Lispro Insulin Decreases Severe Hypoglycemia and Improves Lifestyle
ABSTRACT & COMMENTARY
Synopsis: Substituting lispro insulin for regular insulin in patients receiving multiple injections reduced the severity of hypoglycemia reactions and improved their perception of quality of life.
Source: Hollema F, et al. Diabetic Care 1997;20:1827-1832.
In a recent study, hollema and colleagues evaluated the effects of insulin lispro on glycemic control and hypoglycemic rates in well-controlled IDDM patients. This was an open, randomized, six-month crossover study of 199 IDDM patients. Glycemic control was evaluated by HbA1c home blood glucose measurements and rate and timing of hypoglycemic events. At the end of the study, patients completed an evaluation form regarding therapy-related quality of life.
HbA1c remained constant at ~7.3% throughout the study. Meal-related glucose excursions were significantly lower with insulin lispro compared with regular insulin, as was the within-day variability. The incidence of severe hypoglycemic events (58 vs 36; P = 0.037), including coma (16 vs 3; P = 0.004), was significantly lower with insulin lispro than with regular insulin. Patients felt that insulin lispro increased flexibility and freedom of lifestyle.
In well-controlled IDDM patients, insulin lispro is associated with a lower risk of severe hypoglycemia and coma.
COMMENT BY RALPH R. HALL, MD
This study was conducted in a well-controlled group of patients whose HbA1cs averaged 7.3%. Patients were instructed to inject regular insulin one-half hour before meals and to inject lispro insulin immediately before meals. NPH insulin was given in the morning and was allowed (although discouraged) in the evening, if the evening meal glucose was greater than 140 mg/dL.
Lispro insulin can be given just before meals because of its rapid onset of action (time to peak < 1 hour). Regular insulin has its peak in 2-5 hours. Lispro insulin has been cleared from the circulation by four hours, while regular insulin lasts up to eight hours.
In the Diabetic Control and Complication Trial (DCCT), the incidence of severe hypoglycemia (i.e., necessity for third party assistance) was three times higher in the intensively treated group as compared with conventionally treated patients.1 Therefore, a means of therapy, which can maintain similar control with less severe and frequent hypoglycemia, is welcome to both physicians and patients.
Another end point in this study was a quality of life evaluation. Patients found more flexibility in their lifestyle. Around 86% found that the use of lispro insulin was easier, while only 2% found it more difficult. Approximately 51% vs. 9% found planning of physical activities was easier. I have had a number of reports from athletes and those who exercise in the late afternoon, when their lispro insulin is no longer present, who indicate that they have fewer problems with hypoglycemia and are less likely to have to supplement or alter their eating schedule.
Another interesting observation was that only 27% of the patients reported that they actually took their regular insulin one-half hour before their meals. This confounds the study to some extent, but it is consistent with other studies whose patients were instructed to take insulin one-half hour before meals.2
There are a number of suggestions and observations in this study that make reading the entire report valuable to any physician wishing to begin the use of lispro insulin in the management of their diabetic patients.
References
1. DCCT Research Group. N Engl J Med 1993;329:977-986.
2. Lean MEJ. BMJ 1985;290:105-108.
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