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AACE Patient Safety - Ask the Experts - Discussion Forum

Concurrent Use of Insulin & Byetta

Question from Harry A. Archond:
I am writing this e-mail letter because I am worried about my recent treatment change given to me by an ARNP with a M.S.N. Degree and is a certified diabetic educator. As with my routine treatment I take 25 units of Levemire once a day at midnight as my slow acting Basil 24 hour Insulin and during the day I would take 12 units of Novo Log fifteen minutes before eating as the fast acting Insulin and things worked out pretty good because my original A1C was a 13 and in two months came down to a 7.16. This diabetic educator decided that I would be a good candidate to go on Byetta 5 MCG since I am a Type 2 Diabetic and so instead of taking Novo Log Insulin as before, I use the Byetta Flex Pen only two times a day but I still continue to take the 25 units of Levemire every evening once a day. Now I read there wasn't any study done on using Insulin and Byetta and would appreciate any information as to whether I am hurting my chances of a future A1C good reading and my system in regards to my Type 2 Diabetes??? I would never quote you on any answer you give me but I need to know for my own piece of mind if this treatment in your eyes is acceptable and proper.

Answer from Richard Hellman, MD, FACP, FACE:

Dear Mr Archond:

It is our policy of this website not to advise patients regarding either their diagnosis or treatment, but we will make general comments to provide information both to you and others who read this website.

You are correct that there is very little solid scientific information in the literature about the concurrent use of insulin and exenatide (Byetta). That is at least one of the reasons why the FDA did not approve exenatide for concurrent use with insulin, and in fact, made clear that exenatide would not be appropriate, and should not be used for patients with type 1 diabetes. It also would be not safe in a patient with type 2 diabetes with severe insulin deficiency.

I would wonder why exenatide would be a choice at all with the concurrent use of insulin, because insulin is more potent at lowering glucose levels than exenatide. I note that your glycemic control with insulin alone was very good with an A1c of 7.16%.There are other problems as well that will limit the use of exenatide, such as the presence of gastroparesis, or any person with a high risk or previous history of pancreatitis.

Nevertheless, there are people using both in an off-label fashion, but without good scientific evidence to support it. In general, this means that the problems people may have with the concurrent use of both insulin and exenatide are likely to be under-reported and difficult to interpret. I hope this information would be helpful to you and to others considering this concurrent use. My preference is to wait for sound, rigorous, research studies to guide us as to what is safe for the patients.