Diabetes mellitus and closed-loop insulin delivery

Advances in management of type 1 diabetes mellitus

Treatment of type 1 diabetes mellitus has always posed a challenge to balance hyperglycemia control with hypoglycemia episodes. The quest for newer therapies is continuing and this review attempts to outline the recent developments. The insulin molecule itself has got moulded into different analogues by minor changes in its structure to ensure well controlled delivery, stable half-lives and lesser side effects. Insulin delivery systems have also consistently undergone advances from subcutaneous injections to continuous infusion to trials of inhalational delivery. Continuous glucose monitoring systems are also becoming more accurate and user friendly. Smartphones have also made their entry into therapy of diabetes by integrating blood glucose levels and food intake with calculated adequate insulin required. Artificial pancreas has enabled to a certain extent to close the loop between blood glucose level and insulin delivery with devices armed with meal and exercise announcements, dual hormone delivery and pramlintide infusion. Islet, pancreas-kidney and stem cells transplants are also being attempted though complete success is still a far way off. Incorporating insulin gene and secretary apparatus is another ambitious leap to achieve insulin independence though the search for the ideal vector and target cell is still continuing. Finally to stand up to the statement, prevention is better than cure, immunological methods are being investigated to be used as vaccine to prevent the onset of diabetes mellitus.

Stimuli sensitive polymers and self regulated drug delivery systems: a very partial review

Since the early days of the Journal of Controlled Release, there has been considerable interest in materials that can release drug on an "on-demand" basis. So called "stimuli-responsive" and "intelligent" systems have been designed to deliver drug at various times or at various sites in the body, according to a stimulus that is either endogenous or externally applied. In the past three decades, research along these lines has taken numerous directions, and each new generation of investigators has discovered new physicochemical principles and chemical schemes by which the release properties of materials can be altered. No single review could possibly do justice to all of these approaches. In this article, some general observations are made, and a partial history of the field is presented. Both open loop and closed loop systems are discussed. Special emphasis is placed on stimuli-responsive hydrogels, and on systems that can respond repeatedly. It is argued that the most success at present and in the foreseeable future is with systems in which biosensing and actuation (i.e. drug delivery) are separated, with a human and/or cybernetic operator linking the two.

Effect of varying molecular weight of dextran on acrylic-derivatized dextran and concanavalin A glucose-responsive materials for closed-loop insulin delivery

AIM

Dextran methacrylate (dex-MA) and concanavalin A (con A)-methacrylamide were photopolymerized to produce covalently cross-linked glucose-sensitive gels for the basis of an implantable closed-loop insulin delivery device.

METHODS

The viscoelastic properties of these polymerized gels were tested rheologically in the non-destructive oscillatory mode within the linear viscoelastic range at glucose concentrations between 0 and 5% (w/w).

RESULTS

For each cross-linked gel, as the glucose concentration was raised, a decrease in storage modulus, loss modulus and complex viscosity (compared at 1 Hz) was observed, indicating that these materials were glucose responsive. The higher molecular weight acrylic-derivatized dextrans [degree of substitution (DS) 3 and 8%] produced higher complex viscosities across the glucose concentration range.

CONCLUSIONS

These studies coupled with in vitro diffusion experiments show that dex-MA of 70 kDa and DS (3%) was the optimum mass average molar mass to produce gels that show reduced component leach, glucose responsiveness, and insulin transport useful as part of a self-regulating insulin delivery device.

Glucose-sensitive gel rheology of dextran-concanavalin A mixtures suitable for self-regulating insulin delivery

Aqueous concentrated plain mixtures of dextran and concanavalin A (con A) were examined for their rheological response to glucose for comparison with previously studied partially photopolymerized acrylic derivatives. Non-destructive oscillatory tests were undertaken within the linear viscoelastic range to examine the relationship between the rheometry and the stoichiometry of the interactive materials and to examine rheological parameters as affected by molecular weight, component ratio, temperature and glucose concentrations between 0 and 1% w/w. These simple formulations were studied at 1 and 10 Hz at 0.5% strain at both 20 and 37 degrees C. A second simplified rheological test was undertaken to demonstrate gel-sol reversibility and to produce a measure of equilibria created between these gels and glucose solutions with which they are in contact. This mimics the conditions in which the gel acts as a responsive gateway in the insulin delivery device. It proved that the gels equilibrate with glucose solutions, rather than indiscriminately removing glucose. This is important in terms of producing a delivery device that can respond in a reversible, glucose concentration-dependent manner. The method used for this is capable of relative values only but provides information not obtainable from conventional rheometry.

Insulin-based regimens decrease mortality rates in critically ill patients: a systematic review

OBJECTIVES

To determine whether treatment with glucose-insulin-potassium (GIK), insulin and glucose, or insulin by itself is beneficial in limiting organ damage after acute myocardial infarction (AMI) and reducing mortality and morbidity among critically ill hyperglycaemic patients.

METHODS

Systematic review of randomized controlled trials.

MAIN OUTCOME MEASURE

To assess whether tight glycaemic control reduces morbidity and mortality.

STUDIES REVIEWED

Randomized controlled trials of insulin-based regimens in the treatment of critically ill patients.

RESULTS

Nine hundred and twenty-four potentially relevant studies were identified and screened for retrieval. Of these, 16 randomized controlled trials met the inclusion criteria (Table 1). Ten studies examined the effects of GIK, and six of these studies reported a mortality reduction with GIK treatment in addition to enhanced myocardial performance. Five studies examined the administration of insulin. Among these studies, tight glycaemic control of blood glucose in one study was shown to reduce morbidity and mortality of patients in intensive care. Only one study examined insulin/glucose therapy, and it showed a post-myocardial infarction mortality reduction of one year.

CONCLUSIONS

There is increasing evidence that maintaining normoglycaemia and treatment with insulin-based regimens is beneficial in limiting organ damage and significantly reduces both morbidity and mortality in critically ill patients who require intensive care therapy.

Concanavalin A for in vivo glucose sensing: a biotoxicity review

Over the last two decades there as has been surging scientific interest in employing the glucose- and mannose-specific lectin Concanavalin A (ConA) in affinity biosensors for in vivo glucose monitoring in diabetics. Numerous research groups have successfully shown in in vitro and in vivo studies that ConA-based affinity sensors can monitor glucose very accurately and reproducibly over many months, making ConA-based sensors an extremely interesting prospect for long-term implantation in humans. Despite this progress, there remains concern over the safety of ConA, which has widely been reported as a toxin in the literature. In this article, we review in vitro and in vivo studies related to ConA toxicity in order to assess the health risks posed by ConA in the context of an implantable biosensor. Based on the wealth of information available and on data from our own studies, we can conclude that the site of implantation (subcutaneous skin tissue) and the small amount of ConA (<10 microg/microl) being used in implantable glucose-sensitive detector devices like those proposed by various research groups would pose little or no health risk to its bearer even in the event of unexpected sensor rupture.

Covalent coupling of concanavalin A to a Carbopol 934P and 941P carrier in glucose-sensitive gels for delivery of insulin

A novel glucose-sensitive gel formulation, containing concanavalin A and specific polysaccharides, was stabilised via covalent coupling to two structurally different carbomers. The bonding was done to minimise leaching of gel components thereby preventing toxicity and preserving the working mechanism of the gel. Increased gel stability was introduced by covalently bonding amine groups present on the lysine residues of concanavalin A to carboxylic moieties on Carbopol 934P NF and 941P NF using carbodiimide chemistry. The introduction of dextran then produced a glucose-sensitive formulation that transformed from gel to sol in the presence of free glucose. Rheological examination of glucose-sensitive gels stabilised in this way and containing varying concentrations of glucose was conducted with a cone and plate viscometer used in continual rotation mode. A decrease in viscosity over the chosen glucose concentration range was exhibited by both carbomer-stabilised formulations. The subsequent testing of such formulations in in-vitro diffusion experiments revealed that the leaching of concanavalin A from the covalently coupled gels is restricted significantly with respect to non-coupled formulations. In addition, insulin delivery in response to glucose in the physiologically relevant glucose concentration range has been demonstrated using the carbomer-stabilised gels at 37 degrees C. The performance of this self-regulating drug delivery system has been improved in terms of increased gel stability with reduced component leaching.