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Pieber TR, Leohr J, Bue-Valleskey JM, Juneja R, Chien J, Syring K, Buse JB. Understanding the Pharmacokinetics and Glucodynamics of Once Weekly Basal Insulins to Inform Dosing Principles: An Introduction to Clinicians. Endocr Pract 2024; 30:863-869. [PMID: 38880349 DOI: 10.1016/j.eprac.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/24/2024] [Accepted: 06/07/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE A new generation of basal insulin analogs enabling once-weekly administration is currently under development. Weekly basal insulins have the potential to overcome limitations exhibited by current daily basal insulins. The pharmacokinetic and glucodynamic characteristics differ significantly between weekly and daily basal insulins and will require paradigm shifts in how basal insulins are dosed. METHODS An overview of pharmacokinetic and glucodynamic principles of basal insulins is presented. Specifically, the pharmacokinetic and glucodynamic properties of daily basal insulins and how these differ for the new weekly basal insulins are discussed. Finally, models and simulations are used to describe the impact of weekly insulin properties on dosing. RESULTS Two approaches have been used to extend the half-lives of these insulins, creating fusion proteins with reduced clearance and reduced receptor-mediated degradation of the insulin. The resulting prolonged exposure-response profiles affect dosing and the impact of dosing errors. Specifically, the impact of loading doses, missed doses, and double doses, and the effect on glycemic variability of a once weekly basal insulin option are demonstrated using pharmacokinetic/glucodynamic models and simulations. CONCLUSIONS The transition from daily to weekly basal insulin dosing requires an understanding of the implications of the prolonged exposure-response profiles to effectively and confidently incorporate these weekly basal insulins into clinical practice. By reviewing the application of pharmacokinetic and glucodynamic principles to daily basal insulin analogs, the differences with weekly basal insulins, and the impact of these properties on dosing, this review intends to explain the principles behind weekly basal insulin dosing.
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Affiliation(s)
- Thomas R Pieber
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | | | | | | | - Jenny Chien
- Eli Lilly and Company, Indianapolis, Indiana
| | | | - John B Buse
- Department of Medicine, Division of Endocrinology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
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Blair HA. Insulin Icodec: First Approval. BioDrugs 2024; 38:717-724. [PMID: 39031321 DOI: 10.1007/s40259-024-00670-5] [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: 07/22/2024]
Abstract
Insulin icodec (AWIQLI®) is an ultra-long-acting basal insulin analogue that is being developed by Novo Nordisk for the treatment of diabetes mellitus. Administered once weekly as a subcutaneous injection, insulin icodec is designed to improve treatment adherence and glycaemic control relative to once-daily insulin analogues. On 7 March 2024, insulin icodec was approved in Switzerland for the treatment of diabetes mellitus in adults. Insulin icodec was approved in Canada on 12 March 2024 for the once-weekly treatment of adults with diabetes mellitus to improve glycaemic control and received EU approval in May 2024 for the treatment of diabetes mellitus in adults. This article summarizes the milestones in the development of insulin icodec leading to this first approval for diabetes mellitus.
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Affiliation(s)
- Hannah A Blair
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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3
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Bajaj HS, Ásbjörnsdóttir B, Bari TJ, Begtrup K, Vilsbøll T, Rosenstock J. Once-weekly insulin icodec compared with daily basal insulin analogues in type 2 diabetes: Participant-level meta-analysis of the ONWARDS 1-5 trials. Diabetes Obes Metab 2024; 26:3810-3820. [PMID: 38951942 DOI: 10.1111/dom.15726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 06/03/2024] [Accepted: 06/03/2024] [Indexed: 07/03/2024]
Abstract
AIM To perform a participant-level post hoc meta-analysis of Phase 3a trials in type 2 diabetes (T2D) to characterize the hypoglycaemia safety and glycaemic efficacy of once-weekly insulin icodec (icodec). MATERIALS AND METHODS All ONWARDS 1-5 randomized participants were pooled as overall T2D, insulin-naive, an insulin-experienced subgroups, and by once-daily trial comparator (degludec or glargine U100). The main outcomes included incidence and rates of clinically significant and severe hypoglycaemia. Additional endpoints included change in glycated haemoglobin (HbA1c) from baseline and HbA1c target achievement without clinically significant or severe hypoglycaemia. RESULTS The meta-analysis comprised 3765 participants (1882 icodec vs. 1883 comparators). In the overall T2D pool, clinically significant hypoglycaemia incidence was similar in the icodec group versus the comparator group (17.9% vs. 16.2%, odds ratio [OR] 1.14, 95% confidence interval [CI] 0.94, 1.38); however, rates were low but significantly higher in the icodec group (1.15 vs. 1.00 episodes/participant-year of exposure, estimated rate ratio 1.51 [95% CI 1.24, 1.85]). Fewer severe hypoglycaemic episodes occurred with icodec than with comparators (8 vs. 18). A greater reduction in HbA1c occurred with icodec versus comparators, irrespective of subgroup (estimated treatment difference range [-0.10 to -0.29%]; all p < 0.05). Across subgroups, except for the insulin-experienced subgroup, the odds of achieving HbA1c <53 mmol/mol (7.0%) without clinically significant or severe hypoglycaemia were greater with icodec than with comparators (OR range 1.30-1.55; all p < 0.05). CONCLUSIONS Icodec was associated with a similar incidence but higher rates of clinically significant hypoglycaemia (equating to one additional hypoglycaemic episode every 6 years) and fewer severe hypoglycaemic episodes versus comparators. Our findings also confirmed the greater efficacy of icodec that was demonstrated in the ONWARDS trial programme.
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Affiliation(s)
- Harpreet S Bajaj
- Endocrine and Metabolic Research, LMC Healthcare, Brampton, Canada
| | | | | | | | - Tina Vilsbøll
- Clinical Research, Steno Diabetes Center Copenhagen, University of Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Lisco G, De Tullio A, De Geronimo V, Giagulli VA, Guastamacchia E, Piazzolla G, Disoteo OE, Triggiani V. Once-Weekly Insulin Icodec in Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Clinical Trials (ONWARDS Clinical Program). Biomedicines 2024; 12:1852. [PMID: 39200316 PMCID: PMC11352070 DOI: 10.3390/biomedicines12081852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 08/11/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
BACKGROUND One hundred years have passed since the discovery of insulin, which is one of the most relevant events of the 20th century. This period resulted in extraordinary progress in the development of novel molecules to improve glucose control, simplify the insulin regimen, and ameliorate the quality of life. In late March 2024, the first once-weekly basal analog Icodec was approved for diabetes mellitus, generating high expectations. Our aim was to systematically review and meta-analyze the efficacy and safety of Icodec compared to once-daily insulin analogs in type 1 (T1D) and type 2 diabetes (T2D). METHODS PubMed/MEDLINE, Cochrane Library, and ClinicalTrials.gov were searched for randomized clinical trials (RCTs). Studies were included for the synthesis according to the following prespecified inclusion criteria: uncontrolled T1D or T2D, age ≥ 18 years, insulin Icodec vs. active comparators (Degludec U100, Glargine U100, Glargine U300, and Detemir), phase 3, multicenter, double-blind or open-label RCTs, and a study duration ≥ 24 weeks. RESULTS The systematic review included 4347 patients with T1D and T2D inadequately controlled (2172 randomized to Icodec vs. 2175 randomized to once-daily basal analogs). Icodec, compared to once-daily basal analogs, slightly reduced the levels of glycated hemoglobin (HbA1c) with an estimated treatment difference (ETD) of -0.14% [95%CI -0.25; -0.03], p = 0.01, and I2 68%. Patients randomized to Icodec compared to those on once-daily basal analogs had a greater probability to achieve HbA1c < 7% without clinically relevant or severe hypoglycemic events in 12 weeks from randomization with an estimated risk ratio (ERR) of 1.17, [95%CI 1.01, 1.36], p = 0.03, and I2 66%. We did not find a difference in fasting glucose levels, time in range, and time above range between Icodec and comparators. Icodec, compared to once-daily basal analogs, resulted in a slight but statistically significant weight gain of 0.62 kg [95%CI 0.25; 0.99], p = 0.001, and I2 25%. The frequency of hypoglycemic events (ERR 1.16 [95%CI 0.95; 1.41]), adverse events (ERR 1.04 [95%CI 1.00; 1.08]), injection-site reactions (ERR 1.08 [95%CI 0.62; 1.90]), and the discontinuation of treatments were similar between the two groups. Icodec was found to work better when used in a basal-only than basal-bolus regimen with an ETD in HbA1c of -0.22%, a probability of achieving glucose control of +33%, a probability of achieving glucose control without clinically relevant or severe hypoglycemia of +28%, more time spent in target (+4.55%) and less time spent in hyperglycemia (-5.14%). The risk of clinically relevant or severe hypoglycemic events was significantly higher when background glinides and sulfonylureas were added to basal analogs (ERR 1.42 [95%CI 1.05; 1.93]). CONCLUSION Insulin Icodec is substantially non-inferior to once-daily insulin analogs in T2D, either insulin-naïve or insulin-treated. However, Icodec works slightly better than competitors when used in a basal-only rather than basal-bolus regimen. Weight gain and hypoglycemic risk are substantially low but not negligible. Patients' education, adequate lifestyle and pharmacological interventions, and appropriate therapy adjustments are essential to minimize risks. This systematic review is registered as PROSPERO CRD42024568680.
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Affiliation(s)
- Giuseppe Lisco
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy; (G.L.); (A.D.T.); (V.A.G.); (E.G.); (G.P.); (V.T.)
| | - Anna De Tullio
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy; (G.L.); (A.D.T.); (V.A.G.); (E.G.); (G.P.); (V.T.)
| | | | - Vito Angelo Giagulli
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy; (G.L.); (A.D.T.); (V.A.G.); (E.G.); (G.P.); (V.T.)
| | - Edoardo Guastamacchia
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy; (G.L.); (A.D.T.); (V.A.G.); (E.G.); (G.P.); (V.T.)
| | - Giuseppina Piazzolla
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy; (G.L.); (A.D.T.); (V.A.G.); (E.G.); (G.P.); (V.T.)
| | - Olga Eugenia Disoteo
- Unit of Endocrinology, Diabetology, Dietetics and Clinical Nutrition, Sant Anna Hospital, San Fermo della Battaglia, 22020 Como, Italy
| | - Vincenzo Triggiani
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy; (G.L.); (A.D.T.); (V.A.G.); (E.G.); (G.P.); (V.T.)
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Trevisan R, Conti M, Ciardullo S. Once-weekly insulins: a promising approach to reduce the treatment burden in people with diabetes. Diabetologia 2024; 67:1480-1492. [PMID: 38679644 PMCID: PMC11343872 DOI: 10.1007/s00125-024-06158-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/12/2024] [Indexed: 05/01/2024]
Abstract
Despite the availability of new classes of glucose-lowering drugs that improve glycaemic levels and minimise long-term complications, at least 20-25% of people with type 2 diabetes require insulin therapy. Moreover, a substantial proportion of these individuals do not achieve adequate metabolic control following insulin initiation. This is due to several factors: therapeutic inertia, fear of hypoglycaemia and/or weight gain, poor communication, complexity of insulin titration, and the number of injections needed, with the associated reduced adherence to insulin therapy. Once-weekly insulins provide a unique opportunity to simplify basal insulin therapy and to allow good glycaemic control with a low risk of hypoglycaemia. Several approaches to developing a stable and effective once-weekly insulin have been proposed, but, to date, insulin icodec and basal insulin Fc (insulin efsitora alfa) are the only two formulations for which clinical studies have been reported. The results of Phase I and II studies emphasise both efficacy (in term of glucose levels) and potential risks and adverse events. Phase III studies involving insulin icodec are reassuring regarding the risk of hypoglycaemia compared with daily basal insulin analogues. Despite some concerns raised in ongoing clinical trials, the available data suggest that weekly insulins may also be an option for individuals with type 1 diabetes, especially when adherence is suboptimal. For the first time there is an opportunity to make an important breakthrough in basal insulin therapy, particularly in people with type 2 diabetes, and to improve not only the quality of life of people with diabetes, but also the practice of diabetologists.
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Affiliation(s)
- Roberto Trevisan
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy.
- Endocrine and Diabetology Unit, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy.
| | - Matteo Conti
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
- Department of Medicine and Rehabilitation, Policlinico di Monza, Monza, Italy
| | - Stefano Ciardullo
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
- Department of Medicine and Rehabilitation, Policlinico di Monza, Monza, Italy
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Landgraf R, Aberle J, Birkenfeld AL, Gallwitz B, Kellerer M, Klein HH, Müller-Wieland D, Nauck MA, Wiesner T, Siegel E. Therapy of Type 2 Diabetes. Exp Clin Endocrinol Diabetes 2024; 132:340-388. [PMID: 38599610 DOI: 10.1055/a-2166-6755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
| | - Jens Aberle
- Division of Endocrinology and Diabetology, University Obesity Centre Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | | | - Baptist Gallwitz
- Department of Internal Medicine IV, Diabetology, Endocrinology, Nephrology, University Hospital Tübingen, Germany
| | - Monika Kellerer
- Department of Internal Medicine I, Marienhospital, Stuttgart, Germany
| | - Harald H Klein
- MVZ for Diagnostics and Therapy Bochum, Bergstraße 26, 44791 Bochum, Germany
| | - Dirk Müller-Wieland
- Department of Internal Medicine I, Aachen University Hospital RWTH, Aachen, Germany
| | - Michael A Nauck
- Diabetology, Endocrinology and Metabolism Section, Department of Internal Medicine I, St. Josef Hospital, Ruhr University, Bochum, Germany
| | | | - Erhard Siegel
- Department of Internal Medicine - Gastroenterology, Diabetology/Endocrinology and Nutritional Medicine, St. Josefkrankenhaus Heidelberg GmbH, Heidelberg, Germany
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Kalra S, Bhattacharya S, Kapoor N. Counseling for Insulin Icodec: A Proposed Practitioner's Guide. Diabetes Ther 2024; 15:1491-1499. [PMID: 38743307 PMCID: PMC11211307 DOI: 10.1007/s13300-024-01600-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/29/2024] [Indexed: 05/16/2024] Open
Abstract
Despite insulin being a lifesaving medication, insulin distress, insulin hesitancy, and insulin inertia remain oft-repeated themes in diabetes discourse. The current model lists three issues: temperament, troublesomeness, and technicality, which contribute to insulin perceptions. Therapeutic patienteducation (TPE), value-added therapy (VAT), and medication counseling are concepts that assist in optimizing insulin perceptions. Insulin icodec is a basal insulin with a half-life of 196 h and a once-weekly or circaseptan frequency of administration. Insulin icodec reduces the frequency of basal insulin administration to one-seventh, which along with the lower requirement of glucose monitoring, reduces the burden of plastic and ancillary supply disposal. Because of its unique frequency of injection, insulin icodec usage requires appropriate counseling and education. This reader-friendly counseling guide helps practitioners offer VAT, as well as TPE while prescribing icodec and other insulins.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India.
- University Center for Research and Development, Chandigarh University, Mohali, India.
| | | | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
- Non Communicable Disease Unit, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
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Long SA, Linsley PS. Integrating Omics into Functional Biomarkers of Type 1 Diabetes. Cold Spring Harb Perspect Med 2024; 14:a041602. [PMID: 38772709 PMCID: PMC11216170 DOI: 10.1101/cshperspect.a041602] [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: 05/23/2024]
Abstract
Biomarkers are critical to the staging and diagnosis of type 1 diabetes (T1D). Functional biomarkers offer insights into T1D immunopathogenesis and are often revealed using "omics" approaches that integrate multiple measures to identify involved pathways and functions. Application of the omics biomarker discovery may enable personalized medicine approaches to circumvent the more recently appreciated heterogeneity of T1D progression and treatment. Use of omics to define functional biomarkers is still in its early years, yet findings to date emphasize the role of cytokine signaling and adaptive immunity in biomarkers of progression and response to therapy. Here, we share examples of the use of omics to define functional biomarkers focusing on two signatures, T-cell exhaustion and T-cell help, which have been associated with outcomes in both the natural history and treatment contexts.
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Affiliation(s)
- S Alice Long
- Center for Translational Immunology, Benaroya Research Institute, Seattle, Washington 98101, USA
| | - Peter S Linsley
- Center for Systems Immunology, Benaroya Research Institute, Seattle, Washington 98101, USA
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Colacci M, Raissi A, Ray P, Sholzberg M, Rothman KJ, Fralick M. Randomized controlled trials of switching to a new medication vs continuing a chronic medication may underestimate the risk of adverse events in those continuing because of asymmetric depletion of susceptibles. J Clin Epidemiol 2024; 170:111336. [PMID: 38552726 DOI: 10.1016/j.jclinepi.2024.111336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/21/2024]
Affiliation(s)
- Michael Colacci
- Sinai Health System, Division of General Internal Medicine, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Afsaneh Raissi
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Prachi Ray
- Sinai Health System, Division of General Internal Medicine, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine and Laboratory Medicine & Pathobiology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Kenneth J Rothman
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Michael Fralick
- Sinai Health System, Division of General Internal Medicine, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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Ribeiro SAG, Chavez MP, Hespanhol LC, Almeida Balieiro CC, Paqualotto E, Ribeiro e Silva R, Gauza M, Roberto de Sa J. Once-weekly insulin icodec versus once-daily long-acting insulins for type 2 diabetes mellitus: Systematic review and meta-analysis. Metabol Open 2024; 22:100285. [PMID: 38867845 PMCID: PMC11167387 DOI: 10.1016/j.metop.2024.100285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/15/2024] [Accepted: 05/15/2024] [Indexed: 06/14/2024] Open
Abstract
Background Insulin icodec is a novel, long-acting, once-weekly basal insulin analog. Its comparative efficacy and safety with basal once-daily insulins in type 2 diabetes mellittus is uncertain. Objective Evaluate potential efficacy, benefits and risks associated with icodec compared to once-daily basal insulin analogs (degludec or glargine). Methods We systematically searched PubMed, Cochrane, and Embase for randomized controlled trials (RCTs) published until June 2023 comparing icodec versus long-acting insulin analogs (degludec and glargine) in type 2 diabetes mellitus (T2DM) with at least 12 weeks of follow-up. Binary endpoints were assessed with risk ratios (RRs) and continuous endpoints were compared using mean differences (MDs), with 95% confidence intervals (CIs). The protocol was registered in PROSPERO (CRD42023452468). Results A total of seven RCTs and 3286 patients with T2DM were included, of whom 1509 (60.6%) received icodec treatment. The follow-up period ranged from 16 to 78 weeks. Compared with once-daily basal insulin analogs, icodec led to a greater improvement in HbA1c (MD -0.15%; 95% CI -0.21, -0.10; p < 0.0001; I2 = 0%) and time in range (TIR) (MD 2.83%; 95%CI 0.94; 4.71; p = 0.003; I2 = 22%). Body weight was increased with icodec treatment (MD 0.78 Kg; 95%CI 0.42, 1.15; p < 0.01; I2 = 86%). There was also a higher rate of injection site reactions (RR 1.89; 95%CI 1.12, 3.18; p = 0.016; I2 = 0%) and nasopharyngitis (RR 1.94; 95%CI 1.11, 3.38; p = 0.020; I2 = 0%) in the icodec group, compared with once-daily regimens. There was no significant difference between groups in fasting plasma glucose. Conclusions In this meta-analysis of RCTs, insulin icodec led to better control of HbA1c and TIR as compared with once-daily insulin regimens, albeit with increased weight gain and a higher rate of injection site reaction in the Icodec group.
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Affiliation(s)
| | | | | | | | - Eric Paqualotto
- Universidade Federal de Santa Catarina, Division of Medicine, Brazil
| | | | - Mateus Gauza
- Universidade da Região de Joinville, Division of Medicine, Brazil
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Ayesh H, Suhail S, Ayesh S, Niswender K. Comparative efficacy and safety of weekly dulaglutide versus weekly insulin in type 2 diabetes: A network meta-analysis of randomized clinical trials. Metabol Open 2024; 22:100284. [PMID: 38699397 PMCID: PMC11064603 DOI: 10.1016/j.metop.2024.100284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/19/2024] [Accepted: 04/22/2024] [Indexed: 05/05/2024] Open
Abstract
Background Advancements in type 2 diabetes mellitus (T2DM) therapy, notably with weekly agents like glucagon-like peptide-1 receptor agonists (GLP-RAs) such as dulaglutide, offer promising outcomes in clinical practice. The emergence of once-weekly insulin adds to this therapeutic arsenal. This research aims to explore and compare the efficacy and safety profiles of these agents in diabetes management, facilitating informed decision-making for optimizing their utilization in clinical practice. Methods A systematic search of PubMed, Scopus, Cochrane, and Web of Science databases was conducted. The research protocol was registered at OSF registries (https://osf.io/gd67x). The primary outcome of interest was the change in hemoglobin A1C (HbA1c), with secondary outcomes including the change in fasting plasma glucose, body weight, prevalence of hypoglycemia, and treatment discontinuation due to adverse events. The evaluation of bias risk was conducted utilizing the RoB2 tool developed by the Cochrane Collaboration. Statistical analysis was performed using RStudio version 4.3.2 with the meta package version 7.0-0 and the netmeta package version 2.9-0. Confidence in network meta-analysis estimates was evaluated using the CINeMA (Confidence In Network Meta-Analysis). Heterogeneity was assessed by comparing the magnitude of the common between-study variance (τ2) for each outcome with empirical distributions of heterogeneity variances. Results Dulaglutide 1.5 mg (mg) weekly demonstrated superior reduction in hemoglobin A1C (HbA1c) compared to insulin, with a mean difference (MD) of -0.35 (95 % CI: -0.51 to -0.19). Additionally, Dulaglutide 1.5 mg exhibited greater weight loss, with an MD of -3.12 (95 % CI: -3.55 to -2.68). However, it also showed a higher rate of adverse events, with an odds ratio (OR) of 1.40 (95 % CI: 1.12 to 1.75) compared to insulin. Both doses of Dulaglutide (1.5 mg and 0.75 mg) had lower prevalence of hypoglycemia compared to insulin, with ORs of 0.60 (95 % CI: 0.41 to 0.87) and 0.59 (95 % CI: 0.41 to 0.86), respectively. There was no significant difference in treatment discontinuation among the treatment groups. Conclusion Dulaglutide, particularly at higher doses, demonstrates superior efficacy in lowering hemoglobin A1C and reducing hypoglycemia risk compared to Icodec insulin in type 2 diabetes management. However, its use is also associated with a higher incidence of adverse events. Clinicians should carefully consider these factors when selecting optimal treatment strategies for patients with type 2 diabetes mellitus.
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Affiliation(s)
- Hazem Ayesh
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Kevin Niswender
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
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12
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Zuhair V, Obaid MA, Mustafa MS, Shafique MA, Rangwala BS, Shakil A, Babar A, Rangwala HS, Obaid MI. Evaluating the efficacy and safety of weekly Insulin Icodec vs. Daily Insulin Glargine in type 2 Diabetes Mellitus: a systematic review and meta-analysis. J Diabetes Metab Disord 2024; 23:1337-1349. [PMID: 38932816 PMCID: PMC11196528 DOI: 10.1007/s40200-024-01431-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 03/27/2024] [Indexed: 06/28/2024]
Abstract
Introduction Various insulin therapies for Diabetes Mellitus offer different benefits while having potential risks. We aim to compare Insulin Icodec, a novel Insulin analogue with the ease of once-weekly administration, to the once-daily Insulin Glargine U100 regarding glycemic control and safety profile. Methods We performed a systematic literature search of electronic databases for peer-reviewed articles from inception until September 1 2023. Results A total of 2215 type 2 diabetic patients were included, of which 1209 received Insulin Icodec and1048 recieved Insulin Glargine U100. In terms of glycemic control, Insulin Icodec showed a significantly longer time in the target glucose range (MD: 0.304, CI: 0.069, P = 0.000) and a more significant reduction in HbA1c (MD: -0.154, CI: 0.003, P = 0.005) compared to Insulin Glargine U100. Fasting Plasma Glucose did not differ significantly. Insulin Icodec led to a more significant increase in body weight (MD: 0.161 kg, P = 0.029), while Insulin Glargine required a higher insulin dose (MD: 1.920 IU, P = 0.000). Regarding safety, the two groups had no significant differences in hypoglycemic events or adverse outcomes. Conclusion Once-weekly Insulin Icodec demonstrates superior glycemic control with a reduced HbA1c compared to Once-Daily Insulin Glargine U100 while maintaining similar safety profiles. Supplementary Information The online version contains supplementary material available at 10.1007/s40200-024-01431-5.
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Affiliation(s)
- Varisha Zuhair
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan
| | - Muhammad Adil Obaid
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan
| | - Muhammad Saqlain Mustafa
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan
| | - Muhammad Ashir Shafique
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan
| | | | - Areej Shakil
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan
| | - Areesha Babar
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan
| | - Hussain Sohail Rangwala
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan
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13
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Haahr H, Cieslarová B, Hingst JR, Jiang S, Kristensen NR, Kupčová V, Nørgreen L, Wagner FDH, Ignatenko S. The Effect of Various Degrees of Renal or Hepatic Impairment on the Pharmacokinetic Properties of Once-Weekly Insulin Icodec. Clin Pharmacokinet 2024; 63:819-830. [PMID: 38722461 PMCID: PMC11222188 DOI: 10.1007/s40262-024-01375-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND AND OBJECTIVE Icodec is a once-weekly insulin being developed to provide basal insulin coverage in diabetes mellitus. This study evaluated the effects of renal or hepatic impairment on icodec pharmacokinetics. METHODS Two open-label, parallel-group, single-dose (1.5 U/kg subcutaneously) trials were conducted. In a renal impairment trial, 58 individuals were allocated to normal renal function (measured glomerular filtration rate ≥ 90 mL/min), mild (60 to < 90 mL/min), moderate (30 to < 60 mL/min) or severe (< 30 mL/min) renal impairment or end-stage renal disease. In a hepatic impairment trial, 25 individuals were allocated to normal hepatic function or mild (Child-Pugh Classification grade A), moderate (grade B) or severe (grade C) hepatic impairment. Blood was sampled frequently for a pharmacokinetic analysis until 35 days post-dose. RESULTS The shape of the icodec pharmacokinetic profile was not affected by renal or hepatic impairment. Total icodec exposure was greater for mild (estimated ratio [95% confidence interval]: 1.12 [1.01; 1.24]), moderate (1.24 [1.12; 1.37]) and severe (1.28 [1.16; 1.42]) renal impairment, and for end-stage renal disease (1.14 [1.03; 1.28]), compared with normal renal function. It was also greater for mild (1.13 [1.00; 1.28]) and moderate (1.15 [1.02; 1.29]) hepatic impairment versus normal hepatic function. There was no statistically significant difference between severe hepatic impairment and normal hepatic function. Serum albumin levels (range 2.7-5.1 g/dL) did not statistically significantly influence icodec exposure. CONCLUSIONS The clinical relevance of the slightly higher icodec exposure with renal or hepatic impairment is limited as icodec should be dosed according to individual need. No specific icodec dose adjustment is required in renal or hepatic impairment. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifiers: NCT03723785 and NCT04597697.
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Affiliation(s)
| | | | | | | | | | - Viera Kupčová
- Dérer's Hospital, Comenius University, Bratislava, Slovakia
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14
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Rosenstock J, Bajaj HS, Lingvay I, Heller SR. Clinical perspectives on the frequency of hypoglycemia in treat-to-target randomized controlled trials comparing basal insulin analogs in type 2 diabetes: a narrative review. BMJ Open Diabetes Res Care 2024; 12:e003930. [PMID: 38749508 PMCID: PMC11097869 DOI: 10.1136/bmjdrc-2023-003930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/26/2024] [Indexed: 05/18/2024] Open
Abstract
The objective of this review was to comprehensively present and summarize trends in reported rates of hypoglycemia with one or two times per day basal insulin analogs in individuals with type 2 diabetes to help address and contextualize the emerging theoretical concern of increased hypoglycemic risk with once-weekly basal insulins.Hypoglycemia data were extracted from treat-to-target randomized clinical trials conducted during 2000-2022. Published articles were identified on PubMed or within the US Food and Drug Administration submission documents. Overall, 57 articles were identified: 44 assessed hypoglycemic outcomes in participants receiving basal-only therapy (33 in insulin-naive participants; 11 in insulin-experienced participants), 4 in a mixed population (insulin-naive and insulin-experienced participants) and 9 in participants receiving basal-bolus therapy. For the analysis, emphasis was placed on level 2 (blood glucose <3.0 mmol/L (<54 mg/dL)) and level 3 (or severe) hypoglycemia.Overall, event rates for level 2 or level 3 hypoglycemia across most studies ranged from 0.06 to 7.10 events/person-year of exposure (PYE) for participants receiving a basal-only insulin regimen; the rate for basal-bolus regimens ranged from 2.4 to 13.6 events/PYE. Rates were generally lower with second-generation basal insulins (insulin degludec or insulin glargine U300) than with neutral protamine Hagedorn insulin or first-generation basal insulins (insulin detemir or insulin glargine U100). Subgroup categorization by sulfonylurea usage, end-of-treatment insulin dose or glycated hemoglobin reduction did not show consistent trends on overall hypoglycemia rates. Hypoglycemia rates reported so far for once-weekly basal insulins are consistent with or lower than those reported for daily-administered basal insulin analogs.
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Affiliation(s)
| | | | - Ildiko Lingvay
- Endocrinology Division, Department of Internal Medicine and Peter O'Donnell School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Simon R Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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15
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Nelson M. Insulin Icodec. Clin Diabetes 2024; 42:452-453. [PMID: 39015163 PMCID: PMC11247026 DOI: 10.2337/cd24-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Affiliation(s)
- Matthew Nelson
- Providence Centralia Pharmaceutical Care Clinic, Washington State University College of Pharmacy and Pharmaceutical Sciences, Spokane, WA
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16
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Rosenstock J, Juneja R, Beals JM, Moyers JS, Ilag L, McCrimmon RJ. The Basis for Weekly Insulin Therapy: Evolving Evidence With Insulin Icodec and Insulin Efsitora Alfa. Endocr Rev 2024; 45:379-413. [PMID: 38224978 PMCID: PMC11091825 DOI: 10.1210/endrev/bnad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Indexed: 01/17/2024]
Abstract
Basal insulin continues to be a vital part of therapy for many people with diabetes. First attempts to prolong the duration of insulin formulations were through the development of suspensions that required homogenization prior to injection. These insulins, which required once- or twice-daily injections, introduced wide variations in insulin exposure contributing to unpredictable effects on glycemia. Advances over the last 2 decades have resulted in long-acting, soluble basal insulin analogues with prolonged and less variable pharmacokinetic exposure, improving their efficacy and safety, notably by reducing nocturnal hypoglycemia. However, adherence and persistence with once-daily basal insulin treatment remains low for many reasons including hypoglycemia concerns and treatment burden. A soluble basal insulin with a longer and flatter exposure profile could reduce pharmacodynamic variability, potentially reducing hypoglycemia, have similar efficacy to once-daily basal insulins, simplify dosing regimens, and improve treatment adherence. Insulin icodec (Novo Nordisk) and insulin efsitora alfa (basal insulin Fc [BIF], Eli Lilly and Company) are 2 such insulins designed for once-weekly administration, which have the potential to provide a further advance in basal insulin replacement. Icodec and efsitora phase 2 clinical trials, as well as data from the phase 3 icodec program indicate that once-weekly insulins provide comparable glycemic control to once-daily analogues, with a similar risk of hypoglycemia. This manuscript details the technology used in the development of once-weekly basal insulins. It highlights the clinical rationale and potential benefits of these weekly insulins while also discussing the limitations and challenges these molecules could pose in clinical practice.
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Affiliation(s)
- Julio Rosenstock
- Velocity Clinical Research at Medical City,
Dallas, TX 75230, USA
| | - Rattan Juneja
- Lilly Diabetes and Obesity, Eli Lilly and Company,
Indianapolis, IN 46225, USA
| | - John M Beals
- Lilly Diabetes and Obesity, Eli Lilly and Company,
Indianapolis, IN 46225, USA
| | - Julie S Moyers
- Lilly Diabetes and Obesity, Eli Lilly and Company,
Indianapolis, IN 46225, USA
| | - Liza Ilag
- Lilly Diabetes and Obesity, Eli Lilly and Company,
Indianapolis, IN 46225, USA
| | - Rory J McCrimmon
- School of Medicine, University of Dundee, Dundee
DD1 9SY, Scotland, UK
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17
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Ahmed M, Shafiq A, Javaid H, Jain H, Nashwan AJ, Tul‐Ain Q, Basit J. Clinical Outcomes With Once-Weekly Insulin Icodec Versus Once-Daily Insulin Glargine U100 in Insulin-Naïve and Previously Insulin-Treated Individuals With Type 2 Diabetes: A Meta-Analysis of Randomised Controlled Trials. Endocrinol Diabetes Metab 2024; 7:e00480. [PMID: 38659132 PMCID: PMC11043492 DOI: 10.1002/edm2.480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/24/2023] [Accepted: 03/03/2024] [Indexed: 04/26/2024] Open
Abstract
AIMS The once-weekly insulin icodec, a new basal insulin analog, may positively support a reduction in injection frequency and improve adherence to therapy in type 2 diabetes (T2D). This study aimed to evaluate the safety and efficacy of insulin icodec compared with those of once-daily glargine U100. METHODS A comprehensive literature search was conducted using PubMed/MEDLINE, Embase and the Cochrane Library from inception till September 2023. Data about clinical outcomes in both groups were extracted. Forest plots were generated using the random-effects model by pooling odds ratios (ORs) and mean differences (MDs). RESULTS Five randomised controlled trials and 2019 individuals with T2DM were included. In the pooled analysis, time in range was significantly higher (MD = 4.35; 95% CI: 1.65 to 7.05; p = 0.002) in the icodec group than in the once-daily glargine group. The HbA1c levels were significantly reduced (MD = -0.13; 95% CI: -0.24 to -0.03; p = 0.02) in the weekly icodec group compared with those in the once-daily glargine group. The weight gain was significantly less in the glargine group than in the weekly icodec group (MD = 0.41; 95% CI: 0.04 to 0.78; p = 0.03); however, in the subgroup analysis, this change became statistically insignificant in both insulin-naïve and previously insulin-treated individuals. The results were comparable across two groups for fasting plasma glucose levels, hypoglycaemia alert (Level 1), clinically significant (Level 2) or severe hypoglycaemia (Level 3), and adverse events. CONCLUSION Insulin icodec was associated with a reduction in glycated haemoglobin levels and higher time in range, with a similar safety profile as compared to insulin glargine U100. However, further evidence is still needed to reach a definitive conclusion.
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Affiliation(s)
- Mushood Ahmed
- Department of MedicineRawalpindi Medical UniversityRawalpindiPakistan
| | - Aimen Shafiq
- Department of MedicineDow University of Health SciencesKarachiPakistan
| | - Hira Javaid
- Department of MedicineAllama Iqbal Medical CollegeLahorePakistan
| | - Hritvik Jain
- Department of Internal MedicineAll India Institute of Medical Sciences (AIIMS)JodhpurIndia
| | | | - Qura Tul‐Ain
- Department of PharmacologyShifa Tameer‐e‐Millat UniversityIslamabadPakistan
| | - Jawad Basit
- Department of MedicineRawalpindi Medical UniversityRawalpindiPakistan
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18
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Argano C, Priola L, Manno F, Corrao S. What Is the Role of Basal Weekly Insulin in Clinical Practice? The State of the Art. Biomedicines 2024; 12:900. [PMID: 38672255 PMCID: PMC11048618 DOI: 10.3390/biomedicines12040900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Despite the advent of innovative therapies in the treatment of diabetes, ever-increasing awareness is still directed to the role of insulin since it has continued to be at the centre of diabetes therapy for decades, as a therapeutic integration of innovative agents in type 2 diabetes mellitus (T2DM), as the only replacement therapy in type 1 diabetes mellitus (T1DM) and also in gestational diabetes. In this context, the study of molecules such as weekly basal insulins, both for their technological and pharmacodynamic innovation and their manageability and undoubted benefits in compliance with drug therapy, can only be a turning point in diabetes and for all its phenotypes. This review aims to provide insight into the knowledge of basal weekly insulins and their use in type 1 and 2 diabetes mellitus by examining their safety, efficacy, manageability and increased therapeutic compliance.
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Affiliation(s)
- Christiano Argano
- Department of Internal Medicine, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, 90127 Palermo, Italy; (L.P.); (F.M.); (S.C.)
| | - Laura Priola
- Department of Internal Medicine, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, 90127 Palermo, Italy; (L.P.); (F.M.); (S.C.)
| | - Francesco Manno
- Department of Internal Medicine, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, 90127 Palermo, Italy; (L.P.); (F.M.); (S.C.)
| | - Salvatore Corrao
- Department of Internal Medicine, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, 90127 Palermo, Italy; (L.P.); (F.M.); (S.C.)
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
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19
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Ingrasciotta Y, Vitturi G, Trifirò G. Pharmacological and Benefit-Risk Profile of Once-Weekly Basal Insulin Administration (Icodec): Addressing Patients' Unmet Needs and Exploring Future Applications. J Clin Med 2024; 13:2113. [PMID: 38610878 PMCID: PMC11012332 DOI: 10.3390/jcm13072113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/28/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
Diabetes mellitus (DM) is a chronic metabolic disease affecting over 500 million people worldwide, which leads to severe complications and to millions of deaths yearly. When therapeutic goals are not reached with diet, physical activity, or non-insulin drugs, starting/adding insulin treatment is recommended by international guidelines. A novel recombinant insulin is icodec, a once-weekly insulin that successfully completed phase III trials and that has recently obtained the marketing authorization approval from the European Medicines Agency. This narrative review aims to assess icodec pharmacological and clinical features concerning evidence on benefit-risk profile, as compared to other basal insulins, addressing the potential impact on patients' unmet needs. Icodec is a full agonist, recombinant human insulin analogue characterized by an ultra-long half-life (196 h), enabling its use in once-weekly administration. Phase III randomized clinical trials involving more than 4000 diabetic patients, mostly type 2 DM, documented non-inferiority of icodec, as compared to currently available basal insulins, in terms of estimated mean reduction of glycated hemoglobin levels; a superiority of icodec, compared to control, was confirmed in insulin-naïve patients (ONWARDS 1, 3, and 5), and in patients previously treated with basal insulin (ONWARDS 2). Icodec safety profile was comparable to the currently available basal insulins. Once-weekly icodec has the potential to improve patients' adherence, thus positively influencing patients' treatment satisfaction as well as quality of life, especially in type 2 DM insulin-naïve patients. An improved adherence might positively influence glycemic target achievement, reduce overall healthcare costs and overcome some of the unmet patients' needs. Icodec has the potential to emerge as a landmark achievement in the evolution of insulin therapy, with a positive impact also for the National Health Services and the whole society.
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Affiliation(s)
- Ylenia Ingrasciotta
- Diagnostic and Public Health Department, University of Verona, 37134 Verona, Italy; (Y.I.); (G.V.)
- Academic Spin-off “Innovative Solutions for Medical Prediction and Big Data Integration in Real World Setting Srl—INSPIRE SRL”, University of Messina, 98125 Messina, Italy
| | - Giacomo Vitturi
- Diagnostic and Public Health Department, University of Verona, 37134 Verona, Italy; (Y.I.); (G.V.)
| | - Gianluca Trifirò
- Diagnostic and Public Health Department, University of Verona, 37134 Verona, Italy; (Y.I.); (G.V.)
- Academic Spin-off “Innovative Solutions for Medical Prediction and Big Data Integration in Real World Setting Srl—INSPIRE SRL”, University of Messina, 98125 Messina, Italy
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20
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Saleem SZ, Fareed A, Akhtar SMM, Farhat S, Taha AM, Akilimali A. Efficacy and safety of once-weekly insulin icodec compared to once-daily insulin g U-100 in patients with type II diabetes: a systematic review and meta-analysis. Diabetol Metab Syndr 2024; 16:80. [PMID: 38566252 PMCID: PMC10988795 DOI: 10.1186/s13098-024-01305-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND//OBJECTIVE Diabetes affects millions of people globally, despite treatment options, adherence and other factors pose obstacles. Once-weekly Insulin Icodec, a novel basal Insulin analog with a week-long half-life, offers potential benefits, enhancing convenience, adherence, and quality of life for improved glycemic control. This systematic review and meta-analysis aimed to assess the efficacy and safety of once-weekly Insulin Icodec compared to once-daily Insulin Glargine U-100 in individuals with type II diabetes (T2D). METHODS A comprehensive literature search was conducted using PubMed, and Cochrane Library databases before September 2023 to identify relevant Randomized control trials (RCTs) with no language restrictions following PRISMA guidelines. The Cochrane risk-of-bias tool was used for quality assessment. All statistical analyses were conducted using RevMan (version 5.4; Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). RESULT Four RCTs published from 2020 to 2023 with a cumulative sample size of 1035 were included. The pooled mean difference (MD) revealed a 4.68% longer TIR (%) with Insulin Icodec compared to Insulin Glargine U-100 [{95% CI (0.69, 8.68), p = 0.02}], the estimated mean changes in HbA1c (%) and FPG (mg%) were found to be insignificant between the two groups [MD = - 0.12 {95% CI (- 0.26, 0.01), p = 0.07}] and [MD = - 2.59 {95% CI (- 6.95, 1.78), p = 0.25}], respectively. The overall OR for hypoglycemia was also nonsignificant between the two regimens 1.04 [{95% CI (0.71, 1.52), p = 0.84}]. Other safety parameters were similar between the two groups. CONCLUSIONS Switching from daily Insulin Glargine U-100 to weekly Insulin Icodec showed longer TIR (%) as well as similar blood glycemic control and safety profile. Hence, it may be a good alternate option for management of longstanding T2D.
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Affiliation(s)
- Syed Zia Saleem
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Areeba Fareed
- Department of Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | | | - Solay Farhat
- Faculty of Science, Lebanese University, Beirut, Lebanon
| | | | - Aymar Akilimali
- Department of Research, Medical Research Circle, Bukavu, DR, Congo.
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21
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Bajaj HS, Ásbjörnsdóttir B, Carstensen L, Laugesen C, Mathieu C, Philis-Tsimikas A, Battelino T. Continuous Glucose Monitoring-Based Metrics and Hypoglycemia Duration in Insulin-Experienced Individuals With Long-standing Type 2 Diabetes Switched From a Daily Basal Insulin to Once-Weekly Insulin Icodec: Post Hoc Analysis of ONWARDS 2 and ONWARDS 4. Diabetes Care 2024; 47:729-738. [PMID: 38380954 PMCID: PMC10973898 DOI: 10.2337/dc23-2136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/23/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVE This post hoc analysis assessed continuous glucose monitoring (CGM)-based metrics and hypoglycemia duration with once-weekly insulin icodec versus once-daily basal insulin analogs in insulin-experienced individuals with long-standing type 2 diabetes from two 26-week phase 3a trials (ONWARDS 2 and ONWARDS 4). RESEARCH DESIGN AND METHODS Time in range (TIR) (3.9-10.0 mmol/L), time above range (TAR) (>10.0 mmol/L), and time below range (TBR) (<3.9 mmol/L and <3.0 mmol/L) were assessed during three CGM time periods (switch [weeks 0-4], end of treatment [weeks 22-26], and follow-up [weeks 27-31]) for icodec versus comparators (ONWARDS 2, insulin degludec [basal regimen]; ONWARDS 4, insulin glargine U100 [basal-bolus regimen]) using double-blind CGM data. CGM-derived hypoglycemic episode duration (<3.9 mmol/L) was assessed. RESULTS In both trials, there were no statistically significant differences in TIR, TAR, or TBR (<3.0 mmol/L) for icodec versus comparators across all time periods. In the end-of-treatment period, mean TIR was 63.1% (icodec) vs. 59.5% (degludec) in ONWARDS 2 and 66.9% (icodec) vs. 66.4% (glargine U100) in ONWARDS 4. Mean TBR <3.9 mmol/L and <3.0 mmol/L remained within recommended targets (<4% and <1%, respectively) across time periods and treatment arms. Hypoglycemic episode duration (<3.9 mmol/L) was comparable across time periods and treatment arms (median duration ≤40 min). CONCLUSIONS In insulin-experienced participants with long-standing type 2 diabetes, CGM-based TIR, TAR, and CGM-derived hypoglycemia duration (<3.9 mmol/L) were comparable for icodec and once-daily basal insulin analogs during all time periods. TBR remained within recommended targets.
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Affiliation(s)
| | | | | | | | - Chantal Mathieu
- Clinical and Experimental Endocrinology, University of Leuven, Leuven, Belgium
| | | | - Tadej Battelino
- University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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22
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Galdón Sanz-Pastor A, Justel Enríquez A, Sánchez Bao A, Ampudia-Blasco FJ. Current barriers to initiating insulin therapy in individuals with type 2 diabetes. Front Endocrinol (Lausanne) 2024; 15:1366368. [PMID: 38559691 PMCID: PMC10979640 DOI: 10.3389/fendo.2024.1366368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 02/19/2024] [Indexed: 04/04/2024] Open
Abstract
Insulin is an essential drug in the treatment of diabetes, often necessary for managing hyperglycemia in type 2 diabetes mellitus (T2DM). It should be considered in cases of severe hyperglycemia requiring hospitalization, after the failure of other treatments, in advanced chronic kidney disease, liver cirrhosis, post-transplant diabetes, or during pregnancy. Moreover, in specific patient subgroups, early initiation of insulin is crucial for hyperglycemia control and prevention of chronic complications. Clinical guidelines recommend initiating insulin when other treatments fail, although there are barriers that may delay its initiation. The timing of initiation depends on individual patient characteristics. Typically, insulinization starts by adding basal insulin to the patient's existing treatment and, if necessary, progresses by gradually introducing prandial insulin. Several barriers have been identified that hinder the initiation of insulin, including fear of hypoglycemia, lack of adherence, the need for glucose monitoring, the injection method of insulin administration, social rejection associated with the stigma of injections, weight gain, a sense of therapeutic failure at initiation, lack of experience among some healthcare professionals, and the delayed and reactive positioning of insulin in recent clinical guidelines. These barriers contribute, among other factors, to therapeutic inertia in initiating and intensifying insulin treatment and to patients' non-adherence. In this context, the development of once-weekly insulin formulations could improve initial acceptance, adherence, treatment satisfaction, and consequently, the quality of life for patients. Currently, two once-weekly basal insulins, insulin icodec and basal insulin BIF, which are in different stages of clinical development, may help. Their longer half-life translates to lower variability and reduced risk of hypoglycemia. This review addresses the need for insulin in T2DM, its positioning in clinical guidelines under specific circumstances, the current barriers to initiating and intensifying insulin treatment, and the potential role of once-weekly insulin formulations as a potential solution to facilitate timely initiation of insulinization, which would reduce therapeutic inertia and achieve better early control in people with T2DM.
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Affiliation(s)
- Alba Galdón Sanz-Pastor
- Department of Endocrinology and Nutrition, Gregorio Marañón General University Hospital, Madrid, Spain
- Department of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Alicia Justel Enríquez
- Department of Endocrinology and Nutrition, La Princesa University Hospital, Madrid, Spain
| | - Ana Sánchez Bao
- Department of Endocrinology and Nutrition, Ferrol University Hospital Complex, Ferrol, A Coruña, Spain
| | - Francisco Javier Ampudia-Blasco
- Department of Medicine, Medicine Faculty, University of Valencia (UV), Valencia, Spain
- Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Biomedical Research Networking Center for Diabetes and Associated Metabolic Diseases (CIBERDEM), Biomedical Research Networking Center (CIBER) of Diabetes and Associated Metabolic Diseases, Madrid, Spain
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Hadid S, Zhang E, Frishman WH, Brutsaert E. Insulin's Legacy: A Century of Breakthroughs and Innovation. Cardiol Rev 2024:00045415-990000000-00229. [PMID: 38477588 DOI: 10.1097/crd.0000000000000680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
The clinical use of insulin to treat diabetes started just over 100 years ago. The past century has witnessed remarkable innovations in insulin therapy, evolving from animal organ extracts to bioengineered human insulins with ultra-rapid onset or prolonged action. Insulin delivery systems have also progressed to current automated insulin delivery systems. In this review, we discuss the history of insulin and the pharmacology and therapeutic indications for a variety of available insulins, especially newer analog insulins. We highlight recent advances in insulin pump therapy and review evidence on the therapeutic benefits of automated insulin delivery. As with any form of progress, there have been setbacks, and insulin has recently faced an affordability crisis. We address the challenges of insulin accessibility, along with recent progress to improve insulin affordability. Finally, we mention research on glucose-responsive insulins and hepato-preferential insulins that are likely to shape the future of insulin therapy.
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Affiliation(s)
- Somar Hadid
- From the School of Medicine, New York Medical College, Valhalla NY
| | - Emily Zhang
- From the School of Medicine, New York Medical College, Valhalla NY
| | - William H Frishman
- From the School of Medicine, New York Medical College, Valhalla NY
- Department of Cardiology, Westchester Medical Center, Valhalla NY
| | - Erika Brutsaert
- From the School of Medicine, New York Medical College, Valhalla NY
- Department of Endocrinology, Westchester Medical Center, Hawthorne NY
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24
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Renda S, Freeman J. You may delay, but time will not. Beta cells lost are never found again: a case for timely initiation of basal insulin in type 2 diabetes. Postgrad Med 2024; 136:150-161. [PMID: 38465574 DOI: 10.1080/00325481.2024.2328511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/04/2024] [Indexed: 03/12/2024]
Abstract
Since its first use just over a century ago, insulin treatment has evolved dramatically, such that the molecules are physiologic in nature, and treatment can now closely resemble the natural hormone response over 24 hours. Newer, longer-acting basal insulin analogs have provided insulin therapies with improved characteristics and, therefore, ease of use, and can readily be incorporated as part of routine treatment for type 2 diabetes (T2D), but evidence suggests that insulin remains underused in people with T2D. We review the barriers to initiation of basal insulin and the education needed to address these barriers, and we provide practical pointers, supported by evidence, for primary care physicians and advanced practice providers to facilitate timely initiation of basal insulin in the people with T2D who will benefit from such treatment.
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Affiliation(s)
- Susan Renda
- Johns Hopkins Comprehensive Diabetes Center, Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Jeffrey Freeman
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
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25
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Danne T, Heinemann L, Pieber TR. New Insulins, Biosimilars, and Insulin Therapy. Diabetes Technol Ther 2024; 26:S45-S67. [PMID: 38441455 DOI: 10.1089/dia.2024.2504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Affiliation(s)
- Thomas Danne
- Diabetes-Zentrum für Kinder and Jugendliche, Kinder- und Jugendkrankenhaus "AUF DER BULT," Hannover, Germany
| | - Lutz Heinemann
- Science Consulting in Diabetes GmbH, Düsseldorf, Germany
| | - Thomas R Pieber
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
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26
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Shetty S, Suvarna R. Efficacy and safety of once-weekly insulin icodec in type 2 diabetes: A meta-analysis of ONWARDS phase 3 randomized controlled trials. Diabetes Obes Metab 2024; 26:1069-1081. [PMID: 38192022 DOI: 10.1111/dom.15408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 01/10/2024]
Abstract
AIM Insulin icodec is a novel ultra-long action basal insulin analogue designed for once-weekly administration. With the merit of once-a-week administration, it promises better adherence and greater treatment satisfaction because of reduced injection frequency. The purpose of this study was to ascertain the efficacy and safety of once-weekly insulin icodec in comparison with other basal insulin analogues in the management of type 2 diabetes. MATERIALS AND METHODS The PRISMA guidelines were followed during the conduct of this study. For the eligible studies, five databases and ClinicalTrials.gov were screened until July 2023. All randomized controlled trials comparing the efficacy and safety of insulin icodec in type 2 diabetes versus other insulin analogues were included. The extracted data were then analysed for meta-analysis using RevMan 5.3 software. RESULTS Five clinical trials with 3764 participants were included. The meta-analysis showed that once-weekly insulin icodec had higher glycated haemoglobin (HbA1c) reduction [mean difference -0.17%, 95% confidence interval (CI; -0.28 to -0.06), p = .003], with no significant difference in fasting plasma glucose compared with other insulin analogues. HbA1c achievement <7% [odds ratio 1.51, 95% CI (1.14-1.99), p = .004] and HbA1c achievement <7% without hypoglycaemia [odds ratio 1.45, 95% CI (1.26-1.67), p < .00001] were observed in higher proportions with insulin icodec compared with the comparator group. The percentage of time spent in the target glycaemic range was comparatively similar between insulin icodec and the comparator [mean difference 2.42%, 95% CI (0.01-4.84), p = .05]. There was a significantly higher incidence of level 1 hypoglycaemia with insulin icodec but no significant difference was seen for the incidence of levels 2, 3 and combined 2/3 hypoglycaemia. Any adverse events and adverse events related to basal insulin were comparably similar in insulin icodec and comparators. The subgroup analysis of once-weekly insulin icodec with individual insulin analogues (glargine U100 and degludec) showed that insulin icodec had similar efficacy with insulin glargine U100 but superior efficacy with higher HbA1c reduction with insulin icodec compared with insulin degludec. The safety profile was comparable between insulin icodec and glargine U100, whereas insulin icodec reported higher incidence of hypoglycaemia events and any adverse events when compared with degludec. CONCLUSION Once-weekly insulin icodec showed a better HbA1c reduction with a higher proportion of patients achieving HbA1c targets in comparison with once-daily basal insulin analogues. They were no major safety concerns with respect to hypoglycaemia or adverse events.
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Affiliation(s)
- Sahana Shetty
- Manipal Academy of Higher Education, Department of Endocrinology, Kasturba Medical College, Manipal, India
| | - Renuka Suvarna
- Manipal Academy of Higher Education, Department of Endocrinology, Kasturba Medical College, Manipal, India
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27
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Mukhopadhyay P, Chatterjee P, Pandit K, Sanyal D, Ghosh S. Once-weekly Insulin Icodec as Compared to Once-daily Basal Insulins: A Meta-analysis. Endocr Pract 2024; 30:128-134. [PMID: 37984730 DOI: 10.1016/j.eprac.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Once-weekly basal insulin icodec has been tested in clinical trials for efficacy and safety over currently available glargine-100 and degludec in different clinical settings for type 2 diabetes. We performed this meta-analysis to evaluate its overall safety and efficacy as compared to glargine-100 and degludec (nonicodec), from all available randomized controlled trials. METHODS Seven trials comparing once-daily basal insulin analogs to once-weekly basal insulin icodec were included. Based on available information, outcomes in terms of HbA1c, fasting plasma glucose reduction, and increase in time in range (TIR) were compared. Side-effects were compared for overall hypoglycemia, severe hypoglycemia, and weight gain. The pooled effect size for continuously distributed data was measured as a reduction in "estimated differences in mean (with 95% CI)." For categorical data, the pooled effect size was measured as the Mantel-Haenszel risk ratio (with 95% CI). RESULTS Analyzing against the nonicodec comparators together, the "estimated mean changes" in HbA1c and fasting plasma glucose favoring icodec were -0.22% (-0.35, -0.10) and -1.59 mg% (-9.26, 6.08) respectively. The "estimated mean increment" in weight for icodec was 0.64 kg (0.61, 0.67). The "estimated mean percentage" increment in TIR for icodec was 4.24% (2.99, 5.49). The Mantel-Haenszel risk ratios for all hypoglycemic events and severe hypoglycemia for icodec were 1.24 (1.02, 1.50) (P = .03) and 0.81 (0.31, 2.08) (P is not significant), respectively, suggesting a 24% increased incidence of all hypoglycemia with icodec. CONCLUSION Once-weekly basal insulin icodec as compared to once-daily basal insulin analogs had a slight increase in the risk of overall hypoglycemia and weight gain, without any difference in severe hypoglycemia, with similar glycemic control (in terms of fasting plasma glucose, HbA1c, and TIR).
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Affiliation(s)
- Pradip Mukhopadhyay
- Department of Endocrinology, Institute of Post Graduate Medical Education & Research, Kolkata, West Bengal, India
| | | | - Kaushik Pandit
- Department of Endocrinology, Institute of Post Graduate Medical Education & Research, Kolkata, West Bengal, India
| | - Debmalya Sanyal
- Department of Endocrinology, KPC Medical College & Hospital, Kolkata, West Bengal, India; Department of Medicine, KPC Medical College & Hospital, Jadavpur, Kolkata, West Bengal, India
| | - Sujoy Ghosh
- Department of Endocrinology, Institute of Post Graduate Medical Education & Research, Kolkata, West Bengal, India.
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28
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Abuelazm M, Ibrahim AA, Khlidj Y, Badr A, Amin AM, Elzeftawy MA, Gowaily I, Elsaeidy AS, Abdelazeem B. Once-weekly Insulin Icodec Versus Once-daily Long-acting Insulin for Type II Diabetes: A Meta-analysis of Randomized Controlled Trials. J Endocr Soc 2024; 8:bvad177. [PMID: 38213906 PMCID: PMC10783254 DOI: 10.1210/jendso/bvad177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Indexed: 01/13/2024] Open
Abstract
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.
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Affiliation(s)
| | - Ahmed A Ibrahim
- Faculty of Medicine, Menoufia University, Menoufia 32511, Egypt
| | - Yehya Khlidj
- Faculty of Medicine, Algiers University, Algiers 44002, Algeria
| | - Amr Badr
- Department of Cardiology, Banha Teaching Hospital, Banha 13511, Egypt
| | | | | | | | | | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, Morgantown, WV 26505, USA
- Department of Internal Medicine, Michigan State University, East Lansing, MI 48824, USA
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29
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Wang P, Zhang Y, Xu W, He J, Peng L, Feng Y, Xu P, Chong W, Hai Y, Jia L, Fang F. Efficacy and Safety of Once-Weekly Insulin Regimes on Glycemic Control for Type 2 Diabetes: A Systematic Review and Network Meta-analysis. Diabetol Metab Syndr 2024; 16:3. [PMID: 38172995 PMCID: PMC10763463 DOI: 10.1186/s13098-023-01240-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Randomized controlled trials have found that once-weekly insulin resulted in greater glycemic control compared to once-daily insulin in patients with type 2 diabetes. However, no direct comparisons have been made between different types of once-weekly insulin thus far. This systematic review and network meta-analysis aimed to evaluate the effect of the two most advanced once-weekly insulin analogues, namely insulin icodec and insulin Fc, in patients with type 2 diabetes. METHODS We conducted a thorough search in the databases PubMed, Embase, and the Cochrane Central Register of Controlled Trials. The search included articles published from the beginning to October 10, 2023, with no language limitations. Our aim was to conduct a systematic review of randomized controlled trials that investigated the effectiveness and safety of once-weekly insulin in individuals with type 2 diabetes. Our primary outcome was to evaluate excellent glycemic control, defined as patients achieving glycated hemoglobin levels below 7%. RESULTS We identified a total of 7 trials involving 2829 patients. The results showed that once-weekly insulin icodec is more effective than once-weekly insulin Fc (RR 1.59 [95% CI 1.08-2.38]), once-daily degludec (RR 1.43 [95% CI 1.14-1.83]), and once-daily glargine (RR 1.15 [95% CI 1.00-1.41]). Moreover, the incidence of severe hypoglycemia was lower with once-weekly insulin icodec compared to once-daily degludec (RR 0.00016 [95% CI 0 to 0.41]). However, no significant difference in the incidence of severe hypoglycemia was observed between once-weekly insulin icodec and once-daily glargine (RR 0.39 [95% CI 0.03 to 4.83]). CONCLUSIONS In patients with type 2 diabetes, once-weekly insulin icodec achieved superior glycemic control compared to once-weekly insulin Fc, with no significant difference in the occurrence of hypoglycemia. The ranking probability results have shown that one weekly icodec seems to be the preferred option in patients with type 2 diabetes. TRIAL REGISTRATION PROSPERO Identifier: CRD42023470894.
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Affiliation(s)
- Peng Wang
- West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yu Zhang
- Center for Evidence-based Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Wenhao Xu
- Center for Evidence-based Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Jialing He
- West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Liyuan Peng
- Department of critical care medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yuning Feng
- Center for Evidence-based Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Ping Xu
- Sichuan University Library, Chengdu, Sichuan, China
| | - Weelic Chong
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Yang Hai
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lu Jia
- Department of Surgical Intensive care medicine, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Fang Fang
- West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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30
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Wang X, Xiao W, Liang Z, Li S, Tang Q. Efficacy and safety of once-weekly basal insulin versus once-daily basal insulin in patients with type 2 diabetes: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e36308. [PMID: 38206709 PMCID: PMC10754560 DOI: 10.1097/md.0000000000036308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 11/03/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Once-weekly insulin is expected to improve treatment compliance and durability and lead to better glycemic control. Several clinical trials on once-weekly insulin have recently been published. We conducted a systematic review and meta-analysis to investigate the efficacy and safety of once-weekly insulin versus once-daily insulin in type 2 diabetes (T2D). METHODS The following databases were searched for studies: PubMed, EMBASE, and Cochrane library (From January 1, 1946 to May 9, 2023). All randomized trials comparing weekly versus daily insulin in T2D were eligible for inclusion. Data analysis was performed using STATA 17.0 software (Stata Corporation, College Station, TX). The main outcomes and indexes included reduction in Hemoglobin A1c (HbA1c), fasting plasma glucose and bodyweight, proportion of patients achieving HbA1c < 7%, time-in-range 70 to 180 mg/dL and adverse events. RESULTS This systematic review and meta-analysis included 7 randomized controlled studies involving 2391 patients (1347 receiving 1-week insulin and 1044 receiving 1-day insulin). Once-weekly insulin was not inferior to once-daily insulin in HbA1c change [estimated treatment difference (ETD) = -0.05; 95% confidence intervals (CI): -0.14 to 0.04), HbA1c < 7% (odds ratio = 1.14; 95% CI: 0.87-1.50), fasting plasma glucose (ETD = 0.09; 95% CI: -0.19 to 0.36) and body weight loss (ETD = 0.27; 95% CI: -0.36 to 0.91). In terms of time-in-range 70 to 180 mg/dL, weekly insulin was superior to daily insulin (MTD = 3.84; 95% CI: 1.55-6.08). Icodec was associated with higher incidence of all adverse events (odds ratio = 1.20; 95% CI: 1.03-1.48; P = .024), but did not result in high risk of serious and severe adverse events. Moreover, icodec and Basal Insulin Fc did not result in higher incidence of hypoglycemia compared with insulin daily. CONCLUSION Our meta-analysis found that insulin weekly was well tolerated and effective for glycemic control. Once-weekly insulin was not inferior to once-daily insulin in both efficacy and safety in T2D.
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Affiliation(s)
- Xinxin Wang
- Affiliated Guangdong Hospital of Integrated Traditional Chinese and Western Medicine of Guangzhou University of Chinese Medicine, Nanhai District, Foshan City, Guangdong Province, China
| | - Wei Xiao
- Affiliated Guangdong Hospital of Integrated Traditional Chinese and Western Medicine of Guangzhou University of Chinese Medicine, Nanhai District, Foshan City, Guangdong Province, China
| | - Zhanpeng Liang
- Department of Oncology, Zhongshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Traditional Chinese Medicine, Guangdong Province, China
| | - Shixiang Li
- School of Traditional Chinese Medicine, Jinan University, Tianhe District, Guangzhou City, Guangdong Province, China
| | - Qizhi Tang
- . Department of Endocrinology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Foshan City, Guangdong Province, the People’s Republic of China
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31
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Pieber TR, Asong M, Fluhr G, Höller V, Kristensen NR, Larsen JH, Ribel-Madsen R, Svehlikova E, Vinther S, Voortman M, Haahr H. Pharmacokinetic and pharmacodynamic properties of once-weekly insulin icodec in individuals with type 2 diabetes. Diabetes Obes Metab 2023; 25:3716-3723. [PMID: 37694740 DOI: 10.1111/dom.15266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 09/12/2023]
Abstract
AIMS To characterize the pharmacokinetic and pharmacodynamic properties of once-weekly insulin icodec in type 2 diabetes (T2D). MATERIALS AND METHODS In an open-label trial, 46 individuals with T2D (18-75 years; body mass index 18.0-38.0 kg/m2 ; glycated haemoglobin ≤75 mmol/mol [≤9%]; basal insulin-treated) received subcutaneous once-weekly icodec for ≥8 weeks at individualized doses, aiming at a pre-breakfast plasma glucose concentration of 4.4 to 7.0 mmol/L (80-126 mg/dL) on the last three mornings of each weekly dosing interval. Frequent blood sampling to assess total serum icodec concentration (ie, albumin-bound and unbound) occurred from first icodec dose until 35 days after last dose. Icodec trough concentrations following initiation of once-weekly dosing were predicted by pharmacokinetic modelling. During the final 3 weeks of icodec treatment, while at steady state, the icodec glucose-lowering effect was assessed in three glucose clamps (target 7.5 mmol/L [135 mg/dL]): 0 to 36, 40 to 64 and 144 to 168 h post-dose, thus covering the initial, middle and last part of the 1-week dosing interval. Glucose-lowering effect during a complete dosing interval was predicted by pharmacokinetic-pharmacodynamic modelling. RESULTS Model-predicted icodec steady state was attained after 3 to 4 weeks. At steady state, model-predicted daily proportions of glucose-lowering effect on days 1 to 7 of the 1-week dosing interval were 14.1%, 16.1%, 15.8%, 15.0%, 14.0%, 13.0% and 12.0%, respectively. Icodec duration of action was at least 1 week in all participants. Once-weekly icodec was overall safe and well tolerated in the current trial. CONCLUSIONS The pharmacokinetic and pharmacodynamic characteristics of icodec in individuals with T2D support its potential as a once-weekly basal insulin.
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Affiliation(s)
- Thomas R Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria
| | | | - Gabriele Fluhr
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Vera Höller
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria
| | | | | | | | - Eva Svehlikova
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria
| | | | - Margarete Voortman
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria
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32
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Nkonge KM, Nkonge DK, Nkonge TN. Insulin Therapy for the Management of Diabetes Mellitus: A Narrative Review of Innovative Treatment Strategies. Diabetes Ther 2023; 14:1801-1831. [PMID: 37736787 PMCID: PMC10570256 DOI: 10.1007/s13300-023-01468-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023] Open
Abstract
The discovery of insulin was presented to the international medical community on May 3, 1922. Since then, insulin has become one of the most effective pharmacological agents used to treat type 1 and type 2 diabetes mellitus. However, the initiation and intensification of insulin therapy is often delayed in people living with type 2 diabetes due to numerous challenges associated with daily subcutaneous administration. Reducing the frequency of injections, using insulin pens instead of syringes and vials, simplifying treatment regimens, or administering insulin through alternative routes may help improve adherence to and persistence with insulin therapy among people living with diabetes. As the world commemorates the centennial of the commercialization of insulin, the aims of this article are to provide an overview of insulin therapy and to summarize clinically significant findings from phase 3 clinical trials evaluating less frequent dosing of insulin and the non-injectable administration of insulin.
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Affiliation(s)
- Ken M. Nkonge
- University of Nairobi, P.O. Box 30197, Nairobi, Kenya
| | | | - Teresa N. Nkonge
- University of Nairobi, P.O. Box 30197, Nairobi, Kenya
- McMaster University, Hamilton, ON L8S 4L8 Canada
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33
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Dutta D, Nagendra L, Bhat S, Mohindra R, Surana V, Misra A. Optimal use of once weekly icodec insulin in type-2 diabetes: An updated meta-analysis of phase-2 and phase-3 randomized controlled trials. Diabetes Metab Syndr 2023; 17:102877. [PMID: 37832481 DOI: 10.1016/j.dsx.2023.102877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/14/2023] [Accepted: 09/17/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Previously published meta-analysis have analysed data from 3 small phase-2 randomized controlled trials (RCTs). Since then, 5 big phase-3 RCTs have been published on use of icodec in type-2 diabetes (T2D). This updated systematic review aimed to establish the best practices and safety of icodec in T2D. METHODS Databases were searched for RCTs involving T2D patients receiving icodec. Primary outcome was change in HbA1c. Secondary outcomes were alterations in glycaemic parameters and adverse events. RESULTS Data from 8 studies (4317 patients) was analysed. Compared to other basal insulins, icodec had comparable HbA1c lowering at 16-weeks [MD-0.19 %(95%CI: 0.58-0.20); P = 0.35; I2 = 92 %], better HbA1c lowering at 26-weeks [MD-0.19 %(95%CI: 0.35-0.013); P = 0.02; I2 = 94 %] and 52-weeks [MD -0.28 %(95%CI: 0.45-0.12); P = 0.0008; I2 = 100 %]. Percentage of participants achieving HbA1c<7 % with icodec was higher at 16-weeks [OR2.37(95%CI:1.05-5.35); P = 0.04], comparable at 26-weeks [OR1.38(95%CI:0.91-2.11); P = 0.13; I2 = 80 %], and higher at 52-weeks [OR1.55(95%CI:1.30-1.85); P < 0.00001; I2 = 0 %]. Percentage of participants achieving HbA1c<7 % without level 2/3 hypoglycaemia was higher with icodec at 26-weeks [OR1.37(95%CI:1.10-1.71); P = 0.004; I2 = 28 %] and 52-weeks [OR1.48(95%CI:1.24-1.77); P < 0.001; I2 = 0 %]. At 26-weeks, injection-site reactions was higher with icodec [OR1.95(95%CI:1.06-3.56); P = 0.03; I2 = 0 %]. At 26-weeks level-1 hypoglycemia [OR1.40(95%CI:1.02-1.94); P = 0.04; I2 = 58 %], but not level-2/3 hypoglycaemia was higher with icodec. Subset analysis revealed increased occurrence of level-1 [OR 4.19 (95 % CI: 3.20-5.50); P < 0.00001] and level-2 [OR 3.97 (95 % CI: 3.04-5.18); P < 0.00001] hypoglycaemia in participants who received one-time additional 50 % icodec loading dose as compared to those who did not. At 26-weeks, weight-gain was significantly higher with icodec [MD0.61 kg(95%CI:0.38-0.84); P < 0.00001; I2 = 98 %]. CONCLUSION Icodec insulin is well tolerated with glycaemic efficacy similar to all other available basal insulins.
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Affiliation(s)
- Deep Dutta
- Department of Endocrinology, Center for Endocrinology Diabetes Arthritis & Rheumatism (CEDAR) Superspeciality Healthcare, Dwarka, New Delhi, India.
| | - Lakshmi Nagendra
- Department of Endocrinology, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, India.
| | - Sowrabha Bhat
- Department of Endocrinology, Yenepoya Medical College, Mangalore, India.
| | - Ritin Mohindra
- Department of Medicine, Post-Graduate Medical Education and Research (PGIMER), Chandigarh, India.
| | - Vineet Surana
- Department of Endocrinology, Manipal Hospitals, New Delhi, India.
| | - Anoop Misra
- Department of Endocrinology, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, New Delhi, India.
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Reusch JE. Building a Better Insulin - Whom Will It Help? N Engl J Med 2023; 389:372-373. [PMID: 37494489 DOI: 10.1056/nejme2307280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Affiliation(s)
- Jane E Reusch
- From the University of Colorado Anschutz Medical Campus and Rocky Mountain Regional Veterans Affairs Medical Center - both in Aurora
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Rosenstock J, Bain SC, Gowda A, Jódar E, Liang B, Lingvay I, Nishida T, Trevisan R, Mosenzon O. Weekly Icodec versus Daily Glargine U100 in Type 2 Diabetes without Previous Insulin. N Engl J Med 2023; 389:297-308. [PMID: 37356066 DOI: 10.1056/nejmoa2303208] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
BACKGROUND Insulin icodec is an investigational once-weekly basal insulin analogue for diabetes management. METHODS We conducted a 78-week randomized, open-label, treat-to-target phase 3a trial (including a 52-week main phase and a 26-week extension phase, plus a 5-week follow-up period) involving adults with type 2 diabetes (glycated hemoglobin level, 7 to 11%) who had not previously received insulin. Participants were randomly assigned in a 1:1 ratio to receive once-weekly insulin icodec or once-daily insulin glargine U100. The primary end point was the change in the glycated hemoglobin level from baseline to week 52; the confirmatory secondary end point was the percentage of time spent in the glycemic range of 70 to 180 mg per deciliter (3.9 to 10.0 mmol per liter) in weeks 48 to 52. Hypoglycemic episodes (from baseline to weeks 52 and 83) were recorded. RESULTS Each group included 492 participants. Baseline characteristics were similar in the two groups. The mean reduction in the glycated hemoglobin level at 52 weeks was greater with icodec than with glargine U100 (from 8.50% to 6.93% with icodec [mean change, -1.55 percentage points] and from 8.44% to 7.12% with glargine U100 [mean change, -1.35 percentage points]); the estimated between-group difference (-0.19 percentage points; 95% confidence interval [CI], -0.36 to -0.03) confirmed the noninferiority (P<0.001) and superiority (P = 0.02) of icodec. The percentage of time spent in the glycemic range of 70 to 180 mg per deciliter was significantly higher with icodec than with glargine U100 (71.9% vs. 66.9%; estimated between-group difference, 4.27 percentage points [95% CI, 1.92 to 6.62]; P<0.001), which confirmed superiority. Rates of combined clinically significant or severe hypoglycemia were 0.30 events per person-year of exposure with icodec and 0.16 events per person-year of exposure with glargine U100 at week 52 (estimated rate ratio, 1.64; 95% CI, 0.98 to 2.75) and 0.30 and 0.16 events per person-year of exposure, respectively, at week 83 (estimated rate ratio, 1.63; 95% CI, 1.02 to 2.61). No new safety signals were identified, and incidences of adverse events were similar in the two groups. CONCLUSIONS Glycemic control was significantly better with once-weekly insulin icodec than with once-daily insulin glargine U100. (Funded by Novo Nordisk; ONWARDS 1 ClinicalTrials.gov number, NCT04460885.).
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Affiliation(s)
- Julio Rosenstock
- From Velocity Clinical Research at Medical City (J.R.) and the Division of Endocrinology, Department of Internal Medicine, and the Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center (I.L.) - both in Dallas; Swansea University Medical School, Swansea, United Kingdom (S.C.B.); Novo Nordisk, Søborg, Denmark (A.G., B.L.); Servicio de Endocrinología y Nutrición, Hospital Universitario Quironsalud Madrid, Facultad de Medicina, Universidad Europea, Madrid (E.J.); Novo Nordisk, Tokyo (T.N.); Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo (R.T.), and the Department of Medicine and Surgery, University of Milano Bicocca, Milan (R.T.) - both in Italy; and the Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center (O.M.), and the Faculty of Medicine, Hebrew University of Jerusalem (O.M.) - both in Jerusalem
| | - Stephen C Bain
- From Velocity Clinical Research at Medical City (J.R.) and the Division of Endocrinology, Department of Internal Medicine, and the Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center (I.L.) - both in Dallas; Swansea University Medical School, Swansea, United Kingdom (S.C.B.); Novo Nordisk, Søborg, Denmark (A.G., B.L.); Servicio de Endocrinología y Nutrición, Hospital Universitario Quironsalud Madrid, Facultad de Medicina, Universidad Europea, Madrid (E.J.); Novo Nordisk, Tokyo (T.N.); Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo (R.T.), and the Department of Medicine and Surgery, University of Milano Bicocca, Milan (R.T.) - both in Italy; and the Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center (O.M.), and the Faculty of Medicine, Hebrew University of Jerusalem (O.M.) - both in Jerusalem
| | - Amoolya Gowda
- From Velocity Clinical Research at Medical City (J.R.) and the Division of Endocrinology, Department of Internal Medicine, and the Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center (I.L.) - both in Dallas; Swansea University Medical School, Swansea, United Kingdom (S.C.B.); Novo Nordisk, Søborg, Denmark (A.G., B.L.); Servicio de Endocrinología y Nutrición, Hospital Universitario Quironsalud Madrid, Facultad de Medicina, Universidad Europea, Madrid (E.J.); Novo Nordisk, Tokyo (T.N.); Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo (R.T.), and the Department of Medicine and Surgery, University of Milano Bicocca, Milan (R.T.) - both in Italy; and the Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center (O.M.), and the Faculty of Medicine, Hebrew University of Jerusalem (O.M.) - both in Jerusalem
| | - Esteban Jódar
- From Velocity Clinical Research at Medical City (J.R.) and the Division of Endocrinology, Department of Internal Medicine, and the Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center (I.L.) - both in Dallas; Swansea University Medical School, Swansea, United Kingdom (S.C.B.); Novo Nordisk, Søborg, Denmark (A.G., B.L.); Servicio de Endocrinología y Nutrición, Hospital Universitario Quironsalud Madrid, Facultad de Medicina, Universidad Europea, Madrid (E.J.); Novo Nordisk, Tokyo (T.N.); Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo (R.T.), and the Department of Medicine and Surgery, University of Milano Bicocca, Milan (R.T.) - both in Italy; and the Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center (O.M.), and the Faculty of Medicine, Hebrew University of Jerusalem (O.M.) - both in Jerusalem
| | - Bo Liang
- From Velocity Clinical Research at Medical City (J.R.) and the Division of Endocrinology, Department of Internal Medicine, and the Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center (I.L.) - both in Dallas; Swansea University Medical School, Swansea, United Kingdom (S.C.B.); Novo Nordisk, Søborg, Denmark (A.G., B.L.); Servicio de Endocrinología y Nutrición, Hospital Universitario Quironsalud Madrid, Facultad de Medicina, Universidad Europea, Madrid (E.J.); Novo Nordisk, Tokyo (T.N.); Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo (R.T.), and the Department of Medicine and Surgery, University of Milano Bicocca, Milan (R.T.) - both in Italy; and the Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center (O.M.), and the Faculty of Medicine, Hebrew University of Jerusalem (O.M.) - both in Jerusalem
| | - Ildiko Lingvay
- From Velocity Clinical Research at Medical City (J.R.) and the Division of Endocrinology, Department of Internal Medicine, and the Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center (I.L.) - both in Dallas; Swansea University Medical School, Swansea, United Kingdom (S.C.B.); Novo Nordisk, Søborg, Denmark (A.G., B.L.); Servicio de Endocrinología y Nutrición, Hospital Universitario Quironsalud Madrid, Facultad de Medicina, Universidad Europea, Madrid (E.J.); Novo Nordisk, Tokyo (T.N.); Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo (R.T.), and the Department of Medicine and Surgery, University of Milano Bicocca, Milan (R.T.) - both in Italy; and the Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center (O.M.), and the Faculty of Medicine, Hebrew University of Jerusalem (O.M.) - both in Jerusalem
| | - Tomoyuki Nishida
- From Velocity Clinical Research at Medical City (J.R.) and the Division of Endocrinology, Department of Internal Medicine, and the Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center (I.L.) - both in Dallas; Swansea University Medical School, Swansea, United Kingdom (S.C.B.); Novo Nordisk, Søborg, Denmark (A.G., B.L.); Servicio de Endocrinología y Nutrición, Hospital Universitario Quironsalud Madrid, Facultad de Medicina, Universidad Europea, Madrid (E.J.); Novo Nordisk, Tokyo (T.N.); Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo (R.T.), and the Department of Medicine and Surgery, University of Milano Bicocca, Milan (R.T.) - both in Italy; and the Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center (O.M.), and the Faculty of Medicine, Hebrew University of Jerusalem (O.M.) - both in Jerusalem
| | - Roberto Trevisan
- From Velocity Clinical Research at Medical City (J.R.) and the Division of Endocrinology, Department of Internal Medicine, and the Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center (I.L.) - both in Dallas; Swansea University Medical School, Swansea, United Kingdom (S.C.B.); Novo Nordisk, Søborg, Denmark (A.G., B.L.); Servicio de Endocrinología y Nutrición, Hospital Universitario Quironsalud Madrid, Facultad de Medicina, Universidad Europea, Madrid (E.J.); Novo Nordisk, Tokyo (T.N.); Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo (R.T.), and the Department of Medicine and Surgery, University of Milano Bicocca, Milan (R.T.) - both in Italy; and the Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center (O.M.), and the Faculty of Medicine, Hebrew University of Jerusalem (O.M.) - both in Jerusalem
| | - Ofri Mosenzon
- From Velocity Clinical Research at Medical City (J.R.) and the Division of Endocrinology, Department of Internal Medicine, and the Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center (I.L.) - both in Dallas; Swansea University Medical School, Swansea, United Kingdom (S.C.B.); Novo Nordisk, Søborg, Denmark (A.G., B.L.); Servicio de Endocrinología y Nutrición, Hospital Universitario Quironsalud Madrid, Facultad de Medicina, Universidad Europea, Madrid (E.J.); Novo Nordisk, Tokyo (T.N.); Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo (R.T.), and the Department of Medicine and Surgery, University of Milano Bicocca, Milan (R.T.) - both in Italy; and the Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center (O.M.), and the Faculty of Medicine, Hebrew University of Jerusalem (O.M.) - both in Jerusalem
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Lingvay I, Asong M, Desouza C, Gourdy P, Kar S, Vianna A, Vilsbøll T, Vinther S, Mu Y. Once-Weekly Insulin Icodec vs Once-Daily Insulin Degludec in Adults With Insulin-Naive Type 2 Diabetes: The ONWARDS 3 Randomized Clinical Trial. JAMA 2023; 330:228-237. [PMID: 37354562 PMCID: PMC10354685 DOI: 10.1001/jama.2023.11313] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/06/2023] [Indexed: 06/26/2023]
Abstract
Importance Once-weekly insulin icodec could provide a simpler dosing alternative to daily basal insulin in people with type 2 diabetes. Objective To evaluate the efficacy and safety of once-weekly icodec vs once-daily insulin degludec in people with insulin-naive type 2 diabetes. Design, Setting, and Participants Randomized, double-masked, noninferiority, treat-to-target, phase 3a trial conducted from March 2021 to June 2022 at 92 sites in 11 countries in adults with type 2 diabetes treated with any noninsulin glucose-lowering agents with hemoglobin A1c (HbA1c) of 7%-11% (53-97 mmol/mol). Interventions Participants were randomly assigned in a 1:1 ratio to receive either once-weekly icodec and once-daily placebo (icodec group; n = 294) or once-daily degludec and once-weekly placebo (degludec group; n = 294). Main Outcomes and Measures The primary end point was change in HbA1c from baseline to week 26 (noninferiority margin, 0.3% percentage points). Secondary end points included change in fasting plasma glucose from baseline to week 26, mean weekly insulin dose during the last 2 weeks of treatment, body weight change from baseline to week 26, and number of level 2 (clinically significant; glucose level <54 mg/dL) and level 3 (severe; requiring external assistance for recovery) hypoglycemic episodes. Results Among 588 randomized participants (mean [SD] age, 58 [10] years; 219 [37%] women), 564 (96%) completed the trial. Mean HbA1c level decreased from 8.6% (observed) to 7.0% (estimated) at 26 weeks in the icodec group and from 8.5% (observed) to 7.2% (estimated) in the degludec group (estimated treatment difference [ETD], -0.2 [95% CI, -0.3 to -0.1] percentage points), confirming noninferiority (P < .001) and superiority (P = .002). There were no significant differences between the icodec and degludec groups for fasting plasma glucose change from baseline to week 26 (ETD, 0 [95% CI, -6 to 5] mg/dL; P = .90), mean weekly insulin dose during the last 2 weeks of treatment, or body weight change from baseline to week 26 (2.8 kg vs 2.3 kg; ETD, 0.46 [95% CI, -0.19 to 1.10] kg; P = .17). Combined level 2 or 3 hypoglycemia rates were numerically higher in the icodec group than the degludec group from week 0 to 31 (0.31 vs 0.15 events per patient-year exposure; P = .11) and statistically higher in the icodec group from week 0 to 26 (0.35 vs 0.12 events per patient-year exposure; P = .01). Conclusions and Relevance Among people with insulin-naive type 2 diabetes, once-weekly icodec demonstrated superior HbA1c reduction to once-daily degludec after 26 weeks of treatment, with no difference in weight change and a higher rate of combined level 2 or 3 hypoglycemic events in the context of less than 1 event per patient-year exposure in both groups. Trial Registration ClinicalTrials.gov Identifier: NCT04795531.
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Affiliation(s)
- Ildiko Lingvay
- Division of Endocrinology, Department of Internal Medicine and Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas
| | | | - Cyrus Desouza
- University of Nebraska Medical Center, Omaha, Nebraska
| | - Pierre Gourdy
- CHU de Toulouse & UMR1297/I2MC, Inserm, Université Toulouse 3, Toulouse, France
| | - Soumitra Kar
- Novo Nordisk Service Centre India Private Ltd, Bangalore, India
| | - André Vianna
- Curitiba Diabetes Centre, Department of Endocrine Diseases, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | - Tina Vilsbøll
- Clinical Research, Steno Diabetes Center Copenhagen, University of Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Yiming Mu
- Department of Endocrinology, The First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
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