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OBSERVATIONS Sured, As Indicated in Fig LETTERS blood glucose concentrations were mea- lispro at 40 Ϯ 3 min and aspart at 49 Ϯ 3 OBSERVATIONS sured, as indicated in Fig. 1. If blood glu- min after injection, respectively (P ϭ cose was 3.5 mmol/l or lower, 20 ml 0.01). The maximum insulin concentra- glucose 30% was injected. One patient tion was 316 Ϯ 31 pmol/l on insulin lis- Direct Comparison of was excluded from the analysis because, pro and 295 Ϯ 27 pmol/l on insulin by mistake, he took a large extra dose of aspart (NS) (Fig. 1). The increase from 0 Insulin Lispro and insulin the night before the study. to 15 min after injection was 109 Ϯ 17 Aspart Shows Small Free insulin was measured after poly- pmol/l after injection of insulin lispro and Differences in ethylene glycol precipitation by Mercodia 53 Ϯ 11 pmol/l after injection of insulin Iso-Insulin (ELISA; Mercodia AB, Uppsala, Plasma Insulin aspart (P ϭ 0.02). Fasting insulin lispro Sweden), a two-site enzyme immunoassay levels reached 50% of peak concentration Profiles After containing two monoclonal antibodies at 20 Ϯ 1 min and aspart at 30 Ϯ 3 min against insulin. Identical results were ob- (P ϭ 0.02) (Fig. 2). The decrease of free Subcutaneous tained when equimolar concentrations of Injection in Type 1 insulin concentration from peak concen- human insulin, insulin lispro, and insulin tration to 50% of the maximum concen- aspart were tested, indicating 100% Diabetes tration was found at 113 Ϯ 10 min during cross-reactivity between lispro, aspart, insulin lispro and 154 Ϯ 14 min during and human insulin in this assay. insulin aspart (P ϭ 0.02) (Fig. 2). The Blood glucose was analyzed with the fasting blood glucose concentration was wo rapid-acting insulin analogs, lis- Hemocue method (Hemocue, Mission Vie- 11.2 Ϯ 1.0 mmol/l before injection of in- pro and aspart, are now available for jo, CA). Serum IGF binding protein–1 was sulin aspart and 13.7 Ϯ 1.4 mmol/l before clinical use (1). determined by an immuno-enzymometric T injection of insulin lispro (NS). The The aim of our study was to compare assay with a kit from Medix Biokemica the plasma-insulin profiles of these ana- (Kauniainen, Finland). Differences among course of the blood glucose profiles was logs after subcutaneous injection in pa- groups were tested with Wilcoxon’s similar, with peak concentrations after 40 tients with type 1 diabetes. signed-rank test. Areas under the curve min, and there was no difference between Fourteen patients with type 1 diabe- (AUC) were calculated with the trapezoi- total AUC. tes (six men and eight women, [mean Ϯ dal method. The concentration of fasting IGFBP-1, Ϯ SEM] 35.4 Ϯ 3.3 years of age [range 22– The fasting-free insulin concentration a liver-derived protein (2), was 12.3 3.4 Ϯ Ϯ ␮g/l on insulin aspart and 16.8 Ϯ 3.9 ␮g/l 59], HbA1c 7.3 0.3% [reference range was 56 16 pmol/l before administration 3.2–5.4], BMI 24.7 Ϯ 1.1 kg/m2, and di- of insulin aspart and 30 Ϯ 15 pmol/l be- on insulin lispro. The concentrations fell to abetes duration 22.9 Ϯ 2.6 years) were fore administration of insulin lispro (NS) 8.3 Ϯ 1.4 and 13.5 Ϯ 4.5 ␮g/l 2.5 h after recruited for the study. Only two patients (Fig. 1). Both insulin analogs gave marked injection and to 7.4 Ϯ 1.6 and 11.5 Ϯ 4.1 had measurable C-peptide levels (0.04 peaks of free insulin concentrations— ␮g/l after 5.5 h, respectively (all differ- and 0.11 nmol/l). All patients were on multiple-injection therapy with a break- fast insulin dose of 11.1 Ϯ 0.7 U (range 6–14) and no intermediate-acting insulin in the morning. The study was designed as a single blind randomized crossover study. On the first day, seven patients were random- ized to insulin lispro (Humalog, U-100; Eli Lilly, Indianapolis, IN), and the other seven were randomized to insulin aspart (NovoRapid, U-100; Novo-Nordisk, Bagsveard, Denmark). On the second study day (5–21 days later), the patients received the alternative insulin analog. The patients continued their usual insulin treatment between the study days. All patients arrived to the clinic fast- ing. After an initial blood sampling, they were given 10 U s.c. of one of the insulins in the abdominal wall at 7:30 A.M. A stan- dardized breakfast, which had an energy content of 418 kcal and a nutri- ent content of 21 g protein, 11 g fat, and Figure 1—Plasma concentrations of free insulin in 13 patients with type 1 diabetes after a 10 U 59 g carbohydrates, was served immedi- single subcutaneous injection of insulin lispro (⅜) and insulin aspart (ⅷ) at 7:30 A.M. immediately ately thereafter. Plasma free insulin and before breakfast. The values are means Ϯ SEM. 1120 DIABETES CARE, VOLUME 24, NUMBER 6, JUNE 2001 Letters tively rapid rise of free insulin levels after 3. Home PD, Barriocanal L, Lindholm A: injection of insulin lispro might be an ad- Comparative pharmacokinetics and phar- vantage. The slightly slower decrease of macodynamics of the novel rapid-acting free insulin concentrations after the insu- insulin analogue, insulin aspart, in healthy lin peak of insulin aspart might influence volunteers. Eur J Clin Pharmacol 55:199– 203, 1999 the need for daytime basal insulin and the 4. Heinemann L, Heise T, Jorgensen LN, need for a snack between the main meals Starke AA: Action profile of the rapid of certain patients. acting insulin analogue: human insulin We previously found no difference in B28Asp. Diabet Med 10:535–539, 1993 IGFBP-1 concentrations when using hu- 5. Kang S, Creagh F, Peters JR, Brange J, Vo¨l- man regular insulin or insulin lispro (7), und A, Owens DR: Comparison of sub- and in this study there was no difference cutaneous soluble human insulin and between insulin aspart and lispro. insulin analogues (AspB9, GluB27; AspB10; B28 The main finding of our study is that Asp ) on meal-related plasma glucose the free insulin profiles of aspart and lis- excursions in type 1 diabetic subjects. Di- pro resemble each other, but insulin lis- abetes Care 14:571–577, 1991 Figure 2— Time (minutes) from subcutaneous 6. Lefebvre PJ, Scheen AJ: The postprandial injection of 10 U of insulin lispro (Ⅺ) and in- pro shows a more rapid uptake, reaches state and risk of cardiovascular disease. sulin aspart (f) from fasting levels to 50% of the maximum peak concentration earlier, Diabet Med 15 (Suppl. 4):S63–S68, 1998 the peak free insulin concentration, peak con- and shows a more rapid decline than in- 7. Hedman CA, Lindstrom T, Arnqvist HJ: centration, and 50% decrease from peak con- sulin aspart. We believe this finding may Treatment with insulin lispro changes the centration in 13 patients with type 1 diabetes. be of clinical importance. insulin profile but does not affect the The values are means Ϯ SEM. plasma concentrations of insulin-like 1 CHRISTINA A. HEDMAN MD growth factor-1 and insulin-like growth- 2 TORBJO¨RNLINDSTRO¨MMD, PHD factor binding protein-1 in type 1 diabe- 1,2 ences between the insulin analogs were HANS J. ARNQVIST MD tes. Clin Endocrinol. In Press nonsignificant). The time period from injection to half From the Division of Internal Medicine, the 1Depart- ment of Medicine and Care and the 2Division of the maximum value and to peak insulin Cellbiology, Department of Biomedicine and Sur- Erythropoietin concentration was significantly shorter gery, Faculty of Health Sciences, Linko¨ping Univer- Treatment of during insulin lispro, indicating a faster sity, Linko¨ping, Sweden. absorption of this insulin. Address correspondence to Christina Hedman, Postural The impression from previous studies MD, Division of Internal Medicine, Department of Medicine and Care, The University Hospital, SE-581 Hypotension in is that insulin aspart gives a somewhat 85, Linko¨ping, Sweden. E-mail: christina.hedman@ Anemic Type 1 broader peak than lispro (3,4). We found lio.se. a significantly more rapid lowering of Diabetic Patients the free insulin concentration to 50% of With Autonomic the peak concentration with lispro. The Acknowledgments— Financial support was plasma profile of free insulin obtained is obtained from the Swedish Medical Research Neuropathy dependent on the rate of absorption of Council (04952), the Swedish Diabetes Asso- ciation, Barndiabetesfonden, and the County insulin from subcutaneous tissue and the of O¨ stergo¨tland, Sweden. No support was ob- A case study of four patients elimination of insulin from the circula- tained from any pharmaceutical company for tion. Because the metabolic clearance of this study. insulin analogs is predominately receptor We thank research nurses Ewa Bergstedt, ostural hypotension (PH) is a feature mediated (5) and because lispro and as- Christina Dahlgren, and Kerstin Krogager and of autonomic failure that may result part have about the same affinity for the dieticians Karin Fridell, Ann-Charlotte, and P from various causes and can be very insulin receptor (1), it seems probable Orre Pettersson for their excellent help. difficult to treat. Recently, we and others that they will have about the same clear- (1–3) have shown that some patients with ance rate and that the lowering of free in- ●●●●●●●●●●●●●●●●●●●●●●● severe symptomatic autonomic neuropa- sulin after the peak is mainly due to the References thy from type 1 diabetes (type 1 DAN) have rate of absorption. 1. Kurtzhals P, Scha¨ffer L, So¨rensen A, Kris- a normocytic anemia associated with eryth- From the clinical point of view, the tensen C, Jonassen I, Schmid C, Tru¨b T: ropoietin (EPO) deficiency.
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