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ADAPT: Once-daily detemir was noninferior to twice-daily dosing in basal-bolus therapy
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A once-daily injection of detemir in a basal-bolus regimen was suitable as a routine starting schedule for patients with type 1 diabetes, and switching to twice daily after seven months appeared to further decrease HbA1c levels, according to findings from the Assessment of Detemir Administration in a Progressive Treat-to-Target (ADAPT) trial.
The ADAPT researchers compared the effects of once-daily detemir (Levemir, Novo Nordisk) at bedtime vs. twice-daily detemir at breakfast and bedtime in a basal-bolus insulin regimen. They enrolled 512 patients with type 1 diabetes and randomly assigned each patient to once-daily (n=250) or twice-daily doses (n=262), in addition to bolus insulin aspart three times daily. Insulin doses were titrated after one month and patients were followed for three months. After month four, patients could switch regimens; those who did were followed for an additional three months.
At month four, the primary endpoint — mean HbA1c — was 8.1% among patients assigned once-daily detemir compared with 8% among patients assigned twice-daily detemir. The adjusted between-group difference was 0.12% (95% CI, –0.01 to 0.25).
Target HbA1c <7% was achieved by 14.2% of patients taking once-daily detemir compared with 15.6% of patients taking the twice-daily dose.
Analysis of the per protocol population revealed similar improvements in HbA1c in both groups (once-daily, –0.4%; twice-daily, –0.5%). However, detemir doses were lower with once-daily detemir (29 units per day vs. 39 units per day) and aspart doses were higher (34 IU per day vs. 26 IU per day).
At month seven, patients originally assigned to once-daily detemir who switched to twice-daily administration experienced a decrease in HbA1c from 8.2% at four months to 8% at seven months in association with increased total insulin doses. However, HbA1c increased among patients who switched from twice-daily to once-daily detemir from 7.2% to 7.6% in association with decreased doses. – by Katie Kalvaitis
Diabetes Care. 2009;32:32-37.
This study demonstrates that in patients with type 1 diabetes, once-daily detemir in a basal-bolus regimen can be attempted before advancing to twice-daily detemir; the latter regimen was better. This was confirmed when switching from twice-daily to once-daily, where patients showed an increase in HbA1c. Thus, while once-daily can be effective in some cases, the physician should be aware of the need for twice-daily in many cases.
– Derek LeRoith, MD, PhD
Endocrine Today Editorial Board member