Advances in Insulin Delivery Systems - Episode 5
Experts examine the use of Technosphere insulin, how it is delivered to the body, and the qualities of an ideal rapid-acting insulin analog in type 1 and type 2 diabetes.
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: What would be the ideal rapid-acting insulin analog?
Natalie Bellini, DNP, FNP-BC: Ideally, we would have something that you could take as you’re sitting down, or as you take your first bite, so that it comes in very quickly, peaks, and follows that glucose path. A lot of times when patients inject insulin, we see the blood sugar go up and come back down perfectly and you say, “You just got the right dose at the wrong time. You got the right dose because you came back to the baseline, but we need to move that time.” What would be ideal would be that the insulin comes in and goes out as the glucose exists as well, meaning faster onset and shorter duration.
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: I completely agree. It would be more like true physiologic insulin in a person who doesn’t have diabetes. A person without diabetes doesn’t have to think about it. The second that they start eating, their body is producing insulin, and it’s just the right amount to keep them under 140 and then tail off where there’s no hypoglycemia. We’re trying as much as we can to mimic that. Fortunately, we do have one option that is faster than the other options and that is inhaled insulin, or Technosphere insulin. It’s very interesting. Of course, it’s inhaled vs the other types of insulin, which are injected, and the kinetics are much faster, much more similar to true physiologic insulin. In terms of what these kinetics look like, it will vary depending on the dose of it. I’ll go with a standard 12-unit dose. The time to effect is 12 minutes, which is faster than our other mealtime insulins, which are 15 to 30 minutes. Then, the time to peak is 45 minutes, so it is working much more in line of when you expect that postprandial glucose to peak. To put this into perspective, when you compare this to other insulins, most insulins peak at 1 to 3 hours. So, this truly is a whole lot faster, but what about wearing off? We don’t want this hanging out in the body forever either. Generally, it’s gone out of the system by 3 hours. What we see with our other rapid-acting insulins is generally that they’re hanging out in the body for 5 to 7 hours. This is much more like physiologic insulin. What have you noticed, or what has been your experience [with] Technosphere insulin pharmacokinetic-wise and pharmacodynamic-wise compared to the other insulins?
Natalie Bellini, DNP, FNP-BC: The nicest part about Technosphere insulin is that after a meal, the patient has an ability to treat more quickly because we know that most of it’s gone pretty quickly. This problem with injectable insulin is called stacking. A patient eats a meal and takes however much insulin. A couple of hours later, they’re running at about 240 mg/dL high, but not unexpected after a pretty high-carb meal at 300 mg/dL even sometimes and it’s there for an hour. Now, they’re 2 hours after, and the guilt starts to come in. Then, they get angry, and so they give more insulin. But 2 or 3 hours later when the first dose is finally gone and the second dose is peaking and doing its job, then they end up with a low blood sugar. That’s a challenge. With inhalable insulin, it’s gone sooner. It’s peaking faster and gone sooner so that a patient can return to baseline more quickly. That’s what we like about it.
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: I like what you said about the stacking because in practice, stacking is such an issue, and for that reason, our advice often is, “Wait 4 hours before your re-dose.” But, when you think about it, we say that out of safety because we don’t want people stacking and then having hypoglycemia. However, it’s not the best advice because if you see that you’re running high 2 hours after a meal, why should you have to wait for 4 hours before you do something about it? Having an option that’s faster that you can re-dose if needed to bring glucose down is nice to have.
Natalie Bellini, DNP, FNP-BC: Because you can have 25% or 30% of your initial dose still in you, and to explain that to a patient and say, “Wait, you still have 2 or 3 or 4 units kicking around in there. It just hasn’t started working yet,” is difficult, especially when our patients are people and they just want their blood sugar down. It’s a hard wait.
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: Especially with certain foods like doughnuts, pizza, and Chinese food, we know that it’s common that glucose will spike several hours later. With any food, it’s hard to get the perfect insulin dose, and naturally, everyone with diabetes who is on insulin benefits by being able to correct high glucose values.
Transcript edited for clarity