Clinical Use and Practical

Recommendation of IDegAsp
in Type 2 Diabetes Mellitus
Dr. dr. Himawan Sanusi, Sp.PD, K-EMD
5 March 2022

For Healthcare Professional Only

2022© Novo Nordisk A/S
Disclosure

I have received honorarium as speaker/consultant, support for research/attendance at

educational meetings from:
• Novo Nordisk
• Astra Zeneca
• Sanofi
• Bohringer Engelhiem
• Merck
• MSD
• Eli Lily
Practical recommendation from Australia and multinational
setting
Guidelines in understanding the use of
IDegAsp in people with diabetes came
from Roopa Mehta (published 2020) and
from Sarah Galtras (published 2020)

Providing expert opionion on the use of

IDegAsp for the treatment of T2DM1,2

References: 1. Sarah Galtras et al. J Clin Med 2020. 2. Roopa M et al. Diabetes Obes Metab. 2020;1-15
IDegAsp is the FIRST Co-formulation Insulin1-3

Providing basal and prandial insulin cover when

administered with meals

References: Roopa M et al. Diabetes Obes Metab. 2020;1-15 2, Heller S et al. Diabetes Metab Res Rev. 2012;28(1):50-
61 3. Heise et al. Diabetes Ther 2014;5(1):255-265.
Guidance When & How to use IDegAsp

Clinical guidance For the use in people with T2DM: Initiation

IDegAsp – Intensification - Switching

Co-administration with other

Drug Interaction
antidiabetic medications

Patients profile Use of IDegAsp in special populations

 Clinical guidance For the use in people with T2DM: Initiation
IDegAsp – Intensification - Switching

INITIATION INTENSIFICATION SWITCHING

• From OAD Failure • From basal to • From basal
IDegAsp
• From basal plus
• From IDegAsp OD • From pre-mix
to BID
• From basal bolus

References: 1. Sarah Galtras et al. J Clin Med 2020. 2. Roopa M et al. Diabetes Obes Metab. 2020;1-15
Clinical guidance on initiation

Clinical evidence support the study of …IDegAsp OD to be considered as2,3

IDegAsp initiation of people with T2DM
[Onishi]1:
INITIATION (OAD FAILURE)
Superior reduction of HbA1C
PREFERRABLE TO BASAL INSULIN ALONE
Numerical lower risk of
Nocturnal Hypoglycemia 25% • Max OAD therapy but HbA1C >7 and
PPG 180 mg/dL
More patient achieve target • Extreme & symptomatic Hyperglycemia
without hypoglycemia 2X
• Postprandial Hyperglycaemia is a concern
• People with low BMI

References: 1. Onishi et al. Diabetes Obes Metab 2013;15:826–32 2. Sarah Galtras et al. J Clin Med 2020. 3. Roopa M et al. Diabetes Obes Metab. 2020;1-
15
Recommended starting dose for initiations

Starting dose Severe Hyperglycemia

HbA1c >10% (86 mmol/mol)*

10
With largest meals
Unit/OD > 10
With largest meals
Unit/OD

Followed by subsequent INDIVIDUAL dosage

*This posology is based on expert recommendations from
weekly adjustment until the desired FPG
Sarah G et al. reached

References: 1. Sarah Galtras et al. J Clin Med 2020. 2. Roopa M et al. Diabetes Obes Metab. 2020;1-15 3. Ryzodeg®.
Indonesia Prescribing Information. 2021
 Intensification from IDegAsp OD

If Adequate glycaemic control If HbA1C is not met with IDegAsp OD, glucose monitoring is
needed to determine where hyperglycaemia is occurring.
is not achieved with
TREATMENT INTENSIFICATION

Treatment can be intensified to

IDegAsp OD

A IDegAsp (Split dose)

Treatment can be intensified
to….
B IDegAsp OD + Iasp at one
or more meals

3 C IDegAsp (split dose) + Iasp

+
Alternative at the third meals
Strategy to
achieve adequate
glycaemic control

References: 1. Sarah Galtras et al. J Clin Med 2020. 2. Roopa M et al. Diabetes Obes Metab. 2020;1-15
 IDegAsp Split IDegAsp split + Iasp IDegAsp OD + Iasp

or

When &
How do ‘if there are post prandial `if there are persistent
you glucose excursion after 2 excessive post prandial
intensify: meals’ ‘if post prandial occurs when
glucose excursion’ FPG is normal’
Recommend a max OD dose (i.e 3 reading of >180 mg/dL
30-40 unit before splitting. (i.e in country where meals
over 1 week on SMBG /
capillary blood glucose)* are typically rich in
The dose ratio not necessarily carbohydrate)
(1:1) with a minimum dosing
interval of 4 hours

*: this may be vary with individualise target and monitoring frequency

References: 1. Sarah Galtras et al. J Clin Med 2020. 2. Roopa M et al. Diabetes Obes Metab. 2020;1-15
Switching to IDegAsp from other treatments regimen

SWITCHING
FROM IDegAsp

1:1
BASAL OD/BID OD/Split dose

Initiated at the same dosage as

the basal insulin
Basal Plus OD*

1:1
Premix OD/Split Dose

Initiated at the same

dosage as the basal insulin INDIVIDUAL
Basal Bolus
REQUIREMENT

*This posology is based on expert recommendations from Sarah G et al.

References: 1. Sarah Galtras et al. J Clin Med 2020. 2. Roopa M et al. Diabetes Obes Metab. 2020;1-15 3. Ryzodeg®
Indonesia Prescribing Information 2021.
 Practical recommendation switching from Basal to IDegAsp

GUIDANCE – Switching from Basal1-4 Practical Consideration switching from basal

insulin to IDegAsp 1-2
FROM IDegAsp

1:1 • Whether basal insulin offers appropriate glycaemic

BASAL OD/BID OD/Split dose control; (i.e If HbA1C elevated with normal breakfast
FPG levels, that indicate Post prandial hyperglycaemia)

• If nocturnal hypoglycaemia is a problem with current

basal insulin.
EXAMPLEⱡ

• If fixed administration time of basal insulin is a

BASAL OD IDegAsp OD
problem with current basal insulin 3
20 U 20 U
…Fail to take BASAL Insulin due
to busy lifestyle/travel3 71.1%
BASAL BID Split dose*
20-0-10 u 20-0-10 u …Failed to take BASAL Insulin at
the same time each day3 81.4%

*: Splitting dose not necessarily 50:50, assuming largest meal is in the morning. Titration needed to achieved desire glycaemic control ⱡIDegAsp is given with the largest meals

References: 1. Sarah Galtras et al. J Clin Med 2020. 2. Roopa M et al. Diabetes Obes Metab. 2020;1-15 3. Akiko N et al.
Diabetes Ther (2017):8;385-399 4. Ryzodeg® Indonesia Prescribing Information. 2021
 Practical recommendation switching from Basal Plus to IDegAsp

GUIDANCE – Switching from Basal Plus1-2 Practical Consideration switching from basal plus
to IDegAsp 1-2
FROM Initiated at the same IDegAsp
dosage as the basal People with T2DM not achieving glycaemic control on
insulin • basal-plus
BASAL PLUS OD Basal Dose

• People require simplification of complex regimen

EXAMPLE*
PRACTICAL RECOMMENDATION1-2

Basal 15U IDegAsp OD • Switching from basal plus require individualisation

Prandial 5U 15 U according to glycaemic profile.

• Following switching from basal plus, IDegAsp may be

given OD

2 Injection 1 Injection
• Titrate to achieve optimal FPG.

*: Individual needs, IDegAsp is given with the largest meals, titrate to achieve desired glycaemic control.

References: 1. Sarah Galtras et al. J Clin Med 2020. 2. Roopa M et al. Diabetes Obes Metab. 2020;1-15
 Practical recommendation switching from Premix to IDegAsp

GUIDANCE – Switching from Premix1-3 EXAMPLE*

IDegAsp Premix OD IDegAsp OD

FROM
0-0-15 u 0-0-15 U
1:1
PREMIX OD/Split dose
1:1
Premix BID IDegAsp Split**
10-0-15 u 10-0-15 U
PRACTICAL RECOMMENDATION1-3

• IDegAsp should be started at the same unit dose Premix TID IDegAsp Split**
as the premix insulin 10-5-15 u 10-0-20 U
• Patients switching from Pre-mix OD can be
converted unit-to-unit to IDegAsp OD If the HbA1c level is ≤8.0% or the patient is
• From Pre-mix BID/TID can be converted to IDegASp experiencing hypoglycaemic episodes, the initial dose of
split dose at the same total daily insulin. IDegAsp should be reduced by 10–20% compared
with the original BIAsp 30 dose
*: Individual Needs, ⱡIDegAsp is given with the largest meals **: Assuming largest meals are evening and second largest meals is morning

References: 1. Sarah Galtras et al. J Clin Med 2020. 2. Roopa M et al. Diabetes Obes Metab. 2020;1-15 3. Ryzodeg®
Indonesia Prescribing Information 2021.
 Practical recommendation switching from Basal Bolus to IDegAsp

GUIDANCE – Switching from Basal Bolus1-2

EXAMPLE*

FROM Initiated at the same IDegAsp

dosage as the basal
insulin Iinitiated at the same
IDegAsp 15 u Split
Basal-Bolus Split dose Basal 15u dosage as the basal
Prandial 0-5-5 u insulin 0-7-8 u**

PRACTICAL RECOMMENDATION1-2
• People with T2DM whom did not achieve adequate
glycemic control and require simplification of complex IDegAsp 15 u Split IDegAsp 15 u
regimen Basal 15u
Prandial 5-5-5 u 0-7-8 u** 5-15-5 uⱡ
• Following switching from basal bolus (3 injection),
IDegAsp may be given split dose
or
• Following switching from basal bolus (4-5 injection),
IDegAsp may be given split dose or alternative of
IDegAsp at main meal and asp with other 2 meals

*: Individual needs, IDegAsp is given with the largest meals **: Splitting the dose not necessarily 50:50, Assuming largest meals taken in evening, 2 nd largest meals is lunch. ⱡ Assuming
largest meals is lunch

References: 1. Sarah Galtras et al. J Clin Med 2020. 2. Roopa M et al. Diabetes Obes Metab. 2020;1-15
Suggested once-weekly titration schedule for IDegAsp OD in T2D

Above target
Above target +2 Dose adjustments based on lowest
units
of the 3 preceding FPG
measurements
At
At
individualised Maintain FPG target should be individualised
individualised
target target dose
Do not increase dose if
hypoglycaemia or symptoms
Below target
Below target
-2 suggestive of hypoglycaemia are
units present

FPG, fasting plasma glucose; IDegAsp, insulin degludec/insulin aspart; T2D, type 2 diabetes

1. Fulcher et al. Diabetes Care 2014;37:2084–90; 2. Gerety et al. Endocr Pract 2016;22:546–54; 3. Endocrinologic and Metabolic Drug Advisory Committee. Insulin degludec and insulin degludec/insulin
aspart treatment to improve glycemic control in patients with diabetes mellitus: NDAs 203314 and 203313 briefing document. Published November 8, 2012
 Co-administration

• If SGLT-2 added to IDegASp: decrease dose 10-20%

SGLT- 2
• & titrated weekly to reduce the risk of side effects

• Caution when combining IDegAsp with (SUs) Sulphonylureas.

SUs • For IDegAsp OD, SUs may need to be discontinued or dose reduced
• For IDegAsp BID, SUs should be discontinued

Pioglitazone • The long-term effect still uncertain. The combination has been associated
with the development of heart failure & heart disease or stroke.

Metformin
Acarbose • No additional consideration are required.
DPP4-inh

• Add IDegAsp to GLP-1RA, no decrease in insulin dose. Daily dose 10 u is

recommended.
GLP-1
• If GLP-1RA added to IDegAsp, insulin dose may be decreased, depending
on HbA1C level

References: 1. Sarah Galtras et al. J Clin Med 2020. 2. Roopa M et al. Diabetes Obes Metab. 2020;1-15
 Clinical use

Use of IDegAsp in special populations or situation1-3

Type 1 Diabetes Hepatic or Renal Impairment

in adults with T1D: (IDegAsp OD + Iasp) vs (Idet IDegAsp can be used in renal or hepatic
OD + Iasp basal bolus) shown non-inferior and impaired patients with intensive glucose
relatively lower nocturnal hypoglycaemia risk. monitoring and the usual dose adjustment on
In children: approved in children ≥ 2 years old an individual basis

Elderly patients Hospitalised patients

Elderly may consider a good target for treatment - IDegAsp is not considered suitable for
with IDegAsp: situation in which rapid inpatient glycaemic
- Regimen is simple & flexible control is desired.
- PK of IDegAsp not affected by age
- Shown efficacious & no need special safety - Not the preferred choice for steroid-induced
precautions hyperglycaemia

Patients on very low calorie Pregnancy

Variability in diet pattern, lifestyle (low carbo, There is no clinical experience with the use of
ketogenic diet), religious practice (fasting month) IDegAsp in pregnant woman3
can influence glycaemic control.
IDegAsp may be useful due to flexibility in dosing
schedule

References: 1. Sarah Galtras et al. J Clin Med 2020. 2. Roopa M et al. Diabetes Obes Metab. 2020;1-15 3. Ryzodeg®.
Indonesia Prescribing Information 2021.
Summary
• There is a large choice of Insulin now available for the treatment of T2DM, enabling
clinicians to individualized treatment regimen.
• IDegAsp Co-formulation insulin provide basal and mealtime insulin in a single injection
when administered with meals.
• IDegAsp is particulary useful for patients:

• Failing to achieve glycemic control despite optimizing current non-insulin therapy.

• Problem with PPG spike with basal & pre-mixed insulin despite successful titration to FPG target.
• Patient with increased risk of hypoglycemia
• Patient who struggled to adhere to complex regimen (multiple daily injections)
• Patient requiring flexibility in the timing of insulin dosing.
Thank you

For Healthcare Professional Only

2022© Novo Nordisk A/S