1
|
Steyn LV, Drew D, Vlachos D, Huey B, Cocchi K, Price ND, Johnson R, Putnam CW, Papas KK. Accelerated absorption of regular insulin administered via a vascularizing permeable microchamber implanted subcutaneously in diabetic Rattus norvegicus. PLoS One 2023; 18:e0278794. [PMID: 37384782 PMCID: PMC10310011 DOI: 10.1371/journal.pone.0278794] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/13/2023] [Indexed: 07/01/2023] Open
Abstract
In Type 1 diabetes patients, even ultra-rapid acting insulins injected subcutaneously reach peak concentrations in 45 minutes or longer. The lag time between dosing and peak concentration, as well as intra- and inter-subject variability, render prandial glucose control and dose consistency difficult. We postulated that insulin absorption from subcutaneously implantable vascularizing microchambers would be significantly faster than conventional subcutaneous injection. Male athymic nude R. norvegicus rendered diabetic with streptozotocin were implanted with vascularizing microchambers (single chamber; 1.5 cm2 surface area per side; nominal volume, 22.5 μl). Plasma insulin was assayed after a single dose (1.5 U/kg) of diluted insulin human (Humulin®R U-100), injected subcutaneously or via microchamber. Microchambers were also implanted in additional animals and retrieved at intervals for histologic assessment of vascularity. Following conventional subcutaneous injection, the mean peak insulin concentration was 22.7 (SD 14.2) minutes. By contrast, when identical doses of insulin were injected via subcutaneous microchamber 28 days after implantation, the mean peak insulin time was shortened to 7.50 (SD 4.52) minutes. Peak insulin concentrations were similar by either route; however, inter-subject variability was reduced when insulin was administered via microchamber. Histologic examination of tissue surrounding microchambers showed mature vascularization on days 21 and 40 post-implantation. Implantable vascularizing microchambers of similar design may prove clinically useful for insulin dosing, either intermittently by needle, or continuously by pump including in "closed loop" systems, such as the artificial pancreas.
Collapse
Affiliation(s)
- Leah V. Steyn
- Institute for Cellular Transplantation, Department of Surgery, University of Arizona College of Medicine-Tucson, University of Arizona, Tucson, AZ, United States of America
| | - Delaney Drew
- Institute for Cellular Transplantation, Department of Surgery, University of Arizona College of Medicine-Tucson, University of Arizona, Tucson, AZ, United States of America
| | - Demetri Vlachos
- Institute for Cellular Transplantation, Department of Surgery, University of Arizona College of Medicine-Tucson, University of Arizona, Tucson, AZ, United States of America
| | - Barry Huey
- Institute for Cellular Transplantation, Department of Surgery, University of Arizona College of Medicine-Tucson, University of Arizona, Tucson, AZ, United States of America
| | - Katie Cocchi
- Institute for Cellular Transplantation, Department of Surgery, University of Arizona College of Medicine-Tucson, University of Arizona, Tucson, AZ, United States of America
| | - Nicholas D. Price
- Institute for Cellular Transplantation, Department of Surgery, University of Arizona College of Medicine-Tucson, University of Arizona, Tucson, AZ, United States of America
| | - Robert Johnson
- Procyon Technologies, LLC., Medical Research Building (Room 121), University of Arizona, Tucson, AZ, United States of America
| | - Charles W. Putnam
- Institute for Cellular Transplantation, Department of Surgery, University of Arizona College of Medicine-Tucson, University of Arizona, Tucson, AZ, United States of America
| | - Klearchos K. Papas
- Institute for Cellular Transplantation, Department of Surgery, University of Arizona College of Medicine-Tucson, University of Arizona, Tucson, AZ, United States of America
- Procyon Technologies, LLC., Medical Research Building (Room 121), University of Arizona, Tucson, AZ, United States of America
| |
Collapse
|
2
|
Quattrin T, Mastrandrea LD, Walker LSK. Type 1 diabetes. Lancet 2023; 401:2149-2162. [PMID: 37030316 DOI: 10.1016/s0140-6736(23)00223-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 12/03/2022] [Accepted: 01/26/2023] [Indexed: 04/10/2023]
Abstract
Type 1 diabetes is a chronic disease caused by autoimmune destruction of pancreatic β cells. Individuals with type 1 diabetes are reliant on insulin for survival. Despite enhanced knowledge related to the pathophysiology of the disease, including interactions between genetic, immune, and environmental contributions, and major strides in treatment and management, disease burden remains high. Studies aimed at blocking the immune attack on β cells in people at risk or individuals with very early onset type 1 diabetes show promise in preserving endogenous insulin production. This Seminar will review the field of type 1 diabetes, highlighting recent progress within the past 5 years, challenges to clinical care, and future directions in research, including strategies to prevent, manage, and cure the disease.
Collapse
Affiliation(s)
- Teresa Quattrin
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA; Diabetes Center, John R Oishei Children's Hospital, Buffalo, NY, USA.
| | - Lucy D Mastrandrea
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA; Diabetes Center, John R Oishei Children's Hospital, Buffalo, NY, USA
| | - Lucy S K Walker
- Institute of Immunity and Transplantation, Division of Infection and Immunity, University College London, London, UK
| |
Collapse
|
3
|
Grant M, Heise T, Baughman R. Comparison of Pharmacokinetics and Pharmacodynamics of Inhaled Technosphere Insulin and Subcutaneous Insulin Lispro in the Treatment of Type 1 Diabetes Mellitus. Clin Pharmacokinet 2021; 61:413-422. [PMID: 34773608 PMCID: PMC8891188 DOI: 10.1007/s40262-021-01084-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study was performed to satisfy a US Food and Drug Administration post-marketing requirement to compare the dose responses for Technosphere® Insulin (TI; MannKind Corporation, Westlake Village, CA, USA) and subcutaneous insulin lispro (LIS) across a wide range of doses. OBJECTIVES This single-center, open-label, randomized, cross-over study defined the pharmacokinetic/pharmacodynamic curves for inhaled TI vs subcutaneous LIS in persons with type 1 diabetes mellitus. METHODS Each volunteer received six treatments while undergoing euglycemic clamps: three doses of TI (10, 30 and 120 U) and LIS (8, 30, and 90 U). Primary endpoint was area under the glucose infusion rate vs time curve from start of treatment administration to end of clamp. Key secondary endpoints included readouts of insulin exposure and timing of pharmacokinetic/pharmacodynamic profiles. RESULTS Insulin exposure was more than dose proportional, increasing with dose1.08 for LIS and dose1.35 for TI. Time to reach 10% of the maximum glucose infusion rate was 7 to 15 min for TI vs 21 to 38 min for LIS. End of effect was dose dependent for both treatments, ranging from 2 to 6 h (TI) and 5 to 10 h (LIS). Glucose infusion rate exhibited saturation for both treatments. Technosphere Insulin produced a lesser total effect per unit insulin than LIS due to its faster absorption and correspondingly shorter duration of exposure. The difference was large enough to require significantly different doses to achieve the same total effect. CONCLUSIONS Technosphere Insulin has a considerably faster onset and shorter duration of action than LIS. Consequently, the overall effect of TI is smaller than that of LIS and unit-for-unit dose conversion is not appropriate. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02470637; 12 June, 2015.
Collapse
Affiliation(s)
- Marshall Grant
- MannKind Corporation, 30930 Russell Ranch Rd, Suite 300, Westlake Village, CA, 91362, USA.
| | | | | |
Collapse
|
4
|
Komatsu M, Ekelund M, Horio H, Kadowaki T. Efficacy and safety of fast-acting insulin aspart compared with insulin aspart in combination with insulin degludec in Japanese adults with type 1 diabetes: a subgroup analysis of the randomized onset 8 trial. Endocr J 2021; 68:429-440. [PMID: 33390422 DOI: 10.1507/endocrj.ej20-0606] [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] [Indexed: 11/23/2022] Open
Abstract
This study aimed to confirm the efficacy and safety of mealtime and post-meal fast-acting insulin aspart versus insulin aspart, both with basal insulin degludec, in Japanese patients with type 1 diabetes. This was a subgroup analysis of onset 8, a randomized multicenter, treat-to-target trial of mealtime fast-acting insulin aspart (subgroup n = 73), mealtime insulin aspart (n = 83), or open-label post-meal fast-acting insulin aspart (n = 89), all for 26 weeks. Change from baseline in HbA1c was considered the primary endpoint. After 26 weeks, the estimated treatment difference (ETD, 95% CI) for change from baseline in HbA1c between mealtime fast-acting insulin aspart or post-meal fast-acting insulin aspart vs. insulin aspart was 0.01% (-0.16;0.19) and 0.10% (-0.07;0.27), respectively. Following a standardized meal test, ETD for change from baseline in postprandial glucose (PPG) increment at 1 hour was -16.91 mg/dL (-32.15;-1.68) for mealtime fast-acting insulin aspart and 40.16 mg/dL (25.46;54.87) for post-meal fast-acting insulin aspart, both versus insulin aspart. Mean self-measured blood glucose 1-hour PPG increments also showed a trend towards improved PPG control with mealtime fast-acting insulin aspart versus insulin aspart. Rates of overall hypoglycemia (35.56, 37.72 and 38.75 per patient-year of exposure with mealtime fast-acting insulin aspart, post-meal fast-acting insulin aspart and insulin aspart, respectively) and meal-related hypoglycemia were similar between treatment arms. Consistent with findings of onset 8, this analysis confirmed mealtime and post-meal fast-acting insulin aspart provided effective HbA1c and PPG control versus insulin aspart, with similar safety profiles, in Japanese adults with type 1 diabetes.
Collapse
Affiliation(s)
- Mitsuhisa Komatsu
- Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, Shinshu University School of Medicine, Nagano 390-8621, Japan
| | | | | | | |
Collapse
|
5
|
Maikawa CL, d'Aquino AI, Lal RA, Buckingham BA, Appel EA. Engineering biopharmaceutical formulations to improve diabetes management. Sci Transl Med 2021; 13:eabd6726. [PMID: 33504649 PMCID: PMC8004356 DOI: 10.1126/scitranslmed.abd6726] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 12/22/2020] [Indexed: 12/12/2022]
Abstract
Insulin was first isolated almost a century ago, yet commercial formulations of insulin and its analogs for hormone replacement therapy still fall short of appropriately mimicking endogenous glycemic control. Moreover, the controlled delivery of complementary hormones (such as amylin or glucagon) is complicated by instability of the pharmacologic agents and complexity of maintaining multiple infusions. In this review, we highlight the advantages and limitations of recent advances in drug formulation that improve protein stability and pharmacokinetics, prolong drug delivery, or enable alternative dosage forms for the management of diabetes. With controlled delivery, these formulations could improve closed-loop glycemic control.
Collapse
Affiliation(s)
- Caitlin L Maikawa
- Department of Bioengineering, Stanford University, Stanford, CA 94305, USA
| | - Andrea I d'Aquino
- Department of Materials Science and Engineering, Stanford University, Stanford, CA 94305, USA
| | - Rayhan A Lal
- Department of Medicine (Endocrinology), Stanford University, Stanford, CA 94305, USA
- Department of Pediatrics (Endocrinology), Stanford University, Stanford, CA 94305, USA
- Diabetes Research Center, Stanford University, Stanford, CA 94305, USA
| | - Bruce A Buckingham
- Department of Pediatrics (Endocrinology), Stanford University, Stanford, CA 94305, USA
- Diabetes Research Center, Stanford University, Stanford, CA 94305, USA
| | - Eric A Appel
- Department of Bioengineering, Stanford University, Stanford, CA 94305, USA.
- Department of Materials Science and Engineering, Stanford University, Stanford, CA 94305, USA
- Department of Pediatrics (Endocrinology), Stanford University, Stanford, CA 94305, USA
- Diabetes Research Center, Stanford University, Stanford, CA 94305, USA
- ChEM-H Institute, Stanford University, Stanford, CA 94305, USA
| |
Collapse
|
6
|
Abstract
OBJECTIVE To compare glycemic efficacy of Technosphere insulin (TI) versus that of insulin aspart (IA), each added to basal insulin, in type 2 diabetes. METHODS This randomized, 24-week trial included subjects aged from 18 to 80 years who were treated with subcutaneous insulin for 3 months and had glycated hemoglobin (HbA1C) levels of 7.0% to 11.5%. After receiving stabilized insulin glargine doses during a 4-week lead in, the subjects were randomized to TI or IA. The primary end point was an HbA1C change from baseline, with the differences analyzed by equivalence analyses. RESULTS In the overall cohort (N = 309; males, 23.3%), mean (SD) age was 58.5 (8.4) years, body mass index was 30.8 (4.7) kg/m2, weight was 82.2 (13.6) kg, and duration of diabetes was 12.2 (7.1) years. An intention-to-treat cohort had 150 subjects randomized to TI (mean [SD] HbA1C: 8.9% [1.1%]) and 154 randomized to IA (mean [SD] HbA1C: 9.0% [1.3%]). At 24 weeks, mean (SD) HbA1C value declined to 7.9% (1.3%) and 7.7% (1.1%) in the TI and IA cohorts, respectively. A treatment difference of 0.26% was not statistically significant, but the predefined equivalency margin was not met. Subjects receiving TI lost 0.78 kg compared to baseline; subjects receiving IA gained 0.23 kg (P =.0007). The incidence of mild/moderate hypoglycemia was lower for the TI cohort, though not statistically significant. CONCLUSION Both TI and IA resulted in significant and clinically meaningful HbA1C reductions. TI also resulted in significant and clinically meaningful weight reductions. These data support the use of inhaled insulin as a treatment option for individuals with type 2 diabetes.
Collapse
|
7
|
Levin P, Hoogwerf BJ, Snell-Bergeon J, Vigers T, Pyle L, Bromberger L. Ultra Rapid-Acting Inhaled Insulin Improves Glucose Control in Patients With Type 2 Diabetes Mellitus. Endocr Pract 2020; 27:449-454. [PMID: 33853718 DOI: 10.1016/j.eprac.2020.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/12/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine whether the use of an inhaled insulin would improve HbA1c. METHODS This study was performed in 20 type 2 diabetes mellitus (T2DM) participants with HbA1c values ≥7.5 (58) to ≤11.5% (102 mmol/mol) on a variety of glucose-lowering regimens. Prandial Technosphere insulin (TI) was rapidly titrated based on a treatment algorithm using postprandial blood glucose to calculate premeal doses. A 2-week baseline period was followed by 12 weeks of active treatment with TI. The primary outcome was change in HbA1c. Secondary outcomes included glucose time in range (time in range: 70-180 mg/dL) obtained by a blinded continuous glucose monitoring during the baseline period and at the end of 12 weeks. Goals were to assess how to rapidly and safely initiate TI intensification, determine dosing requirements, and establish an effective dose range in uncontrolled T2DM. RESULTS Mean HbA1c decreased by -1.6% (-17 mmol/mol) from 9.0% (75 mmol/mol) at baseline to 7.4% (57 mmol/mol) at 12 weeks (P < .0001). Mean time in range increased from 42.2% to 65.7% (P < .0002). Mean prandial doses of TI were 18 or 19 units for all meals. Time below range was 1.1% baseline and 2.6% post treatment (P = .01). CONCLUSION Treatment with inhaled TI dosed using a simple algorithm improved glycemic control measured by both HbA1c and time in range, with low rates of hypoglycemia. These data add significantly to understanding TI in the management of T2DM patients for whom prandial insulin is a consideration.
Collapse
Affiliation(s)
- Philip Levin
- MODEL Clinical Research, Endocrinology, Baltimore, Maryland.
| | - Byron J Hoogwerf
- Emeritus, Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, Ohio; Central Michigan University, Mount Pleasant, Michigan
| | - Janet Snell-Bergeon
- University of Colorado Anschutz Medical Campus, Pediatrics, Aurora, Colorado; Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, Colorado
| | - Tim Vigers
- University of Colorado Anschutz Medical Campus, Pediatrics, Aurora, Colorado; Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, Colorado
| | - Laura Pyle
- University of Colorado Anschutz Medical Campus, Pediatrics, Aurora, Colorado; Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, Colorado
| | - Lee Bromberger
- MODEL Clinical Research, Endocrinology, Baltimore, Maryland
| |
Collapse
|
8
|
Greene SF, Nikula KJ, Poulin D, McInally K, Reynolds JA. Long-Term Nonclinical Pulmonary Safety Assessment of Afrezza, a Novel Insulin Inhalation Powder. Toxicol Pathol 2020; 49:334-348. [PMID: 33043802 DOI: 10.1177/0192623320960420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Afrezza delivers inhaled insulin using the Gen2 inhaler for the treatment of patients with type 1 and type 2 Diabetes. Afrezza was evaluated in long-term nonclinical pulmonary safety studies in 2 toxicology species. Chronic inhalation toxicology studies in rat (26 weeks) and dog (39 weeks) and an inhalation carcinogenicity study in rats were conducted with Technosphere insulin (Afrezza) and with Technosphere alone as a vehicle control. Respiratory tract tissues were evaluated by histopathology and cells expressing proliferating cell nuclear antigen (PCNA) were quantified in lungs of rats. Microscopic findings in rats exposed to Afrezza were attributed to the Technosphere particle component, were confined to nasal epithelia, and consisted of eosinophilic globules and nasal epithelial degeneration. There were no Afrezza-related changes in pulmonary PCNA labeling indices in alveoli, large bronchioles, or terminal bronchioles. Microscopic findings in rats exposed to Technosphere particles included eosinophilic globules, mucus cell hyperplasia, and epithelial degeneration in the nasal cavities. PCNA labeling indices were increased in large bronchioles and terminal bronchioles but not in alveoli. There were no Technosphere particle-related findings in the dog study. Afrezza did not exhibit carcinogenic potential in the 2-year study in rats. These nonclinical inhalation studies support the use of Afrezza in humans over extended periods.
Collapse
|
9
|
Klaff L, Cao D, Dellva MA, Tobian J, Miura J, Dahl D, Lucas J, Bue‐Valleskey J. Ultra rapid lispro improves postprandial glucose control compared with lispro in patients with type 1 diabetes: Results from the 26-week PRONTO-T1D study. Diabetes Obes Metab 2020; 22:1799-1807. [PMID: 32488923 PMCID: PMC7539952 DOI: 10.1111/dom.14100] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 12/23/2022]
Abstract
AIMS To evaluate the efficacy and safety of ultra rapid lispro (URLi) versus lispro in adults with type 1 diabetes in a 26-week, treat-to-target, phase 3 trial. MATERIALS AND METHODS After an 8-week lead-in to optimize basal insulin glargine or degludec, patients were randomized to double-blind mealtime URLi (n = 451) or lispro (n = 442), or open-label post-meal URLi (n = 329). The primary endpoint was change from baseline glycated haemoglobin (HbA1c) to 26 weeks (non-inferiority margin 0.4%), with multiplicity-adjusted objectives for postprandial glucose (PPG) excursions after a meal test. RESULTS Both mealtime and post-meal URLi demonstrated non-inferiority to lispro for HbA1c: estimated treatment difference (ETD) for mealtime URLi -0.08% [95% confidence interval (CI) -0.16, 0.00] and for post-meal URLi +0.13% (95% CI 0.04, 0.22), with a significantly higher endpoint HbA1c for post-meal URLi versus lispro (P = 0.003). Mealtime URLi was superior to lispro in reducing 1- and 2-hour PPG excursions during the meal test: ETD -1.55 mmol/L (95% CI -1.96, -1.14) at 1 hour and - 1.73 mmol/L (95% CI -2.28, -1.18) at 2 hours (both P < 0.001). The rate and incidence of severe, documented and postprandial hypoglycaemia (<3.0 mmol/L) was similar between treatments, but mealtime URLi demonstrated a 37% lower rate in the period >4 hours after meals (P = 0.013). Injection site reactions were reported by 2.9% of patients on mealtime URLi, 2.4% on post-meal URLi, and 0.2% on lispro. Overall, the incidence of treatment-emergent adverse events was similar between treatments. CONCLUSIONS The results showed that URLi provided good glycaemic control, with non-inferiority to lispro confirmed for both mealtime and post-meal URLi, while superior PPG control was demonstrated with mealtime dosing.
Collapse
Affiliation(s)
| | - Dachuang Cao
- Eli Lilly and Company, Lilly Corporate CenterIndianapolisIndianaUSA
| | - Mary Anne Dellva
- Eli Lilly and Company, Lilly Corporate CenterIndianapolisIndianaUSA
| | - Janet Tobian
- Eli Lilly and Company, Lilly Corporate CenterIndianapolisIndianaUSA
| | - Junnosuke Miura
- Tokyo Women's Medical University School of MedicineTokyoJapan
| | - Dominik Dahl
- Gemeinschaftspraxis fur Innere Medizin und DiabetologieHamburgGermany
| | - Jean Lucas
- Lucas ResearchMorehead CityNorth CarolinaUSA
| | | |
Collapse
|
10
|
Miura J, Imori M, Nishiyama H, Imaoka T. Ultra-Rapid Lispro Efficacy and Safety Compared to Humalog ® in Japanese Patients with Type 1 Diabetes: PRONTO-T1D Subpopulation Analysis. Diabetes Ther 2020; 11:2089-2104. [PMID: 32728832 PMCID: PMC7435141 DOI: 10.1007/s13300-020-00892-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION We evaluated the efficacy and safety of ultra-rapid lispro (URLi) in comparison to lispro in a subgroup analysis of Japanese adults with type 1 diabetes mellitus from the phase 3 PRONTO-T1D trial. METHODS After an 8-week lead-in to optimize basal insulin treatment, patients were randomized to 52-week double-blind mealtime URLi or lispro, or 26-week open-label postmeal URLi. The primary endpoint was change in hemoglobin A1c (HbA1c) from baseline (week 0) to week 26 between mealtime URLi and lispro. The multiplicity adjusted objectives were 1- and 2-h postprandial glucose (PPG) excursions after a meal test between mealtime URLi and lispro, and change in HbA1c from baseline to week 26 between postmeal URLi and mealtime lispro. RESULTS This manuscript presents pre-specified exploratory analyses of 26-week data from Japanese patients randomized to double-blind URLi (n = 62) or lispro (n = 59), or open-label URLi (n = 46). Mean baseline HbA1c levels were 7.52% for mealtime URLi, 7.44% for lispro, and 7.51% for postmeal URLi at randomization. At week 26, the least squares mean (LSM) difference compared to lispro was 0.04% (95% confidence interval [CI] - 0.14 to 0.22) for mealtime URLi, and 0.16% (95% CI - 0.04 to 0.35) for postmeal URLi. In comparison to lispro, mealtime URLi resulted in statistically significantly lower 1- and 2-h PPG excursions during the mixed-meal tolerance test. LSM differences were - 40.5 mg/dL, 95% CI - 59.5 to 21.4 (- 2.25 mmol/L, 95% CI - 3.3 to - 1.2) for 1-h PPG excursions and - 51.7 mg/dL, 95% CI - 81.7 to - 21.8 (- 2.87 mmol/L, 95% CI - 4.5 to - 1.2) for 2-h PPG excursions at week 26. There were no significant treatment differences in rates of severe/overall hypoglycemia, or incidence of treatment-emergent adverse events. CONCLUSIONS Mealtime and postmeal URLi provide effective and comparable glycemic control in Japanese patients. Mealtime URLi demonstrated more effective PPG control compared to lispro. TRIAL REGISTRATION ClinicalTrials.gov, NCT03214367.
Collapse
Affiliation(s)
- Junnosuke Miura
- Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Makoto Imori
- Medicines Development Unit Japan and Medical Affairs, Eli Lilly Japan K.K., 5-1-28, Isogami-dori, Chuo-ku, Kobe, Hyogo, 651-0086, Japan.
| | - Hiroshi Nishiyama
- Medicines Development Unit Japan and Medical Affairs, Eli Lilly Japan K.K., 5-1-28, Isogami-dori, Chuo-ku, Kobe, Hyogo, 651-0086, Japan
| | - Takeshi Imaoka
- Medicines Development Unit Japan and Medical Affairs, Eli Lilly Japan K.K., 5-1-28, Isogami-dori, Chuo-ku, Kobe, Hyogo, 651-0086, Japan
| |
Collapse
|
11
|
Jinnouchi H, Imori M, Nishiyama H, Imaoka T. Ultra-Rapid Lispro Efficacy and Safety Compared to Humalog® in Japanese Patients With Type 2 Diabetes: PRONTO-T2D Subpopulation Analysis. Diabetes Ther 2020; 11:2075-2088. [PMID: 32728833 PMCID: PMC7434814 DOI: 10.1007/s13300-020-00890-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The aim of this study was to evaluate the efficacy and safety of ultra-rapid lispro (URLi) versus lispro in a subgroup analysis of Japanese adults with type 2 diabetes mellitus (T2DM) from the phase 3 PRONTO-T2D trial. METHODS After an 8-week lead-in period during which patients transitioned to insulin lispro 3 times a day before main meals in association with basal insulin (glargine or degludec), the patients were randomized to 26 weeks of double-blind URLi or lispro injected immediately prior to meals. The primary endpoint was change in hemoglobin A1c (HbA1c) from baseline to week 26 between URLi and lispro. The multiplicity-adjusted objectives were 1- and 2-h postprandial glucose (PPG) excursions after a test meal and change in HbA1c from baseline to week 26 in the URLi and lispro groups. RESULTS Results were obtained from prespecified exploratory analyses of 26-week data in Japanese patients randomized to receive URLi (n = 47) or lispro (n = 46). Mean baseline HbA1c levels significantly improved during the lead-in period to a baseline value of 7.50% and 7.60% in patients subsequently randomized to the URLi and lispro treatment groups, respectively. At week 26, the least squares mean (LSM) difference in HbAc1 between the URLi and lispro groups was 0.13% (95% confidence interval [CI] - 0.12 to 0.39) (1.4 mmol/mol, 95% CI - 1.3 to 4.2). Although there were no significant differences in PPG excursions at any time-point, numerically smaller PPG excursions were consistently observed from 30 min to 3 h during the mixed-meal tolerance test in patients on URLi compared to those on lispro. LSM differences in PPG excursions at week 26 were - 10.5 mg/dL (95% CI - 32.7 to 11.7) (- 0.58 mmol/L, 95% CI - 1.82 to 0.65) at 1 h and - 14.9 mg/dL (95% CI - 40.3 to 10.5) (- 0.83 mmol/L, 95% CI - 2.24 to 0.58) at 2 h. There were no significant differences between treatments in rates of severe/overall hypoglycemia or incidence of treatment-emergent adverse events. CONCLUSIONS URLi administered as prandial insulin in combination with basal insulin provides effective glycemic control when administered immediately before a meal in Japanese patients with T2DM. URLi was well tolerated in this population. TRIAL REGISTRATION ClinicalTrials.gov, NCT03214380.
Collapse
Affiliation(s)
- Hideaki Jinnouchi
- Jinnouchi Hospital, 6 Chome-2-3 Kuhonji, Chuo Ward, Kumamoto, 862-0976, Japan
| | - Makoto Imori
- Medicines Development Unit Japan and Medical Affairs, Eli Lilly Japan K.K, 5-1-28, Isogami-dori, Chuo-ku, Kobe, Hyogo, 651-0086, Japan.
| | - Hiroshi Nishiyama
- Medicines Development Unit Japan and Medical Affairs, Eli Lilly Japan K.K, 5-1-28, Isogami-dori, Chuo-ku, Kobe, Hyogo, 651-0086, Japan
| | - Takeshi Imaoka
- Medicines Development Unit Japan and Medical Affairs, Eli Lilly Japan K.K, 5-1-28, Isogami-dori, Chuo-ku, Kobe, Hyogo, 651-0086, Japan
| |
Collapse
|
12
|
Artificial Pancreas Control Strategies Used for Type 1 Diabetes Control and Treatment: A Comprehensive Analysis. APPLIED SYSTEM INNOVATION 2020. [DOI: 10.3390/asi3030031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This paper presents a comprehensive survey about the fundamental components of the artificial pancreas (AP) system including insulin administration and delivery, glucose measurement (GM), and control strategies/algorithms used for type 1 diabetes mellitus (T1DM) treatment and control. Our main focus is on the T1DM that emerges due to pancreas’s failure to produce sufficient insulin due to the loss of beta cells (β-cells). We discuss various insulin administration and delivery methods including physiological methods, open-loop, and closed-loop schemes. Furthermore, we report several factors such as hyperglycemia, hypoglycemia, and many other physical factors that need to be considered while infusing insulin in human body via AP systems. We discuss three prominent control algorithms including proportional-integral- derivative (PID), fuzzy logic, and model predictive, which have been clinically evaluated and have all shown promising results. In addition, linear and non-linear insulin infusion control schemes have been formally discussed. To the best of our knowledge, this is the first work which systematically covers recent developments in the AP components with a solid foundation for future studies in the T1DM field.
Collapse
|
13
|
Excipient-free pulmonary insulin dry powder: Pharmacokinetic and pharmacodynamics profiles in rats. J Control Release 2020; 323:412-420. [PMID: 32325175 DOI: 10.1016/j.jconrel.2020.04.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/04/2020] [Accepted: 04/09/2020] [Indexed: 12/27/2022]
Abstract
A novel pure insulin spray-dried powder for DPI product (Ins_SD) was studied with respect to physico-chemical stability, in vitro respirability, bioavailability, activity and tolerability. Ins_SD powder exhibited a very high in vitro respirability, independently of the DPI product preparation (manual or semi-automatic). Physico-chemical characteristics of Ins_SD powder remained within the pharmacopoeia limits during 6 months of storage at room temperature. PK/PD profiles were measured in rats that received the pulmonary powders by intratracheal insufflation and compared with Afrezza inhalation insulin. Due to the low drug powder mass to deliver, both insulin powders were diluted with mannitol. Insulin from Ins_SD was promptly absorbed (tmax 15 min and Cmaxx4.9 ± 1.5 mU/ml). Afrezza had a slower absorption (tmax 30 min and Cmax of 1.8 ± 0.37 mU/ml). After glucose injection, Ins_SD determined a rapid reduction of glucose level, similar to Afrezza. As reference, insulin subcutaneous injection showed a long-lasting hypoglycemic effect due to the slow absorption that prolonged insulin plasma level. In summary, Ins_SD product is suitable for post-prandial glucose control, providing a convenient and compliant product, in particular in the event of using a disposable device. Albeit the product has to be stored in fridge, its stability at room temperature allows the diabetic individual to carry the daily dose in normal conditions.
Collapse
|
14
|
Buse JB, Carlson AL, Komatsu M, Mosenzon O, Rose L, Liang B, Buchholtz K, Horio H, Kadowaki T. Fast-acting insulin aspart versus insulin aspart in the setting of insulin degludec-treated type 1 diabetes: Efficacy and safety from a randomized double-blind trial. Diabetes Obes Metab 2018; 20:2885-2893. [PMID: 30259644 PMCID: PMC6231963 DOI: 10.1111/dom.13545] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/11/2018] [Accepted: 09/23/2018] [Indexed: 01/11/2023]
Abstract
AIM To evaluate the efficacy and safety of mealtime or post-meal fast-acting insulin aspart (faster aspart) vs mealtime insulin aspart (IAsp), both in combination with insulin degludec, in participants with type 1 diabetes (T1D). METHODS This multicentre, treat-to-target trial (Clinical trial registry: NCT02500706, ClinicalTrials.gov) randomized participants to double-blind mealtime faster aspart (n = 342) or IAsp (n = 342) or open-label post-meal faster aspart (n = 341). The primary endpoint was change from baseline in HbA1c 26 weeks post randomization. All available information, regardless of treatment discontinuation, was used for evaluation of the effect. RESULTS Non-inferiority for the change from baseline in HbA1c was confirmed for mealtime and post-meal faster aspart vs IAsp (estimated treatment difference [ETD]: 95%CI, -0.02% [-0.11; 0.07] and 0.10% [0.004; 0.19], respectively). Mealtime faster aspart was superior to IAsp for 1-hour PPG increment using a meal test (ETD, -0.90 mmol/L [-1.36; -0.45]; P < 0.001). Self-monitored 1-hour PPG increment favoured faster aspart at breakfast (ETD, -0.58 mmol/L [-0.99; -0.17]; P = 0.006) and across all meals (-0.48 mmol/L [-0.74; -0.21]; P < 0.001). Safety profiles and overall rate of severe or blood glucose-confirmed hypoglycaemia were similar between treatments, but significantly less hypoglycaemia was seen 3 to 4 hours after meals with mealtime faster aspart. CONCLUSION Mealtime and post-meal faster aspart in conjunction with insulin degludec provided effective glycaemic control compared with IAsp, with no increased safety risk. Mealtime faster aspart provided PPG control superior to that of IAsp.
Collapse
Affiliation(s)
- John B. Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina School of MedicineNorth Carolina
| | | | - Mitsuhisa Komatsu
- Division of Diabetes, Endocrinology and Metabolism, Department of Internal MedicineShinshu University School of MedicineNaganoJapan
| | - Ofri Mosenzon
- Diabetes Unit, Division of Internal MedicineHadassah Hebrew University HospitalJerusalemIsrael
| | - Ludger Rose
- Institute of Diabetes ResearchMünsterGermany
| | | | | | | | - Takashi Kadowaki
- Department of Diabetes and Metabolic Diseases, Graduate School of MedicineThe University of TokyoTokyoJapan
| |
Collapse
|
15
|
Mathieu C, Bode BW, Franek E, Philis‐Tsimikas A, Rose L, Graungaard T, Birk Østerskov A, Russell‐Jones D. Efficacy and safety of fast-acting insulin aspart in comparison with insulin aspart in type 1 diabetes (onset 1): A 52-week, randomized, treat-to-target, phase III trial. Diabetes Obes Metab 2018; 20:1148-1155. [PMID: 29316130 PMCID: PMC5947306 DOI: 10.1111/dom.13205] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 12/22/2017] [Accepted: 12/28/2017] [Indexed: 01/09/2023]
Abstract
AIMS To compare the safety and efficacy of fast-acting insulin aspart (faster aspart) with conventional insulin aspart (IAsp) in adults with type 1 diabetes (T1D). MATERIALS AND METHODS onset 1 was a randomized, multicentre, treat-to-target, phase III, 52-week (initial 26 weeks + additional 26 weeks) trial conducted at 165 sites across 9 countries. Adults with T1D were randomly allocated to double-blind mealtime faster aspart or IAsp, each with once- or twice-daily insulin detemir. The primary endpoint, change in glycated haemoglobin (HbA1c) from baseline after the initial 26 weeks, has been reported previously. In the present paper, we report data from the full 52-week study period. RESULTS Between August 2013 and June 2015, 381 participants were assigned to double-blind faster aspart and 380 participants to IAsp. After 52 weeks, estimated mean changes from baseline in HbA1c levels were -0.08% (faster aspart) and +0.01% (IAsp); estimated treatment difference significantly favoured faster aspart (-0.10% [95% confidence interval {CI} -0.19;-0.00]; P = .0424). Changes from baseline in 1-hour postprandial plasma glucose (PPG) increment (meal test; faster aspart -1.05 mmol/L; IAsp -0.14 mmol/L) also significantly favoured faster aspart (estimated treatment difference -0.91 mmol/L [95% CI -1.40;-0.43]; -16.48 mg/dL [95% CI -25.17;-7.80]; P = .0002). There was no difference in overall severe or blood glucose-confirmed hypoglycaemic episodes or treatment-emergent adverse events between treatments. CONCLUSIONS At 52 weeks, overall glycaemic control had significantly improved with faster aspart vs IAsp, consistent with the 26-week study findings. Achieving an insulin profile closer to physiological insulin secretion with faster aspart translates into lower PPG and HbA1c levels compared with those achieved with IAsp in people with T1D.
Collapse
Affiliation(s)
- Chantal Mathieu
- Clinical and Experimental EndocrinologyUniversity Hospital LeuvenLeuvenBelgium
| | | | - Edward Franek
- Mossakowski Clinical Research Centre, Polish Academy of SciencesWarsawPoland
| | | | - Ludger Rose
- Institute of Diabetes ResearchMünsterGermany
| | | | | | - David Russell‐Jones
- Diabetes and EndocrinologyRoyal Surrey County Hospital and University of SurreyGuildfordUK
| |
Collapse
|
16
|
Viceconti M, Cobelli C, Haddad T, Himes A, Kovatchev B, Palmer M. In silico assessment of biomedical products: The conundrum of rare but not so rare events in two case studies. Proc Inst Mech Eng H 2017; 231:455-466. [PMID: 28427321 DOI: 10.1177/0954411917702931] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In silico clinical trials, defined as "The use of individualized computer simulation in the development or regulatory evaluation of a medicinal product, medical device, or medical intervention," have been proposed as a possible strategy to reduce the regulatory costs of innovation and the time to market for biomedical products. We review some of the the literature on this topic, focusing in particular on those applications where the current practice is recognized as inadequate, as for example, the detection of unexpected severe adverse events too rare to be detected in a clinical trial, but still likely enough to be of concern. We then describe with more details two case studies, two successful applications of in silico clinical trial approaches, one relative to the University of Virginia/Padova simulator that the Food and Drug Administration has accepted as possible replacement for animal testing in the preclinical assessment of artificial pancreas technologies, and the second, an investigation of the probability of cardiac lead fracture, where a Bayesian network was used to combine in vivo and in silico observations, suggesting a whole new strategy of in silico-augmented clinical trials, to be used to increase the numerosity where recruitment is impossible, or to explore patients' phenotypes that are unlikely to appear in the trial cohort, but are still frequent enough to be of concern.
Collapse
Affiliation(s)
- Marco Viceconti
- 1 Department of Mechanical Engineering, INSIGNEO Institute for in silico Medicine, The University of Sheffield, Sheffield, UK
| | - Claudio Cobelli
- 2 Department of Information Engineering, University of Padova, Padova, Italy
| | | | | | - Boris Kovatchev
- 4 Center for Diabetes Technology, The University of Virginia, Charlottesville, VA, USA
| | | |
Collapse
|
17
|
Russell-Jones D, Bode BW, De Block C, Franek E, Heller SR, Mathieu C, Philis-Tsimikas A, Rose L, Woo VC, Østerskov AB, Graungaard T, Bergenstal RM. Fast-Acting Insulin Aspart Improves Glycemic Control in Basal-Bolus Treatment for Type 1 Diabetes: Results of a 26-Week Multicenter, Active-Controlled, Treat-to-Target, Randomized, Parallel-Group Trial (onset 1). Diabetes Care 2017; 40:943-950. [PMID: 28356319 DOI: 10.2337/dc16-1771] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 02/27/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This multicenter, treat-to-target, phase 3 trial evaluated the efficacy and safety of fast-acting insulin aspart (faster aspart) versus conventional insulin aspart (IAsp) in adults with type 1 diabetes. RESEARCH DESIGN AND METHODS The primary end point was change from baseline in HbA1c after 26 weeks. After an 8-week run-in, subjects were randomized (1:1:1) to double-blind mealtime faster aspart (n = 381), IAsp (n = 380), or open-label postmeal faster aspart (n = 382)-each with insulin detemir. RESULTS HbA1c was reduced in both treatment groups, and noninferiority to IAsp was confirmed for both mealtime and postmeal faster aspart (estimated treatment difference [ETD] faster aspart-IAsp, mealtime, -0.15% [95% CI -0.23; -0.07], and postmeal, 0.04% [-0.04; 0.12]); mealtime faster aspart statistically significantly reduced HbA1c versus IAsp (P = 0.0003). Postprandial plasma glucose (PPG) increments were statistically significantly lower with mealtime faster aspart at 1 h (ETD -1.18 mmol/L [95% CI -1.65; -0.71], -21.21 mg/dL [-29.65; -12.77]; P < 0.0001) and 2 h (-0.67 mmol/L [-1.29; -0.04], -12.01 mg/dL [-23.33; -0.70]; P = 0.0375) after the meal test; superiority to IAsp for the 2-h PPG increment was confirmed. The overall rate of severe or blood glucose-confirmed (plasma glucose <3.1 mmol/L [56 mg/dL]) hypoglycemic episodes and safety profiles were similar between treatments. CONCLUSIONS Faster aspart effectively improved HbA1c, and noninferiority to IAsp was confirmed, with superior PPG control for mealtime faster aspart versus IAsp. Subjects randomized to postmeal faster aspart for all meals maintained HbA1c noninferior to that obtained with mealtime IAsp.
Collapse
Affiliation(s)
- David Russell-Jones
- Diabetes and Endocrinology, Royal Surrey County Hospital, and University of Surrey, Guildford, U.K.
| | | | - Christophe De Block
- Department of Endocrinology, Diabetology, and Metabolism, Antwerp University Hospital, Antwerp, Belgium
| | - Edward Franek
- Mossakowski Medical Research Center, Polish Academy of Sciences, Warsaw, Poland
| | - Simon R Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, U.K
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, University Hospital Leuven, Catholic University of Leuven, Leuven, Belgium
| | | | - Ludger Rose
- Institute of Diabetes Research, Münster, Germany
| | - Vincent C Woo
- Section of Endocrinology and Metabolism, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | | |
Collapse
|
18
|
Rüppel D, Dahmen R, Boss A, Jäger R, Grant M, Baughman R, Klabunde T. A Population Dose-Response Model for Inhaled Technosphere Insulin Administered to Healthy Subjects. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2017; 6:365-372. [PMID: 28568813 PMCID: PMC5488128 DOI: 10.1002/psp4.12189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/24/2017] [Accepted: 02/16/2017] [Indexed: 11/30/2022]
Abstract
Technosphere insulin (TI), an inhaled insulin with a fast onset of action, provides a novel option for the control of prandial glucose. A euglycemic glucose clamp study was performed to compare the effects of TI and regular human insulin (RHI) on the induced glucose infusion rate (GIR) in healthy volunteers. Generation of a dose–response relationship between insulin dose and effect (expressed as AUC of GIR) was not possible from the clinical data directly. The GIR recording time was too short to capture the full effect and higher doses were not tested. Thus, a pharmacokinetic‐GIR model was developed to simulate GIR for a sufficient time window of 20 h and for higher doses. A dose–response model was then generated from the simulated GIR profiles. The resulting model provides an ED50 for TI that is 5‐fold higher than for RHI, a ratio that can be used as conversion factor for equivalent doses of RHI and TI.
Collapse
Affiliation(s)
- D Rüppel
- Sanofi-Aventis Deutschland GmbH, R&D Frankfurt, Germany
| | - R Dahmen
- Sanofi-Aventis Deutschland GmbH, R&D Frankfurt, Germany
| | - A Boss
- Sanofi US, Bridgewater, New Jersey, USA
| | - R Jäger
- Sanofi-Aventis Deutschland GmbH, R&D Frankfurt, Germany
| | - M Grant
- MannKind Corporation, Danbury, Connecticut, USA
| | - R Baughman
- MannKind Corporation, Danbury, Connecticut, USA
| | - T Klabunde
- Sanofi-Aventis Deutschland GmbH, R&D Frankfurt, Germany
| |
Collapse
|
19
|
Mohanty RR, Das S. Inhaled Insulin - Current Direction of Insulin Research. J Clin Diagn Res 2017; 11:OE01-OE02. [PMID: 28571200 DOI: 10.7860/jcdr/2017/23626.9732] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 01/06/2017] [Indexed: 11/24/2022]
Abstract
Diabetes Mellitus (DM) is a metabolic disorder characterized by relative or absolute deficiency of insulin, resulting in hyperglycemia. Subcutaneous insulin and Oral Hypoglycaemic Agents (OHA) constitute the main treatment option for DM. Insulin is administered by injection or continuous infusion to control glucose levels mainly in Type I diabetes. Newer routes both oral and non oral, for insulin administration are current direction of insulin research as insulin injection therapy is burdensome and painful for many patients. Inhalational insulin is an attractive alternative for systemic administration of insulin given its accessibility and large alveolar-capillary network of lungs for drug absorption. Afrezza, inhaled insulin has been recently approved by Food and Drug Administration (FDA). It is a new, quicker acting inhalable insulin with a different and safer pharmacokinetic profile in comparison to previously failed inhaled form of insulin.
Collapse
Affiliation(s)
| | - Smita Das
- Assistant Professor, Department of Pharmacology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| |
Collapse
|
20
|
Riddle MC. Basal Glucose Can Be Controlled, but the Prandial Problem Persists-It's the Next Target! Diabetes Care 2017; 40:291-300. [PMID: 28223444 DOI: 10.2337/dc16-2380] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 12/10/2016] [Indexed: 02/03/2023]
Abstract
Both basal and postprandial elevations contribute to the hyperglycemic exposure of diabetes, but current therapies are mainly effective in controlling the basal component. Inability to control postprandial hyperglycemia limits success in maintaining overall glycemic control beyond the first 5 to 10 years after diagnosis, and it is also related to the weight gain that is common during insulin therapy. The "prandial problem"-comprising abnormalities of glucose and other metabolites, weight gain, and risk of hypoglycemia-deserves more attention. Several approaches to prandial abnormalities have recently been studied, but the patient populations for which they are best suited and the best ways of using them remain incompletely defined. Encouragingly, several proof-of-concept studies suggest that short-acting glucagon-like peptide 1 agonists or the amylin agonist pramlintide can be very effective in controlling postprandial hyperglycemia in type 2 diabetes in specific settings. This article reviews these topics and proposes that a greater proportion of available resources be directed to basic and clinical research on the prandial problem.
Collapse
Affiliation(s)
- Matthew C Riddle
- Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, OR
| |
Collapse
|
21
|
Abstract
Considerable progress in treatment of diabetes has been made in the nearly 100 years following the discovery of insulin, and advances in insulin therapy have improved convenience, quality of life, overall glycemic control (A1C), and risk of hypoglycemia. An unmet need remains for a mealtime insulin that can faithfully reproduce the metabolic profile that ensues following meal ingestion in healthy persons. A number of "ultra-fast" insulin programs have been initiated, and Afrezza® (insulin human; Inhalation Powder, MannKind Corporation, Danbury, CT) stands as the first such product to be approved by the US FDA. Afrezza is unique as an "ultra-ultra" fast insulin, faster than any other entrant except IV insulin. The benefits and limitations of the Afrezza profile are discussed in this analysis.
Collapse
Affiliation(s)
- Douglas B. Muchmore
- Kinexum Services, La Jolla, CA, USA
- Douglas B. Muchmore, MD, Kinexum Services, 7037 Via Valverde, La Jolla, CA 92037, USA.
| |
Collapse
|
22
|
Heinemann L, Baughman R, Boss A, Hompesch M. Pharmacokinetic and Pharmacodynamic Properties of a Novel Inhaled Insulin. J Diabetes Sci Technol 2017; 11:148-156. [PMID: 27378794 PMCID: PMC5375067 DOI: 10.1177/1932296816658055] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Advances in insulin treatment options over recent decades have markedly improved the management of diabetes. Despite this, glycemic control remains suboptimal in many people with diabetes. Although postprandial glucose control has been improved with the development of subcutaneously injected rapid-acting insulin analogs, currently available insulins are not able to fully mimic the physiological time-action profile of endogenously secreted insulin after a meal. The delayed onset of metabolic action and prolonged period of effect induce the risk of postprandial hyperglycemia and late postprandial hypoglycemia. A number of alternative routes of insulin administration have been investigated over time in an attempt to overcome the limitations associated with subcutaneous administration and to provide an improved time-action insulin profile more closely simulating physiological prandial insulin release. Among these, pulmonary insulin delivery has shown the most promise. Technosphere® Inhaled Insulin (TI) is a rapid-acting inhaled human insulin recently approved by the FDA for prandial insulin therapy. In this article we discuss the pharmacokinetic and pharmacodynamic properties of TI, and, based on key studies performed during its clinical development, the implications for improved postprandial glucose control.
Collapse
Affiliation(s)
- Lutz Heinemann
- Science & Co, Düsseldorf, Germany
- Lutz Heinemann, PhD, Science & Co, Kehler Str 24, Düsseldorf, D-40468, Germany.
| | | | | | | |
Collapse
|
23
|
Abstract
Newer insulin products have advanced the evolution of insulin replacement options to more accurately mimic natural insulin action. There are new, modified, and concentrated insulins; administration devices calibrated for both increased concentrations and administration accuracy to improve adherence and safety; and inhaled insulin. There are new combinations of longer-acting basal insulin and rapid-acting insulin or glucagon like protein-1 receptor agonists. Existing insulin replacement designs and methods can be updated using these tools to improve efficacy and safety. Individualized decisions to use them should be based on patient physiologic needs, self-care ability, comorbidities, and cost considerations.
Collapse
Affiliation(s)
- Alissa R Segal
- Department of Pharmacy Practice, MCPHS University, 179 Longwood Avenue, Boston, MA 02115, USA; Joslin Diabetes Center, 1 Joslin Place, Boston, MA 02215, USA.
| | - Tejaswi Vootla
- Joslin Diabetes Center, 1 Joslin Place, Boston, MA 02215, USA
| | | |
Collapse
|
24
|
Visentin R, Klabunde T, Grant M, Dalla Man C, Cobelli C. Incorporation of inhaled insulin into the FDA accepted University of Virginia/Padova Type 1 Diabetes Simulator. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:3250-3. [PMID: 26736985 DOI: 10.1109/embc.2015.7319085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The University of Virginia/Padova Type 1 Diabetes (T1DM) Simulator has been extensively used in artificial pancreas research mostly for testing and design of control algorithms. However, it also offers the possibility of testing new insulin analogs and alternative routes of delivery given that subcutaneous insulin administration present significant delays & variability. Inhaled insulin appears an important candidate to improve post-prandial glucose control given its rapid appearance in plasma. In this contribution, we present the results of incorporating a pharmacokinetic model of inhaled Technosphere(®) Insulin (TI) into the T1DM simulator. In particular, we successfully reproduced in silico the post-prandial glucose control observed in T1DM subjects treated with TI given at meal time, and the post-prandial glucose dynamics in response to different timing of TI dose.
Collapse
|
25
|
Visentin R, Giegerich C, Jäger R, Dahmen R, Boss A, Grant M, Dalla Man C, Cobelli C, Klabunde T. Improving Efficacy of Inhaled Technosphere Insulin (Afrezza) by Postmeal Dosing: In-silico Clinical Trial with the University of Virginia/Padova Type 1 Diabetes Simulator. Diabetes Technol Ther 2016; 18:574-85. [PMID: 27333446 PMCID: PMC5035370 DOI: 10.1089/dia.2016.0128] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Technosphere(®) insulin (TI), an inhaled human insulin with a fast onset of action, provides a novel option for the control of prandial glucose. We used the University of Virginia (UVA)/Padova simulator to explore in-silico the potential benefit of different dosing regimens on postprandial glucose (PPG) control to support the design of further clinical trials. Tested dosing regimens included at-meal or postmeal dosing, or dosing before and after a meal (split dosing). METHODS Various dosing regimens of TI were compared among one another and to insulin lispro in 100 virtual type-1 patients. Individual doses were identified for each regimen following different titration rules. The resulting postprandial glucose profiles were analyzed to quantify efficacy and the risk for hypoglycemic events. RESULTS This approach allowed us to assess the benefit/risk for each TI dosing regimen and to compare results with simulations of insulin lispro. We identified a new titration rule for TI that could significantly improve the efficacy of treatment with TI. CONCLUSION In-silico clinical trials comparing the treatment effect of different dosing regimens with TI and of insulin lispro suggest that postmeal dosing or split dosing of TI, in combination with an appropriate titration rule, can achieve a superior postprandial glucose control while providing a lower risk for hypoglycemic events than conventional treatment with subcutaneously administered rapid-acting insulin products.
Collapse
Affiliation(s)
- Roberto Visentin
- Department of Information Engineering, University of Padova, Padova, Italy
| | | | - Robert Jäger
- Sanofi-Aventis Deutschland GmbH, Frankfurt, Germany
| | | | | | | | - Chiara Dalla Man
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Claudio Cobelli
- Department of Information Engineering, University of Padova, Padova, Italy
| | | |
Collapse
|
26
|
McGill JB, Ahn D, Edelman SV, Kilpatrick CR, Santos Cavaiola T. Making Insulin Accessible: Does Inhaled Insulin Fill an Unmet Need? Adv Ther 2016; 33:1267-78. [PMID: 27384191 DOI: 10.1007/s12325-016-0370-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Indexed: 01/28/2023]
Abstract
UNLABELLED Glycemic control is fundamental to the management of diabetes. However, studies suggest that a significant proportion of people with diabetes, particularly those using insulin, are not achieving glycemic targets. The reasons for this are likely to be multifactorial. The real and perceived risk of hypoglycemia and the need for multiple daily injections are widely recognized as key barriers to effective insulin therapy. Therefore, there is a clear unmet need for a treatment option which can help mitigate these barriers. Alternative methods of insulin administration have been under investigation for several years, and pulmonary delivery has shown the most promise to date. Inhaled Technosphere(®) Insulin (TI; Afrezza(®); MannKind Corporation) was approved in 2014 for use as prandial insulin in people with diabetes. TI shows a more rapid onset of action and a significantly faster decline in activity than current subcutaneous rapid-acting insulin analogs (RAAs), and TI is more synchronized to the physiologic timing of the postprandial glucose excursion. This results in lower postprandial hypoglycemia with similar glycemic control compared with RAAs, and less weight gain. Together with the ease of use of the TI inhaler and the reduction in the number of daily injections, these findings imply that TI may be useful in helping to overcome patient resistance to insulin, improve adherence and mitigate clinical inertia in health-care providers, with potential beneficial effects on glycemic control. FUNDING Writing and editorial support in the preparation of this publication was funded by Sanofi US, Inc., Bridgewater, New Jersey, USA. Funding for the article processing charges for this publication was provided by MannKind Corporation.
Collapse
Affiliation(s)
- Janet B McGill
- Washington University School of Medicine in St Louis, St Louis, MO, USA.
| | - David Ahn
- University of California San Diego, San Diego, CA, USA
| | | | | | | |
Collapse
|
27
|
Yazdi AK, Smyth HD. Hollow crystalline straws of diclofenac for high-dose and carrier-free dry powder inhaler formulations. Int J Pharm 2016; 502:170-80. [DOI: 10.1016/j.ijpharm.2016.02.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/20/2016] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
|
28
|
Brunton SA, Kruger DF, Funnell MM. Role of Emerging Insulin Technologies in the Initiation and Intensification of Insulin Therapy for Diabetes in Primary Care. Clin Diabetes 2016; 34:34-43. [PMID: 26807007 PMCID: PMC4714724 DOI: 10.2337/diaclin.34.1.34] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In Brief This article explores some of the reasons for the delay in insulin initiation in primary care and evaluates new approaches to insulin therapy that may address these barriers and, therefore, improve insulin use by primary care providers.
Collapse
Affiliation(s)
| | - Davida F. Kruger
- Henry Ford Health System Division of Endocrinology, Diabetes, Bone and Mineral Disease, Detroit, MI
| | - Martha M. Funnell
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
| |
Collapse
|
29
|
Affiliation(s)
- Jack L Leahy
- Division of Endocrinology, Diabetes & Metabolism and the Department of Medicine, The University of Vermont, Burlington, VT
| |
Collapse
|
30
|
Bode BW, McGill JB, Lorber DL, Gross JL, Chang PC, Bregman DB. Inhaled Technosphere Insulin Compared With Injected Prandial Insulin in Type 1 Diabetes: A Randomized 24-Week Trial. Diabetes Care 2015; 38:2266-73. [PMID: 26180109 DOI: 10.2337/dc15-0075] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 06/15/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the efficacy and safety of Technosphere insulin (TI) and insulin aspart in patients with type 1 diabetes. RESEARCH DESIGN AND METHODS This open-label noninferiority trial compared the change in HbA1c from baseline to week 24 of prandial TI (n = 174) with that of subcutaneous aspart (n = 171), both with basal insulin, in patients with type 1 diabetes and HbA1c 7.5-10.0% (56.8-86.0 mmol/mol). RESULTS Mean change in HbA1c in TI patients (-0.21% [-2.3 mmol/mol]) from baseline (7.94% [63.3 mmol/mol]) was noninferior to that in aspart patients (-0.40% [-4.4 mmol/mol]) from baseline (7.92% [63.1 mmol/mol]). The between-group difference was 0.19% (2.1 mmol/mol) (95% CI 0.02-0.36), satisfying the noninferiority margin of 0.4%. However, more aspart patients achieved HbA1c <7.0% (53.0 mmol/mol) (30.7% vs. 18.3%). TI patients had a small weight loss (-0.4 kg) compared with a gain (+0.9 kg) for aspart patients (P = 0.0102). TI patients had a lower hypoglycemia event rate than aspart patients (9.8 vs. 14.0 events/patient-month, P < 0.0001). Cough (generally mild) was the most frequent adverse event (31.6% with TI, 2.3% with aspart), leading to discontinuation in 5.7% of patients. Treatment group difference for mean change from baseline in forced expiratory volume in 1 s was small (40 mL) and disappeared upon TI discontinuation. CONCLUSIONS In patients with type 1 diabetes receiving basal insulin, HbA1c reduction with TI was noninferior to that of aspart, with less hypoglycemia and less weight gain but increased incidence of cough.
Collapse
Affiliation(s)
| | - Janet B McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Daniel L Lorber
- New York Hospital Queens, New York-Presbyterian Healthcare System, Flushing, NY
| | - Jorge L Gross
- Centro de Pesquisas em Diabetes Ltda., Porto Alegre, Brazil
| | | | - David B Bregman
- Sanofi, Bridgewater, NJ Department of Pathology, Albert Einstein College of Medicine, Bronx, NY
| | | |
Collapse
|
31
|
Cengiz E, Bode B, Van Name M, Tamborlane WV. Moving toward the ideal insulin for insulin pumps. Expert Rev Med Devices 2015; 13:57-69. [DOI: 10.1586/17434440.2016.1109442] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
|
32
|
Weers JG, Miller DP. Formulation Design of Dry Powders for Inhalation. J Pharm Sci 2015; 104:3259-88. [DOI: 10.1002/jps.24574] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Revised: 06/11/2015] [Accepted: 06/12/2015] [Indexed: 11/09/2022]
|
33
|
Brashier DBS, Khadka A, Anantharamu T, Sharma AK, Gupta AK, Sharma S, Dahiya N. Inhaled insulin: A "puff" than a "shot" before meals. J Pharmacol Pharmacother 2015; 6:126-9. [PMID: 26311994 PMCID: PMC4544132 DOI: 10.4103/0976-500x.162013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 03/08/2015] [Accepted: 05/15/2015] [Indexed: 12/04/2022] Open
Abstract
Diabetes is a metabolic disorder characterized by relative or absolute deficiency of insulin, resulting in hyperglycemia. The main treatment of diabetes relies on subcutaneous insulin administration by injection or continuous infusion to control glucose levels, besides oral hypoglycemic agents for type 2 diabetes. Novel routes of insulin administration are an area of research in the diabetes field as insulin injection therapy is burdensome and painful for many patients. Inhalational insulin is a potential alternative to subcutaneous insulin in the management of diabetes. The large surface area, good vascularization, immense capacity for solute exchange and ultra-thinness of the alveolar epithelium facilitates systemic delivery of insulin via pulmonary administration. Inhaled insulin has been recently approved by Food and Drug Administration (FDA). It is a novel, rapid-acting inhaled insulin with a pharmacokinetic profile that is different from all other insulin products and comparatively safer than the previous failed inhaled insulin (Exubera).
Collapse
Affiliation(s)
- Dick B S Brashier
- Department of Pharmacology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Anjan Khadka
- Department of Pharmacology, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Tejus Anantharamu
- Department of Pharmacology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Ashok Kumar Sharma
- Department of Pharmacology, Armed Forces Medical College, Pune, Maharashtra, India
| | - A K Gupta
- Department of Pharmacology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Sushil Sharma
- Department of Pharmacology, Armed Forces Medical College, Pune, Maharashtra, India
| | - N Dahiya
- Department of Pharmacology, Armed Forces Medical College, Pune, Maharashtra, India
| |
Collapse
|
34
|
Al-Tabakha MM. Future prospect of insulin inhalation for diabetic patients: The case of Afrezza versus Exubera. J Control Release 2015. [PMID: 26222134 DOI: 10.1016/j.jconrel.2015.07.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The current review was designed to compare between the insulin inhalation systems Exubera and Afrezza and to investigate the reasons why Exubera was unsuccessful, when Afrezza maker is expecting their product to be felicitous. In January 2006, Pfizer secured FDA and EC approval for the first of its kind, regular insulin through Exubera inhaler device for the management of types 1 and 2 diabetes mellitus (DM) in adults. The product was no longer available to the market after less than two years from its approval triggering a setback for competitive new inhalable insulins that were already in various clinical development phases. In contrary, MannKind Corporation started developing its ultra-rapid-acting insulin Afrezza in a bold bid, probably by managing the issues in which Exubera was not successful. Afrezza has been marketed since February, 2015 by Sanofi after getting FDA approval in June 2014. The results from this systematic review indicate the effectiveness of insulin inhalation products, particularly for patients initiating insulin therapy. Pharmaceutical companies should capitalize on the information available from insulin inhalation to produce competitive products that are able to match the bioavailability of subcutaneous (SC) insulin injection and to deal with the single insulin unit increments and basal insulin requirements in some diabetic patients or extending the horizon to inhalable drug products with completely different drug entities for other indications.
Collapse
Affiliation(s)
- Moawia M Al-Tabakha
- Pharmaceutical Sciences Unit, College of Pharmacy, Al Ain University of Science and Technology, P.O. Box 64141, Al Ain, United Arab Emirates.
| |
Collapse
|
35
|
Rubin BK, Williams RW. Emerging aerosol drug delivery strategies: from bench to clinic. Adv Drug Deliv Rev 2014; 75:141-8. [PMID: 24993613 DOI: 10.1016/j.addr.2014.06.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 06/18/2014] [Accepted: 06/19/2014] [Indexed: 12/12/2022]
Abstract
Patients with tracheostomies, those requiring mechanical ventilation, and those too small or compromised for conventional devices, are realizing the benefits of increasingly sophisticated aerosol delivery systems. New medicines and novel aerosol formulations, have enhanced our ability to treat lung disease, and are opening the doors for therapy to treat diseases like diabetes, pulmonary hypertension, and cancer. Progress in the aerosol delivery of drugs has been spurred by the significant benefits, including ease of use, patient comfort, greater selectivity of effect, and the potential to decrease side effects.
Collapse
|
36
|
Santos Cavaiola T, Edelman S. Inhaled insulin: a breath of fresh air? A review of inhaled insulin. Clin Ther 2014; 36:1275-89. [PMID: 25044021 DOI: 10.1016/j.clinthera.2014.06.025] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 06/23/2014] [Indexed: 01/13/2023]
Abstract
PURPOSE Despite many advances in diabetes care over the last century, some elements of insulin therapy remain inadequate for optimal care of the patient with diabetes. There is a need for improved pharmacokinetics and pharmacodynamics of rapid-acting insulin analogues to mimic physiologic insulin secretion. In addition, a major barrier to successful insulin therapy has been patient resistance. Alternative routes of insulin administration, including inhaled insulin, have been under investigation for several years. This review discusses the rationale for pulmonary delivery of insulin, compares previous inhaled insulin products, reviews the literature on the safety and efficacy of a current inhaled insulin formulation under investigation, and compares this product with other prandial insulin products. METHODS English-language studies and reviews of inhaled insulin were searched in MEDLINE, the ClinicalTrials.gov registry (through May 2014), and the US Food and Drug Administration Website. FINDINGS Inhaled insulin has several favorable characteristics due to pulmonary anatomy/physiology and the lack of injections. Pharmacokinetic and pharmacodynamic studies have shown a time-action profile suitable for prandial insulin use. Inhaled insulin seems to be safe and effective compared with other prandial insulin products and may be preferable to subcutaneous rapid-acting insulin analogues in terms of time-action profiles and rates of hypoglycemia. Small decreases in forced expiratory volume in 1 second (FEV1) have been shown with inhaled insulin, although this finding is not progressive over time and reverses with cessation of the medication. IMPLICATIONS Although several inhaled insulin products have been under investigation, only one (Exubera(®) [Nektar Therapeutics, San Carlos, California/Pfizer Inc, New York, New York]) was approved by the US Food and Drug Administration, and it was pulled from the market after only a short period of time. Technosphere(®) insulin (MannKind Corporation, Valencia, California) is currently the only inhaled insulin that remains under investigation. A review of the past and present literature on inhaled insulin is pertinent in understanding the current status of inhaled insulin and its risks and benefits. The current literature suggests that inhaled insulin could be a valuable option for prandial insulin administration, with a favorable risk to benefit ratio in some patients.
Collapse
Affiliation(s)
| | - Steven Edelman
- University of California, San Diego, San Diego, California
| |
Collapse
|
37
|
|
38
|
Affiliation(s)
- Satish K Garg
- Barbara Davis Center for Childhood Diabetes, University of Colorado , Denver Health Sciences Center, Aurora, CO
| | | |
Collapse
|
39
|
Cengiz E, Weinzimer SA, Sherr JL, Tichy EM, Carria L, Cappiello D, Steffen A, Tamborlane WV. Faster in and faster out: accelerating insulin absorption and action by insulin infusion site warming. Diabetes Technol Ther 2014; 16:20-5. [PMID: 24367934 PMCID: PMC3887414 DOI: 10.1089/dia.2013.0187] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE This study was undertaken to investigate the effect of an insulin infusion site warming device, the InsuPatch(40)(™) (IP(40)) (InsuLine Medical Ltd., Petach-Tikvah, Israel), on insulin aspart pharmacodynamics (PD) and pharmacokinetics (PK) in adolescents with type 1 diabetes. SUBJECTS AND METHODS Seventeen subjects with type 1 diabetes (age, 15±1 years; hemoglobin A1c, 7.5±0.2% [58±2.2 mmol/mol]) underwent two euglycemic clamps performed on separate mornings with and without IP(40) activation with warming temperature at 40°C. On both days, the basal infusion was suspended, and glucose levels were maintained between 90 and 100 mg/dL by a variable rate dextrose infusion for up to 5 h after a 0.2 U/kg bolus of insulin aspart. RESULTS Time to peak insulin action and time to half-maximal action occurred earlier with a greater early glucodynamic effect (area under the curve [AUC] for glucose infusion rate from 0 to 30 min) with IP(40) than without the IP(40), whereas the AUC for the time-action profile and the peak action did not differ with and without infusion site warming. PK parameters were in agreement with PD parameters, namely, a significantly earlier time to reach the maximum increment in insulin concentrations and greater early bioavailability (AUC for the change in insulin concentration from 0 to 30 min) with the IP(40). The tail of the plasma insulin response curve was also shortened with infusion site warming, with the time to reach baseline insulin concentration occurring significantly earlier (P=0.04). CONCLUSIONS Our data demonstrate that skin warming around the infusion site to 40°C with the IP(40) is an effective means to accelerate absorption and action of rapid-acting insulin. These improvements in time-action responses have the potential to enhance the performance of open- and closed-loop insulin delivery systems.
Collapse
Affiliation(s)
- Eda Cengiz
- Division of Pediatric Endocrinology, Yale School of Medicine , New Haven, Connecticut
| | | | | | | | | | | | | | | |
Collapse
|
40
|
Mahjub R, Radmehr M, Dorkoosh FA, Ostad SN, Rafiee-Tehrani M. Lyophilized insulin nanoparticles prepared from quaternizedN-aryl derivatives of chitosan as a new strategy for oral delivery of insulin:in vitro, ex vivoandin vivocharacterizations. Drug Dev Ind Pharm 2013; 40:1645-59. [DOI: 10.3109/03639045.2013.841187] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
41
|
Garber AJ. Methods to enhance delivery of prandial insulin and basal-prandial insulin. Diabetes Obes Metab 2013; 15 Suppl 1:11-7. [PMID: 23448198 DOI: 10.1111/dom.12067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 01/22/2013] [Indexed: 11/26/2022]
Abstract
Most physicians are comfortable with initiating basal insulin replacement therapy in their patients with type 2 diabetes who are no longer meeting treatment goals with oral antidiabetic agents. What is more challenging is what to do when treatment goals are no longer being met despite adequate titration of basal insulin. Both fasting plasma glucose and postprandial glucose contribute to hemoglobin A1C levels. Addressing postprandial glucose levels can be accomplished by several approaches. Traditionally this has meant moving to basal bolus insulin, which is considered the gold standard. Premixed insulin may also be used. Data is also emerging for basal "plus" strategies, that is, incremental addition of prandial insulin injections. Newer approaches also reviewed in this article included premixed formulations containing ultra-long acting basal insulin with rapid-acting insulin analogs, inhaled insulin and insulin jet injectors, as well as the use of incretin-based therapies.
Collapse
Affiliation(s)
- A J Garber
- Department of Medicine, Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX 77030, USA.
| |
Collapse
|
42
|
Abstract
Optimal coverage of prandial insulin requirements remains an elusive goal. The invention of rapid-acting insulin analogs (RAIAs) was a big step forward in reducing postprandial glycemic excursions in patients with diabetes in comparison with using regular human insulin; however, even with these, the physiological situation cannot be adequately mimicked. Developing ultrafast-acting insulins (UFIs)-showing an even more rapid onset of action and a shorter duration of action after subcutaneous (SC) administration-is another step forward in achieving this goal. The need for UFIs has been gradually recognized over the years, and subsequently, a number of different approaches to cover this need are in clinical development. A rapid increase in circulating insulin levels can be achieved by different measures: modification of the primary structure of insulin molecule (as we know from RAIAs), addition of excipients that enhance the appearance in the monomeric state post-injection, or addition of enzymes that enable more free spreading of the insulin molecules in the SC tissue. Other measures to increase the insulin absorption rate increase the local blood flow nearby the insulin depot in the SC tissue, injecting the insulin intradermally or applying via another route, e.g., the lung. The development of these approaches is in different stages, from quite early stages to nearing market authorization. In time, daily practice will show if the introduction of UFIs will fulfill their clinical promise. In this review, the basic idea for UFIs will be presented and the different approaches will be briefly characterized.
Collapse
|