# Patent

## Title
Potentiation of glucose elimination

## Abstract

Methods related to the treatment of diabetes and improving the efficiency of insulin utilization are provided. The method enables effective control of prandial glucose levels while reducing the risk of postprandial hypoglycemia. In particular, methods of potentiating the activity of endogenous insulin in type 2 diabetics and exogenous long-acting insulin in diabetics requiring basal insulin replacement are provided.

## Background
CROSS REFERENCE TO RELATED APPLICATIONS
This application claims priority under 35 U.S.C. §119(e) to U.S. Provisional Patent Application No. 60/643,070 filed Jan. 10, 2005 and U.S. Provisional Patent Application No. 60/667,393, filed Mar. 31, 2005 and is a continuation-in-part of U.S. patent application Ser. No. 10/719,734 filed Nov. 21, 2003 which is a continuation of U.S. patent application Ser. No. 10/224,761 filed Aug. 20, 2002, now U.S. Pat. No. 6,652,885, which is a division of U.S. patent application Ser. No. 09/606,468 filed Jun. 29, 2000, now U.S. Pat. No. 6,444,226 which claims priority under 35 U.S.C. §119(e) to U.S. Provisional Patent Application No. 60/141,433 filed Jun. 29, 1999, each of which are incorporated by reference herein in their entirety.


FIELD OF THE INVENTION
The present invention relates to methods of treating diabetes and improving the efficiency of insulin utilization. The method enables effective control of prandial glucose levels while reducing the risk of post-prandial hypoglycemia. In particular the method of the present invention potentiates the activity of endogenous insulin in type 2 diabetics and exogenous long-acting insulin in diabetics requiring basal insulin replacement.
BACKGROUND TO THE INVENTION
Diabetes mellitus currently afflicts at least 200 million people worldwide. Type 1 diabetes accounts for about 10% of this number, and results from autoimmune destruction of insulin-secreting β-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.
In a non-stressed normal individual, 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.
In this normal individual, a meal induces the secretion of a burst of insulin, generating a rapid spike in serum insulin concentration that then decays relatively quickly (see FIG. 1). This is referred to as first-phase kinetics and is responsible for the shut-off of release of glucose from the liver. Homeostatic mechanisms then match insulin secretion (and serum insulin levels) to the glucose load. This is observed as a slow decay of modestly elevated serum insulin levels back to baseline and is referred to as second-phase kinetics.
Type 2 diabetics typically exhibit a delayed response to increases in blood glucose levels. While normal individuals usually 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 continues after consumption and the patient experiences hyperglycemia due to elevated blood glucose levels.
Loss of eating-induced insulin secretion is one of the earliest disturbances of β-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 β-cell function, is to restore the rapid release of insulin following meals.
In addition to the loss of first-phase kinetics, early stage type 2 diabetics do not shut-off glucose release after a meal. As the disease progresses, the demands placed on the pancreas further degrades its ability to produce insulin and control of blood glucose levels gradually deteriorates. If unchecked, the disease can progress to the point that the deficit in insulin production approaches that typical of fully developed type 1 diabetes. Type 1 diabetes can involve an early “honeymoon” stage, following an initial crisis, in which insulin is still produced but defects in release similar to early type 2 disease are exhibited.
Most early stage type 2 diabetics currently are treated with oral agents, but with limited success. Subcutaneous injections are also rarely effective in providing insulin to type 2 diabetics and may actually worsen insulin action because of delayed, variable and shallow onset of action. It has been shown, however, that if insulin is administered intravenously with a meal, early stage type 2 diabetics experience the shutdown of hepatic glucose release and exhibit increased physiologic glucose control. In addition their free fatty acids levels fall at a faster rate that without insulin therapy. While possibly effective in treating type 2 diabetes, intravenous administration of insulin, is not a reasonable solution, as it is not safe or feasible for patients to intravenously administer insulin at every meal.
Significant pathology (and morbidity) in diabetics is associated with inadequate control of blood glucose. Excursions of blood glucose concentration both above and below the desired, normal range are problematic. In treatments that fail to mimic physiologic insulin release, the rise in insulin concentration does not produce sufficiently high glucose elimination rates to completely respond to the glucose load resulting from a meal. This can be further exacerbated by failure to shut off glucose release from the liver. Additionally, with many forms of insulin therapy, serum insulin levels and glucose elimination rates also remain elevated after the prandial glucose load has abated, threatening hypoglycemia. Attempts to better control peak glucose loads by increasing insulin dose further increase this danger.
Current insulin therapy modalities can supplement or replace endogenously-produced insulin to provide basal and second-phase-like profiles but do not mimic first-phase kinetics (see FIG. 2). Additionally, conventional insulin therapy often involves only one or two daily injections of insulin. However, more intensive therapy such as three or more administrations a day, providing better control of blood glucose levels, are clearly beneficial (see for example Nathan, D. M., et al., N Engl J Med 353:2643-53, 2005), but many patients are reluctant to accept the additional injections.
Until recently, subcutaneous (SC) injection has been the only route of delivering insulin to patients with both type 1 and type 2 diabetes. However, SC insulin administration does not lead to optimal pharmacodynamics for the administered insulin. Absorption into the blood (even with rapid acting insulin analogues) does not mimic the prandial physiologic insulin secretion pattern of a rapid spike in serum insulin concentration. Since the discovery of insulin, 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. Oral insulin 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).
Recently, pulmonary application of insulin has become a viable insulin delivery system. Some pulmonary insulin formulations in development provide faster appearance of insulin in the blood than typical subcutaneously delivered products (see FIG. 3), but apparently do not adequately reproduce all aspects of first-phase kinetics.
Therefore, a need exists for an insulin formulation which can mimic first-phase kinetics to provide physiologic postprandial insulin pharmacokinetics and pharmacodynamics for maintenance of normal physiologic blood glucose levels.
SUMMARY OF THE INVENTION
The present invention provides methods of treating diabetes and improving the efficiency of insulin utilization. The method enables effective control of prandial glucose levels while reducing the risk of post-prandial hypoglycemia. In particular the method of the present invention improves the potentiation of exogenous prandial insulin as well as potentiating the activity of endogenous insulin in type 2 diabetics and exogenous long-acting insulin in diabetics requiring basal insulin replacement.
In one embodiment of the present invention, a method of improving potentiation of the glucose elimination rate of the present invention is provided comprising producing a first-phase insulin-like spike in serum insulin levels with an exogenously-administered insulin composition, wherein the exogenously-administered insulin composition is not administered intravenously.
In another embodiment of the method of improving potentiation of the glucose elimination rate of the present invention, the exogenously administered insulin composition is administered in proximity to a meal. In yet another embodiment the exogenously administered insulin composition is administered from approximately 10 minutes prior to a meal to approximately 30 minutes after a meal.
In yet another embodiment of the method of improving potentiation of the glucose elimination rate of the present invention, the insulin-related disorder is diabetes mellitus, such as type 1 or type 2 diabetes mellitus.
In an embodiment of the method of improving potentiation of the glucose elimination rate of the present invention, the first-phase-like spike in serum insulin concentration is greater than about 75 mU/L, greater than about 100 mU/L or greater than about 125 mU/L
In another embodiment of the method of improving potentiation of the glucose elimination rate of the present invention, the first-phase-like spike in serum insulin concentration is achieved within about 20 minutes, within about 15 minutes or within about 10 minutes.
In another embodiment of the method of improving potentiation of the glucose elimination rate of the present invention, the potentiation comprises the glucose elimination rate reaching maximum within about 1 hour. In yet another embodiment the potentiation comprises the glucose elimination rate reaching maximum within about 45 minutes.
In an embodiment of the method of improving potentiation of the glucose elimination rate of the present invention, the glucose elimination rate continues to rise after serum insulin concentration begins to fall.
In another embodiment of the method of improving potentiation of the glucose elimination rate of the present invention, the glucose elimination rate begins to fall by about 1 hour after insulin administration.
In yet another embodiment of the method of improving potentiation of the glucose elimination rate of the present invention, the glucose elimination rate returns to baseline by about 6 hours.
In another embodiment of the method of improving potentiation of the glucose elimination rate of the present invention, the exogenously-administered insulin composition comprises a complex between a diketopiperazine and human insulin. In yet another embodiment the diketopiperazine is fumaryl diketopiperazine.
In an embodiment of the method of improving potentiation of the glucose elimination rate of the present invention, the exogenously-administered insulin composition is inhaled.
In an embodiment of the present invention, a method of mimicking first-phase human beta cell insulin release is provided comprising administering an exogenously-administered insulin composition.
In another embodiment of the method of mimicking first-phase human beta cell insulin release of the present invention, the exogenously-administered insulin composition comprises a complex between a diketopiperazine and human insulin. In another embodiment, the diketopiperazine is fumaryl diketopiperazine. In yet another embodiment, the exogenously-administered insulin composition is inhaled.
In one embodiment of the present invention, a method of treating an insulin-related disorder is provided 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.
In another embodiment of the method of treating an insulin-related disorder of the present invention, the exogenously-administered insulin composition comprises a complex between a diketopiperazine and human insulin. In another embodiment, the diketopiperazine is fumaryl diketopiperazine. In yet another embodiment, the exogenously-administered insulin composition is inhaled.
In yet another embodiment of the method of treating an insulin-related disorder of the present invention, the insulin-related disorder is diabetes mellitus, such as type 1 or type 2 diabetes mellitus.
In one embodiment of the present invention, a method of maintaining blood glucose levels in a patient with an insulin-related disorder in a normal range is provided 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.
In another embodiment of the method of maintaining blood glucose levels of the present invention, the exogenously-administered insulin composition comprises a complex between a diketopiperazine and human insulin. In another embodiment, the diketopiperazine is fumaryl diketopiperazine.
In another embodiment of the method of maintaining blood glucose levels of the present invention, the exogenously administered insulin composition is a non-naturally occurring form of insulin.
In one embodiment of the present invention, a method of restoring normal insulin kinetics in a patient in need thereof is provided 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. In another embodiment, the insulin-related disorder is diabetes mellitus. In yet another embodiment, the method further comprises administering a long-acting basal insulin.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 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). NovologTM is a registered trademark of Novo Nordisk Pharmaceuticals, Bagsvaerd, Denmark.
FIG. 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 Vasc. Dis 4:295-301, 2004).
FIG. 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®/Insulin, TI) according to the teachings of the present invention.
FIG. 5 depicts increased postprandial glucose elimination for Technosphere®/Insulin (48 U TI) 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.
FIGS. 6A-B depict comparisons in intra-patient variability in GIR (FIG. 6A) and insulin concentration (FIG. 6B) in individuals with type 2 diabetes mellitus at various time points for subcutaneous (SC) and pulmonary (TI) insulin according to the teachings of the present invention.
FIGS. 7A-B depict the mean serum insulin concentration (FIG. 7A) and insulin absorption, as AUC (FIG. 7B), in individuals with type 2 diabetes mellitus at different dose levels of Technosphere®/Insulin (TI) and SC insulin according to the teachings of the present invention.
FIG. 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 Technosphere®/Insulin (TI) according to the teachings of the present invention.
FIGS. 9A-B depict blood insulin (FIG. 9A) and glucose levels (FIG. 9B) in individuals with type 2 diabetes mellitus after administration of 14 IU SC insulin or 48 U Technosphere®/Insulin (TI) according to the teachings of the present invention.
FIG. 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 Technosphere®/Insulin (TI) according to the teachings of the present invention.
FIG. 11 depicts maintenance of the effects of inhaled insulin postprandial glucose levels after three months of insulin therapy in individuals with type 2 diabetes mellitus with Technosphere®/Insulin (TI) or placebo (PL) according to the teachings of the present invention.
FIGS. 12A-B depict total (FIG. 12A) and maximum (FIG. 12B) postprandial glucose excursion in individuals with type 2 diabetes mellitus after administration of Technosphere®/Insulin (TI) or placebo (PL) according to the teachings of the present invention.
FIG. 13 depicts the dose effect on maximal postprandial glucose excursions after administration of Technosphere®/Insulin (TI) 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.
FIGS. 14A-B depict the insulin appearance rate over time for TI and endogenous insulin after administration of Technosphere®/Insulin (TI) in patients with type 2 diabetes according to the teachings of the present invention
FIG. 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), SC (10 IU) or inhaled (TI, 100 U) insulin according to the teachings of the present invention.
FIG. 16 depicts the levels of C-peptide after administration of Technosphere®/Insulin (TI) or SC insulin in individuals with type 2 diabetes mellitus according to the teachings of the present invention.
FIG. 17 depicts the change in mean glycosylated hemoglobin (HbA1c) levels after 12 weeks of administration of Technosphere®/Insulin (TI) or placebo in individuals with type 2 diabetes mellitus according to the teachings of the present invention.
FIG. 18 depicts weight levels in individuals with type 2 diabetes mellitus administered Technosphere®/Insulin (TI) or placebo (PL) according to the teachings of the present invention.
FIGS. 19A-B depict pulmonary function, expressed as forced expiratory volume in one second (FEV1, FIG. 19A) and forced vital capacity (FVC, FIG. 19B) over time in a three month placebo-controlled clinical study with Technosphere®/Insulin according to the teachings of the present invention.
FIG. 20 depicts the study schema for the clinical trial disclosed in Example 6.
FIGS. 21A-B depict the baseline-corrected blood glucose concentration versus time by treatment group after administration of Technosphere®/Insulin and a isocaloric meal (FIG. 21A) or a hypercaloric meal (FIG. 21B) according to the teachings of the present invention.
FIGS. 22A-B depict the baseline-corrected serum insulin concentration versus time by treatment group after administration of Technosphere®/Insulin and a isocaloric meal (FIG. 22A) or a hypercaloric meal (FIG. 22B) according to the teachings of the present invention.
FIGS. 23A-B depict the mean blood glucose levels (FIG. 23A) or C-peptide levels (FIG. 23B) over time after administration of IV, SC or TI (inhaled) insulin according to the teachings of the present invention.
FIGS. 24A-B depict glucose infusion rate (FIG. 24A) or mean insulin concentration (FIG. 24B) over time after administration of IV, SC or TI (inhaled) insulin according to the teachings of the present invention.



DEFINITION OF TERMS
Prior to setting forth the invention, it may be helpful to provide an understanding of certain terms that will be used hereinafter:
Dry powder: As used herein “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.
Excursion: As used herein, “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: As used herein, “first-phase” refers to a burst of insulin release from the pancreas induced as a result of a meal. 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: As used herein, “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 (15.6 mM).
Hypoglycemia: As used herein, “hypoglycemia” is a lower than normal blood glucose concentration, usually less than 60 mg/dL, but in some instances less than 3.5 mM (63 mg/dL).
Insulin Composition: As used herein, “insulin composition” refers to any form of insulin suitably 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 Disorder: As used herein, “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.
Periprandial: As used herein, “periprandial” refers to a period of time starting shortly before and ending shortly after the ingestion of a meal or snack.
Postprandial: As used herein, “postprandial” refers to a period of time after ingestion of a meal or snack.
Potentiation: Generally, 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: As used herein, “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®/Insulin: As used herein, “Technosphere®/Insulin” refers to an insulin composition comprising regular human insulin and Technosphere® microparticles, a drug delivery system. Technosphere® microparticles comprise a diketopiperazine. Specifically, Technosphere®/Insulin comprises a fumaryl diketopiperazine/human insulin composition.
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 diketdpiperazine (FDKP) are also reported in IU as are measurements of insulin in the blood. Technosphere®/Insulin 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 in the use of insulin therapy in the treatment of diabetes is that doses sufficient to control prandial glucose loads produce elevated glucose elimination rates for extended intervals that can persist after the meal, leading to post prandial hypoglycemia. It is now disclosed that a short sharp rise to peak serum insulin concentration (which then declines) results in an accelerated approach to maximal glucose elimination rates. This has the effect of compressing the bulk of the effect of the administered insulin to the periprandial time interval reducing the risks of post-prandial hypoglycemia. The field has generally assumed that the rate of glucose elimination at any point in time is a function of insulin concentration at that point in time. In point of fact the glucose elimination rate achieved by any particular insulin concentration is influenced by prior insulin concentration. Thus 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. The present inventors have now surprisingly discovered that 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.
With a typical fast-acting subcutaneously (SC) administered insulin, maximal insulin concentrations can be achieved in about 30 to 45 minutes and remain at this plateau for several hours (FIG. 2). The glucose elimination rate (measured as the glucose infusion rate [GIR]) however continues to rise throughout this plateau phase (FIG. 5), peaking only as insulin concentration begins to decay (FIG. 4). In contrast, with an administration that mimics a physiological first-phase insulin release, insulin concentration peaks at a much higher level and begins to fall by about 15 minutes (FIG. 1). The GIR, however, continues to rise after the peak in insulin concentration but reaches its maximum in less than an hour and then falls in concert with insulin concentration (FIG. 4). By three hours, the bulk of glucose elimination to be accomplished by this insulin has occurred, yet the subcutaneous insulin has exerted less than a third of its effect (FIG. 5).
By taking advantage of the potentiating effects of a rapid spike in insulin concentration, 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. However, since 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. Due to the potentiating effect of an insulin preparation causing a rapid peak in serum insulin concentration, it can be more readily coordinated with a meal. The quick acquisition of maximal glucose elimination rate is well suited to mealtime administration, or even up to an hour after commencing a meal. The second-phase decay in insulin concentration reduces the risk of inducing hypoglycemia hours after the meal. Further advantages are realized in diabetics who retain some ability to produce insulin in that their endogenous second-phase and basal insulin will also be potentiated, increasing the effectiveness of that limited insulin and reducing pancreatic stress. Methods of reducing pancreatic stress with the exogenously-administered insulin compositions of the present invention are disclosed in co-pending U.S. Provisional Patent Application No. 60/704,295 entitled “Methods of Preserving the Function of Insulin-Producing Cells in Diabetes,” which is incorporated by reference herein for all it teaches regarding methods of reducing pancreatic stress by administering diketopiperazine/insulin compositions. The administration of exogenous insulin also suppresses insulin secretion from the pancreas. The quicker return to baseline achieved with a rapidly peaking insulin allows for earlier reassertion of pancreatic secretion and re-establishment of homeostatic control of blood glucose levels, further reducing the risk of post-treatment hypoglycemia. Similar advantages are contemplated from combined treatment with rapid-peaking and long acting exogenous insulin for diabetics who do not produce significant levels of insulin.
As used herein, mimicking physiologic mealtime first-phase insulin release (or pharmacokinetics) 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. It can also refer to methodologies achieving maximal glucose elimination rate within about 30-90 minutes, preferably around 45-60 minutes, after administration. 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. As used herein, “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 (AUCGLU), reduced levels of HbA1c (glycosylated hemoglobin), lessened potential 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 (AUCINS) 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.
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-diketop iperazine (hereinafter fumaryl diketopiperazine or FDKP). The use of diketopiperazines for drug delivery is known in the art (see for example U.S. Pat. No. 5,352,461 entitled “Self Assembling Diketopiperazine Drug Delivery System; U.S. Pat. No. 5,503,852 entitled Method for Making Self-Assembling Diketopiperazine Drug Delivery System; U.S. Pat. No. 6,071,497 entitled Microparticles for Lung Delivery Comprising Diketopiperazine; and U.S. Pat. No. 6,331,318 entitled Carbon-Substituted Diketopiperazine Delivery System, each of which is incorporated herein by reference for all that it teaches regarding diketopiperazines and diketopiperazine-mediated drug delivery). Pulmonary drug delivery using diketopiperazine and other microparticles is disclosed in U.S. Pat. No. 6,428,771 entitled “Method for Drug Delivery to the Pulmonary System,” which is hereby incorporated by reference for all that it teaches regarding delivery of diketopiperazine-based compositions to the pulmonary system. Complexes of insulin and FDKP, their formation, properties, and use are disclosed in U.S. Pat. Nos. 6,444,226 and 6,652,885 both entitled “Purification and Stabilization of Peptide and Protein Pharmaceutical Agents,” each of which is incorporated herein by reference for all that they teach regarding formation and administration of FDKP-complexed agents. Additional methods of manufacture of complexes of diketopiperazines and insulin are disclosed in co-pending U.S. Provisional Patent Application No. 60/717,524 entitled “Method of Drug Formulation Based on Increasing the Affinity of Active Agents for Crystalline Microparticle Surfaces,” which is incorporated herein by reference for all it teaches regarding manufacture of complexes of diketopiperazines and insulin. Particularly advantageous devices for delivery of the powder are disclosed in U.S. patent application Ser. No. 10/655,153 entitled “Unit Dose Cartridge and Dry Powder Inhaler” and in U.S. Pat. No. 6,923,175 entitled “Inhalation Apparatus”, each of which is incorporated herein by reference for all that they teach regarding pulmonary delivery of insulin compositions.
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), self-assemble into microparticles with a mean diameter of about 2 microns. In the process it can entrap or complex with peptides, such as insulin, present in the solution during or after self-assembly. Once dried, these microparticles become a suitable composition for pulmonary delivery to the systemic circulation. When administered by the pulmonary route, 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.
Additionally, salts of diketopiperazines can be used in the compositions of the present invention as disclosed in co-pending U.S. patent application Ser. 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.
For example, it was discovered that hexameric insulin can be delivered to the lung in fumaryl diketopiperazine formulation, reaching peak blood concentrations within 3-10 minutes. In contrast, insulin administered by the pulmonary route without fumaryl diketopiperazine typically takes between 25-60 minutes to reach peak blood concentrations, while hexameric insulin takes 30-90 minutes to reach peak blood level when administered by subcutaneous injection. This feat has been successfully replicated several times and in several species, including humans.
Removing zinc from insulin typically produces unstable insulin with an undesirably short shelf life. Purification to remove zinc, stabilization and enhanced delivery of insulin is demonstrated by the examples. 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 the zinc had been largely removed during the complexation process, yielding monomeric insulin in a stable delivery formulation.
The insulin 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. Alternatively, 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 insulin compositions can be administered to any targeted biological membrane, preferably a mucosal membrane of a patient. In one embodiment, the patient is a human suffering from an insulin-related disorder such as diabetes mellitus. In another embodiment, the 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.
EXAMPLES
Example 1
Insulin Concentration at Different Dose Levels Indicates Linear Absorption
Various dosages of Technosphere®/Insulin (TI, MannKind Corporation) were administered to human subjects and insulin concentration in the blood was measured (FIG. 7A). Insulin absorption, as AUC, was linear with dosage at least up to 100 U TI (FIG. 7B).
Example 2
Mimicry of the Early Phase Insulin Response in Humans with Rapidly Bioavailable Inhaled Insulin Accelerates Post Prandial Glucose Disposal Compared to Insulin with Slower Bioavailability
The relationship between time, insulin concentration and glucose elimination rate in a group of 12 subjects with type 2 diabetes, during an isoglycemic insulin clamp was studied. Each subject received 24 IU subcutaneous insulin (Actrapid®, Novo Nordisk) or 48 U Technosphere®/Insulin on separate study days in a cross-over design.
The glucose elimination rate (GIR) was determined by the amount of glucose infusion required to maintain stable blood glucose of 120 mg/dL during the 540 min study period (FIG. 4). Forty-eight units TI provided a mean maximum concentration of insulin (Cmax) of 114.8±44.1 (mean±SD) mlU/L and had a median time to maximum concentration (Tmax) of 15 min, whereas 24 IU subcutaneous insulin (SC) had a Cmax of 63±10.1 mlU/L with a Tmax of 150 min. Technosphere®/Insulin 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 TI are also plotted individually versus time in FIG. 8. Once maximal insulin effect was reached, the concentration—effect relationship was the same for TI and SC. At 180 min, glucose disposal was 326±119 mg/kg or 61% of total for TI and 330±153 mg/kg (27% of total) for SC.
A fast, sharp increase in insulin concentration, similar to the early phase insulin response, provided maximal glucose elimination rate. Forty-eight units TI achieved maximal effect within 45 min, whereas it took 270 min for 24 IU SC to reach similar effect. This phenomenon is not caused by differences in the dose-effect relationship for the two insulin types, but reflects a difference in response when the increment in insulin concentration is more modest over time as opposed to the more rapid bioavailable insulin provided by Technosphere®/Insulin. This can have consequences for postprandial glucose control.
Additionally, three hours after dosing, 48 U TI and 24 IU SC had exerted the same glucose lowering effect. However, less than 1⁄3 of the total glucose lowering effect for the SC dose had been obtained. The glucose lowering activity 180 minutes after a meal was 74% for TI and 29% for SC insulin (FIG. 5). If the prandial insulin dose is titrated towards a goal of normoglycemia at three hours after a meal, the large remaining glucose lowering effect of SC insulin may increase the risk of late post prandial hypoglycemia, as compared to TI. In addition to confining the bulk of glucose lowering activity to a time period more similar to the glucose load created by a meal, the kinetics exhibited by TI also allowed for the reassertion of endogenous insulin secretion sooner, that is glycemic control is returned to homeostatic mechanisms. At late time points (>150 minutes), the fall in insulin concentration lags behind what would have been expected based on the decay rate seen at earlier time points. This can be understood as the superimposition of falling exogenous insulin (from TI) and rising endogenous insulin (FIG. 14). Endogenous insulin secretion should be accompanied by the production of C-peptide.
Mean serum C-peptide concentrations over time for inhaled Technosphere®/Insulin and injectable SC regular insulin are presented in FIG. 16. C-peptide concentrations were essentially unchanged during SC treatment but rose with TI treatment with a timing consistent with the model depicted in FIG. 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 Technosphere®/Insulin should make it suitable for replacement of prandial insulin secretion in patients with diabetes mellitus.
Example 3
A Fast Insulin Spike does not Increase Risk of Hypoglycemia
It might be feared that the large concentrations of insulin, especially combined with their potentiation effect, would drive glucose elimination rates so high that they would pose a danger of inducing hypoglycemia. However this is not the case. Healthy human subjects under a euglycemic clamp were given intravenous, subcutaneous, or pulmonary insulin and the GIR was plotted against blood insulin concentration starting 20 minutes after administration. In normal subjects GIR hysteresis in response to insulin is much less pronounced than that for type 2 diabetics as disclosed in Example 1 above. Thus for normal subjects, 20 minutes after insulin administration and onward the relation between GIR and insulin concentration approximates a true mathematical function. It was observed that while at lower insulin concentrations the function appeared linear, consideration of higher concentrations showed that the relationship was actually logarithmic; as insulin concentration rose, ever smaller increases in GIR were obtained (FIG. 15). Thus glucose elimination did not reach catastrophically high rates and appeared unable to do so.
Example 4
The Variability and Time-Action Profile of Inhaled Technosphere/Insulin Compares Favorably to that of Subcutaneously Administered Human Insulin
Reproducibility of insulin's metabolic effect is critical to appropriate dose adjustment decisions including the selection of dose titration intervals and absolute dose quantity, in particular when near-normal glucose control is the objective. The intra-subject variability in insulin absorption and insulin effect between repeated doses of 48 U Technosphere®/Insulin and 24 IU subcutaneously injected human insulin (SC, Actrapid®) were compared. Each dose was given on three separate occasions on separate study days in a randomized sequence. Using a euglycemic glucose clamp, insulin concentrations and glucose infusion rates were measured over 540 min following each form of insulin administration (see FIG. 6). Variability of absorption and effect, expressed as CV % of AUC0-t, was determined at 120, 180 and 540 min after dosing. For TI, 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 (FIG. 6A). The variability in insulin concentrations (FIG. 6B) followed a similar pattern (19%, 18% and 16% for TI and 27%, 25% and 15% for SC). Thus for the glucose lowering effect, repeated inhalations of TI exhibited advantageous intra-patient variability compared to SC insulin during the first three hours after dosing. At 270 min, GIR for TI had returned to baseline, and the variability in measured plasma insulin at 540 min was comparable to the variation of SC insulin.
Example 5
A Randomized, Double-Blind, Placebo Controlled Study of the Efficacy and Safety of Inhaled Technosphere®/Insulin in Patients with Type 2 Diabetes
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 (HbA1c>6.5% to 10.5%). A total of 123 patients were enrolled and 119, the intention-to-treat population (ITT), were randomized in a 1:1 ratio to receive prandial inhaled Technosphere®/Insulin (TI) from unit dose cartridges containing between 6 to 48 units of human insulin (rDNA origin) or inhaled Technosphere®/placebo for 12 weeks. TI 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 HbA1c 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 Cmax and Tmax, after a meal challenge.
Patients were given a standardized meal several times during the study and their blood glucose levels measured. The study drug was administered at the study site in conjunction with a standardized breakfast (Uncle Ben's Breakfast BowlTM) that was prepared at the site. Fasting plasma glucose was measured immediately before the meal. Spirometry was performed before the subject took the first dose of study drug. Subjects then inhaled the study drug and, within 60 seconds, performed a single spirometry test procedure. Within 90 seconds of the study drug inhalation, and after the spirometry test, the subject began eating the test meal. Once the meal was completed, the plasma glucose values and glucose meter readings were obtained at immediately before and at 30, 60 and 120 minutes after beginning the meal.
For patients receiving either TI or placebo, blood glucose rose after meal challenge, but significantly less for the TI group and returned to baseline sooner (FIG. 11). Thus total glucose exposure, expressed as AUC0-120, (FIG. 12A) and maximal glucose excursion (Cmax; FIG. 12B) were reduced. FIG. 13 shows the observed difference in maximal glucose excursions between the patients receiving different dosages of TI versus those in the control arm. Note that at a dose of 30 U the maximal glucose excursions for the TI patients were 50% of the level for the patients in the control group. Also note that the average glucose excursion was about 28 mg/dL vs. 50 mg/dL when the TI patients entered the study. An excursion of only 28 mg/dL is within the range that is a goal of clinical treatment.
Glycosylated hemoglobin A1c (HbA1c) results were analyzed by a pre-determined 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 HbA1c of 6.6 to 7.9%), for a PEP Sub-group B (those with baseline HbA1c of 8.0 to 10.5%), as well as for the ITT. These results are summarized in Table 1, and for PEP Sub-group B in FIG. 17. In this “individualized dose” study, the mean dose of TI used before each meal in the active treatment group was approximately 30 units, with 28 units used in PEP Sub-group A and 33.5 units used in PEP Sub-group B.







TABLE 1







HbA1c Pharmacokinetics










Technosphere ®/
Technosphere ®/



Placebo
Insulin





PEP n = 90
n = 42
n = 48


Mean HbA1c Baseline (%)
7.75
7.74


Mean Δ from baseline
−0.32 (p = 0.0028)
−0.76 (p < 0.0001)


Comparison to Placebo

p = 0.0019


PEP Sub-group B n = 35
n = 18
n = 17


Mean HbA1c Baseline (%)
8.52
8.72


Mean Δ from baseline
−0.51 (p = 0.0094)
−1.37 (p < 0.0001)


Comparison to Placebo

p = 0.0007


PEP Sub-group A n = 55
n = 24
n = 31


Mean HbA1c Baseline (%)
7.16
7.19


Mean Δ from baseline
−0.18 (p = 0.1292)
−0.43 (p = 0.0001)


Comparison to Placebo

p < 0.05


IIT (LOCF) n = 119
n = 61
n = 58


Mean HbA1c Baseline (%)
7.78
7.87


Mean Δ from Baseline (%)
−0.31 (p = 0.0020)
−0.72 (p < 0.0001)


Comparison to Placebo

p = 0.0016









No episodes of severe hypoglycemia occurred in the TI group. There was no statistically significant difference in the rate of hypoglycemic events between those subjects receiving placebo and those receiving TI. (Table 2).







TABLE 2







Incidence of Hypoglycemia after Pulmonary Administration of TI










Technosphere ®/Insulin
Technosphere ®/Placebo





Hypoglycemia
42.6%
35.5%


(% of patients)


Hypoglycemia
0.16
0.20


(events/week)









Pulmonary function tests, including DLco (diffusing capacity of the lung for carbon monoxide) (Table 3), FEV1 (forced expiratory volume in one second), and total alveolar volume (forced vital capacity, FVC) showed no significant differences between patients on TI compared to their baseline values or compared to the results of those receiving placebo (FIG. 19).







TABLE 3







Pulmonary Function After Pulmonary Administration of TI









DLco
Technosphere ®/Insulin
Technosphere ®/Placebo





 0 weeks
24.9 ± 4.8
26.5 ± 5.6


12 weeks
25.0 ± 4.5
25.7 ± 5.2









There was no evidence of induction of insulin antibodies with TI (Table 4) or of weight gain (FIG. 18) during the 12 week period of exposure.







TABLE 4







Incidence of Antibodies to Insulin after Pulmonary Administration of TI










Technosphere ®/
Technosphere ®/



Insulin
Placebo












Negative at Visit 1/Negative at
38
34


Visit 9


Negative at Visit 1/Positive at
2
3


Visit 9


Positive at Visit 1/Positive at
8
10


Visit 9


Positive at Visit 1/Negative at
2
4


Visit 9









In conclusion, this study has demonstrated that Technosphere® pulmonary insulin, in replication of the kinetics of the early phase of insulin release, when used in patients with inadequate glycemic control previously on only diet and exercise alone or on oral agent therapy, safely and significantly improved glycemic control with no significantly increased incidence of hypoglycemia, no induction of insulin antibodies, no tendency toward weight gain, and no evidence of overall impact on pulmonary function.
Example 6
A FDKP/Insulin Provides Glycemic Control when Administered from 10 Minutes before to 30 Minutes after the Beginning of a Meal
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/Insulin; also referred to as Technosphere®/Insulin, TI). 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. At each of 8 treatment visits, human subjects inhaled a single individualized dose 10 min before (B10), immediately before (C0), 15 min after (A15), or 30 min after (A30) eating an isocaloric (I; approximately 500 kcal) or hypercaloric (H; approximately 720 kcal) meal. Each subject received each of the eight possible timings of administration/meal combinations (i.e., B10I, B10H, C0I, C0H, A15I, A15H, A30I, and A30H) on separate occasions and in random order, with 1 to 14 days elapsing between treatment visits (see FIG. 20). Blood samples taken before and after inhalation of the TI and meal consumption were used to determine pharmacokinetic parameters for glucose and insulin.
The dose of TI 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 TI 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=(BE*Fi)/0.30

where:

    
    
        IUdose was the number of IU of TI to be administered
        BE (Brot-Einheit, bread unit) 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.
        0.30 was the correction factor for TI bioavailability.
    
    


After calculation, the dose of TI was rounded to the nearest dose that could be administered using multiples of the TI cartridges, which contained 6 U, 12 U, or 24 U insulin.
During treatment visits, insulin was infused intravenously at a rate of 1 IU/hour and glucose was infused at a rate adjusted to achieve a stable capillary blood glucose concentration within the range of 80 to 140 mg/dL before meal consumption and/or TI inhalation. This infusion was continued without adjustment during the study. Venous blood samples were collected at varying intervals, starting at 45 min prior to meal consumption and continuing until four hours after consumption. The samples were used for determination of blood (serum) glucose and serum insulin concentrations.
The primary efficacy variable was blood glucose concentration. As well as providing a profile of the blood glucose concentration before and after TI and meal administration, the blood glucose concentration values were used to calculate the following pharmacokinetic parameters to describe total glucose excursion:

    
    
        Maximal (Cmax) and minimal (Cmin) blood glucose concentrations after the start of meal consumption, corrected for baseline values.
        Minimal (Cmin) blood glucose concentrations after TI inhalation, corrected for baseline values.
        Time to Cmax (Tmax), time to Cmin (Tmin), and time to last glucose excursion above baseline levels after start of meal (Tx).
        Area under the blood glucose concentration curve (AUC) was calculated using trapezoidal method for three separate time periods:
        
            AUC: from 10 min before to 240 min after start of meal
            AUC1: from 10 min before to Tx, and
            AUC2: from Tx to 240 min after start of meal.
        
        
        Blood glucose concentration at 1 hour (BG1) and 2 hours (BG2) after start of meal.
    
    


To ensure baselines were comparable between treatments, blood glucose and serum insulin baselines were computed based on the average of the −45, −30 and −20 min pre-meal measurements.
The secondary efficacy variable was serum insulin concentration. Insulin absorption was assumed to be independent of the time of dose relative to meals. The pharmacokinetic profile for insulin was determined based on serum insulin values normalized for dose and using dosing time as T=0 for all data sets. Mean Cmax (peak insulin concentration), AUC (area under the insulin concentration time curve), Tmax (time from dosing to peak concentration), time from dosing to reach 50% of Cmax (early T50%), and time from Tmax to 50% decline in Cmax (late T50%) were calculated. Following normalization (to a hypothetical 100 IU) for individual dose, intra- and inter-individual variation was determined as the CV % for the mean of individual Cmax and AUC.
The primary efficacy variable was blood glucose concentration. The effect of timing of administration of TI on the mean (SD) baseline-corrected blood glucose concentrations before and after an isocaloric or hypercaloric meal is illustrated in FIG. 21 for the primary efficacy population. Overall, 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 TI (FIG. 21). Notably, when TI 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. By comparison, when TI 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 (FIG. 21).
A comparison of pharmacokinetic parameters for blood glucose following each type of meal and for each timing of administration of TI is shown in Table 5 for the primary efficacy population. As indicated by the mean minimum blood glucose levels (Cmin, expressed as change from baseline) and initial period of the area under the glucose concentration curve (AUC1), the greatest reduction in blood glucose occurred when TI was inhaled 10 min before subjects started eating either the isocaloric or hypercaloric meal (Cmin−21 mg/dL and −27 mg/dL, respectively; AUC1−722 and −907 min*mg/dL, respectively) (Table 5). When TI was inhaled either 10 min before or immediately before meal consumption, blood glucose levels reached a nadir in approximately 10 to 13 min (as indicated by the median Tmin), and did not rise above baseline levels until 20 to 30 min later (as indicated by the median TX) (Table 5). By comparison, when TI was inhaled either 15 min or 30 min after the start of meal consumption, reductions in blood glucose were smaller (Cmin−10 to −13 mg/dL; AUC1−141 to −176 min*mg/dL), they occurred sooner (Tmin 3 to 5 min), and they were more short-lived (approximately 6 to 7 min). The largest individual reductions in blood glucose were in subjects who inhaled TI immediately before isocaloric or hypercaloric meal consumption (Cmin−58 mg/dL and −57 mg/dL, respectively).







TABLE 5







Summary of Blood Gluclose Pharmacokinetic Parameters by Meal and


Timing of Administration of Technosphere ®/Insulin










Isocaloric Meal
Hypercaloric Meal



Timing of Dosing
Timing of Dosing
















B10
C0
A15
A30
B10
C0
A15
A30


Parameter
(N = 12)
(N = 12)
(N = 12)
(N = 12)
(N = 12)
(N = 12)
(N = 12)
(N = 12)





Cmin (mg/dL)
−21 (14) 
−18 (15) 
−11 (14) 
−13 (7) 
−27 (8) 
−16 (14) 
−11 (7) 
−10 (7) 


Tmin (minutes)
10  
 13
 5
5
 13
 10
 5
 3


Cmax (mg/dL)
86 (28)
84 (38)
88 (36)
81 (23)
119 (46) 
130 (40) 
116 (50) 
113 (47) 


Tmax (minutes)
165  
135
150
120
180
180
150
165


AUC1
−722 (950) 
−648 (840) 
−154 (180) 
−176 (176) 
−907 (511) 
−418 (549) 
−149 (148) 
−141 (149) 


(min * mg/dL)


AUC2
11499 (4640) 
10989 (7030) 
13055 (7616) 
12431 (4682) 
14818 (6018) 
17395 (6050) 
16346 (8326) 
18402 (8968) 


(min * mg/dL)


AUC
10777 (5339) 
10342 (7349) 
12901 (7739) 
12255 (4895) 
13911 (5840) 
16977 (6008) 
16197 (8407) 
18261 (8982) 


(min * mg/dL)


BG1 (mg/dL)
21 (32)
23 (25)
41 (32)
55 (23)
16 (23)
33 (21)
38 (31)
65 (24)


BG2 (mg/dL)
68 (34)
71 (34)
78 (32)
68 (32)
81 (28)
101 (33) 
82 (47)
89 (46)


Tx (minutes)
36.6
  36.9
  11.7
  11.3
  42.2
  33.2
  12.4
  10.3





All values are presented as mean (SD) except for Tmin, Tmax and Tx, which are median.






Mean Cmax values (expressed as change from baseline), AUC, and AUC2 were generally comparable whether TI was given before or after a particular type of meal, though all were lower after the isocaloric meal than the hypercaloric meal (Table 5). The median time to Cmax (Tmax) ranged between 120 and 165 min for the isocaloric meal and between 150 to 180 min for the hypercaloric meal. Mean blood glucose levels one hour (BG1) and two hours (BG2) after the start of meal showed no consistent relationship to time of inhalation of TI relative to either meal (Table 5), although BG1 was lowest when TI was given 10 min before the start of a meal and highest when given 30 min after the start of a meal.
The comparative effects of different times of TI inhalation on selected glucose pharmacokinetic parameters was expressed as a ratio of the value at the corresponding C0 (i.e., B10/C0, A15/C0, and A30/C0) for each meal type. These ratios, along with their 95% confidence intervals (CI), are summarized in Table 6 (primary efficacy population). These results indicated that the comparative effects of inhalation of TI immediately before meal consumption were no different than that of inhalation 10 min before meal consumption on any pharmacokinetic parameter (i.e., most B0/C0 ratios were close to 1 and the 95% CI encompassed 1 within their range). Most comparisons also yielded no differences between TI immediately before meal consumption and 15 or 30 min after.







TABLE 6







Comparison of Blood Glucose Pharmacokinetic Parameters Relative to


Inhalation of Technosphere ®/Insulin Immediately Before Meal Consumption










Isocaloric Meal
Hypercaloric Meal



Ratio of Test to Reference Parameter
Ratio of Test to Reference Parameter














B10/C0
A15/C0
A30/C0
B10/C0
A15/C0
A30/C0


Parameter
(N = 12)
(N = 12)
(N = 12)
(N = 12)
(N = 12)
(N = 12)





Cmin
0.997
0.425
0.581
1.748
0.988
0.532



(0.470, 2.112)
(0.210, 0.860)
(0.302, 2.112)
(0.470, 2.112)
(0.470, 2.112)
(0.470, 2.112)


AUC1
0.608
0.300
0.214
1.995
0.381
0.334



(0.133, 2.775)
(0.067, 1.334)
(0.053, 0.863)
(0.803, 4.762)
(0.154, 0.942)
(0.137, 0.814)


Cmax
1.002
1.088
0.953
0.848
0.778
0.814



(0.809, 1.240)
(0.887, 1.334)
(0.784, 1.157)
(0.630, 1.143)
(0.581, 1.041)
(0.616, 1.076)


AUC2
1.077
1.035
1.158
0.780
0.771
0.907



(0.727, 1.596)
(0.711, 1.506)
(0.809, 1.657)
(0.497, 1.226)
(0.496, 1.198)
(0.594, 1.385)


AUC
1.105
0.722
1.245
0.727
0.753
0.910



(0.555, 2.200)
(0.378, 1.380)
(0.671, 2.310)
(0.426, 1.238)
(0.448, 1.266)
(0.553, 1.500)


BG1
0.833
1.203
7.932
0.768
1.256
1.985



(0.451, 1.536)
(0.656, 2.207)
(1.143, 3.267)
(0.491, 1.200)
(0.810, 1.948)
(1.379, 2.857)


BG2
0.630
1.109
0.906
0.771
0.665
0.758



(0.258, 1.536)
(0.468, 2.627)
(0.399, 2.058)
(0.533, 1.114)
(0.464, 0.953)
(0.537, 1.069)





All values are presented as ratio (95% confidence interval).






The secondary efficacy variable was serum insulin concentration. The profile of the mean (SD) baseline-corrected serum insulin concentrations after TI inhalation is illustrated in FIG. 22 for the primary efficacy population. There was a sharp increase in serum insulin immediately after inhalation of TI, which was independent of dosing time and meal type. 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.
A comparison of pharmacokinetic parameters for serum insulin for each timing of administration of TI relative to each type of meal is shown in Table 7 for the primary efficacy population. Overall, the mean Cmax (expressed as change from baseline) and AUC values for serum insulin were generally comparable, irrespective of meal type and whether TI was given before or after the meal (Table 7). Irrespective of meal type and time of dosing relative to the meal, serum insulin concentrations rose rapidly after TI inhalation, with the early T50% ranging between three and five min and peak concentrations being observed 10 to 20 min after administration. Thereafter, serum insulin concentrations declined, with the late T50% ranging between 33 and 43 min, and again showed no consistent variation with time of inhalation of TI or meal type (Table 7).







TABLE 8







Summary of Serum Insulin Pharmacokinetic Parameters by Meal and


Timing of Administration of Technosphere ®/Insulin










Isocaloric Meal
Hypercaloric Meal



Timing of Dosing
Timing of Dosing
















B10
C0
A15
A30
B10
C0
A15
A30


Parameter
(N = 12)
(N = 12)
(N = 12)
(N = 12)
(N = 12)
(N = 12)
(N = 12)
(N = 12)





Cmax (mIU/L)
207 (145)
179 (125)
188 (137)
215 (196)
211 (138)
137 (74) 
191 (114)
193 (163)


Tmax (minutes)
13
15
15
15
10
20
15
15


AUC
12635 (15681)
11291 (17449)
11642 (18373)
12649 (14838)
10654 (7623) 
7710 (7313)
12874 (16785)
11662 (13210)


(min * mIU/L)


Early T50% (min)
 4
 4
 3
 3
 4
 5
 4
 3


Late T50% (min)
40
40
33
43
43
42
39
39





All values are presented as mean (SD) except for Tmax and T50%, which are median.






Thus inhalation of an individualized dose of TI 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 TI 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.
Example 7
Bioavailability of Insulin in Diketopiperazine Pulmonary Formulation
Subjects and Methods
The study was reviewed and approved by the ethical review committee of the Heinrich-Heine-University, Dusseldorf, and conducted according to local regulations, the Declaration of Helsinki and the rules of Good Clinical Practice.
The study was conducted with 5 healthy male volunteers. Inclusion criteria were good health, as judged by physical examination, age: 18 to 40 years, body mass index: 18 to 26 kg/m2, capability to reach peak inspiratory flow of ≧4 L/sec measured by a computer assisted spirometry and a FEV1 equal to or greater than 80% of predicted normal (FEV1=forced expiratory volume in one second). 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.
Conduct of the Study
On the morning of the study days, the subjects came to the hospital (fasting, except for water, from midnight onward) at 7:30 a.m. The subjects were restricted from excessive physical activities and an intake of alcohol for 24 hours before each treatment day. They were randomly assigned to one of the three treatment arms. The subjects received a constant intravenous regular human insulin infusion, which was kept at 0.15 mU min−1 kg−1 so that serum insulin concentrations were established at 10-15 μU/mL during a period of two hours before time point 0. This low-dose infusion was continued throughout the test to suppress endogenous insulin secretion. Blood glucose was kept constant at a level of 90 mg/dL throughout the glucose clamp by a glucose controlled infusion system (BiostatorTM). 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.
Bioefficacy and Bioavailability
To determine bioefficacy, the areas under the curve of the glucose infusion rates were calculated for the first three hours (AUC0-180) after the administration and for the overall observation period of six hours after the administration (AUC0-360) and were correlated to the amount of insulin applied. To determine bioavailability, the areas under the curve of the insulin concentrations were calculated for the first three hours (AUC0-180) after the administration and for the overall observation period of six hours after the administration (AUC0-360) and correlated to the amount of insulin applied.
In this clamp study, inhalation of 100 U of Technosphere®/Insulin was well tolerated and was demonstrated to have a substantial blood glucose lowering effect with a relative bioavailability of 25.8% for the first three hours as calculated from the achieved serum insulin concentrations. 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 μm.
Results
The pharmacokinetic results are illustrated in FIGS. 23 and 24 and in Table 8.
Efficacy Results
Inhalation of 100 U of Technosphere®/Insulin revealed a peak of insulin concentration after 13 min (intravenous (IV) (5 IU): 5 min, subcutaneous (SC) (10 IU): 121 min) and a return of the insulin levels to baseline after 180 min (IV: 60 min, SC: 360 min). Biological action as measured by glucose infusion rate peaked after 39 min IV: 14 min, SC: 163 min) and lasted for more than 360 min (IV: 240 min, SC: >360 min). Absolute bioavailability (comparison to IV application) was 14.6±5.1% for the first three hours and 15.5±5.6% for the first six hours. Relative bioavailability (comparison to SC application) was 25.8±11.7% for the first three hours and 16.4±7.9% for the first six hours.







TABLE 8







Pharmacokinetic Parameters after Pulmonary Administration of TI









Pharmacokinetic Parameters











Intravenous

Subcutaneous



Administration
Inhaled TI
Administration











Parameter Calculated on Glucose Infusion Rate












T50%*
 9 min
13 min
 60 min



Tmax
14 min
39 min
163 min



T-50%**
82 min
240 min 
240 min



T to baseline
240 min 
>360 min   
>360 min  







Parameter Calculated on Insulin Levels












T50%*
 2 min
2.5 min 
 27 min



Tmax
 5 min
13 min
121 min



T-50%**
 6 min
35 min
250 min



T to baseline
60 min
180 min 
360 min







*time from baseline to half-maximal values



**time from baseline to half-maximal after passing Tmax






Safety Results
Technosphere®/Insulin 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.
Conclusions
Inhalation of 100 U of Technosphere®/Insulin was well tolerated and was demonstrated to have a substantial blood glucose lowering effect with a relative bioavailability of 25.8% for the first three hours as calculated from the achieved serum insulin concentrations.
Summary
In this study, the inhalation of Technosphere®/Insulin was demonstrated in healthy human subjects to have a time-action profile with a rapid peak of insulin concentration (Tmax: 13 min) and rapid onset of action (Tmax: 39 min) and a sustained action over more than six hours. The total metabolic effect measured after inhalation of 100 U of Technosphere®/Insulin was larger than after subcutaneous injection of 10 IU of insulin. The relative bioefficacy of Technosphere®/Insulin was calculated to be 19.0%, while the relative bioavailability was determined to be 25.8% in the first three hours.
The data also show that inhalation of Technosphere®/Insulin resulted in a much more rapid onset of action than SC insulin injection that was close to the onset of action of IV insulin injection, while duration of action of Technosphere®/Insulin was comparable to that of SC insulin injection.
The drug was well tolerated and no serious adverse events were reported during the entire trial.
Example 8
Prandial Technosphere®/Insulin Provides Significantly Better Control of Meal-Related Glucose Excursions than Prandial Subcutaneous Insulin
Technosphere®/Insulin (TI) is a dry powder formulation of human insulin comprising insulin complexed to fumaryl diketopiperazine microparticles. Technosphere®/Insulin 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 TI compared to subcutaneous (SC) regular insulin on blood glucose concentration over a 7 day treatment period.
Sixteen non-smoking subjects with Type 2 diabetes (age 59 (range 39-69) yrs; BMI 29.6 (23.8-34.9) kg/m2; mean diabetes duration 12.3 yrs; with normal pulmonary function (forced expiratory volume in 1 sec and forced vital capacity >80% of predicted normal) and treated with intensified insulin therapy were enrolled in this randomized, open-label, two period cross-over study. Subjects covered their prandial insulin needs either by inhaled TI or by SC insulin over a treatment period of one week, respectively, while continuing their usual basal insulin therapy. The doses of TI and SC insulin were determined during a 24 hours in-house period prior to randomization. TI 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 TI, 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 TI or 14±5 IU of SC insulin.
When treated with SC insulin, subjects demonstrated insulin median Tmax of 120 min with median Cmax of 54 μU/mL. In comparison, when treated with TI, subjects demonstrated insulin median Tmax of 14 min and median Cmax of 102 μU/mL (FIG. 9). Total insulin exposure for each treatment cycle was comparable for SC and for TI with mean AUCINS measured at 9155 and 9180 μU/mL respectively (FIG. 10). Mean excursion of glucose from baseline for SC was 85 mg/dL and AUCGLU was 10925 min*mg/dL. In comparison, mean excursion of glucose from baseline for TI was 59 mg/dL and AUCGLU was 6969 min*mg/dL (FIG. 10). Thus the ratio of glucose excursion to insulin exposure in the above units, an indication of the effectiveness of the absorbed insulin dose, was only about 0.76 versus about 1.2 for TI and SC, respectively. The data demonstrate a 31% reduction (p=0.0022) of mean glucose excursion and a 36% reduction (p=0.0073) of glucose exposure over the 240 min measured for TI relative to SC.
With comparable exposure to insulin (as measured in the plasma), to meal quantity, and to meal composition, prandial TI resulted in significantly improved control of post-prandial peak glucose and total glucose exposure compared to prandial SC. The only differences between therapies were the insulin formulations and the methods of insulin administration. TI 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. SC insulin levels were much lower than TI during the early post-prandial period, did not exhibit a clear “peak” as did TI, 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.
Example 9
Markedly Reduced Postprandial Glucose Excursions through Inhaled Technosphere®/Insulin in Comparison to SC Injected Regular Insulin in Subjects with Type 2 Diabetes
Baseline adjusted postprandial total insulin exposure (INS-AUC0-240 min) was comparable for TI and for SC (8187±4269 vs 8302±4025 min*μU/dL; ns) whereas baseline adjusted postprandial glucose excursion. (BG-AUC0-240 min) for TI was only about 50% of that of SC (5095±5923 min*mg/dL vs 9851±5593 min*mg/dL; p<0.008). Thus the ratio of glucose excursion to insulin exposure in the above units, an indication of the effectiveness of the absorbed insulin dose was only about 0.62 for TI versus about 1.2 for SC. In other words, unit for unit of absorbed insulin TI was nearly twice as efficient in removing glucose from the blood. With TI median insulin Tmax was shorter (15 vs 120 min; p<0.001) and median Cmax was higher (100 vs 54 μU/mL; p=0.001) than with SC. Accordingly, postprandial maximum adjusted blood glucose excursions were 28% lower with TI 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 TI 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 TI (12 vs. 4 episodes)—with two patients alone accounting for 8 episodes.
Technosphere®/Insulin markedly improved post-prandial glucose control compared to prandial SC while total serum insulin concentrations were comparable between both treatments. This was attributed to a rapid onset of action of TI in which insulin Tmax resembles first-phase insulin release kinetics. In contrast SC insulin levels were much lower than TI during the early post-prandial period and did not exhibit the clear peak observed with TI. These results support the conclusion that preprandial TI was superior to SC insulin in providing prandial insulin needs and reducing meal related blood glucose excursions.
Example 10
The Variability and Time-Action Profile of Inhaled Technosphere®/Insulin Compares Favorably to that of Subcutaneous Human Regular Insulin
Timing and reproducibility and of insulin's metabolic effect is critical to achieve near-normal glucose control and to enable patients 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®/Insulin (TI) and 24 IU subcutaneous injected human regular insulin (SC) was compared.
Technosphere®/Insulin and SC were given on three separate occasions each on separate study days in a randomized sequence in 12 insulin-treated subjects with type 2 diabetes (10 males, 2 females, age 56 (range 40-65) years, diabetes duration 14.4 (3-29) years, HbA1c 6.9±0.9% (mean±SD), all normal lung function (FVC, FEV1 and VC=80% of predicted normal)). Using a euglycemic glucose clamp (clamp level 120 mg/dL), pharmacokinetic (PK) and pharmacodynamic (PD) time-action profiles were measured over 540 min following each form of insulin administration. Variability of absorption and effect, expressed as CV % of AUC0-1, was determined at 120, 180 and 540 min after dosing.
Technosphere®/Insulin showed a more rapid onset of action and higher peak insulin concentrations (INS) than SC (table, INS-tmax 17±6 vs. 135±68 min, TI vs. SC, p<0.0001). Technosphere®/Insulin 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). The AUCs for both INS and GIR curves were higher for TI compared to SC in the first two and three hours after administration (Table 9). The variability in both insulin concentrations and insulin action was lower for TI compared to SC in the first three hours after administration (Table 9). At 270 min, GIR for TI had returned to baseline, and the variability in measured plasma insulin at 540 min was comparable to the variation of SC (CV %: GIR-AUC0-540 min 26% vs. 18% (TI vs. SC); INS-AUC0-540 min 16% vs. 15%).
Technosphere®/Insulin showed a more rapid onset and a shorter duration of action than subcutaneous human regular insulin which can make it suitable for replacement of prandial insulin secretion in patients with type 2 diabetes. In particular, TI 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. Furthermore, the intra-patient variability of repeated inhalations of TI was superior to SC insulin during the first three hours after dosing which can facilitate dose titration.







TABLE 10







Pharmacokinetic Parameters after Pulmonary Administration of TI










Inhaled




Technosphere ® Insulin
SC Human Regular Insulin













CV (%)

CV (%)



mean ± SD
[95% CI]
mean ± SD
[95% CI]










Pharmacodynamic (PD) Parameters, based on glucose infusion rates (GIR)











GIR-AUC0–2h (mg/kg)
 265 ± 83
23.4
211 ± 84 
39.2



(44% of total)
[13.9–33.0]
(16% of total)
[23.2–55.2]


GIR-AUC0–3h (mg/kg)
 355 ± 119
21.7
363 ± 153
33.4



(59% of total)
[12.9–30.6]
(27% of total)
[19.8–47.1]


GIRmax (mg/kg/min)
4.5 ± 1.0+
22.0
5.5 ± 1.4
17.3




[13.0–30.9]

[10.3–24.4]







Pharmacokinetic (PK) Parameters, based on plasma insulin (INS) concentrations











INS-AUC0–2h (μU/ml)
6965 ± 2233*
19.1
5509 ± 1094
27.1



(56% of total)
[11.3–26.9]
(24% of total)
[16.1–38.2]


INS-AUC0–3h (μU/ml)
8030 ± 2561
18.2
8672 ± 1442
25.0



(64% of total)
[10.8–24.6]
(38% of total)
[14.8–35.2]


INS-Cmax (μU/ml)
124 ± 44+
20.4
63 ± 10
29.2




[12.1–28.8]

[17.3–41.2]





CI: Confidence Interval


*p < 0.05 vs. SC,


+p < 0.0005 vs. SC (ANOVA, Mixed Effects Models)






Example 11
Multi-Center Study of Type 2 Patients Taking Prandial TI in an Ambulatory Setting
Studies of the pharmacokinetics and pharmacodynamics of administering regular human insulin by pulmonary inhalation using Technosphere®/Insulin (TI) have indicated that maximal plasma insulin concentration can be achieved in a median of about 10 to 14 minutes after inhalation, which is ideal for replicating the first-phase insulin release. The administration of insulin with this highly reproducible kinetic profile to ambulatory patients with diabetes has not been possible with other currently available insulin systems. Studies, such as the examples above, have demonstrated a 48% reduction in post-prandial glucose excursion with TI compared to a bio-available equivalent dose of subcutaneous insulin (SC) given before meals. In another multi-center study of type 2 patients taking prandial TI in an ambulatory setting for 12 weeks, the frequency of prospectively monitored hypoglycemia was less than 10% of the frequency historically reported for SC in ambulatory use.
In a randomized, prospective double blind, placebo controlled study of the forced titration of prandial Technosphere®/Insulin in patients with type 2 diabetes mellitus subjects received inhaled Technosphere®/Insulin (TI), dosed prandially, in addition to basal administration of SC insulin glargine (Lantus®; a form of long acting insulin), 227 patients were studied over 18 weeks. During the initial 4-weeks, patients were followed on their existing therapy and then removed from all oral anti-hyperglycemic therapy and placed on fixed doses of SC insulin glargine taken once daily, in a dose sufficient to replicate their documented pre-manipulation fasting plasma glucose levels and stabilized at this dose. The patients were then randomized to blinded doses of added inhaled placebo or blinded doses of inhaled TI 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. Specifically, the subjects, divided into five cohorts, initially received placebo (Technosphere® microparticles without any insulin) along with the sc long acting insulin. After a week one cohort continued to receive placebo and four cohorts were switched to a TI dose of 14 U of insulin. After another week three cohorts were switched to a TI dose of 28 U, and so on until a final cohort reached a TI dose of 56 U. All cohorts then continued on the same dose for the remaining eight weeks of the trial.
HbA1c levels and meal challenges (300 min) were evaluated at the initial visit, at the start of randomized treatment and at completion. Comparisons were made between treatment groups and the placebo group. Safety was assessed by the frequency of defined hypoglycemic episodes and by the measurement of serial pulmonary function tests including FEV1 and DLCO. The addition of TI to insulin glargine produced a dose-dependent reduction in HbA1c levels. In patients treated for eight weeks at 56 units, the mean reduction was 0.79% greater than that observed in the insulin glargine/placebo group (p=0.0002). TI 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 Technosphere®/Insulin was able to improve the glycemic control of patients with type 2 diabetes without increasing the risk of hypoglycemia.
Example 12
A 3 Month Comparison in Type 1 Diabetes of Inhaled Technosphere®/Insulin to SC Administered Rapid-Acting Insulin Analogue as Prandial Insulin in a Basal/Prandial Regimen
This study represents the first evaluation of long-term control in patients with type 1 diabetes, comparing Technosphere®/Insulin (TI) with a rapid-acting insulin analogue (RAA, Novolog®) as a comparator. Previous studies of has shown significantly better postprandial control than regular human insulin over 240 min in patients with type 2 diabetes.
Patients with type 1 diabetes (111 subjects, 18 to 80 years of age; HbA1c≧7.0% and ≦11.5%) were enrolled in a randomized, open label study to receive TI or RAA as meal-time insulin in addition to basal insulin (Lantus®) for 12 weeks. Titration of both prandial and basal insulin was permitted at the physicians discretion. At baseline, week 8 and week 12, standardized meal tests were conducted to assess glucose excursions over 300 min (420 min at week 12), and HbA1c levels and lung function (FEV1 and DLco) was evaluated in both groups. Lower maximum and total glucose excursions were observed in the first two hours following a standard meal in the group receiving TI insulin compared to those who were dosed with sc insulin. Over the following 3-4 hours, glycemia was maintained close to baseline levels in the TI group but fell below baseline in the patients receiving rapid acting insulin. No difference in HbA1c levels were observed between the two treatment groups. No adverse effects on pulmonary function were noted during the course of the study. Therefore, in a basal/prandial regimen in patients with type 1 diabetes, inhaled TI is an appropriate alternative to SC administered RAA and may offer the advantages of reducing both glucose excursions and the risk of late postprandial hypoglycemia.
Unless otherwise indicated, all numbers expressing quantities of ingredients, properties such as molecular weight, reaction conditions, and so forth used in the specification and claims are to be understood as being modified in all instances by the term “about.” Accordingly, unless indicated to the contrary, the numerical parameters set forth in the following specification and attached claims are approximations that may vary depending upon the desired properties sought to be obtained by the present invention. At the very least, and not as an attempt to limit the application of the doctrine of equivalents to the scope of the claims, each numerical parameter should at least be construed in light of the number of reported significant digits and by applying ordinary rounding techniques. Notwithstanding that the numerical ranges and parameters setting forth the broad scope of the invention are approximations, the numerical values set forth in the specific examples are reported as precisely as possible. Any numerical value, however, inherently contains certain errors necessarily resulting from the standard deviation found in their respective testing measurements.
The terms “a” and “an” and “the” and similar referents used in the context of describing the invention (especially in the context of the following claims) are to be construed to cover both the singular and the plural, unless otherwise indicated herein or clearly contradicted by context. Recitation of ranges of values herein is merely intended to serve as a shorthand method of referring individually to each separate value falling within the range. Unless otherwise indicated herein, each individual value is incorporated into the specification as if it were individually recited herein. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (e.g. “such as”) provided herein is intended merely to better illuminate the invention and does not pose a limitation on the scope of the invention otherwise claimed. No language in the specification should be construed as indicating any non-claimed element essential to the practice of the invention.
Groupings of alternative elements or embodiments of the invention disclosed herein are not to be construed as limitations. Each group member may be referred to and claimed individually or in any combination with other members of the group or other elements found herein. It is anticipated that one or more members of a group may be included in, or deleted from, a group for reasons of convenience and/or patentability. When any such inclusion or deletion occurs, the specification is herein deemed to contain the group as modified thus fulfilling the written description of all Markush groups used in the appended claims.
Preferred embodiments of this invention are described herein, including the best mode known to the inventors for carrying out the invention. Of course, variations on those preferred embodiments will become apparent to those of ordinary skill in the art upon reading the foregoing description. The inventor expects skilled artisans to employ such variations as appropriate, and the inventors intend for the invention to be practiced otherwise than specifically described herein. Accordingly, this invention includes all modifications and equivalents of the subject matter recited in the claims appended hereto as permitted by applicable law. Moreover, any combination of the above-described elements in all possible variations thereof is encompassed by the invention unless otherwise indicated herein or otherwise clearly contradicted by context.
Furthermore, numerous references have been made to patents and printed publications throughout this specification. Each of the above cited references and printed publications are herein individually incorporated by reference in their entirety.
In closing, it is to be understood that the embodiments of the invention disclosed herein are illustrative of the principles of the present invention. Other modifications that may be employed are within the scope of the invention. Thus, by way of example, but not of limitation, alternative configurations of the present invention may be utilized in accordance with the teachings herein. Accordingly, the present invention is not limited to that precisely as shown and described.

## Claims

1. A method of potentiating the glucose elimination rate in a human patient with diabetes comprising:
producing a spike in serum insulin concentration with an exogenously-administered inhaled insulin composition, wherein said spike comprises the maximum serum insulin concentration which is obtained by about 20 minutes after administration of said inhaled insulin composition, and wherein said exogenously-administered inhaled insulin composition is administered from approximately 10 minutes prior to a meal to approximately 30 minutes after a meal, wherein said glucose elimination rate returns to baseline by about 6 hours after administration.

2. The method of claim 1 wherein said diabetes is type 2 diabetes.

3. The method of claim 1 wherein said maximum serum insulin concentration is about 75 mU/L or greater than 75 mU/L.

4. The method of claim 3 wherein said maximum serum insulin concentration is about 100 mU/L or greater than 100 mU/L.

5. The method of claim 4 wherein said maximum serum insulin concentration is about 125 mU/L or greater than 125 mU/L.

6. The method of claim 1 wherein said maximum serum insulin concentration is achieved within about 15 minutes.

7. The method of claim 6 wherein said maximum serum insulin concentration is achieved within about 10 minutes.

8. The method of claim 1 wherein said potentiation comprises the glucose elimination rate reaching its maximum within about 30 to 90 minutes after administration of said inhaled insulin composition.

9. The method of claim 8 wherein said potentiation comprises the glucose elimination rate reaching its maximum within about 1 hour.

10. The method of claim 9 wherein said potentiation comprises the glucose elimination rate reaching its maximum within about 45 minutes.

11. The method of claim 1 wherein said serum insulin concentration descends through half-maximal by about 80 minutes after said maximum serum insulin concentration is achieved.

12. The method of claim 11, wherein said serum insulin concentration descends through half-maximal by about 50 minutes after said maximum serum insulin concentration is achieved.

13. The method of claim 1 wherein said glucose elimination rate continues to rise after serum insulin concentration begins to fall.

14. The method of claim 1 wherein said glucose elimination rate begins to fall by about 1 hour after insulin administration.

15. The method of claim 1 wherein said exogenously-administered inhaled insulin composition comprises a complex between a diketopiperazine and human insulin.

16. The method of claim 15 wherein said diketopiperazine is fumaryl diketopiperazine.

17. A method of treating an insulin-related disorder comprising:
administering to a human patient having diabetes an exogenously-administered inhaled insulin composition such that said exogenously-administered inhaled insulin composition produces a spike in serum insulin concentration wherein said spike comprises the maximum serum insulin concentration which is achieved by about 20 minutes after administration of said inhaled insulin composition, and wherein said exogenously-administered inhaled insulin composition is administered from approximately 10 minutes prior to a meal to approximately 30 minutes after a meal, and wherein the glucose elimination rate of the human patient returns to baseline by about 6 hours after administration.

18. The method of claim 17 wherein said exogenously-administered inhaled insulin composition comprises a complex between a diketopiperazine and human insulin.

19. The method of claim 18 wherein said diketopiperazine is fumaryl diketopiperazine.

20. The method of claim 17 wherein said diabetes is type 2 diabetes.

21. The method of claim 17 further comprising administering a long-acting basal insulin.

22. The method of claim 17 wherein said serum insulin concentration descends through half-maximal by about 80 minutes after said maximum serum insulin concentration is achieved.

23. The method of claim 22 wherein said serum insulin concentration descends through half-maximal by about 50 minutes after said maximum serum insulin concentration is achieved.

24. A method of maintaining blood glucose levels in a human patient with diabetes in a normal range comprising:
providing an exogenously-administered inhaled insulin composition, such that said exogenously administered inhaled insulin composition produces a spike in serum insulin concentration comprising maximum serum insulin concentration achieved within about 30 minutes of administration of said inhaled insulin composition, and wherein said exogenously-administered inhaled insulin composition is administered from approximately 10 minutes prior to a meal to approximately 30 minutes after a meal, and wherein the glucose elimination rate of the human patient returns to baseline by about 6 hours after administration.

25. The method of claim 24 wherein said maximum serum insulin concentration is obtained within about 15 minutes of administration.

26. The method of claim 25 wherein said exogenously-administered inhaled insulin composition comprises a complex between a diketopiperazine and human insulin.

27. The method of claim 26 wherein said diketopiperazine is fumaryl diketopiperazine.

28. The method of claim 24 wherein said exogenously-administered inhaled insulin composition is a non-naturally occurring form of insulin.

29. The method of claim 24 wherein said serum insulin concentration descends through half-maximal by about 80 minutes after said maximum serum insulin concentration is achieved.

30. The method of claim 29 wherein said serum insulin concentration descends through half-maximal by about 50 minutes after said maximum serum insulin concentration is achieved.