CLINICAL TRIAL

Comparison of morning basal + 1 bolus insulin
therapy (insulin glulisine + insulin glargine
300 U/mL vs insulin lispro + insulin glargine
biosimilar) using continuous glucose
monitoring: A randomized crossover study
Soichi Takeishi*, Hiroki Tsuboi, Shodo Takekoshi

Department of Diabetes, General Inuyamachuo Hospital, Inuyama-city, Aichi, Japan

Keywords
Continuous glucose monitoring,
Long-acting insulin, Ultra-rapid-acting
insulin*Correspondence
Soichi Takeishi
Tel.: +81-568-62-8111
Fax: +81-568-62-9289
E-mail address:souichi19811225@yahoo.co.jp
J Diabetes Investig 2018; 9: 91–99
doi: 10.1111/jdi.12661
Clinical Trial Registry
University Medical Information Network
UMIN000022094

ABSTRACTIntroduction: We compared the effects of morning administration of insulin
glulisine + insulin glargine 300 U/mL (G + G300) with that of insulin lispro + insulin glargine biosimilar (L + GB).
Materials and Methods: A total of 30 patients with type 2 diabetes who wore a continuous glucose monitoring device on admission after glucose levels were stabilized bymorning long-acting and ultra-rapid-acting insulins were randomly allocated to groups
who received G + G300 on days 1 and 2, and the same dose L + GB on days 3 and 4,
or vice versa. Data collected on days 2 and 4 (mean amplitude of glycemic excursion,mean of daily differences: all days) were analyzed. Insulin was injected at 08.00 h. A day
was defined as the period from 08.00 h one day, to 08.00 h the next day. Test meals
were given.
Results: Increased post-breakfast glucose level, post-breakfast glucose gradient, mean
glucose level, standard deviation and M-value (24 h, 00.00–06.00 h), mean amplitude ofglycemic excursion, and mean of daily differences were significantly lower in patients taking G + G300 than those taking L + GB (P ≤ 0.0001–0.04). The area over the glucose
curve (<70 mg/dL) was not significantly different between groups. Pre-lunch - pre-breakfast glucose levels were significantly lower in patients taking L + GB than those taking
G + G300 (P < 0.0001). The difference in the highest post-breakfast glucose level between
groups (D = G + G300 - L + GB) was significantly correlated to 24-h mean glucose level(r = 0.40, P = 0.03).
Conclusions: Compared with L + GB, G + G300 decreases post-breakfast glucose level
reducing rate of rise of that, nocturnal and 24-h glucose variability and level without causing hypoglycemia, and daily variance.

INTRODUCTION
A relationship between nocturnal hypoglycemia and sudden
death has been suggested.1 As per the Somogyi phenomenon,
nocturnal hypoglycemia causes an increase in the difference
between pre- and post-breakfast glucose levels.2 Thus, hypoglycemia and increased glycemic variability occur at the sametime in the Somogyi phenomenon. Large clinical studies haveshown that hypoglycemia and glycemic variability are associatedwith mortality in patients with diabetes mellitus.3–5 We wanted
to predict the Somogyi phenomenon, in which hypoglycemia
and increased glycemic variability occur concomitantly, and wehave reported that major increases between pre- and postbreakfast glucose levels might predict nocturnal hypoglycemia
in type 2 diabetes patients.6

Received 30 November 2016; revised 13 March 2017; accepted 21 March 2017ª 2017 The Authors. Journal of Diabetes Investigation published by Asian Association for the Study of Diabetes (AASD) and John Wiley & Sons Australia, Ltd
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution andreproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

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CLINICAL TRIAL
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When the Somogyi phenomenon is suspected, reducing both
nocturnal hypoglycemia and increases between pre- and postbreakfast glucose levels, and controlling pre-breakfast glucose
levels properly, is necessary.1,4,7 We consider that morning
long-acting insulin reducing nocturnal hypoglycemia andultra-rapid-acting insulin reducing increases between pre- andpost-breakfast glucose levels accurately are useful. Adding one
ultra-rapid-acting insulin to long-acting insulin is recommended
in the American Diabetes Association’s guideline.8 Therefore,
this treatment is thought to be useful as an insulin therapy thatis injected in the morning only.
Regarding reducing nocturnal hypoglycemia, nocturnal andoverall hypoglycemia were signiﬁcantly reduced in patients taking insulin glargine 300 U/mL (glargine 300 U/mL), as opposed
to insulin glargine 100 U/mL (glargine 100 U/mL) in the Every
Day in the Life of Patients with Diabetes Japan 2 trial.9 Therefore, glargine 300 U/mL is thought to be useful as a long-acting
insulin in reducing nocturnal hypoglycemia.
Regarding increases between pre- and post-breakfast glucose
levels, post-breakfast glucose levels are often increased to agreater extent than post-lunch or post-supper glucose levels,and can cause increased glycemic variability over 24 h.10 The
glucose level after the ﬁrst meal (breakfast),11 and sometimes
the Somogyi phenomenon2 and the dawn phenomenon,12 are
the main causes of increased morning glucose levels. However,the Somogyi phenomenon is mainly caused by nocturnal
hypoglycemia. Differentiating the Somogyi phenomenon fromthe dawn phenomenon is difﬁcult, unless whether nocturnal
hypoglycemia is occurring or not is known. In any case thefollowing are necessary in order to reduce increases in postbreakfast glucose levels: (i) adjusting treatment to avoid nocturnal hypoglycemia when nocturnal hypoglycemia causes
increased morning glucose levels; and (ii) decreasing postbreakfast glucose levels directly by adjusting treatment.
Regarding (ii), knowledge of a patient’s morning glycemic
variability status is important for improving increased glycemic variability over 24 h. We focused on using patient characteristics to predict morning glycemic variability, and wehave reported the relationship between patient characteristics
and morning glycemic variability in a previous study.13 Inthat study, higher age and lower body mass index (BMI) wereobserved to be associated with higher highest increased postbreakfast glucose levels. Furthermore, longer durations ofdiabetes and lower BMI were correlated with a higher postbreakfast glucose gradient. Therefore, we believe that treatments that decrease post-breakfast glucose levels in elderly
diabetes patients, as well as a delay or reduction in theincreases in post-breakfast glucose levels of diabetes patientswith low BMI values, should be considered. Speciﬁcally, we
believe that insulin glulisine (glulisine), which has a fast onsetof action, is beneﬁcial in this clinical scenario. It has beenreported that switching to glulisine from another ultra-rapidacting insulin with almost the same dose improved postprandial glucose levels and glycosylated hemoglobin levels.14
92

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Therefore, we hypothesized that glulisine is useful as theultra-rapid-acting insulin in reducing increases between preand post-breakfast glucose levels.
Thus, a combination therapy of glargine 300 U/mL (considered to reduce nocturnal hypoglycemia and pre-breakfast glucose levels) and glulisine (post-breakfast glucose level, the rateof rise of which was reduced, decreases, because the effects ofthe difference of insulin concentration on glulisine were fasterand stronger) administered in the morning might be beneﬁcial.
We compared the effects of morning administration of insulin
glulisine + insulin glargine 300 U/mL (G + G300) with that of
insulin lispro + insulin glargine biosimilar (L + GB) using continuous glucose monitoring (CGM) in a randomized cross-overstudy.

METHODS
Study design and patient selection

Fasting plasma glucose (FPG) of the glargine 100 U/mL groupin the Every Day in the Life of Patients with Diabetes Japan 2
trial9 was 133.84 – 34.73 mg/dL. The number of individuals
for whom a 30% alteration of the mean FPG could be detectedwith an a value of 0.05 and with a statistical power of 80% was
13. We assumed that 10% of those recruited might drop out of
the trial, and therefore determined the total number of participants required to be 15. The glucose level of the insulin lispro(lispro) group of patients with type 2 diabetes in the clinical
trial investigating efﬁcacy and safety of glulisine reported by
Morishita15 was 162.51 – 58.94 mg/dL, 1 h post-breakfast. The
number of individuals for whom a 30% alteration of the mean
1-h post-breakfast glucose level could be detected with an avalue of 0.05 and with a statistical power of 80% was 24. We
assumed that 10% of those recruited might drop out of thetrial, and therefore determined the total number of participantsrequired to be 27. From the above, the necessary number ofsamples was determined to be 27.
A total of 30 patients with type 2 diabetes treated with basal
insulin for 3 months or longer were investigated. The patients
who wore a CGM device (Medtronic ipro2; Medtronic Minimed, Northridge, CA, USA) on admission were randomly
allocated to separate groups (each group included 15 patients)
who received G + G300 on days 1 and 2, and the same doseof L + GB on days 3 and 4, or who received L + GB on
days 1 and 2, and the same dose of G + G300 on days 3 and4.16 Patients were allocated to groups using a random number
table, and the study design was continuous and prospective.
When basal insulin was insulin degludec, it was changed toanother long-acting insulin after enrollment. All patients’ insulin regimens were uniﬁed into morning long-acting insulin andultra-rapid-acting insulin after enrollment. Insulin was titrated
to stabilize FPG not exceeding 180 mg/dL for 3 days, and thenthe CGM device was attached. Glucose levels were measured
for four consecutive days by the CGM device, and data collected on days 2 and 4 (mean amplitude of glycemic excursion[MAGE],17 mean of daily differences [MODD]18 and averageª 2017 The Authors. Journal of Diabetes Investigation published by AASD and John Wiley & Sons Australia, Ltd

CLINICAL TRIAL
Comparison, morning basal + 1 bolus, CGM

http://onlinelibrary.wiley.com/journal/jdi

daily risk range19: days 1 and 2, and days 3 and 4) were analyzed. Insulin was injected at 08.00 h. A day was deﬁned as
the period from 08.00 h 1 day, to 08.00 h the next day.
Regarding other diabetes treatments, a-glucosidase inhibitors,
rapid-acting insulin secretagogues and glucagon-like peptide-1
receptor agonists were discontinued after enrollment. All othertreatments were continued during the CGM measurement period. The participants received test meals consisting of the same
nutrients and equivalent caloric intake during the CGM measurement period. The total caloric intake for participants wasdeﬁned by the attending physicians, as 1,440 kcal, 1,600 kcal
or 1,840 kcal per day to accommodate differences in physiqueamong the participants.20 Test meals were given to eachpatient based on the recommendation of the Japan Diabetes
Society (component ratio of calories [carbohydrates 60%, proteins 18% and lipids 22%; breakfast 30%; lunch 35%; supper35%]), irrespective of differences in physique during the CGM
measurement period. Physical activity at admission to thestudy was 1.5 metabolic equivalents based on the analysis ofbaseline data. Patients with severe renal dysfunction (serum
creatinine level ≥2.0 mg/dL) or judged to be unsuitable forparticipation for medical reasons were excluded from thisstudy.
The study protocol was approved by the ethical committeeof General Inuyamachuo Hospital (authorization no. I, 2016),
and was registered in a clinical trial database with the University Medical Information Network (no. UMIN000022094).

follows: age, 71.5 years (65.0–80.0 years); duration of diabetes,
15.0 years (10.0–20.0 years); BMI, 25.3 kg/m2 (22.4–26.7 kg/m2); glycosylated hemoglobin, 8.3% (7.6–9.3%); C-peptide
immunoreactivity, 1.2 ng/mL (0.8–1.7 ng/mL); FPG level,
140.5 mg/dL (111.8–190.0 mg/dL); C-peptide index, 0.7 (0.6–1.1); urine C-peptide immunoreactivity, 23.4 lg/day (12.5–
48.9 lg/day); basal insulin dose, 12.0 U/day (8.0–24.0 U/day);bolus insulin dose, 6.0 U/day (4.0–7.5 U/day); total insulindose, 18.0 U/day (14.0–30.0 U/day); and basal/total insulin dose
ratio 70.3% (62.5–75.0%; Table 1).

Statistical analysis

Table 1 | Baseline characteristics

The CGM end-point included M-value (24 h [target glucose
level 100], 08.00–12.00 h [target glucose level = 120], 12.00–
24.00 h [target glucose level 120], 00.00–06.00 h [target glucose
level 90]),21 MAGE (MAGE of increased glucose levels[MAGE+], MAGE of decreased glucose levels [MAGE-]),17
MODD, average daily risk range, mean glucose level (24 h,
08.00–12.00 h, 12.00–24.00 h, 00.00–06.00 h), standard deviation (SD)22 (24 h, 08.00–12.00 h, 12.00–24.00 h, 00.00–06.00 h),
preprandial glucose level (lunch - breakfast),23 highest postprandial glucose level within 3 h after each meal (highest glucose level), time from start of meal to the highest postprandial
glucose level (highest glucose time), difference between preprandial and highest postprandial glucose level for each meal (increased glucose level), postprandial glucose gradient, area under
the glucose curve (AUC; ≥180 mg/dL) within 3 h of each meal,
AUC (≥0 mg/dL) in 24 h and area over the glucose curve(AOC; <70 mg/dL) (24 h, 08.00–12.00 h, 00.00–06.00 h).24
Data are shown as median (interquartile range). Statisticalanalysis was carried out with Wilcoxon signed-rank test. A
P-value of <0.05 was considered signiﬁcant.

RESULTS
Patient characteristics

Table 1 shows the patients’ characteristics. The study included
13 men and 17 women. The baseline characteristics were asª 2017 The Authors. Journal of Diabetes Investigation published by AASD and John Wiley & Sons Australia, Ltd

Primary outcomes

Figure 1 shows the glycemic variability over 24 h of CGM in
all of the patients.
The M-values (24 h, 00.00–06.00 h, 08.00–12.00 h) were signiﬁcantly lower in patients taking G + G300 than those taking
L + GB (P = 0.003, P = 0.0004, P = 0.04, respectively). MAGE,
MAGE+ and MAGE- were signiﬁcantly lower in patients taking G + G300 than those taking L + GB (P = 0.0001,
P < 0.0001, P = 0.0004, respectively). MODD was signiﬁcantly
lower in patients taking G + G300 than those taking L + GB
(P = 0.004). Mean glucose levels (24 h, 00.00–06.00 h, 12.00–
24.00 h) were signiﬁcantly lower in patients taking G + G300
than those taking L + GB (P = 0.0002, P = 0.0002, P = 0.01,
respectively). SDs (24 h, 00.00–06.00 h, 08.00–12.00 h) weresigniﬁcantly lower in patients taking G + G300 than those taking L + GB (P = 0.008, P = 0.0003, P = 0.009, respectively).

CharacteristicValuen (male/female)Age (years)
Duration of diabetes (years)
BMI (kg/m2)
HbA1c, NGSP (%)
GA (%)CPR (ng/mL)
FPG (mg/dL)
CPI
U-CPR (lg/day)Basal insulin dose (U/day)
Bolus insulin dose (U/day)Total insulin dose (U/day)Basal/Total insulin dose ratio (%)
Sulfonylurea agent, n (%)
Biguanide agent, n (%)
Thiazolidine, n (%)
DPP4 inhibitor, n (%)
SGLT 2 inhibitor, n (%)

30 (13/17)
71.5 (65.0–80.0)
15.0 (10.0–20.0)
25.3 (22.4–26.7)
8.3 (7.6–9.3)
21.8 (19.2–24.0)
1.2 (0.8–1.7)
140.5 (111.8–190.0)
0.7 (0.6–1.1)
23.4 (12.5–48.9)
12.0 (8.0–24.0)
6.0 (4.0–7.5)
18.0 (14.0–30.0)
70.3 (62.5–75.0)
3 (10.0)
19 (63.3)
3 (10.0)
21 (70.0)
8 (26.7)

Data are shown as median (interquartile range). BMI, body mass index;
CPI, C-peptide index; CPR, C-peptide immunoreactivity; DPP, dipeptidylpeptidase; FPG, fasting plasma glucose; GA, glycoalbumin; HbA1c,
glycosylated hemoglobin; SGLT, sodium glucose co-transporter; U-CPR,
urine C-peptide immunoreactivity.

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300(n = 30)

Glucose levels (mg/dL)

250

200

150

100

50
Thick lines: medianFine lines: interquartile ranges
0

0:00

2:00

4:00

6:00

8:00

G+G300
L+GB
10:00 12:00 14:00

16:00 18:00 20:00

22:00

24:00
Time

Figure 1 | The graph shows glucose variability over 24 h on continuous glucose monitoring (CGM) in patients during treatment with insulin
glulisine + insulin glargine 300 U/mL (G + G300) or insulin lispro + insulin glargine biosimilar (L + GB). Glucose levels were calculated from thevalue of CGM on the second day after the start of each therapy. Data are shown as median (thick lines) and interquartile ranges (fine lines).

Pre-lunch - pre-breakfast glucose level was signiﬁcantly lower
in patients taking L + GB than those taking G + G300
(P ≤ 0.0001). The highest post-breakfast glucose level was signiﬁcantly lower in patients taking G + G300 than those taking
L + GB (P ≤ 0.0001). Increased post-breakfast glucose level
was signiﬁcantly lower in patients taking G + G300 than thosetaking L + GB (P = 0.0001). The post-breakfast glucose gradient was signiﬁcantly lower in patients taking G + G300 thanthose taking L + GB (P = 0.0007). AUC (≥180 mg/dL) within
3 h after breakfast was signiﬁcantly lower in patients taking
G + G300 than those taking L + GB (P = 0.001). The AUC(≥0 mg/dL) in 24 h was signiﬁcantly lower in patients taking
G + G300 than those taking L + GB (P = 0.0002). The area
over the glucose curve (<70 mg/dL) was not signiﬁcantly different between groups (Table 2).
The difference in the highest post-breakfast glucose levels
between groups (D = G + G300 - L + GB) was signiﬁcantly
correlated to AUC in 24 h (r = 0.39, P = 0.03; Spearman’srank correlation coefﬁcient).

DISCUSSION
The results of the present study suggest that the combination
therapy of G + G300 decreases post-breakfast glucose level
reducing rate of rise of that, nocturnal and 24-h glucose variability and level without causing hypoglycemia, and daily variance. Figure 2 shows a schematic diagram of the estimatedinsulin concentration in both G + G300 and L + GB, to94

J Diabetes Investig Vol. 9 No. 1 January 2018

investigate the basis of the results obtained from the present
study.
The ﬁnding that the highest post-breakfast glucose level,
increased post-breakfast glucose level, post-breakfast glucose
gradient and AUC (≥180 mg/dL) within 3 h after breakfast
were signiﬁcantly lower in patients taking G + G300 than thosetaking L + GB was thought to be caused by the difference of
insulin concentration between glulisine and lispro (part 1 of
Figure 2) because of the rapid onset of action of glulisine.
Namely, we believe that post-breakfast glucose levels decreased
with the reduced rate of rise, because glulisine was affected faster and stronger by the difference (part 1 of Figure 2). In fact,
it has been reported that time to 50% serum insulin concentration of glulisine was signiﬁcantly earlier than that of lispro or
insulin aspart.25 The onset of glulisine’s effect has been suggested to be faster than the other ultra-rapid-acting insulins,
and this is supported by the results of the present study. The
result that the difference in the highest post-breakfast glucose
level between groups (D = G + G300 - L + GB) was signiﬁcantly correlated to AUC in 24 h, suggests that as well as
reducing the highest post-breakfast glucose levels, glulisine also
produces a greater reduction in glucose levels measured over a
24-h period. Conversely, the result that pre-lunch - pre-breakfast glucose levels were signiﬁcantly lower in patients taking
L + GB than those taking G + G300 was thought to be due tothe difference in serum insulin concentration between glulisineand lispro (part 2 of Figure 2), because serum concentrationsª 2017 The Authors. Journal of Diabetes Investigation published by AASD and John Wiley & Sons Australia, Ltd

CLINICAL TRIAL
Comparison, morning basal + 1 bolus, CGM

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Table 2 | Parameters of glucose variability in patients treated with insulin glulisine + insulin glargine 300 U/mL or insulin lispro + insulin glargine
biosimilar
Glulisine + glargine 300 U/mL
24-h M-value (target glucose level 100 mg/dL)
8.4 (4.4–22.4)
00.00–06.00 h M-value (target glucose level 90 mg/dL)
1.5 (0.4–11.2)
08.00–12.00 h M-value (target glucose level 120 mg/dL)
2.1 (0.7–5.9)
12.00–24.00 h M-value (target glucose level 120 mg/dL)
4.6 (2.4–14.9)
MAGE (mg/dL)
47.6 (38.2–55.7)
MAGE of increased glucose levels (mg/dL)
48.3 (38.9–56.9)
MAGE of decreased glucose levels (mg/dL)
46.7 (37.9–54.6)
Mean of daily difference (mg/dL)
24.6 (16.4–31.1)
Average daily risk range
14.4 (9.0–22.4)
24-h mean glucose level (mg/dL)
151.0 (128.1–167.7)
00.00–06.00 h mean glucose level (mg/dL)
113.1 (93.4–137.8)
08.00–12.00 h mean glucose level (mg/dL)
149.2 (126.9–163.6)
12.00–24.00 h mean glucose level (mg/dL)
164.1 (137.9–202.6)
24-h standard deviation (mg/dL)
33.4 (27.2–40.3)
00.00–06.00 h SD (mg/dL)
8.5 (6.1–13.9)
08.00–12.00 h SD (mg/dL)
20.3 (16.5–26.5)
12.00–24.00 h SD (mg/dL)
28.1 (21.5–33.6)
Preprandial glucose level (mg/dL)
Lunch - breakfast
7.5 (-10.5 to 29.3)
Highest postprandial glucose level within 3 h after each meal (mg/dL)
Breakfast
173.5 (160.6–192.8)
Lunch
193.5 (167.5–232.5)
Supper
212.8 (187.0–251.0)
Time from start of meal to the highest postprandial glucose level (min)Breakfast
75.0 (51.3–98.8)
Lunch
97.5 (71.3–158.8)
Supper102.5 (81.3–140.0)
Differences between preprandial and highest postprandial glucose level for each meal (mg/dL)
Breakfast
47.0 (29.5–71.3)
Lunch
77.5 (47.3–100.8)
Supper69.0 (33.8–89.8)
Postprandial glucose gradient (mg/dL min)Breakfast
0.73 (0.31–1.11)
Lunch
0.68 (0.39–1.01)
Supper
0.55 (0.35–1.05)
AUC (≥180 mg/dL) within 3 h after each meal (mg min/dL)
Breakfast
0.0 (0.0–828.1)
Lunch
180.6 (0.0–5,804.1)
Supper
4,009.4 (251.3–13,306.9)
24-h AUC, ≥0 mg/dL (mg min/dL)
217,386.7 (184,660.1–241,610.1)
24-h AOC, <70 mg/dL (mg min/dL)
0 (0–0)00.00–06.00 h AOC, <70 mg/dL (mg min/dL)
0 (0–0)08.00–12.00 h AOC, <70 mg/dL (mg min/dL)
0 (0–0)Lispro + glargine biosimilarP

9.7 (6.2–31.9)
5.1 (1.7–22.4)
2.6 (1.2–7.4)
4.7 (2.7–22.5)
53.2 (46.1–86.8)
54.1 (47.4–86.9)
53.8 (44.3–87.3)
25.2 (19.6–39.0)
17.3 (8.9–24.5)
153.4 (142.2–192.4)
132.1 (115.4–168.8)
150.3 (135.2–166.8)
166.8 (156.2–211.0)
33.5 (27.3–55.0)
10.8 (8.7–18.4)
25.8 (18.0–32.7)
30.4 (21.0–38.8)

0.003
0.00040.04
0.05
0.0001<0.0001
0.00040.004
0.26
0.00020.0002
0.21
0.01
0.008
0.00030.009
0.29-4.0 (-32.0 to 5.8)

<0.0001

198.0 (165.8–217.0)
200.0 (173.8–241.8)
214.5 (198.0–258.8)<0.0001
0.14
0.5

62.5 (50.0–85.0)
100.0 (70.0–125.0)
97.5 (71.3–158.8)

0.98
0.34
0.76

66.0 (47.5–95.5)
76.0 (48.3–104.8)
61.5 (40.3–101.0)

0.00010.31
0.98

1.26 (0.66–1.72)
0.79 (0.52–1.04)
0.59 (0.36–0.98)

0.00070.43
0.4

690.0 (0.0–4,338.1)
1,219.4 (0.0–7,058.8)
3,159.9 (343.1–12,530.6)
220,806.8 (204,782.1–277,096.4)
0 (0–0)0 (0–0)0 (0–0)

0.001
0.13
0.86
0.00020.65
0.32
1Data are shown as median (interquartile range). P, Wilcoxon signed-rank test. AOC, area over the glucose curve; AUC, area under the glucose curve;
MAGE, mean amplitude of glycemic excursion.

of glulisine reduce more rapidly than those of lispro. Namely,
we believe that pre-lunch glucose levels decreased too much,because lispro was affected too much by the difference of insulin concentration (part 2 of Figure 2). It has been reported thatthe mean residence time of glulisine was approximately half ofª 2017 The Authors. Journal of Diabetes Investigation published by AASD and John Wiley & Sons Australia, Ltdthat of lispro or rapid-acting insulin.26 The wearing off of glulisine’s effect has been suggested to be faster than lispro or
rapid-acting insulin, and this supports the present study results.
Therefore, we believe that morning lispro administration mightcause hypoglycemia before lunch, but morning glulisine

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Estimate insulin concentration
0:00 to 6:00 mean glucose levels
AUC (≥0) in 24 h
24-h M-value (100)24-h SD(1)
MAGE
Glulisine

Lispro0:00 to 6:00 M-value (90)0:00 to 6:00 SD(Insulin dose)Highest post-breakfast glucose levels
Increase post-breakfast glucose levels
Post-breakfast glucose gradient
Post-breakfast AUC (≥180)

MAGE+
MAGE–
MAGE

Pre-lunch – breakfast glucose levels

(2)

(3)
Glargine 300 U/ml

Glargine biosimilar

MODD

0:00

8:00

12:00

24:00

Injection

Figure 2 | The graph shows a schematic diagram of the estimated insulin concentration in glulisine + insulin glargine 300 U/mL andlispro + insulin glargine biosimilar. AUC (≥180), area under the glucose curve (≥180 mg/dL) within 3 h; Glargine 300 U/mL, insulin glargine 300
U/mL; Glargine biosimilar, insulin glargine biosimilar; Glulisine, insulin glulisine; Highest post-breakfast glucose levels, highest post-breakfast glucose
level within 3 h; Increase post-breakfast glucose levels, differences between pre-breakfast and highest post-breakfast glucose levels; Lispro, insulin
lispro; MAGE+, mean amplitude of glycemic excursion of increased glucose levels; MAGE-, mean amplitude of glycemic excursion of decreased
glucose levels; MAGE, mean amplitude of glycemic excursion; MODD, mean of daily difference; SD, standard deviation.

administration can avoid the risk of hypoglycemia before lunchin patients with low pre-breakfast glucose levels. We believethat the rapid onset and fast wearing off of glulisine’s effect(Figure 2 [1] and Figure 2 [2]) led to the result that MAGE+,
MAGE- and MAGE were signiﬁcantly lower in patients taking
G + G300 than those taking L + GB, because those characteristics of glulisine’s action reduced rapid increases and decreasesof morning glucose levels. It has been reported that the concentration of protein kinase C-b, which is an index of oxidative
stress, increases when glucose concentration decreases; that is,from hyperglycemia status to normoglycemia status.27 Therefore, it is signiﬁcant that glulisine can reduce not only rapid
increases, but also rapid decreases of glucose levels. The resultthat 00.00–06.00 h M-value and 00.00–06.00 h SD were signiﬁcantly lower in patients taking G + G300 than those taking
L + GB was thought to be caused by the difference in serum
insulin concentration between insulin glargine biosimilar (glargine BS) and glargine 300 U/mL between 00.00–06.00 h
96

J Diabetes Investig Vol. 9 No. 1 January 2018

(Figure 2). The duration of action as a clinical effect of glargine
BS was thought to be approximately 22.8 h.28,29 In contrast, theduration of action as a clinical effect of glargine 300 U/mL wasthought to be just 24 h.30 Therefore, we believe that glargine
300 U/mL improves nocturnal glycemic variability more thanglargine BS, because the serum concentration of glargine BS
varies, but that of glargine 300 U/mL is stable between 00.00–
06.00 h (Figure 2). The result that 00.00–06.00 h mean glucose
levels, AUC (≥0) in 24 h, 24-h SD, 24-h M-value and MAGE
were signiﬁcantly lower in patients taking G + G300 than thosetaking L + GB was thought to be due to the fact that glargine
300 U/mL improves 24-h glycemic variability with a focus onnight-time more than glargine BS30 (Figure 2 [3]), and that glulisine improves 24-h glycemic variability through improvementof pre- and post-breakfast glycemic variability more than lispro,14 namely, the combination therapy of glargine 300 U/mL
and glulisine. The result that MODD was signiﬁcantly lower inpatients taking G + G300 than those taking L + GB wasª 2017 The Authors. Journal of Diabetes Investigation published by AASD and John Wiley & Sons Australia, Ltdhttp://onlinelibrary.wiley.com/journal/jdi

thought to be caused by the small variance in daily effect ofglargine 300 U/mL. Day-to-day variability (coefﬁcient of variation %) in the area under the curve of glucose infusion rateover 24 h of glargine BS is 73%.29,31 In contrast, that of glargine 300 U/mL is 34.8%.32 Daily variance of glargine 300 U/
mL is much smaller than that of glargine BS, and this supports
the present study results. Regarding daily variance, it has beensuggested that larger daily variance of glycosylated hemoglobin
and glucose levels causes a higher incidence of cardiovascular
events and is associated with a poor prognosis.33 Daily stabilityof the glargine 300 U/mL effect is thought to improve cardiovascular events and prognosis.
In the present study, it was suggested that nocturnal glucose level was signiﬁcantly lower in patients taking G + G300
than those taking L + GB. Decreasing nocturnal glucose levels
might be interpreted as increasing the potential risk of hypoglycemia. However, at the same time, nocturnal glycemic variability was signiﬁcantly lower in patients taking G + G300
than those taking L + GB in the present study. We believethat reducing glucose levels with decreasing variability does
not increase the potential risk of hypoglycemia. In the present
study, hypoglycemia was not signiﬁcantly different between
groups.
From the viewpoint of diabetes education, the practice of noteating breakfast in order to decrease post-breakfast glucose
levels might exist amongst the diabetic population. However, it
has been reported that the incidence of diabetes is signiﬁcantly
increased in people who miss breakfast than in those who eat
breakfast.34 Missing breakfast is thought to cause worsening ofglycemic control. In a clinical trial that provides detailed support for this theory, it has been reported that post-lunch andsupper glucose levels increase more in patients missing breakfast than in those eating breakfast.35 In addition, the second
meal effect that increased post-lunch glucose levels was lower
than the increased post-breakfast glucose levels that have beenreported.11 Post-lunch glucose levels increase more in patientsskipping breakfast than those taking breakfast. High serum concentration of free fatty acids reduces insulin sensitivity. Free
fatty acids levels are reduced to a greater extent before lunch
than before breakfast by eating breakfast, and this causes thesecond meal effect. Post-lunch glucose levels increase in patients
missing breakfast, because free fatty acids levels do not decrease,and thus insulin sensitivity does not improve. Therefore, missing breakfast causes an increase in post-lunch and supper glucose levels, and worsening of glycemic control. Patients should
eat breakfast, and post-breakfast glucose levels should be
reduced by medication.
An advantage of the combination therapy of glargine
300 U/mL and glulisine considered from the viewpoint of diabetes education is that the injection is only given in themorning. In this regard, this combination therapy is almost
the same as basal insulin therapy, and signiﬁcant hypoglycemic actions can be expected as a result of adding glulisine. Another combination therapy consisting of basalª 2017 The Authors. Journal of Diabetes Investigation published by AASD and John Wiley & Sons Australia, Ltd

CLINICAL TRIAL
Comparison, morning basal + 1 bolus, CGM

insulin + glucagon-like peptide-1 receptor agonist (GLP-1 RA)
exists. However, GLP-1 RA is costly, and its digestive sideeffects should be considered. Furthermore, goals of treatment
are different between insulin and GLP-1 RA. Therefore, combination therapy of basal insulin and GLP-1 RA should beconsidered as being fundamentally different from combination
therapy of morning long-acting insulin and ultra-rapid-acting
insulin. Combination long-acting and ultra-rapid-acting insulin
given as a single morning injection might be more desirable
to patients, as it is easier to build into a daily routine, in asimilar way to the habit of teeth-brushing, for example, andis thus less likely to be forgotten or delayed. Understandably,
patients might not enjoy injecting insulin, and so administering this necessary treatment at the start of the day could feasibly improve the quality of life for the diabetes patient.
Additionally, given the importance of eating breakfast in the
diabetic population, morning administration of insulin might
help those who would previously have missed breakfast to
remember to eat at this time, by linking the treatment witheating as part of the patient’s daily routine.
In the present study, it was suggested that the combination
therapy of glulisine + glargine 300 U/mL decreases post-breakfast glucose level reducing rate of rise of that, nocturnal and24-h glucose variability and levels without causing hypoglycemia, and daily variance. As an insulin therapy that is
injected in the morning only, the combination therapy ofglulisine + glargine 300 U/mL is suggested to be the best therapy not only to improve glycemic variability, but also from apatient preference viewpoint. Thus, the clinical signiﬁcance ofthe present study is high. However, this study had limitations
as a single facility, open-label study. We shall endeavor toaddress these limitations by gathering more cases and carryingout further clinical studies in the future.

ACKNOWLEDGMENTS
This work was supported in part by the General Inuyamachuo
Hospital.
DISCLOSURE
The authors declare no conﬂict of interest.
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