue damges due to
> its lower pH than other insulins with higher pH?

Not clinically seen.

Andrew <><
--
Andrew B. Chung, MD/PhD
http://EmoryCardiology.com
Kumar - 19 Mar 2007 09:47 GMT
On Mar 18, 11:51 pm, "Andrew B. Chung, MD/PhD" <lov...@thetruth.com>
wrote:
> > Andrew, in the Holy Spirit, boldly wrote:
> > > > Andrew, in the Holy Spirit, boldly wrote:
[quoted text clipped - 24 lines]
> It is precipitation from decreased solubility at neutral pH compared
> to other insulin analogues.

Whether other long acting are not injected in already precipitated/
crystalize form due to higher/neutral pH? If yes, how these can be
different from lantus in effect?
> > > > Is it better suited to diabetics who have persisting
> > > > hyperglycemia and need continual/occasional insulin's exposure during
[quoted text clipped - 8 lines]
>
> All can overcome their insulin resistance by eating less.
Still who are experiancing persisting hyperglycemia, whether lantus is
better for its claimed steady and continual efect?
> > > > In view of its claimed "peakless effect", can it cause lesser cravings
> > > > due to steady(not peak) exposure?
[quoted text clipped - 5 lines]
>
> Insulin does not affect irregular eating habits.
Previously, I think insulin was related to stimulating hunger?
> > > > Can there be some adversities due to its low pH and its continual and
> > > > prolonged exposure on increased synthesis and decreased breakdown of
[quoted text clipped - 6 lines]
>
> Not clinically seen.
Means, if we inject a solution having pH=4 (equal to insulin), it will
not effect and damage?
> Andrew <><
> --
> Andrew B. Chung, MD/PhDhttp://EmoryCardiology.com- Hide quoted text -
>
> - Show quoted text -
matt weber - 19 Mar 2007 21:04 GMT
>> > How such steady any additional long term effect become possible? Is it
>> > different in polymerization into crystals/precipitation after
>> > injection than other long acting insulin?
The Solubility product of the chemical determines how long and how
flat the curve is.  Lantus has a reputation for having a very low
solubility, so it takes a number of doses to reach steady state, i.e.
it takes much longer than 24 hours for all of a single injection to
dissolve.

By contrast NPH is much more soluble at body pH than Lantus, The more
soluble the insulin, the more 'peaky' it becomes.

>> It is precipitation from decreased solubility at neutral pH compared
>> to other insulin analogues.
[quoted text clipped - 5 lines]
>> > > > hyperglycemia and need continual/occasional insulin's exposure during
>> > > > 24hrs?
Kumar - 20 Mar 2007 08:16 GMT
> >> > How such steady any additional long term effect become possible? Is it
> >> > different in polymerization into crystals/precipitation after
[quoted text clipped - 7 lines]
> By contrast NPH is much more soluble at body pH than Lantus, The more
> soluble the insulin, the more 'peaky' it becomes.

Thanks. As such, will lantus be lesser available insulin than NPH
resulting lesser but prolonged steady effect? Will lantus be required
more units to be injected than NPH to control blood glucose levels,
considering its slower/lesser but steady effect?

Btw, in healthy people, how endogenous insulin behave--with peaks or
peakless?

Pls also tell about other questions...as possible tissue damges due to
low pH, positive and negative impacts on continual exposure's specific
to lantus and lantus impact on overeatings (if promoted by more and
continual insulin's exposures?
> >> It is precipitation from decreased solubility at neutral pH compared
> >> to other insulin analogues.
[quoted text clipped - 5 lines]
> >> > > > hyperglycemia and need continual/occasional insulin's exposure during
> >> > > > 24hrs?
matt weber - 20 Mar 2007 23:06 GMT
>> >> > How such steady any additional long term effect become possible? Is it
>> >> > different in polymerization into crystals/precipitation after
[quoted text clipped - 12 lines]
>more units to be injected than NPH to control blood glucose levels,
>considering its slower/lesser but steady effect?
Ultimately total  Lantus dose  and NPH/Ultralente daily doses will be
the same, i.e. at some point you reach equilibirium, but that takes
many days, and until that happens you are either going to live with
high BG numbers, or use a faster acting insulin like  NPH or
R/Humalog/Novolog to provide cover until the Lantus reaches steady
state.

>Btw, in healthy people, how endogenous insulin behave--with peaks or
>peakless?
In circulation, Insulin has a pretty short half life.. on the order of
10-15 minutes. Insuliin is produced as Proinsulin, which is not
active, Proinsulin is broken down into insulin and Peptide C.

We inject insulin under the skin and let it diffuse into the
circulator system. It acts much more rapidly if given by IV. Injected
R insulin is also slowed down because in storage it bonds with itself
toward the back of the B chain, making  a dimer (2 molecules tied
together). The Dimer in inactive, and  has a half life on the order of
30 minutes, which is why there is a lag in effect when R type insulin
is given, even by IV.

Humalog was designed not to have that problem. By re-arranging the
back end of the B chain (Which Humalog, Novolog/Novorapid and Apidra
all do) you can prevent the dimer from forming, so the injected
insulin is immediately active.

>Pls also tell about other questions...as possible tissue damges due to
>low pH, positive and negative impacts on continual exposure's specific
>to lantus and lantus impact on overeatings (if promoted by more and
>continual insulin's exposures?
compared to 'real' acids, Lantus pH is pretty high. It takes very
little to counter the acidity of Lantus. a Ph of 4 means you only need
1/1000th as much base to counter it as you would need from an equal
volume of a real acid (like HCl or H2SO4)....

>> >> It is precipitation from decreased solubility at neutral pH compared
>> >> to other insulin analogues.
[quoted text clipped - 5 lines]
>> >> > > > hyperglycemia and need continual/occasional insulin's exposure during
>> >> > > > 24hrs?
Kumar - 21 Mar 2007 10:21 GMT
> >> >> > How such steady any additional long term effect become possible? Is it
> >> >> > different in polymerization into crystals/precipitation after
[quoted text clipped - 12 lines]
> >more units to be injected than NPH to control blood glucose levels,
> >considering its slower/lesser but steady effect?

> Ultimately total  Lantus dose  and NPH/Ultralente daily doses will be
> the same, i.e. at some point you reach equilibirium, but that takes
> many days, and until that happens you are either going to live with
> high BG numbers, or use a faster acting insulin like  NPH or
> R/Humalog/Novolog to provide cover until the Lantus reaches steady
> state.
Does it also indicates, injecting more lantus units than other long
acting?
> >Btw, in healthy people, how endogenous insulin behave--with peaks or
> >peakless?
> In circulation, Insulin has a pretty short half life.. on the order of
> 10-15 minutes. Insuliin is produced as Proinsulin, which is not
> active, Proinsulin is broken down into insulin and Peptide C.
Ultimate effect of any insulin is in monomerization. How peak effect
by any insulin is calculated?

Btw, in what polymer sized chain, other long acting insulins and
lantus are there--pre/post injected?
> We inject insulin under the skin and let it diffuse into the
> circulator system. It acts much more rapidly if given by IV. Injected
[quoted text clipped - 3 lines]
> 30 minutes, which is why there is a lag in effect when R type insulin
> is given, even by IV.
In body, is it either monomer or dimer of any insulin's molecules?

> Humalog was designed not to have that problem. By re-arranging the
> back end of the B chain (Which Humalog, Novolog/Novorapid and Apidra
[quoted text clipped - 9 lines]
> 1/1000th as much base to counter it as you would need from an equal
> volume of a real acid (like HCl or H2SO4)....
Means, lantus due to its low pH, not specifically damaging to tissues
in any way?
> >> >> It is precipitation from decreased solubility at neutral pH compared
> >> >> to other insulin analogues.
[quoted text clipped - 5 lines]
> >> >> > > > hyperglycemia and need continual/occasional insulin's exposure during
> >> >> > > > 24hrs?
matt weber - 22 Mar 2007 04:57 GMT
>> >> >> > How such steady any additional long term effect become possible? Is it
>> >> >> > different in polymerization into crystals/precipitation after
[quoted text clipped - 28 lines]
>Ultimate effect of any insulin is in monomerization. How peak effect
>by any insulin is calculated?
perhaps in the short term, but long term, once you have reached
equilibirium, a unit of insulin injected  is a unit of insulin
injected.....

>Btw, in what polymer sized chain, other long acting insulins and
>lantus are there--pre/post injected?
[quoted text clipped - 6 lines]
>> is given, even by IV.
>In body, is it either monomer or dimer of any insulin's molecules?
When R insulin is injected it is a dimer. NPH, S,L and U are
cystalline structures built around  6 insulin moleculre wrapped around
a protamine core. The insulin dissociateds from a Hexamer to a Dimer
to a monomer. Only the Monomer is active.

>> Humalog was designed not to have that problem. By re-arranging the
>> back end of the B chain (Which Humalog, Novolog/Novorapid and Apidra
[quoted text clipped - 11 lines]
>Means, lantus due to its low pH, not specifically damaging to tissues
>in any way?
It has a relatively low pH, but we are talking about tiny amounts
(fractions of a cc) of what is at best, only weakly acidic.  The
injection will cause a few milligrams to bicarbonate to be
neutralized, and compared to overall bicarbonate stores,
insignificant.....
The pH is not low enough to cause any significant tissue damage.
It isn't like you are injecting concentrated Sulfuric or Hydrochloric
acid.
Kumar - 22 Mar 2007 05:14 GMT
> >> >> >> > How such steady any additional long term effect become possible? Is it
> >> >> >> > different in polymerization into crystals/precipitation after
[quoted text clipped - 32 lines]
> equilibirium, a unit of insulin injected  is a unit of insulin
> injected.....
Can imbalance/instability in any ICF prminient constitutent as
Potassium caused by added/reduced injected insulin be a reason to show
acute effects of instablities of that constituent? Whether
Hypoglycemia's symptoms resembles with some symptoms of potassium, Mg,
Phosphate instabilities?
> >Btw, in what polymer sized chain, other long acting insulins and
> >lantus are there--pre/post injected?
[quoted text clipped - 11 lines]
> a protamine core. The insulin dissociateds from a Hexamer to a Dimer
> to a monomer. Only the Monomer is active.

Whether lantus is in monomerized form before injected?

Is it possible that solubility/availability of polymerized insulin is
different in different people? If yes how?

> >> Humalog was designed not to have that problem. By re-arranging the
> >> back end of the B chain (Which Humalog, Novolog/Novorapid and Apidra
[quoted text clipped - 20 lines]
> It isn't like you are injecting concentrated Sulfuric or Hydrochloric
> acid.-

Thanks for much information.

Hide quoted text -

> - Show quoted text -- Hide quoted text -
>
> - Show quoted text -
Kumar - 31 Mar 2007 08:04 GMT
> >> >> On 19 Mar 2007 01:47:37 -0700, "Kumar" <lordshiva5...@gmail.com>
> >> >> wrote: Followings are the indicated actions of insulin:-

"Actions on cellular and metabolic level

Effect of insulin on glucose uptake and metabolism. Insulin binds to
its receptor (1) which in turn starts many protein activation cascades
(2). These include: translocation of Glut-4 transporter to the plasma
membrane and influx of glucose (3), glycogen synthesis (4), glycolysis
(5) and fatty acid synthesis (6).The actions of insulin on the global
human metabolism level include:

Control of cellular intake of certain substances, most prominently
glucose in muscle and adipose tissue (about ⅔ of body cells).
Increase of DNA replication and protein synthesis via control of amino
acid uptake.
Modification of the activity of numerous enzymes (allosteric effect).
The actions of insulin on cells include:

Increased glycogen synthesis – insulin forces storage of glucose in
liver (and muscle) cells in the form of glycogen; lowered levels of
insulin cause liver cells to convert glycogen to glucose and excrete
it into the blood. This is the clinical action of insulin which is
directly useful in reducing high blood glucose levels as in diabetes.
Increased fatty acid synthesis – insulin forces fat cells to take in
blood lipids which are converted to triglycerides; lack of insulin
causes the reverse.
Increased esterification of fatty acids – forces adipose tissue to
make fats (ie, triglycerides) from fatty acid esters; lack of insulin
causes the reverse.
Decreased proteinolysis – forces reduction of protein degradation;
lack of insulin increases protein degradation.
Decreased lipolysis – forces reduction in conversion of fat cell lipid
stores into blood fatty acids; lack of insulin causes the reverse.
Decreased gluconeogenesis – decreases production of glucose from
various substrates in liver; lack of insulin causes glucose production
from assorted substrates in the liver and elsewhere.
Increased amino acid uptake – forces cells to absorb circulating amino
acids; lack of insulin inhibits absorption.
Increased potassium uptake – forces cells to absorb serum
potassium[some other mineral also dependant on K homeostatis]; lack of
insulin inhibits absorption.
Arterial muscle tone – forces arterial wall muscle to relax,
increasing blood flow, especially in micro arteries; lack of insulin
reduces flow by allowing these muscles to contract.
http://en.wikipedia.org/wiki/Insulin "

In nature, in normal person, insulin may not be exposed continually
and more. As such and in view of above indicated actions of insulin,
how more and continual exposure of insulin can effect adversely?
shoppa@trailing-edge.com - 09 Mar 2007 20:55 GMT
> 2. How it is diffetrent from other long acting insulins which may also
> be having 24hrs effects?
[quoted text clipped - 9 lines]
> during 24 hrs", can it result lesser hunger (if insulin is a cause to
> getting hunger) hat other insulins with pronounced peaks?

In the perfect world it wouldn't have any peak and would be good for
24 hours, but in the real world it doesn't always work that way for
everybody. Some of us take two shots 12 hours apart to smooth it out.

There is a broad peak at about 6 hours and many of us time our shots
to position that peak where it's most useful.

Tim.
Kumar - 10 Mar 2007 02:25 GMT
On Mar 10, 1:55 am, sho...@trailing-edge.com wrote:

> > 2. How it is diffetrent from other long acting insulins which may also
> > be having 24hrs effects?
[quoted text clipped - 18 lines]
>
> Tim.

Thanks.What about other possibilities?
tseverson - 11 Mar 2007 17:58 GMT
My 94-year-old Mother is a Type 2 diabetic (over 30 years). Her blood
glucose readings have a long history of being in the "out of control"
range. She is currently using "insulin N" (NPH). Could she consider
switching to Lantus or Levemir?
 
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