Jet-injected insulin is associated with decreased antibody production and postprandial glucose variability when compared with needle-injected insulin in gestational diabetic women

Small-volume extensional rheology of concentrated protein and protein-excipient solutions

Limited studies measure extensional rheology in protein solutions due to volume constraints and measurement challenges. We developed a small-volume, dripping-onto-substrate (DoS) extensional rheology device to measure the capillary thinning of protein and protein-excipient solutions via DoS for the first time. Ovalbumin (OVA) was used as a model system, examined via DoS both with and without excipient poloxamer 188 (P188). Water and dilute OVA break apart rapidly and demonstrate inertiocapillary (IC) thinning behavior, where longer breakup times in OVA can be attributed to lower surface tension. Further increasing OVA content leads to longer breakup times and deviations from IC thinning at the start of thinning, however, no evidence of elastic behavior is observed. P188 more effectively lowers the droplet surface tension than OVA, transitioning from IC behavior in dilute solution to weakly elastic behavior at higher concentrations. Combined protein/excipient formulations act synergistically at low concentrations, where breakup times are identical to those of the individual components despite the higher total concentration. However concentrated protein/excipient formulations exhibit elasticity, where extensional rheology parameters depend on P188 content and total concentration. These findings imply that excipients intended to stabilize proteins in shear flow can cause undesirable behavior in extensional flows like injection.

In pursuit of excellence in diabetes care: trends in insulin delivery

Diabetes mellitus has been estimated to affect 2.9 million people in the UK. Large-scale clinical trials conclusively demonstrate that elevated blood glucose levels are associated with an increased risk of micro- and macrovascular complications. The high rates of morbidity and mortality associated with this condition demonstrate how important effective glycaemic control is. Subcutaneous insulin injection continues to be the mainstay of therapy for all people with type 1 diabetes mellitus and the majority of individuals with type 2 diabetes mellitus. However, there are a number of barriers to insulin therapy. For example, conventional insulin delivery is arguably time consuming. Furthermore, it has been associated with common errors, such as inaccurate dosing and administration (National Patient Safety Agency, 2010). Insulin pen devices have various advantages over conventional delivery. Their ease of use and incorporation into busy lifestyles may improve diabetes control with much less effort, while maintaining adherence and quality of life. Research in insulin delivery shows there is a prospect of needle-free delivery in the near future. Despite such progress, the role of the healthcare professionals in involving, assessing, supporting and educating people having insulin therapy, including the attainment of the agreed blood glucose levels, cannot be overestimated.

Use of needle-free injection systems to alleviate needle phobia and pain at injection

Needle phobia affects at least 10% of the general population. Subcutaneous injections are used for many reasons, including immunizations, administration of medications such as insulin and heparin, and to provide local anesthesia, both for surgery and for intravenous cannulation. Whatever the reason for its application, the injection itself may cause discomfort and/or pain. In children, in patients with needle phobia, in those who require frequent intravenous cannulations, or in those who need daily medication, the pain at injection can reach unbearable intensity that could lead to refusal of medical care. Various approaches are employed to alleviate the pain caused by intravenous cannulation. These include the use of topical analgesia [i.e., EMLA, Ametop (tetracaine], Numby Stuff and ethylchloridespray], skin infiltration with lidocaine using 25-30-gauge needles and jet injectors. This article will review the complex topic of needle phobia and needle pain, and will summarize the currently available alternatives and the new developments intended to reduce the intensity of injection pain.

Possibility and effectiveness of drug delivery to skin by needle-free injector

We evaluated a needle-free injector (NFI), which has been studied as an administration device to the subcutaneous tissue, as a device to deliver drugs into skin tissues. ShimaJet used for self-injection of insulin was selected as a spring-powered NFI in this study. Weak (NFI-w) and strong (NFI-s) injectors were evaluated. Rhodamine 6G, as a model compound, was injected onto the skin surface of hairless rats and the skin distribution and amount released from the skin of the compound were followed. A modified nozzle (able to inject at an angle of 45 degrees ) was prepared in addition to the conventional dedicated nozzle. The spring constants, nozzle shapes and penetration enhancer, 1-[2-(decylthio)ethyl] azacyclopentane-2-one (HPE-101), affected not only the skin distribution, but also the release profiles of rhodamine 6G. In addition, the release profiles of rhodamine 6G after injection using NFI-w or NFI-s obeyed diffusion-controlled or membrane-controlled kinetics, respectively. This difference was probably due to the skin site (depth) of rhodamine 6G delivered by the NFI. Furthermore, HPE-101 increased the retention time of rhodamine 6G in the epidermis. The present results suggested that an NFI can be a useful tool for enhanced drug delivery into skin.

Treatments for gestational diabetes

BACKGROUND

Gestational diabetes (GDM) affects 3% to 6% of all pregnancies. Women are often intensively managed with increased obstetric monitoring, dietary regulation, and insulin. However, there has been no sound evidence base to support intensive treatment. The key issue for clinicians and consumers is whether treatment of GDM improves perinatal outcome.

OBJECTIVES

To compare the effect of alternative treatment policies for GDM on both maternal and infant outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2009) and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised controlled trials comparing alternative management strategies for women with GDM and impaired glucose tolerance in pregnancy.

DATA COLLECTION AND ANALYSIS

Two authors and a member of the Cochrane Pregnancy and Childbirth Group's editorial team extracted and checked data independently. Disagreements were resolved through discussion with the third author.

MAIN RESULTS

Eight randomised controlled trials (1418 women) were included.Caesarean section rate was not significantly different when comparing any specific treatment with routine antenatal care (ANC) including data from five trials with 1255 participants (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.80 to 1.12). However, when comparing oral hypoglycaemics with insulin as treatment for GDM, there was a significant reduction (RR 0.46, 95% CI 0.27 to 0.77, two trials, 90 participants). There was a reduction in the risk of pre-eclampsia with intensive treatment (including dietary advice and insulin) compared to routine ANC (RR 0.65, 95% CI 0.48 to 0.88, one trial, 1000 participants). More women had their labours induced when given specific treatment compared to routine ANC (RR 1.33, 95% CI 1.13 to 1.57, two trials, 1068 participants). The composite outcome of perinatal morbidity (death, shoulder dystocia, bone fracture and nerve palsy) was significantly reduced for those receiving intensive treatment for mild GDM compared to routine ANC (RR 0.32, 95% CI 0.14 to 0.73, one trial, 1030 infants).There was a reduction in the proportion of infants weighing more than 4000 grams (RR 0.46, 95% CI 0.34 to 0.63, one trial, 1030 infants) and the proportion of infants weighing greater than the 90th birth centile (RR 0.55, 95% CI 0.30 to 0.99, three trials, 223 infants) of mothers receiving specific treatment for GDM compared to routine ANC. However, there was no statistically significant difference in this proportion between infants of mothers receiving oral drugs compared to insulin as treatment for GDM.

AUTHORS' CONCLUSIONS

Specific treatment including dietary advice and insulin for mild GDM reduces the risk of maternal and perinatal morbidity. However, it is associated with higher risk of labour induction. More research is needed to assess the impact of different types of intensive treatment, including oral drugs and insulin, on individual short- and long-term infant outcomes.

Recent challenges in insulin delivery systems: a review

Relatively, a large percentage of world population is affected by diabetes mellitus, out of which approximately 5-10% with type 1 diabetes while the remaining 90% with type 2. Insulin administration is essential for type 1 patients while it is required at later stage by the patients of type 2. Current insulin delivery systems are available as transdermal injections which may be considered as invasive. Several non-invasive approaches for insulin delivery are being pursued by pharmaceutical companies to reduce the pain, and hypoglycemic incidences associated with injections in order to improve patient compliance. While any new insulin delivery system requires health authorities' approval, to provide long term safety profile and insuring patients' acceptance. The inhalation delivery system Exubera((R)) has already become clinically available in the United States and Europe for patients with diabetes as non-invasive delivery system.

Clinical Evaluation of the Needle-free Injection System VISION(®) for Growth Hormone Therapy in Children

The aim of this study was to compare the therapeutic effects of rhGH administered either by subcutaneous needle-injection (pens) or subcutaneous needle-free jet-injection (VISION(®)). Furthermore, a survey was carried out after using VISION(®) for 12 mo. A needle-free injection group consisting of 18 subjects (11 males and 7 females, mean age 5.87 ± 2.05 yr at the start of hGH therapy) who have not used pen injectors to date, were allowed to use VISION(®) in their third to fifth years of GH therapy. In addition, a group of 8 subjects who had been using pen injectors at our clinic (6 males and 2 females, mean age 6.54 ± 2.78 at the start of GH therapy) was monitored as a control. The results indicate that there are no significant differences between the mean growth rates, growth rate SD scores or height SD scores when comparing injection devices. Furthermore, the survey of VISION(®) revealed that 70% of the subjects found it slightly or not painful at or after injection, 70% found VISION(®) very easy or easy to use, and 80% found the weight of the device appropriate. All subjects expressed a desire to continue using VISION(®) in the future. Our results suggest that there are no problems with the effectiveness of hGH treatment with VISION(®), a needle-free jet-injection device and that VISION(®) is an effective device for children who have an aversion to needle injection.

Treatments for gestational diabetes and impaired glucose tolerance in pregnancy

BACKGROUND

Gestational diabetes and impaired glucose tolerance (IGT) in pregnancy affects between 3 and 6% of all pregnancies and both have been associated with pregnancy complications. A lack of conclusive evidence has led clinicians to equate the risk of adverse perinatal outcome with pre-existing diabetes. Consequently, women are often intensively managed with increased obstetric monitoring, dietary regulation, and in some cases insulin therapy. However, there has been no sound evidence base to support intensive treatment. The key issue for clinicians and consumers is whether treatment of gestational diabetes and IGT will improve perinatal outcome.

OBJECTIVES

The objective of this review was to compare alternative policies of care for women with gestational diabetes and IGT in pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (12 September 2002) and the bibliographies of relevant papers. The Cochrane Central Register of Controlled Trials was also searched (The Cochrane Library, Issue 3, 2002).

SELECTION CRITERIA

Randomised controlled trials comparing alternative management strategies for women with gestational diabetes and IGT in pregnancy.

DATA COLLECTION AND ANALYSIS

Quality was assessed according to the criteria defined by the Cochrane Reviewers' Handbook. Data were extracted and checked independently by two reviewers. Any disagreements were resolved through discussion with the third reviewer.

MAIN RESULTS

Three studies with a total of 223 women were included. All three included studies involved women with IGT. No trials reporting treatments for gestational diabetes met the criteria. There are insufficient data for any reliable conclusions about the effect of treatments for IGT on perinatal outcome. The difference in abdominal operative delivery rates is not statistically significant (relative risk (RR) 0.86, 95% confidence interval 0.51 to 1.45) and the effect on special care baby unit admission is also not significant (RR 0.49, 95% confidence interval (CI) 0.19 to 1.24). Reduction in birthweight greater than 90th centile (RR 0.55, 95% CI 0.19 to 1.61) was not found to be significant. This review suggests that an interventionist policy of treatment may be associated with a reduced risk of neonatal hypoglycaemia (RR 0.25, 95% CI 0.07 to 0.86). No other statistically significant differences were detected. A number of outcomes are only reported by one study resulting in a small sample and wide confidence intervals.

REVIEWER'S CONCLUSIONS

There are insufficient data for any reliable conclusions about the effects of treatments for impaired glucose tolerance on perinatal outcome.

Transdermal drug delivery by jet injectors: energetics of jet formation and penetration

PURPOSE

Pressure-driven jets have been used for intradermal delivery of a variety of drugs. Despite their introduction into clinical medicine, variability and occasional bruising have limited their widespread acceptance. Although numerous clinical studies of jet injectors have been reported in the literature, surprisingly little is known about the mechanisms of jet penetration into the skin. In this article, we report results of our studies aimed at determining the dependence of drug delivery on jet velocity and diameter. These studies were performed using two experimental models, porcine skin and human skin. Our rationale for using two models was to explore the possibility of using porcine skin as a model for human skin.

METHODS

Dermal penetration of jets possessing a range of diameters from 76 microm to 559 microm and a range of velocities from 80 m/s to 190 m/s was studied into human and porcine skin. Penetration was quantified using radiolabeled mannitol. Pressure and velocity of the jets were measured using a calibrated pressure transducer and high-speed photography.

RESULTS

Penetration of the jet into the skin was determined by two main parameters, jet diameter and average jet velocity. Substantial variation in jet penetration into porcine skin was observed for skin pieces obtained from different anatomic locations. For porcine skin, a parabolic dependence of jet delivery on velocity and diameter was observed. The threshold velocity is suggested to be between 80 and 100 m/s for a jet diameter of 152 microm. Above the threshold velocity, the delivery increased for velocities up to 150 m/s, after which delivery decreased with increasing velocity. At a constant velocity of 150 m/s, jet delivery exhibited a maximum at a diameter of 152 microm. Results obtained with human skin were qualitatively similar but quantitatively different. The threshold velocity for jet penetration into human skin was comparable with that in porcine skin; however, the maxima observed in jet delivery into porcine skin with respect to jet velocity was not apparent for human skin over the range of velocities explored.

CONCLUSIONS

These studies offer a quantitative analysis of jet penetration into the skin.

Pharmacokinetics and pharmacodynamics of a new formulation of recombinant human growth hormone administered by ZomaJet 2 Vision, a new needle-free device, compared to subcutaneous administration using a conventional syringe

The objective of the present study was to investigate the applicability of a new human growth hormone (Zomacton) formulation, administered both by a conventional syringe and by a new needle-free device (ZomaJet 2 Vision). The study was performed according to a randomized, controlled, three-period crossover design. On 3 separate days, all subjects received in a random order a single subcutaneous injection of 1.67 mg hGH as follows: Zomacton 4 mg/ml conventional syringe administration (Treatment A), Zomacton 10 mg/ml conventional syringe administration (Treatment B), or Zomacton 10 mg/ml ZomaJet 2 Vision administration (Treatment C). The pharmacokinetic parameters were assessed for the individual subjects in each group by noncompartmental methods. Bioequivalence was assessed based on log-transformed AUC and C(max) values. To investigate the effectiveness of two formulations and the different administration methods, the pharmacodynamic parameters (insulin-like growth factor-1 [IGF-1] and free fatty acids [FFA]) were also evaluated. No subjects were withdrawn due to adverse events. The local tolerance assessment (assessed by inspection)revealed no differences between ZomaJet2 Vision application and conventional injections by syringe. Administration of the new hGH formulation by syringe was found to be bioequivalent with the reference treatment, both based on AUC and C(max) values; the new formulation administered by use of ZomaJet 2 Vision was found to be bioequivalent based on AUC values only. When using the ZomaJet 2 Vision, the absorption of hGH was faster, resulting in higher C(max) values. The maximum hGH serum concentration of around 20 ng/ml was observed 3.5 to 4 hours after drug administration. The terminal half-life was found to be around 2.5 hours. Comparison of the pharmacodynamic profiles (both IGF-1 and FFA) demonstrated bioequieffectiveness. These results support the use of jet injectors as a viable alternative to the traditional injection pens.

Fluid mechanics analysis of a spring-loaded jet injector

A syringe jet injector is a device designed to administer a drug quickly and painlessly through the skin. Though syringe jet injectors have been in use for almost 50 years, current designs still suffer from inconsistent performance. To better understand the fluid mechanics of jet injection and gain insight into how the design might influence performance, two theoretical analyses to determine the fluid pressure profile at the exit orifice were conducted. The first was a continuum analysis assuming static incompressibility. Results demonstrated that the maximum jet pressure was highly sensitive to the spring constant, initial piston velocity, and piston cross-sectional area while the time to achieve the maximum pressure was most sensitive to the injection chamber length, initial piston velocity, bulk modulus of the injectant, and the piston cross-sectional area. The second analysis was a shock wave analysis. Results demonstrated a stepwise pressure-time plot that was similar in magnitude to that for the continuum analysis assuming static incompressibility. Results from these two investigations are useful for design modification of the jet injector to achieve desired pressure-time profiles at the orifice. Control of pressure-time profiles may help to achieve a more consistent and effective injection process.

Current status and future prospects of parenteral insulin regimens, strategies and delivery systems for diabetes treatment

A strong relationship between long term metabolic control and low frequency of chronic diabetes complications was shown in the Diabetes Control Complication Trial (DCCT). However, the subcutaneous intensive insulin therapy required to achieve the glycemic goals defined by the DCCT led to an unacceptable frequency of severe hypoglycemia and a significant weight gain. This limits the benefits of this therapy and excludes groups of patients such as young children, the elderly or hypoglycemia prone patients. The intensive therapy and self blood glucose monitoring (SMBG) necessary to limit hypoglycemia represent a heavy burden for the patients and their family. Improvements in parenteral insulin therapy are possible by either modifying subcutaneous insulin characteristics (analogs, adjunction of peptides such as amylin, GLP1, IGF1), or by developing better routes of administration and making SMBG easier, which is a key to intensive insulin therapy success. The ultimate goal remains the development of an automated, glucose controlled device.

Pharmacokinetics and pharmacodynamics of recombinant human growth hormone by subcutaneous jet- or needle-injection in patients with growth hormone deficiency

Eighteen growth hormone (GH) deficient children and adolescents (11 6/12-20 9/12 y) participated in a randomized open, two-period (4 weeks) cross-over study to evaluate the pharmacokinetics and pharmacodynamics of recombinant human growth hormone (rhGH) administered daily, either by subcutaneous jet-injection or conventional needle-injection. Plasma growth hormone (GH), insulin-like growth factor 1 (IGF-1), insulin-like growth factor binding protein 3 (IGFBP-3), glucose, insulin, HbAlc and serum-free fatty acids (FFA) levels were analysed repeatedly. GH absorption characteristics, expressed as AUC(0-infinity), Cmax and Tmax ratio (%) jet-injected over needle-injected were similar in both groups. IGF-I and IGFBP-3 plasma levels were identical in both groups. Serum FFA concentrations were comparable after GH administration with either injection device. Surprisingly nocturnal blood glucose decreased to asymptomatic hypoglycaemic levels in all patients. The results of this study showed equal responses concerning absorption and bioavailability of growth hormone administered daily for 4 weeks by either a jet- or a needle-injection device in GH-deficient children and adolescents.

Evaluation of a no-needle penile injector: a preliminary study evaluating tissue penetration and its hemodynamic consequences in the rat

OBJECTIVES

Intracavernous needle injection is an effective delivery method for pharmacotherapy of erectile dysfunction. Needle phobia, pain, and concern about local tissue injury have stimulated the search for new, less invasive means of inducing penile erection. In this preliminary communication, we evaluate a jet injector as an alternative to needle injection for intracavernous delivery of vasoactive drugs.

METHODS

Jet injection was evaluated in three groups of rats receiving either India ink, saline, or papaverine into the penis. The ability of the jet injection to penetrate through the tunica albuginea and deliver liquid to the corpora cavernosa smooth muscle was assessed by the degree of staining within the corpus cavernosum (ink group), histologic change (saline group), and rise in intracavernous pressure (papaverine group). Erectile capacity following cavernous nerve electric stimulation was compared before and 1 hour after injection of saline or papaverine.

RESULTS

Ink traversed the skin and tunica albuginea with extensive deposition noted within the cavernous spaces. Varying degree of subcutaneous hemorrhage were seen with saline jet injection; however, the corpus cavernous smooth muscles showed no evidence of injury. Jet injection of papaverine 3250 micrograms significantly increased cavernous pressure (39.4 +/- 4.6 cm H2O) compared with saline injection (2.8 +/- 1.3 cm H2O).

CONCLUSIONS

We conclude that acute jet injection is an effective method for intracavernous delivery of drugs. Long-term effects should be evaluated prior to clinical use.

DNA vaccines

Immunization with plasmid DNA encoding antigenic proteins elicits both antibody and cell-mediated immune responses. This method of producing the protein antigens of interest directly in host cells can provide appropriate tertiary structure for the induction of conformationally specific antibodies, and also facilitates the induction of cellular immune responses. DNA immunization has provided effective protective immunity in various animal models. The immune responses induced by DNA vaccines may in some instances be preferable to those produced by immunization using conventional methods. DNA vaccination appears to be applicable to a variety of pathogens and is a useful method of raising immune responses. Thus this approach to vaccination has the potential to be a successful method of rapidly screening for antigens capable of inducing protective immunity, and of inducing protective immunity against pathogens of clinical importance.