Role of premixed insulin analogues in the treatment of patients with type 2 diabetes mellitus: a narrative review

Real-world study of the concomitant use of biphasic insulin aspart 30/70 with GLP-1 receptor agonist versus first-generation basal insulin with GLP-1 receptor agonist in type 2 diabetes

AIMS

Combining insulin with a glucagon-like peptide-1 receptor agonist (GLP-1RA) to treat type 2 diabetes (T2D) is common. While many studies have investigated concomitant therapy with basal insulin+GLP-1RA, few have reported on premixed insulin+GLP-1RA. We aimed to address this gap using data from the Clinical Practice Research Datalink Aurum database in England.

METHODS

This retrospective cohort study with propensity score matching assessed glycaemic levels and other clinical outcomes in people with T2D, comparing biphasic insulin aspart 30/70 (BIAsp 30) + GLP-1RA with basal insulin (insulin detemir/glargine U100) + GLP-1RA (from 2006 to 2021).

RESULTS

In total, 4770 eligible people were identified; 1511 had a BIAsp 30 + GLP-1RA regimen and were propensity score-matched to an equal number receiving basal+GLP-1RA. There was no significant difference in glycated haemoglobin (HbA1c) reduction between cohorts at 6 months (p = 0.15), with a decrease of -1.07 (95% CI: -1.16; -0.98) %-points (-11.7 mmol/mol [95% CI: -12.7; -10.7]) in the BIAsp 30 + GLP-1RA cohort, versus -0.97 (95% CI: -1.07; -0.88) %-points (-10.6 mmol/mol [95% CI: -11.7; -9.6]) in the basal+GLP-1RA cohort. Body mass index (BMI) decreased by -0.35 kg/m2 (95% CI: -0.52;-0.18) at 6 months with BIAsp 30 + GLP-1RA, versus -0.72 kg/m2 (95% CI: -0.90;-0.54) with basal+GLP-1RA (p = 0.003). BMI was influenced by the initiation sequence of GLP-1RA in relation to insulin (p < 0.0001). Hypoglycaemia rates were low and not significantly different between cohorts.

CONCLUSIONS

Combining BIAsp 30 + GLP-1RA provides glycaemic control with no significant difference to that of propensity score-matched people receiving basal insulin+GLP-1RA, with no increase in hypoglycaemia risk or weight gain.

Insulin's Legacy: A Century of Breakthroughs and Innovation

The clinical use of insulin to treat diabetes started just over 100 years ago. The past century has witnessed remarkable innovations in insulin therapy, evolving from animal organ extracts to bioengineered human insulins with ultra-rapid onset or prolonged action. Insulin delivery systems have also progressed to current automated insulin delivery systems. In this review, we discuss the history of insulin and the pharmacology and therapeutic indications for a variety of available insulins, especially newer analog insulins. We highlight recent advances in insulin pump therapy and review evidence on the therapeutic benefits of automated insulin delivery. As with any form of progress, there have been setbacks, and insulin has recently faced an affordability crisis. We address the challenges of insulin accessibility, along with recent progress to improve insulin affordability. Finally, we mention research on glucose-responsive insulins and hepato-preferential insulins that are likely to shape the future of insulin therapy.

Glycaemia in low-premixed insulin analogue type 2 diabetes patients in a real-world setting: are the CGM targets met?

BACKGROUND

There are insufficient data on continuous glucose monitoring (CGM) in nonintensive insulin therapy patients. Using CGM and the recommended CGM targets, we wanted to evaluate low-premix insulin analogue therapy (biphasic aspart/NovoMix 30 and biphasic lispro 25/Humalog Mix 25) in real-world type 2 diabetes patients for glycaemic efficacy and especially hypoglycaemia.

METHODS

The prospective observational study was performed on 35 patients who were treated with a low-premixed insulin. We used the Dexcom G6 system for CGM (9.6 ± 1 days) to measure the clinically relevant CGM parameters: glycaemic variability (%CV), TBR (time below range) < 3.0 mmol/l = 54 mg/dl (level 2 hypoglycaemia), TBR 3.0-3.8 (= 54-69 mg/dl), TIR (time in range) 3.9-10-0 mmol/l (70-180 mg/dl), TAR (time above range) 10-13.9 mmol/l (180-250 mg/dl) and TAR > 13.9 mmol/l (250 mg/dl). We also assessed clinical and demographic characteristics, laboratory HbA1c, fasting blood glucose, peak postprandial glucose values, and the percentage of hypoglycaemia between 00:00 and 06:00.

RESULTS

In our patients, the average ± SD age was 70.4 ± 9.2 years, diabetes duration 17.4 ± 7.1 years, 51% were females, average daily insulin dose was 46.4 units (80% received biphasic aspart). The average ± SD TIR was 62.1 ± 12.2%, TBR < 3.0 mmol/l 0.8 ± 2.0%, TBR 3.0-3.8 mmol/l 1.5 ± 1.5%, TAR 10-13.9 mmol/l 29.2 ± 12.4%, TAR > 13.9 mmol/l 6.4 ± 7.2% and %CV 29.9 ± 7.1%. The average time in hypoglycemia was 33.1 min daily in our patients (11.5 min in the level 2 range). In the older/high-risk population, the TBR/TIR/TAR/level 2 TAR targets were met in 40/80/77/80%, respectively. For the general T2D people, level 2 TBR/TBR/TIR/TAR/level 2 TAR would be met in 74/83/34/77/49%. Average fasting blood glucose was 8.0 ± 2.5 mmol/l (144 ± 45 mg/dl), BMI 31.3 ± 5.1 kg/m2, daily insulin dose 46.4 ± 12.1 units, HbA1c 57.4 ± 5.4 mmol/mol (7.4 ± 0.7%). The glycaemic variability goal was met in 80% (with 66% meeting the lower 33% CV goal). 17 ± 12% of hypoglycaemia was nocturnal. People with TBR > 4% were significantly older.

CONCLUSIONS

Most of our type 2 diabetes patients, treated with low-premixed insulin, did not meet the recommended TBR target for older/high-risk patients while meeting the TIR and TAR targets. Nevertheless, the time spent in (total and nocturnal) hypoglycemia was short. The study indicates that the general type 2 diabetes population targets would mostly be met for TBR and %CV in our patients but not the TIR and TAR targets. CGM appears to be a useful clinical tool in these patients.

Hypoglycemic events and glycemic control effects between NPH and premixed insulin in patients with type 2 diabetes mellitus: A real-world experience at a comprehensive specialized hospital in Ethiopia

BACKGROUND

Though initiation of insulin results in a significant change in glycemic levels, treating patients without significant hypoglycemic events remains difficult in diabetes patients initiated with different insulin-based regimens. This study assessed the association of hypoglycemic incidence and glycemic control between NPH and premixed insulin regimens in patients with type 2 diabetes mellitus (T2DM).

METHODS

This was a retrospective observational study in patients with T2DM who were treated with insulin-based therapy from 2015 to 2020 at the University of Gondar Comprehensive Specialized hospital. Average fasting blood glucose (FBG) between NPH and premixed insulin regimens was compared using an independent t-test. The Association of NPH and premixed insulin regimens with hypoglycemic incidences and glycemic control was examined by a logistic regression model. P < 0.05 was statistically significant.

RESULTS

From 405 participants, more than half (55.3%) were males with a mean age of 59.2(±9.1) years. Baseline mean HbA1C and FBG levels were 12.73(±1.1) % and 347.7(±48.5) mg/dl, respectively. Within a one-year follow-up period of insulin initiation, the rate of hypoglycemia was 13.1%. The incidence of hypoglycemia was significantly higher in patients initiated with premixed insulin compared with NPH insulin regimens (P < 0.001). After one year of insulin initiation, HbA1C decreased from 12.7 to 7.6 and from 12.8 to 7.3% and FBG levels decreased from 347.5 to 160.7 and from 348.2 to 147.3 mg/dl following initiation of NPH and premixed insulin, respectively. Patients treated with premixed-based insulin were found more likely to achieve target FBG compared with patients treated with NPH insulin regimens after one year of initiation (P = 0.02).

CONCLUSION

Premixed insulin-based regimen has found to have a higher hypoglycemic incidence, but a better level of glycemic control compared to NPH insulin-based therapy. Therefore, patients initiated with premixed insulin need to be highly vigilant and motivated to recognize the symptoms of hypoglycemia.

One hundred years of insulin therapy

At the time of its first clinical application 100 years ago, insulin was presented as the cure for people with diabetes mellitus. That transpired to be an overstatement, yet insulin has proven to be the lifesaver for people with type 1 diabetes mellitus and an essential therapy for many with type 2 diabetes mellitus or other forms of diabetes mellitus. Since its discovery, insulin (a molecule of only 51 amino acids) has been the subject of pharmaceutical research and development that has paved the way for other protein-based therapies. From purified animal-extracted insulin and human insulin produced by genetically modified organisms to a spectrum of insulin analogues, pharmaceutical laboratories have strived to tailor the preparations to the needs of patients. Nonetheless, overall glycaemic control often remains poor as exogenous insulin is still not able to mimic the physiological insulin profile. Circumventing subcutaneous administration and the design of analogues with profiles that mimic that of physiological insulin are ongoing areas of research. Novel concepts, such as once-weekly insulins or glucose-dependent and oral insulins, are on the horizon but their real-world effectiveness still needs to be proven. Until a true cure for type 1 diabetes mellitus is found and the therapeutic arsenal for other forms of diabetes mellitus is expanded, insulin will remain central in the treatment of many people living with diabetes mellitus.

Efficacy and Safety of Insulin Degludec/Insulin Aspart Compared with a Conventional Premixed Insulin or Basal Insulin: A Meta-Analysis

Insulin degludec/insulin aspart (IDegAsp) is a novel co-formulation of 70% insulin degludec and 30% insulin aspart. The present meta-analysis was conducted to assess the efficacy and safety of IDegAsp compared with a conventional premixed insulin or basal insulin. We extracted data from citation databases, including PubMed, EMBASE, and the Cochrane Library, since inception to 2021. We calculated the mean differences for hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), self-measured mean glucose, and postprandial glucose (PPG) and odds ratios for confirmed hypoglycemia events. Compared with twice-daily conventional premixed insulin, twice-daily IDegAsp showed a similar effect on changes in HbA1c, but it significantly reduced FPG and self-measured mean glucose levels. Furthermore, compared to once-daily basal insulin, once-daily IDegAsp had a similar effect on changes in HbA1c, but it significantly reduced self-measured mean glucose and PPG levels. The risk of overall confirmed hypoglycemia was similar between treatments; however, the risk of nocturnal hypoglycemia events was significantly lower with IDegAsp than with conventional premixed insulin and basal insulin. Thus, IDegAsp was more effective than conventional premixed insulin and basal insulin at reducing blood glucose with fewer nocturnal hypoglycemia events.

Type 2 diabetes management in people aged over seventy-five years: targets and treatment strategies

Older people (those aged 65 years or more) with diabetes comprise a heterogenous group of patients with special needs and features; this is particularly true for those aged 75 years or more. It is important that individualized glycemic targets be adopted in this population, after considering life expectancy, presence of diabetic complications and other comorbidities. In general, less rigorous targets and avoidance of overtreatment seems to be a reasonable strategy in daily clinical settings. There is a paucity of data regarding the efficacy and safety of various hypoglycemic agents, especially for those aged over 75. The evidence suggests that sulfonylureas and insulin regimens should be used with caution due to a high risk of hypoglycemia. Dipeptidyl peptidase-4 inhibitors are a good choice for the management of diabetes in older age groups, although a warning against the use of specific agents in people with heart failure is valid. There are insufficient data to decide whether the cardiorenal protective properties of sodium-glucose co-transporter 2 inhibitors outweigh the risks associated with these drugs. The use of glucagon-like peptide-1 receptor agonists by older patients is supported not only by their good safety and efficacy profiles, but also by their potential to improve glucose-independent outcomes, through their pleiotropic actions. The aim of this narrative review is to summarize the evidence on glycemic targets and optimal therapeutic approaches for older patients with type 2 diabetes and discuss the risk-benefit balance of various therapeutic approaches in this group.

The Evolution of Insulin and How it Informs Therapy and Treatment Choices

Insulin has been available for the treatment of diabetes for almost a century, and the variety of insulin choices today represents many years of discovery and innovation. Insulin has gone from poorly defined extracts of animal pancreata to pure and precisely controlled formulations that can be prescribed and administered with high accuracy and predictability of action. Modifications of the insulin formulation and of the insulin molecule itself have made it possible to approximate the natural endogenous insulin response. Insulin and insulin formulations had to be designed to produce either a constant low basal level of insulin or the spikes of insulin released in response to meals. We discuss how the biochemical properties of endogenous insulin were exploited to either shorten or extend the time-action profiles of injectable insulins by varying the pharmacokinetics (time for appearance of insulin in the blood after injection) and pharmacodynamics (time-dependent changes in blood sugar after injection). This has resulted in rapid-acting, short-acting, intermediate-acting, and long-acting insulins, as well as mixtures and concentrated formulations. An understanding of how various insulins and formulations were designed to solve the challenges of insulin replacement will assist clinicians in meeting the needs of their individual patients.

Combining GLP-1 Receptor Agonists and Basal Insulin in Older Adults with Type 2 Diabetes: Focus on Lixisenatide and Insulin Glargine

Estimates suggest that there are currently 122.8 million adults 65-99 years of age living with diabetes, of whom 90-95% are diagnosed with type 2 diabetes (T2D). Over the past two decades, a greater understanding of the complex and multifactorial pathogenesis of T2D has resulted in the development and introduction of new-generation classes of glucose-lowering therapies, which are now extensively endorsed by prevailing guidelines and are increasingly being used worldwide. These newer agents may further assist in the effective pharmacological management of T2D through the provision of patient-centered care that acknowledges multimorbidity and is respectful of and responsive to individual patient preferences and barriers. Given these considerations, the therapeutic approach in older patients with T2D is complex, particularly in those who have functional dependence, frailty, dementia, or who are at end-of-life. It is currently too early to draw conclusions on the long-term use of newer glucose-lowering agents in this population, as their efficacy and safety in older adults remains largely unknown. In this review, we will discuss considerations for the use of glucose-lowering treatments in older adults, with particular focus on the use of basal insulin and glucagon-like peptide-1 receptor agonists, and the rationale for the use of combination therapy comprising these agents. Finally, we will review clinical data from studies of the fixed-ratio combination of insulin glargine and lixisenatide in older patients with T2D. FUNDING: Sanofi US, Inc.

Management of Diabetes in Patients Undergoing Bariatric Surgery

PURPOSE OF REVIEW

The number of bariatric surgeries for patients with type 1 or type 2 diabetes continues to grow. Clinicians are challenged to choose therapies that reach glycemic targets without inducing adverse effects in post-bariatric patients without published guidelines. This review evaluates data supporting the best strategies for diabetes management in patients undergoing bariatric surgery.

RECENT FINDINGS

Though few clinical trials have evaluated the safety and effectiveness of different glucose-lowering therapies following bariatric surgery, remission of diabetes or reduced medications is an established benefit of bariatric surgery. Adverse events including diabetic ketoacidosis in post-bariatric patients on sodium-glucose co-transporter 2 (SGLT2) inhibitors or inadequate insulin have been reported in patient's with both type 1 and type 2 diabetes. Metformin, glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, SGLT2 inhibitors, insulin, and sulfonylureas have been used successfully in the perioperative period for other surgeries and guidelines recommend adjusting the doses of these medications especially in the perioperative period. Clinicians should favor weight-neutral or weight-loss promoting therapies in post-bariatric surgery patients such as medical nutrition therapy, metformin, GLP-1 agonists, SGLT2 inhibitors, and DPP-4 inhibitors.

Capacity and confidence building for general practitioners on optimum insulin use

Type 2 diabetes is characterised by a progressive decline in insulin secretion, and sooner or later patients require insulin therapy. However, physicians are reluctant to initiate insulin therapy because of perceived inadequacy in managing insulin therapy, cost and lack of benefits. Experts from across the country met at a workshop during 12th National Insulin Summit which was held in September at Hyderabad and came up with key recommendations to build capacity and confidence in general practitioners for insulin usage. Barriers can be overcome through self-education and training; effective patient education; imparting coping skill training to patients; and bridging gaps to improve adherence. Moreover, optimum insulinization requires knowledge about the available options for initiation and intensification of insulin therapy; various insulin regimens; dosing and titration; and choosing effective and simple insulin therapy as per patient characteristics. Hence, the objective of this review article is to help build capacity and confidence among general practitioners on optimising insulin therapy.

Use of Insulin Glargine 100 U/mL for the Treatment of Type 2 Diabetes Mellitus in East Asians: A Review

Insulin glargine (IGlar) 100 U/mL (IGlar-100) is widely used in East Asian countries for the treatment of type 2 diabetes mellitus (T2DM) and is the gold standard of basal insulin treatment. In this review we summarize key information about clinical experience with IGlar-100 in East Asian patients with T2DM, including findings from clinical trials and postmarketing studies. We also provide recommendations and opinions on the optimal use of IGlar-100 in this population. The findings from the studies highlighted in our review indicate that IGlar-100 can be a suitable treatment option for East Asians with T2DM, from initial therapy in combination with oral antihyperglycemic medications through to different combinations and intensification models. FUNDING: Eli Lilly and Company.

Comparison of Efficacy and Economic Value of Prandilin 25 and Humalog Mix 25 in Patients with Newly Diagnosed Type 2 Diabetes by a Continuous Glucose Monitoring System

INTRODUCTION

To determine the clinical efficacy and economic value of insulin lispro 25-Prandilin 25 vs. insulin lispro 25-Humalog mix 25 in treatment of newly diagnosed type 2 diabetes mellitus (T2DM) by a continuous glucose monitoring system (CGMS).

METHODS

This was a single-center, randomized, case-crossover clinical trial. Participants were randomly allocated to two groups and underwent two kinds of insulin lispro 25 treatment separated by a 1-day washout period. In total, 81 patients with newly diagnosed T2DM with hemoglobin A1c (HbA1c) above 9% were hospitalized and randomly divided to receive Prandilin 25/Humalog mix 25 or Humalog mix 25/Prandilin 25 treatment. All participants were subjected to metformin therapy simultaneously. Glycemic control was reached after 7-8 days Prandilin 25 or Humalog mix 25 treatment; each patient received continuous glucose monitoring (CGM) for 5 consecutive days (from day 1 to day 5). On day 3 of CGM performance, Prandilin 25 treatment was switched to Humalog mix 25 treatment at the same dosage or vice versa. Parameters representing glycemic variability (GV) and postprandial glucose excursions, including 24-h mean blood glucose (24hMBG), 24-h standard deviation of blood glucose (24hSDBG), 24-h mean amplitude of glycemic excursion (24hMAGE), large amplitude of glycemic excursion (LAGE), incremental area under the curve (AUC) for different glucose levels, and postmeal relative areas under the CGM curve (AUCpp) for 1-4 h of each meal, were calculated for each patient.

RESULTS

No significant differences were found in the 24hMAGE, 24hMBG, 24hSDBG, LAGE, mean 1-h preprandial blood glucose and the incidence of hypoglycemia between the Prandilin 25 treatment group and Humalog mix 25 treatment group. Similarly, there were no between-treatment differences for AUC and time when blood glucose was below 3.9 mmol/l, between 3.9 mmol/l and 10.0 mmol/l, or above 10.0 mmol/l. Further analysis showed the AUCpp for 1-4 h of each meal for two kinds of treatments were similar. However, the mean estimated cost of Prandilin 25 was only 85% of Humalog mix 25 in one treatment course.

CONCLUSION

Prandilin 25 is non-inferior in clinical efficacy compared with Humalog mix 25. In view of the significant difference in the cost of the two kinds of insulin lispro 25, Prandilin 25 is a much more cost-effective anti-diabetes drug for management of T2DM.

TRIAL REGISTRATION

Chinese Clinical Trial Register identifier, ChiCTR1800015829.