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Bolli GB, Cheng AYY, Owens DR. Insulin: evolution of insulin formulations and their application in clinical practice over 100 years. Acta Diabetol 2022; 59:1129-1144. [PMID: 35854185 PMCID: PMC9296014 DOI: 10.1007/s00592-022-01938-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 07/01/2022] [Indexed: 11/22/2022]
Abstract
The first preparation of insulin extracted from a pancreas and made suitable for use in humans after purification was achieved 100 years ago in Toronto, an epoch-making achievement, which has ultimately provided a life-giving treatment for millions of people worldwide. The earliest animal-derived formulations were short-acting and contained many impurities that caused adverse reactions, thereby limiting their therapeutic potential. However, since then, insulin production and purification improved with enhanced technologies, along with a full understanding of the insulin molecule structure. The availability of radio-immunoassays contributed to the unravelling of the physiology of glucose homeostasis, ultimately leading to the adoption of rational models of insulin replacement. The introduction of recombinant DNA technologies has since resulted in the era of both rapid- and long-acting human insulin analogues administered via the subcutaneous route which better mimic the physiology of insulin secretion, leading to the modern basal-bolus regimen. These advances, in combination with improved education and technologies for glucose monitoring, enable people with diabetes to better meet individual glycaemic goals with a lower risk of hypoglycaemia. While the prevalence of diabetes continues to rise globally, it is important to recognise the scientific endeavour that has led to insulin remaining the cornerstone of diabetes management, on the centenary of its first successful use in humans.
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Li C, Wang D, Jiang Z, Gao Y, Sun L, Li R, Chen M, Lin C, Liu D. Non-coding RNAs in diabetes mellitus and diabetic cardiovascular disease. Front Endocrinol (Lausanne) 2022; 13:961802. [PMID: 36147580 PMCID: PMC9487522 DOI: 10.3389/fendo.2022.961802] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
More than 10% of the world's population already suffers from varying degrees of diabetes mellitus (DM), but there is still no cure for the disease. Cardiovascular disease (CVD) is one of the most common and dangerous of the many health complications that can be brought on by DM, and has become the leading cause of death in people with diabetes. While research on DM and associated CVD is advancing, the specific mechanisms of their development are still unclear. Given the threat of DM and CVD to humans, the search for new predictive markers and therapeutic ideas is imminent. Non-coding RNAs (ncRNAs) have been a popular subject of research in recent years. Although they do not encode proteins, they play an important role in living organisms, and they can cause disease when their expression is abnormal. Numerous studies have observed aberrant ncRNAs in patients with DM complications, suggesting that they may play an important role in the development of DM and CVD and could potentially act as biomarkers for diagnosis. There is additional evidence that treatment with existing drugs for DM, such as metformin, alters ncRNA expression levels, suggesting that regulation of ncRNA expression may be a key mechanism in future DM treatment. In this review, we assess the role of ncRNAs in the development of DM and CVD, as well as the evidence for ncRNAs as potential therapeutic targets, and make use of bioinformatics to analyze differential ncRNAs with potential functions in DM.
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Affiliation(s)
- Chengshun Li
- Laboratory Animal Center, College of Animal Science, Jilin University, Changchun, China
| | - Dongxu Wang
- Laboratory Animal Center, College of Animal Science, Jilin University, Changchun, China
| | - Ziping Jiang
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Yongjian Gao
- Department of Gastrointestinal Colorectal and Anal Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Liqun Sun
- Department of Pediatrics, First Hospital of Jilin University, Changchun, China
| | - Rong Li
- Laboratory Animal Center, College of Animal Science, Jilin University, Changchun, China
| | - Minqi Chen
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Chao Lin
- School of Grain Science and Technology, Jilin Business and Technology College, Changchun, China
| | - Dianfeng Liu
- Laboratory Animal Center, College of Animal Science, Jilin University, Changchun, China
- *Correspondence: Dianfeng Liu,
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Pharmacological Management of Diabetes Mellitus: A Century of Expert Opinions in Cecil Textbook of Medicine. Am J Ther 2021; 28:e397-e410. [PMID: 34228650 DOI: 10.1097/mjt.0000000000001401] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Drug therapy for diabetes mellitus (DM) has had a significant impact on quality of life and work potential of affected persons and has contributed to a remarkable decrease in the frequency and severity of complications, hospitalizations, and mortality. The current approach is the result of incremental progress in using technological advances to increase the safety and effectiveness of insulin therapy and the introduction of new molecules as oral and injectable antidiabetic drugs. STUDY QUESTION What are the milestones of the changes in the expert approach to the pharmacological management of DM in the past century? STUDY DESIGN To determine the changes in the experts' approach to the management of DM, as presented in a widely used textbook in the United States. DATA SOURCES The chapters on describing the management of DM in the 26 editions of Cecil Textbook of Medicine published from 1927 to 2020. RESULTS In 1927, DM was treated with insulin extracted from the pancreas of large animals (cattle, hogs, and sheep) and purified with alcohol to prevent the tissues' proteolytic action on the hormone. The therapeutic milestones in DM marked 2 avenues for innovation. The first created advances in insulin therapy, starting with processes that led to the production of crystalline insulin and protamine zinc insulin (1937), synthetic human insulin (1996), and prandial (2000) and basal (2004) insulin analogues. The second was an effort to develop and introduce in clinical practice in the United States oral antidiabetic drugs, starting with tolbutamide, a sulfonylurea (1955), followed by metformin, a biguanide (1996), thiazolidinediones, alpha-glucosidase inhibitors, and benzoic acid derivatives (2000), dipeptidyl peptidase-4 inhibitors and glucagon-like peptide 1 receptor agonists (2008), and sodium glucose cotransporter 2 inhibitors (2020). A latent period of 40 years between significant advances was likely because of searches for new technologies (eg, recombinant DNA for the production of synthetic insulin and analogues) and, at least in part, to the impact of the controversial University Group Diabetes Project on the development and acceptance of oral antidiabetic drugs. CONCLUSIONS The pharmacological management of DM has progressed unevenly, with a long latency period in the second half of the last century followed by highly encouraging advances in the first 2 decades of the 21st century. In chronological order, the major advances were synthetic insulins obtained through DNA recombinant technology, adoption of metformin as first line therapy, and introduction of antidiabetic medication classes that also promote weight reduction and cardiovascular health.
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Role of ultrafast-acting insulin analogues in the management of diabetes. J Am Assoc Nurse Pract 2019; 31:537-548. [DOI: 10.1097/jxx.0000000000000261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sheng X, Yao K, Shao A, Tu S, Zhang X, Chen T, Yao D. The Role of Insulin Glargine and Human Insulin in the Regulation of Thyroid Proliferation Through Mitogenic Signaling. Front Endocrinol (Lausanne) 2019; 10:594. [PMID: 31555212 PMCID: PMC6723759 DOI: 10.3389/fendo.2019.00594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 08/13/2019] [Indexed: 12/29/2022] Open
Abstract
Our aim was to investigate whether human insulin (HI) or insulin glargine treatment could promote the proliferation of thyroid cells and determine the association between type 2 diabetes and thyroid disease. Rats were treated with different doses of HI and insulin glargine. Plasma glucose and the phosphorylation levels of the insulin receptor (IR), insulin-like growth factor 1 receptor (IGF-1R), protein kinase B (Akt), and extracellular signal-regulated kinase 1/2 (ERK1/2) were measured. A total of 105 rats were randomly assigned to three groups as follows: control group, HI group, and glargine group. Both drugs promoted the phosphorylation of IR, Akt, and ERK1/2 in a dose-dependent manner (p < 0.05), and the effect of glargine persisted for longer period. Treatment with ultra-therapeutic doses of HI or glargine (p < 0.05) increased the expression of Ki-67 in thyroid cells. The results demonstrated that therapeutic doses of glargine have a longer-lasting hypoglycemic control than HI. Based on the results, HI or glargine did not stimulate thyroid cell proliferation at therapeutic doses, but high doses did.
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Affiliation(s)
- Xiaoli Sheng
- Department of Obstetrics, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Kannan Yao
- The Second Central Laboratory, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Anwen Shao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Sheng Tu
- Department of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xinxia Zhang
- Department of Geriatrics, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ting Chen
- Department of Ultrasonography, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Dingguo Yao
- Department of Endocrinology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
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Milluzzo A, Tumminia A, Scalisi NM, Frittitta L, Vigneri R, Sciacca L. Insulin degludec in the first trimester of pregnancy: Report of two cases. J Diabetes Investig 2017; 9:629-631. [PMID: 28767190 PMCID: PMC5934254 DOI: 10.1111/jdi.12721] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/18/2017] [Accepted: 07/25/2017] [Indexed: 11/30/2022] Open
Abstract
Insulin degludec is an extra-long-acting insulin analog that allows for enhanced efficacy and flexibility in the injection time. However, it is not approved for use during pregnancy. We report the pregnancy outcome and newborn conditions in two women with type 1 diabetes who continued preconception degludec treatment during embryogenesis. No pregnancy complication or congenital neonatal malformation was observed. Both babies presented with hypoglycemia and required neonatal intensive care unit admission. Degludec treatment did not cause adverse effects in the mothers or malformations in the newborns. The observed neonatal complications were probably independent of early pregnancy degludec treatment.
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Affiliation(s)
- Agostino Milluzzo
- Endocrinology SectionDepartment of Clinical and Experimental MedicineGaribaldi‐Nesima Medical CenterUniversity of CataniaCataniaItaly
| | - Andrea Tumminia
- Endocrinology SectionDepartment of Clinical and Experimental MedicineGaribaldi‐Nesima Medical CenterUniversity of CataniaCataniaItaly
| | - Nunzio M Scalisi
- Endocrinology SectionDepartment of Clinical and Experimental MedicineGaribaldi‐Nesima Medical CenterUniversity of CataniaCataniaItaly
| | - Lucia Frittitta
- Endocrinology SectionDepartment of Clinical and Experimental MedicineGaribaldi‐Nesima Medical CenterUniversity of CataniaCataniaItaly
| | - Riccardo Vigneri
- Endocrinology SectionDepartment of Clinical and Experimental MedicineGaribaldi‐Nesima Medical CenterUniversity of CataniaCataniaItaly
- Institute of Bioimages and BiostructuresCataniaItaly
| | - Laura Sciacca
- Endocrinology SectionDepartment of Clinical and Experimental MedicineGaribaldi‐Nesima Medical CenterUniversity of CataniaCataniaItaly
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Strandberg AY, Hoti FJ, Strandberg TE, Christopher S, Haukka J, Korhonen P. All-Cause and Cause-Specific Mortality among Users of Basal Insulins NPH, Detemir, and Glargine. PLoS One 2016; 11:e0151910. [PMID: 27031113 PMCID: PMC4816506 DOI: 10.1371/journal.pone.0151910] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 03/07/2016] [Indexed: 12/29/2022] Open
Abstract
Background Insulin therapy in type 2 diabetes may increase mortality and cancer incidence, but the impact of different types of basal insulins on these endpoints is unclear. Compared to the traditional NPH insulin, the newer, longer-acting insulin analogues detemir and glargine have shown benefits in randomized controlled trials. Whether these advantages translate into lower mortality among users in real life is unknown. Objective To estimate the differences in all-cause and cause-specific mortality rates between new users of basal insulins in a population-based study in Finland. Methods 23 751 individuals aged ≥40 with type 2 diabetes, who initiated basal insulin therapy in 2006–2009 were identified from national registers, with comprehensive data for mortality, causes of death, and background variables. Propensity score matching was performed on characteristics. Follow-up time was up to 4 years (median 1.7 years). Results 2078 deaths incurred. With NPH as reference, the adjusted HRs for all-cause mortality were 0.39 (95% CI, 0.30–0.50) for detemir, and 0.55 (95% CI, 0.44–0.69) for glargine. As compared to glargine, the HR was 0.71 (95% CI, 0.54–0.93) among detemir users. Compared to NPH, the mortality risk for both cardiovascular causes as well as cancer were also significantly lower for glargine, and especially for detemir in adjusted analysis. Furthermore, the results were robust in various sensitivity analyses. Conclusion In real clinical practice, mortality was substantially higher among users of NPH insulin as compared to insulins detemir or glargine. Considering the large number of patients who require insulin therapy, this difference in risk may have major clinical and public health implications. Due to limitations of the observational study design, further investigation using an interventional study design is warranted.
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Affiliation(s)
- Arto Y. Strandberg
- University of Helsinki, Clinicum, Helsinki, Finland
- Aava Medical Centre, Kerava, Finland
- * E-mail:
| | | | - Timo E. Strandberg
- University of Helsinki, Clinicum, Helsinki, Finland
- Helsinki University Central Hospital, Helsinki, Finland
- University of Oulu, Center for Life Course Health Research, Oulu, Finland
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8
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New Insulins and New Aspects in Insulin Delivery. Can J Diabetes 2015; 39:335-43. [DOI: 10.1016/j.jcjd.2015.04.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 03/23/2015] [Accepted: 04/13/2015] [Indexed: 12/13/2022]
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9
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Cahn A, Miccoli R, Dardano A, Del Prato S. New forms of insulin and insulin therapies for the treatment of type 2 diabetes. Lancet Diabetes Endocrinol 2015; 3:638-52. [PMID: 26051044 DOI: 10.1016/s2213-8587(15)00097-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 03/18/2015] [Accepted: 03/30/2015] [Indexed: 12/17/2022]
Abstract
Insulin is a common treatment option for many patients with type 2 diabetes, and is generally used late in the natural history of the disease. Its injectable delivery mode, propensity for weight gain and hypoglycaemia, and the paucity of trials assessing the risk-to-safety ratio of early insulin use are major shortcomings associated with its use in patients with type 2 diabetes. Development of new insulins-such as insulin analogues, including long-acting and short-acting insulins-now provide alternative treatment options to human insulin. These novel insulin formulations and innovative insulin delivery methods, such as oral or inhaled insulin, have been developed with the aim to reduce insulin-associated hypoglycaemia, lower intraindividual pharmacokinetic and pharmacodynamic variability, and improve imitation of physiological insulin release. Availability of newer glucose-lowering drugs (such as glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, and sodium-glucose co-transporter-2 inhibitors) also offers the opportunity for combination treatment; the results of the first trials in this area of research suggest that such treatment might lead to use of reduced insulin doses, less weight gain, and fewer hypoglycaemic episodes than insulin treatment alone. These and future developments will hopefully offer better opportunities for individualisation of insulin treatment for patients with type 2 diabetes.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Roberto Miccoli
- Department of Clinical and Experimental Medicine, Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
| | - Angela Dardano
- 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.
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10
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Heise T, Hövelmann U, Brøndsted L, Adrian CL, Nosek L, Haahr H. Faster-acting insulin aspart: earlier onset of appearance and greater early pharmacokinetic and pharmacodynamic effects than insulin aspart. Diabetes Obes Metab 2015; 17:682-8. [PMID: 25846340 PMCID: PMC5054830 DOI: 10.1111/dom.12468] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/11/2015] [Accepted: 03/27/2015] [Indexed: 01/17/2023]
Abstract
AIMS To evaluate the pharmacokinetics and pharmacodynamics of faster-acting insulin aspart and insulin aspart in a randomized, single-centre, double-blind study. METHODS Fifty-two patients with type 1 diabetes (mean age 40.3 years) received faster-acting insulin aspart, insulin aspart, or another faster aspart formulation (not selected for further development), each as a single 0.2 U/kg subcutaneous dose, under glucose-clamp conditions, in a three-way crossover design (3-12 days washout between dosing). RESULTS Faster-acting insulin aspart had a faster onset of exposure compared with insulin aspart, shown by a 57% earlier onset of appearance [4.9 vs 11.2 min; ratio 0.43, 95% confidence interval (CI) 0.36; 0.51], a 35% earlier time to reach 50% maximum concentration (20.7 vs 31.6 min; ratio 0.65, 95% CI 0.59; 0.72) and a greater early exposure within 90 min after dosing. The greatest difference occurred during the first 15 min, when area under the serum insulin aspart curve was 4.5-fold greater with faster-acting insulin aspart than with insulin aspart. Both treatments had a similar time to maximum concentration, total exposure and maximum concentration. Faster-acting insulin aspart had a significantly greater glucose-lowering effect within 90 min after dosing [largest difference: area under the curve for the glucose infusion rate (AUC(GIR), 0-30 min) ratio 1.48, 95% CI 1.13; 2.02] and 17% earlier time to reach 50% maximum glucose infusion rate (38.3 vs 46.1 min; ratio 0.83, 95% CI 0.73; 0.94). The primary endpoint (AUC(GIR, 0-2 h)) was 10% greater for faster-acting insulin aspart, but did not reach statistical significance (ratio 1.10, 95% CI 1.00; 1.22). Both treatments had similar total and maximum glucose-lowering effects, indicating similar overall potency. CONCLUSIONS Faster-acting insulin aspart was found to have earlier onset and higher early exposure than insulin aspart, and a greater early glucose-lowering effect, with similar potency.
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11
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Rossetti P, Ampudia-Blasco FJ, Ascaso JF. Old and new basal insulin formulations: understanding pharmacodynamics is still relevant in clinical practice. Diabetes Obes Metab 2014; 16:695-706. [PMID: 24401118 DOI: 10.1111/dom.12256] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 07/05/2013] [Accepted: 12/20/2013] [Indexed: 12/17/2022]
Abstract
Long-acting insulin analogues have been developed to mimic the physiology of basal insulin secretion more closely than human insulin formulations (Neutral Protamine Hagedorn, NPH). However, the clinical evidence in favour of analogues is still controversial. Although their major benefit as compared with NPH is a reduction in the hypoglycaemia risk, some cost/effectiveness analyses have not been favourable to analogues, largely because of their higher price. Nevertheless, these new formulations have conquered the insulin market. Human insulin represents currently no more than 20% of market share. Despite (in fact because of) the widespread use of insulin analogues it remains critical to analyse the pharmacodynamics (PD) of basal insulin formulations appropriately to interpret the results of clinical trials correctly. Importantly, these data may help physicians in tailoring insulin therapy to patients' individual needs and, additionally, when clinical evidence is not available, to optimize insulin treatment. For patients at low risk for/from hypoglycaemia, it might be acceptable and also cost-effective not to use long-acting insulin analogues as basal insulin replacement. Conversely, in patients with a higher degree of insulin deficiency and increased risk for hypoglycaemia, analogues are the best option due to their more physiological profile, as has been shown in PD and clinical studies. From this perspective optimizing basal insulin treatment, especially in type 2 diabetes patients who are less prone to hypoglycaemia, would be suitable making significant resources available for other relevant aspects of diabetes care.
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MESH Headings
- Chemistry, Pharmaceutical
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 2/drug therapy
- Evidence-Based Medicine
- Humans
- Hypoglycemic Agents/chemistry
- Hypoglycemic Agents/pharmacokinetics
- Hypoglycemic Agents/pharmacology
- Hypoglycemic Agents/therapeutic use
- Insulin, Long-Acting/chemistry
- Insulin, Long-Acting/pharmacokinetics
- Insulin, Long-Acting/pharmacology
- Insulin, Long-Acting/therapeutic use
- Insulin, Short-Acting/chemistry
- Insulin, Short-Acting/pharmacokinetics
- Insulin, Short-Acting/pharmacology
- Insulin, Short-Acting/therapeutic use
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Affiliation(s)
- P Rossetti
- Department of Internal Medicine, Sant Francesc de Borja Hospital, Gandia, Spain
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Tennagels N, Welte S, Hofmann M, Brenk P, Schmidt R, Werner U. Differences in metabolic and mitogenic signallingof insulin glargine and AspB10 human insulin in rats [corrected]. Diabetologia 2013; 56:1826-34. [PMID: 23653049 PMCID: PMC3699703 DOI: 10.1007/s00125-013-2923-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 04/05/2013] [Indexed: 01/09/2023]
Abstract
AIMS/HYPOTHESIS In vitro, insulin glargine (A21Gly,B31Arg,B32Arg human insulin) has an insulin receptor (IR) profile similar to that of human insulin, but a slightly higher affinity for the IGF-1 receptor (IGF1R). AspB10 human insulin (AspB10), [corrected] the only insulin analogue with proven carcinogenic activity, has a greater affinity for IGF1R and IR, and a prolonged IR occupancy time. The pharmacological and signalling profile of therapeutic and suprapharmacological doses of glargine were analysed in different tissues of rats, and compared with human insulin and AspB10. METHODS Male Wistar rats were injected s.c. with human insulin or insulin analogue at doses of 1 to 200 U/kg, and the effects on blood glucose and the phosphorylation status of IR, IGF1R, Akt and extracellular signal-regulated protein kinase 1/2 in muscle, fat, liver and heart samples were investigated. RESULTS Glargine, AspB10 and human insulin lowered blood glucose, with the onset of action delayed with glargine. Glargine treatment resulted in phosphorylation levels of IR and Akt that were comparable with those achieved with human insulin, although delayed in time in some tissues. AspB10 treatment resulted in at least twofold higher phosphorylation levels and significantly longer duration of IR and Akt phosphorylation in most tissues. None of the insulin treatments resulted in detectable IGF1R phosphorylation in muscle or heart tissue, whereas intravenous injection of IGF-1 increased IGF1R phosphorylation. CONCLUSIONS/INTERPRETATION The IR signalling pattern of AspB10 in vivo is distinctly different from that of human insulin and insulin glargine, and might challenge the notion that activation of IGF1R plays a role in the observed carcinogenic effect of AspB10.
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Affiliation(s)
- N Tennagels
- Sanofi-Aventis Deutschland GmbH, Frankfurt am Main, Germany.
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13
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Gough SCL, Harris S, Woo V, Davies M. Insulin degludec: overview of a novel ultra long-acting basal insulin. Diabetes Obes Metab 2013; 15:301-9. [PMID: 23240573 DOI: 10.1111/dom.12052] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 11/19/2012] [Accepted: 12/11/2012] [Indexed: 11/27/2022]
Abstract
All the basal insulin products currently available have suboptimal pharmacokinetic (PK) properties, with none reliably providing a reproducible and peakless pharmacodynamic (PD) effect that endures over 24 h from once-daily dosing. Insulin degludec is a novel acylated basal insulin with a unique mechanism of protracted absorption involving the formation of a depot of soluble multihexamer chains after subcutaneous injection. PK/PD studies show that insulin degludec has a very long duration of action, with a half-life exceeding 25 h. Once-daily dosing produces a steady-state profile characterized by a near-constant effect, which varies little from injection to injection in a given patient. Clinically, insulin degludec has been shown consistently to carry a lower risk of nocturnal hypoglycaemia than once-daily insulin glargine, in both basal+bolus and basal-only insulin regimens. The constancy of the steady-state profile of insulin degludec also means that day-to-day irregularities at the time of injection have relatively little PD influence, thereby offering the possibility of greater treatment flexibility for patients.
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Affiliation(s)
- S C L Gough
- Oxford Centre for Diabetes, Endocrinology and Metabolism and NIHR Oxford Biomedical Research Centre, Oxford, UK.
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14
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Sartore G, Chilelli NC, Burlina S, Di Stefano P, Piarulli F, Fedele D, Mosca A, Lapolla A. The importance of HbA1c and glucose variability in patients with type 1 and type 2 diabetes: outcome of continuous glucose monitoring (CGM). Acta Diabetol 2012; 49 Suppl 1:S153-60. [PMID: 22466072 DOI: 10.1007/s00592-012-0391-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 03/14/2012] [Indexed: 12/24/2022]
Abstract
Glucose variability has recently been investigated in diabetic patients in several studies, but most of them considered only a few variability indicators and did not systematically correlate them with patients' HbA1c levels and other important characteristics. In thus study, the correlations between HbA1c levels and metabolic control (average glucose, AG), glucose variability (SD, CONGA, MAGE, MODD, BG ROC), hyperglycemia (HBGI), hypoglycemia (LBGI) and postprandial (AUC PP) indices were investigated in patients with type 1 and type 2 diabetes. The study involved 68 patients divided into 3 groups as follows: 35 patients had type 1 diabetes (group 1); 17 had type 2 diabetes and were taking multiple daily injections (MDI) of insulin (group 2); and 16 patients had type 2 diabetes treated with OHA and/or basal insulin (group 3). The indicators were obtained over at least 48 h using a continuous glucose monitoring (CGM) system. HbA1c levels were measured at the baseline and after CGM. HbA1c correlated significantly with AG (r = 0.74), AUC PP (r = 0.69) and HBGI (r = 0.74), but only in type 1 diabetic patients. Patients with longstanding disease and type 1 diabetes had a greater glucose variability, irrespective of their HbA1c levels. Insulin therapy with MDI correlated strongly with HbA1c, but not with glucose variability. HbA1c levels identify states of sustained hyperglycemia and seem to be unaffected by hypoglycemic episodes or short-lived glucose spikes, consequently revealing shortcomings as a "gold standard" indicator of metabolic control. Glucose variability indicators describe the glucose profile of type 1 diabetic patients and identify any worsening glycemic control (typical of longstanding diabetes) more accurately than HbA1c tests.
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Affiliation(s)
- Giovanni Sartore
- Department of Medical and Surgical Sciences, University of Padova, Via Giustiniani n 2, 35128 Padua, Italy
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15
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Abstract
Insulin is the most effective treatment for both type 1 and type 2 diabetes mellitus. There are several differences in the safety profiles of each type of insulin, including rapid-acting insulin analogs and regular human insulin. The pharmacokinetic and pharmacodynamic properties of those insulin types also differ, as do their safety parameters. Treatment with rapid-acting analogs results in less hypoglycemia overall and decreased frequency of both severe and nocturnal hypoglycemia. In addition, the more rapid onset and shorter duration of action of rapid-acting insulin analogs are associated with greater control of postprandial glucose than regular human insulin. This review will describe the similarities and differences between the safety profiles of rapid-acting insulin analogs.
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16
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Abstract
Inpatients have a high rate of diabetes (12%-26%) and hyperglycemia (~38%). All patients should have their glycosylated hemoglobin (A1C) checked on admission to help differentiate between long-term and new-onset hyperglycemia. Good glycemic control throughout the hospital stay is associated with decreases in short- and long-term risk of mortality, inpatient complications, length of hospital stay, and health care costs. Insulin is first-line therapy for hyperglycemia; patients with hyperglycemia should be managed using either intravenous (IV) or subcutaneous (SC) insulin algorithms. A hypoglycemia management protocol should be in place at the hospital for safety purposes. For successful glycemic control, insulin algorithms should have dynamic scales, require frequent glucose monitoring, and be simple and easy to use. The algorithm should address transitioning patients from IV to SC insulin and a discharge plan. Insulin analogues are preferred for basal, mealtime, and correction doses instead of human insulins (regular and NPH) because analogues have a more predictable absorption and action profile and less pharmacokinetic fluctuation. Institutions can increase safe insulin use by utilizing insulin algorithms, preprinted order sets, and hypoglycemia protocols; by supporting patient and health care provider education; and by implementing needle-stick prevention techniques.
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17
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The initiation of insulin therapy in type 2 diabetic patients treated with oral anti-diabetic drugs: an observational study in multiple institutes across Japan (JDDM27). Diabetol Int 2012. [DOI: 10.1007/s13340-012-0073-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Abstract
Hyperglycemia occurs frequently in hospitalized patients and affects patient outcomes, including mortality, inpatient complications, hospital length of stay, and overall hospital costs. Various degrees of glycemic control have been studied and consensus statements from the American Diabetes Association/American Association of Clinical Endocrinologists and The Endocrine Society recommend a target blood glucose range of 140 to 180 mg/dL in most hospitalized patients. Insulin is the preferred modality for treating all hospitalized patients with hyperglycemia, as it is adaptable to changing patient physiology over the course of hospitalization. Critically ill patients should receive intravenous insulin infusion, and all noncritically ill patients with hyperglycemia (individuals with and without diabetes) should be managed using a subcutaneous insulin algorithm with basal, nutritional, and correctional dose components. Hypoglycemia remains a limiting factor to achieving optimal glycemic targets. Similar to hyperglycemia, hypoglycemia is an independent risk factor for poor outcomes in hospitalized patients. Improvement in glycemic control throughout the hospital includes efforts from all health care providers. Institutions can encourage safe insulin use by using insulin algorithms, preprinted order sets, and hypoglycemia protocols, as well as by supporting patient and health care provider education.
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Affiliation(s)
- Lowell R Schmeltz
- Assistant Professor, Oakland University William Beaumont School of Medicine, Rochester, MI; Associated Endocrinologists, PC and Endocrine Hospital Consultants, PC, West Bloomfield, MI; Chief of Endocrinology, Detroit Medical Center-Huron Valley-Sinai Hospital, Commerce, MI; Department of Endocrinology, William Beaumont Hospital, Royal Oak, MI.
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19
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Ampudia-Blasco FJ, Rossetti P, Ascaso JF. Basal plus basal-bolus approach in type 2 diabetes. Diabetes Technol Ther 2011; 13 Suppl 1:S75-83. [PMID: 21668340 DOI: 10.1089/dia.2011.0001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Type 2 diabetes is characterized by insulin resistance and progressive β-cell deterioration. As β-cell function declines, most patients with type 2 diabetes treated with oral agents, in monotherapy or combination, will require insulin therapy. Addition of basal insulin (glargine, detemir, or NPH/neutral protamine lispro insulin) to previous treatment is accepted as the simplest way to start insulin therapy in those patients. But even when basal insulin is adequately titrated, some patients will also need prandial insulin to achieve or maintain individual glycemic targets over time. Starting with premixed insulin is an effective option, but it is frequently associated with increased hypoglycemia risk, fixed meal schedules, and weight gain. As an alternative, a novel approached known as "basal plus strategy" has been developed. This approach considers the addition of increasing injections of prandial insulin, beginning with the meal that has the major impact on postprandial glucose values. Finally, if this is not enough intensification to basal-bolus will be necessary. In reducing hyperglycemia, this modality still remains the most effective option, even in people with type 2 diabetes. This article will review the currently evidence on the basal plus strategy and also its progression to basal-bolus therapy. In addition, practical recommendations to start and adjust basal plus therapy will be provided.
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Affiliation(s)
- F Javier Ampudia-Blasco
- Diabetes Reference Unit, Endocrinology and Nutrition Department, Clinic University Hospital of Valencia, Valencia, Spain.
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20
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Bolli GB, Andreoli AM, Lucidi P. Optimizing the replacement of basal insulin in type 1 diabetes mellitus: no longer an elusive goal in the post-NPH era. Diabetes Technol Ther 2011; 13 Suppl 1:S43-52. [PMID: 21668336 DOI: 10.1089/dia.2011.0039] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In physiology, insulin is released continuously by the pancreas at a nearly constant rate between meals and in the fasting state (basal insulin secretion). The pivotal role of basal insulin is to restrain release of glucose from the liver and free fatty acids from adipose tissue, thus preventing hyperglycemia and ketosis. In type 1 diabetes mellitus (T1DM) (absolute insulin deficiency), the replacement of basal insulin is challenging because the currently available pharmacological preparations of long-acting insulin do not exactly reproduce the fine physiology of flat action profile of basal insulin of subjects without diabetes. NPH and NPH-based insulin mixtures no longer have a place in the treatment of T1DM because of their early peak effects and relatively short duration of action, which result into risk of nocturnal hypoglycemia and fasting hyperglycemia, respectively, after the evening injection. Only continuous subcutaneous (s.c.) insulin infusion (CSII) or long-acting analogs such as glargine (>24 h in duration, once a day) and detemir (<24 h in duration, once or more often twice a day) should be used as basal insulin in T1DM in combination with mealtime rapid-acting analogs. CSII and the long-acting analogs are nearly peakless and therefore reduce the risk for hypoglycemia (especially at night), blood glucose (BG) variability, and lower A1C with similar or less hypoglycemia. CSII is the "gold standard" of replacement of basal insulin because of better reproducibility of subcutaneous absorption of soluble insulin. Although CSII is not superior to multiple daily insulin injections in the general T1DM population, CSII might be indicated in subsets of T1DM (long-term T1DM with insulin "supersensitivity" and needs for low-dose insulin, some individuals with variable subcutaneous absorption of long-acting analogs) to minimize BG variability, reduce hypoglycemia, and benefit A1C.
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Affiliation(s)
- Geremia B Bolli
- Section of Internal Medicine, Endocrinology and Metabolism, Department of Internal Medicine, University of Perugia, Perugia, Italy.
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21
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Abstract
The two basal insulin analogs, insulin glargine and insulin detemir, were developed to ameliorate the well-known limitations of NPH insulin. In contrast to rapid-acting analogs, which differ exclusively in terms of primary structure while sharing similar pharmacokinetics (PK) and pharmacodynamics (PD), the two long-acting insulin analogs are different chemical and structural entities, exhibiting distinct modes of protracting the insulin effect. So far, PK and PD studies of long-acting analogs have often shown conflicting results, pointing out different conclusions, thereby leading to animated controversies. The methods used in the evaluation of basal insulins might have been partially responsible as, although the euglycemic clamp technique has been broadly acknowledged to be the "gold standard" reference to assess the glucose-lowering effect of an insulin preparation, its execution and interpretation might have been substantially different across studies, in various methodological and analytical aspects, ultimately providing an explanation for some of these controversies. This review will present and describe the basic methods used in the evaluation of basal insulins and will critically summarize the points that might have been responsible for the different outcomes. The findings of glucose clamp studies demonstrate that the two long-acting insulin analogs are different, to some extent, in both their PK and PD profiles. These differences should be taken into consideration when the individual analogs are introduced to provide basal insulin supplementation to optimize blood glucose control in patients with type 1 and type 2 diabetes as well.
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22
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Levich BR. Diabetes management: optimizing roles for nurses in insulin initiation. J Multidiscip Healthc 2011; 4:15-24. [PMID: 21468244 PMCID: PMC3065562 DOI: 10.2147/jmdh.s16451] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Indexed: 12/01/2022] Open
Abstract
Type 2 diabetes is a major public health concern. Screening and early diagnosis followed by prompt and aggressive treatment interventions can help control progression of diabetes and its complications. Nurses are often the first healthcare team members to interact with patients and are being called on to apply their specialized knowledge, training, and skills to educate and motivate patients with diabetes about insulin use and practical ways to achieve treatment goals. Clinical nurse specialists possess specific training and skills to provide this level of care, while staff or office-based nurses may be trained by physicians to fulfill a task-specific role. This manuscript reviews the benefits of intensive glycemic control in type 2 diabetes, therapeutic goals and guidelines, advances in insulin therapy, and contribution of nurses in overcoming barriers to insulin initiation and related aspects of diabetes care. Nurses are particularly well positioned to fill the gap and improve efficiency in diabetes-related healthcare by assisting patients with insulin initiation and other aspects of glycemic self-management.
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Affiliation(s)
- Bridget R Levich
- University of California Davis Health System, Sacramento, CA, USA
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23
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Hernández Mijares A, Solá Izquierdo E, García Malpartida K, Verge D. [Safety of insulin analogues: what to evaluate, how to do it, and how to interpret the results]. ACTA ACUST UNITED AC 2010; 57:376-80. [PMID: 20621572 DOI: 10.1016/j.endonu.2010.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 04/26/2010] [Accepted: 05/17/2010] [Indexed: 11/26/2022]
Abstract
The widespread use of insulin analogues is based not only on the pharmacokinetics of these preparations, which is much closer to the physiology of insulin secretion under normal conditions, but also on their safety and effectiveness. The publication of a possible association between the use of a long-acting insulin analogue (glargine) and breast cancer has caused uneasiness among the medical community regarding the safety of these analogues. The mechanism of increased tumor activity of insulin analogues is explained by the fact that they act through insulin receptors (IR) and insulin-like growth factor-1 (IGF-1R), stimulating cell growth and inhibiting apoptosis. There are two major mechanisms: an increase in the binding time of insulin to IR and increased activation of IGF-1R. Therefore, to evaluate the safety of an analogue, the slower dissociation rate from its insulin receptor must be excluded, as well as the increased affinity for the IGF-1 receptor. This is equivalent to an index of mitogenic/metabolic activity of less than 1. These aspects can only be evaluated through study of cell lines and animal testing, which are reductionist models that cannot always be extrapolated to humans. To date, there are no data to question the safety of insulin analogues in general. However, the results of observational studies and some in vitro studies, suggesting a potential risk of mitogenicity with the administration of glargine, have caused some alarm among the medical community. Until now, there are no data to refute or confirm this risk and, therefore, evaluation of the existing data is crucial to obtain objective information.
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25
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Glycemic control and long-acting insulin analog utilization in patients with type 2 diabetes. Adv Ther 2010; 27:211-22. [PMID: 20449697 DOI: 10.1007/s12325-010-0020-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The objective was to compare glycemic control, insulin utilization, and body weight in patients with type 2 diabetes (T2D) initiated on insulin detemir (IDet) or insulin glargine (IGlar) in a real-life setting in the Netherlands. METHODS Insulin-naïve patients with T2D, starting treatment with IDet or IGlar between January 1, 2004 and June 30, 2008, were selected from the PHARMO data network. Glycemic control (hemoglobin A1c [HbA1c]), target rates (HbA1c <7%), daily insulin dose, and weight gain were analyzed comparing IDet and IGlar for patients with available HbA1c levels both at baseline and at 1-year follow-up. Analysis of all eligible patients (AEP) and a subgroup of patients without treatment changes (WOTC) in the follow-up period were adjusted for patient characteristics, propensity scores, and baseline HbA1c. RESULTS A total of 127 IDet users and 292 IGlar users were included in the WOTC analyses. The mean HbA1c dropped from 8.4%-8.6% at baseline to 7.4% after 1 year. Patients at HbA1c goal increased from 9% at baseline to 32% for IDet and 11% to 35% for IGlar, which was not significantly different (OR 0.75, 95% CI 0.46, 1.24). Weight gain (n=90) was less among IDet users (+0.4 kg) than among IGlar users (+1.1 kg), albeit not significant. The AEP analysis (252 IDet + 468 IGlar users) showed similar results with 33%-36% at goal (OR 0.81, 95% CI 0.57, 1.16), and median daily insulin doses of 25 IU/day (P=0.70). CONCLUSION There was no significant difference between users of IDet and IGlar with respect to glycemic control and insulin dose in a real-life setting. The low proportion of patients on target at baseline may indicate that insulin therapy is initiated too late. Moreover, the observation that one-third of the patients reached HbA1c target at follow-up may indicate that basal insulin analogs are not titrated intensively enough.
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Kannan V, Narayanaswamy P, Gadamsetty D, Hazra P, Khedkar A, Iyer H. A tandem mass spectrometric approach to the identification of O-glycosylated glargine glycoforms in active pharmaceutical ingredient expressed in Pichia pastoris. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2009; 23:1035-1042. [PMID: 19253914 DOI: 10.1002/rcm.3965] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Glycoforms of glargine expressed in Pichia pastoris were isolated by high-performance liquid chromatography and analyzed by a series of chemical and mass spectrometric methods for the identification of various glycoforms, glycosylation position, nature and structure of glycans. Reduction and alkylation, peptide mapping techniques were used to decipher the amino acid site at which glycosylation had taken place. Chemical methods were coupled with mass spectrometry techniques such as electrospray ionization and matrix-assisted laser desorption/ionization for identification of the glycosylation site.
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Affiliation(s)
- Vivekanandan Kannan
- Research and Development, Biocon Limited, 20th KM Hosur Road, 560100 Bangalore, India.
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27
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Abstract
IGF-I and insulin, acting through both IGF-I and insulin receptors, have been studied widely to evaluate their oncogenic and teratogenic properties. These two properties need to be studied for each new insulin analogue, in addition to measurements of their metabolic and pharmacodynamic features. This editorial critiques a study in this issue of the journal of several insulin analogues in their action in vitro on several cancer-related cell lines. The conclusions and limitations of these studies are highlighted, especially as they influence guidelines for using these analogues patients.
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Affiliation(s)
- Renzo Cordera
- Department of Endocrinology and Medicine (DiSEM), University of Genova, Italy.
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29
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Cobelli C, Man CD, Sparacino G, Magni L, De Nicolao G, Kovatchev BP. Diabetes: Models, Signals, and Control. IEEE Rev Biomed Eng 2009; 2:54-96. [PMID: 20936056 PMCID: PMC2951686 DOI: 10.1109/rbme.2009.2036073] [Citation(s) in RCA: 369] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The control of diabetes is an interdisciplinary endeavor, which includes a significant biomedical engineering component, with traditions of success beginning in the early 1960s. It began with modeling of the insulin-glucose system, and progressed to large-scale in silico experiments, and automated closed-loop control (artificial pancreas). Here, we follow these engineering efforts through the last, almost 50 years. We begin with the now classic minimal modeling approach and discuss a number of subsequent models, which have recently resulted in the first in silico simulation model accepted as substitute to animal trials in the quest for optimal diabetes control. We then review metabolic monitoring, with a particular emphasis on the new continuous glucose sensors, on the analyses of their time-series signals, and on the opportunities that they present for automation of diabetes control. Finally, we review control strategies that have been successfully employed in vivo or in silico, presenting a promise for the development of a future artificial pancreas and, in particular, discuss a modular architecture for building closed-loop control systems, including insulin delivery and patient safety supervision layers. We conclude with a brief discussion of the unique interactions between human physiology, behavioral events, engineering modeling and control relevant to diabetes.
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Affiliation(s)
- Claudio Cobelli
- Department of Information Engineering, University of Padova, Via Gradenigo 6B, 35131 Padova, Italy
| | - Chiara Dalla Man
- Department of Information Engineering, University of Padova, Via Gradenigo 6B, 35131 Padova, Italy
| | - Giovanni Sparacino
- Department of Information Engineering, University of Padova, Via Gradenigo 6B, 35131 Padova, Italy
| | - Lalo Magni
- Department of Computer Engineering and Systems Science, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy
| | - Giuseppe De Nicolao
- Department of Computer Engineering and Systems Science, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy
| | - Boris P. Kovatchev
- Department of Psychiatry and Neurobehavioral Sciences, P.O. Box 40888, University of Virginia, Charlottesville, VA 22903 USA
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30
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Abstract
Insulin analogues were developed to try and achieve more physiological insulin replacement from injection in the subcutaneous site. Their pharmacokinetics and pharmacodynamics differ from human insulin when injected subcutaneously because of alterations in the amino acid sequence of the insulin molecule. The rapid-acting insulin analogues, lispro, aspart and glulisine, have a rapid onset of action and shorter duration of action because of changes to the B26-30 portion of insulin inhibiting formation of dimers and hexamers. They appear to improve postprandial glucose, incidence of hypoglycaemia and patient satisfaction and, when used in combination with basal insulin analogues, improve glycosylated haemoglobin in comparison to conventional insulin therapy. Additionally, they have been successfully used in children, pregnant women, in pump therapy and as part of premixed biphasic regimens. The two basal insulin analogues, glargine and detemir, developed by adjusting the isoelectric point and adding a fatty acid residue, respectively, have a protracted duration of action and a relatively smooth profile. Their pharmacokinetic and pharmacodynamic profiles have been assessed using euglycaemic clamp protocols. Both analogues have a longer duration of action, less of a peak of activity and a reduced variability with repeated injection. There is some evidence to suggest that detemir may have a slight hepatoselective effect. Clinical studies have shown a lower relative risk of hypoglycaemia and detemir appears to have a weight-sparing action. Insulin analogues represent a successful example of applied medical science.
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Affiliation(s)
- B Sheldon
- Centre for Diabetes, Endocrinology & Research (CEDAR), Royal Surrey County Hospital, University of Surrey, Guildford, UK.
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31
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Owens DR, Bolli GB. Beyond the era of NPH insulin--long-acting insulin analogs: chemistry, comparative pharmacology, and clinical application. Diabetes Technol Ther 2008; 10:333-49. [PMID: 18715209 DOI: 10.1089/dia.2008.0023] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The new rDNA and DNA-derived "basal" insulin analogs, glargine and detemir, represent significant advancement in the treatment of diabetes compared with conventional NPH insulin. This review describes blood glucose homeostasis by insulin in people without diabetes and outlines the physiological application of exogenous insulin in patients with type 1 and type 2 diabetes. The requirements for optimal basal insulin treatment are discussed and the methods used in the evaluation of basal insulins are presented. An essential criterion in the development of an "ideal" basal insulin preparation is that the molecular modifications made to the human insulin molecule do not compromise safety. It is also necessary to obtain a clear understanding of the pharmacokinetic and pharmacodynamic characteristics of the two currently available basal insulin analogs. When comparing glargine and detemir, the different molar concentration ratios of the two insulin formulations should be considered along with the nonspecificity of assay systems used to determine insulin concentrations. However, euglycemic clamp studies in crossover study design provide a good basis for comparing the pharmacodynamic responses. When the latter is analyzed by results of intervention clinical trials, it is concluded that both glargine and detemir are superior to NPH in type 1 and type 2 diabetes. However, there is sufficient evidence to demonstrate that these two long-acting insulin analogs are different in both their pharmacokinetic and pharmacodynamic profiles. These differences should be taken into consideration when the individual analogs are introduced to provide basal insulin supplementation to optimize blood glucose control in patients with type 1 and type 2 diabetes as well. PubMed-Medline was searched for articles relating to pharmacokinetics and pharmacodynamics of glargine and detemir. Articles retrieved were reviewed and selected for inclusion if (1) the euglycemic clamp method was used with a duration >or=24 h, (2) a single subcutaneous dose of glargine/detemir was used, and (3) area under the curve for insulin concentrations or glucose infusion rates were calculated.
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Affiliation(s)
- D R Owens
- Diabetes Research Unit, Cardiff University, University Hospital Llandough, Penarth, United Kingdom.
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