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Rosenstock J, Juneja R, Beals JM, Moyers JS, Ilag L, McCrimmon RJ. The Basis for Weekly Insulin Therapy: Evolving Evidence With Insulin Icodec and Insulin Efsitora Alfa. Endocr Rev 2024; 45:379-413. [PMID: 38224978 PMCID: PMC11091825 DOI: 10.1210/endrev/bnad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Indexed: 01/17/2024]
Abstract
Basal insulin continues to be a vital part of therapy for many people with diabetes. First attempts to prolong the duration of insulin formulations were through the development of suspensions that required homogenization prior to injection. These insulins, which required once- or twice-daily injections, introduced wide variations in insulin exposure contributing to unpredictable effects on glycemia. Advances over the last 2 decades have resulted in long-acting, soluble basal insulin analogues with prolonged and less variable pharmacokinetic exposure, improving their efficacy and safety, notably by reducing nocturnal hypoglycemia. However, adherence and persistence with once-daily basal insulin treatment remains low for many reasons including hypoglycemia concerns and treatment burden. A soluble basal insulin with a longer and flatter exposure profile could reduce pharmacodynamic variability, potentially reducing hypoglycemia, have similar efficacy to once-daily basal insulins, simplify dosing regimens, and improve treatment adherence. Insulin icodec (Novo Nordisk) and insulin efsitora alfa (basal insulin Fc [BIF], Eli Lilly and Company) are 2 such insulins designed for once-weekly administration, which have the potential to provide a further advance in basal insulin replacement. Icodec and efsitora phase 2 clinical trials, as well as data from the phase 3 icodec program indicate that once-weekly insulins provide comparable glycemic control to once-daily analogues, with a similar risk of hypoglycemia. This manuscript details the technology used in the development of once-weekly basal insulins. It highlights the clinical rationale and potential benefits of these weekly insulins while also discussing the limitations and challenges these molecules could pose in clinical practice.
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Affiliation(s)
- Julio Rosenstock
- Velocity Clinical Research at Medical City,
Dallas, TX 75230, USA
| | - Rattan Juneja
- Lilly Diabetes and Obesity, Eli Lilly and Company,
Indianapolis, IN 46225, USA
| | - John M Beals
- Lilly Diabetes and Obesity, Eli Lilly and Company,
Indianapolis, IN 46225, USA
| | - Julie S Moyers
- Lilly Diabetes and Obesity, Eli Lilly and Company,
Indianapolis, IN 46225, USA
| | - Liza Ilag
- Lilly Diabetes and Obesity, Eli Lilly and Company,
Indianapolis, IN 46225, USA
| | - Rory J McCrimmon
- School of Medicine, University of Dundee, Dundee
DD1 9SY, Scotland, UK
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2
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Hvid H, Brand CL, Hummelshøj T, Jensen S, Bouman SD, Bowler A, Poulsen BR, Tiainen P, Åkertröm T, Demozay D, Hoeg-Jensen T, Ingvorsen C, Pedersen TÅ, McGuire J, Egebjerg T, Cappelen KA, Eliasen IP, Hansen BF, Hennen S, Stidsen CE, Olsen GS, Roed NK. Preclinical exploration of combined glucagon inhibition and liver-preferential insulin for treatment of diabetes using in vitro assays and rat and mouse models. Diabetologia 2023; 66:376-389. [PMID: 36404376 PMCID: PMC9807490 DOI: 10.1007/s00125-022-05828-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/22/2022] [Indexed: 11/22/2022]
Abstract
AIMS/HYPOTHESIS Normalisation of blood glucose in individuals with diabetes is recommended to reduce development of diabetic complications. However, risk of severe hypoglycaemia with intensive insulin therapy is a major obstacle that prevents many individuals with diabetes from obtaining the recommended reduction in HbA1c. Inhibition of glucagon receptor signalling and liver-preferential insulin action have been shown individually to have beneficial effects in preclinical models and individuals with diabetes (i.e. improved glycaemic control), but also have effects that are potential safety risks (i.e. alpha cell hyperplasia in response to glucagon receptor antagonists and increased levels of liver triacylglycerols and plasma alanine aminotransferase activity in response to glucagon receptor antagonists and liver-preferential insulin). We hypothesised that a combination of glucagon inhibition and liver-preferential insulin action in a dual-acting molecule would widen the therapeutic window. By correcting two pathogenic mechanisms (dysregulated glucagon signalling and non-physiological distribution of conventional insulin administered s.c.), we hypothesised that lower doses of each component would be required to obtain sufficient reduction of hyperglycaemia, and that the undesirable effects that have previously been observed for monotreatment with glucagon antagonists and liver-preferential insulin could be avoided. METHODS A dual-acting glucagon receptor inhibitor and liver-preferential insulin molecule was designed and tested in rodent models (normal rats, rats with streptozotocin-induced hyperglycaemia, db/db mice and mice with diet-induced obesity and streptozotocin-induced hyperglycaemia), allowing detailed characterisation of the pharmacokinetic and pharmacodynamic properties of the dual-acting molecule and relevant control compounds, as well as exploration of how the dual-acting molecule influenced glucagon-induced recovery and spontaneous recovery from acute hypoglycaemia. RESULTS This molecule normalised blood glucose in diabetic models, and was markedly less prone to induce hypoglycaemia than conventional insulin treatment (approximately 4.6-fold less potent under hypoglycaemic conditions than under normoglycaemic conditions). However, compared to treatment with conventional long-acting insulin, this dual-acting molecule also increased triacylglycerol levels in the liver (approximately 60%), plasma alanine aminotransferase levels (approximately twofold) and alpha cell mass (approximately twofold). CONCLUSIONS/INTERPRETATION While the dual-acting glucagon receptor inhibitor and liver-preferential insulin molecule showed markedly improved regulation of blood glucose, effects that are potential safety concerns persisted in the pharmacologically relevant dose range.
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Affiliation(s)
- Henning Hvid
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark
| | | | - Tina Hummelshøj
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark
| | - Sanne Jensen
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark
| | | | - Andrew Bowler
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark
- QC Laboratories, Syntese A/S, Hvidovre, Denmark
| | | | - Peter Tiainen
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark
| | | | - Damien Demozay
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark
| | | | | | | | - Jim McGuire
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark
- Catalyst Biosciences, San Francisco, CA, USA
| | - Thomas Egebjerg
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark
| | | | - Ina P Eliasen
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark
| | - Bo F Hansen
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark
| | - Stephanie Hennen
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark
- Grünethal GmbH, Aachen, Germany
| | | | - Grith S Olsen
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark
| | - Nikolaj K Roed
- Research & Early Development, Novo Nordisk A/S, Måløv, Denmark.
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3
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Gorai B, Vashisth H. Structural models of viral insulin-like peptides and their analogs. Proteins 2023; 91:62-73. [PMID: 35962629 PMCID: PMC9772067 DOI: 10.1002/prot.26410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/21/2022] [Accepted: 08/09/2022] [Indexed: 12/24/2022]
Abstract
The insulin receptor (IR), the insulin-like growth factor-1 receptor (IGF1R), and the insulin/IGF1 hybrid receptors (hybR) are homologous transmembrane receptors. The peptide ligands, insulin and IGF1, exhibit significant structural homology and can bind to each receptor via site-1 and site-2 residues with distinct affinities. The variants of the Iridoviridae virus family show capability in expressing single-chain insulin/IGF1 like proteins, termed viral insulin-like peptides (VILPs), which can stimulate receptors from the insulin family. The sequences of VILPs lacking the central C-domain (dcVILPs) are known, but their structures in unbound and receptor-bound states have not been resolved to date. We report all-atom structural models of three dcVILPs (dcGIV, dcSGIV, and dcLCDV1) and their complexes with the receptors (μIR, μIGF1R, and μhybR), and probed the peptide/receptor interactions in each system using all-atom molecular dynamics (MD) simulations. Based on the nonbonded interaction energies computed between each residue of peptides (insulin and dcVILPs) and the receptors, we provide details on residues establishing significant interactions. The observed site-1 insulin/μIR interactions are consistent with previous experimental studies, and a residue-level comparison of interactions of peptides (insulin and dcVILPs) with the receptors revealed that, due to sequence differences, dcVILPs also establish some interactions distinct from those between insulin and IR. We also designed insulin analogs and report enhanced interactions between some analogs and the receptors.
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Affiliation(s)
- Biswajit Gorai
- Department of Chemical Engineering, University of New Hampshire, Durham, NH 03824, USA
| | - Harish Vashisth
- Department of Chemical Engineering, University of New Hampshire, Durham, NH 03824, USA
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4
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Rodgers RL. A reappraisal of the role of cyclic AMP in the physiological action of glucagon. Peptides 2023; 159:170906. [PMID: 36396082 DOI: 10.1016/j.peptides.2022.170906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/11/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022]
Abstract
Effects of the metabolic hormone glucagon can be physiological or supraphysiological, based on agonist concentration and the mediating cellular signal. The threshold concentration (TC) for activating the AC/cAMP signal pathway in liver is ≥ 100 pM. By contrast, mean plasma concentrations are around 20-45 pM, depending on the vascular bed. Accordingly, effects produced at TCs below 100 pM are physiological and mediated by cellular signal pathways other than AC/cAMP. Effects generated at concentrations above 100 pM are supraphysiological, often mediated by simultaneous activation of cAMP-independent and -dependent pathways. Physiological responses, and their established or implicated signal pathways, include stimulation of: glucose mobilization, fatty acid oxidation, and urea synthesis in liver (PLC/IP3/Ca2+/CaM); lipolysis in white and brown adipose tissue and oxygen consumption in brown adipose of the rat but not in humans (PLC/IP3/Ca2+/CaM); renal potassium and phosphate excretion in rodents and GFR in humans (signal undetermined); and glucose utilization in rat heart (PI3K/akt). Supraphysiological responses involve the AC/cAMP pathway and include: enhanced stimulation of glucose mobilization and stimulation of urea synthesis in liver; further stimulation of white and brown adipose lipolysis and thermogenesis in brown adipose tissue; stimulation of renal Cl- transport; and increased rat heart contractility. The AC/cAMP pathway is likely recruited when plasma glucagon rises above 100 pM during periods of elevated metabolic stress and systemic glucose demand, such as in the early neonate or strenuously exercising adult. The current cAMP-centered model should therefore be reconsidered and replaced with one that places more emphasis on cAMP-independent pathways.
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Affiliation(s)
- Robert L Rodgers
- Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, RI 02935, USA.
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5
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Rodgers RL. Glucagon, cyclic AMP, and hepatic glucose mobilization: A half‐century of uncertainty. Physiol Rep 2022; 10:e15263. [PMID: 35569125 PMCID: PMC9107925 DOI: 10.14814/phy2.15263] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/16/2022] [Accepted: 03/18/2022] [Indexed: 12/14/2022] Open
Abstract
For at least 50 years, the prevailing view has been that the adenylate cyclase (AC)/cyclic AMP (cAMP)/protein kinase A pathway is the predominant signal mediating the hepatic glucose‐mobilizing actions of glucagon. A wealth of evidence, however, supports the alternative, that the operative signal most of the time is the phospholipase C (PLC)/inositol‐phosphate (IP3)/calcium/calmodulin pathway. The evidence can be summarized as follows: (1) The consensus threshold glucagon concentration for activating AC ex vivo is 100 pM, but the statistical hepatic portal plasma glucagon concentration range, measured by RIA, is between 28 and 60 pM; (2) Within that physiological concentration range, glucagon stimulates the PLC/IP3 pathway and robustly increases glucose output without affecting the AC/cAMP pathway; (3) Activation of a latent, amplified AC/cAMP pathway at concentrations below 60 pM is very unlikely; and (4) Activation of the PLC/IP3 pathway at physiological concentrations produces intracellular effects that are similar to those produced by activation of the AC/cAMP pathway at concentrations above 100 pM, including elevated intracellular calcium and altered activities and expressions of key enzymes involved in glycogenolysis, gluconeogenesis, and glycogen synthesis. Under metabolically stressful conditions, as in the early neonate or exercising adult, plasma glucagon concentrations often exceed 100 pM, recruiting the AC/cAMP pathway and enhancing the activation of PLC/IP3 pathway to boost glucose output, adaptively meeting the elevated systemic glucose demand. Whether the AC/cAMP pathway is consistently activated in starvation or diabetes is not clear. Because the importance of glucagon in the pathogenesis of diabetes is becoming increasingly evident, it is even more urgent now to resolve lingering uncertainties and definitively establish glucagon’s true mechanism of glycemia regulation in health and disease.
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Affiliation(s)
- Robert L. Rodgers
- Department of Biomedical and Pharmaceutical Sciences College of Pharmacy University of Rhode Island Kingston Rhode Island USA
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6
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Jarosinski MA, Chen YS, Varas N, Dhayalan B, Chatterjee D, Weiss MA. New Horizons: Next-Generation Insulin Analogues: Structural Principles and Clinical Goals. J Clin Endocrinol Metab 2022; 107:909-928. [PMID: 34850005 PMCID: PMC8947325 DOI: 10.1210/clinem/dgab849] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Indexed: 11/19/2022]
Abstract
Design of "first-generation" insulin analogues over the past 3 decades has provided pharmaceutical formulations with tailored pharmacokinetic (PK) and pharmacodynamic (PD) properties. Application of a molecular tool kit-integrating protein sequence, chemical modification, and formulation-has thus led to improved prandial and basal formulations for the treatment of diabetes mellitus. Although PK/PD changes were modest in relation to prior formulations of human and animal insulins, significant clinical advantages in efficacy (mean glycemia) and safety (rates of hypoglycemia) were obtained. Continuing innovation is providing further improvements to achieve ultrarapid and ultrabasal analogue formulations in an effort to reduce glycemic variability and optimize time in range. Beyond such PK/PD metrics, next-generation insulin analogues seek to exploit therapeutic mechanisms: glucose-responsive ("smart") analogues, pathway-specific ("biased") analogues, and organ-targeted analogues. Smart insulin analogues and delivery systems promise to mitigate hypoglycemic risk, a critical barrier to glycemic control, whereas biased and organ-targeted insulin analogues may better recapitulate physiologic hormonal regulation. In each therapeutic class considerations of cost and stability will affect use and global distribution. This review highlights structural principles underlying next-generation design efforts, their respective biological rationale, and potential clinical applications.
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Affiliation(s)
- Mark A Jarosinski
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yen-Shan Chen
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nicolás Varas
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Balamurugan Dhayalan
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Deepak Chatterjee
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael A Weiss
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Chemistry, Indiana University, Bloomington, Indiana, USA
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
- Correspondence: Michael A. Weiss, MD, PhD, Dept of Biochemistry and Molecular Biology, Indiana University School of Medicine, 635 Barnhill Drive, MS 4053, Indianapolis, IN 46202-3082 USA.
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7
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Ibrahim A, Neinast MD, Li K, Noji M, Kim B, Bornstein MR, Mohammed R, Wellen KE, Arany Z. Insulin-stimulated adipocytes secrete lactate to promote endothelial fatty acid uptake and transport. J Cell Sci 2022; 135:jcs258964. [PMID: 34779480 PMCID: PMC8729779 DOI: 10.1242/jcs.258964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 11/07/2021] [Indexed: 01/16/2023] Open
Abstract
Insulin stimulates adipose tissue to extract fatty acids from circulation and sequester them inside adipose cells. How fatty acids are transported across the capillary endothelial barrier, and how this process is regulated, remains unclear. We modeled the relationship of adipocytes and endothelial cells in vitro to test the role of insulin in fatty acid transport. Treatment of endothelial cells with insulin did not affect endothelial fatty acid uptake, but endothelial cells took up more fatty acids when exposed to medium conditioned by adipocytes treated with insulin. Manipulations of this conditioned medium indicated that the secreted factor is a small, hydrophilic, non-proteinaceous metabolite. Factor activity was correlated with lactate concentration, and inhibition of lactate production in adipocytes abolished the activity. Finally, lactate alone was sufficient to increase endothelial uptake of both free fatty acids and lipids liberated from chylomicrons, and to promote transendothelial transport, at physiologically relevant concentrations. Taken together, these data suggest that insulin drives adipocytes to secrete lactate, which then acts in a paracrine fashion to promote fatty acid uptake and transport across the neighboring endothelial barrier.
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Affiliation(s)
- Ayon Ibrahim
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael D. Neinast
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kristina Li
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael Noji
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Cancer Biology and Abramson Family Cancer Research Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Boa Kim
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Marc R. Bornstein
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Raffiu Mohammed
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kathryn E. Wellen
- Department of Cancer Biology and Abramson Family Cancer Research Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Zoltan Arany
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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8
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Wu M, Carballo-Jane E, Zhou H, Zafian P, Dai G, Liu M, Lao J, Kelly T, Shao D, Gorski J, Pissarnitski D, Kekec A, Chen Y, Previs SF, Scapin G, Gomez-Llorente Y, Hollingsworth SA, Yan L, Feng D, Huo P, Walford G, Erion MD, Kelley DE, Lin S, Mu J. Functionally selective signaling and broad metabolic benefits by novel insulin receptor partial agonists. Nat Commun 2022; 13:942. [PMID: 35177603 PMCID: PMC8854621 DOI: 10.1038/s41467-022-28561-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/17/2022] [Indexed: 01/09/2023] Open
Abstract
Insulin analogs have been developed to treat diabetes with focus primarily on improving the time action profile without affecting ligand-receptor interaction or functional selectivity. As a result, inherent liabilities (e.g. hypoglycemia) of injectable insulin continue to limit the true therapeutic potential of related agents. Insulin dimers were synthesized to investigate whether partial agonism of the insulin receptor (IR) tyrosine kinase is achievable, and to explore the potential for tissue-selective systemic insulin pharmacology. The insulin dimers induced distinct IR conformational changes compared to native monomeric insulin and substrate phosphorylation assays demonstrated partial agonism. Structurally distinct dimers with differences in conjugation sites and linkers were prepared to deliver desirable IR partial agonist (IRPA). Systemic infusions of a B29-B29 dimer in vivo revealed sharp differences compared to native insulin. Suppression of hepatic glucose production and lipolysis were like that attained with regular insulin, albeit with a distinctly shallower dose-response. In contrast, there was highly attenuated stimulation of glucose uptake into muscle. Mechanistic studies indicated that IRPAs exploit tissue differences in receptor density and have additional distinctions pertaining to drug clearance and distribution. The hepato-adipose selective action of IRPAs is a potentially safer approach for treatment of diabetes.
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MESH Headings
- Adipose Tissue/drug effects
- Adipose Tissue/metabolism
- Alloxan/administration & dosage
- Alloxan/toxicity
- Animals
- Blood Glucose/drug effects
- Blood Glucose/metabolism
- CHO Cells
- Cricetulus
- Diabetes Mellitus, Experimental/blood
- Diabetes Mellitus, Experimental/chemically induced
- Diabetes Mellitus, Experimental/drug therapy
- Diabetes Mellitus, Experimental/metabolism
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/chemically induced
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 1/metabolism
- HEK293 Cells
- Humans
- Hypoglycemic Agents/pharmacology
- Hypoglycemic Agents/therapeutic use
- Insulin/pharmacology
- Insulin/therapeutic use
- Lipolysis/drug effects
- Liver/drug effects
- Liver/metabolism
- Male
- Mice
- Rats
- Receptor, Insulin/agonists
- Recombinant Proteins/pharmacology
- Recombinant Proteins/therapeutic use
- Signal Transduction/drug effects
- Swine
- Swine, Miniature
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Affiliation(s)
- Margaret Wu
- Merck & Co., Inc., Kenilworth, NJ, 07033, USA
| | | | | | | | - Ge Dai
- Merck & Co., Inc., Kenilworth, NJ, 07033, USA
| | - Mindy Liu
- Merck & Co., Inc., South San Francisco, CA, 94080, USA
| | - Julie Lao
- Merck & Co., Inc., South San Francisco, CA, 94080, USA
| | - Terri Kelly
- Merck & Co., Inc., Kenilworth, NJ, 07033, USA
| | - Dan Shao
- Merck & Co., Inc., South San Francisco, CA, 94080, USA
| | | | | | - Ahmet Kekec
- Merck & Co., Inc., Kenilworth, NJ, 07033, USA
| | - Ying Chen
- Merck & Co., Inc., Kenilworth, NJ, 07033, USA
| | | | | | | | | | - Lin Yan
- Merck & Co., Inc., Kenilworth, NJ, 07033, USA
| | | | - Pei Huo
- Merck & Co., Inc., Kenilworth, NJ, 07033, USA
| | | | | | | | | | - James Mu
- Merck & Co., Inc., South San Francisco, CA, 94080, USA.
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Jarosinski MA, Dhayalan B, Chen YS, Chatterjee D, Varas N, Weiss MA. Structural principles of insulin formulation and analog design: A century of innovation. Mol Metab 2021; 52:101325. [PMID: 34428558 PMCID: PMC8513154 DOI: 10.1016/j.molmet.2021.101325] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/12/2021] [Accepted: 08/17/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The discovery of insulin in 1921 and its near-immediate clinical use initiated a century of innovation. Advances extended across a broad front, from the stabilization of animal insulin formulations to the frontiers of synthetic peptide chemistry, and in turn, from the advent of recombinant DNA manufacturing to structure-based protein analog design. In each case, a creative interplay was observed between pharmaceutical applications and then-emerging principles of protein science; indeed, translational objectives contributed to a growing molecular understanding of protein structure, aggregation and misfolding. SCOPE OF REVIEW Pioneering crystallographic analyses-beginning with Hodgkin's solving of the 2-Zn insulin hexamer-elucidated general features of protein self-assembly, including zinc coordination and the allosteric transmission of conformational change. Crystallization of insulin was exploited both as a step in manufacturing and as a means of obtaining protracted action. Forty years ago, the confluence of recombinant human insulin with techniques for site-directed mutagenesis initiated the present era of insulin analogs. Variant or modified insulins were developed that exhibit improved prandial or basal pharmacokinetic (PK) properties. Encouraged by clinical trials demonstrating the long-term importance of glycemic control, regimens based on such analogs sought to resemble daily patterns of endogenous β-cell secretion more closely, ideally with reduced risk of hypoglycemia. MAJOR CONCLUSIONS Next-generation insulin analog design seeks to explore new frontiers, including glucose-responsive insulins, organ-selective analogs and biased agonists tailored to address yet-unmet clinical needs. In the coming decade, we envision ever more powerful scientific synergies at the interface of structural biology, molecular physiology and therapeutics.
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Affiliation(s)
- Mark A Jarosinski
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, 46202, IN, USA
| | - Balamurugan Dhayalan
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, 46202, IN, USA
| | - Yen-Shan Chen
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, 46202, IN, USA
| | - Deepak Chatterjee
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, 46202, IN, USA
| | - Nicolás Varas
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, 46202, IN, USA
| | - Michael A Weiss
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, 46202, IN, USA; Department of Chemistry, Indiana University, Bloomington, 47405, IN, USA; Weldon School of Biomedical Engineering, Purdue University, West Lafayette, 47907, IN, USA.
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10
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Scherer T, Sakamoto K, Buettner C. Brain insulin signalling in metabolic homeostasis and disease. Nat Rev Endocrinol 2021; 17:468-483. [PMID: 34108679 DOI: 10.1038/s41574-021-00498-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 02/06/2023]
Abstract
Insulin signalling in the central nervous system regulates energy homeostasis by controlling metabolism in several organs and by coordinating organ crosstalk. Studies performed in rodents, non-human primates and humans over more than five decades using intracerebroventricular, direct hypothalamic or intranasal application of insulin provide evidence that brain insulin action might reduce food intake and, more importantly, regulates energy homeostasis by orchestrating nutrient partitioning. This Review discusses the metabolic pathways that are under the control of brain insulin action and explains how brain insulin resistance contributes to metabolic disease in obesity, the metabolic syndrome and type 2 diabetes mellitus.
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Affiliation(s)
- Thomas Scherer
- Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
| | - Kenichi Sakamoto
- Division of Endocrinology, Metabolism & Nutrition, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Christoph Buettner
- Division of Endocrinology, Metabolism & Nutrition, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
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11
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Kurtzhals P, Nishimura E, Haahr H, Høeg-Jensen T, Johansson E, Madsen P, Sturis J, Kjeldsen T. Commemorating insulin's centennial: engineering insulin pharmacology towards physiology. Trends Pharmacol Sci 2021; 42:620-639. [PMID: 34148677 DOI: 10.1016/j.tips.2021.05.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/13/2021] [Accepted: 05/18/2021] [Indexed: 01/14/2023]
Abstract
The life-saving discovery of insulin in Toronto in 1921 is one of the most impactful achievements in medical history, at the time being hailed as a miracle treatment for diabetes. The insulin molecule itself, however, is poorly amenable as a pharmacological intervention, and the formidable challenge of optimizing insulin therapy has been ongoing for a century. We review early academic insights into insulin structure and its relation to self-association and receptor binding, as well as recombinant biotechnology, which have all been seminal for drug design. Recent developments have focused on combining genetic and chemical engineering with pharmaceutical optimization to generate ultra-rapid and ultra-long-acting, tissue-selective, or orally delivered insulin analogs. We further discuss these developments and propose that future scientific efforts in molecular engineering include realizing the dream of glucose-responsive insulin delivery.
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Affiliation(s)
- Peter Kurtzhals
- Research and Development, Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark.
| | - Erica Nishimura
- Research and Development, Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark
| | - Hanne Haahr
- Research and Development, Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark
| | - Thomas Høeg-Jensen
- Research and Development, Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark
| | - Eva Johansson
- Research and Development, Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark
| | - Peter Madsen
- Research and Development, Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark
| | - Jeppe Sturis
- Research and Development, Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark
| | - Thomas Kjeldsen
- Research and Development, Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark
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12
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Kraft G, Coate KC, Smith M, Farmer B, Scott M, Cherrington AD, Edgerton DS. The Importance of the Mechanisms by Which Insulin Regulates Meal-Associated Liver Glucose Uptake in the Dog. Diabetes 2021; 70:1292-1302. [PMID: 33757993 PMCID: PMC8275892 DOI: 10.2337/db20-1271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/18/2021] [Indexed: 12/17/2022]
Abstract
Hepatic glucose uptake (HGU) is critical for maintaining normal postprandial glucose metabolism. Insulin is clearly a key regulator of HGU, but the physiologic mechanisms by which it acts have yet to be established. This study sought to determine the mechanisms by which insulin regulates liver glucose uptake under postprandial-like conditions (hyperinsulinemia, hyperglycemia, and a positive portal vein-to-arterial glucose gradient). Portal vein insulin infusion increased hepatic insulin levels fivefold in healthy dogs. In one group (n = 7), the physiologic response was allowed to fully occur, while in another (n = 7), insulin's indirect hepatic effects, occurring secondary to its actions on adipose tissue, pancreas, and brain, were blocked. This was accomplished by infusing triglyceride (intravenous), glucagon (portal vein), and inhibitors of brain insulin action (intracerebroventricular) to prevent decreases in plasma free fatty acids or glucagon, while blocking increased hypothalamic insulin signaling for 4 h. In contrast to the indirect hepatic effects of insulin, which were previously shown capable of independently generating a half-maximal stimulation of HGU, direct hepatic insulin action was by itself able to fully stimulate HGU. This suggests that under hyperinsulinemic/hyperglycemic conditions insulin's indirect effects are redundant to direct engagement of hepatocyte insulin receptors.
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Affiliation(s)
- Guillaume Kraft
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Katie C Coate
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Marta Smith
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Ben Farmer
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Melanie Scott
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Alan D Cherrington
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Dale S Edgerton
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
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13
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Lewis GF, Carpentier AC, Pereira S, Hahn M, Giacca A. Direct and indirect control of hepatic glucose production by insulin. Cell Metab 2021; 33:709-720. [PMID: 33765416 DOI: 10.1016/j.cmet.2021.03.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/23/2021] [Accepted: 03/05/2021] [Indexed: 01/08/2023]
Abstract
There is general agreement that the acute suppression of hepatic glucose production by insulin is mediated by both a direct and an indirect effect on the liver. There is, however, no consensus regarding the relative magnitude of these effects under physiological conditions. Extensive research over the past three decades in humans and animal models has provided discordant results between these two modes of insulin action. Here, we review the field to make the case that physiologically direct hepatic insulin action dominates acute suppression of glucose production, but that there is also a delayed, second order regulation of this process via extrahepatic effects. We further provide our views regarding the timing, dominance, and physiological relevance of these effects and discuss novel concepts regarding insulin regulation of adipose tissue fatty acid metabolism and central nervous system (CNS) signaling to the liver, as regulators of insulin's extrahepatic effects on glucose production.
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Affiliation(s)
- Gary F Lewis
- Departments of Medicine and Physiology, University of Toronto, Toronto, ON, Canada; Banting & Best Diabetes Centre, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
| | - Andre C Carpentier
- Division of Endocrinology, Department of Medicine, Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Sandra Pereira
- Centre for Addiction and Mental Health and Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Margaret Hahn
- Banting & Best Diabetes Centre, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Adria Giacca
- Departments of Medicine and Physiology, University of Toronto, Toronto, ON, Canada; Banting & Best Diabetes Centre, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
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14
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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.
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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
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15
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Song Y, Yang J, Jing W, Wang Q, Liu Y, Cheng X, Ye F, Tian J, Wei F, Ma S. Systemic elucidation on the potential bioactive compounds and hypoglycemic mechanism of Polygonum multiflorum based on network pharmacology. Chin Med 2020; 15:121. [PMID: 33292335 PMCID: PMC7672844 DOI: 10.1186/s13020-020-00401-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/06/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Diabetes is a complex metabolic disease characterized by hyperglycemia, plaguing the whole world. However, the action mode of multi-component and multi-target for traditional Chinese medicine (TCM) could be a promising treatment of diabetes mellitus. According to the previous research, the TCM of Polygonum multiflorum (PM) showed noteworthy hypoglycemic effect. Up to now, its hypoglycemic active ingredients and mechanism of action are not yet clear. In this study, network pharmacology was employed to elucidate the potential bioactive compounds and hypoglycemic mechanism of PM. METHODS First, the compounds with good pharmacokinetic properties were screened from the self-established library of PM, and the targets of these compounds were predicted and collected through database. Relevant targets of diabetes were summarized by searching database. The intersection targets of compound-targets and disease-targets were obtained soon. Secondly, the interaction net between the compounds and the filtered targets was established. These key targets were enriched and analyzed by protein-protein interactions (PPI) analysis, molecular docking verification. Thirdly, the key genes were used to find the biologic pathway and explain the therapeutic mechanism by genome ontology (GO) and kyoto encyclopedia of genes and genomes (KEGG) analysis. Lastly, the part of potential bioactive compounds were under enzyme activity inhibition tests. RESULTS In this study, 29 hypoglycemic components and 63 hypoglycemic targets of PM were filtrated based on online network database. Then the component-target interaction network was constructed and five key components resveratrol, apigenin, kaempferol, quercetin and luteolin were further obtained. Sequential studies turned out, AKT1, EGFR, ESR1, PTGS2, MMP9, MAPK14, and KDR were the common key targets. Docking studies indicated that the bioactive compounds could stably bind the pockets of target proteins. There were 38 metabolic pathways, including regulation of lipolysis in adipocytes, prolactin signaling pathway, TNF signaling pathway, VEGF signaling pathway, FoxO signaling pathway, estrogen signaling pathway, linoleic acid metabolism, Rap1 signaling pathway, arachidonic acid metabolism, and osteoclast differentiation closely connected with the hypoglycemic mechanism of PM. And the enzyme activity inhibition tests showed the bioactive ingredients have great hypoglycemic activity. CONCLUSION In summary, the study used systems pharmacology to elucidate the main hypoglycemic components and mechanism of PM. The work provided a scientific basis for the further hypoglycemic effect research of PM and its monomer components, but also provided a reference for the secondary development of PM.
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Affiliation(s)
- Yunfei Song
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, 102488, China
- Institute for Control of Chinese Traditional Medicine and Ethnic Medicine, National Institutes for Food and Drug Control, Beijing, 100050, China
| | - Jianbo Yang
- Institute for Control of Chinese Traditional Medicine and Ethnic Medicine, National Institutes for Food and Drug Control, Beijing, 100050, China
| | - Wenguang Jing
- Institute for Control of Chinese Traditional Medicine and Ethnic Medicine, National Institutes for Food and Drug Control, Beijing, 100050, China
| | - Qi Wang
- Institute for Control of Chinese Traditional Medicine and Ethnic Medicine, National Institutes for Food and Drug Control, Beijing, 100050, China
| | - Yue Liu
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, 102488, China
| | - Xianlong Cheng
- Institute for Control of Chinese Traditional Medicine and Ethnic Medicine, National Institutes for Food and Drug Control, Beijing, 100050, China
| | - Fei Ye
- Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100050, China
| | - Jinying Tian
- Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100050, China
| | - Feng Wei
- Institute for Control of Chinese Traditional Medicine and Ethnic Medicine, National Institutes for Food and Drug Control, Beijing, 100050, China.
| | - Shuangcheng Ma
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, 102488, China.
- Institute for Control of Chinese Traditional Medicine and Ethnic Medicine, National Institutes for Food and Drug Control, Beijing, 100050, China.
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16
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Gregory JM, Cherrington AD, Moore DJ. The Peripheral Peril: Injected Insulin Induces Insulin Insensitivity in Type 1 Diabetes. Diabetes 2020; 69:837-847. [PMID: 32312900 PMCID: PMC7171956 DOI: 10.2337/dbi19-0026] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/12/2020] [Indexed: 12/13/2022]
Abstract
Insulin resistance is an underappreciated facet of type 1 diabetes that occurs with remarkable consistency and considerable magnitude. Although therapeutic innovations are continuing to normalize dysglycemia, a sizable body of data suggests a second metabolic abnormality-iatrogenic hyperinsulinemia-principally drives insulin resistance and its consequences in this population and has not been addressed. We review this evidence to show that injecting insulin into the peripheral circulation bypasses first-pass hepatic insulin clearance, which leads to the unintended metabolic consequence of whole-body insulin resistance. We propose restructuring insulin therapy to restore the physiological insulin balance between the hepatic portal and peripheral circulations and thereby avoid the complications of life-long insulin resistance. As technology rapidly advances and our ability to ensure euglycemia improves, iatrogenic insulin resistance will become the final barrier to overcome to restore normal physiology, health, and life in type 1 diabetes.
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Affiliation(s)
- Justin M Gregory
- Ian Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN
| | - Alan D Cherrington
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN
| | - Daniel J Moore
- Ian Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN
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17
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Moore MC, Coate KC, Scott M, Kraft G, Vath JE, Hughes TE, Farmer B, Cherrington AD. MetAP2 inhibitor treatment of high-fat and -fructose-fed dogs: impact on the response to oral glucose ingestion and a hyperinsulinemic hyperglycemic clamp. Am J Physiol Endocrinol Metab 2020; 318:E514-E524. [PMID: 31990576 PMCID: PMC7191409 DOI: 10.1152/ajpendo.00451.2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We examined the methionine aminopeptidase 2 inhibitor fumagillin in dogs consuming a high-fat and -fructose diet (HFFD). In pilot studies (3 dogs that had consumed HFFD for 3 yr), 8 wk of daily treatment with fumagillin reduced food intake 29%, weight 6%, and the glycemic excursion during an oral glucose tolerance test (OGTT) 44%. A second group of dogs consumed the HFFD for 17 wk: pretreatment (weeks 0-4), treatment with fumagillin (FUM; n = 6), or no drug (Control, n = 8) (weeks 4-12), washout period (weeks 12-16), and fumagillin or no drug for 1 wk (week 17). OGTTs were performed at 0, 4, 11, and 16 wk. A hyperinsulinemic hyperglycemic clamp was performed in week 12; 4 chow-fed dogs underwent identical clamps. Kilocalories per day intake during the treatment period was 2,067 ± 50 (Control) versus 1,824 ± 202 (FUM). Body weights (kg) increased 1.9 ± 0.3 vs. 2.7 ± 0.8 (0-4 wk) and 1.2 ± 0.2 vs. -0.02 ± 0.9 (4-12 wk) in Control versus fumagillin. The OGTT glycemic response was 30% greater in Control versus fumagillin at 11 wk. Net hepatic glucose uptake (NHGU; mg·kg-1·min-1) in the Chow, Control, and fumagillin dogs was ~1.5 ± 0.6, -0.1 ± 0.1, and 0.3 ± 0.4 (with no portal glucose infusion) and 3.1 ± 0.6, 0.5 ± 0.3, and 1.5 ± 0.5 (portal glucose infusion at 4 mg·kg-1·min-1), respectively. Fumagillin improved glucose tolerance and NHGU in HFFD dogs, suggesting methionine aminopeptidase 2 (MetAP2) inhibitors have the potential for improving glycemic control in prediabetes and diabetes.
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Affiliation(s)
- Mary Courtney Moore
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Katie C Coate
- Diabetes Research and Training Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melanie Scott
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Guillaume Kraft
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Thomas E Hughes
- Zafgen, Incorporated, Boston, Massachusetts
- Navitor Pharmaceuticals, Incorporated, Cambridge, Massachusetts
| | - Ben Farmer
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alan D Cherrington
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
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18
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Gregory JM, Kraft G, Scott MF, Neal DW, Farmer B, Smith MS, Hastings JR, Madsen P, Kjeldsen TB, Hostrup S, Brand CL, Fledelius C, Nishimura E, Cherrington AD. Peripherally delivered hepatopreferential insulin analog insulin-406 mimics the hypoglycaemia-sparing effect of portal vein human insulin infusion in dogs. Diabetes Obes Metab 2019; 21:2294-2304. [PMID: 31183936 PMCID: PMC8132115 DOI: 10.1111/dom.13808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/26/2019] [Accepted: 06/05/2019] [Indexed: 12/16/2022]
Abstract
AIMS We previously quantified the hypoglycaemia-sparing effect of portal vs peripheral human insulin delivery. The current investigation aimed to determine whether a bioequivalent peripheral vein infusion of a hepatopreferential insulin analog, insulin-406, could similarly protect against hypoglycaemia. MATERIALS AND METHODS Dogs received human insulin infusions into either the hepatic portal vein (PoHI, n = 7) or a peripheral vein (PeHI, n = 7) for 180 minutes at four-fold the basal secretion rate (6.6 pmol/kg/min) in a previous study. Insulin-406 (Pe406, n = 7) was peripherally infused at 6.0 pmol/kg/min, a rate determined to decrease plasma glucose by the same amount as with PoHI infusion during the first 60 minutes. Glucagon was fixed at basal concentrations, mimicking the diminished α-cell response seen in type 1 diabetes. RESULTS Glucose dropped quickly with PeHI infusion, reaching 41 ± 3 mg/dL at 60 minutes, but more slowly with PoHI and Pe406 infusion (67 ± 2 and 72 ± 4 mg/dL, respectively; P < 0.01 vs PeHI for both). The hypoglycaemic nadir (c. 40 mg/dL) occurred at 60 minutes with PeHI infusion vs 120 minutes with PoHI and Pe406 infusion. ΔAUCepinephrine during the 180-minute insulin infusion period was two-fold higher with PeHI infusion compared with PoHI and Pe406 infusion. Glucose production (mg/kg/min) was least suppressed with PeHI infusion (Δ = 0.79 ± 0.33) and equally suppressed with PoHI and Pe406 infusion (Δ = 1.16 ± 0.21 and 1.18 ± 0.17, respectively; P = NS). Peak glucose utilization (mg/kg/min) was highest with PeHI infusion (4.94 ± 0.17) and less with PoHI and Pe406 infusion (3.58 ± 0.58 and 3.26 ± 0.08, respectively; P < 0.05 vs Pe for both). CONCLUSIONS Peripheral infusion of hepatopreferential insulin can achieve a metabolic profile that closely mimics portal insulin delivery, which reduces the risk of hypoglycaemia compared with peripheral insulin infusion.
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Affiliation(s)
- Justin M. Gregory
- Ian Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Guillaume Kraft
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Melanie F. Scott
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Doss W. Neal
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ben Farmer
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Marta S. Smith
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jon R. Hastings
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Peter Madsen
- Global Research Technologies, Novo Nordisk A/S, Maaleov, Denmark
| | | | - Susanne Hostrup
- Global Research Technologies, Novo Nordisk A/S, Maaleov, Denmark
| | | | | | | | - Alan D. Cherrington
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
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19
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Edgerton DS, Scott M, Farmer B, Williams PE, Madsen P, Kjeldsen T, Brand CL, Fledelius C, Nishimura E, Cherrington AD. Targeting insulin to the liver corrects defects in glucose metabolism caused by peripheral insulin delivery. JCI Insight 2019; 5:126974. [PMID: 30830873 DOI: 10.1172/jci.insight.126974] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Peripheral hyperinsulinemia resulting from subcutaneous insulin injection is associated with metabolic defects which include abnormal glucose metabolism. The first aim of this study was to quantify the impairments in liver and muscle glucose metabolism that occur when insulin is delivered via a peripheral vein compared to when it is given through its endogenous secretory route (the hepatic portal vein) in overnight fasted conscious dogs. The second aim was to determine if peripheral delivery of a hepato-preferential insulin analog could restore the physiologic response to insulin that occurs under meal feeding conditions. This study is the first to show that hepatic glucose uptake correlates with insulin's direct effects on the liver under hyperinsulinemic-hyperglycemic conditions. In addition, glucose uptake was equally divided between the liver and muscle when insulin was infused into the portal vein, but when it was delivered into a peripheral vein the percentage of glucose taken up by muscle was 4-times greater than that going to the liver, with liver glucose uptake being less than half of normal. These defects could not be corrected by adjusting the dose of peripheral insulin. On the other hand, hepatic and non-hepatic glucose metabolism could be fully normalized by a hepato-preferential insulin analog.
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Affiliation(s)
- Dale S Edgerton
- Vanderbilt University School of Medicine, Department of Molecular Physiology and Biophysics, Nashville, Tennessee, USA
| | - Melanie Scott
- Vanderbilt University School of Medicine, Department of Molecular Physiology and Biophysics, Nashville, Tennessee, USA
| | - Ben Farmer
- Vanderbilt University School of Medicine, Department of Molecular Physiology and Biophysics, Nashville, Tennessee, USA
| | - Phillip E Williams
- Vanderbilt University Medical Center, Division of Surgical Research, Nashville, Tennessee, USA
| | - Peter Madsen
- Research and Development, Novo Nordisk A/S, Novo Nordisk Park, Maaleov, Denmark
| | - Thomas Kjeldsen
- Research and Development, Novo Nordisk A/S, Novo Nordisk Park, Maaleov, Denmark
| | - Christian L Brand
- Research and Development, Novo Nordisk A/S, Novo Nordisk Park, Maaleov, Denmark
| | - Christian Fledelius
- Research and Development, Novo Nordisk A/S, Novo Nordisk Park, Maaleov, Denmark
| | - Erica Nishimura
- Research and Development, Novo Nordisk A/S, Novo Nordisk Park, Maaleov, Denmark
| | - Alan D Cherrington
- Vanderbilt University School of Medicine, Department of Molecular Physiology and Biophysics, Nashville, Tennessee, USA
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20
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Akbarian M, Ghasemi Y, Uversky VN, Yousefi R. Chemical modifications of insulin: Finding a compromise between stability and pharmaceutical performance. Int J Pharm 2018; 547:450-468. [DOI: 10.1016/j.ijpharm.2018.06.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 02/07/2023]
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21
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Moore MC, Smith MS, Farmer B, Coate KC, Kraft G, Shiota M, Williams PE, Cherrington AD. Morning Hyperinsulinemia Primes the Liver for Glucose Uptake and Glycogen Storage Later in the Day. Diabetes 2018; 67:1237-1245. [PMID: 29666062 PMCID: PMC6014555 DOI: 10.2337/db17-0979] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 04/10/2018] [Indexed: 12/13/2022]
Abstract
We observed that a 4-h morning (AM) duodenal infusion of glucose versus saline doubled hepatic glucose uptake (HGU) and storage during a hyperinsulinemic-hyperglycemic (HIHG) clamp that afternoon (PM). To separate the effects of AM hyperglycemia versus AM hyperinsulinemia on the PM response, we used hepatic balance and tracer ([3-3H]glucose) techniques in conscious dogs. From 0 to 240 min, dogs underwent a euinsulinemic-hyperglycemic (GLC; n = 7) or hyperinsulinemic-euglycemic (INS; n = 8) clamp. Tracer equilibration and basal sampling occurred from 240 to 360 min, followed by an HIHG clamp (360-600 min; four times basal insulin, two times basal glycemia) with portal glucose infusion (4 mg ⋅ kg-1 ⋅ min-1). In the HIHG clamp, HGU (5.8 ± 0.9 vs. 3.3 ± 0.3 mg ⋅ kg-1 ⋅ min-1) and net glycogen storage (6.0 ± 0.8 vs. 2.9 ± 0.5 mg ⋅ kg-1 ⋅ min-1) were approximately twofold greater in INS than in GLC. PM hepatic glycogen content (1.9 ± 0.2 vs. 1.3 ± 0.2 g/kg body weight) and glycogen synthase (GS) activity were also greater in INS versus GLC, whereas glycogen phosphorylase (GP) activity was reduced. Thus AM hyperinsulinemia, but not AM hyperglycemia, enhanced the HGU response to a PM HIHG clamp by augmenting GS and reducing GP activity. AM hyperinsulinemia can prime the liver to extract and store glucose more effectively during subsequent same-day meals, potentially providing a tool to improve glucose control.
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Affiliation(s)
- Mary Courtney Moore
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
- Diabetes Research and Training Center, Vanderbilt University School of Medicine, Nashville, TN
| | - Marta S Smith
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Ben Farmer
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
- Diabetes Research and Training Center, Vanderbilt University School of Medicine, Nashville, TN
| | - Katie C Coate
- Department of Nutrition and Dietetics, Samford University, Birmingham, AL
| | - Guillaume Kraft
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Masakazu Shiota
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
- Diabetes Research and Training Center, Vanderbilt University School of Medicine, Nashville, TN
| | - Phillip E Williams
- Diabetes Research and Training Center, Vanderbilt University School of Medicine, Nashville, TN
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Alan D Cherrington
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
- Diabetes Research and Training Center, Vanderbilt University School of Medicine, Nashville, TN
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22
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Moore MC, Kelley DE, Camacho RC, Zafian P, Ye T, Lin S, Kaarsholm NC, Nargund R, Kelly TM, Van Heek M, Previs SF, Moyes C, Smith MS, Farmer B, Williams P, Cherrington AD. Superior Glycemic Control With a Glucose-Responsive Insulin Analog: Hepatic and Nonhepatic Impacts. Diabetes 2018; 67:1173-1181. [PMID: 29540491 PMCID: PMC5961410 DOI: 10.2337/db18-0099] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/03/2018] [Indexed: 12/18/2022]
Abstract
We evaluated the hepatic and nonhepatic responses to glucose-responsive insulin (GRI). Eight dogs received GRI or regular human insulin (HI) in random order. A primed, continuous intravenous infusion of [3-3H]glucose began at -120 min. Basal sampling (-30 to 0 min) was followed by two study periods (150 min each), clamp period 1 (P1) and clamp period 2 (P2). At 0 min, somatostatin and GRI (36 ± 3 pmol/kg/min) or HI (1.8 pmol/kg/min) were infused intravenously; basal glucagon was replaced intraportally. Glucose was infused intravenously to clamp plasma glucose at 80 mg/dL (P1) and 240 mg/dL (P2). Whole-body insulin clearance and insulin concentrations were not different in P1 versus P2 with HI, but whole-body insulin clearance was 23% higher and arterial insulin 16% lower in P1 versus P2 with GRI. Net hepatic glucose output was similar between treatments in P1. In P2, both treatments induced net hepatic glucose uptake (HGU) (HI mean ± SEM 2.1 ± 0.5 vs. 3.3 ± 0.4 GRI mg/kg/min). Nonhepatic glucose uptake in P1 and P2, respectively, differed between treatments (2.6 ± 0.3 and 7.4 ± 0.6 mg/kg/min with HI vs. 2.0 ± 0.2 and 8.1 ± 0.8 mg/kg/min with GRI). Thus, glycemia affected GRI but not HI clearance, with resultant differential effects on HGU and nonHGU. GRI holds promise for decreasing hypoglycemia risk while enhancing glucose uptake under hyperglycemic conditions.
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MESH Headings
- Absorption, Physiological/drug effects
- Animals
- Blood Glucose/analysis
- Blood Glucose/metabolism
- Dogs
- Dose-Response Relationship, Drug
- Drug Evaluation, Preclinical
- Drugs, Investigational/administration & dosage
- Drugs, Investigational/adverse effects
- Drugs, Investigational/pharmacokinetics
- Energy Metabolism/drug effects
- Gluconeogenesis/drug effects
- Glucose Clamp Technique
- Glycosylation
- Humans
- Hyperglycemia/metabolism
- Hyperglycemia/prevention & control
- Hypoglycemia/chemically induced
- Hypoglycemia/metabolism
- Hypoglycemia/prevention & control
- Hypoglycemic Agents/administration & dosage
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/blood
- Hypoglycemic Agents/pharmacokinetics
- Infusions, Intravenous
- Insulin, Regular, Human/administration & dosage
- Insulin, Regular, Human/adverse effects
- Insulin, Regular, Human/analogs & derivatives
- Insulin, Regular, Human/pharmacokinetics
- Liver/drug effects
- Liver/metabolism
- Male
- Metabolic Clearance Rate
- Random Allocation
- Somatostatin/administration & dosage
- Somatostatin/adverse effects
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Affiliation(s)
- Mary Courtney Moore
- Department of Molecular Biology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
- Diabetes Research and Training Center, Vanderbilt University School of Medicine, Nashville, TN
| | - David E Kelley
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Raul C Camacho
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Peter Zafian
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Tian Ye
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Songnian Lin
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | | | - Ravi Nargund
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Terri M Kelly
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | | | | | | | - Marta S Smith
- Department of Molecular Biology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Ben Farmer
- Department of Molecular Biology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
- Diabetes Research and Training Center, Vanderbilt University School of Medicine, Nashville, TN
| | - Phil Williams
- Diabetes Research and Training Center, Vanderbilt University School of Medicine, Nashville, TN
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Alan D Cherrington
- Department of Molecular Biology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
- Diabetes Research and Training Center, Vanderbilt University School of Medicine, Nashville, TN
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23
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Porksen NK, Linnebjerg H, Lam ECQ, Garhyan P, Pachori A, Pratley RE, Smith SR. Basal insulin peglispro increases lipid oxidation, metabolic flexibility, thermogenesis and ketone bodies compared to insulin glargine in subjects with type 1 diabetes mellitus. Diabetes Obes Metab 2018; 20:1193-1201. [PMID: 29316143 DOI: 10.1111/dom.13215] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 12/19/2017] [Accepted: 12/31/2017] [Indexed: 01/08/2023]
Abstract
AIMS When treated with basal insulin peglispro (BIL), patients with type 1 diabetes mellitus (T1DM) exhibit weight loss and lower prandial insulin requirements versus insulin glargine (GL), while total insulin requirements remain similar. One possible explanation is enhanced lipid oxidation and improved ability to switch between glucose and lipid metabolism with BIL. This study compared the effects of BIL and GL on glucose and lipid metabolism in subjects with T1DM. MATERIALS AND METHODS Fifteen subjects with T1DM were enrolled into this open-label, randomised, crossover study, and received once-daily stable, individualised, subcutaneous doses of BIL and GL for 4 weeks each. Respiratory quotient (RQ) was measured using whole-room calorimetry, and energy expenditure (EE) and concentrations of ketone bodies (3-hydroxybutyrate) and acylcarnitines were assessed. RESULTS Mean sleep RQ was lower during the BIL (0.822) than the GL (0.846) treatment period, indicating greater lipid metabolism during the post-absorptive period with BIL. Increases in carbohydrate oxidation following breakfast were greater during BIL than GL treatment (mean change in RQ following breakfast 0.111 for BIL, 0.063 for GL). Furthermore, BIL treatment increased total daily EE versus GL (2215.9 kcal/d for BIL, 2135.5 kcal/d for GL). Concentrations of ketone bodies and acylcarnitines appeared to be higher following BIL than GL treatment. CONCLUSIONS BIL increased sleeping fat oxidation, EE, ketone bodies, acylcarnitines and post-prandial glucose metabolism when switching from conventional insulin, thus, restoring metabolic flexibility and increasing thermogenesis. These changes may explain the previously observed weight loss with BIL versus GL.
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Affiliation(s)
| | | | - Eric Chen Quin Lam
- Formerly of Lilly-NUS Centre for Clinical Pharmacology, Singapore, Singapore
| | | | - Alok Pachori
- Translational Research Institute for Metabolism and Diabetes, Orlando, Florida
| | - Richard E Pratley
- Translational Research Institute for Metabolism and Diabetes, Orlando, Florida
| | - Steven R Smith
- Translational Research Institute for Metabolism and Diabetes, Orlando, Florida
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24
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Johansen RF, Søndergaard E, Linnebjerg H, Garhyan P, Lam ECQ, Porksen N, Jacober SJ, Nielsen S. Attenuated suppression of lipolysis explains the increases in triglyceride secretion and concentration associated with basal insulin peglispro relative to insulin glargine treatment in patients with type 1 diabetes. Diabetes Obes Metab 2018; 20:419-426. [PMID: 28817248 DOI: 10.1111/dom.13087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/04/2017] [Accepted: 08/12/2017] [Indexed: 01/11/2023]
Abstract
AIMS To test the hypothesis that, as well as lowering weight and increasing plasma triglyceride (TG) levels and hepatic fat compared with insulin glargine (GL) in patients with type 1 diabetes, the attenuated peripheral effects of basal insulin peglispro (BIL) may include increased free fatty acid flux to the liver, causing increased very-low-density lipoprotein (VLDL)-TG secretion and lipid oxidation, and decreased TG adipose tissue deposition. METHODS In this open-label, randomized, 2-period crossover study, 14 patients with type 1 diabetes received once-daily, individualized, stable BIL or GL doses for 3 weeks. Palmitate flux was assessed using [9,10-3 H]palmitate infusion. VLDL-TG secretion, clearance and oxidation rate were assessed using primed-constant infusion of ex vivo labelled [1-14 C]VLDL-TG, while VLDL-TG storage rate was assessed using [9,10-3 H]VLDL-TG bolus injection. RESULTS The VLDL-TG concentration and secretion rate, and palmitate flux were statistically significantly higher during BIL than during GL treatment (58%, 51% and 35%, respectively). The ratios of least squares (LS) geometric means for VLDL-TG clearance and oxidation were 0.92 (95% confidence interval [CI] 0.72, 1.17) and 1.31 (95% CI 0.91, 1.90), respectively. The difference in LS means for VLDL-TG storage rate was -0.36 (95% CI -0.83, 0.12). CONCLUSIONS BIL-treated patients had higher effective lipolysis, VLDL-TG secretion and VLDL-TG concentration compared with GL-treated patients, explaining the increased plasma TG concentrations reported previously. Data support attenuated effects of BIL on lipolysis, in addition to the recently described hepato-preferential glucodynamic effects.
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Affiliation(s)
- Rakel F Johansen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Esben Søndergaard
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Eric C Q Lam
- Formerly of Eli Lilly and Company, Singapore, Singapore
| | - Niels Porksen
- Formerly of Eli Lilly and Company, Indianapolis, Indiana
| | | | - Søren Nielsen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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25
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Qu Y, Luo J, Garhyan P, Antalis CJ, Chang AM, Jacober SJ. Dose Unit Establishment for a New Basal Insulin Using Joint Modeling of Insulin Dose and Glycemic Response. J Diabetes Sci Technol 2018; 12:155-162. [PMID: 28466661 PMCID: PMC5761965 DOI: 10.1177/1932296817707542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For new insulin analogs with properties that vary from human insulin, defining activity in units of human insulin based on glycemic lowering efficacy may be challenging. Here we present a new method that can be used to quantify a unit dose of an experimental insulin when the traditional euglycemic clamp method is not adequate. METHODS Joint modeling of insulin dose and the glycemic outcome variable hemoglobin A1c (HbA1c), where both were response variables, was used to evaluate insulin unit potency for basal insulin peglispro (BIL). The data were from the Phase 3 program for BIL, which included greater than 5500 patients with type 1 or type 2 diabetes who were treated for 26 or 52 weeks with BIL or a comparator insulin. Both basal-bolus and basal insulin only studies were included, and some type 2 diabetes patients were insulin-naïve. RESULTS The analysis showed that 1 unit of BIL, composed of 9 nmol of active ingredient, had similar or slightly greater potency compared to 1 unit insulin glargine or NPH insulin for all populations. CONCLUSIONS Despite some limitations, the joint modeling of HbA1c and insulin dose provides a reasonable approach to estimate the relative potency of a new basal insulin versus an established basal insulin.
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Affiliation(s)
- Yongming Qu
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | | | | | | | - Scott J. Jacober
- Eli Lilly and Company, Indianapolis, IN, USA
- Scott J. Jacober, DO, Eli Lilly and Company, Lilly Corporate Center, Drop Code 2232, Indianapolis, IN 46285, USA.
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26
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Wronkowitz N, Hartmann T, Görgens SW, Dietze-Schroeder D, Indrakusuma I, Choi IY, Park SH, Lee YM, Kwon SC, Kang Y, Hompesch M, Eckel J. LAPS Insulin115: A novel ultra-long-acting basal insulin with a unique action profile. Diabetes Obes Metab 2017; 19:1722-1731. [PMID: 28497570 DOI: 10.1111/dom.13006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/04/2017] [Accepted: 05/08/2017] [Indexed: 12/25/2022]
Abstract
AIMS To conduct a comprehensive pre-clinical study of the novel ultra-long acting insulin analogue LAPS Insulin115. METHODS Pharmacokinetic/pharmacodynamic studies comparing LAPS Insulin115 with other basal insulins were conducted in genetically diabetic (db/db) mice. Insulin signalling in the major target organs was analysed using Western blot after single subcutaneous injection in wild-type male Wistar rats. Using in vitro assays we analysed transendothelial transport, insulin receptor (IR) interaction, and the mitogenic and metabolic properties of LAPS Insulin115. Furthermore, IR downregulation after long-term exposure to high concentrations of LAPS Insulin115 was analysed using an in vitro desensitization/resensitization model. RESULTS The novel Fc-conjugated insulin derivative LAPS Insulin115 showed an extensively prolonged pharmacokinetic and pharmacodynamic profile in rodents. Despite its size of 59 kDa, LAPS Insulin115 passes the vascular endothelial barrier and induces insulin signalling in all major target tissues in rats. In vitro, LAPS Insulin115 showed a very slow onset of action because of its reduced IR affinity; however, after long-term stimulation it was equipotent in respect to its metabolic potency and showed no increased mitogenic action when compared with regular insulin. Remarkably, under conditions of chronic exposure, LAPS Insulin115 does not induce irreversible desensitization of target cells, which is probably attributable to much less prominent IR downregulation. CONCLUSION Thus, LAPS Insulin115 exhibits a unique in vivo and in vitro profile and thereby represents an excellent candidate for a once-weekly insulin analogue.
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MESH Headings
- Absorption, Physiological
- Animals
- Cell Line
- Cells, Cultured
- Drugs, Investigational/chemistry
- Drugs, Investigational/metabolism
- Drugs, Investigational/pharmacology
- Drugs, Investigational/therapeutic use
- Gene Expression Regulation/drug effects
- Half-Life
- Humans
- Hypoglycemic Agents/chemistry
- Hypoglycemic Agents/metabolism
- Hypoglycemic Agents/pharmacology
- Hypoglycemic Agents/therapeutic use
- Immunoglobulin Fc Fragments/genetics
- Immunoglobulin Fc Fragments/metabolism
- Immunoglobulin Fc Fragments/pharmacology
- Immunoglobulin Fc Fragments/therapeutic use
- Insulin, Long-Acting/genetics
- Insulin, Long-Acting/metabolism
- Insulin, Long-Acting/pharmacology
- Insulin, Long-Acting/therapeutic use
- Intra-Abdominal Fat/drug effects
- Intra-Abdominal Fat/metabolism
- Male
- Mice, Mutant Strains
- Organ Specificity
- Phosphorylation/drug effects
- Protein Processing, Post-Translational/drug effects
- Rats, Wistar
- Receptor, Insulin/agonists
- Receptor, Insulin/antagonists & inhibitors
- Receptor, Insulin/genetics
- Receptor, Insulin/metabolism
- Recombinant Fusion Proteins/chemistry
- Recombinant Fusion Proteins/metabolism
- Recombinant Fusion Proteins/pharmacology
- Recombinant Fusion Proteins/therapeutic use
- Signal Transduction/drug effects
- Toxicity Tests, Chronic
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Affiliation(s)
- Nina Wronkowitz
- Paul-Langerhans-Group, German Diabetes Centre, Düsseldorf, Germany
| | | | | | | | - Ira Indrakusuma
- Paul-Langerhans-Group, German Diabetes Centre, Düsseldorf, Germany
| | | | | | - Young-Mi Lee
- Hanmi Pharmaceutical, Co., Ltd., Seoul, South Korea
| | | | | | | | - Jürgen Eckel
- Paul-Langerhans-Group, German Diabetes Centre, Düsseldorf, Germany
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27
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Pillai S, Duvvuru S, Bhatnagar P, Foster W, Farmen M, Shankar S, Harris C, Bastyr E, Hoogwerf B, Haupt A. The PNPLA3 I148M variant is associated with transaminase elevations in type 2 diabetes patients treated with basal insulin peglispro. THE PHARMACOGENOMICS JOURNAL 2017; 18:487-493. [DOI: 10.1038/tpj.2017.45] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 07/24/2017] [Accepted: 08/04/2017] [Indexed: 12/27/2022]
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28
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Sprogøe K, Mortensen E, Karpf DB, Leff JA. The rationale and design of TransCon Growth Hormone for the treatment of growth hormone deficiency. Endocr Connect 2017; 6:R171-R181. [PMID: 28947559 PMCID: PMC5655688 DOI: 10.1530/ec-17-0203] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 09/25/2017] [Indexed: 01/09/2023]
Abstract
The fundamental challenge of developing a long-acting growth hormone (LAGH) is to create a more convenient growth hormone (GH) dosing profile while retaining the excellent safety, efficacy and tolerability of daily GH. With GH receptors on virtually all cells, replacement therapy should achieve the same tissue distribution and effects of daily (and endogenous) GH while maintaining levels of GH and resulting IGF-1 within the physiologic range. To date, only two LAGHs have gained the approval of either the Food and Drug Administration (FDA) or the European Medicines Agency (EMA); both released unmodified GH, thus presumably replicating distribution and pharmacological actions of daily GH. Other technologies have been applied to create LAGHs, including modifying GH (for example, protein enlargement or albumin binding) such that the resulting analogues possess a longer half-life. Based on these approaches, nearly 20 LAGHs have reached various stages of clinical development. Although most have failed, lessons learned have guided the development of a novel LAGH. TransCon GH is a LAGH prodrug in which GH is transiently bound to an inert methoxy polyethylene glycol (mPEG) carrier. It was designed to achieve the same safety, efficacy and tolerability as daily GH but with more convenient weekly dosing. In phase 2 trials of children and adults with growth hormone deficiency (GHD), similar safety, efficacy and tolerability to daily GH was shown as well as GH and IGF-1 levels within the physiologic range. These promising results support further development of TransCon GH.
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29
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Moyers JS, Volk CB, Cao JXC, Zhang C, Ding L, Kiselyov VV, Michael MD. Internalization and localization of basal insulin peglispro in cells. Mol Cell Endocrinol 2017; 454:23-38. [PMID: 28576743 DOI: 10.1016/j.mce.2017.05.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/24/2017] [Accepted: 05/27/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND Basal insulin peglispro (BIL) is a novel, PEGylated insulin lispro that has a large hydrodynamic size compared with insulin lispro. It has a prolonged duration of action, which is related to a delay in insulin absorption and a reduction in clearance. Given the different physical properties of BIL compared with native insulin and insulin lispro, it is important to assess the cellular internalization characteristics of the molecule. METHODS AND MATERIALS Using immunofluorescent confocal imaging, we compared the cellular internalization and localization patterns of BIL, biosynthetic human insulin, and insulin lispro. We assessed the effects of BIL on internalization of the insulin receptor (IR) and studied cellular clearance of BIL. RESULTS Co-localization studies using antibodies to either insulin or PEG, and the early endosomal marker EEA1 showed that the overall internalization and subcellular localization pattern of BIL was similar to that of human insulin and insulin lispro; all were rapidly internalized and co-localized with EEA1. During ligand washout for 4 h, concomitant loss of insulin, PEG methoxy group, and PEG backbone immunostaining was observed for BIL, similar to the loss of insulin immunostaining observed for insulin lispro and human insulin. Co-localization studies using an antibody to the lysosomal marker LAMP1 did not reveal evidence of lysosomal localization for insulin lispro, human insulin, BIL, or PEG using either insulin or PEG immunostaining reagents. BIL and human insulin both induced rapid phosphorylation and internalization of human IR. CONCLUSIONS Our findings show that treatment of cells with BIL stimulates internalization and localization of IR to early endosomes. Both the insulin and PEG moieties of BIL undergo a dynamic cellular process of rapid internalization and transport to early endosomes followed by loss of cellular immunostaining in a manner similar to that of insulin lispro and human insulin. The rate of clearance for the insulin lispro portion of BIL was slower than the rate of clearance for human insulin. In contrast, the PEG moiety of BIL can recycle out of cells.
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Affiliation(s)
- Julie S Moyers
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA.
| | - Catherine B Volk
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Julia X C Cao
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Chen Zhang
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Liyun Ding
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | | | - M Dodson Michael
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
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30
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Tiffner K, Boulgaropoulos B, Höfferer C, Birngruber T, Porksen N, Linnebjerg H, Garhyan P, Lam ECQ, Knadler MP, Pieber TR, Sinner F. Quantification of Basal Insulin Peglispro and Human Insulin in Adipose Tissue Interstitial Fluid by Open-Flow Microperfusion. Diabetes Technol Ther 2017; 19:305-314. [PMID: 28328234 DOI: 10.1089/dia.2016.0384] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Restoration of the physiologic hepatic-to-peripheral insulin gradient may be achieved by either portal vein administration or altering insulin structure to increase hepatic specificity or restrict peripheral access. Basal insulin peglispro (BIL) is a novel, PEGylated basal insulin with a flat pharmacokinetic and glucodynamic profile and altered hepatic-to-peripheral action gradient. We hypothesized reduced BIL exposure in peripheral tissues explains the latter, and in this study assessed the adipose tissue interstitial fluid (ISF) concentrations of BIL compared with human insulin (HI). METHODS A euglycemic glucose clamp was performed in patients with type 1 diabetes during continuous intravenous (IV) infusion of BIL or HI, while the adipose ISF insulin concentrations were determined using open-flow microperfusion (OFM). The ratio of adipose ISF-to-serum concentrations and the absolute steady-state adipose ISF concentrations were assessed using a dynamic no-net-flux technique with subsequent regression analysis. RESULTS Steady-state BIL concentrations in adipose tissue ISF were achieved by ∼16 h after IV infusion. Median time to reach steady-state glucose infusion rate across doses ranged between 8 and 22 h. The average serum concentrations (coefficient of variation %) of BIL and HI were 11,200 pmol/L (23%) and 425 pmol/L (15%), respectively. The ISF-to-serum concentration ratios were 10.2% for BIL and 22.9% for HI. CONCLUSIONS This study indicates feasibility of OFM to measure BIL in ISF. The observed low ISF-to-serum concentration ratio of BIL is consistent with its previously demonstrated reduced peripheral action.
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MESH Headings
- Adult
- Body Mass Index
- Cross-Over Studies
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 1/metabolism
- Dose-Response Relationship, Drug
- Extracellular Fluid/metabolism
- Feasibility Studies
- Female
- Glucose Clamp Technique
- Humans
- Hypoglycemic Agents/administration & dosage
- Hypoglycemic Agents/metabolism
- Hypoglycemic Agents/pharmacokinetics
- Hypoglycemic Agents/therapeutic use
- Infusions, Intravenous
- Insulin Infusion Systems
- Insulin Lispro/administration & dosage
- Insulin Lispro/analogs & derivatives
- Insulin Lispro/metabolism
- Insulin Lispro/pharmacokinetics
- Insulin Lispro/therapeutic use
- Insulin, Regular, Human/administration & dosage
- Insulin, Regular, Human/metabolism
- Insulin, Regular, Human/pharmacokinetics
- Insulin, Regular, Human/therapeutic use
- Male
- Middle Aged
- Monitoring, Ambulatory
- Overweight/complications
- Perfusion
- Polyethylene Glycols/administration & dosage
- Polyethylene Glycols/metabolism
- Polyethylene Glycols/pharmacokinetics
- Polyethylene Glycols/therapeutic use
- Subcutaneous Fat, Abdominal/metabolism
- Tissue Distribution
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Affiliation(s)
- Katrin Tiffner
- 1 HEALTH-Institute for Biomedicine and Health Sciences , Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
| | - Beate Boulgaropoulos
- 1 HEALTH-Institute for Biomedicine and Health Sciences , Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
- 2 Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz , Graz, Austria
| | - Christian Höfferer
- 1 HEALTH-Institute for Biomedicine and Health Sciences , Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
| | - Thomas Birngruber
- 1 HEALTH-Institute for Biomedicine and Health Sciences , Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
| | | | | | | | | | | | - Thomas R Pieber
- 1 HEALTH-Institute for Biomedicine and Health Sciences , Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
- 2 Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz , Graz, Austria
| | - Frank Sinner
- 1 HEALTH-Institute for Biomedicine and Health Sciences , Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
- 2 Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz , Graz, Austria
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31
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Muñoz-Garach A, Molina-Vega M, Tinahones FJ. How Can a Good Idea Fail? Basal Insulin Peglispro [LY2605541] for the Treatment of Type 2 Diabetes. Diabetes Ther 2017; 8:9-22. [PMID: 27896568 PMCID: PMC5306113 DOI: 10.1007/s13300-016-0214-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Lack of control in diabetic patients has stimulated the development of new insulin analogues. One of these was basal insulin peglispro (BIL) or LY2605541; it had a large hydrodynamic size, flat pharmacokinetic profile, half life of 2-3 days and acted preferably in the liver. METHODS We reviewed the recent literature examining the pharmacokinetics, pharmacodynamics, efficacy and safety of BIL treatment in type 2 diabetes patients. RESULTS The pharmacodynamic and pharmacokinetic outline of BIL seemed to have an advantage over neutral protamine Hagedorn and glargine insulins. Recently, phase 3 studies suggested BIL was superior to glargine in reducing glucose levels in type 1 and type 2 diabetes patients in addition to causing less weight gain. It showed a different hypoglycaemia rate profile depending on the study population, with less nocturnal hypoglycaemia compared to glargine. Unfortunately, it caused higher transaminase and triglyceride levels, which led the company to discontinue development. The decision came after it had been analysed by the regulatory authorities and other external experts concerning the worse liver profile data from the IMAGINE trials. CONCLUSIONS BIL was an adequate basal insulin analogue with interesting specific properties. Unfortunately the disadvantages as shown in the lipid values and liver function tests led to its failure.
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Affiliation(s)
- Araceli Muñoz-Garach
- Department of Endocrinology and Nutrition, Virgen de la Victoria Universitary Hospital, Malaga, Spain
- Department of Endocrinology and Nutrition, IBIMA foundation, Malaga, Spain
| | - María Molina-Vega
- Department of Endocrinology and Nutrition, Virgen de la Victoria Universitary Hospital, Malaga, Spain
- Department of Endocrinology and Nutrition, IBIMA foundation, Malaga, Spain
| | - Francisco J Tinahones
- Department of Endocrinology and Nutrition, Virgen de la Victoria Universitary Hospital, Malaga, Spain.
- Department of Endocrinology and Nutrition, IBIMA foundation, Malaga, Spain.
- CIBER Fisiopatologia Obesidad y Nutricion (CIBEROBN), Instituto de Salud Carlos III, Malaga, Spain.
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Hirotsu T, Higashi T, Abu Hashim II, Misumi S, Wada K, Motoyama K, Arima H. Self-Assembly PEGylation Retaining Activity (SPRA) Technology via a Host-Guest Interaction Surpassing Conventional PEGylation Methods of Proteins. Mol Pharm 2017; 14:368-376. [PMID: 28032772 DOI: 10.1021/acs.molpharmaceut.6b00678] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Polyethylene glycol (PEG) modification (PEGylation) is one of the best approaches to improve the stabilities and blood half-lives of protein drugs; however, PEGylation dramatically reduces the bioactivities of protein drugs. Here, we present "self-assembly PEGylation retaining activity" (SPRA) technology via a host-guest interaction between PEGylated β-cyclodextrin (PEG-β-CyD) and adamantane-appended (Ad) proteins. PEG-β-CyD formed stable complexes with Ad-insulin and Ad-lysozyme to yield SPRA-insulin and SPRA-lysozyme, respectively. Both SPRA-proteins showed high stability against heat and trypsin digest, comparable with that of covalently PEGylated protein equivalents. Importantly, the SPRA-lysozyme possessed ca. 100% lytic activity, whereas the activity of the covalently PEGylated lysozyme was ca. 23%. Additionally, SPRA-insulin provided a prolonged and peakless blood glucose profile when compared with insulin glargine. It also showed no loss of activity. In contrast, the covalently PEGylated insulin showed a negligible hypoglycemic effect. These findings indicate that SPRA technology has potential as a generic method, surpassing conventional PEGylation methods for proteins.
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Affiliation(s)
- Tatsunori Hirotsu
- Graduate School of Pharmaceutical Sciences, Kumamoto University , 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan.,Program for Leading Graduate Schools "HIGO (Health life science: Interdisciplinary and Glocal Oriented) Program", Kumamoto University , 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Taishi Higashi
- Graduate School of Pharmaceutical Sciences, Kumamoto University , 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Irhan Ibrahim Abu Hashim
- Graduate School of Pharmaceutical Sciences, Kumamoto University , 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan.,Faculty of Pharmacy, Mansoura University , Mansoura 35516, Egypt
| | - Shogo Misumi
- Graduate School of Pharmaceutical Sciences, Kumamoto University , 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Koki Wada
- Nihon Shokuhin Kako Co., Ltd. , 30 Tajima, Fuji, Shizuoka 417-8539, Japan
| | - Keiichi Motoyama
- Graduate School of Pharmaceutical Sciences, Kumamoto University , 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Hidetoshi Arima
- Graduate School of Pharmaceutical Sciences, Kumamoto University , 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan.,Program for Leading Graduate Schools "HIGO (Health life science: Interdisciplinary and Glocal Oriented) Program", Kumamoto University , 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
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Mittermayer F, Caveney E, De Oliveira C, Fleming GA, Gourgiotis L, Puri M, Tai LJ, Turner JR. Addressing Unmet Medical Needs in Type 1 Diabetes: A Review of Drugs Under Development. Curr Diabetes Rev 2017; 13:300-314. [PMID: 27071617 PMCID: PMC5748875 DOI: 10.2174/1573399812666160413115655] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/21/2016] [Accepted: 04/12/2016] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The incidence of type 1 diabetes (T1D) is increasing worldwide and there is a very large need for effective therapies. Essentially no therapies other than insulin are currently approved for the treatment of T1D. Drugs already in use for type 2 diabetes and many new drugs are under clinical development for T1D, including compounds with both established and new mechanisms of action. Content of the Review: Most of the new compounds in clinical development are currently in Phase 1 and 2. Drug classes discussed in this review include new insulins, SGLT inhibitors, GLP-1 agonists, immunomodulatory drugs including autoantigens and anti-cytokines, agents that regenerate β-cells and others. Regulatory Considerations: In addition, considerations are provided with regard to the regulatory environment for the clinical development of drugs for T1D, with a focus on the United States Food and Drug Administration and the European Medicines Agency. Future opportunities, such as combination treatments of immunomodulatory and beta-cell regenerating therapies, are also discussed.
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Affiliation(s)
| | - Erica Caveney
- Diabetes Center of Excellence, Quintiles,
Durham, NC, USA
| | | | | | | | - Mala Puri
- Cardiovascular and Metabolic Diseases, Quintiles, Durham, NC, USA
| | | | - J. Rick Turner
- Diabetes Center of Excellence, Quintiles,
Durham, NC, USA
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Blevins T, Pieber TR, Colón Vega G, Zhang S, Bastyr EJ, Chang AM. Randomized double-blind clinical trial comparing basal insulin peglispro and insulin glargine, in combination with prandial insulin lispro, in patients with type 2 diabetes: IMAGINE 4. Diabetes Obes Metab 2016; 18:1072-1080. [PMID: 27234693 PMCID: PMC5096023 DOI: 10.1111/dom.12696] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/23/2016] [Accepted: 05/24/2016] [Indexed: 12/18/2022]
Abstract
AIMS To evaluate the efficacy and safety of basal insulin peglispro (BIL) with those of insulin glargine, both in combination with prandial insulin lispro, in patients with type 2 diabetes (T2D). METHODS In this phase III, multicentre, double-blind, 26-week study, we randomized patients with T2D [glycated haemoglobin (HbA1c) ≥7 and <12%, on ≥1 insulin injections daily) to BIL (n = 691) or glargine (n = 678), in combination with lispro. RESULTS At week 26, the primary objective of non-inferiority of BIL versus glargine for HbA1c reduction was achieved (least squares mean difference -0.21%; 95% confidence interval -0.31 to -0.11%), with statistical superiority of BIL with multiplicity adjustment (p < 0.001). HbA1c at baseline was 8.4% versus 8.5% for BIL versus glargine and at 26 weeks it was 6.8% versus 7.0%. At 26 weeks, more patients reached HbA1c <7% with BIL than with glargine (63.3% vs 53.3%; p < 0.001), the nocturnal hypoglycaemia rate (≤3.9 mmol/l) was lower with BIL (0.51 vs 0.92 events/30 days; p < 0.001), but the daytime hypoglycaemia rate was higher with BIL (5.47 vs 4.53 events/30 days; p < 0.001). The total hypoglycaemia relative rate was 1.10 (p = 0.053). At 26 weeks, patients in the BIL group had lower fasting serum glucose levels, higher basal insulin dosing, with no statistically significant difference in prandial or total insulin dosing, reduced glucose variability and less weight gain (1.3 kg vs 2.2 kg) compared with the glargine group. The BIL group had higher mean triglyceride and aminotransferase levels. CONCLUSIONS In patients with T2D, BIL with insulin lispro provided greater improvement in glycaemic control with less nocturnal hypoglycaemia, lower glucose variability and less weight gain compared with glargine. The daytime hypoglycaemia rate and mean triglyceride and aminotransferase levels were higher with BIL.
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Affiliation(s)
- T Blevins
- Texas Diabetes and Endocrinology, Austin, TX, USA
| | - T R Pieber
- Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - G Colón Vega
- American Telemedicine Center, San Juan, Puerto Rico
| | - S Zhang
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - E J Bastyr
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
- Division of Endocrinology and Metabolism, Indiana University School of Medicine, Indianapolis, IN, USA
| | - A M Chang
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA.
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Russell-Jones DL. Hepato-preferential insulins: Is this the end, or the end of the beginning? Diabetes Obes Metab 2016; 18:1053-1054. [PMID: 27491600 PMCID: PMC5297867 DOI: 10.1111/dom.12756] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 07/28/2016] [Indexed: 11/27/2022]
Affiliation(s)
- D L Russell-Jones
- Department of Diabetes & Endocrinology, Royal Surrey County Hospital, University of Surrey - Cedar Centre, Guildford, UK.
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36
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Davies MJ, Russell-Jones D, Selam JL, Bailey TS, Kerényi Z, Luo J, Bue-Valleskey J, Iványi T, Hartman ML, Jacobson JG, Jacober SJ. Basal insulin peglispro versus insulin glargine in insulin-naïve type 2 diabetes: IMAGINE 2 randomized trial. Diabetes Obes Metab 2016; 18:1055-1064. [PMID: 27349219 PMCID: PMC5096014 DOI: 10.1111/dom.12712] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 06/23/2016] [Indexed: 01/09/2023]
Abstract
AIMS To compare, in a double-blind, randomized, multi-national study, 52- or 78-week treatment with basal insulin peglispro or insulin glargine, added to pre-study oral antihyperglycaemic medications, in insulin-naïve adults with type 2 diabetes. MATERIAL AND METHODS The primary outcome was non-inferiority of peglispro to glargine with regard to glycated haemoglobin (HbA1c) reduction (margin = 0.4%). Six gated secondary objectives with statistical multiplicity adjustments focused on other measures of glycaemic control and safety. Liver fat content was measured using MRI, in a subset of patients. RESULTS Peglispro was non-inferior to glargine in HbA1c reduction [least-squares (LS) mean difference: -0.29%, 95% confidence interval (CI) -0.40, -0.19], and had a lower nocturnal hypoglycaemia rate [relative rate 0.74 (95% CI 0.60, 0.91); p = .005), more patients achieving HbA1c <7.0% without nocturnal hypoglycaemia [odds ratio (OR) 2.15 (95% CI 1.60, 2.89); p < .001], greater HbA1c reduction (p < .001), and more patients achieving HbA1c<7.0% [OR 1.97 (95% CI 1.57, 2.47); p < .001]. Total hypoglycaemia rate and fasting serum glucose did not achieve statistical superiority. At 52 weeks, peglispro-treated patients had higher triglyceride (1.9 vs 1.7 mmol/L). alanine transaminase (34 vs 27 IU/L), and aspartate transaminase levels (27 vs 24 IU/L). LS mean liver fat content was unchanged with peglispro at 52 weeks but decreased 3.1% with glargine [difference: 2.6% (0.9, 4.2); p = .002]. More peglispro-treated patients experienced adverse injection site reactions (3.5% vs 0.6%, p < .001). CONCLUSIONS Compared with glargine at 52 weeks, peglispro resulted in a statistically superior reduction in HbA1c, more patients achieving HbA1c targets, less nocturnal hypoglycaemia, no improvement in total hypoglycaemia, higher triglyceride levels, higher aminotransferase levels, and more injection site reactions.
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Affiliation(s)
- M J Davies
- Department of Health Sciences, Diabetes Research Centre, University of Leicester, Leicester, UK
| | - D Russell-Jones
- Department of Endocrinology and Diabetes, Royal Surrey County Hospital, Guildford, UK
| | - J-L Selam
- Diabetes Research Center, Tustin, California
| | | | - Z Kerényi
- Csepel Health Service, Budapest, Hungary
| | - J Luo
- Eli Lilly and Company, Indianapolis, Indiana
| | | | - T Iványi
- Eli Lilly and Company, Budapest, Hungary
| | - M L Hartman
- Eli Lilly and Company, Indianapolis, Indiana
| | | | - S J Jacober
- Eli Lilly and Company, Indianapolis, Indiana.
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37
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Morrow LA, Hompesch M, Jacober SJ, Leng Choi S, Qu Y, Sinha VP. Glucodynamics of long-acting basal insulin peglispro compared with insulin glargine at steady state in patients with type 1 diabetes: substudy of a randomized crossover trial. Diabetes Obes Metab 2016; 18:1065-1071. [PMID: 27169522 DOI: 10.1111/dom.12691] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/29/2016] [Accepted: 05/08/2016] [Indexed: 12/01/2022]
Abstract
AIMS To compare, in an open-label, randomized, crossover phase II substudy, the glucodynamics of insulin glargine and those of basal insulin peglispro (BIL) in patients with type 1 diabetes. METHODS Patients (n = 23) underwent 24-h euglycaemic clamps after 8 weeks of treatment with glargine or with BIL. Clinically-titrated basal insulin doses (BIL group 16-64 U; glargine group 19-60 U) were administered on the morning of the clamp. RESULTS At baseline, the patients' mean ± standard deviation (s.d.) body mass index was 26.78 ± 4.20 kg/m2 and glycated haemoglobin was 7.69 ± 0.99%. The mean ± s.d. endpoint dose for the BIL group was 0.42 ± 0.13 U/kg and for the glargine group was 0.42 ± 0.10. The daily mean ± s.d. blood glucose concentration was 7.7 ± 1.2 in the BIL group and 7.9 ± 1.2 mmol/l in the glargine group (p = 0.641). The mean ± s.d. total and nocturnal hypoglycaemia rates/30 days were 2.7 ± 2.3 and 0.5 ± 0.8, respectively, for the BIL group, and 3.0 ± 2.4 and 0.7 ± 1.1, respectively, for the glargine group (p = 0.112 and 0.428). The mean glucose infusion rate (GIR) normalized to insulin unit was lower for BIL than for glargine. One patient in the glargine group and eight patients in the BIL group had minimal (<0.8 g/kg) GIRs over 24 h. The mean ± s.d. total glucose infused over 24 h (GTOT(0-24) ) was 1.22 ± 0.82 g/kg in the BIL group and 1.90 ± 1.01 g/kg in the glargine group (p = 0.002). The mean ± s.d. total glucose infused during hours 0-6 (GTOT(0-6) ) was 0.21 ± 0.22 in the BIL group and 0.41 ± 0.22 g/kg in the glargine group (p < 0.001), while the mean total glucose infused during hours 18-24 (GTOT(18-24) ) in the BIL group was 0.28 ± 0.18 g/kg and in the glargine group was 0.35 ± 0.23 g/kg (p = 0.198). The peak-to-trough ratio was 1.41 for BIL versus 2.22 for glargine. CONCLUSIONS BIL has a flatter profile than glargine, with potentially more stable metabolic control. The lower GTOT(0-24) observed in the BIL group is consistent with BIL's reduced peripheral action.
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Affiliation(s)
- L A Morrow
- Profil® Institute for Clinical Research, Chula Vista, CA, USA
| | - M Hompesch
- Profil® Institute for Clinical Research, Chula Vista, CA, USA
| | - S J Jacober
- Eli Lilly and Company, Indianapolis, IN, USA.
| | - S Leng Choi
- Lilly-NUS Centre for Pharmacology Pte, Ltd, Singapore
| | - Y Qu
- Eli Lilly and Company, Indianapolis, IN, USA
| | - V P Sinha
- Eli Lilly and Company, Indianapolis, IN, USA
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Bergenstal RM, Lunt H, Franek E, Travert F, Mou J, Qu Y, Antalis CJ, Hartman ML, Rosilio M, Jacober SJ, Bastyr EJ. Randomized, double-blind clinical trial comparing basal insulin peglispro and insulin glargine, in combination with prandial insulin lispro, in patients with type 1 diabetes: IMAGINE 3. Diabetes Obes Metab 2016; 18:1081-1088. [PMID: 27265390 PMCID: PMC5096008 DOI: 10.1111/dom.12698] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 03/27/2016] [Accepted: 06/01/2016] [Indexed: 01/07/2023]
Abstract
AIMS To compare the efficacy and safety of basal insulin peglispro (BIL), which has a flat pharmacokinetic and pharmacodynamic profile and a long duration of action, with insulin glargine (GL) in patients with type 1 diabetes. MATERIALS AND METHODS In this phase III, 52-week, blinded study, we randomized 1114 adults with type 1 diabetes in a 3 : 2 distribution to receive either BIL (n = 664) or GL (n = 450) at bedtime, with preprandial insulin lispro, using intensive insulin management. The primary objective was to compare glycated haemoglobin (HbA1c) in the groups at 52 weeks, with a non-inferiority margin of 0.4%. RESULTS At 52 weeks, mean (standard error) HbA1c was 7.38 (0.03)% with BIL and 7.61 (0.04)% with GL {difference -0.22% [95% confidence interval (CI) -0.32, -0.12]; p < 0.001}. At 52 weeks more BIL-treated patients reached HbA1c <7% (35% vs 26%; p < 0.001), the nocturnal hypoglycaemia rate was 47% lower (p < 0.001) and the total hypoglycaemia rate was 11% higher (p = 0.002) than in GL-treated patients, and there was no difference in severe hypoglycaemia rate. Patients receiving BIL lost weight, while those receiving GL gained weight [difference -1.8 kg (95% CI -2.3, -1.3); p < 0.001]. Treatment with BIL compared with GL at 52 weeks was associated with greater increases from baseline in levels of serum triglyceride [difference 0.19 mmol/l (95% CI 0.11, 0.26); p < 0.001] and alanine aminotransferase (ALT) levels [difference 6.5 IU/l (95% CI 4.1, 8.9), p < 0.001], and more frequent injection site reactions. CONCLUSIONS In patients with type 1 diabetes, treatment with BIL compared with GL for 52 weeks resulted in a lower HbA1c, more patients with HbA1c levels <7%, and reduced nocturnal hypoglycaemia, but more total hypoglycaemia and injection site reactions and higher triglyceride and ALT levels.
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Affiliation(s)
| | - H Lunt
- Christchurch Hospital Diabetes Center, Christchurch, New Zealand
| | - E Franek
- Mossakowski Clinical Research Centre, Polish Academy of Science, Warsaw, Poland
| | - F Travert
- Hopital Bichat Claude Bernard, Paris, France
| | - J Mou
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Y Qu
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - C J Antalis
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - M L Hartman
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - M Rosilio
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - S J Jacober
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - E J Bastyr
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA.
- Indiana University School of Medicine, Indianapolis, IN, USA.
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Ginsberg H, Cariou B, Orchard T, Chen L, Luo J, Bastyr EJ, Bue-Valleskey J, Chang AM, Ivanyi T, Jacober SJ, Hoogwerf BJ. Lipid changes during basal insulin peglispro, insulin glargine, or NPH treatment in six IMAGINE trials. Diabetes Obes Metab 2016; 18:1089-1092. [PMID: 27486125 DOI: 10.1111/dom.12754] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 01/05/2023]
Abstract
Basal insulin peglispro (BIL) is a novel basal insulin with hepato-preferential action resulting from reduced peripheral effects. This report provides an integrated summary of lipid changes at 26 weeks with BIL and comparator insulins (glargine, NPH) from phase III studies in type 1 diabetes (T1D), insulin-naïve patients with type 2 diabetes (T2D), patients with T2D on basal insulin only and patients with T2D on basal-bolus therapy. BIL treatment had little effect on HDL cholesterol and LDL cholesterol in all patients. The effect of both BIL and glargine treatment on triglycerides (TG) depended on whether patients had been previously treated with insulin. When BIL replaced conventional insulin glargine or NPH treatments, increases in TG levels were observed. When BIL or comparator insulins were given for 26 weeks to insulin-naïve patients with T2D, TG levels were unchanged from baseline with BIL but decreased with either glargine or NPH. The decreased peripheral action of BIL may reduce suppression of lipolysis in peripheral adipose tissue resulting in increased free fatty acid delivery to the liver and, hence, increased hepatic TG synthesis and secretion.
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Affiliation(s)
- Henry Ginsberg
- Irving Institute for Clinical and Translational Research, Columbia University, New York, New York, USA
| | - Bertrand Cariou
- Department of Endocrinology, L'Institut du Thorax, CHU Nantes, Nantes, France
| | - Trevor Orchard
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lei Chen
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Junxiang Luo
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Edward J Bastyr
- Eli Lilly and Company, Indianapolis, Indiana, USA
- Division of Endocrinology & Metabolism, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Karnchanasorn R, Ou HY, Lin J, Chuang LM, Chiu KC. Viral Hepatitis and Diabetes: Clinical Implications of Diabetes Prevention Through Hepatitis Vaccination. Curr Diab Rep 2016; 16:101. [PMID: 27620495 DOI: 10.1007/s11892-016-0790-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Viral hepatitis has been posited to play a role in the development of type 2 diabetes. Thus, prevention of viral hepatitis through vaccination has the potential to reduce the burden of type 2 diabetes. We have shown that successful hepatitis B vaccination reduces the risk of diabetes by 33 %. Although diabetes can be prevented by behavior modification and pharmaceutical agents, these require significant personal commitment and cost. In contrast, diabetes prevention through hepatitis B vaccination would require little personal commitment and relatively low cost. In this review, we discuss hepatitis viruses A, B, and C and their interaction with diabetes; explore the potential underlying mechanisms and potential for hepatitis vaccination to reduce diabetes; and estimate the medical expense savings that would result from such an intervention. Given the projected increase of diabetes prevalence in the developing regions, where hepatitis B is endemic, exploration of such an intervention is very timely.
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Affiliation(s)
- Rudruidee Karnchanasorn
- Division of Endocrinology, Metabolism and Genetics, Department of Internal Medicine, University of Kansas Medical Center, Kansas, KS, USA
| | - Horng-Yih Ou
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng-Kung University Medical College and Hospital, Tainan, Taiwan
| | - James Lin
- Department of Gastroenterology, City of Hope National Medical Center, Duarte, CA, USA
| | - Lee-Ming Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Preventive Medicine, School of Public Health, National Taiwan University, Taipei, Taiwan
| | - Ken C Chiu
- Department of Clinical Diabetes, Endocrinology, and Metabolism, City of Hope National Medical Center, Duarte, CA, 91010-3000, USA.
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA.
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Grunberger G, Chen L, Rodriguez A, Tinahones FJ, Jacober SJ, Bue-Valleskey J. A randomized clinical trial of basal insulin peglispro vs NPH in insulin-naïve patients with type 2 diabetes: the IMAGINE 6 trial. Diabetes Obes Metab 2016; 18 Suppl 2:34-42. [PMID: 27723225 DOI: 10.1111/dom.12743] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 07/11/2016] [Indexed: 12/18/2022]
Abstract
AIMS Basal insulin peglispro (BIL) has a longer duration of action than conventional insulin analogues and a hepato-preferential mechanism of action. This study assessed whether BIL was non-inferior to isophane insulin (NPH) in reducing HbA1c in insulin-naïve patients with type 2 diabetes, when added to pre-study oral anti-hyperglycaemic medications. MATERIALS AND METHODS This was a Phase 3, open-label, treat-to-target (TTT), randomized trial with a 2-week lead-in, 26-week treatment and a 4-week safety follow-up period. Patients were randomized to bedtime (pm) NPH, morning (am) BIL or pm BIL in a 1:1:1 ratio. RESULTS Six hundred and forty-one patients [NPH, n = 213; BIL, n = 428 (am, n = 213; pm, n = 215)] received study drug. BIL was non-inferior to NPH for HbA1c change from baseline at Week 26 with a between-treatment difference (95% confidence interval) of -0.37% (-0.50, -0.23%). HbA1c at baseline was 8.5%, and was lower in BIL- vs NPH-treated patients after 26 weeks of treatment (6.8% vs 7.1%; P < .001). More BIL-treated patients achieved HbA1c <7.0% and HbA1c <7.0% without nocturnal hypoglycaemia. Fasting serum glucose levels and nocturnal hypoglycaemia rates were lower in BIL-treated patients; total hypoglycaemia rates were similar. Treatment-emergent adverse events were similar between groups. Fasting triglycerides decreased from baseline in both groups and to a greater extent with NPH, but were not significantly different between groups at Week 26. Mean alanine aminotransferase (ALT) increased with BIL treatment, but there was no evidence of acute severe hepatotoxicity. CONCLUSIONS In this TTT study, BIL treatment showed clinically relevant improvements in glycaemic control and a significant reduction in nocturnal hypoglycaemia compared to NPH.
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Affiliation(s)
- G Grunberger
- Grunberger Diabetes Institute, Bloomfield Hills, Michigan
| | - L Chen
- Eli Lilly and Company, Indianapolis, Indiana
| | | | | | - S J Jacober
- Eli Lilly and Company, Indianapolis, Indiana
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42
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Jacober SJ, Prince MJ, Beals JM, Hartman ML, Qu Y, Linnebjerg H, Garhyan P, Haupt A. Basal insulin peglispro: Overview of a novel long-acting insulin with reduced peripheral effect resulting in a hepato-preferential action. Diabetes Obes Metab 2016; 18 Suppl 2:3-16. [PMID: 27723228 DOI: 10.1111/dom.12744] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 07/12/2016] [Indexed: 01/04/2023]
Abstract
Basal insulin peglispro (BIL) is a novel basal insulin with a flat, prolonged activity profile. BIL has been demonstrated in a dog model, in healthy men and in patients with type 1 diabetes (T1D) to have significant hepato-preferential action resulting from reduced peripheral activity. In the IMAGINE-Phase 3 clinical trial program, more than 6000 patients were included, of whom ~3900 received BIL. Of the 7 pivotal IMAGINE trials, 3 studies were double-blinded and 3 were in T1D patients. BIL consistently demonstrated a greater HbA1c reduction, less glycaemic variability and a clinically relevant reduction in the rates of nocturnal hypoglycaemia across comparator [glargine and isophane insulin (NPH)] studies. Trials using basal/bolus regimens had higher rates of total hypoglycaemia with BIL due to higher rates of daytime hypoglycaemia. Severe hypoglycaemia rates were similar to comparator among both patients with T1D or type 2 diabetes (T2D). T1D patients lost weight compared with glargine (GL). Patients with T2D tended to gain less weight with BIL than with glargine. Compared to glargine, BIL was associated with higher liver fat, triglycerides and alanine aminotransferase (ALT) levels, including a higher frequency of elevation of ALT ≥3 times the upper limit of normal, but without severe, acute drug-induced liver injury. Injection site reactions, primarily lipohypertrophy, were more frequent with BIL. In conclusion, BIL demonstrated better glycaemic control with reduced glucose variability and nocturnal hypoglycaemia but higher triglycerides, ALT and liver fat relative to conventional comparator insulin. The hepato-preferential action of BIL with reduced peripheral activity may account for these findings.
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Affiliation(s)
- S J Jacober
- Eli Lilly and Company, Indianapolis, Indiana.
| | - M J Prince
- Eli Lilly and Company, Indianapolis, Indiana
| | - J M Beals
- Eli Lilly and Company, Indianapolis, Indiana
| | - M L Hartman
- Eli Lilly and Company, Indianapolis, Indiana
| | - Y Qu
- Eli Lilly and Company, Indianapolis, Indiana
| | | | - P Garhyan
- Eli Lilly and Company, Indianapolis, Indiana
| | - A Haupt
- Eli Lilly and Company, Indianapolis, Indiana
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Cusi K, Sanyal AJ, Zhang S, Hoogwerf BJ, Chang AM, Jacober SJ, Bue-Valleskey JM, Higdon AN, Bastyr EJ, Haupt A, Hartman ML. Different effects of basal insulin peglispro and insulin glargine on liver enzymes and liver fat content in patients with type 1 and type 2 diabetes. Diabetes Obes Metab 2016; 18 Suppl 2:50-58. [PMID: 27723227 DOI: 10.1111/dom.12751] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 07/20/2016] [Indexed: 12/15/2022]
Abstract
AIMS To compare effects of basal insulin peglispro (BIL), a hepatopreferential insulin, to insulin glargine (glargine) on aminotransferases and liver fat content (LFC) in patients with type 1 and type 2 diabetes (T1D, T2D). MATERIALS AND METHODS Data from two Phase 2 and five Phase 3 randomized trials comparing BIL and glargine in 1709 T1D and 3662 T2D patients were integrated for analysis of liver laboratory tests. LFC, measured by magnetic resonance imaging (MRI) at baseline, 26 and 52 weeks, was analyzed in 182 T1D patients, 176 insulin-naïve T2D patients and 163 T2D patients previously treated with basal insulin. RESULTS Alanine aminotransferase (ALT) increased in patients treated with BIL, was higher than in glargine-treated patients at 4-78 weeks (difference at 52 weeks in both T1D and T2D: 7 international units/litre (IU/L), P < .001), and decreased after discontinuation of BIL. More BIL patients had ALT ≥3× upper limit of normal (ULN) than glargine. No patient had ALT ≥3× ULN with bilirubin ≥2× ULN that was considered causally related to BIL. In insulin-naїve T2D patients, LFC decreased with glargine but was unchanged with BIL. In T1D and T2D patients previously treated with basal insulin, LFC was unchanged with glargine but increased with BIL. In all three populations, LFC was higher after treatment with BIL vs glargine (difference at 52 weeks: 2.2% to 5.3%, all P < .01). CONCLUSIONS Compared to glargine, patients treated with BIL had higher ALT and LFC at 52-78 weeks. No severe drug-induced liver injury was apparent with BIL treatment for up to 78 weeks.
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Affiliation(s)
- K Cusi
- Division of Endocrinology, Diabetes and Metabolism, University of Florida College of Medicine, Gainesville, FL, USA
| | - A J Sanyal
- Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - S Zhang
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - B J Hoogwerf
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - A M Chang
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - S J Jacober
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - J M Bue-Valleskey
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - A N Higdon
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - E J Bastyr
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - A Haupt
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - M L Hartman
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA.
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Garg S, Dreyer M, Jinnouchi H, Mou J, Qu Y, Hartman ML, Rosilio M, Jacober SJ, Bastyr EJ. A randomized clinical trial comparing basal insulin peglispro and insulin glargine, in combination with prandial insulin lispro, in patients with type 1 diabetes: IMAGINE 1. Diabetes Obes Metab 2016; 18 Suppl 2:25-33. [PMID: 27393697 DOI: 10.1111/dom.12738] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 12/28/2022]
Abstract
AIMS The primary objective was to demonstrate that basal insulin peglispro (BIL) was non-inferior compared with insulin glargine (GL) for haemoglobin A1c (HbA1c) at 26 weeks with a non-inferiority margin of 0.4%. MATERIALS AND METHODS IMAGINE 1 was a Phase 3, open-label, parallel-arm study conducted in nine countries. Adults with type 1 diabetes (n = 455) were randomized (2:1) to bedtime BIL or GL in combination with prandial insulin lispro for 78 weeks, with a primary endpoint of 26 weeks. An electronic diary facilitated data capture and insulin dosing calculations for intensive insulin management. RESULTS At 26 weeks, mean HbA1c was 7.06% ± 0.04% and 7.43% ± 0.06% for patients assigned to BIL (N = 295) and GL (N = 160), respectively (difference -0.37% [95% CI: -0.50 to -0.23], P < .001); more patients on BIL achieved HbA1c <7% (44.9% vs 27.5%, P < .001). Compared with GL, patients using BIL lost weight, with lower fasting serum glucose and between-day fasting blood glucose variability, and 36% less nocturnal hypoglycemia, 29% more total hypoglycemia and more severe hypoglycemia. Total and prandial insulin doses were lower with BIL; basal insulin doses were higher. Alanine aminotransferase increased with BIL, with more patients having elevations ≥3 × ULN. BIL treatment was associated with more frequent injection site reactions and an increase from baseline in serum triglycerides. CONCLUSIONS In patients with type 1 diabetes, treatment with BIL compared to GL for 26 weeks was associated with lower HbA1c, less nocturnal hypoglycemia, lower glucose variability and weight loss. Increases in total and severe hypoglycemia, triglycerides, aminotransferases and injection site reactions were also noted.
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Affiliation(s)
- S Garg
- Barbara Davis Center for Diabetes, University of Colorado Health Sciences Center, Aurora, USA.
| | - M Dreyer
- Wuxi Mingci Cardiovascular Hospital, Wuxi, China
| | - H Jinnouchi
- Diabetes Care Center, Jinnouchi Hospital, Kumamoto, Japan
| | - J Mou
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Y Qu
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - M L Hartman
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - M Rosilio
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - S J Jacober
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - E J Bastyr
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
- Division of Endocrinology and Metabolism, Indiana University School of Medicine, Indianapolis, USA
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Mudaliar S, Henry RR, Ciaraldi TP, Armstrong DA, Burke PM, Pettus JH, Garhyan P, Choi SL, Knadler MP, Lam ECQ, Prince MJ, Bose N, Porksen NK, Sinha VP, Linnebjerg H, Jacober SJ. Reduced peripheral activity leading to hepato-preferential action of basal insulin peglispro compared with insulin glargine in patients with type 1 diabetes. Diabetes Obes Metab 2016; 18 Suppl 2:17-24. [PMID: 27723226 DOI: 10.1111/dom.12753] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 01/05/2023]
Abstract
AIMS Basal insulin peglispro (BIL), a novel PEGylated basal insulin with a large hydrodynamic size, has a delayed absorption and reduced clearance that prolongs the duration of action. The current study compared the effects of BIL and insulin glargine (GL) on endogenous glucose production (EGP), glucose disposal rate (GDR) and lipolysis in patients with type 1 diabetes. MATERIALS AND METHODS This was a randomized, open-label, four-period, crossover study. Patients received intravenous infusions of BIL and GL, each at two dose levels selected for partial and maximal suppression of EGP, during an 8 to 10 h euglycemic clamp procedure with d-[3-3 H] glucose. RESULTS Following correction for equivalent human insulin concentrations (EHIC), low-dose GL infusion resulted in similar EGP at the end of the clamp compared to low-dose BIL infusion (GL/BIL ratio of 1.03) but a higher GDR (GL/BIL ratio of 2.42), indicating similar hepatic activity but attenuated peripheral activity of BIL. Consistent with this, the EHIC-corrected GDR/EGP at the end of the clamp was 1.72-fold greater for GL than BIL following low-dose administration. At the lower dose of BIL and GL (concentrations in the therapeutic range), BIL produced less suppression of lipolysis compared with GL as indicated by free fatty acid and glycerol levels at the end of the clamp. CONCLUSIONS Compared with GL, BIL restored the hepato-peripheral insulin action gradient seen in normal physiology via its peripherally restricted action on target tissues related to carbohydrate and lipid metabolism.
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Affiliation(s)
- S Mudaliar
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Department of Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, CA, USA
| | - R R Henry
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Department of Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, CA, USA
| | - T P Ciaraldi
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Department of Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, CA, USA
| | - D A Armstrong
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - P M Burke
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - J H Pettus
- Department of Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, CA, USA
| | - P Garhyan
- Eli Lilly and Company, Indianapolis, IN, USA
| | - S L Choi
- Eli Lilly and Company, Singapore, Singapore
| | - M P Knadler
- Eli Lilly and Company, Indianapolis, IN, USA
| | - E C Q Lam
- Eli Lilly and Company, Singapore, Singapore
| | - M J Prince
- Eli Lilly and Company, Indianapolis, IN, USA
| | - N Bose
- Department of Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, CA, USA
| | - N K Porksen
- Eli Lilly and Company, Indianapolis, IN, USA
| | - V P Sinha
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - S J Jacober
- Eli Lilly and Company, Indianapolis, IN, USA.
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46
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Pettus J, Santos Cavaiola T, Tamborlane WV, Edelman S. The past, present, and future of basal insulins. Diabetes Metab Res Rev 2016; 32:478-96. [PMID: 26509843 DOI: 10.1002/dmrr.2763] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/23/2015] [Accepted: 10/04/2015] [Indexed: 12/14/2022]
Abstract
Insulin production by the pancreas follows a basic pattern where basal levels of insulin are secreted during fasting periods, with prandial increases in insulin associated with food ingestion. The aim of insulin therapy in patients with diabetes is to match the endogenous pattern of insulin secretion as closely as possible without causing hypoglycaemia. There are several optimal pharmacokinetic and pharmacodynamic properties of long-acting basal insulins that can help to achieve this aim, namely, as follows: activity that is flat and as free of peaks as possible, a duration of action of ≥24-h, and as little day-to-day variation as possible. The long-acting basal insulins are a fundamental therapy for patients with type 1 and type 2 diabetes, and those that are currently available have many benefits; however, the development of even longer-acting insulins and improved insulin delivery techniques may lead to better glycemic control for patients in the future. Established long-acting basal insulins available in the United States and Europe include insulin glargine 100 units/mL and insulin detemir, both of which exhibit similar glycemic control to that of the intermediate-acting neutral protamine Hagedorn insulin, but with a reduction in hypoglycaemia. Newer insulin products available include new insulin glargine 300 units/mL (United States and Europe) and the ultra-long-acting insulin degludec (Europe) with basal insulin peglispro currently in development. These new insulins demonstrate different pharmacokinetic/pharmacodynamic profiles and longer durations of action (>24 h) compared with insulin glargine 100 units/mL, which may lead to potential benefits. The introduction of biosimilar insulins may also broaden access to insulins by reducing treatment costs. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jeremy Pettus
- Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA, USA
| | - Tricia Santos Cavaiola
- Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA, USA
| | | | - Steven Edelman
- Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA, USA
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47
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Hoogwerf BJ, Lincoff AM, Rodriguez A, Chen L, Qu Y. Major adverse cardiovascular events with basal insulin peglispro versus comparator insulins in patients with type 1 or type 2 diabetes: a meta-analysis. Cardiovasc Diabetol 2016; 15:78. [PMID: 27188479 PMCID: PMC4869328 DOI: 10.1186/s12933-016-0393-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/29/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND To identify possible differences in cardiovascular (CV) risk among different insulin therapies, we performed pre-specified meta-analyses across the clinical program for basal insulin peglispro (BIL), in patients randomized to treatment with BIL or comparator insulin [glargine (IG) or NPH]. METHODS One phase 2 (12-week) and 6 phase 3 (26 to 78-week) randomized studies of BIL compared to IG or NPH, in patients with type 1 or type 2 diabetes, were included. The participants were diverse with respect to demographics, baseline glycemic control, and concomitant disease or medications, but treatment groups were comparable in each study. For any potential CV or neurovascular event, relevant medical information was provided to a blinded external clinical events committee (C5Research, Cleveland Clinic, Cleveland, OH, USA) for adjudication. Cox regression analysis was used to compare treatment groups. The primary endpoint was a composite of adjudicated MACE+ [CV death, myocardial infarction (MI), stroke, or hospitalization for unstable angina]. RESULTS The pooled population included 5862 patients in the safety evaluation, with randomization to BIL:IG:NPH of 3578:2072:212. Mean age was 54.1 years, 27 % had type 1 diabetes, 56 % were male, and 88 % were white. Baseline demographic and clinical characteristics, including use of statins or other lipid-lowering drugs, were comparable between BIL and comparators. A total of 83 patients experienced at least 1 MACE+ and 70 patients experienced at least 1 MACE (CV death, MI, or stroke). Overall, there were no treatment-associated differences in time to MACE+ [hazard ratio (HR) for BIL versus comparator insulin (95 % CI): 0.82 (0.53-1.27)] or MACE [0.83 (0.51-1.33)]. In 4297 patients with type 2 diabetes, there were 71 MACE+ events [HR: 1.02 (95 % CI: 0.63-1.65), p = 0.94]. In 1565 patients with type 1 diabetes, there were only 12 MACE+ [0.24 (0.07-0.85), p = 0.027]. There were no differences in all-cause death between BIL and comparators. Sub-group analyses did not identify any sub-population with increased risk with BIL versus comparator insulins. CONCLUSIONS Treatment with BIL versus comparator insulin in patients with type 1 diabetes or type 2 diabetes was not associated with increased risk for major CV events in the studies analyzed.
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Affiliation(s)
- Byron J. Hoogwerf
- />Lilly Corporate Center, Eli Lilly and Company, Drop Code 2240, Indianapolis, IN 46285 USA
| | - A. Michael Lincoff
- />Cleveland Clinic Coordinating Center for Clinical Research (C5 Research), Cleveland Clinic, Cleveland, OH USA
| | | | - Lei Chen
- />Lilly Corporate Center, Eli Lilly and Company, Drop Code 2240, Indianapolis, IN 46285 USA
| | - Yongming Qu
- />Lilly Corporate Center, Eli Lilly and Company, Drop Code 2240, Indianapolis, IN 46285 USA
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48
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Bedinger DH, Kieffer DA, Goldfine ID, Roell MK, Adams SH. Acute Treatment With XMetA Activates Hepatic Insulin Receptors and Lowers Blood Glucose in Normal Mice. J Cell Biochem 2016; 116:2109-19. [PMID: 25808283 DOI: 10.1002/jcb.25168] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 03/19/2015] [Indexed: 01/17/2023]
Abstract
It has been proposed that monoclonal antibodies may become therapeutics for metabolic diseases such as diabetes mellitus. We have previously characterized an allosteric monoclonal antibody to the human insulin receptor (IR), XMetA, that activated metabolic signaling leading to enhanced glucose transport in cultured cells, and chronically reduced fasting blood glucose levels in mouse models of diabetes mellitus. Under acute dosing conditions, the large size of an IR-binding antibody like XMetA (∼ 150 kDa) could lead to a more rapid access into liver, an insulin sensitive tissue with well-fenestrated capillaries, when compared to other insulin sensitive tissues with non-fenestrated capillaries, such as muscle and adipose. Thus, in the present study we administered XMetA (10 mg/kg) and insulin (0.5 U/kg) via IV injection, and for 90 min compared their effects on blood glucose lowering and IR activation in three of the major insulin-sensitive tissues of the normal fasted mouse: liver, adipose, and muscle. Like insulin, XMetA lowered blood glucose levels, although the effect was less rapid. Insulin activated IR autophosphorylation and Akt phosphorylation in liver, fat, and muscle. In contrast, IR activation by XMetA was primarily observed in the liver. Both insulin and XMetA lowered β-hydroxybutyrate levels in plasma; however, only insulin reduced both non-esterified fatty acids (NEFA) and glycerol concentrations. These data indicate that, in normal mice, acute glucose regulation by XMetA is largely mediated by its action on the liver.
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Affiliation(s)
- Daniel H Bedinger
- XOMA Corporation, Berkeley, California.,Molecular, Cellular and Integrative Physiology Graduate Group, University of California, Davis, California
| | - Dorothy A Kieffer
- Graduate Group in Nutritional Biology -and- Department of Nutrition, University of California, Davis, California
| | | | | | - Sean H Adams
- Molecular, Cellular and Integrative Physiology Graduate Group, University of California, Davis, California.,Graduate Group in Nutritional Biology -and- Department of Nutrition, University of California, Davis, California.,Arkansas Children's Nutrition Center -and- University of Arkansas for Medical Sciences, Department of Pediatrics, Little Rock, Arkansas
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49
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Linnebjerg H, Choi SL, Lam ECQ, Mace KF, Hodgson TS, Sinha VP. Pharmacokinetics of the Long-Acting Basal Insulin LY2605541 in Subjects With Varying Degrees of Renal Function. Clin Pharmacol Drug Dev 2016; 5:216-24. [PMID: 27163501 PMCID: PMC5071690 DOI: 10.1002/cpdd.252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 01/22/2016] [Accepted: 01/06/2016] [Indexed: 11/09/2022]
Abstract
The pharmacokinetics of LY2605541 (basal insulin peglispro), a novel long-acting basal insulin analogue, was evaluated in 5 groups of subjects with varying degrees of renal function based on creatinine clearance: normal renal function (>80 mL/min), mild renal impairment (51-80 mL/min), moderate renal impairment (30-50 mL/min), severe renal impairment (<30 mL/min), or end-stage renal disease (ESRD) requiring hemodialysis. Serial blood samples for pharmacokinetic analyses were collected up to 12 days following a single 0.33 U/kg subcutaneous dose of LY2605541. The apparent clearance (CL/F) and half-life across groups were not affected by renal function. Cmax values were lower in subjects with increasing severity of renal impairment; however, the small decrease in Cmax did not affect the overall exposure. Regression analysis showed that LY2605541 clearance is independent of renal function (slope = 0.000863; P = .885). The mean fraction of LY2605541 eliminated by a single hemodialysis session was 13% in subjects with ESRD. LY2605541 was generally well tolerated in healthy subjects and those with renal impairment following a single 0.33 U/kg subcutaneous dose. Given these data, no dose adjustment of LY2605541 based on pharmacokinetics is recommended in renal impairment or in patients undergoing hemodialysis.
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Affiliation(s)
| | | | | | | | | | - Vikram P Sinha
- U.S. Food and Drug Administration, Silver Spring, MD, USA
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50
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Riddle MC. Lessons From Peglispro: IMAGINE How to Improve Drug Development and Affordability. Diabetes Care 2016; 39:499-501. [PMID: 27208365 DOI: 10.2337/dc15-2754] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Matthew C Riddle
- Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, OR
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