Diabetes & Metabolism 44 (2018) 1–3
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Editorial
Pharmacological variability of insulins degludec and glargine 300 U/mL:
Equivalent or not?
A R T I C L E I N F O
Keywords:
Degludec
Glargine U300
Pharmacodynamics
Pharmacokinetics
In this issue of Diabetes & Metabolism, Bailey et al. [1] have
compared the pharmacological variability of two insulin pre-
parations: (i) insulin glargine 300 U/mL (Gla-300), a long-acting
basal insulin analogue that exhibits a longer duration of action
than its mother preparation, insulin glargine 100 U/mL [2]; and (ii)
its ultra-long-acting comparator, insulin degludec 100 U/mL (Deg-
100), which has an estimated half-life of approximately 25 h and a
duration of action exceeding 42 h, and remains detectable in the
circulation for at least 5 days after its subcutaneous injection
[3,4]. By using the euglycaemic clamp technique in type 1 diabetes,
the authors of the above-mentioned comparative study report that
Gla-300 has less within-day variability in its pharmacodynamic/-
kinetic profiles than Deg-100 [1].
The euglycaemic glucose clamp is a method usually considered
the ‘gold standard’ for assessing the pharmacodynamics of new
insulin preparations [5–7]. After subcutaneous injection of the insulin
preparation being tested, the method then computes the glucose
infusion rates required to maintain near-normal glucose concentra-
tion, the so-called ‘steady state’, over the entire duration of the
glucose clamp study. The time taken for the glucose infusion is
calculated to be (theoretically) at least as long as the presumed
duration of action of the tested insulin preparation. The time course
of the glucose infusion rate following insulin injection is referred to as
the ‘pharmacodynamic’ profile of the tested insulin preparation
(Fig. 1). In addition, combining the clamp method with measurement
of plasma concentrations of the specific insulin being tested allows
assessment of the pharmacokinetic profile of the insulin preparation.
However, despite its potential strengths, the euglycaemic
glucose clamp technique is hampered by several weaknesses
[7]. One of them clearly arises when the duration of action of the
insulin preparation is longer than the duration of the glucose
clamp study, which is only rarely prolonged beyond the usual time
interval of 30–36 h, for understandable reasons, in ‘bona fide’
investigations conducted in human subjects.
https://doi.org/10.1016/j.diabet.2017.11.001
1262-3636/
C 2017 Published by Elsevier Masson SAS.
Returning to the Bailey et al. study [1], the results of the metrics
used for analyzing the variability of the pharmacodynamic/-kinetic
profiles of Gla-300 and Deg-100 are consistent with the fact that
both insulin preparations have stable, relatively ‘flat’ metabolic
activity, although Gla-300 provides less-fluctuating pharmacody-
namic/-kinetic profiles than its longer-lasting comparator. How-
ever, these results remain a subject of debate because of the Heise
et al. study [8], which recently reported that insulin degludec
200 U/mL given in the evening rather than in the morning, as with
the two insulin preparations (Deg-100 and Gla-300) tested in the
Bailey et al. study [1], resulted, first, in less day-to-day and within-
day variability and, second, in a more stable glucose-lowering
effect than with Gla-300. As a consequence, these observations
that, strictly speaking, are not truly convergent but actually widely
divergent, raise a number of questions.
The first is whether or not the euglycaemic clamp test is
sufficiently reliable to detect all the tiny differences in pharmaco-
dynamics that may be present between two insulin preparations. If
the answer to this question is equivocal, there then arises the
question of whether insulins Deg-100 and Gla-300 are perhaps
simply equivalent in terms of pharmacodynamic/-kinetic variabil-
ity. In addition, within the wide range of additional questions that
can also be raised, many are related to weaknesses of the
euglycaemic glucose clamp technique.
As a preliminary comment, it should be noted that the test is
probably still highly valuable for assessing the pharmacodynamics
of fast- and intermediate-acting insulins [9–11]. This remark could
also be extended, albeit at a lesser degree, to long-acting insulins,
provided that their duration of action does not exceed 24 h
[2]. However, for ultra-long-acting insulin preparations with
durations of action beyond 24 h, interpretation of the pharmaco-
logical data is somewhat difficult because, ideally, it is necessary
that the amount of glucose infused to maintain euglycaemia be
exclusively dependent on the tested exogenous insulin preparation
injected at the start of the clamp, at the ‘zero-time point’ [6].
Yet, such conditions are rarely achieved, although this was not
clearly evident in the studies by Heise et al. [8] and Bailey et al. [1]
because participants received their last subcutaneous injection of
either insulin degludec 100 [1] or 200 U/mL [8] or glargine 300 U/
mL [1,8] 24 h prior to the start of the clamp procedure. Therefore, it
is highly likely that many patients were still under remnant
hormone exposure from the subcutaneous doses of either insulin,
as it is well known that the two preparations can largely extend
their action beyond 24 h [2–4]. In addition, blood glucose
[(Fig._1)TD$IG]
2 Editorial / Diabetes & Metabolism 44 (2018) 1–3
Fig. 1. The observed (solid line) and theoretically presumed (broken line) time
courses of glucose infusion rates (GIRs) under steady-state conditions during a
euglycaemic clamp study after subcutaneous injection of an extended-acting
insulin preparation at time zero (T0). Steady state is defined as the maintenance of a
stable glucose concentration at a near-normal level throughout the entire clamp
test period. Note that the early and late phases of the observed GIRs during the
clamp are usually perturbed by interference due to, first, overlapping of the insulin
doses administered before T0 and, second, the increasing contribution of hepatic
glucose production to glucose homoeostasis.
concentrations before the clamp should be adjusted to the near-
normal level of 100 mg/dL by starting a priming intravenous
infusion of glucose and/or by administering a fast- or intermedi-
ate-acting insulin delivered as intravenous/subcutaneous boluses
or infusions as appropriate. Therefore, the infusion glucose rates in
the early phases of glucose clamp tests are tainted by the carry-
over effects of these anticipatory measures and, thus, it is simply
not possible to distinguish the relative contributions of the tested
insulin preparations (injected at time zero) from those of either the
extended-acting insulin previously delivered or some other short-/
intermediate-acting insulins administered immediately before the
clamp.
Another practical limitation of the euglycaemic clamp test lies
in the fact that it requires, for several hours, the placement of two
indwelling venous lines, one to deliver the glucose infusion, and
the other to collect blood samples at regular time intervals for
further determinations of plasma glucose and insulin concen-
trations. There is no doubt that this requirement contributes to
rendering the glucose clamp rather constraining if the experiment
is extended for 24 h or even longer periods of time.
Yet, even though there is incontrovertible evidence that the
above-mentioned issues are deserving of due consideration, the
main concern with the euglycaemic clamp is that the investigation
requires achieving a steady state, which is traditionally assessed
with a stable, near-normal glucose concentration maintained at
100 mg/dL. However, setting blood glucose concentrations at this
level throughout the clamp period does not mean that the patient’s
metabolic status in terms of, first, total glucose utilization by
peripheral tissues and, second, glucose production by the liver has
also been held in steady state.
When plasma glucose concentration is stable, glucose
homoeostasis is regulated by the difference between the inputs
and outputs respectively to and from the exchangeable pool of
glucose. The two inputs correspond, first, to the amount of
exogenous glucose infused for maintaining euglycaemia and,
second, to the quantity of glucose produced by the liver. During
metabolic steady states, the sum of these two inputs should be
equal to the outputs, corresponding to the flow of glucose removed
from the exchangeable compartment at peripheral sites, such as
the skeletal muscles, adipose tissue and, more generally, all the
metabolically relevant sites of insulin action. As both hepatic
production and peripheral utilization of glucose are not stable
during the non-physiological conditions of the glucose clamp, any
assessment of exogenous glucose infusion rates will not be a total
reflection of insulin-stimulated glucose disposal at peripheral sites
after subcutaneous injection of tested preparations.
The metabolic drift seen throughout the study period is
probably more marked at the end of clamp studies where the
procedure is extended up to or beyond 24 h, when plasma insulin
concentration, depending on the insulin injected, exhibits a
progressive decrease and returns to its baseline level. As free
circulating insulin ceases to exert its full inhibitory effect on
hepatic glucose output as soon as its concentration falls below
50 mU/mL [12,13], compensatory amounts of glucose begin to be
released from the liver, most likely during the last clamp phase
and, more specifically, at the end of the clamp procedure, when
insulin concentration reaches its lowest level (Fig. 1).
It is highly likely that this unfortunate but unavoidable feature
impairs the validity of the measurements of glucose infusion rates
presumed to assess the metabolic activity of the tested insulin
preparations. Indeed, several observations from the Bailey et al.
study [1] provide arguments favouring this idea. For instance,
measurements of free plasma concentrations of glargine, a key
player of its action [14], were, at the end of the clamp test, reduced
to the very low level of 1 mU/mL, as derived from the following
calculation: 6 mU/mL 5.02 mU/mL. The latter value is usually
considered the lower limit of quantification (LLOQ) for insulin
glargine immunoassay in plasma [1,2].
It should be borne in mind that the total suppression of
endogenous glucose production is approximately achieved when
insulin concentrations are above the threshold of 50 mU/mL
[12,13] and, even more likely, at levels  100 mU/mL, as used by
DeFronzo et al. [15] in their landmark report on the glucose clamp
technique. In the Bailey et al. study [1], their results showed that
the lowest infusion rates of glucose (0.5 mg/min/kg) were reached
between 24 and 30 h of the clamp test conducted with Gla-300.
However, and although there is a remnant non-insulin-dependent
utilization of glucose by the brain, it is surprising to report such
high residual levels for glucose infusion at a time where plasma
insulin concentrations were found to be almost equal to zero.
Such an observation provides an additional piece of evidence
that the data collected at the end of the clamp test for analyzing the
pharmacological characteristics of ultra-long-acting insulin pre-
parations are generally not relevant and somewhat difficult to
interpret. This observation, however, cannot be applied to insulin
degludec because a large fraction of that insulin is bound to
albumin in the blood circulation [14], thereby explaining the wide
discrepancy in the pharmacokinetic profiles of Gla-300 and Deg-
100 observed in the Bailey et al. study [1]. In addition, it should be
noted that the assay used for determining plasma concentrations
of degludec does not allow differentiation of its free and bound
fractions. Therefore, we are sadly lacking any information on the
free active circulating moiety of insulin degludec, thereby
rendering any discussion of its potential inhibitory effect on
hepatic glucose production inappropriate at the end of a 30-h
clamp period.
In summary, it appears that the glucose infusion rates at the
beginning and end of the euglycaemic clamp procedure are
dependent on several different variables/factors that are difficult to
quantify because of their unpredictability, which may be linked to
the lack of total suppression of hepatic glucose production and the
poor overall achievement of metabolic steady-state conditions. As
a consequence, readers of this editorial may be left with the
impression that glucose clamp studies, founded on the solid basis
[7] of being able to determine activity profiles, including the
duration and peak activity of insulin preparations, are in fact
 Editorial / Diabetes & Metabolism 44 (2018) 1–3
methods too crude to detect the subtle differences that may be
present in the fluctuating pharmacodynamics of insulin prepara-
tions like degludec and glargine.
This might explain why clamp results can fall towards either
one side or its opposite [1,8] when we are on the ‘cutting edge’ of
fluctuations in pharmacological profiles that characterize, and
perhaps even separate, two insulin preparations. For the moment,
it would appear that the two insulin preparations tested in the
studies of Heise et al. [8] and Bailey et al. [1] are more similar than
dissimilar in terms of their pharmacodynamic variability. As there is
compelling evidence that it is important to know whether this
parameter differs between the two insulins, it is to be hoped that, in
the near future, additional studies, perhaps with the help of new
methods of investigation, will provide further insights into this issue.
Funding
The authors declare that they have received no funding for
writing the content of this editorial.
Disclosure of interest
The authors declare that they have no competing interest.
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L. Monnier*, C. Colette
University institute of clinical research, university of Montpellier, 641,
avenue du Doyen-Gaston-Giraud, 34093 Montpellier cedex 5, France
*Corresponding author
E-mail address: louis.monnier@inserm.fr (L. Monnier).
Received 3 November 2017
Accepted 4 November 2017
Available online 14 November 2017