A prospective, multicentre, randomized, open-label comparison of a long-acting basal insulin analog glargine plus glulisine with premixed insulin in insulin naïve patients with Type 2 diabetes - A study from India

AIMS

We aimed to compare the effectiveness of Glargine plus Glulisine to premixed insulin analogue, as measured by HbA1c ≤ 7.0% in insulin naive Type 2 Diabetes (T2D) patients with elevated fasting and/or postprandial plasma glucose.

METHODS

Insulin-naive T2D patients (116 men, 84 women) on ≥ 2 oral hypoglycemic agents with inadequate glycemic control were randomized either to group 1 (insulin Glargine plus Glulisine, n = 101) or group 2 (Premixed Insulin analogue, n = 99).

RESULTS

In the intention to treat analysis, at week 24, percentage of patients with good glycaemic control (HbA1c ≤ 7.0%) was similar between the two groups (16.8% in Group 1 vs. 13.1% in Group 2, χ2 - 0.535, p = 0.47). Significant reductions in fasting and postprandial levels were observed in groups 1 and 2 at both post-baseline time points (Week 12 and 24). In group 1, reduction in HbA1c from baseline to week 12 was 0.6 ± 0.1 and 0.7 ± 0.2 at week 24, p < 0.0001 for all. In group 2, no significant change in HbA1c was observed. In group 1, 83.2% required an additional dose of glulisine and in group 2, 88.9% required an additional dose of premixed insulin. Hypoglycemic events were similar in both groups (0.12 events per person-year in group 1 and 0.13 events per person-year in group 2). Weight gain was non-significant in both groups.

CONCLUSIONS

Glargine plus Glulisine, though in higher dose was effective as premixed insulin in lowering HbA1c. Hypoglycemic events per person-year were similar in both groups.

The quaternary structure of insulin glargine and glulisine under formulation conditions

The quaternary structures of insulin glargine and glulisine under formulation conditions and upon dilution using placebo or water were investigated using synchrotron small-angle X-ray scattering. Our results revealed that insulin glulisine in Apidra® is predominantly hexameric in solution with significant fractions of dodecamers and monomers. Upon dilution with placebo, this equilibrium shifts towards monomers. Insulin glargine in Lantus® and Toujeo® is present in a stable hexamer/dimer equilibrium, which is hardly affected by dilution with water down to 1 mg/ml insulin concentration. The results provide exclusive insight into the quaternary structure and thus the association/dissociation properties of the two insulin analogues in marketed formulations.

A higher blood glucose level pre-breakfast in comparison to bedtime is a contraindication for intensification of prandial insulin therapy in patients with type 2 diabetes - The impact of a negative BeAM value

Aims

The BeAM value refers to the difference between a patient’s blood glucose level at bedtime (Be) and the following morning before breakfast (AM). The clinical impact of a negative BeAM value (AM blood glucose reading compared to that taken at bedtime) is unknown.

Methods

T2DM patients of the OPAL and POC trials were pooled and their BeAM values calculated.

Results

From a total of 358 patients, 31 were calculated as having a negative BeAM value at baseline, while 182 had a high value. Patients in the negative BeAM group were younger, had shorter diabetes duration, and lower HbA1c levels. Fasting blood glucose levels were higher in the negative BeAM group, and these increased to a greater extent during the trial periods. No significant differences in hypoglycaemia occurrence were observed. Multivariate adjusted analysis indicated no association between a negative BeAM value and achievement of HbA1c < 7%, or composite endpoints that additionally included no hypoglycaemia and no weight gain.

Conclusions

Supplementation of BOT with prandial insulin is not beneficial for patients who have a higher blood glucose reading before breakfast in comparison to before bedtime. Further investigation into the cause of the high morning reading in these patients is indicated.

Number-Based Approach to Insulin Taxonomy

This article describes a number-based system for the classification of insulin regimes. It utilizes a patient-centered variable (number of injections per day) and pharmacokinetic/dynamic characteristics to craft a taxonomic system that is able to incorporate all available insulin preparations and coformulations. This framework of systematics is robust enough to include various molecules that have been recently developed. It serves to enhance understanding of the subject, and facilitates the practical or clinical usage of theoretical knowledge. We propose that number-based insulin taxonomic models should be used in clinical guidelines and recommendations rather than restricting ourselves to pharmaceutical-based classifications. PubMed articles including both review articles and clinical trials published since the year 1990 were searched, to gather evidence and information on the various types of insulins available, and how they can be used, based on the number or frequency of injections prescribed per day.

Detemir plus aspart and glulisine induced lipoatrophy: 2015 literature review and report of a new case

BACKGROUND

In the first and only literature review, conducted in 2009, of human insulin analog- induced lipoatrophy, there were 12 published cases, including 1 with aspart, 1 with detemir, 1 with NovoMix 30 and none with detemir plus aspart. It is perceived that insulin analog induced-lipoatrophy is increasing. We conducted a 2015 literature review of published reports of lipoatrophy induced by aspart, detemir, detemir plus aspart, and NovoMix30. We also report a new case of detemir plus aspart and glulisine induced lipoatrophy.

METHODS

Our focused literature searches (limited to 1995-2014) in PubMed, Embase, and Web of Science, using a combination of insulin analog and lipoatrophy terminology, was conducted in early January 2015.

RESULTS

From the 520 unique citations there were 33 (from 13 papers and 9 abstracts) lipoatrophy cases induced by detemir (n = 5), aspart (n = 21), detemir plus aspart (n = 4) and NovoMix 30 (n = 3), representing 30 new cases since 2009. Many of these reported cases were females (76 %), had type 1 diabetes mellitus (T1DM) (94 %) and were in young persons (61 %). A 41-year-old T1DM woman developed lipoatrophy on her upper thighs, arms and abdomen 14 months after injecting detemir plus aspart at the same sites. Later on, after a year on continuous subcutaneous insulin infusion (CSII) using aspart and then glulisine, she developed lipoatrophy at the infusion sites. When CSII insulin was switched to lispro she did not develop lipoatrophy after 10 months. Meanwhile, the original lipoatrophy sites significantly improved.

CONCLUSIONS

Our literature review uncovered 30 new published cases of aspart, detemir, aspart plus detemir and NovoMix 30-induced lipoatrophy since 2009. The largest increase in cases was in aspart- induced lipoatrophy. Recent surveys showed most rapid acting insulin analog-induced lipoatrophy were associated with CSII. In our review of the reported cases, 85.7 % cases of aspart-induced lipoatrophy were associated with CSII. As in previous reports, we showed lipoatrophy was more common in females, T1DM and young persons. Our patient may be the 5^th published case of detemir plus aspart-induced lipoatrophy and possibly the first case report of glulisine induced lipoatrophy. She believed both detemir plus aspart and glulisine induced the lipoatrophy.

Efficacy and safety of switching to insulin glulisine from other rapid-acting insulin analogs in children with type 1 diabetes

We investigated the efficacy and safety of switching to insulin glulisine (GLU) from other rapid-acting insulin analogs (Ra) in children with type 1 diabetes treated with multiple daily injections of insulin or continuous subcutaneous insulin infusion. A total of 26 children with type 1 diabetes were included. Ra in all of these patients was changed to GLU, and they were observed for a 6-month period after having previously finished treatment with other Ra. The mean glycated hemoglobin value decreased from 7.6 ± 1.0 to 7.4 ± 0.9% (P = 0.0034), and mean plasma glucose values after breakfast and supper also improved from 183 ± 50 to 153 ± 32 mg/dL (P = 0.0035), and from 203 ± 29 to 164 ± 23 mg/dL (P < 0.0001), respectively. Furthermore, the mean frequency of hypoglycemia was reduced from 7 ± 6 to 4 ± 4/month (P = 0.0004), while insulin doses and obesity degree were stable with statistically non-significant differences. In conclusion, switching to GLU might be a good treatment option for improving glycemic control in children with type 1 diabetes.

Differences in inpatient glycemic control and response to subcutaneous insulin therapy between medicine and surgery patients with type 2 diabetes

OBJECTIVE

To determine differences in inpatient glycemic control and response to two different glargine-based insulin regimens in general medicine and surgery patients with type 2 diabetes (T2D).

METHODS

This is a post-hoc analysis of a prospective, multicenter, randomized trial of 298 non-ICU medicine and surgery patients with T2D treated with Basal Bolus regimen with glargine once daily and glulisine before meals and with Basal Plus regimen with glargine once daily and supplemental doses of glulisine before meals for blood glucose (BG)>140mg/dl. Major study outcomes included differences in mean daily BG, frequency of treatment failures (defined as >2 consecutive BG>240mg/dl or a mean daily BG>240mg/dl), and hypoglycemia between the medicine and surgery cohorts.

RESULTS

Patients treated with Basal Bolus or with Basal Plus experienced similar improvement in mean daily BG after 1st day of therapy (p=0.16), number of treatment failures (p=0.11) and hypoglycemic events (p=0.50). Compared to surgery patients (n=130), medicine patients (n=168) had higher admission BG (p=0.01) and HbA1c levels (p<0.01); however, they had similar response to either treatment regimen without differences in mean daily BG after 1st day of therapy (p=0.18), number of treatment failures (p=0.58), daily insulin requirements (p=0.36), or in the frequency of hypoglycemia (p=0.79).

CONCLUSION

The Basal Plus regimen with glargine once daily and correction doses with glulisine before meals resulted in similar glycemic control to basal bolus regimen. We observed no differences in response to either basal insulin regimen between medicine and surgery patients with type 2 diabetes.