Inhaled insulin (Exubera): Combining efficacy and convenience

Overcoming barriers to patient adherence: the case for developing innovative drug delivery systems

Poor medication adherence is a pervasive issue with considerable health and socioeconomic consequences. Although the underlying reasons are generally understood, traditional intervention strategies rooted in patient-centric education and empowerment have proved to be prohibitively complex and/or ineffective. Formulating a pharmaceutical in a drug delivery system (DDS) is a promising alternative that can directly mitigate many common impediments to adherence, including frequent dosing, adverse effects and a delayed onset of action. Existing DDSs have already positively influenced patient acceptability and improved rates of adherence across various disease and intervention types. The next generation of systems have the potential to instate an even more radical paradigm shift by, for example, permitting oral delivery of biomacromolecules, allowing for autonomous dose regulation and enabling several doses to be mimicked with a single administration. Their success, however, is contingent on their ability to address the problems that have made DDSs unsuccessful in the past.

Solid Dosage Forms of Biopharmaceuticals in Drug Delivery Systems Using Sustainable Strategies

Drug delivery systems (DDS) often comprise biopharmaceuticals in aqueous form, making them susceptible to physical and chemical degradation, and therefore requiring low temperature storage in cold supply and distribution chains. Freeze-drying, spray-drying, and spray-freeze-drying are some of the techniques used to convert biopharmaceuticals-loaded DDS from aqueous to solid dosage forms. However, the risk exists that shear and heat stress during processing may provoke DDS damage and efficacy loss. Supercritical fluids (SCF), specifically, supercritical carbon dioxide (scCO₂), is a sustainable alternative to common techniques. Due to its moderately critical and tunable properties and thermodynamic behavior, scCO₂ has aroused scientific and industrial interest. Therefore, this article reviews scCO₂-based techniques used over the year in the production of solid biopharmaceutical dosage forms. Looking particularly at the use of scCO₂ in each of its potential roles—as a solvent, co-solvent, anti-solvent, or co-solute. It ends with a comparison between the compound’s stability using supercritical CO₂-assisted atomization/spray-drying and conventional drying.

Novel formulations and drug delivery systems to administer biological solids

Recent advances in formulation sciences have expanded the previously limited design space for biological modalities, including peptide, protein, and vaccine products. At the same time, the discovery and application of new modalities, such as cellular therapies and gene therapies, have presented formidable challenges to formulation scientists. We explore these challenges and highlight the opportunities to overcome them through the development of novel formulations and drug delivery systems as biological solids. We review the current progress in both industry and academic laboratories, and we provide expert perspectives in those settings. Formulation scientists have made a tremendous effort to accommodate the needs of these novel delivery routes. These include stability-preserving formulations and dehydration processes as well as dosing regimes and dosage forms that improve patient compliance.

The effect of the medicine administration route on health-related quality of life: Results from a time trade-off survey in patients with bipolar disorder or schizophrenia in 2 Nordic countries

BACKGROUND

Agitation episodes are common among patients with schizophrenia or bipolar disorder. Oral and intramuscular administration methods are commonly used in pharmacological treatment of acute agitation. Recently, an innovative inhalation product with loxapine(Adasuve®)has become available for treatment of acute agitation episodes associated with bipolar disorder or schizophrenia. The objective for the present study was to investigate the impact of the pharmacological treatment's administration methods on the health-related quality of life (HRQoL) in patients with bipolar disorder or schizophrenia in Denmark and Sweden using a time trade-off (TTO) approach.

METHODS

The TTO methodology was used to examine the HRQoL impact of administration method of pharmacological treatment of acute agitation. Data were collected via an internet-based survey, using an existing panel of respondents with schizophrenia or bipolar disorder.

RESULTS

Respondents considered living with schizophrenia/ bipolar disorder, having one yearly agitation episode treated with inhaler better than living with the same conditions and receiving treatment with tablet or injection. The utility value was 0.762 for inhalable treatment, 0.707 for injection and 0.734 for tablet treatment.

CONCLUSIONS

Patients' preference for treatment delivery options showed that inhalation was associated with a significant utility gain when compared to injection or tablets. Inhalable loxapine may be a new tool for control of agitation episodes for strengthening the patient provider alliance when taking patient's preference for delivery method into consideration.

A comparative study of the beneficial effects of ipratropium and beclomethasone against insulin-induced tracheal tissue contraction in a guinea pig model

OBJECTIVE

To evaluate the acute effects of insulin on airway reactivity and the protective effects of beclomethasone and ipratropium against insulin-induced airway hyperresponsiveness on isolated tracheal smooth muscle in a guinea pig model.

MATERIALS AND METHODS

The trachea of each guinea pig was excised; one end of the tracheal strip was attached to the hook of the oxygen tube of a tissue bath and the other end was connected to a research-grade isometric force displacement transducer. The effects of varying concentrations of insulin (10(-7) to 10(-3)M) and insulin pretreated with a fixed concentration of beclomethasone (10(-6)M) and ipratropium (10(-6)M) on the isolated tracheal tissue were studied by constructing cumulative concentration-response curves. Changes in tracheal smooth muscle contractions were recorded on a 4-channel oscillograph.

RESULTS

The means ± standard error of the mean of the maximum amplitude of contraction with increasing concentrations of insulin and of insulin pretreated with fixed concentrations of beclomethasone and ipratropium were 35 ± 1.13, 22 ± 1.15 and 27.8 ± 1.27 mm, respectively.

CONCLUSION

The data showed that beclomethasone inhibited the contractile response of insulin to a greater extent than ipratropium. Thus we suggest that inhalational insulin pretreated with beclomethasone may be more efficacious than with ipratropium for the amelioration of potential respiratory adverse effects such as bronchoconstriction.

The benefits of growth hormone therapy in patients with Turner syndrome, Noonan syndrome and children born small for gestational age

This review will summarize the effects of growth hormone (GH) on height, body composition, bone and psychosocial parameters in children with Turner syndrome or Noonan syndrome and those born small for gestational age. The safety of GH treatment in children with these diagnoses is also reported. Despite the reported efficacy and safety of GH in these indications, however, not all children achieve their target height potential, due in some part to poor adherence to GH therapy regimens; indeed up to 50% of children are less than fully compliant with treatment. With this in mind the present and future administration of GH therapy is discussed with respect to advances being made in the presentation of GH for injection and advances in GH injection devices. It is hoped that such progress, aimed at making the administration of GH easier and less painful for the patient will improve treatment adherence and outcome benefits.

Adherence to disease-modifying drugs in patients with multiple sclerosis: a consensus statement from the Middle East MS Advisory Group

Adherence to therapy is a key issue in chronic illnesses. In addition, several features of multiple sclerosis (MS) and its treatment may increase the likelihood of patient nonadherence and discontinuation of treatment. Nonadherence will obviously compromise the efficacy of disease-modifying drugs in patients with MS. This subject was discussed by a group of local MS specialists from the Middle East. The group debated several key questions about the features and causes of patient nonadherence and its management. Further, they made recommendations for optimizing treatment adherence in this area.

Ease of use and acceptability of a new pen device for the administration of growth hormone therapy in pediatric patients: an open-label, uncontrolled usability test

BACKGROUND

Recombinant human growth hormone (GH) is used for the treatment of several conditions associated with growth retardation and metabolic dysfunction. These patients are typically diagnosed and treated from childhood, and treatment adherence in children might be problematic. To potentially improve treatment adherence in children who self-inject GH, it is important that devices for the administration of GH are simple to learn to use, simple to use, and well accepted by patients and their parents or guardians.

OBJECTIVE

This study compared the usability and acceptability of the Norditropin FlexPro pen and NovoFine needles (Novo Nordisk A/S, Bagsvaerd, Denmark) for the administration of GH in pediatric patients with GH deficiency (GHD).

METHODS

Patients aged 10 to <18 years with GHD and who were receiving daily treatment with selfinjectable GH were included in this open-label, uncontrolled usability test. Patients used the Norditropin FlexPro pen and NovoFine G32 needles to inject test medium into an injection pad; this test was repeated. For the assessment of patients' acceptance of the device, patients completed a 21-item questionnaire regarding pen performance before and during injection.

RESULTS

Seventy patients participated in the study (mean age, 14 years; 67% male; 23% left-handed). No significant differences in demographic characteristics (age, sex, duration of treatment with GH, current device used, and left- or right-handedness) were found between boys and girls, younger and older children, or children who had been receiving short-term (months) or long-term (years) GH treatment. Sixty-eight patients (97%) rated attachment of the needle, priming the device, dialing up the dose, and reading the scale on the device as very easy or quite easy. A total of 99% of patients rated injection of their usual dose and of a 4-mg dose as very easy or quite easy, and pushing the dose button as very easy or quite easy as well as very comfortable or quite comfortable. All of the patients rated hearing the click while performing the injection as very easy or easy. Overall, 64% of patients indicated a preference for the Norditropin FlexPro pen over the device they were currently using.

CONCLUSIONS

In this preliminary usability test in pediatric patients, the Norditropin FlexPro pen was perceived as reliable and easy to use and was well accepted. There was also a high level of comfort that GH had been injected properly and that the correct dose had been delivered among the children and adolescents with GHD who participated in the study.

Optimizing the benefit of multiple sclerosis therapy: the importance of treatment adherence

Poor treatment adherence is problematic in many therapy areas, including multiple sclerosis (MS). Several immunomodulatory drugs are available for the treatment of MS, all of which require frequent parenteral administration. Current first-line therapies are two formulations of interferon (IFN) beta-1a, one of IFN beta-1b, and one of glatiramer acetate. Discontinuation of treatment is common, particularly in the first few months after initiation. Although the true effect of poor adherence to MS therapy is not known, it is likely to lead to a fall in treatment efficacy. Many factors influence a patient's adherence to treatment, including the patient's MS subtype and disability level, cognitive impairment resulting from MS, perceived lack of efficacy of the prescribed medication, and adverse events associated with MS therapy. This article summarizes the barriers to adherence to MS therapies, and discusses patient management strategies that can be employed to encourage adherence. Future advances in the field of MS treatment will be explored, including the development of orally administered drugs, which may enhance adherence.

Observations of nonadherence to recombinant human growth hormone therapy in clinical practice

BACKGROUND

The effectiveness of all prescribed treatments is contingent on patient adherence. The reported levels of adherence to recombinant human growth hormone (r-hGH) therapy are highly variable, but it has been suggested that nonadherence might be as high as 36% to 49%.

OBJECTIVES

This commentary discusses the factors that affect long-term adherence to injection treatment, of which r-hGH therapy is a particular challenge. It also explores potential strategies to improve adherence to injection treatments in clinical practice.

METHODS

The opinion of the authors was validated and supported by published literature. A PubMed literature search was conducted in November 2006, identifying English-language articles containing key terms growth hormone, adherence, and compliance.

RESULTS

This study found that factors associated with poor adherence to injection treatments include patients' lack of understanding of their disease, patient age, chronicity of the disease, complex treatment regimens, and insufficient information on the implications of nonadherence. Strengthening the patient-physician relationship by providing the patient with a clear understanding of his/her disease and the benefits of adherence, making improvements in injection devices, and eliminating subjective illness concepts, might increase adherence to SC injection treatments, thereby reducing increasing health care costs associated with nonadherence.

CONCLUSIONS

Poor adherence to r-hGH therapy has a dual effect, in that it leads to reduced efficacy out-comes and increased health care costs. Implementing strategies to improve adherence with injection treatment might be of particular clinical benefit to patients undergoing r-hGH therapy.

Pure insulin nanoparticle agglomerates for pulmonary delivery

Diabetes is a set of diseases characterized by defects in insulin utilization, either through autoimmune destruction of insulin-producing cells (Type I) or insulin resistance (Type II). Treatment options can include regular injections of insulin, which can be painful and inconvenient, often leading to low patient compliance. To overcome this problem, novel formulations of insulin are being investigated, such as inhaled aerosols. Sufficient deposition of powder in the peripheral lung to maximize systemic absorption requires precise control over particle size and density, with particles between 1 and 5 microm in aerodynamic diameter being within the respirable range. Insulin nanoparticles were produced by titrating insulin dissolved at low pH up to the pI of the native protein, and were then further processed into microparticles using solvent displacement. Particle size, crystallinity, dissolution properties, structural stability, and bulk powder density were characterized. We have demonstrated that pure drug insulin microparticles can be produced from nanosuspensions with minimal processing steps without excipients, and with suitable properties for deposition in the peripheral lung.

Psychological insulin resistance: patient beliefs and implications for diabetes management

PURPOSE

To define and understand patient psychological insulin resistance (PIR) and its impact on diabetes management.

METHODS

Systematic literature review of peer-refereed journals using the MEDLINE database, including all articles in English from 1985 to 2007. The population included patients with type 1 and type 2 diabetes, insulin naïve, and those currently using insulin. A total of 116 articles were reviewed.

RESULTS

PIR is impacted by patients' beliefs and knowledge about diabetes and insulin, negative self-perceptions and attitudinal barriers, the fear of side effects and complications from insulin use, as well as lifestyle adaptations, restrictions required by insulin use, and social stigma. These etiological influences, both independently and in combination, constitute a patient's PIR and may result in the reluctance of patients to both initiate and intensify treatment, leading to delayed treatment initiation and compromised glucose control.

CONCLUSIONS

PIR is complex and multifaceted. It plays an important, although often ignored, role in diabetes management. Assisting health care professionals in better understanding PIR from the patient's perspective should result in improved treatment outcomes. By tailoring treatments to patients' PIR, clinicians may be better able to help their patients begin insulin treatment sooner and improve compliance, thus facilitating target glycemic control.