Insulin pharmacology

Once-weekly Insulin Icodec Versus Once-daily Long-acting Insulin for Type II Diabetes: A Meta-analysis of Randomized Controlled Trials

Background

Insulin icodec is a novel basal insulin analog with once-weekly subcutaneous administration. We aim to estimate the efficacy and safety of insulin icodec vs long-acting insulin (insulin glargine and degludec) in type II diabetic patients.

Methods

We conducted a systematic review and meta-analysis synthesizing randomized controlled trials (RCTs), which were retrieved by systematically searching PubMed, Web of Science, SCOPUS, and Cochrane through May 29, 2023. We used RevMan V. 5.4 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI). Our primary outcome was glycated hemoglobin (HbA1C) change.

Results

We included 7 RCTs with a total of 3183 patients. Insulin icodec was associated with significantly decreased HbA1C (MD: -0.15 with 95% CI [-0.24, -0.06], P = .002) and increased percentage of time with glucose in range (TIR) (MD: 4.06 with 95% CI [2.06, 6.06], P = .0001). However, insulin icodec was associated with increased body weight (MD: 0.57 with 95% CI [0.45, 0.70], P = .00001). Also, there was no difference regarding any serious adverse events (AEs) (RR: 0.96 with 95% CI [0.76, 1.20], P = .7) or AEs leading to withdrawal (RR: 1.54 with 95% CI [0.84, 2.82], P = .16). However, insulin icodec was associated with increased any AEs incidence (RR: 1.06 with 95% CI [1.01, 1.12], P = .02).

Conclusion

Insulin icodec was associated with decreased HbA1C, increased TIR, with similar hypoglycemic and serious AEs. However, it was also associated with increased body weight and the incidence of any AEs.

Diabetes Research and Care Through the Ages

As has been well established, the Diabetes Care journal's most visible signature event is the Diabetes Care Symposium held each year during the American Diabetes Association's Scientific Sessions. Held this past year on 10 June 2017 in San Diego, California, at the 77th Scientific Sessions, this event has become one of the most attended sessions during the Scientific Sessions. Each year, in order to continue to have the symposium generate interest, we revise the format and content of this event. For this past year, our 6th annual symposium, I felt it was time to provide a comprehensive overview of our efforts in diabetes care to determine, first and foremost, how we arrived at our current state of management. I also felt the narrative needed to include the current status of management, especially with a focus toward cardiovascular disease, and finally, we wanted to ask what the future holds. Toward this goal, I asked four of the most noted experts in the world to provide their opinion on this topic. The symposium started with a very thoughtful presentation by Dr. Jay Skyler entitled "A Look Back as to How We Got Here." That was followed by two lectures on current concepts by Dr. Bernard Zinman entitled "Current Treatment Paradigms Today-How Well Are We Doing?" and by Dr. Matthew Riddle entitled "Evolving Concepts and Future Directions for Cardiovascular Outcomes Trials." The final lecture for the symposium was delivered by Dr. Ele Ferrannini and was entitled "What Does the Future Hold?" As always, a well-attended and well-received symposium is now the norm for our signature event and our efforts were rewarded by the enthusiasm of the attendees. This narrative summarizes the lectures held at the symposium.-William T. CefaluChief Scientific, Medical & Mission Officer, American Diabetes Association.

Hypoglycemia prevalence in prepubertal children with type 1 diabetes on standard insulin regimen: use of continuous glucose monitoring system

OBJECTIVE

To determine hypoglycemia prevalence in prepubertal children on thrice (TID) and twice (BID) daily insulin regimens, using the Medtronic Minimed Continuous Glucose Monitoring System.

RESEARCH DESIGN AND METHODS

Twenty-eight children aged <12 years (median 9.8, range 6.9-11.8) wore the sensor for three consecutive days and nights. Hypoglycemia was defined as glucose <60 mg/dl for >15 min. Data are expressed as the percentage of time period spent hypoglycemic.

RESULTS

Hypoglycemia prevalence was 10.1% (mean 2.6 h. subject(-1) x day(-1)). Hypoglycemia was more common at night compared with daytime (18.81 vs. 4.4%, P < 0.001); 78 and 43% of subjects showed hypoglycemia on at least one night and two or more nights, respectively. Nocturnal episodes were prolonged (median 3.3 h) and asymptomatic (91% of episodes). Prevalence was greater between 0400 and 0730 h than between 2200 and 0400 h (25.5 vs. 15.4%, P < 0.001). On a TID compared with a BID regimen, nocturnal hypoglycemia prevalence was reduced, particularly between 0400-0730 h (22.9 vs. 27.4%, P = 0.005), whereas hypoglycemia the following morning (0730-1200 h) was greater (7.8 vs. 2.8%, P < 0.001). Nocturnal hypoglycemia risk was associated with decreasing age (by a factor of 0.6 for a year less in age), increased insulin dose (by 1.6 for an increase of 0.1 units. kg(-1) x day(-1)), insulin regimen (by 0.2 on a BID compared with a TID regimen), and increased weight standard deviation score (SDS) (by 2.7 for a one SDS rise).

CONCLUSIONS

Use of standard insulin regimens results in high prevalence and large intraindividual variation in hypoglycemia, particularly at night. Independent risk factors for nocturnal hypoglycemia were younger age, greater daily insulin dose, insulin regimen, and increasing weight.

Established therapies for diabetes mellitus

Traditional oral anti-diabetic agents for the treatment of diabetes mellitus include the sulfonylureas, metformin, and the alpha-glucosidase inhibitors. Insulin has traditionally been used in various forms with an aim to mimic physiological insulin secretion patterns. Combinations of any of these treatment classes have also been utilized for their additive effects. All of these options have specific advantages and disadvantages, making them ideal for certain patients and less ideal for others. Each of these treatment classes is briefly discussed with respect to mechanisms of action, clinical efficacy, side-effects and current controversies associated with their use. Newer agents (such as the thiazolidinediones, newer insulin secretagogues, and insulin analogues) will be discussed elsewhere.

Efficacy of inhaled human insulin in type 1 diabetes mellitus: a randomised proof-of-concept study

BACKGROUND

Effective glycaemic control in type 1 diabetes mellitus usually requires two or more insulin injections daily. Inhaled intrapulmonary delivery of insulin offers a potential new way to deliver meal-related insulin, eliminating the need for preprandial injections.

METHODS

73 patients with type 1 diabetes mellitus were studied in an open-label, proof-of-concept, parallel-group randomised trial. Patients in the experimental group received preprandial inhaled insulin plus a bedtime subcutaneous ultralente insulin injection. Patients in the control group received their usual insulin regimen of two to three injections per day. Participants monitored their blood glucose four times daily, and adjusted insulin doses weekly to achieve preprandial glucose targets of 5.6-8.9 mmol/L. The primary outcome measure was change in glycosylated haemoglobin (HbA1c) after 12 weeks. Secondary outcomes were fasting and postprandial glucose response to a mixed meal; hypoglycaemia frequency and severity; pulmonary function; and patients' satisfaction.

FINDINGS

Changes in HbA1c were indistinguishable between groups (difference 0.2% [95% CI -0.2 to 0.5]). Changes in fasting and postprandial glucose concentrations, and occurrence and severity of hypoglycaemia were also similar between groups. Inhaled insulin was well tolerated and had no effect on pulmonary function (ie, spirometry, lung volumes, diffusion capacity, and oxygen saturation).

INTERPRETATION

This proof-of-concept study shows that preprandial insulin can be given by inhalation in individuals with insulin-deficient type 1 diabetes as a less invasive alternative to conventional preprandial insulin injections.

Fluid snacks to help persons with type 1 diabetes avoid late onset postexercise hypoglycemia

PURPOSE

The present study assessed whether whole milk, skim milk, or two commercially available sports drinks are effective in preventing late onset postexercise hypoglycemia (LOPEH) in persons with type 1 diabetes mellitus.

METHODS

Subjects ingested water, whole milk, skim milk, sport drink A (carbohydrate and electrolytes), or sport drink B (carbohydrate, fat, and protein) before, during, and after 1 h of bicycle exercise at 60% VO2max in the late afternoon. Drinks were isocaloric (470 +/- 150 kcal) and the number of calories consumed was based on individual energy expenditure. No adjustment in insulinization was allowed in anticipation of exercise.

RESULTS

During water trials all subjects became hypoglycemic. Most drinks lead to a moderate hyperglycemia (range of mean values = 200-280 mg x dL(-1)) during the period between the end of exercise and dinner, but this was not the case for whole milk (range 80-120 mg x dL(-1)). Glycemia peaked about 1.5 h after dinner and declined over the next 90 min. Persistent hyperglycemia (range of means = 200-310 mg x dL(-1)) from after exercise to about 4 h postexercise was observed with sports drink B. A decline in glycemia in the evening was greatest during the skim milk trial and required subjects to ingest more carbohydrate as a late evening snack. The least decline during this period occurred during the whole milk trial. Subjects experienced pre-bed and early morning (0300 h) hypoglycemia in 7 of the 28 trials.

CONCLUSIONS

These data show that whole milk and sports drinks that are designed for both quick (sport drink A) and long lasting (sport drink B) nutrient replenishment can be used by persons with type 1 diabetes in an effort to avoid LOPEH.

Current understanding of feline diabetes: part 2, treatment

When treating diabetic cats, the primary aim is to control clinical signs without causing clinical hypoglycaemia. Secondary goals are to maximise the chances of attaining diabetic remission and to minimise the risk of complications due to chronic hyperglycaemia. A treatment plan that is convenient for the owner is important for compliance. Underweight or overweight diabetic cats should be fed with the aim of normalising bodyweight. Current evidence suggests that non-obese diabetic cats can be fed ad libitum. The oral hypoglycaemic drug glipizide is well established as a treatment for about a third of diabetic cats, which have residual beta cell function. Preliminary studies on other oral agents such as vanadium salts, metformin, and troglitazone indicate a potential use in some diabetic cats. Insulin treatment remains the treatment of choice for the majority of diabetic cats. Choice of insulin, dose rates and monitoring of treatment are discussed.

Inadequate suspension of neutral protamine Hagendorn (NPH) insulin in pens

BACKGROUND

Neutral protamine Hagedorn (NPH) insulin is one of the most commonly used insulins in insulin pens. NPH in pen cartridges is in a two-phase solution with either a solvent or a short-acting insulin, and needs adequate mixing for complete resuspension. We assessed whether NPH insulin is accurately resuspended by patients and the association of suspension errors with diabetes control.

METHODS

109 patients (39 with type 1 diabetes) who had received conventional diabetic education had the NPH content of their cartridges measured by an optical system; a control cartridge was designated as 100%. A questionnaire was used to assess clinical details and insulin suspension habits. After the information about residual insulin error was known, all 109 patients were instructed to resuspend their insulin by rolling and tipping the pen 20 times. 52 patients were randomly selected to have cartridges re-analysed 3 months or 6 months later and to complete another questionnaire.

FINDINGS

Only 10 (9%) of 109 patients tipped and rolled their pen more than ten times. NPH insulin content ranged from 5% to 214% and varied by more than 20% in 71 (65%) of 109 cartridges. There was no relation between inadequate suspension and the frequency of hypoglycaemic episodes (r=0.2, p=0.08). For all patients, there was a correlation between the absolute error of NPH suspension and cycles of rolling and tipping the pen (r=-0.23, p<0.05). After education on resuspending the pen's contents, data were available from 44 of 52 patients; suspension errors decreased in 35 (80%), were unchanged in three (7%), and increased in six (13%). The 35 patients with improved NPH insulin suspension had fewer mean hypoglycaemic episodes per month compared with the previous period (0.4 [SD 0.1] vs 1.0 [0.3], p<0.05). Mean HbA1c values in patients with improved suspension quality did not differ from baseline (8.4% [0.3] vs 8.9% [0.4], p=0.07). Mixing of NPH insulin by a mechanical device showed that at least 20 cycles were necessary before complete resuspension was obtained.

INTERPRETATION

Inadequate NPH insulin suspension is common. We recommended that patients tip pens that contain NPH insulin at least 20 times, since inadequate mixing may impair diabetes control.

Combined response of plasma and platelet catecholamines to different types of short-term stress

Platelet catecholamines (CAs) do not seem to reflect the acute increases in plasma CAs observed during stress, at least over short periods of time. However, it is well known that stress, via the release of plasma CAs, is capable of affecting platelet function. To better address this issue, we studied platelet and plasma levels of free noradrenaline (NA), adrenaline (A), and dopamine (DA) in 10 healthy subjects undergoing three different stress tests: insulin tolerance test (ITT), cold pressor test (CPT) and handgrip test (HT). We also evaluated platelet count and platelet mean volume (MPV). ITT caused a considerable increase in plasma NA and a massive release of plasma A, while CPT and HT induced discrete increases only in plasma NA. ITT induced a significant decrease in platelet DA and a trend toward a decrease in platelet NA, along with a significant increase in MPV. All these changes occurred in coincidence with the peak levels of plasma CAs. No changes in platelet variables were observed in response to both CPT and HT. The modifications observed during ITT are likely to represent signs of an initial platelet activation in response to the acute plasma CA elevations this test was able to elicit. Our data show that platelet CA content does not represent a mere reflection of the circulating concentrations of plasma CAs, but it is the result of a dynamic balance between these two compartments.