Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K38/00—Medicinal preparations containing peptides
  • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
  • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
  • A61K38/22—Hormones
  • A61K38/28—Insulins
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
  • A61K47/50—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient the non-active ingredient being chemically bound to the active ingredient, e.g. polymer-drug conjugates
  • A61K47/51—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient the non-active ingredient being chemically bound to the active ingredient, e.g. polymer-drug conjugates the non-active ingredient being a modifying agent
  • A61K47/54—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient the non-active ingredient being chemically bound to the active ingredient, e.g. polymer-drug conjugates the non-active ingredient being a modifying agent the modifying agent being an organic compound
  • A61K47/545—Heterocyclic compounds
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/007—Pulmonary tract; Aromatherapy
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/007—Pulmonary tract; Aromatherapy
  • A61K9/0073—Sprays or powders for inhalation; Aerolised or nebulised preparations generated by other means than thermal energy
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/007—Pulmonary tract; Aromatherapy
  • A61K9/0073—Sprays or powders for inhalation; Aerolised or nebulised preparations generated by other means than thermal energy
  • A61K9/0075—Sprays or powders for inhalation; Aerolised or nebulised preparations generated by other means than thermal energy for inhalation via a dry powder inhaler [DPI], e.g. comprising micronized drug mixed with lactose carrier particles
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P3/00—Drugs for disorders of the metabolism
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P3/00—Drugs for disorders of the metabolism
  • A61P3/08—Drugs for disorders of the metabolism for glucose homeostasis
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P3/00—Drugs for disorders of the metabolism
  • A61P3/08—Drugs for disorders of the metabolism for glucose homeostasis
  • A61P3/10—Drugs for disorders of the metabolism for glucose homeostasis for hyperglycaemia, e.g. antidiabetics
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P5/00—Drugs for disorders of the endocrine system
  • A61P5/48—Drugs for disorders of the endocrine system of the pancreatic hormones
  • A61P5/50—Drugs for disorders of the endocrine system of the pancreatic hormones for increasing or potentiating the activity of insulin

Definitions

• the present invention relates to methods of treating diabetes and improving control of blood glucose. Specifically, the method of the present invention provides superior control of postprandial glucose levels while reducing the risk of late postprandial hypoglycemia by mimicking the insulin response kinetics of a non-diabetic individual.
• Type 1 diabetes accounts for about 10% of this number, and results from autoimmune destruction of insulin-secreting ⁇ -cells in the pancreatic islets of Langerhans. Survival depends on multiple daily insulin injections.
• Type 2 diabetes accounts for the remaining 90% of individuals affected, and the rate of prevalence is increasing. Type 2 diabetes is often, but not always, associated with obesity, and although previously termed late-onset or adult diabetes, is now increasingly manifest in younger individuals. It is caused by a combination of insulin resistance and inadequate insulin secretion.
• the basal glucose level will tend to remain the same from day to day because of an intrinsic feedback loop. Any tendency for the plasma glucose concentration to increase is counterbalanced by an increase in insulin secretion and a suppression of glucagon secretion, which regulate hepatic glucose production (gluconeogenesis and release from glycogen stores) and tissue glucose uptake to keep the plasma glucose concentration constant. If the individual gains weight or becomes insulin resistant for any other reason, blood glucose levels will increase, resulting in increased insulin secretion to compensate for the insulin resistance. Therefore the glucose and insulin levels are modulated to minimize changes in these concentrations while relatively normal production and utilization of glucose are maintained.
• basal insulin secretion wherein insulin is released in the postabsorptive state
• cephalic phase wherein insulin secretion is triggered by the sight, smell and taste of food, before any nutrient is absorbed by the gut, mediated by pancreatic innervation
• first-phase insulin secretion wherein an initial burst of insulin is released within the first 5-10 minutes after the ⁇ -cell is exposed to a rapid increase in glucose, or other secretagogues
• second-phase insulin secretion wherein the insulin levels rise more gradually and are related to the degree and duration of the stimulus and (5) a third-phase of insulin secretion that has only been described in vitro.
• Oscillations include rapid pulses (occurring every 8-15 minutes) superimposed on slower oscillations (occurring every 80-120 minutes) that are related to fluctuations in blood glucose concentration.
• Insulin secretion can be induced by other energetic substrates besides glucose (particularly amino acids) as well as by hormones and drugs.
• glucose particularly amino acids
• Type 2 diabetics typically exhibit a delayed response to increases in blood glucose levels. While normal individuals usually begin to release insulin within 2-3 minutes following the consumption of food, type 2 diabetics may not secrete endogenous insulin until blood glucose begins to rise, and then with second-phase kinetics, that is a slow rise to an extended plateau in concentration. As a result, endogenous glucose production is not shut off and continues after consumption and the patient experiences hyperglycemia (elevated blood glucose levels).
• Loss of eating-induced insulin secretion is one of the earliest disturbances of ⁇ - cell function. While genetic factors play an important role, some insulin secretory disturbances seem to be acquired and may be at least partly reversible through optimal glucose control. Optimal glucose control via insulin therapy after a meal can lead to a significant improvement in natural glucose-induced insulin release by requiring both normal tissue responsiveness to administered insulin and an abrupt increase in serum insulin concentrations. Therefore, the challenge presented in treatment of early stage type 2 diabetics, those who do not have excessive loss of ⁇ -cell function, is to restore the rapid increase in insulin following meals.
• hypoglycemia is a common result of insulin therapy often causing, or even necessitating, patients to eat snacks between meals, depending on the severity of hypoglycemia. This contributes to the weight gain often associated with insulin therapy.
• SC subcutaneous
• Absorption into the blood does not mimic the prandial physiologic insulin secretion pattern of a rapid spike in serum insulin concentration.
• alternative routes of administration have been investigated for their feasibility in improving the pharmacodynamics of the administered insulin and improving compliance by reducing the discomfort associated with SC injections.
• the alternative routes of insulin administration which have been evaluated in detail include the dermal, oral, buccal, nasal and pulmonary routes.
• Dermal insulin application does not result in reproducible and sufficient transfer of insulin across the highly efficient skin barrier.
• Effective oral insulin administration has not yet been achieved, primarily due to digestion of the protein and lack of a specific peptide carrier system in the gut.
• Nasal insulin application leads to a more rapid absorption of insulin across the nasal mucosa, however not with first-phase kinetics.
• the relative bioavailability of nasal administered insulin is low and there is a high rate of side effects and treatment failures.
• Buccally absorbed insulin also fails to mimic a first-phase release (Raz, I. et al., Fourth Annual Diabetes Meeting, Philadelphia, PA, 2004).
• the present invention provides methods of treating diabetes and yielding superior control of blood glucose levels in patient with diabetes.
• the method enables reassertion of homeostatic control of postprandial glucose levels while reducing the risk of hypoglycemia by administering an inhaled insulin composition at or shortly after the beginning of a meal which mimics the insulin release kinetics of a non-diabetic individual.
• a method of reducing postprandial glucose excursions in a patient with an insulin-related disorder comprising administering an insulin composition in a form suitable for pulmonary administration wherein the incidence of clinically relevant late postprandial hypoglycemia is reduced.
• the insulin composition is administered in proximity to beginning a meal. In one embodiment the insulin composition is administered from approximately 10 minutes prior to beginning a meal to approximately 30 minutes after beginning a meal.
• the insulin composition comprises a complex between a diketopiperazine and human insulin and the diketopiperazine is fumaryl diketopiperazine.
• the composition is administered by inhalation as a dry powder.
• the method of reducing postprandial glucose excursions in a patient with an insulin-related disorder comprising administering an insulin composition in a form suitable for pulmonary administration wherein the incidence of clinically relevant late postprandial hypoglycemia is reduced further comprises administering a long-acting basal insulin.
• the insulin-related disorder is diabetes mellitus. In another embodiment, the insulin-related disorder is type 2 diabetes mellitus. In yet another embodiment, the insulin-related disorder is type 1 diabetes mellitus.
• a method for reducing postprandial glucose excursions in a patient with an insulin-related disorder comprising administering an insulin composition in a form suitable for pulmonary administration, wherein the postprandial glucose excursions are less that the postprandial glucose excursions resulting from a dose of subcutaneously administered insulin providing substantially similar insulin exposure and wherein the mean glucose excursion is at least about 25% less than for subcutaneous administration.
• the postprandial glucose excursions are reduced from those produced by treatment with an appropriate subcutaneous dose of insulin alone.
• the frequency of episodes of clinically relevant late postprandial hypoglycemia are reduced compared to treatment with an appropriate subcutaneous dose of insulin alone.
• a method of reducing postprandial glucose excursions in a patient with an insulin-related disorder comprising administering an inhaled insulin composition comprising human insulin and fumaryl diketopiperazine in proximity to beginning a meal wherein the incidence of clinically relevant late postprandial hypoglycemia is reduced.
• the insulin composition is administered from approximately 10 minutes prior to beginning a meal to approximately 30 minutes after beginning a meal.
• the insulin- related disorder is diabetes mellitus.
• the method further comprises administering a long-acting basal insulin.
• a method of reducing postprandial glucose excursions in a patient with an insulin-related disorder being treated with basal insulin comprising administering an inhaled insulin composition comprising human insulin and fumaryl diketopiperazine in proximity to beginning a meal, wherein the incidence of clinically relevant late postprandial hypoglycemia is reduced.
• a method for reducing postprandial glucose excursions in a patient with an insulin-related disorder comprising administering an insulin composition in a form suitable for pulmonary administration wherein the patient's total insulin exposure (INS-AUC 0-y , 3 ⁇ y ⁇ 6 hours) does not substantially exceed that produced by an appropriate subcutaneous dose of insulin, and wherein postprandial glucose excursion is reduced.
• the risk of late postprandial hypoglycemia is not increased.
• Figure 1 depicts the measurement of first-phase insulin release kinetics following artificial stimulation by bolus glucose infusion.
• FIG. 2 depicts serum insulin concentration after administration of subcutaneous (SC) regular human insulin or SC fast acting insulin (NovologTM).
• SC subcutaneous
• NovologTM SC fast acting insulin
• Figure 3 depicts a composite of time-action profiles of a variety of forms of inhaled (MannKind, Pfizer/Aventis/Nektar, Alkermes, Aerogen, KOS, Novo Nordisk/Aradigm) and injected (Lispro SC) insulin from different manufacturers (from: Br J Diab Vase. Dis 4:295-301, 2004).
• Figure 4 depicts the relationship over time between serum insulin concentration and glucose elimination rate, as glucose infusion rate (GIR) under a glucose clamp, for a fast-acting subcutaneously administered insulin (SC) and a pulmonary dry powder insulin formulated with fumaryl diketopiperazine (Technosphere ® /lnsulin, Tl) according to the teachings of the present invention.
• GIR glucose infusion rate
• SC subcutaneously administered insulin
• pulmonary dry powder insulin formulated with fumaryl diketopiperazine Technosphere ® /lnsulin, Tl
• Figure 5 depicts increased postprandial glucose elimination for Technosphere ® /lnsulin (48 U Tl) versus a fast-acting subcutaneously administered insulin (24 IU SC) in individuals with type 2 diabetes mellitus- according to the teachings of the present invention.
• Figures 6A-B depict comparisons in intra-patient variability in GIR ( Figure 6A) and insulin concentration (Figure 6B) in individuals with type 2 diabetes mellitus at various time points for subcutaneous (SC) and pulmonary (Tl) insulin according to the teachings of the present invention.
• Figures 7A-B depict the mean serum insulin concentration (Figure 7A) and insulin absorption, as AUC ( Figure 7B), in individuals with type 2 diabetes mellitus at different dose levels of Tl and SC insulin according to the teachings of the present invention.
• Figure 8 depicts a comparison of insulin concentration and glucose elimination rate over time in individuals with type 2 diabetes mellitus after administration of 48 U of Tl according to the teachings of the present invention.
• Figures 9A-B depict blood insulin (Figure 9A) and glucose levels (Figure 9B) in individuals with type 2 diabetes mellitus after administration of 14 IU SC insulin or 48 U Tl according to the teachings of the present invention.
• Figure 10 depicts the improved postprandial glucose exposure with similar insulin exposure in individuals with type 2 diabetes mellitus after administration of 14 IU SC insulin or 48 U Tl according to the teachings of the present invention.
• Figure 11 depicts maintenance of the effects of inhaled insulin on postprandial glucose levels after three months of insulin therapy in individuals with type 2 diabetes mellitus with Tl or placebo (PL) according to the teachings of the present invention.
• Figures 12A-B depict total ( Figure 12A) and maximum ( Figure 12B) postprandial glucose excursion in individuals with type 2 diabetes mellitus after administration of Tl or PL according to the teachings of the present invention.
• Figure 13 depicts the dose effect on maximal postprandial glucose excursions after administration of Tl compared to the assumed dose in a control group (Control) in individuals with type 2 diabetes mellitus according to the teachings of the present invention.
• Figures 14A-B depict the insulin appearance rate over time for Tl and endogenous insulin after administration of Tl in patients with type 2 diabetes according to the teachings of the present invention
• Figure 15 depicts the relationship between insulin concentration and glucose elimination rate in individuals with type 2 diabetes mellitus after administration of intravenous (IV, 5 IU) 1 SC (10 IU) or inhaled (Tl, 100 U) insulin according to the teachings of the present invention.
• IV intravenous
• Tl inhaled
• Figure 16 depicts the levels of C-peptide after administration of Tl or SC insulin in individuals with type 2 diabetes mellitus according to the teachings of the present invention.
• Figure 17 depicts the change in mean glycosylated hemoglobin (HbAIc) levels after 12 weeks of administration of Tl or placebo in individuals with type 2 diabetes mellitus according to the teachings of the present invention.
• HbAIc mean glycosylated hemoglobin
• Figure 18 depicts weight levels in individuals with type 2 diabetes mellitus administered Tl or placebo (PL) according to the teachings of the present invention.
• Figures 19A-B depict pulmonary function, expressed as forced expiratory volume in one second (FEV1 , Figure 19A) and forced vital capacity (FVC, Figure 19B) over time in a three month placebo-controlled clinical study with Tl according to the teachings of the present invention.
• Figure 20 depicts the study schema for the clinical trial disclosed in Example 6.
• Figures 21A-B depict the baseline-corrected blood glucose concentration versus time by treatment group after administration of Tl and a isocaloric meal (Figure 21A) or a hypercaloric meal ( Figure 21 B) according to the teachings of the present invention.
• Figures 22A-B depict the baseline-corrected serum insulin concentration versus time by treatment group after administration of Tl and a isocaloric meal (Figure 22A) or a hypercaloric meal ( Figure 22B) according to the teachings of the present invention.
• Figures 23A-B depict the mean blood glucose levels (Figure 23A) or C-peptide levels ( Figure 23B) over time after administration of IV, SC or Tl (inhaled) insulin according to the teachings of the present invention.
• FIGs 24A-B depict glucose infusion rate (Figure 24A) or mean insulin concentration ( Figure 24B) over time after administration of IV, SC or Tl (inhaled) insulin according to the teachings of the present invention.
• Dry powder refers to a fine particulate composition that is not suspended or dissolved in a propellant, carrier, or other liquid. It is not meant to imply a complete absence of all water molecules.
• Early phase refers to the rise in blood insulin concentration induced in response to a meal. This early rise in insulin in response to a meal is sometimes referred to as first-phase.
• Excursion refers to blood glucose concentrations that fall either above or below a pre-meal baseline or other starting point. Excursions are generally expressed as the area under the curve (AUC) of a plot of blood glucose over time. AUC can be expressed in a variety of ways. In some instances there will be both a fall below and rise above baseline creating a positive and negative area. Some calculations will subtract the negative AUC from the positive, while others will add their absolute values. The positive and negative AUCs can also be considered separately. More sophisticated statistical evaluations can also be used. In some instances it can also refer to blood glucose concentrations that rise or fall outside a normal range. A normal blood glucose concentration is usually between 70 and 110 mg/dL from a fasting individual, less than 120 mg/dL two hours after eating a meal, and less than 180 mg/dL after eating.
• First-Phase refers to the spike in insulin levels as induced by a bolus intravenous injection of glucose. A first-phase insulin release generates a spike in blood insulin concentration that is a rapid peak which then decays relatively quickly.
• Glucose Elimination Rate is the rate at which glucose disappears from the blood and is determine by the amount of glucose infusion required to maintain stable blood glucose, often around 120 mg/dL during the study period. This glucose elimination rate is equal to the glucose infusion rate, abbreviated as GIR.
• Hyperglycemia As used herein, "hyperglycemia” is a higher than normal fasting blood glucose concentration, usually 126 mg/dL or higher. In some studies hyperglycemic episodes were defined as blood glucose concentrations exceeding 280 mg/dL (15.6mM).
• hypoglycemia is a lower than normal blood glucose concentration, usually less than 63 mg/dL 3.5 mM),.
• Clinically relevant hypoglycemia is defined as blood glucose concentration below 63 mg/dL or causing patient symptoms such as hypotonia, flush and weakness that are recognized symptoms of hypoglycemia and that disappear with appropriate caloric intake.
• Severe hypoglycemia is defined as a hypoglycemic episode that required glucagon injections, glucose infusions, or help by another party.
• proximity As used herein, "in proximity,” as used in relation to a meal, refers to a period near in time to the beginning of a meal.
• Insulin composition refers to any form of insulin suitable for administration to a mammal and includes insulin isolated from mammals, recombinant insulin, insulin associated with other molecules and also includes insulin administered by any route including pulmonary, subcutaneous, nasal, oral, buccal and sublingual. Insulin compositions can be formulated as dry powders or aqueous solutions for inhalation; aqueous solutions for subcutaneous, sublingual, buccal, nasal or oral administration and solid dosage forms for oral and sublingual administration.
• Insulin-related disorders refers to disorders involving production, regulation, metabolism, and action of insulin in a mammal. Insulin related disorders include, but are not limited to, type 1 diabetes mellitus, type 2 diabetes mellitus, hypoglycemia, hyperglycemia, insulin resistance, loss of pancreatic beta cell function and loss of pancreatic beta cells.
• Microparticles includes microcapsules having an outer shell composed of either a diketopiperazine alone or a combination of a diketopiperazine and one or more drugs. It also includes microspheres containing drug dispersed throughout the sphere; particles of irregular shape; and particles in which the drug is coated in the surface(s) of the particle or fills voids therein.
• Periprandial refers to a period of time starting shortly before and ending shortly after the ingestion of a meal or snack.
• Postprandial refers to a period of time after ingestion of a meal or snack. As used herein, late postprandial refers to a period of time 3, 4, or more hours after ingestion of a meal or snack.
• Potentiation refers to a condition or action that increases the effectiveness or activity of some agent over the level that the agent would otherwise attain. Similarly it may refer directly to the increased effect or activity. As used herein, “potentiation” particularly refers to the ability of elevated blood insulin concentrations to boost effectiveness of subsequent insulin levels to, for example, raise the glucose elimination rate.
• Prandial As used herein, "prandial” refers to a meal or a snack.
• Second-phase refers to the slow decay of modestly elevated blood insulin levels back to baseline after the first-phase has passed. Second-phase can also refer to the non-spiking release of insulin in response to elevated blood glucose levels.
• Technosphere ® /lnsulin As used herein, "Technosphere @ /lnsulin” or “Tl” refers to an insulin composition comprising regular human insulin and Technosphere ® microparticles, a drug delivery system. Technosphere ® microparticles comprise a diketopiperazine, specifically 3,6-di(fumaryl-4-aminobutyl)-2,5-diketopiperazine (fumaryl diketopiperazine, FDKP). Specifically, Technosphere ® /lnsulin comprises a FDKP/human insulin composition.
• diketopiperazine or “DKP” includes diketopiperazines and salts, derivatives, analogs and modifications thereof falling within the scope of the general Formula 1 , wherein the ring atoms E 1 and E 2 at positions 1 and 4 are either O or N and at least one of the side-chains R-i and R 2 located at positions 3 and 6 respectively contains a carboxylic acid (carboxylate) group.
• Compounds according to Formula 1 include, without limitation, diketopiperazines, diketomorpholines and diketodioxanes and their substitution analogs.
• Diketopiperazines in addition to making aerodynamically suitable microparticles, also facilitate transport across cell layers, further speeding absorption into the circulation.
• Diketopiperazines can be formed into particles that incorporate a drug or particles onto which a drug can be adsorbed. The combination of a drug and a diketopiperazine can impart improved drug stability. These particles can be administered by various routes of administration. As dry powders these particles can be delivered by inhalation to specific areas of the respiratory system, depending on particle size. Additionally, the particles can be made small enough for incorporation into an intravenous suspension dosage form. Oral delivery is also possible with the particles incorporated into a suspension, tablets or capsules. Diketopiperazines may also facilitate absorption of an associated drug.
• the DKP is a derivative of 3,6- di(4-aminobutyl)-2,5-diketopiperazine, which can be formed by (thermal) condensation of the amino acid lysine.
• Exemplary derivatives include 3,6-di(succinyl-4-aminobutyl)-, 3,6- di(maleyl-4-aminobutyl)-, 3,6-di(glutaryl-4-aminobutyl)-, 3,6-di(malonyl-4-aminobutyl)-, 3,6- di(oxalyl-4-aminobutyl)-, and 3,6-di(fumaryl-4-aminobutyl)-2,5-diketopiperazine.
• DKPs for drug delivery is known in the art (see for example U.S. Patent Nos.
• Technosphere ® /Placebo As used herein, "Technosphere ® /Placebo" refers to Technosphere ® particles which are not associated with insulin.
• Units of measure Subcutaneous and intravenous insulin dosages are expressed in IU which is defined by a standardized biologic measurement. Amounts of insulin formulated with fumaryl diketopiperazine are also reported in IU as are measurements of insulin in the blood. Technosphere ® /lnsulin dosages are expressed in arbitrary units (U) which are numerically equivalent to the amount of insulin formulated in the dosage. DETAILED DESCRIPTION OF THE INVENTION
• a common problem with insulin therapy for the treatment of diabetes is that insulin doses sufficient to control prandial glucose loads produce elevated glucose elimination rates for extended intervals that can persist after the meal, leading to postprandial hypoglycemia.
• the increase in blood levels of insulin, after subcutaneous administration, is significantly slower in diabetics than the physiologic response to prandial glucose seen in normal individuals. Therefore insulin compositions and methods which result in a more rapid rise in serum insulin levels, which then decline, result in an more physiologic means to achieve maximal glucose elimination rates.
• This has the effect of compressing the bulk of the effect of the administered insulin to the periprandial time interval thereby reducing the risks of post-prandial hypoglycemia and resulting in a more normal physiologic insulin response to prandial glucose.
• glucose elimination rate is a function of insulin concentration at that point in time.
• glucose elimination rate is potentiated by previous high insulin levels such that, for any particular insulin concentration, the glucose elimination rate is greater when the subject has experienced a high insulin concentration in a preceding time interval.
• This potentiation drives the glucose elimination rate to maximum much more quickly in response to a large and rapid peak in insulin concentration than when peak insulin concentration is approached more gradually.
• an insulin/diketopiperazine microparticle (Technosphere ® /lnsulin, Tl)
• Tl insulin/diketopiperazine microparticle
• an insulin therapy methodology that mimics first-phase kinetics can offer several advantages.
• Such insulin formulations are generally administered within a few minutes of commencing a meal, unlike more slowly absorbed insulins which are usually taken at defined period before a meal.
• the interval is generally based on the time needed to achieve maximal insulin concentration on the tacit assumption that glucose elimination rate is a function of insulin concentration.
• glucose elimination rate continues to increase throughout the plateau in insulin concentration, doses large enough to keep glucose levels from exceeding the normal range pose a risk that the resultant high glucose elimination rate hours after the meal will lead to hypoglycemia.
• mimicking physiologic mealtime or first-phase insulin release does not necessarily indicate exact replication of all features of the physiologic response. It can refer to methodologies producing a spike or peak of insulin concentration in the blood that constitutes both a relatively quick rise (less than about 15 minutes from administration or first departure from baseline) and fall (descent through half maximal by 80 minutes, preferably 50 minutes, more preferably 35 minutes after peak) in concentration. This is in contrast to methods producing a more gradual rise (from over 20 minutes to several hours) to the maximal insulin concentration achieved and a prolonged plateau at near maximal concentrations. It can also refer to methodologies in which the spike in insulin concentration can be reliably coordinated with the start of a meal.
• a methodology that mimics first-phase release is generally also one that can be practiced by diabetics upon themselves without special medical training, such as training in intravenous injection. Special medical training would not include training to use medical devices, such as dry powder inhalers, that are routinely used by persons who are not medical professionals.
• medical devices such as dry powder inhalers, that are routinely used by persons who are not medical professionals.
• “meal”, “meals”, and/or “mealtime”, etc. include traditional meals and meal times; however, these also include the ingestion of any sustenance regardless of size and/or timing.
• Superior blood glucose control can be appreciated as reduced exposure to (elevated) glucose concentrations (AUC G LU). reduced levels of HbAIc (glycosylated hemoglobin), lessened potential (risk) or incidence of hypoglycemia, reduced variability of response to treatment, and the like. Glycosylated hemoglobin levels correlate with the overall blood glucose control over the past three months. Generally one compares outcomes of different procedures at similar levels of exposure to insulin (Alices) for various time intervals. Glucose exposure and risk of hypoglycemia ultimately depends on how well glucose elimination rate matches glucose load over time. This in turn will generally depend on the shape of the insulin concentration curve rather than simply on the area under the curve. The rapid rise and fall of insulin concentration typical of physiologic first-phase response is well suited to matching glucose elimination rate to prandial glucose load.
• AUC G LU elevated glucose concentrations
• the desirable first-phase kinetics can be obtained through the pulmonary administration of a dry powder insulin formulation containing insulin complexed to 3,6- di(fumaryl-4-aminobutyl)-2,5-diketopiperazine (hereinafter fumaryl diketopiperazine or FDKP).
• fumaryl diketopiperazine or FDKP 3,6- di(fumaryl-4-aminobutyl)-2,5-diketopiperazine
• FDKP 3,6- di(fumaryl-4-aminobutyl)-2,5-diketopiperazine
• Tl to substantially mimic normal insulin responses to glucose and substantially reduced post-meal glucose excursions may have additional benefits to the general health of diabetics. Excessive post-meal glucose excursions are linked to atherosclerosis and diabetic vascular disease, a complication of diabetes that affects the yeye, kinesy and peripheral autonomic nervous systems. Therefore administration of Tl according to the teachings of the present invention provides superior control of blood glucose levels leading to better management of diabetic symptoms and better overall health of the diabetic patient.
• diketopiperazines Complexation of large polymers, such as proteins and peptides, in diketopiperazines can be used to remove impurities or contaminants such as metal ions or other small molecules.
• the diketopiperazines also serve both to stabilize and enhance delivery of the complexed materials.
• Formulations also have been developed facilitate transport of active agents across biological membranes. These formulations include microparticles formed of (i) the active agent, which may be charged or neutral, and (ii) a transport facilitator that masks the charge of the agent and/or that forms hydrogen bonds with the membrane.
• the formulations can provide rapid increases in the concentration of active agent in the blood following administration of the formulations.
• Technosphere ® refers to a diketopiperazine-based drug delivery system which can complex and stabilize peptides in small particles.
• Diketopiperazines particularly fumaryl diketopiperazine (FDKP)
• FDKP fumaryl diketopiperazine
• Technosphere ® particles dissolve in the pH neutral environment of the deep lung and facilitate the rapid and efficient absorption of the peptide into systemic circulation.
• the FDKP molecules are excreted un-metabolized in the urine within hours of administration.
• salts of diketopiperazines can be used in the compositions of the present invention as disclosed in co-pending U.S. Patent Application No. 11/210,710 entitled “Diketopiperazine Salts for Drug Delivery and Related Methods” which is incorporated by reference herein for all it teaches regarding diketopiperazine salts and their use to in pulmonary delivery of insulin.
• Insulin a polypeptide with a nominal molecular weight of 6,000 daltons, traditionally has been produced by processing pig and cow pancreas to isolate the natural product. More recently, however, recombinant technology has been used to produce human insulin in vitro. Natural and recombinant human insulin in aqueous solution is in a hexameric conformation, that is, six molecules of recombinant insulin are noncovalently associated in a hexameric complex when dissolved in water in the presence of zinc ions. Hexameric insulin is not rapidly absorbed. In order for recombinant human insulin to be absorbed into a patient's circulation, the hexameric form must first disassociate into dimeric and/or monomeric forms before the material can move into the bloodstream.
• Removing zinc from insulin typically produces unstable insulin with an undesirably short shelf life.
• Purification to remove zinc, stabilization and enhanced delivery of insulin has been demonstrated using diketopiperazine microparticles.
• Formulations of insulin complexed with fumaryl diketopiperazine were found to be stable and have an acceptable shelf life. Measurement of the zinc levels demonstrated that when a washing step was included the zinc had been largely removed during the complexation process, yielding monomeric insulin in a stable delivery formulation.
• compositions of the present invention can be administered to patients in need of insulin therapy.
• the compositions preferably are administered in the form of microparticles, which can be in a dry powder form for pulmonary administration or suspended in an appropriate pharmaceutical carrier, such as saline.
• the microparticles preferably are stored in dry or lyophilized form until immediately before administration.
• the microparticles then can be administered directly as a dry powder, such as by inhalation using, for example, dry powder inhalers known in the art.
• the microparticles can be suspended in a sufficient volume of pharmaceutical carrier, for example, as an aqueous solution for administration as an aerosol.
• the microparticles also can be administered via oral, subcutaneous, and intravenous routes.
• the inhalable insulin compositions can be administered to any targeted biological membrane, preferably a mucosal membrane of a patient.
• the patient is a human suffering from an insulin-related disorder such as diabetes mellitus.
• the inhalable insulin composition delivers insulin in biologically active form to the patient, which provides a spike of serum insulin concentration which simulates the normal response to eating.
• the inhalable insulin composition is administered to a patient in combination with long-acting basal insulin.
• the dose and administration of the long-acting basal insulin is established by the patient's physician according to standard medical practice.
• the inhalable insulin composition is administered peri-prandially according the teachings of the present invention, independently of the administration parameters of the basal insulin. Therefore for the purposes of this disclosure "in combination" refers to a patient administered both the inhalable insulin composition of the present invention and a long-acting basal insulin however, the two forms of insulin are administered independently.
• a pharmaceutical composition comprising insulin in a form suitable for pulmonary administration which, when administered in proximity in time to the beginning of a meal, induces a lower coefficient of variation at the 95% confidence interval of insulin exposure, INS-AUC O-X , x ⁇ 3, than subcutaneously administered insulin, wherein total insulin exposure [INS-AUC 0 . y , 3 ⁇ y ⁇ 6] is substantially similar.
• a pharmaceutical composition comprising insulin in a form suitable for pulmonary administration which, when administered in proximity in time to the beginning of a meal, induces a lower coefficient of variation at the 95% confidence interval in glucose elimination than subcutaneously administered insulin, wherein glucose elimination is measured as glucose infusion rate (GIR-)AUCo- ⁇ , x ⁇ 3 hours, wherein total insulin exposure [INS-AUC 0-y , 3 ⁇ y ⁇ 6] is substantially similar.
• GIR- glucose infusion rate
• a pharmaceutical composition comprising insulin in a form suitable for pulmonary administration which, when administered in proximity in time to the beginning of a meal, produces a mean glucose excursion that is less than subcutaneous administration of a dose of insulin providing substantially similar insulin exposure wherein the mean glucose excursion is at least about 28%, particularly at least about 25%, less than for the subcutaneous administration.
• a pharmaceutical composition comprising insulin in a form suitable for pulmonary administration which, when administered in proximity in time to the beginning of a meal, produces a mean glucose exposure that is less than subcutaneous administration of a dose of insulin providing substantially similar insulin exposure wherein the mean glucose exposure is at least about 35% less than for the subcutaneous administration, preferably about 50% less than for the subcutaneous administration.
• a pharmaceutical composition comprising insulin in a form suitable for pulmonary administration which, when administered in proximity in time to the beginning of a meal, exhibits a ratio of HbAIc after treatment to HbAIc before treatment, that is less than for subcutaneous administration of a dose of insulin providing substantially similar insulin exposure.
• a pharmaceutical composition comprising insulin in a form suitable for pulmonary administration which, when administered in proximity in time to the beginning of a meal, exhibits a ratio of glucose exposure, AUC G LU in min*mg/dl_, to insulin exposure, AUQNS in ⁇ U/mL, that is less than the ratio for subcutaneous administration of a dose of insulin providing substantially similar insulin exposure.
• a pharmaceutical composition comprising insulin in a rapidly absorbable form suitable for administration to an ambulatory patient which, when administered in proximity in time to the beginning of a meal, exhibits a ratio of glucose exposure, AUC G LU in min*mg/dL, to insulin exposure, Alices in ⁇ U/mL, that is less than 1.
• the pharmaceutical composition is suitable for pulmonary delivery.
• a pharmaceutical composition wherein the insulin is complexed with a diketopiperazine microparticle, preferably fumaryl diketopiperazine.
• a method of improving the reproducibility of insulin therapy comprising administering the pharmaceutical composition in proximity in time to beginning meals.
• a method of treating an insulin- related disorder comprising administering to a patient having an insulin-related disorder an exogenously-administered composition such that the exogenously-administered insulin composition mimics first-phase insulin kinetics, and wherein the exogenously- administered insulin composition is not administered intravenously.
• the exogenously-administered insulin composition comprises a complex between a diketopiperazine and human insulin.
• the diketopiperazine is fumaryl diketopiperazine.
• the exogenously- administered insulin composition is inhaled.
• the insulin-related disorder is diabetes mellitus, such as type 1 or type 2 diabetes mellitus.
• a method of maintaining blood glucose levels in a patient with an insulin-related disorder in a normal range comprising providing an exogenously-administered insulin composition wherein first-phase insulin pharmacokinetics are obtained within about 30 minutes of administration, alternatively within about 15 minutes of administration and wherein the exogenously-administered insulin composition is not administered intravenously.
• the exogenously-administered insulin composition comprises a complex between a diketopiperazine and human insulin.
• the diketopiperazine is fumaryl diketopiperazine.
• the exogenously administered insulin composition is a non-naturally occurring form of insulin.
• a method of restoring normal insulin kinetics in a patient in need thereof comprising administering to a patient having an insulin-related disorder an inhaled insulin composition such that the inhaled insulin composition mimics first-phase insulin kinetics.
• the insulin-related disorder is diabetes mellitus.
• the method further comprises administering a long-acting basal insulin.
• Insulin Concentration at Different Dose Levels Indicates Linear Absorption [0119] Various dosages of Technosphere ® /lnsulin (Tl, MannKind Corporation) were administered to human subjects and insulin concentration in the blood was measured (Figure 7A). Insulin absorption, as AUC, was linear with dosage at least up to 100 U Tl ( Figure 7B).
• the glucose elimination rate was determined by the amount of glucose infusion required to maintain stable blood glucose of 120 mg/dL during the 540 min study period (Figure 4). Forty-eight units Tl provided a mean maximum concentration of insulin (C max ) of 114.8 ⁇ 44.1 (mean ⁇ SD) mlU/L and had a median time to maximum concentration (T m ax) of 15 min, whereas 24 IU subcutaneous insulin (SC) had a C max of 63 ⁇ 10.1 mlU/L with a T ma x of 150 min.
• C max mean maximum concentration of insulin
• SC subcutaneous insulin
• Technosphere ® /lnsulin reached maximal GIR values, 3.33 ⁇ 1.35 mg/min/kg, at 45 min, while at that timepoint, SC was only 1.58 + 1.03 and did not reach maximal value, 3.38 ⁇ 1.45 before 255 min, despite almost constant insulin concentrations.
• the data for GIR and insulin concentration for Tl are also plotted individually versus time in Figure 8. Once maximal insulin effect was reached, the concentration - effect relationship was the same for Tl and SC ( Figure 4). At 180 min, glucose disposal was 326 ⁇ 119 mg/kg or 61 % of total for Tl and 330 ⁇ 153 mg/kg (27% of total) for SC.
• Endogenous insulin secretion should be accompanied by the production of C- peptide.
• Mean serum C-peptide concentrations over time for inhaled Tl and injectable SC regular insulin are presented in Figure 16.
• C-peptide concentrations were essentially unchanged during SC treatment but rose with Tl treatment with a timing consistent with the model depicted in Figure 14.
• One of the most important aims of drug therapy in patients with type 2 diabetes is to restore or to replace the first phase of the meal-related insulin response which is lost early in the course of type 2 diabetes mellitus. The rapid onset and short duration of action of inhaled Tl should make it suitable for replacement of prandial insulin secretion in patients with diabetes mellitus.
• Timing and reproducibility and of insulin's metabolic effect is critical to achieve near-normal glucose control and to enable patients and doctors to make appropriate dose adjustments.
• the time-action profiles and the intra-subject variability in insulin absorption and insulin effect between repeated doses of 48 U inhaled Technosphere ® /lnsulin (Tl) and 24 IU subcutaneous injected human regular insulin (SC) was compared.
• FVC, FEV1 and VC 80% of predicted normal
• PK pharmacokinetic
• PD pharmacodynamic
• Technosphere ® /lnsulin showed a more rapid onset of action (INS-T max 17 ⁇ 6 vs. 135 ⁇ 68 min, Tl vs. SC, p ⁇ 0.0001) and higher peak insulin concentrations (INS-C max ) than SC (Table 1).
• Technosphere ® /lnsulin reached maximal glucose infusion rate (GIR) values already at 79 ⁇ 47 min, while the maximum effect of the SC dose occurred at 293 ⁇ 83 min (p ⁇ 0.00001).
• GIR maximal glucose infusion rate
• the AUCs for both INS and GIR curves were higher for Tl compared to SC in the first two and three hours after administration (Table 1).
• the variability in both insulin concentrations and insulin action was lower for Tl compared to SC in the first three hours after administration. Specifically, for Tl the variability in insulin effect (GIR) was 23%, 22% and 26% at 120, 180 and 540 min respectively, as compared to 39%, 33% and 18% for SC ( Figure 6A). The variability in insulin concentrations ( Figure 6B) followed a similar pattern (19%, 18% and 16% for Tl and 27%, 25% and 15% for SC).. At 270 min, GIR for Tl had returned to baseline, and the variability in measured plasma insulin at 540 min was comparable to the variation of SC (CV%: GIR-AUCo -540 min 26% vs. 18% (Tl vs. SC); INS- AUC 0-540 min 16% vs. 15%).
• Technosphere ® /lnsulin showed a more rapid onset and a shorter duration of action than subcutaneous regular human insulin which can make it suitable for replacement of prandial insulin secretion in patients with type 2 diabetes.
• Tl can provide a lower risk of late postprandial hypoglycemia as, in contrast to SC, most of its glucose lowering effect occurred before the three hour point.
• the intra-patient variability of repeated inhalations of Tl was superior to SC insulin during the first three hours after dosing which can facilitate dose titration.
• Technosphere ® dry powder pulmonary insulin delivered via the small MannKindTM inhaler has a bioavailability that mimics normal, meal-related, first- or early- phase insulin release.
• This multicenter, randomized, double-blind, placebo-controlled study was conducted in type 2 diabetes mellitus patients inadequately controlled on diet or oral agent therapy (HbAIc >6.5% to 10.5%).
• Tl inhaled Technosphere ® /lnsulin
• rDNA origin unit dose cartridges containing between 6 to 48 units of human insulin (rDNA origin) or inhaled Technosphere ® /placebo for 12 weeks.
• Tl was inhaled at the time of the first mouthful of food at each main or substantive meal of the day, amounting to 3 or 4 administrations per day throughout the 12 week trial.
• Subjects continued whatever oral diabetes drugs they were using prior to entering the study. Differences in HbAIc from the first and final treatment visits, and between the first and two intermediate visits, were determined, as was the change in blood glucose, as AUC at various time points, and C max and T max , after a meal challenge.
• HbAIc Glycosylated hemoglobin A1c results were analyzed by a predetermined statistical analysis plan for the Primary Efficacy Population (PEP, defined prior to un-blinding as those who adhered to study requirements including minimal dosing and no adjustments of concomitant diabetes drugs), for a PEP Sub-group A (those with baseline HbAIc of 6.6 to 7.9%), for a PEP Sub-group B (those with baseline HbAIc of 8.0 to 10.5%), as well as for the ITT. These results are summarized in Table 2, and for PEP Sub-group B in Figure 17. In this "individualized dose" study, the mean dose of Tl used before each meal in the active treatment group was approximately 30 units, with 28 units used in PEP Subgroup A and 33.5 units used in PEP Sub-group B.
• Pulmonary function tests including DLco (diffusing capacity of the lung for carbon monoxide) (Table 4), FEV1 (forced expiratory volume in one second), and total alveolar volume (forced vital capacity, FVC) showed no significant differences between patients on Tl compared to their baseline values or compared to the results of those receiving placebo (Figure 19).
• FDKP/lnsulin Provides Glvcemic Control When Administered From 10 Minutes Before to 30
• a clinical trial was conducted to evaluate the effect of the timing of pulmonary administration of an FDKP-insulin complex as a dry powder (FDKP/lnsulin; also referred to as Technosphere ® /lnsulin, Tl).
• Subjects were type 1 diabetics who were not receiving any drug, other than insulin, for treatment of their diabetes, nor any other drug affecting carbohydrate metabolism.
• the trial was a prospective, single-center, randomized, crossover, open-label study.
• the dose of Tl was individualized for each subject.
• the individualized dose was based on the carbohydrate content of the meal to be consumed during the treatment visit, a correction factor for Tl bioavailability, and the subject's individual "insulin factor" (Fi), which was determined during a preliminary visit before the first treatment visit.
• the method of dose individualization was calculated at each treatment visit according to the following formula:
• IUdose was the number of IU of Tl to be administered
• BE Brot-Einheit, bread unit
• Fi was 1/10 of the carbohydrate content (in grams) of the meal to be consumed (5 for the isocaloric and 8.5 for the hypercaloric meals, respectively)
• Fi was the individual insulin factor, equivalent to the units of insulin required to cover one BE.
• the dose of Tl was rounded to the nearest dose that could be administered using multiples of the Tl cartridges, which contained 6 U, 12 U, or 24 U insulin.
• the primary efficacy variable was blood glucose concentration. As well as providing a profile of the blood glucose concentration before and after Tl and meal administration, the blood glucose concentration values were used to calculate the following pharmacokinetic parameters to describe total glucose excursion:
• Time to C max (T max ), time to C min (T min ), and time to last glucose excursion above baseline levels after start of meal (Tx).
• AUC blood glucose concentration curve
• AUC from 10 min before to 240 min after start of meal
• AUC1 from 10 min before to T x
• AUC2 from T x to 240 min after start of meal.
• the primary efficacy variable was blood glucose concentration.
• the effect of timing of administration of Tl on the mean (SD) baseline-corrected blood glucose concentrations before and after an isocaloric or hypercaloric meal is illustrated in Figure 21 for the primary efficacy population.
• the comparative excursions in blood glucose, while greater after the hypercaloric meal than the isocaloric meal were similar in profile for the two meal types but were dependent upon the timing of administration of Tl (Figure 21).
• Tl was inhaled 10 min before either meal, there was an initial decrease in blood glucose levels. After reaching a nadir about 10 min after the start of the meal, blood glucose levels rose above baseline levels approximately 30 min later.
• Tl was inhaled 15 or 30 min after the start of the meal glucose levels rose above baseline approximately 10-15 min after starting meal consumption (Figure 21).
• the secondary efficacy variable was serum insulin concentration.
• the profile of the mean (SD) baseline-corrected serum insulin concentrations after Tl inhalation is illustrated in Figure 22 for the primary efficacy population.
• Serum insulin concentrations peaked approximately 15 min after dosing and thereafter rapidly declined until 60 min after administration, after which there was a slower decline, consistent with first-order elimination.
• Tl provides glycemic control in subjects with type 1 diabetes who consume isocaloric or hypercaloric meals. There were no differences in the pharmacokinetics of insulin based on the timing of administration relative to the meals. The administration of Tl between 10 minutes prior to the time of the first bite of food and up to 30 minutes after starting a meal provides comparable glycemic control in the postprandial period.
• Exclusion criteria were diabetes mellitus type 1 or 2, prevalence of human insulin antibodies, history of hypersensitivity to the study medication or to drugs with similar chemical structures, history or severe or multiple allergies, treatment with any other investigational drug in the last three months before study entry, progressive fatal disease, history of drug or alcohol abuse, current drug therapy with other drugs, history significant cardiovascular, respiratory, gastrointestinal, hepatic, renal, neurological, psychiatric and/or hematological disease, ongoing respiratory tract infection or subjects defined as being smokers with evidence or history of tobacco or nicotine use. [0156] Conduct of the Study
• the glucose clamp algorithm was based on the actual measured blood glucose concentration and the grade of variability in the minutes before to calculate the glucose infusion rates for keeping the blood glucose concentration constant.
• the insulin application (5 IU IV or 10 IU SC injection or three deep breaths inhalation per capsule (2 capsules with 50 U each) applied with a commercial inhalation device (Boehringer Ingelheim)) had to be finished immediately before time point 0.
• the duration of the clamp experiment was six hours from time point 0. Glucose infusion rates, blood glucose, serum- insulin and C-peptide were measured.
• the areas under the curve of the glucose infusion rates were calculated for the first three hours (AUC o- i 8 o) after the administration and for the overall observation period of six hours after the administration (AUC o-3 6o) and were correlated to the amount of insulin applied.
• the areas under the curve of the insulin concentrations were calculated for the first three hours (AUC 0- i 80 ) after the administration and for the overall observation period of six hours after the administration (AUC o- 36o) and correlated to the amount of insulin applied.
• Technospheres ® are microparticles (also referred to herein as microspheres) formed of diketopiperazine that self-assembles into an ordered lattice array at particular pHs, typically a low pH. They typically are produced to have a mean diameter between about 1 and about 5 ⁇ m.
• Technosphere ® /lnsulin was shown to be safe in all patients. One patient was coughing during the inhalation without any further symptoms or signs of deterioration of the breathing system.
• Tl inhalation of Tl was demonstrated in healthy human subjects to have a time-action profile with a rapid peak of insulin concentration (T max : 13 min) and rapid onset of action (T max : 39 min) and a sustained action over more than six hours.
• the total metabolic effect measured after inhalation of 100 U of Tl was larger than after subcutaneous injection of 10 IU of insulin.
• the relative bioefficacy of Tl was calculated to be 19.0%, while the relative bioavailability was determined to be 25.8% in the first three hours.
• Prandial Technosphere @ /lnsulin Provides Significantly Better Control of Meal-Related Glucose Excursions than Prandial Subcutaneous Insulin
• Technosphere ® /lnsulin (Tl) is a dry powder formulation of human insulin comprising insulin complexed to fumaryl diketopiperazine microparticles. Technosphere ® /lnsulin was delivered by pulmonary administration with a dry powder inhaler (MedTone ® Inhaler) accomplishing a rapid onset of action and a duration of action long enough to cover meal-related glucose absorption. The primary objective of this study was to assess safety and efficacy of pre-prandially administered Tl compared to subcutaneous (SC) regular insulin on blood glucose concentration over a 7 day treatment period.
• SC subcutaneous
• Technosphere ® /lnsulin was inhaled using a 12 U or 24 U cartridge via a hand-held inhaler. After an out-patient period during which subjects administered the assigned pre-meal therapy with either SC or Tl, performed 4-point blood glucose self-measurements, and pursued their usual activities and diet for 5 to 7 days, postprandial blood glucose and serum insulin (INS) excursions were determined under in-house conditions after ingestion of a standardized breakfast (496 kcal, 55% carbohydrates) covered with either 48 ⁇ 9 (mean ⁇ SD) U of Tl or 14 ⁇ 5 IU of SC insulin. [0175] When treated with SC insulin, subjects demonstrated insulin median T m3x of 120 m ' in with median C max of 54 ⁇ U/mL.
• INS blood glucose and serum insulin
• prandial Tl resulted in significantly improved control of post-prandial peak glucose and total glucose exposure compared to prandial SC.
• therapies were the insulin formulations and the methods of insulin administration. Tl provided insulin Tmax that mimicked first-phase insulin release kinetics and which occurred at a time when it would be expected to have an effect on hepatic glucose release.
• Subcutaneous insulin levels were much lower than Tl during the early post-prandial period, did not exhibit a clear "peak” as did Tl, and demonstrated a slow rise to maximum concentration - too late to be expected to control hepatic glucose release but sufficient to represent a risk for late post-prandial hypoglycemia.
• Tl was nearly twice as efficient in removing glucose from the blood.
• postprandial maximum adjusted blood glucose excursions were 28% lower with Tl compared to SC (49 vs 82 mg/dL; p ⁇ 0.003).
• the incidence of hypoglycemia (BG ⁇ 63 mg/dL or hypoglycemic symptoms) was comparable between Tl and SC (6 vs. 5 episodes) as was the number of treatment emerged (mild to moderate) adverse events (5 vs. 4 episodes). Hyperglycemia (BG >280 mg/dL) occurred more often with Tl (12 vs. 4 episodes) - with two patients alone accounting for 8 episodes.
• Example 10 Multi-center Study of Type 2 Patients Taking Prandial Tl in an Ambulatory Setting.
• the patients were then randomized to blinded doses of added inhaled placebo or blinded doses of inhaled Tl containing 14, 28, 42 or 56 U of regular human insulin taken at the time of each main meal of the day in a forced titration scenario over 4 weeks.
• the subjects divided into five cohorts, initially received placebo (Technosphere ® microparticles without any insulin) along with the SC long acting insulin.
• placebo Technosphere ® microparticles without any insulin
• the subjects divided into five cohorts, initially received placebo and four cohorts were switched to a Tl dose of 14 U of insulin.
• After another week three cohorts were switched to a Tl dose of 28 U, and so on until a final cohort reached a Tl dose of 56 U. All cohorts then continued on the same dose for the remaining eight weeks of the trial.
• Technosphere ® /lnsulin also produced a dose-dependent reduction in post-prandial glucose excursions with a maximal excursion averaging only 34 mg/dL at 56 U (p ⁇ 0.0001). There were no severe hypoglycemic episodes, and the frequency of mild/moderate hypoglycemic episodes was not increased above that in subjects on insulin glargine alone. No changes were observed from baseline or between dosage groups in weight or pulmonary function. Thus inhaled Tl was able to improve the glycemic control of patients with type 2 diabetes without increasing the risk of hypoglycemia.
• inhaled Tl was an appropriate alternative to SC administered RAA providing similar overall glycemic control (expressed as change from baseline HbA1 c) to RAA while post-prandial excursions were significantly less.

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