Levemir
Levemir
Generic Name
Levemir
Mechanism
Levemir (insulin detemir) is a long‑acting, recombinant human insulin analog that binds to albumin in the subcutaneous space.
• Albumin binding slows absorption, producing a flat, steadier insulin profile (≈24 h).
• Unmodified action: once bound, it functions like normal human insulin, activating the insulin receptor to stimulate glucose uptake in muscle and adipose tissue, inhibit hepatic gluconeogenesis, and promote glycogen synthesis.
• No significant hormopeptide synthetic effect—it purely mimics physiological insulin release without stimulating lipogenesis beyond basal needs.
Pharmacokinetics
| Parameter | Value | Notes |
| Absorption | T_max 6‑12 h (after SC injection) | Slows via albumin binding |
| Bioavailability | ~60–70 % SC | Depends on injection site and mix |
| Half‑life | ~4 h (free) / >30 h (albumin‑bound) | Steady‑state trough maintained >20 h |
| Metabolism | Degraded by proteases to des‑fibrinogen peptides | No active metabolites |
| Excretion | Renal & hepatic | No active metabolites; normal in CKD‑GFR>30 mL/min |
> Key take‑away: Levemir’s long, flat action eliminates typical peaks, reducing nocturnal hypoglycemic risk.
Indications
- Type 1 diabetes: Basal insulin replacement in combination with prandial insulin.
- Type 2 diabetes: Basal insulin in patients inadequately controlled on oral agents or basal‑bolus strategy.
Contraindications
| Category | Detail |
| Contraindications |
• Known hypersensitivity to insulin detemir or any component. • Severe hypoglycemia unresponsive to glucagon. |
| Warnings |
• Hypoglycemia (especially nocturnal). • Lipid accumulation or increased lipogenesis with high doses. • Pregnancy – use only if benefits outweigh risks; not FDA‑approved for systemic use. |
| Precautions |
• Renal or hepatic impairment: minimal effect, but adjust if signs of accumulative effect. • Elderly: increased insulin sensitivity → lower starting dose. |
Dosing
- Starting dose: 10 units SC once daily (usually before bedtime) or twice daily (commonly before breakfast and bedtime).
- Titration: Incrementally adjust by 2–4 units every 3–4 days based on fasting glucose.
- Maximum recommended: 50 units/day (individualized, often lower for type 1).
- Injection sites: Abdomen, thighs, or upper arm (rotating sites).
- Mixing: If mixing with rapid‑acting insulin, use a single syringe; keep in the refrigerator when stored mixed.
- Missed dose: Skip and resume regular timing; no correction dose required.
Adverse Effects
- Common:
- Hypoglycemia (especially at night).
- Injection‑site reactions: erythema, pruritus, induration.
- Mild edema or weight gain.
- Serious:
- Severe hypoglycemia → altered sensorium or seizures.
- Hypokalemia or hypophosphatemia with hypoglycemia.
- Rare hypersensitivity reactions (anaphylaxis).
- Lipohypertrophy if injection sites are not rotated adequately.
Monitoring
- Blood glucose: Capillary fasting, pre‑meal, bedtime, especially during titration.
- HbA1c: Every 3 months (or as per protocol).
- Body weight & BMI: Monitor for unintended weight gain.
- Serum lipids: Baseline, then annually if high‑dose used.
- Renal & hepatic panels: Baseline; repeat if dose change >20 %.
- Hypoglycemia symptoms: Document episodes, adjust dose accordingly.
- Insulin injection site survey: Inspect for lipohypertrophy or abscess.
Clinical Pearls
- “No‑peak” advantage: Levemir’s flat profile is ideal for patients prone to post‑prandial glucose spikes but at risk of nighttime lows.
- Age matters: Start 5 units lower in patients >75 yrs or with frailty; tailor to sensitivity.
- Mixing etiquette: If co‑administered with rapid‑acting analogs, use a single syringe to avoid isotonic differences; discard after 24 h.
- Glycemic tags: Label the insulin vial with “leaving‑no‑peak” to remind nurses or caregivers of its unique pharmacodynamic curve.
- PBM: Pancreatic beta cell stability – Because Levemir’s sustained action prevents glucagon over‑release, the risk of lipolysis‑driven weight loss is lower compared to intermediate‑acting insulins.
- Safe ‑less: A 10‑unit starting dose is clinically safe even in those with marginal renal function; renal impairment does not clear insulin detemir appreciably.
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• *Prepared by: Precise Pharmacology Assistant*