Efficacy and safety comparison of rapid-acting insulin aspart and regular human insulin in the treatment of type 1 and type 2 diabetes mellitus: a systematic review

Prandial Insulins: A Person-Centered Choice

PURPOSE OF REVIEW

Postprandial hyperglycemia, or elevated blood glucose after meals, is associated with the development and progression of various diabetes-related complications. Prandial insulins are designed to replicate the natural insulin release after meals and are highly effective in managing post-meal glucose spikes. Currently, different types of prandial insulins are available such as human regular insulin, rapid-acting analogs, ultra-rapid-acting analogs, and inhaled insulins. Knowledge about diverse landscape of prandial insulin will optimize glycemic management.

RECENT FINDINGS

Human regular insulin, identical to insulin produced by the human pancreas, has a slower onset and extended duration, potentially leading to post-meal hyperglycemia and later hypoglycemia. In contrast, rapid-acting analogs, such as lispro, aspart, and glulisine, are new insulin types with amino acid modifications that enhance their subcutaneous absorption, resulting in a faster onset and shorter action duration. Ultra-rapid analogs, like faster aspart and ultra-rapid lispro, offer even shorter onset of action, providing better meal-time flexibility. The Technosphere insulin offers an inhaled route for prandial insulin delivery. The prandial insulins can be incorporated into basal-bolus, basal plus, or prandial-only regimens or delivered through insulin pumps. Human regular insulin, aspart, lispro, and faster aspart are recommended for management of hyperglycemia during pregnancy. Ongoing research is focused on refining prandial insulin replacement and exploring newer delivery methods. The article provides a comprehensive overview of various prandial insulin options and their clinical applications in the management of diabetes.

Evaluating the Impact of Intensifying Treatment from Human to Analogue Insulin on Glycaemic Control and Insulin Expenditure in Patients with Type 2 Diabetes: A Retrospective Cohort Study

Background

Achieving good glycaemic control is essential to reducing the risk of diabetes complications. Insulin is the most effective therapy for achieving good glycaemic control; however, it is associated with a higher risk of hypoglycaemia, especially with human insulin. This study aimed to evaluate the efficacy of intensification from human to analogue insulin and its added cost.

Methods

This retrospective study was conducted at the Hospital Universiti Sains Malaysia (HUSM). Patients with type 2 diabetes mellitus (T2DM) who underwent intensification for at least 3 months from human to analogue insulin were included in this study. The patients' medical records, haemoglobin A1c (Hba1c) and fasting blood sugar (FBS) were retrieved. The total cost pre- and post-intensification of insulin was obtained from the pharmacy database. Differences in HbA1c, FBS and total insulin cost pre- and post-intensification were analysed.

Results

A total of 163 patients with T2DM who had intensification from human to analogue insulin were included in this study. HbA1c and FBS levels were significantly lower in analogue insulin. However, the differences were not clinically significant, as the mean reduction in HbA1c was less than 0.5%. Meanwhile, the total costs of analogue insulin for 3 months were higher.

Conclusion

There were no clinically significant improvements in patients' HbA1c and FBS after the intensification of insulin, despite the extra costs spent. Hence, it is vital to choose the right group of patients to receive an insulin analogue to maximise its benefit but at the most optimal cost.

Performance of Fast-Acting Aspart Insulin as Compared to Aspart Insulin in Insulin Pump for Managing Type 1 Diabetes Mellitus: A Meta-Analysis

BACKGROUND

No meta-analysis has analysed efficacy and safety of fast-acting aspart insulin (FIAsp) with insulin pump in type 1 diabetes mellitus (T1DM).

METHODS

Electronic databases were searched for randomised controlled trials (RCTs) involving T1DM patients on insulin pump receiving FIAsp in intervention arm, and placebo/active comparator insulin in control arm. Primary outcome was to evaluate changes in 1- and 2-hour post-prandial glucose (1hPPG and 2hPPG). Secondary outcomes were to evaluate alterations in percentage time with blood glucose <3.9 mmol/L (hypoglycaemia), time in range (TIR) blood glucose 3.9 to 10 mmol/L, insulin requirements and adverse events.

RESULTS

Data from four RCTs involving 640 patients was analysed. FIAsp use in insulin pump was associated with significantly greater lowering of 1hPPG (mean difference [MD], -1.35 mmol/L; 95% confidence interval [CI], -1.72 to -0.98; P<0.01; I2=63%) and 2hPPG (MD, -1.19 mmol/L; 95% CI, -1.38 to -1.00; P<0.01; I2=0%) as compared to controls. TIR was comparable among groups (MD, 1.06%; 95% CI, -3.84 to 5.96; P=0.67; I2=70%). Duration of blood glucose <3.9 mmol/L was lower in FIAsp group, approaching significance (MD, -0.91%; 95% CI, -1.84 to 0.03; P=0.06; I2=0%). Total hypoglycaemic episodes (risk ratio [RR], 1.35; 95% CI, 0.55 to 3.31; P=0.51; I2=0%), severe hypoglycaemia (RR, 2.26; 95% CI, 0.77 to 6.66; P=0.14), infusion site reactions (RR, 1.35; 95% CI, 0.63 to 2.93; P=0.77; I2=0%), and treatment-emergent adverse events (RR, 1.13; 95% CI, 0.80 to 1.60; P=0.50; I2=0%) were comparable.

CONCLUSION

FIAsp use in insulin pump is associated with better post-prandial glycaemic control with no increased hypoglycaemia or glycaemic variability.

Proteomic Changes to the Updated Discovery of Engineered Insulin and Its Analogs: Pros and Cons

The destruction of β-cells of the pancreas leads to either insulin shortage or the complete absence of insulin, which in turn causes diabetes Mellitus. For treating diabetes, many trials have been conducted since the 19th century until now. In ancient times, insulin from an animal's extract was taken to treat human beings. However, this resulted in some serious allergic reactions. Therefore, scientists and researchers have tried their best to find alternative ways for managing diabetes with progressive advancements in biotechnology. However, a lot of research trials have been conducted, and they discovered more progressed strategies and approaches to treat type I and II diabetes with satisfaction. Still, investigators are finding more appropriate ways to treat diabetes accurately. They formulated insulin analogs that mimic the naturally produced human insulin through recombinant DNA technology and devised many methods for appropriate delivery of insulin. This review will address the following questions: What is insulin preparation? How were these devised and what are the impacts (both positive and negative) of such insulin analogs against TIDM (type-I diabetes mellitus) and TIIDM (type-II diabetes mellitus)? This review article will also demonstrate approaches for the delivery of insulin analogs into the human body and some future directions for further improvement of insulin treatment.

Technological Developments and Quality of Life in Type 1 Diabetes Mellitus Patients: A Review of the Modern Insulin Analogues, Continuous Glucose Monitoring and Insulin Pump Therapy

BACKGROUND

Type 1 Diabetes Mellitus (T1DM) is a chronic autoimmune disease, which is characterized by an increased prevalence worldwide, which, in fact, tends to take extensive dimensions. The recent rapid development of science and technology has significantly contributed to the improvement of the management of type 1 diabetes mellitus, both in achieving the required euglycaemic regulation and reducing the psychological burden associated with the disease, consequently improving the quality of life of the patients with type 1 diabetes mellitus.

METHODS

A literature review from 2010, related to the contribution of the modern insulin analogues, continuous glucose monitoring and the insulin pump, was performed using Scopus, ScienceDirect and PubMed databases.

RESULTS

Studies included in the review support a direct and indirect association of technological innovations with the quality of life. The use of type 1 diabetes mellitus technology was negatively associated with the frequency of the hypoglycaemias and the value of the glycosylated hemoglobin, while at the same time, the development and use of the related technology were highly associated with an improvement in the quality of life.

CONCLUSION

Patients' quality of life is an indicator of the management of type 1 diabetes mellitus, and it is just as important as glycaemic regulation. Through this review, it was concluded that a better quality of life of T1DM patients was associated with the improvement of glycosylated hemoglobin and hypoglycemic episodes.

Rapid-acting insulin analogues: Theory and best clinical practice in type 1 and type 2 diabetes

Since the discovery of insulin 100 years ago, insulin preparations have improved significantly. Starting from purified animal insulins, evolving to human insulins produced by genetically modified organisms, and ultimately to insulin analogues, all in an attempt to mimic physiological insulin action profiles seen in individuals without diabetes. Achieving strict glucose control without hypoglycaemia and preventing chronic complications of diabetes while preserving quality of life remains a challenging goal, but the advent of newer ultra-rapid-acting insulin analogues may enable intensive insulin therapy without being too disruptive to daily life. Ultra-rapid-acting insulin analogues can be administered shortly before meals and give better coverage of mealtime-induced glucose excursions than conventional insulin preparations. They also increase convenience with timing of bolus dosing. In this review, we focus on the progress that has been made in rapid-acting insulins. We summarize pharmacokinetic and pharmacodynamic data, clinical trial data supporting the use of these new formulations as part of a basal-bolus regimen and continuous subcutaneous insulin infusion, and provide a clinical perspective to help guide healthcare professionals when and for whom to use ultra-fast-acting insulins.

Clinical approaches to treat impaired awareness of hypoglycaemia

Impaired awareness of hypoglycaemia (IAH) affects between 25% and 30% of all people with type 1 diabetes (T1D) and markedly increases risk of severe hypoglycaemia. This greatly feared complication of T1D impairs quality of life and has a recognised morbidity. People with T1D have an increased propensity to hypoglycaemia as a result of fundamental physiological defects in their ability to respond appropriately to a fall in blood glucose levels. With repeated exposure to low glucose, many then develop a condition referred to as IAH, where there is a reduced ability to perceive the onset of hypoglycaemia and take appropriate corrective action. The management of individuals with IAH relies initially on its identification in the clinic through a detailed exploration of the frequency of hypoglycaemia and an assessment of the individual's ability to recognise these episodes. In this review article, we will address the clinical strategies that may help in the management of the patient with IAH once identified, who may or may not also suffer from problematic hypoglycaemia. The initial focus is on how to identify such patients and then on the variety of approaches involving educational programmes and technological approaches that may be taken to minimise hypoglycaemia risk. No single approach can be advocated for all patients, and it is the role of the health care professional to identify the clinical strategy that best enables their patient to achieve this goal.

Randomized Double-Blind Clinical Trial Comparing Ultra Rapid Lispro With Lispro in a Basal-Bolus Regimen in Patients With Type 2 Diabetes: PRONTO-T2D

OBJECTIVE

To evaluate the efficacy and safety of ultra rapid lispro (URLi) versus lispro in patients with type 2 diabetes on a basal-bolus insulin regimen.

RESEARCH DESIGN AND METHODS

This was a phase 3, treat-to-target, double-blind 26-week study. After an 8-week lead-in to optimize basal insulin glargine or degludec in combination with prandial lispro treatment, patients were randomized to blinded URLi (n = 336) or lispro (n = 337) injected 0-2 min prior to meals. Patients could continue metformin and/or a sodium-glucose cotransporter 2 inhibitor. The primary end point was change in HbA1c from baseline to 26 weeks (noninferiority margin 0.4%), with multiplicity-adjusted objectives for postprandial glucose (PPG) excursions during a standardized meal test.

RESULTS

HbA1c improved for both URLi and lispro, and noninferiority was confirmed: estimated treatment difference (ETD) 0.06% (95% CI -0.05; 0.16). Mean change in HbA1c was -0.38% for URLi and -0.43% for lispro, with an end-of-treatment HbA1c of 6.92% and 6.86%, respectively. URLi was superior to lispro in controlling 1- and 2-h PPG excursions: 1-h ETD, -0.66 mmol/L (95% CI -1.01, -0.30); 2-h ETD, -0.96 mmol/L (-1.41, -0.52). Significantly lower PPG excursions were evident from 0.5 to 4.0 h postmeal with URLi treatment. There were no significant treatment differences in rates of severe or documented hypoglycemia (<3.0 mmol/L). Incidence of overall treatment-emergent adverse events was similar between treatments.

CONCLUSIONS

URLi compared with lispro in a basal-bolus regimen was confirmed to be noninferior for HbA1c and superior to lispro for PPG control in patients with type 2 diabetes.

Physician related barriers towards insulin therapy at primary care centres in Trinidad: a cross-sectional study

BACKGROUND

Physician related factors with respect to insulin therapy can contribute to diabetes mellitus (DM) mismanagement. Patient related factors have been previously explored in a Trinidad survey. The main objective of this study was to explore primary care physicians' (PCPs) related barriers towards insulin therapy.

METHODS

A cross-sectional study on a convenience sample of PCPs in the public primary care system was done using an online survey.

RESULTS

Of the 170 PCPs contacted, 75 (44%) responded. There were 47 females (62.7%) and 28 males (37.3%) with a mean age of 35.9 yrs. Nearly 40% of physicians admitted that the education given to patients was inadequate to allow initiation of insulin therapy. Half the respondents admitted to insufficient consultation times and inadequate appointment frequency to allow for intensification of insulin therapy. Forty percent of PCPs admitted that HbA1c results were unavailable to guide their management decisions. Only 6.7% of physicians said they had access to rapid acting insulin, while 5.3% said they had access to insulin pens.

CONCLUSION

PCPs in Trinidad treating diabetes at the public primary care clinics face several barriers in administering proper insulin therapy. Addressing these factors can improve glycemic control in this population.

Management of pregestational diabetes mellitus: a comparison of guidelines

Background: Pregestational diabetes is associated with adverse maternal and neonatal outcomes. The aim of this study was to summarize and compare evidence-based recommendations on pregestational diabetes and to focus especially on issues related to the management of this entity.Materials and methods: A descriptive review of three recently published national guidelines on pregestational diabetes was conducted: the American Diabetes Association on "Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2019," the National Institute for Health and Care Excellence on "Diabetes in pregnancy: management from preconception to the postnatal period" and the American College of Obstetricians and Gynecologists on "Pregestational Diabetes Mellitus." These guidelines were compared according to recommendations on management, during the preconception, antenatal, intrapartum and postpartum period.Results: There were many similar recommendations regarding the preconception counseling, the antepartum assessment by specialists, the glycemic control target levels, the pharmacologic treatment and the postpartum period among the three guidelines. On the other hand, the American Diabetes Association makes no recommendations regarding fetal monitoring and obstetric management during pregnancy and the intrapartum period, while there are several similarities between the other two guidelines.Conclusions: The adoption of an international consensus based on evidence - based guidelines will increase the awareness of the healthcare professionals on the management of pregestational diabetes, leading that way to more favorable perinatal outcomes.

Short-acting insulin analogues versus regular human insulin on postprandial glucose and hypoglycemia in type 1 diabetes mellitus: a systematic review and meta-analysis

INTRODUCTION

Strict glucose control using multiple doses of insulin is the standard treatment for type 1 diabetes mellitus (T1DM), but increased risk of hypoglycemia is a frequent drawback. Regular insulin in multiple doses is important for achieving strict glycemic control for T1DM, but short-acting insulin analogues may be better in reducing hypoglycemia and postprandial glucose levels.

OBJECTIVE

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the effects of short-acting insulin analogues vs regular human insulin on hypoglycemia and postprandial glucose in patients with T1DM.

METHODS

Searches were run on the electronic databases MEDLINE, Cochrane-CENTRAL, EMBASE, ClinicalTrials.gov, LILACS, and DARE for RCTs published until August 2017. To be included in the study, the RCTs had to cover a minimum period of 4 weeks and had to assess the effects of short-acting insulin analogues vs regular human insulin on hypoglycemia and postprandial glucose levels in patients with T1DM. Two independent reviewers extracted the data and assessed the quality of the selected studies. The primary outcomes analyzed were hypoglycemia (total episodes, nocturnal hypoglycemia, and severe hypoglycemia) and postprandial glucose (at all times, after breakfast, after lunch, and after dinner). Glycated hemoglobin (HbA1c) levels and quality of life were considered secondary outcomes. The risk of bias of each RCT was assessed using the Cochrane Collaboration Risk of Bias table, while the quality of evidence for each outcome was assessed using the GRADEpro software. The pooled mean difference in the number of hypoglycemic episodes and postprandial glucose between short-acting insulin analogues vs. regular human insulin was calculated using the random-effects model.

RESULTS

Of the 2897 articles retrieved, 22 (6235 patients) were included. Short-acting insulin analogues were associated with a decrease in total hypoglycemic episodes (risk rate 0.93, 95% CI 0.87-0.99; 6235 patients; I² = 81%), nocturnal hypoglycemia (risk rate 0.55, 95% CI 0.40-0.76, 1995 patients, I² = 84%), and severe hypoglycemia (risk rate 0.68, 95% CI 0.60-0.77; 5945 patients, I² = 0%); and with lower postprandial glucose levels (mean difference/MD - 19.44 mg/dL; 95% CI - 21.49 to - 17.39; 5031 patients, I² = 69%) and lower HbA1c (MD - 0,13%; IC 95% - 0.16 to - 0.10; 5204 patients; I² = 73%) levels.

CONCLUSIONS

Short-acting insulin analogues are superior to regular human insulin in T1DM patients for the following outcomes: total hypoglycemic episodes, nocturnal hypoglycemia, severe hypoglycemia, postprandial glucose, and HbA1c.

Short-acting insulin analogues versus regular human insulin for adult, non-pregnant persons with type 2 diabetes mellitus

BACKGROUND

The use of short-acting insulin analogues (insulin lispro, insulin aspart, insulin glulisine) for adult, non-pregnant people with type 2 diabetes is still controversial, as reflected in many scientific debates.

OBJECTIVES

To assess the effects of short-acting insulin analogues compared to regular human insulin in adult, non-pregnant people with type 2 diabetes mellitus.

SEARCH METHODS

For this update we searched CENTRAL, MEDLINE, Embase, the WHO ICTRP Search Portal, and ClinicalTrials.gov to 31 October 2018. We placed no restrictions on the language of publication.

SELECTION CRITERIA

We included all randomised controlled trials with an intervention duration of at least 24 weeks that compared short-acting insulin analogues to regular human insulin in the treatment of people with type 2 diabetes, who were not pregnant.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias. We assessed dichotomous outcomes by risk ratios (RR), and Peto odds ratios (POR), with 95% confidence intervals (CI). We assessed continuous outcomes by mean differences (MD) with 95% CI. We assessed trials for certainty of the evidence using the GRADE approach.

MAIN RESULTS

We identified 10 trials that fulfilled the inclusion criteria, randomising 2751 participants; 1388 participants were randomised to receive insulin analogues and 1363 participants to receive regular human insulin. The duration of the intervention ranged from 24 to 104 weeks, with a mean of about 41 weeks. The trial populations showed diversity in disease duration, and inclusion and exclusion criteria. None of the trials were blinded, so the risk of performance bias and detection bias, especially for subjective outcomes, such as hypoglycaemia, was high in nine of 10 trials from which we extracted data. Several trials showed inconsistencies in the reporting of methods and results.None of the included trials defined all-cause mortality as a primary outcome. Six trials provided Information on the number of participants who died during the trial, with five deaths out of 1272 participants (0.4%) in the insulin analogue groups and three deaths out of 1247 participants (0.2%) in the regular human insulin groups (Peto OR 1.66, 95% CI 0.41 to 6.64; P = 0.48; moderate-certainty evidence). Six trials, with 2509 participants, assessed severe hypoglycaemia differently, therefore, we could not summarise the results with a meta-analysis. Overall, the incidence of severe hypoglycaemic events was low, and none of the trials showed a clear difference between the two intervention arms (low-certainty evidence).The MD in glycosylated haemoglobin A1c (HbA1c) change was -0.03% (95% CI -0.16 to 0.09; P = 0.60; 9 trials, 2608 participants; low-certainty evidence). The 95% prediction ranged between -0.31% and 0.25%. The MD in the overall number of non-severe hypoglycaemic episodes per participant per month was 0.08 events (95% CI 0.00 to 0.16; P = 0.05; 7 trials, 2667 participants; very low-certainty evidence). The 95% prediction interval ranged between -0.03 and 0.19 events per participant per month. The results provided for nocturnal hypoglycaemic episodes were of questionable validity. Overall, there was no clear difference between the two short-acting insulin analogues and regular human insulin. Two trials assessed health-related quality of life and treatment satisfaction, but we considered the results for both outcomes to be unreliable (very low-certainty evidence).No trial was designed to investigate possible long term effects (all-cause mortality, microvascular or macrovascular complications of diabetes), especially in participants with diabetes-related complications. No trial reported on socioeconomic effects.

AUTHORS' CONCLUSIONS

Our analysis found no clear benefits of short-acting insulin analogues over regular human insulin in people with type 2 diabetes. Overall, the certainty of the evidence was poor and results on patient-relevant outcomes, like all-cause mortality, microvascular or macrovascular complications and severe hypoglycaemic episodes were sparse. Long-term efficacy and safety data are needed to draw conclusions about the effects of short-acting insulin analogues on patient-relevant outcomes.

Strategies for implementing effective mealtime insulin therapy in type 2 diabetes

BACKGROUND

Type 2 diabetes mellitus (T2D) is a growing global epidemic. Due to the progressive nature of the disease, many people with T2D require insulin at some point, most commonly a long-acting (basal) insulin to assist with 24-h control of glucose levels.

OBJECTIVE

This opinion paper provides an overview of considerations for primary care providers (PCPs) in intensifying the treatment regimen when basal insulin therapy is inadequate.

RESULTS

Control of mealtime hyperglycemia, in addition to fasting hyperglycemia, has been shown to be crucial in reaching A1c goals of <7.0%. However, initiating and optimizing mealtime insulin therapy can be challenging for both people with T2D and PCPs, due to a perceived lack of efficacy and burden of insulin treatment, causing "psychological insulin resistance" in people with T2D and clinical inertia among PCPs. Successful implementation of mealtime insulin therapy requires not only choosing appropriate treatment strategies, but also addressing patient-related behavioral and emotional barriers. Simplified treatment algorithms, combined with the use of advanced technology (devices such as insulin pens, pumps, and patches), and collaborative decision-making can help decrease barriers to effective mealtime insulin therapy.

CONCLUSIONS

It is possible to implement an effective basal-bolus insulin regimen in people with T2D in a way that improves glucose control while minimizing negative effects on quality-of-life, treatment satisfaction, and psychological well-being.

Faster insulin action is associated with improved glycaemic outcomes during closed-loop insulin delivery and sensor-augmented pump therapy in adults with type 1 diabetes

We aimed to evaluate the relationship between insulin pharmacodynamics and glycaemic outcomes during closed-loop insulin delivery and sensor-augmented pump therapy. We retrospectively analysed data from a multicentre randomized control trial involving 32 adults with type 1 diabetes receiving day-and-night closed-loop insulin delivery and sensor-augmented pump therapy over 12 weeks. We estimated time-to-peak insulin action (t _max,IA ) and insulin sensitivity ( S _I ) during both interventions, and correlated these with demographic factors and glycaemic outcomes. During both interventions, t _max,IA was positively correlated with pre- and post-intervention HbA1c (r = 0.50-0.52, P  < .01) and mean glucose (r = 0.45-0.62, P  < .05), and inversely correlated with time sensor glucose, which was in target range 3.9 to 10 mmol/L (r = -0.64 to -0.47, P  < .05). Increased body mass index was associated with higher t _max,I and lower S _I (both P  < .05). During closed-loop insulin delivery, t _max,IA was positively correlated with glucose variability ( P  < .05). Faster insulin action is associated with improved glycaemic control during closed-loop insulin delivery and sensor-augmented pump therapy.

Titration of basal insulin or immediate addition of rapid acting insulin in patients not at target using basal insulin supported oral antidiabetic treatment - A prospective observational study in 2202 patients

AIM

Optimal treatment intensification strategies in patients with type-2 diabetes mellitus (T2DM) receiving basal insulin supported oral antidiabetic therapy (BOT) remain controversial. The objective of the present study was to compare outcomes of BOT-intensification by either the uptitration of long-acting insulin glargine or by the immediate addition of a rapid acting insulin analogue (RAIA).

METHODS

This was a prospective, observational, 24-week study in T2DM patients with BOT using insulin glargine and baseline glycated hemoglobin (HbA1c) between 7.0 and 8.5%. Patients were stratified by their physicians to one of the following treatment intensification strategies: Basal insulin titration to target with discretionary subsequent addition of RAIA at weeks 12 or 24 (GLAR), or immediate addition of RAIA at baseline (GLARplus).

RESULTS

A total of 3266 patients were prescreened of whom 2202 fulfilled the selection criteria. Of these, 1684 patients were documented in the GLAR group and 518 in the GLARplus group. In the GLAR group, in 91 (5.5%) and 21 patients (1.3%) RAIA was added at weeks 12 and 24, respectively. The groups displayed similar baseline characteristics; except, mean diabetes duration was slightly shorter in the GLAR group (8.7 vs. 9.4 years). During the study, insulin glargine dose was increased from 18.7 to 26.4U (plus 7.7U) in GLAR and from 24.9 to 27.3U (plus 2.4U) in GLARplus patients. Mean RAIA dose was 9.6±4.7U at the final visit. After 24 weeks, HbA1c was reduced by 0.8 and 0.9% in the GLAR and GLARplus groups, respectively (both p<0.001). An HbA1c of ≤7.0% was achieved in 49.2% of GLAR and 48.5% of GLARplus patients. In both groups, we observed improvements in cardiovascular risk factors such as lipids and blood pressure. The rates of symptomatic (1.6 vs. 1.7%) and severe (0.18 vs. 0.19%) hypoglycemic episodes were low and comparable in both groups.

CONCLUSION

These findings provide evidence that treatment intensification in patients with type 2 diabetes not at glycemic target on BOT with insulin glargine is equally safe and effective using either long-acting insulin titration alone or the addition of a rapid-acting insulin analogue.

Adherence to Insulin Therapy

IN BRIEF Six million people with diabetes use insulin either alone or in combination with an oral medication. Many barriers exist that lead to poor adherence with insulin. However, there is an underwhelming amount of data on interventions to address these barriers and improve insulin adherence. Until pharmacological advancements create easier, more acceptable insulin regimens, it is imperative to involve patients in shared decision-making.

Short-acting insulin analogues versus regular human insulin for adults with type 1 diabetes mellitus

BACKGROUND

Short-acting insulin analogue use for people with diabetes is still controversial, as reflected in many scientific debates.

OBJECTIVES

To assess the effects of short-acting insulin analogues versus regular human insulin in adults with type 1 diabetes.

SEARCH METHODS

We carried out the electronic searches through Ovid simultaneously searching the following databases: Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R) (1946 to 14 April 2015), EMBASE (1988 to 2015, week 15), the Cochrane Central Register of Controlled Trials (CENTRAL; March 2015), ClinicalTrials.gov and the European (EU) Clinical Trials register (both March 2015).

SELECTION CRITERIA

We included all randomised controlled trials with an intervention duration of at least 24 weeks that compared short-acting insulin analogues with regular human insulins in the treatment of adults with type 1 diabetes who were not pregnant.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trials for risk of bias, and resolved differences by consensus. We graded overall study quality using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) instrument. We used random-effects models for the main analyses and presented the results as odds ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes.

MAIN RESULTS

We identified nine trials that fulfilled the inclusion criteria including 2693 participants. The duration of interventions ranged from 24 to 52 weeks with a mean of about 37 weeks. The participants showed some diversity, mainly with regard to diabetes duration and inclusion/exclusion criteria. The majority of the trials were carried out in the 1990s and participants were recruited from Europe, North America, Africa and Asia. None of the trials was carried out in a blinded manner so that the risk of performance bias, especially for subjective outcomes such as hypoglycaemia, was present in all of the trials. Furthermore, several trials showed inconsistencies in the reporting of methods and results.The mean difference (MD) in glycosylated haemoglobin A1c (HbA1c) was -0.15% (95% CI -0.2% to -0.1%; P value < 0.00001; 2608 participants; 9 trials; low quality evidence) in favour of insulin analogues. The comparison of the risk of severe hypoglycaemia between the two treatment groups showed an OR of 0.89 (95% CI 0.71 to 1.12; P value = 0.31; 2459 participants; 7 trials; very low quality evidence). For overall hypoglycaemia, also taking into account mild forms of hypoglycaemia, the data were generally of low quality, but also did not indicate substantial group differences. Regarding nocturnal severe hypoglycaemic episodes, two trials reported statistically significant effects in favour of the insulin analogue, insulin aspart. However, due to inconsistent reporting in publications and trial reports, the validity of the result remains questionable.We also found no clear evidence for a substantial effect of insulin analogues on health-related quality of life. However, there were few results only based on subgroups of the trial populations. None of the trials reported substantial effects regarding weight gain or any other adverse events. No trial was designed to investigate possible long-term effects (such as all-cause mortality, diabetic complications), in particular in people with diabetes related complications.

AUTHORS' CONCLUSIONS

Our analysis suggests only a minor benefit of short-acting insulin analogues on blood glucose control in people with type 1 diabetes. To make conclusions about the effect of short acting insulin analogues on long-term patient-relevant outcomes, long-term efficacy and safety data are needed.

Drug-related risk of severe hypoglycaemia in observational studies: a systematic review and meta-analysis

BACKGROUND

Diabetes mellitus (DM) leads to multiple complications, including severe hypoglycaemia events (SHEs). SHEs can impact a patient's quality of life and compliance and may directly result in additional costs to the health care system. The aim of this review was to evaluate the risk of severe hypoglycaemia in patients with type 1 (T1) and 2 (T2) DM as observed in everyday clinical practice for various drug regimens.

METHODS

We conducted a systematic review of observational (retrospective or prospective) studies in the MEDLINE, Embase, and Cochrane Library databases that covered at least 100 children or adults with T1/T2 DM. In T1 DM, basal-bolus/pre-mix insulin (human or analogue) and insulin pump were reviewed, and in T2 DM, basal-bolus/pre-mix insulin (human or analogue), oral antidiabetic drugs supported with basal insulin (human or analogue), sulfonylureas in monotherapy, and combined oral treatment were reviewed. In order to estimate SHE rates, we extracted data on the time horizon of the study, number of patients, number of SHEs, and number of patients experiencing at least one SHE. We used a random effects model to estimate the annual SHE rate. We considered the risk for other antidiabetic medications in T2 DM to be negligible and the results of our main review yielded no observational data for premixes in T1 DM so they were assessed based on relative rates taken from additional systematic reviews. The study, being a desk research, did not involve any human subjects (including human material or human data) and no ethical committee approval was asked for. For the same reason there was no need to collect informed consent for participation in the study.

RESULTS

We identified 76 observational studies encompassing 707,722.30 patient-years. The estimated annual SHE rate varied from 0.168 (95 % CI 0.123-0.237) for insulin pump up to 1.628 for biphasic human insulin in T1 DM patients, and from 0.0035 for oral antidiabetic drugs up to 0.554 (95 % CI 0.157-7.534) for basal-bolus with human insulin in T2 DM patients.

CONCLUSIONS

Our review indicates that SHE rates differ between patients depending on treatment regimen. However, SHEs are also driven by other factors. Proper modelling techniques are needed to use various types of information in published studies.

Modern insulins, old paradigms and pragmatism: choosing wisely when deciding how to treat type 1 diabetes

There is a clinical imperative to improve metabolic control in the treatment of patients with type 1 diabetes, but in doing so, hypoglycemia should be avoided at all costs. Insulin analogues and the assumption they would better mimic the pharmacokinetic profile of endogenous insulin secretion emerged as a magic bullet in the treatment of patients with type 1 diabetes. However, although insulin analogues have pharmaceutical properties, such as pharmacodynamic stability, reproducibility of action, and a more physiological timing of action, which could possibly facilitate insulin use, the results obtained in clinical practice have not been as good as expected. Like all clinical decisions, the decision regarding which insulin would be better for the patient should be, if possible, evidence based. Here, we briefly discuss evidence for the use of insulin analogues and the different views with respect to the available evidence that lead to different interpretations and decisions regarding the use of this new technology.

Evolution of insulin: from human to analog

The development of insulin analogs has made improved treatment of type 2 diabetes possible. In this article, structural alterations, pharmacokinetics and pharmacodynamics, clinical end points, and safety issues are reviewed for the currently available basal insulins, rapid-acting insulins, and premixes. The flatter activity profiles of insulin glargine and insulin detemir translate into good clinical efficacy with a lower risk of hypoglycemia relative to neutral protamine Hagedorn insulin. Weight gain is consistently lower with insulin detemir than with neutral protamine Hagedorn insulin. Insulin degludec, licensed in Europe and Japan but not yet in the United States, has a mean half-life of 25.4 hours, a duration of action of >42 hours, and low variability. In trials in type 2 diabetes, rates of nocturnal hypoglycemia were lower with insulin degludec than with insulin glargine, and more flexible; once-daily dose timing was shown to be possible. Insulin lispro, insulin aspart, and insulin glulisine are rapidly absorbed after injection and thus provide better coverage of the post-prandial glucose surge compared with human insulin. Trials and meta-analyses show that reductions in glycated hemoglobin are similar and control of postprandial glucose is better with the rapid-acting analogs versus human insulin. Convenience is greater for patients because the analogs can be injected just before a meal. In premix or biphasic insulins, a proportion of the rapid-acting analog is protaminated, providing both rapid-acting and intermediate-acting components in one formulation, thus reducing the number of injections required. Alterations to human insulin have resulted in improvements in safety, efficacy, tolerability, and convenience for patients.

Safety, tolerability, and efficacy of insulin aspart in people with type 2 diabetes, as biphasic insulin aspart or with Basal insulin: findings from the multinational, non-interventional a1chieve study

INTRODUCTION

The aim of the study was to investigate the clinical safety and effectiveness of starting insulin aspart (aspart) therapy in people with type 2 diabetes mellitus (T2DM) as a sub-analysis of the multinational, non-interventional A1chieve study.

METHODS

Insulin-naïve and insulin-experienced people with T2DM in routine clinical care starting aspart alone at baseline and continuing aspart alone, changing to biphasic insulin aspart 30 (aspart premix) or adding a basal insulin by study end, were included. Safety, tolerability, and efficacy were evaluated over 24 weeks.

RESULTS

Overall, 3,898 people started aspart at baseline. Of the 3,313 with 24-week data, 1,545 (46.6%) continued with aspart, 1,379 (41.6%) switched to aspart premix, and 214 (6.5%) added basal insulin, while the remainder switched to other regimens. No serious adverse drug reactions were reported. The proportion of participants reporting hypoglycemia decreased from baseline to week 24 in the aspart alone group (11.2% versus 4.1%, p < 0.001) and in the aspart + basal insulin group (13.1% versus 7.5%, p = 0.040), and was 3.7% at week 24 in the aspart premix group. The mean HbA1c decreased from baseline to week 24 (aspart: -2.1 ± 2.0% [-23 ± 22 mmol/mol], aspart premix: -2.3 ± 1.7% [-25 ± 19 mmol/mol], aspart + basal insulin: -2.0 ± 2.1% [-22 ± 23 mmol/mol]; p < 0.001).

CONCLUSION

Insulin aspart therapy was well tolerated and was associated with improved glucose control over 24 weeks in people with T2DM.

Safety and effectiveness of insulin aspart in Basal-bolus regimens regardless of age: a1chieve study results

INTRODUCTION

Hypoglycemia is a complication in the management of type 2 diabetes, and elderly people are at greater risk of experiencing hypoglycemia events than younger patients. Insulin analogs achieve glycemic control with minimal risk of hypoglycemia and may therefore be a good treatment option for all patients.

METHODS

A1chieve was an international, multicenter, prospective, open-label, non-interventional, 24-week study in people with type 2 diabetes who started/switched to therapy with biphasic insulin aspart 30, insulin detemir or insulin aspart (alone/in combination) in routine clinical practice. This sub-analysis evaluated clinical safety and effectiveness of insulin aspart as part of a basal-bolus regimen (±oral glucose-lowering drugs) in three age-groups (≤40, >40-65, and >65 years) of insulin-experienced and insulin-naive people with type 2 diabetes.

RESULTS

In total, 4,032 patients were included in the sub-analysis. After 24 weeks of insulin aspart treatment, significant improvements versus baseline were observed in all age-groups for: proportion of people with ≥1 hypoglycemia events (18.3-27.1% and 11.0-12.7%, at baseline and 24 weeks, respectively), ≥1 major hypoglycemia events (3.3-6.7% and 0-0.2%), and ≥1 nocturnal hypoglycemia events (9.2-13.7% and 2.9-4.9%); glycated hemoglobin (9.6-9.8% and 7.4%); fasting plasma glucose (change from baseline ranged from -3.6 to -4.4 mmol/l); and post-breakfast post-prandial plasma glucose (change from baseline ranged from -5.5 to -5.9 mmol/l). Fourteen serious adverse drug reactions were reported. Health-related quality of life was significantly improved for all age-groups (all, p < 0.001).

CONCLUSION

All age-groups showed improved glycemic control and reduced risk of hypoglycemia when starting/switching to insulin aspart therapy within a basal-bolus regimen; this may be particularly important for elderly patients given their greater risk of hypoglycemia versus younger patients.

Clinical utility of insulin and insulin analogs

Diabetes is a pandemic disease characterized by autoimmune, genetic and metabolic abnormalities. While insulin deficiency manifested as hyperglycemia is a common sequel of both Type-1 and Type-2 diabetes (T1DM and T2DM), it does not result from a single genetic defect--rather insulin deficiency results from the functional loss of pancreatic β cells due to multifactorial mechanisms. Since pancreatic β cells of patients with T1DM are destroyed by autoimmune reaction, these patients require daily insulin injections. Insulin resistance followed by β cell dysfunction and β cell loss is the characteristics of T2DM. Therefore, most patients with T2DM will require insulin treatment due to eventual loss of insulin secretion. Despite the evidence of early insulin treatment lowering macrovascular (coronary artery disease, peripheral arterial disease and stroke) and microvascular (diabetic nephropathy, neuropathy and retinopathy) complications of T2DM, controversy exists among physicians on how to initiate and intensify insulin therapy. The slow acting nature of regular human insulin makes its use ineffective in counteracting postprandial hyperglycemia. Instead, recombinant insulin analogs have been generated with a variable degree of specificity and action. Due to the metabolic variability among individuals, optimum blood glucose management is a formidable task to accomplish despite the presence of novel insulin analogs. In this article, we present a recent update on insulin analog structure and function with an overview of the evidence on the various insulin regimens clinically used to treat diabetes.

The need for better insulin therapy

Insulin replacement therapy corrects a core defect of diabetes pathophysiology. Since its introduction as a therapeutic modality almost 100 years ago, insulin therapy has undergone remarkable changes in purity and ability to provide more physiologic control of blood glucose levels. With glucose-lowering potential limited only by risks of hypoglycaemia, which remains the major limitation in our ability to achieve glycaemic goals, insulin replacement therapy remains a cornerstone of therapy. Major progress in reducing the risks of hypoglycemia has occurred with the development of insulin analogs. This review article briefly chronicles the evolution of insulin replacement strategies, highlighting both challenges in pharmaceutical development and patient acceptance, underscoring achievements, as well as denoting what improvements are still needed.

Evolution of insulin development: focus on key parameters

INTRODUCTION

Although insulin products and treatment strategies have improved significantly, clinical challenges still exist. Meeting glycemic goals while minimizing glucose variability and hypoglycemia is of utmost importance when considering existing insulin therapies and designing investigational insulin treatments.

METHODS

A PubMed search identified relevant, peer-reviewed articles related to the evolution of insulin development for this nonsystematic review. Search terms included "animal insulin," "synthetic insulin," "regular human insulin," "insulin lispro," "insulin aspart," "insulin glulisine," "insulin glargine," "insulin detemir," "insulin degludec," "biphasic human insulin," "insulin premixes," "ultra-long acting," "oral insulin," and "inhaled insulin."

RESULTS

While the discovery of animal insulin significantly decreased mortality rates from diabetes, issues with availability and large variability between batches led to difficulty in determining proper doses and, subsequently, challenges in achieving glycemic control and avoiding hypoglycemia. The development of synthetic insulin created a more readily available supply, but hypoglycemia still persisted. Recombinant DNA technology solved insulin production problems and allowed for the development of better retarding agents, but pharmacokinetic/pharmacodynamic profiles still did not mimic natural insulin. Insulin premixes offered improved glycemic control, decreased intrapatient variability versus self-mixing, and required fewer injections per day; however, patient adherence remained a problem due to the need to inject 30-60 minutes before a meal for optimal control. This prompted the development of rapid-acting insulin analogs that could be injected right before a meal and long-acting insulin analogs with flatter time-action profiles.

CONCLUSION

Despite advances in insulin development, a need to provide more physiologic basal insulin coverage and reduce hypoglycemic risk in patients with diabetes remains. Newer insulin analogs and more convenient routes of insulin delivery have shown promising safety and efficacy results. Many patients with diabetes have not reached glycemic goals on currently available insulins. Additional studies are necessary to tailor optimal insulin delivery strategies to specific subsets of diabetes patients.

A comparison of pharmacokinetics and pharmacodynamics of insulin aspart, biphasic insulin aspart 70, biphasic insulin aspart 50, and human insulin: a randomized, quadruple crossover study

BACKGROUND

We compared the pharmacokinetic and pharmacodynamic profiles of insulin aspart, biphasic insulin aspart 70 (BIAsp70) and 50 (BIAsp50) (containing 70% and 50% rapid-acting insulin aspart, respectively), and soluble human insulin under experimental conditions.

SUBJECTS AND METHODS

In this randomized, four-period crossover study, 19 type 1 diabetes patients received subcutaneous injections of identical doses (0.2 U/kg) of insulin aspart, BIAsp70, or BIAsp50 immediately before a standardized meal or human insulin 30 min before meal. Plasma glucose and serum insulin were measured for 12 h postprandially.

RESULTS

The pharmacokinetic and pharmacodynamic profiles of human insulin differed from those of insulin aspart, BIAsp70, and BIAsp50. The three different aspart preparations had easily distinguishable features with regard to onset and duration of action. Insulin aspart preparations were, on average, absorbed twice as fast as human insulin. In the initial phases (0-4 h and 0-6 h), the insulin area under the concentration-time curve (AUC(ins)) was significantly higher during insulin aspart treatment compared with the others, whereas insulin aspart had a significantly lower AUC(ins) over the last 6 h (P<0.05). BIAsp70 and BIAsp50 provided insulin coverage comparable to that of human insulin over the last 6 h. Insulin aspart had the most pronounced onset of action and the shortest duration. Comparing with insulin aspart and BIAsp70, BIAsp50 revealed a closer treatment ratio to human insulin on pharmacodynamic end points.

CONCLUSIONS

BIAsp70 and BIAsp50 injected immediately before a meal are at least as effective as human insulin injected 30 min earlier in controlling postprandial glycemic excursions. BIAsp50 showed the greatest similarity to human insulin with regard to pharmacokinetic and pharmacodynamic profiles.

Effect of the α-glucosidase inhibitor miglitol on the glucose profile in Japanese type 2 diabetic patients receiving multiple daily insulin injections

Strict postprandial glycemic control may have a preventive effect on atherogenesis in patients with type 2 diabetes. The α-glucosidase inhibitor (α-GI) miglitol is useful for controlling the early postprandial increase of glucose, but the combined effect of miglitol and multiple daily insulin injections (MDI) on glucose excursion has not been evaluated. First, we retrospectively compared the daily glucose profile, evaluated by self-monitoring of blood glucose (SMBG) at nine times on the day before discharge from hospital, between type 2 diabetic patients receiving MDI (n=81) or MDI plus miglitol at 150 mg daily (n=24). Second, we prospectively examined the effect of adding miglitol to MDI on the daily glucose profile (SMBG) in 19 other type 2 diabetic patients. Although the daily insulin dosage and the glucose level before meals did not differ between the two groups, the 1-h postprandial glucose level after each meal, 2-h glucose level after lunch and dinner, mean and standard deviation of glucose, and amplitude of glucose excursion were significantly lower or smaller in the MDI plus miglitol group than in the MDI group. All of these glucose parameters were significantly improved by adding miglitol to MDI in the prospective cohort of 19 patients. In conclusion, adding miglitol to MDI reduces postprandial glucose levels and attenuates daily glucose fluctuation in type 2 diabetic patients. This trial was registered with UMIN (no. UMIN000005383).