Insulins as Drugs or Biologics in the USA: What Difference Does it Make and Why Does it Matter?

The Nuances Surrounding Insulin Prescribing

Knowledge of and expertise in insulin prescribing is crucial for health care providers who care for people with diabetes. This article reviews the available insulin preparations, how they are packaged, and nuances related to storage and use that inform the prescribing of this life-saving medication for patients. Insulin prescribing that is done correctly will save time and reduce problematic errors that could put patients at risk.

Interchangeability for Biologics is a Legal Distinction in the USA, Not a Clinical One

Biologics are increasingly vital medicines that significantly reduce morbidity as well as mortality, yet access continues to be an issue even in apparently wealthy countries, such as the USA. While patient access is expected to improve with the introduction of biosimilars, misperceptions in a significant part based on terminology continue to make a sustained contribution by biosimilars difficult. Patients are and will continue to suffer needlessly if biosimilars continue to be impugned. Consequently, it is increasingly urgent that semantics are clarified, and in particular, the implication that interchangeable biologics are better biosimilars dismissed. This paper distinguishes between the real differences between biologics that matter clinically to patients and discusses the actual meaning of a US Food and Drug Administration designation of interchangeability for a biosimilar product. This will help highlight where there is need for further Food and Drug Administration education and which stakeholders likely need that education the most.

Using the Power of Junctional Adhesion Molecules Combined with the Target of CAR-T to Inhibit Cancer Proliferation, Metastasis and Eradicate Tumors

Decades of evidence suggest that alterations in the adhesion properties of neoplastic cells endow them with an invasive and migratory phenotype. Tight junctions (TJs) are present in endothelial and epithelial cells. Tumors arise from such tissues, thus, the role of TJ proteins in the tumor microenvironment is highly relevant. In the TJ, junctional adhesion molecules (JAM) play a key role in assembly of the TJ and control of cell–cell adhesion. Reprogramming of immune cells using chimeric antigen receptors (CAR) to allow for target recognition and eradication of tumors is an FDA approved therapy. The best-studied CAR-T cells recognize CD19, a B-cell surface molecule. CD19 is not a unique marker for tumors, liquid or solid. To address this limitation, we developed a biologic containing three domains: (1) pH-low-insertion peptide (pHLIP), which recognizes the low pH of the cancer cells, leading to the insertion of the peptide into the plasma membrane. (2) An extracellular domain of JAM proteins that fosters cell–cell interactions. (3) CD19 to be targeted by CAR-T cells. Our modular design only targets cancer cells and when coupled with anti-CD19 CAR-T cells, it decreases proliferation and metastasis in at least two cancer cell lines.

Who Will Be Responsible for the Dialysis Bill? A Case Report and Narrative Review of Insulin Affordability 100 Years After the Discovery of Insulin

A 46-year-old woman was type 1 diabetes diagnosed at the age of 9 who had previously been on an insulin pump. Other co-morbidities included CKD IV, HTN, and hypothyroidism. She presented with hyperglycemia of 400 mg/dl and fluid retention. Her GFR had decreased to 13. Her physical exam was notable for respiratory distress and anasarca. She failed to respond to aggressive IV diuresis and urgent hemodialysis was initiated. The patient had been lost to outpatient follow-up for a year. She had been co-managed by an endocrinologist and a primary care physician but had stopped going to her endocrinologist over a year ago due to inability to afford the co-pays. She subsequently lost her insurance and had to pay out of pocket for her insulin; at this point, she decided to stop seeing her PCP and began to ration her insulin. Due to social stigma, she did not mention her financial issues to her healthcare providers. After identifying these challenges, we decided to start her on a more affordable regimen of NPH insulin. Through social work assistance, we were able to obtain a charity hemodialysis chair and discharge her home. She applied to Medicaid. Healthcare expenditure with regard to diabetes rose to $327 billion from $245 billion in 2012. The price of insulin has continued to increase even after the drug's patent has expired due to the combination of FDA requirements, a monopoly in the insulin market, and the lack of federal price controls and Pharmacy Benefits Managers. The high out of pocket costs for insulin has led to many instances of insulin rationing among both uninsured and insured. This led to death in some cases as well as poorly controlled diabetes with increased complications and mortality as in our case. We present a case report and narrative review on insulin affordability.

Targeting impaired nutrient sensing with repurposed therapeutics to prevent or treat age-related cognitive decline and dementia: A systematic review

BACKGROUND

Dementia is a debilitating syndrome that significantly impacts individuals over the age of 65 years. There are currently no disease-modifying treatments for dementia. Impairment of nutrient sensing pathways has been implicated in the pathogenesis of dementia, and may offer a novel treatment approach for dementia.

AIMS

This systematic review collates all available evidence for Food and Drug Administration (FDA)-approved therapeutics that modify nutrient sensing in the context of preventing cognitive decline or improving cognition in ageing, mild cognitive impairment (MCI), and dementia populations.

METHODS

PubMed, Embase and Web of Science databases were searched using key search terms focusing on available therapeutics such as 'metformin', 'GLP1', 'insulin' and the dementias including 'Alzheimer's disease' and 'Parkinson's disease'. Articles were screened using Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia). The risk of bias was assessed using the Cochrane Risk of Bias tool v 2.0 for human studies and SYRCLE's risk of bias tool for animal studies.

RESULTS

Out of 2619 articles, 114 were included describing 31 different 'modulation of nutrient sensing pathway' therapeutics, 13 of which specifically were utilized in human interventional trials for normal ageing or dementia. Growth hormone secretagogues improved cognitive outcomes in human mild cognitive impairment, and potentially normal ageing populations. In animals, all investigated therapeutic classes exhibited some cognitive benefits in dementia models. While the risk of bias was relatively low in human studies, this risk in animal studies was largely unclear.

CONCLUSIONS

Modulation of nutrient sensing pathway therapeutics, particularly growth hormone secretagogues, have the potential to improve cognitive outcomes. Overall, there is a clear lack of translation from animal models to human populations.