Attainment of glycaemic goals by step-up therapy with biphasic insulin aspart-70/30 in Japanese type 2 diabetic patients

Science of premix insulin: where have we reached?

Diabetes is a progressive disease and by achieving and maintaining optimal glycemic control, the onset of complications can be prevented or delayed. Insulin is most effective at any stage of diabetes. Although basal-bolus therapy is the gold standard treatment, it has its own limitations such as multiple pricks, close monitoring and cost. Premixed insulin on the other hand is convenient, requires fewer injections, is a single device and delivers both the basal and bolus component till the next meal. Although premixed insulin analogs have the advantages of mealtime flexibility, compliance and better post-prandial glucose control, no significant differences have been observed in HbA1c reduction and overall hypoglycemia when compared to premixed human insulin. This review will attempt to analyze the efficacy, safety and limitations of currently available premix human insulin and premix analogs including recent advancements in the area.

A Randomized Trial of Step-up Treatment with Premixed Insulin Lispro-50/50 vs. Aspart-70/30 in Patients with Type 2 Diabetes Mellitus

INTRODUCTION

When insulin treatment is started in patients with type 2 diabetes mellitus (T2DM), there are many regimens that control serum glucose levels to a normal range. Basal-bolus insulin therapy is one of the most effective treatments for improving glycemic control to prevent the progression of diabetic microvascular complications. This study was conducted to determine whether step-up insulin treatment with premixed insulin aspart-30/70 (BIAsp 30) or lispro-50/50 (Mix50) in Japanese patients with type 2 diabetes mellitus could achieve better glycemic control.

METHODS

In this open label study, 72 insulin-naïve patients with poorly controlled T2DM (HbA1c ≥8.4%), who had been taking oral antidiabetic drugs for at least 12 months, were randomized to receive BIAsp 30 or Mix50 therapy. Patients started treatment of a pre-dinner injection of each type of insulin (Step 1). At 16 ± 2 weeks, a pre-breakfast injection of each type of insulin was added if HbA1c exceeded 7.4% (step 2). If patients had still not achieved HbA1c <7.4% after an additional 16 ± 2 weeks, a pre-lunch insulin injection was added (step 3). Hypoglycemic episodes were also recorded.

RESULTS

The cumulative percentages of subjects who achieved HbA1c <7.4% were 36.1% (13/36) for both Mix50 and BIAsp 30 in step 1, 62.9% (23/36) for BIAsp 30 and 52.8% (19/36) for Mix50 in step 2, and 66.7% (24/36) in BIAsp 30 and 72.2% (26/36) in Mix50 in step 3. The achievement rates of HbA1c <7.4% were not statistically different between the two groups. A total of ten hypoglycemic episodes occurred in this study. However, there were no severe hypoglycemic episodes. All cases recovered by taking glucose and drinking juice.

CONCLUSION

Mix50 step-up treatment has a clinical effect in achieving good glycemic control equal to that of BIAsp 30 treatment.

Ten years of experience with biphasic insulin aspart 30: from drug development to the latest clinical findings

Biphasic insulin aspart 30 (BIAsp 30) includes 30% soluble rapid-acting insulin aspart (IAsp) along with an intermediate-acting 70% protaminated IAsp that provides coverage of prandial and basal insulin in a single injection. As BIAsp 30 has been available internationally for 10 years, this review provides a comprehensive overview of the discovery of BIAsp 30, its pharmacokinetic and pharmacodynamic profile, safety and efficacy outcomes from the clinical trial programme, 'real-life' clinical insights provided by observational study data, and cost effectiveness and quality-of-life information. These studies have demonstrated that BIAsp 30 once or twice daily is an appropriate option for insulin initiation. BIAsp 30 also provides a switch option in patients on biphasic human insulin (BHI). Switching from BHI to BIAsp 30 is associated with improved postprandial glucose (PPG) and reduced nocturnal and major hypoglycaemia, although daytime hypoglycaemia is higher with BIAsp 30. Intensification of BIAsp 30 can be achieved by increasing the number of daily doses up to three times daily with meals. Therefore, BIAsp 30 provides an intensification option for individuals who are not achieving control with basal insulin and would prefer the simplicity of a single biphasic insulin instead of progressing to a basal-bolus approach. BIAsp 30 has a simple dose-titration algorithm, which enables patients to effectively self-titrate their insulin dose. Cost-effectiveness analyses have demonstrated that BIAsp 30 is cost effective or dominant compared with BHI 30 or insulin glargine in a number of healthcare settings. In conclusion, BIAsp 30 offers a simple and flexible option for insulin initiation and intensification that provides coverage of both fasting and prandial glucose.