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Nkonge KM, Nkonge DK, Nkonge TN. Insulin Therapy for the Management of Diabetes Mellitus: A Narrative Review of Innovative Treatment Strategies. Diabetes Ther 2023; 14:1801-1831. [PMID: 37736787 PMCID: PMC10570256 DOI: 10.1007/s13300-023-01468-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023] Open
Abstract
The discovery of insulin was presented to the international medical community on May 3, 1922. Since then, insulin has become one of the most effective pharmacological agents used to treat type 1 and type 2 diabetes mellitus. However, the initiation and intensification of insulin therapy is often delayed in people living with type 2 diabetes due to numerous challenges associated with daily subcutaneous administration. Reducing the frequency of injections, using insulin pens instead of syringes and vials, simplifying treatment regimens, or administering insulin through alternative routes may help improve adherence to and persistence with insulin therapy among people living with diabetes. As the world commemorates the centennial of the commercialization of insulin, the aims of this article are to provide an overview of insulin therapy and to summarize clinically significant findings from phase 3 clinical trials evaluating less frequent dosing of insulin and the non-injectable administration of insulin.
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Affiliation(s)
- Ken M. Nkonge
- University of Nairobi, P.O. Box 30197, Nairobi, Kenya
| | | | - Teresa N. Nkonge
- University of Nairobi, P.O. Box 30197, Nairobi, Kenya
- McMaster University, Hamilton, ON L8S 4L8 Canada
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2
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Khan AB, Ahmad A, Ahmad S, Gul M, Iqbal F, Ullah H, Laiba S, Orakzai UK. Comparative Analysis of Inhaled Insulin With Other Types in Type 1 Diabetes Mellitus: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e23731. [PMID: 35509734 PMCID: PMC9057175 DOI: 10.7759/cureus.23731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 11/09/2022] Open
Abstract
To analyze the effect of Inhaled insulin in Type 1 Diabetes Mellitus and compare it with other routes of administration of Insulin. A systemic search was conducted from the following electronic databases: PubMed/Medline, Cochrane Library, and Google Scholar, from inception to 28th January 2022. All statistical analysis was conducted in Review Manager 5.4.1. All studies meeting inclusion criteria were selected. A random-effect model was used to pool the studies, and the result was reported in the Standard Mean Difference (SMD), Mean Difference (MD), and Risk Ratio (RR) with their corresponding 95% Confidence interval (CI). Thirteen randomized control trials were selected for our meta-analysis. Statistically significant results were obtained for comparing change in weight after insulin administration (MD= -1.08 [-1.21, -0.94]; p< 0.00001; I2= 74%). Other factors assessed were found to be non-significant like HbA1c (SMD= 0.03 [-0.80, 0.86]; p= 0.95; I2= 99%), fasting blood sugar (SMD= -0.31 [-1.52, 0.91]; p= 0.62; I2= 99%) and adverse effects (RR= 1.06 [0.97, 1.16]; p= 0.18; I2= 96%). In this systematic review and meta-analysis, we found that inhaled insulin is equally effective as subcutaneously administered insulin in patients with Type 1 Diabetes. The inhaled insulin was found to show less weight gain and fewer hypoglycemic shifts, with a similar effect on the blood glucose level. No significant difference was observed in the incidence of adverse events.
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Affiliation(s)
- Abu Baker Khan
- Surgery, District Headquarter Hospital, Dera Ismail Khan, PAK
| | - Aftab Ahmad
- Internal Medicine, Category D Hospital, South Waziristan, PAK
| | - Saad Ahmad
- Internal Medicine, Taj Medical Center, Nowshera, PAK
| | - Maryam Gul
- Internal Medicine, Taj Medical Center, Nowshera, PAK
| | | | - Hazrat Ullah
- Medicine, Khalifa Gulnawaz Teaching Hospital, Bannu, PAK
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3
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Karimi M, Kamali H, Mohammadi M, Tafaghodi M. Evaluation of various techniques for production of inhalable dry powders for pulmonary delivery of peptide and protein. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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4
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Vallianou NG, Stratigou T, Geladari E, Tessier CM, Mantzoros CS, Dalamaga M. Diabetes type 1: Can it be treated as an autoimmune disorder? Rev Endocr Metab Disord 2021; 22:859-876. [PMID: 33730229 DOI: 10.1007/s11154-021-09642-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 02/06/2023]
Abstract
Type 1 Diabetes Mellitus (T1DM) is characterized by progressive autoimmune-mediated destruction of the pancreatic beta-cells leading to insulin deficiency and hyperglycemia. It is associated with significant treatment burden and necessitates life-long insulin therapy. The role of immunotherapy in the prevention and management of T1DM is an evolving area of interest which has the potential to alter the natural history of this disease.In this review, we give insight into recent clinical trials related to the use of immunotherapeutic approaches for T1DM, such as proinflammatory cytokine inhibition, cell-depletion and cell-therapy approaches, autoantigen-specific treatments and stem cell therapies. We highlight the timing of intervention, aspects of therapy including adverse effects and the emergence of a novel lymphocyte crucial in T1DM autoimmunity. We also discuss the role of cardiac autoimmunity and its link to excess CVD risk in T1DM.We conclude that significant advances have been made in development of immunotherapeutic targets and agents for the treatment and prevention of T1DM. These immune-based therapies promise preservation of beta-cells and decreasing insulin dependency. In their current state, immunotherapeutic approaches cannot yet halt the progression from a preclinical state to overt T1DM nor can they replace standard insulin therapy in existing T1DM. It remains to be seen whether immunotherapy will ultimately play a key role in the prevention of progression to overt T1DM and whether it may find a place in our therapeutic armamentarium to improve clinical outcomes and quality of life in established T1DM.
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Affiliation(s)
- Natalia G Vallianou
- Department of Internal Medicine, Evangelismos General Hospital, 45-47 Ipsilantou str, 10676, Athens, Greece
| | - Theodora Stratigou
- Department of Endocrinology, Diabetes and Metabolic Diseases, Evangelismos General Hospital, 45-47 Ipsilantou str, 10676, Athens, Greece
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias, 11527, Athens, Goudi, Greece
| | - Eleni Geladari
- Department of Internal Medicine, Evangelismos General Hospital, 45-47 Ipsilantou str, 10676, Athens, Greece
| | - Christopher M Tessier
- Endocrinology Section, VA Boston Healthcare System, 1400 VFW Parkway West Roxbury, Boston, MA, 02132, USA.
| | - Christos S Mantzoros
- Endocrinology Section, VA Boston Healthcare System, 1400 VFW Parkway West Roxbury, Boston, MA, 02132, USA
| | - Maria Dalamaga
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias, 11527, Athens, Goudi, Greece
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5
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Chen XY, Du GS, Sun X. Targeting Lymphoid Tissues to Promote Immune Tolerance. ADVANCED THERAPEUTICS 2021. [DOI: 10.1002/adtp.202100056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Xiao Yan Chen
- Key Laboratory of Drug‐Targeting and Drug Delivery System of the Education Ministry Sichuan Engineering Laboratory for Plant‐Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology West China School of Pharmacy Sichuan University No.17, Block 3, Southern Renmin Road Chengdu 610041 China
| | - Guang Sheng Du
- Key Laboratory of Drug‐Targeting and Drug Delivery System of the Education Ministry Sichuan Engineering Laboratory for Plant‐Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology West China School of Pharmacy Sichuan University No.17, Block 3, Southern Renmin Road Chengdu 610041 China
| | - Xun Sun
- Key Laboratory of Drug‐Targeting and Drug Delivery System of the Education Ministry Sichuan Engineering Laboratory for Plant‐Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology West China School of Pharmacy Sichuan University No.17, Block 3, Southern Renmin Road Chengdu 610041 China
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6
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Kopf S, Kumar V, Kender Z, Han Z, Fleming T, Herzig S, Nawroth PP. Diabetic Pneumopathy-A New Diabetes-Associated Complication: Mechanisms, Consequences and Treatment Considerations. Front Endocrinol (Lausanne) 2021; 12:765201. [PMID: 34899603 PMCID: PMC8655305 DOI: 10.3389/fendo.2021.765201] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/22/2021] [Indexed: 01/04/2023] Open
Abstract
Patients with diabetes are over-represented among the total cases reported with "idiopathic" pulmonary fibrosis (IPF). This raises the question, whether this is an association only or whether diabetes itself can cause pulmonary fibrosis. Recent studies in mouse models of type 1 and type 2 diabetes demonstrated that diabetes causes pulmonary fibrosis. Both types of diabetes trigger a cascade, starting with increased DNA damage, an impaired DNA repair, and leading to persistent DNA damage signaling. This response, in turn, induces senescence, a senescence-associated-secretory phenotype (SASP), marked by the release of pro-inflammatory cytokines and growth factors, finally resulting in fibrosis. Restoring DNA repair drives fibrosis into remission, thus proving causality. These data can be translated clinically to patients with type 2 diabetes, characterized by long-term diabetes and albuminuria. Hence there are several arguments, to substitute the term "idiopathic" pulmonary fibrosis (IPF) in patients with diabetes (and exclusion of other causes of lung diseases) by the term "diabetes-induced pulmonary fibrosis" (DiPF). However, future studies are required to establish this term and to study whether patients with diabetes respond to the established therapies similar to non-diabetic patients.
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Affiliation(s)
- Stefan Kopf
- Department of Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Varun Kumar
- Department of Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
- European Molecular Biology Laboratory, Advanced Light Microscopy Facility, Heidelberg, Germany
| | - Zoltan Kender
- Department of Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Zhe Han
- Department of Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Fleming
- Department of Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Stephan Herzig
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
- Institute for Diabetes and Cancer, Helmholtz Center Munich, Munich-Neuherberg, Germany
- Joint Heidelberg-Institute for Diabetes and Cancer (IDC) Translational Diabetes Programme, Helmholtz-Zentrum, Munich, Germany
| | - Peter P. Nawroth
- Department of Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
- Joint Heidelberg-Institute for Diabetes and Cancer (IDC) Translational Diabetes Programme, Helmholtz-Zentrum, Munich, Germany
- *Correspondence: Peter P. Nawroth,
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7
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Abstract
Diabetes mellitus is a chronic, progressive, incompletely understood metabolic disorder whose prevalence has been increasing steadily worldwide. Even though little attention has been paid to lung disorders in the context of diabetes, its prevalence has recently been challenged by newer studies of disease development. In this review, we summarize and discuss the role of diabetes mellitus involved in the progression of pulmonary diseases, with the main focus on pulmonary fibrosis, which represents a chronic and progressive disease with high mortality and limited therapeutic options.
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Affiliation(s)
- Saeed Kolahian
- Department of Pharmacology and Experimental Therapy, Institute of Experimental and Clinical Pharmacology and Toxicology, and Interfaculty Center of Pharmacogenomics and Drug Research (ICePhA), Eberhard Karls University Hospitals and Clinics, Tübingen, Germany.
- Department of Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Eberhard Karls University Hospitals and Clinics, Tübingen, Germany.
- Department of Pharmacogenomics, University of Tübingen, Wilhelmstrasse. 56, D-72074, Tübingen, Germany.
| | - Veronika Leiss
- Department of Pharmacology and Experimental Therapy, Institute of Experimental and Clinical Pharmacology and Toxicology, and Interfaculty Center of Pharmacogenomics and Drug Research (ICePhA), Eberhard Karls University Hospitals and Clinics, Tübingen, Germany
| | - Bernd Nürnberg
- Department of Pharmacology and Experimental Therapy, Institute of Experimental and Clinical Pharmacology and Toxicology, and Interfaculty Center of Pharmacogenomics and Drug Research (ICePhA), Eberhard Karls University Hospitals and Clinics, Tübingen, Germany
- Department of Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Eberhard Karls University Hospitals and Clinics, Tübingen, Germany
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8
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Stabler CL, Li Y, Stewart JM, Keselowsky BG. Engineering immunomodulatory biomaterials for type 1 diabetes. NATURE REVIEWS. MATERIALS 2019; 4:429-450. [PMID: 32617176 PMCID: PMC7332200 DOI: 10.1038/s41578-019-0112-5] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
A cure for type 1 diabetes (T1D) would help millions of people worldwide, but remains elusive thus far. Tolerogenic vaccines and beta cell replacement therapy are complementary therapies that seek to address aberrant T1D autoimmune attack and subsequent beta cell loss. However, both approaches require some form of systematic immunosuppression, imparting risks to the patient. Biomaterials-based tools enable localized and targeted immunomodulation, and biomaterial properties can be designed and combined with immunomodulatory agents to locally instruct specific immune responses. In this Review, we discuss immunomodulatory biomaterial platforms for the development of T1D tolerogenic vaccines and beta cell replacement devices. We investigate nano- and microparticles for the delivery of tolerogenic agents and autoantigens, and as artificial antigen presenting cells, and highlight how bulk biomaterials can be used to provide immune tolerance. We examine biomaterials for drug delivery and as immunoisolation devices for cell therapy and islet transplantation, and explore synergies with other fields for the development of new T1D treatment strategies.
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Affiliation(s)
- CL Stabler
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
- Interdisciplinary Graduate Program in Biomedical Sciences, University of Florida, Gainesville, FL, USA
- University of Florida Diabetes Institute, Gainesville, FL, USA
| | - Y Li
- Interdisciplinary Graduate Program in Biomedical Sciences, University of Florida, Gainesville, FL, USA
| | - JM Stewart
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - BG Keselowsky
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
- Interdisciplinary Graduate Program in Biomedical Sciences, University of Florida, Gainesville, FL, USA
- University of Florida Diabetes Institute, Gainesville, FL, USA
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9
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Serra P, Santamaria P. Antigen-specific therapeutic approaches for autoimmunity. Nat Biotechnol 2019; 37:238-251. [PMID: 30804535 DOI: 10.1038/s41587-019-0015-4] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 01/04/2019] [Indexed: 12/12/2022]
Abstract
The main function of the immune system in health is to protect the host from infection by microbes and parasites. Because immune responses to nonself bear the risk of unleashing accidental immunity against self, evolution has endowed the immune system with central and peripheral mechanisms of tolerance, including regulatory T and B cells. Although the past two decades have witnessed the successful clinical translation of a whole host of novel therapies for the treatment of chronic inflammation, the development of antigen-based approaches capable of selectively blunting autoimmune inflammation without impairing normal immunity has remained elusive. Earlier autoantigen-specific approaches employing peptides or whole antigens have evolved into strategies that seek to preferentially deliver these molecules to autoreactive T cells either indirectly, via antigen-presenting cells, or directly, via major histocompatibility complex molecules, in ways intended to promote clonal deletion and/or immunoregulation. The disease specificity, mechanistic underpinnings, developability and translational potential of many of these strategies remain unclear.
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Affiliation(s)
- Pau Serra
- Institut D'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.
| | - Pere Santamaria
- Institut D'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain. .,Julia McFarlane Diabetes Research Centre (JMDRC) and Department of Microbiology, Immunology and Infectious Diseases, Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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10
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Abstract
PURPOSE OF REVIEW The immunosuppressive agent cyclosporine was first reported to lower daily insulin dose and improve glycemic control in patients with new-onset type 1 diabetes (T1D) in 1984. While renal toxicity limited cyclosporine's extended use, this observation ignited collaborative efforts to identify immunotherapeutic agents capable of safely preserving β cells in patients with or at risk for T1D. RECENT FINDINGS Advances in T1D prediction and early diagnosis, together with expanded knowledge of the disease mechanisms, have facilitated trials targeting specific immune cell subsets, autoantigens, and pathways. In addition, clinical responder and non-responder subsets have been defined through the use of metabolic and immunological readouts. Herein, we review emerging T1D biomarkers within the context of recent and ongoing T1D immunotherapy trials. We also discuss responder/non-responder analyses in an effort to identify therapeutic mechanisms, define actionable pathways, and guide subject selection, drug dosing, and tailored combination drug therapy for future T1D trials.
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Affiliation(s)
- Laura M Jacobsen
- Department of Pediatrics, College of Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - Brittney N Newby
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida Diabetes Institute, 1275 Center Drive, Biomedical Sciences Building J-589, Box 100275, Gainesville, FL, 32610, USA
| | - Daniel J Perry
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida Diabetes Institute, 1275 Center Drive, Biomedical Sciences Building J-589, Box 100275, Gainesville, FL, 32610, USA
| | - Amanda L Posgai
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida Diabetes Institute, 1275 Center Drive, Biomedical Sciences Building J-589, Box 100275, Gainesville, FL, 32610, USA
| | - Michael J Haller
- Department of Pediatrics, College of Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - Todd M Brusko
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida Diabetes Institute, 1275 Center Drive, Biomedical Sciences Building J-589, Box 100275, Gainesville, FL, 32610, USA.
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Emami F, Vatanara A, Park EJ, Na DH. Drying Technologies for the Stability and Bioavailability of Biopharmaceuticals. Pharmaceutics 2018; 10:E131. [PMID: 30126135 PMCID: PMC6161129 DOI: 10.3390/pharmaceutics10030131] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/10/2018] [Accepted: 08/13/2018] [Indexed: 01/29/2023] Open
Abstract
Solid dosage forms of biopharmaceuticals such as therapeutic proteins could provide enhanced bioavailability, improved storage stability, as well as expanded alternatives to parenteral administration. Although numerous drying methods have been used for preparing dried protein powders, choosing a suitable drying technique remains a challenge. In this review, the most frequent drying methods, such as freeze drying, spray drying, spray freeze drying, and supercritical fluid drying, for improving the stability and bioavailability of therapeutic proteins, are discussed. These technologies can prepare protein formulations for different applications as they produce particles with different sizes and morphologies. Proper drying methods are chosen, and the critical process parameters are optimized based on the proposed route of drug administration and the required pharmacokinetics. In an optimized drying procedure, the screening of formulations according to their protein properties is performed to prepare a stable protein formulation for various delivery systems, including pulmonary, nasal, and sustained-release applications.
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Affiliation(s)
- Fakhrossadat Emami
- College of Pharmacy, Tehran University of Medical Sciences, Tehran 1417614411, Iran.
| | - Alireza Vatanara
- College of Pharmacy, Tehran University of Medical Sciences, Tehran 1417614411, Iran.
| | - Eun Ji Park
- College of Pharmacy, Chung-Ang University, Seoul 06974, Korea.
| | - Dong Hee Na
- College of Pharmacy, Chung-Ang University, Seoul 06974, Korea.
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12
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George C, Ducatman AM, Conway BN. Increased risk of respiratory diseases in adults with Type 1 and Type 2 diabetes. Diabetes Res Clin Pract 2018; 142:46-55. [PMID: 29802957 DOI: 10.1016/j.diabres.2018.05.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 05/09/2018] [Accepted: 05/17/2018] [Indexed: 01/09/2023]
Abstract
AIMS Diabetes is linked with decreases in lung elasticity and in capacity to transfer carbon monoxide. Systemic inflammation, a common concern with diabetes, may contribute to airflow obstruction. We examined the association of self-reported diabetes with self-reported respiratory diseases (RDs) among 53,146 adults from the C8 Health Project. METHODS Participants were categorized into three groups: Type 1 (T1D, n = 781), Type 2 (T2D, n = 4277), or no diabetes (n = 48,088). ORs (95% CIs) for the association of diabetes with four RDs were computed: emphysema, chronic obstructive pulmonary disease (COPD), chronic bronchitis (CB), and asthma. Covariates controlled for were age, sex, estimated glomerular filtration rate, C-reactive protein, smoking history, BMI, and perfluorooctonaoic acid (C8). RESULTS RDs were present in 26%, 21% and 13% of persons with T1D, T2D, and no diabetes, respectively. In multivariable analyses, persons with T1D were 62% more likely to have any RD (OR: 1.62, CI: (1.36-1.93)), while those with T2D were 1.3 times as likely (OR: 1.26, CI: 1.15-1.37)). Compared to those without diabetes, in those with T1D and T2D diabetes respectively, ORs (CIs) for COPD were 1.89 (1.38-2.57), 1.45 (1.23-1.71), asthma: 1.51 (1.21-1.87), 1.38 (1.24-1.53), CB: 1.96 (1.57-2.45), 1.35 (1.20-1.52) and emphysema: 1.25 (0.85-1.82), 1.31 (1.10-1.56). Population attributable risks for any RDs associated with a history of smoking were 19%, 30%, and 26% for those with Type 1, Type 2, and no diabetes respectively. CONCLUSIONS Diabetes, more so in T1D, appears to increase RD risk. Smoking is an important risk factor, but not as informative in Type 1 diabetes.
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Affiliation(s)
- Chelsey George
- Department of Epidemiology, School of Public Health, West Virginia University, Morgantown, WV, United States
| | - Alan M Ducatman
- Department of Occupational and Environmental Health, School of Public Health, West Virginia University, Morgantown, WV, United States
| | - Baqiyyah N Conway
- Department of Epidemiology, School of Public Health, West Virginia University, Morgantown, WV, United States; Department of Epidemiology and Biostatistics, School of Rural and Community Health, University of Texas Health Science Center at Tyler, Tyler, TX, United States.
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13
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Knip M. Metabolically inactive insulin: friend or foe in the prevention of autoimmune diabetes? Diabetologia 2017; 60:1382-1384. [PMID: 28580535 DOI: 10.1007/s00125-017-4319-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/09/2017] [Indexed: 11/29/2022]
Abstract
About 20 years ago an American study suggested that daily subcutaneous injections of a metabolically inactive insulin analogue with a single amino acid substitution (aspartic acid instead of phenylalanine) at position 25 of the B chain was as effective as intact insulin in preventing autoimmune diabetes in NOD mice. In this issue of Diabetologia Grönholm et al (DOI: 10.1007/s00125-017-4276-5 ) report that parenteral administration of the same insulin analogue has no preventive effect whatsoever on the development of diabetes in NOD mice; in fact, high doses of the metabolically inactive insulin accelerated disease development. The authors were also unable to show any tolerogenic effect of an insulin peptide mimetope given via a subcutaneous osmotic pump. These data do not support the use of metabolically inactive insulin for the prevention of autoimmune diabetes and question whether insulin alone, intact or inactivated has any role in preventing progression to symptomatic diabetes. Future and ongoing intervention trials in humans with preclinical type 1 diabetes should indicate whether the administration of oral insulin has any protective, neutral or even predisposing effects on the development of symptomatic diabetes.
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Affiliation(s)
- Mikael Knip
- Children's Hospital, University of Helsinki, and Helsinki University Hospital, P.O. Box 22, (Stenbäckinkatu 11), 00014, Helsinki, Finland.
- Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland.
- Tampere Center for Child Health Research, Tampere University Hospital, Tampere, Finland.
- Folkhälsan Research Center, Helsinki, Finland.
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14
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Yeo L, Peakman M. Antigen-specific immunotherapy and influenza vaccination in type 1 diabetes: timing is everything. Diabetologia 2017; 60:1180-1184. [PMID: 28540458 DOI: 10.1007/s00125-017-4304-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 04/25/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Lorraine Yeo
- Department of Immunobiology, Faculty of Life Sciences & Medicine, King's College London, 2nd Floor Borough Wing, Guy's Hospital, London, SE1 9RT, UK
- National Institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas' Hospital and King's College London, London, UK
| | - Mark Peakman
- Department of Immunobiology, Faculty of Life Sciences & Medicine, King's College London, 2nd Floor Borough Wing, Guy's Hospital, London, SE1 9RT, UK.
- National Institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas' Hospital and King's College London, London, UK.
- Institute of Diabetes, Endocrinology and Obesity, King's Health Partners, London, UK.
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15
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Abstract
Type 1 diabetes mellitus (T1DM), also known as autoimmune diabetes, is a chronic disease characterized by insulin deficiency due to pancreatic β-cell loss and leads to hyperglycaemia. Although the age of symptomatic onset is usually during childhood or adolescence, symptoms can sometimes develop much later. Although the aetiology of T1DM is not completely understood, the pathogenesis of the disease is thought to involve T cell-mediated destruction of β-cells. Islet-targeting autoantibodies that target insulin, 65 kDa glutamic acid decarboxylase, insulinoma-associated protein 2 and zinc transporter 8 - all of which are proteins associated with secretory granules in β-cells - are biomarkers of T1DM-associated autoimmunity that are found months to years before symptom onset, and can be used to identify and study individuals who are at risk of developing T1DM. The type of autoantibody that appears first depends on the environmental trigger and on genetic factors. The pathogenesis of T1DM can be divided into three stages depending on the absence or presence of hyperglycaemia and hyperglycaemia-associated symptoms (such as polyuria and thirst). A cure is not available, and patients depend on lifelong insulin injections; novel approaches to insulin treatment, such as insulin pumps, continuous glucose monitoring and hybrid closed-loop systems, are in development. Although intensive glycaemic control has reduced the incidence of microvascular and macrovascular complications, the majority of patients with T1DM are still developing these complications. Major research efforts are needed to achieve early diagnosis, prevent β-cell loss and develop better treatment options to improve the quality of life and prognosis of those affected.
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Iltz JL, Odegard PS, Setter SM, Campbell RK. Pharmacy Update. DIABETES EDUCATOR 2016; 33:215-6, 220, 223-4 passim. [PMID: 17426300 DOI: 10.1177/0145721707299264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The prevalence of diabetes mellitus has increased to more than 20 million people in the United States, and current estimates indicate that one third of all Americans born in the year 2000 will develop diabetes mellitus in their lifetime. The need for diabetes therapies offering improved glucose control by mimicking normal physiological properties of glucose metabolism and improving on logistics such as ease of use, self-management, monitoring, and delivery is clear. This article, part 2 of a 3-part series, reviews newer injectable insulin preparations and examines the first-to-market orally inhaled dry powdered insulin (IDPI). The information provided is tailored to diabetes educators and includes mechanism of action, pharmacokinetics, drug interactions, clinical trials, dosage and administration guidelines, side effects, and educational pearls for each insulin discussed. A detailed patient case designed to acquaint the reader with these newer insulin products and provide an understanding of clinical issues to consider when providing diabetes education to patients is included.
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Affiliation(s)
- Jason L Iltz
- Department of Pharmacotherapy, College of Pharmacy, Washington State University, and Integrated Health Professionals, Spokane, Washington
| | - Peggy Soule Odegard
- Plein Geriatrics Certificate Program, School of Pharmacy, University of Washington, Seattle, and Evergreen Senior Health Specialists, Kirkland, Washington
| | - Stephen M Setter
- Department of Pharmacotherapy, College of Pharmacy, Washington State University, and Elder Services/Visiting Nurse Association, Spokane, Washington
| | - R Keith Campbell
- Department of Pharmacotherapy, College of Pharmacy, Washington State University, Pullman
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17
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Abstract
nhaled insulin is a new route of insulin delivery that can be used in the treatment of type 1 and type 2 diabetes. It offers an alternative and additional means of insulin administration, and has been received with particular satisfaction by patients who dislike injections. Trials indicate that inhaled insulin can be used effectively for pre-meal bolus intensification of treatment. Pre-meal inhaled insulin with Exubera® has shown faster absorption and similar duration of action to regular subcutaneous insulin with an overall similar glucodynamic effect. Although bioavailability is lower, mainly due to losses in the upper airways, this is compensated for by dose. The commonest side effect reported with inhaled insulin, as with subcutaneous insulin, was hypoglycaemia, almost a quarter of patients noted a cough which settled with continued treatment. Increased antibody titres and changes in lung function return to normal on discontinuation of inhaled insulin. Quality of life scores indicate patient preference for inhaled versus injected insulin, thus increased choice may improve adherence to treatment regimens. However, true cost:benefit analyses have to be undertaken as do studies in children, smokers and people with respiratory conditions, e.g. asthma.
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Affiliation(s)
- Srikanth Bellary
- Department of Medicine-Undergraduate Centre, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK
| | - Anthony H Barnett
- Department of Medicine-Undergraduate Centre, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK,
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18
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Akbarpour M, Goudy KS, Cantore A, Russo F, Sanvito F, Naldini L, Annoni A, Roncarolo MG. Insulin B chain 9-23 gene transfer to hepatocytes protects from type 1 diabetes by inducing Ag-specific FoxP3+ Tregs. Sci Transl Med 2016; 7:289ra81. [PMID: 26019217 DOI: 10.1126/scitranslmed.aaa3032] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antigen (Ag)-specific tolerance in type 1 diabetes (T1D) in human has not been achieved yet. Targeting lentiviral vector (LV)-mediated gene expression to hepatocytes induces active tolerance toward the encoded Ag. The insulin B chain 9-23 (InsB9-23) is an immunodominant T cell epitope in nonobese diabetic (NOD) mice. To determine whether auto-Ag gene transfer to hepatocytes induces tolerance and control of T1D, NOD mice were treated with integrase-competent LVs (ICLVs) that selectively target the expression of InsB9-23 to hepatocytes. ICLV treatment induced InsB9-23-specific effector T cells but also FoxP3(+) regulatory T cells (Tregs), which halted islet immune cell infiltration, and protected from T1D. Moreover, ICLV treatment combined with a single suboptimal dose of anti-CD3 monoclonal antibody (mAb) is effective in T1D reversal. Splenocytes from LV.InsB9-23-treated mice, but not from LV.OVA (ovalbumin)-treated control mice, stopped diabetes development, demonstrating that protection is Ag-specific. Depletion of CD4(+)CD25(+)FoxP3(+) T cells led to diabetes progression, indicating that Ag-specific FoxP3(+) Tregs mediate protection. Integrase-defective LVs (IDLVs).InsB9-23, which alleviate the concerns for insertional mutagenesis and support transient transgene expression in hepatocytes, were also efficient in protecting from T1D. These data demonstrate that hepatocyte-targeted auto-Ag gene expression prevents and resolves T1D and that stable integration of the transgene is not required for this protection. Gene transfer to hepatocytes can be used to induce Ag-specific tolerance in autoimmune diseases.
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Affiliation(s)
- Mahzad Akbarpour
- San Raffaele Telethon Institute for Gene Therapy, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy. Vita-Salute San Raffaele University, Milan 20132, Italy
| | - Kevin S Goudy
- San Raffaele Telethon Institute for Gene Therapy, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy
| | - Alessio Cantore
- San Raffaele Telethon Institute for Gene Therapy, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy
| | - Fabio Russo
- San Raffaele Telethon Institute for Gene Therapy, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy
| | - Francesca Sanvito
- Pathology Unit, Department of Oncology, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy
| | - Luigi Naldini
- San Raffaele Telethon Institute for Gene Therapy, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy. Vita-Salute San Raffaele University, Milan 20132, Italy
| | - Andrea Annoni
- San Raffaele Telethon Institute for Gene Therapy, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy
| | - Maria Grazia Roncarolo
- San Raffaele Telethon Institute for Gene Therapy, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy. Vita-Salute San Raffaele University, Milan 20132, Italy. Department of Pediatrics, Stanford School of Medicine, Stanford, CA 94305, USA.
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Ledet G, Graves RA, Bostanian LA, Mandal TK. A second-generation inhaled insulin for diabetes mellitus. Am J Health Syst Pharm 2016; 72:1181-7. [PMID: 26150567 DOI: 10.2146/ajhp140540] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The pharmacologic properties of a recently approved inhaled insulin product, its unique delivery system, and the results of clinical safety and efficacy trials are reviewed. SUMMARY Afrezza (also called Technosphere Insulin, MannKind Corporation, Valencia, CA) is a novel ultrarapid-acting insulin formulation indicated for use in improving glycemic control in selected patients with type 1 or type 2 diabetes mellitus. Afrezza is not intended as a substitute for traditional basal therapy with injectable long-acting insulin but may be used to provide prandial insulin coverage; it must be used in combination with long-acting insulin in patients with type 1 diabetes. Administered before meals using a dry-powder inhalation device, Afrezza is formulated with a novel excipient (fumaryl diketopiperazine) that dissolves instantly in lung fluid and releases recombinant human insulin for absorption. In clinical trials, rates of hypoglycemia in Afrezza-treated patients were significantly lower than rates reported in comparator groups receiving injectable insulin products. The most commonly reported adverse effect of Afrezza is coughing, which tends to occur shortly after inhalation and is typically mild. Afrezza is not recommended for use in patients who smoke (or have recently stopped smoking) and those with a chronic lung disease such as asthma or chronic obstructive pulmonary disease. Afrezza is not recommended for the treatment of diabetic ketoacidosis. CONCLUSION Afrezza is a safe and effective treatment for selected adults with type 1 or type 2 diabetes, potentially providing an alternative to injectable insulin for prandial blood glucose control.
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Affiliation(s)
- Grace Ledet
- Grace Ledet, M.S., is Research Associate; Richard A. Graves, M.S., is Senior Research Associate; and Levon A. Bostanian, Ph.D., is Professor of Pharmaceutics, Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans. Tarun K. Mandal, Ph.D., is Professor and Director, Center for Nanomedicine and Drug Delivery, Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana
| | - Richard A Graves
- Grace Ledet, M.S., is Research Associate; Richard A. Graves, M.S., is Senior Research Associate; and Levon A. Bostanian, Ph.D., is Professor of Pharmaceutics, Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans. Tarun K. Mandal, Ph.D., is Professor and Director, Center for Nanomedicine and Drug Delivery, Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana
| | - Levon A Bostanian
- Grace Ledet, M.S., is Research Associate; Richard A. Graves, M.S., is Senior Research Associate; and Levon A. Bostanian, Ph.D., is Professor of Pharmaceutics, Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans. Tarun K. Mandal, Ph.D., is Professor and Director, Center for Nanomedicine and Drug Delivery, Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana
| | - Tarun K Mandal
- Grace Ledet, M.S., is Research Associate; Richard A. Graves, M.S., is Senior Research Associate; and Levon A. Bostanian, Ph.D., is Professor of Pharmaceutics, Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans. Tarun K. Mandal, Ph.D., is Professor and Director, Center for Nanomedicine and Drug Delivery, Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana.
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Type 1 diabetes vaccine candidates promote human Foxp3(+)Treg induction in humanized mice. Nat Commun 2016; 7:10991. [PMID: 26975663 PMCID: PMC4796321 DOI: 10.1038/ncomms10991] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 02/09/2016] [Indexed: 01/13/2023] Open
Abstract
Immune tolerance is executed partly by Foxp3+regulatory T (Treg) cells, which suppress autoreactive T cells. In autoimmune type 1 diabetes (T1D) impaired tolerance promotes destruction of insulin-producing β-cells. The development of autoantigen-specific vaccination strategies for Foxp3+Treg-induction and prevention of islet autoimmunity in patients is still in its infancy. Here, using human haematopoietic stem cell-engrafted NSG-HLA-DQ8 transgenic mice, we provide direct evidence for human autoantigen-specific Foxp3+Treg-induction in vivo. We identify HLA-DQ8-restricted insulin-specific CD4+T cells and demonstrate efficient human insulin-specific Foxp3+Treg-induction upon subimmunogenic vaccination with strong agonistic insulin mimetopes in vivo. Induced human Tregs are stable, show increased expression of Treg signature genes such as Foxp3, CTLA4, IL-2Rα and TIGIT and can efficiently suppress effector T cells. Such Foxp3+Treg-induction does not trigger any effector T cells. These T1D vaccine candidates could therefore represent an expedient improvement in the challenge to induce human Foxp3+Tregs and to develop novel precision medicines for prevention of islet autoimmunity in children at risk of T1D. Type 1 diabetes is associated with the loss of self-tolerance to the insulin-producing β-cells in the pancreas. Here the authors show that vaccination with insulin mimetopes can induce human insulin-specific regulatory T cells to mediate tolerance in a humanized mouse model.
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21
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Maahs DM, Shalitin S. Diabetes Technology and Therapy in the Pediatric Age Group. Diabetes Technol Ther 2016; 18 Suppl 1:S86-100. [PMID: 26836433 DOI: 10.1089/dia.2016.2509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- David M Maahs
- 1 Barbara Davis Center for Childhood Diabetes, University of Colorado , Denver, CO
| | - Shlomit Shalitin
- 2 Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel , Petah Tikva, Israel
- 3 Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv, Israel
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22
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Zhang J, Liang X, Zhang Y, Shang Q. Fabrication and evaluation of a novel polymeric hydrogel of carboxymethyl chitosan-g-polyacrylic acid (CMC-g-PAA) for oral insulin delivery. RSC Adv 2016. [DOI: 10.1039/c6ra05078f] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The CMC-g-PAA hydrogels could release INS in alkaline environment (i.e. intestinal), specifically. This method could prevent IND from destroying by pepsase. Therefore, the CMC-g-PAA hydrogel had a potential application on the oral delivery of protein drugs.
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Affiliation(s)
- Jing Zhang
- Chemical and Pharmaceutical Engineering Institute
- Hebei University of Science and Technology
- China
| | - Xiaoyang Liang
- Chemical and Pharmaceutical Engineering Institute
- Hebei University of Science and Technology
- China
| | - Ying Zhang
- Chemical and Pharmaceutical Engineering Institute
- Hebei University of Science and Technology
- China
| | - Qing Shang
- Chemical and Pharmaceutical Engineering Institute
- Hebei University of Science and Technology
- China
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23
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Grimaldi N, Andrade F, Segovia N, Ferrer-Tasies L, Sala S, Veciana J, Ventosa N. Lipid-based nanovesicles for nanomedicine. Chem Soc Rev 2016; 45:6520-6545. [DOI: 10.1039/c6cs00409a] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Multifunctional lipid-based nanovesicles (L-NVs) prepared by molecular self-assembly of membrane components together with (bio)-active molecules, by means of compressed CO2-media or other non-conventional methods lead to highly homogeneous, tailor-made nanovesicles that are used for advanced nanomedicine. Confocal microscopy image of siRNA transfection using L-NVs, reprinted with permission from de Jonge,et al.,Gene Therapy, 2006,13, 400–411.
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Affiliation(s)
- N. Grimaldi
- Institut de Ciència de Materials de Barcelona (ICMAB-CSIC)
- Campus Universitari de Bellaterra
- Cerdanyola del Vallès
- Spain
- Nanomol Technologies SA
| | - F. Andrade
- Institut de Ciència de Materials de Barcelona (ICMAB-CSIC)
- Campus Universitari de Bellaterra
- Cerdanyola del Vallès
- Spain
- Centro de Investigación Biomédica en Red de Bioingeniería
| | - N. Segovia
- Institut de Ciència de Materials de Barcelona (ICMAB-CSIC)
- Campus Universitari de Bellaterra
- Cerdanyola del Vallès
- Spain
- Centro de Investigación Biomédica en Red de Bioingeniería
| | - L. Ferrer-Tasies
- Institut de Ciència de Materials de Barcelona (ICMAB-CSIC)
- Campus Universitari de Bellaterra
- Cerdanyola del Vallès
- Spain
- Nanomol Technologies SA
| | - S. Sala
- Institut de Ciència de Materials de Barcelona (ICMAB-CSIC)
- Campus Universitari de Bellaterra
- Cerdanyola del Vallès
- Spain
- Centro de Investigación Biomédica en Red de Bioingeniería
| | - J. Veciana
- Institut de Ciència de Materials de Barcelona (ICMAB-CSIC)
- Campus Universitari de Bellaterra
- Cerdanyola del Vallès
- Spain
- Centro de Investigación Biomédica en Red de Bioingeniería
| | - N. Ventosa
- Institut de Ciència de Materials de Barcelona (ICMAB-CSIC)
- Campus Universitari de Bellaterra
- Cerdanyola del Vallès
- Spain
- Centro de Investigación Biomédica en Red de Bioingeniería
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Simmons KM, Michels AW. Alternate Ways to Quantify Antibodies. Diabetes Technol Ther 2015; 17:854-6. [PMID: 26544921 PMCID: PMC4677111 DOI: 10.1089/dia.2015.0328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Kimber M Simmons
- Barbara Davis Center for Childhood Diabetes, University of Colorado , Aurora, Colorado
| | - Aaron W Michels
- Barbara Davis Center for Childhood Diabetes, University of Colorado , Aurora, Colorado
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25
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Bode BW, McGill JB, Lorber DL, Gross JL, Chang PC, Bregman DB. Inhaled Technosphere Insulin Compared With Injected Prandial Insulin in Type 1 Diabetes: A Randomized 24-Week Trial. Diabetes Care 2015; 38:2266-73. [PMID: 26180109 DOI: 10.2337/dc15-0075] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 06/15/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the efficacy and safety of Technosphere insulin (TI) and insulin aspart in patients with type 1 diabetes. RESEARCH DESIGN AND METHODS This open-label noninferiority trial compared the change in HbA1c from baseline to week 24 of prandial TI (n = 174) with that of subcutaneous aspart (n = 171), both with basal insulin, in patients with type 1 diabetes and HbA1c 7.5-10.0% (56.8-86.0 mmol/mol). RESULTS Mean change in HbA1c in TI patients (-0.21% [-2.3 mmol/mol]) from baseline (7.94% [63.3 mmol/mol]) was noninferior to that in aspart patients (-0.40% [-4.4 mmol/mol]) from baseline (7.92% [63.1 mmol/mol]). The between-group difference was 0.19% (2.1 mmol/mol) (95% CI 0.02-0.36), satisfying the noninferiority margin of 0.4%. However, more aspart patients achieved HbA1c <7.0% (53.0 mmol/mol) (30.7% vs. 18.3%). TI patients had a small weight loss (-0.4 kg) compared with a gain (+0.9 kg) for aspart patients (P = 0.0102). TI patients had a lower hypoglycemia event rate than aspart patients (9.8 vs. 14.0 events/patient-month, P < 0.0001). Cough (generally mild) was the most frequent adverse event (31.6% with TI, 2.3% with aspart), leading to discontinuation in 5.7% of patients. Treatment group difference for mean change from baseline in forced expiratory volume in 1 s was small (40 mL) and disappeared upon TI discontinuation. CONCLUSIONS In patients with type 1 diabetes receiving basal insulin, HbA1c reduction with TI was noninferior to that of aspart, with less hypoglycemia and less weight gain but increased incidence of cough.
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Affiliation(s)
| | - Janet B McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Daniel L Lorber
- New York Hospital Queens, New York-Presbyterian Healthcare System, Flushing, NY
| | - Jorge L Gross
- Centro de Pesquisas em Diabetes Ltda., Porto Alegre, Brazil
| | | | - David B Bregman
- Sanofi, Bridgewater, NJ Department of Pathology, Albert Einstein College of Medicine, Bronx, NY
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Abstract
Type 1 diabetes is a chronic autoimmune disease resulting from T cell-mediated destruction of insulin-producing beta cells within pancreatic islets. Disease incidence has increased significantly in the last two decades, especially in young children. Type 1 diabetes is now predictable in humans with the measurement of serum islet autoantibodies directed against insulin and beta cell proteins. Knowledge regarding the presentation of insulin and islet antigens to T cells has increased dramatically over the last several years. Here, we review the trimolecular complex in diabetes, which consists of a major histocompatibility molecule,self-peptide, and T cell receptor, with a focus on insulin peptide presentation to T cells. With this increased understanding of how antigens are presented to T cells comes the hope for improved therapies for type 1 diabetes prevention.
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Affiliation(s)
- Maki Nakayama
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kimberly M Simmons
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Aaron W Michels
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO, USA.
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Abstract
Type 1 diabetes (T1D) affects 1.93 in 1000 youth in the USA. Over the last 40 years, a combination of genetic and immunological markers has been developed allowing for the accurate prediction of progression to T1D. Despite our abilities to predict disease and the marked improvement in our understanding of the natural history of T1D, therapies capable of preventing or reversing T1D remain elusive. This article will review recent and ongoing efforts to understand the causes of T1D and related efforts to study potential therapies aimed at preventing T1D.
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Affiliation(s)
| | - Michael J Haller
- University of Florida, PO Box 100296, Gainesville, FL, 32610, USA.
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Insel RA, Dunne JL, Ziegler AG. General population screening for type 1 diabetes: has its time come? Curr Opin Endocrinol Diabetes Obes 2015; 22:270-6. [PMID: 26087338 DOI: 10.1097/med.0000000000000173] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review was to describe the potential for general childhood population-based screening of risk of symptomatic type 1 diabetes (T1D) RECENT FINDINGS: The earliest stages of T1D can be identified and risk and rate of progression to symptomatic disease can be estimated by the presence of multiple islet autoantibodies and glucose intolerance (dysglycemia) in individuals screened for risk. Screening for human leukocyte antigen risk genotypes in neonates with follow-up detection of islet autoantibodies in childhood has been explored. An alternative approach of general childhood population-based detection of autoantibodies at well child visits provides an approach to detect a high proportion of children who will develop T1D. The Fr1da study was launched in Bavaria in 2015 to explore this concept. SUMMARY General childhood population-based screening for risk of T1D will allow detection of an at-risk population that can participate in natural history studies to better understand disease pathogenesis and intervention trials to prevent symptomatic disease and will provide a framework for public health-based prevention of childhood-onset T1D.
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Affiliation(s)
- Richard A Insel
- aJDRF, New York, USA bInstitute of Diabetes Research, Helmholtz Zentrum München, Munich cForschergruppe Diabetes, Klinikum rechts der Isar, Technische Universität München, Neuherberg, Germany
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29
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Roep BO. Primary prevention for type 1 diabetes mellitus? Nat Rev Endocrinol 2015; 11:451-2. [PMID: 26077263 DOI: 10.1038/nrendo.2015.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Bart O Roep
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, P.O. Box 9600, NL-2300RC Leiden, Netherlands
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30
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Abstract
Studies over the past 35 years in the nonobese diabetic (NOD) mouse have shown that a number of agents can prevent or even reverse type 1 diabetes mellitus (T1DM); however, these successes have not been replicated in human clinical trials. Although some of these interventions have delayed disease onset or progression in subsets of participants, none have resulted in a complete cure. Even in the most robust responders, the treatments do not permanently preserve insulin secretion or stimulate the proliferation of β cells, as has been observed in mice. The shortfalls of translating NOD mouse studies into the clinic questions the value of using this model in preclinical studies. In this Perspectives, we suggest how immunological and genetic differences between NOD mice and humans might contribute to the differential outcomes and suggest ways in which the mouse model might be modified or applied as a tool to develop treatments and improve understanding of clinical trial outcomes.
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Affiliation(s)
- James C Reed
- Department of Immunobiology, 300 George Street, #353E, New Haven, CT 06520, USA
| | - Kevan C Herold
- Department of Immunobiology, Department of Internal Medicine, Yale University, 300 George Street, #353E, New Haven, CT 06520, USA
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Regulatory vs. inflammatory cytokine T-cell responses to mutated insulin peptides in healthy and type 1 diabetic subjects. Proc Natl Acad Sci U S A 2015; 112:4429-34. [PMID: 25831495 DOI: 10.1073/pnas.1502967112] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Certain class II MHC (MHCII) alleles in mice and humans confer risk for or protection from type 1 diabetes (T1D). Insulin is a major autoantigen in T1D, but how its peptides are presented to CD4 T cells by MHCII risk alleles has been controversial. In the mouse model of T1D, CD4 T cells respond to insulin B-chain peptide (B:9-23) mimotopes engineered to bind the mouse MHCII molecule, IA(g7), in an unfavorable position or register. Because of the similarities between IA(g7) and human HLA-DQ T1D risk alleles, we examined control and T1D subjects with these risk alleles for CD4 T-cell responses to the same natural B:9-23 peptide and mimotopes. A high proportion of new-onset T1D subjects mounted an inflammatory IFN-γ response much more frequently to one of the mimotope peptides than to the natural peptide. Surprisingly, the control subjects bearing an HLA-DQ risk allele also did. However, these control subjects, especially those with only one HLA-DQ risk allele, very frequently made an IL-10 response, a cytokine associated with regulatory T cells. T1D subjects with established disease also responded to the mimotope rather than the natural B:9-23 peptide in proliferation assays and the proliferating cells were highly enriched in certain T-cell receptor sequences. Our results suggest that the risk of T1D may be related to how an HLA-DQ genotype determines the balance of T-cell inflammatory vs. regulatory responses to insulin, having important implications for the use and monitoring of insulin-specific therapies to prevent diabetes onset.
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Ilonen J, Knip M, Vaarala O. Heterogeneity in diabetes-associated autoantibodies and susceptibility to Type 1 diabetes: lessons for disease prevention. Expert Rev Endocrinol Metab 2015; 10:25-34. [PMID: 30289041 DOI: 10.1586/17446651.2015.955474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Autoantibodies against pancreatic islets are strong predictors of Type 1 diabetes. When persistent β-cell autoantibodies against at least two autoantigens are detected, the probability of diabetes is extremely high, although the time period before disease development can vary from days up to more than 20 years. Insulin autoantibodies or antibodies specific to glutamate decarboxylase 65 enzyme are in most cases, the first autoantibodies to appear. Insulin autoantibodies typically emerge very early with a peak at the age of 1.5 years, whereas the onset of glutamic acid decarboxylase 65 antibody positivity has a more even distribution, peaking later in childhood. These differences in the timing of appearance suggest that different environmental factors might be involved in the initiation of β-cell autoimmunity beginning either already in infancy or later on. This should be taken into account in studies aimed at identifying environmental factors triggering islet cell-specific autoimmunity and also in the design of prevention trials.
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Affiliation(s)
- Jorma Ilonen
- a 1 Immunogenetics Laboratory, University of Turku, Turku, Finland
- b 2 Department of Clinical Microbiology, University of Eastern Finland, Kuopio, Finland
| | - Mikael Knip
- c 3 Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- d 4 Diabetes and Obesity Research Program, University of Helsinki, Helsinki, Finland
- e 5 Folkhälsan Research Center, Helsinki, Finland
- f 6 Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Outi Vaarala
- g 7 Department of Vaccination and Immune Protection, National Institute for Health and Welfare, Helsinki, Finland
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Hunt L, Emery P. Defining populations at risk of rheumatoid arthritis: the first steps to prevention. Nat Rev Rheumatol 2014; 10:521-30. [DOI: 10.1038/nrrheum.2014.82] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Type 1 diabetes mellitus (T1DM) is the result of autoimmune destruction of pancreatic β cells in genetically predisposed individuals with impaired immune regulation. The insufficiency in the modulation of immune attacks on the β cells might be partly due to genetic causes; indeed, several of the genetic variants that predispose individuals to T1DM have functional features of impaired immune regulation. Whilst defects in immune regulation in patients with T1DM have been identified, many patients seem to have immune regulatory capacities that are indistinguishable from those of healthy individuals. Insight into the regulation of islet autoimmunity might enable us to restore immune imbalances with therapeutic interventions. In this Review, we discuss the current knowledge on immune regulation and dysfunction in humans that is the basis of tissue-specific immune regulation as an alternative to generalized immune suppression.
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Affiliation(s)
- Bart O Roep
- Leiden University Medical Center, Department of Immunohaematology & Blood Transfusion, P. O. Box 9600, NL-2300 RC Leiden, Netherlands
| | - Timothy I M Tree
- Department of Immunobiology, King's College London, School of Medicine, London SE1 9RT, UK
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Regulatory T-cell vaccination independent of auto-antigen. Exp Mol Med 2014; 46:e82. [PMID: 24626168 PMCID: PMC3972794 DOI: 10.1038/emm.2014.4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 12/06/2013] [Indexed: 12/21/2022] Open
Abstract
To date, efforts to treat autoimmune diseases have primarily focused on the disease symptoms rather than on the cause of the disease. In large part, this is attributed to not knowing the responsible auto-antigens (auto-Ags) for driving the self-reactivity coupled with the poor success of treating autoimmune diseases using oral tolerance methods. Nonetheless, if tolerogenic approaches or methods that stimulate regulatory T (Treg) cells can be devised, these could subdue autoimmune diseases. To forward such efforts, our approach with colonization factor antigen I (CFA/I) fimbriae is to establish bystander immunity to ultimately drive the development of auto-Ag-specific Treg cells. Using an attenuated Salmonella vaccine expressing CFA/I fimbriae, fimbriae-specific Treg cells were induced without compromising the vaccine's capacity to protect against travelers' diarrhea or salmonellosis. By adapting the vaccine's anti-inflammatory properties, it was found that it could also dampen experimental inflammatory diseases resembling multiple sclerosis (MS) and rheumatoid arthritis. Because of this bystander effect, disease-specific Treg cells are eventually induced to resolve disease. Interestingly, this same vaccine could elicit the required Treg cell subset for each disease. For MS-like disease, conventional CD25+ Treg cells are stimulated, but for arthritis CD39+ Treg cells are induced instead. This review article will examine the potential of treating autoimmune diseases without having previous knowledge of the auto-Ag using an innocuous antigen to stimulate Treg cells via the production of transforming growth factor-β and interleukin-10.
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Harrison LC, Wentworth JM, Zhang Y, Bandala-Sanchez E, Böhmer RM, Neale AM, Stone NL, Naselli G, Bosco JJ, Auyeung P, Rashidi M, Augstein P, Morahan G. Antigen-based vaccination and prevention of type 1 diabetes. Curr Diab Rep 2013; 13:616-23. [PMID: 23888323 DOI: 10.1007/s11892-013-0415-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Insulin-dependent or type 1 diabetes (T1D) is a paradigm for prevention of autoimmune disease: Pancreatic β-cell autoantigens are defined, at-risk individuals can be identified before the onset of symptoms, and autoimmune diabetes is preventable in rodent models. Intervention in asymptomatic individuals before or after the onset of subclinical islet autoimmunity places a premium on safety, a requirement met only by lifestyle-dietary approaches or autoantigen-based vaccination to induce protective immune tolerance. Insulin is the key driver of autoimmune β-cell destruction in the nonobese diabetic (NOD) mouse model of T1D and is an early autoimmune target in children at risk for T1D. In the NOD mouse, mucosal administration of insulin induces regulatory T cells that protect against diabetes. The promise of autoantigen-specific vaccination in humans has yet to be realized, but recent trials of oral and nasal insulin vaccination in at-risk humans provide grounds for cautious optimism.
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Affiliation(s)
- Leonard C Harrison
- Walter & Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia,
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Xu D, Prasad S, Miller SD. Inducing immune tolerance: a focus on Type 1 diabetes mellitus. ACTA ACUST UNITED AC 2013; 3:415-426. [PMID: 24505231 DOI: 10.2217/dmt.13.36] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Tolerogenic strategies that specifically target diabetogenic immune cells in the absence of complications of immunosuppression are the desired treatment for the prevention or even reversal of Type 1 diabetes (T1D). Antigen (Ag)-based therapies must not only suppress disease-initiating diabetogenic T cells that are already activated, but, more importantly, prevent activation of naive auto-Ag-specific T cells that may become autoreactive through epitope spreading as a result of Ag liberation from damaged islet cells. Therefore, identification of auto-Ags relevant to T1D initiation and progression is critical to the design of effective Ag-specific therapies. Animal models of T1D have been successfully employed to identify potential diabetogenic Ags, and have further facilitated translation of Ag-specific tolerance strategies into human clinical trials. In this review, we highlight important advances using animal models in Ag-specific T1D immunotherapies, and the application of the preclinical findings to human subjects. We provide an up-to-date overview of the strengths and weaknesses of various tolerance-inducing strategies, including infusion of soluble Ags/peptides by various routes of delivery, genetic vaccinations, cell- and inert particle-based tolerogenic approaches, and various other strategies that target distinct tolerance-inducing pathways.
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Affiliation(s)
- Dan Xu
- Department of Microbiology-Immunology & Interdepartmental Immunobiology Center, Feinberg School of Medicine, Northwestern University, 303 E Chicago Avenue, Chicago, IL 60611, USA
| | - Suchitra Prasad
- Department of Microbiology-Immunology & Interdepartmental Immunobiology Center, Feinberg School of Medicine, Northwestern University, 303 E Chicago Avenue, Chicago, IL 60611, USA
| | - Stephen D Miller
- Department of Microbiology-Immunology & Interdepartmental Immunobiology Center, Feinberg School of Medicine, Northwestern University, 303 E Chicago Avenue, Chicago, IL 60611, USA
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Gottlieb P, Utz PJ, Robinson W, Steinman L. Clinical optimization of antigen specific modulation of type 1 diabetes with the plasmid DNA platform. Clin Immunol 2013; 149:297-306. [PMID: 24094739 DOI: 10.1016/j.clim.2013.08.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Accepted: 08/08/2013] [Indexed: 12/16/2022]
Abstract
Some clinical trials in humans have aimed at modulation of type 1 diabetes (T1D) via alteration of the immune response to putative islet cell antigens, particularly proinsulin and insulin, glutamic acid decarboxylase and the peptide, DiaPep 277, derived from heat shock protein 60. The focus here is on development of a specially engineered DNA plasmid encoding proinsulin to treat T1D. The plasmid is engineered to turn off adaptive immunity to proinsulin. This approach yielded exciting results in a randomized placebo controlled trial in 80 adult patients with T1D. The implications of this trial are explored in regards to the potential for sparing inflammation in islets and thus allowing the functioning beta cells to recover and produce more insulin. Strategies to further strengthen the effects seen thus far with the tolerizing DNA plasmid to proinsulin will be elucidated. The DNA platform affords an opportunity for easy modifications. In addition standard exploration of dose levels, route of administration and frequency of dose are practical. Optimization of the effects seen to date on C-peptide and on depletion of proinsulin specific CD8 T cells are feasible, with expected concomitant improvement in other parameters like hemoglobin A1c and reduction in insulin usage. T1D is one of the few autoimmune conditions where antigen specific therapy can be achieved, provided the approach is tested intelligently. Tolerizing DNA vaccines to proinsulin and other islet cell autoantigens is a worthy pursuit to potentially treat, prevent and to perhaps even 'cure' or 'prevent' type 1 diabetes.
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Affiliation(s)
- Peter Gottlieb
- Barbara Davis Center for Childhood Diabetes, Aurora, CO 80045-6511, USA
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Krischer JP. The use of intermediate endpoints in the design of type 1 diabetes prevention trials. Diabetologia 2013; 56:1919-24. [PMID: 23744306 PMCID: PMC3743228 DOI: 10.1007/s00125-013-2960-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 05/16/2013] [Indexed: 01/13/2023]
Abstract
AIMS/HYPOTHESIS This paper presents a rationale for the selection of intermediate endpoints to be used in the design of type 1 diabetes prevention clinical trials. METHODS Relatives of individuals diagnosed with type 1 diabetes were enrolled on the TrialNet Natural History Study and screened for diabetes-related autoantibodies. Those with two or more such autoantibodies were analysed with respect to increased HbA1c, decreased C-peptide following an OGTT, or abnormal OGTT values as intermediate markers of disease progression. RESULTS Over 2 years, a 10% increase in HbA1c, and a 20% or 30% decrease in C-peptide from baseline, or progression to abnormal OGTT, occurred with a frequency between 20% and 41%. The 3- to 5-year risk of type 1 diabetes following each intermediate endpoint was high, namely 47% to 84%. The lower the incidence of the endpoint being reached, the higher the risk of diabetes. A diabetes prevention trial using these intermediate endpoints would require a 30% to 50% smaller sample size than one using type 1 diabetes as the endpoint. CONCLUSIONS/INTERPRETATION The use of an intermediate endpoint in diabetes prevention is based on the generally held view of disease progression from initial occurrence of autoantibodies through successive immunological and metabolic changes to manifest type 1 diabetes. Thus, these markers are suitable for randomised phase 2 trials, which can more rapidly screen promising new therapies, allowing them to be subsequently confirmed in definitive phase 3 trials.
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Affiliation(s)
- Jeffrey P Krischer
- Division of Informatics and Biostatistics, Department of Pediatrics, University of South Florida, Tampa, FL 33612, USA.
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41
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Therapeutic opportunities for manipulating T(Reg) cells in autoimmunity and cancer. Nat Rev Drug Discov 2013; 12:51-63. [PMID: 23274471 DOI: 10.1038/nrd3683] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Forkhead box P3 (FOXP3)-expressing regulatory T (T(Reg)) cells have a pivotal role in the regulation of immune responses and in the maintenance of immunological self-tolerance. These cells have emerged as attractive targets for strategies that allow the steering of immune responses in desired directions - arming the immune system to destroy infected cells and cancer cells or downregulating it to limit tissue destruction in autoimmunity. Efforts to understand the generation, activation and function of T(Reg) cells should permit the development of therapeutics for reprogramming the immune system. In this Review, we discuss insights into the generation of T(Reg) cells, their involvement in disease and the molecular basis of the dominant tolerance exerted by FOXP3(+) T(Reg) cells that could permit their safe and specific manipulation in humans.
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42
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Roep BO, Solvason N, Gottlieb PA, Abreu JRF, Harrison LC, Eisenbarth GS, Yu L, Leviten M, Hagopian WA, Buse JB, von Herrath M, Quan J, King RS, Robinson WH, Utz PJ, Garren H, Steinman L. Plasmid-encoded proinsulin preserves C-peptide while specifically reducing proinsulin-specific CD8⁺ T cells in type 1 diabetes. Sci Transl Med 2013; 5:191ra82. [PMID: 23803704 PMCID: PMC4516024 DOI: 10.1126/scitranslmed.3006103] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In type 1 diabetes (T1D), there is an intense inflammatory response that destroys the β cells in the pancreatic islets of Langerhans, the site where insulin is produced and released. A therapy for T1D that targets the specific autoimmune response in this disease while leaving the remainder of the immune system intact, has long been sought. Proinsulin is a major target of the adaptive immune response in T1D. We hypothesized that an engineered DNA plasmid encoding proinsulin (BHT-3021) would preserve β cell function in T1D patients through reduction of insulin-specific CD8⁺ T cells. We studied 80 subjects over 18 years of age who were diagnosed with T1D within the past 5 years. Subjects were randomized 2:1 to receive intramuscular injections of BHT-3021 or BHT-placebo, weekly for 12 weeks, and then monitored for safety and immune responses in a blinded fashion. Four dose levels of BHT-3021 were evaluated: 0.3, 1.0, 3.0, and 6.0 mg. C-peptide was used both as an exploratory efficacy measure and as a safety measure. Islet-specific CD8⁺ T cell frequencies were assessed with multimers of monomeric human leukocyte antigen class I molecules loaded with peptides from pancreatic and unrelated antigens. No serious adverse events related to BHT-3021 were observed. C-peptide levels improved relative to placebo at all doses, at 1 mg at the 15-week time point (+19.5% BHT-3021 versus -8.8% BHT-placebo, P < 0.026). Proinsulin-reactive CD8⁺ T cells, but not T cells against unrelated islet or foreign molecules, declined in the BHT-3021 arm (P < 0.006). No significant changes were noted in interferon-γ, interleukin-4 (IL-4), or IL-10 production in CD4 T cells. Thus, we demonstrate that a plasmid encoding proinsulin reduces the frequency of CD8⁺ T cells reactive to proinsulin while preserving C-peptide over the course of dosing.
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Affiliation(s)
- Bart O. Roep
- Department for Immunohematology and Blood Transfusion, Leiden University Medical Center, 2333 ZA Leiden, the Netherlands
| | - Nanette Solvason
- Bayhill Therapeutics, Palo Alto, CA 94304, USA
- Foothill College, Los Altos, CA 94022, USA
| | - Peter A. Gottlieb
- Barbara Davis Center for Childhood Diabetes, Aurora, CO 80045–6511, USA
| | - Joana R. F. Abreu
- Department for Immunohematology and Blood Transfusion, Leiden University Medical Center, 2333 ZA Leiden, the Netherlands
| | - Leonard C. Harrison
- Division of Molecular Medicine, Walter and Eliza Hall Institute for Medical Research, Parkville, Victoria 3052, Australia
| | | | - Liping Yu
- Barbara Davis Center for Childhood Diabetes, Aurora, CO 80045–6511, USA
| | | | - William A. Hagopian
- Pacific Northwest Diabetes Research Institute and University of Washington, Seattle, WA 98122, USA
| | - John B. Buse
- Diabetes Center for Research, University of North Carolina, Chapel Hill, NC 27599, USA
| | | | - Joanne Quan
- Bayhill Therapeutics, Palo Alto, CA 94304, USA
| | | | - William H. Robinson
- Bayhill Therapeutics, Palo Alto, CA 94304, USA
- Departments of Medicine and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA
- Tolerion Inc., 321 Dedalera Drive, Portola Valley, CA 94028, USA
| | - Paul J. Utz
- Bayhill Therapeutics, Palo Alto, CA 94304, USA
- Departments of Medicine and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA
- Tolerion Inc., 321 Dedalera Drive, Portola Valley, CA 94028, USA
| | - Hideki Garren
- Bayhill Therapeutics, Palo Alto, CA 94304, USA
- Tolerion Inc., 321 Dedalera Drive, Portola Valley, CA 94028, USA
| | | | - Lawrence Steinman
- Bayhill Therapeutics, Palo Alto, CA 94304, USA
- Departments of Medicine and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA
- Tolerion Inc., 321 Dedalera Drive, Portola Valley, CA 94028, USA
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43
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Skyler JS, Pugliese A. Immunotherapy trials for type 1 diabetes: the contribution of George Eisenbarth. Diabetes Technol Ther 2013; 15 Suppl 2:S2-13-S2-20. [PMID: 23786294 PMCID: PMC3676656 DOI: 10.1089/dia.2013.0107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Type 1 diabetes (T1D) results from the autoimmune destruction of pancreatic β-cells, and as such it should respond to immunotherapy. George Eisenbarth gave many significant contributions to this field. He has been involved at some level in most immunotherapy trials during the past three decades. He was among the pioneers who attempted immunotherapy approaches in patients with recent-onset T1D. In the early 1980s he began studying relatives of those with the disease, leading to the concept that T1D was a chronic autoimmune disease, in which islet autoimmune responses would silently destroy β-cells and cause progressive impairment of insulin secretion, years to months before a diagnosis was made. Consequently, he was one of the first to attempt immune intervention in people at high risk of T1D. Throughout his career he developed autoantibody assays and predictive models (which included metabolic testing and later genetics) to identify individuals at risk of T1D. He provided seminal intellectual contributions and critical tools for prevention trials. His focus on insulin as a critical autoantigen led to multiple prevention trials, including the Diabetes Prevention Trial-Type 1 (DPT-1), which studied both parenteral and oral insulin. In the DPT-1 Oral Insulin Trial, a cohort with higher levels of insulin autoantibodies was identified that appeared to have delayed disease progression. Type 1 Diabetes TrialNet is conducting a new trial to verify or refute this observation. Moreover, George identified and tested in the mouse small molecules that block or modulate presentation of a key insulin peptide and in turn prevent the activation of insulin-specific T-lymphocytes. Thus, we believe his greatest contribution is yet to come, as in the near future we should see this most recent work translate into clinical trials.
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Affiliation(s)
- Jay S Skyler
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, Florida 33136, USA.
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44
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Spain LM, Martey L, Akolkar B, Leschek E, Appel M, Fradkin J. NIH research to prevent type 1 diabetes: George Eisenbarth's legacy. Diabetes Technol Ther 2013; 15 Suppl 2:S2-1-S2-3. [PMID: 23786293 PMCID: PMC3676659 DOI: 10.1089/dia.2013.0096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Lisa M Spain
- Division of Diabetes, Endocrinology & Metabolism, National Institute of Diabetes, Digestive, & Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20817, USA.
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Michels AW. Targeting the trimolecular complex: the pathway towards type 1 diabetes prevention. Diabetes Technol Ther 2013; 15 Suppl 2:S2-8-S2-12. [PMID: 23786298 PMCID: PMC3676662 DOI: 10.1089/dia.2013.0114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
George Eisenbarth devoted his life to understanding the basic immunology of the autoimmune polyglandular syndromes and type 1 diabetes, while providing exceptional clinical care to individuals afflicted with these disorders. Over the last 5 years, I was privileged to know George Eisenbarth as a mentor, colleague, and friend. His enthusiasm for science and specifically understanding the basic immunology of type 1 diabetes was infectious. George was the first to initially hypothesize that type 1 diabetes is a chronic autoimmune disorder. He made diabetes a predictable disease by developing biochemical assays to measure islet autoantibodies and provided this technology worldwide to researchers and the medical community. His work identifying and detecting islet autoantibodies allowed for clinical intervention trials aimed at preventing type 1 diabetes. George worked fervently to prevent the disease. During my time as a fellow in George's laboratory and faculty member at the Barbara Davis Center for Diabetes, we focused our efforts for diabetes prevention at the trimolecular complex (human leukocyte antigen molecule, self-peptide, and T cell receptor), which plays a pivotal role in diabetes pathogenesis. It is our belief that targeting this complex with safe and specific therapies will lead to the prevention of type 1 diabetes and an improved understanding as to why diabetes develops.
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Affiliation(s)
- Aaron W Michels
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, Colorado 80045, USA.
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46
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Depreter F, Pilcer G, Amighi K. Inhaled proteins: Challenges and perspectives. Int J Pharm 2013; 447:251-80. [DOI: 10.1016/j.ijpharm.2013.02.031] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 02/12/2013] [Indexed: 12/26/2022]
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47
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Pham DQ, Cohen H, Chu V. Inhaled Human [rDNA Origin] Insulin, a Novel Formulation for Diabetes Mellitus. J Clin Pharmacol 2013; 47:890-903. [PMID: 17585117 DOI: 10.1177/0091270007301798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diabetic complications have been reduced significantly with the introduction of insulin more than 8 decades prior. Despite the proven benefits of normal glycemic levels, patients are deterred by the inconvenience and expect worse pain than there is on average with multiple daily insulin injections. Inhaled insulin was approved by the Food and Drug Administration in early 2006 and is a novel product that introduces inhaled insulin as an alternate to the traditional subcutaneous delivery system, and hence could potentially improve patient compliance. The objective of this article is to review the clinical pharmacology, pharmacokinetic and pharmacodynamic properties, clinical efficacy, and tolerability of inhaled insulin.
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Affiliation(s)
- David Q Pham
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Division of Pharmacy Practice, 75 DeKalb Avenue, Brooklyn, NY 11201-5497, USA.
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48
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Abstract
Type 1 diabetes mellitus (T1DM) is an autoimmune disorder directed against the β cells of the pancreatic islets. The genetic risk of the disease is linked to HLA-DQ risk alleles and unknown environmental triggers. In most countries, only 10-15% of children or young adults newly diagnosed with T1DM have a first-degree relative with the disease. Autoantibodies against insulin, GAD65, IA-2 or the ZnT8 transporter mark islet autoimmunity. These islet autoantibodies may already have developed in children of 1-3 years of age. Immune therapy in T1DM is approached at three different stages. Primary prevention is treatment of individuals at increased genetic risk. For example, one trial is testing if hydrolyzed casein milk formula reduces T1DM incidence in genetically predisposed infants. Secondary prevention is targeted at individuals with persistent islet autoantibodies. Ongoing trials involve nonautoantigen-specific therapies, such as Bacillus Calmette-Guérin vaccine or anti-CD3 monoclonal antibodies, or autoantigen-specific therapies, including oral and nasal insulin or alum-formulated recombinant human GAD65. Trial interventions at onset of T1DM have also included nonautoantigen-specific approaches, and autoantigen-specific therapies, such as proinsulin peptides. Although long-term preservation of β-cell function has been difficult to achieve in many studies, considerable progress is being made through controlled clinical trials and animal investigations towards uncovering mechanisms of β-cell destruction. Novel therapies that prevent islet autoimmunity or halt progressive β-cell destruction are needed.
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Affiliation(s)
- Ake Lernmark
- Lund University, Department of Clinical Sciences, Skåne University Hospital SUS, Malmö, Sweden. ake.lernmark@ med.lu.se
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49
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de Galan BE. Can inhaled insulin be used for the treatment of diabetes mellitus? Expert Rev Pharmacoecon Outcomes Res 2012; 8:33-42. [PMID: 20528354 DOI: 10.1586/14737167.8.1.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Reluctance to start and adequately titrate subcutaneous insulin are major reasons why many patients with diabetes mellitus are insufficiently metabolically controlled. Pulmonary insulin administration has the advantage over subcutaneous insulin in that it is noninvasive, seems better accepted by the diabetic population and exerts equal efficacy in terms of glycemic control. As such, inhaled insulin has the potential to increase the diabetic (Type 2) patient's willingness to commence and adhere to insulin therapy. Inhaled insulin's short duration of action makes it suitable for prandial administration provided that basal insulin requirements are met by residual b-cell function, or by supplemental long-acting subcutaneous insulin. In clinical trials, inhaled insulin is comparable to short-acting subcutaneous insulin with regard to efficacy and hypoglycemic risk. Adverse effects associated with inhaled insulin include dry cough, which tends to diminish over time, a slight drop in pulmonary function that does not progress and is reversible in most patients if treatment is discontinued, and increased insulin antibody formation, albeit without clinical sequelae. Long-term safety remains an issue for a product intended to be used chronically for many years. Exubera((R)) was thus far the only inhaled insulin product to receive approval in the USA and Europe for use in adults with Type 1 or Type 2 diabetes, but was recently withdrawn from the market. At present it is unclear how this decision will affect programs from other companies with inhaled insulin products under development.
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Affiliation(s)
- Bastiaan E de Galan
- The George Institute for International Health, Level 10, King George V Building, Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney NSW 2050, Australia; Department of Internal Medicine, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands. ;
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50
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Pitocco D, Fuso L, Conte EG, Zaccardi F, Condoluci C, Scavone G, Incalzi RA, Ghirlanda G. The diabetic lung--a new target organ? Rev Diabet Stud 2012; 9:23-35. [PMID: 22972442 DOI: 10.1900/rds.2012.9.23] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Several abnormalities of the respiratory function have been reported in patients with type 1 and type 2 diabetes. These abnormalities concern lung volume, pulmonary diffusing capacity, control of ventilation, bronchomotor tone, and neuroadrenergic bronchial innervation. Many hypotheses have emerged, and characteristic histological changes have been described in the "diabetic lung", which could explain this abnormal respiratory function. Given the specific abnormalities in diabetic patients, the lung could thus be considered as a target organ in diabetes. Although the practical implications of these functional changes are mild, the presence of an associated acute or chronic pulmonary and/or cardiac disease could determine severe respiratory derangements in diabetic patients. Another clinical consequence of the pulmonary involvement in diabetes is the accelerated decline in respiratory function. The rate of decline in respiratory function in diabetics has been found to be two-to-three times faster than in normal non-smoking subjects, as reported in longitudinal studies. This finding, together with the presence of anatomical and biological changes similar to those described in the aging lung, indicates that the "diabetic lung" could even be considered a model of accelerated aging. This review describes and analyses the current insight into the relationship of diabetes and lung disease, and suggests intensifying research into the lung as a possible target organ in diabetes.
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Affiliation(s)
- Dario Pitocco
- Diabetes Care Unit, Catholic University of Rome, Rome, Italy.
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