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Arai K, Okumura M, Lee YH, Katayama H, Mizutani K, Lin Y, Park SY, Sawada K, Toyoda M, Hojo H, Inaba K, Iwaoka M. Diselenide-bond replacement of the external disulfide bond of insulin increases its oligomerization leading to sustained activity. Commun Chem 2023; 6:258. [PMID: 37989850 PMCID: PMC10663622 DOI: 10.1038/s42004-023-01056-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/07/2023] [Indexed: 11/23/2023] Open
Abstract
Seleno-insulin, a class of artificial insulin analogs, in which one of the three disulfide-bonds (S-S's) of wild-type insulin (Ins) is replaced by a diselenide-bond (Se-Se), is attracting attention for its unique chemical and physiological properties that differ from those of Ins. Previously, we pioneered the development of a [C7UA,C7UB] analog of bovine pancreatic insulin (SeIns) as the first example, and demonstrated its high resistance against insulin-degrading enzyme (IDE). In this study, the conditions for the synthesis of SeIns via native chain assembly (NCA) were optimized to attain a maximum yield of 72%, which is comparable to the in vitro folding efficiency for single-chain proinsulin. When the resistance of BPIns to IDE was evaluated in the presence of SeIns, the degradation rate of BPIns became significantly slower than that of BPIns alone. Furthermore, the investigation on the intermolecular association properties of SeIns and BPIns using analytical ultracentrifugation suggested that SeIns readily forms oligomers not only with its own but also with BPIns. The hypoglycemic effect of SeIns on diabetic rats was observed at a dose of 150 μg/300 g rat. The strategy of replacing the solvent-exposed S-S with Se-Se provides new guidance for the design of long-acting insulin formulations.
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Affiliation(s)
- Kenta Arai
- Department of Chemistry, School of Science, Tokai University, Kitakaname, Hiratsuka-shi, Kanagawa, 259-1292, Japan.
- Institute of Advanced Biosciences, Tokai University, Kitakaname, Hiratsuka-shi, Kanagawa, 259-1292, Japan.
| | - Masaki Okumura
- Frontier Research Institute for Interdisciplinary Sciences, Tohoku University, 6-3, Aramakiaza Aoba, Aoba-ku, Sendai, 980-8578, Japan
| | - Young-Ho Lee
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, 162, Yeongudanji-ro, Ochang-eup, Cheongwon-gu, Cheongju-si, 28119, Korea
- Bio-Analytical Science, University of Science and Technology, 217, Gajeong-ro, Yuseong-gu, Daejeon, 34113, Korea
- Graduate School of Analytical Science and Technology, Chungnam National University, 99, Daehak-ro, Yuseong-gu, Daejeon, 34134, Korea
- Research Headquarters, Korea Brain Research Institute, 61, Cheomdan-ro, Dong-gu, Daegu, 41068, Korea
| | - Hidekazu Katayama
- Department of Bioengineering, School of Engineering, Tokai University, Kitakaname, Hiratsuka-shi, Kanagawa, 259-1292, Japan
| | - Kenji Mizutani
- Drug Design Laboratory, Graduate School of Medical Life Science, Yokohama City University, 1-7-29 Suehiro, Tsurumi, Yokohama, 230-0045, Japan
| | - Yuxi Lin
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, 162, Yeongudanji-ro, Ochang-eup, Cheongwon-gu, Cheongju-si, 28119, Korea
| | - Sam-Yong Park
- Drug Design Laboratory, Graduate School of Medical Life Science, Yokohama City University, 1-7-29 Suehiro, Tsurumi, Yokohama, 230-0045, Japan
| | - Kaichiro Sawada
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University, School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Masao Toyoda
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University, School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Hironobu Hojo
- Institute for Protein Research, Osaka University, Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
| | - Kenji Inaba
- Institute of Multidisciplinary Research for Advanced Materials, Tohoku University, Aoba-ku, Sendai, 2-1-1, Japan
- Medical Institute of Bioregulation, Kyushu University, Fukuoka, 812-8582, Japan
| | - Michio Iwaoka
- Department of Chemistry, School of Science, Tokai University, Kitakaname, Hiratsuka-shi, Kanagawa, 259-1292, Japan.
- Institute of Advanced Biosciences, Tokai University, Kitakaname, Hiratsuka-shi, Kanagawa, 259-1292, Japan.
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Shrivastava A, Kesavadev J, Mohan V, Saboo B, Shrestha D, Maheshwari A, Makkar BM, Modi KD, Das AK. Clinical Evidence and Practice-Based Guidelines on the Utility of Basal Insulin Combined Oral Therapy (Metformin and Glimepiride) in the Current Era. Curr Diabetes Rev 2023; 19:e090123212444. [PMID: 36624650 PMCID: PMC10617787 DOI: 10.2174/1573399819666230109104300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 11/19/2022] [Accepted: 11/24/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIM Basal insulin combined oral therapy consisting of insulin and oral anti-diabetic drugs (OADs) is recommended for type 2 diabetes uncontrolled on OADs. There is a lack of clear evidence and recommendations on the combined use of basal insulin analogues to more than one OADs (glimepiride plus metformin) in effective control of glycemic parameters and its safety in terms of reduced hypoglycemic events, weight gain and cardiovascular risk. In this context, a group of clinical experts discussed the utility of basal insulin combined oral therapy with metformin and glimepiride in the current era. METHODS The clinical experts discussed and provided their inputs virtually. The expert panel included clinical experts comprising endocrinologists and diabetologists from India and Nepal. RESULTS The panel thoroughly reviewed existing literature on the subject and proposed clinical evidence and practice-based guidelines. CONCLUSION These current clinical practice guidelines highlight the efficacy and safety of basal insulin combination therapy with various available basal insulins including neutral protamine hagedorn, detemir, glargine and degludec in addition to metformin and glimepiride therapy.
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Affiliation(s)
| | - Jothydev Kesavadev
- Jothydev's Diabetes Research Centre, Konkalam Road, Mudavanmugal, Trivandrum, Kerala, India
| | - Viswanathan Mohan
- Dr. Mohan’s Diabetes Specialities Centre and Madras Diabetes Research Foundation, Chennai, India
| | - Banshi Saboo
- Diabetes Care and Hormone Clinic, Ahmedabad, Gujarat, India
| | - Dina Shrestha
- Norvic International Hospital and Medical College, and Hospital for Advanced Medicine and Surgery, Maharajganj, Kathmandu, Nepal
| | - Anuj Maheshwari
- Department of Medicine, American College of Physicians, BBD University, Lucknow, India
| | - Brij Mohan Makkar
- Dr. Makkar’s Diabetes & Obesity Centre, Paschim Vihar, New Delhi, India
| | | | - Ashok Kumar Das
- Pondicherry Institute of Medical Sciences, Puducherry, India
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Piro S, Purrello F. Acute diabetes complications. JOURNAL OF GERONTOLOGY AND GERIATRICS 2021. [DOI: 10.36150/2499-6564-n457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Strain WD, Morgan AR, Evans M. The Value of Insulin Degludec in Frail Older Adults with Type 2 Diabetes. Diabetes Ther 2021; 12:2817-2826. [PMID: 34608609 PMCID: PMC8489546 DOI: 10.1007/s13300-021-01162-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/21/2021] [Indexed: 12/25/2022] Open
Abstract
Insulin represents a mainstay of glucose-lowering therapy for many adults with type 2 diabetes mellitus (T2DM). Insulin treatments prescribed as standard care for the majority of people with T2DM, such as basal human insulin, may not be optimal in the treatment of frail older adults because of the increased demand on health care staff to administer multiple daily injections and monitor the patient. When choosing an insulin regimen for a frail older person with T2DM, predictability of glucose lowering effect, risk of hypoglycaemia, ease of administration, and simplicity and flexibility of dosing are major determining factors. Multiple daily injections may be too complex for older frail adults, whilst providing an unnecessary degree of tight glycaemic control and low doses of once-daily basal insulin analogues such as insulin degludec may be a reasonable option as cognitive decline or functional disability increases. Although insulin degludec has a substantially higher acquisition cost than routinely used basal human insulin, it has a longer, more predictable pharmacological profile and is more amenable to once-daily administration, translating into a reduced burden of care and potential cost savings for insulin-treated frail older adults. Insulin acquisition cost represents only a small proportion of the total cost of treatment, and it is important to consider the value perspective of insulin therapy in frail older adults from all stakeholders in the health care system.
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Affiliation(s)
- W David Strain
- Diabetes and Vascular Research Centre, University of Exeter Medical School, and the Academic Department of Healthcare for Older Adults, Royal Devon & Exeter Hospital, Exeter, UK.
| | | | - Marc Evans
- Diabetes Resource Centre, University Hospital Llandough, Cardiff, UK
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Abstract
The pancreatic peptide hormone insulin, first discovered exactly 100 years ago, is essential for glycemic control and is used as a therapeutic for the treatment of type 1 and, increasingly, type 2 diabetes. With a worsening global diabetes epidemic and its significant health budget imposition, there is a great demand for new analogues possessing improved physical and functional properties. However, the chemical synthesis of insulin's intricate 51-amino acid, two-chain, three-disulfide bond structure, together with the poor physicochemical properties of both the individual chains and the hormone itself, has long represented a major challenge to organic chemists. This review provides a timely overview of the past efforts to chemically assemble this fascinating hormone using an array of strategies to enable both correct folding of the two chains and selective formation of disulfide bonds. These methods not only have contributed to general peptide synthesis chemistry and enabled access to the greatly growing numbers of insulin-like and cystine-rich peptides but also, today, enable the production of insulin at the synthetic efficiency levels of recombinant DNA expression methods. They have led to the production of a myriad of novel analogues with optimized structural and functional features and of the feasibility for their industrial manufacture.
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Cheng AYY, Wong J, Freemantle N, Acharya SH, Ekinci E. The Safety and Efficacy of Second-Generation Basal Insulin Analogues in Adults with Type 2 Diabetes at Risk of Hypoglycemia and Use in Other Special Populations: A Narrative Review. Diabetes Ther 2020; 11:2555-2593. [PMID: 32975710 PMCID: PMC7547921 DOI: 10.1007/s13300-020-00925-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/03/2020] [Indexed: 12/16/2022] Open
Abstract
Hypoglycemia is a major barrier impeding glycemic control in persons with type 2 diabetes mellitus and creates a substantial burden on the healthcare system. Certain populations that require special attention, such as older adults and individuals with renal impairment, a longer duration of diabetes or those who have experienced prior hypoglycemia, may be at a higher risk of hypoglycemia, particularly with insulin treatment. Second-generation basal insulin analogues (insulin glargine 300 U/mL and degludec) have demonstrated reductions in hypoglycemia compared with insulin glargine 100 U/mL although evidence of this benefit across specific populations is less clear. In this review we summarize the literature with respect to the efficacy and safety data for second-generation basal insulin analogues in adults with type 2 diabetes mellitus who are at risk of hypoglycemia or who require special attention. Randomized controlled trials, meta-analyses and real-world evidence demonstrate that the use of second-generation basal insulin analogues is associated with less hypoglycemia compared with insulin glargine 100 U/mL without compromising glycated hemoglobin control. A reduced risk of hypoglycemia with second-generation basal insulin analogues was evident in older adults and in individuals with obesity, renal impairment, a history of cardiovascular disease or a long duration of insulin use. Further studies are needed in other populations, including those with more severe renal impairment or hepatic dysfunction, the hospitalized population and those with cognitive impairment. Overall, less hypoglycemia associated with second-generation basal insulin analogues may help reduce barriers for insulin use, improve adherence and offset the costs of hypoglycemia-related healthcare resource utilization.
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Affiliation(s)
- Alice Y Y Cheng
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
| | - Jencia Wong
- Diabetes Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Central Clinical School, Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Nick Freemantle
- Institute for Clinical Trials and Methodology, University College London, London, UK
| | - Shamasunder H Acharya
- Department of Diabetes, John Hunter Hospital, Hunter New England Health-University of Newcastle, New Lambton, NSW, Australia
| | - Elif Ekinci
- Department of Medicine, Austin Health-University of Melbourne, Melbourne, VIC, Australia
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Woo V, Berard L, Roscoe R. Understanding the Clinical Profile of Insulin Degludec, the Latest Basal Insulin Approved for Use in Canada: a Narrative Review. Diabetes Ther 2020; 11:2539-2553. [PMID: 32940879 PMCID: PMC7547940 DOI: 10.1007/s13300-020-00915-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Indexed: 12/26/2022] Open
Abstract
In recent years, the development of basal insulin therapies has focused on insulin analogues that have longer durations of action and more predictable pharmacokinetic/pharmacodynamic (PK/PD) profiles than their human insulin-based predecessors, such as neutral protamine Hagedorn (NPH) insulin. Dosed once-daily, such analogues can provide a more stable glucose-lowering action, which translates clinically into a reduced risk of hypoglycemia. Insulin degludec (degludec) became available in Canada in 2017 and is the first basal insulin analogue to have a half-life exceeding the dosing interval. As well as offering the promise of an exceptionally flat PK/PD profile when at steady state, this characteristic means that insulin degludec can be dosed with some flexibility with regard to time of day and that it need not be taken at the same time each day. However, the approximately 25-h half-life also has some implications concerning dose titration. This article provides an up-to-date review of the study data describing the clinical profile of degludec, and aims to give helpful and practical advice to prescribers about its use. While the clinical benefits of degludec are described, it is also acknowledged that further study is required to better understand how its clinical performance compares with that of insulin glargine 300 units/mL.
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Affiliation(s)
- Vincent Woo
- University of Manitoba, Winnipeg, MB, Canada.
| | - Lori Berard
- University of Manitoba, Winnipeg, MB, Canada
| | - Robert Roscoe
- Diabetes Education Centre, Saint John Regional Hospital, Saint John, NB, Canada
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Koufakis T, Grammatiki M, Kotsa K. Type 2 diabetes management in people aged over seventy-five years: targets and treatment strategies. Maturitas 2020; 143:118-126. [PMID: 33308617 DOI: 10.1016/j.maturitas.2020.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/06/2020] [Accepted: 10/10/2020] [Indexed: 02/06/2023]
Abstract
Older people (those aged 65 years or more) with diabetes comprise a heterogenous group of patients with special needs and features; this is particularly true for those aged 75 years or more. It is important that individualized glycemic targets be adopted in this population, after considering life expectancy, presence of diabetic complications and other comorbidities. In general, less rigorous targets and avoidance of overtreatment seems to be a reasonable strategy in daily clinical settings. There is a paucity of data regarding the efficacy and safety of various hypoglycemic agents, especially for those aged over 75. The evidence suggests that sulfonylureas and insulin regimens should be used with caution due to a high risk of hypoglycemia. Dipeptidyl peptidase-4 inhibitors are a good choice for the management of diabetes in older age groups, although a warning against the use of specific agents in people with heart failure is valid. There are insufficient data to decide whether the cardiorenal protective properties of sodium-glucose co-transporter 2 inhibitors outweigh the risks associated with these drugs. The use of glucagon-like peptide-1 receptor agonists by older patients is supported not only by their good safety and efficacy profiles, but also by their potential to improve glucose-independent outcomes, through their pleiotropic actions. The aim of this narrative review is to summarize the evidence on glycemic targets and optimal therapeutic approaches for older patients with type 2 diabetes and discuss the risk-benefit balance of various therapeutic approaches in this group.
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Affiliation(s)
- Theocharis Koufakis
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 1 St. Kiriakidi Street, Thessaloniki, 54636, Greece
| | - Maria Grammatiki
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 1 St. Kiriakidi Street, Thessaloniki, 54636, Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 1 St. Kiriakidi Street, Thessaloniki, 54636, Greece.
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Cersosimo E, Lee PG, Pandya N. Challenges of Diabetes Care in Older People With Type 2 Diabetes and the Role of Basal Insulin. Clin Diabetes 2019; 37:357-367. [PMID: 31660009 PMCID: PMC6794221 DOI: 10.2337/cd18-0074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IN BRIEF The use of long-acting basal insulin analogs is a recommended strategy in older people with diabetes because of their lower risk of hypoglycemia compared to intermediate-acting insulins. In this article, we review the results from recent clinical trials of second-generation basal insulin preparations. We conclude that, although these preparations have improved the management of insulin-requiring older people with type 2 diabetes, there is a need for additional and more specific studies to address the complexities of hyperglycemia management in this population.
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Affiliation(s)
- Eugenio Cersosimo
- Texas Diabetes Institute, University Health System and the University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Pearl G. Lee
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Naushira Pandya
- Department of Geriatrics, Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL
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Pratley RE, Emerson SS, Franek E, Gilbert MP, Marso SP, McGuire DK, Pieber TR, Zinman B, Hansen CT, Hansen MV, Mark T, Moses AC, Buse JB. Cardiovascular safety and lower severe hypoglycaemia of insulin degludec versus insulin glargine U100 in patients with type 2 diabetes aged 65 years or older: Results from DEVOTE (DEVOTE 7). Diabetes Obes Metab 2019; 21:1625-1633. [PMID: 30850995 PMCID: PMC6617815 DOI: 10.1111/dom.13699] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/06/2019] [Accepted: 03/06/2019] [Indexed: 12/26/2022]
Abstract
AIMS The aim of this study was to describe the risks of cardiovascular (CV) events and severe hypoglycaemia with insulin degludec (degludec) vs insulin glargine 100 units/mL (glargine U100) in patients with type 2 diabetes (T2D) aged 65 years or older. MATERIALS AND METHODS A total of 7637 patients in the DEVOTE trial, a treat-to-target, randomized, double-blind trial evaluating the CV safety of degludec vs glargine U100, were divided into three age groups (50-64 years, n = 3682; 65-74 years, n = 3136; ≥75 years, n = 819). Outcomes by overall age group and randomized treatment differences were analysed for major adverse cardiovascular events (MACE), all-cause mortality, severe hypoglycaemia and serious adverse events (SAEs). RESULTS Patients with increasing age had higher risks of CV death, all-cause mortality and SAEs, and there were non-significant trends towards higher risks of MACE and severe hypoglycaemia. Treatment effects on the risk of MACE, all-cause mortality, severe hypoglycaemia and SAEs were consistent across age groups, based on the non-significant interactions between treatment and age with regard to these outcomes. CONCLUSIONS There were higher risks of CV death, all-cause mortality and SAEs, and trends towards higher risks of MACE and severe hypoglycaemia with increasing age after adjusting for baseline differences. The effects across age groups of degludec vs glargine U100 on MACE, all-cause mortality and severe hypoglycaemia were comparable, suggesting that the risk of MACE, as well as all-cause mortality, is similar and the risk of severe hypoglycaemia is lower with degludec regardless of age. Evidence is conclusive only until 74 years of age.
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Affiliation(s)
- Richard E. Pratley
- AdventHealth Translational Research Institute for Metabolism and DiabetesOrlandoFlorida
| | | | - Edward Franek
- Mossakowski Clinical Research Centre, Polish Academy of SciencesWarsawPoland
| | - Matthew P. Gilbert
- Larner College of Medicine at The University of VermontBurlingtonVermont
| | - Steven P. Marso
- HCA Midwest Health Heart and Vascular InstituteKansas CityMissouri
| | | | | | - Bernard Zinman
- Lunenfeld‐Tanenbaum Research Institute, Mount Sinai HospitalUniversity of TorontoTorontoOntarioCanada
| | | | | | | | | | - John B. Buse
- University of North Carolina School of MedicineChapel HillNorth Carolina
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Heller SR, DeVries JH, Wysham C, Hansen CT, Hansen MV, Frier BM. Lower rates of hypoglycaemia in older individuals with type 2 diabetes using insulin degludec versus insulin glargine U100: Results from SWITCH 2. Diabetes Obes Metab 2019; 21:1634-1641. [PMID: 30891886 PMCID: PMC6618254 DOI: 10.1111/dom.13708] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/06/2019] [Accepted: 03/16/2019] [Indexed: 01/09/2023]
Abstract
AIM This study aimed to investigate the safety of insulin degludec (degludec) in relation to age and risk of hypoglycaemia post hoc in individuals with type 2 diabetes (T2D) (SWITCH 2 trial). METHODS In this crossover study, individuals with T2D who were at risk of hypoglycaemia were randomized to double-blind treatment with degludec or insulin glargine 100 units/mL (glargine U100) ± oral antidiabetic drugs. After 32 weeks, patients crossed over to the other treatment. Primary endpoint was number of overall severe (positively adjudicated) or glucose-confirmed (plasma glucose <56 mg/dL; 3.1 mmol/L) symptomatic hypoglycaemia events during the two 16-week maintenance periods. RESULTS For individuals ≤65 (n = 450) and >65 (n = 270) years, baseline median (range) duration of diabetes was 12 (1-40) vs 15 (1-54) years, mean HbA1c was 7.7% vs 7.4% and mean estimated glomerular filtration rate was 87.0 vs 63.7 mL/min/1.73 m2 , respectively. No significant differences in HbA1c reduction were seen in individuals ≤65 or >65 years. During both maintenance periods, treatment with degludec lowered rates of hypoglycaemia (overall/nocturnal symptomatic) vs those with glargine U100 in individuals ≤65 (31% vs 43%) and >65 (30% vs 41%) years. With degludec and glargine U100, respectively, six vs nine severe hypoglycaemic events occurred in individuals ≤65 years and four vs eight events occurred in those >65 years. Adverse event rates were 3.2 and 3.3 events/patient-year for individuals ≤65 years and were 3.5 and 4.1 events/patient-year for individuals >65 years with degludec and glargine U100, respectively. CONCLUSION Treatment with degludec was safe and effective, with a frequency of hypoglycaemia lower than that with glargine U100 in both younger and older individuals (>65 years) with T2D.
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Affiliation(s)
- Simon R. Heller
- Academic Unit of Diabetes, Endocrinology and MetabolismUniversity of SheffieldSheffieldUK
| | - J. Hans DeVries
- Academic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
| | - Carol Wysham
- School of MedicineUniversity of Washington/Multicare Rockwood ClinicSpokaneWashington
| | | | | | - Brian M. Frier
- The Queen's Medical Research CentreUniversity of EdinburghEdinburghUK
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Meneilly GS, Knip A, Miller DB, Sherifali D, Tessier D, Zahedi A. Diabetes in Older People. Can J Diabetes 2018; 42 Suppl 1:S283-S295. [PMID: 29650107 DOI: 10.1016/j.jcjd.2017.10.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 12/15/2022]
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Zhang XW, Zhang XL, Xu B, Kang LN. Comparative safety and efficacy of insulin degludec with insulin glargine in type 2 and type 1 diabetes: a meta-analysis of randomized controlled trials. Acta Diabetol 2018; 55:429-441. [PMID: 29423761 DOI: 10.1007/s00592-018-1107-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 01/19/2018] [Indexed: 12/17/2022]
Abstract
AIMS To determine the safety and efficacy of insulin degludec versus glargine in patients with type 1 (T1D) and type 2 (T2D) diabetes mellitus. METHODS Databases were searched until July 5, 2017. We included randomized controlled trials comparing degludec with glargine in diabetic patients, each with a minimum of 16 weeks of follow-up. RESULTS Eighteen trials with 16,791 patients were included. Degludec was associated with a statistically significant reduction in risk for all confirmed hypoglycemia at the maintenance treatment period [estimated rate ratio (ERR) 0.81; 95% confidence interval (CI) 0.72‒0.92; P = 0.001], nocturnal confirmed hypoglycemia at the entire (ERR 0.71; 95% CI 0.63‒0.80; P < 0.001) and maintenance treatment period (ERR 0.65; 95% CI 0.59‒0.71; P < 0.001), all irrespective of the pooled diabetic populations and follow-up durations. The differences in the rate of hypoglycemia were more pronounced in nocturnal period and maintenance period and in T2D than T1D patients. Degludec reduced the incidence of severe hypoglycemia in T2D [ERR 0.65; (0.52; 0.89); P = 0.005] but not T1D patients. HbA1c concentration was slightly higher in degludec over glargine but was not clinically relevant [estimated treatment difference (ETD) 0.03; 95% CI - 0.00 to 0.06%; P = 0.06]. Fasting plasma glucose level was lower in degludec-treated patients (ETD - 0.28 mmol/L; 95% CI - 0.44 to - 0.11 mmol/L; P = 0.001). Several subgroup analyses showed largely consistent findings. The rates of adverse events including total mortality and cardiovascular events were not significantly different between two treatment strategies. CONCLUSIONS Insulin degludec appears to have better safety in reducing hypoglycemic events with similar efficacy compared with insulin glargine.
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Affiliation(s)
- Xiao-Wen Zhang
- Department of Endocrinology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xin-Lin Zhang
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Biao Xu
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Li-Na Kang
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China.
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Gómez-Huelgas R, Gómez Peralta F, Rodríguez Mañas L, Formiga F, Puig Domingo M, Mediavilla Bravo JJ, Miranda C, Ena J. [Treatment of type 2 diabetes mellitus in elderly patients]. Rev Esp Geriatr Gerontol 2018; 53:89-99. [PMID: 29439834 DOI: 10.1016/j.regg.2017.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 06/08/2023]
Abstract
The prevalence of type 2 diabetes mellitus (DM2) increases markedly with age. Antidiabetic treatment and the objectives of glycaemic control in elderly patients with DM2 should be individualised according to their biopsychosocial characteristics. In elderly patients for whom the benefits of intensive antidiabetic treatment are limited, the basic objectives should be to improve the quality of life, preserve functionality and avoid adverse effects, especially hypoglycaemia. Treatment of DM2 in the elderly was the subject of a consensus document published in 2012 and endorsed by several Spanish scientific societies. Since then, new therapeutic groups and evidence have emerged that warrant an update to this consensus document. The present document focuses on the therapeutic aspects of DM2 in elderly patients, understood as being older than 75 years or frail.
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Affiliation(s)
- R Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA); CIBER de Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III; Sociedad Española de Medicina Interna (SEMI).
| | - F Gómez Peralta
- Unidad de Endocrinología y Nutrición, Hospital General de Segovia, Segovia, España; Sociedad Española de Diabetes (SED)
| | - L Rodríguez Mañas
- Servicio de Geriatría, Hospital Universitario de Getafe, Madrid, España; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III; Sociedad Española de Medicina Geriátrica (SEMEG)
| | - F Formiga
- Unidad de Geriatría, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España; Sociedad Española de Geriatría y Gerontología (SEGG)
| | - M Puig Domingo
- Servicio de Endocrinología y Nutrición, Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, España; CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III; Sociedad Española de Endocrinología y Nutrición (SEEN)
| | - J J Mediavilla Bravo
- Centro de Salud Burgos Rural, Burgos, España; Sociedad Española de Medicina General (SEMERGEN)
| | - C Miranda
- Centro de Salud Buenavista, Toledo, España; Sociedad Española de Médicos Generales y de Familia (SEMG)
| | - J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, La Vila Joiosa, Alicante, España; Sociedad Española de Medicina Interna (SEMI)
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Gómez-Huelgas R, Gómez Peralta F, Rodríguez Mañas L, Formiga F, Puig Domingo M, Mediavilla Bravo JJ, Miranda C, Ena J. Treatment of type 2 diabetes mellitus in elderly patients. Rev Clin Esp 2018; 218:74-88. [PMID: 29366502 DOI: 10.1016/j.rce.2017.12.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/03/2017] [Indexed: 02/06/2023]
Abstract
The prevalence of type 2 diabetes mellitus (DM2) increases markedly with age. Antidiabetic treatment and the objectives of glycaemic control in elderly patients with DM2 should be individualised according to their biopsychosocial characteristics. In elderly patients for whom the benefits of intensive antidiabetic treatment are limited, the basic objectives should be to improve the quality of life, preserve functionality and avoid adverse effects, especially hypoglycaemia. Treatment of DM2 in the elderly was the subject of a consensus document published in 2012 and endorsed by several Spanish scientific societies. Since then, new therapeutic groups and evidence have emerged that warrant an update to this consensus document. The present document focuses on the therapeutic aspects of DM2 in elderly patients, understood as being older than 75 years or frail.
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Affiliation(s)
- R Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA); CIBER de Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III; Sociedad Española de Medicina Interna (SEMI).
| | - F Gómez Peralta
- Unidad de Endocrinología y Nutrición, Hospital General de Segovia, Segovia, España; Sociedad Española de Diabetes (SED)
| | - L Rodríguez Mañas
- Servicio de Geriatría, Hospital Universitario de Getafe, Madrid, España; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III; Sociedad Española de Medicina Geriátrica (SEMEG)
| | - F Formiga
- Unidad de Geriatría, Hospital Universitari de Bellvitge, ĹHospitalet de Llobregat, Barcelona, España; Sociedad Española de Geriatría y Gerontología (SEGG)
| | - M Puig Domingo
- Servicio de Endocrinología y Nutrición, Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, España; CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III; Sociedad Española de Endocrinología y Nutrición (SEEN)
| | - J J Mediavilla Bravo
- Centro de Salud Burgos Rural, Burgos, España; Sociedad Española de Medicina General (SEMERGEN)
| | - C Miranda
- Centro de Salud Buenavista, Toledo, España; Sociedad Española de Médicos Generales y de Familia (SEMG)
| | - J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, La Vila Joiosa, Alicante, España; Sociedad Española de Medicina Interna (SEMI)
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17
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Advances in Managing Type 2 Diabetes in the Elderly: A Focus on Inpatient Care and Transitions of Care. Am J Ther 2018. [DOI: 10.1097/mjt.0000000000000667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Selivanova OM, Grishin SY, Glyakina AV, Sadgyan AS, Ushakova NI, Galzitskaya OV. Analysis of Insulin Analogs and the Strategy of Their Further Development. BIOCHEMISTRY (MOSCOW) 2018; 83:S146-S162. [DOI: 10.1134/s0006297918140122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/09/2017] [Indexed: 08/30/2023]
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Frias PF, Frias JP. New Basal Insulins: a Clinical Perspective of Their Use in the Treatment of Type 2 Diabetes and Novel Treatment Options Beyond Basal Insulin. Curr Diab Rep 2017; 17:91. [PMID: 28822051 DOI: 10.1007/s11892-017-0926-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review was to review advances in basal insulin formulations and new treatment options for patients with type 2 diabetes not achieving glycemic targets despite optimized basal insulin therapy. RECENT FINDINGS Advances in basal insulin formulations have resulted in products with increasingly favorable pharmacokinetic and pharmacodynamic properties, including flatter, peakless action profiles, less inter- and intra-patient variability, and longer duration of activity. These properties have translated to significantly reduced risk of hypoglycemia (particularly during the night) compared with previous generation basal insulins. When optimized basal insulin therapy is not sufficient to obtain or maintain glycemic goals, various options exist to improve glycemic control, including intensification of insulin therapy with the addition of prandial insulin or changing to pre-mixed insulin and, more recently, the addition of a GLP-1 receptor agonist, either as a separate injection or as a component of one of the new fixed-ratio combinations of a basal insulin and GLP-1 RA. New safer and often more convenient basal insulins and fixed ratio combinations containing basal insulin (and GLP-1 receptor agonist) are available today for patients with type 2 diabetes not achieving glycemic goals. Head-to-head studies comparing the latest generation basal insulins are underway, and future studies assessing the fixed-ratio combinations will be important to better understand their differentiating features.
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Affiliation(s)
| | - Juan Pablo Frias
- National Research Institute, 2010 Wilshire Boulevard, Suite 302, Los Angeles, CA, 90057, USA.
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20
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Bloomgarden Z, Drexler A. Treatment: Concepts and new developments. J Diabetes 2016; 8:297-9. [PMID: 26854013 DOI: 10.1111/1753-0407.12381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
Insulin remains indispensable in the treatment of diabetes, but its use is hampered by its narrow therapeutic index. Although advances in peptide chemistry and recombinant DNA-based macromolecule synthesis have enabled the synthesis of structurally optimized insulin analogues, the growing epidemics of obesity and diabetes have emphasized the need for diabetes therapies that are more efficacious, safe and convenient. Accordingly, a broad set of drug candidates, targeting hyperglycaemia plus other disease abnormalities, is now progressing through the clinic. The development of an insulin therapy that is responsive to glucose concentration remains an ultimate goal, with initial prototypes now reaching the proof-of-concept stage. Simultaneously, the first alternatives to injectable delivery have progressed to registration.
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Abstract
INTRODUCTION Insulin therapy plays a critical role in the treatment of type 1 and type 2 diabetes mellitus. However, there is still a need to find basal insulins with 24-hour coverage and reduced risk of hypoglycemia. Additionally, with increasing obesity and insulin resistance, the ability to provide clinically necessary high doses of insulin at low volume is also needed. AREAS COVERED This review highlights the published reports of the pharmacokinetic (PK) and glucodynamic properties of concentrated insulins: Humulin-R U500, insulin degludec U200, and insulin glargine U300, describes the clinical efficacy, risk of hypoglycemic, and metabolic changes observed, and finally, discusses observations about the complexity of introducing a new generation of concentrated insulins to the therapeutic market. CONCLUSION Humulin-R U500 has a similar onset but longer duration of action compared with U100 regular insulin. Insulin glargine U300 has differential PK/pharmacodynamic effects when compared with insulin glargine U100. In noninferiority studies, glycemic control with degludec U200 and glargine U300 is similar to insulin glargine U100 and nocturnal hypoglycemia is reduced. Concentrated formulations appear to behave as separate molecular entities when compared with earlier U100 insulin analog compounds. In the review of available published data, newer concentrated basal insulins may offer an advantage in terms of reduced intraindividual variability as well as reducing the injection burden in individuals requiring high-dose and large volume insulin therapy. Understanding the PK and pharmacodynamic properties of this new generation of insulins is critical to safe dosing, dispensing, and administration.
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Affiliation(s)
- Elizabeth M Lamos
- Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lisa M Younk
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stephen N Davis
- Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
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23
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Heise T, Korsatko S, Nosek L, Coester HV, Deller S, Roepstorff C, Segel S, Kapur R, Haahr H, Hompesch M. Steady state is reached within 2-3 days of once-daily administration of degludec, a basal insulin with an ultralong duration of action. J Diabetes 2016; 8:132-8. [PMID: 25581159 DOI: 10.1111/1753-0407.12266] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/24/2014] [Accepted: 12/25/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Various factors influence the pharmacokinetic and pharmacodynamic properties of insulin analogs. The aim of the present study was to determine time to steady state of insulin degludec (IDeg), a basal insulin analog with an ultralong duration of action, after once-daily subcutaneous administration in subjects of varying age, diabetes type, and ethnicity. METHODS Time to steady state was analyzed in 195 subjects across five Phase I randomized single-center double-blind studies: three in subjects with type 1 diabetes (T1DM), including one in elderly subjects, and two in subjects with type 2 diabetes (T2DM), including one with African American and Hispanic/Latino subpopulations. Subjects received once-daily IDeg (100 U/mL, s.c.) at doses of 0.4-0.8 U/kg for 6-12 days. Time to clinical steady state was measured from first dose until the serum IDeg trough concentration exceeded 90% of the final plateau level. The IDeg concentrations were log-transformed and analyzed using a mixed-effects model with time from first dose and dose level (where applicable) as fixed effects, and subject as a random effect. RESULTS Steady state serum IDeg concentrations were reached after 2-3 days in all subjects. In trials with multiple dose levels, time to steady state was independent of dose level in T1DM (P = 0.51) and T2DM (P = 0.75). CONCLUSIONS Serum IDeg concentrations reached steady state within 2-3 days of once-daily subcutaneous administration in all subjects with T1DM or T2DM, including elderly and African American and Hispanic/Latino subjects. At steady state, serum IDeg concentrations were unchanged from day to day.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Marcus Hompesch
- Profil Institute for Clinical Research, Chula Vista, California, USA
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24
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Kaku K, Eid MA. Safety, efficacy, and early clinical experience of insulin degludec in Japanese people with diabetes mellitus: A first-year report from Japan. J Diabetes Investig 2015; 6:610-9. [PMID: 26543532 PMCID: PMC4627535 DOI: 10.1111/jdi.12348] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 02/23/2015] [Accepted: 03/02/2015] [Indexed: 01/26/2023] Open
Abstract
In Japan, insulin therapy is recommended for the treatment of type 2 diabetes mellitus either directly after diet, exercise and lifestyle improvements, or if the target for glycemic control is not achieved with other hypoglycemic agents. Insulin degludec is an ultra-long-acting insulin that was launched in Japan in 2013, having shown good efficacy and safety in its clinical development program. It has now been used in clinical practice for more than 1 year. During this time, clinicians and researchers have identified possible factors that could influence the decision as to which patients might be appropriate for insulin degludec treatment. In the present review, we describe how to initiate and manage insulin degludec therapy in routine clinical practice. We also discuss several important topics related to the use of insulin degludec, including patient selection, dosing, handling of bolus insulin, hypoglycemia and other potential safety considerations.
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Affiliation(s)
- Kohei Kaku
- Department of Internal Medicine, Kawasaki Medical School Okayama, Japan
| | - Mohamed A Eid
- Medical & Scientific Affairs, Novo Nordisk Pharma Limited Tokyo, Japan
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25
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Mathur S, Zammitt NN, Frier BM. Optimal glycaemic control in elderly people with type 2 diabetes: what does the evidence say? Drug Saf 2015; 38:17-32. [PMID: 25481812 DOI: 10.1007/s40264-014-0247-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The global prevalence of type 2 diabetes mellitus (T2DM) is rising in an ageing population through a combination of lifestyle changes and greater longevity. However, by excluding participants aged over 70 years, most major interventional trials on which current diabetes therapeutic guidelines are based have failed to provide specific evidence to support the prescribed management of diabetes in elderly people. While diabetes per se has a significant impact on the elderly person, the side effects of medications, particularly hypoglycaemia, prevent optimisation of diabetes treatment. Hypoglycaemia is associated with significant morbidity, to which elderly people are often more vulnerable because of factors such as the effects of ageing, progressive renal impairment, frailty, polypharmacy and cognitive decline. T2DM is associated with accelerated cognitive decline in some individuals, and recurrent severe hypoglycaemia has been implicated as a potential contributory factor. Although the evidence for selection of appropriate glycaemic targets in elderly patients is sparse, it is now acknowledged that prevention of hypoglycaemia must influence individualisation of treatment goals in this vulnerable group. This should also be reflected by the choice of anti-diabetes agents that are initiated when diet and lifestyle advice is ineffective. Recently developed international guidelines, which have specifically addressed the management of diabetes in elderly people, highlight the importance of a pragmatic management approach rather than attempting to achieve a generic glycated haemoglobin goal and are summarised in this article.
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Affiliation(s)
- Supriya Mathur
- Department of Diabetes, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
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26
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Tambascia MA, Eliaschewitz FG. Degludec: the new ultra-long insulin analogue. Diabetol Metab Syndr 2015; 7:57. [PMID: 26136850 PMCID: PMC4486707 DOI: 10.1186/s13098-015-0037-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 04/21/2015] [Indexed: 01/18/2023] Open
Abstract
The development of extended-action insulin analogues was motivated by the unfavorable pharmacokinetic (PK) profile of the conventional long-acting insulin formulations, generally associated with marked inter and intra patient variability and site- and dose-dependent effect variation. The new ultra-long insulin analogue degludec (IDeg) has the same amino acid sequence as human insulin except for the removal of threonine in the position 30 of the B chain (Des-B30, "De") and the attachment, via a glutamic acid linker ("glu"), of a 16-carbon fatty diacid (hexadecanoic diacid, "dec") to lysine in the position 29 of the B chain. These modifications allow that, after changing from the pharmaceutical formulation to the subcutaneous environment, IDeg precipitates in the subcutaneous tissue, forming a depot that undergoes a highly predictable gradual dissociation. Thus, once-daily dosing of IDeg results in a low peak: trough ratio, with consequent low intra-individual variability and plasmatic concentrations less critically dependent upon the time of injections. The clinical development program of IDeg (BEGIN) was comprised of 9 therapeutic confirmatory trials of longer duration (26-52 weeks) and showed that the efficacy of IDeg is comparable to insulin glargine in type 1 (T1D) and type 2 (T2D) diabetes patients across different age, body mass index and ethnic groups. This new ultra-long insulin analogue presents as advantages flexibility in dose timing and lower risk of hypoglycemia.
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Affiliation(s)
| | - Freddy Goldberg Eliaschewitz
- />Hospital Israelita Albert Einstein – São Paulo Brazil, and CPClin Clinical Research Center, Rua Goias 91, São Paulo, CEP01244-030 Brazil
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27
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Evans M, McEwan P. Clinical and cost-effectiveness of insulin degludec: from clinical trials to clinical practice. J Comp Eff Res 2015; 4:279-286. [PMID: 25959645 DOI: 10.2217/cer.15.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The increasing prevalence of diabetes presents one of the greatest challenges to healthcare provision in modern times, with the cost of treating diabetes and its related complications representing a significant proportion of healthcare expenditure. In recent years, many new therapeutic entities have been developed with the aim of improving glycemic control, and thus slowing the development of micro- and macrovascular complications. Insulin degludec is a new-generation basal insulin analog with an ultra-long duration of action and low day-to-day and hour-to-hour intrapatient variability in blood glucose-lowering action. In this review, we consider evidence from clinical trials and real-world studies demonstrating the clinical benefits and cost-effectiveness of insulin degludec and its potential for improving patient care.
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Affiliation(s)
- Marc Evans
- University Hospital Llandough, Penlan Road, Penarth, Cardiff CF64 2XX, UK
| | - Phil McEwan
- Swansea Centre for Health Economics, University of Swansea, Singleton Park, Swansea, UK
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28
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Dżygało K, Golicki D, Kowalska A, Szypowska A. The beneficial effect of insulin degludec on nocturnal hypoglycaemia and insulin dose in type 1 diabetic patients: a systematic review and meta-analysis of randomised trials. Acta Diabetol 2015; 52:231-8. [PMID: 25430705 DOI: 10.1007/s00592-014-0604-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 05/19/2014] [Indexed: 02/02/2023]
Abstract
AIMS Insulin degludec is a new-generation ultra-long-acting basal insulin which offers a significantly more predictable glucose-lowering effect than other long-acting insulin analogues. The aim of this study was to compare the effect of treatment with insulin degludec and long-acting insulin analogues glargine and detemir in type 1 diabetic (T1D) patients by means of a systematic review and meta-analysis. METHODS The following electronic databases were searched up to January 2014: MEDLINE, EMBASE and The Cochrane Library. Additional references were obtained from the reviewed articles. There were included randomised controlled trials of at least 12-week duration with basal-bolus regimen therapies in T1D patients. RESULTS Current analysis included four studies involving 1,846 T1D patients. The combined data from all trials showed a statistically significant reduction in the basal insulin dose (MD -0.042, 95 % CI -0.067 to -0.018, p = 0.001) and the total daily insulin dose (MD -0.072, 95 % CI 0.016 to -0.027, p = 0.002) in the degludec group compared to other long-acting analogues. There was also a significant reduction of nocturnal hypoglycaemia in the degludec group compared to the controls (rate ratio 0.697, 95 % CI 0.617-0.786, p = 0.000). There were no differences between the groups in terms of glycated haemoglobin values, fasting plasma glucose (FPG) and adverse events. CONCLUSIONS Basal-bolus treatment with insulin degludec was superior to long-acting insulin analogues detemir and glargine in reducing the rate of nocturnal hypoglycaemia. In comparison with other long-acting analogues, treatment with insulin degludec was safe and patients obtained similar metabolic control expressed by HbA1c and FPG levels with the added benefit of a reduced basal and total insulin dose.
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Affiliation(s)
- K Dżygało
- Department of Paediatrics, Medical University of Warsaw, Dzialdowska 1, 01-184, Warsaw, Poland
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29
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Du YF, Ou HY, Beverly EA, Chiu CJ. Achieving glycemic control in elderly patients with type 2 diabetes: a critical comparison of current options. Clin Interv Aging 2014; 9:1963-80. [PMID: 25429208 PMCID: PMC4241951 DOI: 10.2147/cia.s53482] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the elderly. Because of the unique characteristics of elderly people with T2DM, therapeutic strategy and focus should be tailored to suit this population. This article reviews the guidelines and studies related to older people with T2DM worldwide. A few important themes are generalized: 1) the functional and cognitive status is critical for older people with T2DM considering their life expectancy compared to younger counterparts; 2) both severe hypoglycemia and persistent hyperglycemia are deleterious to older adults with T2DM, and both conditions should be avoided when determining therapeutic goals; 3) recently developed guidelines emphasize the avoidance of hypoglycemic episodes in older people, even in the absence of symptoms. In addition, we raise the concern of glycemic variability, and discuss the rationale for the selection of current options in managing this patient population.
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Affiliation(s)
- Ye-Fong Du
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Horng-Yih Ou
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Elizabeth A Beverly
- Department of Social Medicine, Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Ching-Ju Chiu
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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30
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Ultra-long pharmacokinetic properties of insulin degludec are comparable in elderly subjects and younger adults with type 1 diabetes mellitus. Drugs Aging 2014; 31:47-53. [PMID: 24263619 PMCID: PMC3880476 DOI: 10.1007/s40266-013-0138-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background Management of diabetes in elderly subjects is complex and careful management of glucose levels is of particular importance in this population because of an increased risk of diabetes-related complications and hypoglycaemia. Objective The aim of this study was to evaluate the pharmacokinetic and pharmacodynamic properties of insulin degludec (IDeg), a basal insulin with an ultra-long duration of action, in elderly subjects with type 1 diabetes compared with younger adults. Methods This trial was a randomised, double-blind, two-period, crossover trial conducted in a single centre and included both inpatient and outpatient periods. Subjects were men and women aged 18–35 years inclusive (younger adult group) or ≥65 years (elderly group) with type 1 diabetes who received IDeg (0.4 U/kg) via subcutaneous injection in the thigh once-daily for six days. Following 6-day dosing, a 26-hour euglycaemic glucose clamp procedure was conducted to evaluate the steady-state pharmacodynamic effects of IDeg. Blood samples were taken for pharmacokinetic analysis up to 120 h post-dose. Pharmacokinetic endpoints included the total exposure of IDeg, ie the area under the IDeg serum concentration curve during one dosing interval at steady state (AUCIDeg,τ,SS) (τ = 0–24 h, equal to one dosing interval) and the maximum IDeg serum concentration at steady state (Cmax,IDeg,SS). Pharmacodynamic endpoints included the total glucose-lowering effect of IDeg, ie the area under the glucose infusion rate (GIR) curve at steady state (AUCGIR,τ,SS), and the maximum GIR at steady state (GIRmax,IDeg,SS). Results Total exposure (AUCIDeg,τ,SS) and maximum concentration (Cmax,IDeg,SS) of IDeg were comparable between elderly subjects and younger adults. Estimated mean age group ratios (elderly/younger adult) for AUCIDeg,τ,SS and Cmax,IDeg,SS and corresponding two-sided 95 % confidence intervals (CIs) were 1.04 (95 % CI 0.73–1.47) and 1.02 (95 % CI 0.74–1.39), respectively. Mean AUCIDeg,0–12h,SS/AUCIDeg,τ,SS was 53 % in both younger adult and elderly subjects, showing that in both age groups IDeg exposure was evenly distributed across the first and second 12 h of the 24-hour dosing interval. No statistically significant differences were observed between younger adult and elderly subjects with regard to AUCGIR,τ,SS (the primary endpoint of this study) and GIRmax,IDeg,SS. Estimated mean age group ratios (elderly/younger adult) for AUCGIR,τ,SS and GIRmax,IDeg,SS and corresponding two-sided 95 % CIs were 0.78 (95 % CI 0.47–1.31) and 0.80 (95 % CI 0.54–1.17), respectively. Duration of action was beyond the clamp duration of 26 h in all subjects.
Conclusions The exposure of IDeg at steady state during once-daily dosing was similar in younger adult and elderly subjects. The glucose-lowering effect of IDeg was numerically lower in elderly subjects compared with younger adults, but no significant differences were observed between age groups. The ultra-long pharmacokinetic and pharmacodynamic properties of IDeg observed in younger adults were preserved in elderly subjects with type 1 diabetes. Clinical trials.gov number: NCT00964418
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31
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Stokes V, Gough SC. Recent advances with insulin degludec for the treatment of Type 2 diabetes. Expert Rev Endocrinol Metab 2014; 9:301-312. [PMID: 30763990 DOI: 10.1586/17446651.2014.917045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Type 2 diabetes has been referred to as the global epidemic of the 21st century, and is associated with significant morbidity and premature mortality. Estimates suggest that over 50% of people with Type 2 diabetes will at some point need insulin injections to help treat their diabetes. Once daily insulin injections are being increasingly used to initiate insulin in people with Type 2 diabetes and the development of novel, safe, once daily basal insulins with low rates of hypoglycaemia are important to help achieve internationally recommended glycaemic targets for individual patients. Insulin degludec is a novel once daily basal insulin analogue that has been developed for use in people with Type 2 diabetes. A comprehensive drug development program suggests that it can achieve comparable glycaemic control to existing basal insulins but with reduced rates of hypoglycaemia.
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Affiliation(s)
- Victoria Stokes
- a Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, OX3 7LE, UK
| | - Stephen Cl Gough
- a Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, OX3 7LE, UK
- b NIHR Oxford Biomedical Research Centre, Oxford, UK
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Aye MM, Atkin SL. Patient safety and minimizing risk with insulin administration - role of insulin degludec. DRUG HEALTHCARE AND PATIENT SAFETY 2014; 6:55-67. [PMID: 24812526 PMCID: PMC4010638 DOI: 10.2147/dhps.s59566] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetes is a lifelong condition requiring ongoing medical care and patient self-management. Exogenous insulin therapy is essential in type 1 diabetes and becomes a necessity in patients with longstanding type 2 diabetes who fail to achieve optimal control with lifestyle modification, oral agents, and glucagon-like peptide 1-based therapy. One of the risks that hinders insulin use is hypoglycemia. Optimal insulin therapy should therefore minimize the risk of hypoglycemia while improving glycemic control. Insulin degludec (IDeg) is a novel basal insulin that, following subcutaneous injection, assembles into a depot of soluble multihexamer chains. These subsequently release IDeg monomers that are absorbed at a slow and steady rate into the circulation, with the terminal half-life of IDeg being ~25 hours. Thus, it requires only once-daily dosing unlike other basal insulin preparations that often require twice-daily dosing. Despite its long half-life, once-daily IDeg does not cause accumulation of insulin in the circulation after reaching steady state. IDeg once a day will produce a steady-state profile with a lower peak:trough ratio than other basal insulins. In clinical trials, this profile translates into a lower frequency of nocturnal hypoglycemia compared with insulin glargine, as well as an ability to allow some flexibility in dose timing without compromising efficacy and safety. Indeed, a study that tested the extremes of dosing intervals of 8 and 40 hours showed no detriment in either glycemic control or hypoglycemic frequency versus insulin glargine given at the same time each day. While extreme flexibility in dose timing is not recommended, these findings are reassuring. This may be particularly beneficial to elderly patients, patients with learning difficulties, or others who have to rely on health-care professionals for their daily insulin injections. Further studies are required to confirm whether this might benefit adherence to treatment, reduce long-term hypoglycemia or reduce diabetes-related complications.
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Affiliation(s)
- Myint M Aye
- Hull Royal Infirmary, Michael White Diabetes Centre, Hull, UK
| | - Stephen L Atkin
- Weill Cornell Medical College Qatar, Qatar Foundation, Doha, Qatar
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Dardano A, Penno G, Del Prato S, Miccoli R. Optimal therapy of type 2 diabetes: a controversial challenge. Aging (Albany NY) 2014; 6:187-206. [PMID: 24753144 PMCID: PMC4012936 DOI: 10.18632/aging.100646] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 03/24/2014] [Indexed: 02/07/2023]
Abstract
Type 2 diabetes mellitus (T2DM) is one of the most common chronic disorders in older adults and the number of elderly diabetic subjects is growing worldwide. Nonetheless, the diagnosis of T2DM in elderly population is often missed or delayed until an acute metabolic emergency occurs. Accumulating evidence suggests that both aging and environmental factors contribute to the high prevalence of diabetes in the elderly. Clinical management of T2DM in elderly subjects presents unique challenges because of the multifaceted geriatric scenario. Diabetes significantly lowers the chances of "successful" aging, notably it increases functional limitations and impairs quality of life. In this regard, older diabetic patients have a high burden of comorbidities, diabetes-related complications, physical disability, cognitive impairment and malnutrition, and they are more susceptible to the complications of dysglycemia and polypharmacy. Several national and international organizations have delivered guidelines to implement optimal therapy in older diabetic patients based on individualized treatment goals. This means appreciation of the heterogeneity of the disease as generated by life expectancy, functional reserve, social support, as well as personal preference. This paper will review current treatments for achieving glycemic targets in elderly diabetic patients, and discuss the potential role of emerging treatments in this patient population.
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Affiliation(s)
- Angela Dardano
- Department of Clinical and Experimental Medicine, Section of Diabetes and Metabolic Diseases, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
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