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Ozgul M, Nesburn AB, Nasralla N, Katz B, Taylan E, Kuppermann BD, Kenney MC. Stability Determination of Intact Humanin-G with Characterizations of Oxidation and Dimerization Patterns. Biomolecules 2023; 13:biom13030515. [PMID: 36979450 PMCID: PMC10046509 DOI: 10.3390/biom13030515] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 03/14/2023] Open
Abstract
Humanin is the first identified mitochondrial-derived peptide. Humanin-G (HNG) is a variant of Humanin that has significantly higher cytoprotective properties. Here, we describe the stability features of HNG in different conditions and characterize HNG degradation, oxidation, and dimerization patterns over short-term and long-term periods. HNG solutions were prepared in high-performance liquid chromatography (HPLC) water or MO formulation and stored at either 4 °C or 37 °C. Stored HNG samples were analyzed using HPLC and high-resolution mass spectrometry (HRMS). Using HPLC, full-length HNG peptides in HPLC water decreased significantly with time and higher temperature, while HNG in MO formulation remained stable up to 95% at 4 °C on day 28. HNG peptides in HPLC water, phosphate-buffered saline (PBS) and MO formulation were incubated at 37 °C and analyzed at day 1, day 7 and day 14 using HRMS. Concentrations of full-length HNG peptide in HPLC water and PBS declined over time with a corresponding appearance of new peaks that increased over time. These new peaks were identified to be singly oxidized HNG, doubly oxidized HNG, homodimerized HNG, singly oxidized homodimerized HNG, and doubly oxidized homodimerized HNG. Our results may help researchers improve the experimental design to further understand the critical role of HNG in human diseases.
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Affiliation(s)
- Mustafa Ozgul
- Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine, Irvine, CA 92617, USA
- Correspondence: (M.O.); (M.C.K.)
| | - Anthony B. Nesburn
- Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine, Irvine, CA 92617, USA
- Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | | | - Benjamin Katz
- Department of Chemistry, University of California Irvine, Irvine, CA 92697, USA
| | - Enes Taylan
- Department of Obstetrics and Gynecology, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Baruch D. Kuppermann
- Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine, Irvine, CA 92617, USA
| | - Maria Cristina Kenney
- Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine, Irvine, CA 92617, USA
- Department of Pathology and Laboratory Medicine, University of California Irvine, Irvine, CA 92617, USA
- Correspondence: (M.O.); (M.C.K.)
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2
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van Veldhuisen CL, Latenstein AEJ, Blauw H, Vlaskamp LB, Klaassen M, Lips DJ, Bonsing BA, van der Harst E, Stommel MWJ, Bruno MJ, van Santvoort HC, van Eijck CHJ, van Dieren S, Busch OR, Besselink MG, DeVries JH. Bihormonal Artificial Pancreas With Closed-Loop Glucose Control vs Current Diabetes Care After Total Pancreatectomy: A Randomized Clinical Trial. JAMA Surg 2022; 157:950-957. [PMID: 36069928 PMCID: PMC9453632 DOI: 10.1001/jamasurg.2022.3702] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/11/2022] [Indexed: 12/26/2022]
Abstract
Importance Glucose control in patients after total pancreatectomy is problematic because of the complete absence of α- and β-cells, leading to impaired quality of life. A novel, bihormonal artificial pancreas (BIHAP), using both insulin and glucagon, may improve glucose control, but studies in this setting are lacking. Objective To assess the efficacy and safety of the BIHAP in patients after total pancreatectomy. Design, Setting, and Participants This randomized crossover clinical trial compared the fully closed-loop BIHAP with current diabetes care (ie, insulin pump or pen therapy) in 12 adult outpatients after total pancreatectomy. Patients were recruited between August 21 and November 16, 2020. This first-in-patient study began with a feasibility phase in 2 patients. Subsequently, 12 patients were randomly assigned to 7-day treatment with the BIHAP (preceded by a 5-day training period) followed by 7-day treatment with current diabetes care, or the same treatments in reverse order. Statistical analysis was by Wilcoxon signed rank and Mann-Whitney U tests, with significance set at a 2-sided P < .05. Main Outcomes and Measures The primary outcome was the percentage of time spent in euglycemia (70-180 mg/dL [3.9-10 mmol/L]) as assessed by continuous glucose monitoring. Results In total, 12 patients (7 men and 3 women; median [IQR] age, 62.5 [43.1-74.0] years) were randomly assigned, of whom 3 did not complete the BIHAP phase and 1 was replaced. The time spent in euglycemia was significantly higher during treatment with the BIHAP (median, 78.30%; IQR, 71.05%-82.61%) than current diabetes care (median, 57.38%; IQR, 52.38%-81.35%; P = .03). In addition, the time spent in hypoglycemia (<70 mg/dL [3.9 mmol/L]) was lower with the BIHAP (median, 0.00% [IQR, 0.00%-0.07%] vs 1.61% [IQR, 0.80%-3.81%]; P = .004). No serious adverse events occurred. Conclusions and Relevance Patients using the BIHAP after total pancreatectomy experienced an increased percentage of time in euglycemia and a reduced percentage of time in hypoglycemia compared with current diabetes care, without apparent safety risks. Larger randomized trials, including longer periods of treatment and an assessment of quality of life, should confirm these findings. Trial Registration trialregister.nl Identifier: NL8871.
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Affiliation(s)
- Charlotte L. van Veldhuisen
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Anouk E. J. Latenstein
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Helga Blauw
- Amsterdam UMC, Department of Internal Medicine, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
- Inreda Diabetic, Goor, the Netherlands
| | | | | | - Daan J. Lips
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Susan van Dieren
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Olivier R. Busch
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Marc G. Besselink
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - J. Hans DeVries
- Amsterdam UMC, Department of Internal Medicine, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
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3
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Story LH, Wilson LM. New Developments in Glucagon Treatment for Hypoglycemia. Drugs 2022; 82:1179-1191. [PMID: 35932416 DOI: 10.1007/s40265-022-01754-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/28/2022]
Abstract
Glucagon is essential for endogenous glucose regulation along with the paired hormone, insulin. Unlike insulin, pharmaceutical use of glucagon has been limited due to the unstable nature of the peptide. Glucagon has the potential to address hypoglycemia as a major limiting factor in the treatment of diabetes, which remains very common in the type 1 and type 2 diabetes. Recent developments are poised to change this paradigm and expand the use of glucagon for people with diabetes. Glucagon emergency kits have major limitations for their use in treating severe hypoglycemia. A complicated reconstitution and injection process often results in incomplete or aborted administration. New preparations include intranasal glucagon with an easy-to-use and needle-free nasal applicator as well as two stable liquid formulations in pre-filled injection devices. These may ease the burden of severe hypoglycemia treatment. The liquid preparations may also have a role in the treatment of non-severe hypoglycemia. Despite potential benefits of expanded use of glucagon, undesirable side effects (nausea, vomiting), cost, and complexity of adding another medication may limit real-world use. Additionally, more long-term safety and outcome data are needed before widespread, frequent use of glucagon is recommended by providers.
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Affiliation(s)
- LesleAnn Hayward Story
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Leah M Wilson
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA.
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4
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Ahmed T, Liu FCF, Lu B, Lip H, Park E, Alradwan I, Liu JF, He C, Zetrini A, Zhang T, Ghavaminejad A, Rauth AM, Henderson JT, Wu XY. Advances in Nanomedicine Design: Multidisciplinary Strategies for Unmet Medical Needs. Mol Pharm 2022; 19:1722-1765. [PMID: 35587783 DOI: 10.1021/acs.molpharmaceut.2c00038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Globally, a rising burden of complex diseases takes a heavy toll on human lives and poses substantial clinical and economic challenges. This review covers nanomedicine and nanotechnology-enabled advanced drug delivery systems (DDS) designed to address various unmet medical needs. Key nanomedicine and DDSs, currently employed in the clinic to tackle some of these diseases, are discussed focusing on their versatility in diagnostics, anticancer therapy, and diabetes management. First-hand experiences from our own laboratory and the work of others are presented to provide insights into strategies to design and optimize nanomedicine- and nanotechnology-enabled DDS for enhancing therapeutic outcomes. Computational analysis is also briefly reviewed as a technology for rational design of controlled release DDS. Further explorations of DDS have illuminated the interplay of physiological barriers and their impact on DDS. It is demonstrated how such delivery systems can overcome these barriers for enhanced therapeutic efficacy and how new perspectives of next-generation DDS can be applied clinically.
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Affiliation(s)
- Taksim Ahmed
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
| | - Fuh-Ching Franky Liu
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
| | - Brian Lu
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
| | - HoYin Lip
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
| | - Elliya Park
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
| | - Ibrahim Alradwan
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
| | - Jackie Fule Liu
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
| | - Chunsheng He
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
| | - Abdulmottaleb Zetrini
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
| | - Tian Zhang
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
| | - Amin Ghavaminejad
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
| | - Andrew M Rauth
- Departments of Medical Biophysics and Radiation Oncology, University of Toronto, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada
| | - Jeffrey T Henderson
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
| | - Xiao Yu Wu
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2, Canada
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5
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Comparison of the Purity and Impurity of Glucagon-for-Injection Products under Various Stability Conditions. Sci Pharm 2022. [DOI: 10.3390/scipharm90020032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Glucagon is a polypeptide hormone that serves as an essential therapeutic agent in the emergency treatment of hypoglycemia. Recently, the first generic glucagon for injection was approved. However, unlike its brand name counterpart, which is produced via recombinant DNA, the generic glucagon is produced using a chemical synthesis method. Regardless of its origin, impurities may occur in both glucagon drug products. While these impurities may greatly compromise the safety and efficacy of the glucagon drug products, studies accessing the impurities of glucagon for injection are limited. This manuscript analyzed the stability and impurities of a generic and brand glucagon for injection, including desamido and non-desamido impurities, under various storage and temperature conditions using an ultra-performance liquid chromatography method. The glucagon products were analyzed after 6 and 24 months of storage under room temperatures (20–25 °C). In addition, the products were also assessed after 6 months of storage under high temperatures (40 °C). Under each stability storage condition, three lots of the synthetic glucagon were evaluated by UPLC with at least one lot of the recombinant glucagon for comparison. A total of 37 peaks were identified (except for the solvent peaks, which appeared at retention times less than 1.5 min) from the synthetic and recombinant glucagon lots. It was found that the number of impurities observed in the synthetic glucagon were lower than the referenced recombinant glucagon across all stability conditions. Throughout all tested conditions, the synthetic glucagon for injection had an averaged purity of 92.8–99.3%, while the referenced recombinant drug had an averaged purity of 70.3–91.7%. Based on the study results, it can be concluded that the impurity profile for the synthetic glucagon for injection has a comparable and even lower level of impurities than the recombinant version under all stability conditions.
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Abstract
Closed-loop insulin delivery systems are fast becoming the standard of care in the management of type 1 diabetes and have led to significant improvements in diabetes management. Nevertheless, there is still room for improvement for the closed-loop systems to optimize treatment and meet target glycemic control. Adjunct treatments have been introduced as an alternative method to insulin-only treatment methods to overcome diabetes treatment challenges and improve clinical and patient reported outcomes during closed-loop treatment. The adjunct treatment agents mostly consist of medications that are already approved for type 2 diabetes treatment and aim to complete the missing physiologic factors, such as the entero-endocrine system, that regulate glycemia in addition to insulin. This paper will review many of these adjunct therapies, including the basic mechanisms of action, potential benefits, side effects, and the evidence supporting their use during closed-loop treatment.
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Affiliation(s)
- Shylaja Srinivasan
- Division of Pediatric Endocrinology and
Diabetes, University of San Francisco, CA, USA
| | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and
Diabetes, Stanford University, Palo Alto, CA, USA
| | - Eda Cengiz
- Division of Pediatric Endocrinology and
Diabetes, Yale University, New Haven, NJ, USA
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7
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Liu M, Zhao P, Uddin MH, Li W, Lin F, Chandrashekar C, Nishiuchi Y, Kajihara Y, Forbes BE, Wootten D, Wade JD, Hossain MA. Chemical Synthesis and Characterization of a Nonfibrillating Glycoglucagon. Bioconjug Chem 2021; 32:2148-2153. [PMID: 34494823 DOI: 10.1021/acs.bioconjchem.1c00419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The current commercially available glucagon formulations for the treatment of severe hypoglycemia must be reconstituted immediately prior to use, owing to the susceptibility of glucagon to fibrillation and aggregation in an aqueous solution. This results in the inconvenience of handling, misuse, and wastage of this drug. To address these issues, we synthesized a glycosylated glucagon analogue in which the 25th residue (Trp) was replaced with a cysteine (Cys) and a Br-disialyloligosaccharide was conjugated at the Cys thiol moiety. The resulting analogue, glycoglucagon, is a highly potent full agonist at the glucagon receptor. Importantly, glycoglucagon exhibits markedly reduced propensity for fibrillation and enhanced thermal and metabolic stability. This novel analogue is thus a valuable lead for producing stable liquid glucagon formulations that will improve patient compliance and minimize wastage.
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Affiliation(s)
| | - Peishen Zhao
- Monash Institute of Pharmaceutical Sciences, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Md Hemayet Uddin
- Melbourne Centre for Nanofabrication, Melbourne, Victoria 3168, Australia
| | | | | | | | - Yuji Nishiuchi
- GlyTech, Inc., 134 Chudoji Minamimachi, Kyoto, 600-8813, Japan
- Graduate School of Science, Tohoku University, Sendai, Miyagi 980-8579, Japan
| | - Yasuhiro Kajihara
- Graduate School of Science, Osaka University, Toyonaka, Osaka 560-0043 Japan
| | - Briony E Forbes
- Discipline of Medical Biochemistry, College of Medicine and Public Health, Flinders University, Adelaide, South Australia 5042, Australia
| | - Denise Wootten
- Monash Institute of Pharmaceutical Sciences, 381 Royal Parade, Parkville, Victoria 3052, Australia
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8
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Jarosinski MA, Dhayalan B, Rege N, Chatterjee D, Weiss MA. 'Smart' insulin-delivery technologies and intrinsic glucose-responsive insulin analogues. Diabetologia 2021; 64:1016-1029. [PMID: 33710398 PMCID: PMC8158166 DOI: 10.1007/s00125-021-05422-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/15/2021] [Indexed: 02/08/2023]
Abstract
Insulin replacement therapy for diabetes mellitus seeks to minimise excursions in blood glucose concentration above or below the therapeutic range (hyper- or hypoglycaemia). To mitigate acute and chronic risks of such excursions, glucose-responsive insulin-delivery technologies have long been sought for clinical application in type 1 and long-standing type 2 diabetes mellitus. Such 'smart' systems or insulin analogues seek to provide hormonal activity proportional to blood glucose levels without external monitoring. This review highlights three broad strategies to co-optimise mean glycaemic control and time in range: (1) coupling of continuous glucose monitoring (CGM) to delivery devices (algorithm-based 'closed-loop' systems); (2) glucose-responsive polymer encapsulation of insulin; and (3) mechanism-based hormone modifications. Innovations span control algorithms for CGM-based insulin-delivery systems, glucose-responsive polymer matrices, bio-inspired design based on insulin's conformational switch mechanism upon insulin receptor engagement, and glucose-responsive modifications of new insulin analogues. In each case, innovations in insulin chemistry and formulation may enhance clinical outcomes. Prospects are discussed for intrinsic glucose-responsive insulin analogues containing a reversible switch (regulating bioavailability or conformation) that can be activated by glucose at high concentrations.
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Affiliation(s)
- Mark A Jarosinski
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Balamurugan Dhayalan
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nischay Rege
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Deepak Chatterjee
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael A Weiss
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Chemistry, Indiana University, Bloomington, IN, USA.
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA.
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9
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Tower SJ, Hetcher WJ, Myers TE, Kuehl NJ, Taylor MT. Selective Modification of Tryptophan Residues in Peptides and Proteins Using a Biomimetic Electron Transfer Process. J Am Chem Soc 2020; 142:9112-9118. [PMID: 32348670 DOI: 10.1021/jacs.0c03039] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We report here a photochemical process for the selective modification of tryptophan (Trp) residues in peptides and small proteins using electron-responsive N-carbamoylpyridinium salts and UV-B light. Preliminary mechanistic experiments suggest that the photoconjugation process proceeds through photoinduced electron transfer (PET) between Trp and the pyridinium salt, followed by fragmentation of the pyridinium N-N bond and concomitant transfer of this group to Trp. The reaction displays excellent site selectivity for Trp and is tolerant to other, redox-active amino-acid residues. Moreover, the reaction proceeds in pure aqueous conditions without the requirement of organic cosolvents or photocatalysts, is enhanced by glutathione, and operates efficiently over a wide range of peptide concentrations (10-700 μM). The scope of the process was explored through the labeling of 6-Trp-containing peptides and proteins ranging from 1 to 14 kDa. We demonstrate the versatility of the N-carbamoylpyridinium salt both by tuning the electrochemical and photochemical properties of the pyridinium scaffold to enable challenging photoconjugation reactions and by using the carbamoyl moiety to tether a plethora of productive functional groups, including reactive handles, purification tags, and removable protecting groups.
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Affiliation(s)
- Samantha J Tower
- University of Wyoming, Department of Chemistry, Laramie, Wyoming 82071, United States
| | - Wesley J Hetcher
- University of Wyoming, Department of Chemistry, Laramie, Wyoming 82071, United States
| | - Tyler E Myers
- University of Wyoming, Department of Chemistry, Laramie, Wyoming 82071, United States
| | - Nicholas J Kuehl
- University of Wyoming, Department of Chemistry, Laramie, Wyoming 82071, United States
| | - Michael T Taylor
- University of Wyoming, Department of Chemistry, Laramie, Wyoming 82071, United States
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10
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Abstract
Treatment of type 1 diabetes with exogenous insulin often results in unpredictable daily glucose variability and hypoglycemia, which can be dangerous. Automated insulin delivery systems can improve glucose control while reducing burden for people with diabetes. One approach to improve treatment outcomes is to incorporate the counter-regulatory hormone glucagon into the automated delivery system to help prevent the hypoglycemia that can be induced by the slow pharmacodynamics of insulin action. This article explores the advantages and disadvantages of incorporating glucagon into dual-hormone automated hormone delivery systems.
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Affiliation(s)
- Leah M Wilson
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 3181 Southwest Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA.
| | - Peter G Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Mail Code: CH13B, 3303 Southwest Bond Avenue, Portland, OR 97239, USA
| | - Jessica R Castle
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 3181 Southwest Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA
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11
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Lal RA, Ekhlaspour L, Hood K, Buckingham B. Realizing a Closed-Loop (Artificial Pancreas) System for the Treatment of Type 1 Diabetes. Endocr Rev 2019; 40:1521-1546. [PMID: 31276160 PMCID: PMC6821212 DOI: 10.1210/er.2018-00174] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 02/28/2019] [Indexed: 01/20/2023]
Abstract
Recent, rapid changes in the treatment of type 1 diabetes have allowed for commercialization of an "artificial pancreas" that is better described as a closed-loop controller of insulin delivery. This review presents the current state of closed-loop control systems and expected future developments with a discussion of the human factor issues in allowing automation of glucose control. The goal of these systems is to minimize or prevent both short-term and long-term complications from diabetes and to decrease the daily burden of managing diabetes. The closed-loop systems are generally very effective and safe at night, have allowed for improved sleep, and have decreased the burden of diabetes management overnight. However, there are still significant barriers to achieving excellent daytime glucose control while simultaneously decreasing the burden of daytime diabetes management. These systems use a subcutaneous continuous glucose sensor, an algorithm that accounts for the current glucose and rate of change of the glucose, and the amount of insulin that has already been delivered to safely deliver insulin to control hyperglycemia, while minimizing the risk of hypoglycemia. The future challenge will be to allow for full closed-loop control with minimal burden on the patient during the day, alleviating meal announcements, carbohydrate counting, alerts, and maintenance. The human factors involved with interfacing with a closed-loop system and allowing the system to take control of diabetes management are significant. It is important to find a balance between enthusiasm and realistic expectations and experiences with the closed-loop system.
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Affiliation(s)
- Rayhan A Lal
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Laya Ekhlaspour
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Korey Hood
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Department of Psychiatry, Stanford University School of Medicine, Stanford, California
| | - Bruce Buckingham
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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12
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GhavamiNejad A, Li J, Lu B, Zhou L, Lam L, Giacca A, Wu XY. Glucose-Responsive Composite Microneedle Patch for Hypoglycemia-Triggered Delivery of Native Glucagon. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2019; 31:e1901051. [PMID: 31165524 DOI: 10.1002/adma.201901051] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/14/2019] [Indexed: 06/09/2023]
Abstract
Insulin-dependent patients with diabetes mellitus require multiple daily injections of exogenous insulin to combat hyperglycemia. However, administration of excess insulin can lead to hypoglycemia, a life-threatening condition characterized by abnormally low blood glucose levels (BGLs). To prevent hypoglycemia associated with intensive insulin therapy, a "smart" composite microneedle (cMN) patch is developed, which releases native glucagon at low glucose levels. The cMN patch is composed of a photo-crosslinked methacrylated hyaluronic acid (MeHA) microneedle array with embedded multifunctional microgels. The microgels incorporate zwitterionic moieties that stabilize loaded glucagon and phenylboronic acid moieties that provide glucose-dependent volume change to facilitate glucagon release. Hypoglycemia-triggered release of structurally unchanged glucagon from the cMN patch is demonstrated in vitro and in a rat model of type 1 diabetes (T1D). Transdermal application of the patch prevented insulin-induced hypoglycemia in the diabetic rats. This work is the first demonstration of a glucose-responsive glucagon-delivery MN patch for the prevention of hypoglycemia, which has a tremendous potential to reduce the dangers of intensive insulin therapy and improve the quality of life of patients with diabetes and their caregivers.
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Affiliation(s)
- Amin GhavamiNejad
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, M5S 3M2, Canada
| | - Jason Li
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, M5S 3M2, Canada
| | - Brian Lu
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, M5S 3M2, Canada
| | - Liwei Zhou
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, M5S 1A8, Canada
| | - Loretta Lam
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, M5S 1A8, Canada
| | - Adria Giacca
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, M5S 1A8, Canada
| | - Xiao Yu Wu
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, M5S 3M2, Canada
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Tauschmann M, Hovorka R. Technology in the management of type 1 diabetes mellitus - current status and future prospects. Nat Rev Endocrinol 2018; 14:464-475. [PMID: 29946127 DOI: 10.1038/s41574-018-0044-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Type 1 diabetes mellitus (T1DM) represents 5-10% of diabetes cases worldwide. The incidence of T1DM is increasing, and there is no immediate prospect of a cure. As such, lifelong management is required, the burden of which is being eased by novel treatment modalities, particularly from the field of diabetes technologies. Continuous glucose monitoring has become the standard of care and includes factory-calibrated subcutaneous glucose monitoring and long-term implantable glucose sensing. In addition, considerable progress has been made in technology-enabled glucose-responsive insulin delivery. The first hybrid insulin-only closed-loop system has been commercialized, and other closed-loop systems are under development, including dual-hormone glucose control systems. This Review focuses on well-established diabetes technologies, including glucose sensing, pen-based insulin delivery, data management and data analytics. We also cover insulin pump therapy, threshold-based suspend, predictive low-glucose suspend and single-hormone and dual-hormone closed-loop systems. Clinical practice recommendations for insulin pump therapy and continuous glucose monitoring are presented, and ongoing research and future prospects are highlighted. We conclude that the management of T1DM is improved by diabetes technology for the benefit of the majority of people with T1DM, their caregivers and guardians and health-care professionals treating patients with T1DM.
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Affiliation(s)
- Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
- Department of Paediatrics, University of Cambridge, Cambridge, UK.
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Abstract
Glycemic control is the mainstay of preventing diabetes complications at the expense of increased risk of hypoglycemia. Severe hypoglycemia negatively impacts the quality of life of patients with type 1 diabetes and can lead to morbidity and mortality. Currently available glucagon emergency kits are effective at treating hypoglycemia when correctly used, however use is complicated especially by untrained persons. Better formulations and devices for glucagon treatment of hypoglycemia are needed, specifically stable liquid glucagon. Out of the scope of this review, other potential uses of stable liquid glucagon include congenital hyperinsulinism, post-bariatric surgery hypoglycemia, and insulinoma induced hypoglycemia. In the 35 years since Food and Drug Administration (FDA) approval of the first liquid stable human recombinant insulin, we continue to wait for the glucagon counterpart. For mild hypoglycemia, a commercially available liquid stable glucagon would enable more widespread implementation of mini-dose glucagon use as well as glucagon in dual hormone closed-loop systems. This review focuses on the current and upcoming pharmaceutical uses of glucagon in the treatment of type 1 diabetes with an outlook on stable liquid glucagon preparations that will hopefully be available for use in patients in the near future.
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Affiliation(s)
- Leah M. Wilson
- Division of Endocrinology, Diabetes and
Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
| | - Jessica R. Castle
- Division of Endocrinology, Diabetes and
Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
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Taleb N, Coriati A, Khazzaka C, Bayonne J, Messier V, Rabasa-Lhoret R. Stability of Commercially Available Glucagon Formulation for Dual-Hormone Artificial Pancreas Clinical Use. Diabetes Technol Ther 2017; 19:589-594. [PMID: 28846447 PMCID: PMC5653137 DOI: 10.1089/dia.2017.0204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Available glucagon formulations are approved for immediate use after reconstitution for severe hypoglycemia emergency treatment. However, they are used in dual-hormone artificial pancreas (insulin and glucagon) studies through subcutaneous infusion pumps over 24 h. Chemical and physical stability of such glucagon use have not been reported in a comprehensive manner. MATERIALS AND METHODS Recombinant Glucagon DNA (Eli Lilly) was used. Compatibility and sterility of glucagon delivery through subcutaneous pump systems were verified. Glucagon degradation through liquid chromatography with tandem mass spectrometry (LC-MS/MS), fibrillation using intrinsic tryptophan fluorescence shift, and bioactivity through a cell-protein kinase A-based fluorescent bioassay were assessed over a range of different physical conditions (temperature, movement, and air bubbles). RESULTS Subcutaneous infusion pump systems administered glucagon in sterile conditions and with comparable accuracy to insulin delivery; mean absolute relative difference of actual versus expected weights were 1.2% ± 1.1% for glucagon and 1.1% ± 0.5% for insulin (P = 0.9). In comparison to freshly reconstituted samples, glucagon analyzed through LC-MS/MS was intact at 93.0% ± 7.0% after 24 h (P = 0.42) and 83.04% ± 6.0% after 48 h (P = 0.02) of incubation in pumps at 32°C. Peak wavelengths for Trp fluorescence did not differ from samples exposed to air bubbles or movement whether incubated (in infusion sets for 24 h at 32°) immediately or 24- and 48-h poststorage at 4°C (P = 0.10, 0.70 and 0.80, respectively) and no significant differences in bioactivity (shifts in EC50) were found for the same conditions (P = 0.13, 0.83, and 0.63). CONCLUSION Available glucagon formulations are chemically and physically stable, as well as compatible with delivery through subcutaneous infusion pumps over 24 h and can be used in long-term clinical trials.
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Affiliation(s)
- Nadine Taleb
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
- Division of Biomedical Sciences, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Adèle Coriati
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | | | - Jonathan Bayonne
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Virginie Messier
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Rémi Rabasa-Lhoret
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
- Montreal Diabetes Research Center, Québec, Canada
- Department of Nutrition, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
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Tauschmann M, Hovorka R. Insulin delivery and nocturnal glucose control in children and adolescents with type 1 diabetes. Expert Opin Drug Deliv 2017; 14:1367-1377. [PMID: 28819992 PMCID: PMC5942151 DOI: 10.1080/17425247.2017.1360866] [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] [Indexed: 01/22/2023]
Abstract
Introduction: Nocturnal glucose control remains challenging in children and adolescents with type 1 diabetes due to highly variable overnight insulin requirements. The issue may be addressed by glucose responsive insulin delivery based on real-time continuous glucose measurements. Areas covered: This review outlines recent developments of glucose responsive insulin delivery systems from a paediatric perspective. We cover threshold-based suspend application, predictive low glucose suspend, and more advanced single hormone and dual-hormone closed-loop systems. Approaches are evaluated in relation to nocturnal glucose control particularly during outpatient randomised controlled trials. Expert opinion: Significant progress translating research from controlled clinical centre settings to free-living unsupervised home studies have been achieved over the past decade. Nocturnal glycaemic control can be improved whilst reducing the risk of hypoglycaemia with closed-loop systems. Following the US regulatory approval of the first hybrid closed-loop system in non-paediatric population, large multinational closed-loop clinical trials and pivotal studies including paediatric populations are underway or in preparation to facilitate the use of closed-loop systems in clinical practice.
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Affiliation(s)
- Martin Tauschmann
- a Wellcome Trust-MRC Institute of Metabolic Science , University of Cambridge , Cambridge , UK.,b Department of Paediatrics , University of Cambridge , Cambridge , UK
| | - Roman Hovorka
- a Wellcome Trust-MRC Institute of Metabolic Science , University of Cambridge , Cambridge , UK.,b Department of Paediatrics , University of Cambridge , Cambridge , UK
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Ang KH, Sherr JL. Moving beyond subcutaneous insulin: the application of adjunctive therapies to the treatment of type 1 diabetes. Expert Opin Drug Deliv 2017; 14:1113-1131. [DOI: 10.1080/17425247.2017.1360862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Kathleen H. Ang
- Yale Children’s Diabetes Program, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer L. Sherr
- Yale Children’s Diabetes Program, Yale University School of Medicine, New Haven, CT, USA
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18
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Graf A, McAuley SA, Sims C, Ulloa J, Jenkins AJ, Voskanyan G, O’Neal DN. Moving Toward a Unified Platform for Insulin Delivery and Sensing of Inputs Relevant to an Artificial Pancreas. J Diabetes Sci Technol 2017; 11:308-314. [PMID: 28264192 PMCID: PMC5478040 DOI: 10.1177/1932296816682762] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Advances in insulin pump and continuous glucose monitoring technology have primarily focused on optimizing glycemic control for people with type 1 diabetes. There remains a need to identify ways to minimize the physical burden of this technology. A unified platform with closely positioned or colocalized interstitial fluid glucose sensing and hormone delivery components is a potential solution. Present challenges to combining these components are interference of glucose sensing from proximate insulin delivery and the large discrepancy between the life span of current insulin infusion sets and glucose sensors. Addressing these concerns is of importance given that the future physical burden of this technology is likely to be even greater with the ongoing development of the artificial pancreas, potentially incorporating multiple hormone delivery, glucose sensing redundancy, and sensing of other clinically relevant nonglucose biochemical inputs.
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Affiliation(s)
- Anneke Graf
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Sybil A. McAuley
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Catriona Sims
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | | | - Alicia J. Jenkins
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
- NHMRC Clinical Trials Centre, Sydney, Australia
| | | | - David N. O’Neal
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
- David N. O’Neal, MBBS, MD, Department of Medicine, University of Melbourne, 29 Regent St, Fitzroy, Melbourne, VIC 3065, Australia.
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19
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Abstract
The artificial pancreas (closed-loop system) addresses the unmet clinical need for improved glucose control whilst reducing the burden of diabetes self-care in type 1 diabetes. Glucose-responsive insulin delivery above and below a preset insulin amount informed by sensor glucose readings differentiates closed-loop systems from conventional, threshold-suspend and predictive-suspend insulin pump therapy. Insulin requirements in type 1 diabetes can vary between one-third-threefold on a daily basis. Closed-loop systems accommodate these variations and mitigate the risk of hypoglycaemia associated with tight glucose control. In this review we focus on the progress being made in the development and evaluation of closed-loop systems in outpatient settings. Randomised transitional studies have shown feasibility and efficacy of closed-loop systems under supervision or remote monitoring. Closed-loop application during free-living, unsupervised conditions by children, adolescents and adults compared with sensor-augmented pumps have shown improved glucose outcomes, reduced hypoglycaemia and positive user acceptance. Innovative approaches to enhance closed-loop performance are discussed and we also present the outlook and strategies used to ease clinical adoption of closed-loop systems.
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Affiliation(s)
- Hood Thabit
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Level 4, Institute of Metabolic Science, Box 289, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0QQ, UK
- Department of Diabetes & Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Level 4, Institute of Metabolic Science, Box 289, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0QQ, UK.
- Department of Paediatrics, University of Cambridge, Cambridge, UK.
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20
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Blauw H, van Bon AC, Koops R, DeVries JH. Performance and safety of an integrated bihormonal artificial pancreas for fully automated glucose control at home. Diabetes Obes Metab 2016; 18:671-7. [PMID: 26996542 PMCID: PMC5111773 DOI: 10.1111/dom.12663] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 12/24/2015] [Accepted: 03/15/2016] [Indexed: 01/22/2023]
Abstract
AIMS To assess the performance and safety of an integrated bihormonal artificial pancreas system consisting of one wearable device and two wireless glucose sensor transmitters during short-term daily use at home. METHODS Adult patients with type 1 diabetes using an insulin pump were invited to enrol in this randomized crossover study. Treatment with the artificial pancreas started with a day and night in the clinical research centre, followed by 3 days at home. The control period consisted of 4 days of insulin pump therapy at home with blinded continuous glucose monitoring for data collection. Days 2-4 were predefined as the analysis period, with median glucose as the primary outcome. RESULTS A total of 10 patients completed the study. The median [interquartile range (IQR)] glucose level was similar for the two treatments [7.3 (7.0-7.6) mmol/l for the artificial pancreas vs. 7.7 (7.0-9.0) mmol/l for the control; p = 0.123]. The median (IQR) percentage of time spent in euglycaemia (3.9-10 mmol/l) was longer during use of the artificial pancreas [84.7 (82.2-87.8)% for the artificial pancreas vs. 68.5 (57.9-83.6)% for the control; p = 0.007]. Time in hypoglycaemia was 1.3 (0.2-3.2)% for the artificial pancreas and 2.4 (0.4-10.3)% for the control treatment (p = 0.139). Separate analysis of daytime and night-time showed that the improvements were mainly achieved during the night. CONCLUSIONS The results of this pilot study suggest that our integrated artificial pancreas provides better glucose control than insulin pump therapy in patients with type 1 diabetes at home and that the treatment is safe.
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Affiliation(s)
- H Blauw
- Department of Endocrinology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
- Inreda Diabetic BV, Goor, The Netherlands
| | | | - R Koops
- Inreda Diabetic BV, Goor, The Netherlands
| | - J H DeVries
- Department of Endocrinology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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21
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Castle JR, El Youssef J, Bakhtiani PA, Cai Y, Stobbe JM, Branigan D, Ramsey K, Jacobs P, Reddy R, Woods M, Ward WK. Effect of Repeated Glucagon Doses on Hepatic Glycogen in Type 1 Diabetes: Implications for a Bihormonal Closed-Loop System. Diabetes Care 2015; 38:2115-9. [PMID: 26341131 PMCID: PMC4613914 DOI: 10.2337/dc15-0754] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 08/10/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate subjects with type 1 diabetes for hepatic glycogen depletion after repeated doses of glucagon, simulating delivery in a bihormonal closed-loop system. RESEARCH DESIGN AND METHODS Eleven adult subjects with type 1 diabetes participated. Subjects underwent estimation of hepatic glycogen using (13)C MRS. MRS was performed at the following four time points: fasting and after a meal at baseline, and fasting and after a meal after eight doses of subcutaneously administered glucagon at a dose of 2 µg/kg, for a total mean dose of 1,126 µg over 16 h. The primary and secondary end points were, respectively, estimated hepatic glycogen by MRS and incremental area under the glucose curve for a 90-min interval after glucagon administration. RESULTS In the eight subjects with complete data sets, estimated glycogen stores were similar at baseline and after repeated glucagon doses. In the fasting state, glycogen averaged 21 ± 3 g/L before glucagon administration and 25 ± 4 g/L after glucagon administration (mean ± SEM) (P = NS). In the fed state, glycogen averaged 40 ± 2 g/L before glucagon administration and 34 ± 4 g/L after glucagon administration (P = NS). With the use of an insulin action model, the rise in glucose after the last dose of glucagon was comparable to the rise after the first dose, as measured by the 90-min incremental area under the glucose curve. CONCLUSIONS In adult subjects with well-controlled type 1 diabetes (mean A1C 7.2%), glycogen stores and the hyperglycemic response to glucagon administration are maintained even after receiving multiple doses of glucagon. This finding supports the safety of repeated glucagon delivery in the setting of a bihormonal closed-loop system.
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Affiliation(s)
- Jessica R Castle
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
| | - Joseph El Youssef
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
| | - Parkash A Bakhtiani
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
| | - Yu Cai
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR
| | - Jade M Stobbe
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR
| | - Deborah Branigan
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
| | - Katrina Ramsey
- Oregon Clinical and Translational Research Institute Biostatistics & Design Program, Oregon Health & Science University, Portland, OR
| | - Peter Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Ravi Reddy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Mark Woods
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR Portland State University, Portland, OR
| | - W Kenneth Ward
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
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22
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Reiband HK, Schmidt S, Ranjan A, Holst JJ, Madsbad S, Nørgaard K. Dual-hormone treatment with insulin and glucagon in patients with type 1 diabetes. Diabetes Metab Res Rev 2015; 31:672-9. [PMID: 25533565 DOI: 10.1002/dmrr.2632] [Citation(s) in RCA: 9] [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: 09/10/2014] [Accepted: 12/08/2014] [Indexed: 11/09/2022]
Abstract
Intensive insulin treatment in type 1 diabetes reduces the incidence and slows the progression of microvascular and macrovascular complications; however, it is associated with an increased risk of hypoglycaemia and weight gain. In this review, we propose dual-hormone treatment with insulin and glucagon as a method for achieving near normalization of blood glucose levels without increasing hypoglycaemia frequency and weight gain. We briefly summarize glucagon pathophysiology in type 1 diabetes as well as the current applications of glucagon for the treatment of hypoglycaemia. Until now, the use of glucagon has been limited by the need for reconstitution immediately before use, because of instability of the available compounds; however, stabile compounds are soon to be launched and will render long-term intensive dual-hormone treatment in type 1 diabetes possible.
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Affiliation(s)
- H K Reiband
- Department of Endocrinology, Copenhagen University Hospital, Hvidovre, Denmark
| | - S Schmidt
- Department of Endocrinology, Copenhagen University Hospital, Hvidovre, Denmark
- Danish Diabetes Academy, Odense University Hospital, Odense, Denmark
| | - A Ranjan
- Department of Endocrinology, Copenhagen University Hospital, Hvidovre, Denmark
- Danish Diabetes Academy, Odense University Hospital, Odense, Denmark
| | - J J Holst
- NNF Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - S Madsbad
- Department of Endocrinology, Copenhagen University Hospital, Hvidovre, Denmark
| | - K Nørgaard
- Department of Endocrinology, Copenhagen University Hospital, Hvidovre, Denmark
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23
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Rylander D. Treating severe hypoglycemia: rapid mixing of lyophilized glucagon and diluent at point of care with the Enject GlucaPen. J Diabetes Sci Technol 2015; 9:34-7. [PMID: 25182147 PMCID: PMC4495522 DOI: 10.1177/1932296814549597] [Citation(s) in RCA: 8] [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: 01/23/2023]
Abstract
Severe hypoglycemia (SH) is a common problem in type 1 diabetes (T1D). Annually, nearly 1 of 5 persons with long-standing T1D will have SH. Though injections of glucagon are effective in treating SH, liquid formulations of glucagon are biochemically very unstable. For this reason, available preparations of glucagon are lyophilized; the powder and the diluent must be mixed at the point of care prior to administration and any remaining drug must be discarded. The process of mixing and delivery is complex. Coupled with the emotional stress of the caregiver, errors in glucagon delivery are very common. For these reasons, workers at Enject, Inc are in the process of developing a device that addresses the shortcomings of this currently approved method of glucagon delivery. The Enject device will store the glucagon powder and the diluent in separate compartments and will rapidly mix and inject the components only upon activation of the pen at the point of care.
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Caputo N, Jackson MA, Castle JR, El Youssef J, Bakhtiani PA, Bergstrom CP, Carroll JM, Breen ME, Leonard GL, David LL, Roberts CT, Ward WK. Biochemical stabilization of glucagon at alkaline pH. Diabetes Technol Ther 2014; 16:747-58. [PMID: 24968220 PMCID: PMC4201307 DOI: 10.1089/dia.2014.0047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND For patients with type 1 diabetes mellitus, a bihormonal artificial endocrine pancreas system utilizing glucagon and insulin has been found to stabilize glycemic control. However, commercially available formulations of glucagon cannot currently be used in such systems because of physical instability characterized by aggregation and chemical degradation. Storing glucagon at pH 10 blocks protein aggregation but results in chemical degradation. Reductions in pH minimize chemical degradation, but even small reductions increase protein aggregation. We hypothesized that common pharmaceutical excipients accompanied by a new excipient would inhibit glucagon aggregation at an alkaline pH. METHODS AND RESULTS As measured by tryptophan intrinsic fluorescence shift and optical density at 630 nm, protein aggregation was indeed minimized when glucagon was formulated with curcumin and albumin. This formulation also reduced chemical degradation, measured by liquid chromatography with mass spectrometry. Biological activity was retained after aging for 7 days in an in vitro cell-based bioassay and also in Yorkshire swine. CONCLUSIONS Based on these findings, a formulation of glucagon stabilized with curcumin, polysorbate-80, l-methionine, and albumin at alkaline pH in glycine buffer may be suitable for extended use in a portable pump in the setting of a bihormonal artificial endocrine pancreas.
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Affiliation(s)
- Nicholas Caputo
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, Oregon
| | - Melanie A. Jackson
- School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Jessica R. Castle
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, Oregon
- School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, Oregon
- School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Parkash A. Bakhtiani
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, Oregon
- School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Colin P. Bergstrom
- School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Julie M. Carroll
- Oregon National Primate Research Center, Oregon Health and Science University, Portland, Oregon
| | - Matthew E. Breen
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, Oregon
| | - Gerald L. Leonard
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, Oregon
| | - Larry L. David
- Department of Biochemistry and Molecular Biology, Oregon Health and Science University, Portland, Oregon
| | - Charles T. Roberts
- School of Medicine, Oregon Health and Science University, Portland, Oregon
- Oregon National Primate Research Center, Oregon Health and Science University, Portland, Oregon
| | - W. Kenneth Ward
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, Oregon
- School of Medicine, Oregon Health and Science University, Portland, Oregon
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25
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Shah VN, Shoskes A, Tawfik B, Garg SK. Closed-loop system in the management of diabetes: past, present, and future. Diabetes Technol Ther 2014; 16:477-90. [PMID: 25072271 DOI: 10.1089/dia.2014.0193] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Intensive insulin therapy (IIT) has been shown to reduce micro- and macrovascular complications in patients with type 1 diabetes mellitus (T1DM). However, IIT is associated with a significant increase in severe hypoglycemic events, resulting in increased morbidity and mortality. Optimization of glycemic control without hypoglycemia (especially nocturnal) should be the next major goal for subjects on insulin treatment. The use of insulin pumps along with continuous glucose monitors (CGMs) has made it easier but requires significant resources and patient education. Research is ongoing to close the loop by integrating the pump and the CGM using different algorithms. The currently available closed-loop system is the threshold suspend. Steps needed to achieve a near-perfect closed-loop are (1) a control-to-range system that will reduce the incidence and/or severity of hyper- and/or hypoglycemia by adjusting the insulin dose and (2) a control-to-target system, a fully automated or hybrid system that sets target glucose levels to individual needs and maintains glucose levels throughout the day using insulin (unihormonal) alone or with other hormones such as glucagon or possibly pramlintide (bihormonal). Future research is also focusing on better insulin delivery devices (pumps), more accurate CGMs, better predictive algorithms, and ultra-rapid-acting insulin analogs to make the closed-loop system as physiological as possible.
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Affiliation(s)
- Viral N Shah
- 1 Barbara Davis Center for Diabetes, University of Colorado Denver , Aurora, Colorado
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26
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Peyser T, Dassau E, Breton M, Skyler JS. The artificial pancreas: current status and future prospects in the management of diabetes. Ann N Y Acad Sci 2014; 1311:102-23. [PMID: 24725149 DOI: 10.1111/nyas.12431] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Recent advances in insulins, insulin pumps, continuous glucose-monitoring systems, and control algorithms have resulted in an acceleration of progress in the development of artificial pancreas devices. This review discusses progress in the development of external systems that are based on subcutaneous drug delivery and subcutaneous continuous glucose monitoring. There are two major system-level approaches to achieving closed-loop control of blood glucose in diabetic individuals. The unihormonal approach uses insulin to reduce blood glucose and relies on complex safety mitigation algorithms to reduce the risk of hypoglycemia. The bihormonal approach uses both insulin to lower blood glucose and glucagon to raise blood glucose, and also relies on complex algorithms to provide for safety of the user. There are several major strategies for the design of control algorithms and supervision control for application to the artificial pancreas: proportional-integral-derivative, model predictive control, fuzzy logic, and safety supervision designs. Advances in artificial pancreas research in the first decade of this century were based on the ongoing computer revolution and miniaturization of electronic technology. The advent of modern smartphones has created the ability to utilize smartphone technology as the engineering centerpiece of an artificial pancreas. With these advances, an artificial or bionic pancreas is within reach.
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27
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Abstract
PURPOSE OF REVIEW To highlight the recent advances in closed-loop research, the development and progress towards utilizing closed loop outside of the clinical research setting and at patients' homes. RECENT FINDINGS In spite of the modern insulin therapy in type 1 diabetes, hypoglycaemia is still a major limiting factor. This often leads to suboptimal glycaemic control and risk of diabetes complications. Closed loop has been shown to improve glycaemic control whilst avoiding hypoglycaemia. Incremental progress has been made in this field, from the use of automated systems and bihormonal closed-loop systems in clinical research facility settings under close supervision to the use of ambulatory closed-loop prototype at patients' homes in free-living conditions. Different population of patients with type 1 diabetes and control algorithm approaches have been studied, assessing the efficacy and safety. Transitional and home studies present different challenges at achieving better glycaemic outcome with closed loop. Improved glucose sensor reliability may accelerate the clinical use and faster insulin analogues increase the clinical utility. SUMMARY Results and experience with closed-loop insulin delivery have been encouraging, leading the way for future improvements and development in the field, to make closed loop suitable for use in clinical practice.
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Affiliation(s)
- Hood Thabit
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
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Kudva YC, Carter RE, Cobelli C, Basu R, Basu A. Closed-loop artificial pancreas systems: physiological input to enhance next-generation devices. Diabetes Care 2014; 37:1184-90. [PMID: 24757225 PMCID: PMC3994931 DOI: 10.2337/dc13-2066] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To provide an understanding of both the preclinical and clinical aspects of closed-loop artificial pancreas systems, we provide a discussion of this topic as part of this two-part Bench to Clinic narrative. Here, the Bench narrative provides an in-depth understanding of insulin-glucose-glucagon physiology in conditions that mimic the free-living situation to the extent possible in type 1 diabetes that will help refine and improve future closed-loop system algorithms. In the Clinic narrative, Doyle and colleagues compare and evaluate technology used in current closed-loop studies to gain further momentum toward outpatient trials and eventual approval for widespread use.
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Caputo N, Castle JR, Bergstrom CP, Carroll JM, Bakhtiani PA, Jackson MA, Roberts CT, David LL, Ward WK. Mechanisms of glucagon degradation at alkaline pH. Peptides 2013; 45:40-7. [PMID: 23651991 PMCID: PMC3947653 DOI: 10.1016/j.peptides.2013.04.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 04/06/2013] [Accepted: 04/08/2013] [Indexed: 11/18/2022]
Abstract
Glucagon is unstable and undergoes degradation and aggregation in aqueous solution. For this reason, its use in portable pumps for closed loop management of diabetes is limited to very short periods. In this study, we sought to identify the degradation mechanisms and the bioactivity of specific degradation products. We studied degradation in the alkaline range, a range at which aggregation is minimized. Native glucagon and analogs identical to glucagon degradation products were synthesized. To quantify biological activity in glucagon and in the degradation peptides, a protein kinase A-based bioassay was used. Aged, fresh, and modified peptides were analyzed by liquid chromatography with mass spectrometry (LCMS). Oxidation of glucagon at the Met residue was common but did not reduce bioactivity. Deamidation and isomerization were also common and were more prevalent at pH 10 than 9. The biological effects of deamidation and isomerization were unpredictable; deamidation at some sites did not reduce bioactivity. Deamidation of Gln 3, isomerization of Asp 9, and deamidation with isomerization at Asn 28 all caused marked potency loss. Studies with molecular-weight-cutoff membranes and LCMS revealed much greater fibrillation at pH 9 than 10. Further work is necessary to determine formulations of glucagon that minimize degradation and fibrillation.
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Affiliation(s)
| | | | | | | | | | | | - Charles T. Roberts
- Oregon Health and Science University
- Oregon National Primate Research Center
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