Insulin analog

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An insulin analog (also called an insulin analogue) is any of several types of medical insulin that are altered forms of the hormone insulin, different from any occurring in nature, but still available to the human body for performing the same action as human insulin in terms of controlling blood glucose levels in diabetes. Through genetic engineering of the underlying DNA, the amino acid sequence of insulin can be changed to alter its ADME (absorption, distribution, metabolism, and excretion) characteristics. Officially, the U.S. Food and Drug Administration (FDA) refers to these agents as insulin receptor ligands (because, like insulin itself, they are ligands of the insulin receptor), although they are usually just referred to as insulin analogs or even (loosely but commonly) just insulin (without further specification).

Contents

These modifications have been used to create two types of insulin analogs: those that are more readily absorbed from the injection site and therefore act faster than natural insulin injected subcutaneously, intended to supply the bolus level of insulin needed at mealtime (prandial insulin); and those that are released slowly over a period of between 8 and 24 hours, intended to supply the basal level of insulin during the day and particularly at nighttime (basal insulin). The first insulin analog (insulin Lispro rDNA) was approved for human therapy in 1996 and was manufactured by Eli Lilly and Company.

Fast acting

Lispro

Eli Lilly and Company developed and marketed the first rapid-acting insulin analogue (insulin lispro rDNA) Humalog. It was engineered through recombinant DNA technology so that the penultimate lysine and proline residues on the C-terminal end of the B-chain were reversed. This modification did not alter the insulin receptor binding, but blocked the formation of insulin dimers and hexamers. This allowed larger amounts of active monomeric insulin to be available for postprandial (after meal) injections. [1]

Aspart

Novo Nordisk created "aspart" and marketed it as NovoLog/NovoRapid (UK-CAN) as a rapid-acting insulin analogue. It was created through recombinant DNA technology so that the amino acid, B28, which is normally proline, is substituted with an aspartic acid residue. The sequence was inserted into the yeast genome, and the yeast expressed the insulin analogue, which was then harvested from a bioreactor. This analogue also prevents the formation of hexamers, to create a faster acting insulin. It is approved for use in CSII pumps and Flexpen, Novopen delivery devices for subcutaneous injection. [2]

Glulisine

Glulisine is rapid acting insulin analog from Sanofi-Aventis, approved for use with a regular syringe, in an insulin pump. Standard syringe delivery is also an option. It is sold under the name Apidra. The FDA-approved label states that it differs from regular human insulin by its rapid onset and shorter duration of action. [3]

Long acting

Detemir insulin

Novo Nordisk created insulin detemir and markets it under the trade name Levemir as a long-lasting insulin analogue for maintaining the basal level of insulin. [1] [4] The basal level of insulin may be maintained for up to 20 hours, but the time is affected by the size of the injected dose. This insulin has a high affinity for serum albumin, increasing its duration of action.

Degludec insulin

This is an ultralong-acting insulin analogue developed by Novo Nordisk, which markets it under the brand name Tresiba. It is administered once daily and has a duration of action that lasts up to 40 hours (compared to 18 to 26 hours provided by other marketed long-acting insulins such as insulin glargine and insulin detemir). [5] [6]

Glargine insulin

Sanofi-Aventis developed glargine as a longer-lasting insulin analogue, and sells it under the brand name Lantus. It was created by modifying three amino acids. Two positively charged arginine molecules were added to the C-terminus of the B-chain, and they shift the isoelectric point from 5.4 to 6.7, making glargine more soluble at a slightly acidic pH and less soluble at a physiological pH. Replacing the acid-sensitive asparagine at position 21 in the A-chain by glycine is needed to avoid deamination and dimerization of the arginine residue. These three structural changes and formulation with zinc result in a prolonged action when compared with biosynthetic human insulin. When the pH 4.0 solution is injected, most of the material precipitates and is not bioavailable. A small amount is immediately available for use, and the remainder is sequestered in subcutaneous tissue. As the glargine is used, small amounts of the precipitated material will move into solution in the bloodstream, and the basal level of insulin will be maintained up to 24 hours. The onset of action of subcutaneous insulin glargine is somewhat slower than NPH human insulin. It is clear solution as there is no zinc in formula. [7] [ better source needed ] The biosimilar insulin glargine-yfgn (Semglee) was approved for medical use in the United States in July 2021, [8] and in the European Union in March 2018. [9]

Comparison with other insulins

NPH

NPH (Neutral Protamine Hagedorn) insulin is an intermediate-acting insulin with delayed absorption after subcutaneous injection, used for basal insulin support in diabetes type 1 and type 2. NPH insulins are suspensions that require shaking for reconstitution prior to injection. Many people reported problems when being switched to intermediate acting insulins in the 1980s, using NPH formulations of porcine/bovine insulins. Basal insulin analogs were subsequently developed and introduced into clinical practice to achieve more predictable absorption profiles and clinical efficacy. [10] [11] [12]

Animal insulin

Ribbon diagram of a porcine insulin hexamer. Porcine insulin differs from human insulin by only one amino acid. Insulin hexamer 4INS.png
Ribbon diagram of a porcine insulin hexamer. Porcine insulin differs from human insulin by only one amino acid.

The amino acid sequence of animal insulins in different mammals may be similar to human insulin (insulin human INN), there is however considerable viability within vertebrate species. [13] Porcine insulin has only a single amino acid variation from the human variety, and bovine insulin varies by three amino acids. Both are active on the human receptor with approximately the same strength. Bovine insulin and porcine insulin may be considered as the first clinically used insulin analogs (naturally occurring, produced by extraction from animal pancreas), at the time when biosynthetic human insulin (insulin human rDNA) was not available. There are extensive reviews on structure-relationship of naturally occurring insulins (phylogenic relationship in animals) and structural modifications. [14] Prior to the introduction of biosynthetic human insulin, insulin derived from sharks was widely used in Japan. Insulin from some species of fish may be also effective in humans. Non-human insulins have caused allergic reactions in some patients related to the extent of purification, formation of non-neutralising antibodies is rarely observed with recombinant human insulin (insulin human rDNA) but allergy may occur in some patients. This may be enhanced by the preservatives used in insulin preparations, or occur as a reaction to the preservative. Biosynthetic insulin (insulin human rDNA) has largely replaced animal insulin.

Modifications

Before biosynthetic human recombinant analogues were available, porcine insulin was chemically converted into human insulin. Chemical modifications of the amino acid side chains at the N-terminus and/or the C-terminus were made in order to alter the ADME characteristics of the analogue. Semisynthetic insulins were clinically used for some time based on chemical modification of animal insulins, for example Novo Nordisk enzymatically converted porcine insulin into semisynthetic 'human' insulin by removing the single amino acid that varies from the human variety, and chemically adding the human amino acid.

Normal unmodified insulin is soluble at physiological pH. Analogues have been created that have a shifted isoelectric point so that they exist in a solubility equilibrium in which most precipitates out but slowly dissolves in the bloodstream and is eventually excreted by the kidneys. These insulin analogues are used to replace the basal level of insulin, and may be effective over a period of up to 24 hours. However, some insulin analogues, such as insulin detemir, bind to albumin rather than fat like earlier insulin varieties, and results from long-term usage (e.g. more than 10 years) are currently not available but required for assessment of clinical benefit.

Unmodified human and porcine insulins tend to complex with zinc in the blood, forming hexamers. Insulin in the form of a hexamer will not bind to its receptors, so the hexamer has to slowly equilibrate back into its monomers to be biologically useful. Hexameric insulin delivered subcutaneously is not readily available for the body when insulin is needed in larger doses, such as after a meal (although this is more a function of subcutaneously administered insulin, as intravenously dosed insulin is distributed rapidly to the cell receptors, and therefore, avoids this problem). Zinc combinations of insulin are used for slow release of basal insulin. Basal insulin support is required throughout the day representing about 50% of daily insulin requirement, [15] the insulin amount needed at mealtime makes up for the remaining 50%. Non hexameric insulins (monomeric insulins) were developed to be faster acting and to replace the injection of normal unmodified insulin before a meal. There are phylogenetic examples for such monomeric insulins in animals. [16]

Carcinogenicity

All insulin analogs must be tested for carcinogenicity, as insulin engages in cross-talk with IGF pathways, which can cause abnormal cell growth and tumorigenesis. Modifications to insulin always carry the risk of unintentionally enhancing IGF signalling in addition to the desired pharmacological properties. [17] There has been concern with the mitogenic activity and the potential for carcinogenicity of glargine. [18] Several epidemiological studies have been performed to address these issues. Recent study result of the 6.5 years Origin study with glargine have been published. [19] [20]

Research on safety, efficacy, and comparative effectiveness

A meta-analysis completed in 2007 and updated in 2020 of numerous randomized controlled trials by the international Cochrane Collaboration found that the effects on blood glucose and glycated haemoglobin A1c (HbA1c) were comparable, treatment with glargine and detemir resulted in fewer cases of hypoglycemia when compared to NPH insulin. [21] Treatment with detrimir also reduced the frequency of serious hypoglycemia. [21] This review did note limitations, such as low glucose and HbA1c targets, that could limit the applicability of these findings to daily clinical practice. [21]

In 2007, Germany's Institute for Quality and Cost Effectiveness in the Health Care Sector (IQWiG) report, concluded that there is currently "no evidence" available of the superiority of rapid-acting insulin analogs over synthetic human insulins in the treatment of adult patients with type 1 diabetes. Many of the studies reviewed by IQWiG were either too small to be considered statistically reliable and, perhaps most significantly, none of the studies included in their widespread review were blinded, the gold-standard methodology for conducting clinical research. However, IQWiG's terms of reference explicitly disregard any issues which cannot be tested in double-blind studies, for example a comparison of radically different treatment regimes. IQWiG is regarded with skepticism by some doctors in Germany, being seen merely as a mechanism to reduce costs. But the lack of study blinding does increase the risk of bias in these studies. The reason this is important is because patients, if they know they are using a different type of insulin, might behave differently (such as testing blood glucose levels more frequently, for example), which leads to bias in the study results, rendering the results inapplicable to the diabetes population at large. Numerous studies have concluded that any increase in testing of blood glucose levels is likely to yield improvements in glycemic control, which raises questions as to whether any improvements observed in the clinical trials for insulin analogues were the result of more frequent testing or due to the drug undergoing trials.[ citation needed ]

In 2008, the Canadian Agency for Drugs and Technologies in Health (CADTH) found, in its comparison of the effects of insulin analogues and biosynthetic human insulin, that insulin analogues failed to show any clinically relevant differences, both in terms of glycemic control and adverse reaction profile. [22]

Timeline

Related Research Articles

<span class="mw-page-title-main">Insulin</span> Peptide hormone

Insulin is a peptide hormone produced by beta cells of the pancreatic islets encoded in humans by the insulin (INS) gene. It is considered to be the main anabolic hormone of the body. It regulates the metabolism of carbohydrates, fats and protein by promoting the absorption of glucose from the blood into liver, fat and skeletal muscle cells. In these tissues the absorbed glucose is converted into either glycogen via glycogenesis or fats (triglycerides) via lipogenesis, or, in the case of the liver, into both. Glucose production and secretion by the liver is strongly inhibited by high concentrations of insulin in the blood. Circulating insulin also affects the synthesis of proteins in a wide variety of tissues. It is therefore an anabolic hormone, promoting the conversion of small molecules in the blood into large molecules inside the cells. Low insulin levels in the blood have the opposite effect by promoting widespread catabolism, especially of reserve body fat.

Intensive insulin therapy or flexible insulin therapy is a therapeutic regimen for diabetes mellitus treatment. This newer approach contrasts with conventional insulin therapy. Rather than minimize the number of insulin injections per day, the intensive approach favors flexible meal times with variable carbohydrate as well as flexible physical activities. The trade-off is the increase from 2 or 3 injections per day to 4 or more injections per day, which was considered "intensive" relative to the older approach. In North America in 2004, many endocrinologists prefer the term "flexible insulin therapy" (FIT) to "intensive therapy" and use it to refer to any method of replacing insulin that attempts to mimic the pattern of small continuous basal insulin secretion of a working pancreas combined with larger insulin secretions at mealtimes. The semantic distinction reflects changing treatment.

Drugs used in diabetes treat diabetes mellitus by decreasing the glucose level in the blood. With the exception of insulin, most GLP receptor agonists, and pramlintide, all are administered orally and are thus also called oral hypoglycemic agents or oral antihyperglycemic agents. There are different classes of hypoglycemic drugs, and their selection depends on the nature of diabetes, age, and situation of the person, as well as other factors.

Diabetes is a chronic disease in cats whereby either insufficient insulin response or insulin resistance leads to persistently high blood glucose concentrations. Diabetes affects up to 1 in 230 cats, and may be becoming increasingly common. Diabetes is less common in cats than in dogs. The condition is treatable, and if treated properly the cat can experience a normal life expectancy. In cats with type 2 diabetes, prompt effective treatment may lead to diabetic remission, in which the cat no longer needs injected insulin. Untreated, the condition leads to increasingly weak legs in cats and eventually to malnutrition, ketoacidosis and/or dehydration, and death.

<span class="mw-page-title-main">Insulin glargine</span> Long-acting insulin

Insulin glargine sold under the brand name Lantus among others is a long-acting modified form of medical insulin, used in the management of type I and type II diabetes. It is injected just under the skin. Effects generally begin an hour after use.

<span class="mw-page-title-main">NPH insulin</span> Intermediate acting insulin formulation

Neutral Protamine Hagedorn (NPH) insulin, also known as isophane insulin, is an intermediate-acting insulin given to help control blood sugar levels in people with diabetes. It is used by injection under the skin once to twice a day. Onset of effects is typically in 90 minutes and they last for 24 hours. Versions are available that come premixed with a short-acting insulin, such as regular insulin.

<span class="mw-page-title-main">Insulin glulisine</span> Rapid-acting insulin analogue

Insulin glulisine is a rapid-acting modified form of medical insulin that differs from human insulin in that the amino acid asparagine at position B3 is replaced by lysine and the lysine in position B29 is replaced by glutamic acid. It was developed by Sanofi-Aventis and approved for marketing by the FDA and the EMA in 2004; it is sold under the trade name Apidra. When injected subcutaneously, it appears in the blood earlier than regular human insulin (RHI). When used as a meal time insulin, the dose is to be administered within 15 minutes before or 20 minutes after starting a meal. Intravenous injections may also be used for extreme hyperglycemia, but must be performed under the supervision of a medical professional.

Insulin detemir, sold under the brand name Levemir among others, is a long-acting modified form of medical insulin used to treat both type 1 and type 2 diabetes. It is used by injection under the skin. It is effective for up to 24 hours.

<span class="mw-page-title-main">Insulin aspart</span> Rapid-acting man-made insulin

Insulin aspart, sold under the brand name NovoLog, among others, is a modified type of medical insulin used to treat type 1 and type 2 diabetes. It is generally used by injection under the skin but may also be used by injection into a vein. Maximum effect occurs after about 1–3 hours and lasts for 3–5 hours. Generally a longer-acting insulin like insulin NPH is also needed.

<span class="mw-page-title-main">Insulin lispro</span> Rapid-acting insuline analog

Insulin lispro, sold under the brand name Humalog among others, is a modified type of medical insulin used to treat type 1 and type 2 diabetes. It is used by injection under the skin or within an insulin pump. Onset of effects typically occurs within 30 minutes and lasts about 5 hours. Often a longer-acting insulin like insulin NPH is also needed.

<span class="mw-page-title-main">Liraglutide</span> Anti-diabetic medication

Liraglutide, sold under the brand names Victoza and Saxenda among others, is an anti-diabetic medication used to treat type 2 diabetes, and chronic obesity. It is a second-line therapy for diabetes following first-line therapy with metformin. Its effects on long-term health outcomes like heart disease and life expectancy are unclear. It is given by injection under the skin.

Albiglutide is a glucagon-like peptide-1 agonist drug marketed by GlaxoSmithKline (GSK) for treatment of type 2 diabetes. As of 2017 it is unclear if it affects a person's risk of death. GSK has announced that it intends to withdraw the drug from the worldwide market by July 2018 for economic reasons.

<span class="mw-page-title-main">Insulin (medication)</span> Use of insulin protein and analogs as medical treatment

As a medication, insulin is any pharmaceutical preparation of the protein hormone insulin that is used to treat high blood glucose. Such conditions include type 1 diabetes, type 2 diabetes, gestational diabetes, and complications of diabetes such as diabetic ketoacidosis and hyperosmolar hyperglycemic states. Insulin is also used along with glucose to treat hyperkalemia. Typically it is given by injection under the skin, but some forms may also be used by injection into a vein or muscle. There are various types of insulin, suitable for various time spans. The types are often all called insulin in the broad sense, although in a more precise sense, insulin is identical to the naturally occurring molecule whereas insulin analogues have slightly different molecules that allow for modified time of action. It is on the World Health Organization's List of Essential Medicines. In 2020, regular human insulin was the 307th most commonly prescribed medication in the United States, with more than 1 million prescriptions.

<span class="mw-page-title-main">Lente insulin</span> Historical formulation of insulin as medication

Lente insulin was an intermediate duration insulin that is no longer used in humans. The onset of lente insulin is one to two hours after the dose is administered, and the peak effect is approximately 8 to 12 hours after administration, with some effects lasting over 24 hours.

<span class="mw-page-title-main">Insulin degludec</span> Ultralong-acting basal insulin analogue

Insulin degludec (INN/USAN) is an ultralong-acting basal insulin analogue that was developed by Novo Nordisk under the brand name Tresiba. It is administered via subcutaneous injection once daily to help control the blood sugar level of those with diabetes. It has a duration of action that lasts up to 42 hours, making it a once-daily basal insulin, that is one that provides a base insulin level, as opposed to the fast- and short-acting bolus insulins.

Ultralente insulin was a long-acting form of insulin. It has an onset of 4 to 6 hours, a peak of 14 to 24 hours, and a duration of 28 to 36 hours. Ultralente insulin, along with lente insulin, were discontinued in the US by manufacturers in the mid-2000s. One of the reasons for discontinuation was declining use in favor of NPH insulin and other newer insulin products. The FDA withdrew approval for ultralente insulin products by 2011.

Semaglutide is an antidiabetic medication used for the treatment of type 2 diabetes and an anti-obesity medication used for long-term weight management. It was developed by Novo Nordisk in 2012 and approved for use in the US in 2017. It is a peptide similar to the hormone glucagon-like peptide-1 (GLP-1), modified with a side chain. It can be administered by subcutaneous injection or taken orally. It is sold under the brand names Ozempic (injectable) and Rybelsus (pill) for diabetes, and under the brand name Wegovy for weight loss.

Insulin glargine/lixisenatide, sold under the brand name Soliqua 100/33 among others, is a fixed-dose combination medication that combines insulin glargine and lixisenatide and is used to treat diabetes.

<span class="mw-page-title-main">Tirzepatide</span> Anti-diabetic medication

Tirzepatide, sold under the brand name Mounjaro among others, is an antidiabetic medication used for the treatment of type 2 diabetes and for weight loss. Tirzepatide is administered through subcutaneous injection.

Insulin icodec is an investigational ultralong-acting basal insulin analogue that is developed by Novo Nordisk.

References

  1. 1 2 Walton, Bill; Johnston, Elizabeth; Noble, Sara L. (1998-01-15). "Insulin Lispro: A Fast-Acting Insulin Analog". American Family Physician. 57 (2): 279–86, 289–92. PMID   9456992. Archived from the original on 2007-09-29. Retrieved 2007-06-08.
  2. ↑ "Aspart insulin (rDNA origin) injection". Archived from the original on 2007-06-10. Retrieved 2007-06-08.
  3. ↑ "Apidra insulin glulisine (rDNA origin) injection" . Retrieved 2007-06-08.
  4. ↑ "Levemir insulin detemir (rDNA origin) injection" . Retrieved 2007-06-08.
  5. ↑ Klein et al. "Albumin-bound basal insulin analogues (insulin detemir and NN344): comparable time-action profiles but less variability. Diabetes Obes Metab 2007 May;9(3):290-9
  6. ↑ Haahr H et Heise T: "A review of the Pharmacological Properties of Insulin Degludec and Their Clinical Relevance" Clin Pharmacokinet (2014) 53:787-800
  7. ↑ "Lantus insulin glargine (rDNA origin) injection" . Retrieved 2007-06-08.
  8. ↑ "FDA Approves First Interchangeable Biosimilar Insulin Product for Treatment of Diabetes". U.S. Food and Drug Administration (FDA) (Press release). 28 July 2021. Retrieved 28 July 2021.
  9. ↑ "Semglee EPAR". European Medicines Agency (EMA). 17 September 2018. Retrieved 28 July 2021.
  10. ↑ Owens DR, Bolli GB. 2008 Beyond the era of NPH insulin--long-acting insulin analogs: chemistry, comparative pharmacology, and clinical application. Diabetes Technol Ther. Oct;10(5):333-49.
  11. ↑ Jonassen I, Havelund S, Hoeg-Jensen T, Steensgaard DB, Wahlund PO, Ribel U. 2012 Design of the novel protraction mechanism of insulin degludec, an ultra-long-acting basal insulin. Pharm Res. 2012 Aug;29(8):2104-14.
  12. ↑ Zinman B. 2013 Newer insulin analogs: advances in basal insulin replacement. Diabetes Obes. Metab. 2013 Mar;15 Suppl 1:6-10
  13. ↑ Conlon JM. 2001 Evolution of the insulin molecule: insights into structure-activity and phylogenetic relationships Peptides. 2001 Jul;22(7):1183-93
  14. ↑ Mayer JP, Zhang F, DiMarchi RD. 2007 Insulin structure and function. Biopolymers. 2007;88(5):687-713.
  15. ↑ Owens DR. 2011 Insulin preparations with prolonged effect. Diabetes Technol Ther. 2011 Jun;13 Suppl 1:S5-14.
  16. ↑ Horuk R, Blundell TL, Lazarus NR, Neville RW, Stone D, Wollmer A. 1980 A monomeric insulin from the porcupine (Hystrix cristata), an Old World hystricomorph. Nature Aug 21;286(5775):822-4.
  17. ↑ Tennagels N, Werner U. 2013 The metabolic and mitogenic properties of basal insulin analogues. Arch Physiol Biochem. 2013 Feb;119(1):1-14.
  18. ↑ Varewijck AJ, Yki-Järvinen H, Schmidt R, Tennagels N, Janssen JA. 2013 Concentrations of insulin glargine and its metabolites during long-term insulin therapy in type 2 diabetic patients and comparison of effects of insulin glargine, its metabolites, IGF-I, and human insulin on insulin and igf-I receptor signaling. Diabetes. 2013 Jul;62(7):2539-44.
  19. ↑ Gerstein HC, Bosch J, Dagenais GR, Díaz R, Jung H, Maggioni AP, Pogue J, Probstfield J, Ramachandran A, Riddle MC, Rydén LE, Yusuf S. 2012 Basal insulin and cardiovascular and other outcomes in dysglycemia. N Engl J Med. 2012 Jul 26;367(4):319-28.
  20. ↑ Hanefeld M, Bramlage P. 2013 Insulin use early in the course of type 2 diabetes mellitus: the ORIGIN trial. Curr Diab Rep. 2013 Jun;13(3):342-9.
  21. 1 2 3 Semlitsch, Thomas; Engler, Jennifer; Siebenhofer, Andrea; Jeitler, Klaus; Berghold, Andrea; Horvath, Karl (November 9, 2020). "(Ultra-)long-acting insulin analogues versus NPH insulin (human isophane insulin) for adults with type 2 diabetes mellitus". The Cochrane Database of Systematic Reviews. 2020 (11): CD005613. doi:10.1002/14651858.CD005613.pub4. ISSN   1469-493X. PMC   8095010 . PMID   33166419.
  22. ↑ Banerjee S, Tran K, Li H, Cimon K, Daneman D, Simpson S, Campbell K (March 2007). Short-acting insulin analogues for diabetes mellitus: meta-analysis of clinical outcomes and assessment of cost-effectiveness (Report). Canadian Agency for Drugs and Technologies in Health (CADTH). Technology Report no 87. Archived from the original on 4 November 2019. Retrieved 10 September 2020.
  23. ↑ Glucose Control – Lantus receives FDA approval for flexible administration
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