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Human insulin

Classification: A

Drug products: Actrapid, Actrapid PenSet, Actrapid®, Actrapid® NovoLet®, Actrapid® Penfill®, Humulin M3, Humulin M3 KwikPen, Humulin® Mix 30/70, Humulin® NPH, Humulin® NPH KwikPen, Humulin® Regular, Insulatard, Insulatard NovoLet, Insulatard PenSet, Insulatard®, Insulatard® FlexPen®, Insulatard® InnoLet, Insulatard® Penfill®, Insulin HOE21 PH U 400, Insuman Comb 25 Optiset, Insuman Implantable, Insuman® Basal, Insuman® Basal OptiSet®, Insuman® Basal SoloStar, Insuman® Comb 25, Insuman® Comb 25 OptiSet®, Insuman® Comb 25 SoloStar, Insuman® Infusat, Insuman® Rapid, Insuman® Rapid OptiSet®, Insuman® Rapid SoloStar, Mixtard 10/90 PenSet, Mixtard 20/80 PenSet, Mixtard 30/70 Innolet, Mixtard 30/70 PenSet, Mixtard 40/60 PenSet, Mixtard 50/50 PenSet, Mixtard® 10 NovoLet®, Mixtard® 10 Penfill®, Mixtard® 20 NovoLet®, Mixtard® 20 Penfill®, Mixtard® 30, Mixtard® 30 NovoLet®, Mixtard® 30 Penfill®, Mixtard® 40 NovoLet®, Mixtard® 40 Penfill®, Mixtard® 50 NovoLet®, Mixtard® 50 Penfill®, Monotard®, Velosulin®

ATC code: A10AB01, A10AC01, A10AD01

Summary

Controlled studies on differences between men and women are lacking. Meta-analyses have shown a possible higher risk of hypoglycemia in women.
 

Additional information

Three meta-analyses have looked at pooled data from randomized clinical trials on sex-differences and treatment outcome in patients with type 2 diabetes. The majority of patients included in the three meta-analyses are from the same studies.

Kautzky-Willer et al performed a meta-analysis published in 2014/2015 based on pooled data from six randomized clinical trial data (1349 men, 1251 women). The patients had inadequately controlled type 2 diabetes treated with oral antidiabetics. Insulin glargine or NPH insulin was added and evaluated after 24-36 weeks [1].

McGill et al performed a meta-analysis published in 2013 with pooled data from nine similarly designed randomized controlled studies. They evaluated 1651 adult men and 1287 women who were treated with insulin glargine or comparators (NPH insulin, insulin lispro, premixed insulin, oral antidiabetic drugs, or diet), respectively, for 24 weeks [2].

Owens et al performed a meta-analysis published in 2017 with pooled data from 16 randomized treat-to-target clinical trials including a total of 3188 patients (1680 men, 1508 women). Insulin glargine 100 U/mL was added to oral antidiabetic agents and evaluated after 24 weeks [3].

Pharmacokinetics and dosing

Kautzky-Willer et al found a higher insulin dose/kg after 24 weeks of treatment, (0.47 U/kg for women vs 0.42 U/kg for men) [1]. McGill et al found that at study end, men were receiving lower weight-adjusted insulin doses of insulin glargine vs comparators than (least squares mean difference for men  compared to women  -0.03 IU/kg) [2]. It is unlikely that these subtle differences have any clinical relevance.

Effects

Kautzky-Willer et al studied the effect of insulins on HbA1c, when insulin glargine and NPH insulin were added to oral antidiabetic drugs. Comparison of baseline demographics showed no effect of patient sex for glargine/NPH insulin use, HbA1c levels or fasting blood glucose levels (FBG). In the overall comparison, men had a lower HbA1c at study end (HbA1c 7.6% vs 7.8% in women), with a greater change in HbA1c for men (-1.36 vs -1.22 for women). Also in the overall comparison, a sex difference was seen in patients achieving a glycemic target of HbA1c 7% (53 mmol/mol) (32.99% of men vs 26.54% of women). A difference in change in FBG from baseline was seen (-4.33 mmol/L for women vs -3.93 mmol/L for men) [1].

McGill et al found no difference between men and women in the likelihood of achieving a glycemic target of HbA1c 7% for patients receiving comparator treatment, nor in the overall comparison (comparator treatment or insulin glargine) between men and women. For patients receiving insulin glargine, women were less likely than men to achieve a glycemic target of HbA1c 7%, (54.5% vs 60.8%), with a mean HbA1c of 6.9% (0.9) for men vs 7.1% (0.9) for women (unknowen if significant). Men receiving NPH insulin were similarly more likely to reach HbA1c 7% than women (OR 1.59 (1.06-2.40)). No difference in FBG was seen at baseline. At study end, women receiving insulin glargine or comparators had a 3.1 mg/dl (0,02 mmol/L) greater reduction from baseline in FBG compared with men [2].

Owens et al found that women had an overall slightly smaller reduction in HbA1c from baseline to week 24, reduced by 1.4% reaching 7.3% compared to a reduction by 1.6% for men, reaching HbA1c 7.1% (unknown if significant). No sex differences were found in reductions in HbA1c for patients using SU only prior to initiation of insulin treatment [3].

It is unclear if the subtle differences described above have any clinical implication.

Adverse effects

The three above mentioned meta-analyses all found a higher frequency of hypoglycemia, defined as blood glucose levels 70 mg/dl (4 mmol/l), in women than in men.

Kautzky-Willer et al found that a higher proportion of women overall (oral antidiabetic drugs (OAD) + insulin glargine (Lantus) or NPH insulin) experienced a severe hypoglycaemic episode (3.28% of women compared to 1.85% of men). Severe nocturnal hypoglycaemia was seen overall in 2.24% of women vs 0.59% of men  [1].

McGill et al found that women overall (treated with insulin glargine or comparator treatment NPH insulin, insulin lispro, premixed insulin, oral antidiabetes drugs, or diet) were more likely to experience at least one severe hypoglycemic event than men (OR 1.85, 95% CI 1.03-3.34 ) [2].

Owens et al found an overall (OAD + insulin glargine) incidence of hypoglycemia of 44.9% for women vs 41.3% for men, and an event rate (events per patient-year) of 4.8 vs 3.7 [3].

One study retrospectively analysed four large trials including 713 patients (47% women) with type 2 diabetes. Insulin glulisine was added to a basal treatment with OAD and insulin glargine. Female gender was identified as a predictor of nocturnal and symptomatic hypoglycemia (OR 1.82; 95% CI 1.07-3.11 and OR 1.89; 95% CI 1.31-2.78) [4].

Reproductive health issues

Concurrent administration of human insulin and oral contraceptives may decrease the effect of human insulin [5]. Regarding drug-drug interactions aspects, please consult Janusmed Interactions (in Swedish, Janusmed interaktioner).

Human insulin can be used in pregnant women. Insulin requirements may change during pregnancy, and quickly return to normal after delivery [5]. Regarding teratogenic aspects, please consult Janusmed Drugs and Birth Defects (in Swedish, Janusmed fosterpåverkan).

Other information

Two observational studies from the 1990’s with a total of 418 patients (43 men, 374 women) reported intentional insulin omission among 1/3 of women to control their weight [6,7].

In a retrospective study in 124 women, perimenstrual changes in selfreported glucose concentrations were found in 61%. Use of oral contraceptives did not diminish variability in blood glucosis [8]. In another study based on questionnaires (406 women) 67% of the participants reported changes in blood glucose levels or glycosuria premenstrually and 70% during the menstrual phase. Those with more cravings had larger elevations in blood glucosis levels suggesting that giving in to cravings might cause the changes [9].

Updated: 2018-01-07

Date of litterature search: 2017-09-05

References

  1. Kautzky-Willer A, Kosi L, Lin J, Mihaljevic R. Gender-based differences in glycaemic control and hypoglycaemia prevalence in patients with type 2 diabetes: results from patient-level pooled data of six randomized controlled trials. Diabetes Obes Metab. 2015;17:533-40. PubMed
  2. McGill JB, Vlajnic A, Knutsen PG, Recklein C, Rimler M, Fisher SJ. Effect of gender on treatment outcomes in type 2 diabetes mellitus. Diabetes Res Clin Pract. 2013;102:167-74. PubMed
  3. Owens DR, Bolli GB, Charbonnel B, Haak T, Landgraf W, Porcellati F et al. Effects of age, gender, and body mass index on efficacy and hypoglycaemia outcomes across treat-to-target trials with insulin glargine 100 U/mL added to oral antidiabetes agents in type 2 diabetes. Diabetes Obes Metab. 2017;19:1546-1554. PubMed
  4. Seufert J, Brath H, Pscherer S, Borck A, Bramlage P, Siegmund T. Composite efficacy parameters and predictors of hypoglycaemia in basal-plus insulin therapy--a combined analysis of 713 type 2 diabetic patients. Diabetes Obes Metab. 2014;16:248-54. PubMed
  5. Insulatard (insulin human). Summary of Product Characteristics. European Medicines Agency (EMA); 2017.
  6. Polonsky WH, Anderson BJ, Lohrer PA, Aponte JE, Jacobson AM, Cole CF. Insulin omission in women with IDDM. Diabetes Care. 1994;17:1178-85. PubMed
  7. Bryden KS, Neil A, Mayou RA, Peveler RC, Fairburn CG, Dunger DB. Eating habits, body weight, and insulin misuse A longitudinal study of teenagers and young adults with type 1 diabetes. Diabetes Care. 1999;22:1956-60. PubMed
  8. Lunt H, Brown LJ. Self-reported changes in capillary glucose and insulin requirements during the menstrual cycle. Diabet Med. 1996;13:525-30. PubMed
  9. Cawood EH, Bancroft J, Steel JM. Perimenstrual symptoms in women with diabetes mellitus and the relationship to diabetic control. Diabet Med. 1993;10:444-8. PubMed
  10. Läkemedelsstatistik. Stockholm: Socialstyrelsen. 2016 [cited 2017-12-08.] länk

Authors: Anna Törring

Reviewed by: Mia von Euler

Approved by: Karin Schenck-Gustafsson