Medically reviewed by Drugs.com. Last updated on Apr 8, 2019.
(IN soo lin DE te mir)
- Detemir Insulin
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Levemir: 100 units/mL (10 mL) [contains metacresol, phenol]
Solution Pen-injector, Subcutaneous:
Levemir FlexTouch: 100 units/mL (3 mL) [contains metacresol, phenol]
Brand Names: U.S.
- Levemir FlexTouch
- Insulin, Long-Acting
Insulin acts via specific membrane-bound receptors on target tissues to regulate metabolism of carbohydrate, protein, and fats. Target organs for insulin include the liver, skeletal muscle, and adipose tissue.
Within the liver, insulin stimulates hepatic glycogen synthesis. Insulin promotes hepatic synthesis of fatty acids, which are released into the circulation as lipoproteins. Skeletal muscle effects of insulin include increased protein synthesis and increased glycogen synthesis. Within adipose tissue, insulin stimulates the processing of circulating lipoproteins to provide free fatty acids, facilitating triglyceride synthesis and storage by adipocytes; also directly inhibits the hydrolysis of triglycerides. In addition, insulin stimulates the cellular uptake of amino acids and increases cellular permeability to several ions, including potassium, magnesium, and phosphate. By activating sodium-potassium ATPases, insulin promotes the intracellular movement of potassium.
Normally secreted by the pancreas, insulin products are manufactured for pharmacologic use through recombinant DNA technology using either E. coli or Saccharomyces cerevisiae. Insulin detemir differs from human insulin by the omission of threonine in position B30 and the addition of a C14 fatty acid chain to the amino acid located at position B29. Insulins are categorized based on the onset, peak, and duration of effect (eg, rapid-, short-, intermediate-, and long-acting insulin).
Vd: 0.1 L/kg
Onset of Action
3 to 4 hours; Peak effect: 3 to 9 hours (Plank 2005)
Time to Peak
Plasma: 6 to 8 hours
Duration of Action
Dose dependent: 6 to 23 hours; Note: At lower dosages (0.1 to 0.2 units/kg), mean duration is variable (5.7 to 12.1 hours). At 0.4 units/kg, the mean duration was 19.9 hours. At high dosages (≥0.8 units/kg) the duration is longer and less variable (mean of 22 to 23 hours) (Plank 2005).
5 to 7 hours (dose-dependent)
Special Populations: Renal Function Impairment
Insulin Cl may be reduced in patients with impaired renal function.
Special Populations: Elderly
The AUC was 35% higher in healthy elderly patients (68 y and older) compared with younger patients (25 to 35 y of age) because of reduced Cl in elderly patients. Higher insulin detemir AUC levels in elderly patients because of reduced Cl.
Special Populations: Children
AUC and Cmax were higher by 10% and 24%, respectively, in children (6 to 12 y of age) compared with adolescents and adults.
Use: Labeled Indications
Diabetes mellitus, types 1 and 2: Treatment of type 1 diabetes mellitus and type 2 diabetes mellitus to improve glycemic control
Hypersensitivity to insulin detemir or any component of the formulation
Note: Insulin detemir is a long-acting insulin. Insulin requirements vary dramatically between patients and dictates frequent monitoring and close medical supervision.
Diabetes mellitus, type 1: SubQ:
Note: Insulin detemir must be used concomitantly with rapid- or short-acting insulins (ie, multiple daily injection regimen). The total daily doses (TDD) presented below are expressed as the total units/kg/day of all insulin formulations combined.
General insulin dosing:
Initial TDD: ~0.4 to 0.5 units/kg/day (AACE/ACE [Handelsman 2015]; ADA 2018); conservative initial doses of 0.2 to 0.4 units/kg/day may be considered to avoid the potential for hypoglycemia; higher initial doses may be required in patients who are obese, sedentary, or presenting with ketoacidosis (AACE/ACE [Handelsman 2015]; ADA 2018).
Usual TDD maintenance range: 0.4 to 1 units/kg/day in divided doses (ADA 2018)
Division of TDD (multiple daily injections):
Basal insulin: Generally, 40% to 50% of the TDD is given as basal insulin (intermediate- or long-acting) (AACE/ACE [Handelsman 2015]; ADA 2018). Insulin detemir may be administered as a single dose or in two divided doses daily.
Prandial insulin: The remaining portion (ie, 50% to 60%) of the TDD is then divided and administered before or at mealtimes (depending on the formulation) as a rapid-acting (eg, aspart, glulisine, lispro; insulin for inhalation) or short-acting (regular) insulin (AACE/ACE [Handelsman 2015]; ADA 2018).
Dosage adjustment: Dosage must be titrated to achieve glucose control and avoid hypoglycemia. Adjust dose to maintain premeal and bedtime glucose in target range. Since combinations of agents are frequently used, dosage adjustment must address the individual component of the insulin regimen which most directly influences the blood glucose value in question, based on the known onset and duration of the insulin component. Treatment and monitoring regimens must be individualized. To minimize hypoglycemia risk, basal insulins are generally titrated once or twice weekly (eg, every 3 to 7 days) (ADA 2018; McCall 2012).
Diabetes mellitus, type 2: SubQ: Note: Basal insulin therapy is usually initiated if adequate glycemic control has not been achieved with step-wise trials of metformin ± other noninsulin agents. However, if HbA1c ≥10%, blood glucose is ≥300 mg/dL or if patient is symptomatic (eg, polyuria, polydipsia), insulin (with or without additional agents) should be considered as part of initial therapy (ADA 2018). Use of long-acting basal analogs may be preferred if minimization of hypoglycemia is a primary concern (ADA-EASD [Davies 2018]).
Patients inadequately controlled on oral antidiabetic agents: Initial: 10 units (or 0.1 to 0.2 units/kg) once daily in the evening or in 2 divided doses (ADA 2018; manufacturer’s labeling). If HbA1c >8% prior to initiation of basal insulin, 0.2 to 0.3 units/kg/day is recommended (AACE/ACE [Garber 2018]).
Patients inadequately controlled on GLP-1 receptor agonist: Initial: 10 units once daily in the evening (manufacturer's labeling).
Dosage adjustment (ADA 2018):
To reach fasting blood glucose target: Adjust dose by 10% to 15% or 2 to 4 units; may adjust at weekly or twice weekly intervals
For hypoglycemia: If no clear reason for hypoglycemia, decrease dose by 4 units or by 10% to 20%
Dosage adjustment when adding prandial insulin (ADA-EASD 2018): Consider reducing the basal insulin dose by 4 units (or ~10%) if HbA1c is <8% when initiating prandial insulin.
Patients with diabetes receiving enteral feedings (ADA 2018): Note: TDD of insulin is divided into a basal component (intermediate- or long-acting insulin) and nutritional and correctional components (regular insulin or rapid-acting insulins). Basal component: SubQ: Continue previous basal insulin dose or administer 30% to 50% of current TDD as insulin detemir; if basal insulin naive, administer insulin detemir 5 units every 12 hours.
Patients with diabetes undergoing surgery (ADA 2018): SubQ: On the morning of surgery or procedure, give 60% to 80% of the usual dose of long-acting analogs (eg, detemir, glargine, or degludec) (ADA 2018)
Conversion from insulin glargine or NPH insulin to insulin detemir: Initial: May be substituted on an equivalent unit-per-unit basis; some patients with Type 2 diabetes may require higher doses of detemir than NPH.
Refer to adult dosing.
Note: Insulin detemir is a long-acting insulin administered by SubQ injection. When compared to insulin NPH, insulin detemir has slower, more prolonged absorption; duration of activity is dose-dependent. Insulin detemir may be given once or twice daily when used as the basal insulin component of therapy. Changing the basal insulin component from another insulin to insulin detemir can be done on a unit-to-unit basis. Insulin requirements vary dramatically between patients and dictate frequent monitoring and close medical supervision. See Insulin Regular for additional information.
General insulin dosing: Type 1 diabetes mellitus (DM): Infants, Children, and Adolescents: Note: Insulin regimens should be individualized to achieve glycemic goals without causing hypoglycemia. Multiple daily doses are utilized and guided by blood glucose monitoring. Combinations of insulin formulations are commonly used. The daily doses presented below are expressed as the total units/kg/day of all insulin formulations combined.
Usual maintenance range: SubQ: 0.5 to 1 unit/kg/day in divided doses; doses must be individualized; however, an estimate can be determined based on phase of diabetes and level of maturity (ISPAD [Couper 2014]; ISPAD [Danne 2014]).
Partial remission phase (Honeymoon phase): <0.5 units/kg/day
Prepubertal children (not in partial remission): 0.7 to 1 units/kg/day
Pubescent Children and Adolescents: During puberty, requirements may substantially increase to >1.2 unit/kg/day and in some cases up to 2 units/kg/day
Adjustment of dose: Dosage must be titrated to achieve glucose control and avoid hypoglycemia. Adjust dose to maintain premeal and bedtime glucose in target range. Since combinations of agents are frequently used, dosage adjustment must address the individual component of the insulin regimen which most directly influences the blood glucose value in question, based on the known onset and duration of the insulin component.
Insulin detemir-specific dosing:
Type 1 diabetes mellitus: Children ≥2 years and Adolescents: SubQ: Initial dose: Approximately one-third of the total daily insulin requirement; a rapid-acting or short-acting insulin should also be used. If administered once daily, doses are generally administered with evening meals or at bedtime.
Conversion from insulin glargine or NPH insulin: SubQ: May be substituted on an equivalent unit-per-unit basis; in one Type 2 diabetes clinical trial, higher doses of insulin detemir were required than insulin NPH.
SubQ: Do not administer IM or IV; for SubQ administration only. Do not use if solution is viscous or cloudy; use only if clear and colorless with no visible particles. Insulin detemir should be administered once or twice daily. When given once daily, administer with the evening meal or at bedtime. When given twice daily, administer the evening dose with the evening meal, at bedtime, or 12 hours following the morning dose. SubQ administration is usually made into the thighs, upper arms, or abdomen; absorption rates vary amongst injection sites; be consistent with area used while rotating injection sites within the same region to avoid lipodystrophy. Do not dilute or mix insulin detemir with any other insulin formulation or solution; not recommended for use in external SubQ insulin infusion pump. For Levemir FlexTouch pen, prime the needle before each injection with 2 units of insulin (use a new needle for each injection). Once injected, hold the pen device in the skin for a count of 6 after the dose dial has returned to 0 units before removing the needle to ensure the full dose has been administered.
Individualized medical nutrition therapy (MNT) based on ADA recommendations is an integral part of therapy.
Unopened vials, cartridges, and prefilled pens may be stored under refrigeration between 2°C and 8°C (36°F to 46°F) until the expiration date or at room temperature <30°C (<86°F) for 42 days; do not freeze; keep away from heat and sunlight. Once punctured (in use), vials may be stored under refrigeration or at room temperature <30°C (<86°F); use within 42 days. Cartridges and prefilled pens that have been punctured (in use) should be stored at temperatures <30°C (<86°F) and used within 42 days; do not freeze or refrigerate.
Alpha-Lipoic Acid: May enhance the hypoglycemic effect of Antidiabetic Agents. Monitor therapy
Androgens: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Exceptions: Danazol. Monitor therapy
Antidiabetic Agents: May enhance the hypoglycemic effect of Hypoglycemia-Associated Agents. Monitor therapy
Beta-Blockers: May enhance the hypoglycemic effect of Insulins. Exceptions: Levobunolol; Metipranolol. Monitor therapy
Dipeptidyl Peptidase-IV Inhibitors: May enhance the hypoglycemic effect of Insulins. Management: Consider a decrease in insulin dose when initiating therapy with a dipeptidyl peptidase-IV inhibitor and monitor patients for hypoglycemia. Consider therapy modification
Direct Acting Antiviral Agents (HCV): May enhance the hypoglycemic effect of Antidiabetic Agents. Monitor therapy
Edetate CALCIUM Disodium: May enhance the hypoglycemic effect of Insulins. Monitor therapy
Glucagon-Like Peptide-1 Agonists: May enhance the hypoglycemic effect of Insulins. Management: Consider insulin dose reductions when used in combination with glucagon-like peptide-1 agonists. Avoid the use of lixisenatide in patients receiving both basal insulin and a sulfonylurea. Exceptions: Liraglutide. Consider therapy modification
Guanethidine: May enhance the hypoglycemic effect of Antidiabetic Agents. Monitor therapy
Herbs (Hypoglycemic Properties): May enhance the hypoglycemic effect of Hypoglycemia-Associated Agents. Monitor therapy
Hyperglycemia-Associated Agents: May diminish the therapeutic effect of Antidiabetic Agents. Monitor therapy
Hypoglycemia-Associated Agents: May enhance the hypoglycemic effect of other Hypoglycemia-Associated Agents. Monitor therapy
Hypoglycemia-Associated Agents: Antidiabetic Agents may enhance the hypoglycemic effect of Hypoglycemia-Associated Agents. Monitor therapy
Liraglutide: May enhance the hypoglycemic effect of Insulins. Management: If liraglutide is used for the treatment of diabetes (Victoza), consider insulin dose reductions. The combination of liraglutide and insulin should be avoided if liraglutide is used exclusively for weight loss (Saxenda). Consider therapy modification
Macimorelin: Insulins may diminish the diagnostic effect of Macimorelin. Avoid combination
Maitake: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy
Metreleptin: May enhance the hypoglycemic effect of Insulins. Management: Insulin dosage adjustments (including potentially large decreases) may be required to minimize the risk for hypoglycemia with concurrent use of metreleptin. Monitor closely. Consider therapy modification
Monoamine Oxidase Inhibitors: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy
Pegvisomant: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy
Pioglitazone: May enhance the adverse/toxic effect of Insulins. Specifically, the risk for hypoglycemia, fluid retention, and heart failure may be increased with this combination. Management: If insulin is combined with pioglitazone, dose reductions should be considered to reduce the risk of hypoglycemia. Monitor patients for fluid retention and signs/symptoms of heart failure. Consider therapy modification
Pramlintide: May enhance the hypoglycemic effect of Insulins. Management: Upon initiation of pramlintide, decrease mealtime insulin dose by 50% to reduce the risk of hypoglycemia. Monitor blood glucose frequently and individualize further insulin dose adjustments based on glycemic control. Consider therapy modification
Prothionamide: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy
Quinolones: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Quinolones may diminish the therapeutic effect of Blood Glucose Lowering Agents. Specifically, if an agent is being used to treat diabetes, loss of blood sugar control may occur with quinolone use. Monitor therapy
Ritodrine: May diminish the therapeutic effect of Antidiabetic Agents. Monitor therapy
Rosiglitazone: Insulins may enhance the adverse/toxic effect of Rosiglitazone. Specifically, the risk of fluid retention, heart failure, and hypoglycemia may be increased with this combination. Avoid combination
Salicylates: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy
Selective Serotonin Reuptake Inhibitors: May enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy
Sodium-Glucose Cotransporter 2 (SLGT2) Inhibitors: May enhance the hypoglycemic effect of Insulins. Management: Consider a decrease in insulin dose when initiating therapy with a sodium-glucose cotransporter 2 inhibitor and monitor patients for hypoglycemia. Consider therapy modification
Thiazide and Thiazide-Like Diuretics: May diminish the therapeutic effect of Antidiabetic Agents. Monitor therapy
Central nervous system: Headache (adults: 7% to 23%, children: 31%)
Endocrine & metabolic: Hypoglycemia (Type 1 combination regimens: children & adolescents: 93% to 95%, adults: 82% to 88%; Type 2 combination regimens: adults: 9% to 41%), severe hypoglycemia (Type 1 combination regimens: children & adolescents: 2% to 16%; adults 5% to 9%; Type 2 combination regimens: adults: ≤2%)
Gastrointestinal: Gastroenteritis (children & adolescents: 17%), abdominal pain (6%; children & adolescents: 13%)
Respiratory: Upper respiratory tract infection (13% to 26%; children & adolescents: 36%), pharyngitis (10%; children & adolescents: 17%), flu-like symptoms (8%; children & adolescents: 14%)
1% to 10%:
Gastrointestinal: Nausea (children & adolescents: 7%), vomiting (children & adolescents: 7%)
Infection: Viral infection (children & adolescents: 7%)
Respiratory: Cough (children & adolescents: 8%), rhinitis (children & adolescents: 7%)
Miscellaneous: Fever (children & adolescents: 10%)
<1%, postmarketing, and/or case reports: Pain at injection site
Concerns related to adverse effects:
• Anaphylactoid/hypersensitivity reactions: Allergic reactions, including anaphylaxis, may occur with insulin products.
• Glycemic control: Hyper- or hypoglycemia may result from changes in insulin strength, manufacturer, type, and/or administration method. The most common adverse effect of insulin is hypoglycemia. The timing of hypoglycemia differs among various insulin formulations. Hypoglycemia may result from changes in meal pattern (eg, macronutrient content, timing of meals), changes in the level of physical activity, increased work or exercise without eating, or changes to coadministered medications. Use of long-acting insulin preparations (eg, insulin degludec, insulin detemir, insulin glargine) may delay recovery from hypoglycemia. Patients with renal or hepatic impairment may be at a higher risk. Symptoms differ in patients and may change over time in the same patient; awareness may be less pronounced in those with long-standing diabetes, diabetic nerve disease, patients taking beta-blockers, or in those who experience recurrent hypoglycemia. Profound and prolonged episodes of hypoglycemia may result in convulsions, unconsciousness, temporary or permanent brain damage, or even death. Insulin requirements may be altered during illness, emotional disturbances, or other stressors. Instruct patients to use caution with ethanol; may increase risk of hypoglycemia. In clinical trials insulin NPH has been associated with a modestly increased risk of hypoglycemia (including nocturnal hypoglycemia) compared with long-acting analogs (Lipska 2017; Rosenstock 2005; Rys 2015; Singh 2009). However, an observational study in patients with type 2 diabetes from a large health care delivery system found no difference in the incidence of ER visits or hospitalization for hypoglycemia with NPH compared with glargine/detemir when treating to conventional targets in a real world setting (Lipska 2018).
• Hypokalemia: Insulin (especially IV insulin) causes a shift of potassium from the extracellular space to the intracellular space, possibly producing hypokalemia. If left untreated, hypokalemia may result in respiratory paralysis, ventricular arrhythmia and even death. Use with caution in patients at risk for hypokalemia (eg, loop diuretic use). Monitor serum potassium and supplement potassium when necessary.
• Diabetic ketoacidosis (DKA): Should not be used in patients with DKA; use of an IV rapid acting or short acting insulin is preferred.
• Hepatic impairment: Use with caution in patients with hepatic impairment. Dosage requirements may be reduced.
• Renal impairment: Use with caution in patients with renal impairment. Dosage requirements may be reduced.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
• Hospitalized patients with diabetes: Exclusive use of a sliding scale insulin regimen (insulin regular) in the inpatient hospital setting is strongly discouraged. In the critical care setting, continuous IV insulin infusion (insulin regular) has been shown to best achieve glycemic targets. In noncritically ill patients with either poor oral intake or taking nothing by mouth, basal insulin or basal plus bolus is preferred. In noncritically ill patients with adequate nutritional intake, a combination of basal insulin, nutritional, and correction components is preferred. An effective insulin regimen will achieve the goal glucose range without the risk of severe hypoglycemia. A blood glucose value <70 mg/dL should prompt a treatment regimen review and change, if necessary, to prevent further hypoglycemia (ADA 2018).
Dosage form specific issues:
• Multiple dose injection pens: According to the Centers for Disease Control and Prevention (CDC), pen-shaped injection devices should never be used for more than one person (even when the needle is changed) because of the risk of infection. The injection device should be clearly labeled with individual patient information to ensure that the correct pen is used (CDC 2012).
• Administration: Insulin detemir, although a clear solution, is NOT intended for IV or IM administration.
• Dosage adjustments: The duration of action of insulin detemir is dose-dependent; consider this factor during dosage adjustment and titration.
• Patient education: Diabetes self-management education (DSME) is essential to maximize the effectiveness of therapy.
Diabetes mellitus: Plasma glucose, electrolytes, HbA1c (at least twice yearly in patients who have stable glycemic control and are meeting treatment goals; quarterly in patients not meeting treatment goals or with therapy change [ADA 2017c]), lipid profile, renal function; hepatic function; weight
Pregnancy Risk Factor
Insulin detemir has been detected in cord blood. An increased risk of fetal abnormalities has not been observed following the use of insulin detemir in pregnancy; pregnancy outcomes are similar following maternal use of insulin detemir and NPH insulin.
In women with diabetes, maternal hyperglycemia can be associated with congenital malformations as well as adverse effects in the fetus, neonate, and the mother (ACOG 2005; ADA 2018; Metzger 2007). To prevent adverse outcomes, prior to conception and throughout pregnancy maternal blood glucose and HbA1c should be kept as close to target goals as possible but without causing significant hypoglycemia (ADA 2018; Blumer 2013; Lambert 2013).
Insulin therapy is the preferred treatment of type 1 and type 2 diabetes in pregnant women, as well as GDM when pharmacologic therapy is needed (ACOG 190 2018; ADA 2018). Insulin requirements tend to fall during the first trimester of pregnancy and increase in the later trimesters, peaking at 28 to 32 weeks' gestation. Following delivery, insulin requirements decrease rapidly (ACOG 2005). Women who are stable on insulin detemir prior to conception may continue it during pregnancy. Pregnant women may also be switched to insulin detemir during pregnancy when therapy with NPH insulin is not adequate (Blumer 2013).
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience common cold symptoms, pharyngitis, flu-like symptoms, headache, abdominal pain, nausea, vomiting, or back pain. Have patient report immediately to prescriber signs of low blood sugar (dizziness, headache, fatigue, feeling weak, shaking, tachycardia, confusion, increased hunger, or sweating), signs of low potassium (muscle pain or weakness, muscle cramps, or an abnormal heartbeat), severe injection site irritation, blurred vision, chills, severe dizziness, passing out, mood changes, seizures, slurred speech, shortness of breath, excessive weight gain, swelling of arms or legs, or injection site change in skin to thick or thin (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.
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Other brands: Levemir