WO2019046952A1 - A subcutaneous pharmaceutical preparation comprising insulin(s) and an anti-inflammatory agent to reduce tissue inflammation response in diabetic patients. - Google Patents

Abstract

A subcutaneous pharmaceutical composition comprising insulin(s) and an anti-inflammatory agent to treat diabetes and reduce tissue inflammation response in diabetic patients.

Description

A SUBCUTANEOUS PHARMACEUTICAL PREPARATION COMPRISING INSULIN(S) AND AN ANTI-INFLAMMATORY AGENT TO REDUCE TISSUE

INFLAMMATION RESPONSE IN DIABETIC PATIENTS.

CROSS REFERENCE TO RELATED APPLICATION

This application claims benefit of US provisional application 62/555932 filed on September 8, 2017, the content of which is herein incorporated by reference in its entirety.

FIELD OF THE DISCLOSURE

The present disclosure relates to novel compositions, combinations of drugs and methods for the treatment of diabetes i.e. for increasing catheter life and wear of continuous subcutaneous insulin infusion systems (CSIIs), so called insulin pumps, in a patient in need thereof.

BACKGROUND OF THE DISCLOSURE

Diabetes is a chronic metabolic disease that is characterised by high glucose levels in the blood (hyperglycemia). Depending on the type of diabetes, the organism does not produce insulin (type 1) and/or has difficulty reacting to its hyperglycemic signal (type 2). Insulin is a hormone produced by beta pancreatic cells and its secretion is mainly stimulated by an increase of glucose in the blood, but also by free fatty acids, amino acids, incretins, and other factors. Insulin controls hyperglycemia by stimulating the uptake of glucose by the tissues. In other words, insulin activates energy storage and simultaneously inhibits the release of energy reserves.

Among the diabetic population, 10% of patients are of type 1 (T1D) and 90% are of type 2 (T2D). Insulin is lifesaving pharmacological therapy for people with T1D. Insulin preparations are primarily produced by recombinant DNA technology and are formulated either as structurally identical to human insulin or as a modification of human insulin (insulin analogues) or as a combination of insulin and excipients to improve pharmacokinetics. Insulin can be administered by syringe, pen or pump (CSII). CSII therapy is a safe and effective method of intensive insulin therapy in T1D and T2D and has shown improvements in glucose control over traditional multiple daily insulin injections regimens with less severe hypoglycemia. In patients using CSII, insulin aspart and insulin lispro have been shown to be superior to regular insulin by improving postprandial glycemic control and reducing hypoglycemia.

Insulin pumps were first used to deliver insulin almost 35 years ago. The pump delivers the basal component of the regimen by constant infusion of insulin, with meal boluses delivered when required by button presses on the machine, or with some more recent pumps by the use of a hand held control. Delivering basal insulin in this way allows more precise adjustment of basal rates at different times of the day, theoretically providing a better fit to the diurnal profile of basal requirements. It also allows for changes in basal rates to cover exercise, illness or stress. CSII involves attachment (via catheter - herein abbreviated as "KT" - inserted into the subcutaneous adipose tissue) to an insulin pump that is programmed to deliver insulin to match the individual's needs, and doses are self-administered by users to deliver insulin therefore to cover meals and correct blood glucose fluctuation.

Inflammation at the infusion site of the KT is a common complication experienced by insulin pump users and a major reason for discontinuation of CSII. In fact, removal of the KT leads to rapid tissue recovery, pointing to KT as both a source of inflammation and a major factor in KT site failure. Inflammatory reactions at KT sites usually manifest in clinical local signs and symptoms that include erythema, swelling, pain, and itching.

The present disclosure successfully addresses the shortcomings of the presently known problems or limitations of infusion sets for CSIIs by providing an original method making use of antiinflammatory agents to reduce or prevent skin and adjacent subcutaneous tissue inflammation responses in diabetic patients under subcutaneous insulin therapy delivered by pumps.

SUMMARY OF THE DISCLOSURE

In an aspect of the disclosure, there is provided a method for increasing KT life and wear of CSII comprising subcutaneously administering to the same exact location/site as said KT in a subject in need thereof, a subcutaneously anti-inflammatory effective amount of an anti-inflammatory agent.

In another aspect of the disclosure, there is provided a pharmaceutical composition comprising a therapeutically effective amount of one or more insulins and a subcutaneously anti-inflammatory effective amount of an anti-inflammatory agent.

In another aspect of the disclosure, there is provided a combination comprising a therapeutically effective amount of one or more insulins and a subcutaneously anti-inflammatory effective amount of an anti-inflammatory agent.

In another aspect of the disclosure, there is provided a method for treating diabetes comprising simultaneously administering subcutaneously to the same exact site in a subject in need thereof, a therapeutically effective amount of one or more insulins and a subcutaneously anti-inflammatory effective amount of an anti-inflammatory agent. BRIEF DESCRIPTION OF THE DRAWINGS

Reference will now be made to the accompanying drawings.

FIG 1 represents the stability of insulin analog lispro (Humalog^®, Eli Lilly; 90 units/ml) alone or in the presence of ketorolac (3 mg/ml) over a period of 7 days, as assessed by liquid chromatography -tandem mass spectrometry (LC-MS/MS). Stabilities of insulin and the new insulin-ketorolac formulation were carried out under laboratory condition consisting of infusing the insulin or new formulation (contained in a prefilled syringe) via a multi-channel syringe pump at room temperature. Samples were collected into tubes and then injected into the LC- MS/MS system. Values are means ± Standard Deviation (SD) of 3 experiments.

FIG 2 represents the stability of insulin lispro (90 units/ml) over a period of 7 days in presence of ketorolac (3 mg/ml) under real-life conditions. Two subjects volunteered to wear in pocket the same insulin pump (Accu-Check^® Combo system, Roche Diagnostics) filled with the lispro- ketorolac formulation and programmed with a baseline 1 unit/hour rate and 3 boluses of 2 units (30 units/day). The KT (Accu-Chek® Tender) was connected to a vial. The vial was changed every day and analyses were performed on the daily amount of solute. Vials of one volunteer were kept at room temperature (series no. 1) while vials of the second volunteer were kept at 4°C in a fridge (series no 2). Analyses of insulin stability were performed using the LC-MS/MS method as above. Abbreviation: CTL: insulin-ketorolac formulation at Day 0.

FIG 3 represents the relative amounts of ketorolac and its major oxidative metabolites (Kl, K2, K3, K4, K5) formulated with lispro during a 7 day period under real life conditions. CTL = ketorolac alone taken from the vial. Day 0 = at start, first drops taken from the KT. Analyses of ketorolac and its oxidative metabolites were performed using the LC-MS/MS method. Values are means ± SD of 3 experiments.

FIG 4 represents the number of days of wearing the KT for 4 T1D subjects receiving, via CSII, equivalent doses of insulin alone or as lispro-ketorolac formulation.

FIG 5 represents plasma ketorolac concentration during lispro-ketorolac infusion in 4 T1D subjects using CSII, as assessed by LC-MS/MS analyses. Abscissa. Visits 1, 2, 3, 4, 5 correspond to: 1 : at screening visit; 2: at KT insertion at baseline, 3: 3 days after insertion, 4: 7 days after insertion, 5: at time of changing KT i.e. 8.42 days after insertion. Values are means ± SD.

FIG 6 represents plasma inflammatory markers concentrations during lispro-ketorolac infusion in 4 T1D subjects using CSII. Values are means ± SD. DESCRIPTION OF THE EMBODIMENTS

In clinical practice, KTs for CSIIs are worn for 2 to 3 days in patients using insulin pump. However, continuous glucose monitoring systems (CGMs) are transitioning from 7- to 14-day periods of wear. For CSIIs users, frequent KT replacement is costly, out of synch for KT vs. CGM time of wear, and inconvenient.

In accordance with this disclosure, it is desired to prolonge KT life and wear beyond 3 days, ultimately to 14 days as CGM. This could result in significant savings, increase convenience, better quality of life, and contribute to the development of a unified device using a single port for hormone infusion and CGM. As insulin pump usage is on the rise and associated technology is perfected, the time has come to prolonge KT life and wear.

In accordance with one embodiment, there is provided a method for increasing KT life and wear of CSII comprising subcutaneously administering simultaneously to the same location/site as said KT in a subject in need thereof, a subcutaneously anti-inflammatory effective amount of an antiinflammatory agent.

In another embodiment of the disclosure, there is provided a pharmaceutical composition comprising a therapeutically effective amount of an insulin and asubcutaneously antiinflammatory effective amount of an anti-inflammatory agent.

Unless otherwise defined, the word "insulin" applies for regular insulin, human insulin, analog insulin, short acting insulin analog (SAIA), biosimilar short acting insulin or any other way to refer to fast insulin, alone or combined with excipients aiming at improving pharmacokinetics of insulin.

As used herein "anti-inflammatory agents" are drugs or substances that reduce inflammation (redness, swelling, and pain) in the body. Anti-inflammatory agents block certain substances in the body that cause inflammation. They are used to treat many different conditions.

As used herein "simultaneous" or "simultaneously" refers to the administration of an antiinflammatory agent and one or more insulins substantially at the same time. What is understood by administration substantially at the same time is that the anti-inflammatory agent must be administered at the same time with regard to the insulin, as long as the KT is wear to allow exposure time of the anti-inflammatory agent at the infusion site to delay the occurrence of inflammation. What is understood by administration "to the same site", is that insulin and the anti-inflammatory agent are mixed and then they are co-administered resulting in a solution administered via the KT, infused at one site.

In one embodiment, the anti-inflammatory agent and insulin(s) are administered as a pharmaceutical composition comprising the nonsteroidal anti-inflammatory drug (NSAID) and insulin(s) (i.e in a combined dosage form).

In one embodiment, the anti-inflammatory agent is used in combination with regular mammalian insulin(s) or any transformed (genetically or by any other means) insulin such as currently available SAIA (e.g., insulin lispro (Humalog^®), insulin glulisine (Apidra^®), insulin aspart (Novolog^®)), biosimilar insulin (e.g., insulin glargine (Abasaglar^®)), or fast-acting mealtime insulin (FAMI) (Fiasp^®, biochaperone lispro) and whichever the composition of excipients or dilution liquid.

As defined herein "patient" refers to both human and non-human subjects (e.g., dog, cat, horse, other). The subject is preferably human.

Diabetes can be divided into two broad types of diseases: T1D and T2D. T1D is caused by beta- cell destruction, usually leading to insulin deficiency. T2D (historically called non-insulin- dependent diabetes) may range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance, leading to insulin therapy.

In one embodiment, the patient is a human T1D patient, using CSIIs.

In one embodiment, the patient is a human T2D patient, using CSIIs.

In one embodiment, the patient is a human with diabetes under insulin therapy, using CSIIs.

As used herein, "using CSIIs" refers to an adult using external insulin pump therapy or patch-pump insulin therapy to control diabetes.

The term "Short Acting Insulin Analogue" or "SAIA" is understood to mean a polypeptide derived from the naturally occurring insulin, such as human insulin. The analog is typically obtained by addition and/or deletion and/or substitution and/or inversion of one or more amino acids of the naturally occurring insulin (Hirsch IB. N Engl J Med 2005:352: 174-83 herein incorporated by reference). SAIA are also sometimes refered to as "Rapid Acting Insulin Analog". Both expressions can be used interchangeably herein.

The term fast-acting mealtime insulin or FAMI refers to insulin analogs combined with excipients (niacinamide and L-arginine, polysaccharide derivatives). In one embodiment, the anti-inflammatory agent is a NSAID.

In the present disclosure, it is contemplated that NSAIDs for use herein should be appropriate to delay the occurrence of inflammation at the insertion site of the KT, it would be desirable that the NSAIDs: 1) is operative, 2) is operative in diabetic patients 3) provide a sufficient stability into the subcutaneous adipose tissue in the patient and/or 4) be compatible (i.e. not detrimental) for use in diabetic patients.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed medications worldwide. They are highly effective in relieving pain and inflammation in many disorders. The main mechanism of action of NSAIDS is the inhibition of cyclooxygenases (COXs), the enzymes responsible for the bioconversion of arachidonic acid into prostanoids, such as prostaglandins, prostacyclins, and thromboxanes. There are many different types of NSAIDs, which are categorized according to their chemical structures (e.g., salicylates (aspirin), pyrroles (ketorolac), enolic acids (oxicams), indole (indomethacin), propionic acids (profens) and coxibs (celebrex)) and actions on the two subclasses of COX enzymes, COX-1 and COX-2. Currently marketed NSAIDS are either non-selective COX inhibitors or selective COX2 inhibitors.

NSAIDs for use herein are used at dosages typically substantially lower than typical doses approved by health and medical authorities. Such dosages can be used in the present method because the NSAID locally provides an immediate action where insulin is administered. It is rationally believed that the use of low doses of NSAIDs may offer advantages such as reducing side effects normally encountered by effective systemic doses. It is also believed that subcutaneous administration reduces the biovailability of the agents compared to the doses delivered by intramuscular bolus. An example of a suitable dose of NSAID (pyrrolo-pyrrole group) such as ketorolac is provided in Table 1. Ketorolac is a classic NSAID and non-selective inhibitor of both COX-1 and COX-2, which possesses significant anti-inflammatory activities with efficacy comparable to other NSAIDs as well as strong analgesic activity, with efficacy comparable to opioids. Table 1. Comparison of intramuscular doses of ketorolac and maximum subcutaneous doses used in this description.

Suggested doses in Canada are: 30 mg QID for 2 days.

That is a 3.3% ketorolac dilution, comparable to ophthalmic solution at 5%.

In one embodiment, the anti-inflammatory agent is a G protein-coupled receptor (GPCR) antagonist.

By virtue of their recognized high anti-inflammatory and analgesic activities and their specificity for GPCRs, unrelated to COXs, antagonists such as, but not limited to, those of bradykinin or neurokinin/tachykinin receptors, may prove useful as an alternative to NSAIDs particularly where such NSAIDs may be contraindicated such as in patients showing allergic, hypersensitivity and/or intolerant reactions to NSAIDs.

In one embodiment, the anti-inflammatory agent is a receptor tyrosine kinase antagonists such as cytokine interleukin-1 (IL-1) antagonists and tumor necrosis factor (TNF) antagonists.

In one embodiment, the anti-inflammatory agent is a peroxisome proliferator-activated receptors (PPARs) agonists such as thiazolidinediones.

In another embodiment, the dosage form of the invention can be adjusted by varying the amount and types of NSAIDs for a greater effect in increasing KT life and wear.

In one embodiment, the methods defined herein are for use of the same KT more than 3 consecutive days in said patient, preferably for up to a week and more preferably for up to two weeks. The excipient(s) for use in pharmaceutical compositions in accordance with the disclosure must be "pharmaceutically acceptable" in the sense of being compatible with the other ingredients of the formulation and not being deleterious to the recipient thereof. The pharmaceutical composition, or for instance each component of the combination, in particular the composition comprising insulin, may optionally comprise excipients such as preservatives, chelating agents, tonicity modifiers, bulking agents, stabilizers, antioxidants, polymers and surfactants, metal ions, arginine, oleaginous vehicles, vitamins, L-arginine and proteins (e.g., human serum albumin, gelatine or proteins).

Examples of buffer include sodium acetate, sodium carbonate, citrate, sodium dihydrogen phosphate, disodium hydrogen phosphate, sodium phosphate, and tris(hydroxymethyl)- aminomethan, bicine, tricine, malic acid, succinate, maleic acid, fumaric acid, tartaric acid, aspartic acid or mixtures thereof.

Examples of preservative in the composition comprising insulin include those of conventional insulin compositions, such as phenol, m-cresol, methylparaben, and zinc or other ions.

In one embodiment, the present disclosure further comprises, in the methods, compositions and combinations described herein, a therapeutically effective amount of at least one or more useful therapeutic agents. Examples of such agents include sulfonylureas, meglitinides, biguanides, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, glucagon-like peptide analogs, gastric inhibitory peptide analogs, and inhibitor of renal sodium-dependent glucose cotransporters and any other compounds refuted to be effective at lowering plasma glucose.

It will be clear to a person of ordinary skill that if a further additional therapeutic agent is required or desired, ratios will be readily adjusted. It will be understood that the scope of combinations described herein is not particularly limited, but includes in principle any therapeutic agent useful for the prevention and treatment of diseases and conditions related to diabetes described herein.

Pharmaceutical compositions and combinations suitable for use herein may be presented as a solution, a suspension or as an emulsion. The compositions and combinations may be presented in unit dose form in ampoules, bottles, vials, etc, and any other tool for subcutaneous injection. Further description of methods suitable for use in preparing pharmaceutical compositions and combinations of the present disclosure and of ingredients suitable for use in said compositions and combinations is provided in Remington's Pharmaceutical Sciences, 18(th) edition, edited by A. R. Gennaro, Mack Publishing Co., 1990. The subcutaneous administration of the NSAID and said insulin can be done by means of an infusion pump or transdermal administration (such as by needle-free injection, microneedles, and/or from a patch).

EXAMPLES

Laboratory experiments

We prepared a lispro-based formula containing 90 units of lispro (Humalog) and 3 mg of ketorolac (ketorolac Tromethamine Injection USP) per ml. Accordingly, for example, 1 mg of ketorolac is co-infused with a 30 units daily dose of insulin.

We determined how long our mixture will stay in reservoir. We collected data over 3 months in 104 consecutive patients CSII users (age: 42.6±14.3 years, T1D duration: 24.1±13.4 years, BMI 26.0±3.7 kg/m²) followed at our two Pump clinics in order to estimate their daily needs. Patients used 44.8±16.2 units/day (from 19.2 to 114.8 units/day). As the bigger available insulin pump reservoirs (3.15 ml) contain 283.5 units of lispro when combined with ketorolac, we believe that subjects would refill or changed their reservoirs every 5-6 days on average. Accordingly, we decided that 7-day laboratory stability tests were appropriate.

In the laboratory, we used 6 calibrated precision laboratory pumps attached to 6 insulin reservoirs and KT; 3 devices were filed with lispro, 3 with lispro-ketorolac solution. Speed of pumps allowed an infusion dose of 1 unit/hour i.e. 24 units/day. The set-up was maintained at laboratory temperature (23.4°C) in order to mimic real-life infusion. Samples of solutions were drawn on day 0, 1, 3 and 7, from the end of KT and conserved at 4°C. Samples were visually inspected and examined under the microscope. No precipitate was observed. We next used a high-resolution quantitative LC-MS/MS method to assess stability of the lispro formulation (FIG 2).

We also performed a real-life pilot clinical study. For 7 days, two healthy volunteers wore the same insulin pump (Accu-Check^® Combo system, Roche Diagnostics) filled with our lispro+ketorolac preparation and programmed with a baseline 1 unit/hour rate and 3 boluses of 2 units (30 units/day). The KT (Accu-Chek® Tender) was connected to a vial. The vial was changed every day and analyses were performed from the daily amount of solute. Vials of one volunteer were kept at room temperature (series no. 1) while vials of the second volunteer were kept at 4°C in a fridge (series no 2). No difference was observed between both series of vials. LC-MS/MS analyses of monomers and hexamers (ratio - FIG 3) showed no difference from day 0 to day 7. Signal intensity for hexamers and monomers were constant over time. The variability observed throughout the experiment fell within method variability. We found no difference in the amounts of ketorolac and its oxidative metabolites (Kl, K2, K3, K4, K5) over time in real life conditions (FIG 3). Again, the variability observed throughout the experiment fell within method variability. No significant differences were observed either for the ketorolac dose or for the levels of oxidative metabolites. Together these data indicate that the insulin-ketorolac formulation remains stable over 7 days in near-clinical condition usage.

Human experiments

We performed the first human use safety/efficacy experiments with our lispro-ketorolac formulation in 4 participants CSII users over a single-day at our research center, followed by daily monitoring.

1- Patient recruitment and inclusion

TID CSII user subjects were recruted at the Insulin Pump Clinic at the Centre hospitalier universitaire de Sherbrooke (CHUS).

2- Inclusion criteria: Men or women, age > 18 years, diagnosed with TID for more than 2 years, Ale < 9.0%, using lispro and a CSII system for more than 6 months, changing KT every 2 or 3 days, followed by an endocrinologist of the CHUS, able to read and understand French or English, otherwise in good health status. In case of women in childbearing age volunteering, initial pregnancy testing prior to participation in the clinical trial should be performed and women were asked to use a reliable method(s) of contraception throughout participation in this study and up to one week after end of study medication.

3- Exclusion criteria: T2D, treatment interfering with glucose metabolism other than insulin, anti-inflammatory treatment, gastro-intestinal disease, any acute or non-controlled disease, severe heart failure, history of asthma, urticaria or allergic reaction after taking acetylsalicylic acid (ASA) or another NSAID including those over the counter ones (such as ASA and Ibuprofen), bleeding disorders, use of probenecid, methotrexate, ACE-inhibitors or oxpentifyline, severe renal impairment defined as creatinine > 442 μηιοΙ/L, Hb < 100 g/L, platelets < 100 10^"9/L, ALT and AST > 2 X upper limit normal, ALP > 1.5 X upper limit normal, pregnant women, breastfeeding women, deficit that may hinder the understanding of the study. Visit 1.

Subjects performed a first visit to record medical history, to carry out safety blood and urine samples. Height, weight, blood pressure, current medications, and previous and current KT sites were assessed.

Patient Clinical Profiles

Subjects recruited varied in age, weight, BMI, T1D duration and pump user duration (Table 2). They were representative of CSII user patients with T1D commonly treated by endocrinologists.

Table 2. Characteristics of subjects involved in our experiment.

Visit 2.

Participants arrived at 7.30 AM at the Research Center of the CHUS. Weight and blood pressure were measured. Blood samples were drawn to measure plasma inflammatory markers (hsCRP,

IL-6, sE-selectin, sICAM-1, PGE2) and plasma ketorolac. The skin around the present KT injection site was examined. Participants filled the reservoir of their pump with the insulin- ketorolac formulation. They installed a new KT. The date and time of insertion were recorded.

Meals (breakfast at 8h00 and lunch at 12h00) were offered according to the menu of the cafeteria of the CHUS. Participants recorded their capillary blood glucose before and 2 hours after the beginning of each meal (breakfast and dinner), and at end of the visit. They counted bolus of insulin as they usually did and according to the quantity of carbohydrates contained in each meal. During waiting hours, participants were allowed to watch TV, read, do office work related to their work or took a walk in the research center i.e. activities as similar as possible to usual routine. If the participant's glycemia indicated a hyperglycemia (glycemia before meal > 7.0 mmol/L or 2-hour after meal glycemia > 13.8 mmol/L), she/he/the PI proposed an adjustment. In case of a hypoglycemia (< 3.3 mmol/L), participants received a fruit juice. Glycemia were measured 15 minutes later to insure return to normal value. Participants left the research center by mid-afternoon.

Instructions to patients

Subjects were instructed to use lispro-ketorolac formulation and to wear their KT for as long as they can, under lispro-ketorolac infusion conditions, i.e. as long as it felt locally comfortable and as long as glucose values remained satisfactory. In other words, KT may be kept in place as long as the infusion site was still asymptomatic and glucose control remains in usual values. Subjects measured capillary blood glycemia before meal, 2 hours after the beginning of each meal and at bedtime over the course of the study (7 tests daily). They wrote down in a booklet glucose values and bolus of insulin.

Visit 3.

This visit took place 2 or 3 days after visit 2 (as it represented the day that participants would usually change their KT). Weight and blood pressure were measured. Blood samples were drawn to measure inflammation markers and plasma ketorolac. The skin around the KT injection site was examined for any skin problems.

Visit 4.

This visit took place 7 days after visit 2 and was similar to visit 3. Visit 5.

This visit took place when participants needed to change their KT. Reasons of KT change were recorded. Pump data and capillary glucose values since visit 1 were collected. Otherwise, visit 5 was similar to visit 3 and visit 4. The skin at the abnormal KT injection site was checked and skin problems recorded. The date and time of KT removal were recorded. After visit 5, participants returned to their usual insulin regimen.

In our formula, 1 ml of the lispro-ketorolac formulation contains 90 units of lispro and 3 mg of ketorolac. On average, patients took 36.8±9.8 units of lispro per day, thus 1.2 mg of ketorolac. Using our new formulation, these T1D patients wore the KT for about 2.5 times longer than when they were under lispro insulin alone (8.42±0.54 days versus 3.50±0.71 days, respectively) (FIG 4).

Safety

Our new highly sensitive LC-MS/MS method (microUHPLC coupled to a SCIEX-QTRAP 6500⁺) of detection of ketorolac in the lispro-ketorolac formulation allowed to detect as little as 0.5 ng/ml of ketorolac in plasma of patients with T1D. The maximum concentration detected in the plasma of one of our subjects was 31.4 ng/ml, corresponding to 83 nM (FIG 5). This concentration of ketorolac is considerably below than those required to inhibit human COX-1 and COX-2 in vitro (IC₅o of 1.23 μΜ and 3.50 μΜ, respectively (Jett MF, et al. J Pharmacol Exp Ther, 1999, 288(3), 1288-12). Subcutaneous administration of ketorolac at such a low dose is therefore not thought to achieve sufficient drug levels to inhibit prostaglandin synthesis in blood and in other target tissues such as the kidney. This assumption is supported by the facts that the blood levels of PGE₂, a COX-l/2-derived product, remained unchanged in our T1D patients receiving the lispro-ketorolac formulation via CSII (FIG 6). There was also no change in the blood levels of all other inflammatory biomarkers investigated (FIG 6), suggesting that the low dose of ketorolac used in our study is not associated with systemic adverse side effects. Our results also imply that the anti-inflammatory/analgesic effects of ketorolac is mainly KT bed- localised.

Long-term stability

We also measured (through LC-MS/MS analyses) the stability of lispro and ketorolac in two vials of our formula kept at laboratory temperature, at 3 and 4 months after preparation. There was no difference in ketorolac when incubated alone (control) versus in the presence of lispro (Table 3). Lispro remained stable (within the experimental variability i.e. 20-30%). These results indicate that our formula can be used during four months. Table 3. Long-term stability of lispro-ketorolac formulation

Chromatogram pic area

Our laboratory experiments showed that addition of ketorolac to lispro does not interfere with the stability of lispro as well as ketorolac at 1 or 7 days, and over 4 months.

Our experiments in humans with T1D showed that addition of ketorolac to lispro multiply KT life by 2.4 (from 3.5 to 8.42 days).

The maximal plasma concentration of ketorolac was 15 to 42 times lower than those required for inhibiting Cox-1 and Cox-2 activities by 50% in vitro.

Plasma inflammatory markers remain low and stable over the duration of our experiments in humans.

The very low plasma concentration of ketorolac and the absence of change in plasma inflammatory markers suggest that inflammation was KT-bed localized. Using small ketorolac dose co-infused with insulin, we achieved pharmacologically local active concentration without systemic effect.

While the disclosure has been described in connection with specific embodiments thereof, it is understood that it is capable of further modifications and that this application is intended to cover any variation, use, or adaptation of the disclosure following, in general, the principles of the disclosure and including such departures from the present disclosure that come within known, or customary practice within the art to which the disclosure pertains and as may be applied to the essential features hereinbefore set forth.

All references cited herein are expressly incorporated by reference.

Claims

Claims:

1. A method for treating diabetes comprising subcutaneously administering simultaneously to the same exact location/site in a subject in need thereof, a therapeutically effective amount of one or more insulins and a subcutaneously anti-inflammatory effective amount of an anti-inflammatory agent.

2. The method of claim 1 wherein said insulin is SAIA.

3. The method of claim 1 or 2 wherein said anti-inflammatory agent is a nonsteroidal antiinflammatory drug (NSAID).

4. The method of any one of claims 1 to 3 wherein said anti-inflammatory agent is a G protein- coupled receptor (GPCR) antagonist, a cytokine receptor tyrosine kinase antagonists or a peroxisome proliferator-activated receptors (PPARs) agonists.

5. The method of any one of claims 1 to 4 wherein said subject is a human Type-1 diabetes (T1D) patient.

6. The method of any one of claims 1 to 4 wherein said subject is a human Type-2 diabetes (T2D) patient.

7. A pharmaceutical composition comprising a therapeutically effective amount of one or more insulin(s) and a subcutaneously anti-inflammatory effective amount of an anti-inflammatory agent.

8. The composition of claim 7 wherein said insulin is regular mammalian insulin, short acting insulin analog (SAIA), biosimilar insulin, or fast-acting mealtime insulin (FAMI).

9. The composition of claim 7 or 8 wherein said insulin is SAIA.

10. The composition of any one of claims 7 to 9, wherein said anti -inflammatory agent is a nonsteroidal anti-inflammatory drug (NSAID), a G protein-coupled receptor (GPCR) antagonist, a receptor tyrosine kinase antagonists or a peroxisome proliferator-activated receptors (PPARs) agonists.

11. The composition of any one of claims 7 to 10 wherein said anti-inflammatory agent is a nonsteroidal anti-inflammatory drug (NSAID).

12. The composition of any one of claims 7 to 11, wherein said insulin is a lispro insulin and said anti-inflammatory agent is ketorolac.

13. The composition of any one of claims 7 to 12 further comprising one or more pharmaceutically acceptable excipient(s).

14. A combination comprising a therapeutically effective amount of one or more insulins and a subcutaneously effective amount of an anti-inflammatory agent.

15. The combination of claim 14 wherein said insulin is regular mammalian insulin, short acting insulin analog (SAIA), biosimilar insulin, or fast-acting mealtime insulin (FAMI).

16. The combination of claim 14 or 15, wherein said anti-inflammatory agent is a nonsteroidal anti-inflammatory drug (NSAID), a G protein-coupled receptor (GPCR) antagonist, a receptor tyrosine kinase antagonists or a peroxisome proliferator-activated receptors (PPARs) agonists.

17. The combination of any one of claims 14 to 16 further comprising a therapeutically effective amount of at least one or more therapeutic agents.

18. A method for increasing catheter life and wear of continuous subcutaneous insulin infusion systems (CSIIs) comprising subcutaneously administering simultaneously to the same exact location/site as said catheter in a subject in need thereof, a subcutaneously anti -inflammatory effective amount of an anti-inflammatory agent.

19. The methods of claim 18 wherein the same catheter is used for more than 3 consecutive days in said patient, preferably for up to a week and more preferably for up to two weeks.

20. The method of claim 18 or 19 wherein said insulin is a short acting insulin analog (SAIA).

21. The method of any one of claims 18 to 20 wherein said anti-inflammatory agent is a nonsteroidal anti-inflammatory drug (NSAID).

22. The method of any one of claims 18 to 21 wherein said subject is a human Type-1 diabetes (TID) or Type-2 diabetes (T2D) patient, using continuous subcutaneous insulin infusion systems (CSIIs).