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Dehghani M, Sadeghi M, Barzkar F, Maghsoomi Z, Janani L, Motevalian SA, Loke YK, Ismail-Beigi F, Baradaran HR, Khamseh ME. Efficacy and safety of basal insulins in people with type 2 diabetes mellitus: a systematic review and network meta-analysis of randomized clinical trials. Front Endocrinol (Lausanne) 2024; 15:1286827. [PMID: 38586456 PMCID: PMC10997219 DOI: 10.3389/fendo.2024.1286827] [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: 08/31/2023] [Accepted: 02/22/2024] [Indexed: 04/09/2024] Open
Abstract
Aim The comparative effectiveness of basal insulins has been examined in several studies. However, current treatment algorithms provide a list of options with no clear differentiation between different basal insulins as the optimal choice for initiation. Methods A comprehensive search of MEDLINE, Embase, Cochrane Library, ISI, and Scopus, and a reference list of retrieved studies and reviews were performed up to November 2023. We identified phase III randomized controlled trials (RCTs) comparing the efficacy and safety of basal insulin regimens. The primary outcomes evaluated were HbA1c reduction, weight change, and hypoglycemic events. The revised Cochrane ROB-2 tool was used to assess the methodological quality of the included studies. A random-effects frequentist network meta-analysis was used to estimate the pooled weighted mean difference (WMD) and odds ratio (OR) with 95% confidence intervals considering the critical assumptions in the networks. The certainty of the evidence and confidence in the rankings was assessed using the GRADE minimally contextualized approach. Results Of 20,817 retrieved studies, 44 RCTs (23,699 participants) were eligible for inclusion in our network meta-analysis. We found no significant difference among various basal insulins (including Neutral Protamine Hagedorn (NPH), ILPS, insulin glargine, detemir, and degludec) in reducing HbA1c. Insulin glargine, 300 U/mL (IGlar-300) was significantly associated with less weight gain (mean difference ranged from 2.9 kg to 4.1 kg) compared to other basal insulins, namely thrice-weekly insulin degludec (IDeg-3TW), insulin degludec, 100 U/mL (IDeg-100), insulin degludec, 200 U/mL (IDeg-200), NPH, and insulin detemir (IDet), but with low to very low certainty regarding most comparisons. IDeg-100, IDeg-200, IDet, and IGlar-300 were associated with significantly lower odds of overall, nocturnal, and severe hypoglycemic events than NPH and insulin lispro protamine (ILPS) (moderate to high certainty evidence). NPH was associated with the highest odds of overall and nocturnal hypoglycemia compared to others. Network meta-analysis models were robust, and findings were consistent in sensitivity analyses. Conclusion The efficacy of various basal insulin regimens is comparable. However, they have different safety profiles. IGlar-300 may be the best choice when weight gain is a concern. In contrast, IDeg-100, IDeg-200, IDet, and IGlar-300 may be preferred when hypoglycemia is the primary concern.
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Affiliation(s)
- Mohsen Dehghani
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Masoumeh Sadeghi
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Epidemiology, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farzaneh Barzkar
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Zohreh Maghsoomi
- Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Leila Janani
- Imperial Clinical Trials Unit, Imperial College London, London, United Kingdom
| | - Seyed Abbas Motevalian
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Yoon K. Loke
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Faramarz Ismail-Beigi
- Department of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Hamid Reza Baradaran
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
- Ageing Clinical and Experimental Research Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, United Kingdom
| | - Mohammad E. Khamseh
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
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Wang W, Chang X, Lehrskov LL, Li L, Nordentoft M, Quan J, Sha Y, Zhong X, Yang C, Zhu D. Insulin Degludec in People with Type 2 Diabetes in China: A Non-interventional, Retrospective Chart Review Study (CN-TREAT). Diabetes Ther 2024; 15:725-739. [PMID: 38438707 PMCID: PMC10942918 DOI: 10.1007/s13300-024-01533-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/16/2024] [Indexed: 03/06/2024] Open
Abstract
INTRODUCTION Insulin degludec (degludec), an ultra-long-acting basal insulin analogue, provides equivalent glycemic control to other basal insulin analogues, with lower risk of hypoglycemia and flexible dosing. Chinese TREsiba AudiT (CN-TREAT) investigated outcomes with degludec in people with type 2 diabetes (T2D) in routine clinical practice in China. METHODS This was a retrospective chart review study in adults with T2D initiating or switching to degludec at 50 sites in China between January 2020 and July 2021. The primary endpoint was change in glycated hemoglobin (HbA1c) from baseline to end of study (EOS; week 20). Secondary endpoints included change from baseline to EOS in fasting plasma glucose (FPG), self-measured plasma glucose (SMPG), daily insulin dose, and rate of hypoglycemia. RESULTS Data from 936 participants were included (499 insulin-naïve; 437 insulin-experienced). Mean (95% confidence interval [CI]) HbA1c change from baseline to EOS was - 1.48%-points (- 1.57; - 1.38; P < 0.0001) overall: - 1.95%-points (- 2.08; - 1.81; P < 0.0001) in insulin-naïve participants and - 0.95%-points (- 1.08; - 0.82; P < 0.0001) in insulin-experienced participants. Mean (95% CI) changes in FPG and SMPG were - 2.27 mmol/L (- 2.69; - 1.85; P < 0.0001) and - 2.89 mmol/L (- 3.52; - 2.25; P < 0.0001), respectively, with similar reductions in insulin-naïve and insulin-experienced subgroups. Rate of hypoglycemia did not change statistically significantly from baseline to EOS overall, or in insulin-experienced participants, except when adjusted for baseline hypoglycemia. Basal insulin dose did not change statistically significantly in insulin-experienced participants. CONCLUSION In routine clinical practice in China, initiation or switching to degludec was associated with improvements in glycemic control in people with T2D, with no increased risk of hypoglycemia. TRIAL REGISTRATION ClinialTrials.gov, NCT04227431.
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Affiliation(s)
- Weimin Wang
- Department of Endocrinology and Metabolism, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiangyun Chang
- Department of Endocrinology and Metabolism, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | | | - Ling Li
- Department of Endocrinology and Metabolism, Zhongda Hospital Southeast University, Nanjing, China
| | | | - Jinxing Quan
- Department of Endocrinology, Gansu Provincial Hospital, Lanzhou, China
| | - Yubo Sha
- Department of Endocrinology, No. 1 People's Hospital of Dali City, Dali, China
| | - Xing Zhong
- Department of Medical Affairs, CMRQ, Novo Nordisk (Shanghai) Pharma Trading Co, Ltd, Shanghai, China
| | - Caixian Yang
- Department of Endocrinology, People's Hospital of Qingyuan City, Qingyuan, China
| | - Dalong Zhu
- Department of Endocrinology and Metabolism, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
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Wollenhaupt D, Wolters J, Abd El Aziz M, Nauck MA. Impact of concomitant oral glucose-lowering medications on the success of basal insulin titration in insulin-naïve patients with type 2 diabetes: a systematic analysis. BMJ Open Diabetes Res Care 2023; 11:e003296. [PMID: 37433696 DOI: 10.1136/bmjdrc-2022-003296] [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: 12/24/2022] [Accepted: 05/28/2023] [Indexed: 07/13/2023] Open
Abstract
Basal insulin treatment for type 2 diabetes is usually initiated on a background of oral glucose-lowering medications (OGLM). We wanted to examine the influence of various OGLMs on fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) values achieved after titration. A PubMed literature search retrieved 42 publications (clinical trials introducing basal insulin in 17 433 insulin-naïve patients with type 2 diabetes on a defined background of OGLM) and reporting FPG, HbA1c, target achievement, hypoglycemic events, and insulin doses. 60 individual study arms were grouped by OGLM (combinations) allowed during the titration process: (a) metformin only; (b) sulfonylureas only; (c) metformin and sulfonylureas; or (d) metformin and dipeptidyl peptidase-4 (DPP-4) inhibitors. For all OGLM categories, weighted means and SD were calculated for baseline and end-of-treatment FPG, HbA1c, target achievement, incidence of hypoglycemic events, and insulin doses. Primary end point was a difference in FPG after titration between OGLM categories. Statistics: analysis of variance and post hoc comparisons. Sulfonylureas, alone or in combination with metformin, impair the titration of basal insulin (insulin doses 30%-40% lower, more hypoglycemic episodes), thus leading to poorer final glycemic control (p<0.05 for FPG and HbA1c after titration). Conversely, adding a DPP-4 inhibitor to metformin is superior to metformin alone (p<0.05 for FPG and HbA1c achieved) in patients with type 2 diabetes initiating basal insulin therapy. In conclusion, OGLM are a major determinant of the success of basal insulin therapy. Sulfonylureas impair, while DPP-4 inhibitors (added to metformin) may facilitate the achievement of ambitious fasting glucose targets. PROSPERO registration number CRD42019134821.
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Affiliation(s)
- Dominik Wollenhaupt
- Diabetes, Endocrinology, Metabolism Section, Department of Medicine I, Katholisches Klinikum Bochum Sankt Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Jannik Wolters
- Diabetes, Endocrinology, Metabolism Section, Department of Medicine I, Katholisches Klinikum Bochum Sankt Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Mirna Abd El Aziz
- Diabetes, Endocrinology, Metabolism Section, Department of Medicine I, Katholisches Klinikum Bochum Sankt Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Michael A Nauck
- Diabetes, Endocrinology, Metabolism Section, Department of Medicine I, Katholisches Klinikum Bochum Sankt Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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Valencia WM, Florez HJ, Palacio AM. Suitable Use of Injectable Agents to Overcome Hypoglycemia Risk, Barriers, and Clinical Inertia in Community-Dwelling Older Adults with Type 2 Diabetes Mellitus. Drugs Aging 2020; 36:1083-1096. [PMID: 31565780 PMCID: PMC7481154 DOI: 10.1007/s40266-019-00706-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The management of type 2 diabetes mellitus in older adults requires a comprehensive understanding of the relationship between the disease (medical) and the functional, psychological/cognitive, and social geriatric domains, to individualize both glycemic targets and therapeutic approaches. Prevention of hypoglycemia is a major priority that should be addressed as soon as its presence or risk is detected, adjusting the target and therapeutics accordingly. Nonetheless, treatment intensification should not be neglected when applicable, consistent with recommendations from organizations such as the American Geriatrics Society and the American Diabetes Association, to reduce not only long-term macrovascular and microvascular complications (individualization), but also short-term complications from hyperglycemia (polyuria, volume depletion, urinary incontinence). Such complications can negatively impact the physical and cognitive function of older adults, worsen their quality of life, and additionally affect their families and society. We emphasize individualization, utilizing the multiple classes of antihyperglycemic agents available. Metformin remains as first-line therapy, and additional agents offer advantages and disadvantages that ought to be considered when developing a patient-centric plan of care. For selected cases, injectable therapies such as long-acting basal insulin analogs and glucagon-like peptide-1 receptor agonists can offer advantages to counter hypoglycemia risk, patient-related barriers, and clinical inertia. Furthermore, some injectable agents could potentially simplify regimens while providing safe and effective glycemic control. In this review, we discuss the use of injectable therapies for selected community-dwelling older adults, barriers to transition to injectable therapy, and measures aimed at removing these barriers and assisting physicians and their teams to transition older patients to injectable therapies when appropriate.
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Affiliation(s)
- Willy M Valencia
- Geriatrics Research, Education and Clinical Center (GRECC), Miami VA Healthcare System, 1201 NW 16th St., 11 GRC, CLC 207 A2, Miami, FL, 33125, USA. .,Department of Humanities, Health and Society, Florida International University Herbert Wertheim College of Medicine, Miami, FL, 33199, USA. .,Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, 33136, USA.
| | - Hermes J Florez
- Geriatrics Research, Education and Clinical Center (GRECC), Miami VA Healthcare System, 1201 NW 16th St., 11 GRC, CLC 207 A2, Miami, FL, 33125, USA.,Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, 33136, USA.,Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Ana M Palacio
- Geriatrics Research, Education and Clinical Center (GRECC), Miami VA Healthcare System, 1201 NW 16th St., 11 GRC, CLC 207 A2, Miami, FL, 33125, USA.,Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, 33136, USA.,Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
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Frier BM, Ratzki‐Leewing A, Harris SB. Reporting of hypoglycaemia in clinical trials of basal insulins: A need for consensus. Diabetes Obes Metab 2019; 21:1529-1542. [PMID: 30924567 PMCID: PMC6767397 DOI: 10.1111/dom.13732] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/13/2019] [Accepted: 03/26/2019] [Indexed: 12/31/2022]
Abstract
Hypoglycaemia is a common side-effect of diabetes therapies, particularly insulin, and imposes a substantial burden on individuals and healthcare systems. Consequently, regulatory approval of newer basal insulin (BI) therapies has relied on demonstration of a balance between achievement of good glycaemic control and less hypoglycaemia. Randomized controlled trials (RCTs) are the gold standard for assessing efficacy and safety, including hypoglycaemia risk, of BIs and are invaluable for obtaining regulatory approval. However, their highly selected patient populations and their conditions lead to results that may not be representative of real-life situations. Real-world evidence (RWE) studies are more representative of clinical practice, but they also have limitations. As such, data both from RCTs and RWE studies provide a fuller picture of the hypoglycaemia risk with BI therapies. However, substantial differences exist in the way hypoglycaemia is reported across these studies, which confounds comparisons of hypoglycaemia frequency among different BIs. This problem is ongoing and persists in recent trials of second-generation BI analogues. Although they provide a lower risk of hypoglycaemia when compared with earlier BIs, they do not eliminate it. This review describes differences in the way hypoglycaemia is reported across RCTs and RWE studies of second-generation BI analogues and examines potential reasons for these differences. For studies of BIs, there is a need to standardize aspects of design, analysis and methods of reporting to better enable interpretation of the efficacy and safety of such insulins among studies; such aspects include length of follow-up, glycaemic targets, hypoglycaemia definitions and time intervals for determining nocturnal events.
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Affiliation(s)
- Brian M. Frier
- British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research Institute, University of EdinburghEdinburghUK
| | - Alexandria Ratzki‐Leewing
- Department of Epidemiology and BiostatisticsSchulich School of Medicine and Dentistry, Western UniversityLondonOntario, Canada
| | - Stewart B. Harris
- Department of Family MedicineSchulich School of Medicine and Dentistry, Western UniversityLondonOntario, Canada
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Zhou W, Tao J, Zhou X, Chen H. Insulin Degludec, a Novel Ultra-Long-Acting Basal Insulin versus Insulin Glargine for the Management of Type 2 Diabetes: A Systematic Review and Meta-Analysis. Diabetes Ther 2019; 10:835-852. [PMID: 31020539 PMCID: PMC6531575 DOI: 10.1007/s13300-019-0624-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The purpose of this study was to compare insulin degludec with insulin glargine in terms of efficacy and safety in patients with type 2 diabetes. METHODS We systematically searched PubMed, Embase, Web of Science, and Cochrane Library databases for randomized controlled trials published prior to 13 August 2018 (no language restrictions) which compared insulin degludec with insulin glargine. Our main endpoints were glycemic control, hypoglycemic event, weight gain, and serious adverse events (SAEs). We assessed pooled data using random-effects models. RESULTS A total of 15 studies that included 9619 patients in the insulin degludec arm of the studies and 7075 patients in the insulin glargine arm were identified and subsequently assessed. Our analysis showed that compared with insulin glargine, insulin degludec yielded an improved mean reduction in fasting plasma glucose (FPG) (weighted mean difference [WMD] - 5.20 mg/dL, 95% confidence interval [CI] - 7.34, - 3.07, P < 0.00001) and a lower ratio of participants experiencing ≥ 1 severe hypoglycemic event (relative risk [RR] 0.68, 95% CI 0.50, 0.93, P = 0.01) and nocturnal hypoglycemia (RR 0.81, 95% CI 0.75, 0.88, P < 0.0001); however, in the insulin degludec group there was a lower ratio of participants with glycated hemoglobin (HbA1c) of ≤ 7.0% (RR 0.92, 95% CI 0.86, 0.98, P = 0.01). There was no statistically significant difference between the two treatment groups for HbA1c reduction (WMD 0.03, 95% CI - 0.00, 0.07, P = 0.08), body weight gain (WMD 0.12, 95% CI - 0.19, 0.43, P = 0.46), and proportion of participants with SAEs (RR 0.97, 95% CI 0.92, 1.02, P = 0.20). CONCLUSIONS Insulin degludec and insulin glargine provide similar glycemic control, but insulin degludec also lowers the risk of hypoglycemia. Consequently, insulin degludec may be an alternative treatment for the management of patients with type 2 diabetes who are prone to hypoglycemia with insulin glargine.
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Affiliation(s)
- Wenchuan Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Road, Donghu District, Nanchang, 330006 China
- Department of Clinical Medicine, The Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Jinxin Tao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Road, Donghu District, Nanchang, 330006 China
- Department of Clinical Medicine, The Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Xiaodong Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Road, Donghu District, Nanchang, 330006 China
| | - Hongxia Chen
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Patel D, Triplitt C, Trujillo J. Appropriate Titration of Basal Insulin in Type 2 Diabetes and the Potential Role of the Pharmacist. Adv Ther 2019; 36:1031-1051. [PMID: 30900198 PMCID: PMC6824379 DOI: 10.1007/s12325-019-00907-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Indexed: 02/06/2023]
Abstract
A substantial proportion of patients with suboptimal control of their type 2 diabetes experience delays in treatment intensification. Additionally, patients often experience overuse of basal insulin, commonly referred to as "over-basalization," whereby basal insulin continues to be uptitrated in order to meet targets, when addition of a mealtime bolus insulin dose may be a more appropriate option. In order to overcome these challenges, there is a need to develop the capacity of allied healthcare professionals to provide appropriate support to these patients, such as during initiation or titration of basal insulin. Pharmacists play an integral role in healthcare delivery, with patients seeing their pharmacist, on average, seven times more often than their primary care physician. This places pharmacists in a unique position to provide diabetes education and care, which may help patients avoid clinical inertia. Nevertheless, the management of the disease with basal insulin is becoming increasingly complex, with growing numbers of treatment options (such as recent second-generation longer-acting basal insulin formulations) and frequently updated titration algorithms. The two most common titration schedules specify either increasing doses by a set amount every 2-3 days or a treat-to-target strategy. Neither schedule has been shown to be superior, and the decision to use one or the other should be based on a discussion between the clinician and patient after assessment of mental and physical acumen, comfort of both parties, and follow-up plans. This review article discusses basal insulin therapy options and titration algorithms from the unique perspective of the pharmacist in order to help ensure that optimal antidiabetes therapy is initiated, appropriately titrated, and maintained.Funding: Sanofi US, Inc.
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Affiliation(s)
- Dhiren Patel
- School of Pharmacy, MCPHS University, Boston, MA, USA.
| | - Curtis Triplitt
- Texas Diabetes Institute, University of Texas Health Science Center, San Antonio, TX, USA
| | - Jennifer Trujillo
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
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Abstract
INTRODUCTION Although premixed fixed ratio NPH insulin products are commonly used in type 2 diabetes patients, the advent of Glargine insulin which cannot be formulated together with a rapid-acting insulin (basal-bolus) has largely eliminated premixed insulin from use in type 1 diabetes. Degludec insulin can be formulated together with Aspart insulin in a 70/30 fixed ratio product. We review the potential use of Degludec-Aspart in type 1 diabetes. Areas covered: A historical search of the development and use of premixed insulin preparations was performed relying on Pubmed, FDA, and European Union records. Expert opinion: Degludec is a once daily insulin. There appears to be little advantage to administration of Degludec-Aspart twice daily, and basal bolus injections have proved superior to premixed insulin in type 1 diabetes. There may still be a role for this premixed fixed ratio formulation in patients who have opted to use Technosphere inhaled insulin prior to and post meals. In such patients, the use of a single injection of Degludec-Aspart prior to the largest meal of the day might provide an anchor to allow patients to then self-administer multiple inhalations around mealtimes.
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Affiliation(s)
- Marc Rendell
- a The Rose Salter Medical Research Foundation , Newport Coast , CA , USA.,b The Association of Diabetes Investigators , Newport Coast , CA , USA
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Madenidou AV, Paschos P, Karagiannis T, Katsoula A, Athanasiadou E, Kitsios K, Bekiari E, Matthews DR, Tsapas A. Comparative Benefits and Harms of Basal Insulin Analogues for Type 2 Diabetes: A Systematic Review and Network Meta-analysis. Ann Intern Med 2018; 169:165-174. [PMID: 29987326 DOI: 10.7326/m18-0443] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Basal insulin analogues aim for protracted glycemic control with minimal adverse effects. PURPOSE To assess the comparative efficacy and safety of basal insulin analogues for adults with type 2 diabetes mellitus (T2DM). DATA SOURCES Several databases from inception to April 2018 without language restrictions, ClinicalTrials.gov to April 2018, references of reviews, and meeting abstract books. STUDY SELECTION Randomized trials lasting at least 12 weeks that compared efficacy (change in hemoglobin A1c [HbA1c] level from baseline [primary outcome]; percentage of patients with HbA1c level <7% at end of study and change in body weight [secondary outcomes]) and safety (hypoglycemia) of basal insulin analogues. DATA EXTRACTION Two authors independently extracted data and assessed risk of bias for each outcome. All authors evaluated overall confidence in the evidence. DATA SYNTHESIS Thirty-nine trials (26 195 patients) assessed 10 basal insulin analogues. Low- to very-low-quality evidence indicated that thrice-weekly degludec (Deg-3TW) was inferior to most other regimens for reducing HbA1c level, with mean differences ranging from 0.21% (vs. degludec, 100 U/mL [Deg-100]) to 0.32% (vs. glargine, 300 U/mL [Glar-300]). High- to moderate-quality evidence suggested that detemir had a favorable weight profile versus all comparators, and Glar-300 was associated with less weight gain than glargine, 100 U/mL (Glar-100); Deg-100; degludec, 200 U/mL (Deg-200); Deg-3TW; and LY2963016. Low- and very-low-quality evidence suggested that Deg-100, Deg-200, and Glar-300 were associated with lower incidence of nocturnal hypoglycemia than detemir, Glar-100, LY2963016, and neutral protamine lispro (NPL). Incidence of severe hypoglycemia did not differ among regimens, except NPL, which was associated with increased risk versus Deg-100, detemir, Glar-100, and Glar-300. LIMITATIONS Results are based mostly on indirect comparisons. Confidence in summary estimates is low or very low due to individual-study limitations, imprecision, or inconsistency. CONCLUSION Low-quality evidence suggests that basal insulin analogues for T2DM do not substantially differ in their glucose-lowering effect. Low- and very-low-quality evidence suggests some regimens may be associated with lower risk for nocturnal hypoglycemia (Deg-100, Deg-200, and Glar-300) or less weight gain (detemir and Glar-300). PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42016037055).
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Affiliation(s)
| | - Paschalis Paschos
- Aristotle University of Thessaloniki, Thessaloniki, Greece (A.M., P.P., T.K., A.K., E.A., K.K., E.B.)
| | - Thomas Karagiannis
- Aristotle University of Thessaloniki, Thessaloniki, Greece (A.M., P.P., T.K., A.K., E.A., K.K., E.B.)
| | - Anastasia Katsoula
- Aristotle University of Thessaloniki, Thessaloniki, Greece (A.M., P.P., T.K., A.K., E.A., K.K., E.B.)
| | - Eleni Athanasiadou
- Aristotle University of Thessaloniki, Thessaloniki, Greece (A.M., P.P., T.K., A.K., E.A., K.K., E.B.)
| | - Konstantinos Kitsios
- Aristotle University of Thessaloniki, Thessaloniki, Greece (A.M., P.P., T.K., A.K., E.A., K.K., E.B.)
| | - Eleni Bekiari
- Aristotle University of Thessaloniki, Thessaloniki, Greece (A.M., P.P., T.K., A.K., E.A., K.K., E.B.)
| | | | - Apostolos Tsapas
- Aristotle University of Thessaloniki, Thessaloniki, Greece, and University of Oxford, Oxford, United Kingdom (A.T.)
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Ovalle F, Segal AR, Anderson JE, Cohen MR, Morwick TM, Jackson JA. Understanding concentrated insulins: a systematic review of randomized controlled trials. Curr Med Res Opin 2018; 34:1029-1043. [PMID: 29166786 DOI: 10.1080/03007995.2017.1409426] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To compile, analyze, and summarize the literature on concentrated insulins (i.e. concentrations >100 units/mL) from randomized controlled trials and derive guidance on appropriate use of these agents. METHODS Searches were conducted in Medline, Embase, the Cochrane Central Register of Controlled Trials, Trialtrove (through April 2016) and ClinicalTrials.gov (through April 2017) for phase 1-4 clinical studies using concentrated insulins. Selected studies included multiple-arm, randomized controlled trials evaluating subcutaneously administered concentrated insulins. Trial registration numbers (selected studies) were searched in Medline, Embase and Google Scholar (through April 2017). Late-phase studies were graded using guidance from the Agency for Healthcare Research and Quality. RESULTS Thirty-eight completed trials (7900 participants) and 34 qualifying publications were identified. Four marketed concentrated insulins were evaluated: two long-acting basal (insulin glargine 300 units/mL and insulin degludec 200 units/mL [IDeg200]), one rapid-acting prandial (insulin lispro 200 units/mL [ILis200]), and one prandial/basal (human regular insulin 500 units/mL). Early-phase trials established bioequivalence for IDeg200 and ILis200 with the corresponding 100 units/mL formulations. Efficacy studies showed noninferior glycemic control between comparators for long-acting basal and prandial/basal products with generally low severe hypoglycemia. Six additional concentrated insulins with completed early-phase development were also identified. CONCLUSION Concentrated-insulin products demonstrated efficacious and safe outcomes in appropriate patients. Clinical findings (HbA1c and hypoglycemia) and methodology (initiation and titration), patient factors (insulin experience and dosing requirements) and treatment characteristics (bioequivalence, potency and device features) are important considerations. This overview of these and other factors provides essential information and guidance for using concentrated insulins in clinical practice.
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Affiliation(s)
- Fernando Ovalle
- a Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism , University of Alabama at Birmingham , Birmingham , AL , USA
| | - Alissa R Segal
- b Department of Pharmacy Practice, School of Pharmacy , MCPHS University , Boston , MA , USA
- c Joslin Diabetes Center , Boston , MA , USA
| | | | - Michael R Cohen
- e Institute for Safe Medication Practices , Horsham , PA , USA
| | - Tina M Morwick
- f Lilly Diabetes, Eli Lilly and Company , Indianapolis , IN , USA
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11
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Zhang XW, Zhang XL, Xu B, Kang LN. Comparative safety and efficacy of insulin degludec with insulin glargine in type 2 and type 1 diabetes: a meta-analysis of randomized controlled trials. Acta Diabetol 2018; 55:429-441. [PMID: 29423761 DOI: 10.1007/s00592-018-1107-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 01/19/2018] [Indexed: 12/17/2022]
Abstract
AIMS To determine the safety and efficacy of insulin degludec versus glargine in patients with type 1 (T1D) and type 2 (T2D) diabetes mellitus. METHODS Databases were searched until July 5, 2017. We included randomized controlled trials comparing degludec with glargine in diabetic patients, each with a minimum of 16 weeks of follow-up. RESULTS Eighteen trials with 16,791 patients were included. Degludec was associated with a statistically significant reduction in risk for all confirmed hypoglycemia at the maintenance treatment period [estimated rate ratio (ERR) 0.81; 95% confidence interval (CI) 0.72‒0.92; P = 0.001], nocturnal confirmed hypoglycemia at the entire (ERR 0.71; 95% CI 0.63‒0.80; P < 0.001) and maintenance treatment period (ERR 0.65; 95% CI 0.59‒0.71; P < 0.001), all irrespective of the pooled diabetic populations and follow-up durations. The differences in the rate of hypoglycemia were more pronounced in nocturnal period and maintenance period and in T2D than T1D patients. Degludec reduced the incidence of severe hypoglycemia in T2D [ERR 0.65; (0.52; 0.89); P = 0.005] but not T1D patients. HbA1c concentration was slightly higher in degludec over glargine but was not clinically relevant [estimated treatment difference (ETD) 0.03; 95% CI - 0.00 to 0.06%; P = 0.06]. Fasting plasma glucose level was lower in degludec-treated patients (ETD - 0.28 mmol/L; 95% CI - 0.44 to - 0.11 mmol/L; P = 0.001). Several subgroup analyses showed largely consistent findings. The rates of adverse events including total mortality and cardiovascular events were not significantly different between two treatment strategies. CONCLUSIONS Insulin degludec appears to have better safety in reducing hypoglycemic events with similar efficacy compared with insulin glargine.
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Affiliation(s)
- Xiao-Wen Zhang
- Department of Endocrinology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xin-Lin Zhang
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Biao Xu
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Li-Na Kang
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China.
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12
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Chan WB, Chen JF, Goh SY, Vu TTH, Isip-Tan IT, Mudjanarko SW, Bajpai S, Mabunay MA, Bunnag P. Challenges and unmet needs in basal insulin therapy: lessons from the Asian experience. Diabetes Metab Syndr Obes 2017; 10:521-532. [PMID: 29276400 PMCID: PMC5733912 DOI: 10.2147/dmso.s143046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Basal insulin therapy can improve glycemic control in people with type 2 diabetes. However, timely initiation, optimal titration, and proper adherence to prescribed basal insulin regimens are necessary to achieve optimal glycemic control. Even so, glycemic control may remain suboptimal in a significant proportion of patients. Unique circumstances in Asia (eg, limited resources, management of diabetes primarily in nonspecialist settings, and patient populations that are predominantly less educated) coupled with the limitations of current basal insulin options (eg, risk of hypoglycemia and dosing time inflexibility) amplify the challenge of optimal basal insulin therapy in Asia. Significant progress has been made with long-acting insulin analogs (insulin glargine 100 units/mL and insulin detemir), which provide longer coverage and less risk of hypoglycemia over intermediate-acting insulin (Neutral Protamine Hagedorn insulin). Furthermore, recent clinical evidence suggests that newer long-acting insulin analogs, new insulin glargine 300 units/mL and insulin degludec, may address some of the unmet needs of current basal insulin options in terms of risk of hypoglycemia and dosing time inflexibility. Nevertheless, more can be done to overcome barriers to basal insulin therapy in Asia, through educating both patients and physicians, developing better patient support models, and improving accessibility to long-acting insulin analogs. In this study, we highlight the unique challenges associated with basal insulin therapy in Asia and, where possible, propose strategies to address the unmet needs by drawing on clinical experiences and perspectives in Asia.
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Affiliation(s)
- Wing Bun Chan
- Qualigenics Diabetes Centre, Hong Kong SAR, People’s Republic of China
| | - Jung Fu Chen
- Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Su-Yen Goh
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Thi Thanh Huyen Vu
- Out-patient Department and Department of Internal Medicine, National Geriatric Hospital, Hanoi Medical University, Hanoi, Vietnam
| | - Iris Thiele Isip-Tan
- Section of Endocrinology, Diabetes and Metabolism, University of the Philippines–Philippine General Hospital, Manila, Philippines
| | - Sony Wibisono Mudjanarko
- Diabetes and Nutrition Centre, Dr. Soetomo Hospital, School of Medicine Airlangga University, Surabaya, Indonesia
| | | | | | - Pongamorn Bunnag
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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13
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Johansen MY, MacDonald CS, Hansen KB, Karstoft K, Christensen R, Pedersen M, Hansen LS, Zacho M, Wedell-Neergaard AS, Nielsen ST, Iepsen UW, Langberg H, Vaag AA, Pedersen BK, Ried-Larsen M. Effect of an Intensive Lifestyle Intervention on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Clinical Trial. JAMA 2017; 318:637-646. [PMID: 28810024 PMCID: PMC5817591 DOI: 10.1001/jama.2017.10169] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 07/10/2017] [Indexed: 11/14/2022]
Abstract
Importance It is unclear whether a lifestyle intervention can maintain glycemic control in patients with type 2 diabetes. Objective To test whether an intensive lifestyle intervention results in equivalent glycemic control compared with standard care and, secondarily, leads to a reduction in glucose-lowering medication in participants with type 2 diabetes. Design, Setting, and Participants Randomized, assessor-blinded, single-center study within Region Zealand and the Capital Region of Denmark (April 2015-August 2016). Ninety-eight adult participants with non-insulin-dependent type 2 diabetes who were diagnosed for less than 10 years were included. Participants were randomly assigned (2:1; stratified by sex) to the lifestyle group (n = 64) or the standard care group (n = 34). Interventions All participants received standard care with individual counseling and standardized, blinded, target-driven medical therapy. Additionally, the lifestyle intervention included 5 to 6 weekly aerobic training sessions (duration 30-60 minutes), of which 2 to 3 sessions were combined with resistance training. The lifestyle participants received dietary plans aiming for a body mass index of 25 or less. Participants were followed up for 12 months. Main Outcomes and Measures Primary outcome was change in hemoglobin A1c (HbA1c) from baseline to 12-month follow-up, and equivalence was prespecified by a CI margin of ±0.4% based on the intention-to-treat population. Superiority analysis was performed on the secondary outcome reductions in glucose-lowering medication. Results Among 98 randomized participants (mean age, 54.6 years [SD, 8.9]; women, 47 [48%]; mean baseline HbA1c, 6.7%), 93 participants completed the trial. From baseline to 12-month follow-up, the mean HbA1c level changed from 6.65% to 6.34% in the lifestyle group and from 6.74% to 6.66% in the standard care group (mean between-group difference in change of -0.26% [95% CI, -0.52% to -0.01%]), not meeting the criteria for equivalence (P = .15). Reduction in glucose-lowering medications occurred in 47 participants (73.5%) in the lifestyle group and 9 participants (26.4%) in the standard care group (difference, 47.1 percentage points [95% CI, 28.6-65.3]). There were 32 adverse events (most commonly musculoskeletal pain or discomfort and mild hypoglycemia) in the lifestyle group and 5 in the standard care group. Conclusions and Relevance Among adults with type 2 diabetes diagnosed for less than 10 years, a lifestyle intervention compared with standard care resulted in a change in glycemic control that did not reach the criterion for equivalence, but was in a direction consistent with benefit. Further research is needed to assess superiority, as well as generalizability and durability of findings. Trial Registration clinicaltrials.gov Identifier: NCT02417012.
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Affiliation(s)
- Mette Yun Johansen
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christopher Scott MacDonald
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- CopenRehab, University of Copenhagen, Copenhagen, Denmark
| | - Katrine Bagge Hansen
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kristian Karstoft
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Robin Christensen
- Musculoskeletal Statistics Unit, Parker Institute, Copenhagen, Denmark
- Frederiksberg Hospital, Copenhagen, Denmark
| | - Maria Pedersen
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine, Herlev Hospital, Herlev, Denmark
| | - Louise Seier Hansen
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Morten Zacho
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne-Sophie Wedell-Neergaard
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Signe Tellerup Nielsen
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ulrik Wining Iepsen
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henning Langberg
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- CopenRehab, University of Copenhagen, Copenhagen, Denmark
| | - Allan Arthur Vaag
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Translational Research and Early Clinical Development, Cardiovascular and Metabolic Research, AstraZeneca, Mölndal, Sweden
| | - Bente Klarlund Pedersen
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mathias Ried-Larsen
- Centre of Inflammation and Metabolism, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Danish Diabetes Academy, Odense University Hospital, Odense, Denmark
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14
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Bohn B, Zimmermann A, Wagner C, Merger S, Dunstheimer D, Kopp F, Gollisch K, Zindel V, Holl RW. Real-life experience of patients starting insulin degludec. A multicenter analysis of 1064 subjects from the German/Austrian DPV registry. Diabetes Res Clin Pract 2017; 129:52-58. [PMID: 28505544 DOI: 10.1016/j.diabres.2017.03.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/06/2017] [Accepted: 03/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The long-acting insulin analogue degludec is a therapeutic option for patients with type 1 (T1D) or type 2 diabetes (T2D). Aim of this analysis was to investigate differences in clinical characteristics of patients before and after initiating degludec use in a cohort of German/Austrian patients. METHODS 1064 subjects with T1D/T2D and documented degludec use from the Diabetes-Patient-Follow-Up (DPV) registry were included. The follow-up cohort (n=421) comprised patients with available data before and 3-15months after switching to degludec. A t-test for paired values was implemented to compare rates of severe hypoglycaemia, and mean values for HbA1C, BMI, basal insulin dose/kg bodyweight/day, and the number of basal insulin injections/day before and after switching to degludec Results were stratified by type of diabetes. In T1D, subgroup analyses were conducted (age, sex, basal insulin used before switching). P<0.05 was considered significant. FINDINGS In T1D (n=360), basal insulin dose (0.43±0.17 to 0.38±0.13IU) and the number of basal injections/day (1.7±0.6 to 1.1±0.3) decreased whereas BMI increased from 23.2±4.8 to 24.0±5.0kg/m2 (all p<0.0001) after switching to degludec. No significant changes were observed regarding rates of severe hypoglycaemia or HbA1C-values. Findings were comparable for subgroups. In T2D (n=61), basal insulin dose (0.41±0.23 to 0.38±0.21; p=0.1730) and the number of basal injections/day (1.3±0.4 to 1.1±0.3; p=0.0097) decreased after switching to degludec. HbA1C improved from 7.9±1.6 to 7.1±1.5% (p<0.0001). CONCLUSIONS The DPV registry provides data from real-life diabetes care. Our analysis predominantly confirmed results from clinical trials and provides additional information complementing the clinical study program of degludec.
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Affiliation(s)
- Barbara Bohn
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany; German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany.
| | | | | | - Sigrun Merger
- Medical Clinic IV, Clinic for Endocrinology, Diabetology, Metabolism, and Nutrition Medicine, Clinic Coburg, Coburg, Germany
| | | | - Florian Kopp
- Diabetes Center, Clinical Center Augsburg, Augsburg, Germany
| | - Katja Gollisch
- Department of Gastroenterology and Endocrinology, University of Göttingen, Göttingen, Germany
| | - Volker Zindel
- Hospital for Pediatrics and Adolescent Medicine, Clinic Bad Salzungen, Bad Salzungen, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany; German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
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15
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Lajara R, Cengiz E, Tanenberg RJ. The role of the new basal insulin analogs in addressing unmet clinical needs in people with type 1 and type 2 diabetes. Curr Med Res Opin 2017; 33:1045-1055. [PMID: 28277867 DOI: 10.1080/03007995.2017.1298522] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite improvements in anti-hyperglycemic therapies, there are many unmet clinical needs that hinder successful glycemic control in people being treated with current basal insulin analogs. OBJECTIVE This paper reviews the unmet needs associated with current basal insulin therapy and describes the most recent basal insulins for the treatment of diabetes. METHODS PubMed was searched for articles on basal insulin analogs published between 2000 and April 2016. RESULTS Although long-acting insulin analogs, such as insulin glargine 100 units/mL and insulin detemir, have come towards approximating physiologic basal insulin levels, limitations such as hypoglycemia and intra- and inter-individual variability are associated with their use resulting in glycemic fluctuations. Some basal insulins lack 24 hour coverage, requiring some patients to split their dose, increasing the number of injections required to maintain glycemic control. Fear of hypoglycemia and the need for additional injections often leads to poor compliance and suboptimal glycemic control. Long-acting insulin analogs, such as insulin glargine 300 units/mL and insulin degludec, have improved upon the shortcomings of the current basal insulin analogs. Improved pharmacodynamic/pharmacokinetic profiles afford lower intra-patient variability and an extended duration of action, providing full and stable 24 hour basal insulin coverage with once daily dosing, and comparable efficacy to insulin glargine with lower rates of hypoglycemia. CONCLUSION The improved pharmacodynamic/pharmacokinetic profiles of new long-acting insulin formulations provide greater glycemic control with once daily dosing. With the growing number of therapeutic choices available, physicians have more scope to individualize patient options for basal insulin therapy.
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Affiliation(s)
| | - Eda Cengiz
- b Yale University School of Medicine , New Haven , CT , USA
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16
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Rendell M. United States experience of insulin degludec alone or in combination for type 1 and type 2 diabetes. Drug Des Devel Ther 2017; 11:1209-1220. [PMID: 28458515 PMCID: PMC5402881 DOI: 10.2147/dddt.s132581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Insulin degludec has been the product of a sophisticated and systematic biochemical engineering program which began with the release of insulin detemir. The goal was to produce a long-lasting basal insulin with low individual variability. Certainly, this goal has been achieved. Degludec has a duration of action approaching twice that of glargine. Another advantage of degludec is in its lack of unpredictable copolymerization of added aspart. In several studies, degludec has shown lower rates of nocturnal hypoglycemia than glargine. Degludec can be administered flexibly with a very flat insulin concentration curve at any time of day. Initial US Food and Drug Administration concerns about a possible increase in cardiac events in degludec-treated patients have been allayed by the results of a study targeting individuals with high cardiac risk. Degludec is now marketed in the US competing with glargine. Despite the long duration of action of degludec, attempted administration three times weekly resulted in less effective lowering of glycated hemoglobin and an increased incidence of hypoglycemia compared to daily glargine. Conversely the coformulation of degludec and liraglutide has proven very successful in reducing glycated hemoglobin levels with less hypoglycemia and less weight gain than with degludec alone and with less gastrointestinal symptoms than with liraglutide alone. A large study comparing glargine insulin and degludec in patients with increased cardiac risk is now ongoing. This study may or may not prove superiority of one or the other insulin, but, with the coming of biosimilar glargine insulin, cost factors may be dominant in determining which basal insulin is to be used. Nonetheless, the coformulation with liraglutide will likely insure the future of degludec insulin in the treatment of type 2 diabetes.
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Affiliation(s)
- Marc Rendell
- The Rose Salter Medical Research Foundation
- The Association of Diabetes Investigators, Newport Coast, CA, USA
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17
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Woo VC. A Review of the Clinical Efficacy and Safety of Insulin Degludec and Glargine 300 U/mL in the Treatment of Diabetes Mellitus. Clin Ther 2017; 39:S12-S33. [PMID: 28187863 DOI: 10.1016/j.clinthera.2017.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 12/30/2016] [Accepted: 01/04/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE The treatment of type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) using insulin is not ideal at this time. Despite advances made with basal insulin analogues, many individuals achieve less than optimal glycemic control or are at risk for hypoglycemia. Currently available basal insulin analogues do not deliver steady, peakless, continuous insulin for >24 hours and are associated with adverse events, including hypoglycemia. The objective of this paper was to review the clinical efficacy and safety of upcoming long-acting insulin analogues such as insulin degludec and insulin glargine 300 U/mL (Gla-300). METHODS A comprehensive literature search of PubMed and Google Scholar was conducted from 1966 to 2015. The search included randomized controlled trials that specifically assessed the efficacy and safety of insulin degludec and Gla-300 in patients with T1DM and T2DM. FINDINGS The efficacy of insulin degludec and Gla-300 in achieving glycemic control has been reported in clinical trials in adults with T1DM and T2DM. Not only did a large number of patients succeed in meeting glycosylated hemoglobin targets, but they also experienced reductions in hypoglycemic events. These 2 therapies are associated with a reduced risk of nocturnal hypoglycemia and are generally well tolerated. IMPLICATIONS The long-acting insulin analogues insulin degludec and Gla-300 are promising therapies in the treatment of T1DM and T2DM. Their improved insulin delivery for >24 hours offers glycemic control with a good safety profile.
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Affiliation(s)
- Vincent C Woo
- Section of Endocrinology and Metabolism, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada.
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18
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Nagai Y, Murakami M, Igarashi K, Nakamura Y, Tsukiyama H, Matsubara F, Nishine A, Ohshige T, Ishii S, Kato H, Tanaka Y. Efficacy and safety of thrice-weekly insulin degludec in elderly patients with type 2 diabetes assessed by continuous glucose monitoring. Endocr J 2016; 63:1099-1106. [PMID: 27593174 DOI: 10.1507/endocrj.ej16-0252] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
As life expectancy becomes longer in Japan, there has been an increase of elderly patients with type 2 diabetes who need insulin therapy but cannot perform self-injection due to dementia or other conditions. Therefore, the aim of this study was to investigate the efficacy and safety of thrice-weekly insulin degludec therapy in elderly patients with poorly controlled diabetes. The subjects were 22 hospitalized elderly Japanese patients with type 2 diabetes who had difficulty with self-injection. After becoming stable on once-daily insulin degludec treatment, they were assigned to continue once-daily injection (OD group) or were switched to thrice-weekly injection (TW group) for one week. In the TW group, insulin degludec (IDeg) was injected at twice the OD dose before lunch on Monday, Wednesday, and Friday. Glycemic control was assessed by continuous glucose monitoring (CGM) over 7 days. The mean 7-day glucose level (131±25 mg/dL with OD vs. 152±30 mg/dL with TW, p=0.11) and the mean 7-day standard deviation (32±10 mg/dL with OD vs. 36±14 mg/dL with TW, p=0.45) did not differ significantly between the two groups. The percent duration of glucose <70 mg/dL (2.4±3.1% with OD vs. 1.3±2.5% with TW, p=0.39) and glucose >200 mg/dL (7.2±12.1% with OD vs. 15.6±18.0% with TW, p=0.22) over 7 days also showed no significant differences between the two groups. In conclusion, thrice-weekly IDeg provided by a visiting nurse could be a practical option for elderly diabetic patients who have difficulty performing self-injection of insulin.
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Affiliation(s)
- Yoshio Nagai
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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Pettus J, Santos Cavaiola T, Tamborlane WV, Edelman S. The past, present, and future of basal insulins. Diabetes Metab Res Rev 2016; 32:478-96. [PMID: 26509843 DOI: 10.1002/dmrr.2763] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/23/2015] [Accepted: 10/04/2015] [Indexed: 12/14/2022]
Abstract
Insulin production by the pancreas follows a basic pattern where basal levels of insulin are secreted during fasting periods, with prandial increases in insulin associated with food ingestion. The aim of insulin therapy in patients with diabetes is to match the endogenous pattern of insulin secretion as closely as possible without causing hypoglycaemia. There are several optimal pharmacokinetic and pharmacodynamic properties of long-acting basal insulins that can help to achieve this aim, namely, as follows: activity that is flat and as free of peaks as possible, a duration of action of ≥24-h, and as little day-to-day variation as possible. The long-acting basal insulins are a fundamental therapy for patients with type 1 and type 2 diabetes, and those that are currently available have many benefits; however, the development of even longer-acting insulins and improved insulin delivery techniques may lead to better glycemic control for patients in the future. Established long-acting basal insulins available in the United States and Europe include insulin glargine 100 units/mL and insulin detemir, both of which exhibit similar glycemic control to that of the intermediate-acting neutral protamine Hagedorn insulin, but with a reduction in hypoglycaemia. Newer insulin products available include new insulin glargine 300 units/mL (United States and Europe) and the ultra-long-acting insulin degludec (Europe) with basal insulin peglispro currently in development. These new insulins demonstrate different pharmacokinetic/pharmacodynamic profiles and longer durations of action (>24 h) compared with insulin glargine 100 units/mL, which may lead to potential benefits. The introduction of biosimilar insulins may also broaden access to insulins by reducing treatment costs. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jeremy Pettus
- Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA, USA
| | - Tricia Santos Cavaiola
- Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA, USA
| | | | - Steven Edelman
- Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA, USA
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Barnosky A, Shah L, Meah F, Emanuele N, Emanuele MA, Mazhari A. A primer on concentrated insulins: what an internist should know. Postgrad Med 2016; 128:381-90. [DOI: 10.1080/00325481.2016.1159909] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Successful glycemic control with three times a week degludec injection by medical staff for an elderly hemodialysis patient with type 2 diabetes. Diabetol Int 2016; 7:95-99. [DOI: 10.1007/s13340-015-0220-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 06/26/2015] [Indexed: 10/23/2022]
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22
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Freemantle N, Chou E, Frois C, Zhuo D, Lehmacher W, Vlajnic A, Wang H, Chung HW, Zhang Q, Wu E, Gerrits C. Safety and efficacy of insulin glargine 300 u/mL compared with other basal insulin therapies in patients with type 2 diabetes mellitus: a network meta-analysis. BMJ Open 2016; 6:e009421. [PMID: 26880669 PMCID: PMC4762107 DOI: 10.1136/bmjopen-2015-009421] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 10/27/2015] [Accepted: 12/22/2015] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety of a concentrated formulation of insulin glargine (Gla-300) with other basal insulin therapies in patients with type 2 diabetes mellitus (T2DM). DESIGN This was a network meta-analysis (NMA) of randomised clinical trials of basal insulin therapy in T2DM identified via a systematic literature review of Cochrane library databases, MEDLINE and MEDLINE In-Process, EMBASE and PsycINFO. OUTCOME MEASURES Changes in HbA1c (%) and body weight, and rates of nocturnal and documented symptomatic hypoglycaemia were assessed. RESULTS 41 studies were included; 25 studies comprised the main analysis population: patients on basal insulin-supported oral therapy (BOT). Change in glycated haemoglobin (HbA1c) was comparable between Gla-300 and detemir (difference: -0.08; 95% credible interval (CrI): -0.40 to 0.24), neutral protamine Hagedorn (NPH; 0.01; -0.28 to 0.32), degludec (-0.12; -0.42 to 0.20) and premixed insulin (0.26; -0.04 to 0.58). Change in body weight was comparable between Gla-300 and detemir (0.69; -0.31 to 1.71), NPH (-0.76; -1.75 to 0.21) and degludec (-0.63; -1.63 to 0.35), but significantly lower compared with premixed insulin (-1.83; -2.85 to -0.75). Gla-300 was associated with a significantly lower nocturnal hypoglycaemia rate versus NPH (risk ratio: 0.18; 95% CrI: 0.05 to 0.55) and premixed insulin (0.36; 0.14 to 0.94); no significant differences were noted in Gla-300 versus detemir (0.52; 0.19 to 1.36) and degludec (0.66; 0.28 to 1.50). Differences in documented symptomatic hypoglycaemia rates of Gla-300 versus detemir (0.63; 0.19 to 2.00), NPH (0.66; 0.27 to 1.49) and degludec (0.55; 0.23 to 1.34) were not significant. Extensive sensitivity analyses supported the robustness of these findings. CONCLUSIONS NMA comparisons are useful in the absence of direct randomised controlled data. This NMA suggests that Gla-300 is also associated with a significantly lower risk of nocturnal hypoglycaemia compared with NPH and premixed insulin, with glycaemic control comparable to available basal insulin comparators.
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Affiliation(s)
- Nick Freemantle
- Department of Primary Care and Population Health, University College London, London, UK
| | - Engels Chou
- Global Evidence & Value Development/Health Economics & Outcomes Research, Sanofi, Bridgewater, New Jersey, USA
| | | | - Daisy Zhuo
- Analysis Group, AG, Boston, Massachusetts, USA
| | - Walter Lehmacher
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | | | - Hongwei Wang
- Global Evidence & Value Development/Health Economics & Outcomes Research, Sanofi, Bridgewater, New Jersey, USA
| | - Hsing-wen Chung
- TechData Service Company, LLC, King of Prussia, Pennsylvania, USA
| | - Quanwu Zhang
- Global Evidence & Value Development/Health Economics & Outcomes Research, Sanofi, Bridgewater, New Jersey, USA
| | - Eric Wu
- Analysis Group, AG, Boston, Massachusetts, USA
| | - Charles Gerrits
- Global Evidence & Value Development/Health Economics & Outcomes Research, Sanofi, Bridgewater, New Jersey, USA
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Røder ME. PEGylated insulin Lispro (LY2605541): clinical overview of a new long-acting basal insulin analog in the treatment of Type 2 diabetes mellitus. Expert Rev Endocrinol Metab 2015; 10:365-374. [PMID: 30293492 DOI: 10.1586/17446651.2015.1043270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Neutral Protamine Hagedorn insulin with an intermediate action profile has been in use for many years for the treatment of Type 1 diabetes and as an option for Type 2 diabetes. It is efficacious in reducing blood sugars, but shows substantial variability and risk of hypoglycemia. Basal insulin analogs have been developed in recent years to overcome these issues. Three basal insulin analogs are currently in the market in Europe. PEGylated insulin lispro is a new second-generation basal insulin analog which most likely will undergo review in 2016 by the US FDA and EMA in Europe for possible approval for marketing. Phase III trials are finalized, but not yet published. Phase II studies suggest antiglycemic efficacy, possible with a preferential hepato-specific action, a low rate of hypoglycemia, minor weight loss and acceptable tolerability. The benefit-risk profile needs, however, to be established.
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Affiliation(s)
- Michael E Røder
- a Center for Diabetes Research, Department of Medicine F, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
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Thurston MM, Galdo JA, Bourg CA. Clinical considerations for insulin pharmacotherapy in ambulatory care, part two: review of primary literature and an evidence-based approach for treatment. Clin Diabetes 2015; 33:20-7. [PMID: 25653469 PMCID: PMC4299748 DOI: 10.2337/diaclin.33.1.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
IN BRIEF This article reinforces the dosing guidance from the package inserts of available insulin products and supplemental information provided by the manufacturers of insulin products. It reviews and evaluates pertinent primary literature detailing algorithms for the initiation and titration of insulin therapy that have helped to shape current clinical practice guidelines. The article discusses the clinical applicability of the evidence on insulin pharmacotherapy and offers recommendations for initiation and titration of various insulin products for insulin-requiring people with type 2 diabetes in the ambulatory care setting.
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Affiliation(s)
| | - John A Galdo
- Barney's Pharmacy, Augusta, GA ; Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA
| | - Catherine A Bourg
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA
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Thuillier P, Alavi Z, Kerlan V. Long-term safety and efficacy of insulin degludec in the management of type 2 diabetes. Diabetes Metab Syndr Obes 2015; 8:483-93. [PMID: 26457056 PMCID: PMC4598200 DOI: 10.2147/dmso.s54953] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Insulin degludec (IDeg) is a novel antiglycemic agent belonging to the therapeutic class of ultra-long duration basal insulin analogs. Its half-life and duration of action are 25 hours and 42 hours, respectively. This pharmacodynamic profile leads to a strict dosing schedule, ie, IDeg is injected at the same time each day to ensure optimal biological action and consistent glycemic control. According to the literature, IDeg provides glycemic control and nocturnal hypoglycemia reduction comparable with other long-acting analogs in type 2 diabetes mellitus. The risk of severe hypoglycemic episodes seems also to be reduced when using IDeg therapy; however, long-term follow-up is warranted for monitoring of possible but relatively infrequent adverse events. IDeg is also available in combination with aspart insulin and with liraglutide. The above preparations have been approved by the European Medicines Agency and other national health authorities. In 2012, the US Food and Drug Administration asked for a complementary study on IDeg-associated cardiovascular risk. Future prospective evaluation of large cohorts of patients with type 2 diabetes mellitus treated with IDeg, with long-term follow-up, can provide further relevant information on the safety of IDeg therapy.
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Affiliation(s)
- Philippe Thuillier
- Department of Endocrinology, Diabetology and Metabolic Diseases, Medical University Hospital of Brest La Cavale Blanche, Brest, France
- Correspondence: Philippe Thuillier, Department of Endocrinology, Diabetology and Metabolic Diseases, University Hospital Center of BREST La Cavale Blanche, Boulevard Tanguy Prigent, 29609 Brest Cedex, France, Tel +33 2983 47119, Fax +33 29834 7800, Email
| | - Zarrin Alavi
- French Institute of Health and Medical Research CIC 1412, Medical University Hospital of Brest La Cavale Blanche, Brest, France
| | - Véronique Kerlan
- Department of Endocrinology, Diabetology and Metabolic Diseases, Medical University Hospital of Brest La Cavale Blanche, Brest, France
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Abstract
The currently available basal insulin does not completely mimic the endogenous insulin secretion. This has continued to promote the search for ideal basal insulin. The newer basal insulin have primarily focused on increasing the duration of action, reducing variability, and reducing the incidence of hypoglycemia, particularly nocturnal. However, the changing criteria of hypoglycemia within a short span of a few years along with the surprising introduction of major cardiac events as another outcome measure has not only clouded the assessment of basal insulin but has also polarized opinion worldwide about the utility of the newer basal insulin. A critical review of both the pre and post FDA analysis of all the basal insulin in this article attempts to clear some of the confusion surrounding the issues of hypoglycemia and glycemic control. This article also discusses all the trials and meta-analysis done on all the current basal insulin available along with their head-to-head comparison with particular attention to glycemic control and hypoglycemic events including severe and nocturnal hypoglycemia. This in-depth analysis hopes to provide a clear interpretation of the various analyses available in literature at this point of time thereby acting as an excellent guide to the readers in choosing the most appropriate basal insulin for their patient.
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Affiliation(s)
- Awadhesh Kumar Singh
- Senior Consultant Endocrinologist, G.D Diabetes Hospital, Kolkata, West Bengal, India
- Sun Valley Diabetes Hospital, Guwahati, Assam, India
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27
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Dardano A, Bianchi C, Del Prato S, Miccoli R. Insulin degludec/insulin aspart combination for the treatment of type 1 and type 2 diabetes. Vasc Health Risk Manag 2014; 10:465-75. [PMID: 25143741 PMCID: PMC4132254 DOI: 10.2147/vhrm.s40097] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Glycemic control remains the major therapeutic objective to prevent or delay the onset and progression of complications related to diabetes mellitus. Insulin therapy represents a cornerstone in the treatment of diabetes and has been used widely for achieving glycemic goals. Nevertheless, a large portion of the population with diabetes does not meet the internationally agreed glycemic targets. Moreover, insulin treatment, especially if intensive, may be associated with emergency room visits and hospitalization due to hypoglycemic events. Therefore, fear of hypoglycemia or hypoglycemic events represents the main barriers to the attainment of glycemic targets. The burden associated with multiple daily injections also remains a significant obstacle to initiating and maintaining insulin therapy. The most attractive insulin treatment approach should meet the patients’ preference, rather than demanding patients to change or adapt their lifestyle. Insulin degludec/insulin aspart (IDegAsp) is a new combination, formulated with ultra-long-acting insulin degludec and rapid-acting insulin aspart, with peculiar pharmacological features, clinical efficacy, safety, and tolerability. IDegAsp provides similar, noninferior glycemic control to a standard basal–bolus regimen in patients with type 1 diabetes mellitus, with additional benefits of significantly lower episodes of hypoglycemia (particularly nocturnal) and fewer daily insulin injections. Moreover, although treatment strategy and patients’ viewpoint are different in type 1 and type 2 diabetes, trial results suggest that IDegAsp may be an appropriate and reasonable option for initiating insulin therapy in patients with type 2 diabetes inadequately controlled on maximal doses of conventional oral agents. This paper will discuss the role of IDegAsp combination as a novel treatment option in diabetic patients.
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Affiliation(s)
- Angela Dardano
- Department of Clinical and Experimental Medicine, Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
| | - Cristina Bianchi
- Department of Clinical and Experimental Medicine, Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
| | - Roberto Miccoli
- Department of Clinical and Experimental Medicine, Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
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Aye MM, Atkin SL. Patient safety and minimizing risk with insulin administration - role of insulin degludec. DRUG HEALTHCARE AND PATIENT SAFETY 2014; 6:55-67. [PMID: 24812526 PMCID: PMC4010638 DOI: 10.2147/dhps.s59566] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetes is a lifelong condition requiring ongoing medical care and patient self-management. Exogenous insulin therapy is essential in type 1 diabetes and becomes a necessity in patients with longstanding type 2 diabetes who fail to achieve optimal control with lifestyle modification, oral agents, and glucagon-like peptide 1-based therapy. One of the risks that hinders insulin use is hypoglycemia. Optimal insulin therapy should therefore minimize the risk of hypoglycemia while improving glycemic control. Insulin degludec (IDeg) is a novel basal insulin that, following subcutaneous injection, assembles into a depot of soluble multihexamer chains. These subsequently release IDeg monomers that are absorbed at a slow and steady rate into the circulation, with the terminal half-life of IDeg being ~25 hours. Thus, it requires only once-daily dosing unlike other basal insulin preparations that often require twice-daily dosing. Despite its long half-life, once-daily IDeg does not cause accumulation of insulin in the circulation after reaching steady state. IDeg once a day will produce a steady-state profile with a lower peak:trough ratio than other basal insulins. In clinical trials, this profile translates into a lower frequency of nocturnal hypoglycemia compared with insulin glargine, as well as an ability to allow some flexibility in dose timing without compromising efficacy and safety. Indeed, a study that tested the extremes of dosing intervals of 8 and 40 hours showed no detriment in either glycemic control or hypoglycemic frequency versus insulin glargine given at the same time each day. While extreme flexibility in dose timing is not recommended, these findings are reassuring. This may be particularly beneficial to elderly patients, patients with learning difficulties, or others who have to rely on health-care professionals for their daily insulin injections. Further studies are required to confirm whether this might benefit adherence to treatment, reduce long-term hypoglycemia or reduce diabetes-related complications.
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Affiliation(s)
- Myint M Aye
- Hull Royal Infirmary, Michael White Diabetes Centre, Hull, UK
| | - Stephen L Atkin
- Weill Cornell Medical College Qatar, Qatar Foundation, Doha, Qatar
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Maiorino MI, Petrizzo M, Capuano A, Giugliano D, Esposito K. The development of new basal insulins: is there any clinical advantage with their use in type 2 diabetes? Expert Opin Biol Ther 2014; 14:799-808. [PMID: 24673155 DOI: 10.1517/14712598.2014.895812] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The basal insulin products currently on market do not optimally mimic endogenous insulin secretion. These unmet clinical needs have fueled the development of new basal insulin analogues for improving their pharmacokinetics/pharmacodynamics profile. AREAS COVERED We review the recent literature investigating the efficacy and safety of new basal insulin analogues in type 2 diabetes, as in the USA, insulin utilization accounted for 26% of treatment visits for these patients in 2012. Insulin degludec is a desB30 insulin acylated at the LysB29 residue with a glutamate linker and 16-carbon fatty diacyl side chain. Insulin lispro has been PEGylated at lysine B28, via a urethane bond, which increases the hydrodynamic size of the molecule and reduces its absorption and clearance following subcutaneous administration. Glargine U300 represents a new high-strength glargine formulation (300 U/ml): once injected, U300 forms a compact subcutaneous depot with a smaller surface area to produce a more gradual and prolonged release. Both PEG-lispro and glargine U300 are not yet on the market. EXPERT OPINION Ultra-long acting and high-strength formulations of new basal analogues have the potential for less glycemic variability, less (nocturnal) hypoglycemia and weight-loss advantage for PEG-lispro. However, these new basal insulin analogues need to be monitored closely for adverse signals.
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Affiliation(s)
- Maria Ida Maiorino
- Second University of Naples, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging , Naples , Italy
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30
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Owens DR, Matfin G, Monnier L. Basal insulin analogues in the management of diabetes mellitus: What progress have we made? Diabetes Metab Res Rev 2014; 30:104-19. [PMID: 24026961 DOI: 10.1002/dmrr.2469] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 08/15/2013] [Accepted: 09/08/2013] [Indexed: 02/06/2023]
Abstract
Insulin remains the most effective and consistent means of controlling blood glucose levels in diabetes. Since 1946, neutral protamine Hagedorn (NPH) has been the predominant basal insulin in clinical use. However, absorption is variable due to the need for resuspension and the time-action profile (peak activity 4-6 h after subcutaneous administration) confers an increased propensity for between-meal and nocturnal hypoglycaemia. In the 1980s, recombinant DNA technology enabled modifications to the insulin molecule resulting in the soluble long-acting insulin analogues, glargine and detemir. Both exhibit a lower risk of hypoglycaemia compared with neutral protamine Hagedorn due to improved time-action profiles and reduced day-to-day glucose variability. Glargine is indicated for administration once daily and detemir once or twice daily. Degludec is the latest prolonged-acting insulin which forms long subcutaneous multi-hexamers that delay absorption. Recent phase III trials in type 1 and type 2 diabetes show that degludec was non-inferior to comparators (predominantly glargine) with a minimal although inconsistent reduction in overall hypoglycaemia and a small absolute difference in nocturnal hypoglycaemia. Newer developmental agents include LY2605541 and glargine U300. LY2605541 comprises insulin lispro combined with polyethylene glycol, thereby increasing its hydrodynamic size and retarding absorption from the subcutaneous tissue. Glargine U300 is a new formulation of glargine resulting in a flatter and more prolonged time-action profile than its predecessor. This article reviews recent advances in basal insulin analogues, including a critical appraisal of the degludec trials.
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MESH Headings
- Animals
- Chemistry, Pharmaceutical/trends
- Clinical Trials as Topic
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 2/drug therapy
- Drugs, Investigational/adverse effects
- Drugs, Investigational/chemistry
- Drugs, Investigational/therapeutic use
- Humans
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/chemistry
- Hypoglycemic Agents/therapeutic use
- Insulin, Long-Acting/adverse effects
- Insulin, Long-Acting/chemistry
- Insulin, Long-Acting/genetics
- Insulin, Long-Acting/therapeutic use
- Insulin, Regular, Human/analogs & derivatives
- Insulin, Regular, Human/chemistry
- Insulin, Regular, Human/genetics
- Insulin, Regular, Human/therapeutic use
- Recombinant Proteins/adverse effects
- Recombinant Proteins/chemistry
- Recombinant Proteins/therapeutic use
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Affiliation(s)
- David R Owens
- Diabetes Research Group, Swansea University, Swansea, Wales, UK
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