1
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Bao Z, Cheng YC, Luo MZ, Zhang JY. Analysis of aggregation profile of glucagon using SEC-HPLC and FFF-MALS methods. PLoS One 2024; 19:e0304086. [PMID: 38771849 PMCID: PMC11108154 DOI: 10.1371/journal.pone.0304086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 05/03/2024] [Indexed: 05/23/2024] Open
Abstract
Recently, the first generic glucagon for injection was approved for the treatment of severe hypoglycemia. Unlike its brand name recombinant glucagon, the generic glucagon is synthetic. Since glucagon has a high propensity to form aggregates in solution, it is essential to assess the aggregation profile of the synthetic glucagon compared to the recombinant glucagon. In this study, two robust separation methods, size-exclusion chromatography (SEC-HPLC) and field-flow fractionation coupled with a multi-angle light scattering detector (FFF-MALS), were employed to characterize generic and brand glucagon aggregation in six lots (three newly released, three expired). The presence of aggregation in samples was determined from the generated chromatograms and analyzed. The study showed that both products have comparable aggregation profiles. The SEC-HPLC demonstrated that in both glucagon versions, the expired lots had a higher percentage of dimers than the newly released lots, but even at expiration, the amount was negligible (∼0.1%). The FFF-MALS method did not detect any dimers or higher molecular weight aggregates. Further evaluation of the detection limit found that FFF-MALS was unable to detect aggregates at amounts lower than 0.5% of total glucagon. The negligible amounts of dimer detected in the generic and brand glucagon indicate that both versions are physically stable and are not prone to aggregation under clinically relevant conditions.
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Affiliation(s)
- Zhongli Bao
- Amphastar Pharmaceuticals, Inc., Rancho Cucamonga, California, California, United States of America
| | - Ya-Chi Cheng
- Amphastar Pharmaceuticals, Inc., Rancho Cucamonga, California, California, United States of America
| | - Mary Ziping Luo
- Amphastar Pharmaceuticals, Inc., Rancho Cucamonga, California, California, United States of America
| | - Jack Yongfeng Zhang
- Amphastar Pharmaceuticals, Inc., Rancho Cucamonga, California, California, United States of America
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2
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Yu X, Wen X, Xu J, Zhou Q, Chen Y, Qu F, He M, Chang H, Zheng C. Rapid Correction of the Hypoglycemia State in Nonhuman Primates Using a Glucagon Long-Dissolving Microneedle Patch. ACS Biomater Sci Eng 2024; 10:3086-3096. [PMID: 38588325 DOI: 10.1021/acsbiomaterials.3c01962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
The timely administration of glucagon is a standard clinical practice for the treatment of severe hypoglycemia. However, the process involves cumbersome steps, including the reconstitution of labile glucagon and filling of the syringe, which cause considerable delays in emergency situations. Moreover, multiple dosages are often required to prevent the recurrence of the hypoglycemic episode because of the short half-life of glucagon in plasma. Herein, we develop a glucagon-loaded long-dissolving microneedle (GLMN) patch that exhibits the properties of fast onset and sustained activity for the effective treatment of severe hypoglycemia. Three types of MN patches were fabricated with different dimensions (long, medium, and short). The longer MN patch packaged a higher dosage of glucagon and exhibited supreme mechanical strength compared to the shorter one. Additionally, the longer MN patch could insert more deeply into the skin, resulting in higher permeability of glucagon across the skin tissue and more rapid systemic absorption as compared with the shorter MN patch. The GLMN patch was observed to reverse the effects of hypoglycemia within 15 min of application in animal models (specifically, rat and rhesus monkey models) and maintained long-term glycemic control, owing to highly efficient drug permeation and the drug reservoir effect of the MN base. The current study presents a promising strategy for the rapid reversal of severe hypoglycemia that exhibits the desirable properties of easy use, high efficiency, and sustained action.
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Affiliation(s)
- Xiang Yu
- Affiliated Huzhou Hospital, School of Medicine, Zhejiang University, Huzhou Central Hospital, Huzhou, Zhejiang 313000, China
| | - Xueyu Wen
- Hangzhou Institute of Medicine, Chinese Academy of Sciences, Hangzhou, Zhejiang 310022, China
| | - Jianchen Xu
- Department of Endocrinology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310058, China
| | - Qiao Zhou
- Department of Endocrinology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310058, China
| | - Yingrong Chen
- Affiliated Huzhou Hospital, School of Medicine, Zhejiang University, Huzhou Central Hospital, Huzhou, Zhejiang 313000, China
| | - Fengli Qu
- Hangzhou Institute of Medicine, Chinese Academy of Sciences, Hangzhou, Zhejiang 310022, China
| | - Min He
- Hangzhou Institute of Medicine, Chinese Academy of Sciences, Hangzhou, Zhejiang 310022, China
| | - Hao Chang
- Hangzhou Institute of Medicine, Chinese Academy of Sciences, Hangzhou, Zhejiang 310022, China
| | - Chao Zheng
- Affiliated Huzhou Hospital, School of Medicine, Zhejiang University, Huzhou Central Hospital, Huzhou, Zhejiang 313000, China
- Department of Endocrinology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310058, China
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3
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Kumar S, Sanap SN, Pandey P, Khopade A, Sawant KK. Glucagon: Delivery advancements for hypoglycemia management. Int J Pharm 2024; 652:123785. [PMID: 38224759 DOI: 10.1016/j.ijpharm.2024.123785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/18/2023] [Accepted: 01/03/2024] [Indexed: 01/17/2024]
Abstract
As the 100th anniversary of glucagon's discovery approaches, we reflect on the remarkable journey of understanding its pivotal role in glucose regulation. Advancements in glucagon delivery systems for managing hypoglycemia are unfolding with promise, albeit accompanied by formulation and implementation challenges. Recent developments include non-injectable methods like BAQSIMI® (Nasal glucagon) offers a user-friendly option, but stability, bioavailability, and rapid onset remain formulation hurdles. Closed-loop systems, combining glucagon with insulin, aim to automate glucose control, demanding stable and precise formulations compatible with complex algorithms. However, achieving co-delivery harmony and effective dual-hormone responses poses substantial challenges. Ogluo® and Gvoke HypoPen® are auto-injector pens, a ready-to-use solution that can rapidly control hypoglycemia and eliminate the need for mixing powder and liquid. GlucaGen® Hypokit® and Glucagon Emergency Kits are traditional deliveries that possess complexity during administration and are still widely used in clinical practice. In addition to this advancement, we have covered the recent patents and clinical trials of glucagon delivery. The synergy of patent innovation and clinical validation offers a glimpse into the transformative potential of glucagon delivery yet underscores the intricate path toward widespread adoption and improved diabetes care. Finally, this review will help the formulation scientist, clinicians, healthcare providers, and patient to manage hypoglycemia using glucagon.
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Affiliation(s)
- Samarth Kumar
- Formulation Research & Development-Non Orals, Sun Pharmaceutical Industries Ltd, Vadodara 390020, Gujrat, India; Faculty of Pharmacy, The Maharaja Sayajirao University of Baroda, Vadodara, Gujarat, India.
| | - Sachin N Sanap
- Formulation Research & Development-Non Orals, Sun Pharmaceutical Industries Ltd, Vadodara 390020, Gujrat, India
| | - Prachi Pandey
- Krishna School of Pharmacy & Research, KPGU, Vadodara, Gujarat, India
| | - Ajay Khopade
- Formulation Research & Development-Non Orals, Sun Pharmaceutical Industries Ltd, Vadodara 390020, Gujrat, India
| | - Krutika K Sawant
- Faculty of Pharmacy, The Maharaja Sayajirao University of Baroda, Vadodara, Gujarat, India.
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4
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Wang X, Ma Y, Qi X, Ruan X, Cao D, Zhao F. Practicality of non-invasive glucagon-loaded dissolving microneedle for life-saving treatment of severe hypoglycemia in a diabetic rat model. Int J Pharm 2023; 644:123340. [PMID: 37625601 DOI: 10.1016/j.ijpharm.2023.123340] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/30/2023] [Accepted: 08/19/2023] [Indexed: 08/27/2023]
Abstract
The development of dissolving microneedles (DMNs) has brought light to the transdermal delivery of biomolecules that are released into the skin through the rapid dissolution of the matrix material to enter the systemic circulation and exert therapeutic effects. Herein, we aimed to prepare, characterize, and analyze the effectiveness of a glucagon-loaded DMN system that rapidly increases blood sugar levels in rats with diabetic hypoglycemia. The stability and content of biological drugs following DMNs preparation was assessed using circular dichroism and bicinchoninic acid kit for protein determination kits(BCA kits). The maximum drug loading capacity of DMNs was approximately 140 μg in each patch, and the microneedles could be stored for up to 14 days under dry storage conditions. In vitro skin permeation studies were conducted using a Franz diffusion cell apparatus for glucagon-loaded DMNs. To investigate the efficacy of transdermal drug delivery, drug-laden DMNs were administered to rats with hypoglycemic diabetes. Compared to subcutaneous injections, microneedle drug release demonstrated comparable efficacy in raising blood glucose levels in vivo. Therefore, this study demonstrated that glucagon-loaded DMNs may be a promising approach for efficient transdermal drug delivery as an alternative to subcutaneous injection for the treatment of severe hypoglycemia in patients with diabetes.
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Affiliation(s)
- Xuejiao Wang
- School of Pharmacy, Hebei Medical University, Shijiazhuang 050017, China
| | - Yinling Ma
- School of Pharmacy, Hebei Medical University, Shijiazhuang 050017, China; National Clinical Drug Monitoring Center, Department of Pharmacy, Hebei Province General Center, Shijiazhuang 050051, China
| | - Xiaodan Qi
- School of Pharmacy, Hebei Medical University, Shijiazhuang 050017, China
| | - Xi Ruan
- School of Pharmacy, Hebei Medical University, Shijiazhuang 050017, China
| | - Deying Cao
- School of Pharmacy, Hebei Medical University, Shijiazhuang 050017, China.
| | - Feng Zhao
- School of Pharmacy, Hebei Medical University, Shijiazhuang 050017, China.
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5
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Hofland J, Falconi M, Christ E, Castaño JP, Faggiano A, Lamarca A, Perren A, Petrucci S, Prasad V, Ruszniewski P, Thirlwell C, Vullierme MP, Welin S, Bartsch DK. European Neuroendocrine Tumor Society 2023 guidance paper for functioning pancreatic neuroendocrine tumour syndromes. J Neuroendocrinol 2023; 35:e13318. [PMID: 37578384 DOI: 10.1111/jne.13318] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/09/2023] [Accepted: 06/13/2023] [Indexed: 08/15/2023]
Abstract
This ENETS guidance paper aims to provide practical advice to clinicians for the diagnosis, treatment and follow-up of functioning syndromes in pancreatic neuroendocrine tumours (NET). A NET-associated functioning syndrome is defined by the presence of a clinical syndrome combined with biochemical evidence of inappropriately elevated hormonal levels. Different hormonal syndromes can be encountered in pancreatic NET patients, including insulinoma, gastrinoma as well as the rare glucagonoma, VIPoma, ACTHoma, PTHrPoma, carcinoid syndrome, calcitoninoma, GHRHoma and somatostatinoma. The recommendations provided in this paper focus on the biochemical, genetic and imaging work-up as well as therapeutic management of the individual hormonal syndromes in well-differentiated, grade 1-3, functioning NET with the primary tumour originating in the pancreas, and for specific subtypes also in the duodenum.
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Affiliation(s)
- Johannes Hofland
- Department of Internal Medicine, Section of Endocrinology, ENETS Centre of Excellence, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Massimo Falconi
- Pancreatic Surgery and Transplantation Unit, Pancreas Translational and Clinical Research Centre, ENETS Center of Excellence, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Emanuel Christ
- ENETS Centre of Excellence for Neuroendocrine and Endocrine Tumours, University Hospital Basel, Basel, Switzerland
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Justo P Castaño
- Maimonides Biomedical Research Institute of Córdoba, Córdoba, Spain
- Department of Cell Biology, Physiology, and Immunology, University of Córdoba, Córdoba, Spain
- Hospital Universitario Reina Sofía, Córdoba, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain
| | - Antongiulio Faggiano
- Endocrinology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, ENETS Centre of Excellence, Sapienza University of Rome, Rome, Italy
| | - Angela Lamarca
- Department of Oncology - OncoHealth Institute, Fundación Jiménez Díaz University Hospital, Madrid, Spain
- Department of Medical Oncology, The Christie NHS Foundation, Manchester, Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Aurel Perren
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Simona Petrucci
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
- Medical Genetics and Advanced Cell Diagnostics Unit, Sant Andrea University Hospital, Rome, Italy
| | - Vikas Prasad
- Division of Nuclear Medicine, Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Philippe Ruszniewski
- Department of Pancreatology, FHU MOSAIC, Université Paris Cité - APHP Hôpital Beaujon, Clichy, France
| | | | - Marie-Pierre Vullierme
- Centre Hospitalier Annecy Genevois (CHANGE), Université Paris-Cité, Praticien Hospitalier Imagerie Médicale, Annecy, France
| | - Staffan Welin
- Department of Endocrine Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Phillips-University Marburg and University Hospital Gießen Marburg GmbH, Marburg, Germany
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6
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Novikoff A, Müller TD. The Molecular Pharmacology of Glucagon Agonists in Diabetes and Obesity. Peptides 2023; 165:171003. [PMID: 36997003 DOI: 10.1016/j.peptides.2023.171003] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Abstract
Within the past couple decades glucagon receptor agonism has drawn attention as a therapeutic tool for the treatment of type 2 diabetes and obesity. In both mice and humans glucagon-induced enhancements in energy expenditure and suppression of food intake suggest promising utility, therefore interest has advanced in the synthetic optimization of glucagon-based pharmacology to further resolve the physiological and cellular underpinnings. Modifications within the glucagon peptide sequence have allowed for greater solubility, stability, circulating half-life, and understanding of the structure-function potential behind partial and "super"-agonists. This knowledge gained from such modifications has provided a basis for the development of long-acting therapeutically useful glucagon analogues, chimeric unimolecular dual- and tri-agonists, and novel strategies for the targeting of nuclear hormones into glucagon receptor-expressing tissues. In this review, we summarize the peptide path leading to these glucagon-based developments in the field of anti-diabetes and anti-obesity pharmacology, while highlighting the associated biological and therapeutic effects.
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Affiliation(s)
- Aaron Novikoff
- Institute of Diabetes and Obesity, Helmholtz Center Munich, Neuherberg, Germany; German Center for Diabetes Research (DZD), Neuherberg, Germany.
| | - Timo D Müller
- Institute of Diabetes and Obesity, Helmholtz Center Munich, Neuherberg, Germany; German Center for Diabetes Research (DZD), Neuherberg, Germany.
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7
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Scheen AJ, Lefèbvre PJ. Glucagon, from past to present: a century of intensive research and controversies. Lancet Diabetes Endocrinol 2023; 11:129-138. [PMID: 36566754 DOI: 10.1016/s2213-8587(22)00349-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 12/24/2022]
Abstract
2022 corresponds to the 100th anniversary of the discovery of glucagon. This TimeCapsule aims to recall the main steps leading to the discovery, characterisation, and clinical importance of the so-called second pancreatic hormone. We describe the early historical findings in basic research (ie, discovery, purification, structure, α-cell origin, radioimmunoassay, glucagon gene [GCG], and glucagon receptor [GLR]), in which three future Nobel Prize laureates were actively involved. Considered as an anti-insulin hormone, glucagon was rapidly used to treat insulin-induced hypoglycaemic coma episodes in people with type 1 diabetes. A key step in the story of glucagon was the discovery of its role and the role of α cells in the physiology and pathophysiology (ie, paracrinopathy) of type 2 diabetes. This concept led to the design of different strategies targeting glucagon, among which GLP-1 receptor (GLP1R) agonists were a major breakthrough, and combination of inhibition of glucagon secretion with stimulation of insulin secretion (both in a glucose-dependent manner). Taking advantage of the glucagon-induced increase in energy metabolism, biased coagonists were developed. Besides the GLP-1 receptor, these coagonists also target the glucagon receptor to further promote weight loss. Thus, the 100-year story of glucagon has most probably not come to an end.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of medicine, CHU Liège, Liège University, Liège, Belgium.
| | - Pierre J Lefèbvre
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of medicine, CHU Liège, Liège University, Liège, Belgium
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8
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Heller S, Battelino T, Bailey TS, Pieber TR, Hövelmann U, Plum-Mörschel L, Melgaard AE, Aronson R, DiMeglio LA, Johansen T, Danne T. Integrated safety and efficacy analysis of dasiglucagon for the treatment of severe hypoglycaemia in individuals with type 1 diabetes. Diabetes Obes Metab 2023; 25:1351-1360. [PMID: 36692230 DOI: 10.1111/dom.14987] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/25/2023]
Abstract
AIMS To perform an integrated analysis of the safety and efficacy of dasiglucagon, a glucagon analogue available in a ready-to-use aqueous formulation, to treat severe hypoglycaemia (SH) in type 1 diabetes (T1D). MATERIALS AND METHODS An integrated analysis of dasiglucagon safety was conducted on data from two placebo-controlled trials (placebo-controlled pool) and two placebo-controlled and four non-placebo-controlled trials (broad pool) in adults with T1D. An integrated analysis of dasiglucagon efficacy was conducted of pooled data and within demographic subgroups from the two placebo-controlled and two non-placebo-controlled trials in adults with T1D. RESULTS Dasiglucagon had a similar safety and tolerability profile to that of reconstituted glucagon. In the placebo-controlled datasets, no serious adverse events (AEs), AEs leading to withdrawal from the trial, or deaths were reported. The most common causally related AEs were nausea (56.5%) and vomiting (24.6%). The broad pool safety analysis showed similar results. Dasiglucagon efficacy in time to plasma glucose recovery from insulin-induced SH was similar to that of reconstituted glucagon (median 10.0 and 12.0 minutes, respectively) and superior to placebo (median 40.0 minutes; P < 0.0001). The median recovery time was consistent across all placebo-controlled trial subgroups. CONCLUSIONS Dasiglucagon was well tolerated and effective as a rapid rescue agent for insulin-induced SH in people with T1D.
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Affiliation(s)
| | - Tadej Battelino
- University Medical Center Ljubljana, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | | | | | | | | | - Ronnie Aronson
- LMC Diabetes and Endocrinology, Toronto, Ontario, Canada
| | | | | | - Thomas Danne
- Children's Hospital AUF DER BULT, Hannover, Germany
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9
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Kalra S, Unnikrishnan AG, Prasanna Kumar KM, Sahay R, Chandalia HB, Saboo B, Annamalai S, Kesavadev J, Shukla R, Wangnoo SK, Baruah MP, Jacob J, Arora S, Singla R, Sharma SK, Damodaran S, Bantwal G. Addendum 1: Forum for Injection Technique and Therapy Expert Recommendations, India. Diabetes Ther 2023; 14:29-45. [PMID: 36380217 PMCID: PMC9880128 DOI: 10.1007/s13300-022-01332-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022] Open
Abstract
With the emerging complexities in chronic diseases and people's lifestyles, healthcare professionals (HCPs) need to update their methods to manage and educate patients with chronic lifestyle disorders, particularly diabetes. The insulin injection technique (IIT), along with various parameters, must also be updated with newer methods. Forum for Injection Technique and Therapy Expert Recommendations (FITTER), India, has updated its recommendations to cover newer ways of detecting hypoglycaemia and lipohypertrophy, preventing needlestick injuries (NSIs), discouraging the reuse of insulin needles and encouraging good disposal. FITTER, India, is also introducing recommendations to calculate insulin bolus dose. These updated recommendations will help HCPs better manage patients with diabetes and achieve improved outcomes.
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10
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Dholariya S, Parchwani D, Dutta S, Singh R. Clinical efficacy and safety of dasiglucagon in severe hypoglycemia associated with patients of type 1 diabetes mellitus: a systematic review and meta-analysis. Expert Rev Clin Pharmacol 2023; 16:61-71. [PMID: 36266088 DOI: 10.1080/17512433.2023.2138343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIMS This study was carried out to analyze the clinical safety and efficacy of dasiglucagon for the treatment of severe hypoglycemia in patients with type 1 diabetes mellitus (T1DM). METHODS We searched PubMed, Cochrane Library, Embase, and ClinicalTrials.gov for randomized controlled trials (RCTs) investigating the safety and efficacy of dasiglucagon in the treatment of hypoglycemia in patients with T1DM. Furthermore, time required for the recovery of blood glucose or to elevate blood glucose levels ≥20.0 mg/dL from baseline was analyzed. The data was analyzed in version 5.4 of review manager 5 (RevMan). RESULTS We included five published RCTs with a total of 347 patients . Dasiglucagon was significantly better at reducing the recovery time of blood glucose or increasing blood glucose levels 20.0 mg/dL from baseline compared to glucagon [pooled mean difference (PMD): 1.08%, 95% confidence interval (CI): 1.96 to 0.21, p = 0.02] and placebo (PMD: - 23.30%, 95% CI: 23.97 to 22.63, p < 0.00001). Overall, the safety outcome results of dasiglucagon were comparable with the native glucagon. CONCLUSIONS Dasiglucagon appears to be a promising human glucagon analog peptide for the safe and effective treatment of severe hypoglycemia in T1DM.
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Affiliation(s)
- Sagar Dholariya
- Department of Biochemistry, All India Institute of Medical Sciences, Rajkot, India
| | - Deepak Parchwani
- Department of Biochemistry, All India Institute of Medical Sciences, Rajkot, India
| | - Siddhartha Dutta
- Department of Pharmacology, All India Institute of Medical Sciences, Rajkot, India
| | - Ragini Singh
- Department of Biochemistry, All India Institute of Medical Sciences, Rajkot, India
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11
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Sanchez-Rangel E, Deajon-Jackson J, Hwang JJ. Pathophysiology and management of hypoglycemia in diabetes. Ann N Y Acad Sci 2022; 1518:25-46. [PMID: 36202764 DOI: 10.1111/nyas.14904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In the century since the discovery of insulin, diabetes has changed from an early death sentence to a manageable chronic disease. This change in longevity and duration of diabetes coupled with significant advances in therapeutic options for patients has fundamentally changed the landscape of diabetes management, particularly in patients with type 1 diabetes mellitus. However, hypoglycemia remains a major barrier to achieving optimal glycemic control. Current understanding of the mechanisms of hypoglycemia has expanded to include not only counter-regulatory hormonal responses but also direct changes in brain glucose, fuel sensing, and utilization, as well as changes in neural networks that modulate behavior, mood, and cognition. Different strategies to prevent and treat hypoglycemia have been developed, including educational strategies, new insulin formulations, delivery devices, novel technologies, and pharmacologic targets. This review article will discuss current literature contributing to our understanding of the myriad of factors that lead to the development of clinically meaningful hypoglycemia and review established and novel therapies for the prevention and treatment of hypoglycemia.
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Affiliation(s)
- Elizabeth Sanchez-Rangel
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jelani Deajon-Jackson
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Janice Jin Hwang
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA.,Division of Endocrinology, Department of Internal Medicine, University of North Carolina - Chapel Hill, Chapel Hill, North Carolina, USA
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12
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Bao Z, Cheng YC, Wei JJ, Luo MZ, Zhang JY. Secondary Structure Characterization of Glucagon Products by Circular Dichroism and Nuclear Magnetic Resonance Spectroscopy. MOLECULES (BASEL, SWITZERLAND) 2022; 27:molecules27227805. [PMID: 36431905 PMCID: PMC9696263 DOI: 10.3390/molecules27227805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022]
Abstract
Glucagon, a 29-amino acid polypeptide hormone, is an essential therapeutic agent used in the emergency treatment of hypoglycemia. However, glucagon is inherently unstable in aqueous solution. While glucagon equilibrates between unordered and the secondary α-helix state in solution, it can quickly transform into a different secondary β-sheet-rich amyloid-like fibril/oligomer structure under various conditions. Since changes in the secondary structure of glucagon can cause significant impacts, structure analysis is necessary and essential to assess the safety of the product. This study analyzed the secondary structure of glucagon products at the release and at the expiry using circular dichroism spectroscopy (CD) and 2D Nuclear Overhauser effect spectroscopy (2D NOESY). In order to also determine if structural differences exist between glucagon produced through different manufacturing processes, synthetic and recombinant glucagon products were used and compared. The CD results indicated that for all release and expired glucagon products, the structure compositions were 14 to 16% α-helix, 17 to 19% β-strand, 14 to 15% Turn, and 53 to 54% Unordered. This was consistent with the 2D NOESY analysis which showed that both products had an approximate α-helix composition of 14 to 17%. Overall, there were no significant differences in terms of the secondary structure between synthetic and recombinant glucagon products both at the release and at the expiry.
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13
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Story LH, Wilson LM. New Developments in Glucagon Treatment for Hypoglycemia. Drugs 2022; 82:1179-1191. [PMID: 35932416 DOI: 10.1007/s40265-022-01754-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/28/2022]
Abstract
Glucagon is essential for endogenous glucose regulation along with the paired hormone, insulin. Unlike insulin, pharmaceutical use of glucagon has been limited due to the unstable nature of the peptide. Glucagon has the potential to address hypoglycemia as a major limiting factor in the treatment of diabetes, which remains very common in the type 1 and type 2 diabetes. Recent developments are poised to change this paradigm and expand the use of glucagon for people with diabetes. Glucagon emergency kits have major limitations for their use in treating severe hypoglycemia. A complicated reconstitution and injection process often results in incomplete or aborted administration. New preparations include intranasal glucagon with an easy-to-use and needle-free nasal applicator as well as two stable liquid formulations in pre-filled injection devices. These may ease the burden of severe hypoglycemia treatment. The liquid preparations may also have a role in the treatment of non-severe hypoglycemia. Despite potential benefits of expanded use of glucagon, undesirable side effects (nausea, vomiting), cost, and complexity of adding another medication may limit real-world use. Additionally, more long-term safety and outcome data are needed before widespread, frequent use of glucagon is recommended by providers.
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Affiliation(s)
- LesleAnn Hayward Story
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Leah M Wilson
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA.
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14
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Domingo-Lopez DA, Lattanzi G, H. J. Schreiber L, Wallace EJ, Wylie R, O'Sullivan J, Dolan EB, Duffy GP. Medical devices, smart drug delivery, wearables and technology for the treatment of Diabetes Mellitus. Adv Drug Deliv Rev 2022; 185:114280. [PMID: 35405298 DOI: 10.1016/j.addr.2022.114280] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 02/21/2022] [Accepted: 04/05/2022] [Indexed: 12/13/2022]
Abstract
Diabetes mellitus refers to a group of metabolic disorders which affect how the body uses glucose impacting approximately 9% of the population worldwide. This review covers the most recent technological advances envisioned to control and/or reverse Type 1 diabetes mellitus (T1DM), many of which will also prove effective in treating the other forms of diabetes mellitus. Current standard therapy for T1DM involves multiple daily glucose measurements and insulin injections. Advances in glucose monitors, hormone delivery systems, and control algorithms generate more autonomous and personalised treatments through hybrid and fully automated closed-loop systems, which significantly reduce hypo- and hyperglycaemic episodes and their subsequent complications. Bi-hormonal systems that co-deliver glucagon or amylin with insulin aim to reduce hypoglycaemic events or increase time spent in target glycaemic range, respectively. Stimuli responsive materials for the controlled delivery of insulin or glucagon are a promising alternative to glucose monitors and insulin pumps. By their self-regulated mechanism, these "smart" drugs modulate their potency, pharmacokinetics and dosing depending on patients' glucose levels. Islet transplantation is a potential cure for T1DM as it restores endogenous insulin and glucagon production, but its use is not yet widespread due to limited islet sources and risks of chronic immunosuppression. New encapsulation strategies that promote angiogenesis and oxygen delivery while protecting islets from recipients' immune response may overcome current limiting factors.
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15
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Comparison of the Purity and Impurity of Glucagon-for-Injection Products under Various Stability Conditions. Sci Pharm 2022. [DOI: 10.3390/scipharm90020032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Glucagon is a polypeptide hormone that serves as an essential therapeutic agent in the emergency treatment of hypoglycemia. Recently, the first generic glucagon for injection was approved. However, unlike its brand name counterpart, which is produced via recombinant DNA, the generic glucagon is produced using a chemical synthesis method. Regardless of its origin, impurities may occur in both glucagon drug products. While these impurities may greatly compromise the safety and efficacy of the glucagon drug products, studies accessing the impurities of glucagon for injection are limited. This manuscript analyzed the stability and impurities of a generic and brand glucagon for injection, including desamido and non-desamido impurities, under various storage and temperature conditions using an ultra-performance liquid chromatography method. The glucagon products were analyzed after 6 and 24 months of storage under room temperatures (20–25 °C). In addition, the products were also assessed after 6 months of storage under high temperatures (40 °C). Under each stability storage condition, three lots of the synthetic glucagon were evaluated by UPLC with at least one lot of the recombinant glucagon for comparison. A total of 37 peaks were identified (except for the solvent peaks, which appeared at retention times less than 1.5 min) from the synthetic and recombinant glucagon lots. It was found that the number of impurities observed in the synthetic glucagon were lower than the referenced recombinant glucagon across all stability conditions. Throughout all tested conditions, the synthetic glucagon for injection had an averaged purity of 92.8–99.3%, while the referenced recombinant drug had an averaged purity of 70.3–91.7%. Based on the study results, it can be concluded that the impurity profile for the synthetic glucagon for injection has a comparable and even lower level of impurities than the recombinant version under all stability conditions.
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16
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Scharbarg E, Greck J, Le Carpentier E, Chaillous L, Moog CH. A metamodel-based flexible insulin therapy for type 1 diabetes patients subjected to aerobic physical activity. Sci Rep 2022; 12:8017. [PMID: 35577814 PMCID: PMC9110411 DOI: 10.1038/s41598-022-11772-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/26/2022] [Indexed: 11/09/2022] Open
Abstract
Patients with type 1 diabetes are subject to exogenous insulin injections, whether manually or through (semi)automated insulin pumps. Basic knowledge of the patient's characteristics and flexible insulin therapy (FIT) parameters are then needed. Specifically, artificial pancreas-like closed-loop insulin delivery systems are some of the most promising devices for substituting for endogenous insulin secretion in type 1 diabetes patients. However, these devices require self-reported information such as carbohydrates or physical activity from the patient, introducing potential miscalculations and delays that can have life-threatening consequences. Here, we display a metamodel for glucose-insulin dynamics that is subject to carbohydrate ingestion and aerobic physical activity. This metamodel incorporates major existing knowledge-based models. We derive comprehensive and universal definitions of the underlying FIT parameters to form an insulin sensitivity factor (ISF). In addition, the relevance of physical activity modelling is assessed, and the FIT is updated to take physical exercise into account. Specifically, we cope with physical activity by using heart rate sensors (watches) with a fully automated closed insulin loop, aiming to maximize the time spent in the glycaemic range (75.5% in the range and 1.3% below the range for hypoglycaemia on a virtual patient simulator).These mathematical parameter definitions are interesting on their own, may be new tools for assessing mathematical models and can ultimately be used in closed-loop artificial pancreas algorithms or to extend distinguished FIT.
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Affiliation(s)
- Emeric Scharbarg
- Nantes Université, École Centrale Nantes, CNRS, LS2N, UMR 6004, Nantes, F-44000, France.
- Nantes Université, CHU Nantes, Department of Endocrinology, l'Institut du Thorax, Nantes, F-44000, France.
| | - Joachim Greck
- Nantes Université, École Centrale Nantes, CNRS, LS2N, UMR 6004, Nantes, F-44000, France
| | - Eric Le Carpentier
- Nantes Université, École Centrale Nantes, CNRS, LS2N, UMR 6004, Nantes, F-44000, France
| | - Lucy Chaillous
- Nantes Université, CHU Nantes, Department of Endocrinology, l'Institut du Thorax, Nantes, F-44000, France
| | - Claude H Moog
- Nantes Université, École Centrale Nantes, CNRS, LS2N, UMR 6004, Nantes, F-44000, France
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17
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Bailey NC, Dimsits J, Hammer M, Kendall DM, Bailey TS. A Comparative Study of Dasiglucagon Ready-to-Use Autoinjector and Glucagon Emergency Kit During Rescue from Simulated Severe Hypoglycemia. Diabetes Technol Ther 2022; 24:231-240. [PMID: 34809479 PMCID: PMC9057872 DOI: 10.1089/dia.2021.0367] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background: Severe hypoglycemic episodes are life-threatening events demanding rapid administration of glucagon by a caregiver or bystander. The glucagon analog dasiglucagon is stable in aqueous formulation and therefore suitable for delivery in a ready-to-use autoinjector, potentially increasing speed and ease of use compared with standard glucagon emergency kits (GEKs). Methods: In an open label, randomized, crossover, comparative device handling study, trained caregivers and untrained bystanders administered the dasiglucagon autoinjector or Eli Lilly GEK to manikins in a simulated emergency hypoglycemia situation. Results: In total, 54 participants were randomized (18 patient-caregiver pairs and 18 bystanders). Overall, 94% of trained caregivers were able to administer the dasiglucagon autoinjector successfully within 15 min, compared with 56% for the GEK (P < 0.05). A greater proportion of trained caregivers and untrained bystanders successfully prepared and administered the dasiglucagon autoinjector within 2 min compared with the GEK (P < 0.005 and P < 0.05, respectively). Time to successful completion was also significantly faster with the dasiglucagon autoinjector than with the GEK (P < 0.005 for both groups). Most study participants preferred the dasiglucagon autoinjector over the GEK (94%, P < 0.001) and rated it as easier (90%, P < 0.001) and less stressful to use (94%, P < 0.001) than the GEK. Conclusion: Dasiglucagon autoinjector was more rapidly and reliably administered, and users reported greater ease of use and usage satisfaction than with the GEK. Thus, dasiglucagon autoinjector has the potential to improve speed and ease of treatment in severe hypoglycemic events, providing a better usage experience for rescuing individuals and enabling faster recovery for patients.
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18
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Walsh EPG, Alsweiler JM, Ardern J, Hanning SM, Harding JE, McKinlay CJD. Glucagon for Neonatal Hypoglycaemia: Systematic Review and Meta-Analysis. Neonatology 2022; 119:285-294. [PMID: 35263748 DOI: 10.1159/000522415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/31/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Glucagon is often used in neonatal hypoglycaemia, but its effects have not been systematically assessed. We undertook a systematic review to determine the efficacy and safety of glucagon treatment for neonatal hypoglycaemia. METHODS We searched MEDLINE, CINAHL, EMBASE, and CENTRAL from inception until May 2021. We included studies that reported one or more prespecified outcomes and compared glucagon with placebo or no glucagon. Studies were excluded if the majority (>70%) of participants were >1 month of age. Two authors independently extracted data. We used ROB-2/modified ROBINS-I to assess risk of bias, GRADE for certainty of evidence, and RevMan for meta-analysis. RESULTS 100 studies were screened, 37 reviewed in full, and seven single-arm non-randomised intervention studies, involving 348 infants, were included (no trials). Data were insufficient to undertake meta-analysis of the critical outcomes (time to blood glucose normalization, recurrent hypoglycaemia, neurocognitive impairment). In 3 studies, ≥80% of neonates achieved normoglycaemia within 4 h of glucagon administration. However, recurrent hypoglycaemia was common (up to 55%). Glucagon increased blood glucose concentration at 1-2 h by 2.3 mmol/L (95% CI 2.1, 2.5) (low certainty evidence, 6 studies, N = 323). There were few data for other important clinical outcomes. CONCLUSION There is a paucity of evidence about the efficacy and safety of glucagon for treatment of neonatal hypoglycaemia. Low certainty evidence suggests that glucagon may increase blood glucose by ∼2.3 mmol/L but recurrent hypoglycaemia appears common. High-quality, randomized controlled trials are required to determine the role of glucagon in managing neonatal hypoglycaemia.
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Affiliation(s)
- Eamon P G Walsh
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Julena Ardern
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
| | - Sara M Hanning
- School of Pharmacy, University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Christopher J D McKinlay
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
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19
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Liu M, Zhao P, Uddin MH, Li W, Lin F, Chandrashekar C, Nishiuchi Y, Kajihara Y, Forbes BE, Wootten D, Wade JD, Hossain MA. Chemical Synthesis and Characterization of a Nonfibrillating Glycoglucagon. Bioconjug Chem 2021; 32:2148-2153. [PMID: 34494823 DOI: 10.1021/acs.bioconjchem.1c00419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The current commercially available glucagon formulations for the treatment of severe hypoglycemia must be reconstituted immediately prior to use, owing to the susceptibility of glucagon to fibrillation and aggregation in an aqueous solution. This results in the inconvenience of handling, misuse, and wastage of this drug. To address these issues, we synthesized a glycosylated glucagon analogue in which the 25th residue (Trp) was replaced with a cysteine (Cys) and a Br-disialyloligosaccharide was conjugated at the Cys thiol moiety. The resulting analogue, glycoglucagon, is a highly potent full agonist at the glucagon receptor. Importantly, glycoglucagon exhibits markedly reduced propensity for fibrillation and enhanced thermal and metabolic stability. This novel analogue is thus a valuable lead for producing stable liquid glucagon formulations that will improve patient compliance and minimize wastage.
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Affiliation(s)
| | - Peishen Zhao
- Monash Institute of Pharmaceutical Sciences, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Md Hemayet Uddin
- Melbourne Centre for Nanofabrication, Melbourne, Victoria 3168, Australia
| | | | | | | | - Yuji Nishiuchi
- GlyTech, Inc., 134 Chudoji Minamimachi, Kyoto, 600-8813, Japan
- Graduate School of Science, Tohoku University, Sendai, Miyagi 980-8579, Japan
| | - Yasuhiro Kajihara
- Graduate School of Science, Osaka University, Toyonaka, Osaka 560-0043 Japan
| | - Briony E Forbes
- Discipline of Medical Biochemistry, College of Medicine and Public Health, Flinders University, Adelaide, South Australia 5042, Australia
| | - Denise Wootten
- Monash Institute of Pharmaceutical Sciences, 381 Royal Parade, Parkville, Victoria 3052, Australia
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20
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Amyloidogenicity of peptides targeting diabetes and obesity. Colloids Surf B Biointerfaces 2021; 209:112157. [PMID: 34715595 DOI: 10.1016/j.colsurfb.2021.112157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/20/2021] [Accepted: 10/09/2021] [Indexed: 12/15/2022]
Abstract
Since the discovery of insulin, a century ago, the repertoire of therapeutic polypeptides targeting diabetes - and now also obesity - have increased substantially. The focus on quality has shifted from impure and unstable preparations of animal insulin to highly pure, homologous recombinant insulin, along with other peptide-based hormones and analogs such as amylin analogs (pramlintide, davalintide, cagrilintide), glucagon and glucagon-like peptide-1 receptor agonists (GLP-1, liraglutide, exenatide, semaglutide). Proper formulation, storage, manipulation and usage by professionals and patients are required in order to avoid agglomeration into high molecular weight products (HMWP), either amorphous or amyloid, which could result in potential loss of biological activity and short- or long-term immune reaction and silent inactivation. In this narrative review, we present perspective of the aggregation of therapeutic polypeptides used in diabetes and other metabolic diseases, covering the nature and mechanisms, analytical techniques, physical and chemical stability, strategies aimed to hamper the formation of HMWP, and perspectives on future biopharmaceutical developments.
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21
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Porcellati F, Di Mauro S, Mazzieri A, Scamporrino A, Filippello A, De Fano M, Fanelli CG, Purrello F, Malaguarnera R, Piro S. Glucagon as a Therapeutic Approach to Severe Hypoglycemia: After 100 Years, Is It Still the Antidote of Insulin? Biomolecules 2021; 11:biom11091281. [PMID: 34572493 PMCID: PMC8464883 DOI: 10.3390/biom11091281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 12/11/2022] Open
Abstract
Hypoglycemia represents a dark and tormented side of diabetes mellitus therapy. Patients treated with insulin or drug inducing hypoglycemia, consider hypoglycemia as a harmful element, which leads to their resistance and lack of acceptance of the pathology and relative therapies. Severe hypoglycemia, in itself, is a risk for patients and relatives. The possibility to have novel strategies and scientific knowledge concerning hypoglycemia could represent an enormous benefit. Novel available glucagon formulations, even now, allow clinicians to deal with hypoglycemia differently with respect to past years. Novel scientific evidence leads to advances concerning physiopathological mechanisms that regulated glycemic homeostasis. In this review, we will try to show some of the important aspects of this field.
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Affiliation(s)
- Francesca Porcellati
- Department of Medicine and Surgery, Perugia University School of Medicine, Via Gambuli 1, 06126 Perugia, Italy; (F.P.); (A.M.); (M.D.F.); (C.G.F.)
| | - Stefania Di Mauro
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
| | - Alessio Mazzieri
- Department of Medicine and Surgery, Perugia University School of Medicine, Via Gambuli 1, 06126 Perugia, Italy; (F.P.); (A.M.); (M.D.F.); (C.G.F.)
| | - Alessandra Scamporrino
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
| | - Agnese Filippello
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
| | - Michelantonio De Fano
- Department of Medicine and Surgery, Perugia University School of Medicine, Via Gambuli 1, 06126 Perugia, Italy; (F.P.); (A.M.); (M.D.F.); (C.G.F.)
| | - Carmine Giuseppe Fanelli
- Department of Medicine and Surgery, Perugia University School of Medicine, Via Gambuli 1, 06126 Perugia, Italy; (F.P.); (A.M.); (M.D.F.); (C.G.F.)
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
| | - Roberta Malaguarnera
- Faculty of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy
- Correspondence: ; Tel.: +39-0935-536577
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
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22
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Infante M, Baidal DA, Rickels MR, Fabbri A, Skyler JS, Alejandro R, Ricordi C. Dual-hormone artificial pancreas for management of type 1 diabetes: Recent progress and future directions. Artif Organs 2021; 45:968-986. [PMID: 34263961 DOI: 10.1111/aor.14023] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/09/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023]
Abstract
Over the last few years, technological advances have led to tremendous improvement in the management of type 1 diabetes (T1D). Artificial pancreas systems have been shown to improve glucose control compared with conventional insulin pump therapy. However, clinically significant hypoglycemic and hyperglycemic episodes still occur with the artificial pancreas. Postprandial glucose excursions and exercise-induced hypoglycemia represent major hurdles in improving glucose control and glucose variability in many patients with T1D. In this regard, dual-hormone artificial pancreas systems delivering other hormones in addition to insulin (glucagon or amylin) may better reproduce the physiology of the endocrine pancreas and have been suggested as an alternative tool to overcome these limitations in clinical practice. In addition, novel ultra-rapid-acting insulin analogs with a more physiological time-action profile are currently under investigation for use in artificial pancreas devices, aiming to address the unmet need for further improvements in postprandial glucose control. This review article aims to discuss the current progress and future outlook in the development of novel ultra-rapid insulin analogs and dual-hormone closed-loop systems, which offer the next steps to fully closing the loop in the artificial pancreas.
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Affiliation(s)
- Marco Infante
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Endocrinology, Metabolism and Diabetes, Department of Systems Medicine, CTO A. Alesini Hospital, Diabetes Research Institute Federation, University of Rome Tor Vergata, Rome, Italy.,UniCamillus, Saint Camillus International University of Health Sciences, Rome, Italy
| | - David A Baidal
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Institute for Diabetes, Obesity and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrea Fabbri
- Division of Endocrinology, Metabolism and Diabetes, Department of Systems Medicine, CTO A. Alesini Hospital, Diabetes Research Institute Federation, University of Rome Tor Vergata, Rome, Italy
| | - Jay S Skyler
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rodolfo Alejandro
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Camillo Ricordi
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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23
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Rabinovich A, Priefer R. Glucagon delivery - An overview of current and future devices. Diabetes Metab Syndr 2021; 15:102155. [PMID: 34198107 DOI: 10.1016/j.dsx.2021.05.028] [Citation(s) in RCA: 4] [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] [Received: 05/05/2021] [Accepted: 05/25/2021] [Indexed: 01/21/2023]
Abstract
Glucagon is crucial in the treatment of Type 1 diabetes mellitus due to the prevalence of hypoglycemia in patients with this disorder. Hypoglycemia can be life-threatening, leading to loss of consciousness, and requiring emergency glucagon to reverse the effects. Emergency kits are difficult to use, requiring reconstitution of glucagon, which itself is not stable for lengthy periods. Approaches have aimed to improve stability which has allowed for use in pens or pumps. Glucagon can now also be delivered intranasally. This review discusses the history of glucagon, its current delivery methods as well as some modern approaches being introduced.
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Affiliation(s)
- Arthur Rabinovich
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA
| | - Ronny Priefer
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA.
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24
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Ingle RG, Fang WJ. Prefilled dual chamber devices (DCDs) - Promising high-quality and convenient drug delivery system. Int J Pharm 2021; 597:120314. [PMID: 33540011 DOI: 10.1016/j.ijpharm.2021.120314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/14/2021] [Accepted: 01/23/2021] [Indexed: 12/22/2022]
Abstract
Prefilled dual chamber devices (DCDs) are combination products containing freeze-dried drug and diluent in two separate chambers of the device. DCDs provide high stability and convenience to patients and doctors, thus significantly improving product quality, patient compliance and market competitiveness. DCDs should also provide seal integrity, sterility and compatibility with biopharmaceuticals and avoid leachability and needle stick injuries. DCDs are promising alternatives to traditional containers or devices for biopharmaceuticals. The regulatory and medical practice to choose plastic DCDs as better alternatives over well-established glass syringes will be addressed here. The impact and major issues during processing, manufacturing, and storage of DCDs are also highlighted. Further discussion clears its business potential, composition, stability testing, and quality standard requirements to deal with market competition. It also covers major role of extractables and leachables in storage stability of the product.
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Affiliation(s)
- Rahul G Ingle
- Institute of Drug Metabolism and Pharmaceutical Analysis, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China; Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310016, China
| | - Wei-Jie Fang
- Institute of Drug Metabolism and Pharmaceutical Analysis, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China; Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310016, China.
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25
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Wilson LM, Jacobs PG, Ramsey KL, Resalat N, Reddy R, Branigan D, Leitschuh J, Gabo V, Guillot F, Senf B, El Youssef J, Steineck IIK, Tyler NS, Castle JR. Dual-Hormone Closed-Loop System Using a Liquid Stable Glucagon Formulation Versus Insulin-Only Closed-Loop System Compared With a Predictive Low Glucose Suspend System: An Open-Label, Outpatient, Single-Center, Crossover, Randomized Controlled Trial. Diabetes Care 2020; 43:2721-2729. [PMID: 32907828 DOI: 10.2337/dc19-2267] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 08/16/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the efficacy and feasibility of a dual-hormone (DH) closed-loop system with insulin and a novel liquid stable glucagon formulation compared with an insulin-only closed-loop system and a predictive low glucose suspend (PLGS) system. RESEARCH DESIGN AND METHODS In a 76-h, randomized, crossover, outpatient study, 23 participants with type 1 diabetes used three modes of the Oregon Artificial Pancreas system: 1) dual-hormone (DH) closed-loop control, 2) insulin-only single-hormone (SH) closed-loop control, and 3) PLGS system. The primary end point was percentage time in hypoglycemia (<70 mg/dL) from the start of in-clinic aerobic exercise (45 min at 60% VO2max) to 4 h after. RESULTS DH reduced hypoglycemia compared with SH during and after exercise (DH 0.0% [interquartile range 0.0-4.2], SH 8.3% [0.0-12.5], P = 0.025). There was an increased time in hyperglycemia (>180 mg/dL) during and after exercise for DH versus SH (20.8% DH vs. 6.3% SH, P = 0.038). Mean glucose during the entire study duration was DH, 159.2; SH, 151.6; and PLGS, 163.6 mg/dL. Across the entire study duration, DH resulted in 7.5% more time in target range (70-180 mg/dL) compared with the PLGS system (71.0% vs. 63.4%, P = 0.044). For the entire study duration, DH had 28.2% time in hyperglycemia vs. 25.1% for SH (P = 0.044) and 34.7% for PLGS (P = 0.140). Four participants experienced nausea related to glucagon, leading three to withdraw from the study. CONCLUSIONS The glucagon formulation demonstrated feasibility in a closed-loop system. The DH system reduced hypoglycemia during and after exercise, with some increase in hyperglycemia.
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Affiliation(s)
- Leah M Wilson
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Peter G Jacobs
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Katrina L Ramsey
- Oregon Clinical and Translational Research Institute Biostatistics and Design Program, Oregon Health & Science University & Portland State University School of Public Health, Portland, OR
| | - Navid Resalat
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Ravi Reddy
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Deborah Branigan
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Joseph Leitschuh
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Virginia Gabo
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Florian Guillot
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Brian Senf
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR.,Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | | | - Nichole S Tyler
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Jessica R Castle
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
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Sherman JJ, Lariccia JL. Glucagon Therapy: A Comparison of Current and Novel Treatments. Diabetes Spectr 2020; 33:347-351. [PMID: 33223773 PMCID: PMC7666610 DOI: 10.2337/ds19-0076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
Treatments for type 1 diabetes have advanced significantly over recent years. There are now multiple hybrid closed-loop systems commercially available and additional systems are in development. Challenges remain, however. This review outlines the recent advances in closed-loop systems and outlines the remaining challenges, including post-prandial hyperglycemia and exercise-related dysglycemia.
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Affiliation(s)
- Melanie Jackson
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon
| | - Jessica R. Castle
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon
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Pontiroli AE, Tagliabue E. Intranasal versus injectable glucagon for hypoglycemia in type 1 diabetes: systematic review and meta-analysis. Acta Diabetol 2020; 57:743-749. [PMID: 32025860 DOI: 10.1007/s00592-020-01483-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/14/2020] [Indexed: 02/07/2023]
Abstract
AIMS Glucagon is used to resolve severe hypoglycemia in unconscious patients with diabetes, requiring third-party assistance. A few studies have shown that intranasal (IN) glucagon causes resolution of hypoglycemia in insulin-treated patients with type 1 (T1DM) diabetes. This systematic review and meta-analysis updates the comparison of the effectiveness of IN glucagon with injected intramuscular/subcutaneous (IM/SC) glucagon in treatment of hypoglycemia in T1DM. METHODS Controlled randomized studies were considered; eight studies, published in English, were included in a meta-analysis (random-effects model). Intervention effect (resolution of hypoglycemia) was expressed as odds ratio (OR), with 95% confidence intervals. Meta-regression was employed to correlate the effect with size of studies, age of patients, basal blood glucose levels. RESULTS In a total of 467 treatments in 269 patients with IN and IM/SC glucagon, the OR IN versus IM/SC was 0.61 (CI 0.13-2.82); since four of eight studies showed 100% effectiveness, a simulation was made with 1 failure for each treatment; in this simulation analysis, the OR was 0.80 (95% CI 0.28-2.32). Heterogeneity was low and not statistically significant. Publication bias was absent, and quality of papers was high. At meta-regression, no correlation was found between the effect and number of patients in each study, age of patients, basal blood glucose levels. No study formally compared IN versus IM/SC in unconscious patients. CONCLUSIONS This meta-analysis indicates that in conscious T1DM patients IN glucagon and IM/SC glucagon are equally effective in resolution of hypoglycemia.
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Affiliation(s)
- Antonio E Pontiroli
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Ospedale San Paolo, Via Antonio di Rudinì 8, 20142, Milan, Italy.
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Li S, Hu Y, Tan X, Wang D, Hu J, Zou P, Wang L. Evaluating dasiglucagon as a treatment option for hypoglycemia in diabetes. Expert Opin Pharmacother 2020; 21:1311-1318. [PMID: 32267182 DOI: 10.1080/14656566.2020.1747432] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Shujuan Li
- Department of Pharmacy, Zhejiang Pharmaceutical College, Ningbo, Zhejiang, China
| | - Ying Hu
- Department of Pharmacy, Zhejiang Pharmaceutical College, Ningbo, Zhejiang, China
| | - Xueying Tan
- Department of Pharmacy, Zhejiang Pharmaceutical College, Ningbo, Zhejiang, China
| | - Dongwei Wang
- Institute of Drug Discovery Technology, Ningbo University, Ningbo, Zhejiang, China
| | - Jingbo Hu
- Institute of Drug Discovery Technology, Ningbo University, Ningbo, Zhejiang, China
| | - Ping Zou
- Department of Pharmacy, the Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Li Wang
- Department of Pharmacy, the Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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30
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Patil M, Deshmukh NJ, Patel M, Sangle GV. Glucagon-based therapy: Past, present and future. Peptides 2020; 127:170296. [PMID: 32147318 DOI: 10.1016/j.peptides.2020.170296] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/05/2020] [Accepted: 03/04/2020] [Indexed: 02/07/2023]
Abstract
Diabesity and its related cardio-hepato-renal complications are of absolute concern globally. Last decade has witnessed a growing interest in the scientific community in investigating novel pharmaco-therapies employing the pancreatic hormone, glucagon. Canonically, this polypeptide hormone is known for its use in rescue treatment for hypoglycaemic shocks owing to its involvement in the counter-regulatory feedback mechanism. However, substantial studies in the recent past elucidated the pleiotropic effects of glucagon in diabesity and related complications like non-alcoholic steatohepatitis (NASH) and non-alcoholic fatty liver disease (NAFLD). Thus, the dual nature of this peptide has sparked the search for drugs that can modify glucagon signalling to combat hypoglycaemia or diabesity. Thus far, researchers have explored various pharmacological approaches to utilise this peptide in imminent modern therapies. The research endeavours in this segment led to explorations of stable glucagon formulations/analogues, glucagon receptor antagonism, glucagon receptor agonism, and incretin poly-agonism as new strategies for the management of hypoglycaemia or diabesity. This 'three-dimensional' research on glucagon resulted in the discovery of various drug candidates that proficiently modify glucagon signalling. Currently, several emerging glucagon-based therapies are under pre-clinical and clinical development. We sought to summarise the recent progress to comprehend glucagon-mediated pleiotropic effects, provide an overview of drug candidates currently being developed and future perspectives in this research domain.
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Affiliation(s)
- Mohan Patil
- Diabetes Research Lab, New Drug Discovery, Wockhardt Research Centre, Aurangabad, Maharashtra, India
| | - Nitin J Deshmukh
- Diabetes Research Lab, New Drug Discovery, Wockhardt Research Centre, Aurangabad, Maharashtra, India
| | - Mahesh Patel
- Diabetes Research Lab, New Drug Discovery, Wockhardt Research Centre, Aurangabad, Maharashtra, India; New Drug Discovery, Wockhardt Research Centre, Aurangabad, Maharashtra, India
| | - Ganesh V Sangle
- Diabetes Research Lab, New Drug Discovery, Wockhardt Research Centre, Aurangabad, Maharashtra, India.
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31
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Abstract
Treatment of type 1 diabetes with exogenous insulin often results in unpredictable daily glucose variability and hypoglycemia, which can be dangerous. Automated insulin delivery systems can improve glucose control while reducing burden for people with diabetes. One approach to improve treatment outcomes is to incorporate the counter-regulatory hormone glucagon into the automated delivery system to help prevent the hypoglycemia that can be induced by the slow pharmacodynamics of insulin action. This article explores the advantages and disadvantages of incorporating glucagon into dual-hormone automated hormone delivery systems.
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Affiliation(s)
- Leah M Wilson
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 3181 Southwest Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA.
| | - Peter G Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Mail Code: CH13B, 3303 Southwest Bond Avenue, Portland, OR 97239, USA
| | - Jessica R Castle
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 3181 Southwest Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA
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32
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Tinti D, Rabbone I. Mini-doses of glucagon to prevent hypoglycemia in children with type 1 diabetes refusing food: a case series. Acta Diabetol 2020; 57:359-365. [PMID: 31673895 DOI: 10.1007/s00592-019-01443-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/22/2019] [Indexed: 12/27/2022]
Abstract
AIMS Hypoglycemia in small children with type 1 diabetes is difficult to manage if nausea, vomit or food refusal occurs. If oral carbohydrate cannot be used, there is a hypothetical risk of severe hypoglycemia. The present article describes the effect on glucose of small doses of subcutaneous glucagon to revert hypoglycemia and prevent severe events in small children with type 1 diabetes using a continuous glucose monitoring. METHODS We analyzed 4 episodes of impending or mild hypoglycemia in 3 children with type 1 diabetes who refused to eat carbohydrates. Using a standard U-100 insulin syringe, children received one "unit" (10 μg) of glucagon subcutaneously for every year of age up to 15 units (150 μg). If the blood glucose did not increase within 30 min, the initial dosage was repeated at that time. Instructions were given by phone from the physician. At the following visit data from continuous glucose monitoring devices, insulin pump and glucometer were downloaded and reviewed retrospectively from the physician. RESULTS Blood glucose from continuous glucose monitoring after one and 2 h was 127 ± 80 mg/dl and 165 ± 78 mg/dl, respectively. After a glucagon injection, there was a single recurrence of hypoglycemia, requiring another shot. The glucagon was well tolerated, except for nausea, present before the injection. None of the children were taken to our hospital because of concerns for hypoglycemia. CONCLUSION Mini-doses of glucagon given subcutaneously were effective and safe in preventing frank or impending hypoglycemia in type 1 diabetes children refusing food.
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Affiliation(s)
- Davide Tinti
- Department of Pediatrics, University of Turin, Piazza Polonia, 94, 10126, Turin, Italy
| | - Ivana Rabbone
- Department of Pediatrics, University of Turin, Piazza Polonia, 94, 10126, Turin, Italy.
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Chabenne JR, Mroz PA, Mayer JP, DiMarchi RD. Structural Refinement of Glucagon for Therapeutic Use. J Med Chem 2019; 63:3447-3460. [PMID: 31774682 DOI: 10.1021/acs.jmedchem.9b01493] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Glucagon counters insulin's effects on glucose metabolism and serves as a rescue medicine in the treatment of hypoglycemia. Acute hypoglycemia, a common occurrence in insulin-dependent diabetes, is the central obstacle to correcting high blood glucose, a primary cause of long-term microvascular complications. As a result, there has been a resurgence of interest in improved glucagon therapy, including nonconventional liquid formulations, alternative routes of administration, and novel analogs with optimized biophysical properties. These options collectively minimize the complexity of glucagon delivery and enable its application in ways not feasible with conventional emergency rescue kits. These advances have indirectly promoted the integrated use of glucagon agonism with other hormones in a manner that runs counter to the long-standing pursuit of glucagon antagonism. This review summarizes novel approaches to glucagon optimization, methods with potential application to the broader family of therapeutic peptides, where biophysical challenges may be encountered.
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Affiliation(s)
- Joseph R Chabenne
- Novo Nordisk Research Center, Indianapolis, Indiana 46241, United States
| | - Piotr A Mroz
- Department of Chemistry, Indiana University, Bloomington, Indiana 47405, United States
| | - John P Mayer
- MCD Biology, University of Colorado, Boulder, Colorado 80309, United States
| | - Richard D DiMarchi
- Novo Nordisk Research Center, Indianapolis, Indiana 46241, United States.,Department of Chemistry, Indiana University, Bloomington, Indiana 47405, United States
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Abstract
PURPOSE OF REVIEW New more stable formulations of glucagon have recently become available, and these provide an opportunity to expand the clinical roles of this hormone in the prevention and management of insulin-induced hypoglycemia. This is applicable in type 1 diabetes, hyperinsulinism, and alimentary hypoglycemia. The aim of this review is to describe these new formulations of glucagon and to provide an overview of current and future therapeutic opportunities that these may provide. RECENT FINDINGS Four main categories of glucagon formulation have been studied: intranasal glucagon, biochaperone glucagon, dasiglucagon, and non-aqueous soluble glucagon. All four have demonstrated similar glycemic responses to standard glucagon formulations when administered during hypoglycemia. In addition, potential roles of these formulations in the management of congenital hyperinsulinism, alimentary hypoglycemia, and exercise-induced hypoglycemia in type 1 diabetes have been described. As our experience with newer glucagon preparations increases, the role of glucagon is likely to expand beyond the emergency use that this medication has been limited to in the past. The innovations described in this review likely represent early examples of a pending large repertoire of indications for stable glucagon.
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Affiliation(s)
- Colin P Hawkes
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Diva D De Leon
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Institute for Diabetes, Obesity & Metabolism, Perelman School of Medicine, University of Pennsylvania, 12-134 Smilow Center for Translational Research, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Michael R Rickels
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Institute for Diabetes, Obesity & Metabolism, Perelman School of Medicine, University of Pennsylvania, 12-134 Smilow Center for Translational Research, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Pöhlmann J, Mitchell BD, Bajpai S, Osumili B, Valentine WJ. Nasal Glucagon Versus Injectable Glucagon for Severe Hypoglycemia: A Cost-Offset and Budget Impact Analysis. J Diabetes Sci Technol 2019; 13:910-918. [PMID: 30700165 PMCID: PMC6955465 DOI: 10.1177/1932296819826577] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Severe hypoglycemic events (SHEs) in patients with diabetes are associated with substantial health care costs in the United States (US). Injectable glucagon (IG) is currently available for treatment of severe hypoglycemia but is associated with frequent handling errors. Nasal glucagon (NG) is a novel, easier-to-use treatment that is more often administered successfully. The economic impact of this usability advantage was explored in cost-offset and budget impact analyses for the US setting. METHODS A health economic model was developed to estimate mean costs per SHE for which treatment was attempted using NG or IG, which differed only in the probability of treatment success, based on a published usability study. The budget impact of NG was projected over 2 years for patients with type 1 diabetes (T1D) and type 2 diabetes treated with basal-bolus insulin (T2D-BB). Epidemiologic and cost data were sourced from the literature and/or fee schedules. RESULTS Mean costs were $992 lower if NG was used compared with IG per SHE for which a user attempted treatment. NG was estimated to reduce SHE-related spending by $1.1 million and $230 000 over 2 years in 10 000 patients each with T1D and T2D-BB, respectively. Reduced spending resulted from reduced professional emergency services utilization as successful treatment was more likely with NG. CONCLUSIONS The usability advantage of NG over IG was projected to reduce SHE-related treatment costs in the US setting. NG has the potential to improve hypoglycemia emergency care and reduce SHE-related treatment costs.
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Zimmerman C, Albanese-O'Neill A, Haller MJ. Advances in Type 1 Diabetes Technology Over the Last Decade. EUROPEAN ENDOCRINOLOGY 2019; 15:70-76. [PMID: 31616496 PMCID: PMC6785958 DOI: 10.17925/ee.2019.15.2.70] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/20/2019] [Indexed: 12/17/2022]
Abstract
The past 10 years have witnessed rapid advances in the technology used to treat patients with type 1 diabetes (T1D). While the disease burden is still high, these advances have contributed to improvements in both glycaemic control and quality of life for many of those affected. New technologies allow for individualisation of care, as patients are able to work with their providers to determine which systems best fit their lifestyle and needs. In addition, thanks to improved glucose monitoring technologies, patients can now simultaneously improve glycaemic control and reduce hypoglycaemia, thereby mitigating risk for acute and chronic complications. Technological advances in T1D care are rapidly moving us toward increasingly automated devices, which offer the promise of reduced disease burden. In this article, we review advances in glucose monitoring, insulin and glucagon delivery, and the applications and algorithms seeking to integrate novel technologies.
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Haidar A. Insulin-and-Glucagon Artificial Pancreas Versus Insulin-Alone Artificial Pancreas: A Short Review. Diabetes Spectr 2019; 32:215-221. [PMID: 31462876 PMCID: PMC6695257 DOI: 10.2337/ds18-0097] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IN BRIEF The advantage of the insulin-and-glucagon artificial pancreas is based on the rapid effect of subcutaneous glucagon delivery in preventing hypoglycemia compared to suspension of insulin delivery. In short-term studies, the dual-hormone artificial pancreas reduced daytime hypoglycemia, especially during exercise, compared to the insulin-alone artificial pancreas, but the insulin-alone system seemed sufficient in eliminating nocturnal hypoglycemia. The comparative benefits of the single- and dual-hormone systems for improving A1C and preventing severe hypoglycemia remain unknown.
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Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
- Division of Endocrinology and Metabolism, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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38
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Beato-Víbora PI, Arroyo-Díez FJ. New uses and formulations of glucagon for hypoglycaemia. Drugs Context 2019; 8:212599. [PMID: 31402931 PMCID: PMC6675539 DOI: 10.7573/dic.212599] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/23/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Hypoglycaemia is the more frequent complication of insulin therapy and the main barrier to tight glycaemic control. Injectable glucagon and oral intake of carbohydrates are the recommended treatments for severe and non-severe hypoglycaemia episodes, respectively. Nasal glucagon is currently being developed as a ready-to-use device, to simplify severe hypoglycaemia rescue. Stable forms of liquid glucagon could open the field for different approaches for mild to moderate hypoglycaemia treatment, such as mini-doses of glucagon or continuous subcutaneous glucagon infusion as a part of dual-hormone closed-loop systems. Pharmaceutical companies are developing stable forms of native glucagon or glucagon analogues for that purpose.
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Affiliation(s)
- Pilar I Beato-Víbora
- Department of Endocrinology and Nutrition, Department of Paediatrics, Badajoz University Hospital, Badajoz, Spain
| | - Francisco J Arroyo-Díez
- Department of Endocrinology and Nutrition, Department of Paediatrics, Badajoz University Hospital, Badajoz, Spain
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Pontiroli AE, Tagliabue E. Therapeutic Use of Intranasal Glucagon: Resolution of Hypoglycemia. Int J Mol Sci 2019; 20:E3646. [PMID: 31349701 PMCID: PMC6695717 DOI: 10.3390/ijms20153646] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/24/2019] [Accepted: 07/24/2019] [Indexed: 02/06/2023] Open
Abstract
Episodes of hypoglycemia are frequent in patients with diabetes treated with insulin or sulphonylureas. Hypoglycemia can lead to severe acute complications, and, as such, both prevention and treatment of hypoglycemia are important for the well-being of patients with diabetes. The experience of hypoglycemia also leads to fear of hypoglycemia, that in turn can limit optimal glycemic control in patients, especially with type 1 diabetes. Treatment of hypoglycemia is still based on administration of carbohydrates (oral or parenteral according to the level of consciousness) or of glucagon (intramuscular or subcutaneous injection). In 1983, it was shown for the first time that intranasal (IN) glucagon drops (with sodium glycocholate as a promoter) increase blood glucose levels in healthy volunteers. During the following decade, several authors showed the efficacy of IN glucagon (drops, powders, and sprays) to resolve hypoglycemia in normal volunteers and in patients with diabetes, both adults and children. Only in 2010, based on evaluation of patients' beliefs and patients' expectations, a canadian pharmaceutical company (Locemia Solutions, Montreal, Canada) reinitiated efforts to develop glucagon for IN administration. The project has been continued by Eli Lilly, that is seeking to obtain registration in order to make IN glucagon available to insulin users (children and adolescents) worldwide. IN glucagon is as effective as injectable glucagon, and devoid of most of the technical difficulties associated with administration of injectable glucagon. IN glucagon appears to represent a major breakthrough in the treatment of severe hypoglycemia in insulin-treated patients with diabetes, both children and adults.
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Affiliation(s)
- Antonio E Pontiroli
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Ospedale San Paolo, Via Antonio di Rudinì 8, 20142 Milan, Italy.
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40
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Castle JR, Elander M. Long-Term Safety and Tolerability of Dasiglucagon, a Stable-in-Solution Glucagon Analogue. Diabetes Technol Ther 2019; 21:94-96. [PMID: 30707621 DOI: 10.1089/dia.2018.0363] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Jessica R Castle
- 1 Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon
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41
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Affiliation(s)
- Piotr Foltynski
- Nalecz Institute of Biocybernetics and Biomedical Engineering, PAS - Department of Modeling and Supporting of Internal Organs Functions; Warsaw Poland
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42
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Castle JR. Is Mini-Dose Glucagon the Answer to Preventing Exercise-Related Dysglycemia? Diabetes Care 2018; 41:1842-1843. [PMID: 30135198 DOI: 10.2337/dci18-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Jessica R Castle
- Division of Endocrinology, Diabetes & Clinical Nutrition, Department of Medicine, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR
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43
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Yardley JE, Brockman NK, Bracken RM. Could Age, Sex and Physical Fitness Affect Blood Glucose Responses to Exercise in Type 1 Diabetes? Front Endocrinol (Lausanne) 2018; 9:674. [PMID: 30524371 PMCID: PMC6262398 DOI: 10.3389/fendo.2018.00674] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 10/29/2018] [Indexed: 12/17/2022] Open
Abstract
Closed-loop systems for patients with type 1 diabetes are progressing rapidly. Despite these advances, current systems may struggle in dealing with the acute stress of exercise. Algorithms to predict exercise-induced blood glucose changes in current systems are mostly derived from data involving relatively young, fit males. Little is known about the magnitude of confounding variables such as sex, age, and fitness level-underlying, uncontrollable factors that might influence blood glucose control during exercise. Sex-related differences in hormonal responses to physical exercise exist in studies involving individuals without diabetes, and result in altered fuel metabolism during exercise. Increasing age is associated with attenuated catecholamine responses and lower carbohydrate oxidation during activity. Furthermore, higher fitness levels can alter hormonal and fuel selection responses to exercise. Compounding the limited research on these factors in the metabolic response to exercise in type 1 diabetes is a limited understanding of how these variables affect blood glucose levels during different types, timing and intensities of activity in individuals with type 1 diabetes (T1D). Thus, there is currently insufficient information to model a closed-loop system that can predict them accurately and consistently prevent hypoglycemia. Further, studies involving both sexes, along with a range of ages and fitness levels, are needed to create a closed-loop system that will be more precise in regulating blood glucose during exercise in a wide variety of individuals with T1D.
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Affiliation(s)
- Jane E. Yardley
- Augustana Faculty, University of Alberta, Camrose, AB, Canada
- Physical Activity and Diabetes Laboratory, Alberta Diabetes Institute, Edmonton, AB, Canada
- Faculty of Kinesiology, Sport and Recreation, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Jane E. Yardley
| | | | - Richard M. Bracken
- Diabetes Research Unit and School of Sport and Exercise Science, Swansea University, Swansea, United Kingdom
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