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Valent AM, Barbour LA. Insulin Management for Gestational and Type 2 Diabetes in Pregnancy. Obstet Gynecol 2024:00006250-990000000-01098. [PMID: 38870526 DOI: 10.1097/aog.0000000000005640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 04/18/2024] [Indexed: 06/15/2024]
Abstract
Insulin is preferred as the first-line agent for glucose management of gestational diabetes mellitus and type 2 diabetes in pregnancy when nutritional and lifestyle modifications are unable to achieve pregnancy-specific glucose targets. Individual heterogeneity in defects of insulin secretion or sensitivity in liver and muscle, unique genetic influences on pregnancy glycemic regulation, and variable cultural and lifestyle behaviors that affect meal, activity, sleep, and occupational schedules necessitate a personalized approach to insulin regimens. Newer insulin preparations have been developed to mimic the physiologic release of endogenous insulin, maintaining appropriate basal levels to cover hepatic gluconeogenesis and simulate the rapid, meal-related, bolus rise of insulin. Such physiologic basal-bolus dosing of insulin can be administered safely, achieving tighter glycemic control while reducing episodes of hypoglycemia. Insulin initiation and titration require understanding the pharmacodynamics of different insulin preparations in addition to a patient's glycemic profiles, effect of variable nutritional intake and mealtimes, physical activity, stress, timing of sleep cycles, and cultural habits. Educating and empowering patients to learn how their glucose responds to insulin, portion and content of meals, and physical activity can increase personal engagement in therapy, flexibility in eating patterns, and improved glycemic control. This Clinical Expert Series article is focused on optimizing insulin management (initiation, dosing, and titration) of gestational and type 2 diabetes in pregnancy.
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Affiliation(s)
- Amy M Valent
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon; and the Divisions of Endocrinology, Metabolism, and Diabetes and Maternal-Fetal Medicine, Departments of Medicine and Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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2
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Piersanti A, Pacini G, Tura A, D'Argenio DZ, Morettini M. An in-silico modeling approach to separate exogenous and endogenous plasma insulin appearance, with application to inhaled insulin. Sci Rep 2024; 14:10936. [PMID: 38740832 PMCID: PMC11091049 DOI: 10.1038/s41598-024-61293-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 05/03/2024] [Indexed: 05/16/2024] Open
Abstract
The aim of this study was to develop a dynamic model-based approach to separately quantify the exogenous and endogenous contributions to total plasma insulin concentration and to apply it to assess the effects of inhaled-insulin administration on endogenous insulin secretion during a meal test. A three-step dynamic in-silico modeling approach was developed to estimate the two insulin contributions of total plasma insulin in a group of 21 healthy subjects who underwent two equivalent standardized meal tests on separate days, one of which preceded by inhalation of a Technosphere® Insulin dose (22U or 20U). In the 30-120 min test interval, the calculated endogenous insulin component showed a divergence in the time course between the test with and without inhaled insulin. Moreover, the supra-basal area-under-the-curve of endogenous insulin in the test with inhaled insulin was significantly lower than that in the test without (2.1 ± 1.7 × 104 pmol·min/L vs 4.2 ± 1.8 × 104 pmol·min/L, p < 0.01). The percentage of exogenous insulin reaching the plasma, relative to the inhaled dose, was 42 ± 21%. The proposed in-silico approach separates exogenous and endogenous insulin contributions to total plasma insulin, provides individual bioavailability estimates, and can be used to assess the effect of inhaled insulin on endogenous insulin secretion during a meal.
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Affiliation(s)
- Agnese Piersanti
- Department of Information Engineering, Università Politecnica Delle Marche, Via Brecce Bianche 12, Ancona, Italy
| | | | | | - David Z D'Argenio
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA
| | - Micaela Morettini
- Department of Information Engineering, Università Politecnica Delle Marche, Via Brecce Bianche 12, Ancona, Italy.
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3
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Subramanian S, Khan F, Hirsch IB. New advances in type 1 diabetes. BMJ 2024; 384:e075681. [PMID: 38278529 DOI: 10.1136/bmj-2023-075681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
Type 1 diabetes is an autoimmune condition resulting in insulin deficiency and eventual loss of pancreatic β cell function requiring lifelong insulin therapy. Since the discovery of insulin more than 100 years ago, vast advances in treatments have improved care for many people with type 1 diabetes. Ongoing research on the genetics and immunology of type 1 diabetes and on interventions to modify disease course and preserve β cell function have expanded our broad understanding of this condition. Biomarkers of type 1 diabetes are detectable months to years before development of overt disease, and three stages of diabetes are now recognized. The advent of continuous glucose monitoring and the newer automated insulin delivery systems have changed the landscape of type 1 diabetes management and are associated with improved glycated hemoglobin and decreased hypoglycemia. Adjunctive therapies such as sodium glucose cotransporter-1 inhibitors and glucagon-like peptide 1 receptor agonists may find use in management in the future. Despite these rapid advances in the field, people living in under-resourced parts of the world struggle to obtain necessities such as insulin, syringes, and blood glucose monitoring essential for managing this condition. This review covers recent developments in diagnosis and treatment and future directions in the broad field of type 1 diabetes.
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Affiliation(s)
- Savitha Subramanian
- University of Washington Diabetes Institute, Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA
| | - Farah Khan
- University of Washington Diabetes Institute, Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA
| | - Irl B Hirsch
- University of Washington Diabetes Institute, Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA
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Hye T, Moinuddin SM, Sarkar T, Nguyen T, Saha D, Ahsan F. An evolving perspective on novel modified release drug delivery systems for inhalational therapy. Expert Opin Drug Deliv 2023; 20:335-348. [PMID: 36720629 PMCID: PMC10699164 DOI: 10.1080/17425247.2023.2175814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/30/2023] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Drugs delivered via the lungs are predominantly used to treat various respiratory disorders, including asthma, chronic obstructive pulmonary diseases, respiratory tract infections and lung cancers, and pulmonary vascular diseases such as pulmonary hypertension. To treat respiratory diseases, targeted, modified or controlled release inhalation formulations are desirable for improved patient compliance and superior therapeutic outcome. AREAS COVERED This review summarizes the important factors that have an impact on the inhalable modified release formulation approaches with a focus toward various formulation strategies, including dissolution rate-controlled systems, drug complexes, site-specific delivery, drug-polymer conjugates, and drug-polymer matrix systems, lipid matrix particles, nanosystems, and formulations that can bypass clearance via mucociliary system and alveolar macrophages. EXPERT OPINION Inhaled modified release formulations can potentially reduce dosing frequency by extending drug's residence time in the lungs. However, inhalable modified or controlled release drug delivery systems remain unexplored and underdeveloped from the commercialization perspective. This review paper addresses the current state-of-the-art of inhaled controlled release formulations, elaborates on the avenues for developing newer technologies for formulating various drugs with tailored release profiles after inhalational delivery and explains the challenges associated with translational feasibility of modified release inhalable formulations.
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Affiliation(s)
- Tanvirul Hye
- Oakland University William Beaumont School of Medicine, 586 Pioneer Dr, 48309, Rochester, MI, USA
| | - Sakib M. Moinuddin
- California Northstate University, College of Pharmacy, 9700 West Taron Drive, 95757, Elk Grove, CA, USA
- East Bay Institute for Research & Education (EBIRE), 95655, Mather, CA, USA
| | - Tanoy Sarkar
- California Northstate University, College of Pharmacy, 9700 West Taron Drive, 95757, Elk Grove, CA, USA
- East Bay Institute for Research & Education (EBIRE), 95655, Mather, CA, USA
| | - Trieu Nguyen
- California Northstate University, College of Pharmacy, 9700 West Taron Drive, 95757, Elk Grove, CA, USA
- East Bay Institute for Research & Education (EBIRE), 95655, Mather, CA, USA
| | - Dipongkor Saha
- California Northstate University, College of Pharmacy, 9700 West Taron Drive, 95757, Elk Grove, CA, USA
| | - Fakhrul Ahsan
- California Northstate University, College of Pharmacy, 9700 West Taron Drive, 95757, Elk Grove, CA, USA
- East Bay Institute for Research & Education (EBIRE), 95655, Mather, CA, USA
- MedLuidics, 95757, Elk Grove, CA, USA
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5
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An overview of recent advances in insulin delivery and wearable technology for effective management of diabetes. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Pei Y, Bao Y, Sacchetti C, Brady J, Gillard K, Yu H, Roberts S, Rajappan K, Tanis SP, Perez-Garcia CG, Chivukula P, Karmali PP. Synthesis and bioactivity of readily hydrolysable novel cationic lipids for potential lung delivery application of mRNAs. Chem Phys Lipids 2022; 243:105178. [PMID: 35122738 DOI: 10.1016/j.chemphyslip.2022.105178] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 12/25/2022]
Abstract
Lipid nanoparticles (LNPs) mediated mRNA delivery has gained prominence due to the success of mRNA vaccines against Covid-19, without which it would not have been possible. However, there is little clinical validation of this technology for other mRNA-based therapeutic approaches. Systemic administration of LNPs predominantly targets the liver, but delivery to other organs remains a challenge. Local approaches remain a viable option for some disease indications, such as Cystic Fibrosis, where aerosolized delivery to airway epithelium is the preferred route of administration. With this in mind, novel cationic lipids (L1-L4) have been designed, synthesized and co-formulated with a proprietary ionizable lipid. These LNPs were further nebulized, along with baseline control DOTAP-based LNP (DOTAP+), and tested in vitro for mRNA integrity and encapsulation efficiency, as well as transfection efficiency and cytotoxicity in cell cultures. Improved biodegradability and potentially superior elimination profiles of L1-L4, in part due to physicochemical characteristics of putative metabolites, are thought to be advantageous for prospective therapeutic lung delivery applications using these lipids.
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Affiliation(s)
- Yihua Pei
- Arcturus Therapeutics. 10628 Science Center Drive, Suite 250, San Diego, CA 92121, USA
| | - Yanjie Bao
- Arcturus Therapeutics. 10628 Science Center Drive, Suite 250, San Diego, CA 92121, USA
| | - Cristiano Sacchetti
- Arcturus Therapeutics. 10628 Science Center Drive, Suite 250, San Diego, CA 92121, USA
| | - Juthamart Brady
- Arcturus Therapeutics. 10628 Science Center Drive, Suite 250, San Diego, CA 92121, USA
| | - Kyra Gillard
- Arcturus Therapeutics. 10628 Science Center Drive, Suite 250, San Diego, CA 92121, USA
| | - Hailong Yu
- Arcturus Therapeutics. 10628 Science Center Drive, Suite 250, San Diego, CA 92121, USA
| | - Scott Roberts
- Arcturus Therapeutics. 10628 Science Center Drive, Suite 250, San Diego, CA 92121, USA
| | - Kumar Rajappan
- Arcturus Therapeutics. 10628 Science Center Drive, Suite 250, San Diego, CA 92121, USA.
| | - Steven P Tanis
- Arcturus Therapeutics. 10628 Science Center Drive, Suite 250, San Diego, CA 92121, USA.
| | - Carlos G Perez-Garcia
- Arcturus Therapeutics. 10628 Science Center Drive, Suite 250, San Diego, CA 92121, USA
| | - Padmanabh Chivukula
- Arcturus Therapeutics. 10628 Science Center Drive, Suite 250, San Diego, CA 92121, USA
| | - Priya P Karmali
- Arcturus Therapeutics. 10628 Science Center Drive, Suite 250, San Diego, CA 92121, USA
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Swain J, Jena S, Manglunia A, Singh J. The journey of insulin over 100 years. JOURNAL OF DIABETOLOGY 2022. [DOI: 10.4103/jod.jod_100_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Affiliation(s)
- Patrick Sharp
- Adult Community Diabetes Service, Royal South Hants Hospital Southampton UK
| | - Emma Ives
- Adult Community Diabetes Service, Royal South Hants Hospital Southampton UK
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Bhattacharya R, Johnson AP, T S, Rahamathulla M, H V G. Strategies to improve insulin delivery through oral route: A review. Curr Drug Deliv 2021; 19:317-336. [PMID: 34288838 DOI: 10.2174/1567201818666210720145706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/29/2021] [Accepted: 04/29/2021] [Indexed: 11/22/2022]
Abstract
Diabetes mellitus is found to be among the most suffered and lethal diseases for mankind. Diabetes mellitus type-1 is caused by the demolition of pancreatic islets responsible for the secretion of insulin. Insulin is the peptide hormone (anabolic] that regulates the metabolism of carbohydrates, fats, and proteins. Upon the breakdown of the natural process of metabolism, the condition leads to hyperglycemia (increased blood glucose levels]. Hyperglycemia demands outsourcing of insulin. The subcutaneous route was found to be the most stable route of insulin administration but faces patient compliance problems. Oral Insulin delivery systems are the patient-centered and innovative novel drug delivery system, eliminating the pain caused by the subcutaneous route of administration. Insulin comes in contact across various barriers in the gastrointestinal tract, which has been discussed in detail in this review. The review describes about the different bioengineered formulations, including microcarriers, nanocarriers, Self-Microemulsifying drug delivery systems (SMEDDs), Self-Nanoemulsifying drug delivery systems (SNEDDs), polymeric micelles, cochleates, etc. Surface modification of the carriers is also possible by developing ligand anchored bioconjugates. A study on evaluation has shown that the carrier systems facilitate drug encapsulation without tampering the properties of insulin. Carrier-mediated transport by the use of natural, semi-synthetic, and synthetic polymers have shown efficient results in drug delivery by protecting insulin from harmful environment. This makes the formulation readily acceptable for a variety of populations. The present review focuses on the properties, barriers present in the GI tract, overcome the barriers, strategies to formulate oral insulin formulation by enhancing the stability and bioavailability of insulin.
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Affiliation(s)
- Rohini Bhattacharya
- Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education and Research, Sri Shivarathreshwara Nagara, Bannimantap, Mysuru- 570015, Karnataka, India
| | - Asha P Johnson
- Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education and Research, Sri Shivarathreshwara Nagara, Bannimantap, Mysuru- 570015, Karnataka, India
| | - Shailesh T
- Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education and Research, Sri Shivarathreshwara Nagara, Bannimantap, Mysuru- 570015, Karnataka, India
| | - Mohamed Rahamathulla
- Department of Pharmaceutics, College of Pharmacy, King Khalid University, Guraiger, Abha, 62529. Saudi Arabia
| | - Gangadharappa H V
- Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education and Research, Sri Shivarathreshwara Nagara, Bannimantap, Mysuru- 570015, Karnataka, India
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Mann JL, Maikawa CL, Smith AAA, Grosskopf AK, Baker SW, Roth GA, Meis CM, Gale EC, Liong CS, Correa S, Chan D, Stapleton LM, Yu AC, Muir B, Howard S, Postma A, Appel EA. An ultrafast insulin formulation enabled by high-throughput screening of engineered polymeric excipients. Sci Transl Med 2021; 12:12/550/eaba6676. [PMID: 32611683 DOI: 10.1126/scitranslmed.aba6676] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 05/20/2020] [Indexed: 12/13/2022]
Abstract
Insulin has been used to treat diabetes for almost 100 years; yet, current rapid-acting insulin formulations do not have sufficiently fast pharmacokinetics to maintain tight glycemic control at mealtimes. Dissociation of the insulin hexamer, the primary association state of insulin in rapid-acting formulations, is the rate-limiting step that leads to delayed onset and extended duration of action. A formulation of insulin monomers would more closely mimic endogenous postprandial insulin secretion, but monomeric insulin is unstable in solution using present formulation strategies and rapidly aggregates into amyloid fibrils. Here, we implement high-throughput-controlled radical polymerization techniques to generate a large library of acrylamide carrier/dopant copolymer (AC/DC) excipients designed to reduce insulin aggregation. Our top-performing AC/DC excipient candidate enabled the development of an ultrafast-absorbing insulin lispro (UFAL) formulation, which remains stable under stressed aging conditions for 25 ± 1 hours compared to 5 ± 2 hours for commercial fast-acting insulin lispro formulations (Humalog). In a porcine model of insulin-deficient diabetes, UFAL exhibited peak action at 9 ± 4 min, whereas commercial Humalog exhibited peak action at 25 ± 10 min. These ultrafast kinetics make UFAL a promising candidate for improving glucose control and reducing burden for patients with diabetes.
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Affiliation(s)
- Joseph L Mann
- Department of Materials Science and Engineering, Stanford University, Stanford, CA 94025, USA
| | - Caitlin L Maikawa
- Department of Bioengineering, Stanford University, Stanford, CA 94305, USA
| | - Anton A A Smith
- Department of Materials Science and Engineering, Stanford University, Stanford, CA 94025, USA.,Department of Science and Technology, Aarhus University, 8000 Aarhus, Denmark
| | - Abigail K Grosskopf
- Department of Chemical Engineering, Stanford University, Stanford, CA 94305, USA
| | - Sam W Baker
- Department of Comparative Medicine, Stanford University, Palo Alto, CA 94305, USA
| | - Gillie A Roth
- Department of Bioengineering, Stanford University, Stanford, CA 94305, USA
| | - Catherine M Meis
- Department of Materials Science and Engineering, Stanford University, Stanford, CA 94025, USA
| | - Emily C Gale
- Department of Biochemistry, Stanford University, Palo Alto, CA 94305, USA
| | - Celine S Liong
- Department of Bioengineering, Stanford University, Stanford, CA 94305, USA
| | - Santiago Correa
- Department of Materials Science and Engineering, Stanford University, Stanford, CA 94025, USA
| | - Doreen Chan
- Department of Chemistry, Stanford University, Stanford, CA 94305, USA
| | | | - Anthony C Yu
- Department of Materials Science and Engineering, Stanford University, Stanford, CA 94025, USA
| | - Ben Muir
- CSIRO Manufacturing, Clayton, VIC 3168, Australia
| | - Shaun Howard
- CSIRO Manufacturing, Clayton, VIC 3168, Australia
| | - Almar Postma
- CSIRO Manufacturing, Clayton, VIC 3168, Australia
| | - Eric A Appel
- Department of Materials Science and Engineering, Stanford University, Stanford, CA 94025, USA. .,Department of Bioengineering, Stanford University, Stanford, CA 94305, USA.,ChEM-H Institute, Stanford University, Stanford, CA 94305, USA.,Department of Pediatrics (Endocrinology), Stanford University, Stanford, CA 94305, USA
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Polyzos SA, Mantzoros CS. Diabetes mellitus: 100 years since the discovery of insulin. Metabolism 2021; 118:154737. [PMID: 33610498 DOI: 10.1016/j.metabol.2021.154737] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/16/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Stergios A Polyzos
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos S Mantzoros
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Section of Endocrinology, Boston VA Healthcare System, Harvard Medical School, Boston, MA, USA.
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Ergun-Longmire B, Clemente E, Vining-Maravolo P, Roberts C, Buth K, Greydanus DE. Diabetes education in pediatrics: How to survive diabetes. Dis Mon 2021; 67:101153. [PMID: 33541707 DOI: 10.1016/j.disamonth.2021.101153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diabetes mellitus is the most common abnormal carbohydrate metabolism disorder affecting millions of people worldwide. It is characterized by hyperglycemia as a result of ß-cell destruction or dysfunction by both genetic and environmental factors. Over time chronic hyperglycemia leads to microvascular (i.e., retinopathy, nephropathy and neuropathy) and macrovascular (i.e., ischemic heart disease, peripheral vascular disease, and cerebrovascular disease) complications of diabetes. Diabetes complication trials showed the importance of achieving near-normal glycemic control to prevent and/or reduce diabetes-related morbidity and mortality. There is a staggering rate of increased incidence of diabetes in youth, raising concerns for future generations' health, quality of life and its enormous economic burden. Despite advancements in the technology, diabetes management remains cumbersome. Training individuals with diabetes to gain life-long survival skills requires a comprehensive and ongoing diabetes education by a multidisciplinary team. Diabetes education and training start at the time of diagnosis of diabetes and should be continuous throughout the course of disease. The goal is to empower the individuals and families to gain diabetes self-management skills. Diabetes education must be individualized depending on the individual's age, education, family dynamics, and support. In this article, we review the history of diabetes, etiopathogenesis and clinical presentation of both type 1 and type 2 diabetes in children as well as adolescents. We then focus on diabetes management with education methods and materials.
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Affiliation(s)
- Berrin Ergun-Longmire
- Associate Professor, Department of Pediatric and Adolescent Medicine, Western Michigan University, Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA.
| | - Ethel Clemente
- Department of Pediatric and Adolescent Medicine, Western Michigan University, Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Patricia Vining-Maravolo
- Department of Pediatric and Adolescent Medicine, Western Michigan University, Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Cheryl Roberts
- Department of Pediatric and Adolescent Medicine, Western Michigan University, Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Koby Buth
- Western Michigan University, Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Donald E Greydanus
- Professor, Department of Pediatric and Adolescent Medicine, Western Michigan University, Homer Stryker M.D. School of Medicine, Kalamazoo, MI United States
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McGill JB, Weiss D, Grant M, Jones MC, Kendall DM, Hoogwerf BJ. Understanding inhaled Technosphere Insulin: Results of an early randomized trial in type 1 diabetes mellitus. J Diabetes 2021; 13:164-172. [PMID: 32737923 DOI: 10.1111/1753-0407.13099] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/15/2020] [Accepted: 07/24/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Technosphere Insulin (TI) is an inhaled insulin. Studies comparing TI with short-acting insulin analogues provide important insights on efficacy, dosing, and time course of action. METHODS Planned enrollment of 230 subjects was limited to 138 due to premature study discontinuation. The primary efficacy endpoint was a noninferiority of glycosylated hemoglobin (HbA1c) of 0.4% for TI compared with insulin lispro (LIS) in a 16-week phase 3 randomized clinical trial in type 1 diabetes mellitus. RESULTS HbA1c values were similar in the TI and LIS groups at the beginning of the trial (7.8% and 7.6%, respectively) and at trial endpoint (7.7% and 7.6%, respectively). Least squares mean changes from baseline were similar between study groups. Glucose values after a standard meal were significantly lower with TI in the first 90 minutes post meal compared with LIS. Mild or moderate hypoglycemia event rates were also significantly lower with TI compared with LIS (5.97 vs 8.01, respectively; P = .0269). Cough was the most commonly reported adverse event with TI. Pulmonary function as measured by forced expiratory volume in 1 second was not different between groups at baseline, 16 weeks, or 4 weeks off study drug. CONCLUSIONS HbA1c was unchanged and overall glucose control was comparable between groups. Treatment with TI resulted in improved post-meal glucose and a lower risk of hypoglycemia compared with LIS.
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Affiliation(s)
- Janet B McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St Louis, Missouri, USA
| | - Daniel Weiss
- Your Diabetes Endocrine Nutrition Group, Inc, Mentor, Ohio, USA
| | | | | | | | - Byron J Hoogwerf
- Endocrinology, Diabetes and Metabolism (Emeritus), Cleveland Clinic, Cleveland, Ohio, USA
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Maikawa CL, d'Aquino AI, Lal RA, Buckingham BA, Appel EA. Engineering biopharmaceutical formulations to improve diabetes management. Sci Transl Med 2021; 13:eabd6726. [PMID: 33504649 PMCID: PMC8004356 DOI: 10.1126/scitranslmed.abd6726] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 12/22/2020] [Indexed: 12/12/2022]
Abstract
Insulin was first isolated almost a century ago, yet commercial formulations of insulin and its analogs for hormone replacement therapy still fall short of appropriately mimicking endogenous glycemic control. Moreover, the controlled delivery of complementary hormones (such as amylin or glucagon) is complicated by instability of the pharmacologic agents and complexity of maintaining multiple infusions. In this review, we highlight the advantages and limitations of recent advances in drug formulation that improve protein stability and pharmacokinetics, prolong drug delivery, or enable alternative dosage forms for the management of diabetes. With controlled delivery, these formulations could improve closed-loop glycemic control.
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Affiliation(s)
- Caitlin L Maikawa
- Department of Bioengineering, Stanford University, Stanford, CA 94305, USA
| | - Andrea I d'Aquino
- Department of Materials Science and Engineering, Stanford University, Stanford, CA 94305, USA
| | - Rayhan A Lal
- Department of Medicine (Endocrinology), Stanford University, Stanford, CA 94305, USA
- Department of Pediatrics (Endocrinology), Stanford University, Stanford, CA 94305, USA
- Diabetes Research Center, Stanford University, Stanford, CA 94305, USA
| | - Bruce A Buckingham
- Department of Pediatrics (Endocrinology), Stanford University, Stanford, CA 94305, USA
- Diabetes Research Center, Stanford University, Stanford, CA 94305, USA
| | - Eric A Appel
- Department of Bioengineering, Stanford University, Stanford, CA 94305, USA.
- Department of Materials Science and Engineering, Stanford University, Stanford, CA 94305, USA
- Department of Pediatrics (Endocrinology), Stanford University, Stanford, CA 94305, USA
- Diabetes Research Center, Stanford University, Stanford, CA 94305, USA
- ChEM-H Institute, Stanford University, Stanford, CA 94305, USA
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Abstract
OBJECTIVE To compare glycemic efficacy of Technosphere insulin (TI) versus that of insulin aspart (IA), each added to basal insulin, in type 2 diabetes. METHODS This randomized, 24-week trial included subjects aged from 18 to 80 years who were treated with subcutaneous insulin for 3 months and had glycated hemoglobin (HbA1C) levels of 7.0% to 11.5%. After receiving stabilized insulin glargine doses during a 4-week lead in, the subjects were randomized to TI or IA. The primary end point was an HbA1C change from baseline, with the differences analyzed by equivalence analyses. RESULTS In the overall cohort (N = 309; males, 23.3%), mean (SD) age was 58.5 (8.4) years, body mass index was 30.8 (4.7) kg/m2, weight was 82.2 (13.6) kg, and duration of diabetes was 12.2 (7.1) years. An intention-to-treat cohort had 150 subjects randomized to TI (mean [SD] HbA1C: 8.9% [1.1%]) and 154 randomized to IA (mean [SD] HbA1C: 9.0% [1.3%]). At 24 weeks, mean (SD) HbA1C value declined to 7.9% (1.3%) and 7.7% (1.1%) in the TI and IA cohorts, respectively. A treatment difference of 0.26% was not statistically significant, but the predefined equivalency margin was not met. Subjects receiving TI lost 0.78 kg compared to baseline; subjects receiving IA gained 0.23 kg (P =.0007). The incidence of mild/moderate hypoglycemia was lower for the TI cohort, though not statistically significant. CONCLUSION Both TI and IA resulted in significant and clinically meaningful HbA1C reductions. TI also resulted in significant and clinically meaningful weight reductions. These data support the use of inhaled insulin as a treatment option for individuals with type 2 diabetes.
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Levin P, Hoogwerf BJ, Snell-Bergeon J, Vigers T, Pyle L, Bromberger L. Ultra Rapid-Acting Inhaled Insulin Improves Glucose Control in Patients With Type 2 Diabetes Mellitus. Endocr Pract 2020; 27:449-454. [PMID: 33853718 DOI: 10.1016/j.eprac.2020.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/12/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine whether the use of an inhaled insulin would improve HbA1c. METHODS This study was performed in 20 type 2 diabetes mellitus (T2DM) participants with HbA1c values ≥7.5 (58) to ≤11.5% (102 mmol/mol) on a variety of glucose-lowering regimens. Prandial Technosphere insulin (TI) was rapidly titrated based on a treatment algorithm using postprandial blood glucose to calculate premeal doses. A 2-week baseline period was followed by 12 weeks of active treatment with TI. The primary outcome was change in HbA1c. Secondary outcomes included glucose time in range (time in range: 70-180 mg/dL) obtained by a blinded continuous glucose monitoring during the baseline period and at the end of 12 weeks. Goals were to assess how to rapidly and safely initiate TI intensification, determine dosing requirements, and establish an effective dose range in uncontrolled T2DM. RESULTS Mean HbA1c decreased by -1.6% (-17 mmol/mol) from 9.0% (75 mmol/mol) at baseline to 7.4% (57 mmol/mol) at 12 weeks (P < .0001). Mean time in range increased from 42.2% to 65.7% (P < .0002). Mean prandial doses of TI were 18 or 19 units for all meals. Time below range was 1.1% baseline and 2.6% post treatment (P = .01). CONCLUSION Treatment with inhaled TI dosed using a simple algorithm improved glycemic control measured by both HbA1c and time in range, with low rates of hypoglycemia. These data add significantly to understanding TI in the management of T2DM patients for whom prandial insulin is a consideration.
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Affiliation(s)
- Philip Levin
- MODEL Clinical Research, Endocrinology, Baltimore, Maryland.
| | - Byron J Hoogwerf
- Emeritus, Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, Ohio; Central Michigan University, Mount Pleasant, Michigan
| | - Janet Snell-Bergeon
- University of Colorado Anschutz Medical Campus, Pediatrics, Aurora, Colorado; Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, Colorado
| | - Tim Vigers
- University of Colorado Anschutz Medical Campus, Pediatrics, Aurora, Colorado; Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, Colorado
| | - Laura Pyle
- University of Colorado Anschutz Medical Campus, Pediatrics, Aurora, Colorado; Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, Colorado
| | - Lee Bromberger
- MODEL Clinical Research, Endocrinology, Baltimore, Maryland
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17
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Abstract
Insulin therapy has advanced remarkably over the past few decades. Ultra-rapid-acting and ultra-long-acting insulin analogs are now commercially available. Many additional insulin formulations are in development. This review outlines recent advances in insulin therapy and novel therapies in development.
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Affiliation(s)
- Leah M. Wilson
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Jessica R. Castle
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon, USA
- Address correspondence to: Jessica R. Castle, MD, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA
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18
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Hirsch IB, Juneja R, Beals JM, Antalis CJ, Wright EE. The Evolution of Insulin and How it Informs Therapy and Treatment Choices. Endocr Rev 2020; 41:5836295. [PMID: 32396624 PMCID: PMC7366348 DOI: 10.1210/endrev/bnaa015] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 05/05/2020] [Indexed: 01/05/2023]
Abstract
Insulin has been available for the treatment of diabetes for almost a century, and the variety of insulin choices today represents many years of discovery and innovation. Insulin has gone from poorly defined extracts of animal pancreata to pure and precisely controlled formulations that can be prescribed and administered with high accuracy and predictability of action. Modifications of the insulin formulation and of the insulin molecule itself have made it possible to approximate the natural endogenous insulin response. Insulin and insulin formulations had to be designed to produce either a constant low basal level of insulin or the spikes of insulin released in response to meals. We discuss how the biochemical properties of endogenous insulin were exploited to either shorten or extend the time-action profiles of injectable insulins by varying the pharmacokinetics (time for appearance of insulin in the blood after injection) and pharmacodynamics (time-dependent changes in blood sugar after injection). This has resulted in rapid-acting, short-acting, intermediate-acting, and long-acting insulins, as well as mixtures and concentrated formulations. An understanding of how various insulins and formulations were designed to solve the challenges of insulin replacement will assist clinicians in meeting the needs of their individual patients.
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Affiliation(s)
- Irl B Hirsch
- University of Washington Diabetes Institute, Seattle, Washington
| | - Rattan Juneja
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana
| | - John M Beals
- Eli Lilly and Company, Lilly Biotechnology Center, San Diego, California
| | - Caryl J Antalis
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana
| | - Eugene E Wright
- Charlotte Area Health Education Center, Charlotte, North Carolina
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19
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Galderisi A, Cohen N, Calhoun P, Kraemer K, Breton M, Weinzimer S, Cengiz E. Effect of Afrezza on Glucose Dynamics During HCL Treatment. Diabetes Care 2020; 43:2146-2152. [PMID: 32661108 PMCID: PMC7440894 DOI: 10.2337/dc20-0091] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/15/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE A major obstacle in optimizing the performance of closed-loop automated insulin delivery systems has been the delay in insulin absorption and action that results from the subcutaneous (SC) route of insulin delivery leading to exaggerated postmeal hyperglycemic excursions. We aimed to investigate the effect of Afrezza inhaled insulin with ultrafast-in and -out action profile on improving postprandial blood glucose control during hybrid closed-loop (HCL) treatment in young adults with type 1 diabetes. RESEARCH DESIGN AND METHODS We conducted an inpatient, three-way, randomized crossover standardized meal study to assess the efficacy and safety of Afrezza at a low (AL) and a high (AH) dose as compared with a standard SC rapid-acting insulin (aspart) premeal bolus during Diabetes Assistant (DiAs) HCL treatment. Participants received two sequential meals on three study days, and premeal insulin bolus was determined based on home insulin-to-carbohydrate ratio for each meal (rounded up to the closest available Afrezza cartridge dose for AH and down for AL). The primary efficacy outcome was the peak postprandial plasma glucose (PPG) level calculated by pooling data for up to 4 h after the start of each meal. Secondary outcomes included hyperglycemic, hypoglycemic, and euglycemic venous glucose metrics. RESULTS The mean ± SD PPG for the rapid-acting insulin control arm and AH was similar (185 ± 50 mg/dL vs. 195 ± 46 mg/dL, respectively; P = 0.45), while it was higher for meals using AL (208 ± 54 mg/dL, P = 0.04). The AH achieved significantly lower early PPG level than the control arm (30 min; P < 0.001), and improvement in PPG waned at later time points (120 and 180 min; P = 0.02) coinciding with the end of Afrezza glucodynamic action. CONCLUSIONS Afrezza (AH) premeal bolus reduced the early glycemic excursion and improved PPG during HCL compared with aspart premeal bolus. The improvement in PPG was not sustained after the end of Afrezza glucodynamic action at 120 min.
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Affiliation(s)
- Alfonso Galderisi
- Department of Pediatrics, Yale School of Medicine, New Haven, CT .,Department of Women's and Children's Health, University of Padova, Padova, Italy
| | | | | | - Kristen Kraemer
- Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Marc Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Stuart Weinzimer
- Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Eda Cengiz
- Department of Pediatrics, Yale School of Medicine, New Haven, CT.,Bahcesehir University School of Medicine, Istanbul, Turkey
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20
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Nitulescu GM, Paunescu H, Moschos SA, Petrakis D, Nitulescu G, Ion GND, Spandidos DA, Nikolouzakis TK, Drakoulis N, Tsatsakis A. Comprehensive analysis of drugs to treat SARS‑CoV‑2 infection: Mechanistic insights into current COVID‑19 therapies (Review). Int J Mol Med 2020; 46:467-488. [PMID: 32468014 PMCID: PMC7307820 DOI: 10.3892/ijmm.2020.4608] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/18/2020] [Indexed: 12/16/2022] Open
Abstract
The major impact produced by the severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) focused many researchers attention to find treatments that can suppress transmission or ameliorate the disease. Despite the very fast and large flow of scientific data on possible treatment solutions, none have yet demonstrated unequivocal clinical utility against coronavirus disease 2019 (COVID‑19). This work represents an exhaustive and critical review of all available data on potential treatments for COVID‑19, highlighting their mechanistic characteristics and the strategy development rationale. Drug repurposing, also known as drug repositioning, and target based methods are the most used strategies to advance therapeutic solutions into clinical practice. Current in silico, in vitro and in vivo evidence regarding proposed treatments are summarized providing strong support for future research efforts.
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Affiliation(s)
| | - Horia Paunescu
- Faculty of Medicine, ′Carol Davila′ University of Medicine and Pharmacy, 020956 Bucharest, Romania
| | - Sterghios A. Moschos
- Department of Applied Sciences, Faculty of Health and Life Sciences, Northumbria University
- PulmoBioMed Ltd., Newcastle-Upon-Tyne NE1 8ST, UK
| | | | | | | | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion
| | | | - Nikolaos Drakoulis
- Research Group of Clinical Pharmacology and Pharmacogenomics, Faculty of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, 15771 Athens, Greece
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21
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Cowart K. Overbasalization: Addressing Hesitancy in Treatment Intensification Beyond Basal Insulin. Clin Diabetes 2020; 38:304-310. [PMID: 32699482 PMCID: PMC7364465 DOI: 10.2337/cd19-0061] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Kevin Cowart
- Department of Pharmacotherapeutics & Clinical Research, Taneja College of Pharmacy and Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL
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22
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Kesavadev J, Saboo B, Krishna MB, Krishnan G. Evolution of Insulin Delivery Devices: From Syringes, Pens, and Pumps to DIY Artificial Pancreas. Diabetes Ther 2020; 11:1251-1269. [PMID: 32410184 PMCID: PMC7261311 DOI: 10.1007/s13300-020-00831-z] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Indexed: 12/24/2022] Open
Abstract
The year 2021 will mark 100 years since the discovery of insulin. Insulin, the first medication to be discovered for diabetes, is still the safest and most potent glucose-lowering therapy. The major challenge of insulin despite its efficacy has been the occurrence of hypoglycemia, which has resulted in sub-optimal dosages being prescribed in the vast majority of patients. Popular devices used for insulin administration are syringes, pens, and pumps. An artificial pancreas (AP) with a closed-loop delivery system with > 95% time in range is believed to soon become a reality. The development of closed-loop delivery systems has gained momentum with recent advances in continuous glucose monitoring (CGM) and computer algorithms. This review discusses the evolution of syringes, disposable, durable pens and connected pens, needles, tethered and patch insulin pumps, bionic pancreas, alternate controller-enabled infusion (ACE) pumps, and do-it-yourself artificial pancreas systems (DIY-APS).
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Affiliation(s)
- Jothydev Kesavadev
- Jothydev's Diabetes Research Centre, Mudavanmugal, Thiruvananthapuram, Kerala, India.
| | | | - Meera B Krishna
- Jothydev's Diabetes Research Centre, Mudavanmugal, Thiruvananthapuram, Kerala, India
| | - Gopika Krishnan
- Jothydev's Diabetes Research Centre, Mudavanmugal, Thiruvananthapuram, Kerala, India
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23
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Seaquist ER, Blonde L, McGill JB, Heller SR, Kendall DM, Bumpass JB, Pompilio FM, Grant ML. Hypoglycaemia is reduced with use of inhaled Technosphere ® Insulin relative to insulin aspart in type 1 diabetes mellitus. Diabet Med 2020; 37:752-759. [PMID: 31811662 PMCID: PMC7216876 DOI: 10.1111/dme.14202] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2019] [Indexed: 12/21/2022]
Abstract
AIM To evaluate the effect of final HbA1c levels on the incidences of hypoglycaemia in participants with type 1 diabetes treated with inhaled Technosphere® Insulin or subcutaneous insulin aspart, reported in alignment with the International Hypoglycaemia Study Group recommendations. METHODS In the randomized, phase 3, multicentre AFFINITY-1 study, adults (N = 375) who had type 1 diabetes for ≥ 12 months and an HbA1c level of 58-86 mmol/mol (7.5-10.0%) were randomized to receive basal insulin plus either inhaled Technosphere Insulin or subcutaneous insulin aspart. This was a post-hoc regression analysis on a subset (N = 279) of the randomized AFFINITY-1 cohort for whom baseline and end-of-treatment HbA1c values were reported. Primary outcome measures were incidence and event rates for levels 1, 2 and 3 hypoglycaemia, respectively defined as blood glucose levels of ≤ 3.9 mmol/l, < 3.0 mmol/l or requiring external assistance for recovery. RESULTS Participants treated with Technosphere Insulin experienced statistically significantly fewer level 1 and 2 hypoglycaemic events and a lower incidence of level 3 hypoglycaemia than participants treated with insulin aspart. The lower rate of hypoglycaemia with Technosphere Insulin was observed across the range of end-of-treatment HbA1c levels. Technosphere Insulin was associated with higher rates of hypoglycaemia 30-60 min after meals, but significantly lower rates 2-6 h after meals. CONCLUSIONS Participants using Technosphere Insulin experienced clinically non-inferior glycaemic control and lower hypoglycaemia rates across a range of HbA1c levels compared with participants receiving insulin aspart. ClinicalTrials.gov: NCT01445951.
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Affiliation(s)
| | - L. Blonde
- Ochsner Medical CenterNew OrleansLAUSA
| | - J. B. McGill
- Washington University School of MedicineSt LouisMOUSA
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24
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Excipient-free pulmonary insulin dry powder: Pharmacokinetic and pharmacodynamics profiles in rats. J Control Release 2020; 323:412-420. [PMID: 32325175 DOI: 10.1016/j.jconrel.2020.04.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/04/2020] [Accepted: 04/09/2020] [Indexed: 12/27/2022]
Abstract
A novel pure insulin spray-dried powder for DPI product (Ins_SD) was studied with respect to physico-chemical stability, in vitro respirability, bioavailability, activity and tolerability. Ins_SD powder exhibited a very high in vitro respirability, independently of the DPI product preparation (manual or semi-automatic). Physico-chemical characteristics of Ins_SD powder remained within the pharmacopoeia limits during 6 months of storage at room temperature. PK/PD profiles were measured in rats that received the pulmonary powders by intratracheal insufflation and compared with Afrezza inhalation insulin. Due to the low drug powder mass to deliver, both insulin powders were diluted with mannitol. Insulin from Ins_SD was promptly absorbed (tmax 15 min and Cmaxx4.9 ± 1.5 mU/ml). Afrezza had a slower absorption (tmax 30 min and Cmax of 1.8 ± 0.37 mU/ml). After glucose injection, Ins_SD determined a rapid reduction of glucose level, similar to Afrezza. As reference, insulin subcutaneous injection showed a long-lasting hypoglycemic effect due to the slow absorption that prolonged insulin plasma level. In summary, Ins_SD product is suitable for post-prandial glucose control, providing a convenient and compliant product, in particular in the event of using a disposable device. Albeit the product has to be stored in fridge, its stability at room temperature allows the diabetic individual to carry the daily dose in normal conditions.
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25
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Sala V, Murabito A, Ghigo A. Inhaled Biologicals for the Treatment of Cystic Fibrosis. ACTA ACUST UNITED AC 2020; 13:19-26. [PMID: 30318010 PMCID: PMC6751348 DOI: 10.2174/1872213x12666181012101444] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 10/09/2018] [Accepted: 10/09/2018] [Indexed: 12/20/2022]
Abstract
Background: Cystic Fibrosis (CF), one of the most frequent genetic diseases, is characterized by the production of viscous mucus in several organs. In the lungs, mucus clogs the airways and traps bacteria, leading to recurrent/resistant infections and lung damage. For cystic fibrosis patients, respiratory failure is still lethal in early adulthood since available treatments display incomplete efficacy. Objective: The objective of this review is to extend the current knowledge in the field of available treat-ments for cystic fibrosis. A special focus has been given to inhaled peptide-based drugs. Methods: The current review is based on recent and/or relevant literature and patents already available in various scientific databases, which include PubMed, PubMed Central, Patentscope and Science Direct. The information obtained through these diverse databases is compiled, critically interpreted and presented in the current study. An in-depth but not systematic approach to the specific research question has been adopted. Results: Recently, peptides have been proposed as possible pharmacologic agents for the treatment of respiratory diseases. Of note, peptides are suitable to be administered by inhalation to maximize efficacy and reduce systemic side effects. Moreover, innovative delivery carriers have been developed for drug administration through inhalation, allowing not only protection against proteolysis, but also a prolonged and controlled release. Conclusion: Here, we summarize newly patented peptides that have been developed in the last few years and advanced technologies for inhaled drug delivery to treat cystic fibrosis.
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Affiliation(s)
- Valentina Sala
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy.,S.C. Medicina d'Urgenza, A.O.U. Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
| | - Alessandra Murabito
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Alessandra Ghigo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
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26
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Fast-Acting Insulin Aspart and the Need for New Mealtime Insulin Analogues in Adults With Type 1 and Type 2 Diabetes: A Canadian Perspective. Can J Diabetes 2019; 43:515-523. [DOI: 10.1016/j.jcjd.2019.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/06/2018] [Accepted: 01/16/2019] [Indexed: 12/12/2022]
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Abstract
Microparticles, microspheres, and microcapsules are widely used constituents of multiparticulate drug delivery systems, offering both therapeutic and technological advantages. Microparticles are generally in the 1–1000 µm size range, serve as multiunit drug delivery systems with well-defined physiological and pharmacokinetic benefits in order to improve the effectiveness, tolerability, and patient compliance. This paper reviews their evolution, significance, and formulation factors (excipients and procedures), as well as their most important practical applications (inhaled insulin, liposomal preparations). The article presents the most important structures of microparticles (microspheres, microcapsules, coated pellets, etc.), interpreted with microscopic images too. The most significant production processes (spray drying, extrusion, coacervation, freeze-drying, microfluidics), the drug release mechanisms, and the commonly used excipients, the characterization, and the novel drug delivery systems (microbubbles, microsponges), as well as the preparations used in therapy are discussed in detail.
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28
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Abstract
INTRODUCTION Although premixed fixed ratio NPH insulin products are commonly used in type 2 diabetes patients, the advent of Glargine insulin which cannot be formulated together with a rapid-acting insulin (basal-bolus) has largely eliminated premixed insulin from use in type 1 diabetes. Degludec insulin can be formulated together with Aspart insulin in a 70/30 fixed ratio product. We review the potential use of Degludec-Aspart in type 1 diabetes. Areas covered: A historical search of the development and use of premixed insulin preparations was performed relying on Pubmed, FDA, and European Union records. Expert opinion: Degludec is a once daily insulin. There appears to be little advantage to administration of Degludec-Aspart twice daily, and basal bolus injections have proved superior to premixed insulin in type 1 diabetes. There may still be a role for this premixed fixed ratio formulation in patients who have opted to use Technosphere inhaled insulin prior to and post meals. In such patients, the use of a single injection of Degludec-Aspart prior to the largest meal of the day might provide an anchor to allow patients to then self-administer multiple inhalations around mealtimes.
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Affiliation(s)
- Marc Rendell
- a The Rose Salter Medical Research Foundation , Newport Coast , CA , USA.,b The Association of Diabetes Investigators , Newport Coast , CA , USA
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29
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He J, Zhang G, Zhang Q, Chen J, Zhang Y, An X, Wang P, Xie S, Fang F, Zheng J, Tang Y, Zhu J, Yu Y, Chen X, Lu Y. Evaluation of inhaled recombinant human insulin dry powders: pharmacokinetics, pharmacodynamics and 14-day inhalation. J Pharm Pharmacol 2018; 71:176-184. [PMID: 30324757 DOI: 10.1111/jphp.13026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/17/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The present study was designed to assess the pharmacokinetic and pharmacodynamic performance of inhaled recombinant human insulin (rh-insulin) dry powders together with their safety profiles after 14-day inhalation. METHODS In the pharmacokinetic and pharmacodynamic study, pulmonary surfactant (PS)-loaded and phospholipid hexadecanol tyloxapol (PHT)-loaded rh-insulin dry powders were intratracheally administered to male rats at the dose of 20 U/kg. Novolin R was used as control. Serum glucose and rh-insulin concentrations were determined by glucose oxidase method and human rh-insulin CLIA kit, respectively. For the safety study, rats were exposed to rh-insulin dry powders or air for 14-day by nose-only inhalation chambers. Bronchoalveolar lavage and histopathology examinations were performed after inhalation. KEY FINDINGS There were no significant differences in the major pharmacokinetic and pharmacodynamic parameters between PS-loaded and PHT-loaded rh-insulin dry powders. The relative bioavailabilities and pharmacodynamic availabilities were 39.9%, 25.6% for PS-loaded dry powders and 30.1%, 23% for PHT-loaded dry powders, respectively. Total protein was the only injury marker that was significantly altered. Histopathology examinations showed the ranking of irritations (from slight to severe) were PHT-loaded rh-insulin, negative air control and PS-loaded rh-insulin. CONCLUSIONS Both PS- and PHT-loaded rh-insulin dry powders were able to deliver rh-insulin systemically with appropriate pharmacokinetic, pharmacodynamic and safety profiles.
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Affiliation(s)
- Jiake He
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Pharmacy, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ge Zhang
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Qiuyang Zhang
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Jiayin Chen
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Yongjie Zhang
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Xiaoxia An
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Pan Wang
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Shan Xie
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Fang Fang
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Jianheng Zheng
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Yue Tang
- Department of Pharmaceutics, School of Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Jiabi Zhu
- Department of Pharmaceutics, School of Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Yang Yu
- Department of Pharmacy, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xijing Chen
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Yang Lu
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
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30
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Akturk HK, Snell-Bergeon JK, Rewers A, Klaff LJ, Bode BW, Peters AL, Bailey TS, Garg SK. Improved Postprandial Glucose with Inhaled Technosphere Insulin Compared with Insulin Aspart in Patients with Type 1 Diabetes on Multiple Daily Injections: The STAT Study. Diabetes Technol Ther 2018; 20:639-647. [PMID: 30207748 PMCID: PMC6161328 DOI: 10.1089/dia.2018.0200] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The majority of therapies have generally targeted fasting glucose control, and current mealtime insulin therapies have longer time action profiles than that of endogenously secreted insulin. The primary purpose of this study was to assess both glucose time-in-range (TIR: 70-180 mg/dL) and postprandial glucose excursions (PPGE) in 1-4 h using a real-time continuous glucose monitor (CGM) with Technosphere insulin (TI) versus insulin aspart in patients with type 1 diabetes (T1DM) on multiple daily injections (MDI). RESEARCH DESIGN AND METHODS This pilot, investigator-led, collaborative, open-label, multicenter, clinical research trial enrolled 60 patients with T1DM with HbA1c levels ≥6.5% and ≤10%. Individuals were randomized to treatment with titrated TI (n = 26) or titrated insulin aspart (n = 34), stratified by baseline HbA1c levels (≤8% or >8%). All were required to wear a real-time CGM throughout the trial. All patients in the TI group were advised to take supplemental inhalations at 1 and 2 h after meals if indicated based on postprandial glucose (PPG) values. The coprimary outcomes were assessed both in the full intent-to-treat population and in those individuals randomized to TI who were compliant with supplemental doses ≥90% of the time (n = 15). The CGM data were analyzed using linear regression models. RESULTS Overall, those treated with TI versus aspart achieved comparable TIR, but less time spent in hypoglycemia (<60 and <50 mg/dL, both P < 0.05). In the TI-compliant group (n = 15), TIR was significantly greater (62.5% ± 2.6% vs. 53.8% ± 1.7%, P = 0.009) and time in hyperglycemia >180 mg/dL was lower (34.2% ± 2.7% vs. 41.0% ± 1.7%, P = 0.045) as compared with the aspart group. PPG was also significantly lower in the TI cohort at 60 and 90 min postmeal, and PPGE were lower in the TI-compliant group as compared with the aspart group over 1-4-h postmeal (P < 0.05). In addition, there was weight gain in the aspart group compared with weight loss in the TI group (P = 0.006) despite higher prandial TI insulin dose. CONCLUSIONS We conclude that using TI appropriately at mealtimes with supplemental dosing improves prandial glucose (TIR and 1-4 h) control without any increase in time in hypoglycemia or weight gain in patients with T1DM on MDI. The study results support a larger study using a treat-to-target design to confirm these findings. Clinical trial reg. no. NCT03143816, clinicaltrials.gov .
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Affiliation(s)
- Halis Kaan Akturk
- Barbara Davis Center for Diabetes, University of Colorado Denver, Aurora, Colorado
| | | | - Amanda Rewers
- Barbara Davis Center for Diabetes, University of Colorado Denver, Aurora, Colorado
| | | | | | - Anne L. Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | | | - Satish K. Garg
- Barbara Davis Center for Diabetes, University of Colorado Denver, Aurora, Colorado
- Address correspondence to:Satish K. Garg, MDBarbara Davis Center for DiabetesUniversity of Colorado Denver1775 Aurora Ct, Room 1319Aurora, CO, 80045
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31
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Pettus J, Santos Cavaiola T, Edelman SV. Recommendations for Initiating Use of Afrezza Inhaled Insulin in Individuals with Type 1 Diabetes. Diabetes Technol Ther 2018; 20:448-451. [PMID: 29901406 DOI: 10.1089/dia.2017.0463] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Treatment with Afrezza® (insulin human) inhalation powder in individuals with type 1 diabetes (T1D) reduces HbA1c levels similar to rapid-acting insulin analogs, but with significantly less hypoglycemia due to its unique time action profile. Examinations of studies of Afrezza pharmacokinetics/pharmacodynamics, relevant clinical trials, and U.S. Food and Drug Administration (FDA) documentation suggest that current FDA-mandated dosing recommendations for initiating Afrezza treatment may not result in optimal glycemic control for individuals with T1D. Recommendations for initiating Afrezza insulin therapy in T1D patients are presented in this article.
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Affiliation(s)
- Jeremy Pettus
- 1 Department of Medicine, Clinical and Translational Research Institute (CTRI), University of California San Diego , San Diego, California
| | - Tricia Santos Cavaiola
- 1 Department of Medicine, Clinical and Translational Research Institute (CTRI), University of California San Diego , San Diego, California
| | - Steven V Edelman
- 1 Department of Medicine, Clinical and Translational Research Institute (CTRI), University of California San Diego , San Diego, California
- 2 University of California San Diego and Taking Control of Your Diabetes 501c3 , San Diego, California
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32
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Akturk HK, Rewers A, Joseph H, Schneider N, Garg SK. Possible Ways to Improve Postprandial Glucose Control in Type 1 Diabetes. Diabetes Technol Ther 2018; 20:S224-S232. [PMID: 29916737 DOI: 10.1089/dia.2018.0114] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Halis Kaan Akturk
- Barbara Davis Center for Diabetes - Adult Clinic, University of Colorado , Aurora, Colorado
| | - Amanda Rewers
- Barbara Davis Center for Diabetes - Adult Clinic, University of Colorado , Aurora, Colorado
| | - Hal Joseph
- Barbara Davis Center for Diabetes - Adult Clinic, University of Colorado , Aurora, Colorado
| | - Nicole Schneider
- Barbara Davis Center for Diabetes - Adult Clinic, University of Colorado , Aurora, Colorado
| | - Satish K Garg
- Barbara Davis Center for Diabetes - Adult Clinic, University of Colorado , Aurora, Colorado
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Abstract
New therapies, monitoring, and revolutionary enabling technologies applied to healthcare represent an historic opportunity to improve the lives of people with diabetes. These advances enable more meaningful monitoring of blood glucose values with the facilitation of more optimal insulin dosing and delivery. Newer insulins and delivery systems are in development that seek to mitigate both hyperglycemia and hypoglycemia and increase time in range. Information systems now exist that may be leveraged to merge data from previously discrete systems into new models of connected care. This review highlights important developments that serve to increase effectiveness while reducing the burden of diabetes care in the near future.
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Affiliation(s)
| | - John Walsh
- 2 Advanced Metabolic Care + Research , Escondido, California
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34
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Affiliation(s)
- Lutz Heinemann
- Science & Co, Düsseldorf, Germany
- Lutz Heinemann, PhD, Science & Co, Kehler Strasse 24, D-40468, Düsseldorf, Germany.
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35
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Affiliation(s)
- Satish K Garg
- 1 Barbara Davis Center for Diabetes, University of Colorado, Aurora, Colorado
| | - Amanda H Rewers
- 1 Barbara Davis Center for Diabetes, University of Colorado, Aurora, Colorado
| | - H Kaan Akturk
- 1 Barbara Davis Center for Diabetes, University of Colorado, Aurora, Colorado
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36
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Heinemann L, Parkin CG. Rethinking the Viability and Utility of Inhaled Insulin in Clinical Practice. J Diabetes Res 2018; 2018:4568903. [PMID: 29707584 PMCID: PMC5863311 DOI: 10.1155/2018/4568903] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 12/21/2017] [Accepted: 01/23/2018] [Indexed: 01/01/2023] Open
Abstract
Despite considerable advances in pharmacotherapy and self-monitoring technologies in the last decades, a large percentage of adults with diabetes remain unsuccessful in achieving optimal glucose due to suboptimal medication adherence. Contributors to suboptimal adherence to insulin treatment include pain, inconvenience, and regimen complexity; however, a key driver is hypoglycemia. Improvements in the PK/PD characteristics of today's SC insulins provide more physiologic coverage of basal and prandial insulin requirements than regular human insulin; however, they do not achieve the rapid on/rapid off characteristics of endogenously secreted insulin seen in healthy, nondiabetic individuals. Pulmonary administration of prandial insulin represents an attractive option that overcomes limitations of SC insulin by providing more a rapid onset of action and a faster return of action to baseline levels than SC administration of rapid-acting insulin analogs. This article reviews the unique PK/PD properties of a novel inhaled formulation that support its use in patient populations with T1D or T2D.
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37
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Yacoub T. Impact of improving postprandial glycemic control with intensifying insulin therapy in type 2 diabetes. Postgrad Med 2017; 129:791-800. [PMID: 29032696 DOI: 10.1080/00325481.2017.1389601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Worldwide, many people with type 2 diabetes are not at recommended glycemic targets and remain at increased risk of microvascular and macrovascular complications. Reaching recommended glycemic targets requires normalizing both fasting and postprandial glucose (PPG). For some patients, this will require addition of a prandial insulin delivered by injection to control PPG excursions. Evidence from epidemiological studies suggests an association between postprandial hyperglycemia and cardiovascular disease, and thus, expert guidelines recommend that treatment for elevated PPG not be delayed. Indeed, studies have demonstrated that PPG makes the greatest contribution to HbA1c in patients who are approaching, but have not yet reached HbA1c <7.0%. Appropriately timed exposure of the liver to insulin is critical in suppressing hepatic glucose output (and therefore PPG levels) after a meal. Rapid-acting insulin analogs, with their faster onset and shorter duration of action, offer advantages over regular human insulin. Unfortunately, even with improved pharmacokinetic/pharmacodynamic characteristics, rapid-acting insulin analogs are still unable to fully reproduce the rapid release of insulin into the portal circulation and suppression of hepatic glucose output that occurs in the individual without diabetes after starting a meal. The next generation of rapid-acting insulin analogs will have an even more favorable pharmacokinetic profile that should allow patients to further improve glycemic control. Continuous subcutaneous insulin infusion (CSII) represents another option for intensifying therapy and improving postprandial control in some patients, and studies have shown that the benefits are sustainable long-term. However, it is currently unclear which patients stand to benefit the most from the extra expense and complexity of a CSII regimen, and further studies are needed.
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Affiliation(s)
- Tamer Yacoub
- a Endocrinology Division , Prima-Care Medical Center , Fall River , MA , USA
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38
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Uduku C, Oliver N. Pharmacological aspects of closed loop insulin delivery for type 1 diabetes. Curr Opin Pharmacol 2017; 36:29-33. [DOI: 10.1016/j.coph.2017.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 12/11/2022]
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39
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Henninot A, Collins JC, Nuss JM. The Current State of Peptide Drug Discovery: Back to the Future? J Med Chem 2017; 61:1382-1414. [PMID: 28737935 DOI: 10.1021/acs.jmedchem.7b00318] [Citation(s) in RCA: 638] [Impact Index Per Article: 91.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Over the past decade, peptide drug discovery has experienced a revival of interest and scientific momentum, as the pharmaceutical industry has come to appreciate the role that peptide therapeutics can play in addressing unmet medical needs and how this class of compounds can be an excellent complement or even preferable alternative to small molecule and biological therapeutics. In this Perspective, we give a concise description of the recent progress in peptide drug discovery in a holistic manner, highlighting enabling technological advances affecting nearly every aspect of this field: from lead discovery, to synthesis and optimization, to peptide drug delivery. An emphasis is placed on describing research efforts to overcome the inherent weaknesses of peptide drugs, in particular their poor pharmacokinetic properties, and how these efforts have been critical to the discovery, design, and subsequent development of novel therapeutics.
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Affiliation(s)
- Antoine Henninot
- Ferring Research Institute , 4245 Sorrento Valley Boulevard, San Diego, California 92121, United States
| | - James C Collins
- Ferring Research Institute , 4245 Sorrento Valley Boulevard, San Diego, California 92121, United States
| | - John M Nuss
- Ferring Research Institute , 4245 Sorrento Valley Boulevard, San Diego, California 92121, United States
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40
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Abstract
Considerable progress in treatment of diabetes has been made in the nearly 100 years following the discovery of insulin, and advances in insulin therapy have improved convenience, quality of life, overall glycemic control (A1C), and risk of hypoglycemia. An unmet need remains for a mealtime insulin that can faithfully reproduce the metabolic profile that ensues following meal ingestion in healthy persons. A number of "ultra-fast" insulin programs have been initiated, and Afrezza® (insulin human; Inhalation Powder, MannKind Corporation, Danbury, CT) stands as the first such product to be approved by the US FDA. Afrezza is unique as an "ultra-ultra" fast insulin, faster than any other entrant except IV insulin. The benefits and limitations of the Afrezza profile are discussed in this analysis.
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Affiliation(s)
- Douglas B. Muchmore
- Kinexum Services, La Jolla, CA, USA
- Douglas B. Muchmore, MD, Kinexum Services, 7037 Via Valverde, La Jolla, CA 92037, USA.
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41
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42
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Mikhail N. Place of technosphere inhaled insulin in treatment of diabetes. World J Diabetes 2016; 7:599-604. [PMID: 28031777 PMCID: PMC5155233 DOI: 10.4239/wjd.v7.i20.599] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/18/2016] [Indexed: 02/05/2023] Open
Abstract
Technosphere insulin (TI), Afrezza, is a powder form of short-acting regular insulin taken by oral inhalation with meals. Action of TI peaks after approximately 40-60 min and lasts for 2-3 h. TI is slightly less effective than subcutaneous insulin aspart, with mean hemoglobin A1c (HbA1c) reduction of 0.21% and 0.4%, respectively. When compared with technosphere inhaled placebo, the decrease in HbA1c levels was 0.8% and 0.4% with TI and placebo, respectively. Compared with insulin aspart, TI is associated with lower risk of late post-prandial hypoglycemia and weight gain. Apart from hypoglycemia, cough is the most common adverse effect of TI reported by 24%-33% of patients vs 2% with insulin aspart. TI is contraindicated in patients with asthma and chronic obstructive pulmonary disease. While TI is an attractive option of prandial insulin, its use is limited by frequent occurrence of cough, need for periodic monitoring of pulmonary function, and lack of long-term safety data. Candidates for use of TI are patients having frequent hypoglycemia while using short-acting subcutaneous insulin, particularly late post-prandial hypoglycemia, patients with needle phobia, and those who cannot tolerate subcutaneous insulin due to skin reactions.
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