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Fleeman L, Gilor C. Insulin Therapy Part 3: Cats. Vet Clin North Am Small Anim Pract 2023; 53:635-644. [PMID: 36906468 DOI: 10.1016/j.cvsm.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
No insulin formulation should be considered best by default for management of feline diabetes. Rather, the choice of insulin formulation should be tailored to the specific clinical situation. In most cats that have some residual beta cell function, administering only a basal insulin might lead to complete normalization of blood glucose concentrations. Basal insulin requirements are constant throughout the day. Therefore, for an insulin formulation to be effective and safe as a basal insulin, its action should be roughly the same every hour of the day. At present, only insulin glargine U300 approaches this definition in cats.
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Affiliation(s)
- Linda Fleeman
- Animal Diabetes Australia, Melbourne, Victoria, Australia.
| | - Chen Gilor
- Small Animal Internal Medicine, Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, 2015 Southwest 16th Avenue, Gainesville, FL 32608, USA
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Fleeman L, Gilor C. Insulin Therapy in Small Animals, Part 3: Dogs. Vet Clin North Am Small Anim Pract 2023; 53:645-656. [PMID: 36906466 DOI: 10.1016/j.cvsm.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Insulin therapy should ideally mimic a basal-bolus pattern. Lente, NPH, NPH/regular mixes, PZI, glargine U100, and detemir are intermediate-acting formulations that are administered twice daily in dogs. To minimize hypoglycemia, intermediate-acting insulin protocols are usually geared towards alleviating (but not eliminating) clinical signs. Insulin glargine U300 and insulin degludec meet the criteria for an effective and safe basal insulin in dogs. In most dogs, good control of clinical signs is achieved when using a basal insulin alone. In a small minority, bolus insulin at the time of at least one meal per day may be added to optimize glycemic control.
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Affiliation(s)
- Linda Fleeman
- Animal Diabetes Australia, Melbourne, Victoria, Australia.
| | - Chen Gilor
- Small Animal Internal Medicine, Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, 2015 Southwest 16th Avenue, Gainesville, FL 32608, USA
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Gilor C, Fleeman LM. One hundred years of insulin: Is it time for smart? J Small Anim Pract 2022; 63:645-660. [PMID: 35560042 DOI: 10.1111/jsap.13507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 10/10/2021] [Accepted: 11/16/2021] [Indexed: 11/26/2022]
Abstract
Smarter understanding of diabetes pathophysiology and pharmacology of insulin therapy can lead to better clinical outcomes. Rather than looking for an insulin formulation that is considered "best" for a general population, it could be appropriate to seek the "smart" insulin choice, tailored to the specific clinical situation. Different treatment goals should be considered, with pros and cons to each. Ideally, insulin therapy in most diabetic dogs should mimic a "basal-bolus" pattern. The "intermediate"-acting insulin formulations might provide better "bolus" treatment in dogs than the rapid-acting formulations used in people. In patients with some residual beta cell function such as many diabetic cats, administering only a "basal" insulin might lead to complete normalisation of blood glucose concentrations. Insulin suspensions (neutral protamine Hagedorn, neutral protamine Hagedorn/regular mixes, lente and protamine zinc insulin) as well as insulin glargine U100 and detemir are "intermediate"-acting formulations that are administered twice daily. For a formulation to be an effective and safe "basal" insulin, its action should be roughly the same every hour of the day. Currently, only insulin glargine U300 and insulin degludec meet this standard in dogs, whereas in cats, insulin glargine U300 is the closest option.
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Affiliation(s)
- C Gilor
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - L M Fleeman
- Animal Diabetes Australia, Melbourne, Victoria, Australia
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Shiel RE, Mooney CT. Insulins for the long term management of diabetes mellitus in dogs: a review. Canine Med Genet 2022; 9:1. [PMID: 35152907 PMCID: PMC8842735 DOI: 10.1186/s40575-022-00114-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/02/2022] [Indexed: 01/13/2023] Open
Abstract
The year 2021 marked the centenary of the isolation of a therapeutic form of insulin and its successful use in dogs. This was a landmark moment that subsequently and rapidly led to the commercial manufacture of insulin for use in humans. The impact of insulin was almost miraculous as those destined to die from their diabetes mellitus returned to life. Over the past 100 years, insulin formulations have been modified to attempt to provide a predictable and prolonged duration of action while avoiding the development of hypoglycaemia. This has led to an ever-growing variety of insulin types in human medicine, many of which have subsequently been used in dogs. The purpose of this review article is to provide an overview of available insulin types and their application to the chronic management of canine diabetes mellitus.
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Affiliation(s)
- Robert E Shiel
- School of Veterinary Medicine, University College Dublin, Belfield, Dublin 4, Ireland.
| | - Carmel T Mooney
- School of Veterinary Medicine, University College Dublin, Belfield, Dublin 4, Ireland
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Ward CR, Christiansen K, Li J, Bryson WL, Jerrentrup KA, Kroh C. Field efficacy and safety of protamine zinc recombinant human insulin in 276 dogs with diabetes mellitus. Domest Anim Endocrinol 2021; 75:106575. [PMID: 33186842 DOI: 10.1016/j.domaniend.2020.106575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 09/11/2020] [Accepted: 09/17/2020] [Indexed: 11/25/2022]
Abstract
Twice-daily (BID) insulin injections are a major deterrence to owners treating dogs with diabetes mellitus (DM). The hypothesis for this study was that Protamine Zinc Recombinant Human Insulin (PZIR) is safe and efficacious as a once-daily (SID) treatment for canine DM. This was a prospective, baseline-controlled, multi-center study over 182 ± 5 d. Two hundred seventy-six client-owned dogs with naturally occurring DM (naïve or pre-treated with insulin) were enrolled in the study. Enrollment was based upon demonstration of hyperglycemia, glycosuria, and ≥1 diabetic clinical sign (polyuria (PU), polydipsia (PD), or weight loss). Insulin treatment was initiated at 0.5-1.0 IU/kg SID. An improvement in at least one lab parameter related to DM (mean BG, min BG, Fructosamine) and one clinical parameter (PU/PD, body weight) was achieved in 72% of dogs (80% of naive, 62% of pre-treated). Dogs treated SID and BID showed improvement in 71% and 74% of cases, respectively. In naïve dogs, mean and minimum BG and fructosamine were significantly decreased (P < 0.05) by d 7 and 21, respectively, and in pre-treated dogs by d 63. By d 84, PU/PD improved in 90% and 88% of dogs, respectively, and the mean successful insulin dose was 1.4 IU/kg/d. Safety parameters were measured in 276 dogs for up to 182 d; clinical hypoglycemia occurred in 8.9% of dogs. We conclude that PZIR safely and effectively improved glycemic parameters and clinical signs in naïve and pre-treated diabetic dogs. The significant percentage of dogs on SID treatment with improvement in hyperglycemia and clinical signs confirms the prolonged action of PZIR in many dogs.
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Affiliation(s)
- C R Ward
- Department of Small Animal Medicine and Surgery, University of Georgia, Athens, GA.
| | - K Christiansen
- Boehringer Ingelheim Animal Health USA Ltd., St. Joseph, MO
| | - J Li
- Boehringer Ingelheim Animal Health USA Ltd., St. Joseph, MO
| | - W L Bryson
- Boehringer Ingelheim Animal Health USA Ltd., St. Joseph, MO
| | - K A Jerrentrup
- Boehringer Ingelheim Vetmedica GmbH, Ingelheim am Rhein, Germany
| | - C Kroh
- Boehringer Ingelheim Vetmedica GmbH, Ingelheim am Rhein, Germany
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Werner U, Tennagels N, Fanelli CG, Bolli GB. Equipotency of insulin glargine 300 and 100 U/mL with intravenous dosing but differential bioavailability with subcutaneous dosing in dogs. Diabetes Obes Metab 2021; 23:166-174. [PMID: 33001554 PMCID: PMC7821234 DOI: 10.1111/dom.14212] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/25/2020] [Accepted: 09/27/2020] [Indexed: 12/25/2022]
Abstract
AIMS Insulin glargine 300 U/mL (Gla-300) contains the same units versus glargine 100 U/mL (Gla-100) in three-fold lower volume, and higher subcutaneous (SC) doses are required in people with diabetes. To investigate blood glucose (BG) lowering potency, Gla-300 and Gla-100 were compared after intravenous (IV, for 4 h) and SC (for 24 h) injection in healthy Beagle dogs. MATERIALS AND METHODS The dose of 0.15 U/kg Gla-300 and Gla-100 was injected IV in 12 dogs. BG, C-peptide, glucagon and the active metabolite 21A-Gly-human insulin (M1; liquid chromatography-tandem mass spectrometry method) were measured. Twelve other dogs were studied after SC injection of 0.3 U/kg Gla-300 and Gla-100. RESULTS After IV injection, Gla-300 and Gla-100 were equally potent [BG_AUC0-4 h ratio 1.01 (95% confidence interval, 0.94; 1.09)]. After SC injection, BG decreased slower and less with Gla-300. Similar metabolism of Gla-300 and Gla-100 to M1 occurred with IV dosing [M1_AUC0-1 h ratio 0.99 (95% confidence interval, 0.82; 1.22)], but with SC dosing M1_Cmax and AUC0-24h were 44% and 17% lower; mean residency time and bioavailability were 32% longer and 50% lower, with Gla-300. CONCLUSIONS IV Gla-300 and Gla-100 have the equivalent of BG-lowering potency and M1 metabolism. SC Gla-300 has lower M1 bioavailability with a reduced BG-lowering effect and need for greater doses versus Gla-100.
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Affiliation(s)
- Ulrich Werner
- Insulin Biology, R&D Research Therapeutic Area Diabetes Cardiovascular, SanofiFrankfurt a.M.Germany
| | - Norbert Tennagels
- Insulin Biology, R&D Research Therapeutic Area Diabetes Cardiovascular, SanofiFrankfurt a.M.Germany
| | - Carmine G. Fanelli
- Section of Endocrinology and Metabolism, Department of MedicineUniversity of Perugia Medical SchoolPerugiaItaly
| | - Geremia B. Bolli
- Section of Endocrinology and Metabolism, Department of MedicineUniversity of Perugia Medical SchoolPerugiaItaly
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Dong S, Zeng Y, Wei G, Si D, Liu C. Determination of human insulin in dog plasma by a selective liquid chromatography-tandem mass spectrometry method: Application to a pharmacokinetic study. J Chromatogr B Analyt Technol Biomed Life Sci 2018; 1077-1078:85-91. [DOI: 10.1016/j.jchromb.2017.12.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 12/18/2017] [Accepted: 12/22/2017] [Indexed: 11/24/2022]
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Comparison of the pharmacodynamics of protamine zinc insulin and insulin degludec and validation of the continuous glucose monitoring system iPro2 in healthy cats. Res Vet Sci 2018; 118:79-85. [PMID: 29421488 DOI: 10.1016/j.rvsc.2018.01.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 11/29/2017] [Accepted: 01/20/2018] [Indexed: 11/24/2022]
Abstract
With the aim to improve current therapeutic and monitoring options for diabetic cats, the present study compared pharmacodynamic parameters of protamine zinc insulin (PZI) and insulin degludec and validated the continuous glucose monitoring system (CGMS) iPro2 with Sof-sensor and Enlite-sensor focusing on the low glycemic range. Three doses (0.1, 0.2 and 0.3IU/kg) of the two insulin preparations and the CGMS iPro2 with two different sensors were tested in six healthy cats. After each insulin administration, onset of action, time to glucose nadir and duration of action were calculated by measuring glucose concentrations with a portable blood glucose meter (PBGM). After sensor placement, paired PBGM and sensor glucose measurements were done and analytical and clinical accuracy were calculated according to the ISO 15197:2013 criteria. Onset of action, time to glucose nadir and glucose nadir were similar for both insulin formulations. Duration of action of insulin degludec was significantly longer than those of PZI at 0.1IU/kg (P=0.043) and 0.2IU/kg (P=0.043). Overall, 166/191 (87%) Sof-sensor measurements and 106/121 (88%) Enlite-sensor measurements met ISO criteria for analytical accuracy, and all sensor measurements fulfilled ISO criteria for clinical accuracy. Insulin degludec was well tolerated in healthy cats and showed longer duration of action than PZI. Further studies on the use of insulin degludec in diabetic cats might be recommended. Both sensors had good clinical accuracy, when used with the CGMS iPro2, but the analytical accuracy was below the minimum set by ISO 15197:2013.
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Pipe-Martin HN, Fletcher JM, Gilor C, Mitchell MA. Pharmacodynamics and pharmacokinetics of insulin aspart assessed by use of the isoglycemic clamp method in healthy cats. Domest Anim Endocrinol 2018; 62:60-66. [PMID: 29101821 DOI: 10.1016/j.domaniend.2017.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 09/07/2017] [Accepted: 09/07/2017] [Indexed: 11/21/2022]
Abstract
The objective of this study was to determine the pharmacodynamics (PD) and pharmacokinetics (PK) of insulin aspart in healthy cats following intramuscular (IM) and subcutaneous (SC) injection. Eight healthy, purpose-bred cats were used in a randomized, crossover study design. Each cat had 2 isoglycemic clamps performed, one after receiving 0.25 IU/kg of insulin aspart by IM injection and one after receiving the same dose by SC injection. The two isoglycemic clamps were performed on different days, at least 48 h apart. The blood glucose, plasma endogenous insulin, and plasma insulin aspart concentrations were measured and the glucose infusion rate (GIR) was recorded during the clamp. The GIR over time was used to create a time-action curve for each clamp which was used to describe the PD of insulin aspart. Data that are normally distributed are reported as mean ± SD, while data that are not normally distributed are reported as median (25-75 percentile). When compared to the PD data that have been reported for regular insulin in healthy cats, insulin aspart had a more rapid onset (IM: 10 min [10-21.25 min], SC: 12.5 min [10-18.75 min]) and shorter duration of action (IM: 182.5 ± 34.33 min, SC: 159.38 ± 41.87 min). The onset of action (P = 0.795), time to peak action (P = 0.499), duration of action (P = 0.301), and total metabolic effect (P = 0.603) did not differ with route of administration; however, SC administration did result in a higher maximum plasma insulin aspart concentration (IM: 1,265.17 pmol/L [999.69-1,433.89 pmol/L], SC: 3,278.19 pmol/L [2,485.29-4,132.01 pmol/L], P = 0.000) and larger area under the insulin aspart vs time curve (IM: 82,662 ± 30,565 pmol/L, SC: 135,060 ± 39,026 pmol/L, P = 0.010). Insulin aspart has a rapid onset of action and short duration of effect in healthy cats when administered by IM and SC injection. Although it cannot be assumed that the PD and PK of insulin aspart will be the same in cats with diabetic ketoacidosis (DKA), our data support further investigation into the use of SC insulin aspart as an alternative to regular insulin for the treatment of DKA in cats.
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Affiliation(s)
- H N Pipe-Martin
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana 70803, USA
| | - J M Fletcher
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana 70803, USA.
| | - C Gilor
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, California 95616, USA
| | - M A Mitchell
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana 70803, USA
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