1
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Zhang Y, Kuo L, Woodhouse KA, Fitzpatrick LE. Therapeutic Insulin Analogue Concentrations at Infusion Sites Enhanced the Pro-Inflammatory Response and Apoptosis in an In Vitro Macrophage-Material Interaction Model. ACS Pharmacol Transl Sci 2024; 7:2544-2556. [PMID: 39156741 PMCID: PMC11325997 DOI: 10.1021/acsptsci.4c00363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 06/19/2024] [Indexed: 08/20/2024]
Abstract
Continuous subcutaneous insulin infusion for Type 1 diabetes relies upon insulin infusion sets (IIS) to reliably deliver insulin to a subcutaneous depot, where it is absorbed into systemic circulation. However, IIS are plagued by short wear times and high failure rates, due in part to inconsistent insulin absorption that can arise over time. While emerging evidence suggests that the local inflammatory response to the IIS cannula may impact both wear times and unreliable insulin adsorption, the mechanisms are poorly understood. Here, we investigated the effects of local infused insulin concentrations on the biomaterial host response to better understand the underlying factors that limit the IIS performance. We first modeled the insulin concentration for a constant basal infusion rate to select a relevant insulin concentration range of 0.1-10 U/mL within the infusion site. We then examined the influence of a commercial insulin analogue (Humulin-N) using an in vitro macrophage-material model, which uses adsorbed fibroblast lysate (containing damage-associated molecular patterns) to activate macrophages and recapitulates macrophage responses on implanted biomaterials. RAW-Blue macrophages cultured on lysate-adsorbed surfaces had increased nuclear factor-κB (NF-κB) and activating protein 1 (AP-1) activity and intracellular reactive oxygen species (ROS) accumulation compared to control surfaces. Humulin-N concentration (0.5-10 U/mL) enhanced the NF-κB/AP-1 activity and ROS accumulation in macrophages on lysate-adsorbed surfaces. However, Humulin-N had no effect on NF-κB/AP-1 or ROS in the absence of the inflammatory stimulus. Additionally, high insulin concentrations arising from therapeutic doses induced macrophage apoptosis with and without adsorbed lysate. This study contributes to emerging evidence that infused insulin affects the tissue response to IIS.
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Affiliation(s)
- Yuxi Zhang
- Department
of Chemical Engineering, Queen’s
University, Kingston, ON K7L 3N6, Canada
| | - Luke Kuo
- Department
of Chemical Engineering, Queen’s
University, Kingston, ON K7L 3N6, Canada
| | - Kimberly A. Woodhouse
- Department
of Chemical Engineering, Queen’s
University, Kingston, ON K7L 3N6, Canada
| | - Lindsay E. Fitzpatrick
- Department
of Chemical Engineering, Queen’s
University, Kingston, ON K7L 3N6, Canada
- Department
of Biomedical and Molecular Sciences, Queen’s
University, Kingston, ON K7L 3N6, Canada
- Centre
for Health Innovation, Queen’s University, Kingston, ON K7L 3N6, Canada
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2
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Jacquemier P, Retory Y, Virbel-Fleischman C, Schmidt A, Ostertag A, Cohen-Solal M, Alzaid F, Potier L, Julla JB, Gautier JF, Venteclef N, Riveline JP. New ex vivo method to objectively assess insulin spatial subcutaneous dispersion through time during pump basal-rate based administration. Sci Rep 2023; 13:20052. [PMID: 37973963 PMCID: PMC10654403 DOI: 10.1038/s41598-023-46993-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023] Open
Abstract
Glycemic variability remains frequent in patients with type 1 diabetes treated with insulin pumps. Heterogeneous spreads of insulin infused by pump in the subcutaneous (SC) tissue are suspected but were barely studied. We propose a new real-time ex-vivo method built by combining high-precision imaging with simultaneous pressure measurements, to obtain a real-time follow-up of insulin subcutaneous propagation. Human skin explants from post-bariatric surgery are imaged in a micro-computed tomography scanner, with optimised parameters to reach one 3D image every 5 min during 3 h of 1UI/h infusion. Pressure inside the tubing is recorded. A new index of dispersion (IoD) is introduced and computed upon the segmented 3D insulin depot per time-step. Infusions were hypodermal in 58.3% among 24 assays, others being intradermal or extradermal. Several minor bubbles and one occlusion were observed. IoD increases with time for all injections. Inter-assay variability is the smallest for hypodermal infusions. Pressure elevations were observed, synchronised with air bubbles arrivals in the tissue. Results encourage the use of this method to compare infusion parameters such as pump model, basal rate, catheter characteristics, infusion site characteristics or patient phenotype.
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Affiliation(s)
- Pauline Jacquemier
- Institut Necker Enfants Malades (INEM), IMMEDIAB Laboratory, Université de Paris Cité, INSERM U1151, Paris, France
- Centre Explor, ALHIST - Air Liquide Healthcare, Bagneux, France
| | - Yann Retory
- LVL Médical Groupe, Lyon, France
- CIAMS, Univ. Paris-Sud, Université Paris-Saclay, 91405, Orsay Cedex, France
- CIAMS, Université d'Orléans, 45067, Orléans, France
| | | | | | - Agnes Ostertag
- Université Paris Cité, Inserm U1132 BIOSCAR, 75010, Paris, France
| | - Martine Cohen-Solal
- Université Paris Cité, Inserm U1132 BIOSCAR, 75010, Paris, France
- Service de Rhumatologie, Lariboisiere Hospital, AP-HP, 75010, Paris, France
| | - Fawaz Alzaid
- Institut Necker Enfants Malades (INEM), IMMEDIAB Laboratory, Université de Paris Cité, INSERM U1151, Paris, France
- Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Louis Potier
- Institut Necker Enfants Malades (INEM), IMMEDIAB Laboratory, Université de Paris Cité, INSERM U1151, Paris, France
- Université Paris Cité, UFR de Médecine, Paris, France
- Department of Diabetology, Endocrinology and Nutrition, Bichat Hospital, APHP, Paris, France
| | - Jean-Baptiste Julla
- Institut Necker Enfants Malades (INEM), IMMEDIAB Laboratory, Université de Paris Cité, INSERM U1151, Paris, France
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, 75013, Paris, France
- Service of Diabetology, Endocrinology and Nutrition, Federation de Diabetologie, Lariboisiere Hospital, 2 Rue Ambroise Paré, 75010, Paris, AP-HP, France
| | - Jean-François Gautier
- Institut Necker Enfants Malades (INEM), IMMEDIAB Laboratory, Université de Paris Cité, INSERM U1151, Paris, France
- Université Paris Cité, UFR de Médecine, Paris, France
- Service of Diabetology, Endocrinology and Nutrition, Federation de Diabetologie, Lariboisiere Hospital, 2 Rue Ambroise Paré, 75010, Paris, AP-HP, France
| | - Nicolas Venteclef
- Institut Necker Enfants Malades (INEM), IMMEDIAB Laboratory, Université de Paris Cité, INSERM U1151, Paris, France
| | - Jean-Pierre Riveline
- Institut Necker Enfants Malades (INEM), IMMEDIAB Laboratory, Université de Paris Cité, INSERM U1151, Paris, France.
- Université Paris Cité, UFR de Médecine, Paris, France.
- Service of Diabetology, Endocrinology and Nutrition, Federation de Diabetologie, Lariboisiere Hospital, 2 Rue Ambroise Paré, 75010, Paris, AP-HP, France.
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3
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Kastner JR, Eisler G, Torjman MC, Khalf A, Diaz D, Dinesen AR, Loeum C, Strasma PJ, Joseph JI. In Vivo Study of the Inflammatory Tissue Response Surrounding a Novel Extended-Wear Kink-Resistant Insulin Infusion Set Prototype Compared With a Commercial Control Over Two Weeks of Wear Time. J Diabetes Sci Technol 2023; 17:1563-1572. [PMID: 35533132 PMCID: PMC10658669 DOI: 10.1177/19322968221093362] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Infusion set function remains the limiting factor of insulin pump therapy due to nonmetabolic complications. Here, we tested an investigational extended-wear infusion set prototype with a soft, angled, wire-reinforced cannula with three additional side holes, and compared failure mechanisms and tissue response with a commercial Teflon control. METHODS A total of 48 Teflon and 48 prototype infusion sets were inserted subcutaneously every other day for 14 days in 12 swine and infused with dilute insulin. After two weeks, tissue around cannulas was excised, and occlusions, leaks, and kinks were determined. Tissue was processed and stained to assess the total area of inflammation (TAI) and the inflammatory layer thickness (ILT) around the cannulas. Data were analyzed using Fisher's exact, analysis of variance-general linear model, Kruskal-Wallis, and post hoc tests. RESULTS On average, the TAI surrounding the investigational cannula was 52.6% smaller than around the commercial control. The ILT was 66.3% smaller around investigational cannulas. Kinks occurred in 2.1% (investigational) vs 32.4% (commercial) cannulas (P < .001). There was no difference in occlusion alarms and leaks onto skin. CONCLUSIONS The data suggest that the infusion set prototype elicits less inflammation over an extended wear time and is resistant to kinking, compared with a commercial Teflon device. This is consistent with previously published data on the impact of cannula material/angle on the inflammatory tissue response. We highlight the following important aspects of infusion set design: (1) secure skin adhesion, (2) reliable cannula insertion, (3) automatic removal of the stylet, (4) cannula material/design that resists kinking, and (5) minimization of local tissue inflammation.
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Affiliation(s)
- Jasmin R. Kastner
- Department of Anesthesiology, The Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, PA, USA
- Capillary Biomedical Inc, Irvine, CA, USA
| | - Gabriella Eisler
- Department of Anesthesiology, The Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marc C. Torjman
- Department of Anesthesiology, The Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Abdurizzagh Khalf
- Department of Anesthesiology, The Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - David Diaz
- Department of Anesthesiology, The Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alek R. Dinesen
- Department of Anesthesiology, The Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Channy Loeum
- Department of Anesthesiology, The Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Jeffrey I Joseph
- Department of Anesthesiology, The Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, PA, USA
- Capillary Biomedical Inc, Irvine, CA, USA
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4
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Zhang E, Shi Y, Han X, Zhu H, Song B, Yang C, Cao Z. An injectable and biodegradable zwitterionic gel for extending the longevity and performance of insulin infusion catheters. Nat Biomed Eng 2023:10.1038/s41551-023-01108-z. [PMID: 37884794 DOI: 10.1038/s41551-023-01108-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 09/18/2023] [Indexed: 10/28/2023]
Abstract
Continuous subcutaneous insulin infusion (CSII) is an essential insulin replacement therapy in the management of diabetes. However, the longevity of clinical CSII is limited by skin complications, by impaired insulin absorption and by occlusions associated with the subcutaneous insertion of CSII catheters, which require replacement and rotation of the insertion site every few days. Here we show that a biodegradable zwitterionic gel covering the tip end of commercial off-the-shelf CSII catheters fully resolves early skin irritations, extends the longevity of catheters and improves the rate of insulin absorption (also with respect to conventional syringe-based subcutaneous injection) for longer than 6 months in diabetic mice, and by 11 days in diabetic minipigs (from 2 to 13 days, under standard CSII-wearing conditions of insulin pump therapy and in a continuous basal-plus-bolus-infusion setting). The implanted gel displayed anti-inflammatory and anti-foreign-body-reaction properties and promoted the local formation of new blood vessels. The gel is subcutaneously injected before the tip of catheter is inserted into it, and should be generally applicable to CSII catheters and other implantable devices.
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Affiliation(s)
- Ershuai Zhang
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA
| | - Yuanjie Shi
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA
| | - Xiangfei Han
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA
| | - Hui Zhu
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA
| | - Boyi Song
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA
| | - Chengbiao Yang
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA
| | - Zhiqiang Cao
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA.
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5
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Huang J, Yeung AM, Kerr D, Gentile S, Heinemann L, Al-Sofiani ME, Joseph JI, Seley JJ, Klonoff DC. Lipohypertrophy and Insulin. An Old Dog that Needs New Tricks. Endocr Pract 2023:S1530-891X(23)00386-5. [PMID: 37098370 DOI: 10.1016/j.eprac.2023.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/27/2023]
Abstract
OBJECTIVE To review the current status of practical knowledge related to insulin-associated lipohypertrophy (LH) - an accumulation of fatty subcutaneous nodules commonly caused by repeated injections and/or infusions of insulin into the same site. METHODS Review of published literature with additional contributions from leading multidisciplinary experts with the emphasis on clinical aspects including pathophysiology, clinical and economic consequences, diagnosis, prevention and treatment. RESULTS LH is the most common dermatologic complication of insulin therapy. Risk factors for the development of lipohypertrophy include repeated delivery of large amounts of insulin into the same location over time, repeated injection trauma to the skin and subcutaneous tissue, and multiple injections using the same needle. Subcutaneous insulin injection in skin areas with lipohypertrophy is associated with reduced pain; however, this problem can interfere with insulin absorption, thereby increasing the likelihood of glucose variability, hypo- and hyperglycemia when a site is changed. Modern visualization technology of the subcutaneous space with ultrasound can demonstrate lipohypertrophy early in the course of its development. CONCLUSIONS The physiological and psychological consequences of developing insulin lipohypertrophy can be prevented and treated with education focusing on insulin injection techniques.
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Affiliation(s)
- Jingtong Huang
- Diabetes Technology Society, Burlingame, California, USA.
| | - Andrea M Yeung
- Diabetes Technology Society, Burlingame, California, USA
| | - David Kerr
- Diabetes Technology Society, Burlingame, California, USA
| | - Sandro Gentile
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy; NefroCenter Research Network, Torre del Greco, Naples, Italy
| | | | - Mohammed E Al-Sofiani
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University, Baltimore, Maryland, USA; Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jeffrey I Joseph
- Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - David C Klonoff
- Diabetes Technology Society, Burlingame, California, USA; Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, California, USA
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6
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Hendel K, Stumpe T, Ozer K. Impact of Infusion Set Materials and Designs on the Subcutaneous Response in People With Diabetes: A Rapid Review of the Literature. J Diabetes Sci Technol 2023; 17:314-321. [PMID: 36398844 PMCID: PMC10012358 DOI: 10.1177/19322968221138076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Insulin infusion sets (IISs) are an integral and intricate part of continuous subcutaneous insulin infusion for subjects with type 1 diabetes, infusing insulin from pump to the subcutaneous space. Insulin infusion sets interface with the skin surface, the dermis, and the subcutaneous space and may be the cause of infusion failure due to biological events or mechanical problems. Novel IISs with extended wear time and anti-inflammatory properties to mitigate these issues are described in the literature although material-tissue interactions are poorly understood. This rapid review focuses on the impact of IIS materials and designs on the subcutaneous response in people with diabetes and includes literature identified in PubMed, Embase, and Cochrane databases. Twenty-one studies were identified for qualitative synthesis that encompassed a limited and heterogenic body of evidence including 10 clinical reports, six reviews, one case report, two abstracts, and two communications. Two clinical reports were randomized crossover studies. Reports on materials mostly compared steel versus polytetrafluoroethylene (Teflon) cannulas and suggested no substantial difference in tissue response to these materials. Reports on designs focused mostly on the angle of cannula insertion. To drive and improve research on extended wear and nonimmunogenic IISs, future studies should focus on material-tissue interaction as dedicated outcome measures, quantified with punch biopsy and imaging techniques such as ultrasound, optical coherence tomography, and confocal reflectance microscopy. Original studies are required to further a field too young for a systematic meta-analysis.
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Affiliation(s)
| | - Tobias Stumpe
- Technology & Innovation, Convatec
Infusion Care, Søborg, Denmark
| | - Kerem Ozer
- Technology & Innovation, Convatec
Infusion Care, Lexington, MA, USA
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7
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Garhyan P, Pratt E, Klein O, Famulla S, Zijlstra E, Lalonde A, Swinney M, Kazda C, Dassau E. Evaluation of Insulin Lispro Pharmacokinetics and Pharmacodynamics Over 10 Days of Continuous Insulin Infusion in People With Type 1 Diabetes. J Diabetes Sci Technol 2023; 17:274-282. [PMID: 36575993 PMCID: PMC10012385 DOI: 10.1177/19322968221145200] [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] [Indexed: 12/29/2022]
Abstract
BACKGROUND We evaluated the effect of meloxicam on insulin lispro pharmacokinetics and glucose pharmacodynamics over 10 days of continuous subcutaneous insulin infusion (CSII) at one infusion site in people with type 1 diabetes (T1D). METHOD This phase 1, randomized, double-blind, single-center, two-way crossover study enrolled adults with T1D for ≥1 year on stable CSII for ≥3 months. Participants randomly received U100 insulin lispro and LY900027 (U100 insulin lispro + 0.25 mg/mL meloxicam). Primary end points were area under the insulin lispro curve from 0 to 5 hours (AUCIns.0-5h) after bolus administration prior to a mixed-meal tolerance test (MMTT) and maximum observed concentration of insulin lispro (CIns.max) on days 5, 7, and 10, versus day 3 (baseline). RESULTS A total of 20 participants were randomized. Insulin absorption was accelerated for insulin lispro and LY900027 from days 1 to 7. The AUCIns.0-5h was significantly lower on day 10 versus day 3 for LY900027 (-19%) and insulin lispro (-14%); the AUCIns.0-5h did not differ significantly between treatments. The CIns.max increased with LY900027 and insulin lispro (by ~14%-23% and ~16%-51%) on days 5, 7, and 10 versus day 3. The CIns.max of LY900027 was ~14%-23% lower than insulin lispro CIns.max on days 7 and 10 (P ≤ .0805). Accelerated insulin absorption and a modest loss of total insulin exposure led to a loss of MMTT glycemic control at later time points. CONCLUSIONS The pharmacokinetics of insulin changed over catheter wear time even when an anti-inflammatory agent was present. Postprandial glycemic control was adversely affected by the accelerated insulin absorption and decreased insulin exposure.
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Affiliation(s)
| | - Edward Pratt
- Lilly Centre for Clinical Pharmacology,
Singapore, Singapore
| | | | | | | | - Amy Lalonde
- Eli Lilly and Company, Indianapolis,
IN, USA
| | | | | | - Eyal Dassau
- Eli Lilly and Company, Indianapolis,
IN, USA
- Eli Lilly and Company, Cambridge, MA,
USA
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8
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Lal RA, Leelarathna L. Insulin Delivery Hardware: Pumps and Pens. Diabetes Technol Ther 2023; 25:S30-S43. [PMID: 36802186 PMCID: PMC10081698 DOI: 10.1089/dia.2023.2503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Rayhan A Lal
- Division of Endocrinology, Department of Medicine & Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Lalantha Leelarathna
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester, UK and Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
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9
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desJardins-Park HE, Wan DC. Leveraging Mechanical Forces to Target Insulin Injection-Induced Lipohypertrophy and Fibrosis. Diabetes Spectr 2021; 34:308-312. [PMID: 34511858 PMCID: PMC8387605 DOI: 10.2337/ds20-0048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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10
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Mulka A, Lewis BE, Mao L, Sharafieh R, Kesserwan S, Wu R, Kreutzer DL, Klueh U. Phenolic Preservative Removal from Commercial Insulin Formulations Reduces Tissue Inflammation while Maintaining Euglycemia. ACS Pharmacol Transl Sci 2021; 4:1161-1174. [PMID: 34151206 DOI: 10.1021/acsptsci.1c00047] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Indexed: 11/28/2022]
Abstract
Background: Exogenous insulin therapy requires stabilization of the insulin molecule, which is achieved through the use of excipients (e.g., phenolic preservatives (PP)) that provide protein stability, sterility and prolong insulin shelf life. However, our laboratory recently reported that PP, (e.g., m-creosol and phenol) are also cytotoxic, inducing inflammation and fibrosis. Optimizing PP levels through filtration would balance the need for insulin preservation with PP-induced inflammation. Method: Zeolite Y (Z-Y), a size-exclusion-based resin, was employed to remove PP from commercial insulin formulations (Humalog) before infusion. Results: PP removal significantly decreased cell toxicity in vitro and inflammation in vivo. Infusion site histological analysis after a 3 day study demonstrated that leukocyte accumulation increased with nonfiltered preparations but decreased after filtration. Additional studies demonstrated that a Z-Y fabricated filter effectively removed excess PP such that the filtered insulin solution achieved equivalent glycemic control in diabetic mice when compared to nonfiltered insulin. Conclusion: This approach represents the proof of concept that using Z-Y for in-line PP removal assists in lowering inflammation at the site of insulin infusion and thus could lead to extending the functional lifespan of insulin infusion sets in vivo.
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Affiliation(s)
- Adam Mulka
- Department of Biomedical Engineering, Integrative Biosciences Center, Wayne State University, Detroit, Michigan 48202,United States
| | - Brianne E Lewis
- Department of Biomedical Engineering, Integrative Biosciences Center, Wayne State University, Detroit, Michigan 48202,United States
| | - Li Mao
- Department of Biomedical Engineering, Integrative Biosciences Center, Wayne State University, Detroit, Michigan 48202,United States
| | - Roshanak Sharafieh
- Department of Surgery, School of Medicine, University of Connecticut, Farmington, Connecticut 06030-2100, United States
| | - Shereen Kesserwan
- Department of Biomedical Engineering, Integrative Biosciences Center, Wayne State University, Detroit, Michigan 48202,United States
| | - Rong Wu
- Connecticut Convergence Institute, School of Medicine, University of Connecticut, Farmington, Connecticut 06030-6022, United States
| | - Donald L Kreutzer
- Department of Surgery, School of Medicine, University of Connecticut, Farmington, Connecticut 06030-2100, United States
| | - Ulrike Klueh
- Department of Biomedical Engineering, Integrative Biosciences Center, Wayne State University, Detroit, Michigan 48202,United States
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11
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Swinney MR, Cox AL, Hawkins ED, Xue J, Garhyan P, Stanley JRL, Sule SV, Adragni K, Michael MD. Insulin, Not the Preservative m-cresol, Instigates Loss of Infusion Site Patency Over Extended Durations of CSII in Diabetic Swine. J Pharm Sci 2020; 110:1418-1426. [PMID: 33321138 DOI: 10.1016/j.xphs.2020.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/03/2020] [Accepted: 12/03/2020] [Indexed: 12/26/2022]
Abstract
Insulin infusion sets worn for more than 4-5 days have been associated with a greater risk of unexplained hyperglycemia, a phenomenon that has been hypothesized to be caused by an inflammatory response to preservatives such as m-cresol and phenol. In this cross-over study in diabetic swine, we examined the role of the preservative m-cresol in inflammation and changes in infusion site patency. Insulin pharmacokinetics (PK) and glucose pharmacodynamics (PD) were measured on delivery of a bolus of regular human insulin U-100 (U-100R), formulated with or without 2.5 mg/mL m-cresol, to fasted swine following 0, 3, 5, 7, and 10 days of continuous subcutaneous insulin infusion (CSII). In a subsequent study with the same animals, biopsies were evaluated from swine wearing infusion sets infusing nothing, saline, or U-100R either with or without 2.5 mg/mL m-cresol, following 3, 7, and 10 days of CSII. Exposure to m-cresol did not impact any PK or PD endpoints. PK and PD responses dropped markedly from Days 7-10, regardless of the presence of m-cresol. Histopathology results suggest an additive inflammatory response to both the infusion set and the insulin protein itself, peaking at Day 7 and remaining stable beyond.
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Affiliation(s)
| | - Amy L Cox
- Eli Lilly and Company, Indianapolis, IN
| | | | - Jie Xue
- Eli Lilly and Company, Indianapolis, IN
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12
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Kesserwan S, Mulka A, Sharafieh R, Qiao Y, Wu R, Kreutzer DL, Klueh U. Advancing continuous subcutaneous insulin infusion in vivo: New insights into tissue challenges. J Biomed Mater Res A 2020; 109:1065-1079. [PMID: 32896081 DOI: 10.1002/jbm.a.37097] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 01/13/2023]
Abstract
Continuous Subcutaneous Insulin Infusion (CSII) is superior to conventional insulin therapy as it improves glycemic control thus reducing the probability of diabetic complications. Notwithstanding CSII's benefits, insulin dependent diabetic patients rarely achieve optimal glucose control. Moreover, CSII is only FDA approved for 3 days and often fails prematurely for reasons that have not been fully elucidated. We hypothesize that phenolic compounds, such as m-cresol and phenol, which are present in all commercial insulin formulations are responsible for the tissue reaction occurring at the insulin infusion site. This hypothesis was examined with in vitro cell cultures and a mouse air-pouch model to determine cellular and tissue reactions following infusions with saline, phenolic compounds, (i.e., commercial diluent), and insulin. We demonstrated that diluent and insulin were cytotoxic to cells in culture at sub-clinical concentrations (e.g., >1:10 of commercial insulin). Air pouch studies demonstrated that infusion of either diluted insulin or diluent itself induced three to five-fold level of recruited leukocytes as compared to saline. At both 3- and 7-days post infusion, these were predominantly neutrophils and macrophages. We conclude that phenolic compounds in commercial insulin preparations are cell and tissue toxic, which contributes to the failure of effective insulin infusion therapy.
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Affiliation(s)
- Shereen Kesserwan
- Integrative Biosciences Center (IBio), Department of Biomedical Engineering, Wayne State University, Detroit, Michigan, USA
| | - Adam Mulka
- Integrative Biosciences Center (IBio), Department of Biomedical Engineering, Wayne State University, Detroit, Michigan, USA
| | - Roshanak Sharafieh
- Department of Surgery, UConn Health, School of Medicine, Farmington, Connecticut, USA
| | - Yi Qiao
- Department of Surgery, UConn Health, School of Medicine, Farmington, Connecticut, USA
| | - Rong Wu
- Connecticut Convergence Institute for Translation in Regenerative Engineering, UConn Health, Farmington, Connecticut, USA
| | - Donald L Kreutzer
- Department of Surgery, UConn Health, School of Medicine, Farmington, Connecticut, USA
| | - Ulrike Klueh
- Integrative Biosciences Center (IBio), Department of Biomedical Engineering, Wayne State University, Detroit, Michigan, USA.,Department of Surgery, UConn Health, School of Medicine, Farmington, Connecticut, USA
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