JP2008505087A - Compositions and methods for prevention and control of insulin-induced hypoglycemia - Google Patents

Abstract

A pharmaceutical composition containing both insulin and glucagon can be administered to control and treat diabetes while reducing or eliminating the risk of insulin-induced hypoglycemia. In one aspect, the present invention provides a pharmaceutical comprising both insulin and glucagon in an amount that not only achieves therapeutically effective control of diabetes as a result of administration to a diabetic patient, but can also prevent hypoglycemia. A functional composition. Formulations include, for example, formulations suitable for injection, including by subcutaneous (sc), formulations suitable for oral administration, formulations suitable for transdermal administration, formulations suitable for ocular administration. And formulations suitable for inhalation.

Description

(Cross-reference of related applications)
This application claims the benefit of US Provisional Patent Application No. 60 / 584,449 (filed Jun. 29, 2004), the entire contents of which are incorporated herein by reference.

(Technical field)
The present invention relates to the fields of biology, pharmacology, and medicine. In particular, the present invention relates to compositions for controlling blood glucose levels and methods of using the compositions.

(Background of the Invention)
Insulin is produced by β cells in the pancreatic islets of Langerhans and glucagon is produced by α cells. One of the main effects of insulin is to lower blood glucose by inhibiting hepatic glucose release and stimulating peripheral glucose uptake. Endogenous insulin levels may be low or undetectable in some patients with diabetes mellitus. Exogenous insulin is usually administered to lower hyperglycemia when circulating insulin levels are low or ineffective. Glucagon generally has the opposite effect of that of insulin, including first increasing hepatic glucose release and thereby increasing blood glucose levels. Glucagon levels tend to increase when blood glucose levels abnormally drop to low levels, especially in patients who utilize exogenous insulin.

  Current goals for diabetes management include approaching normal blood glucose levels to delay or prevent microvascular complications, and achieving this goal usually requires intensive insulin therapy. To do. Physicians faced a substantial increase in the frequency and severity of hypoglycemia in diabetic patients in an effort to achieve this goal.

  Hypoglycemia, characterized by low glucose levels, results in autonomic and adrenergic symptoms, and neuroglycemic symptoms, which are typically mild and excessive insulin. Occurs as a result of administration. Currently, hypoglycemia is defined as blood glucose below 70 mg / dl (eg, greater than 50 mg / dl or greater than 60 mg / dl). Frequent recurrent seizures of hypoglycemia are associated with unconsciousness of hypoglycemia, which can further contribute to the development of sometimes severe hypoglycemia. Thus, efforts to achieve normal glucose levels with insulin can result in the development of hypoglycemia of varying frequency and severity in patients. Hypoglycemia and lack of awareness of its presence is a serious complication of insulin treatment, which is more frequent and greater when there is counter-regulatory (anti-insulin) response impairment in diabetic patients Occurs with severity. One of the major reverse-control hormones that normally respond to hypoglycemia is glucagon. In patients with advanced type 1 and type 2 diabetes, the glucagon response to acute hypoglycemia is often impaired or lost.

(Summary of the Invention)
There remains a need for new methods for treating diabetes and new preparations of insulin and glucagon that reduce the risk of hypoglycemia induced by insulin therapy. The present invention fulfills this and other needs.

  In one aspect, the present invention provides a pharmaceutical comprising both insulin and glucagon in an amount that not only achieves therapeutically effective control of diabetes as a result of administration to a diabetic patient, but can also prevent hypoglycemia. A functional composition. Formulations include, for example, formulations suitable for injection, including by subcutaneous (sc), formulations suitable for oral administration, formulations suitable for transdermal administration, formulations suitable for ocular administration. And formulations suitable for inhalation. In some embodiments, the composition comprises s. c. Constituted for administration and contains sufficient glucagon for administration of 5 to about 20 ng / kg / min (eg, more than 5 ng to 20 ng / min effectiveness per kg of human). In one embodiment, 5 to about 20 ng / kg / min glucagon is administered for 1 to 20 units of insulin. For example, the rate administered can be administered once per hour. In a preferred embodiment, the composition is suitable for administration of 5 or more to about 20 ng / kg / min for each 1-2 units of insulin administered. As will be appreciated, in some embodiments glucagon and insulin may be kept in separate containers and are not administered simultaneously, but an appropriate ratio between the two is maintained. In one embodiment, these separate containers are housed in a single device suitable for administration of glucagon and insulin (eg, for subcutaneous administration); in another embodiment, the two devices are , One for each drug.

  In another aspect, a method of treating diabetes in humans and other mammals without inducing hypoglycemia or with a substantially reduced risk of inducing hypoglycemia is provided. In one embodiment, the composition containing insulin and glucagon is administered to the patient before symptoms of mild, moderate, or severe hypoglycemia appear. In some embodiments, the methods of the invention are practiced to prevent nocturnal hypoglycemia in Type I diabetic patients treated with insulin therapy, including intensive insulin therapy. This method involves the simultaneous administration of insulin and glucagon, which is administered in a therapeutically effective amount for the control of diabetes, and this glucagon is therapeutically effective for the prevention of hypoglycemia. Both insulin and glucagon are preferably administered simultaneously or simultaneously, ie within about 4 hours of each other (when regular insulin, LISPRO insulin, and ASPART insulin are used), or about 6 hours of each other Administered within -12 hours (if longer acting insulin is used) and in any event prior to the onset of clinically observable hypoglycemia. In one embodiment, glucagon is administered before insulin is administered. In another embodiment, insulin is administered before glucagon is administered. In one embodiment, the method includes maintaining blood glucose levels greater than 70 mg / dL and less than 180 mg / dL by simultaneous administration of insulin and glucagon to a diabetic patient. In another embodiment, the method s. Glucagon in an amount between about 6 ng / kg and 18 ng / kg per minute. c. The step of administering to. In one embodiment, 1-20 units or 2-20 units of insulin is s. c. Is administered to diabetic patients receiving glucagon in an amount between 6 ng / kg / min and 18 ng / kg / min. In another embodiment, the method s. Glucagon between about 8 ng / kg and 12 ng / kg per minute. c. The step of administering at a. In one embodiment, 0.1 unit to 2 units or 2 units to 20 units of insulin is s. c. Is administered to diabetic patients receiving glucagon in an amount between 8 ng / kg / min and 12 ng / kg / min. In another embodiment, the glucagon is administered by means other than intravenous or subcutaneous and is provided as described above. c. A dose equivalent to the dosage is administered.

  In another aspect, a method is provided for maintaining blood glucose levels in a range that is neither hyperglycemia nor hypoglycemia. These methods include simultaneous administration of insulin and glucagon.

  In another aspect, glucagon formulations and modified glucagons suitable for co-administration with insulin according to the methods of the invention are provided.

  In another aspect, a kit is provided for preventing hypoglycemia. In one embodiment, these kits preferably comprise instructions for the simultaneous administration of insulin, glucagon, and appropriate combinations thereof.

  In another aspect, these kits comprise insulin, a long acting form of glucagon, and instructions for use.

  In some aspects, methods are provided for ameliorating or preventing hypoglycemia loss of consciousness or loss of sensitivity. The method includes administering to the patient an amount of glucagon for a period of time sufficient to prevent or restore hypoglycemia awareness to the patient. In one embodiment, the patient is administered insulin concurrently with glucagon administration.

  In one aspect, a pharmaceutical formulation is provided, the pharmaceutical formulation comprising an amount of insulin effective to control diabetes and an amount of glucagon effective to prevent hypoglycemia in a human or other mammal. Including. The pharmaceutical formulation is configured to be administered subcutaneously, and the ratio of insulin to glucagon is typically 1 unit of insulin to between 40 and more than 200 milligrams of glucagon. In some embodiments, the amount of glucagon is between about 50 and 100 millimeters. In some embodiments, the glucagon is a long acting form of glucagon. In some embodiments, the long acting form of glucagon comprises iodine. In some embodiments, the long acting form of glucagon further comprises protamine.

  In another aspect, a method of treating diabetes in a human or other mammal without inducing hypoglycemia is provided. The method includes administering insulin in a therapeutically effective amount to control diabetes. The insulin can be an amount of insulin between 0.5 and 20 units. The method further includes administering glucagon in a time and amount that is therapeutically effective in preventing hypoglycemia. The glucagon can be administered simultaneously and can be in an amount between 5 ng and 100 ng per patient per minute for the desired glucagon effectiveness. In some embodiments, the amount of glucagon administered can be between 6 and 18 ng per kg patient per minute for the desired glucagon efficacy. In some embodiments, the glucagon is a glucagon having an extended duration of action. In some embodiments, the glucagon is included in a liposomal formulation. In some embodiments, the glucagon is included in a microsphere. In some embodiments, a formulation comprising both insulin and glucagon is administered. In some embodiments, the insulin and glucagon are included in a pump that controls the administration of the drug to the patient. In some embodiments, the glucagon is administered concurrently with insulin. In some embodiments, the ratio of glucagon to insulin is about 40 milliunits or more to 200 milliunits of glucagon to 1 unit of insulin. In some embodiments, 2 units of insulin are administered. In some embodiments, 10 units of insulin are administered and between 30 and 90 ng glucagon per kg administered per minute subcutaneously.

  In another aspect, a kit for administration of an amount of glucagon and insulin that prevents hypoglycemia is provided. This kit comprises glucagon and insulin. The glucagon and insulin is a ratio of 1 to 20 units of insulin to 32 to 480 millimeters of glucagon. The kit further comprises means for co-administering glucagon and instructions for administering insulin and glucagon so that glucagon prevents hypoglycemic events. In some embodiments, the concentration of glucagon when fully dissolved in a glycerin solution is greater than 500 micrograms per milliliter but less than 2000 micrograms per milliliter. In some embodiments, the glucagon and insulin is a ratio of 1 unit to 3 units insulin to 32 milliunits to 96 milliunits glucagon. In some embodiments, the means for administering glucagon subcutaneously is a pump, and the pump is configured to deliver between about 6 ng / kg / min and 20 ng / kg / min of glucagon.

  In another aspect, the use of glucagon in combination with insulin in the preparation of a medicament for the treatment of diabetes is provided. Glucagon is used in an amount sufficient to prevent the development of hypoglycemia, and the ratio of glucagon to insulin is between 40 micrograms and less than 500 micrograms of glucagon to 1 unit to 20 units of insulin. In some embodiments, this amount is sufficient to prevent the development of unconscious hypoglycemia. In some embodiments, the amount of insulin is between 1 and 20 units, and the amount of glucagon is between 41 and 200 millimeters. In some embodiments, the ratio of insulin to glucagon is approximately between 1 unit and 3 units of insulin vs. between 40 milliunits and about 96 milliunits of glucagon. In some embodiments, the glucagon further comprises protamine.

(Detailed description of the invention)
Methods and compositions are provided that can prevent hypoglycemia or significantly reduce the frequency and severity of hypoglycemia in insulin-treated diabetic patients (both type 1 and type 2). In one aspect, the methods and compositions are utilized to treat diabetes while adjusting the glucose level above the level of hypoglycemia. This method and composition can be used to supplement or restore the abnormally low glucagon response that often coincides with insulin administration, thereby preventing hypoglycemia.

  One problem that complicates prevention of hypoglycemia is that repeated events of hypoglycemia result in a loss of hypoglycemic awareness; thus, patients identify symptoms of hypoglycemia, even if initially recognized by the patient The ability to do can eventually be lost or lost. Accordingly, compositions and methods that can prevent or subvert the loss of hypoglycemic awareness are desirable. One way this can be achieved is to increase glucagon, or blood glucose levels as described herein, at relatively low doses over a period of time that insulin acts to prevent the development of mild hypoglycemia. To administer another drug. This can also be used to reverse or prevent the loss of hypoglycemic awareness.

  In one embodiment, the present invention optimizes glycemia management and the pharmaceutical of two hormones (insulin and glucagon) combined in a molar ratio that reduces the incidence of hypoglycemia or prevents hypoglycemia Provide a formulation. In another embodiment, methods and compositions for simultaneous but separate administration of insulin and glucagon to achieve this benefit are provided. While co-administration of two hormones with activities that have been thought to act in the opposite direction has traditionally been thought to have no beneficial effect, some of the embodiments of the present invention are in part From the recognition that such administration can achieve the beneficial effect of preventing hypoglycemia by alleviating or slowing the effect of glucagon without diminishing the beneficial effect of glucose regulation provided by insulin Occur. In some embodiments, the low amount of glucagon is continuously administered to patients who are receiving, having received or intending to receive insulin. Accordingly, the use of hyperglycemic factors (eg, glucagon) to prevent the development of hypoglycemia and associated symptoms resulting from insulin administration is contemplated. In some embodiments, hyperglycemic agents (eg, glucagon) are used to prevent the development of iatrogenic hypoglycemia.

  Accordingly, some of the embodiments of the present invention provide a method for controlling diabetes that reduces the risk of hypoglycemia by co-administering insulin and glucagon to a diabetic patient. In one embodiment, the patient is treated with insulin by administering a therapeutically effective amount of glucagon to prevent hypoglycemia, and in diabetic patients who are not suffering from hypoglycemia symptoms, A method for preventing blood glucose is provided. In one embodiment, glucagon is administered concurrently with insulin. In another embodiment, the glucagon is administered 10 minutes to several hours before the additional insulin is administered, and more preferably, 30 minutes to 60 minutes before the additional insulin is administered. In other embodiments, the glucagon is administered after the patient is last administered insulin or within about 1 minute to about 4 hours. In one embodiment, prevention of hypoglycemia includes preventing symptoms associated with hypoglycemia that are manifested in the subject. In another embodiment, prevention of hypoglycemia is achieved by maintaining a subject's average blood glucose level above about 70 mg / dL or above about 50 mg / dL to 60 mg / dL. Preferably, the subject's blood glucose level is maintained below about 140-200 and at least below about 350 mg / dL. Preferably, the subject's blood glucose level is maintained such that normoglycemia is maintained.

  In view of the disclosure herein, any of many different forms of insulin, including those approved by the FDA and those in development, as well as many Any of the different routes of administration can be used in the presently disclosed methods and formulations. Furthermore, any currently available formulation of glucagon can be used in the methods and formulations as well. However, prior to this disclosure, glucagon was only administered parenterally to control hypoglycemia, so this disclosure includes delayed-acting glucagon and / or long-acting glucagon, Provided are novel glucagon derivatives, new formulations of glucagon and glucagon derivatives, and new formulations for administering glucagon and glucagon derivatives, which are particularly suitable for achieving the benefits provided by some of the embodiments of the present invention, and Provide a method.

  The exact dosage of insulin and glucagon varies from patient to patient and depends on various factors, including the age and sex of the patient, the type and severity of diabetes, the patient's history (hypoglycemia and high Including, but not limited to, the type of insulin and glucagon used), and the dosage for any patient will be determined by one of skill in the art in light of the present disclosure. The beneficial effects for some of the embodiments of the present invention are typically both insulin and glucagon, where glucagon V. Can be achieved by administering about 0.02 to 40 milligrams of glucagon (0.02 to 40 micrograms) to about 1 unit of insulin. One unit of insulin is typically defined as a term used for the treatment of diabetes (eg, from about 34.2 micrograms to about 40 micrograms). The amount of insulin can also be measured in international units (IU). One unit of glucagon corresponds to 1 milligram of glucagon. In one embodiment, this ratio is determined by glucagon V. And insulin is administered s. c. When administered at a dose of 0.2 to 4.0 milligrams (0.2 to 4.0 micrograms) of glucagon per unit of insulin. When this glucagon is administered subcutaneously, one unit of insulin can be administered in an amount of glucagon from 40 milliunits to 200 milliunits (eg, to a 100 kg human for each unit of insulin administered). 40 to 200 millimeters per hour). In another embodiment, 48-150 mU, 50-120 mU, or 80-100 mU glucagon is administered for each unit of insulin. In a preferred embodiment, glucagon is administered subcutaneously and the rate is about 1 unit of insulin to greater than 5 ng / kg to about 20 ng / kg of glucagon, the amount of glucagon being at the duration of the insulin dose effectiveness. In between every minute. In one embodiment, 1 unit of insulin is administered and glucagon is administered at a rate of 8-12 ng / kg / min. For example, in conjunction with 1 unit of insulin, a standard dose can be made to treat a 100 kg person per hour. As will be appreciated by those skilled in the art, this dose may be a dose for a basal insulin rate. If postprandial levels of insulin are desired, the amount of glucagon at this dose is increased accordingly. In some embodiments, glucagon is administered subcutaneously in an amount between 5 ng / kg / min or more and less than about 20 ng / kg / min. More preferably, this amount is between about 8 ng / kg / min and 16 ng / kg / min glucagon per minute for subcutaneous administration. Of course, those skilled in the art will recognize that other equivalent doses (ie, the same effective amount administered by alternative methods) can also be determined in view of the teachings herein. This amount can be adjusted to correspond to the amount of glucagon needed to prevent hypoglycemia without inducing hyperglycemia, as recognized by those skilled in the art and shown in more detail below. . Thus, in some embodiments, s. c. Even by administration, the amount of glucagon administered is less than 5-20 ng / kg / min, which is stated to be effective in preventing insulin-induced hypoglycemia. As will be appreciated by those skilled in the art, while the present disclosure focuses on type 1 diabetes, similar methods and compositions may be used for type 2 diabetes. In general, the amount of glucagon can be increased several fold beyond that disclosed herein for type 1 diabetes. For example, type 2 diabetes may further require glucagon 1.5 to 5 times, and preferably comprises 2-3 times more glucagon than type 1 diabetes.

  Any currently available form of insulin (soluble recombinant human (regular) insulin, human insulin analogues such as animal insulin from cattle, pigs and other species, and medium and long acting Can be used for the compositions and methods disclosed herein, including but not limited to delayed release forms including sex insulin. In addition, any of the currently used routes of administration, as well as newer developmental routes, can be used, including subcutaneous, intramuscular, and intravenous, as well as oral and buccal administration Nasal administration, transdermal administration, sublingual administration, and pulmonary airway administration, but are not limited thereto. Representative doses and dose ranges for insulin administration to control diabetes known in the art are suitable for use in the methods and compositions of some embodiments.

  For example, short-acting insulin at mealtime (such as regular insulin and its LISPRO derivatives, ASPART derivatives and GLULISINE derivatives) is well known in the art and is commonly used to treat diabetes. Such insulins include other forms (NPH, LENTE, SEMI-LENTE, DETEMIR, ULTRA-LENTE, and GLARGINE (LANTUS), as well as premixed formulations of regular and long acting insulins. Can be used to illustrate embodiments in a manner applicable to (but not limited to). In this example, the molecular weight of all three short-acting insulins during meals is similar, with 5808 for LISPRO, 5825.8 for ASPART, 5823 for GLULISINE, and 5807 for regular insulin. The molecular weight for glucagon is 3483.

  In type 1 diabetes, the normal range of mealtime insulin injections can be approximated as two standard deviations from the mean, resulting in an insulin dose range of 2-20 units. More than 95% of patients with type 1 diabetes are administered a dietary insulin dose within this range. All three dietary insulins described above reach peak serum concentrations within 1-2 hours after subcutaneous administration and have a duration of effectiveness of about 5 hours.

  Currently, hypoglycemia is treated with a single injection of glucagon at a dose of about 1 mg (1 unit), but this dose is in excess of what is actually needed to control hypoglycemia. It has been determined. When glucagon is administered subcutaneously or intramuscularly, serum glucagon peaks within 1 hour and the effect can last for several hours. However, currently marketed forms of glucagon are not stable in liquid form for long periods (either isolated or in vivo), and in one embodiment, the present invention provides a novel form of glucagon that is more stable. Provided are novel methods for using pharmaceutical formulations and more stable forms of glucagon that are currently available but not widely used.

  There is a discrepancy between subcutaneous insulin pharmacokinetics and glucagon pharmacokinetics, based in part on the time to peak serum levels and the duration of action of prandial insulin and glucagon administered subcutaneously It was discovered. One embodiment of the present invention provides longer acting glucagon formulations and glucagon derivatives that can be used to correct this discrepancy if desired or beneficial to the patient. To do. As used herein, “long-acting” glucagon refers to glucagon having a half-life that exceeds that of standard glucagon, including natural glucagon or synthetic glucagon produced by rDNA. .

  A dose close to the basal replacement dose can be used to provide the dose of glucagon needed to achieve an effect duration similar to that of mealtime insulin. The usual basal glucagon replacement dose by intravenous infusion is 0.5 to 0.75 ng / kg / min, and includes the patient, insulin dose, method of administration (eg, IV vs. sc), and other Depending on the factors, it can be assumed that a wide range of glucagon infusions as high as 0.10 to 5.00 ng / kg / min (more often 0.10 to 3.00 ng / kg / min) may be effective. For example, s. c. In administration, we determined that the amount of glucagon administered when the bioavailability of glucagon administered by subcutaneous injection is as low as 10% and as low as about 35% for bolus subcutaneous administration. Has found that it can be higher. Accordingly, this dose is increased or decreased accordingly to obtain a therapeutic effect equivalent to administration of glucagon at a rate of 5-20 ng / kg / min. In order to match the PK of insulin, these glucagon infusion rates are continued for a period of 150 to 300 minutes. In some embodiments, the duration of the infusion can last about 6 hours or more (eg, 6-7 hours, 7-10 hours, 10-15 hours, 15-20 hours, 20-24 hours, or more). . Thus, the replenishment rate can be multiplied by the minimum and maximum times to obtain a total dose / kg. Assuming that a typical type 1 diabetic has a body weight in the range of 50-100 kg and the upper and lower range of the dose of subcutaneous injection of dietary insulin is between 2 and 20 units, the insulin / glucagon ratio is It can be calculated as shown in Table 1 below (indicating percentages for sc administration). In one embodiment, the same calculation as described above results in a delayed release of glucagon administered to the patient, taking into account that there are lower levels of glucagon available early and higher amounts of glucagon available later Used to determine the amount of form or sustained release form. The amount of glucagon released at any point in time is not known exactly, but sufficient glucagon is released per unit time from the administered formulation, so that glucagon is V. On average, about 0.1-5.0 ng / kg / min is released into the patient. In one embodiment, 0.5-fold, 2-fold, 3-fold, or 4-fold glucagon is released in any given unit time, depending on the patient, the type of diabetes being treated, and the mode of administration. Can be done.

  In some embodiments, and as shown in Table 1, glucagon is administered subcutaneously and between about 5.0 ng / kg / min and more to about 30 ng / kg / min, about 6 ng / kg / min to It is administered in an amount between 25 ng / kg / min, between 6 ng / kg / min and 20 ng / kg / min, or between about 8.0 ng / kg / min and about 12.0 ng / kg / min.

  (Table 1. Insulin (sc) / glucagon (sc) weight ratio (ng / ng) and inverse ratio [in%])

表の項目の説明：
２Ｕ Ｉｎｓ／６ｎｇ／ｋｇ／分 Ｇｌｕｃについて：合計２単位のインスリンが、所与の注入期間にわたって投与され、グルカゴンが、６ｎｇ／ｋｇ／分の速度で注入期間にわたって投与されることを意味する。５０ｋｇの人について１５０分に関して示される表中の２つの数字は、インスリンとグルカゴンとの重量比（絶対的な数字）、ならびにグルカゴン対インスリンの重量比（パーセントで表した数字）である（例えば、１．８＝８００００ｎｇ（２単位のインスリン）／７５０ｎｇ（５０×１５０^＊６グルカゴン）；５６．３％＝１／１．８（パーセントで表した数字＝逆比））。

Explanation of table items:
For 2U Ins / 6 ng / kg / min Gluc: means a total of 2 units of insulin is administered over a given infusion period and glucagon is administered over the infusion period at a rate of 6 ng / kg / min. The two numbers in the table shown for 150 minutes for a 50 kg person are the weight ratio of insulin to glucagon (absolute number), as well as the weight ratio of glucagon to insulin (number expressed as a percentage) (e.g. 1.8 = 80000 ng (2 units of insulin) / 750 ng (50 × 150 ^* 6 glucagon); 56.3% = 1 / 1.8 (number in percent = inverse ratio)).

  In Table 1, the amount of glucagon administered ranges from 5.6% to 675% of the amount of insulin administered (by weight) for many patients, but this glucagon is 225% of the weight of insulin. Less than 225% of the weight of insulin or present in the composition. As will be appreciated by those skilled in the art, the amount of glucagon administered can vary depending on many factors. Thus, the range of% glucagon to insulin can vary between 5.6% and 675% (eg, greater than or equal to 188% and less than 675%). In one embodiment, the amount of glucagon administered is expressed as a percentage of the amount of insulin administered; for example, the ratio of glucagon administered is between 5.6% and 11.1 of the amount of insulin administered. It can be 3%. In some embodiments, the amount of glucagon administered can be 112% to 225% of the amount of insulin administered. As shown in Example 7 below, these amounts of glucagon are high blood glucose, as it is believed that a lower dose range may be sufficient to prevent hypoglycemia without the risk of hyperglycemia. High blood glucose levels approaching can be induced. The lower range or dose can be, for example, 0.09% to 188% of the weight of insulin. As will be appreciated by those skilled in the art, patient weight can vary from infants (eg, 2 kg) to full adults (eg, 150 kg to 200 kg or more).

  In other embodiments, the amount of glucagon administered can be described as the amount of glucagon by weight or activity, regardless of the amount of insulin administered; for example, in one embodiment, the amount of glucagon administered The amount is 360-900 micrograms over a 9 hour period. In one embodiment, the glucagon administered is s. c. 5 ng / kg / min to about 30 ng / kg / min. In one embodiment, the amount is s. c. About 8 ng / kg / min to about 16 ng / kg / min, or about 12 ng / kg / min. In some embodiments, a substantially lower value may be sufficient as well, depending on the circumstances and mode of administration.

  In one embodiment, hypoglycemia is a blood glucose level of less than about 50-60 mg / dL, and generally a blood glucose level of less than about 70 mg / dL, and hyperglycemia is about 140 Blood glucose levels higher than ~ 200 mg / dL. In one embodiment, excessive hyperglycemia is defined as a blood glucose level above 350 mg / dL. The ratio of glucagon to insulin and the respective amounts are set according to the method of the invention to efficiently maintain blood sugar levels between low and high blood glucose levels. In another embodiment, the blood glucose level is maintained between a level of hypoglycemia and a level of excessive hyperglycemia. In another embodiment, the blood sugar level is maintained between a level of hyperglycemia and a level of excessive hyperglycemia. As will be appreciated by those skilled in the art, this level does not need to be observed accurately, and minor drops below these ranges or peaks above these ranges are acceptable. In one embodiment, the dose to be administered to a patient is: V. Is therapeutically equivalent to a dose of 0.5 to 0.75 ng / kg / min of glucagon administered in step s. c. Is therapeutically equivalent to a dose of greater than 5 ng / kg / min and up to about 20 ng / kg / min (ie, 8-16 ng / kg / min glucagon via sc administration). In some embodiments, the same amount of glucagon (or an effective ratio of glucagon to insulin) is used, even when an agent other than insulin is used to reduce or control blood sugar levels. Is done. Thus, in some embodiments, the methods of the invention can be practiced with agents other than insulin when co-administration of glucagon with a hypoglycemic agent is contemplated in light of the present disclosure. Similarly, in some embodiments, a hyperglycemic agent other than glucagon is used to prevent the development of hypoglycemia in diabetic patients treated with insulin. In some embodiments, neither insulin nor glucagon is used, and the diabetic patient receives both a hyperglycemic agent (an agent that increases blood sugar levels) and a hypoglycemic agent (an agent that decreases blood sugar levels). It is administered at the same time.

  As will be appreciated by those skilled in the art in view of the present disclosure, the amount of glucagon or insulin administered to a patient can vary depending on the mode of administration. For example, the amount of glucagon added (or the ratio of insulin to glucagon) V. In terms of the amount administered via (as per PCT Publication No. WO 2004/060387, incorporated herein by reference). This amount can vary greatly depending on how the glucagon is administered (eg, subcutaneously or via inhalation). For simplicity, the amount of glucagon required to achieve an equivalent result can be described as a “dose equivalent”. For example, “a dose equivalent of 10 ng / kg / min in sc” is the amount required to achieve the same result as that achieved by subcutaneously administering 10 ng / kg / min to a patient. is there. “Sc Dose Equivalent to IV Administration” is administered intravenously as needed to obtain the same amount of blood glucose or glucagon achieved by subcutaneous administration of that amount of glucagon The amount of glucagon. Thus, in the latter expression, the first method of administration describes what the administered dose is equivalent to using another mode of administration, and the second mode of administration listed is actually utilized. The mode of administration to be performed. I. glucagon administered subcutaneously. V. Dose equivalents are typically determined by comparison of the above table with Table 1 of PCT Publication No. WO 2004/060387. V. Greater than the amount listed for administration. For example, I.I. V. While one unit delivered in is 0.1 ng / kg / min in some patients, the amount delivered subcutaneously for the same effect can be 8 ng / kg / min in those patients . Furthermore, in the clinical trials described in the examples below, the amount of glucagon that needs to be administered to induce hyperglycemia in diabetic patients treated with insulin is 8-16 ng / kg for some patients. Per minute (but lower doses were found to be equally effective), so the amount of glucagon needed simply to prevent hypoglycemia is Below range. Given the disclosure of the present invention, one of ordinary skill in the art can determine the appropriate amount in each situation.

  As will be appreciated by those skilled in the art, the “amount of glucagon administered” is not necessarily the amount of glucagon that actually enters the patient's bloodstream. Rather, for example, 9 g / kg / min glucagon is s. c. Administering to the patient means that the first known amount of the initial solution is made and 9 ng / kg / min of glucagon is administered based on that amount. If there is glucagon loss or degradation prior to administration, less effective glucagon will enter the patient and if there is glucagon loss or degradation as it progresses into the patient's bloodstream and tissues, the effective therapeutic dose will be even lower . As will be appreciated by those skilled in the art, the actual amount of glucagon that is active and enters the patient's circulation is in this case less than 9 ng / kg / min in this example.

  In view of the present disclosure, one of ordinary skill in the art can determine dose equivalents for various methods of administration or modes of administration. This dose equivalent can also vary depending on patient-to-patient and intra-patient diversity and drug bioavailability. For example, I.I. V. Assuming that the glucagon administered by is 100% bioavailable, s. c. Certain glucagon formulations administered by a bolus of may have a bioavailability of about 35%, while the same glucagon formulation administered by continuous subcutaneous infusion is shown by patient data in the examples below. As such, it may have 10% bioavailability. Furthermore, the difference between the method of administration of insulin and the method of administration of glucagon can also be considered and determined by the methods and examples provided herein. On the other hand, this can be determined by various assays of insulin, glucose and glucagon in the patient, for example, as shown in Example 7, according to various routes of administration of glucagon.

  Pharmaceutical compositions for use in many embodiments of the present invention can include compositions useful in conventional methods for the control of diabetes and the treatment of hypoglycemia. Such conventional methods include those that have been approved by the FDA, those under development, and S. V. Edelman and R.M. R. Described by Henry in Diagnosis and Management of Type II Diabes (5th edition, PCI Publishers, the entire text of which is hereby incorporated by reference) (parts 7 and 8 are particularly relevant) Can be mentioned. As used herein, a pharmaceutical formulation or composition can contain pharmaceutically acceptable excipients, diluents, or carriers. The phrase “pharmaceutically acceptable” means that the carrier, diluent or excipient must be compatible with the other ingredients and administration equipment of the formulation and not harmful to the recipient. Means that. Pharmaceutically acceptable excipients are well known in the art. See, for example, Remington: The Science and Practice of Pharmacy (19th edition, 1995, edited by Gennavo).

  In one embodiment, glucagon or similar substance is administered in a buffer. A suitable buffer is one that maintains the mixture at a pH in the range of about 6.0 to about 9.0, but does not interfere with the function of glucagon. Examples of buffers include, but are not limited to, Goode buffer, HEPES, Tris, ammonium acetate, sodium acetate, Bis-Tris, phosphate, citrate, arginine, histidine and Tris acetate. The selection of one or more suitable buffers is within the skill of the artisan.

  Controlling diabetes with insulin therapy, as well as controlling hypoglycemia with glucagon therapy, can include parenteral administration of insulin or glucagon. Parenteral administration may be performed by a syringe (optionally a pen-type syringe), by subcutaneous injection, or by intramuscular injection. Some embodiments of this method may be performed using such a methodology, but as described above, when the risk of hypoglycemia is greatest (generally after a relatively long period of feeding, but administered) Provide glucagon to ensure that the duration of the insulin used and the duration of action of glucagon more closely match so that glucagon is present (within the period during which the insulin remains active) It may be preferable in some cases.

  If subcutaneous administration of insulin and glucagon is desired, various methods can be utilized to achieve the benefits of diabetes control and prevention of hypoglycemia. In one such method, glucagon, which has a shorter duration of action than insulin, is administered within about 1-4 hours after the insulin is administered. The onset of most hypoglycemia begins a few hours after the patient's last meal, and many patients administer insulin immediately before the meal, so this method provides benefits. Thus, the benefits of the methods of the invention can be achieved by delivering glucagon several hours after insulin but before the onset of hypoglycemic symptoms. Certain embodiments provide a method for controlling diabetes with a reduced risk of inducing hypoglycemia by sequentially administering insulin with long acting glucagon and formulations thereof. Accordingly, in one embodiment, a composition having a long acting form of glucagon is provided.

  In general, long acting forms are also known as sustained release forms, extended release forms or controlled release forms (or similar terms). In one embodiment, the delayed acting or slow acting glucagon is a particular form of a sustained or extended release form of glucagon. Delayed-acting glucagon is within the general classification of long-acting glucagon. Because glucagon acting late or slowly allows glucagon activity to occur after a period after administration of glucagon; however, delayed action glucagon is more This is because it is effective in low amounts and increases effectiveness over time. The glucagon itself can be long acting in nature or can be combined with other ingredients that release glucagon over an extended amount of time.

  In another embodiment, insulin and glucagon can be administered simultaneously, and insulin, and optionally glucagon, is delivered parenterally, typically by subcutaneous injection. In this method, preferably glucagon with a longer duration of action is used, or glucagon provides a longer duration of action, for example by continuous infusion as shown in the examples below. Administered by

  Such glucagons include, but are not limited to, the glucagons, glucagon formulations, and routes of administration described below: liposomal formulations of glucagon that provide reduced dosage effects and long-acting properties. US Patent Publication Nos. 2002214829 and 6,197,333 and 6,348,214 describing PCT patent publications describing the delivery of glucagon through transdermal patches WO0243566; US Pat. No. 5,445,832 describing long acting glucagon formulations in polymeric microspheres; sustained release capable of having a duration of action measured in weeks PCT Patent Publication No. WO0222154 describing glucagon; and possessing glucagon by iodination And U.S. Patent No. 3,897,551 which describes an extension of the time U.K. Patent No. 1,363,954 (each of these publications are incorporated in their entirety by reference herein). In one embodiment, glucagon is administered as a sustained release formulation or a depot formulation (eg, including polyethylene glycol).

  There are a number of techniques known to those skilled in the art for modifying the release and / or pharmacokinetic properties of a protein, including the amino acid sequence at the site corresponding to the metabolic deactivation point associated with the protein. The modification of this is mentioned. These techniques and compositions include the following: “pegylation” or PEG modification of proteins (eg, PCT Patent Publication Nos. WO 0235957, WO 9831383, and WO 9724440, EP patent applications). See publication numbers EP0816381 and EP0444224, and US Patent Publication Nos. 2002/0115592, 5,234,903, and 6,284,727); other polymer encapsulations (EP patent application publications). No. EP06884044); lipophilic modification (US Pat. Nos. 5,359,030, 6,239,107, 5,869,602, and 2001/0016643, EP) Patent application publication number EP1264837 PCT Patent Publication Nos. WO9808871 and WO9943708); formulation in liposomes (see US Pat. Nos. 6,348,214 and 6,197,333); serum Albumin modifications (discussed in more detail in PCT Patent Publication Nos. WO02066511 and WO0246227 and US Pat. No. 4,492,684); emulsions, microspheres, microemulsions, nanoencapsulation, and microbeads Formulating in the form (US Pat. Nos. 4,492,684, 5,445,832, 6,191,105, 6,217,893, 5,643,604, 5th , 643,607, and 5,637,568); ligands Formulation comprising (see PCT Patent Publication No. WO0222154); and (see U.S. Pat. No. 3,897,551) iodination.

  In one embodiment, an iodination method that increases half-life (as described in US Pat. No. 3,897,551; see Form I3G) is used. Iodinated glucagon has an activity prolongation (measured with respect to increased glucose levels) between 1 and 3 hours, depending on the degree of iodination. In one embodiment, the LISPRO insulin and I3 glucagon are mixed so that the modified glucagon is present at about 1.5% by weight of insulin in the mixture (insulin concentration per ml is kept constant in the LISPRO formulation). Is done. Due to the longer lasting effect of the modified glucagon, a smaller ratio (by weight) of glucagon to insulin is required to prevent hypoglycemia in some patients.

  Another form of long acting glucagon is a zinc-protamine-glucagon formulation. Examples of such protamine zinc-glucagon formulations are known in the art (eg, Kaindl et al., Verh Dtsch Ges Inn Med., 1972; 78: 1099-101; Kaindl and Kuhn, Z Gesamte Med Med., 1972 December, 15; 27 (24): 1097-8; Christiansen and Tonnensen, Med Scand., December 1974; 196 (6): 495-6; Gamba et al., Minerva Med., November 1977, 3; 68 (53): 3613-26; Kolee et al., Arch Dis Child., May 1978; 53 (5): 422-4; Kalima and Lempinen, Ann Chir Gynecol., 1 980; 69 (6): 293-5; Aynsley-Green et al., Arch Dis Child., July 1981; 56 (7): 495-508; Schmid and Wietholter, Dtsch Med Wochenschr. 107 (47): 1809-11; Day and Mastglia, Aust NZ J Med., December 1985; 15 (6): 748-50; Cederblad et al., Horm Res. 1998; 50 (2): 94- 8 (all of which are incorporated herein by reference in their entirety)).

  In addition, Pichler et al. (Wien Klin Wochenschr 19:91 (2): 49-51 (1979)) showed that the glucagon zinc protamine form had the greatest effect up to 3 hours after the actual administration of the drug, at 4 hours. After that we showed only a decrease in activity. Thus, the effective half-life of zinc protaminglucagon is in the range of several hours.

  In one embodiment, glucagon is associated with protamine as described in Tarding et al. (European Journal of Pharmacology, 7: 206-210 (1969), which is incorporated by reference herein in its entirety). Without being combined with zinc. This also results in a long acting form of glucagon. In one embodiment, the mixture comprises a 1 to 2 ratio of zinc to glucagon.

  In one embodiment, the zinc protamine lucagon is made in a manner similar to the manner in which zinc protamine insulin is made, except that insulin is replaced by glucagon. In one embodiment, zinc glucagon and protamine zinc glucagon are made as described in Tarding et al. (European Journal of Pharmacology 7: 206-210 (1969)). For example, glucagon zinc can be made by suspending lyophilized glucagon zinc crystals in zinc acetate buffer to a final concentration of 1 mg glucagon per ml and 0.05 mg zinc per ml. Alternatively, the protamine zinc glucagon is lyophilized to a final concentration of 2 mg glucagon per ml, 0.15 mg zinc per ml, and 0.5 mg protamine per ml in a zinc acetate buffer containing protamine. Can be prepared by suspending.

  Another example of an agent that can be included in glucagon in a composition useful in the methods of the present invention is described in GLP- And protamine sulfate as described in combination with 1. The GLP-1 combination disclosed therein exhibits an increased half-life and likewise an increased shelf life. Any glucagon that exhibits increased half-life may be useful in the methods and compositions of the invention.

  Another method by which the half-life of the protein can be extended is by use of a “serum binder” (eg, by conjugation of albumin to glucagon with a connector) ). In one embodiment, the glucagon comprises a moiety that binds itself to albumin in vivo. Alternatively, glucagon can link the glucagon to a binder, which can then be modified to bind glucagon to a protein (eg, albumin) in vivo. Thus, the modified glucagon can be given to the patient as is, after which the glucagon binds to albumin in the host, which in turn causes the useful life extension of glucagon in the system. This approach includes GLP-1 in Bridon et al., US Patent Publication No. 20030108568 (published June 12, 2003), and various other proteins (eg, Krantz et al. US Pat. No. 6,277,863 (2001)). U.S. Pat. No. 6,500,918 issued December 31, 2002, U.S. Pat. No. 6,107,489 issued to Kranz et al. Issued August 22, 2000 ), Bridon et al., US Pat. No. 6,329,336 (issued December 11, 2001), and Poulety et al., US Pat. No. 6,103,233 (issued August 15, 2000) (all of these) Have been described for other purposes with respect to)), which is incorporated by reference in its entirety. In one embodiment, the binding between glucagon and albumin occurs with the aid of biotin and avidin or streptavidin. In another embodiment, glucagon can be coupled to other proteins through the use of maleimide groups and sulfur groups. This glucagon can be bound to any suitable protein, not just albumin.

  In one embodiment, the extended release form of glucagon is a gel-based or fibril-based form of glucagon. These can be prepared as described in Gratzer and Davies (European J. Biochem., 11: 37-42 (1969), which is hereby incorporated by reference in its entirety).

  Other forms of extended release glucagon are also contemplated for use in the methods of the invention. Extended release preparations can be made using a polymer that forms a complex or absorbs glucagon. Controlled delivery can be triggered by selecting the appropriate polymer and the concentration of the polymer and the built-in method to control the release. For example, a dispersion controlled system can be used. Examples of such materials include particles of polymeric materials such as polyester, polyamino acid, polyvinylpyrrolidone, methylcellulose, carboxymethylcellulose, hydrogel, poly (lactic acid), or ethylene vinyl acetate copolymer. Alternatively, instead of incorporation of the compound by these polymer particles, some embodiments of the compound can be prepared by, for example, coacervation techniques or interfacial polymerization (eg, hydroxymethylcellulose or gelatin-microcapsules, respectively). Capturing in a capsule or capturing in a colloidal drug delivery system (eg, liposomes, albumin microspheres, microemulsions, nanoparticles, and nanocapsules) or trapping in a macroemulsion Is possible. Such teachings are disclosed in Remington's Pharmaceutical Sciences (1980). In one embodiment, the dissolution rate of the drug is controlled primarily by the dissolution of the shell encapsulating the drug.

In one embodiment, an osmotic pump system is used to provide an extended release of glucagon, which is a drug that flows into the reservoir with the osmotic factor by flowing water across the semipermeable membrane. Makes it possible to control the release rate. In another embodiment, ion exchange resins are used to control the release of glucagon. In one embodiment, the sustained release form of glucagon is preproglucagon [Lund et al., Proc. Natl. Acad. Sci. U. S. A. 79: 345-349 (1982)]. The polypeptide is later processed to form proglucagon, which is then cleaved into glucagon and a second peptide (Patzelt, C. et al., Nature, 282: 260-266 (1979)). . Therefore, administration of preproglucagon or this form of proglucagon can delay the development of glucagon activity.

  In one embodiment, the glucagon is administered in a form that initially does not substantially allow the release of active glucagon and then permits a small amount of release of glucagon over time. Such forms of glucagon are useful when a long period occurs during drug intake and the desired result is an effect until the end of this long period (eg, nighttime). This form depends on the composition associated with the glucagon protein, the route and method by which the glucagon is administered, and the other reasons described herein, the glucagon protein itself. (Ie, a semi-synthetic glucagon variant).

  Low activity levels of glucagon are desirable in some cases. Glucagon compositions containing components that reduce glucagon activity can be difficult to deliver in small volumes of accurate amounts (especially over long periods of time) May be desirable in this situation. Alternatively, a variant or variant of glucagon having a lower level of activity can be used to achieve this result. The term “glucagon” can encompass both wild-type glucagon and variants or derivatives of glucagon.

  In some embodiments, the combination of an insulin component provided by the present invention and a sustained release form of glucagon is utilized in the methods of the present invention. As will be appreciated by those skilled in the art, this combination can be achieved by single or multiple formulations and single or multiple means for administering the insulin component or the glucagon component.

  In one embodiment, parenteral administration is performed using means of an insulin pump. A variety of insulin pumps are available and commonly used, these pumps for delivery of insulin and glucagon compositions (as well as delivery of insulin with glucagon delivered by another route (eg, transdermal)). Suitable. Such pumps include, but are not limited to, pumps marketed by Medtronic (eg, MiniMed), Animas Corporation, Distronic, and Dana. Glucagon can be administered with insulin as needed, and glucagon with a short duration of action can be utilized if glucagon can be administered when needed. In preferred embodiments, glucagon is administered subcutaneously and in an amount between about 5 ng / kg / min and up to 30 ng / kg / min, between about 5.0 ng / kg / min and up to 25 ng / kg / min. Between about 8.0 ng / kg / min and 20 ng / kg / min, or between about 8.0 ng / kg / min and 12.0 ng / kg / min. Lower doses of glucagon can be administered subcutaneously (0.1-5 ng / kg / min or 2-5 ng / kg / min) to prevent hypoglycemia in some patients. In one embodiment, the dose prevents hypoglycemia without causing excessive hyperglycemia. Hyperglycemia is blood glucose that exceeds the normal range. Glucagon can elevate blood glucose over blood glucose that cannot exist without the administration of exogenous glucagon, and in preferred embodiments, the dose administered is still protective against hypoglycemia. There is a dose that slightly increases above the level maintained in patients not suffering from hypoglycemia.

  Thus, in one embodiment, the present invention provides a novel drug delivery device (pump) suitable for the delivery of insulin, which delivers glucagon for the control of diabetes and for the control of human hypoglycemia. (Ie, this pump contains both insulin and glucagon). The pump can include a reservoir containing both insulin and glucagon. In other embodiments, the pump includes insulin and glucagon in two separately controlled reservoirs. A method of controlling diabetes in a human patient to reduce the risk of hypoglycemia comprising administering both insulin and glucagon to the diabetic patient using one pump of the embodiments described above. A method of inclusion is provided.

  In another method, either insulin or glucagon, or both, is provided in a formulation that is a powder or liquid suitable for administration as a nasal or pulmonary spray, or for ocular administration. Various such formulations are known for insulin and glucagon, and the present disclosure provides methods for using these known formulations for independent administration of any one, and hypoglycemia A method is provided for administering a corresponding formulation in an embodiment comprising both insulin and glucagon for controlling diabetes while reducing the risk of inducing.

  Methods and formulations for nasal, pulmonary or ocular administration include those in the following literature: PCT Patent Publication Nos. WO0182874 and No. 1, which describe aerosolized insulin and glucagon. WO0182981; European Patent Application Publication No. EP12224929 and US Pat. No. 6,004,574 describing glucagon inhaled with meletitose diluent; describes insulin and glucagon formulations suitable for nasal administration US Pat. No. 5,942,242; US Pat. No. 5,661,130 describing formulations suitable for ocular, nasal and nasolacrimal duct, or inhalation routes of administration; for nasal administration of insulin US Pat. No. 5,693,608, which also describes methods and formulations for glucagon; US Pat. No. 5,428,006, describing methods and formulations for nasal and other mucosal administration of Surin, and for glucagon, methods and formulations for mucosal administration of insulin and glucagon US Pat. No. 5,397,771 describing U.S. Pat. No. 5,283,236 describing methods and formulations for ocular administration of insulin and glucagon; and for nasal administration European Patent Application Publication No. EP 0 272 097 describing glucagon formulations. In addition to these formulations, methods of delivering these formulations as described are also contemplated.

  In one embodiment, compositions and methods for controlling diabetes while reducing the risk of inducing hypoglycemia by administering insulin and glucagon, wherein one or both of insulin and glucagon are transdermal Compositions and methods are provided that are administered manually (eg, from a patch (optionally from an iontophoretic patch)) or transmucosally (eg, intraoral). The manufacture and use of transdermal delivery devices is well known in the art (see, for example, US Pat. Nos. 4,943,435 and 4,839,174, and US Patent Publication US2001033858). While patent publications describing transdermal delivery of glucagon, as well as transdermal formulations of glucagon, have been listed above, US Pat. No. 5,707,641 provides for transdermal delivery of insulin. Methods and formulations are described.

  In addition, some of the above method embodiments may be practiced by oral administration of both the therapeutically effective amounts of insulin and / or glucagon described herein, and their dose equivalents. Methods and formulations for oral administration of insulin and glucagon include those described in PCT Patent Publication No. WO973688.

  Insulin and / or glucagon used in the above methods and formulations may be supplemented or replaced by compounds and compositions having similar activities or effects. For example, glucagon can be replaced with a glucagon mimic or a variant of glucagon.

  Insulin may be replaced or supplemented by hypoglycemic agents (including but not limited to insulin sensitizers, DPP IV inhibitors, and GLP1 analogs), as insulin secretagogues Include, but are not limited to, sulfonylureas (eg, acetohexamide (DYMELOR), chlorpropamide (DIAINESE), tolazamide (TOLINASE), tolbutamide (ORINASE), glimepiride (AMARYL), glipcotide (GLUCOTROL) ), Glipizide sustained release type (GLUCOTROLXL), glyburide (DIABETA, MICRONASE), micronized glyburide (GLYNASE, PRESTAB)); meglitinide (eg, Teglinide (STARLIX) and Repaglinide (PRANDIN)); gastric inhibitory polypeptide (GIP); glucagon-like peptide (GLP) -1; morphilinoguanide BTS 67582; phosphodiesterase inhibitor; and succinate derivative; insulin receptor Insulin-sensitive biguanides, such as activators; (eg, thiazolidinediones (TZD), pioglitazone (ACTOS), and rosiglitazone (AVANDIA) such as metformin (GLUCOPHAGE), troglitazone (REZULIN)); non-TZD peroxy Zome growth factor activated receptor gamma (PPARγ) agonists GL262570; acarbose (PRECOSE) and miglitol ( Α-glucosidase inhibitors such as (LYSET); combinations such as glucobans (GLYBRIDE and GLUCOPHAGE); tyrosine phosphatase inhibitors such as vanadium, PTP-1B inhibitors, and 5-aminoimidazole-4-carboxamide ribonucleoside (AICAR) AMPK activators; and exendin (EXENATIDE (synthetic exendin-4) and amylin (SYMLIN® (pramlintide acetate)), D-Chiro-inositol, modified peptide ligand (NBI-6024), Anergix DB complex, GABA inhibitory melanocortin, glucose lowering agent (ALT-4037), Aerodose (Aerogen), insulin mimic, Germany or BP3 (SOMATOKLINE) insulin-like growth factor-1 is a complex with, metoclopramide HCL (Emitasol / SPD 425), motillde / erythromycin analogs, and other agents such as GAG mimetics.

  In one embodiment, a variant of glucagon is contemplated. Such variants may contain single or many amino acid changes to the native human glucagon sequence as long as the resulting variant functions as required herein (eg, 1 to all amino acids can be changed). In one embodiment, the HELIX component is adjusted at the C-terminus and the partial agonists are combined to provide more than the “basic” input. In one embodiment, transient PEG modifications at the N-terminus to control activation can be complemented by mutations introduced at the C-terminus to control affinity. Examples of such modified glucagon molecules, their properties and activities obtained are available in the art. For example, Sturm et al. (J. Med. Chem. 41: 2693- 2700 (1998)) teaches general structural function relationships for some of the salt bridges in glucagon. In one embodiment, the modified glucagon has a Lys substitution at positions 17 and 18, and a Glu substitution at position 21, which substitutions are 500% binding affinity and 700% relative. This produces a variant with efficacy. In one embodiment, the modified glucagon amide has only a Lys substitution at position 17, which results in a variant with 220% binding affinity and 230% potency. In another embodiment, the modified glucagon amide has a Nle substitution at the 17 position, a Lys substitution at the 18 position, and a Glu substitution at the 21 position, these substitutions comprising 150% binding affinity and 300% Result in a variant with the following potency: In another embodiment, the modified glucagon molecule exhibits low binding ability or low activity. Thus, for example, a glucagon amide variant having a lysine at position 18 with a normal binding affinity of only 36% and a normal potency of only 12% may be used. Another example is a glucagon variant with Phe at position 18, which has a normal binding affinity of only 4.7% and a relative potency of only 0.9%.

  In one embodiment, the only pharmaceutically active ingredients of the formulation are insulin and glucagon. In one embodiment, the pharmaceutical composition (eg, containing both insulin and glucagon) is not formulated as an aerosol and / or does not contain troglitazone hydrochloride (and may not contain any thiazolidinedione). ). In one embodiment, the formulation is not administered orally and / or is not administered nasally. In one embodiment, the pharmaceutically active ingredients of the formulation are administered transdermally without a patch. For example, the active ingredient can be administered by use of a cream.

  As discussed above, effective co-administration of low doses of glucagon and insulin can help to prevent insulin-induced hypoglycemic events. Prevention of these events has various beneficial consequences.

  Repeated mild to moderate hypoglycemia events can result in a loss of hypoglycemia awareness by the subject. Thus, a subject may no longer be able to sense that the subject is actually experiencing a hypoglycemic event, which increases the risk that a hypoglycemic event may occur. Thus, the compositions and methods described above can be optimized to reduce this emerging risk. The ratio of insulin and glucagon described above and the amount of glucagon described for the prevention of hypoglycemia may be sufficient to treat this condition, and the method of the present invention may be a desired therapy for a particular patient. It includes methods for adjusting the amount administered to achieve an effect, the desired mode of delivery, or the desired formulation. In some embodiments, the combination of glucagon and insulin is administered to prevent loss of hypoglycemia awareness by the subject. In other embodiments, the glucagon and insulin are administered to restore hypoglycemia awareness to the subject. This can be achieved by administering an amount of glucagon so that further episodes of hypoglycemia are reduced or prevented. This amount can vary, for example, from 8 ng / kg / min to 16 ng / kg / min when administered subcutaneously.

  As will be appreciated by those skilled in the art, these therapies and compositions may be useful not only for those with diabetes, but also for those receiving insulin or other hypoglycemic agents.

  As will be appreciated by those skilled in the art, not all mild or moderate hypoglycemia episodes need to be prevented. The amount or% of events that are inhibited can vary depending on the particular situation and subject, and these are 2-5%, 5-10%, 10% for all mild / moderate hypoglycemic events. Inhibit -20%, 20-30%, 30-40%, 40-50%, 50-60%, 60-70%, 70-80%, 80-90%, 90-99% or 99% Can be included. Furthermore, hypoglycemia does not need to be prevented in all cases and can be delayed in some embodiments. Any amount of delay can be useful (eg, 1-10 minutes, 10-30 minutes, 30-60 minutes, 60-120 minutes, 120-300 minutes, 300-600 minutes or more delay). Alternatively, additional 1-20%, 20-60%, 60-100%, 100-200%, or 200% -10 times delay may be useful. Furthermore, the patient's susceptibility to hypoglycemia does not have to be all restored or preserved (eg, 1-10%, 10-20%, 20-30%, 30-40%, 40-50%, 50-60%, 60-70%, 70-80%, 80-90%, 90-99%, or 99-100% can be recovered from loss or prevented). “Hypoglycemic sensitivity” or “subconscious hypoglycemia” is based on an individual's ability to sense the appearance of a hypoglycemic event. For example, unconscious hypoglycemia is 1 to 20%, 20 to 40%, 40 to 50%, 50 to 50% of hypoglycemic events (e.g., glucose levels drop below 50 mg / dL in the blood). It may be that 70% or more cannot be sensed. Alternatively, the inability to sense certain symptoms of hypoglycemia can also be used to determine how unconscious hypoglycemia and how unconscious hypoglycemia is successfully treated. Signs and symptoms include, for example, trembling, dizziness, sweating, hunger, headache, irritability, pale skin color, sudden moody or attitude changes, awkward or jerky movements, Difficulties with attention, confusion, and tingling around the mouth. A description of the various possible classifications of hypoglycemia can be found in “Defining and Reporting Hypoglycemia in Diabetes”, Diabetes Care, 28: 1245-1249 (2005), which is incorporated by reference herein in its entirety. obtain. In particular, symptomatic hypoglycemia, asymptomatic hypoglycemia, and possibly symptomatic hypoglycemia include plasma glucose levels of 70 mg / dl or less. As described herein, in some situations, lower levels of blood glucose may also be used as a threshold.

(kit)
In some embodiments, the compositions described herein are provided in kit form. In one embodiment, the kit comprises a glucagon vial, an insulin vial, a means for administration (eg, a syringe or pump), and instructions for administration of glucagon and insulin. In some embodiments, the glucagon and insulin are premixed in a single vial. In other embodiments, the insulin and glucagon are premixed in a syringe. The specific instructions will vary depending on the desired use of the kit, for example for nightly control of hypoglycemia or otherwise. The instructions can be determined by one skilled in the art given the disclosure of the invention and the specific use intended for the kit. In one embodiment, the instructions describe the methods disclosed herein.

  Exemplary kits include glucagon and one or more of the following packaged together: (1) insulin; (2) solutions for resuspending or diluting glucagon (eg, excipients) (3) a device for administering glucagon and / or insulin; and (4) instructions. In one embodiment, device (3) comprises glucagon and / or comprises insulin.

  The kit may comprise glucagon in powder form in a sterile vial with a standard septum seal. In one embodiment, the vial is adjusted to 1 mg lyophilized glucagon, 49 mg lactose, pH (glucagon dissolves at a pH lower than 3 or higher than 9.5). A mixture of with hydrochloric acid. The kit also has a pre-filled glycerin syringe containing 12 mg / ml glycerin in a mixture of water and hydrochloric acid. The second container holds a 1 mg / mL solution of insulin that can be stored in liquid form in a syringe. The kit further has instructions to instruct the user to inject 1 mL of diluent into the vial from the pre-filled glycerin syringe. The instructions then instruct the user to collect an amount of glucagon / glycerin solution into the syringe containing this insulin. This amount will vary depending on the intended use and the particular user, and can be determined by a physician.

  In one embodiment, the volume of glucagon recovered in the syringe is between 0% and 5% of the volume of insulin injected. The kit may include tables and / or charts that allow for the determination of the amount or ratio to be used for each user and situation for each use and customization.

  The entire dose in the syringe of insulin can then be injected (children are typically administered 50% of the standard dose, and the kit can be modified accordingly). In one embodiment, the syringe of insulin and the syringe of glycerin are one and the same if the starting amount of glucagon is lower to maintain an appropriate ratio of glucagon to insulin injected. In another embodiment, the insulin, glucagon and glycerin are premixed in the kit. The instructions will be adjusted accordingly according to the particular embodiment used. In one embodiment, the kit comprises a glucagon kit, an insulin kit, and instructions for a method for combining the two kits. As will be appreciated by those skilled in the art, any of the compositions or methods discussed above can be included in the kit as components or instructions. Thus, for example, various methods of administration, various compositions of insulin or glucagon, and various buffers or solvents can be used in the kit. In one embodiment, the means for rapidly administering insulin is combined with the means for more slowly administering glucagon. In one embodiment, the kit comprises only one form of glucagon with a set of instructions.

  In one embodiment, the instructions include administering to the user subcutaneously 5 g / kg / min or more to 20 ng / kg / min (eg, 6 ng / kg / min to 16 ng / kg / min) of glucagon. Can command. The kit can include a device for subcutaneous administration. In one embodiment, the unit of glucagon is a dose of 36 micrograms for a 50 kg person per dose taken per hour. In another embodiment, the units of glucagon are doses as large as 36-96 micrograms for a 100 kg person for each dose taken per hour. These subcutaneous values may be sufficient to produce hyperglycemia in some diabetic patients; therefore, in some embodiments, less glucagon is required (eg, administered intravenously) (0.1 ng / kg / min to 5 ng / kg / min or higher) In some embodiments, the kit relates to doses for the age, weight, and sex of the individual. In one embodiment, the instructions provide information about the dose received taking into account future activities (eg, sleeping, eating (eg, amount and type of food), sitting or exercise). As will be appreciated by those skilled in the art, IV dose equivalent or sc dose equivalent can also be used if glucagon is to be administered in another manner. In embodiments, the kit comprises a unit dose of glucagon to be added with insulin, for example, the unit dose may be sufficient to protect a 100 kg subject from hypoglycemia for 1 hour, about 50 The unit dose can be 1 hour, 2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 7 hours, 8 hours, 9 hours, 10 hours, 11 Can be prepared for hours, 12 hours, 14 hours, 16 hours, 18 hours, 20 hours, 22 hours, 24 hours or longer hours or days. Also contemplated.

(Unit dose of glucagon)
In one embodiment, rather than providing a mixture of glucagon and insulin, a unit dose of glucagon alone can be immediately administered to a subject as needed to prevent insulin-induced hypoglycemia. Provided to. If the ratio of glucagon to insulin can be low, the amount of glucagon in a unit dose can also be low. As will be appreciated by those skilled in the art, the actual amount of glucagon in each dose will depend on the characteristics of the individual, the possible activities performed or performed by the individual, the manner in which the dose is administered and the form of glucagon. Thus, the doses described below are only representative of some of the possible doses. The dosage can be determined by one skilled in the art in view of the present disclosure.

  Glucagon unit dosage forms contain discrete amounts of glucagon for administration, and tablets, capsules in containers (eg, vials or ampoules, cartridges, syringes, inhalers, transdermal patches, or other containers or packages) Or in powder form. s. c. For administration, the amount of glucagon in a unit dose can be, for example, 0.036 mg to 0.4 mg for a 100 kg person, and this dose is effective for at least 1 hour. Preferably, this unit dose is between about 40 and 300 micrograms, and more preferably between about 50 and 100 micrograms. Of course, these numbers can be adjusted based on the size of the average person being treated and the duration of hypoglycemia prevention desired per unit dose. For example, it may be particularly advantageous to include sufficient glucagon for release over a period of 2-3 hours, 3-5 hours, 5-8 hours or longer depending on the sustained release formulation. Thus, in certain situations, larger doses are possible. s. c. Even by administration, lower amounts can also be used to ensure that hyperglycemia does not even occur transiently.

  A single unit dosage form contains sufficient glucagon for a single administration of glucagon as described herein. Unit dosages can be designed for specific events. For example, they can be designed for use before and after the administration of insulin. Alternatively, they can be designed for administration considering activity (eg eating or exercising or sleeping). Where the amount of glucagon to be administered depends on various factors of the patient (eg lifestyle and body weight), the unit dose can be expressed in a universal unit for ease of dose adjustment . Furthermore, the manner in which this unit is administered can also vary the amount of glucagon placed in each unit dose. In fact, these common unit dosages are unit doses that are divided into smaller individual parts. Thus, a 50 kg individual can receive 5 parts of these common unit doses, while a 100 kg individual can receive 10 parts. This allows for better personalization of this glucagon intake. Of course, lower amounts of glucagon (eg, amounts similar to IV administration) can also be used when lower levels of elevated blood glucose are required. Thus, even for subcutaneous administration, the unit dose can be, for example, between 0.036 mg and 0.2 mg.

  In a related aspect, a pharmaceutical preparation of glucagon in a daily dosage form is provided. A daily dosage form contains sufficient glucagon for a day, including when glucagon is administered multiple times during a single day, as described herein. For example, there may be multiple (eg, 2 or more) glucagon administrations following the meal during the day (eg, administration for Example 1 and / or prevention of hypoglycemia at night; or, eg, Continuous administration via skin patch or pump). For subcutaneous administration, 960 to 4800 micrograms of glucagon can be provided for administration over a day. In one embodiment, glucagon is a sustained release form that is administered at once. In another embodiment, glucagon is in the form of 6 pills taken, for example, one every 4 hours.

  In a related aspect, a pharmaceutical preparation of glucagon in multiple dosage forms is provided. Multiple dosage forms of glucagon may comprise a dose sufficient to be administered for 1, 2, 3, 4, 5, 6 days, 1 week, or even more than 1 week. In one embodiment, for example, 0.02 mg to 0.036 mg to 1 mg of glucagon is to be administered as separate doses over the course of one or more days, such as instructions (eg, a label) Provided in an accompanying container.

In one embodiment, a daily dose or multiple doses of glucagon is prepared by resuspending the powder in a liquid excipient, and the portion of the resulting solution is that day (or some multiple dose forms) In the case of several days). .
In addition to glucagon, the unit dosage form, daily dosage form, or multiple dosage form may contain other ingredients such as excipients, buffers, stabilizers, carriers, and other pharmaceutically active agents. May be included. In one embodiment, as discussed above, the unit dose comprises insulin or an insulin secretagogue.

  Multiple doses of glucagon (eg, multiple daily doses) can be packaged together in a box, bubble wrap or other well known format.

  In general, the dosage forms are labeled or accompanied by instructions for proper dosing. For example, a daily dosage form can be labeled to indicate the number and / or weight or volume of the unit dose in the container. The dosage form can also be labeled, or otherwise indicate the age of the patient intended for preparation. For example, the dosage form may be displayed as suitable for an adult, a child over 15 years old, a child over 10 years old, a child over 5 years old, and the like.

  In one embodiment, any of the above glucagon dosages may comprise a sustained release glucagon. In such embodiments, the dosage is appropriately adjusted as disclosed herein to maintain blood glucose levels within the desired range, as disclosed herein. Is done.

(Glucagon solution)
Administration of low doses (eg, less than 0.01 U) of glucagon using formulations prepared according to conventional methods (eg, resulting in a solution of about 1 mg / ml) can be inconvenient. Thus, in some embodiments, a lower concentration glucagon solution is made and / or administered. As used in this context, administration includes self-administration (whether by injection, by infusion using a pump or by other methods) and administration by another method. In various embodiments, the glucagon is less than about 0.25 mg / ml (eg, less than about 0.2 mg / ml, less than about 0.1 mg / ml, less than about 0.05 mg / ml, less than about 0.01 mg / ml). Or even as a solution having a concentration of glucagon of less than about 0.005 mg / ml). Such an amount is V. Appropriate for administration, and dose equivalent amounts may be given for other methods of administration. For example, the method of administration is s. c. If injection, the concentration of glucagon can be higher (at least about 0.01 mg / ml, or 0.05 mg / ml, or 0.2 mg / ml, 0.5 mg / ml, or about 0.5 mg / Glucagon between 2 and 2 mg / ml). In some embodiments, these doses are combined with a device (eg, a pump) that can administer the doses in low amounts over a long period of time.

  Glucagon can be resuspended in any pharmaceutically acceptable carrier, diluent, or excipient.

  In one embodiment, a pharmaceutically acceptable formulation of glucagon wherein the formulation is I.V. V. Less than about 0.25 mg / ml, less than about 0.2 mg / ml, less than about 0.1 mg / ml, less than about 0.05 mg / ml, less than about 0.01 mg / ml, or even more about Contains a concentration of less than 0.005 mg / ml, or includes dose equivalent amounts for other methods of administration. For example, for compositions administered subcutaneously, a pharmaceutically acceptable formulation of glucagon contains between 0.5 mg / ml and 2 mg / ml glucagon.

  In a related embodiment, a method of preparing a glucagon formulation for therapeutic use comprises: V. Less than about 0.25 mg / ml, less than about 0.2 mg / ml, less than about 0.1 mg / ml, less than about 0.05 mg / ml, less than about 0.1 mg / ml, or even about 0.0. Glucagon (eg, a single unit dose of glucagon, a daily dose of glucagon or multiple doses of glucagon, as described above, in an amount that results in a solution containing glucagon at a concentration of less than 05 mg / ml. A solution containing, but not limited to, an aqueous solution is provided and includes that step. Concentrations of 2-10 times (or more) can be used for other methods of administration (eg, subcutaneous administration). This solution may contain other agents, both pharmaceutically active and / or pharmaceutically inert.

  In one embodiment, the glucagon solution is loaded or included in a device for delivery to a patient. In some embodiments, the device has at least about 0.1 ml, at least about 0.2 ml, at least about 0.3 ml, at least about 0.4 ml, at least about 0.5 ml, or 0.5 ml or more of glucagon solution. Including.

  In a related aspect, additional steps of administration or self-administration to a human subject with diabetes are provided. In one embodiment, the subject does not exhibit symptoms of hypoglycemia. In one embodiment, the human is an adult. In one embodiment, the human is older than 10 years and optionally older than 15 years. In one embodiment, the subject does not have a stomach illness.

  In one embodiment, any of the above glucagon solutions can comprise a sustained release glucagon. In such embodiments, the dosage is appropriately adjusted as disclosed herein to maintain blood glucose levels within the desired ranges described herein. The

  The methods and compositions disclosed herein can be used to treat human patients, as well as other mammals (eg, rats, mice, pigs, non-human primates, etc.). In some embodiments, the human patient is a child or a juvenile, and in one embodiment the human patient is an adult. In certain embodiments, the patient is a type I diabetic patient. In one embodiment, the patient is a type II diabetic patient. In one embodiment, the patient is an unstable, type I or type II diabetic patient. In one embodiment, the non-human mammal is an animal model for the study of diabetes (eg, Zucker diabetic-fatty (ZDF) rats and dB / dB mice).

  While many of the examples and many of the descriptions provided herein are explicitly related to the subcutaneous administration of low doses of glucagon, other aspects are also disclosed. For example, the subcutaneous doses described herein are generally greater than 5 ng / kg / min and less than 20 ng / kg / min, while other doses are also described herein. It is contemplated for the various embodiments described. For example, I.I. V. Administration or s. c. Doses of 0.1 ng / kg / min to 5 ng / kg / min for administration (especially in combination with long acting forms of glucagon (eg, zinc protamine), various kits and unit doses) Contemplated with doses of 5 ng / kg / min or more to 20 ng / kg / min or 5 ng / kg / min or more to 30 ng / kg / min. In addition, as shown below, s. c. A 4 ng / kg / min dose of glucagon and lower doses may also be effective in preventing or delaying hypoglycemia. Thus, in some embodiments, the dose administered subcutaneously to prevent or delay hypoglycemia is about 0.1-5 ng / kg / min, 1 ng / kg / min, 1-2 ng / kg. / Min, 2-3 ng / kg / min, 3-4 ng / kg / min, 4-5 ng / kg / min, 5 ng / kg / min or more, 5-6 ng / kg / min, 6-8 ng / kg / min, 8-12 ng / kg / min, 12-16 ng / kg / min, 16-20 ng / kg / min, or 20-30 ng / kg / min. An amount corresponding to a unit dose, other doses for administration, or kits are also contemplated. For example, a unit dose per hour of glucagon at 4 ng / kg / min for a 100 kg person is 24 micrograms of glucagon and the pharmaceutical composition per hour is 24 micrograms of glucagon and 1 to Contains 3 units of insulin. As will be appreciated by those skilled in the art, any of the disclosed doses can be varied into unit doses per hour, or other aspects described herein and provided by the present disclosure. This includes dose amount (eg, 0.1-30 ng / kg / min or 6-16 ng / kg / min), presence and amount of insulin (eg, 0 or 2-20 units), patient size ( For example, 3 to 200 kg), as well as the number of hours of effectiveness desired (eg, 0.5 to 24 or more).

  The following examples describe exemplary embodiments of the invention and are not intended to be limiting in any manner.

Example 1. Parenteral glucagon and insulin co-administration for diabetes control and prevention of hypoglycemia
Glucagon currently available in the North American market is rDNA-derived human glucagon produced by Eli Lilly & Co or Bedford Labs (Novo). The following four trade names are known: Glucagon Diagnostics Kit (Lilly), Glucagon Emergency Kit (Lilly), Glucagon Emergency Kit for Low Blood (L), and Glucagon Emergency Kit for Low Bould (L).

  Novo produces glucagon under its own name outside of North America. Novo produces its glucagon in yeast; The glucagon is generated in E. coli. The following examples illustrate some implementations of this method using such commercially available glucagon and insulin administered via various routes.

  Lilly glucagon is typically provided in the form of a kit. The glucagon in this kit is in the form of a powder in a sterile vial with a standard rubber sealed neck. This vial contains a mixture of 1 mg lyophilized glucagon, 49 mg lactose, and hydrochloric acid to adjust the pH (glucagon dissolves at a pH lower than 3 or higher than 9.5). Including. The patient injects 1 ml of diluent from a prefilled syringe (containing 12 mg / ml glycerin in a mixture of water and hydrochloric acid) into a vial. Shake the vial until the solution is clear. This liquid is returned to the syringe and the entire dose is infused (children are usually given 50% of the standard dose).

  Glucagon is administered parenterally by the subcutaneous, intramuscular, and intravenous routes, but its pharmacokinetic properties are different as will be appreciated by those skilled in the art. Maximum plasma concentration is achieved about 20 minutes after subcutaneous administration. The in vivo half-life ranges from 8 to 18 minutes. A peak plasma concentration of about 8 ng / ml is achieved after about 20 minutes, glucose levels begin to rise almost immediately after administration, and high glucose levels persist for about an hour and a half after administration. Patients with insulin-induced coma typically recover consciousness within 15 minutes after glucagon administration. When administered to treat hypoglycemia, parenteral glucagon is primarily capable of using serum glucose through increased release of glucose by the liver (conversion of glycogen to glucose and formation of new glucose by gluconeogenesis). This is done by increasing.

  There are a wide variety of insulin dosing regimens in use. The regimen used depends on whether type 1 diabetes or type 2 diabetes is being treated, and on a number of factors specific to the individual being treated. Replacing insulin with the following parenteral (usually subcutaneously) administered insulin combination is normal medicine: rapid onset / short duration of action (LISPRO (HUMALOG) or ASPART ( NOVOLOG)), slower onset / short duration of action (regular human insulin), intermediate duration (NPH or LENTE), long duration of action (ULTRALENTE), BASULIN (Bristol Myers Squibb) and 24 hour peak Duration without (GLARGINE (LANTUS) and DETEMIR).

  Dosing regimens can be quite complex. For example, a typical twice daily regimen may include administering a short acting and intermediate duration insulin before breakfast and dinner. Thus, in addition to providing basal insulin levels over any 24-hour period, the resulting insulin profile has many peaks that roughly correspond to the expected postprandial glucose release. This is illustrated in FIG. 1, which shows the ideal pharmacokinetics for a mixture of regular insulin and medium time acting insulin. This graph shows the effect of a twice-daily insulin regimen: regular (solid line) and medium-time acting LENTE or NPH (dotted line) insulin twice a day before breakfast and dinner It provides a later insulin peak, as well as a relatively constant baseline level of insulin throughout the day after injection of the mid-time acting insulin.

  Insulin levels can vary between individuals and between individuals depending on factors such as the site and depth of injection, local blood flow, total volume and type of insulin injection, and other factors recognized by those skilled in the art. Can vary considerably. Thus, there can be significant patient-to-patient and intra-patient variation in subcutaneous absorption of insulin, which increases the likelihood of serum glucose fluctuations, including the possibility of hypoglycemia.

  Due to the emergence of rapid onset insulin and long acting insulin with little or no peak, GLARGINE (LANTUS); DETEMIR is a long acting insulin under development; Although it is a time-acting insulin, most patients tend to have some peak effect), making it possible to manage insulin levels (and hence blood glucose levels) more accurately. The basic methodology is to replace basal insulin and mealtime insulin with a combination of insulin preparations with different onset rates and durations of action. This is due to the use of separately administered insulins (eg, GLARGINE and LISPRO) that are marketed for this purpose, or the use of various premixed formulations (eg, 70/30 is NPH70 % And regular 30%).

  When glucagon is administered, the insulin action is most unopposed, for example, before, during, or just before the point where significant insulin action persists when serum glucose availability is not sufficient It is. Thus, whenever there is a mismatch between circulating insulin and glucose levels (relative excess of insulin effect on glucose availability), insulin-induced hypoglycemia can occur.

(A. Insulin administered parenterally)
(I) GLARGINE / LISPRO / ASPART / GLULISINE insulin For this illustrative example, patients (all patients referred to herein, except for any references to patients in the examples describing actual clinical trials) Is fictitious and any similarity to a real person is due to coincidence) is an adult male who is 50 years old and weighs 75 kg, has 5L of blood, suffers from type 2 diabetes, insulin therapy (accompanying No oral combination therapy). This patient has been using insulin for over 10 years and has a minimal glucagon response to hypoglycemia. The patient's insulin regimen is between 5 and 10 units of LISPRO (HUMALOG), ASPART (NOVOLOG), GLULISINE (APIDRA) meals administered at mealtime (depending on the amount of carbohydrates ingested) In addition to insulin injection, it includes basal insulin supplementation using a 20 unit dosage level of GLARGINE (LANTUS) subcutaneous injection administered at bedtime.

  The insulin profile of this patient is very simple and is the basis given by the flat line (GLARGINE (LANTUS) interrupted by the peak corresponding to dietary LISPRO (HUMALOG), ASPART (NOVOLOG), GLULISINE (APIDRA) insulin injections. Level). This insulin profile is shown in FIG. In this patient, the risk of hypoglycemia typically occurs between 2 and 5 hours after meals. It is during this period that glucagon administration is most effective and effective in preventing the possibility of developing hypoglycemia. In non-diabetic patients, glucagon usually falls after a carbohydrate meal (in response to increased glucose levels) and then recovers when glucose levels return to normal. In patients with type 1 diabetes (and patients with type 2 diabetes over 5 years), the glucagon response to low serum glucose is limited. Thus, if insulin reduces the serum glucose concentration well below the basal level, it will definitely be hypoglycemic.

  Symptoms of hypoglycemia are typically observed in diabetic patients with glucose levels below 50 mg / dl and sometimes below 40 mg / dl. In normal individuals, glucagon release increases (above about 40 pg / ml (eg, increases over about 60 pg / ml)) before glucose levels fall to this low level, and causes the development of hypoglycemic symptoms. prevent. However, glucagon production (or regulation) is lacking in many insulin-treated diabetic patients. Thus, administering glucagon to reach these levels during a protracted period prevents or reduces the severity of hypoglycemic attacks.

  The glucagon s. Required to provide prevention. c. The dose is, in some embodiments, about 6-20 ng / kg / min for basal insulin levels and proportionally higher for higher levels of insulin.

  Thus, according to this method, the patient is administered 41-90 micrograms of glucagon subcutaneously after a meal. Similar doses are administered twice and every hour for the next 2 hours. This results in 3 doses at 2, 3, and 4 hours, providing protection from hypoglycemia for 3 hours starting 2 hours after the meal. Because the risk and extent of hypoglycemia is (to some extent) insulin dose dependent, a lower percentage of glucagon (5.6%) can be used with formulations containing both insulin and glucagon. In this example, the glucagon concentration from the dose administered 2 hours after the meal will drop to near basal levels after 1 hour, but the increase in blood glucose due to this dose lasts longer than 1 hour. The second dose gives time for it to take effect. The same pharmacokinetics applies to the third dose of glucagon. In alternative embodiments, two or even one dose of glucagon may be administered.

  This example uses a simple basal insulin and a mealtime insulin model, but it will be appreciated by those skilled in the art that it is applicable to all currently performed dosing regimens. The timing (and frequency) of glucagon injections can be adjusted to suit the time period when the patient is most prone to hypoglycemia (ie, when insulin action and glucose availability are most disproportionate).

(Ii) NPH / Human Insulin A typical diabetic patient is an adult male, age 63, weighing 75 kg, suffering from type 2 diabetes for 18 years and using concomitant insulin therapy (no accompanying oral anti-diabetic treatment) ing. In the past, this patient has typically used oral antidiabetic medications that include glyburide and glipizide, which have consistently resulted in a patient's serum glucose level of 250 mg / dl or higher. Stop and start insulin. This patient has been using one or another type of insulin for over 10 years and is mild with nonproliferative retinopathy, 1.9 mg / dl serum creatinine and 60 ml / min creatinine clearance He developed signs of renal dysfunction, mild proteinuria, neurological disorders that are distally symmetric in both feet, and exertion angina. The patient's insulin regimen is typically 20 units before breakfast, intended to provide a reasonable post-meal coverage for lunch and dinner (and supper), in addition to the all-day basal insulin coverage. And includes 15 units of a split-mixed regimen of subcutaneous NPH insulin before dinner. In addition, the patient is injected with regular insulin between 6 and 10 units before these meals (depending on the level of serum glucose before meals and the size and carbohydrate content of the meal).

  The insulin profile of this patient is similar to that shown in FIG. 1, with less rapid peaks and slower decay from regular injections of regular insulin, and twice daily mid-time acting NPH insulin Has a slower onset and delayed decay effect. The patient's fasting glucose level is typically well controlled in the range of 90-130 mg / dl, but the patient's glucose level at 1-2 hours after meal is suboptimal and generally 180 It will be in the range of ~ 240 mg / dl. Glycosylated hemoglobin increases to 7.9% (normal range 4-6%). In order to reduce postprandial glucose levels, efforts to increase the patient's regular insulin breakfast or dinner dose are usually mild to moderate, often 1-2 hours before lunch or several hours after dinner. With frequent and intermittent hypoglycemia of severity. These episodes of hypoglycemia can be quite serious, especially if the patient's diet is delayed, and can be associated with symptoms of sweating, tremors, nausea, and headaches. The patient has never experienced a coma due to insulin-induced hypoglycemia, but does not want to increase insulin medication because this must happen. The patient is afraid that if a coma due to insulin-induced hypoglycemia occurs, he may lose his driver's license or possibly lose his job as a night guard. Due to the patient's long history of diabetes and the presence of serious complications, this patient exhibits impaired glucose control (particularly manifested as a tempered or missing glucagon response) to hypoglycemia Is predicted.

  In this patient, circulating insulin levels increase further above fasting levels, but if glucose availability (from gastrointestinal absorption and liver production) is minimal, the risk of hypoglycemia is usually that of diet Between 3 and 5 hours is greatest (slow postprandial hypoglycemia). It is during this period that the administration of glucagon is most effective and effective in preventing the possibility of hypoglycemia onset by increasing the availability of circulating glucose before the onset of hypoglycemia . In those who do not have diabetes, both insulin and glucagon are tightly regulated after a meal to balance glucose production and utilization to maintain normoglycemia. The insulin effect is naturally significant, and glucagon levels are raised to offset this hypoglycemic potential.

  In order to prevent the development of hypoglycemia according to one embodiment of a method, the patient is administered 36-96 milligrams of glucagon administered subcutaneously (optionally as described above, Eli Lilly 's Glucagon Emergency Kit) is administered 2-3 hours after each meal. In one embodiment, glucagon is added when glucose measurements indicate that the glucose level is approaching a hypoglycemic level. This administration provides the required protection between 3 and 5 hours as described above.

  It will be appreciated by those skilled in the art that this illustrative example uses a simple basal insulin and a mealtime insulin model, but is applicable to virtually any insulin dosing regimen currently practiced. Glucagon injections are optimally timed and vary depending on the insulin regimen used, but to reach sustained glucagon levels during periods where insulin action is expected to be relatively uncompetitive Designed to.

  In this hypothetical example, this situation tends to occur several times throughout the day. For example, hypoglycemia is likely to occur when the “last” of absorption of injected regular insulin is combined with peak insulin availability from medium-acting NPH. This situation occurs several hours after breakfast when serum glucose availability (mainly from intestinal absorption and liver production) is minimal or diminished. Similar situations also often occur before dinner, before going to bed, and at night. Thus, for all insulin dosing regimens, the timing of glucagon injection can vary depending on the pharmacological characteristics and timing of the insulin used.

  In order to offset the glucose-elevating potential of the administered glucagon, the dose of insulin acting during that hypoglycemic period can be somewhat increased to maintain normoglycemia. However, the increased availability of glucagon provides a buffering or mitigating action against the excessive glucose-lowering action of insulin and relieves or prevents hypoglycemia under certain circumstances as described above. Is done.

(B. Insulin administered by pump)
In this example, Example 1. A. The patient described in i uses a pump to administer the patient's insulin requirements. Example 1. A. Instead of administering basal insulin by GLARGINE (LANTUS) once a day as in i, the patient's insulin pump is programmed to provide a continuous flow of rapidly initiated insulin (eg LISPRO or ASPART). The In this example, the patient administers ASPART at a dose between 5 and 10 units at meal time according to pre-meal glucose levels and the amount of carbohydrates and calories consumed. The patient then administers glucagon 2 hours after the meal (eg, using Bedford Lab's GLUCAGE product) and repeats this administration every hour for an additional 2 hours according to this method. This amount is s. c. Between about 36 micrograms and 96 micrograms of glucagon delivered to This glucagon is administered subcutaneously. Example 1. A. As described in i, this administration provides protection from hypoglycemia between 2 and 5 hours. As will be appreciated by those skilled in the art, the glucagon can also be administered via a pump. In an alternative embodiment, the amount of glucagon is scaled up according to units of insulin, so 36-96 micrograms are used according to units of insulin.

(C. [Including patch and topical cream] transdermally administered insulin)
In this example, the patient is a 62 year old, lean, 6 year old type 2 diabetic patient. The patient was initially treated with 20 mg glyburide twice daily, followed by 1 gram metformin twice daily, but fasting and postprandial blood glucose was consistently 200-350 mg. / Dl range. This patient is advised to the doctor that he needs insulin. To discontinue oral antidiabetic medication and provide the patient's all-day basal insulin supplementation requirement, 15 units of GLARGINE (LANTUS) insulin is administered before bedtime. Postprandial insulin is administered by a transdermal patch to provide 2-6 units of fast acting insulin (the patch is available in units of 2; this example refers to the use of the patch It will be appreciated that substantially similar methodologies can be used with insulin or glucagon delivered transdermally by other means such as creams or lotions to perform embodiments of the present invention. Recognized by the merchant). Alternatively, the patient is given a 24 hour basal insulin supplement patch instead of once daily GLARGINE. A basal insulin supplement patch is one that contains insulin in a unique formulation designed to provide stable continuous absorption throughout the day and low constant serum insulin levels. Due to a sustained increase in fasting plasma glucose, physicians gradually increase the patient's dose of GLARGINE insulin to 24 units over 6 months and transdermal patches from 4 to 10 units. With this increase in GLARGINE and transdermal insulin dosing, fasting glucose levels ranged from 70-110 mg / dl and 1-2 hours after meals in the range of 130-180 mg / dl within 3 months. .

  Patients apply a fast acting insulin patch 30-60 minutes before meals. This timing is chosen so that meal absorption is consistent with the kinetics and effects of insulin patch absorption. This patient exhibits near normal glycemic control as indicated above, but begins to fall into hypoglycemia from early morning, usually at 1 or 2 am. At such times, this virtual patient is often confused, irritable and sometimes anxious. Several measurements of fingerstick glucose made during these events show blood glucose values of 35-40 mg / dl, and juice intake quickly resolves symptoms. To control these periods of hyperglycemia, physicians gradually reduce the evening dose of GLARGINE, which is accompanied by a worsening of glycemic control and mainly increases glucose levels before meals. Accompany.

  In accordance with some embodiments of the methods of the present invention, to restore near normal blood glucose as well as prevent early morning hypoglycemia symptoms, the physician returns GLARGINE insulin to 24 units at bedtime, 23: Immediately following the injection of GLARGINE by around 00, the administration of subcutaneous glucagon (using Bedford Labs glucagon product) at 18 ng / kg / min with the intended protection is defined. The time of administration of glucagon depends primarily on the absorption rate, which is fast, reaching peak levels within 15-30 minutes, and the duration of action is about 2-3 hours. In one embodiment, plasma glucagon close to “high normal basal level” is maintained during this period and exhibits an uncompetitive effect of insulin from GLARGINE insulin or a delayed action of evening (before dinner) patches. To prevent. For example, glucose levels higher than 120-160 mg / dl are contemplated. In an alternative embodiment, the lower end of the level of glycemia is set as a target for blood glucose level. This treatment provides the required protection from hypoglycemia about 3 hours after the GLARGINE injection, as described above. By adding bedtime glucagon to the patient's diabetes regimen, early morning hypoglycemic episodes should subside, and almost normal blood sugar should be maintained throughout the day. As will be appreciated by those skilled in the art, s. c. A dose equivalent of glucagon or i. v. Dose-equivalent glucagon can also be administered in the same manner as insulin (eg, transdermally through a patch or cream).

(D. Insulin by inhalation [including transpulmonary, buccal, nasal, and sublingual])
This example differs from Example 1. except that the patient administers insulin by inhalation rather than by subcutaneous injection. A. Same as i. It will be appreciated by those skilled in the art that when insulin is administered orally, nasally, or sublingually according to these methods, a similar method applies, but dose equivalent amounts apply. The The patient continues to administer the patient's basal requirement via GLARGINE (LANTUS) or administers the basal insulin requirement using an insulin inhaler. Patients use an insulin inhaler (either transpulmonary, nasal, buccal, or sublingual) at mealtime (equal between 5 and 10 units administered by subcutaneous administration) Administer insulin requirements.

  According to these methods, the patient is then given 45 micrograms of glucagon (subsequently using Lilly's Glucagon kit) 2 hours after the meal and twice more thereafter every hour. To do. This patient will receive glucagon subcutaneously. Example 1. A. As described in i, this provides the required protection from hypoglycemia between 2 and 5 hours. As will be appreciated by those skilled in the art, the glucagon can also be administered via inhalation in dose equivalent amounts. As will be appreciated by those skilled in the art, the exact amount of glucagon administered can vary and can be determined for various amounts of insulin via the method shown in Example 8 below.

(Example 2. Simultaneous administration of glucagon by insulin and pump for the control of diabetes and prevention of hypoglycemia)
In one embodiment, insulin can be administered by a pump according to the method of the invention. There are many pumps in the US and abroad that are available (or will soon be available) as commercial products suitable for use with the method of the present invention. These include, but are not limited to:
ANIMAS (IR-1000 and IR-1200)
・ DELTEC (Cozmo pump)
・ DISETRONIC (H-TRONplus and D-TRONplus)
・ LIFESCAN & DEBIOTECH (under development of MEMS insulin pump)
・ MEDRONIC MINIMED (PARADIGM insulin pump and 508 insulin pump)
・ MEDRONIC MINIMED (2007 implantable insulin pump system (EU only))
If both insulin and glucagon are to be administered by a pump (from separate reservoirs), a number of configurations can be used in the practice of the method of the invention. A typical configuration is as follows:
(1) A single device with a single pump and two reservoirs where each drug is delivered through two separate lines that are integrated prior to cannulation (for example, U.S. Pat. No. 5,474,552);
(2) A single device with a single pump and two reservoirs, where each drug is delivered through two separate lines, each independently cannulated;
(3) A single device with two independent pumps and two reservoirs where each drug is delivered through two lines integrated prior to cannulation;
(4) A single device with two independent pumps and two reservoirs where each drug is delivered through two separate lines, each independently cannulated;
(5) each drug is delivered through two separate lines integrated prior to cannulation, two devices each comprising a single pump and one reservoir; and (6) each drug is Two devices, each with a single pump and one reservoir, delivered through two separate lines that are independently cannulated.

  It will be appreciated by those skilled in the art that other structures are possible and that implementations of embodiments of the invention are not limited to the devices and device structures listed above. For example, an implantable pump can be used in much the same way as is accomplished using an external pump.

  The above embodiment (1) minimizes trauma to the patient during cannulation, reduces costs, simplifies infusion, and minimizes complexity. In this embodiment, a single pump can be programmed to deliver the appropriate volume from each reservoir, each containing one of two hormones of different concentrations. Examples of such pumps are provided herein.

  In a typical insulin pump, an internal pump mechanism typically delivers such drugs to the patient to pump the drug out of an internal storage chamber (reservoir) and through a delivery line and then via a cannula or microcannula. In order to do this, an electromagnetically driven pulsation pump having a piston actuated by a solenoid mounted for reciprocation in the cylinder is provided.

  Delivery lines for use with pump insulin are typically 0.5 to 1 meter in length and lumen diameters are on the order of 1 / 10th of a millimeter (dead volume is 1 / 10th of a milliliter) The time lag between the arrival of a new drug and the start of pump infusion can be substantial (about half a day).

  To reduce this delay, one embodiment provides a pump with a line that is significantly shorter and / or has a very small lumen diameter that can significantly reduce the time lag between drug switches. To do. The present invention also provides a peristaltic pump that operates on two delivery lines.

  One embodiment provides a system comprising a pump and a set of four valves, two immediately before the pump and two immediately after. This valve, when operated in pairs, controls which drug is pumped out. In one embodiment, the two lines are integrated at the time of cannulation, thereby eliminating the misalignment or (dead volume) time. The extra space required for an electronically operated microvalve is minimal, adds little volume and expense, and can be assembled using commercially available devices. Further possibilities including the use of less than 4 valves are described below.

  An economical pumping system suitable for use in some of the methods is a micropump known as MEMS (Micro-Electro-Mechanical System) and has been developed for diabetes by Debiotech under the trade name Chronojet. The use of two such micropumps in a single device adds little volume and only minimal cost to existing designs. As mentioned above, the two delivery lines are integrated (in the sense that the two drugs are in direct contact) where they pierce the skin and connect to a cannula or similar microneedle device used to deliver the drug. obtain.

  In one embodiment, a single lumen split (two lumens) line is used instead of two physically separate lines. This method has the advantage that the patient only needs to go through one flexible delivery line instead of two. Alternatively, two standard lines physically attached along their entire length can be used in accordance with some embodiments of the method to provide the same advantages.

  Thus, in one embodiment, the pump is a currently used insulin pump modified to have two drug reservoirs instead of one, each of these drug reservoirs being a single Independently (or two) pumps and a single control system for managing the dose and relative timing of the two drugs. As described above, the device may include one, two, or four valves and a suitable connecting tube in some embodiments. A schematic of a device that can be used in accordance with some of the methods is shown in FIGS. In FIG. 3, the insulin reservoir (1) and the glucagon reservoir (2) have lines that are in fluid communication with the pump (3), pass through four valves (6) and (7), and have a lumen It leads to the cannula (5) via the divided delivery line (4). When valve (6) opens and valve (7) closes, only insulin is pumped out. When valve (6) closes and valve (7) opens, only glucagon is pumped. In this way, a single pump can be used to deliver insulin or glucagon to the patient simultaneously or separately, dividing the lumen where the liquid only mixes with the cannula (ie at the time of delivery) The advantage of delivery through a separate delivery line minimizes mixing of the two substances. In FIG. 4, the insulin reservoir (1) and the glucagon reservoir (2) have a line in fluid communication with the pump (3), via two valves (6) and (7), the lumen is It leads to the cannula (5) via the divided delivery line (4). These are two-way valves that can be opened by either the insulin or glucagon pathway (but only one at a time). A small amount of mixing of the two fluids occurs in a small area of the line through the pump, but this is insignificant when compared to a typical pumping volume. Thus, glucagon and insulin can be delivered to the patient in this line with minimal mixing and dead space. The advantage of this structure over the described structure disclosed in FIG. 3 is that only two valves are required for operation. In FIG. 5, this configuration is similar to that disclosed in FIG. In this case, however, the two valves (6) and (7) are integrated into a single device with a single actuation mechanism. Thus, this mechanism is kept as cheap and simple as possible, and only one valve and one pump is required to achieve the desired result.

  Setting the pump to deliver basal levels of insulin, and manually interrupting to administer mealtime insulin as needed, is the normal practice for patients to use pump-delivered insulin. is there.

  In one embodiment, glucagon delivery is automatically administered over an appropriate period of time (eg, continuously between 3 hours and 5 hours after a manual command to deliver mealtime insulin). The control logic necessary to produce such a sequence of events can be programmed into the pump.

(A. Insulin administered by pump)
This example illustrates how some of the methods can be performed using pump-based administration. A typical hypothetical patient is an adult male who is 35 years old and weighs 75 kg, has been suffering from type 1 diabetes since the age of 15 and has been using insulin therapy since diagnosis. This patient had previously received many different insulin regimens, but glycemic control was not optimal. In the last five years, this patient began to develop severe nonproliferative retinopathy, mild renal failure, and hypertension, improving glycemic control from the current glycated hemoglobin levels of 7.8% of this patient There is concern that these complications will continue to progress rapidly unless possible. Until recently, the patient had taken ULTRALENTE 22 units at bedtime and 4-8 units of LISPRO insulin just before each meal and snack. The dose of ULTRALENTE is adjusted to provide basal supplementation of insulin, but the dietary LISPRO dose varies with general pre-injection serum glucose and the total caloric and carbohydrate content of each meal.

  Capillary blood glucose was automatically monitored by glucometer 4-6 times a day, but this patient's blood glucose control is often unstable, from high values in the range of 200 mg / dl to occasional hypoglycemia fluctuate. In the previous year, the patient had 3 severe hypoglycemic attacks with coma or near-coma. Two happened at work and the other one after a handball game. All needed help from another person and, after exercise, intramuscular administration of glucagon by a medical assistant was required.

  When using insulin pump therapy, short acting insulin is typically used because the pump provides a continuous supply and simulates basal insulin over a long period of time. In this example, the patient uses ASPART (NOVOLOG) as the optimal insulin for the patient. Pumps, reservoirs, and control mechanisms (in this case, MEDTRONIC MINIMED PARADIGM INSULIN PUMP) can be attached to various parts of the patient's body (most commonly, for example, on a belt) A flexible plastic tube into a microcannula inserted into the abdomen, thigh, or arm (men tend to choose the upper abdomen, whereas women tend to make the injection site the lower abdomen) Connected by

  The patient is programmed so that the device delivers 1 IU of insulin (20 units per day) every 50 minutes. If the patient eats during the day, the patient releases an amount of insulin (between 3 and 8 units) appropriate to the patient's dietary status (pre-meal glucose, total calories, and carbohydrate content). To program. The patient does this by pressing the appropriate button on the device (or by using a remote control device, if available) to select the required insulin bolus size.

  After using a programmable insulin infusion pump, the patient can achieve a significant improvement in glycemic control, with a pre-meal glucose level of 70-110 mg / dl and a post-meal (1-2 hours) level of 120-160 mg / dl The glycosylated hemoglobin is 6.4%. However, the patient continues to suffer from frequent mild to moderate hypoglycemic episodes that they often do not recognize until they measure fingerstick glucose. Many of these low glucose values are in the range of 30-40 mg / dl. The patient's wife and friends sometimes say that the patient behaves inappropriately but is improved by eating food or juice.

  Due to the long duration of type 1 diabetes and frequent hypoglycemia that is often unrecognized, this patient is deficient in glucagon, has severe impairment of glucose counter-regulation, and the epinephrine response to hypoglycemia is significantly weakened. ing. That is, the patient is unable to initiate an effective response to abnormally low blood glucose and the attendant risks that may result. In addition, this patient is unaware of hypoglycemia, which frequently accompanies recurrent hypoglycemia and increases the risk of developing severe hypoglycemia. Because the patient's body's mechanism of recognizing low blood glucose is incomplete, the patient is unaware when blood glucose is dangerously low. This is a common scenario with long duration diabetes, and it most commonly appears when efforts to achieve normal or near-normal glycemic control are attempted in such individuals. Due to concerns about increased frequency and the severity of hypoglycemic episodes and the inability of this patient to recognize them frequently, this patient "relaxes" glycemic control to reduce low blood glucose Seriously thinking. The patient understands that this may have adverse consequences, including increased microvascular complications, but feels that the risk of severe hypoglycemia is greater and more pressing ing.

  This hypothetical patient is based on the understanding that as long as the patient's all-day glycemia approaches levels that are not diabetic, the risk of developing microvascular complications is minimized. Strive to achieve control. Despite adopting the most advanced and flexible form of insulin delivery system currently available and achieving a significant improvement in glycemic control relative to the recommended goal, this patient has frequent and potential hypoglycemia Annoyed by dangerous seizures. In order to alleviate this situation and further allow the patient to maintain the same level of glycemic control, the methods provided herein are used, and in one embodiment, a second pump device (Which may be the same as the first device, but with a glucagon cartridge instead of an insulin cartridge) is used. This device can be independently cannulated and controlled independently for continuous subcutaneous infusion of glucagon as needed.

  In one embodiment, the patient is instructed to do as follows. After having a meal, the patient is administered insulin (3-8 units) at the same time, and at the same time, the glucagon pump is programmed to administer 162 μg glucagon per hour subcutaneously for 3 hours. Time is adjusted to begin 2-3 hours after administration of insulin. In one embodiment, the above instructions are included in a kit comprising a composition for the control of hypoglycemia. In this example, Example 1. A. Unlike ii, continuous release of glucagon results in a smooth profile with less peak appearance and decay period than a single subcutaneous injection of glucagon. By increasing the availability of glucagon during the patient's most prone hypoglycemia period, both the likelihood and severity of such events are substantially reduced. To offset the glucose rise potential of subcutaneously administered glucagon, the dose of insulin injected can be increased to maintain normoglycemia during the period of glucagon administration. By administering glucagon in this way, the patient is provided with sufficient glucagon to act as a cushion or buffer against the uncompetitive effects of insulin to prevent the risk of hypoglycemic episodes. Thus, administration of glucagon allows the patient to maintain excellent glycemic control without the excessive risk of frequent severe hypoglycemia.

(B. Insulin administered parenterally)
In one embodiment, glucagon is administered by a pump and insulin is administered parenterally (including by pump or other subcutaneous administration). In one embodiment, a pump suitable for insulin administration is also suitable for glucagon administration. Insulin was prepared in Example 1. A. It can be administered parenterally as described in i. However, Example 1. A. Rather than injecting glucagon as described in i, the pump is programmed (or activated) to deliver glucagon continuously between 2 and 5 hours after the meal. The total amount of glucagon released is about 121 to 324 millimeters over the 3 hour period, which is sufficient to provide protection from hypoglycemia.

(C. [Including patch and topical cream] transdermally administered insulin)
In one embodiment, insulin can be administered transdermally in the practice of the invention. Example 1. According to C, the patient administers the patient's insulin requirement by using a transdermal patch (or cream). However, patients do not administer glucagon parenterally as described in the examples, but use an insulin pump (containing glucagon instead of insulin) to administer glucagon early in the morning. Prevent hypoglycemia. Before going to bed, the patient should be administered 50 to 120 millimetres subcutaneously during the time the pump is between 01:00 and 02:00 (the period during which this patient is most prone to hypoglycemia). Program to deliver the glucagon. By doing so, the patient can maintain normoglycemia using the method of embodiments of the present invention without the risk of hypoglycemia during sleep.

(D. [Insulin administered by inhalation, including transpulmonary, buccal, nasal, and sublingual])
Example 1. A. According to i, the patient administers insulin by inhalation rather than by subcutaneous injection. It will be appreciated by those skilled in the art that similar methods can be used when insulin is administered orally, nasally, or sublingually. Patients continue to administer their basal requirements via GLARGINE (LANTUS) or administer basal insulin requirements using an insulin inhaler. The patient uses an insulin inhaler to deliver the patient's dietary insulin requirement (equal between 5 and 10 units administered by subcutaneous administration) (transpulmonary, nasal, buccal, or tongue) (Underly). However, Example 1. A. Instead of injecting glucagon as described in i, an insulin pump (containing glucagon rather than insulin) should deliver glucagon subcutaneously continuously between 2 and 5 hours after meal Program (or activate). The total amount of glucagon released is between 121 and 500 millimeters over the three hours, which is sufficient to protect the patient from hypoglycemia during the most prone period.

Example 3. Simultaneous administration of mixed glucagon and insulin by pump for diabetes control and prevention of hypoglycemia
Some embodiments of the methods of the invention can also be practiced using pump-based administration of a mixture of both insulin and glucagon. This method provides protection from hypoglycemia that is directly proportional to the amount of insulin used that is inherently delayed. This also supplements basal levels of glucagon throughout the day and especially after meals. It is also administered with basal insulin administered by a pump. This embodiment is currently available and can be implemented using the standard pump described in Example 2. One difference is that the insulin cartridge used contains a mixture of insulin and glucagon (optionally modified release glucagon) (the glucagon component is between 41 and 96 mU, the desired protection) (Administered each time (prevention of hypoglycemia)). In some embodiments, the amount of glucagon administered subcutaneously is about 6 ng / kg per minute of desired protection to about 20 ng / kg per minute of desired protection, and in some embodiments 12 ng / kg / min.

  The insulin / glucagon mixture is then administered by pump (for both basal and mealtime insulin). The resulting glucagon (modified glucagon) plasma concentration is entered on the insulin profile (including the attenuation characteristics of the glucagon variant used). This is illustrated in FIG. This method provides protection from hypoglycemia over the sensitive period required. In one embodiment, the pump comprises a glucose sensor (see US Pat. No. 5,474,552).

Example 4. Oral co-administration of glucagon and insulin for diabetes control and prevention of hypoglycemia
Oral delivery of large molecules (eg, proteins) is well known in the art. Typically this involves enteral administration (see US Pat. No. 5,641,515). In one embodiment, a similar method is used to deliver glucagon orally. In a typical scenario using oral delivery of a mixture of insulin and glucagon, the patient takes an enteric tablet containing insulin suitable for his meal up to 1 hour before the meal. The insulin component is designed to start quickly once it begins to release. The glucagon component is designed to release after the insulin component (in one embodiment, after 2-3 hours). If necessary, a modified glucagon with a long half-life can be used to ensure that the glucagon level has increased over time. When administered in this way, glucagon is timed accurately and appropriately to prevent hypoglycemia. In another embodiment, the patient administers insulin using any of the methods described herein to prevent hypoglycemia, eg, with each meal, as needed, with glucagon pills. Is administered.

Example 5. Composition for glucagon suspension and method of characterizing it
This example is one composition of one embodiment of the present invention that has been found to be useful for the preservation of glucagon, and the desired degree of the composition for preserving glucagon against glucagon. Fig. 4 illustrates a method of one embodiment of the present invention for verifying that it provides stability. GlucaGen® was mixed at 200 μg / mL and 500 μg / mL in 5% mannitol in water for injection in an infusion pump cartridge. This solution was kept at 30 ° C. for the set duration. After the set duration, the pH and remaining glucagon% were tested. The remaining glucagon% was determined by HPLC analysis. The results are shown below in Table 2 for 200 μg / mL GlucaGen® and in Table 3 for 500 μg / mL GlucaGen®. The results were obtained from 3 sets of tests and this data was averaged ± s. e. m. Represent as

調製の時点において全ての溶液は、透明かつ無色であった。これらの溶液は、適合性研究を全体を通して、透明かつ無色なままであった。可視的な粒子は、観察されなかった。かなりの量のグルカゴンが、高濃度および検査した時間（２４時間を含む）の全てにおいてでさえ、このマンニトール溶液中に残存する。さらに、より高い濃度のグルカゴンは、残りのグルカゴンのより高い相対的％をもたらした。したがって、この組み合わせは、グルカゴンを有用な期間維持するのに十分であるようである。

All solutions were clear and colorless at the time of preparation. These solutions remained clear and colorless throughout the compatibility studies. Visible particles were not observed. A significant amount of glucagon remains in this mannitol solution even at high concentrations and all of the times examined (including 24 hours). Furthermore, the higher concentration of glucagon resulted in a higher relative percentage of the remaining glucagon. Thus, this combination appears to be sufficient to maintain glucagon for a useful period of time.

Example 6. Composition for Glucagon Suspension and Method for Characterizing It
This example illustrates the composition of one embodiment of the present invention and one method by which such a composition can be analyzed to determine the lifetime of a glucagon solution, which glucagon solution is active use ( I.e., "use"). Samples of 200 μg / mL and 500 μg / mL Glucagon Infuseate in 5% mannitol solution were prepared. Approximately 3 mL aliquots of each Glucagon Infuseate sample were added in triplicate to individual cartridges. The cartridge was inverted 10 times and a 0.5 mL aliquot was removed from each for HPLC analysis as “Time Zero”. The filled cartridge was placed on a Platform Shaker set at 50 RPM and incubated at 30 ° C. for 24 hours. At 3, 6, 9, 12, and 24 hours, these cartridges were removed from the oven, inverted 10 times, and 0.5 mL aliquots were dispensed from each for HPLC analysis. Appearance and pH were also recorded at each time point.

  All solutions were clear and colorless at the time of preparation. These solutions remained clear and colorless throughout the compatibility studies. Visible particles were not observed. Further results are shown in Tables 4 and 5.

５０ＲＰＭにおける継続的な振盪によって、５％マンニトール中の２００μｇ／ｍＬのＧｌｕｃａＧｅｎ（登録商標）は、３０℃で１２時間保存した後に、２５％のグルカゴンの喪失を示し、そして３０℃で２４時間保存した後に、２５％のグルカゴンの喪失を示した。５％マンニトール中の５００μｇ／ｍＬのＧｌｕｃａＧｅｎ（登録商標）は、２４時間に対して、７％の喪失を示した。したがって、より低い濃度（例えば、２００μｇ／ｍＬ）のグルカゴンによってでさえ、かなりの量のグルカゴンが、長期間の後に溶液中に残存する。さらに、より大きい濃度のグルカゴンは、処方物の活発な２４時間の振盪を経た後でさえ、より安定な処方物を生じるようである。

By continuous shaking at 50 RPM, 200 μg / mL GlucaGen® in 5% mannitol showed 25% loss of glucagon after storage at 30 ° C. and was stored at 30 ° C. for 24 hours. Later, it showed a 25% loss of glucagon. 500 μg / mL GlucaGen® in 5% mannitol showed 7% loss over 24 hours. Thus, even with lower concentrations (eg, 200 μg / mL) of glucagon, a significant amount of glucagon remains in solution after an extended period of time. Furthermore, higher concentrations of glucagon appear to yield more stable formulations even after vigorous 24 hours of shaking of the formulation.

In one embodiment, glucagon and variants thereof are stored at high concentrations. The high concentration can be, for example, greater than 100 micrograms / mL. In one embodiment, the high concentration is 200 μg / mL or higher, 200-300 μg / mL, 300-400 μg / mL, 400-500 μg / mL, 500 μg / mL, 500-600 μg / mL, 600-800 μg / mL, 800 μg. Glucagon / mL or greater (to the limit of saturation (or supersaturation)). In one embodiment, the less active form of glucagon is stored at a higher concentration. This allows greater stability of the glucagon solution and allows a larger volume of glucagon solution to be administered to the recipient (Example 7. Very low dose (VLD) glucagon is an insulin-treated diabetic patient). Can be used for high blood glucose in
This example demonstrates the effectiveness of applying a low dose of glucagon to a patient via a specific route of administration to raise the patient's blood glucose level. This example describes a clinical trial examining the level of glucagon required to increase blood levels of glucagon and glucose. As explained in more detail below, these results indicate that the methods of some embodiments of the invention can be used to avoid insulin-induced hypoglycemia.

(A. Glucagon from 0.8 ng / kg / min to 4 ng / kg / min)
Six patients with type 1 diabetes were stabilized overnight at a blood glucose level of 90-120 mg / dl during a nocturnal titration period. Stabilization of blood glucose levels in this range of 90-120 mg / dL was achieved using doses of insulin that generally varied between 0.65 units / hour and 1.4 units / hour.

  The next morning, these patients were given glucagon subcutaneously in the range of 0.8-4.0 ng / kg / min by a continuous infusion pump. (Specific doses are 0.8 ng / kg / min, 1.6 ng / kg / min, 2.4 ng / kg / min, 3.2 ng / kg / min and 4.0 ng according to the patient's normal dose of insulin. / Kg / min glucagon). Each dose level within this range was infused in 2-3 hours. Under this lower dose (0.8-4.0 ng / kg / min) of glucagon, there was no obvious consistent trend in glucagon or glucose levels in these patients.

(B. 8 ng / kg / min to 16 ng / kg / min glucagon)
After experiencing a nocturnal titration period in which the patient's blood glucose level was maintained between 90 mg / dl and 120 mg / dl, 6 patients were dosed with glucagon in the range of 8-16 ng / kg / min. Glucagon was administered subcutaneously by a continuous infusion pump. The specific doses administered were 8 ng / kg / min, 12 ng / kg / min and 16 ng / kg / min (each dose level was infused at 3 hours). The patient was maintained at the patient's standard basal level of insulin by continuous subcutaneous pumping prior to glucagon administration.

  In 3 patients, a 9 hour subcutaneous infusion of 12 ng / kg / min glucagon resulted in increased plasma glucagon levels lasting 6-8 hours in the range of 100-200 pg / ml (see FIG. 8). thing). The peak average plasma level at a dose of 12 ng / kg / min was 185 pg / ml. These patients' blood glucose levels also increased substantially (see FIG. 9). This clearly showed that a sustained, very low dose of glucagon could be efficiently administered to the patient over an extended period of time with the desired result of controllably increasing blood glucose levels.

  Two patients were treated with subcutaneous glucagon for 16 hours at 16 ng / kg / min. In both subjects, dosing at 16 ng / kg / min resulted in a peak plasma glucagon level that was higher than the peak plasma glucagon level achieved by the 12 ng / kg / min peak plasma glucagon level (see FIG. 8). thing). In both subjects, this peak level was achieved during the first 3 hours of infusion and then tended to decrease to the level observed at the 12 ng / kg / min dose. At the 16 ng / kg / min dose level, this peak average plasma level was approximately 254 pg / mL. Despite the decrease in glucagon levels during the second half of the infusion, glucose levels remained increased throughout the course of the infusion (see FIGS. 8-11). Glucose levels achieved at the 16 ng / kg / min dose were generally higher than those achieved at the lower dose of 12 ng / kg / min (see FIG. 9).

  The above subjects were generally maintained at a basal rate of insulin subjects throughout the fasting evaluation period. The administered insulin varied between patients and over time from 0.5 to 1.8 units per hour. Glucose levels began to rise as early as 30 minutes after initiating glucagon infusion. On average, this increase persisted throughout the glucagon infusion.

  These results indicated that very low doses of continuously administered glucagon could be used to increase blood glucose levels in insulin-treated patients who do not experience hypoglycemia.

  These data indicate that administration of doses of glucagon in the range of 8-16 ng / kg / min results in increased plasma glucagon levels in the range of about 100-200 + pg / mL, and these levels are maintained for a significant period of time Supported that could be done. The normal reference range for glucagon is 50-150 pg / mL. As will be appreciated by those skilled in the art, these results provide that glucagon's low and continuous dosing can increase blood glucose levels in diabetic patients and thus prevent hypoglycemia in those patients Indicates to do. These results indicate the amount of glucagon required to induce increased blood glucose levels. One of ordinary skill in the art will be able to use lower glucagon doses to prevent hypoglycemia in other patients, while the 8 ng / kg / min dose and higher doses exemplified herein prevent hypoglycemia. Recognize that it is effective. The actual minimum amount may vary from patient to patient, and a given disclosure of the present invention, one of ordinary skill in the art can readily determine that this minimum amount is for a particular patient.

  Interestingly, the levels achieved in the examples of the present invention with VLD glucagon in an amount of 12-16 ng / kg / min are the levels observed in non-diabetic patients in response to experimentally induced hypoglycemic conditions. It is the same.

The following examples show how these doses of glucagon are hypoglycemic even in the presence of insulin challenge (ie, the dose of insulin that otherwise induces hypoglycemia in the patient). (Example 8. Prevention of insulin-induced hypoglycemia by glucagon)
This example shows that insulin-induced hypoglycemia (for this example, blood glucose below 50 mg / dl) can be prevented by low doses of continuously administered glucagon. This study was set up in three visits. The first visit included increasing the amount of insulin administered to the subject without supplying any glucagon; the blood glucose level of the subject was monitored. This first study defined the insulin load required to induce hypoglycemia in these patients. In the next two visits, two different doses of glucagon were administered to these patients and their blood glucose levels were monitored and glucagon was otherwise induced by an insulin load. It was determined whether any hypoglycemia was prevented or delayed. Therefore, by comparing the glucose level measured in the first examination with the glucose level measured in the latter two examinations, it can be determined whether glucagon prevented hypoglycemia.

  During the first visit, the basal insulin rate for each subject was increased by 50% every 90 minutes (eg, 1.5 units per hour for 90 minutes from a basal rate of 1.0 units / hour. Titration upwards (to unit, up to 2.0 for 90 minutes, up to 2.5)) to induce hypoglycemia (blood glucose below 50 gm / dl). The result for one patient is shown in FIG. 12 together with the examination 1 represented by a square. The lower set of lines traces the increase or decrease in insulin administered to the subject. Dosing insulin was returned to the basal rate of infusion (and dosing glucose) after 12:30; therefore, a spike after 12:30 should be expected. Blood glucose levels could vary between 50 mg / dL and 350 mg / dL. Glucose levels below 50 mg / dL were considered indicative of hypoglycemia.

  During Visits 2 and 3, the subject will determine whether the dose prevents insulin-induced hypoglycemia or delays the time for the onset of hypoglycemia observed in the first outpatient To determine this, we received continuous infusions of various doses of glucagon (starting at 7:00 am and ending around 4:00 pm). Since the onset of effects on glucose levels is approximately 60-90 minutes, glucagon infusion was initiated one hour before intensifying insulin infusion.

  Two different doses (8 ng / kg / min (triangle) and 16 ng / kg / min (circle)) of glucagon were examined. The results of these low dose sequential glucagons on blood glucose levels are shown in FIG. As shown in FIG. 12, the 8 ng / kg / min dose of glucagon (triangles) maintained higher levels of blood glucose compared to the study that did not receive glucagon. Again, the control line (no glucagon, increasing insulin only, square) ends efficiently at 12:30; no insulin is administered after this point on the graph, so the comparison is 7: Should be made between 00 and 12:30. Hypoglycemia was delayed by about 2 hours.

  As shown in FIG. 12, a dose of 16 ng / kg / min (circles) substantially exceeded the control level and even exceeded the blood glucose level beyond the glucagon dose of 8 ng / kg / min (triangle). Maintained. Furthermore, a dose of 8 ng / kg / min prevented hypoglycemia and was able to maintain blood glucose levels above 50 mg / dL, while a dose of 16 ng / kg / min is closer to 100 mg / dL Blood glucose levels were maintained. This shows the usefulness and dose dependence of both of these ranges.

  These lines in the lower part of the graph (ie, triangles, squares, and circles shown below the 50 mg / dl line in FIG. 12) represent the steps in insulin infusion over the time of this study. Thus, the lower square line indicates the insulin level during Visit 1, and the lower circle line and the lower triangle line are between Visit 3 and 2 respectively. Insulin levels during are shown.

  In another patient, the effect of the 8 ng / kg / min dose was not as obvious as the effect shown in FIG. This patient therefore requires a higher dose or infusion rate to prevent hypoglycemia. This is shown by the 16 ng / kg / min dose data, which is similar to that shown in FIG. 12 for the first patient (ie, increased blood glucose levels above 200 mg / dl). )showed that.

  In addition to the glucagon levels tested above, the effectiveness of lower levels of glucagon was also tested using a similar protocol. In another patient examined, the above experiment was repeated with a lower dose (4.0 ng / kg / min) of glucagon and a slightly lower upper limit of insulin (1.5 times the basal rate of insulin). . These results are shown in FIG. As can be seen in the graph, an increase in BRI during the first visit (diamonds) resulted in lower blood glucose levels (squares) while 4 ng / kg / min in the second visit Administration of glucagon (asterisk) helped maintain increased blood glucose levels ("X") and delay the decrease in blood glucose levels even when insulin levels increased (circles). In this patient, the presence of glucagon at 4.0 ng / kg / min was sufficient to prevent and prevent hypoglycemia, otherwise elevated levels of insulin induced hypoglycemia. It was.

  In addition to the above identified benefits from administering low doses of glucagon to prevent hypoglycemia, there appears to be a long-term benefit to this dosing schedule for glucagon administered subcutaneously. Blood glucose levels remained elevated even after the administered glucagon was discontinued (see the portion after 4:00 pm in FIG. 12). Thus, continuous administration of glucagon is not required to maintain long-term increased blood glucose levels.

  The above methodology can be used to determine the appropriate amount of glucagon to administer to a particular patient. For example, testing a patient taking a larger amount of insulin (eg, 2-10 units, 10-20 units, 20-30 units or more insulin per hour) in this manner may be used to reduce the Appropriate dosing regimens for glucagon can be determined to prevent blood glucose. In the above example, the amount of insulin is increased from 1.5 times to about 2.5 times. In one embodiment, the amount of glucagon is increased in proportion to the increase in the amount of insulin, after which whether the new glucagon dose is corrected to prevent hypoglycemia (via the methodology described above). )decide. In this manner, an appropriate dosage of glucagon for a particular patient can be determined. One skilled in the art can recognize that this correlation need not be 100% proportional and that some routine experimentation can be useful in optimizing the final value. Thus, the above example of determining a dosing schedule can be used to understand how often glucagon actually needs to be administered. In some embodiments, in addition to constant administration, glucagon is 99% -90%, 90% -80%, 80% -60%, 60% -40%, 40% -20%, 20%- Administered for 10%, 10% to 1% or less time.

  As will be appreciated by those skilled in the art, variations in the method of administration (eg, patches, inhalation, topical creams, IV, etc.) can also be examined using this methodology. Furthermore, as will be appreciated by those skilled in the art, this methodology can be modified to determine the appropriate timing of administration of glucagon to a patient. For example, the glucagon may be administered one hour before the insulin level is adjusted and may be increased to 90 minutes or less or decreased to 45 minutes or less (eg, good control of glucose blood levels). To determine whether or not to be maintained). As will be appreciated by those skilled in the art, the time of administration and the method of administration may affect the dosage requirements. Therefore, the importance of various additives can also be examined by the above methodology.

Example 9. Determine the amount of VLD glucagon for prevention of hypoglycemia
This example describes a clinical trial to show that glucagon administered according to the methods of the present invention plays a desired role in maintaining a desired blood glucose level. This method also provides a means of determining the optimal ratio of insulin to glucagon for administration to a particular patient to prevent insulin-induced hypoglycemia.

  Subjects report in the evening and have a standard meal at about 1700-1800 hours. The subject is instructed to bolus the subject's normal dose of insulin with the subject's pump based on the carbohydrate calculation. At 2000 o'clock, another pump (pump 2) is started with saline infused at the same rate as insulin infusion on the opposite side of the abdomen. From around 2200 hours the subject is fasted and at CSII's normal basal dose of the subject by CSII. Plasma glucose is confirmed using YSI every hour throughout the night (or more often if necessary). This plasma glucose is adjusted to the rate of basal insulin and, if necessary, the use of IV 5% dextrose (if this plasma glucose decreases below 90 mg / dl) and the use of IV insulin (subject's plasma To maintain between about 100 mg / dl and 125 mg / dl (if glucose increases above 160 mg / dl).

  From 0700 hours to 0800 hours, baseline blood samples were drawn and tested for plasma glucose levels, free fatty acid levels, ketone body levels, glucagon levels and insulin levels. At 0800, the subject receives twice the subject's normal basal dose of insulin via the subject's insulin pump 1 to induce control of hypoglycemia. With Anima Pump 2, the subject receives VLD glucagon on the opposite side of the abdomen. The dose of glucagon administered will be individualized based on previous studies. The selected dose is the highest dose that does not cause hyperglycemia (> 180 mg / dl) in each individual study subject.

  From 0800 hours to 1200 hours, blood and YSI plasma glucose are determined. Blood is also drawn every 15-30 minutes from 0800 hours to 1200 hours to measure free fatty acid levels, ketone body levels, glucagon levels and insulin levels. Despite receiving much higher insulin than the basal dose via CSII (insulin continuous subcutaneous infusion), plasma glucose levels in these study subjects offset the glucose lowering effect of the higher basal dose of insulin. Is not reduced to hypoglycemic levels (<60 mg / dl). If during this study it is found that the subject's plasma glucose begins to decrease and consistently drops below 90 mg / dl (the two occur in succession), continuous glucagon infusion The dose is titrated in 25% increments to counteract this decrease in plasma glucose. On the other hand, if the subject's plasma glucose begins to increase and rises above 25% in 1 hour, the glucagon infusion dose is titrated down 25% to counter this increase in blood glucose. . Therefore, this study shows that a small amount of glucagon and insulin combination can prevent insulin-induced hypoglycemia. Both the insulin and the glucagon can be administered subcutaneously.

  With the above methodology, various forms of glucagon formulations and methods of administration can also be tested. Thus, the optimal timing and mode of delivery for glucagon or glucagon mimetics or variants, or formulations thereof can be determined. These methods can be used to test the suitability of other hypoglycemic and hyperglycemic substances for the methods and compositions disclosed herein.

(Example 10. Preventing hypoglycemia at night)
This example is effective, for example, in preventing nocturnal hypoglycemia, where the glucagon composition, glucagon variant composition, or formulation thereof is blunt insulin-induced in humans. One way to show this is shown. In addition, this example provides a method for testing the effectiveness of either glucagon or a variant or formulation of glucagon to prevent nocturnal hypoglycemia.

  Two hours after the standardized dinner (around 1800 o'clock), the subject receives twice the subject's standard dose of insulin to induce the development of nocturnal hypoglycemia via the first pump. At 2200 h, the subject receives an infusion of glucagon via a second pump (CSI). Thereafter, blood glucose levels are monitored throughout the night. The appropriate dose of glucagon prevents blood glucose levels from decreasing to hypoglycemic levels. Both glucagon and insulin can be administered subcutaneously.

(Example 11. Administer low dose of glucagon to prevent loss of awareness of hypoglycemia)
To prevent loss of hypoglycemic awareness in subjects who take insulin, glucagon from 5 ng / kg / min to about 16 ng / kg / min is used to reduce the level of hypoglycemia where blood glucose levels are undesirable (eg, Administered to the subject subcutaneously to prevent entry (less than 50 mg / dL). To determine that the dose administered is sufficient, to ensure that the blood glucose level does not fall below a certain point (eg, less than 50 mg / dL) in the subject, It can be measured throughout the various time points during the test period. Such tests can also be used to optimize the dose of glucagon administered to the patient. Glucagon administration is long-term (ie, throughout the prophylactic administration of low doses of glucagon), and patients avoid hypoglycemia and thus are low because of repeated episodes of hypoglycemia due to long-term use of insulin. Does not develop consciousness of blood sugar.

(Example 12. Administer low dose of glucagon to restore awareness of hypoglycemia)
Identify patients suffering from loss of hypoglycemic awareness by screening to determine if they can identify when their blood glucose level falls below 70 mg / dl blood glucose Can do. Once identified, an appropriate dose of glucagon is then administered subcutaneously to the subject to prevent blood glucose levels from falling to a certain level (eg, less than 50 mg / dL, for example). And in one embodiment, the dose is 8-16 ng / kg / min.

  Blood glucose levels can be obtained throughout various time points to determine that the subject's glucose levels have not dropped to the extent of hypoglycemia. These measurements can also be used to optimize the amount of glucagon administered to the patient. With this glucagon administration, the patient experiences fewer hypoglycemic episodes and the patient's awareness of hypoglycemia improves. The patient's awareness of hypoglycemia, as described above, can determine whether the patient can identify when the patient's blood glucose level is below a certain degree (eg, 70 mg / dl). Test by making a decision.

  Different doses, different forms of formulations, and different methods of application (administration) to determine whether the optimal dose or formulation or method of administration is optimal for the prevention of hypoglycemia All can be tested using the above methodology.

Example 13. [Including patch and topical cream] Simultaneous administration of insulin and transdermal glucagon for diabetes control and prevention of hypoglycemia
The use of transdermal patches for the delivery of therapeutic agents is becoming increasingly common. Patches provide a non-invasive and simple way to deliver a drug into the bloodstream. Nicotine and hormone replacement therapy is probably the best known use of this technique. One feature of drug delivery by transdermal patches is that the rate of delivery is usually constant and lasts for a long period (as long as the patch is worn). This feature has been found to be beneficial in the fields of pain management (FENTANYL) and nicotine replacement therapy where a long-term flat profile is ideal. This feature makes the transdermal patch suitable for basal supplementation of insulin or glucagon. See PCT Patent Publication No. WO0243566 (incorporated herein by reference).

  Fast-acting patches are also known. Transdermal delivery of proteins (especially insulin) into the bloodstream in much less than 1 hour has been reported in US Pat. No. 5,707,641, incorporated herein by reference. The ability to deliver other proteins using similar formulations in the same manner is also detailed. Thus, glucagon can be administered in this manner.

  Insulin patch development is currently underway by Canada's Helix BioPharmacia, where Phase II trials are currently underway, and Germany's IDEA. The IDEA technology (TRANSFEROME®) relates to transporting large molecules such as peptides through the epidermal barrier. FIG. 6 shows the case of penetration (upper and lower gray curves for larger or smaller lipophilic substances, respectively) or TRANSFERROME®-mediated penetration (black lines and black circles). Illustrates the effect of molecular weight and lipophilicity on the rate of transdermal transport. Gray bullets correspond to over-the-counter drugs in transdermal patches. Regardless of technology, the ability to deliver peptides efficiently transcutaneously has been proven and imminent. In particular, both insulin and glucagon can be delivered transdermally, thus providing some embodiments of the present invention implemented using transdermal patches and similar devices.

  The various possible structures and matrices of the patch can be utilized in a particular type selected according to the specific mode of intended use. For example, two basic types of insulin matrices (for basal insulin supplementation and for mealtime insulin supplementation) can be used. Glucagon patches can be prescribed to provide post-prandial glucagon for protection from hypoglycemia, or basal glucagon supplementation. In one embodiment, the present invention can be implemented using a patch matrix that includes a combination of these basic types, either together in the same matrix or separately in a sub-matrix.

Thus, the following patch matrix may be useful in the practice of some embodiments:
A matrix containing insulin for basal insulin supplementation;
A matrix containing insulin for insulin supplementation during meals;
A matrix containing glucagon for basic glucagon supplementation;
A matrix containing glucagon for postprandial protection from hypoglycemia;
A matrix containing insulin for dietary insulin supplementation and glucagon for postprandial protection from hypoglycemia;
A matrix containing insulin and glucagon for basal supplementation of both insulin and glucagon; and a matrix consisting of two or more auxiliary matrices, each auxiliary matrix being one of the matrices described above.

  As an alternative to patches, topical creams can be used.

  For a mealtime insulin matrix, short acting insulins such as LISPRO (HUMALOG), ASPART (NOVOLOG), or GLULISINE (APIDRA) may be used. A mealtime insulin matrix is usually applied at mealtimes or some time before mealtimes, depending on the rate of its start. A mealtime insulin patch with minimal time to start can be used to apply the patch at approximately mealtime. The time to start depends on the insulin concentration and nature of the formulation. For example, a simple wet matrix of insulin is slower onset than an insulin patch formulated according to US Pat. No. 5,707,641. Monomeric insulin acts faster and is more readily absorbed than larger clusters of insulin molecules because the size of the molecule affects bioavailability from the transdermal patch.

  Many different ways of managing delivery of mealtime insulin can be utilized. For example, different concentrations of patches can be used for a period of time, with the concentration selected by the patient depending on the amount of carbohydrates ingested. The time for wearing the patch can also be fixed. Patches are not necessarily depleted when removed, i.e. they may deliver a constant concentration from the beginning to the end of their use. As another example, a single concentration of a meal patch can be used as follows. The time that the patch is worn varies depending on the amount of carbohydrates ingested. When a patch is removed, it is not necessarily exhausted. That is, it may deliver a constant concentration from the beginning to the end of its use.

  As another example, a meal patch containing a fixed dose of insulin can be used. The advantage of a self-consumable patch is that failure to remove it does not create the risk of hypoglycemia by itself. Such a patch is substantially depleted at the time of removal, and the rate of injection will be brought forward. In one embodiment, the mealtime insulin patch used has a variable insulin concentration (suitable for the amount of carbohydrates ingested), is very quick to start (preferably immediate, at most 1 hour), constant It is removed or deactivated after a time (preferably between 3 and 5 hours) and activated at mealtime (or at a later time than 1 hour before mealtime). A meal glucagon patch is applied at a meal time or at a certain time after a meal, depending on the start rate for the patch. The rate of initiation is determined by both the concentration of glucagon used and the nature of the formulation used. For example, a simple wet matrix of glucagon is expected to start later than a glucagon patch formulated according to the technique described in US Pat. No. 5,707,641.

  In one embodiment, the glucagon patch is constructed so that the glucagon release peak is reached at some time between 2 and 5 hours after application. This patch is applied at mealtimes. The amount of glucagon in this patch is sufficient to deliver to the patient, and the amount is from 5 ng / kg / min to 30 ng / kg / min consisting of glucagon administered subcutaneously, and even more preferably Is equivalent to 8 ng / kg / min to 16 ng / kg / min consisting of glucagon administered subcutaneously.

Many different patch structures can be used. These include the following:
A patch containing a single matrix or a series of auxiliary matrices within a single compartment;
A patch containing two or more separate compartments, each containing its own matrix or series of auxiliary matrices (this patch is activated or deactivated as a single unit), and Patch containing two or more separate and independent compartments, each containing its own matrix or series of auxiliary matrices, each compartment being activated or deactivated independently.

  Other patch configurations may be used and implementations of the invention are not limited to the configurations described above.

(A. Insulin administered transdermally [including patches and topical creams])
(I) [Including patch and topical cream] Insulin administered transdermally and insulin administered by subcutaneous injection In this example, only dietary insulin and dietary glucagon were administered by transdermal patch Is done. This can be accomplished in various ways including: (i) the use of a single matrix of mixed glucagon and insulin; (ii) two auxiliary matrices (one containing insulin and one Use of a single compartment comprising two compartments (one containing insulin and the other containing glucagon) (both compartments simultaneously containing glucagon) Activated or inactivated); and (iv) the use of two separate patches (or two compartments within a single patch) (one containing insulin and the other containing glucagon) (each Patches or compartments are activated or deactivated independently). Basal insulin is obtained by subcutaneous injection of a long acting insulin such as GLARGINE or ULTRALENTE according to Example 1. A. Delivered parenterally as described in i. In one embodiment, method (i) is used. If different matrices are used to achieve the desired pharmacokinetics, method (ii) or (iii) can be used. Method (iv) may be used when the timing of insulin start and glucagon start is misaligned.

  In this illustrative example, method (ii) above is used. The user activates the meal patch at mealtime (or preferably within 1 hour before mealtime), so that both auxiliary matrices are activated simultaneously. If a constant concentration patch is used, the user removes the patch after a period proportional to the amount of carbohydrates ingested. If a variable concentration patch is used, the user removes the patch after a period of time, usually between 1 hour and 3 hours after a meal. In one embodiment, a constant concentration is used. In such embodiments, the amount of glucagon administered can be increased with the amount of insulin administered.

(Ii) Insulin administered transdermally [including patches and topical creams] In this example, both insulin and glucagon are administered transdermally. Two different types of patches (or independently operated compartments) may be utilized. One patch (or compartment) contains a matrix designed to replenish basal insulin over a 24 hour period. Contains both mealtime insulin and glucagon in a separate supplemental matrix suitable for applying mealtime patches (or activating mealtime compartments) at mealtime (or near mealtime) start time A single patch (or compartment) may be used.

  In one embodiment, a single device containing four independently actuable compartments is used. One contains basal insulin and is activated when applied and remains active for 24 hours. The other three compartments contain mealtime insulin and glucagon in separate auxiliary matrices within the same compartment, each compartment is activated separately at mealtime, inactivated at some time after meals, and the activation time is , Proportional to the amount of carbohydrates ingested.

  At the start of a meal (or some time up to an hour before the meal), the patient can remove one of these meal compartments [eg, by pulling off a hermetic plastic seal between the patch and the skin]. Once activated, this process initiates transdermal injection of insulin and glucagon. At some later time (a period that is directly proportional to the amount of carbohydrates ingested) [for example, by replacing the barrier used to activate the compartment, or completely removing the compartment from the edge of the patch By] the mealtime compartment is deactivated. The insulin formulation in the insulin supplement matrix is a short acting insulin and this patch is designed for rapid initiation. Since the glucagon formulation in the glucagon auxiliary matrix is designed to reach an effective concentration in the blood stream between 1 and 3 hours after compartment activation, Example 13. A. Provides protection from hypoglycemia at the appropriate part of the cycle as described in i.

  In an alternative embodiment, a single device that allows for three or more meals per day can be easily devised by taking into account three or more mealtime compartments. In an alternative embodiment, as described above, the meal drug can be contained in a completely separate (independently activated) meal patch. In an alternative embodiment, the dietary patch can consist of separate insulin and glucagon compartments so that each can be activated and deactivated independently.

  A single device containing separate and independently controlled compartments for insulin and glucagon can have seven separate compartments, one for basal insulin, three for mealtime insulin, Three are for glucagon at mealtime. The basal patch is designed to replenish basal insulin (change after wearing for 24 hours). The insulin used can be any insulin suitable for transdermal delivery. The basal insulin compartment may also optionally contain a sufficient amount of glucagon (mixed or in an auxiliary matrix) to supply basal glucagon over each 24 hour period. This has the beneficial effect of protecting against hypoglycemia throughout the day, especially during sleep.

  The amount of glucagon in the patch is sufficient to deliver to the patient, and the amount is from 5 ng / kg / min to 30 ng / kg / min consisting of glucagon administered subcutaneously (eg, subcutaneously Equivalent to 6 ng / kg / min to 20 ng / kg / min consisting of glucagon administered, and for another example 8 ng / kg / min to 16 ng / kg / min consisting of glucagon administered subcutaneously) . It may be present when larger amounts of glucagon, greater than or equal to 0 units to 3 units of insulin are administered. For example, larger amounts of glucagon may be present when 3 to 20 units of insulin are applied in 1 hour. Alternatively, the same amount of glucagon is present regardless of the amount of insulin.

(B. [Insulin administered by inhalation, including transpulmonary, buccal, nasal, and sublingual])
In this example, insulin is delivered by inhalation as described above. Inhalation can be used only for meal insulin delivery applications (basal delivered parenterally) or all insulin can be delivered by inhalation. The patient administers an amount of insulin suitable for the patient's diet by inhalation (in one or more manipulations). The patient can increase her insulin as needed after a meal, if necessary.

  Glucagon was prepared according to Example 13. A. Administer by patch described in i. The patch (or series of glucagon compartments in a single patch) is attached to the skin and the patch or (sub-compartment) is activated at mealtime. Since glucagon need only be present in the body in an effective amount after 2 hours, the patch is designed to be delayed onset. The patch is removed after 4 hours of wear, but the glucagon remaining in the body is sufficient to provide protection from hypoglycemia over the required period of 2-5 hours.

  In one embodiment, as described herein, the glucagon in the patch is a long acting glucagon (eg, iodinated glucagon). The protection afforded by the modified glucagon is still reliably provided over the required period of 2-5 hours, but here the patch may be worn for a shorter time in some embodiments.

  In another embodiment, the user can apply glucagon by a transdermal cream that acts like a transdermal patch (at least about 8 ng / kg / min to 16 ng / kg / min consisting of glucagon administered subcutaneously). Can be administered by this cream). Such cream formulations may differ from the formulations used within the patch, but may serve essentially the same function. When glucagon is administered in this way, it may be advantageous to encapsulate glucagon in liposomes or TRANSFEROME® to prevent the supply of glucagon that is dry on the skin and has reduced bioavailability.

(C. Insulin administered parenterally)
Example 1. A. According to i, the patient's insulin requirements are met by parenteral administration. Glucagon was prepared according to Example 13. A. Administer by patch as described in i. Patches (or a series of glucagon compartments within a single patch) are attached to the skin, and these patches or (sub-compartments) are activated during the meal. Since glucagon need only be present in the body in an effective amount after 2 hours, the patch is designed to be delayed onset. The patch is removed after 4 hours of wearing, but the glucagon remaining in the body is sufficient to provide protection from hypoglycemia over the required period of 2-5 hours.

  In one embodiment, as described herein, the glucagon in the patch is a long acting glucagon (eg, iodinated glucagon). The protection afforded by the modified glucagon is still reliably provided over the required period of 2-5 hours, but here the patch may be worn for a shorter time.

  In an alternative embodiment, the user may apply glucagon by a transdermal cream that acts like a transdermal patch. Such cream formulations may differ from the formulations used in patches, but serve essentially the same function. When glucagon is administered in this way, it may be advantageous to encapsulate the glucagon in liposomes or TRANSFEROME® so that the glucagon does not dry on the skin and does not reduce bioavailability.

(D. Insulin administered by pump)
In this example, the patient's insulin requirement is administered by a pump as described in Example 2. Glucagon was prepared according to Example 13. A. Administer by patch as described in i. Patches (or a series of glucagon compartments within a single patch) are attached to the skin and these patches or (sub-compartments) are activated during the meal. Since glucagon need only be present in the body in an effective amount after 2 hours, the patch is designed to be delayed onset. The patch is removed after 4 hours of wearing, but the glucagon remaining in the body is sufficient to provide protection from hypoglycemia over the required period of 2-5 hours.

  In one embodiment, as described herein, the glucagon in the patch is a long acting glucagon (eg, iodinated glucagon). The protection afforded by the modified glucagon is still reliably provided over the required period of 2-5 hours, but here the patch may be worn for a shorter time.

  In an alternative embodiment, the user may apply glucagon by a transdermal cream that acts like a transdermal patch. Such cream formulations may differ from the formulations used in patches, but serve essentially the same function. When glucagon is administered in this way, it may be advantageous to encapsulate glucagon in liposomes or TRANSFEROME® so that glucagon does not dry on the skin and does not reduce bioavailability.

(Example 14)
([Including pulmonary, buccal, nasal, and sublingual] co-administration of glucagon with insulin and inhalation to control diabetes and prevent hypoglycemia)
A number of dry powder inhalation technologies are currently under development and include: Aradigm's AERx®, Inhale Therapeutics Exubera®, Alkermes and Eli Lilly's AIR, Insulin Technologies (Mankind / PDC), and Aerogense from Aerogen and Destronic. Methods and devices for delivering insulin to the alveoli, where it can be absorbed into the bloodstream, are described in US Pat. Nos. 5,997,848, 6,131,567, 6,024. No. 090, No. 5,970,973, No. 5,672,581, No. 5,660,166, No. 5,404,871, and No. 5,450,336. Are listed. The main problems that had to be overcome to enable aerosol macromolecule delivery were as follows: low system efficiency (bioavailability); low drug mass / inhalation (compare asthma) ; And insufficient dosing reproducibility.

  One related factor is efficiency (bioavailability). Bioavailability depends primarily on the aerosol particle size rather than the nature of the drug being administered (most existing systems only deliver 10% to 20% of the drug administered to the alveoli. Absent). When the drug delivered actually reaches the alveoli, its bioavailability is very high, almost independent of the drug in question. Since the technical problems (and solutions) related to delivering insulin are similar to those for delivering glucagon, solutions that enable delivery of insulin are similar to those like glucagon Can be applied directly to macromolecules of size. One embodiment provides a dry powder formulation prepared by mixing insulin and glucagon. The use of an inhaler to deliver insulin is primarily aimed at supplying rapid insulin for meal purposes. Long acting insulin may be delivered by inhalation if desired.

  Some embodiments may be implemented using an inhaler in a number of ways, including: with insulin and glucagon in separate inhalers; mixed at a constant ratio in one inhaler Using a dual chamber inhaler with insulin and glucagon administered separately; using a dual chamber inhaler with insulin and glucagon administered simultaneously. Meal inhalers usually contain rapid acting insulin and are therefore unsuitable for delivery of basal insulin (insulin pump). If both mealtime insulin and basal insulin are to be delivered by inhalation, separate pumps or chambers may be provided.

(A. Insulin administered by inhalation [including transpulmonary, buccal, nasal, and sublingual)
The hypothetical patient uses ULTRALENTE to administer basal insulin by subcutaneous injection at a dosage level of 20 units administered at bedtime. Alternatively, the patient may choose to administer the same drug by inhalation (at a dose that will provide 20 units of daily bioavailability). It may also be beneficial or desirable for the patient to administer a basal dose several times during the day, for example by inhaler at meal time in addition to bedtime. Since there is a slight delay (about 20 minutes) before insulin achieves a significant serum concentration when compared to subcutaneous delivery, the user administers a meal insulin requirement about 20 minutes before eating. To do. The patient does this by administering between 25 and 50 units of insulin (assuming about 20% bioavailability) by metered dose inhaler.

  The inhaler may be dose variable (US Pat. Nos. 5,970,973, 5,672,581, 5,660,166, 5,404,871, And see US Pat. No. 5,450,336), which may be similar to currently used asthma devices that deliver a predetermined dose during each operation. Regardless of which type is used, it may be desirable to administer insulin in multiple operations. By doing so, the patient “supplements” the dose at some point after the start of the meal, adjusting the inhalation according to the amount of carbohydrate this patient actually consumes rather than the expected amount of this patient's diet Can do. In addition, inhalation administration tends to vary with manipulation, and delivery with multiple manipulations has an averaging or smoothing effect, so the more manipulations used to administer insulin, the corresponding dose confidence. (Reproducibility) is improved.

  To prevent hypoglycemia associated with the use of inhaled insulin that occurs between 2 and 5 hours after a meal, using a glucagon inhaler, between 2 and 5 hours after the meal Of glucagon administered by inhalation of 5 ng / kg / min to 16 ng / kg / min. c. A dose equivalent of glucagon is administered. In one embodiment, different inhalers for each type of insulin and different inhalers for glucagon are used. In one embodiment, a single inhaler capable of independent operation is used, comprising at least two drug chambers (for mealtime insulin, glucagon, and / or basal insulin as needed).

(B. Insulin administered parenterally)
Example 1. A. According to 1, patients administer basal and dietary insulin parenterally. Since the hypoglycemia risk associated with the use of LISPRO insulin usually occurs between 2 and 5 hours after meals, 6 ng / kg between 2 and 5 hours after meals using a glucagon inhaler / Min to 16 ng / kg / min (ie, the effect on blood glucose with glucagon administered subcutaneously from 6 ng / kg / min to 16 ng / kg / min and the amount by inhalation to achieve the same effect) s. c. A dose equivalent of glucagon is administered. Alternatively, a delayed-onset, long-acting modified glucagon (eg, glucagon iodide) is used in a glucagon inhaler and administered at meal time with mealtime insulin.

(C. Insulin administered by pump)
Example 2 According to A, basal and mealtime insulin is delivered by a pump. Since the risk of hypoglycemia occurs after 2 to 3 hours, the patient administers glucagon by inhaler 2 hours after the meal. The patient administers 1 puff from a metered dose inhaler at 2 hours, 3 hours, and 4 hours, thereby providing protection during a sensitive period. The dose per operation is s.d. in the amount of 5 ng / kg / min or more to 16 ng / kg / min. c. Corresponds to dose equivalent. Alternatively, a delayed-onset, long-acting modified glucagon (eg, glucagon iodide) is used in a glucagon inhaler and administered at meal time with mealtime insulin.

(D. Insulin administered transdermally, including patches and topical creams)
Example 3 A. According to ii, the patient administers insulin (both basal and at mealtime) by transdermal patch or by topical cream. Since the risk of hypoglycemia occurs after 2 to 3 hours, the patient administers glucagon by inhaler 2 hours after the meal. The patient administers 1 puff from the metered dose inhaler at 2 hours, 3 hours, and 4 hours, thereby providing protection during the sensitive period. The dose per operation is s.d. in the amount of glucagon from 5 ng / kg / min to 16 ng / kg / min. c. Corresponds to dose equivalent. Alternatively, a delayed-onset, long-acting modified glucagon (eg, glucagon iodide) is used in a glucagon inhaler and administered at meal time with mealtime insulin.

Example 15. Mixed parenteral glucagon and insulin co-administration for diabetes control and prevention of hypoglycemia
In Example 1, insulin and glucagon were administered parenterally separately. In one embodiment of the invention, the two drugs are administered simultaneously in mixed form. Both insulin and glucagon can be mixed with little, if any, interaction or degradation. In non-diabetic people, after a carbohydrate diet, after an increase in insulin release, concomitantly increases glucagon release (actually an initial increase in blood glucose induced by the intestine after carbohydrate intake) (Recovery of release after initial decline in glucagon release due to) is usually known. This pattern of insulin production followed by glucagon production exhibits a relatively fixed relationship.

  (To prevent hypoglycemia between 2 and 5 hours after a meal at a dose equivalent of 5 ng / kg / min to 30 ng / kg / min) Equivalent glucagon is required if desired To ensure that it provides protection over time, the amount of glucagon component in the mixture can be increased so that it is present at the required concentration. Alternatively, delayed onset glucagon formulations can be used. In one embodiment, the glucagon formulation is delayed release and sustained release [eg, delayed by 2 to 3 hours and released over about 3 hours or more]. For example, any of the formulations discussed herein can be used.

  This example uses an iodination method (as described in US Pat. No. 3,897,551; see Form I3G) that increases half-life. LISPRO insulin and I3 glucagon modified glucagon are present at about 1.5% based on the weight of insulin in the mixture (to keep the insulin concentration per ml constant in the inventors) Are mixed. Due to the longer lasting effect of the modified glucagon, the ratio of glucagon (by weight) to insulin needs to be smaller.

  The hypothetical patient then administers an insulin-glucagon formulation between 5 and 10 units (measured with respect to the insulin contained therein) at meal time in a standard manner. In doing so, this patient has a s.d. c. A dose equivalent of modified glucagon is administered. Given the longer action of the modified glucagon, this is similar to Example 1. Provides the same protection as described in A (assuming that the modified glucagon has, for example, twice the effect on glucose levels compared to standard glucagon). Glucagon administered in this way is effective continuously between the required 2 and 5 hours.

Example 16: Simultaneous administration of mixed transdermal glucagon and insulin [including patch and topical cream] for diabetes control and prevention of hypoglycemia
In this example, both insulin and glucagon are administered by transdermal delivery. Meal insulin and glucagon are mixed in the same matrix or cream. Two different types of patches (or independently operated compartments) can be used. One patch (or compartment) will contain a matrix designed to replenish basal insulin for 24 hours. This patch has a s.d. of 5 ng / kg / min to 20 ng / kg / min. c. An amount of glucagon may be included to deliver a dose equivalent of glucagon to the patient. The other patch (or independently controlled compartment) is used in Example 3. A. Functions as described in i and provides dietary glucagon and insulin within a single matrix. When the patch is activated, the glucagon and insulin start times are combined so that insulin reaches effective plasma levels very rapidly, whereas glucagon finally reaches effective levels after 2-3 hours. The patch is applied at meal times, preferably up to 1 hour before meals.

  In one embodiment, four independently operable compartments (one containing basal insulin, activated upon application and left active for 24 hours, the other three compartments within the same matrix Contains insulin and glucagon at meal time, each compartment is activated separately at meal time (or almost at meal time), inactivated at some time after meal, and the time of activation is consumed carbohydrates A single device is used which is proportional to the amount of When starting a meal (or up to 1 hour before the meal), the patient activates one of these mealtime compartments (eg, by pulling off the sealed plastic seal between the patch and the skin) This process initiates a transdermal infusion of mixed insulin and glucagon. At some later time (a period that is directly proportional to the amount of carbohydrates ingested) (for example, by replacing the barrier used to activate the compartment, or completely removing the compartment from the edge of the patch) The mealtime compartment is deactivated.

  The combined insulin and glucagon formulation in the mealtime compartment contains short acting insulin, and this patch is designed for rapid onset of insulin. The glucagon component is designed to reach an effective concentration in the bloodstream between 1 and 3 hours after activation of the component, thus protecting against hypoglycemia in the appropriate part of the cycle. provide.

  In an alternative embodiment, a single device containing three or more mealtime compartments may be used, allowing for three or more meals per day. Basal patches are designed to replenish basal insulin (change after 24 hours of wearing). The insulin used can be any insulin suitable for transdermal delivery. It is more convenient to use an intermediate duration insulin than a short acting insulin, as the relatively long life of the insulin used will minimize fluctuations in insulin absorption during the life of the patch. There is a possibility. The basal insulin compartment may also optionally contain a sufficient amount of (mixed) glucagon to supply basal glucagon over each 24 hour period. This has the beneficial effect of protecting against hypoglycemia throughout the day, especially during sleep.

Example 17. Simultaneous administration of mixed insulin and glucagon by inhalation [including pulmonary, buccal, nasal, and sublingual delivery] for diabetes control and prevention of hypoglycemia
Embodiments of the invention provide methods and pharmaceutical compositions for delivery by inhalation of glucagon mixed with insulin. In this example, a long-acting glucagon (eg, glucagon iodide as described in US Pat. No. 3,897,551 (eg, I2G or protamine zinc glucagon), etc. is mixed with LISPRO insulin, Delivered by a typical insulin inhaler (eg, as disclosed in patent US Pat. No. 5,970,973) Basal insulin is delivered in a standard manner by subcutaneous injection as described in Example 1A. Glucagon may optionally be included in this formulation of sustained release formulation as needed to provide basal glucagon supplementation.

  The insulin powder used has a modified glucagon content of from 5 ng / kg / min to 20 ng / kg / min, and preferably from 8 ng / kg / min to 16 ng / min for 1 to 3 units of insulin used. s. between kg / min. c. Mixed with modified glucagon to be dose equivalent. Larger proportional amounts of glucagon can be used when larger amounts of insulin are used (but the amount of glucagon can remain constant regardless of the amount of insulin used). This amount can be adjusted as needed in light of the previous examples for this particular embodiment. The patient administers combined insulin and glucagon at mealtime and provides systemic insulin equal between 5 and 10 units.

  Although the invention has been described in detail with reference to specific embodiments, those skilled in the art will recognize that modifications and improvements are within the scope and spirit of the invention as set forth in the claims that follow. You will understand. All publications and patent literature cited herein are hereby incorporated by reference (as if each individually indicated that such publication or document is incorporated herein by reference). Include in the book. Citation of publications and patent literature is not intended to acknowledge that any such document is pertinent prior art, and does not give any approval as to its content or date. The definitions provided herein dominate the listed references or definitions found elsewhere. Although the present invention has been described with reference to the specification and examples, those skilled in the art can implement the present invention in various embodiments, and the foregoing description and examples are illustrative. It will be appreciated that the invention is for the purpose of, and is not intended to limit the scope of the following claims.

FIG. 1 is a graph illustrating the ideal pharmacokinetics of a mixture of regular insulin and medium time acting (Lente or NPH) insulin. FIG. 2 is a very simple, flat line graph interrupted by a peak corresponding to a branded LISPRO (HUMALOG) insulin injection as described in Example 1, Part A (i) ( FIG. 4 is a graph illustrating an hypothetical patient insulin profile showing a basal level given by GLARGINE (LANTUS). FIG. 3 is a schematic diagram of a drug delivery pump set up for implementation of the embodiment described in Example 2. FIG. 4 is a schematic diagram of a drug delivery pump set up for implementation of the embodiment described in Example 2. FIG. 5 is a schematic diagram of a drug delivery pump set up for implementation of the embodiment described in Example 2. FIG. 6 shows the case of penetration (top and bottom gray curves for larger or smaller lipophilic substances, respectively), or the case of penetration mediated by TRANSFEROME® (black lines and black circles). FIG. 5 is a diagram illustrating the influence of molecular weight and lipophilicity on the rate of transdermal transport. Dot-shaped black circles correspond to commercially available drugs for transdermal patches. FIG. 7 shows a very simple and flat for both drugs, interrupted by the peak corresponding to when glucagon and insulin are administered in a mixed formulation (corresponding to mealtime insulin and glucagon infusion). FIG. 6 is a graph illustrating a hypothetical patient insulin and glucagon profile as described in Example 3, showing a line graph (basal insulin and glucagon infusion). FIG. 8 is a graph showing the effect of continuous glucagon infusion on mean glucagon levels as described in Example 7. FIG. 9 is a graph showing the effect of continuous glucagon infusion on average glucose levels as described in Example 7. FIG. 10 is a graph comparing the effect of continuous glucagon infusion at 12 ng / kg / min on average glucose levels and average glucagon levels as described in Example 7. FIG. 11 is a graph comparing the effect of continuous glucagon infusion at 16 ng / kg / min on average glucose levels and average glucagon levels as described in Example 7. FIG. 12 shows the effect of various glucagons (0 ng / kg / min, 8 ng / kg / min, and 16 ng / kg / min glucagon) on increasing insulin levels (about 1 unit to about 2.7 units). It is a graph to compare. This graph shows that low doses of glucagon can prevent insulin-induced hypoglycemia, as described in Example 8. FIG. 13 is a graph showing the effect of low doses of glucagon on blood glucose levels as described in Example 8 and how it can prevent hypoglycemia.

Claims (26)

A pharmaceutical formulation comprising:
An amount of insulin effective to control diabetes; and an amount of glucagon effective to prevent hypoglycemia in humans or other mammals;
Wherein the pharmaceutical formulation is configured to be administered subcutaneously, and the ratio of insulin to glucagon is about 1 unit insulin to between 40 milliunits and 200 milliunits of glucagon. Pharmaceutical formulation. 2. The pharmaceutical composition of claim 1, wherein the amount of glucagon is between about 50 milliunits and 100 milliunits. 2. The pharmaceutical composition of claim 1, wherein the glucagon is a long acting form of glucagon. 4. The pharmaceutical composition of claim 3, wherein the long acting form of glucagon comprises iodine. 4. The pharmaceutical composition of claim 3, wherein the long acting form of glucagon comprises zinc. 6. The pharmaceutical composition of claim 5, wherein the long acting form of glucagon further comprises protamine. A method of treating diabetes in humans or other mammals without inducing hypoglycemia, the method comprising:
Administering insulin in a therapeutically effective amount for the control of diabetes, wherein the insulin is an amount of insulin between 0.5 and 20 units of insulin; and hypoglycemia Administering glucagon in a therapeutically effective time and amount for the prevention of gut, wherein the glucagon is administered subcutaneously and the amount of glucagon administered is greater than 5 ng per kg patient per minute A desired glucagon effectiveness between 1 and 100 ng or less,
Including the method. 8. The method of claim 7, wherein the amount of glucagon administered is between 6 ng and less than 18 ng of desired glucagon effectiveness per kg patient per minute. 8. The method of claim 7, wherein the glucagon is a glucagon having a long duration of action. 8. The method of claim 7, wherein the glucagon is included in a liposomal formulation. The method of claim 7, wherein the glucagon is contained in a microsphere. 8. The method of claim 7, comprising administering a formulation comprising both insulin and glucagon. 8. The method of claim 7, wherein the insulin and glucagon are included in a pump that controls administration of a drug to a patient. 14. The method of claim 13, wherein the glucagon is administered concurrently with insulin. 15. The method of claim 14, wherein the ratio of glucagon to insulin is about 40 milliunits or more to 200 milliunits of glucagon to 1 unit insulin. 16. The method of claim 15, wherein 2 units of insulin are administered. 8. The method of claim 7, wherein 10 units of insulin are administered and between 30 and 90 ng glucagon per kg patient per minute is administered subcutaneously. A kit for administration of an amount of glucagon and insulin to prevent hypoglycemia, the kit comprising:
Glucagon;
Insulin, wherein the glucagon and insulin are in a ratio of 1 unit to 20 units insulin to 32 milliunits to 480 milliunits glucagon;
Means for administering glucagon subcutaneously; and instructions for administering insulin and glucagon so that the glucagon prevents hypoglycemic events;
A kit comprising: 19. The kit of claim 18, wherein the concentration of glucagon completely dissolved in the glycerin solution is greater than 500 micrograms per milliliter but less than 2000 micrograms per milliliter. 19. The kit of claim 18, wherein the glucagon and insulin are in a ratio of 1 unit to 3 units insulin to 32 milliunits to 96 milliunits glucagon. 19. The means for administering glucagon subcutaneously is a pump, and the pump is configured to deliver between about 6 ng / kg / min and 20 ng / kg / min glucagon. The described kit. Use of glucagon in combination with insulin in the preparation of a medicament for the treatment of diabetes, wherein glucagon is used in an amount sufficient to prevent the development of hypoglycemia and the ratio of glucagon to insulin is 40 micrograms Use above and below 500 micrograms of glucagon versus 1 unit to 20 units of insulin. 23. Use according to claim 22, wherein the amount is sufficient to prevent the development of unconscious hypoglycemia. 24. Use according to any of claims 22 and 23, wherein the amount of insulin is between 1 and 20 units and the amount of glucagon is between 41 and 200 millimeters. 24. Any of claims 22 and 23, wherein the ratio of insulin to glucagon is between 1 and 3 units and the amount of glucagon is between greater than 40 milliunits and less than about 96 milliunits. Use of description. 26. Use according to any one of claims 22 to 25, wherein the glucagon further comprises protamine.

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