Efficacy and safety of insulin glulisine in patients with type 1 diabetes

A comparison of the rapid-acting insulin analogue glulisine with lispro and aspart for the pump treatment of patients with type 1 diabetes

AIMS

(1) To describe the population of patients with type 1 diabetes (T1DM) using the rapid-acting insulin analogue glulisine versus lispro and aspart during continuous subcutaneous insulin infusion (CSII); (2) to describe insulin relative effectiveness based on hemoglobin A1c (HbA1c), fasting blood glucose (FBG) and dose; (3) to determine rates of hyperglycemia, hypoglycemia, and diabetic ketoacidosis (DKA).

METHODS

The analysis used March 2021 data from the Diabetes-Patienten-Verlaufsdokumentation registry, which contains data of 618,903 patients with diabetes. Patients were propensity-matched by age, sex, and diabetes duration.

RESULTS

Overall, 42,736 patients of any age were eligible for analysis based on insulin pump usage with either glulisine (N = 707) or lispro/aspart (N = 42,029) between 2004 and 2020. Patients receiving glulisine were older (median 20.0 vs. 16.2 years), equally often male (47.2% vs. 47.8%) and had a longer diabetes duration (median 9.4 vs. 7.4 years). After propensity score matching, 707 pairs remained (total N = 1414). Patient characteristics between groups were similar. Achieved HbA1c values were also comparable: 8.04%, 64 mmol/mol versus 7.96%, 63 mmol/mol for glulisine and lispro/aspart [LS mean difference 0.08 (95%CI - 0.08, 0.25)]. FBG was 9.37 mmol/L (168.9 mg/dL) and 9.58 mmol/L (172.6 mg/dL) in the glulisine and lispro/aspart groups [LS mean diff. - 0.21; (95%CI - 1.13, 0.72)]. Total daily insulin doses and prandial to total insulin ratios were also similar. Glulisine group patients had higher rates of lipodystrophy (0.85% vs. 0.71%) (LS mean diff. 0.18 [95% CI - 1.01, 1.38]) and non-severe DKA (3.11% vs. 0.57%; p = 0.002). Fewer patients in the glulisine group had severe hypoglycemic events (7.66 vs. 9.09; p = 0.333) and severe ketoacidosis events (0.57% vs. 1.56%; p = 0.082) but more had hypoglycemic coma events (p = 0.773), although the differences were not statistically significant.

CONCLUSIONS

Insulin glulisine had comparable glucose control to lispro/aspart. The use of glulisine was less frequent in the present analysis compared to the previous trials.

Proteomic Changes to the Updated Discovery of Engineered Insulin and Its Analogs: Pros and Cons

The destruction of β-cells of the pancreas leads to either insulin shortage or the complete absence of insulin, which in turn causes diabetes Mellitus. For treating diabetes, many trials have been conducted since the 19th century until now. In ancient times, insulin from an animal's extract was taken to treat human beings. However, this resulted in some serious allergic reactions. Therefore, scientists and researchers have tried their best to find alternative ways for managing diabetes with progressive advancements in biotechnology. However, a lot of research trials have been conducted, and they discovered more progressed strategies and approaches to treat type I and II diabetes with satisfaction. Still, investigators are finding more appropriate ways to treat diabetes accurately. They formulated insulin analogs that mimic the naturally produced human insulin through recombinant DNA technology and devised many methods for appropriate delivery of insulin. This review will address the following questions: What is insulin preparation? How were these devised and what are the impacts (both positive and negative) of such insulin analogs against TIDM (type-I diabetes mellitus) and TIIDM (type-II diabetes mellitus)? This review article will also demonstrate approaches for the delivery of insulin analogs into the human body and some future directions for further improvement of insulin treatment.

Rapid-acting insulin analogues: Theory and best clinical practice in type 1 and type 2 diabetes

Since the discovery of insulin 100 years ago, insulin preparations have improved significantly. Starting from purified animal insulins, evolving to human insulins produced by genetically modified organisms, and ultimately to insulin analogues, all in an attempt to mimic physiological insulin action profiles seen in individuals without diabetes. Achieving strict glucose control without hypoglycaemia and preventing chronic complications of diabetes while preserving quality of life remains a challenging goal, but the advent of newer ultra-rapid-acting insulin analogues may enable intensive insulin therapy without being too disruptive to daily life. Ultra-rapid-acting insulin analogues can be administered shortly before meals and give better coverage of mealtime-induced glucose excursions than conventional insulin preparations. They also increase convenience with timing of bolus dosing. In this review, we focus on the progress that has been made in rapid-acting insulins. We summarize pharmacokinetic and pharmacodynamic data, clinical trial data supporting the use of these new formulations as part of a basal-bolus regimen and continuous subcutaneous insulin infusion, and provide a clinical perspective to help guide healthcare professionals when and for whom to use ultra-fast-acting insulins.

One hundred years of insulin therapy

At the time of its first clinical application 100 years ago, insulin was presented as the cure for people with diabetes mellitus. That transpired to be an overstatement, yet insulin has proven to be the lifesaver for people with type 1 diabetes mellitus and an essential therapy for many with type 2 diabetes mellitus or other forms of diabetes mellitus. Since its discovery, insulin (a molecule of only 51 amino acids) has been the subject of pharmaceutical research and development that has paved the way for other protein-based therapies. From purified animal-extracted insulin and human insulin produced by genetically modified organisms to a spectrum of insulin analogues, pharmaceutical laboratories have strived to tailor the preparations to the needs of patients. Nonetheless, overall glycaemic control often remains poor as exogenous insulin is still not able to mimic the physiological insulin profile. Circumventing subcutaneous administration and the design of analogues with profiles that mimic that of physiological insulin are ongoing areas of research. Novel concepts, such as once-weekly insulins or glucose-dependent and oral insulins, are on the horizon but their real-world effectiveness still needs to be proven. Until a true cure for type 1 diabetes mellitus is found and the therapeutic arsenal for other forms of diabetes mellitus is expanded, insulin will remain central in the treatment of many people living with diabetes mellitus.

Improving the treatment of patients with diabetes using insulin analogues: current findings and future directions

Introduction: The aim of insulin replacement in insulin-deficient people (type 1 diabetes, pancreatic causes of diabetes, long-standing type 2 diabetes) is to approximate the physiologic insulin action profile as closely as possible. However, short-acting human insulins start too slow and act too long, causing postprandial hyperglycemia and delayed hypoglycemia, while the insulin action profile of long-acting human insulins is too variable in duration and strength of action, leading to insufficient basal insulin covering and peak insulin levels after injection causing early nocturnal hypoglycemia. Insulin analogues were designed to overcome these shortcomings. In insulin-resistant people (type 2 diabetes), insulin analogues contribute to more efficient and safer insulin supplementation. Areas covered: In this review, we describe the unmet needs for insulin therapy, the currently available short- and long-acting insulin analogues and some considerations on cardiovascular outcomes, use in special populations, and cost-effectiveness. Finally, we discuss what is new in the field of insulin analogues. Expert opinion: The development of insulin analogues is an important step in diabetes treatment. Despite many patients meeting their glycemic targets with the newest analogues, hypoglycemic episodes remain a major problem. More physiologic insulin regimens, with glucose-sensitive or organ-targeting insulin analogues may be the answer to these issues.

Insulin Therapy in Adults with Type 1 Diabetes Mellitus: a Narrative Review

Here, we review insulin management options and strategies in nonpregnant adult patients with type 1 diabetes mellitus (T1DM). Most patients with T1DM should follow a regimen of multiple daily injections of basal/bolus insulin, but those not meeting individual glycemic targets or those with frequent or severe hypoglycemia or pronounced dawn phenomenon should consider continuous subcutaneous insulin infusion. The latter treatment modality could also be an alternative based on patient preferences and availability of reimbursement. Continuous glucose monitoring may improve glycemic control irrespective of treatment regimen. A glycemic target of glycated hemoglobin < 7% (53 mmol/mol) is appropriate for most nonpregnant adults. Basal insulin analogues with a reduced peak profile and an extended duration of action with lower intraindividual variability relative to neutral protamine Hagedorn insulin are preferred. The clinical advantages of basal analogues compared with older basal insulins include reduced injection burden, better efficacy, lower risk of hypoglycemic episodes (especially nocturnal), and reduced weight gain. For prandial glycemic control, any rapid-acting prandial analogue (aspart, glulisine, lispro) is preferred over regular human insulin. Faster-acting insulin aspart is a relatively new option with the advantage of better postprandial glucose coverage. Frequent blood glucose measurements along with patient education on insulin dosing based on carbohydrate counting, premeal blood glucose, and anticipated physical activity is paramount, as is education on the management of blood glucose under different circumstances.Plain Language Summary: Plain language summary is available for this article.

A Review of Basal-Bolus Therapy Using Insulin Glargine and Insulin Lispro in the Management of Diabetes Mellitus

Basal-bolus therapy (BBT) refers to the combination of a long-acting basal insulin with a rapid-acting insulin at mealtimes. Basal insulin glargine 100 U/mL and prandial insulin lispro have been available for many years and there is a substantial evidence base to support the efficacy and safety of these agents when they are used in BBT or basal-plus therapy for patients with type 1 or type 2 diabetes mellitus (T1DM, T2DM). With the growing availability of alternative insulins for use in such regimens, it seems timely to review the data regarding BBT with insulin glargine 100 U/mL and insulin lispro. In patients with T1DM, BBT with insulin glargine plus insulin lispro provides similar or better glycemic control and leads to less nocturnal hypoglycemia compared to BBT using human insulin as the basal and/or prandial component, and generally provides similar glycemic control and rates of severe hypoglycemia to those achieved with insulin lispro administered by continuous subcutaneous insulin infusion (CSII). Studies evaluating BBT with insulin glargine plus insulin lispro in patients with T2DM also demonstrate the efficacy and safety of these insulins. Available data suggest that BBT with insulin glargine and insulin lispro provides similar levels of efficacy and safety in pediatric and adult populations with T1DM and in adult patients and those aged more than 65 years with T2DM. These insulin preparations also appear to be safe and effective for controlling T2DM in people of different ethnicities and in patients with T1DM or T2DM and comorbidities.

FUNDING

Eli Lilly and Company.

Hypoglycemia awareness among insulin-treated patients with diabetes in Malaysia: A cohort subanalysis of the HAT study

AIMS

The present Malaysian cohort analysis determined the prevalence of hypoglycemia among patients with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) attending primary care- or hospital-based diabetes clinics in Malaysia and their awareness of the symptoms of hypoglycemia.

METHODS

The Hypoglycemia Assessment Tool (HAT) study was a non-interventional, 6-month retrospective and 4-week prospective analysis of hypoglycemic events in 24 countries, using self-assessment questionnaires and diaries among patients with T1DM/T2DM aged ≥18years, using insulin for >12months. This report focuses on prospective data, as they are less prone to recall bias.

RESULTS

There were 1153 participants in the Malaysian cohort (114 T1DM; 1039 T2DM). In the prospective period, 50.4% and 33.4% of patients reported ≥1 hypoglycemic events, with estimated rates of 20.3 and 13.1 events per patient-year of exposure in patients with T1DM and T2DM, respectively. 24.8% and 16.1% of patients with T1DM or T2DM, respectively, reported ≥1 nocturnal hypoglycemic event. The majority of patients (96.5%, T1DM; 91.8%, T2DM) knew what hypoglycemia was prior to the study. Impaired awareness was present in 48.0% (T1DM) and 36.9% (T2DM) of patients. In the prospective period, 50% of patients with T1DM or T2DM consulted a doctor or nurse following a hypoglycemia episode.

CONCLUSIONS

Half of patients with T1DM and a third of patients with T2DM reported ≥1 hypoglycemic event during the prospective period. Although the majority of patients knew the typical features of hypoglycemia, many reported impaired ability to recognize symptoms in real life. The present findings highlight the importance of patient education and physician awareness in dealing with hypoglycemia, in particular the burden of hypoglycemic unawareness.

CLINICAL TRIAL NUMBER

This trial was registered at www.clinicaltrials.gov as NCT01696266 on 26 September 2012.

Challenges in the design of insulin and relaxin/insulin-like peptide mimetics

Peptidomimetics are designed to overcome the poor pharmacokinetics and pharmacodynamics associated with the native peptide or protein on which they are based. The design of peptidomimetics starts from developing structure-activity relationships of the native ligand-target pair that identify the key residues that are responsible for the biological effect of the native peptide or protein. Then minimization of the structure and introduction of constraints are applied to create the core active site that can interact with the target with high affinity and selectivity. Developing peptidomimetics is not trivial and often challenging, particularly when peptides' interaction mechanism with their target is complex. This review will discuss the challenges of developing peptidomimetics of therapeutically important insulin superfamily peptides, particularly those which have two chains (A and B) and three disulfide bonds and whose receptors are known, namely insulin, H2 relaxin, H3 relaxin, INSL3 and INSL5.

Insulin analogues in type 1 diabetes mellitus: getting better all the time

The treatment of type 1 diabetes mellitus consists of external replacement of the functions of β cells in an attempt to achieve blood levels of glucose as close to the normal range as possible. This approach means that glucose sensing needs to be replaced and levels of insulin need to mimic physiological insulin-action profiles, including basal coverage and changes around meals. Training and educating patients are crucial for the achievement of good glycaemic control, but having insulin preparations with action profiles that provide stable basal insulin coverage and appropriate mealtime insulin peaks helps people with type 1 diabetes mellitus to live active lives without sacrificing tight glycaemic control. Insulin analogues enable patients to achieve this goal, as some have fast action profiles, and some have very slow action profiles, which gives people with type 1 diabetes mellitus the tools to achieve dynamic insulin-action profiles that enable tight glycaemic control with a risk of hypoglycaemia that is lower than that with human short-acting and long-acting insulins. This Review discusses the established and novel insulin analogues that are used to treat patients with type 1 diabetes mellitus and provides insights into the future development of insulin analogues.

Clinical effects, cardiovascular and renal outcomes associated with rapid-acting insulin analogs among individuals with type 2 diabetes: a nation-wide observational cohort study

Background

Rapid-acting insulin analogs (RAIs) have not been examined for long-term safety in randomized clinical trials. We performed a nationwide longitudinal cohort study among individuals with type 2 diabetes (T2DM) to address cardiovascular safety and mortality among users of lispro, aspart and glulisine insulins.

Methods

We used four national registers, following patients previously not treated with RAI but with continuous use of RAIs in 2005-2014 up to 6.4 years, to examine HbA1c and weight, and the occurrence of severe hyperglycemia or hypoglycemia, renal failure, cardiovascular events or death. The treatment groups were compared using a weighted Cox proportional hazards model.

Results

We included 17,620 patients, mean age slightly higher than 60 years, diabetes duration 9.9–11.7 years, mean BMI 30.5 kg/m², HbA1c around 70 mmol/mol (8.6% NGSP), and 40.9–54.0% of the patients exhibiting eGFR <60 ml/min/1.73 m² in the three groups. Around 95% of the patients also used another insulin, and 24.2–24.7% had a history of cardiovascular disease (CVD).

Mean HbA1c and weight levels were stable and similar. Incidence rates of death were 234.4, 284.9 and 156.7 per 1000 person-years among users of lispro, aspart, and glulisine; incidence rates of all cardiovascular events were 668.4, 622.4, and 699.5 per 1000 person-years, respectively.

There were no differences in mortality, CVD, renal failure or severe hypoglycemia or hyperglycemia, although a lower mortality risk in patients on glulisine compared with aspart, and lower risk of stroke in users of glulisine was suggested. The risk of severe hyperglycemia was higher with lispro than aspart, and lower of severe hypoglycemia than aspart or glulisine among the older age group.

Conclusions

Overall, there do not appear to be any major important differences in effects on hypoglycemia, hyperglycemia, weight or long-term safety between the three available RAIs among insulin-naive individuals with T2DM in clinical practice.

Pharmacy Update

The prevalence of diabetes mellitus has increased to more than 20 million people in the United States, and current estimates indicate that one third of all Americans born in the year 2000 will develop diabetes mellitus in their lifetime. The need for diabetes therapies offering improved glucose control by mimicking normal physiological properties of glucose metabolism and improving on logistics such as ease of use, self-management, monitoring, and delivery is clear. This article, part 2 of a 3-part series, reviews newer injectable insulin preparations and examines the first-to-market orally inhaled dry powdered insulin (IDPI). The information provided is tailored to diabetes educators and includes mechanism of action, pharmacokinetics, drug interactions, clinical trials, dosage and administration guidelines, side effects, and educational pearls for each insulin discussed. A detailed patient case designed to acquaint the reader with these newer insulin products and provide an understanding of clinical issues to consider when providing diabetes education to patients is included.

Clinical Effects and Safety of Direct-Acting Insulin Analogs in Patients with Type 1 Diabetes: A Nation-Wide Observational Cohort Study

INTRODUCTION

Studies comparing direct-acting insulin analogs (DAIs) in terms of effectiveness and long-term safety are scarce. Our aim was to explore these variables in clinical practice among patients with type 1 diabetes, including the elderly and those with renal impairment.

METHODS

We linked four national registers in a population-based cohort study. Patients with type 1 diabetes and continuous use of all currently available DAIs (lispro, aspart, or glulisine) in 2005-2013 were monitored for up to 7.5 years. Inverse probability of treatment weighting was used to adjust for differences in baseline characteristics between treatment groups. Unadjusted mean HbA1c and weights were plotted. Hazard ratios and 95% confidence intervals of cardiovascular events (CVEs) and mortality were estimated using Cox proportional hazards regression models.

RESULTS

We included 41,165 patients-14,047 lispro, 26,813 aspart, and 305 glulisine users. At baseline, the mean age was highest among glulisine users (49.4 years), followed by 41.0 years for lispro users and 40.1 years for aspart users. A total of 9.2% of the patients were 65 years or older. Diabetes duration was shortest among glulisine users (11.6 years), followed by 15.4 years for aspart users and 19.5 years for lispro users. The mean HbA1c and weights during the follow-up period were similar. The numerical differences at baseline were subsequently adjusted for. There were no significant differences between groups regarding hyperglycemia requiring hospitalization, CVE, or mortality, while Cox regression suggested lower rates of hypoglycemia among glulisine users. Severe hypoglycemia was more common, and severe hyperglycemia was less common among patients aged 65 years or older, while severe hypoglycemia and hyperglycemia were more common in patients with low renal function (estimated glomerular filtration rate).

CONCLUSION

There were no pronounced differences in effectiveness and long-term cardiovascular safety and mortality between the DAIs, although there were some differences in clinical characteristics between patients using the three types of insulin. Severe hypoglycemia was more common among older patients, while severe hypoglycemia and hyperglycemia were more common among patients with impaired renal function.

FUNDING

Sanofi.

The treatment of type 2 diabetes in the presence of renal impairment: what we should know about newer therapies

Worldwide, an estimated 200 million people have chronic kidney disease (CKD), the most common causes of which include hypertension, arteriosclerosis, and diabetes. Importantly, ~40% of patients with diabetes develop CKD, yet evidence from major multicenter randomized controlled trials shows that intensive blood glucose control through pharmacological intervention can reduce the incidence and progression of CKD. Standard therapies for the treatment of type 2 diabetes include metformin, sulfonylureas, meglitinides, thiazolidinediones, and insulin. While these drugs have an important role in the management of type 2 diabetes, only the thiazolidinedione pioglitazone can be used across the spectrum of CKD (stages 2–5) and without dose adjustment; there are contraindications and dose adjustments required for the remaining standard therapies. Newer therapies, particularly dipeptidyl peptidase-IV inhibitors, glucagon-like peptide-1 receptor agonists, and sodium-glucose cotransporter-2 inhibitors, are increasingly being used in the treatment of type 2 diabetes; however, a major consideration is whether these newer therapies can also be used safely and effectively across the spectrum of renal impairment. Notably, reductions in albuminuria, a marker of CKD, are observed with many of the drug classes. Dipeptidyl peptidase-IV inhibitors can be used in all stages of renal impairment, with appropriate dose reduction, with the exception of linagliptin, which can be used without dose adjustment. No dose adjustment is required for liraglutide, albiglutide, and dulaglutide in CKD stages 2 and 3, although all glucagon-like peptide-1 receptor agonists are currently contraindicated in stages 4 and 5 CKD. At stage 3 CKD or greater, the sodium-glucose cotransporter-2 inhibitors (dapagliflozin, canagliflozin, and empagliflozin) either require dose adjustment or are contraindicated. Ongoing trials, such as CARMELINA, MARLINA, CREDENCE, and CANVAS-R, will help determine the position of these new therapy classes and if they have renoprotective effects in patients with CKD.

Pursuit of a perfect insulin

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.

Efficacy and safety of switching to insulin glulisine from other rapid-acting insulin analogs in children with type 1 diabetes

We investigated the efficacy and safety of switching to insulin glulisine (GLU) from other rapid-acting insulin analogs (Ra) in children with type 1 diabetes treated with multiple daily injections of insulin or continuous subcutaneous insulin infusion. A total of 26 children with type 1 diabetes were included. Ra in all of these patients was changed to GLU, and they were observed for a 6-month period after having previously finished treatment with other Ra. The mean glycated hemoglobin value decreased from 7.6 ± 1.0 to 7.4 ± 0.9% (P = 0.0034), and mean plasma glucose values after breakfast and supper also improved from 183 ± 50 to 153 ± 32 mg/dL (P = 0.0035), and from 203 ± 29 to 164 ± 23 mg/dL (P < 0.0001), respectively. Furthermore, the mean frequency of hypoglycemia was reduced from 7 ± 6 to 4 ± 4/month (P = 0.0004), while insulin doses and obesity degree were stable with statistically non-significant differences. In conclusion, switching to GLU might be a good treatment option for improving glycemic control in children with type 1 diabetes.

Impact of insulins glulisine and aspart on postprandial glycemia after a high-glycemic index meal in children with type 1 diabetes

OBJECTIVE

According to current knowledge, glulisine insulin (GLU) has a slightly faster onset of action than aspart (ASP) insulin. Therefore, GLU might lead to a better postprandial profile than ASP following the consumption of high-glycemic index (H-GI) meals. The aim of this study was to assess differences in the action of GLU and ASP after the consumption of a H-GI meal in type 1 diabetic children treated with insulin pumps.

DESIGN

FIFTY-SIX TYPE 1 DIABETIC CHILDREN OF MEAN AGE 14.72.0 YEARS WERE INCLUDED IN A RANDOMIZED, DOUBLE-BLIND, TWO-WAY CROSSOVER STUDY.

THE SUBJECTS WERE ALLOCATED TO ONE OF TWO TREATMENT ORDERS

GLU-ASP and ASP-GLU. They were given a H-GI breakfast for two subsequent days.

METHODS

The primary outcome was postprandial glycemia (PPG) based on continuous glucose monitoring system and self monitoring of blood glucose levels during 3 h of follow-up. The secondary outcomes were the frequency of hypoglycemia, glucose area under the curve, mean amplitude of glycemic excursion, and glycemic rise.

RESULTS

THERE WERE NO SIGNIFICANT DIFFERENCES BETWEEN THE GROUPS WITH REGARD TO PPG IN THE DETERMINED TIME INTERVALS AS WELL AS WITH RESPECT TO THE SECONDARY OUTCOMES. BETWEEN 60 AND 120MIN AFTER FOOD CONSUMPTION IN BOTH STUDY GROUPS, BLOOD GLUCOSE LEVELS WERE CLOSE TO OR ABOVE 10.0MMOL/L. GLUCOSE PEAKS WERE HIGHER IN THE GLUASP GROUP THAN IN THE ASPGLU GROUP (90MIN: P=0.065; 120 min: P=0.052). Most of the episodes of hypoglycemia were observed after the second hour of follow-up.

CONCLUSIONS

No statistically significant difference was found between GLU and ASP with regard to PPG after the consumption of a H-GI breakfast. Neither GLU nor ASP stabilized the glycemic profile after the consumption of a H-GI meal.

Safety of rapid-acting insulin analogs versus regular human insulin

Insulin is the most effective treatment for both type 1 and type 2 diabetes mellitus. There are several differences in the safety profiles of each type of insulin, including rapid-acting insulin analogs and regular human insulin. The pharmacokinetic and pharmacodynamic properties of those insulin types also differ, as do their safety parameters. Treatment with rapid-acting analogs results in less hypoglycemia overall and decreased frequency of both severe and nocturnal hypoglycemia. In addition, the more rapid onset and shorter duration of action of rapid-acting insulin analogs are associated with greater control of postprandial glucose than regular human insulin. This review will describe the similarities and differences between the safety profiles of rapid-acting insulin analogs.

The pharmacokinetics and pharmacodynamics of rapid-acting insulin analogues and their clinical consequences

Postprandial glucose excursions can inhibit achievement of good glycaemic control, and possibly have a specific effect on the risk of vascular comorbidities. Rapid-acting analogues control these excursions better than human insulin because their pharmacokinetic/pharmacodynamic (PK/PD) profile is closer to that of meal-time endogenous insulin secretion. Review of the findings of PK/PD studies and clinical trials suggests that the three marketed rapid-acting analogues--insulin lispro, insulin aspart and insulin glulisine--are equally efficacious and safe. In comparison with human insulin when using the same basal insulin, they provide comparable glycaemic control with a reduced risk of hypoglycaemia, although the combination of rapid-acting and basal analogues reduces glycated haemoglobin (HbA(1c)) more than human meal-time insulin combined with neutral protamine Hagedorn (NPH) insulin. Some studies have suggested that insulin glulisine has a slightly faster onset of action compared with insulin lispro or insulin aspart, but this has not been translated into demonstrable clinical benefit. Treatment satisfaction in patients with diabetes has been higher when therapy with a rapid-acting analogue is used instead of human insulin, perhaps due to differences in advised timing of injection. The largest benefits in efficacy, hypoglycaemia incidence, treatment satisfaction and quality of life have occurred when patients receive an all-analogue meal-time plus basal regimen as compared with an all-human insulin regimen. No new safety issues have been identified with the marketed rapid-acting analogues, and their insulin-like growth factor 1 receptor affinity and mitogenic activity are comparable to human insulin.

Cumulative clinical experience with use of insulin lispro: critical appraisal, role in therapy, and patient considerations

We have now at our disposal the new rapid-acting insulin analogs, of which insulin lispro was the first to become commercially available. While the differences in pharmacokinetic and pharmacodynamic characteristics are indisputable, the clinical benefits attained by these changes have not been as clear. In the present review, we discuss the structure, pharmacology, and landmark studies related to insulin lispro. The clinical characteristics of insulin lispro are compared with those of insulin regular and other insulin analogs in different clinical situations. Also included are the aspects of quality of life and cost-effectiveness that may modify the modern practitioner's decision to adopt one type of insulin over another.

Comparison of pharmacokinetic properties, physicochemical stability, and pump compatibility of 3 rapid-acting insulin analogues-aspart, lispro, and glulisine

OBJECTIVE

To compare how the rapid-acting insulin analogues (RAIAs) aspart, lispro, and glulisine perform in continuous subcutaneous insulin infusion (CSII) therapy regarding (1) pharmacokinetic properties, (2) chemical and physical stability, and (3) pump compatibility.

METHODS

PubMed was searched for articles pertaining to the use of RAIAs in CSII, without a restriction on the time period.

RESULTS

These RAIAs have pharmacokinetic profiles that more closely mimic endogenous insulin in comparison with regular human insulin and tend to produce less hypoglycemia. Among these RAIAs, the rates of absorption and clinical efficacy in terms of glycemic control were similar. Although glulisine showed a faster onset of action in some studies with aspart and lispro, this advantage lasted only for a maximum of 1 hour, after which results were similar for glulisine and aspart or lispro. Each RAIA is created by making minor amino acid substitutions to the regular human insulin molecule and adding a stabilizer to help prevent fibrillation. A series of chemical and covalent changes affecting the primary structure of an insulin preparation, however, may cause decomposition during storage, handling, and use, diminishing the potency of the insulin molecule while contained in an insulin pump. Precipitation, fibrillation, and occlusion may ensue, undermining compatibility for CSII pump use. Aspart has demonstrated the greatest chemical and physical stability in the insulin pump, with the lowest rates of overall occlusion in comparison with lispro and glulisine (aspart 9.2%, lispro 15.7%, and glulisine 40.9%; P<.01).

CONCLUSION

Aspart is the most compatible of the 3 RAIAs for pump use.

Insulin glulisine compared to insulin aspart and to insulin lispro administered by continuous subcutaneous insulin infusion in patients with type 1 diabetes: a randomized controlled trial

BACKGROUND

In a previous pilot study comparing insulin glulisine (GLU) with insulin aspart (ASP) administered by continuous subcutaneous insulin infusion (CSII), GLU-treated patients did show a trend toward fewer catheter occlusions compared with ASP-treated patients. Here we performed a randomized open-label, three-way crossover, controlled multicenter study comparing GLU with ASP and insulin lispro (LIS).

METHODS

Subjects with type 1 diabetes were allocated to one of three treatment orders-GLU-ASP-LIS, ASP-LIS-GLU, or LIS-GLU-ASP-with each insulin used for 13 weeks. The study was designed to demonstrate the superiority of GLU over ASP and LIS on unexplained hyperglycemia and/or perceived infusion set occlusion. A prespecified P value of 0.025 was considered significant to correct for multiple testing.

RESULTS

Percentages of subjects with at least one unexplained hyperglycemia and/or infusion set occlusion were not significantly different between GLU and ASP (68.4% [62.7-74.1%] vs. 62.1% [56.2-68.1%], P = 0.04) and GLU and LIS (68.4% [62.7-74.1%] vs. 61.3% [55.4-67.3%], P = 0.03). No differences were seen in hemoglobin A1c at end point, most points of the seven-point glucose curves, severe hypoglycemia, and symptomatic ketoacidosis. The overall rate of hypoglycemia with a plasma glucose level below 70 mg/dL per patient-year was significantly different between GLU and ASP (73.84 vs. 65.01, P = 0.008) and GLU and LIS (73.84 vs. 62.69, P < 0.001). Insulin doses remained unchanged during the trial.

CONCLUSIONS

GLU was not superior to ASP and LIS with no significant difference seen among GLU, ASP, and LIS in CSII use with respect to unexplained hyperglycemia and/or perceived catheter set occlusion. GLU was associated with a higher frequency of symptomatic hypoglycemia, possibly because of slight overdosing, as previous trials suggested lower insulin requirements when GLU is initiated in type 1 diabetes.

Comparable efficacy and safety of insulin glulisine and insulin lispro when given as part of a Basal-bolus insulin regimen in a 26-week trial in pediatric patients with type 1 diabetes

BACKGROUND

We compared the efficacy and safety of insulin glulisine with insulin lispro as part of a basal-bolus regimen in children and adolescents with type 1 diabetes.

METHODS

Overall, 572 children and adolescents (4-17 years old) using insulin glargine or neutral protamine Hagedorn insulin as basal insulin were enrolled in a 26-week, multicenter, open, centrally randomized, parallel-group, noninferiority study. Subjects were randomized to receive glulisine (n = 277) or lispro (n= 295) 0-15 min premeal.

RESULTS

Baseline-to-endpoint hemoglobin A1c changes were similar between the two insulins: adjusted mean change (glulisine vs. lispro), 0.10% versus 0.16%; between-treatment difference (glulisine-lispro), &minsu;0.06, 95% confidence interval (-0.24; 0.12); and prespecified noninferiority margin, 0.4%. Overall, for all age groups together, the percentage of patients achieving American Diabetes Association age-specific A1c targets at endpoint was significantly higher (P = 0.039) with glulisine (38.4%) versus lispro (32.0%). From Month 4 to endpoint, both "all" and "severe" symptomatic hypoglycemia rates were similar (3.10 vs. 2.91 and 0.06 vs. 0.07 events/patient-month, respectively). Frequency and type of adverse events, serious adverse events, or hypoglycemia reported as serious adverse events were similar between both groups.

CONCLUSIONS

Glulisine was as effective as lispro in baseline-to-endpoint A1c change, and both treatments were similarly well tolerated.

The role of insulin glulisine to improve glycemic control in children with diabetes mellitus

Glulisine (Apidra(®)) is a rapid-acting human insulin analog approved for use in children with diabetes mellitus ≥4 years of age. Management of children with type 1 diabetes has seen a shift in favor of mimicking normal physiological insulin responses with multiple daily injections or continuous subcutaneous insulin infusions (CSII). Few studies have compared the rapid-acting insulin analogs in this population but limited data indicate that glulisine is as effective as lispro when used in a basal-bolus regimen. This review appraises the current available studies and reviews on insulin glulisine in children. An extensive keyword search of 'insulin glulisine', 'insulin analogs', and 'Apidra' in the pediatric population was performed. These studies have suggested that glulisine is safe, well tolerated, and is an effective option in the diabetes armamentarium. Further studies are needed to determine its safety for use in CSII pumps in the pediatric population.

Insulin glulisine: a review of its use in the management of diabetes mellitus

Insulin glulisine (Apidra) is a human insulin analogue approved for the improvement of glycaemic control in adults, adolescents and children with diabetes mellitus. It has similar binding properties, and is associated with a faster onset but similar level of glucose disposal, to regular human insulin (RHI). Insulin glulisine and insulin lispro have similar effects on glucose levels. Insulin glulisine is effective when compared to other short- and rapid-acting insulins, demonstrating either noninferiority, no significant difference, or superiority in primary endpoints in studies involving patients with type 1 and type 2 diabetes. It is more effective and has a faster onset and shorter duration of activity than RHI. Insulin glulisine is as effective as insulin lispro in patients with type 1 diabetes; however, there is a need for further, well designed head-to-head comparisons with insulin lispro in patients with type 2 diabetes and with insulin aspart in patients with type 1 or type 2 diabetes to fully establish the place of insulin glulisine in the management of diabetes. Insulin glulisine has a flexible administration period, as it can be administered immediately before or after meals. Hypoglycaemia, a common risk with insulins, occurs at a similar rate among recipients of insulin glulisine to that seen with other insulins. Thus, insulin glulisine is an effective and well tolerated option for the treatment of patients with type 1 and type 2 diabetes.

Efficacy and safety of insulin glulisine in Japanese patients with type 1 diabetes mellitus

AIM

The rapid-acting insulin analogue insulin glulisine (glulisine) was compared with insulin lispro (lispro) for efficacy and safety in Japanese patients with type 1 diabetes mellitus (T1DM), using insulin glargine (glargine) as basal insulin.

METHODS

This was an open, randomized, parallel-group, comparative non-inferiority study. The primary efficacy measure was change in adjusted mean haemoglobin A1c (HbA1c) from baseline to endpoint. Safety and treatment satisfaction using the Diabetes Treatment Satisfaction Questionnaire (DTSQ) were also assessed. Patients were treated for 28 weeks with either glulisine or lispro administered 0-15 min before a meal. Doses were titrated to obtain 2-h postprandial plasma glucose (2h-PPG) of 7.11-9.55 mmol/l (128-172 mg/dl). All patients were concomitantly treated with glargine at bedtime, titrated to obtain a fasting (prebreakfast) plasma glucose level of 5.27-7.11 mmol/l (95-128 mg/dl).

RESULTS

Baseline mean HbA1c values were similar for the glulisine (n = 132) and lispro (n = 135) groups (7.44 and 7.50% respectively). From baseline to endpoint, adjusted mean HbA1c increased by 0.10% in the glulisine group and by 0.04% in the lispro group. Non-inferiority of glulisine compared with lispro was shown. There were no significant differences between glulisine and lispro in adjusted mean 2h-PPG [glulisine, 9.06 mmol/l (163 mg/dl) vs. lispro, 8.13 mmol/l (146 mg/dl); p = 0.065] and change in adjusted mean daily rapid-acting insulin dose (glulisine, 0.26 U vs. lispro, 0.26 U; p = 0.994) at study endpoint. There was a significant difference for change in adjusted mean daily basal insulin dose from baseline to study endpoint (glulisine, -0.54 U vs. lispro, 0.26 U; p = 0.013). The most common serious adverse events were hypoglycaemia-related events (hypoglycaemia, hypoglycaemic seizure and hypoglycaemic coma) with no difference observed between the two groups [glulisine, 6.8% (9/132) vs. lispro, 4.4% (6/135); p = 0.437]. No noteworthy differences were observed for change in insulin antibodies from baseline to endpoint. Assessment of treatment satisfaction score and perceived frequency of hyperglycaemia and hypoglycaemia by DTSQ showed no changes from baseline in either group.

CONCLUSIONS

Glulisine was as effective as lispro with respect to change in HbA1c and was well tolerated when used in combination with glargine in Japanese patients with T1DM.

Insulin glulisine in the management of diabetes

Insulin glulisine is appealing in principle, but the advantages of this drug over the other rapid-acting insulin analogs are still relatively unknown. The frequency of hypoglycemia, convenience in the timing of administration, and improvements in terms of HbA(1c) seem similar among the rapid-acting insulin analogs, including insulin glulisine. Only properly randomized long-term clinical studies with insulin glulisine will reveal the true value of this novel insulin analog.

Insulin glulisine: an evaluation of its pharmacodynamic properties and clinical application

OBJECTIVE

To evaluate the pharmacodynamic properties, efficacy, safety, and clinical application of insulin glulisine, a rapid-acting insulin analog, in the treatment of diabetes mellitus in ambulatory and hospitalized patients.

DATA SOURCES

Searches were performed with the headings glulisine, insulin analog, [LysB3, GluB29] insulin, insulin glulisine, rDNA insulin, rapid-acting insulin, SoloStar, safety, efficacy, pharmacodynamics, and cost analysis within MEDLINE and PubMed, American Diabetes Association (ADA), the Food and Drug Administration (FDA), and Sanofi-aventis Pharmaceuticals (1990-August 2008).

STUDY SELECTION AND DATA EXTRACTION

Phase 1, Phase 2, Phase 3, and postmarketing trials examining the efficacy and safety of glulisine in type 1 or type 2 diabetes were reviewed. Studies published as abstracts and the manufacturer's product information supplemented data absent from clinical trials.

DATA SYNTHESIS

Insulin glulisine is a rapid-acting insulin with relative equivalence in efficacy and safety to other short- and rapid-acting insulins. Glulisine's onset of action of 20 minutes and 4-hour duration of action allow for bolus administration 15-20 minutes prior to or up to 20 minutes after meals. Clinical trials have demonstrated the safety and efficacy in adults with type 1 or type 2 diabetes. Several studies indicated a statistically significant decrease of hemoglobin A1C (A1C) with glulisine compared with regular insulin (0.10 decrease); however, no difference in A1C control was found compared with insulin aspart or lispro. Significant adverse effects appear to be limited to localized and systemic allergic reactions and hypoglycemia.

CONCLUSIONS

Insulin glulisine is a safe and effective rapid-acting insulin analog for the treatment of adults with diabetes. Clinical benefit over other short- and rapid-acting insulin products is not established. Addition of insulin glulisine to a formulary should be based on institution-specific availability and cost differences between glulisine, lispro, and aspart in the absence of superiority of clinical efficacy or safety and data beyond 26 weeks.

Adjust to target in type 2 diabetes: comparison of a simple algorithm with carbohydrate counting for adjustment of mealtime insulin glulisine

OBJECTIVE

Carbohydrate counting is an effective approach to mealtime insulin adjustment in type 1 diabetes but has not been rigorously assessed in type 2 diabetes. We sought to compare an insulin-to-carbohydrate ratio with a simple algorithm for adjusting the dose of prandial insulin glusiline.

RESEARCH AND DESIGN METHODS

This 24-week, multicenter, randomized, controlled study compared two algorithms for adjusting mealtime (glulisine) insulin along with a standard algorithm for adjusting background (glargine) insulin in 273 intent-to-treat patients with type 2 diabetes. Glulisine and glargine were adjusted weekly in both groups based on self-monitored blood glucose (SMBG) results from the previous week. The simple algorithm group was provided set doses of glulisine to take before each meal. The carbohydrate counting (carb count) group was provided an insulin-to-carbohydrate ratio to use for each meal and adjusted their glulisine dose based on the amount of carbohydrate consumed.

RESULTS

A1C levels at week 24 were 6.70% (simple algorithm) and 6.54% (carb count). The respective mean A1C changes from baseline to 24 weeks were -1.46 and -1.59% (P = 0.24). A1C <7.0% was achieved by 73.2% (simple algorithm) and 69.2% (carb count) (P = 0.70) of subjects; respective values for A1C <6.5% were 44.3 and 49.5% (P = 0.28). The total daily dose of insulin was lower, and there was a trend toward less weight gain in carb count group patients. Severe hypoglycemia rates were low and equal in the two groups.

CONCLUSIONS

Weekly basal-bolus insulin adjustments based on premeal and bedtime glucose patterns resulted in significant reductions in A1C. Having two effective approaches to delivering and adjusting rapid-acting mealtime insulin may increase physicians' and patients' willingness to advance therapy to a basal-bolus insulin regimen.

A review on the actual trends of insulin treatment in elderly with diabetes

The diabetes of the elderly subjects has two forms: diabetes of long duration, manifesting itself in younger or medium ages, and senile diabetes, appearing above the age of 65 years. The diabetes of the elderly has usually only modest symptoms: it is not ketosic, but in spite of this, in order to avoid the chronic-degenerative complications, it is important to maintain a good, even if not an optimal compensation. The therapeutic intervention cannot neglect a correct alimentary regime and a programmed physical activity in correlation with the clinical conditions of the patient. If the compensation is not achieved only with these tools, one can add oral antidiabetic treatments. In the elderly patients we usually observe primary or secondary failure of the oral antidiabetic treatments, and in such context we have to apply insulin treatment, even in cases of moderate glycometabolic decompensations. While we are waiting for the gene-therapy or the inhalatory insulin preparations, actually there are at disposal only the insulin analogs in rapid, slow and mixed forms. We propose two treatment schemes: (i) The first one consists of three administrations of rapid insulin with the meals, and on dose of slow insulin 2h after the last meal in the evening. (ii) The second scheme consists of one administration of rapid insulin at lunch, one administration of mixed insulin at dinner, with the addition of oral antidiabetics of peripheric action, in the morning and the evening. A better compliance can be obtained, being a fundamental aspect in the elderly diabetics, and a reduction of the number and severity of the hypoglycemia, which are the most important aspects in the elderly diabetes.

Insulin glulisine, insulin lispro and regular human insulin show comparable end-organ metabolic effects: an exploratory study

AIMS

To compare the end-organ metabolic effects of insulin glulisine (glulisine), insulin lispro (lispro) and regular human insulin (RHI) in patients with type 1 diabetes mellitus.

METHODS

Eighteen patients with type 1 diabetes mellitus (mean age 36.9 +/- 8.6 years, BMI 23.6 +/- 2.8 kg/m(2), haemoglobin A(1c) 7.4 +/- 0.9%) were randomized in this single-centre, double-blind, three-period cross-over, standard Latin-square, euglycaemic glucose clamp trial. Patients received sequential, primed stepwise intravenous infusions of glulisine, lispro or RHI (infusion rates were increased in a stepwise manner from an initial rate of 0.33 [180 min] to 0.66 [180 min] and 1.00 [180 min] mU/kg/min). The primary variables were the suppression of endogenous glucose production (S(EGP)) and glucose uptake (GU).

RESULTS

Mean basal endogenous glucose production (EGP) was 1.88, 2.12 and 2.12 mg/kg/min for glulisine, lispro and RHI respectively. Mean (+/-s.e.) maximum absolute S(EGP) (adjusted for basal EGP) was -1.64 +/- 0.06, -1.72 +/- 0.05 and -1.56 +/- 0.05 mg/kg/min respectively. Mean (+/-s.e.) maximum absolute increase in GU (adjusted for basal GU) was 6.46 +/- 0.26, 6.23 +/- 0.24 and 6.72 +/- 0.24 mg/kg/min respectively. There were no clinically relevant differences between the three insulin treatments with respect to serum insulin, free fatty acid (FFA), glycerol or lactate levels. No serious adverse events and no episodes of severe hypoglycaemia were reported.

CONCLUSIONS

This study shows that glulisine, lispro and RHI have similar effects on S(EGP), GU, FFA, glycerol and lactate levels, providing evidence for similar end-organ metabolic effects.

Protein therapeutics: a summary and pharmacological classification

Once a rarely used subset of medical treatments, protein therapeutics have increased dramatically in number and frequency of use since the introduction of the first recombinant protein therapeutic--human insulin--25 years ago. Protein therapeutics already have a significant role in almost every field of medicine, but this role is still only in its infancy. This article overviews some of the key characteristics of protein therapeutics, summarizes the more than 130 protein therapeutics used currently and suggests a new classification of these proteins according to their pharmacological action.

Insulin structure and function

Throughout much of the last century insulin served a central role in the advancement of peptide chemistry, pharmacology, cell signaling and structural biology. These discoveries have provided a steadily improved quantity and quality of life for those afflicted with diabetes. The collective work serves as a foundation for the development of insulin analogs and mimetics capable of providing more tailored therapy. Advancements in patient care have been paced by breakthroughs in core technologies, such as semisynthesis, high performance chromatography, rDNA-biosynthesis and formulation sciences. How the structural and conformational dynamics of this endocrine hormone elicit its biological response remains a vigorous area of study. Numerous insulin analogs have served to coordinate structural biology and biochemical signaling to provide a first level understanding of insulin action. The introduction of broad chemical diversity to the study of insulin has been limited by the inefficiency in total chemical synthesis, and the inherent limitations in rDNA-biosynthesis and semisynthetic approaches. The goals of continued investigation remain the delivery of insulin therapy where glycemic control is more precise and hypoglycemic liability is minimized. Additional objectives for medicinal chemists are the identification of superagonists and insulins more suitable for non-injectable delivery. The historical advancements in the synthesis of insulin analogs by multiple methods is reviewed with the specific structural elements of critical importance being highlighted. The functional refinement of this hormone as directed to improved patient care with insulin analogs of more precise pharmacology is reported.

A comparison of preprandial insulin glulisine versus insulin lispro in people with Type 2 diabetes over a 12-h period

A comparison of the plasma glucose and insulin day profiles between two prandial rapid-acting insulin analogues, insulin glulisine (glulisine) and insulin lispro (lispro), in 18 obese subjects with Type 2 diabetes. Subjects (body mass index: males, 36.7 [33.2-43.8] kg/m(2); females, 40.0 [35.7-46.5] kg/m(2)) received subcutaneous glulisine or lispro (0.15 U/kg) at 4-h intervals immediately (within 2 min) before three standard test meals during each of two 12-h, randomised, open-label, crossover studies (7+/-2-day interval between each). Overall, preprandial-subtracted glucose concentrations (area under the curve) were similar on the glulisine and lispro study days. However, the mean of the three maximal preprandial subtracted plasma glucose concentrations (DeltaGLU(max)) were lower with glulisine versus lispro (12%; p<0.01). Mean concentrations of insulin analogue were significantly higher post-meal with glulisine (p<0.01 for all). Post hoc analysis showed a significantly faster absorption rate for glulisine versus lispro in the first 30 min post-meal (estimated difference 0.48 microU/min; p<0.0001). Only two cases of hypoglycaemia were reported; both from one subject during the lispro day. When glulisine is injected immediately before a meal in obese patients with Type 2 diabetes, glulisine achieves significantly lower glucose excursions over lispro. Significantly faster absorption with higher and sustained post-meal levels of insulin analogue was achieved at every meal with glulisine versus lispro.

Insulin analogues: action profiles beyond glycaemic control

A variety of studies have documented significant improvements in the treatment of type 1 and 2 diabetes after the introduction of artificial insulins. This review gives an overview of insulin analogues which are currently approved for therapeutical use. Clinical data regarding the efficiency to control blood glucose level as well as improving HbA1c level in comparison to conventional insulin preparations in type 1 and 2 diabetic patients are summarized. Furthermore, special features of insulin analogues regarding their signalling properties are discussed with focus on the proliferative effects of insulin glargine as well as some recent data of insulin detemir.

Insulin glulisine: a faster onset of action compared with insulin lispro

AIM

This randomized, single-centre, double-blind, crossover study compared the pharmacodynamic and pharmacokinetic properties of two different doses of insulin glulisine (glulisine) and insulin lispro (lispro) in lean to obese subjects.

METHODS

Eighty subjects without diabetes, stratified into four body mass index (BMI) classes (<25, >or=25 to <30, >or=30 to <35 and >or=35 kg/m(2)), were randomized to receive single injections of glulisine and lispro (0.2 and 0.4 U/kg) on four study days under glucose clamp conditions. Glucose infusion rates (GIR) and insulin (INS) concentrations were assessed for 10 h postdose.

RESULTS

Glulisine showed a greater early metabolic action than lispro [GIR-area under the curve (GIR-AUC) between 0 and 1 h (0.2 U/kg: 102.3 +/- 75.1 vs. 83.1 +/- 72.8 mg/kg, p < 0.05; 0.4 U/kg: 158.0 +/- 100.0 vs. 112.3 +/- 70.8 mg/kg, p < 0.001)], with an earlier time to 10% of total GIR-AUC (0.2 U/kg: 1.4 +/- 0.4 vs. 1.5 +/- 0.4 h; 0.4 U/kg: 1.4 +/- 0.3 vs. 1.5 +/- 0.3 h, p < 0.05). The total metabolic effect was not different between the two insulins. In accordance with these findings, the time to 10% of total INS-AUC was faster with glulisine compared with lispro at either dose (0.2 U/kg: 0.7 +/- 0.2 vs. 0.8 +/- 0.2 h; 0.4 U/kg: 0.8 +/- 0.2 vs. 0.9 +/- 0.2 h, p < 0.001). The faster rise in insulin concentrations and the earlier onset of activity of glulisine vs. lispro was consistently observed in each individual BMI class.

CONCLUSIONS

Glulisine shows a faster onset of action than lispro, independent of BMI and dose.

Insulin glulisine imparts effective glycaemic control in patients with Type 2 diabetes

INTRODUCTION

Insulin glulisine (glulisine) was evaluated versus regular human insulin (RHI) in Type 2 diabetes (T2DM) patients.

METHODS

Patients previously on >6 months' continuous insulin treatment aged >or=18 years in a randomized, multinational, controlled, open-label, parallel group, 26-week study received twice-daily NPH insulin and either glulisine (0-15 min before breakfast and dinner; n=448) or RHI (30-45 min before breakfast and dinner; n=442) at least twice daily.

RESULTS

Mean baseline characteristics were similar between groups. There were no differences in baseline to endpoint HbA(1c) reductions (glulisine: -0.32%; RHI: -0.35%; p=0.5726), and the non-inferiority of glulisine versus RHI was demonstrated (difference in adjusted mean change 0.03%; 95% CI: -0.07, 0.13). Postprandially, glulisine lowered plasma glucose significantly more versus RHI at 2h (14.14 mmol/L versus 15.28 mmol/L; p=0.0025) and excursions at 1h (3.99 versus 4.59; p=0.0151) and 2h (4.87 versus 6.03; p=0.0002). No between-group differences occurred in the frequencies and monthly rates of all symptomatic hypoglycaemia; nocturnal hypoglycaemia from Month 4 to treatment end was less frequent with glulisine versus RHI (9.1% versus 14.5%; p=0.029).

CONCLUSION

Glulisine was non-inferior to RHI in reducing HbA(1c) in T2DM. Glulisine demonstrated superior postprandial glucose control and was associated with fewer nocturnal hypoglycaemic episodes, indicating clinical benefits.

Insulin glulisine: efficacy and safety compared with other rapid-acting insulin analogues

Glulisine insulin is the latest addition to the class of rapid-acting insulin analogues. It is important that it is comparable in safety not only to human regular insulin, but also to the well established analogue insulins, aspart and lispro. In this summary the evidence comparing the safety and efficacy of glulisine with its counterpart insulins in various groups of diabetic patients is discussed.

Rapid-acting insulin glulisine: a new tool for postprandial glucose control

Insulin glulisine (Apidra^®, Sanofi-Aventis) is a novel, rapid-acting insulin analog that replicates normal mealtime insulin secretion more closely than regular human insulin. Compared with regular human insulin, glulisine has a more rapid onset of action and shorter duration of effect, affording greater flexibility in the timing and content of meals. Additionally, optional pre- or postmeal administration makes glulisine well suited for patients who eat erratically or have difficulty remembering premeal injections. This attribute is clinically relevant because addressing postprandial hyperglycemia may help attenuate cardiovascular morbidity and mortality among diabetic patients. Insulin glulisine is safe when used for pump therapy and its rapid-acting properties are maintained consistently across patient types and body mass indices, making it an effective and versatile tool for postprandial glucose control.

Insulin Glulisine

Insulin glulisine is a rapid-acting human insulin analogue that has a faster onset of action and shorter duration of action than regular human insulin (RHI) in patients with type 1 or 2 diabetes mellitus and is efficacious in controlling prandial blood glucose levels in these patients. In large, well designed trials in patients with type 1 diabetes, insulin glulisine demonstrated a similar degree of glycaemic control, as measured by glycosylated haemoglobin (HbA(1c)) levels, to RHI after 12 weeks and insulin lispro after 26 weeks. Pre-meal insulin glulisine was also more effective than RHI at controlling 2-hour post-prandial glucose excursions in patients with type 1 or 2 diabetes over a period of 12 weeks. In patients with type 2 diabetes, insulin glulisine induced significantly greater reductions in HbA(1c) levels and 2-hour post-breakfast and post-dinner blood glucose levels than RHI over a period of 26 weeks. Insulin glulisine was generally well tolerated by patients with type 1 or 2 diabetes and had a similar safety profile to insulin lispro or RHI. Severe hypoglycaemia was experienced by similar proportions of insulin glulisine or comparator insulin (insulin lispro or RHI) recipients with type 1 or type 2 diabetes.

Pharmacokinetics, prandial glucose control, and safety of insulin glulisine in children and adolescents with type 1 diabetes

OBJECTIVE

The aim of this study was to investigate the pharmacokinetics, postprandial blood glucose excursions, and safety of insulin glulisine as compared with regular human insulin (RHI), both administered immediately before meals in pediatric patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

A total of 10 children (aged 5-11 years) and 10 adolescents (aged 12-17 years) were enrolled in a randomized, single-center, single-dose, double-blind, cross-over study. The blood glucose of fasting patients was stabilized with intravenous insulin, following which patients received 0.15 IU/kg of subcutaneously injected insulin glulisine or RHI 2 min before a weight-adjusted standardized liquid meal.

RESULTS

For insulin glulisine versus RHI, maximum insulin concentrations (58 vs. 33 microIU/ml, P < 0.05) and initial insulin concentrations (insulin [area under the curve] AUC(0-2h) 5,232 vs. 2,994 microIU.min(-1).ml(-1), P < 0.05; data are geometric means) were higher after insulin glulisine than RHI. Both time to maximum insulin concentration (54 vs. 66 min) and mean residence time (88 vs. 137 min, P < 0.05) were shorter with insulin glulisine versus RHI. Postprandial glucose excursions after insulin glulisine were lower than after RHI (glucose AUC(0-6h) 641 vs. 801 mg.h(-1).dl(-1), P < 0.05). The pharmacokinetic profile for insulin glulisine was similar for children and adolescents, whereas the pharmacokinetic profile for RHI demonstrated a 64% higher concentration in adolescents. Insulin glulisine was safe and well tolerated.

CONCLUSIONS

The rapid-acting properties of insulin glulisine that have been previously demonstrated in adults are also observed in children and adolescents with type 1 diabetes. Further, these initial data indicate that insulin glulisine is safe and well tolerated in this patient population.