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Rosenstock J, Juneja R, Beals JM, Moyers JS, Ilag L, McCrimmon RJ. The Basis for Weekly Insulin Therapy: Evolving Evidence With Insulin Icodec and Insulin Efsitora Alfa. Endocr Rev 2024; 45:379-413. [PMID: 38224978 PMCID: PMC11091825 DOI: 10.1210/endrev/bnad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Indexed: 01/17/2024]
Abstract
Basal insulin continues to be a vital part of therapy for many people with diabetes. First attempts to prolong the duration of insulin formulations were through the development of suspensions that required homogenization prior to injection. These insulins, which required once- or twice-daily injections, introduced wide variations in insulin exposure contributing to unpredictable effects on glycemia. Advances over the last 2 decades have resulted in long-acting, soluble basal insulin analogues with prolonged and less variable pharmacokinetic exposure, improving their efficacy and safety, notably by reducing nocturnal hypoglycemia. However, adherence and persistence with once-daily basal insulin treatment remains low for many reasons including hypoglycemia concerns and treatment burden. A soluble basal insulin with a longer and flatter exposure profile could reduce pharmacodynamic variability, potentially reducing hypoglycemia, have similar efficacy to once-daily basal insulins, simplify dosing regimens, and improve treatment adherence. Insulin icodec (Novo Nordisk) and insulin efsitora alfa (basal insulin Fc [BIF], Eli Lilly and Company) are 2 such insulins designed for once-weekly administration, which have the potential to provide a further advance in basal insulin replacement. Icodec and efsitora phase 2 clinical trials, as well as data from the phase 3 icodec program indicate that once-weekly insulins provide comparable glycemic control to once-daily analogues, with a similar risk of hypoglycemia. This manuscript details the technology used in the development of once-weekly basal insulins. It highlights the clinical rationale and potential benefits of these weekly insulins while also discussing the limitations and challenges these molecules could pose in clinical practice.
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Affiliation(s)
- Julio Rosenstock
- Velocity Clinical Research at Medical City,
Dallas, TX 75230, USA
| | - Rattan Juneja
- Lilly Diabetes and Obesity, Eli Lilly and Company,
Indianapolis, IN 46225, USA
| | - John M Beals
- Lilly Diabetes and Obesity, Eli Lilly and Company,
Indianapolis, IN 46225, USA
| | - Julie S Moyers
- Lilly Diabetes and Obesity, Eli Lilly and Company,
Indianapolis, IN 46225, USA
| | - Liza Ilag
- Lilly Diabetes and Obesity, Eli Lilly and Company,
Indianapolis, IN 46225, USA
| | - Rory J McCrimmon
- School of Medicine, University of Dundee, Dundee
DD1 9SY, Scotland, UK
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2
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Herskind AEJ, Nørgaard B. Gender representation in drug development studies for diabetes mellitus. A systematic review. Diabetes Metab Syndr 2023; 17:102815. [PMID: 37413814 DOI: 10.1016/j.dsx.2023.102815] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND During the last 20 years, the prevalence of diabetes mellitus (DM) has increased drastically, and so has the number of associated medicine and drug development studies. Despite knowing that men and women respond differently to DM medicines, biological gender differences still tend not to be prioritized during medicine development. OBJECTIVE This study examined gender representation in medicine development studies for DM. METHOD We conducted a systematic review, and in February 2022, we searched EMBASE (Excerpta Medica Database), MEDLINE (Medical Literature Analysis and Retrieval System Online) and PubMed using a block search strategy. Randomized controlled studies (RCTs) including people diagnosed with DM (any type) aged 18-65 years were included. The Consolidated Standards of Reporting Trial 2010 checklist was applied to assess the studies' reported quality. The results are presented in a narrative synthesis. RESULTS Nine studies met the inclusion criteria. On average, women represented 31.4% of study participants, and similarly, for each trial phase, women were less represented than men. CONCLUSION This review showed an unequal gender representation in drug development studies for DM, with women and men representing 31.4% and 68.6% of the study participants, respectively, in the included studies. However, gender differences in medical drug studies might be due to specific exclusion criteria, participants' behaviour toward attending in medicine development or the law in the country of origin.
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Affiliation(s)
| | - Birgitte Nørgaard
- Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej9, 5000, Odense C, Denmark.
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3
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Weinstock RS, Bode BW, Garg SK, Klonoff DC, El Sanadi C, Geho WB, Muchmore DB, Penn MS. Reduced hypoglycaemia using liver-targeted insulin in individuals with type 1 diabetes. Diabetes Obes Metab 2022; 24:1762-1769. [PMID: 35546449 PMCID: PMC9546184 DOI: 10.1111/dom.14761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/03/2022] [Accepted: 05/08/2022] [Indexed: 11/27/2022]
Abstract
AIM To investigate whether an increased bolus: basal insulin ratio (BBR) with liver-targeted bolus insulin (BoI) would increase BoI use and decrease hypoglycaemic events (HEv). PATIENT POPULATION AND METHODS We enrolled 52 persons (HbA1c 6.9% ± 0.12%, mean ± SEM) with type 1 diabetes using multiple daily injections. Hepatic-directed vesicle (HDV) was used to deliver 1% of peripheral injected BoI to the liver. A 90-day run-in period was used to introduce subjects to unblinded continuous glucose monitoring and optimize standard basal insulin (BaI) (degludec) and BoI (lispro) dosing. At 90 days, BoI was changed to HDV-insulin lispro and subjects were randomized to an immediate 10% or 40% decrease in BaI dose. RESULTS At 90 days postrandomization, total insulin dosing was increased by ~7% in both cohorts. The -10% and -40% BaI cohorts were on 7.7% and 13% greater BoI with 6.9% and 30% (P = .02) increases in BBR, respectively. Compared with baseline at randomization, nocturnal level 2 HEv were reduced by 21% and 43%, with 54% and 59% reductions in patient-reported HEv in the -10% and -40% BaI cohorts, respectively. CONCLUSIONS Our study shows that liver-targeted BoI safely decreases HEv and symptoms without compromising glucose control. We further show that with initiation of liver-targeted BoI, the BBR can be safely increased by significantly lowering BaI dosing, leading to greater BoI usage.
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Affiliation(s)
| | | | - Satish K. Garg
- Barbara Davis Center for Childhood DiabetesUniversity of Colorado DenverAuroraColorado
| | | | | | | | | | - Marc S. Penn
- Diasome Pharmaceuticals, Inc.ClevelandOhio
- Summa HealthAkronOhio
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Abstract
Although insulin therapy was already introduced one-hundred years ago, insulin formulations are still being refined to reduce the risk of hypoglycaemia and of other insulin side effects such as weight gain. This review summarises the available clinical data for some ongoing developments of new insulins and evaluates their potential for future insulin therapy. Once-weekly insulins will most likely be the next addition to the insulin armamentarium. First clinical studies indicate low peak-to-trough fluctuations with these insulins indicating the potential to achieve better glycaemic control or reduce hypoglycaemic events versus available basal insulins. Proof-of-concept has also been established for hepato-preferential and oral insulins; however, adverse effects and low bioavailability still need to be overcome. It will take much longer, before glucose-responsive "smart" insulins will be available. A first clinical study and numerous pre-clinical data show the potential, but also the challenges of designing an insulin that quickly reacts to blood glucose changes and prevents hypoglycaemia and pronounced hyperglycaemia. Nevertheless, it is reassuring that the search for better insulins has never stopped since its first use one-hundred years ago and is still ongoing. New developments have a high potential of further improving the safety and efficacy of insulin therapy in the future.
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Abstract
The growing proportion of type 1 diabetes mellitus (T1DM) patients with clinical features of insulin resistance (IR) has led to the description of a distinctive T1DM subgroup, still unrecognised by current guidelines, called double diabetes, assumingly associated with poorer metabolic phenotype and increased risk of micro- and macrovascular complications. The main goal of identifying double diabetes, estimated to be present in up to half of T1DM patients, is timely implementation of appropriate therapeutic interventions to reduce the increased risk of chronic complications and other adverse metabolic traits associated with this condition. Proposed diagnostic criteria are largely divided into three different groups: family history of type 2 diabetes mellitus (T2DM), obesity/metabolic syndrome, and IR. Estimated glucose disposal rate may prove the most reliable marker of double diabetes. In addition to general measures (diet, physical activity, antihypertensive, and lipid-lowering medications, etc.) and development of new insulin preparations with more hepatic action, double diabetes patients may derive more benefit from agents developed for T2DM. Indeed, such potentially promising agents include glucagon-like peptide-1 receptor agonists, sodium-glucose contrasporter-2 inhibitors, and their combination. We are now awaiting long-term trials assessing metabolic and vascular benefits of these medications in double diabetes.
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Affiliation(s)
- Djordje S Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Center of Vojvodina, Novi Sad, SERBIA.,Medical Faculty, University of Novi Sad, Novi Sad, SERBIA
| | - Nikolaos Papanas
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, GREECE
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Liu L, Yan H, Xia M, Zhao L, Lv M, Zhao N, Rao S, Yao X, Wu W, Pan B, Bian H, Gao X. Efficacy of exenatide and insulin glargine on nonalcoholic fatty liver disease in patients with type 2 diabetes. Diabetes Metab Res Rev 2020; 36:e3292. [PMID: 31955491 DOI: 10.1002/dmrr.3292] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 01/11/2020] [Accepted: 01/14/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of this study was to investigate the efficacy of exenatide and insulin glargine in patients with newly diagnosed type 2 diabetes mellitus (T2DM) and nonalcoholic fatty liver disease (NAFLD). METHODS We performed a 24-week randomized controlled multicentre clinical trial. Seventy-six patients were randomly assigned 1:1 to receive exenatide or insulin glargine treatment. The endpoints included changes in liver fat content (LFC), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) measured by magnetic resonance spectroscopy, blood glucose, liver enzymes, lipid profile, body weight, and Fibrosis-4 index (FIB-4). RESULTS LFC, VAT, SAT, and FIB-4 were significantly reduced after exenatide treatment (ΔLFC, -17.55 ± 12.93%; ΔVAT, -43.57 ± 68.20 cm2 ; ΔSAT, -28.44 ± 51.48 cm2 ; ΔFIB-4, -0.10 ± 0.26; all P < .05). In comparison, only LFC (ΔLFC, -10.49 ± 11.38%; P < .05), and not VAT, SAT, or FIB-4 index (all P > .05), was reduced after insulin glargine treatment. Moreover, exenatide treatment resulted in greater reductions in alanine transaminase (ALT), aspartate transaminase (AST), and gamma glutamyl transpeptidase (GGT) than insulin glargine (P < 0.05). The body weight, waist circumference, postprandial plasma glucose, and low-density lipoprotein cholesterol (LDL-C) in the exenatide group also presented greater reductions than the insulin glargine group (P < .05). The proportion of adverse events were comparable between the two groups. CONCLUSION Both exenatide and insulin glargine reduced LFC in patients with drug-naive T2DM and NAFLD; however, exenatide showed greater reductions in body weight, visceral fat area, liver enzymes, FIB-4, postprandial plasma glucose, and LDL-C.
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Affiliation(s)
- Lin Liu
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
- Fudan Institute for Metabolic Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hongmei Yan
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
- Fudan Institute for Metabolic Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - MingFeng Xia
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
- Fudan Institute for Metabolic Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lin Zhao
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
- Fudan Institute for Metabolic Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Minzhi Lv
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Naiqin Zhao
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China
| | - Shengxiang Rao
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiuzhong Yao
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiyun Wu
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Baishen Pan
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hua Bian
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
- Fudan Institute for Metabolic Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Gao
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
- Fudan Institute for Metabolic Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
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7
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Gregory JM, Cherrington AD, Moore DJ. The Peripheral Peril: Injected Insulin Induces Insulin Insensitivity in Type 1 Diabetes. Diabetes 2020; 69:837-847. [PMID: 32312900 PMCID: PMC7171956 DOI: 10.2337/dbi19-0026] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/12/2020] [Indexed: 12/13/2022]
Abstract
Insulin resistance is an underappreciated facet of type 1 diabetes that occurs with remarkable consistency and considerable magnitude. Although therapeutic innovations are continuing to normalize dysglycemia, a sizable body of data suggests a second metabolic abnormality-iatrogenic hyperinsulinemia-principally drives insulin resistance and its consequences in this population and has not been addressed. We review this evidence to show that injecting insulin into the peripheral circulation bypasses first-pass hepatic insulin clearance, which leads to the unintended metabolic consequence of whole-body insulin resistance. We propose restructuring insulin therapy to restore the physiological insulin balance between the hepatic portal and peripheral circulations and thereby avoid the complications of life-long insulin resistance. As technology rapidly advances and our ability to ensure euglycemia improves, iatrogenic insulin resistance will become the final barrier to overcome to restore normal physiology, health, and life in type 1 diabetes.
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Affiliation(s)
- Justin M Gregory
- Ian Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN
| | - Alan D Cherrington
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN
| | - Daniel J Moore
- Ian Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN
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8
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Gregory JM, Kraft G, Scott MF, Neal DW, Farmer B, Smith MS, Hastings JR, Madsen P, Kjeldsen TB, Hostrup S, Brand CL, Fledelius C, Nishimura E, Cherrington AD. Peripherally delivered hepatopreferential insulin analog insulin-406 mimics the hypoglycaemia-sparing effect of portal vein human insulin infusion in dogs. Diabetes Obes Metab 2019; 21:2294-2304. [PMID: 31183936 PMCID: PMC8132115 DOI: 10.1111/dom.13808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/26/2019] [Accepted: 06/05/2019] [Indexed: 12/16/2022]
Abstract
AIMS We previously quantified the hypoglycaemia-sparing effect of portal vs peripheral human insulin delivery. The current investigation aimed to determine whether a bioequivalent peripheral vein infusion of a hepatopreferential insulin analog, insulin-406, could similarly protect against hypoglycaemia. MATERIALS AND METHODS Dogs received human insulin infusions into either the hepatic portal vein (PoHI, n = 7) or a peripheral vein (PeHI, n = 7) for 180 minutes at four-fold the basal secretion rate (6.6 pmol/kg/min) in a previous study. Insulin-406 (Pe406, n = 7) was peripherally infused at 6.0 pmol/kg/min, a rate determined to decrease plasma glucose by the same amount as with PoHI infusion during the first 60 minutes. Glucagon was fixed at basal concentrations, mimicking the diminished α-cell response seen in type 1 diabetes. RESULTS Glucose dropped quickly with PeHI infusion, reaching 41 ± 3 mg/dL at 60 minutes, but more slowly with PoHI and Pe406 infusion (67 ± 2 and 72 ± 4 mg/dL, respectively; P < 0.01 vs PeHI for both). The hypoglycaemic nadir (c. 40 mg/dL) occurred at 60 minutes with PeHI infusion vs 120 minutes with PoHI and Pe406 infusion. ΔAUCepinephrine during the 180-minute insulin infusion period was two-fold higher with PeHI infusion compared with PoHI and Pe406 infusion. Glucose production (mg/kg/min) was least suppressed with PeHI infusion (Δ = 0.79 ± 0.33) and equally suppressed with PoHI and Pe406 infusion (Δ = 1.16 ± 0.21 and 1.18 ± 0.17, respectively; P = NS). Peak glucose utilization (mg/kg/min) was highest with PeHI infusion (4.94 ± 0.17) and less with PoHI and Pe406 infusion (3.58 ± 0.58 and 3.26 ± 0.08, respectively; P < 0.05 vs Pe for both). CONCLUSIONS Peripheral infusion of hepatopreferential insulin can achieve a metabolic profile that closely mimics portal insulin delivery, which reduces the risk of hypoglycaemia compared with peripheral insulin infusion.
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Affiliation(s)
- Justin M. Gregory
- Ian Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Guillaume Kraft
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Melanie F. Scott
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Doss W. Neal
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ben Farmer
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Marta S. Smith
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jon R. Hastings
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Peter Madsen
- Global Research Technologies, Novo Nordisk A/S, Maaleov, Denmark
| | | | - Susanne Hostrup
- Global Research Technologies, Novo Nordisk A/S, Maaleov, Denmark
| | | | | | | | - Alan D. Cherrington
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee
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Porksen NK, Linnebjerg H, Lam ECQ, Garhyan P, Pachori A, Pratley RE, Smith SR. Basal insulin peglispro increases lipid oxidation, metabolic flexibility, thermogenesis and ketone bodies compared to insulin glargine in subjects with type 1 diabetes mellitus. Diabetes Obes Metab 2018; 20:1193-1201. [PMID: 29316143 DOI: 10.1111/dom.13215] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 12/19/2017] [Accepted: 12/31/2017] [Indexed: 01/08/2023]
Abstract
AIMS When treated with basal insulin peglispro (BIL), patients with type 1 diabetes mellitus (T1DM) exhibit weight loss and lower prandial insulin requirements versus insulin glargine (GL), while total insulin requirements remain similar. One possible explanation is enhanced lipid oxidation and improved ability to switch between glucose and lipid metabolism with BIL. This study compared the effects of BIL and GL on glucose and lipid metabolism in subjects with T1DM. MATERIALS AND METHODS Fifteen subjects with T1DM were enrolled into this open-label, randomised, crossover study, and received once-daily stable, individualised, subcutaneous doses of BIL and GL for 4 weeks each. Respiratory quotient (RQ) was measured using whole-room calorimetry, and energy expenditure (EE) and concentrations of ketone bodies (3-hydroxybutyrate) and acylcarnitines were assessed. RESULTS Mean sleep RQ was lower during the BIL (0.822) than the GL (0.846) treatment period, indicating greater lipid metabolism during the post-absorptive period with BIL. Increases in carbohydrate oxidation following breakfast were greater during BIL than GL treatment (mean change in RQ following breakfast 0.111 for BIL, 0.063 for GL). Furthermore, BIL treatment increased total daily EE versus GL (2215.9 kcal/d for BIL, 2135.5 kcal/d for GL). Concentrations of ketone bodies and acylcarnitines appeared to be higher following BIL than GL treatment. CONCLUSIONS BIL increased sleeping fat oxidation, EE, ketone bodies, acylcarnitines and post-prandial glucose metabolism when switching from conventional insulin, thus, restoring metabolic flexibility and increasing thermogenesis. These changes may explain the previously observed weight loss with BIL versus GL.
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Affiliation(s)
| | | | - Eric Chen Quin Lam
- Formerly of Lilly-NUS Centre for Clinical Pharmacology, Singapore, Singapore
| | | | - Alok Pachori
- Translational Research Institute for Metabolism and Diabetes, Orlando, Florida
| | - Richard E Pratley
- Translational Research Institute for Metabolism and Diabetes, Orlando, Florida
| | - Steven R Smith
- Translational Research Institute for Metabolism and Diabetes, Orlando, Florida
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Qu Y, Luo J, Garhyan P, Antalis CJ, Chang AM, Jacober SJ. Dose Unit Establishment for a New Basal Insulin Using Joint Modeling of Insulin Dose and Glycemic Response. J Diabetes Sci Technol 2018; 12:155-162. [PMID: 28466661 PMCID: PMC5761965 DOI: 10.1177/1932296817707542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For new insulin analogs with properties that vary from human insulin, defining activity in units of human insulin based on glycemic lowering efficacy may be challenging. Here we present a new method that can be used to quantify a unit dose of an experimental insulin when the traditional euglycemic clamp method is not adequate. METHODS Joint modeling of insulin dose and the glycemic outcome variable hemoglobin A1c (HbA1c), where both were response variables, was used to evaluate insulin unit potency for basal insulin peglispro (BIL). The data were from the Phase 3 program for BIL, which included greater than 5500 patients with type 1 or type 2 diabetes who were treated for 26 or 52 weeks with BIL or a comparator insulin. Both basal-bolus and basal insulin only studies were included, and some type 2 diabetes patients were insulin-naïve. RESULTS The analysis showed that 1 unit of BIL, composed of 9 nmol of active ingredient, had similar or slightly greater potency compared to 1 unit insulin glargine or NPH insulin for all populations. CONCLUSIONS Despite some limitations, the joint modeling of HbA1c and insulin dose provides a reasonable approach to estimate the relative potency of a new basal insulin versus an established basal insulin.
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Affiliation(s)
- Yongming Qu
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | | | | | | | - Scott J. Jacober
- Eli Lilly and Company, Indianapolis, IN, USA
- Scott J. Jacober, DO, Eli Lilly and Company, Lilly Corporate Center, Drop Code 2232, Indianapolis, IN 46285, USA.
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11
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Sanyal A, Cusi K, Hartman ML, Zhang S, Bastyr EJ, Bue-Valleskey JM, Chang AM, Haupt A, Jacober SJ, Konrad RJ, Zhang Q, Hoogwerf BJ. Cytokeratin-18 and enhanced liver fibrosis scores in type 1 and type 2 diabetes and effects of two different insulins. J Investig Med 2017; 66:661-668. [PMID: 29167192 DOI: 10.1136/jim-2017-000609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2017] [Indexed: 02/07/2023]
Abstract
Data on cytokeratin-18 (K-18) and enhanced liver fibrosis (ELF) score in insulin-treated diabetes patients with non-alcoholic fatty liver disease (NAFLD) are limited. This study analyzed phase III data comparing basal insulin peglispro (BIL) and insulin glargine in type 1 (T1D), and type 2 diabetes (T2D) (insulin-naïve and insulin-treated). Alanine aminotransferase (ALT), K-18, ELF scores and liver fat content (LFC), measured by MRI, were obtained longitudinally. Baseline K-18 (U/L) was higher in T2D (range: 207‒247) than T1D (range: 148‒183), correlated with ALT in all populations (r (range) 0.264‒0.637, p<0.05), but with LFC only in T2D (r (range) 0.474‒0.586, p<0.05). K-18 increased significantly from baseline in BIL-treated, but not glargine-treated patients. Change from baseline (CFB) K-18 was significantly correlated with CFB in ALT in BIL-treated T2D populations. Baseline ELF scores were higher in T2D (range: 9.12‒9.20) than T1D (range: 8.24‒8.36), correlated with ALT in T1D only (0.209, p<0.05), and not correlated with LFC in any population. ELF scores increased significantly from baseline in BIL-treated but not glargine-treated patients. There were no correlations between CFB in LFC and ELF score at week 52 in any treatment group/population. In all BIL-treated populations, CFB in ALT and CFB in ELF score at week 52 were positively correlated. These data characterize associations of K-18 and ELF score with ALT and LFC in insulin-treated patients with T1D and T2D. Hepatopreferential insulins may be associated with increased K-18 and ELF scores but mechanisms and clinical significance are unknown. ClinicalTrials.gov identifiers are NCT01481779, NCT01435616, NCT01454284 and NCT01582451.
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Affiliation(s)
- Arun Sanyal
- Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida, USA
| | - Mark L Hartman
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Shuyu Zhang
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Edward J Bastyr
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana, USA.,Division of Endocrinology & Metabolism, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Annette M Chang
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Axel Haupt
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Scott J Jacober
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Robert J Konrad
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Qianyi Zhang
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Byron J Hoogwerf
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana, USA
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12
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Pillai S, Duvvuru S, Bhatnagar P, Foster W, Farmen M, Shankar S, Harris C, Bastyr E, Hoogwerf B, Haupt A. The PNPLA3 I148M variant is associated with transaminase elevations in type 2 diabetes patients treated with basal insulin peglispro. THE PHARMACOGENOMICS JOURNAL 2017; 18:487-493. [DOI: 10.1038/tpj.2017.45] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 07/24/2017] [Accepted: 08/04/2017] [Indexed: 12/27/2022]
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13
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Harris C, Forst T, Heise T, Plum-Mörschel L, Watkins E, Zhang Q, Fan L, Garhyan P, Porksen N. Hypoglycemia Risk Related to Double Dose Is Markedly Reduced with Basal Insulin Peglispro Versus Insulin Glargine in Patients with Type 2 Diabetes Mellitus in a Randomized Trial: IMAGINE 8. Diabetes Technol Ther 2017; 19:463-470. [PMID: 28817342 PMCID: PMC5567880 DOI: 10.1089/dia.2016.0414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Basal insulin peglispro (BIL) has a peripheral-to-hepatic distribution of action that resembles endogenous insulin and a prolonged duration of action with a flat pharmacokinetic/pharmacodynamic profile at steady state, characteristics that tend to reduce hypoglycemia risk compared to insulin glargine (GL). The primary objective was to demonstrate that clinically significant hypoglycemia (blood glucose ≤54 mg/dL [3.0 mmol/L] or symptoms of severe hypoglycemia) occurred less frequently within 84 h after a double dose (DD) of BIL than a DD of GL. METHODS This was a randomized, double-blind, two-period crossover study in patients with type 2 diabetes (T2D) previously treated with insulin (N = 68). For the first 3 weeks of each of the two crossover periods, patients received an individualized dose of BIL or GL once nightly (stable dose for 2 weeks/period). Then, during a 7-day inpatient stay with frequent blood glucose monitoring and standardized meals, one DD of study insulin was given. Glucose was infused if blood glucose was ≤54 mg/dL (3.0 mmol/L) or for symptoms of severe hypoglycemia. RESULTS Within 84 h after the DD, a significantly smaller proportion of patients experienced clinically significant hypoglycemia with BIL compared to GL (BIL, 6.6%; GL, 35.5%; odds ratio for BIL/GL 0.13 [95% confidence interval 0.04-0.39]; P < 0.001). Adverse event profiles were similar for the two insulins. Serum alanine aminotransferase and triglyceride levels were significantly higher with BIL versus GL. CONCLUSIONS BIL has a markedly lower risk of hypoglycemia than GL when replicating a double-dose error in patients with T2D.
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Affiliation(s)
| | | | | | | | - Elaine Watkins
- Profil Institute for Clinical Research, Chula Vista, California, USA
- Pharmaceutical Product Development, Inc., Wilmington, North Carolina, USA
| | - Qianyi Zhang
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Ludi Fan
- Eli Lilly and Company, Indianapolis, Indiana, USA
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Orchard TJ, Cariou B, Connelly MA, Otvos JD, Zhang S, Antalis CJ, Ivanyi T, Hoogwerf BJ. The effects of basal insulin peglispro vs. insulin glargine on lipoprotein particles by NMR and liver fat content by MRI in patients with diabetes. Cardiovasc Diabetol 2017; 16:73. [PMID: 28587667 PMCID: PMC5461740 DOI: 10.1186/s12933-017-0555-1] [Citation(s) in RCA: 3] [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: 03/06/2017] [Accepted: 05/26/2017] [Indexed: 12/23/2022] Open
Abstract
Background In Phase 2/3 studies of basal insulin peglispro (BIL) compared to insulin glargine, patients with type 1 or type 2 diabetes previously treated with insulin and randomized to BIL had an increase in serum triglycerides (TGs). To further understand lipoprotein changes, a lipid substudy which included liver fat content was designed to assess relationships among the measured variables for each diabetes cohort and compare the hepato-preferential insulin BIL to glargine. Methods In three cohorts of patients with diabetes (type 1, type 2 insulin naïve, and type 2 previously on insulin; n = 652), liver fat content (LFC) was determined by magnetic resonance imaging (MRI) and blood lipids were analyzed by nuclear magnetic resonance (NMR) spectroscopy at baseline, 26 and 52 weeks of treatment. Apolipoproteins, adiponectin, and other lipid parameters were also measured. Descriptive statistics were done, as well as correlation analyses to look for relationships among LFC and lipoproteins or other lipid measures. Results In patients with type 1 diabetes treated with BIL, but not glargine, small LDL and medium and large VLDL subclass concentrations increased from baseline. In patients with type 2 diabetes previously on insulin and treated with BIL, large VLDL concentration increased from baseline. In insulin naïve patients with type 2 diabetes treated with BIL, there were very few changes, while in those treated with glargine, small LDL and large VLDL decreased from baseline. Baseline LFC correlated significantly in one or more cohorts with baseline large VLDL, small LDL, VLDL size, and Apo C3. Changes in LFC by treatment showed generally weak correlations with lipoprotein changes, except for positive correlations with large VLDL and VLDL size. Adiponectin was higher in patients with type 1 diabetes compared to patients with type 2 diabetes, but decreased with treatment with both BIL and glargine. Conclusions The lipoprotein changes were in line with the observed changes in serum TGs; i.e., the cohorts experiencing increased TGs and LFC with BIL treatment had decreased LDL size and increased VLDL size. These data and analyses add to the currently available information on the metabolic effects of insulins in a very carefully characterized cohort of patients with diabetes. Clinicaltrials.gov registration numbers and dates NCT01481779 (2011), NCT01435616 (2011), NCT01454284 (2011), NCT01582451 (2012) Electronic supplementary material The online version of this article (doi:10.1186/s12933-017-0555-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Trevor J Orchard
- Department of Epidemiology, GSPH, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bertrand Cariou
- l'Institut du Thorax, CHU Nantes INSERM, CNRS, UNIV Nantes, Nantes, France
| | - Margery A Connelly
- LipoScience, Laboratory Corporation of America Holdings, Morrisville, NC, 27560, USA
| | - James D Otvos
- LipoScience, Laboratory Corporation of America Holdings, Morrisville, NC, 27560, USA
| | - Shuyu Zhang
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - Caryl J Antalis
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | | | - Byron J Hoogwerf
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA.
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15
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Cusi K, Sanyal AJ, Zhang S, Hoogwerf BJ, Chang AM, Jacober SJ, Bue-Valleskey JM, Higdon AN, Bastyr EJ, Haupt A, Hartman ML. Different effects of basal insulin peglispro and insulin glargine on liver enzymes and liver fat content in patients with type 1 and type 2 diabetes. Diabetes Obes Metab 2016; 18 Suppl 2:50-58. [PMID: 27723227 DOI: 10.1111/dom.12751] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 07/20/2016] [Indexed: 12/15/2022]
Abstract
AIMS To compare effects of basal insulin peglispro (BIL), a hepatopreferential insulin, to insulin glargine (glargine) on aminotransferases and liver fat content (LFC) in patients with type 1 and type 2 diabetes (T1D, T2D). MATERIALS AND METHODS Data from two Phase 2 and five Phase 3 randomized trials comparing BIL and glargine in 1709 T1D and 3662 T2D patients were integrated for analysis of liver laboratory tests. LFC, measured by magnetic resonance imaging (MRI) at baseline, 26 and 52 weeks, was analyzed in 182 T1D patients, 176 insulin-naïve T2D patients and 163 T2D patients previously treated with basal insulin. RESULTS Alanine aminotransferase (ALT) increased in patients treated with BIL, was higher than in glargine-treated patients at 4-78 weeks (difference at 52 weeks in both T1D and T2D: 7 international units/litre (IU/L), P < .001), and decreased after discontinuation of BIL. More BIL patients had ALT ≥3× upper limit of normal (ULN) than glargine. No patient had ALT ≥3× ULN with bilirubin ≥2× ULN that was considered causally related to BIL. In insulin-naїve T2D patients, LFC decreased with glargine but was unchanged with BIL. In T1D and T2D patients previously treated with basal insulin, LFC was unchanged with glargine but increased with BIL. In all three populations, LFC was higher after treatment with BIL vs glargine (difference at 52 weeks: 2.2% to 5.3%, all P < .01). CONCLUSIONS Compared to glargine, patients treated with BIL had higher ALT and LFC at 52-78 weeks. No severe drug-induced liver injury was apparent with BIL treatment for up to 78 weeks.
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Affiliation(s)
- K Cusi
- Division of Endocrinology, Diabetes and Metabolism, University of Florida College of Medicine, Gainesville, FL, USA
| | - A J Sanyal
- Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - S Zhang
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - B J Hoogwerf
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - A M Chang
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - S J Jacober
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - J M Bue-Valleskey
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - A N Higdon
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - E J Bastyr
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - A Haupt
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - M L Hartman
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA.
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