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Wang X, Xiao W, Liang Z, Li S, Tang Q. Efficacy and safety of once-weekly basal insulin versus once-daily basal insulin in patients with type 2 diabetes: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e36308. [PMID: 38206709 PMCID: PMC10754560 DOI: 10.1097/md.0000000000036308] [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: 06/09/2023] [Accepted: 11/03/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Once-weekly insulin is expected to improve treatment compliance and durability and lead to better glycemic control. Several clinical trials on once-weekly insulin have recently been published. We conducted a systematic review and meta-analysis to investigate the efficacy and safety of once-weekly insulin versus once-daily insulin in type 2 diabetes (T2D). METHODS The following databases were searched for studies: PubMed, EMBASE, and Cochrane library (From January 1, 1946 to May 9, 2023). All randomized trials comparing weekly versus daily insulin in T2D were eligible for inclusion. Data analysis was performed using STATA 17.0 software (Stata Corporation, College Station, TX). The main outcomes and indexes included reduction in Hemoglobin A1c (HbA1c), fasting plasma glucose and bodyweight, proportion of patients achieving HbA1c < 7%, time-in-range 70 to 180 mg/dL and adverse events. RESULTS This systematic review and meta-analysis included 7 randomized controlled studies involving 2391 patients (1347 receiving 1-week insulin and 1044 receiving 1-day insulin). Once-weekly insulin was not inferior to once-daily insulin in HbA1c change [estimated treatment difference (ETD) = -0.05; 95% confidence intervals (CI): -0.14 to 0.04), HbA1c < 7% (odds ratio = 1.14; 95% CI: 0.87-1.50), fasting plasma glucose (ETD = 0.09; 95% CI: -0.19 to 0.36) and body weight loss (ETD = 0.27; 95% CI: -0.36 to 0.91). In terms of time-in-range 70 to 180 mg/dL, weekly insulin was superior to daily insulin (MTD = 3.84; 95% CI: 1.55-6.08). Icodec was associated with higher incidence of all adverse events (odds ratio = 1.20; 95% CI: 1.03-1.48; P = .024), but did not result in high risk of serious and severe adverse events. Moreover, icodec and Basal Insulin Fc did not result in higher incidence of hypoglycemia compared with insulin daily. CONCLUSION Our meta-analysis found that insulin weekly was well tolerated and effective for glycemic control. Once-weekly insulin was not inferior to once-daily insulin in both efficacy and safety in T2D.
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Affiliation(s)
- Xinxin Wang
- Affiliated Guangdong Hospital of Integrated Traditional Chinese and Western Medicine of Guangzhou University of Chinese Medicine, Nanhai District, Foshan City, Guangdong Province, China
| | - Wei Xiao
- Affiliated Guangdong Hospital of Integrated Traditional Chinese and Western Medicine of Guangzhou University of Chinese Medicine, Nanhai District, Foshan City, Guangdong Province, China
| | - Zhanpeng Liang
- Department of Oncology, Zhongshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Traditional Chinese Medicine, Guangdong Province, China
| | - Shixiang Li
- School of Traditional Chinese Medicine, Jinan University, Tianhe District, Guangzhou City, Guangdong Province, China
| | - Qizhi Tang
- . Department of Endocrinology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Foshan City, Guangdong Province, the People’s Republic of China
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Fritsche A, Anderten H, Pfohl M, Pscherer S, Borck A, Pegelow K, Bramlage P, Seufert J. HbA1c target achievement in the elderly: results of the Titration and Optimization trial for initiation of insulin glargine 100 U/mL in patients with type 2 diabetes poorly controlled on oral antidiabetic drugs. BMJ Open Diabetes Res Care 2019; 7:e000668. [PMID: 31423316 PMCID: PMC6688703 DOI: 10.1136/bmjdrc-2019-000668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/19/2019] [Accepted: 07/02/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To identify real-world, age-related trends in the use of insulin glargine 100 U/mL (Gla-100) as part of basal-supported oral therapy (BOT). RESEARCH DESIGN AND METHODS The prospective, observational Titration and Optimization registry enrolled patients with poorly controlled type 2 diabetes mellitus initiated on Gla-100 BOT. The primary outcome was the proportion of patients with capillary fasting blood glucose (FBG) ≤110 mg/dL on ≥2 occasions and/or who met their individual HbA1c target within 12 months. RESULTS 2462 patients were analyzed (<65 years: n=1122; 65-74 years: n=771; ≥75 years: n=569). Diabetes duration (6.8, 8.9, and 11.2 years, p<0.0001) and proportion of women (40.7%, 47.9%, and 55.7%, p<0.0001) increased with age. Baseline HbA1c was highest in <65-year-olds (8.6% vs 8.4% and 8.5%, p<0.0001). Gla-100 up-titration until 12 months was highest in <65-year-olds (+11.6 U/day), compared with 65-74 (+10.2 U/day) and ≥75 years (+8.8; p<0.0001) but similar by units per kilogram, as was the decrease in FBG (<65: -64.1 mg/dL; 65-74: -56.1 mg/dL; ≥75: -53.4 mg/dL) and HbA1c (<65: -1.47%; 65-74: -1.31%; ≥75: -1.22%, p<0.0001). At 12 months, 65.9% of participants met the primary endpoint, with no significant difference between age groups. The proportion achieving their individual HbA1c target was lower for <65-year-olds (46.0% vs 54.3% and 54.7%; p<0.02). Symptomatic hypoglycemia incidence was more common in the ≥75-year-old group (3.4% vs 1.4% and 1.4%; p=0.0126). CONCLUSIONS BOT with Gla-100 results in similar improvements of glycemic values with low risk of hypoglycemia across age groups. Given the link between HbA1c and long-term cardiovascular risk, ensuring appropriately stringent target-setting, intensification of basal insulin and making sure hypoglycemia is avoided is of paramount importance. TRIAL REGISTRATION NUMBER Database: https://awbdb.bfarm.de; Identifier: 1641; Date of registration: September 23, 2013.
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Affiliation(s)
| | - Helmut Anderten
- Gemeinschaftspraxis Anderten-Krok & Partner, Hildesheim, Germany
| | - Martin Pfohl
- Medizinische Klinik I, Evang. Krankenhaus Bethesda gGmbH, Duisburg, Germany
| | - Stefan Pscherer
- Klinik für Innere Medizin III, Sophien- undHufeland-Klinikum, Weimar, Germany
| | - Anja Borck
- Sanofi-Aventis Deutschland GmbH, Berlin, Germany
| | | | - Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin, Cloppenburg, Germany
| | - J Seufert
- Abteilung Endokrinologie und Diabetologie, Klinik für Innere Medizin II, Medizinische Fakultät, Albert-Ludwig-Universität Freiburg, Freiburg, Germany
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Fleischmann H, Göke R, Bramlage P. Addition of once daily prandial lixisenatide to basal insulin therapy in patients with type-2 diabetes results in a reduction of HbA1c as an effect of postprandial glucose lowering. Diabetes Metab Syndr 2017; 11 Suppl 1:S91-S97. [PMID: 27986406 DOI: 10.1016/j.dsx.2016.12.014] [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: 09/28/2016] [Accepted: 12/12/2016] [Indexed: 11/30/2022]
Abstract
AIMS Basal insulin has been shown to effectively reduce fasting blood glucose (FBG), but postprandial plasma glucose (PPG) excursions may remain higher than normal. Glucagon-like peptide (GLP)-1 receptor agonists such as the short-acting lixisenatide are able to control such excursions by slowing gastric emptying. However, data regarding its use in a real world clinical setting are scarce. METHODS 24 week, prospective, multicentre, non-interventional study in 1437 patients with type-2 diabetes receiving 20μg lixisenatide once daily in combination with basal insulin. The per-protocol set (PPS) comprised 540 patients. RESULTS HbA1c levels were found to decrease significantly over 24 weeks of treatment in the PPS (0.94±0.99% [7.9±8.5]; p≤0.001). An HbA1c of <7% (53mmol/mol) was achieved in 26.9% of patients, with 9.8% reaching <6.5% (48mmol/mol) and 30.0% reaching their individual treatment goal. There was a slight decrease in FBG (2.84±30.4mg/dl; p≤0.001), and a significant reduction in PPG, with levels decreasing by between 35mg/dl (1.9mmol/l) and 38mg/dl (2.1mmol/l), respectively on average after all main meals in basal optimised patients (PPS; ≤140mg/dl). Body weight decreased from 101 to 98kg with a mean difference of 3.10±4.10kg (p≤0.001). There were few reports of hypoglycaemia and no reports of serious hypoglycaemia and need for external help. AEs were infrequent, and were in line with previous studies. CONCLUSIONS Lixisenatide in combination with basal insulin was shown to be an effective treatment strategy for patients with type 2 diabetes, controlling HbA1c levels by reduction of PPG excursions during the whole day.
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Affiliation(s)
| | - Rüdiger Göke
- Diabetes Schwerpunktpraxis, Kirchhain, Marburg, Germany.
| | - Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin, Mahlow, Germany.
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Muhammad SA, Raza W, Nguyen T, Bai B, Wu X, Chen J. Cellular Signaling Pathways in Insulin Resistance-Systems Biology Analyses of Microarray Dataset Reveals New Drug Target Gene Signatures of Type 2 Diabetes Mellitus. Front Physiol 2017; 8:13. [PMID: 28179884 PMCID: PMC5264126 DOI: 10.3389/fphys.2017.00013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/09/2017] [Indexed: 01/09/2023] Open
Abstract
Purpose: Type 2 diabetes mellitus (T2DM) is a chronic and metabolic disorder affecting large set of population of the world. To widen the scope of understanding of genetic causes of this disease, we performed interactive and toxicogenomic based systems biology study to find potential T2DM related genes after cDNA differential analysis. Methods: From the list of 50-differential expressed genes (p < 0.05), we found 9-T2DM related genes using extensive data mapping. In our constructed gene-network, T2DM-related differentially expressed seeder genes (9-genes) are found to interact with functionally related gene signatures (31-genes). The genetic interaction network of both T2DM-associated seeder as well as signature genes generally relates well with the disease condition based on toxicogenomic and data curation. Results: These networks showed significant enrichment of insulin signaling, insulin secretion and other T2DM-related pathways including JAK-STAT, MAPK, TGF, Toll-like receptor, p53 and mTOR, adipocytokine, FOXO, PPAR, P13-AKT, and triglyceride metabolic pathways. We found some enriched pathways that are common in different conditions. We recognized 11-signaling pathways as a connecting link between gene signatures in insulin resistance and T2DM. Notably, in the drug-gene network, the interacting genes showed significant overlap with 13-FDA approved and few non-approved drugs. This study demonstrates the value of systems genetics for identifying 18 potential genes associated with T2DM that are probable drug targets. Conclusions: This integrative and network based approaches for finding variants in genomic data expect to accelerate identification of new drug target molecules for different diseases and can speed up drug discovery outcomes.
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Affiliation(s)
- Syed Aun Muhammad
- Institute of Molecular Biology and Biotechnology, Bahauddin Zakariya UniversityMultan, Pakistan; Institute of Biopharmaceutical Informatics and Technologies, Wenzhou Medical UniversityWenzhou, China; Wenzhou Medical University, 1st Affiliate Hospital WenzhouWenzhou, China
| | - Waseem Raza
- Institute of Molecular Biology and Biotechnology, Bahauddin Zakariya University Multan, Pakistan
| | - Thanh Nguyen
- Institute of Biopharmaceutical Informatics and Technologies, Wenzhou Medical UniversityWenzhou, China; Wenzhou Medical University, 1st Affiliate Hospital WenzhouWenzhou, China; Department of Computer and Information Science, Purdue UniversityIndianapolis, IN, USA
| | - Baogang Bai
- Institute of Biopharmaceutical Informatics and Technologies, Wenzhou Medical University Wenzhou, China
| | - Xiaogang Wu
- Institute for Systems Biology Seattle, WA, USA
| | - Jake Chen
- Institute of Biopharmaceutical Informatics and Technologies, Wenzhou Medical UniversityWenzhou, China; Wenzhou Medical University, 1st Affiliate Hospital WenzhouWenzhou, China; Department of Computer and Information Science, Purdue UniversityIndianapolis, IN, USA; Indiana Center for Systems Biology and Personalized Medicine, Indiana University-Purdue UniversityIndianapolis, IN, USA; Informatics Institute, School of Medicine, The University of AlabamaBirmingham, AL, USA
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5
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Fiesselmann A, Wiesner T, Fleischmann H, Bramlage P. Real-world therapeutic benefits of patients on insulin glargine versus NPH insulin. Acta Diabetol 2016; 53:717-26. [PMID: 27093968 DOI: 10.1007/s00592-016-0862-0] [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: 02/04/2016] [Accepted: 03/29/2016] [Indexed: 10/21/2022]
Abstract
AIMS The addition of a single injection of insulin to the oral drugs (basal supported oral therapy; BOT) has been shown to greatly reduce blood glucose levels. The intermediate-acting NPH insulin (NPH) and the long-acting insulin glargine (Lantus(®)) have been compared for use in BOT in numerous clinical trials; however, their efficacy and safety in a real-life setting have not been described. METHODS TIP (therapeutic benefits of patients on insulin glargine vs. NPH insulin being poorly controlled on prior short-time basal-insulin supported therapy with NPH insulin or insulin glargine) is a non-interventional, multicentre, observational study over 24 weeks. A total of 2629 patients were enrolled and 1931 were fully evaluable (1614 insulin glargine, 303 NPH insulin). Propensity scoring (PSM) was used to match 570 patients into 2 similar cohorts of 285 patients. RESULTS In the PSM cohort, a slightly greater reduction in FBG and HbA1c levels was seen in the insulin glargine group compared to the NPH group. A weight loss, which was slightly more pronounced in insulin glargine patients despite receiving a lower insulin dose relative to the NPH group, was seen in both the groups. Additionally, hypoglycaemia, including nocturnal and severe events, was more prevalent in the patients receiving BOT with NPH. The occurrence of new micro- or macro-vascular complications and adverse events was low for both groups. A large proportion of patients changed from NPH therapy to insulin glargine therapy during the study, which was mainly attributable to insufficient glucose modulation. Improvements in quality of life and treatment satisfaction were found for both types of insulin. CONCLUSIONS This observational study provides evidence from a real-life setting that BOT with insulin glargine provides slightly greater reductions in weight, FBG and HbA1c levels, with a lower risk of hypoglycaemia than patients receiving NPH. This conclusion indicates that insulin glargine may be preferable to NPH insulin for BOT.
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Affiliation(s)
| | - Tobias Wiesner
- MVZ Stoffwechselmedizin Leipzig, Prager Str. 34, 04317, Leipzig, Germany
| | | | - Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin, Menzelstrasse 21, 15831, Mahlow, Germany.
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Wang Q, Li H, Xiao Y, Li S, Li B, Zhao X, Ye L, Guo B, Chen X, Ding Y, Bao C. Locally controlled delivery of TNFα antibody from a novel glucose-sensitive scaffold enhances alveolar bone healing in diabetic conditions. J Control Release 2015; 206:232-42. [DOI: 10.1016/j.jconrel.2015.03.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 03/02/2015] [Accepted: 03/17/2015] [Indexed: 01/01/2023]
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Abstract
Insulin is the most powerful glycemic control agent available. However, its use as a therapeutic modality requires education of the patient and regimentation of food intake, exercise, and frequent glucose monitoring. Such regimentation is particularly important when using a basal-bolus therapy approach. The introduction of many novel noninsulin drugs in the past decade has resulted in better glycemic control and often a need to reduce previously instituted insulin therapy. Although many of these novel therapies by themselves do not cause hypoglycemia, by reducing the overall glycemic burden through a myriad of mechanisms, they function in an insulin-sparing fashion. The doses of exogenously administered insulin may therefore need to be reduced in the presence of these new drugs to mitigate hypoglycemia. For insulin therapy (or any other drug treatment) to be successful, it is critical that the physician not only establish glycemic goals, but communicate these goals to the patient. The measurement of HbA1c helps in achieving a long-term goal, but on a day-today basis, patients need to be cognizant of their own BG goals and what they need to do if falling outside of target. The patients' understanding of self-management skills and empowerment are therefore foundational to insulin therapy.
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Affiliation(s)
- Farah Meah
- Division of Endocrinology, Indiana University School of Medicine, 541 Clinical Drive, CL 365, Indianapolis, IN 46202, USA
| | - Rattan Juneja
- Division of Endocrinology, Indiana University School of Medicine, 541 Clinical Drive, CL 365, Indianapolis, IN 46202, USA.
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8
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Owens DR, Traylor L, Dain MP, Landgraf W. Efficacy and safety of basal insulin glargine 12 and 24 weeks after initiation in persons with type 2 diabetes: a pooled analysis of data from treatment arms of 15 treat-to-target randomised controlled trials. Diabetes Res Clin Pract 2014; 106:264-74. [PMID: 25195151 DOI: 10.1016/j.diabres.2014.08.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 05/30/2014] [Accepted: 08/03/2014] [Indexed: 02/01/2023]
Abstract
AIM Evaluate early (0-12 weeks) and later (12-24 weeks) treatment outcomes in subjects with type 2 diabetes not achieving glycaemic control with oral antidiabetes drugs (OADs). METHODS Selected data were pooled from 15 randomised, controlled treat-to-target (fasting plasma glucose < 100mg/dL [< 5.6 mmol/L]) trials adding insulin glargine to metformin, a sulphonylurea, or both. Glycaemic and hypoglycaemia parameters, insulin dose, and body weight at weeks 12 and 24 were assessed using individualised subject-level data. RESULTS Data from 2837 subjects were analysed. HbA1c decreased from 8.8% (73 mmol/mol) at baseline by 1.4% (15 mmol/mol) at Week 12, and a further 0.2% (2 mmol/mol) at Week 24 in the pooled population. Similar reductions were observed across the different treatment groups. HbA1c < 7.0% (<53 mmol/mol) was reached by 34.8% of participants at Week 12 and an additional 24.3% by Week 24. Hypoglycaemia incidence and rates were similar during the early and continued treatment periods across all treatment combinations, but were markedly lower for insulin glargine plus metformin versus the other 2 regimens. CONCLUSIONS Early and sustained glycaemic benefits with a low-risk of hypoglycaemia are observed after initiation of insulin glargine in a pooled type 2 diabetes cohort previously uncontrolled on OADs.
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Affiliation(s)
- David R Owens
- Institute of Life Sciences, Swansea University, Swansea, UK.
| | | | | | - Wolfgang Landgraf
- Sanofi, Frankfurt, Germany; Third Medical Department, University of Dresden, Germany
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9
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Wei W, Zhou S, Miao R, Pan C, Xie L, Baser O, Gill J. Much ado about nothing? A real-world study of patients with type 2 diabetes switching Basal insulin analogs. Adv Ther 2014; 31:539-60. [PMID: 24831915 PMCID: PMC4033813 DOI: 10.1007/s12325-014-0120-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Indexed: 12/02/2022]
Abstract
Introduction Type-2 diabetes mellitus (T2DM) is a progressive disease, and many patients eventually require insulin therapy. This study examined real-world outcomes of switching basal insulin analogs among patients with T2DM. Methods Using two large United States administrative claims databases (IMPACT® and Humana®), this longitudinal retrospective study examined two cohorts of adult patients with T2DM. Previously on insulin glargine, Cohort 1 either continued insulin glargine (GLA-C) or switched to insulin detemir (DET-S), while Cohort 2 was previously on insulin detemir, and either continued insulin detemir (DET-C) or switched to insulin glargine (GLA-S). One-year follow-up treatment persistence and adherence, glycated hemoglobin (HbA1c), hypoglycemia events, healthcare utilization and costs were assessed. Selection bias was minimized by propensity score matching between treatment groups within each cohort. Results A total of 5,921 patients (mean age 60 years, female 50.0%, HbA1c 8.6%) were included in the analysis (Cohort 1: IMPACT®: n = 536 DET-S matched to n = 2,668 GLA-C; Humana®: n = 256 DET-S matched to n = 1,262 GLA-C; Cohort 2: n = 419 GLA-S matched to n = 780 DET-C), with similar baseline characteristics between treatment groups in each cohort. During 1-year follow-up, in Cohort 1, DET-S patients, when compared with GLA-C patients, had lower treatment persistence/adherence with 33–40% restarting insulin glargine, higher rapid-acting insulin use, worse HbA1c outcomes, significantly higher diabetes drug costs, and similar hypoglycemia rates, health care utilization and total costs. However, in Cohort 2 overall opposite outcomes were observed and only 19.8% GLA-S patients restarted insulin detemir. Conclusions This study showed contrasting clinical and economic outcomes when patients with T2DM switched basal insulin analogs, with worse outcomes observed for patients switching from insulin glargine to insulin detemir and improved outcomes when switching from insulin detemir to insulin glargine. Further investigation into the therapeutic interchangeability of insulin glargine and insulin detemir in the real-world setting is needed. Electronic supplementary material The online version of this article (doi:10.1007/s12325-014-0120-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wenhui Wei
- Sanofi US, Inc., Mail Stop 55C-220A, 55 Corporate Drive, Bridgewater, NJ, 08807, USA,
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Caparrotta TM, Evans M. PEGylated insulin Lispro, (LY2605541)--a new basal insulin analogue. Diabetes Obes Metab 2014; 16:388-95. [PMID: 23941279 DOI: 10.1111/dom.12196] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 04/19/2013] [Accepted: 08/05/2013] [Indexed: 12/25/2022]
Abstract
There is a clinical rationale for a basal insulin with a predictable action and low inter- and intra-individual variability coupled with an improved side effect and metabolic profile. Since insulin therapy is anabolic and its initiation is commonly associated with weight gain, an insulin preparation associated with a beneficial weight profile would represent a particularly valuable therapeutic entity. LY2605541, or PEGylated insulin Lispro, has a large hydrodynamic size while still exerting the metabolic effects of insulin. This may reduce absorption and clearance of the compound following subcutaneous administration. A number of preclinical and clinical studies have been constructed to evaluate the utility of this novel insulin. The currently available data from preclinical, phase I and phase II studies suggests LY2605541 has a non-inferior glucose-lowering efficacy compared to insulin glargine in people with type 1 and type 2 diabetes and may afford a weight-loss advantage. Pre-clinical studies indicate that LY2605541 has low mitogenic potency, exerting a preferential hepatic effect on glucose homeostasis. LY2605541 appears to cause elevated transaminases and derangement of lipid profiles. On the basis of these initial observations, LY2605541 requires further extensive clinical evaluation to fully assess its risk/benefit profile in the management in people with diabetes.
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Affiliation(s)
- T M Caparrotta
- Department of Medicine, University Hospital Llandough, Penarth, UK
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11
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Vähätalo MA, Viikari J, Rönnemaa T. Starting bedtime glargine versus NPH insulin in poorly controlled type 2 diabetic patients with various hyperglycemia types (fasting type or postprandial type). Acta Diabetol 2014; 51:233-8. [PMID: 23880900 PMCID: PMC3969512 DOI: 10.1007/s00592-013-0505-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 07/11/2013] [Indexed: 11/01/2022]
Abstract
Our aim was to compare the effects of an intermediate acting human insulin (NPH) and a long-acting insulin analog, insulin glargine, in insulin naïve type 2 diabetes patients, stratified by the type of hyperglycemia (fasting or postprandial type). Based on different action profiles, we hypothesized that patients having different hyperglycemia types would react differently when treated with these insulins. This is a post hoc analysis of the Lanmet study data. The Lanmet study was a randomized, 36-week controlled insulin initiation study in type 2 diabetes patients. 109 subjects with baseline HbA1c >8.0% (64 mmol/mol) completed the study. The patients were divided into two groups according to fasting glucose (mmol/l)/HbA1c (%) ratio. Patients with a ratio ≥1.3 were defined as having fasting type and those with a ratio <1.3 as having postprandial type hyperglycemia. The main outcome measures were change in HbA1c and body weight, and final insulin dose. Independently of insulin type, compared to patients with postprandial type hyperglycemia, those with fasting type hyperglycemia had 2.1 kg/m(2) greater initial BMI (p = 0.044), gained 2.0 kg more weight (p = 0.020, adjusted for baseline BMI p = 0.035), and had 36% greater final insulin dose/kg (p = 0.001). With respect to hyperglycemia type, there was no difference between NPH and glargine in their effects on HbA1c. When starting bedtime insulin in type 2 diabetes patients, those with fasting type hyperglycemia are prone to greater weight gain. Hyperglycemia type does not help in identifying patients who would benefit specially from either NPH insulin or insulin glargine.
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Affiliation(s)
- Markku A Vähätalo
- City of Loimaa Health Care Services, Department of Medicine, University of Turku, Turku, Finland,
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12
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Pistrosch F, Köhler C, Schaper F, Landgraf W, Forst T, Hanefeld M. Effects of insulin glargine versus metformin on glycemic variability, microvascular and beta-cell function in early type 2 diabetes. Acta Diabetol 2013; 50:587-95. [PMID: 23430192 PMCID: PMC3778903 DOI: 10.1007/s00592-012-0451-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 12/19/2012] [Indexed: 12/21/2022]
Abstract
We investigated whether basal insulin as first-line treatment in recently diagnosed type 2 diabetes (T2D) can improve glucose control, microvascular function and preserve insulin secretion in comparison with metformin (MET). In this open-label, randomized, prospective 36-week study, 75 patients (44 m, 31 f, mean age 60.7 ± 9.2 year) were allocated to treatment with either MET 1,000 mg b.i.d. (n = 36) or insulin glargine (GLA) at bedtime (n = 39). At baseline and study end, we performed a continuous glucose monitoring for assessment of interstitial glucose (IG) and measured microvascular function using Laser-Doppler fluxmetry. GLA versus MET treatment resulted in a more pronounced reduction in FPG (Δ: 3.1 ± 2.5 vs. 1.4 ± 1.5 mmol/l; p < 0.001) and overall IG (Δ AUC. 671 ± 507 vs. 416 ± 537 mmol/l min; p = 0.04). Postprandial PG and IG differences after a standardized test meal did not reach significance. Proinsulin/C-peptide and HOMA B as marker of endogenous insulin secretion were significantly more improved by GLA. Microvascular blood flow improved only in MET-treated patients. Early basal insulin treatment with GLA in T2D patients provided a better control of FPG, overall IG load and biomarker of beta-cell function compared to the standard treatment with MET. MET treatment resulted in an improvement of microvascular function. Studies of longer duration are needed to evaluate the durability of glucose control and β cell protection with early GLA treatment.
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Affiliation(s)
- F Pistrosch
- Study Centre Prof. Hanefeld, GWT, Technical University Dresden, Dresden, Germany,
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Ng CJ, Liew SM, Vethakkan SR, Abdullah A, Teng CL. Patient-adjusted versus health professional-adjusted insulin dosing for type 2 diabetes mellitus. Hippokratia 2013. [DOI: 10.1002/14651858.cd010574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Chirk Jenn Ng
- University of Malaya; Department of Primary Care Medicine; Faculty of Medicine Kuala Lumpur Malaysia Kuala
| | - Su May Liew
- University of Malaya; Department of Primary Care Medicine; Faculty of Medicine Kuala Lumpur Malaysia Kuala
| | - Shireene R Vethakkan
- University of Malaya; Department of Primary Care Medicine; Faculty of Medicine Kuala Lumpur Malaysia Kuala
| | - Adina Abdullah
- University of Malaya; Department of Primary Care Medicine; Faculty of Medicine Kuala Lumpur Malaysia Kuala
| | - Cheong Lieng Teng
- International Medical University Jalan Rasah; Department of Family Medicine; Seremban Negeri Sembilan Darul Khusus Malaysia 70300
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14
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Abstract
Type 2 diabetes mellitus has become a worldwide major health problem, and the number of people affected is steadily increasing. Thus, not all patients suffering from the disease can be treated by specialized diabetes centers or outpatient clinics, but by primary care physicians. The latter, however, might have time constraints and have to deal with many kinds of diseases or with multimorbid patients, so their focus is not so much on lowering high blood glucose values. Thus, the physicians, as well as the patients themselves, are often reluctant to initiate and adjust insulin therapy, although basal insulin therapy is considered the appropriate strategy after oral antidiabetic drug failure, according to the latest international guidelines. A substantial number of clinical studies have shown that insulin initiation and optimization can be managed successfully by using titration algorithms-even in cases where patients themselves are the drivers of insulin titration. Nevertheless, tools and strategies are needed to facilitate this process in the daily life of both primary health care professionals and patients with diabetes.
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Affiliation(s)
- Sabine Arnolds
- Profil, Neuss, Germany, Hellersbergstrasse 9, Neuss, Germany.
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15
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Abstract
OBJECTIVES Degludec is a novel long-acting insulin analogue, providing an adequate supply of basal insulin over 24 hours with one daily injection, with a supposed greater reproducibility and flexibility than other basal insulins. METHODS An extensive search of Medline and the Cochrane Library for 'degludec' was performed, up to July 1st, 2012, collecting all randomised trials with a duration of at least 16 weeks and enrolling patients with diabetes. The principal outcome was the effect of degludec, compared with other basal insulins, on endpoint HbA1c and hypoglycaemia. Secondary outcomes included BMI, FPG at endpoint, and the incidence of cardiovascular events and cancer. RESULTS In the four trials comparing degludec with glargine, endpoint HbA1c was similar in the two groups, whereas FPG was significantly lower in degludec-treated patients. Degludec was associated with a lower rate of overall and nocturnal hypoglycaemia in type 2 and type 1 diabetes, respectively. No differences were observed for cardiovascular events and cancer. STUDY LIMITATIONS The number of available trials and the duration of exposure were limited, so the results obtained should be considered preliminary. CONCLUSIONS Degludec appears to be associated with a lower incidence of hypoglycaemia in comparison with glargine, for similar levels of glycaemic control. The use of this agent could represent one step further in insulin therapy.
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Affiliation(s)
- Matteo Monami
- Section of Geriatric Cardiology and Medicine, Department of Cardiovascular Medicine, University of Florence and Careggi Teaching Hospital, Florence, Italy
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16
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Abstract
Structure-based protein design has enabled the engineering of insulin analogs with improved pharmacokinetic and pharmacodynamic properties. Exploiting classical structures of zinc insulin hexamers, the first insulin analog products focused on destabilization of subunit interfaces to obtain rapid-acting (prandial) formulations. Complementary efforts sought to stabilize the insulin hexamer or promote higher-order self-assembly within the subcutaneous depot toward the goal of enhanced basal glycemic control with reduced risk of hypoglycemia. Current products either operate through isoelectric precipitation (insulin glargine, the active component of Lantus; Sanofi-Aventis, Paris, France) or employ an albumin-binding acyl tether (insulin detemir, the active component of Levemir; Novo-Nordisk, Basværd, Denmark). In the past year second-generation basal insulin analogs have entered clinical trials in an effort to obtain ideal flat 24-hour pharmacodynamic profiles. The strategies employ non-standard protein modifications. One candidate (insulin degludec; Novo-Nordisk a/s) undergoes extensive subcutaneous supramolecular assembly coupled to a large-scale allosteric reorganization of the insulin hexamer (the TR transition). Another candidate (LY2605541; Eli Lilly and Co., Indianapolis, IN, USA) utilizes coupling to polyethylene glycol to delay absorption and clearance. On the other end of the spectrum, advances in delivery technologies (such as microneedles and micropatches) and excipients (such as the citrate/zinc-ion chelator combination employed by Biodel, Inc., Danbury, CT, USA) suggest strategies to accelerate PK/PD toward ultra-rapid-acting insulin formulations. Next-generation insulin analogs may also address the feasibility of hepatoselective signaling. Although not in clinical trials, early-stage technologies provide a long-range vision of "smart insulins" and glucose-responsive polymers for regulated hormone release.
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Affiliation(s)
- Vijay Pandyarajan
- Departments of Biochemistry, Biomedical Engineering and Medicine, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Michael A. Weiss
- Departments of Biochemistry, Biomedical Engineering and Medicine, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA
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17
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Hasani-Ranjbar S, Fazlollahi MR, Mehri A, Larijani B. Allergy to human insulin and specific immunotherapy with glargine; case report with review of literature. Acta Diabetol 2012; 49:69-73. [PMID: 21279523 DOI: 10.1007/s00592-011-0254-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 01/07/2011] [Indexed: 10/18/2022]
Abstract
Insulin has an important role in the treatment of diabetic patients. Further, it can result in undesirable side effects. One of the problems that are associated with insulin therapy is allergic reactions. Although insulin allergy is uncommon, especially in patients with type-2 diabetes, but when it occurs, its management can be difficult. We report a 55-year-old woman with poorly controlled type-2 diabetes and insulin allergy. She revealed hypersensitivity reactions including urticaria and respiratory symptoms, immediately after injection. So, specific immunotherapy with other insulin preparations was done. Finally, after specific immunotherapy, we were able to treat the patient with short- and long-acting analogs successfully.
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Affiliation(s)
- S Hasani-Ranjbar
- Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Shariati Hospital, Iran.
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18
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Berenson DF, Weiss AR, Wan ZL, Weiss MA. Insulin analogs for the treatment of diabetes mellitus: therapeutic applications of protein engineering. Ann N Y Acad Sci 2011; 1243:E40-E54. [PMID: 22641195 PMCID: PMC3360579 DOI: 10.1111/j.1749-6632.2012.06468.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The engineering of insulin analogs represents a triumph of structure-based protein design. A framework has been provided by structures of insulin hexamers. Containing a zinc-coordinated trimer of dimers, such structures represent a storage form of the active insulin monomer. Initial studies focused on destabilization of subunit interfaces. Because disassembly facilitates capillary absorption, such targeted destabilization enabled development of rapid-acting insulin analogs. Converse efforts were undertaken to stabilize the insulin hexamer and promote higher-order self-assembly within the subcutaneous depot toward the goal of enhanced basal glycemic control with reduced risk of hypoglycemia. Current products either operate through isoelectric precipitation (insulin glargine, the active component of Lantus(®); Sanofi-Aventis) or employ an albumin-binding acyl tether (insulin detemir, the active component of Levemir(®); Novo-Nordisk). To further improve pharmacokinetic properties, modified approaches are presently under investigation. Novel strategies have recently been proposed based on subcutaneous supramolecular assembly coupled to (a) large-scale allosteric reorganization of the insulin hexamer (the TR transition), (b) pH-dependent binding of zinc ions to engineered His-X(3)-His sites at hexamer surfaces, or (c) the long-range vision of glucose-responsive polymers for regulated hormone release. Such designs share with wild-type insulin and current insulin products a susceptibility to degradation above room temperature, and so their delivery, storage, and use require the infrastructure of an affluent society. Given the global dimensions of the therapeutic supply chain, we envisage that concurrent engineering of ultra-stable protein analog formulations would benefit underprivileged patients in the developing world.
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Affiliation(s)
- Daniel F. Berenson
- Department of Molecular Biophysics and Biochemistry Yale University. New Haven, CT
| | - Allison R. Weiss
- National Institute of Diabetes, Digestive and Kidney Diseases National Institutes of Health, Bethesda, MD
| | - Zhu-li Wan
- Departments of Biochemistry, Biomedical Engineering and Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Michael A. Weiss
- Departments of Biochemistry, Biomedical Engineering and Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
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19
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D’Aleo V, Mancarella R, Del Guerra S, Boggi U, Filipponi F, Marchetti P, Lupi R. Direct effects of rapid-acting insulin analogues on insulin signaling in human pancreatic islets in vitro. DIABETES & METABOLISM 2011; 37:324-9. [DOI: 10.1016/j.diabet.2010.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 11/16/2010] [Accepted: 12/15/2010] [Indexed: 10/18/2022]
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20
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Abstract
Primary goals in the treatment of type 2 diabetes mellitus (T2DM) include lowering blood glucose levels sufficiently to prevent micro- and macrovascular complications while limiting side effects, such as hypoglycemia and excessive weight gain. Patients with T2DM are typically treated initially with oral antidiabetes agents; however, as the disease progresses, most will require insulin to maintain glycemic control. Often insulin therapy is initiated with basal insulin, and the objective of this article is to present the conceptual aspects of basal insulin therapy and use these concepts to illustrate important clinical aspects. This will be accomplished within a broader contextual discussion of the normal physiologic patterns of insulin secretion, which consist of sustained levels of basal insulin production throughout the day, superimposed with bursts of insulin secretion following a meal (termed bolus or prandial insulin secretion) that slowly decay over 1 to 3 hours. Long-acting basal insulin analogs form a key component of basal-bolus therapy and provide basal support for patients with T2DM. Insulin therapy is often initiated with basal insulin, and newer long-acting analogs, such as insulin glargine and insulin detemir, provide steady, reliable basal insulin coverage in addition to significant advantages over traditional long-acting insulins. This article will integrate conceptual aspects of basal insulin therapy in the context of physiology, molecular pharmacology, and clinical implications of modern basal insulin analogs to provide a foundational understanding of basal insulin biology and physiology.
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Affiliation(s)
- Kevin D Niswender
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Vanderbilt University School of Medicine, Nashville, TN 37232-0475, USA.
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21
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Kim MK, Suk JH, Kwon MJ, Chung HS, Yoon CS, Jun HJ, Ko JH, Kim TK, Lee SH, Oh MK, Rhee BD, Park JH. Nateglinide and acarbose for postprandial glucose control after optimizing fasting glucose with insulin glargine in patients with type 2 diabetes. Diabetes Res Clin Pract 2011; 92:322-8. [PMID: 21376417 DOI: 10.1016/j.diabres.2011.01.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 01/17/2011] [Accepted: 01/24/2011] [Indexed: 11/17/2022]
Abstract
AIMS Basal insulin treatment is frequently used in type 2 diabetes, but the successful control of postprandial glucose is challenging. We compared the effect of preferential postprandial glucose targeting drugs for postprandial glucose control after optimizing fasting glucose with basal insulin. METHODS This study was performed in 58, insulin naïve type 2 diabetes. After fasting glucose was optimized by insulin glargine, nateglinide or acarbose was initiated and then crossed over after second wash out period. 75 g oral glucose tolerance test and 7 point self monitoring blood glucose for 3 days at the end of each period was performed. RESULTS Both drugs effectively reduced postprandial glucose levels compared with the insulin glargine monotherapy. No significant differences were found between nateglinide and acarbose in terms of mean glucose level, standard deviation of glucose levels, mean average glucose excursion and average daily risk range. Homeostasis model analysis (HOMA)% β, corrected insulin response and insulin-to-glucose ratio were significantly higher in the responder group compared with the non-responder. There was no episode of severe hypoglycemia. CONCLUSIONS Nateglinide and acarbose are equally effective in type 2 diabetes for postprandial glucose excursions during basal insulin treatment. The markers of beta cell function might be used for predicting response. (Clinical trial reg. no. NCT 00437918, clinicaltrial.gov.).
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Affiliation(s)
- Mi K Kim
- Department of Internal Medicine, Maryknoll Medical Center, Busan, Republic of Korea; Molecular Therapy Lab, Paik Memorial Institute for Clinical Research, Inje University, Busan, Republic of Korea
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22
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Diabetesbezogene Kosten und Therapiezufriedenheit bei ICT-behandelten Typ-2-Diabetikern in der ambulanten Versorgung: Ergebnisse der LIVE-COM-Studie. ACTA ACUST UNITED AC 2010; 105:792-801. [DOI: 10.1007/s00063-010-1136-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 09/02/2010] [Indexed: 10/18/2022]
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23
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Phillips NB, Wan ZL, Whittaker L, Hu SQ, Huang K, Hua QX, Whittaker J, Ismail-Beigi F, Weiss MA. Supramolecular protein engineering: design of zinc-stapled insulin hexamers as a long acting depot. J Biol Chem 2010; 285:11755-9. [PMID: 20181952 DOI: 10.1074/jbc.c110.105825] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Bottom-up control of supramolecular protein assembly can provide a therapeutic nanobiotechnology. We demonstrate that the pharmacological properties of insulin can be enhanced by design of "zinc staples" between hexamers. Paired (i, i+4) His substitutions were introduced at an alpha-helical surface. The crystal structure contains both classical axial zinc ions and novel zinc ions at hexamer-hexamer interfaces. Although soluble at pH 4, the combined electrostatic effects of the substitutions and bridging zinc ions cause isoelectric precipitation at neutral pH. Following subcutaneous injection in a diabetic rat, the analog effected glycemic control with a time course similar to that of long acting formulation Lantus. Relative to Lantus, however, the analog discriminates at least 30-fold more stringently between the insulin receptor and mitogenic insulin-like growth factor receptor. Because aberrant mitogenic signaling may be associated with elevated cancer risk, such enhanced specificity may improve safety. Zinc stapling provides a general strategy to modify the pharmacokinetic and biological properties of a subcutaneous protein depot.
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Affiliation(s)
- Nelson B Phillips
- Department of Biochemistry, Western Reserve University School of Medicine, Cleveland, Ohio 44106, USA
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25
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Torlone E, Di Cianni G, Mannino D, Lapolla A. Insulin analogs and pregnancy: an update. Acta Diabetol 2009; 46:163-72. [PMID: 19572099 DOI: 10.1007/s00592-009-0130-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 05/12/2009] [Indexed: 10/20/2022]
Abstract
It is well known that good metabolic control maintained throughout pregnancy reduces maternal and fetal complications in diabetes. Before conception and throughout pregnancy, insulin therapy needs to be optimized and, in this context, the insulin analogs currently available in the market may help to achieve good metabolic control. We therefore review here what is known about the potential benefits and risks related to the use of these new insulins in pregnancy. Clinical and experimental data on insulin aspart and lispro strongly suggest that they have no adverse maternal or fetal effects during pregnancy in women with pregestational and gestational diabetes, and that their use results in improved glycemic control, fewer hypoglycemic episodes, and improved patient satisfaction. At present there are no published data on the use of glulisine in pregnancy. Insulin glargine during pregnancy is not recommended but, in the last years, larger surveys (retrospective and case-control studies) have been published on this field and, to date, results of about 335 pregnancies with type 1 diabetes are available showing an incidence of congenital malformation similar to that obtained with human insulin. There are no published data concerning the use of detemir in pregnancy but the results of a prospective study are expected in 2010.
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Affiliation(s)
- Elisabetta Torlone
- Dipartimento Medicina Interna Endocrinologia e Metabolismo, Azienda Ospedaliera S. Maria della Misericordia, Perugia, Italy.
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26
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Demssie YN, Younis N, Soran H. The role of insulin detemir in overweight type 2 diabetes management. Vasc Health Risk Manag 2009; 5:553-60. [PMID: 19590589 PMCID: PMC2704896 DOI: 10.2147/vhrm.s4326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Indexed: 01/31/2023] Open
Abstract
The recent evidence-based shift towards an algorithm of early initiation and aggressive titration of insulin therapy in the management of type 2 diabetes requires the use of an effective insulin formulation that is both safe and acceptable to patients and physicians alike. The advent of the long-acting insulin analogues, insulin detemir and glargine, in the last decade has revolutionized insulin therapy in type 2 diabetes. Their unique pharmacokinetic and pharmacodynamic properties have offered tangible advantage over the conventional intermediate and long-acting insulin preparations in terms of improving glucose control as well as reducing risk of hypoglycemia and weight gain. This review focuses on the pharmacodynamic properties of the long-acting insulin analogue detemir, the outcome of studies on its relative efficacy and safety as well as its proposed place in the management of type 2 diabetes.
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Affiliation(s)
- Yared N Demssie
- Department of Diabetes and Endocrinology, Salford Royal Foundation NHS Trust, Salford, UK
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27
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Current literature in diabetes. Diabetes Metab Res Rev 2009; 25:i-xii. [PMID: 19405078 DOI: 10.1002/dmrr.973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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