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Sokolov V, Yakovleva T, Stolbov L, Penland RC, Boulton D, Parkinson J, Tang W. A mechanistic modeling platform of SGLT2 inhibition: Implications for type 1 diabetes. CPT Pharmacometrics Syst Pharmacol 2023; 12:831-841. [PMID: 36912425 PMCID: PMC10272306 DOI: 10.1002/psp4.12956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/01/2023] [Accepted: 02/24/2023] [Indexed: 03/14/2023] Open
Abstract
Type 1 diabetes mellitus (T1DM) is an autoimmune disease characterized by abnormally high blood glucose concentrations due to dysfunction of the insulin-producing beta-cells in the pancreas. Dapagliflozin, an inhibitor of renal glucose reabsorption, has the potential to improve often suboptimal glycemic control in patients with T1DM through insulin-independent mechanisms and to partially mitigate the adverse effects associated with long-term insulin administration. In this work, we have adapted a systems pharmacology model of type 2 diabetes mellitus to describe the T1DM condition and characterize the effect of dapagliflozin on short- and long-term glycemic markers under various treatment scenarios. The developed platform serves as a quantitative tool for the in silico evaluation of the insulin-glucose-dapagliflozin crosstalk, optimization of the treatment regimens, and it can be further expanded to include additional therapies or other aspects of the disease.
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Affiliation(s)
| | | | | | - Robert C. Penland
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZenecaWalthamMassachusettsUSA
| | - David Boulton
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZenecaGaithersburgMarylandUSA
| | - Joanna Parkinson
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZenecaGothenburgSweden
| | - Weifeng Tang
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZenecaGaithersburgMarylandUSA
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Liu H, Yu H, Sun L, Qiao J, Li J, Tan H, Yu Y. Effects of Unsuppressed Endogenous Insulin on Pharmacokinetics and/or Pharmacodynamics of Study Insulin in the Healthy: A Retrospective Study. Clin Pharmacol Drug Dev 2022; 11:930-937. [PMID: 35384402 PMCID: PMC9546084 DOI: 10.1002/cpdd.1093] [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: 11/12/2021] [Accepted: 02/28/2022] [Indexed: 02/05/2023]
Abstract
C‐peptide, a marker of endogenous insulin, should be consistently inhibited during euglycemic clamping, while an elevated postdosing C‐peptide (CPpostdosing) is not an occasional phenomenon. This was a retrospective study that included 33 men who underwent a manual euglycemic clamp with a subcutaneous injection of insulin aspart (IAsp) aiming to describe the effects of insufficient suppression of endogenous insulin on estimates of the pharmacokinetics and pharmacodynamics of injected insulin. The time profiles of whole blood glucose, human insulin, glucose infusion rate (GIR), and C‐peptide were recorded. The subjects were divided into 2 groups at a ratio of 2:1: group A ([CPpostdosing]max>baseline CP [CPbaseline]), group B ([CPpostdosing]max ≤ CPbaseline). The endogenous insulin was approximately equal to the measured value of human insulin or calculated from the C‐peptide. The basal glucose, CPbaseline, basal human insulin, homeostatic model assessment of insulin resistance, IAsp dose, and demographic statistics were all comparable between the 2 groups except the “clamped” glucose. The average clamped glucose was 99.7% (group A) and 94.9% (group B) of baseline. After correction for clamped glucose, GIR area under the concentration‐time curve from time 0 to 8 hours was higher in group A (P < .05) under comparable IAsp exposure. Endogenous insulin area under the concentration‐time curve from time 0 to 8 hours calculated from C‐peptide was different from that measured from human insulin in group A (P < .05), whereas no statistical difference between these measures was observed in group B. Hence, blood glucose should be controlled below the baseline to ensure the inhibition of endogenous insulin. Unsuppressed endogenous insulin may contribute to observed GIR, and the endogenous insulin–corrected pharmacokinetics estimated by C‐peptide may be inaccurate with insufficient endogenous insulin suppression.
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Affiliation(s)
- Hui Liu
- Department of General Practice, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hongling Yu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lisi Sun
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jingtao Qiao
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiaqi Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Huiwen Tan
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yerong Yu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Varkhede N, Bommana R, Schöneich C, Forrest ML. Proteolysis and Oxidation of Therapeutic Proteins After Intradermal or Subcutaneous Administration. J Pharm Sci 2020; 109:191-205. [PMID: 31408633 PMCID: PMC6937400 DOI: 10.1016/j.xphs.2019.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 12/12/2022]
Abstract
The intradermal (ID) and subcutaneous (SC) routes are commonly used for therapeutic proteins (TPs) and vaccines; however, the bioavailability of TPs is typically less than small molecule drugs given via the same routes. Proteolytic enzymes in the dermal, SC, and lymphatic tissues may be responsible for the loss of TPs. In addition, the TPs may be exposed to reactive oxygen species generated in the SC tissue and the lymphatic system in response to injection-related trauma and impurities within the formulation. The reactive oxygen species can oxidize TPs to alter their efficacy and immunogenicity potential. Mechanistic understandings of the dominant proteolysis and oxidative routes are useful in the drug discovery process, formulation development, and to assess the potential for immunogenicity and altered pharmacokinetics (PK). Furthermore, in vitro tools representing the ID or SC and lymphatic system can be used to evaluate the extent of proteolysis of the TPs after the injection and before systemic entry. The in vitro clearance data may be included in physiologically based pharmacokinetic models for improved PK predictions. In this review, we have summarized various physiological factors responsible for proteolysis and oxidation of TPs after ID and SC administration.
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Affiliation(s)
- Ninad Varkhede
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047; Department of Pharmacokinetics, Pharmacodynamics & Drug Metabolism (PPDM), Merck Research Laboratories, West Point, Pennsylvania 19486
| | - Rupesh Bommana
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047; MedImmune, Gaithersburg, Maryland 20878
| | - Christian Schöneich
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047
| | - M Laird Forrest
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047.
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4
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Dagdelen S, Deyneli O, Olgun N, Siva ZO, Sargin M, Hatun S, Kulaksizoglu M, Kaya A, Gürlek CA, Hirsch LJ, Strauss KW. Turkish Insulin Injection Technique Study: Population Characteristics of Turkish Patients with Diabetes Who Inject Insulin and Details of Their Injection Practices as Assessed by Survey Questionnaire. Diabetes Ther 2018; 9:1629-1645. [PMID: 29961245 PMCID: PMC6064578 DOI: 10.1007/s13300-018-0464-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Over 7 million people in Turkey have diabetes. Of the 1 million who inject insulin little is known of their habits and injection techniques. METHODS We conducted an Injection Technique Questionnaire (ITQ) survey throughout Turkey that involved 1376 patients from 56 centers. Turkish values were compared with those from 41 other countries participating in the ITQ, known here as Rest of World (ROW). RESULTS The majority (50.4%) of Turkish insulin users give four injections/ day as opposed to ROW, where only 30.9% do. The abdomen is the most common injection site used by Turkish patients, but they also inject insulin in multiple body sites more often than do patients in ROW. Body mass index values in Turkey were 0.75 units higher than those in ROW as was the mean total daily dose (average daily dose [ADD]) of insulin (54.0 IU in Turkey vs. 47.4 IU in ROW). Mean glycated hemoglobin (HbA1c) in Turkey was 9.1%, which is higher than in ROW and possibly related to the higher BMI and ADD. Turkish patients use insulin analogs (short and long-acting) more frequently than do patients in ROW. The shortest pen needles (4 mm) are used by about one-third of patients in Turkey, but the longer ones (8 mm) are equally common. Needles are reused in Turkey at a rate of 3.4 injections/single needle. However, needle reuse, whether with pens or syringes, is lower in Turkey than ROW, as is the number of times a reused needle is used. More than 75% of used sharps in Turkey go into the rubbish, with nearly 6% having no protection of the tip. CONCLUSION The continued use of 8-mm needles raises the risk of intramuscular injections in Turkish patients. Despite full reimbursement, needle reuse still remains an important issue. More focus needs to be given to dwell times under the skin, reconstitution of cloudy insulant, correct use of skin folds and safe disposal of sharps. FUNDING BD Diabetes Care.
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Affiliation(s)
- Selcuk Dagdelen
- Department of Endocrinology and Metabolism, Hacettepe University School of Medicine, Hacettepe Mah., Sıhhıye, 06230, Ankara, Turkey
| | - Oguzhan Deyneli
- Department of Endocrinology and Metabolism, School of Medicine, Koc University, Davutpasa Cad. No:4, Topkapı, 34010, Istanbul, Turkey
| | - Nermin Olgun
- Nursing Department, Faculty of Health Sciences, Hasan Kalyoncu University, Havaalanı Yolu Üzeri 8. km. Sahinbey, Gaziantep, Turkey
| | - Zeynep Osar Siva
- Department of Endocrinology, Diabetes and Metabolism, Istanbul University Cerrahpasa School of Medicine, Cerrahpasa Mah. Kocamustafapasa Cad. No:53, Fatih, 34098, Istanbul, Turkey
| | - Mehmet Sargin
- Faculty of Medicine, Istanbul Medeniyet University, Egitim Mah. Dr. Erkin Cad, Kadıköy, 34722, Istanbul, Turkey
| | - Sükrü Hatun
- Department of Pediatric Endocrinology and Diabetes, Koc University School of Medicine, Davutpasa Cad. No: 4, Topkapı, 34010, Istanbul, Turkey
| | - Mustafa Kulaksizoglu
- Faculty of Medicine Department of Endocrinology and Metabolism, Necmettin Erbakan University Meram, Yunus Emre Mah. Beysehir Cad. No:281, Meram, 42080, Konya, Turkey
| | - Ahmet Kaya
- Faculty of Medicine Department of Endocrinology and Metabolism, Necmettin Erbakan University Meram, Yunus Emre Mah. Beysehir Cad. No:281, Meram, 42080, Konya, Turkey
| | - Cansu Aslan Gürlek
- BD Diabetes Care, Ruzgarlibahce Mah. S.Sinan Eroglu Cad. No:6, Akel Is Merkezi A Blok -3. Kat 34805 Kavacik Beykoz, Istanbul, Turkey
| | | | - Kenneth W Strauss
- BD Diabetes Care, POB 13, Erembodegem-Dorp 86, 9320, Erembodegem, Belgium.
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Kalra S, Mithal A, Sahay R, John M, Unnikrishnan AG, Saboo B, Ghosh S, Sanyal D, Hirsch LJ, Gupta V, Strauss KW. Indian Injection Technique Study: Population Characteristics and Injection Practices. Diabetes Ther 2017; 8:637-657. [PMID: 28289893 PMCID: PMC5446372 DOI: 10.1007/s13300-017-0243-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION It was estimated that 3.2 million Indians with diabetes injected insulin in 2010, but little is known about the techniques used. METHODS In 2015 we conducted an injection technique questionnaire (ITQ) survey throughout India involving 1011 patients. Indian values were compared with those from 41 other countries participating in the ITQ, known here as rest of world (ROW). RESULTS Mean HbA1c was 8.6. BMI values in India were 1.5-3 units lower than in ROW depending on patient group, meaning the risk of intramuscular (IM) injections is high in India. The mean total daily dose (TDD) of insulin was lower in every category of Indian patient than in ROW, perhaps reflecting the lower BMI. Needle reuse, whether with pens or syringes, is much higher in India than ROW and so is the number of times the needle is used. The majority (56.8%) of Indian insulin users performed only 2 injections/day as opposed to ROW where 45% of patients performed at least 4 injections/day. Indian patients inject insulin in the thighs more often than patients in ROW, a site where IM injections are more risky. Many patients do not have proper access to sharps containers or have other risk factors that could lead to blood-borne pathogen spread. More than 60% of used sharps in India go into the rubbish, with nearly 12% not even having the minimum protection of a cap. DISCUSSION The shortest needles are very common in India; however, the level of needle reuse is high. Multiple daily injections therapy is not as common in India as ROW. More focus needs to be given to dwell times under the skin, reconstitution of cloudy insulins, skinfolds, and safe sharps disposal.
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Affiliation(s)
| | - Ambrish Mithal
- Medanta the Medicity, CH Baktawar Singh Road, Sector 38, Gurgaon, Haryana, India
| | - Rakesh Sahay
- Osmania Medical College, Turrebaz Khan Rd, Esamiya Bazaar, Koti, Hyderabad, Telangana, India
| | - Mathew John
- Providence Endocrine & Diabetes Specialty Centre, TC 1/2138, Near GG Hospital, Murinjapalam, Thiruvanthapuram, Kerala, India
| | - A G Unnikrishnan
- Chellaram Diabetes Institute, Pune-Bangalore, NH4, Bavdhan, Pune, Maharashtra, India
| | - Banshi Saboo
- Diacare-Diabetes Care & Hormone Clinic, 1 & 2 Gandhi Park Society, Nehrunagar Cross Roads, Ambavadi, Ahmedabad, Gujarat, India
| | - Sujoy Ghosh
- AMRI Medical Centre Kolkata, No. 97 A, Southern Avenue, Above Maruti Showroom, Opposite Lake Stadium, Kolkata, West Bengal, India
| | - Debmalya Sanyal
- KPC Medical College and Hospital, Raja Subodh Chandra Mullick Road, Jadavpur, Near Jadavpur Railway Station, Kolkata, West Bengal, India
| | - Laurence J Hirsch
- BD Diabetes Care, 1 Becton Dr. MC 378, Franklin Lakes, New Jersey, USA
| | - Vandita Gupta
- BD Diabetes Care, BD, 6th Floor Signature Tower-B, South City I, NH 8, Gurgaon, Haryana, India
| | - Kenneth W Strauss
- BD Diabetes Care, POB 13, Erembodegem-Dorp 86, 9320, Erembodegem, Belgium.
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Tham LS, Schneck K, Ertekin A, Reviriego J. Modeling Pharmacokinetic Profiles of Insulin Regimens to Enhance Understanding of Subcutaneous Insulin Regimens. J Clin Pharmacol 2017; 57:1126-1137. [PMID: 28394405 PMCID: PMC5573917 DOI: 10.1002/jcph.899] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/28/2017] [Indexed: 11/29/2022]
Abstract
Insulin pharmacokinetics following subcutaneous administration were modeled, simulated, and displayed through an interactive and user‐friendly interface to illustrate the time course of administered insulins frequently prescribed, providing a simple tool for clinicians through a straightforward visualization of insulin regimens. Pharmacokinetic data of insulin formulations with different onset and duration of action from several clinical studies, including insulin glargine, regular insulin, neutral protamine Hagedorn (NPH), insulin lispro, and premixed preparations of NPH with regular insulin (Mix 70/30), and insulin lispro protamine suspension with insulin lispro (Mix 50/50, Mix 75/25), were used to develop a predictive population pharmacokinetic model of insulins with consideration of factors such as insulin formulation, weight‐based dosing, body‐weight effect on volume of distribution, and administration time relative to meals, on the insulin time‐action profile. The model‐predicted insulin profile of each insulin was validated and confirmed to be comparable to observed data via an external validation method. Model‐based simulations of clinically relevant insulin‐dosing scenarios to cater to specific initial patient and prescribing conditions were then implemented with differential equations using the R statistical program (version 3.2.2). The R package Shiny was subsequently applied to build a web browser interface to execute and visualize the model simulation outputs. The application of insulin pharmacokinetic modeling enabled informative visualization of insulin time‐action profiles and provided an efficient and intuitive educational tool to quickly convey and interactively explore many insulin time‐action profiles to ease the understanding of insulin formulations in clinical practice.
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Affiliation(s)
- Lai San Tham
- Lilly-NUS Center for Clinical Pharmacology Pte Ltd, Singapore, Singapore
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Frid AH, Kreugel G, Grassi G, Halimi S, Hicks D, Hirsch LJ, Smith MJ, Wellhoener R, Bode BW, Hirsch IB, Kalra S, Ji L, Strauss KW. New Insulin Delivery Recommendations. Mayo Clin Proc 2016; 91:1231-55. [PMID: 27594187 DOI: 10.1016/j.mayocp.2016.06.010] [Citation(s) in RCA: 171] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/15/2016] [Accepted: 06/22/2016] [Indexed: 12/14/2022]
Abstract
Many primary care professionals manage injection or infusion therapies in patients with diabetes. Few published guidelines have been available to help such professionals and their patients manage these therapies. Herein, we present new, practical, and comprehensive recommendations for diabetes injections and infusions. These recommendations were informed by a large international survey of current practice and were written and vetted by 183 diabetes experts from 54 countries at the Forum for Injection Technique and Therapy: Expert Recommendations (FITTER) workshop held in Rome, Italy, in 2015. Recommendations are organized around the themes of anatomy, physiology, pathology, psychology, and technology. Key among the recommendations are that the shortest needles (currently the 4-mm pen and 6-mm syringe needles) are safe, effective, and less painful and should be the first-line choice in all patient categories; intramuscular injections should be avoided, especially with long-acting insulins, because severe hypoglycemia may result; lipohypertrophy is a frequent complication of therapy that distorts insulin absorption, and, therefore, injections and infusions should not be given into these lesions and correct site rotation will help prevent them; effective long-term therapy with insulin is critically dependent on addressing psychological hurdles upstream, even before insulin has been started; inappropriate disposal of used sharps poses a risk of infection with blood-borne pathogens; and mitigation is possible with proper training, effective disposal strategies, and the use of safety devices. Adherence to these new recommendations should lead to more effective therapies, improved outcomes, and lower costs for patients with diabetes.
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Affiliation(s)
- Anders H Frid
- Department of Endocrinology, Skane University Hospital, Malmö, Sweden
| | - Gillian Kreugel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Giorgio Grassi
- Città della Salute e della Scienza Torino, Torino, Italy
| | - Serge Halimi
- University for Sciences and Medicine Joseph Fourier Grenoble and Diabetology Department CHU Grenoble, Grenoble Cedex, France
| | - Debbie Hicks
- Barnet, Enfield & Haringey Mental Health Trust, London, UK
| | | | | | | | | | - Irl B Hirsch
- University of Washington Medical Center-Roosevelt, Seattle
| | | | - Linong Ji
- Peking University Peoples Hospital, Beijing, China
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Frid AH, Hirsch LJ, Menchior AR, Morel DR, Strauss KW. Worldwide Injection Technique Questionnaire Study: Population Parameters and Injection Practices. Mayo Clin Proc 2016; 91:1212-23. [PMID: 27594185 DOI: 10.1016/j.mayocp.2016.06.011] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/15/2016] [Accepted: 06/22/2016] [Indexed: 12/17/2022]
Abstract
From February 1, 2014, through June 30, 2015, 13,289 insulin-injecting patients from 423 centers in 42 countries took part in one of the largest surveys ever performed in diabetes. The goal was to assess patient characteristics, as well as historical and practical aspects of their injection technique. Results show that 4- and 8-mm needle lengths are each used by nearly 30% of patients and 5- and 6-mm needles each by approximately 20%. Higher consumption of insulin (as measured by total daily dose) is associated with having lipohypertrophy (LH), injecting into LH, leakage from the injection site, and failing to reconstitute cloudy insulin. Glycated hemoglobin values are, on average, 0.5% higher in patients with LH and are significantly higher with incorrect rotation of sites and with needle reuse. Glycated hemoglobin values are lower in patients who distribute their injections over larger injection areas and whose sites are inspected routinely. The frequencies of unexpected hypoglycemia and glucose variability are significantly higher in those with LH, those injecting into LH, those who incorrectly rotate sites, and those who reuse needles. Needles associated with diabetes treatment are the most commonly used medical sharps in the world. However, correct disposal of sharps after use is critically suboptimal. Many used sharps end up in public trash and constitute a major accidental needlestick risk. Use of these data should stimulate renewed interest in and commitment to optimizing injection practices in patients with diabetes.
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Affiliation(s)
- Anders H Frid
- Department of Endocrinology, Skane University Hospital, Malmö, Sweden
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