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Dr. Tsimikas:
Hello. This is CME on PACE CME and ReachMD, and I'm Dr. Athena Philis-Tsimikas. And today, I'll be talking to you about starting and titrating once-weekly basal insulins.
We have two basal insulins which have been introduced and are in series of clinical trials, actually have completed phase 3 clinical trials now and are available in some countries across the world.
For people starting out, they need insulin and you want to be able to start them once-weekly, how should you dose them? And if you remember, for our once-daily insulins, we use a dose of 10 units once a day. For insulin icodec, you would simply multiply this by 7 and start with 70 units once a week, and that is the starting dose.
For insulin efsitora alpha, the starting dose was done in two different ways in the two trials that were conducted, either 100 units were started once a week or patients were given 300 units as an initial dose and then 100 units thereafter every week with titration then based on what their average blood sugars were.
How about those switching from once-daily insulin to once-weekly, and let's start with icodec in people with type 2 diabetes. We would convert their daily basal insulin dose by multiplying that dose by 7. So, for example, if their daily dose is 20 units, multiply it by 7, it would be 140 units. But in addition, for the first injection only, we add an additional 50% dose in order to achieve a faster level of glycemic control and allow them to reach their steady state. So, for that patient on 20 units, multiply by 7, they’re now on 140 units, you add an additional 50%. And this would now lead to 210 units for that first dose only.
After that, you would continue with 140 units every week, titrating as needed to achieve target glucose management.
How about efsitora alpha? How do you switch for this one? And this one, in a similar way, you would take their starting dose of daily basal insulin and multiply by 7. So, again, if you're 20 units, multiplied by 7 they would be 140 units. But for efsitora alpha, in the trials, what was done is it was multiplied 3 instead of 1.5. So, for the first dose, they would require 420 units in our example, but subsequent doses would go back to 140 units, and then titration thereafter.
OK. You have successfully started your patients, now, on once-weekly insulin, how do you titrate? For insulin icodec, this was a pretty easy titration schedule. If they were at target, and you would look at their blood glucoses for 3 days prior to their next dose, and the target used was between 80 to 130. If their average on those three days was above 130, you'd increase the dose by 20 units. If it's below 80, then you would decrease the dose by 20 units. And in addition, if they had any events of hypoglycemia, you would be reducing the dose by 20 units as well.
How about for efsitora alpha for titration? This was done in two different ways. There it was a fixed dose escalation of efsitora alpha. So, pens that were available started at 100 units. They could be titrated if they were above target to 150, 250 and up to 400. Once again, if– there were any episodes of hypoglycemia, you would reduce down to the previous fixed dose. And then, if you wanted to do individualized titration, for efsitora alpha, the target was 80 to 120. If you were from 121 to 140, you would increase by 20 units. If you were above 140, the recommendation was to increase by 40 units. And also, if there was hypoglycemic episodes below 80, reduce by 20 units. If there was significant and severe hypoglycemia, you would reduce by 40 units.
So, the once-weekly scheduling that can be offered to our patients can be beneficial in terms of reducing their complications in the long run and maintaining their targets.
Thanks so much. It’s been a pleasure speaking to you today.
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