Patient safety and minimizing risk with insulin administration - role of insulin degludec

Clinical perspectives on the frequency of hypoglycemia in treat-to-target randomized controlled trials comparing basal insulin analogs in type 2 diabetes: a narrative review

The objective of this review was to comprehensively present and summarize trends in reported rates of hypoglycemia with one or two times per day basal insulin analogs in individuals with type 2 diabetes to help address and contextualize the emerging theoretical concern of increased hypoglycemic risk with once-weekly basal insulins.Hypoglycemia data were extracted from treat-to-target randomized clinical trials conducted during 2000-2022. Published articles were identified on PubMed or within the US Food and Drug Administration submission documents. Overall, 57 articles were identified: 44 assessed hypoglycemic outcomes in participants receiving basal-only therapy (33 in insulin-naive participants; 11 in insulin-experienced participants), 4 in a mixed population (insulin-naive and insulin-experienced participants) and 9 in participants receiving basal-bolus therapy. For the analysis, emphasis was placed on level 2 (blood glucose <3.0 mmol/L (<54 mg/dL)) and level 3 (or severe) hypoglycemia.Overall, event rates for level 2 or level 3 hypoglycemia across most studies ranged from 0.06 to 7.10 events/person-year of exposure (PYE) for participants receiving a basal-only insulin regimen; the rate for basal-bolus regimens ranged from 2.4 to 13.6 events/PYE. Rates were generally lower with second-generation basal insulins (insulin degludec or insulin glargine U300) than with neutral protamine Hagedorn insulin or first-generation basal insulins (insulin detemir or insulin glargine U100). Subgroup categorization by sulfonylurea usage, end-of-treatment insulin dose or glycated hemoglobin reduction did not show consistent trends on overall hypoglycemia rates. Hypoglycemia rates reported so far for once-weekly basal insulins are consistent with or lower than those reported for daily-administered basal insulin analogs.

Pancreatic transplant surgery and stem cell therapy: Finding the balance between therapeutic advances and ethical principles

The latest achievements in the field of pancreas transplantation and stem cell therapy require an effort by the scientific community to clarify the ethical implications of pioneering treatments, often characterized by high complexity from a surgical point of view, due to transplantation of multiple organs at the same time or at different times, and from an immunological point of view for stem cell therapy. The fundamental value in the field of organ transplants is, of course, a solidarity principle, namely that of protecting the health and life of people for whom transplantation is a condition of functional recovery, or even of survival. The nature of this value is that of a concept to which the legal discipline of transplants entrusts its own ethical dignity and for which it has ensured a constitutional recognition in different systems. The general principle of respect for human life, both of the donor and of the recipient, evokes the need not to put oneself and one’s neighbor in dangerous conditions. The present ethical reflection aims to find a balance between the latest therapeutic advances and several concepts including the idea of the person, the respect due to the dead, the voluntary nature of the donation and the consent to the same, the gratuitousness of the donation, the scientific progress and the development of surgical techniques, and the policies of health promotion.

Use of Insulin Degludec/Insulin Aspart in the Management of Diabetes Mellitus: Expert Panel Recommendations on Appropriate Practice Patterns

Insulin degludec/insulin aspart (IDegAsp) is a fixed-ratio co-formulation of insulin degludec (IDeg), which provides long-lasting basal insulin coverage, and insulin aspart (IAsp), which targets post-prandial glucose. This expert panel aimed to provide a practical and implementable guidance document to assist clinicians in prescribing IDegAsp in the diabetes management with respect to different patient populations including children and adults with type 1 diabetes (T1D) or type 2 diabetes (T2D) as well as pregnant, elderly and hospitalized patients and varying practice patterns (insulin-naive, insulin-treated, switching from basal, basal bolus and premix regimens). The experts recommended that IDegAsp can be used in insulin-naive T2D patients with poor glycemic control (HbA1c >8.5%) despite optimal oral antidiabetic drugs (OADs) as well as in insulin-treated T2D patients by switching from basal insulin, basal-bolus therapy or premixed insulins in relation to lower risk of nocturnal hypoglycemia, fewer injections and lower intraday glycemic variability, respectively. The experts considered the use of IDegAsp in children with T2D as a basal bolus alternative rather than as an alternative to basal insulin after metformin failure, use of IDegAsp in adult T1D patients as a simplified basal bolus regimen with lesser nocturnal hypoglycemia, fewer injections and better fasting plasma glucose control and in children with T1D as an alternative insulin regimen with fewer injection to increase treatment adherence. The proposed expert opinion provides practical information on use of IDegAsp in different patient populations and practice patterns to assist clinicians, which seems to compensate the need for easily implementable guidance on this novel insulin regimen.

In vivo hyperglycaemia exposure elicits distinct period-dependent effects on human pancreatic progenitor differentiation, conveyed by oxidative stress

AIM

The loss of insulin-secreting β-cells, ultimately characterizing most diabetes forms, demands the development of cell replacement therapies. The common endpoint for all ex vivo strategies is transplantation into diabetic patients. However, the effects of hyperglycaemia environment on the transplanted cells were not yet properly assessed. Thus, the main goal of this study was to characterize global effect of brief and prolonged in vivo hyperglycaemia exposure on the cell fate acquisition and maintenance of transplanted human pancreatic progenitors.

METHODS

To rigorously study the effect of hyperglycaemia, in vitro differentiated human-induced pluripotent stem cells (hiPSC)-derived pancreatic progenitors were xenotransplanted in normoglycaemic and diabetic NSG rat insulin promoter (RIP)-diphtheria toxin receptor (DTR) mice. The transplants were retrieved after 1-week or 1-month exposure to overt hyperglycaemia and analysed by large-scale microscopy or global proteomics. For this study we pioneer the use of the NSG RIP-DTR system in the transplantation of hiPSC, making use of its highly reproducible specific and absolute β-cell ablation property in the absence of inflammation or other organ toxicity.

RESULTS

Here we show for the first time that besides the presence of an induced oxidative stress signature, the cell fate and proteome landscape response to hyperglycaemia was different, involving largely different mechanisms, according to the period spent in the hyperglycaemic environment. Surprisingly, brief hyperglycaemia exposure increased the bihormonal cell number by impeding the activity of specific islet lineage determinants. Moreover, it activated antioxidant and inflammation protection mechanisms signatures in the transplanted cells. In contrast, the prolonged exposure was characterized by decreased numbers of hormone + cells, low/absent detoxification signature, augmented production of oxygen reactive species and increased apoptosis.

CONCLUSION

Hyperglycaemia exposure induced distinct, period-dependent, negative effects on xenotransplanted human pancreatic progenitor, affecting their energy homeostasis, cell fate acquisition and survival.

Differentiating Basal Insulin Preparations: Understanding How They Work Explains Why They Are Different

Since the introduction of insulin as a life-saving agent for patients with type 1 diabetes, insulin preparations have evolved to approximate physiologic insulin delivery profiles to meet prandial and basal insulin needs. While prandial insulins are designed to have quick time–action profiles that minimize postprandial glucose excursions, basal insulins are designed to have a protracted time–action profile to facilitate basal glucose control over 24 h. Given that all insulins have the same mechanism of action at the target tissue level, the differences in time–action profiles are achieved through different mechanisms of protraction, resulting in different behaviors in the subcutaneous space and different rates of absorption into the circulation. Herein, we evaluate the differences in basal insulin preparations based on their differential mechanisms of protraction, and the resulting clinical action profiles. Multiple randomized control trials and real-world evidence studies have demonstrated that the newer second-generation basal insulin analogs, insulin glargine 300 units/mL and insulin degludec 100 or 200 units/mL, provide stable glycemic control with once-daily dosing and are associated with a reduced risk of hypoglycemia compared with previous-generation basal insulin analogs insulin glargine 100 units/mL and insulin detemir. These advantages can lead to decreased healthcare resource utilization and cost. With this collective knowledge, healthcare providers and payers can make educated and well-informed decisions when determining which treatment regimen best meets the needs of each individual patient.

Funding: Sanofi US, Inc.

Differentiating Basal Insulin Preparations: Understanding How They Work Explains Why They Are Different

Since the introduction of insulin as a life-saving agent for patients with type 1 diabetes, insulin preparations have evolved to approximate physiologic insulin delivery profiles to meet prandial and basal insulin needs. While prandial insulins are designed to have quick time-action profiles that minimize postprandial glucose excursions, basal insulins are designed to have a protracted time-action profile to facilitate basal glucose control over 24 h. Given that all insulins have the same mechanism of action at the target tissue level, the differences in time-action profiles are achieved through different mechanisms of protraction, resulting in different behaviors in the subcutaneous space and different rates of absorption into the circulation. Herein, we evaluate the differences in basal insulin preparations based on their differential mechanisms of protraction, and the resulting clinical action profiles. Multiple randomized control trials and real-world evidence studies have demonstrated that the newer second-generation basal insulin analogs, insulin glargine 300 units/mL and insulin degludec 100 or 200 units/mL, provide stable glycemic control with once-daily dosing and are associated with a reduced risk of hypoglycemia compared with previous-generation basal insulin analogs insulin glargine 100 units/mL and insulin detemir. These advantages can lead to decreased healthcare resource utilization and cost. With this collective knowledge, healthcare providers and payers can make educated and well-informed decisions when determining which treatment regimen best meets the needs of each individual patient.Funding: Sanofi US, Inc.

Novel route of insulin delivery using an implant-mediated drug delivery system

Patients with diabetes mellitus (DM) frequently require multiple painful injections of insulin to manage their blood glucose level. A newly introduced, modified titanium implant, the implant-mediated drug delivery system (IMDDS), has the advantage of sustained, needle-free drug delivery. We evaluated the feasibility of the IMDDS as an alternative route of insulin delivery in an alloxan-induced rabbit DM model. Among a total of 30 rabbits with IMDDSs, 25 survived the induction and had a blood glucose level (BGL) higher than 300 mg/dl. The animals were divided into two groups: 13 in the test group to which insulin was administered via the IMDDS and 12 in the untreated control group. The BGL was monitored and measured at 0, 2, 4, 6, 8, 12, and 24 hours on the first day and every 12 hours thereafter for a total of 2 weeks. Marked hypoglycemic effects of insulin in the test rabbits were detected from the 2-h time point, and the mean BGL fell below the normal range from 12 h after insulin administration via the IMDDS. The effects lasted the entire 2-week period. Control rabbits did not show a pronounced decrease in BGL except for three animals who exhibited spontaneous recovery. The mean body weight of the test group was significantly higher than that of the control group at the end of the observation period. Although this implant requires several improvements, the IMDDS exhibited promise as an alternative route of insulin delivery with the advantages of being a sustained, needle-free insulin delivery system.

Forum for Injection Technique and Therapy Expert Recommendations, India: The Indian Recommendations for Best Practice in Insulin Injection Technique, 2017

Health-care professionals in India frequently manage injection or infusion therapies in persons with diabetes (PWD). Patients taking insulin should know the importance of proper needle size, correct injection process, complication avoidance, and all other aspects of injection technique from the first visit onward. To assist health-care practitioners in their clinical practice, Forum for Injection Technique and Therapy Expert Recommendations, India, has updated the practical advice and made it more comprehensive evidence-based best practice information. Adherence to these updated recommendations, learning, and translating them into clinical practice should lead to effective therapies, improved outcomes, and lower costs for PWD.

Cell Therapy for Type 1 Diabetes: Current and Future Strategies

PURPOSE OF THE REVIEW

Type 1 diabetes (T1D) is defined by an autoimmune destruction of insulin producing β-cells located in the endocrine part of the pancreas, the islets of Langerhans. As exogenous insulin administration fails at preventing severe complications associated with this disease, cell replacement therapies are being considered as a means to treat T1D. The purpose of this manuscript is to review the challenges associated with current strategies and discuss the potential of stem cell therapy for the treatment of T1D.

RECENT FINDINGS

The most prominent therapy offered to T1D patients is exogenous insulin administration which, despite formulations improvement, remains a suboptimal treatment, due to the frequency of injections and the issues associated with precise dosing. As immunotherapy approaches have remained unsuccessful, the only cure for T1D is transplantation of donor-derived pancreas or islets. However, donor scarcity, graft loss, and immune response to the foreign tissue are issues challenging this approach and limiting the number of patients who can benefit from such treatments. In this review, we discuss the causes of T1D and the shortcomings of the current treatments. Furthermore, we summarize the cutting edge research that aims to tackle the current challenges in reaching a quality-controlled product with long-term effects, with a focus on regenerative medicine approaches using human pluripotent stem cells.

Efficacy of oral versus insulin therapy for newly diagnosed diabetes in low-income settings

BACKGROUND

There are conflicting recommendations and highly variable practices regarding the level of A1c to initiate insulin for individuals with newly diagnosed diabetes. This is complicated in low-income settings where adverse reactions or negative perceptions of insulin are often magnified.

OBJECTIVES

Compare the clinical outcomes of insulin and Oral Agents (OAs) in low-income settings in the United States.

METHODS

We conducted a retrospective chart review in community clinics serving low -income individuals with newly diagnosed type 2 diabetes who were initiated on insulin or OAs. The primary outcome was change of hemoglobin A1c (A1c) from baseline to 12 months. Secondary outcomes consisted of other clinical measures including Emergency Department (ED) visits.

RESULTS

A total of 18% (88/489) of patients were started on insulin. The adjusted average decrease of A1c from baseline was greater in the OA group (insulin: -1.97% vs. OA: -2.52%; p<0.001). In a subset analysis of individuals with A1cs >11%, significantly more patients were started on OAs (insulin: n=51, OA: n=93; p<0.001) and A1c improvements were similar at 12 months (insulin: -5.06% [12.94% to 7.88%] OA: -4.62% [12.57% to 7.96%]; p=0.846). Baseline A1c predicted insulin initiation (p<0.001): For every one-unit increase in baseline A1c, the odds of insulin initiation increased by 47.5%. Individuals in the insulin group had more ED visits per year (0.169 vs. 0.0025; p<0.005).

CONCLUSIONS

Given the positive clinical outcomes of OAs even with markedly elevated A1c levels in addition to the healthcare system benefits, they are a promising initial therapy for low-income adults with newly diagnosed type 2 diabetes.

Preclinical and Clinical Studies for Sodium Tungstate: Application in Humans

Diabetes is a complex metabolic disorder triggered by the deficient secretion of insulin by the pancreatic β-cell or the resistance of peripheral tissues to the action of the hormone. Chronic hyperglycemia is the major consequence of this failure, and also the main cause of diabetic problems. Indeed, several clinical trials have agreed in that tight glycemic control is the best way to stop progression of the disease. Many anti-diabetic drugs for treatment of type 2 diabetes are commercially available, but no ideal normoglycemic agent has been developed yet. Moreover, weight gain is the most common side effect of many oral anti-diabetic agents and insulin, and increased weight has been shown to worsen glycemic control and increase the risk of diabetes progression. In this sense, the inorganic salt sodium tungstate (NaW) has been studied in different animal models of metabolic syndrome and diabetes, proving to have a potent effect on normalizing blood glucose levels and reducing body weight, without any hypoglycemic action. Although the liver has been studied as the main site of NaW action, positive effects have been also addressed in muscle, pancreas, brain, adipose tissue and intestine, explaining the effective anti-diabetic action of this salt. Here, we review NaW research to date in these different target organs. We believe that NaW deserves more attention, since all available anti-diabetic treatments remain suboptimal and new therapeutics are urgently needed.