Hybrid Closed-Loop Control with Ultrarapid Lispro Compared with Standard Insulin Aspart and Faster Insulin Aspart: An In Silico Study

JL, Garcia-Tirado J, DeBoer MD, Breton MD. Adjusting Therapy Profiles When Switching to Ultra-Rapid Lispro in an Advanced Hybrid Closed-Loop System: An in Silico Study

BACKGROUND

It has been shown that insulin acceleration by itself might not be sufficient to see clear improvements in glycemic metrics, and insulin therapy may need to be adjusted to fully leverage the extra safety margin provided by faster pharmacokinetic (PK) and pharmacodynamic (PD) profiles. The objective of this work is to explore how to perform such adjustments on a commercially available automated insulin delivery (AID) system.

METHODS

Ultra-rapid lispro (URLi) is modeled within the UVA/Padova simulation platform using data from previously published clamp studies. The Control-IQ AID algorithm is selected as it leverages carbohydrate-to-insulin ratio (CR in g/U), correction factor (CF in mg/dL/U), and basal rate (BR in U/h) daily profiles that are fully customizable. An experiment roadmap is proposed to understand how to safely modify these profiles when switching from lispro to URLi.

RESULTS

Simulations show that a 7% decrease in CR (approximately an 8% increase in prandial insulin) and a 7.5% increase in BR lead to cumulative improvements in glucose control with URLi. Comparing with baseline metrics using lispro, a clinically significant increase in time in the range of 70 to 180 mg/dL (overall: 70.2%-75.2%, P < .001; 6 am-12 am: 62.4%-68.5%, P < .001) and a reduction in time below 70 mg/dL (overall: 1.8%-1.2%, P < .001; 6 am-12 am: 1.8%-1.3%, P < .001) were observed.

CONCLUSION

Properly adjusting therapy parameters allows to fully leverage glucose control benefits provided by faster insulin analogues, opening opportunities to take another step forward into a next generation of more effective AID solutions.

The Role of Ultra-Rapid-Acting Insulin Analogs in Diabetes: An Expert Consensus

Ultra-rapid-acting insulin analogs (URAA) are a further development and refinement of rapid-acting insulin analogs. Because of their adapted formulation, URAA provide an even faster pharmacokinetics and thus an accelerated onset of insulin action than conventional rapid-acting insulin analogs, allowing for a more physiologic delivery of exogenously applied insulin. Clinical trials have confirmed the superiority of URAA in controlling postprandial glucose excursions, with a safety profile that is comparable to the rapid-acting insulins. Consequently, many individuals with diabetes mellitus may benefit from URAA in terms of prandial glycemic control. Unfortunately, there are only few available recommendations from authoritative sources for use of URAA in clinical practice. Therefore, this expert consensus report aims to define populations of people with diabetes mellitus for whom URAA may be beneficial and to provide health care professionals with concrete, practical recommendations on how best to use URAA in this context.

First Generation of a Modular Interoperable Closed-Loop System for Automated Insulin Delivery in Patients With Type 1 Diabetes: Lessons From Trials and Real-Life Data

BACKGROUND

DBLG1 (Diabeloop Generation 1) stands as one of the five commercially available closed-loop solution worldwide for patients with type 1 diabetes as of 2023. Our aim was to provide an overview of all data obtained with this system regarding outcomes and populations, with an emphasis on interoperability.

METHODS

This report includes all available sources of data (three randomized control trials and five surveys on real-life data). Collection ran from March 3, 2017 to April 30, 2022.

RESULTS

We gathered data from 6859 adult patients treated with closed-loop from three to 12 months. Overall, all sources of data showed that time in range (TIR) 70 to 180 mg/dL, starting from 47.4% to 56.6%, improved from 12.2 to 17.3 percentage points. Time in hypoglycemia was reduced by 48% in average (range: 26%-70%) and reached a level of 1.3% in the largest and most recent cohort. In patients with excessive time in hypoglycemia at baseline (≥5%), closed-loop allowed a reduction in time below range (TBR) by 59%. The comparison of days with declared physical activity versus days without physical activity did not show differences in TBR. The improvement in TIR observed with three different pump systems (Vicentra Kaleido, n = 117; Sooil Dana-I, n = 84; and Roche Insight, n = 6684) ranged from 15.4 to 17.3 percentage points.

DISCUSSION

These data obtained in different European countries were consistent throughout all reports, showing that this closed-loop system is efficient (high improvement in TIR), safe (remarkably low level of TBR), and interoperable (three pump settings so far).

Rapid-acting insulin analogues: Theory and best clinical practice in type 1 and type 2 diabetes

Since the discovery of insulin 100 years ago, insulin preparations have improved significantly. Starting from purified animal insulins, evolving to human insulins produced by genetically modified organisms, and ultimately to insulin analogues, all in an attempt to mimic physiological insulin action profiles seen in individuals without diabetes. Achieving strict glucose control without hypoglycaemia and preventing chronic complications of diabetes while preserving quality of life remains a challenging goal, but the advent of newer ultra-rapid-acting insulin analogues may enable intensive insulin therapy without being too disruptive to daily life. Ultra-rapid-acting insulin analogues can be administered shortly before meals and give better coverage of mealtime-induced glucose excursions than conventional insulin preparations. They also increase convenience with timing of bolus dosing. In this review, we focus on the progress that has been made in rapid-acting insulins. We summarize pharmacokinetic and pharmacodynamic data, clinical trial data supporting the use of these new formulations as part of a basal-bolus regimen and continuous subcutaneous insulin infusion, and provide a clinical perspective to help guide healthcare professionals when and for whom to use ultra-fast-acting insulins.