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Pedersen KM, Gradel AKJ, Ludvigsen TP, Christoffersen BØ, Fuglsang-Damgaard CA, Bendtsen KM, Madsen SH, Manfé V, Refsgaard HHF. Optimization of pig models for translation of subcutaneous pharmacokinetics of therapeutic proteins: Liraglutide, insulin aspart and insulin detemir. Transl Res 2022; 239:71-84. [PMID: 34428585 DOI: 10.1016/j.trsl.2021.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/16/2021] [Accepted: 08/17/2021] [Indexed: 11/19/2022]
Abstract
Prediction of human pharmacokinetics (PK) from data obtained in animal studies is essential in drug development. Here, we present a thorough examination of how to achieve good pharmacokinetic data from the pig model for translational purposes by using single-species allometric scaling for selected therapeutic proteins: liraglutide, insulin aspart and insulin detemir. The predictions were based on non-compartmental analysis of intravenous and subcutaneous PK data obtained from two injection regions (neck, thigh) in two pig breeds, domestic pig and Göttingen Minipig, that were compared with PK parameters reported in humans. The effects of pig breed, injection site and injection depth (insulin aspart only) on the PK of these proteins were also assessed. Results show that the prediction error for human PK was within two-fold for most PK parameters in both pig breeds. Furthermore, pig breed significantly influenced the plasma half-life and mean absorption time (MAT), both being longer in Göttingen Minipigs compared to domestic pigs (P <0.01). In both breeds, thigh vs neck dosing was associated with a higher dose-normalized maximum plasma concentration and area under the curve as well as shorter MAT and plasma half-life (P <0.01). Finally, more superficial injections resulted in faster absorption, higher Cmax/dose and bioavailability of insulin aspart (P <0.05, 3.0 vs 5.0 mm injection depth). In conclusion, pig breed and injection region affected the PK of liraglutide, insulin aspart and insulin detemir and reliable predictions of human PK were demonstrated when applying single-species allometric scaling with the pig as a pre-clinical animal model.
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Affiliation(s)
| | - Anna Katrina Jógvansdóttir Gradel
- Global Drug Discovery, Novo Nordisk A/S, Novo Nordisk Park 1, DK-2760 Måløv; Department of Veterinary and Animal Sciences, Section for Experimental Animal Models, University of Copenhagen.
| | | | | | | | | | - Suzi Høgh Madsen
- Translational Medicine, Novo Nordisk A/S, Novo Nordisk Park 1, DK-2760 Måløv
| | - Valentina Manfé
- Global Research Technologies, Novo Nordisk A/S, Novo Nordisk Park 1, DK-2760 Måløv
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2
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Porumb M, Griffen C, Hattersley J, Pecchia L. Nocturnal low glucose detection in healthy elderly from one-lead ECG using convolutional denoising autoencoders. Biomed Signal Process Control 2020. [DOI: 10.1016/j.bspc.2020.102054] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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3
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Porumb M, Stranges S, Pescapè A, Pecchia L. Precision Medicine and Artificial Intelligence: A Pilot Study on Deep Learning for Hypoglycemic Events Detection based on ECG. Sci Rep 2020; 10:170. [PMID: 31932608 PMCID: PMC6957484 DOI: 10.1038/s41598-019-56927-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 12/18/2019] [Indexed: 01/21/2023] Open
Abstract
Tracking the fluctuations in blood glucose levels is important for healthy subjects and crucial diabetic patients. Tight glucose monitoring reduces the risk of hypoglycemia, which can result in a series of complications, especially in diabetic patients, such as confusion, irritability, seizure and can even be fatal in specific conditions. Hypoglycemia affects the electrophysiology of the heart. However, due to strong inter-subject heterogeneity, previous studies based on a cohort of subjects failed to deploy electrocardiogram (ECG)-based hypoglycemic detection systems reliably. The current study used personalised medicine approach and Artificial Intelligence (AI) to automatically detect nocturnal hypoglycemia using a few heartbeats of raw ECG signal recorded with non-invasive, wearable devices, in healthy individuals, monitored 24 hours for 14 consecutive days. Additionally, we present a visualisation method enabling clinicians to visualise which part of the ECG signal (e.g., T-wave, ST-interval) is significantly associated with the hypoglycemic event in each subject, overcoming the intelligibility problem of deep-learning methods. These results advance the feasibility of a real-time, non-invasive hypoglycemia alarming system using short excerpts of ECG signal.
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Affiliation(s)
- Mihaela Porumb
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK
| | - Saverio Stranges
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
- Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
- Department of Population Health, Luxembourg Institute of Health, Luxembourg, Luxembourg
| | - Antonio Pescapè
- Department of Electrical Engineering, University of Napoli "Federico II", Naples, Italy
| | - Leandro Pecchia
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK.
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4
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Halama A, Kahal H, Bhagwat AM, Zierer J, Sathyapalan T, Graumann J, Suhre K, Atkin SL. Metabolic and proteomic signatures of hypoglycaemia in type 2 diabetes. Diabetes Obes Metab 2019; 21:909-919. [PMID: 30525282 DOI: 10.1111/dom.13602] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/20/2018] [Accepted: 12/01/2018] [Indexed: 12/31/2022]
Abstract
AIMS To determine the biochemical changes that underlie hypoglycaemia in a healthy control group and in people with type 2 diabetes (T2D). MATERIALS AND METHODS We report a hypoglycaemic clamp study in seven healthy controls and 10 people with T2D. Blood was withdrawn at four time points: at baseline after an overnight fast; after clamping to euglycaemia at 5 mmol/L; after clamping to hypoglycaemia at 2.8 mmol/L; and 24 hours later, after overnight fast. Deep molecular phenotyping using non-targeted metabolomics and the SomaLogic aptamer-based proteomics platform was performed on collected samples. RESULTS A total of 955 metabolites and 1125 proteins were identified, with significant alterations in >90 molecules. A number of metabolites significantly increased during hypoglycaemia, but only cortisol, adenosine-3',5'-cyclic monophosphate (cyclic AMP), and pregnenolone sulphate, were independent of insulin. By contrast, identified protein changes were triggered by hypoglycaemia rather than insulin. The T2D group had significantly higher levels of fatty acids including 10-nonadecenoate, linolenate and dihomo-linoleate during hypoglycaemia compared with the control group. Molecules contributing to cardiovascular complications such as fatty-acid-binding protein-3 and pregnenolone sulphate were altered in the participants with T2D during hypoglycaemia. Almost all molecules returned to baseline at 24 hours. CONCLUSIONS The present study provides a comprehensive description of molecular events that are triggered by insulin-induced hypoglycaemia. We identified deregulated pathways in T2D that may play a role in the pathophysiology of hypoglycaemia-induced cardiovascular complications.
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Affiliation(s)
- Anna Halama
- Department of Physiology and Biophysics, Weill Cornell Medicine Qatar, Education City, Doha, Qatar
| | - Hassan Kahal
- Academic Endocrinology, Diabetes and Metabolism, Hull York Medical School, Hull, UK
| | - Aditya M Bhagwat
- Department of Physiology and Biophysics, Weill Cornell Medicine Qatar, Education City, Doha, Qatar
| | - Jonas Zierer
- Caryl and Israel Englander Institute for Precision Medicine, Institute for Computational Biomedicine, Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine, New York, New York
| | | | - Johannes Graumann
- Proteomics Core, Weill Cornell Medicine-Qatar, Education City, Doha, Qatar
- Scientific Service Group Biomolecular Mass Spectrometry, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany
| | - Karsten Suhre
- Department of Physiology and Biophysics, Weill Cornell Medicine Qatar, Education City, Doha, Qatar
| | - Stephen L Atkin
- Department of Physiology and Biophysics, Weill Cornell Medicine Qatar, Education City, Doha, Qatar
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5
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Kwok R, Sztal-Mazer S, Hopkins RE, Poole SG, Grannell L, Coutsouvelis J, Topliss DJ. Evaluation of NovoRapid infusion as a treatment option in the management of diabetic ketoacidosis. Intern Med J 2018; 47:1317-1320. [PMID: 29105262 DOI: 10.1111/imj.13607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 06/01/2017] [Accepted: 06/04/2017] [Indexed: 12/01/2022]
Abstract
This study evaluates the clinical efficacy and safety of NovoRapid (insulin aspart) compared to Actrapid™ (human neutral insulin) for diabetic ketoacidosis (DKA). In this retrospective study involving 40 patients, no statistically significant differences were observed between biochemical variables, infusion duration or complications in patients treated with insulin aspart or human neutral insulin. These results support the use of insulin aspart as an effective and safe alternative to human neutral insulin in DKA.
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Affiliation(s)
- Raylene Kwok
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Shoshana Sztal-Mazer
- Department of Endocrinology and Diabetes, Alfred Health, Melbourne, Victoria, Australia
| | - Ria E Hopkins
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Susan G Poole
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Louise Grannell
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - John Coutsouvelis
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Duncan J Topliss
- Department of Endocrinology and Diabetes, Alfred Health, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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6
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A molecular pathway analysis informs the genetic risk for arrhythmias during antipsychotic treatment. Int Clin Psychopharmacol 2018; 33:1-14. [PMID: 29064910 DOI: 10.1097/yic.0000000000000198] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Arrhythmias are a frequent and potentially fatal side effect of antipsychotic treatment. Strict ECG monitoring and clinical interviews are the standards used to prevent arrhythmias. A biologic predictive tool is missing. The identification of a genetic makeup at risk of antipsychotic-induced arrhythmias is the aim of the present investigation. The aim of this study was to identify a molecular pathway enriched in single nucleotide polymorphisms associated with antipsychotic-induced QTc modifications. In total, 661 schizophrenic individuals from the CATIE study, M=486 (73.52%), mean age=40.92±11.02, were included. QTc variation was measured as a phase-specific change-created variable. A nested mixed regression for a repeated-measures model served in R for the analysis of the clinical and treatment-related covariates and molecular pathway analysis. Plink was used for the genetic genome-wide analysis. Quality checking was the standard (genotype call rate>0.95; minor allele frequency>0.01; Hardy-Weinberg equilibrium<0.0001) and the inflation factor was controlled by λ values. Quetiapine and perphenazine were associated with QTc variation during phase 1. No other significant association was detected. No significant inflation was detected. A number of molecular pathways were associated with QT variation at a conservative (adjusted) P value less than 0.05, including pathways related to neuronal wiring and collagen biosynthesis, along with pathways related to K+ currents and cardiac contraction. Pathways related to neuronal wiring, collagen biosynthesis, and ion currents were identified as possibly involved in QTc modifications during antispsychotic treatment in SKZ patients.
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Ling SH, San PP, Nguyen HT. Non-invasive hypoglycemia monitoring system using extreme learning machine for Type 1 diabetes. ISA TRANSACTIONS 2016; 64:440-446. [PMID: 27311357 DOI: 10.1016/j.isatra.2016.05.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/20/2016] [Accepted: 05/12/2016] [Indexed: 06/06/2023]
Abstract
Hypoglycemia is a very common in type 1 diabetic persons and can occur at any age. It is always threatening to the well-being of patients with Type 1 diabetes mellitus (T1DM) since hypoglycemia leads to seizures or loss of consciousness and the possible development of permanent brain dysfunction under certain circumstances. Because of that, an accurate continuing hypoglycemia monitoring system is a very important medical device for diabetic patients. In this paper, we proposed a non-invasive hypoglycemia monitoring system using the physiological parameters of electrocardiography (ECG) signal. To enhance the detection accuracy, extreme learning machine (ELM) is developed to recognize the presence of hypoglycemia. A clinical study of 16 children with T1DM is given to illustrate the good performance of ELM.
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Affiliation(s)
- Sai Ho Ling
- Centre for Health Technologies, Faculty of Engineering and IT, University of Technology Sydney, Ultimo, NSW, Australia.
| | - Phyo Phyo San
- Institute for Infocomm Research, A(⁎) Star, Singapore
| | - Hung T Nguyen
- Centre for Health Technologies, Faculty of Engineering and IT, University of Technology Sydney, Ultimo, NSW, Australia
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8
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Yang SW, Park KH, Zhou YJ. The Impact of Hypoglycemia on the Cardiovascular System: Physiology and Pathophysiology. Angiology 2015; 67:802-9. [PMID: 26685181 DOI: 10.1177/0003319715623400] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Intensive glycemic control may increase cardiovascular (CV) risk and mortality due to hypoglycemia. The pathophysiology of glucose counter-regulation in patients with type 1 or type 2 diabetes for over 15 years is characterized by impairment of the defense mechanisms against hypoglycemia. Hypoglycemia causes pronounced physiological and pathophysiological effects on the CV system as consequences of autonomic system activation and counter regulatory hormones release. These effects provoke a series of hemodynamic changes that include an increase in heart rate and peripheral systolic blood pressure, a decrease in central blood pressure, reduced peripheral arterial resistance, and increased myocardial contractility and cardiac output. Cardiac electrophysiological changes including flattening or inversion of T waves, QT prolongation, and ST segment depression were observed in both insulin-induced and spontaneous hypoglycemia. Sympathoadrenal activation is the main cause of these changes through mechanisms that involve, but are not limited to, catecholamine-mediated hypokalemia. Hypoglycemia is also involved in platelet activation. There is growing concern about the long-term effects of hypoglycemia, especially as related to inflammation and atherogenesis.
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Affiliation(s)
- Shi-Wei Yang
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Beijing, China
| | - Kyoung-Ha Park
- Division of Cardiology, Department of Internal Medicine, Hallym University Medical Center, Anyang, Korea
| | - Yu-Jie Zhou
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Beijing, China
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9
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Heller S, Darpö B, Mitchell MI, Linnebjerg H, Leishman DJ, Mehrotra N, Zhu H, Koerner J, Fiszman ML, Balakrishnan S, Xiao S, Todaro TG, Hensley I, Guth BD, Michelson EL, Sager P. Considerations for assessing the potential effects of antidiabetes drugs on cardiac ventricular repolarization: A report from the Cardiac Safety Research Consortium. Am Heart J 2015; 170:23-35. [PMID: 26093861 DOI: 10.1016/j.ahj.2015.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
Abstract
Thorough QT studies conducted according to the International Council on Harmonisation E14 guideline are required for new nonantiarrhythmic drugs to assess the potential to prolong ventricular repolarization. Special considerations may be needed for conducting such studies with antidiabetes drugs as changes in blood glucose and other physiologic parameters affected by antidiabetes drugs may prolong the QT interval and thus confound QT/corrected QT assessments. This review discusses potential mechanisms for QT/corrected QT interval prolongation with antidiabetes drugs and offers practical considerations for assessing antidiabetes drugs in thorough QT studies. This article represents collaborative discussions among key stakeholders from academia, industry, and regulatory agencies participating in the Cardiac Safety Research Consortium. It does not represent regulatory policy.
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10
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Chawla M, Malve H, Shah H, Shinde S, Bhoraskar A. Safety of intravenous insulin aspart compared to regular human insulin in patients undergoing ICU monitoring post cardiac surgery: an Indian experience. J Diabetes Metab Disord 2015; 14:20. [PMID: 25874191 PMCID: PMC4396566 DOI: 10.1186/s40200-015-0152-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 03/19/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Poor perioperative glycemic control increases risk of infection, cardiovascular accidents and mortality in patients undergoing surgery. Tight glycemic control by insulin therapy is known to yield better outcomes in such patients. Intravenous (IV) insulin therapy with or without adjunctive subcutaneous insulin therapy is the mainstay of managing hyperglycemia in perioperative period. This observational study assessed the safety of IV Insulin Aspart (IAsp) as compared to Regular Human Insulin (RHI) in patients undergone cardiac surgery at a tertiary care hospital. METHODS 203 patients received IV IAsp (n = 103) and RHI (n = 100) respectively. Safety was assessed by frequency and severity of adverse events (AEs) & serious adverse events (SAEs) during hospitalization. RESULTS IAsp effectively controlled mean blood glucose levels to 159.87 ± 41.41 mg/dl similar to RHI (160.77 ± 44.39 mg/dl). No serious adverse event was reported. The incidence of hypoglycemia was similar in both the groups. The insulin infusion rate, time for which insulin infusion was withheld and mean blood glucose during hypoglycemia was significantly high in RHI group. CONCLUSION This study has shown similar safety of IV IAsp as compared to IV RHI in the post cardiac surgery patients. However physicians preferred IAsp as it offers advantage during transition. IV IAsp offers an effective and safe option for managing hyperglycemia in patients in ICU post cardiac procedures.
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Affiliation(s)
- Manoj Chawla
- />Department of Diabetology, Asian Heart Institute, G/N Block, Bandra Kurla Complex, Bandra East, Mumbai, Maharashtra 400051 India
| | - Harshad Malve
- />Lead Medical for Asia Pacific region, Ferring Pharmaceuticals, 24th Floor, Sunshine Towers, Senapati Bapat Marg, Elphinstone (West), Mumbai, 400013 India
| | - Harshvi Shah
- />Department of Diabetology, Asian Heart Institute, G/N Block, Bandra Kurla Complex, Bandra East, Mumbai, Maharashtra 400051 India
| | - Shwetal Shinde
- />Department of Diabetology, Asian Heart Institute, G/N Block, Bandra Kurla Complex, Bandra East, Mumbai, Maharashtra 400051 India
| | - Anil Bhoraskar
- />Department of Diabetology, Asian Heart Institute, G/N Block, Bandra Kurla Complex, Bandra East, Mumbai, Maharashtra 400051 India
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11
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Simonyi G. Electrocardiological features in obesity: the benefits of body surface potential mapping. Cardiorenal Med 2014; 4:123-9. [PMID: 25254034 DOI: 10.1159/000365012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 05/27/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Various ECG abnormalities are commonly observed in obesity and in metabolic syndrome. SUMMARY Some of these abnormalities are caused by the pushed-up position of the diaphragm due to obesity and others occur as a result of the complications of the condition. The position of the R wave may change, various arrhythmias may develop or the QT interval may be prolonged, which increases the tendency to malignant arrhythmias. In obesity, the ECG signs of ventricular hypertrophy are less informative due to the accumulation of epicardial and subcutaneous adipose tissue. In general, it can be concluded that a microcirculation disorder is present in metabolic syndrome that may primarily be associated with ST-T wave abnormalities. KEY MESSAGES Body surface potential mapping is a more sensitive method than traditional ECG with potentially greater use for diagnosis mainly in the early phase of non-ST elevation myocardial infarctions.
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Affiliation(s)
- Gábor Simonyi
- Metabolic Center, Szent Imre Teaching Hospital, Budapest, Hungary
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12
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Rasmussen CH, Røge RM, Ma Z, Thomsen M, Thorisdottir RL, Chen JW, Mosekilde E, Colding-Jørgensen M. Insulin aspart pharmacokinetics: an assessment of its variability and underlying mechanisms. Eur J Pharm Sci 2014; 62:65-75. [PMID: 24878388 DOI: 10.1016/j.ejps.2014.05.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 04/18/2014] [Accepted: 05/06/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Insulin aspart (IAsp) is used by many diabetics as a meal-time insulin to control post-prandial glucose levels. As is the case with many other insulin types, the pharmacokinetics (PK), and consequently the pharmacodynamics (PD), is associated with clinical variability, both between and within individuals. The present article identifies the main physiological mechanisms that govern the PK of IAsp following subcutaneous administration and quantifies them in terms of their contribution to the overall variability. MATERIAL AND METHODS CT scanning data from Thomsen et al. (2012) are used to investigate and quantify the properties of the subcutaneous depot. Data from Brange et al. (1990) are used to determine the effects of insulin chemistry in subcutis on the absorption rate. Intravenous (i.v.) bolus and infusion PK data for human insulin are used to understand and quantify the systemic distribution and elimination (Pørksen et al., 1997; Sjöstrand et al., 2002). PK and PD profiles for type 1 diabetics from Chen et al. (2005) are analyzed to demonstrate the effects of IAsp antibodies in terms of bound and unbound insulin. PK profiles from Thorisdottir et al. (2009) and Ma et al. (2012b) are analyzed in the nonlinear mixed effects software Monolix® to determine the presence and effects of the mechanisms described in this article. RESULTS The distribution of IAsp in the subcutaneous depot show an initial dilution of approximately a factor of two in a single experiment. Injected insulin hexamers exist in a chemical equilibrium with monomers and dimers, which depends strongly on the degree of dilution in subcutis, the presence of auxiliary substances, and a variety of other factors. Sensitivity to the initial dilution in subcutis can thus be a cause of some of the variability. Temporal variations in the PK are explained by variations in the subcutaneous blood flow. IAsp antibodies are found to be a large contributor to the variability of total insulin PK in a study by Chen et al. (2005), since only the free fraction is eliminated via the receptors. The contribution of these and other sources of variability to the total variability is quantified via a population PK analysis and two recent clinical studies (Thorisdottir et al., 2009; Ma et al., 2012b), which support the presence and significance of the identified mechanisms. CONCLUSIONS IAsp antibody binding, oligomeric transitions in subcutis, and blood flow dependent variations in absorption rate seem to dominate the PK variability of IAsp. It may be possible via e.g. formulation design to reduce some of these variability factors.
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Affiliation(s)
- Christian Hove Rasmussen
- Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark; Department of Physics, Technical University of Denmark, Fysikvej 309, DK-2800 Kgs. Lyngby, Denmark.
| | - Rikke Meldgaard Røge
- Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark; Department of Pharmaceutical Biosciences, Uppsala University, P.O. Box 591, SE-75124 Uppsala, Sweden
| | - Zhulin Ma
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Nørrebrogade 44, DK-8000 Aarhus C, Denmark
| | - Maria Thomsen
- Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark; Niels Bohr Institute, University of Copenhagen, Universitetsparken 5, DK-2100 Copenhagen, Denmark
| | | | - Jian-Wen Chen
- Novo Nordisk International Operations A/S, Thurgauerstrasse 36/38, CH-8050 Zürich, Switzerland
| | - Erik Mosekilde
- Department of Physics, Technical University of Denmark, Fysikvej 309, DK-2800 Kgs. Lyngby, Denmark
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13
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Affiliation(s)
- Natalia Yakubovich
- McMaster University Department of Medicine, Hamilton, Ontario L8N 3Z5, Canada.
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14
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Ihlo CA, Lauritzen T, Sturis J, Skyggebjerg O, Christiansen JS, Laursen T. Explorative study of pharmacokinetics and pharmacodynamics after change in basal insulin infusion rate. J Diabetes Sci Technol 2011; 5:120-8. [PMID: 21303634 PMCID: PMC3045247 DOI: 10.1177/193229681100500117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of insulin pumps is rapidly increasing and new, technologically more advanced pumps are continuously being developed. It is of interest to assess the clinical relevance of the many technical features of these pumps, e.g., the effect on pharmacokinetics and pharmacodynamics with change in infusion rate. METHOD The aim of this study was to explore the sequence of pharmacokinetic and pharmacodynamic changes after dose doubling of the basal insulin infusion rate with subcutaneous bolus insulin injections once an hour, continuous subcutaneous insulin infusion, and continuous intravenous insulin infusion. Ten type 1 diabetes mellitus patients were included. The insulin doses were calculated based on the habitual insulin doses. The study was designed as an open-labeled, single-center, randomized, crossover exploratory trial. RESULTS Dose doubling of the basal insulin infusion rate with the three different administration protocols did not result in any clinically relevant differences in the time courses of the pharmacokinetic and pharmacodynamic parameters. With all three administration protocols, we observed a time interval of more than 6 hours before a new steady state of insulin was achieved. CONCLUSIONS Our results indicate that frequent changes in basal subcutaneous insulin infusion rates are not of significant clinical relevance on a 24-hour basis. Regarding technological features of subcutaneous insulin pumps, no discernable advantages of increasing pump stroke frequency were found. This indicates that pump stroke frequency sophistication might not be of clinical relevance in pumps used for basal subcutaneous insulin infusion.
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Affiliation(s)
- Charlotte A Ihlo
- Department of Endocrinology M, Aarhus University Hospital, Aarhus C, Denmark.
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15
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Christensen TF, Randløv J, Kristensen LE, Eldrup E, Hejlesen OK, Struijk JJ. QT Measurement and Heart Rate Correction during Hypoglycemia: Is There a Bias? Cardiol Res Pract 2010; 2010:961290. [PMID: 21234404 PMCID: PMC3014697 DOI: 10.4061/2010/961290] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 08/20/2010] [Accepted: 11/25/2010] [Indexed: 01/08/2023] Open
Abstract
Introduction. Several studies show that hypoglycemia causes QT interval prolongation. The aim of this study was to investigate the effect of QT measurement methodology, heart rate correction, and insulin types during hypoglycemia. Methods. Ten adult subjects with type 1 diabetes had hypoglycemia induced by intravenous injection of two insulin types in a cross-over design. QT measurements were done using the slope-intersect (SI) and manual annotation (MA) methods. Heart rate correction was done using Bazett's (QTcB) and Fridericia's (QTcF) formulas. Results. The SI method showed significant prolongation at hypoglycemia for QTcB (42(6) ms; P < .001) and QTcF (35(6) ms; P < .001). The MA method showed prolongation at hypoglycemia for QTcB (7(2) ms, P < .05) but not QTcF. No difference in ECG variables between the types of insulin was observed. Discussion. The method for measuring the QT interval has a significant impact on the prolongation of QT during hypoglycemia. Heart rate correction may also influence the QT during hypoglycemia while the type of insulin is insignificant. Prolongation of QTc in this study did not reach pathologic values suggesting that QTc prolongation cannot fully explain the dead-in-bed syndrome.
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Nagashima M, Higaki T, Seike Y, Yokoyama Y. Cardiac Surgery for a Patient With Andersen-Tawil Syndrome. Ann Thorac Surg 2010; 90:285-7. [DOI: 10.1016/j.athoracsur.2009.12.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Revised: 12/09/2009] [Accepted: 12/15/2009] [Indexed: 11/24/2022]
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17
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Petersen SB, Kildegaard J, Nielsen FS, Søndergaard E, Parkner T, Laursen T, Lauritzen T, Skyggebjerg O, Christiansen JS. Pharmacokinetics following continuous subcutaneous insulin infusion of insulin aspart with or without initial subcutaneous bolus. Diabetes Obes Metab 2010; 12:334-40. [PMID: 20380654 DOI: 10.1111/j.1463-1326.2009.01168.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To evaluate time to steady state insulin concentration (C(ss)) following continuous subcutaneous insulin infusion (CSII) of insulin aspart (IAsp) with or without an initial s.c. bolus. METHODS In random order 10 healthy volunteers were given a basal insulin infusion rate (0.5 U/h) for 8 h with or without an initial s.c. bolus (1.4 U). Serum IAsp was measured until 3 h after infusion was stopped. RESULTS An overshoot of IAsp was seen before C(ss) was achieved following an initial bolus of insulin as compared to no bolus. The apparent half-life (t((1/2))) with or without bolus did not differ (p = 0.15). Time to steady state (T(ss)) was evaluated in two ways: (1) T(ss) defined as the first point within an interval of C(ss)+/- 2 x CV was 233 vs. 166 min with and without a bolus respectively (p = 0.068). (2) A t-test was performed for each concentration-time point vs. mean C(ss), and the first point with no significance was defined, T(ss). This gave 208 (p = 0.09) and 178 min (p = 0.24) with and without bolus respectively. Mathematical modelling suggests that an ideal mean bolus should be 0.89 U, and that this bolus dose may result in a shorter T(ss). CONCLUSION A bolus of 1.4 U resulted in an overshoot of serum IAsp before C(ss) and a longer period before C(ss) is achieved. Mathematical modelling suggests that a mean bolus of 0.89 U would result in a faster achievement of C(ss) compared to no bolus.
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Affiliation(s)
- S B Petersen
- Novo Nordisk A/S, Diabetes Research Unit, 2760 Maaloev, Denmark
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18
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Abstract
Hypoglycemia is a common and serious problem among patients with diabetes mellitus. It is also perceived as the most important obstacle to tight glucose control using intensive insulin therapy in critically ill patients. Because glucose is an obligatory metabolic fuel for the brain, hypoglycemia always represents an emergency that signals the inability of the brain to meet its energy needs. When left untreated, hypoglycemia can result in permanent brain damage and ultimately, death. In the context of critical illness that limits endogenous glucose production and increases glucose utilization, inadequate nutrition, or insufficient provision of glucose, intensive insulin therapy is the most frequent cause of hypoglycemia. Neurogenic and neuroglycopenic symptoms of hypoglycemia can remain unknown because of the underlying critical illness and sedation. Thus, close and reliable monitoring of the glycemic level is crucial in detecting hypoglycemia. In prospective randomized controlled studies comparing the effects of two glucose regimens, intensive insulin therapy aimed to reach strict glucose control (<110 mg/dl) but increased the incidence of severe hypoglycemia (<40 mg/dl) by four- to sixfold. Severe hypoglycemia is statistically associated with adverse outcomes in intensive care unit patients, although a direct causal relationship has not been demonstrated.
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Affiliation(s)
- J-C Lachérade
- Service de réanimation polyvalente, centre hospitalier de Poissy, 10, rue du Champ-Gaillard, 78300 Poissy, France.
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Koivikko ML, Karsikas M, Salmela PI, Tapanainen JS, Ruokonen A, Seppänen T, Huikuri HV, Perkiömäki JS. Effects of controlled hypoglycaemia on cardiac repolarisation in patients with type 1 diabetes. Diabetologia 2008; 51:426-35. [PMID: 18097646 DOI: 10.1007/s00125-007-0902-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Accepted: 10/31/2007] [Indexed: 10/22/2022]
Abstract
AIMS/HYPOTHESIS Nocturnal hypoglycaemia may contribute to sudden death in diabetic patients. However, it is not well known why hypoglycaemia makes these patients prone to death. METHODS We assessed the effects of controlled hypoglycaemia on cardiac repolarisation using novel electrocardiographic descriptors of T-wave and QRS complex morphology in 16 type 1 diabetic patients and eight healthy counterparts. Several electrocardiographic variables characterising repolarisation were analysed from digitised 12-lead electrocardiograms during a euglycaemic and a hypoglycaemic clamp. RESULTS Hypoglycaemia did not result in significant changes either in the QT interval corrected for heart rate by the nomogram method or in QT dispersion. However, the morphology of the T-wave changed significantly during hypoglycaemia. The T-wave amplitude and area in precordial leads decreased significantly in both groups (p<0.05 to p<0.001). The spatial QRS-T angle (total cosine R to T) (p<0.05) and the height and the width of the T-wave loop (p<0.05 and p<0.01, respectively) were also reduced in the diabetic patients. The changes in the repolarisation parameters did not exhibit any significant association with changes in catecholamine levels or in heart rate variability in either group. CONCLUSIONS/INTERPRETATION Hypoglycaemia results in distinct alterations in cardiac repolarisation, which may increase the vulnerability to arrhythmic events.
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Affiliation(s)
- M L Koivikko
- Department of Internal Medicine, University of Oulu, P.O. Box 5000, (Kajaanintie 50), 90014 Oulu, Finland
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21
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Christiansen JS. Insulin aspart: rapid control for postmeal glucose excursions. Expert Rev Endocrinol Metab 2007; 2:587-597. [PMID: 30736121 DOI: 10.1586/17446651.2.5.587] [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] [Indexed: 11/08/2022]
Abstract
Insulin aspart is a rapid-acting insulin analog that can be used to control prandial glucose levels as part of basal-bolus therapy, in continuous subcutaneous insulin infusion or in combination with oral antidiabetic drugs. Compared with exogenous human soluble insulin, insulin aspart has a faster onset of action, a higher peak concentration and a shorter duration of action, and is therefore more comparable to the physiological prandial insulin response. Randomized clinical trials have shown efficacy and safety advantages with insulin aspart over human soluble insulin, in particular, improved postprandial glucose control and lower rates of hypoglycemia. Currently, insulin aspart has been approved for use not only in adults and children with diabetes mellitus, but also for pregnant women with diabetes, including those with gestational diabetes.
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Affiliation(s)
- Jens Sandahl Christiansen
- a Professor of Medicine, Department of Endocrinology M, Aarhus University Hospital, Kommunehospitalet, DK 8000 Aarhus C, Denmark.
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22
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Clausen WHO, De Gaetano A, Vølund A. Within-patient variation of the pharmacokinetics of subcutaneously injected biphasic insulin aspart as assessed by compartmental modelling. Diabetologia 2006; 49:2030-8. [PMID: 16865361 DOI: 10.1007/s00125-006-0327-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Accepted: 04/04/2006] [Indexed: 11/25/2022]
Abstract
AIMS/HYPOTHESIS Pharmacokinetics of s.c. administered insulin preparations have been widely studied, mostly using descriptive measures such as AUC, time to peak, or the peak plasma concentration. Several compartmental modelling studies of single-bolus s.c. insulin pharmacokinetics have also appeared, with contrasting results regarding the feasibility of insulin pharmacokinetics modelling and the appropriate level of detail for such models. In this paper, we used compartmental models to study the pharmacokinetics of biphasic insulin aspart administered by multiple s.c. injections. The main objective was to assess the magnitude of the inter-and intra-subject variation in the kinetics. MATERIALS AND METHODS Analyses were performed on 24-h serum insulin concentrations measured in 20 type 1 diabetes subjects given three daily s.c. injections of biphasic insulin aspart. RESULTS Preliminary analysis of the AUC:dose ratio showed that the apparent kinetics are not constant throughout the three daily injections of the compound. A simple and robust compartmental model was shown to be appropriate for interpreting the observations, provided that one of its parameters (the first-order rate constant for transfer from the s.c. depot to plasma) is allowed to vary between injections. CONCLUSIONS/INTERPRETATION Population estimates of the chosen model show that intra-subject variations between injections is of the same order of magnitude as inter-subject variation, partially explaining the difficulties encountered when individually tailoring intensified insulin therapy. We conclude that the explicit consideration of a rather simple kinetic model will allow better experimental designs in the future study of s.c. insulin preparations.
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Affiliation(s)
- W H O Clausen
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark.
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23
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Abstract
The analogue insulins were developed to more clearly mimic the basal and prandial components of insulin secretion for subjects with diabetes mellitus. Analogues are now widely used and have largely taken over from the conventional human recombinant insulins. It is important that these insulins are not only as effective as their predecessors, but are also safe and well-tolerated. In this manuscript, the authors review the adverse effects reported with analogue insulins and make a comparison with standard insulin treatments.
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Affiliation(s)
- Ali D Kamal
- University of Birmingham, Undergraduate Centre, Birmingham Heartlands & Solihull NHS Trust, Birmingham & Division of Medical Sciences, UK
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Robinson RTCE, Harris ND, Ireland RH, Macdonald IA, Heller SR. Changes in cardiac repolarization during clinical episodes of nocturnal hypoglycaemia in adults with Type 1 diabetes. Diabetologia 2004; 47:312-5. [PMID: 14712347 DOI: 10.1007/s00125-003-1292-4] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2003] [Revised: 10/09/2003] [Indexed: 12/24/2022]
Abstract
AIMS/HYPOTHESIS Experimental hypoglycaemia leads to abnormal cardiac repolarization manifest by a lengthened QT interval and caused by adrenergic stimulation. However it is less clear whether spontaneous clinical episodes lead to similar changes. We have therefore measured cardiac ventricular repolarization and counterregulatory responses in patients with Type 1 diabetes during hypoglycaemic and euglycaemic nights. METHODS We studied 22 patients with Type 1 diabetes (mean age 40.4+/-17.2 years, duration of diabetes 17.2+/-9.3 years, HbA1c 8.2+/-1.2% overnight). Measurements were taken hourly of blood glucose, plasma potassium, catecholamines and high resolution electrocardiograms. RESULTS Hypoglycaemia (blood glucose level <2.5 mmol/l) occurred on 7 of the 22 nights. During overnight hypoglycaemia, QTc interval increased by 27 ms (+/-15) above baseline, compared with 9 ms (+/-19) during nights with no nocturnal hypoglycaemia (p=0.034, 95%CI 2, 35). Adrenaline increased by 0.33 nmol/l (+/-0.21) above baseline during hypoglycaemia, compared with -0.05 nmol/l (+/-0.08) during euglycaemia (p=0.001, 95%CI 0.19, 0.56 nmol/l). There was no significant difference between potassium, and noradrenaline concentrations between the two groups. CONCLUSION/INTERPRETATION QTc interval lengthens significantly during spontaneous nocturnal hypoglycaemia. Increases are generally less than those observed during experimental hypoglycaemia and could reflect attenuated sympathoadrenal responses during clinical episodes. The clinical relevance of these changes is uncertain but is consistent with the hypothesis that clinical hypoglycaemia can cause abnormal cardiac repolarization and an attendant risk of cardiac arrhythmia.
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25
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Abstract
Insulin aspart (NovoRapid, NovoLog) is a short-acting insulin analogue, which has a faster onset and shorter duration of action than regular human insulin. Insulin aspart administered immediately before meals provided significantly greater improvements in glycosylated haemoglobin and better postprandial glycaemic control than regular human insulin administered 30 minutes before meals, when used in a basal-bolus regimen with neutral protamine Hagedorn (NPH) insulin, in randomised, nonblind studies in patients with type 1 diabetes mellitus. In patients with type 2 diabetes, insulin aspart provided similar glycaemic control to regular human insulin, administered in a basal-bolus regimen with NPH insulin. Small studies suggest that the use of insulin aspart in combination with oral hypoglycaemic agents may be beneficial. Insulin aspart, administered by continuous subcutaneous insulin infusion (CSII) provided better glycaemic control than insulin aspart multiple daily injection regimens in patients with type 1 (but not type 2) diabetes, and had similar efficacy to CSII with insulin lispro or regular human insulin in type 1 diabetes. Limited studies show insulin aspart to be effective in children, adolescents and young adults with type 1 diabetes. Insulin aspart had a tolerability profile similar to that of regular human insulin in clinical trials. The incidence of major or nocturnal hypoglycaemic events reported in patients receiving insulin aspart was lower than that of regular human insulin in several studies. In conclusion, insulin aspart, administered immediately before meals in a basal-bolus regimen with NPH insulin, provided better long-term glycaemic control than regular human insulin administered 30 minutes before meals in patients with type 1 diabetes, and was as effective as regular human insulin in patients with type 2 diabetes. A significantly lower risk of hypoglycaemia was seen in several trials. Insulin aspart CSII provided better glycaemic control than insulin aspart multiple daily subcutaneous injection (MDI) in patients with type 1 (but not type 2) diabetes and had similar efficacy to CSII with insulin lispro or regular human insulin in type 1 diabetes. Insulin aspart is an effective and well tolerated alternative to regular human insulin and insulin lispro for the maintenance of glycaemic control in patients with type 1 or 2 diabetes.
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26
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Robinson RTCE, Harris ND, Ireland RH, Lee S, Newman C, Heller SR. Mechanisms of abnormal cardiac repolarization during insulin-induced hypoglycemia. Diabetes 2003; 52:1469-74. [PMID: 12765959 DOI: 10.2337/diabetes.52.6.1469] [Citation(s) in RCA: 182] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Prolonged cardiac repolarization causes fatal cardiac arrhythmias. There is evidence that these contribute to sudden death associated with nocturnal hypoglycemia in young people with diabetes. We measured cardiac repolarization (QT interval [QTc] and QT dispersion [QTd]) during experimental hypoglycemia with and without beta-blockade and potassium infusion to establish possible mechanisms. Two groups of 10 nondiabetic men (study 1 and study 2) each underwent four hyperinsulinemic clamps: two euglycemic (5 mmol/l) and two hypoglycemic (5 mmol/l and 2.5 mmol/l for 60 min each). Study 1 was performed with and without potassium infusion to maintain normal concentrations and study 2 with and without beta-blockade (atenolol, 100 mg/day for 7 days). QTd was unchanged during euglycemia but increased during hypoglycemia (55 ms, P < 0.0001 vs. baseline), which was prevented by potassium (6 ms, P = 0.78). QTc increased significantly during hypoglycemia alone (67 ms, P < 0.0001) and during potassium replacement (46 ms, P = 0.02). In study 2, the increase in QTd during hypoglycemia (68 ms, P < 0.0001) was prevented by beta-blockade (3 ms, P = 0.88). The increase in QTc during hypoglycemia (55 ms, P < 0.0001) was prevented by beta-blockade (1 ms, P = 0.98). Our data indicate that hypoglycemia causes an acquired long QT syndrome. Sympathoadrenal stimulation is the main cause, through mechanisms that involve but are not limited to catecholamine-mediated hypokalemia. These abnormalities are prevented by selective beta-blockade.
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Affiliation(s)
- Robert T C E Robinson
- Clinical Sciences Center, Northern General Hospital, University of Sheffield, Sheffield S57 AU, U.K
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