diabetes update new insulins and insulin delivery systems bruce w. bode, md, face atlanta diabetes...
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Diabetes UpdateNew Insulins
and Insulin Delivery Systems
Bruce W. Bode, MD, FACE
Atlanta Diabetes Associates
Atlanta, Georgia
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American Diabetes Association. Facts and Figures. Available at: http://www.diabetes.org/ada/facts.asp. Accessed January 18, 2000.
Diagnosed Diagnosed Type 1 Diabetes Type 1 Diabetes0.5 – 1.0 Million0.5 – 1.0 Million
Diagnosed Diagnosed Type 2 Type 2
DiabetesDiabetes10.3 Million10.3 Million
Undiagnosed Undiagnosed DiabetesDiabetes
5.4 Million5.4 Million
Prevalence of Diabetes in the US
33
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ADA: Clinical Practice Recommendations. 2001.
Goals of Intensive Diabetes Management
Near-normal glycemia– HbA1c less than 6.5 to 7.0%
Avoid short-term crisis– Hypoglycemia– Hyperglycemia– DKA
Minimize long-term complications Improve QOL
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ACE / AACE Targets for Glycemic Control
HbA1c < 6.5 %
Fasting/preprandial glucose < 110 mg/dL
Postprandial glucose < 140 mg/dL
ACE / AACE Consensus Conference, Washington DC August 2001
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Type 2 Diabetes: Two Principal Defects
Reaven GM. Physiol Rev. 1995;75:473-486Reaven GM. Diabetes/Metabol Rev. 1993;9(Suppl 1):5S-12S;Polonsky KS. Exp Clin Endocrinol Diabetes. 1999;107 Suppl 4:S124-S127.
Insulin resistance-cell dysfunction/
failure
± Environment ± Environment
IGT IGT
GenesGenes
Type 2 diabetesGlucose
Toxicity
Glucose
Toxicity
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Role of Free Fatty Acids in HyperglycemiaRole of Free Fatty Acids in Hyperglycemia
Boden G. Proc Assoc Am Physicians. 1999;111:241-248.
MUSCLEMUSCLELIVERLIVER
FFA oxidation FFA oxidation
Gluconeogenesis Glucose utilization
Hyperglycemia
ADIPOSE TISSUEADIPOSE TISSUE
Lipolysis
FFA mobilization
Liver insulin resistance
Adipose tissue insulin resistance
Muscleinsulin resistance
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HbA1c in the UKPDS
06
7
8
9
0 3 6 9 12 15
HbA
1c (
%)
Years from randomisation
Conventional
Intensive
6.2% upper limit of normal range
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UKPDS: -Cell Function for the Patients Remaining on Diet for 6 Years
0
20
40
60
80
100
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6
Years After Diagnosis
-C
ell F
un
ctio
n (
%
)
Adapted from UKPDS Group. Diabetes. 1995; 44:1249-1258.
N=376
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Multiple factors may drive progressive decline of -cell function
-cell(genetic background)
Hyperglycaemia(glucose toxicity)
Proteinglycation
Amyloiddeposition
Insulin resistance
“lipotoxicity”elevated FFA,TG
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UKPDS: Benefits of Glycemic UKPDS: Benefits of Glycemic Control in Type 2 DiabetesControl in Type 2 Diabetes
Risk reduction Risk reduction over 10 yearsover 10 years
Any diabetes-related endpointAny diabetes-related endpoint 12% 12% P = 0.029P = 0.029Microvascular endpointsMicrovascular endpoints 25% 25% P = 0.0099P = 0.0099Myocardial infarctionMyocardial infarction 16% 16% P = 0.052P = 0.052Cataract extractionCataract extraction 24% 24% P = 0.046P = 0.046Retinopathy at 12 yearsRetinopathy at 12 years 21% 21% P = 0.015P = 0.015Microalbuminuria at 12 yearsMicroalbuminuria at 12 years 33% 33% P < 0.001P < 0.001
UKPDS 33. Lancet. 1998;352:837-853.
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Metformin Prevents Heart Attacks and Reduces Deaths in Type 2 Diabetes
0
5
10
15
20
0
2
4
6
8
10
Inci
den
ce(p
er 1
,00
0 p
atie
nt y
ears
)
39%Reduction
P=0.01
50%Reduction
P=0.02
Heart Attacks Coronary Deaths
Conventional MetforminTherapy
Conventioal Metformin Therapy
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Diabetes Prevention Program
3234 obese patients with IGT
BMI average 34; A1C 5.9%, 55% Caucasion
4 year study to compare diet and exercise to metformin, troglitazone or control
Troglitazone stopped at 8 months
Study ended after 3 years
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Diabetes Prevention Program
58% prevention with diet (low fat) and exercise (2.5 hours per week)
31% prevention with metformin (more effective if < 60 years old and obese)
Troglitazone patients equal to metformin group at three years and equal to the diet and exercise group at 8 months.
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Management of Type 2 DMStep Therapy
Diet
Exercise
Sulfonylurea or Metformin
Add Alternate Agent
Add hs NPH vs TZD
Switch to Mixed Insulin bid
Switch to Multiple Dose Insulin
Utilitarian, Common Sense, Recommended
Prone to Failure fromMisscheduling and Mismanagement
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Management of Type 2 DM Stumble Therapy
WAG Diet
Golf Cart Exercise
Sample of the Week Medication
– Interrupted
– Not Combined
Poor Understanding of Goals
Poor Monitoring
HbA1c >8% (If Seen)
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Consider A New Treatment Paradigm
Treatment designed to correct the dual impairments
Vigorous effort to meet glycemic targets
Simultaneous rather than sequential therapy
Combination therapy from the outset
Early step-wise titrations to meet glycemic targets
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Goals in Management of Type 2 Diabetes
Fasting BG < 110 mg/dL
Post-meal < 140 mg/dL
HbA1c < 6.5%
Blood Pressure < 130/80
LDL < 100 mg/dl
HDL > 45 mg/dl
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Approach to Combination Oral Therapy
Intensifying of Oral Therapies
m etform in &/or glitazone+
sulfonylurea/repaglinide&/or glucosidase inh
sulfonylurea/repaglinide&/or glucosidase inh
+m etform in &/or glitazone
Continue
FPG < 120 m g/dl HbA1c < 7.0% FPG > 120 m g/dl HbA1c >7.0%
Add Insulin
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Insulin
The most powerful agent we have
to control glucose
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Comparison of Human Insulins / Analogues
Insulin Onset of Duration ofpreparations action Peak action
Regular 30–60 min 2–4 h 6–10 h
Lispro/aspart 5–15 min 1–2 h 4–6 h
NPH/Lente 1–2 h 4–8 h 10–20 h
Ultralente 2–4 h Unpredictable 16–20 h
Glargine 1–2 h Flat ~24 h
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400
350
300
250
200
150
100
MealSC injection
50
00 30 60
Time (min)90 120 180 210150 240
Regular Lispro
500450400350300250
150
50
200
100
00 50 100
Time (min)150 200 300250
Pla
sm
a i
ns
uli
n (
pm
ol/
L)
Pla
sm
a i
ns
uli
n (
pm
ol/
L)
MealSC injection
Heinemann, et al. Diabet Med. 1996;13:625–629; Mudaliar, et al. Diabetes Care. 1999;22:1501–1506.
Short-Acting Insulin AnalogsLispro and Aspart Plasma Insulin Profiles
Regular Aspart
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Limitations of NPH, Lente,and Ultralente
Do not mimic basal insulin profile
– Variable absorption
– Pronounced peaks
– Less than 24-hour duration of action
Cause unpredictable hypoglycemia
– Major factor limiting insulin adjustments
– More weight gain
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1 5 10 15 20 25 30
1 5 10 15 20 Asp
Gly
ArgExtension
Substitution
Arg
Insulin GlargineA New Long-Acting Insulin Analog
Modifications to human insulin chain
– Substitution of glycine at position A21
– Addition of 2 arginines at position B30
Gradual release from injection site
Peakless, long-lasting insulin profile
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Lepore, et al. Diabetes. 1999;48(suppl 1):A97.
6
5
4
3
2
1
00 10
Time (h) after SC injection
End of observation period
20 30
GlargineNPH
Glu
cose
uti
lizat
ion
rat
e(m
g/k
g/h
)
Glargine vs NPH Insulin in Type 1 DiabetesAction Profiles by Glucose Clamp
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Glargine
Plasma Glucose
Time (hours)
220
200
180
160
140
120
12
11
10
9
8
7
0 4 8 12 16 20 24
mg
/dL
mm
ol/L
Lepore M, et al. Diabetes. 2000;49:2142–2148.
n = 20 T1DMMean ± SEM
SC insulin
NPH
Ultralente
CSII
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Overall Summary: Glargine
Insulin glargine has the following
clinical benefits
– Once-daily dosing because of its prolonged
duration of action and smooth, peakless time-
action profile (23.5 hours on repeat injections)
– Comparable or better glycemic control (FBG)
– Lower risk of nocturnal hypoglycemic events
– Safety profile similar to that of human insulin
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Type 2 Diabetes … A Progressive Disease
Over time, most patients will need insulin
to control glucose
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Insulin Therapy in Type 2 Diabetes Indications
Significant hyperglycemia at presentation Hyperglycemia on maximal doses of oral agents Decompensation
– Acute injury, stress, infection, myocardial ischemia– Severe hyperglycemia with ketonemia and/or ketonuria– Uncontrolled weight loss– Use of diabetogenic medications (eg, corticosteroids)
Surgery Pregnancy Renal or hepatic disease
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Mimicking Nature
The Basal/Bolus Insulin Concept
6-16
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The Basal/Bolus Insulin Concept
Basal insulin
– Suppresses glucose production between meals and overnight
– 40% to 50% of daily needs
Bolus insulin (mealtime)
– Limits hyperglycemia after meals
– Immediate rise and sharp peak at 1 hour
– 10% to 20% of total daily insulin requirement at each meal
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Basal vs Mealtime Hyperglycemia in Diabetes
Riddle. Diabetes Care. 1990;13:676-686.
Pla
sma
Glu
cose
(m
g/d
L)
200
100
00600 1200
Time of Day1800 2400
Type 2 Diabetes
0600
150
250
50
Basal hyperglycemia Mealtime hyperglycemia
6-18
Normal
AUC from normal basal >1875 mgm/dL.hr; Est HbA1c >8.7%
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When Basal Corrected
Pla
sma
Glu
cose
(m
g/d
L)
200
100
00600 1200
Time of Day1800 2400 0600
150
250
50
Basal hyperglycemia Mealtime hyperglycemia
6-18
Normal
Basal vs Mealtime Hyperglycemia in Diabetes
AUC from normal basal 900 mgm/dL.hr; Est HbA1c 7.2%
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When Mealtime Hyperglycemia Corrected
Pla
sma
Glu
cose
(m
g/d
L)
200
100
00600 1200
Time of Day1800 2400 0600
150
250
50
Basal hyperglycemia Mealtime hyperglycemia
6-18
Normal
Basal vs Mealtime Hyperglycemia in Diabetes
AUC from normal basal 1425 mgm/dL.hr; Est HbA1c 7.9
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When Both Basal & Mealtime Hyperglycemia Corrected
Pla
sma
Glu
cose
(m
g/d
L)
200
100
00600 1200
Time of Day1800 2400 0600
150
250
50
Basal hyperglycemia Mealtime hyperglycemia
6-18
Normal
Basal vs Mealtime Hyperglycemia in Diabetes
AUC from normal basal 225 mgm/dL.hr; Est HbA1c 6.4%
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MIMICKING NATURE WITH INSULIN THERAPY
Over time,
most patients will need
both basal and mealtime insulin
to control glucose
6-19
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Starting With Basal Insulin Advantages
1 injection with no mixing
Insulin pens for increased acceptance
Slow, safe, and simple titration
Low dosage
Effective improvement in glycemic control
Limited weight gain
6-37
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Treat to Target Study: Glargine vs NPH Added to Oral Therapy of Type 2 Diabetes
Type 2 DM on 1 or 2 oral agents (SU, MET, TZD)
Age 30 to 70
BMI 26 to 40
A1C 7.5 to 10% and FPG > 140 mg/dL
Anti GAD negative
Willing to enter a 24 week randomized, open labeled study
Riddle et al, Diabetes June 2002, Abstract 457-p
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Treat to Target Study: Glargine vs NPH Added to Oral Therapy of Type 2 Diabetes
Add 10 units Basal insulin at bedtime (NPH or Glargine)
Continue current oral agents
Titrate insulin weekly to fasting BG < 100 mg/dL
- if 100-120 mg/dL, increase 2 units
- if 120-140 mg/dL, increase 4 units
- if 140-160 mg/dL, increase 6 units
- if 160-180 mg/dL, increase 8 unitsRiddle et al, Diabetes June 2002, Abstract 457-p
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Treat to Target Study; A1C Decrease
8.6
7.5
7.16.9 7
6.5
7
7.5
8
8.5
9
0 5 10 15 20 25 30
Weeks in Study (N=756)
Mea
n H
bA
1c%
Riddle et al, Diabetes June 2002, Abstract 457-p
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Treat to Target Study: Patients in Target (A1C < 7%)
2.5
32.3
48.8
66.2
57
0
10
20
30
40
50
60
70
Percentage of Patients
Week 0 Week 8 Week 12 Week 18 Week 24
Riddle et al, Diabetes June 2002, Abstract 457-p
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Treat to Target Study: Glargine vs NPH Added to Oral Therapy of Type 2 Diabetes
Nocturnal Hypoglycemia reduced by 40% in the Glargine group (532 events) vs NPH group (886 events)
Riddle et al, Diabetes June 2002, Abstract 457-p
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Advancing Basal/Bolus Insulin
Indicated when FBG acceptable but– HbA1c > 7% or > 6.5%
and/or– SMBG before dinner > 140 mg/dL
Insulin options– To glargine or NPH, add mealtime aspart / lispro– To suppertime 70/30, add morning 70/30– Consider insulin pump therapy
Oral agent options– Usually stop sulfonylurea– Continue metformin for weight control– Continue glitazone for glycemic stability?
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Case #1: DM 2 on SU with infection
49 year old white male
DM 2 onset age 43, wt 180 lbs, Ht 70 inches
On glimepiride (Amaryl) 4 mg/day , HbA1c 7.3% (intolerant to metformin)
Infection in colostomy pouch (ulcerative colitis) glucose up to 300 mg/dL plus
SBGM 3 times per day
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Case #1: DM 2 on SU with infection
Started on MDI; starting dose 0.2 x wgt. in lbs.
Wgt. 180 lbs which = 36 units
Bolus dose (lispro/aspart) = 20% of starting dose at each meal, which = 7 units ac (tid)
Basal dose (glargine) = 40% of starting dose at HS, which = 14 units at HS
Correction bolus = (BG - 100)/ SF, where SF = 1500/total daily dose = 1500/36 = 40
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Correction Bolus Formula
Example:
–Current BG: 220 mg/dl
– Ideal BG: 100 mg/dl
–Glucose Correction Factor: 40 mg/dl
Current BG - Ideal BGGlucose Correction factor
220 - 100 40
=3.0u
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Case #1: DM 2 on SU with infection
Started on MDI
Did well, average BG 138 mg/dL at 1 month and 117 mg/dL at 2 months post episode with HbA1c 6.1%
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Strategies to Improve Glycemic Control: Type 2 Diabetes
Monitor glycemic targets – Fasting and postprandial glucose, HbA1c
Self-monitoring of blood glucose is essential
Nutrition and activity are cornerstones of therapy
Combinations of pharmacologic agents are often necessary to achieve glycemic targets
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Options in Insulin Therapy for Type 1 Diabetes
Current
– Multiple injections
– Insulin pump (CSII)
Future
– Implant (artificial pancreas)
– Transplant (pancreas; islet cells)
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1.0
0.8
0.6
0
Insulin
Time
Multiple Injection TherapyIntermediate & Short-Acting Insulin Pre-Meal
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Injections1.0
0.8
0.6
0
Insulin
Time
Multiple Injection TherapyIntermediate & Short-Acting Insulin Pre-Meal
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Injections1.0
0.8
0.6
0
Insulin
Time
Multiple Injection Therapy Intermediate & Short-Acting Insulin Pre-Meal
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Injections1.0
0.8
0.6
0
Insulin
Time
Multiple Injection Therapy Glargine & Short-Acting Insulin Pre-Meal
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Case #2: DM 1 on MDI 46 year old white male power line supervisor
DM 1 age 40
On MDI: 10 u lispro pre-meal, 20 u NPH HS
HbA1c 7.4%
SMBG avg 124 mg/dL based on 1.9 tests/day (fasting 171 mg/dL, noon 105 mg/dL, pm 125 mg/dL, HS 75 mg/dL)
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Case #2: DM 1 on MDI Lantus (glargine) 20 u HS added in place of NPH
No change in behavior (diet, SMBG frequency)
Seen three months later (8-16-01)
HbA1c 6.3%
SMBG average 104 mg/dL (fasting BG 91 mg/dL, noon 126 mg/dL, pm 116 mg/dL, HS 126 mg/dL
NO HYPOGLYCEMIA
HAPPY
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Insulin Pens
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InDuo™ - IntegrationFeature
Combined insulin doser and blood glucose monitor
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InDuo™ - Compact Size
Feature
Compact, discreet design
Benefit
Allows discreet testing and injecting anywhere, anytime
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InDuo™ - Doser RemembersFeature
Remembers amount of insulin delivered and time since last dose
Benefit
Helps people inject the right amount of insulin at the right time
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Pump TherapyBasal & Bolus Short-Acting Insulin
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Pump TherapyBasal & Bolus Short-Acting Insulin
Combined with SMBG, physiologic insulin requirements can be achieved more closely
Flexibility in lifestyle
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History of Pumps
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PARADIGM PUMP
Paradigm. Simple. Easy.
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Metabolic Advantages with CSII
Improved glycemic control
Better pharmacokinetic delivery of insulin
– Less hypoglycemia
– Less insulin required
Improved quality of life
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If HbA1c is Not to Goal
SMBG frequency and recording
Diet practiced
– Do they know what they are eating?
– Do they bolus for all food and snacks?
Infusion site areas
– Are they in areas of lipohypertrophy?
Other factors:
– Fear of low BG
– Overtreatment of low BG
Must look at:
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Future ofDiabetes Management
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Improvements in Insulin & Delivery
Insulin analogs and inhaled insulin
External pumps
Internal pumps
Continuous glucose sensors
Closed-loop systems
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Pulmonary Insulin
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Oral Agents + Mealtime Inhaled InsulinEffect on HbA1c
*P < .001
Weiss, et al. Diabetes. 1999;48(suppl 1):A12.
10
9
8
7
5Baseline
(0)Follow-up
(12)
Oral Agents +Inhaled InsulinOral Agents Alone
Baseline(0)
Follow-up(12)
2.3%*
Weeks
6
Hb
A1c
(%
)
6-55
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Implantable Pump
Average HbA1c 7.1%
Hypoglycemic events reduce to 4 episodes per 100 pt-years
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MiniMed 2007 System
Implantable Insulin Pump Placement
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Long-Term Glucose Sensor
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Re-Calibrated
0
50
100
150
200
250
300
350
26 Thu
Oct 2000
27 Fri 28 Sat 29 Sun 30 Mon 31 Tue 1 Nov 2 Thu 3 Fri 4 Sat 5 Sun 6 Mon 7 Tue
Sensor Vs. HemoCue (Finger) Glucose --- Sensor # 6989Long-Term Implanted Glucose Sensor System (12 Days)
Glu
cose
(m
g/d
L)
LONG TERM IMPLANTABLE SYSTEM
Source: Medical Research Group, Inc.
Human Clinical Trial
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Combine Pump and Sensor Technology
+
LTSS => Long Term Sensor System (“Open Loop Control”)
Using an RF Telemetry Link…...
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Medtronic MiniMed’s Implantable Biomechanical Beta Cell
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Today’s RealityOpen-Loop Glucose Control
Sensor # - 6347
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Source: Medical Research Group, Inc.
50
100
150
200
250
300
350
400
16 Wed 17 Thu 18 Fri 19 Sat 20 Sun 21 Mon 22 Tue 23 WedAugust 2000
Glu
cose
(mg/
dL)
LONG TERM IMPLANTABLE SYSTEMAutomatic Glucose Regulation
in a Fully Pancreatectomized Canine
CLOSED LOOP CONTROL
ManualControl
ManualControl
Automatic ControlBegins
ControlTerminated
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Summary
Insulin remains the most powerful agent we have to control diabetes
When used appropriately in a basal/bolus format, near-normal glycemia can be achieved
Newer insulins and insulin delivery devices along with glucose sensors will revolutionize our care of diabetes
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Conclusion
Intensive therapy is
the best way to treat
patients with diabetes
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QUESTIONS
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