Immunogenicity of the Novel Glucagon Analogue Dasiglucagon: Results of a Dedicated Immunogenicity Trial in Type 1 Diabetes

Dasiglucagon is a next-generation glucagon analogue that is stable in aqueous formulation. This dedicated immunogenicity trial to support use as rescue treatment for severe hypoglycemia was conducted to evaluate the immunogenicity of repeated subcutaneous doses of dasiglucagon in subjects with type 1 diabetes. A total of 112 subjects were randomized 1:1 to receive three subcutaneous weekly doses of either 0.6 mg dasiglucagon or 1.0 mg recombinant glucagon (GlucaGen^®) according to a double-blind parallel-group trial design. Subjects were followed for 15 weeks, with a multitiered testing approach planned for assessment of antidrug antibody (ADA) formation. For the primary immunogenicity endpoint, the overall ADA incidence was zero, as no subject demonstrated any treatment-induced or treatment-boosted ADA response at any time point in this trial involving three consecutive weekly doses of trial drug. No injection site reactions were reported for subjects receiving dasiglucagon. There were no unexpected safety findings for the trial.

Evaluating the Effectiveness of Switching to Insulin Degludec from Other Basal Insulins in a Real-World Canadian Population with Type 1 or Type 2 Diabetes: The CAN-TREAT Study

INTRODUCTION

The aim of the study was to examine glycaemic control and safety of insulin degludec (degludec) in patients with either type 1 diabetes (T1D) or type 2 diabetes (T2D) under routine care settings in Canada.

METHODS

Data were extracted from medical records of adults with T1D or T2D who switched to degludec (± prandial insulin) from another basal insulin (± prandial insulin) ≥ 6 months prior to data collection. The primary endpoint was change in glycated haemoglobin (HbA_1c) at 6 ± 3 months after degludec initiation. Secondary endpoints included change in hypoglycaemia rate in the 6 months before versus the 6 months after switching, and change in mean total daily insulin dose.

RESULTS

Of 667 patients assessed for eligibility, 626 were included. After 6 ± 3 months, HbA_1c decreased from baseline in patients with T1D (- 0.3% [- 0.42, - 0.14]_95% CI; p < 0.001) and in patients with T2D (- 0.4% [- 0.55, - 0.30]_95% CI; p < 0.001). In patients with T1D, there were significant reductions in the rates of overall (rate ratio [RR] 0.70), non-severe (RR 0.69), non-severe nocturnal (RR 0.36), and severe nocturnal hypoglycaemia (RR 0.12; all p ≤ 0.004). In patients with T2D there was a significant reduction in non-severe nocturnal hypoglycaemia (RR 0.22; p < 0.001). Mean daily basal insulin dose decreased in patients with T1D (- 1.6 units [- 2.8, - 0.4]_95% CI; p = 0.008); there was no significant change in patients with T2D (- 0.6 units [- 2.7, 1.4]_95% CI; p = 0.543).

CONCLUSION

In routine clinical practice, improved glycaemic control was observed in patients with T1D or T2D switching to insulin degludec from other basal insulins, with either improvement or no change in hypoglycaemia rates.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03674866.

Ethnic differences in antepartum glucose values that predict postpartum dysglycemia and neonatal macrosomia

BACKGROUND AND OBJECTIVE

Gestational diabetes (GDM) occurs more often in women from certain ethnic groups and is also associated with fetal macrosomia. In this study, we investigated the ability of a gestational diabetes screening test (GDS), the 2 h 75 g-Oral Glucose Tolerance Test (OGTT), and glycated hemoglobin (HbA1c) in predicting postpartum dysglycemia and fetal macrosomia in women of Caucasian, Filipino, Chinese and South-Asian descent.

METHODS

848 women diagnosed with carbohydrate intolerance in pregnancy who completed a 2 h 75 g- OGTT within 6 months postpartum, were included in the study. Receiver Operating Characteristic curve analysis was used to test the ability of antepartum GDS, HbA1c and OGTT in predicting postpartum hyperglycemia, type 2 diabetes (T2D) and neonatal macrosomia (birth weight >4000 g).

RESULTS

20.2% had postpartum hyperglycemia while 3.8% had T2D. Those with postpartum dysglycemia were more likely to be non-Caucasian (South-Asian > Filipino > Chinese), have higher antepartum glucose values, require insulin during pregnancy and have cesarean births. Of HbA1c and the antepartum glucose values, a fasting glucose of ≥5.25 mmol/L was predictive of fetal macrosomia in Caucasians. 1 h glucose of ≥11.05 mmol/L was predictive of postpartum hyperglycemia, while 2 h glucose of ≥9.75 mmol/L was predictive of T2D; ethnicity influenced the predictive ability of these tests.

CONCLUSIONS

Ethnicity influences the ability of antepartum glucose and HbA1c to predict the risk of macrosomia and postpartum dysglycemia. This information will help detect those most at risk of T2D.

Childhood predictors of cardiovascular disease in adulthood. A systematic review and meta-analysis

Childhood obesity predicts the risk of adult adiposity, which is associated with the earlier onset of cardiovascular disease [adult atherosclerotic cardiovascular disease, ACVD: hypertension, increased carotid intima media thickness (CIMT) stroke, ischemic heart disease (IHD)] and dysglycaemia. Because it is not known whether childhood obesity contributes to these diseases, we conducted a systematic review of studies that examine the ability of measures of obesity in childhood to predict dysglycaemia and ACVD. Data sources were Web of Science, MEDLINE, PubMed, CINAHL, Cochrane, SCOPUS, ProQuest and reference lists. Studies measuring body mass index (BMI), skin fold thickness and waist circumference were selected; of 1,954 studies, 18 met study criteria. Childhood BMI predicted CIMT: odds ratio (OR), 3.39 (95% confidence interval (CI), 2.02 to 5.67, P < 0.001) and risk of impaired glucose tolerance in adulthood, but its ability to predict ACVD events (stroke, IHD; OR, 1.04; 95% CI, 1.02 to 1.07; P < 0.001) and hypertension (OR, 1.17, 95% CI 1.06 to 1.27, P = 0.003) was weak-moderate. Body mass index was not predictive of systolic BP (r -0.57, P = 0.08) and weakly predicted diastolic BP (r 0.21, P = 0.002). Skin fold thickness in childhood weakly predicted CIMT in female adults only (r_s 0.09, P < 0.05). Childhood BMI predicts the risk of dysglycaemia and abnormal CIMT in adulthood, but its ability to predict hypertension and ACVD events was weak and moderate, respectively. Skin fold thickness was a weak predictor of CIMT in female adults.

Women with a history of gestational diabetes on long-term follow up have normal vascular function despite more dysglycemia, dyslipidemia and adiposity

AIMS

Previous gestational diabetes (GDM) is a risk factor for type 2 diabetes and increased metabolic risk, but the link with vascular dysfunction is not clear. This study examined vascular function in women 4-10 years after a diagnosis of GDM who had a normal oral glucose tolerance test (OGTT) in the first postpartum year.

METHODS

We studied 90 women with a history of GDM and 59 age-matched controls, examining differences in insulin resistance as measured by the Homeostatic Model Assessment (HOMA-IR) and glucose responses during an OGTT, adiposity, lipid profile and C-reactive protein (CRP). Using pulse wave analysis, we also measured cardiac function, vascular compliance, and systemic vascular resistance.

RESULTS

Women with a history of GDM had higher measures of adiposity (body mass index 28.9 ± 6.5 vs. 26.6 ± 6.9 kg/m(2), P=0.04, waist-hip ratio 0.85 ± 0.06 vs. 0.79 ± 0.07, P<0.001), dyslipidemia (LDL cholesterol 2.78 ± 0.64 vs. 2.41 ± 0.56 mmol/L, P<0.001, total cholesterol: HDL cholesterol 3.93 ± 1.2 vs. 3.21 ± 0.82 mmol/L, P<0.001) and abnormal glucose metabolism (50% vs. 12%, P<0.001). However, there was no difference in CRP, HOMA-IR, or measures of cardiovascular function including pulse rate, pulse pressure, mean arterial pressure, cardiac output, systemic vascular resistance, small and large artery elasticity index. After controlling for adiposity, blood pressure, lipids and CRP, glycemic status did not contribute to vascular function.

CONCLUSION

Despite a higher incidence of adiposity, dyslipidemia, and impaired glycemia, women with a history of GDM who had a normal postpartum OGTT did not have impaired vascular function 4-10 years postpartum, when compared to healthy controls.

Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes

BACKGROUND

There is evidence that reducing blood glucose concentrations, inducing weight loss, and improving the lipid profile reduces cardiovascular risk in people with type 2 diabetes.

OBJECTIVE

We assessed the effect of various diets on glycemic control, lipids, and weight loss.

DESIGN

We conducted searches of PubMed, Embase, and Google Scholar to August 2011. We included randomized controlled trials (RCTs) with interventions that lasted ≥6 mo that compared low-carbohydrate, vegetarian, vegan, low-glycemic index (GI), high-fiber, Mediterranean, and high-protein diets with control diets including low-fat, high-GI, American Diabetes Association, European Association for the Study of Diabetes, and low-protein diets.

RESULTS

A total of 20 RCTs were included (n = 3073 included in final analyses across 3460 randomly assigned individuals). The low-carbohydrate, low-GI, Mediterranean, and high-protein diets all led to a greater improvement in glycemic control [glycated hemoglobin reductions of -0.12% (P = 0.04), -0.14% (P = 0.008), -0.47% (P < 0.00001), and -0.28% (P < 0.00001), respectively] compared with their respective control diets, with the largest effect size seen in the Mediterranean diet. Low-carbohydrate and Mediterranean diets led to greater weight loss [-0.69 kg (P = 0.21) and -1.84 kg (P < 0.00001), respectively], with an increase in HDL seen in all diets except the high-protein diet.

CONCLUSION

Low-carbohydrate, low-GI, Mediterranean, and high-protein diets are effective in improving various markers of cardiovascular risk in people with diabetes and should be considered in the overall strategy of diabetes management.

Depth and duration of hypoglycaemia achieved during the insulin tolerance test

CONTEXT

The insulin tolerance test (ITT) is the gold standard for assessment of the pituitary adrenal axis but its use is limited because of concerns relating to the risk of hypoglycaemia.

OBJECTIVE

This study examined the depth and duration of hypoglycaemia achieved during the test in a large cohort of patients.

DESIGN

Two hundred and twenty ITTs were performed from 2005 to 2010.

SETTING

A 1200-bed University Teaching Hospital.

PATIENTS

Two hundred and twenty ITTs were carried out in patients with suspected or known pituitary disorders.

INTERVENTIONS

Intravenous insulin was administered to achieve nadir plasma glucose (NPG) of 2.2 mmol/l (39.6 mg/dl). Blood chemistry to show the cortisol and GH response to hypoglycaemic stress was measured.

MAIN OUTCOME MEASURES

Predictors of depth and duration of hypoglycaemia, adverse events and within-subject variability of nadir glucose, peak cortisol and peak GH were studied.

RESULTS

Thirty percent of the cohort achieved a nadir glucose of <2.0 mmol/l (36 mg/dl) that lasted for 60 min or more. The NPG correlated positively with fasting plasma glucose (FPG; r=0:56; P<0.0005), insulin dose (r=0.27; P<0.0005) and weight (r=0.21; P<0.004). The within subject variability of nadir glucose was 15.2%, peak cortisol was 11.7% and peak GH was 6.4%. The factors determining nadir blood glucose were FPG (b=0.56, P<0.0005, 20% contribution) and weight (b=0.14, P<0.05, 2% contribution). The five patients with adverse events had NPG and insulin dose comparable with the rest of the population.

CONCLUSIONS

The hypoglycaemia achieved during the ITT is much lower than the target required. However, adverse events are few and do not relate to the depth of hypoglycaemia.

The contribution of parental BMI to the metabolic health of their offspring: a longitudinal cohort study (EarlyBird 55)

OBJECTIVE

The objective of this study was to establish the extent to which parental factors influence the metabolic health of their offspring.

DESIGN

The study was designed as a prospective longitudinal cohort study

SUBJECTS

The study's subjects were 226 healthy trios from a 1995 to 1996 birth cohort randomly recruited in the city of Plymouth, UK MEASUREMENTS: Body mass index (BMI) and metabolic z-score (derived from natural log HOMA-IR, triglycerides, total/high-density lipoprotein cholesterol ratio), measured at nine annual time points, from 5 to 13 years.

RESULTS

As expected, the metabolic z score was closely related to BMI in both genders and at all ages (r = 0.40-0.57, P < 0.001). Accordingly, there were large and significant differences in the metabolic z-score between children categorized as normal weight or overweight/obese. At 13 years, for example, the metabolic z score of the overweight/obese girls was 14-fold greater than that of the normal-weight girls (P < 0.001). However, parental BMI and metabolic status had little effect on these differences. Indeed, mixed effects modelling showed that, as the child's BMI increased, so the influence of parental factors became less relevant. Time-lag analyses confirmed that weight gain preceded metabolic disturbances in the children.

CONCLUSION

The impact of obesity on the metabolic health of contemporary children is a function of their own weight gain, rather than that of their parents, and is therefore potentially preventable.

Note: high capacity digital laser beam steering system

The combination of liquid crystal cells with polarizing cube beam splitters has been used to direct a beam of light to multiple directions. The polarization at each beam splitter is controlled by applying a signal to a corresponding liquid crystal cell. Ten cascaded stages have deflected a HeNe laser beam to 1024 digitally selectable angles.

The relationship of height and body fat to gender-assortative weight gain in children. A longitudinal cohort study (EarlyBird 44)

OBJECTIVE

Height, body fat and body mass index (BMI) are correlated in children, so we hypothesized that the gender-assortative associations in BMI recently reported in contemporary children might extend to their height and body fat.

DESIGN

Prospective longitudinal cohort study.

SUBJECTS

A total of 226 healthy trios (mother, father and child) from a 1995?1996 birth cohort randomly recruited in the city of Plymouth, UK.

MEASUREMENTS

Height, weight, and BMI (kg/m(2)) were measured in each of the parents and, in addition, sum of five skin-folds (SF) in their children at 5, 6, 7 and 8 y.

RESULTS

BMI and SF were strongly height-dependent in the children by 8 y (r = 0.41-0.56). SF was gender-assortative insofar as the mean SF was significantly greater in the daughters (but not the sons) of obese mothers (obese vs. normal weight: +2.5 cm p < 0.001) and in the sons (but not the daughters) of obese fathers (obese vs. normal: +1.3 cm p < 0.001). As expected, offspring height correlated with that of their parents, but overweight/obese children were systematically taller than normal weight children (boys: +1.02 SDS, girls: +1.14 SDS, p < 0.01), and this difference was independent of parental height or BMI.

CONCLUSIONS

Height is transmitted by both parents, and the body fat of overweight/obese children largely by the same-sex parent, but the extra height associated with more fat in the child is unrelated to the height or weight of either parent. The secular trend in height among contemporary children may simply reflect their rising body fat. Excess fat is unhealthy, so the trend in height may not be healthy either.