ES2724731T3 - Pharmaceutical composition - Google Patents

Abstract

A combination comprising at least a first insulin type compound and a second insulin type compound for use in the treatment of type 1 diabetes or type 2 diabetes in a subject in need thereof where the administration of insulin would be beneficial for said subject; wherein said first insulin-like compound is human insulin LysB29 (Ne-hexadecandioyl-y-Glu) des (B30) and said second insulin-like compound is human insulin AspB28; wherein said combination is administered once a day in an amount to achieve beneficial glycemic control in said subject as determined by HbA1c levels in said subject after once daily administration of said combination in food plus big of the day for said subject; wherein said beneficial glycemic control by said combination comprises decreasing HbA1c levels in said subject to 7.0% or less after once daily administration of said combination in the largest meal of the day.

Description

DESCRIPTION

Pharmaceutical composition

Field of the Invention

The present invention relates to a pharmaceutical composition and a novel administration scheme. Background of the invention

Diabetes mellitus often requires treatment with insulin to establish adequate metabolic control (which mainly includes glycemic control, but other metabolic parameters also benefit from insulin treatment). The established practice of insulin treatment is to administer the insulin product at a frequency of one or more times a day, optionally in combination with other treatment modalities, as described in the available treatment guidelines. Intravenous and subcutaneous insulin infusion is also used in clinical practice.

A widely used insulin treatment option is to administer a long-acting insulin product, also called basal insulin, to fully or partially cover the patient's need for insulin. Long-acting insulin is given as often as one or more times a day, at the same time each day, and is used in both type 1 and type 2 diabetes as well as other forms of pathological conditions that require insulin (hyperglycemia of any cause).

Currently, the treatment of diabetes, both type 1 diabetes and type 2 diabetes, is increasingly dependent on the so-called intensive insulin treatment. In accordance with this regimen, patients are treated with multiple injections of insulin per day comprising one or two injections per day of a long-acting insulin, provided at the same time each day, to cover the basal insulin requirement supplemented by injections. bolus of a fast-acting insulin to meet the insulin requirement related to meals.

Current practice in the control of diabetes and hyperglycemia is exposed, for example, in:

- Working Group on Clinical Guidelines of the IDF. Guideline for postprandial glucose control. Brussels: International Diabetes Federation, 2007, http://www.idf.org/webdata/docs/Guideline PMG final.pdf - SE Inzucchi, RM Bergenstal, JB Buse, M. Diamant, E. Ferrannini, M. Nauck, AL Peters, A. Tsapas, R. Wender, and DR Matthews. Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach: Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care, 2012.

Reviews related to basal insulin analogues and their characteristics and current clinical use can be found, for example, in:

- T. Heise and T. R. Pieber. Towards peakless, reproducible and long-acting insulins. An assessment of the basal analogues based on isoglycaemic clamp studies. Diabetes Obes Metab 9 (5): 648-659, 2007, and

- A. H. Barnett. A review of basal insulins. Diabet Med 20 (11): 873-885, 2003.

Human insulin has three primary amino groups: the N-terminal group of chain A and chain B and the ^g- amino group of LysB29. Several insulin derivatives that are substituted in one or more of these groups are known in the state of the art.

In addition, long-acting insulin compositions are known in the art. A major type of long-acting insulin compositions comprises injectable aqueous suspensions of amorphous insulin or insulin crystals. In these compositions, the insulin compounds typically used are insulin protamine, insulin with zinc or insulin protamine with zinc.

WO 2005/012347 (Novo Nordisk A / S) describes acylated insulin derivatives comprising an additional negative charge compared to the acylated insulins described in WO 95/07931. The pharmaceutical formulation of these acylated insulins is provided as 2, 3 or 4 zinc atoms per hexamer of insulin.

WO 2010/049488 describes an insulin derivative for the treatment of a condition or disease where the administration of insulin will be beneficial, which comprises administering, to a patient in need, effective doses of the insulin derivative, wherein said derivative of Insulin exhibits a prolonged action profile and where these doses are administered at intervals greater than 24 hours.

Description of the invention

The present invention is based on the surprising finding that it is possible to treat a condition or a disease where the administration of insulin would be beneficial, such as diabetes or hyperglycemia, by administering a pharmaceutical combination comprising insulin-like compounds that act as different way in a particular event in the day. With respect to this, the combination is administered in the largest meal of the day for said subject.

In accordance with the present invention, the combination comprises at least a first insulin type compound and a second insulin type compound to treat type 1 or type 2 diabetes in a subject in need thereof where insulin administration would be beneficial for said subject. ; wherein said first insulin-like compound is human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) and said second insulin-like compound is human insulin AspB28; wherein said combination is administered once daily in an amount to achieve beneficial glycemic control in said subject as determined by HbA ¹ c levels in said subject after once daily administration of said combination in the subject. biggest meal of the day for said subject; wherein said beneficial glycemic control by said combination comprises decreasing HbA ¹ c levels in said subject to 7.0% or less after administration of said combination in the largest meal of the day.

The term "insulin type compound" includes naturally occurring insulins, insulin analogues, insulin derivatives and insulin mimetics. Sometimes insulin-like compounds are called "insulin compounds," or the like.

The term "administration of said combination in the largest meal of the day for said subject" means that the combination is administered during or about - typically from a little earlier, such as about 30 minutes before, or until a little later, such as approximately 30 minutes later - of the biggest meal of the day in a period of more than one day. As used herein, "in", "with" or "in relation to" the largest meal of the day also includes "during" the meal itself, as well as a short time before and after such meal, for example, up to approximately 30 minutes before the first food intake and up to approximately 30 minutes after the last food intake of said food. In other words, and for example, the combination is administered during or around (typically from a little before, such as about 30 minutes before, or until a little later, such as about 30 minutes after) of the biggest meal of the day during each day (or at least substantially every day) for a period of at least about 1 week, or at least about 2 weeks, or at least about 3 weeks, or at least about 4 weeks, or at least about 5 weeks, or at least about 6 weeks, or at least about 7 weeks, or at least about 8 weeks, or at least about 9 weeks, or at least about 10 weeks, or at least about 15 weeks, or at least about 20 weeks, or at less about 25 weeks, or even more.

In one aspect, said patient determines which is the biggest meal of the day. In one aspect, said patient is instructed to determine which meal is the largest meal of the day. The biggest meal of the day is not necessarily the same meal for each patient, that is, it is not at the same time of day. It can vary from one patient to another, for example, depending on the lifestyle, culture, time constraints of patients, for example, due to work, etc. For a given patient, the biggest meal of the day is not necessarily the same meal every day, that is, it is not at the same time of day every day. This may vary from day to day.

In accordance with the present invention, HbA ¹ c levels are an important objective. Until now, achieving improvements in HbA ¹ c levels has proven difficult in patients suffering from a condition or disease in a subject in need where insulin administration would be beneficial, such as type 1 diabetes, Type 2 diabetes as well as other forms of pathological conditions that require insulin (hyperglycemia of any cause).

By using the combination of the present invention it is possible to achieve improvements in HbA ¹ c levels in patients suffering from type 1 diabetes, type 2 diabetes as well as other forms of pathological conditions that require insulin (hyperglycemia of any cause). ). This is an important finding and has a great therapeutic value in the treatment of such conditions or diseases.

Therefore, the combination comprising at least a first insulin type compound and a second insulin type compound according to the present invention can be used to treat a condition or disease in a subject in need where insulin administration would be beneficial for said subject. Therefore, the diseases and conditions that are the main objectives for the use or method of the present invention are diabetes mellitus (type 1 or 2) or other conditions characterized by hyperglycemia, and metabolic diseases and conditions are also of interest. general where the metabolic effects of insulin have a clinical relevance, such as prediabetes, impaired glucose tolerance, metabolic syndrome, obesity, cachexia, loss / death of beta cells in vivo, excessive appetite, and inflammation. It is known or believed that All these types of conditions benefit from a stable metabolic state in the subject who has the disease / condition.

Accordingly, any therapeutic regimen where the administration of insulin or insulin compounds is included can be modified by the implementation of the present invention.

In one aspect, the beneficial control of glycemia by said combination is superior to any glycemic control achieved by an equivalent dose of IGlar in said subject as determined by HbA1c levels in said subject after administration of IGlar to said subject. subject.

The term "said combination is superior to any glycemic control achieved by an equivalent dose of IGlar in said subject as determined by HbA ¹ c levels in said subject after administration of IGlar to said subject" means that the combination is higher than an equivalent dose of IGlar under an administration regimen according to the IGlar label in achieving better glycemic control as determined by HbA ¹ c levels in said subject after administration of the combination or the IGlar.

IGlar (insulin glargine) is a basal insulin marketed by the company Sanofi Aventis under the brand name Lantus®. According to the brochure in Lantus packages, IGlar must be provided once a day and at the same time each day.

In one aspect, the beneficial control of glycemia by said combination comprises decreasing HbA ¹ c levels in said subject to 7.0% or less after administration of said combination in the largest meal of the day. The decrease in HbA ¹ c levels in said subject to 7.0% can be achieved in approximately 26 weeks, or even less.

In one aspect, beneficial glycemic control by said combination is defined as superior to any glycemic control achieved by an equivalent dose of IGlar in said subject as determined by HbA ¹ c levels in said subject after administration. IGlar to said subject and comprises lowering HbA ¹ c levels in said subject to 7.0% or less after administration of said combination in the largest meal of the day.

In addition to having a beneficial effect on the HbA1c level, the combination of the present invention can also have a beneficial effect on blood glucose levels.

The combination of the present invention is administered in the largest meal of the day for said subject. This means that the combination of the present invention is administered with, or about the same time as, the largest meal of the day for said subject, typically from a little earlier, such as about 30 minutes before, or until a little later, such as about 30 minutes later.

It is advantageous that the combination of the present invention achieves beneficial glycemic control since it provides flexibility to the subject. A flexible treatment regime of this type directly generates a number of advantages.

For example, it improves patient comfort due to the possibility of flexible administration. For example, patients can adapt the administration to their lifestyle instead of relying on dosing at fixed time points, which can be advantageous in cases of non-compliance or distraction in which a dose is administered before or after the expected injection time; if the patient is, for example, traveling, is a child or teenager, is playing sports or is a shift worker; or for any other reason has an irregular lifestyle or for which irregularities occur in or cannot be avoided in daily routines. Another example where flexible administration is advantageous is whether the patient lives in a nursing home or if otherwise the patient depends on the assisted administration of insulin compounds. The increased comfort potentially improves patient compliance, which ultimately improves the long-term outcome for the patient.

The patient has even greater flexibility compared to the use of basal insulins, such as IGlar, which must be injected at the same time each day.

Therefore, it has surprisingly been discovered that beneficial glycemic control (as defined in the present description) can be achieved by administering the combination of the present invention during or around the time of the largest meal, typically from a little earlier, such as about 30 minutes before, or until a little later, such as about 30 minutes later.

In the experimental studies presented in the present description, IDegAsp was administered to patients with type 2 diabetes at the largest meal of the day. The results presented in this description come from a Phase 3 trial, controlled and randomized. The Examples Section provides data for the combination of IDegAsp - a soluble combination of ultra-prolonged degludec insulin (70%) and aspartic insulin (30%) - which provides insulin coverage at both mealtime and baseline . This essay of treatment up to a goal, open, of 26 weeks, investigated the efficacy and safety of IDegAsp in virgin subjects for insulin with type 2 diabetes. In these studies, participants (mean: 60.5 years; A1C 8.4%; FPG 162 mg / dl; BMI 25.1 kg / m2; duration of diabetes 11.7 years) were randomized to injections once daily (OD) of IDegAsp (n = 147) or insulin glargine (IGlar; n = 149 ), both ⁺ up to 2 OAD (excluding SU, DPP-4 inhibitors and glinides). The IDegAsp was provided before the largest meal of the day according to the criteria of each participant (and was maintained throughout the trial); IGlar was dosed as on the label. The doses of both insulins were adjusted for FPG <90 mg / dl. After 26 weeks, the average HbA ¹ C was 7.0% with IDegAsp and 7.3% with IGlar. The superiority of IDegAsp over IGlar (difference between estimated treatments (ETD) IDegAsp-IGlar was demonstrated: -0.28% -points [-0.46; -0.10], p <0.001). The mean FPG was similar for IDegAsp and IGlar (103 vs. 100 mg / dl; ETD IDegAsp-IGlar: 2.7 mg / dl [-5.2; 10.8], p = NS). Confirmed hypoglycemia (PG <56 mg / dl) was reported for 44% of the subjects in both groups. In addition, IDegAsp was associated with numerically lower rates of confirmed total (27%) and confirmed nocturnal (25%) hypoglycemia. IGlar (ratio of estimated rates IDegAsp / IGlar: 0.73 [0.50; 1.08] p = NS and 0.75 [0.34; 1.64], p = NS, respectively). The average daily doses of insulin were similar between the groups at the end of the trial (IDegAsp: 0.41 U / kg; IGlar: 0.41 U / kg) as well as increases in body weight with respect to the initial value (0, 7 kg in both groups). The total rates of adverse events were similar between groups without a pattern or specific grouping of treatment. In conclusion, the results show that the IDegAsp dosed once a day with the largest meal of the day provided superior long-term glycemic control with an IGG-like FPG at a numerically lower rate of total and nocturnal hypoglycemia. Therefore, in summary, a once-daily administration of IDegAsp is superior to IGlar in subjects with type 2 diabetes. Therefore, in the experimental studies presented in the present description, it was found that the combination of human insulin LysB29 ( N ^g -hexadecandioyl- ^and -Glu) des (B30) and IAsp when provided with the larger meal resulted in beneficial levels of HbA ¹ c, whose levels were higher than the levels achieved by the administration of IGlar (data not shows).

The results are surprising when considering the findings of Strojek et al. (2009) Current Medical Research & Opinion vol 25 pages 2887 to 2894. Here, the authors studied once-daily initiation with aspartic biphasic insulin 30 against IGlar in patients with diabetes Type 2 improperly controlled with oral drugs. At the end of the treatment, the authors found that the average HbA1c level was 7.1% and 7.3% for BIAsp 30 and insulin glargine, respectively. The authors also found that the relative risk (RR) of experiencing a nocturnal hypoglycemic episode (00: 00-06.00 am) was significantly higher with BIAsp 30 than with insulin glargine (1.1 versus 0.5 episodes / year, RR% 2 , 41, 95% CI [1.34; 4.34], p% 0.003). The authors also reported three major hypoglycemia episodes in each group.

Our findings are surprising given that, in our previous studies, we found that the combination of human insulin LysB29 (N £ -hexadecandioyl- ^and -Glu) des (B30) and IAsp when provided with food that was not the largest meal - such as breakfast - resulted in HbA ¹ c levels comparable to the levels achieved by the administration of IGlar (data not shown).

Diabetes

The term "diabetes" or "diabetes mellitus" includes type 1 diabetes, type 2 diabetes, gestational diabetes (during pregnancy) and other conditions that cause hyperglycemia. The term is used for a metabolic disorder in which the pancreas produces insufficient amounts of insulin, or in which the body's cells do not respond adequately to insulin, thus preventing cells from absorbing glucose. As a result, glucose accumulates in the blood.

Type 1 diabetes, also called insulin-dependent diabetes mellitus (IDDM) and juvenile diabetes, is caused by the destruction of B cells, which usually leads to absolute insulin deficiency.

Type 2 diabetes, also known as non-insulin-dependent diabetes mellitus (NIDDM) and adult diabetes, is associated with predominant insulin resistance and therefore with relative insulin deficiency and / or with a defect predominantly in the secretion of insulin with insulin resistance.

Other indications

The combination according to the present invention can be used for the preparation of a medicament for the treatment or prevention of hyperglycemia that includes stress-induced hyperglycemia, type 2 diabetes, impaired glucose tolerance, type 1 diabetes, burns, wounds surgical, other diseases or injuries where an anabolic effect is needed in the treatment, myocardial infarction, stroke, coronary heart disease, other cardiovascular disorders, treatment of critical diabetic and non-diabetic patients and polyneuropathy. In another embodiment, the combination according to the present invention can be used as a medicament to delay or prevent the progression of the disease in type 2 diabetes.

In one embodiment of the invention, the combination according to the present invention can be used as a medicament for the treatment or prevention of hyperglycemia that includes stress-induced hyperglycemia, type 2 diabetes, impaired glucose tolerance, type 1 diabetes. , and burns, surgical wounds and other diseases or injuries where an anabolic effect is needed in the treatment, myocardial infarction, stroke, coronary heart disease and other cardiovascular disorders.

The present description describes a method for the treatment or prevention of hyperglycemia that includes stress-induced hyperglycemia, type 2 diabetes, impaired glucose tolerance, type 1 diabetes, and burns, surgical wounds and other diseases or injuries where an anabolic effect is needed in the treatment, myocardial infarction, coronary heart disease and other cardiovascular disorders, stroke, the method comprises administering to a patient in need of said treatment an effective amount for such treatment of the combination according to the present invention.

Specific combination treatment

The treatment with the combination according to the present invention may also be combined with a second or more pharmacologically active substances, for example, selected from antidiabetic agents, anti-obesity agents, appetite regulating agents, antihypertensive agents, treatment and / or prevention agents. of complications resulting from or associated with diabetes and agents for the treatment and / or prevention of complications and disorders resulting from or associated with obesity.

The components of the combination according to the present invention can be administered simultaneously or sequentially. The factors can be supplied in a single dosage form wherein the single dosage form contains both compounds, or in the form of a kit of parts comprising a preparation of the combination according to the present invention as a first unit dosage form and a Preparation of the combination according to the present invention as a second unit dosage form. When a first or second or third, etc., unit dose is mentioned throughout this description this does not indicate the preferred order of administration, but is simply done for practical purposes.

By "simultaneous" dosing of a preparation of the combination according to the present invention is meant the administration of the compounds in a single dosage form, or the administration of a first agent followed by the administration of a second agent with a temporary separation of no more than 15 minutes, preferably 10, more preferably 5, more preferably 2 minutes. Any of the factors can be administered first.

"Sequential" dosing means the administration of a first agent followed by the administration of a second agent with a temporary separation of more than 15 minutes. Either of the unit dosage forms can be administered first. Preferably, both products are injected through the same intravenous access.

Preferably the combination according to the present invention comprises the first insulin type compound and the second insulin type compound in the same formulation - that is, in the same composition. Insulin

The term "human insulin" as used herein means the human insulin hormone whose structure and properties are well known. Human insulin has two polypeptide chains, called chain A and chain B. Chain A is a peptide of 21 amino acids and chain B is a peptide of 30 amino acids, the two chains are connected by disulfide bridges: a first bridge between cysteine at position 7 of chain A and cysteine at position 7 of chain B, and a second bridge between cysteine at position 20 of chain A and cysteine at position 19 of chain B. A third bridge is present between the cysteines at position 6 and 11 of the A chain.

In the human body, the hormone is synthesized as a single chain precursor proinsulin (preproinsulin) consisting of a 24 amino acid prepeptide followed by proinsulin containing 86 amino acids in the configuration: BArg-Arg-C-Lys Arg-A prepeptide , in which C is a 31 amino acid linker peptide. Arg-Arg and Lys-Arg are cleavage sites for cleavage of the peptide linker of the A and B chains.

In the present description an "insulin" according to the invention should be understood as human insulin or an insulin of another species such as porcine or bovine insulin.

The term "insulin peptide" as used herein means a peptide that is human insulin or an analogue or derivative thereof with insulin activity.

The term "parental insulin" as used herein refers to an insulin before any modification has been applied to it.

Insulin analogues

The term "insulin analogue" as used herein means a modified human insulin wherein one or more amino acid residues of insulin have been replaced by other amino acid residues and / or where one or more amino acid residues are have been removed from insulin and / or where one or more amino acid residues have been added and / or inserted into insulin.

In one embodiment an insulin analogue comprises less than 10 amino acid modifications (substitutions, deletions, additions (including insertions) and any combination thereof) with respect to human insulin, alternatively less than 9, 8, 7, 6, 5 , 4, 3, 2 or 1 modification with respect to human insulin.

Modifications in the insulin molecule are denoted by indication of the chain (A or B), the position, and the one or three letter code for the amino acid residue that replaces the native amino acid residue.

By "desB30" or "B (1-29)" is meant a natural insulin B chain or an analogue thereof lacking the amino acid B30 and "A (1-21)" means the natural insulin A chain. Therefore, for example, human insulin A21Gly, B28Asp, desB30 is a human insulin analogue where the amino acid at position 21 in chain A is replaced with glycine, the amino acid at position 28 in chain B is replaced with aspartic acid, and the amino acid at position 30 in the B chain is removed.

The terms in this description as "A1", "A2" and "A3" etc. indicate the amino acid at position 1, 2 and 3 etc., respectively, in the A chain of insulin (counted from the N-terminal end). Similarly, terms like B1, B2 and B3 etc. indicate the amino acid at position 1, 2 and 3 etc., respectively, in the insulin B chain (counted from the N-terminal end). With the use of the one-letter codes for amino acids, terms such as A21A, A21G and A21Q indicate that the amino acid at position A21 is A, G and Q, respectively. With the use of three-letter codes for amino acids, the corresponding expressions are A21Ala, A21Gly and A21Gln, respectively.

In the present description the terms "A (0)" or "B (0)" indicate the positions of the N-terminal amino acids relative to A1 or B1, respectively. The terms A (-1) or B (-1) indicate the positions of the first N-terminal amino acids relative to A (0) or B (0), respectively. Therefore A (-2) and B (-2) indicate the positions of the N-terminal amino acids with respect to A (-1) and B (-1), respectively, A (-3) and B (-3) indicate the positions of the N-terminal amino acids with respect to A (-2) and B (-2), respectively, and so on. The terms A22 or B31 indicate the positions of the C-terminal amino acids relative to A21 or B30, respectively. The terms A23 or B32 indicate the positions of the first C-terminal amino acids relative to A22 or B31, respectively. Therefore A24 and B33 indicate the positions of the C-terminal amino acids relative to A23 and B32, respectively, and so on.

In the present description, the term "amino acid residue" is an amino acid from which, formally, a hydroxy group has been removed from a carboxy group and / or from which, formally, a hydrogen atom has been removed from an amino group.

Examples of insulin analogs are such where Pro in position 28 of chain B is substituted with Asp, Lys, Leu, Val, or Ala and / or Lys in position B29 is substituted with Pro, Glu or Asp. In addition, the Asn in position B3 can be substituted with Thr, Lys, Gin, Glu or Asp. The amino acid residue at position A21 can be substituted with Gly. One or more amino acids may also be added to the C-terminal of the A chain and / or the B chain such as, for example, Lys. The amino acid in position B1 can be substituted with Glu. The amino acid at position B16 can be substituted with Glu or His. Other examples of insulin analogs are deletion analogs, for example, analogs where the amino acid B30 in human insulin has been removed (human insulin des (B30)), insulin analogs where amino acid B1 in human insulin has been removed. removed (human insulin des (B1)), human insulin des (B28-B30) and human insulin des (B27). Insulin analogs where the A chain and / or the B chain have an N-terminal extension and the insulin analogs where the A chain and / or the B chain have a C-terminal extension such as with two arginine residues added to the C-terminal of the B chain are also examples of insulin analogs. Other examples are insulin analogs comprising combinations of the aforementioned mutations. Insulin analogs wherein the amino acid at position A14 is Asn, Gin, Glu, Arg, Asp, Gly or His, the amino acid at position B25 is His and which optionally further comprises one or more additional mutations are other examples of analogs of insulin Insulin analogs of human insulin where the amino acid residue at position A21 is Gly and where the insulin analog extends further in the C-terminal with two arginine residues are also examples of insulin analogs.

Other examples of insulin analogs include:

human insulin DesB30; human insulin AspB28; human insulin AspB28, desB30;

human insulin LysB3, GluB29; human insulin LysB28, ProB29;

human insulin GlyA21, ArgB31, ArgB32; human insulin GluA14, HisB25;

human insulin HisA14, HisB25; human insulin GluA14, HisB25, desB30; human insulin HisA14, HisB25, desB30; human insulin GluA14, HisB25, desB27, desB28, desB29, desB30; human insulin GluA14, HisB25, GluB27, desB30; human insulin GluA14, HisB16, HisB25, desB30; human insulin HisA14, HisB16, HisB25, desB30;

human insulin HisA8, GluA14, HisB25, GluB27, desB30;

human insulin HisA8, GluA14, GluB1, GluB16, HisB25, GluB27, desB30; and

Human insulin HisA8, GluA14, GluB16, HisB25, desB30.

Therefore, the insulin analog may include a polypeptide having a molecular structure that can be formally derived from the structure of a naturally occurring insulin, for example, that of human insulin, by deletion and / or exchange of the less an amino acid residue that appears in naturally occurring insulin and / or the addition of at least one amino acid residue. The amino acid residues added and / or exchanged may be encodable amino acid residues or other naturally occurring residues or purely synthetic amino acid residues

For example, insulin analogs can be such where position 28 of chain B can be modified from the natural Pro residue to one of Asp, Lys, or Ile. In another mode the Lys in position B29 is modified to Pro. In a mode B30 it can be Lys and then B29 can be any encodable amino acid except Cys, Met, Arg and Lys.

For example, the Asn at position A21 can be modified to Ala, Gln, Glu, Gly, His, Ile, Leu, Met, Ser, Thr, Trp, Tyr or Val, in particular to Gly, Ala, Ser, or Thr and preferably to Gly.

For example, the Asn in position B3 can be modified to Lys or Asp.

Other examples of insulin analogs are human insulin des (B30); human insulin analogs des (B30); insulin analogs where PheB1 has been removed; Insulin analogs wherein the A chain and / or the B chain have an N-terminal extension and insulin analogs where the A chain and / or the B chain have a C-terminal extension. Therefore one or two Arg can be added to position B1.

The term "an encodable amino acid" or "an encodable amino acid residue" is used to indicate an amino acid or amino acid residue that can be encoded by a triplet ("codon") of nucleotides.

Other examples of insulin analogs include those that have an amino acid residue having a carboxylic acid group in the side chain. The expression "an amino acid residue having a carboxylic acid group in the side chain" indicates amino acid residues such as Asp, Glu and hGlu. The amino acids can be in the L or D configuration. If nothing is specified it is understood that the amino acid residue is in the L configuration.

Other examples of insulin analogs include those that have an amino acid residue that has an amino acid residue that has a neutral side chain. The expression "an amino acid residue having a neutral side chain" indicates amino acid residues such as Gly, Ala, Val, Leu, Ile, Phe, Pro, Ser, Thr, Cys, Met, Tyr, Asn and Gln.

Insulin derivatives

The term "insulin derivative" as used herein means a chemically modified parental insulin or an analogue thereof, wherein the modification (s) is (are) in the form of the union of amides, carbohydrates, groups alkyl, acyl groups, esters, PEGylations, and the like. Examples of human insulin derivatives according to the invention are human insulin LysB29 (NE-hexadecandioyl- ^and -Glu) des (B30), human insulin NEB29-w-carboxy-pentadecanoyl- ^and -L-glutamylamide desB30, human insulin NEB29 -w-carbox¡-pentadecanoyl- ^and -amino-butanoyl desB30, human insulin NEB29- (Na- (Sar-OC (CH2) 13CO) - ^and -Glu) desB30, human insulin NEB29-hexadecandioyl- ^and -amino-butanoyl desB30 , insulin NEB29-hexadecandioyl- ^and -LGlu-amide desB30.

To effect covalent binding of the polymeric molecule (s) to the polypeptide, the terminal hydroxyl groups of the polymeric molecule are provided in activated form, that is, with reactive functional groups. Suitable activated polymer molecules are commercially available, for example, from Shearwater Corp., Huntsville, Ala., USA, or from PolyMASC Pharmaceuticals plc, United Kingdom. Alternatively, the polymer molecules can be activated by conventional methods known in the art, for example, as described in WO 90/13540. Specific examples of activated linear or branched polymer molecules for use in the present invention are described in the Shearwater Corp. 1997 and 2000 Catalogs (Biocompatible polymers functionalized for research and pharmaceuticals, polyethylene glycol and derivatives, which is incorporated into the present description as a reference). Specific examples of activated PEG polymers They include the following linear PEGs: NHS-PEG (for example, SPA-PEG, SSPA-PEG, SBA-PEG, SS-PEG, SSA-PEG, SC-PEG, SG-PEG, and SCM-PEG), and NOR- PEG), BTC-PEG, EPOX-PEG, NCO-PEG, NPC-PEG, CDIPEG, ALD-PEG, THREE-PEG, VS-PeG, IODO-PEG, and MAL-PEG, and branched PEG, such as PEG2-NHS and those described in US Pat. no. 5,932,462 and U.S. Pat. no. 5,643,575.

The conjugation of the polypeptide and activated polymer molecules is performed by using any conventional method, for example, as described in the following references (which further describe suitable methods for the activation of polymer molecules): RF Taylor, (1991) , "Protein immobilization. Fundamental and applications", Marcel Dekker, NY; S. S. Wong, (1992), "Chemistry of Protein Conjugation and Crosslinking", CRC Press, Boca Raton; G. T. Hermanson et al. (1993), "Immobilized Affinity Ligand Techniques", Academic Press, N.Y.). The expert will be aware that the activation method and / or conjugation chemistry for use depends on the polypeptide binding group (s) (examples of which were provided additionally above), as well as the functional groups of the polymer. (for example, they are amine, hydroxyl, carboxyl, aldehyde, sulfhydryl, succinimidyl, maleimide, vinylsulfone or haloacetate).

Therefore, the insulin derivative may include a naturally occurring insulin or an insulin analogue that has been chemically modified, for example, by the introduction of a side chain at one or more positions of the main insulin chain or by the oxidation or reduction of groups of amino acid residues in insulin or by converting a free carboxylic group to an ester group or acylation of a free amino group or a hydroxy group.

Pharmaceutical protein formulations

Injectable compositions containing the combination of the present invention can be prepared using conventional pharmaceutical industry techniques that involve dissolving and mixing the ingredients as appropriate to provide the desired final product. Therefore, according to one procedure, the combination of the present invention is dissolved in an amount of water that is somewhat smaller than the final volume of the composition to be prepared. An isotonic agent, a preservative and a buffer are added as required and the pH value of the solution is adjusted, if necessary, with the use of an acid, for example, hydrochloric acid, or a base, for example, hydroxide of aqueous sodium, as necessary. Finally, the volume of the solution is adjusted with water to provide the desired concentration of the ingredients.

More precisely, an insulin preparation of this invention, for example a solution or suspension, can be prepared by dissolving the combination of the present invention in an aqueous medium under slightly acidic conditions, for example, in a concentration in the range of approximately 240 to about 2400 nmol / ml. The aqueous medium is made isotonic, for example, with sodium chloride or glycerol. In addition, the aqueous medium may contain buffers such as acetate or citrate, preservatives such as m-cresol or phenol and zinc ions, for example, zinc may be present in a concentration of more than 4 zinc atoms per 6 molecules of the insulin derivatives, such as 4.5 zinc atoms per 6 molecules of insulin derivatives, 5 zinc atoms per 6 molecules of insulin derivatives, 6 zinc atoms per 6 molecules of insulin derivatives or up to 12 atoms of zinc per 6 molecules of insulin derivatives. The pH value of the solution is adjusted towards neutrality without getting too close to the isoelectric point of the compound of this invention to avoid potential precipitation. The pH value of the final insulin preparation depends on what compounds of this invention are used, the concentration of zinc ions and the concentration of the compound of this invention. The insulin preparation is sterilized, for example, by sterile filtration.

First insulin type compound

The combination of the present invention comprises a first insulin-like compound that is longer in action than the second insulin-like compound, wherein said first insulin-like compound is human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30).

In one embodiment, the first and / or second insulin-type compound exhibits under physiological conditions, at least in part, the binding and / or activation (potency) of the naturally occurring insulin insulin receptor, preferably, at least 0 , 01% of the binding and / or activation (potency) of the insulin insulin receptor of natural origin, for example, at least 0.1%, at least 1%, at least 5%, at least 10%, at minus 15%, at least 20%, at least 25% at least 50%, at least 65%, at least 75%, at least 85%, at least 95%, at least 100%, at least 110%, at least 120%, at least 130%, at least 140% or at least 150% of the binding and / or activation (potency) of the naturally occurring insulin insulin receptor

Insulin receptor binding can be determined by any suitable means known in the art. However, preferably, the binding to the insulin receptor is determined with the use of the method provided in the previous examples (assay (I) - Insulin receptor binding).

The activation of the insulin receptor (potency) can be determined by any suitable means known in the art. However, preferably, the binding to the insulin receptor is determined with the use of the method provided in the previous examples (test (II) -Power).

In one embodiment, the first and / or second insulin compound has a half-life of at least 18 hours, such as at least 24 hours, wherein the half-life can be determined as described in Clinical Example 1 in the present description. In one embodiment the first and / or the second insulin compound has a half-life of at least 12 hours, such as at least 12 hours and less than 24 hours, where the half-life can be determined as described in Clinical Example 1 herein. description.

In one embodiment, the term "long-acting insulin" means that the insulin-like compound has an insulin-like action or a long-acting profile (for example, it maintains blood sugar levels at a stable and balanced level) for up to 24 hours.

In one embodiment, a long-lasting insulin exhibits a half-life of at least 10 hours under physiological conditions when injected subcutaneously, for example, at least 12.5 hours, at least 15 hours, at least 17.5 hours, at at least 20 hours, at least 22.5 hours, at least 25 hours, at least 27.5 hours, at least 30 hours, at least 32.5, at least 35 hours, at least 37.5 hours or at least 40 hours . Preferably, a long-lasting insulin also exhibits a half-life less than or equal to 24 h under physiological conditions when injected subcutaneously, for example, less than or equal to 22 h, less than or equal to 20 h, less than or equal to 18 h, less than or equal to 16 h or less than or equal to 14 h.

Insulin half-life can be determined by any suitable means known in the art (for example, see Gnovo SC, Harris S, Woo V, Davies M, 2013, 'Insulin degludec: overview of a novel ultra-acting basal insulin' Diabetes Obes Metab., 15 (4): 301-9; and / or Heise T, Nosek L, B ⁰ ttcher SG, Hastrup H, Haahr H, 2012, 'Ultra-long-acting insulin degludec has a flat and stable glucose-lowering effect in type 2 diabetes' Diabetes Obes Metab., 14 (10): 944-50, whose descriptions are incorporated herein by reference). The half-life of insulin can also be determined as described in Clinical Example 1 in the present description. Preferably, the half-life of insulin is determined with the use of the method provided in Test (III) in the present description.

With respect to this, for some embodiments the first insulin-type compound is an ultraprolonged insulin.

In one embodiment, the term "ultraprolonged-acting insulin" means that the insulin-like compound has an insulin-like action or a long-acting profile (for example, it maintains blood sugar levels in a balanced and stable level) for more than 24 hours.

In one embodiment, an ultraprolonged insulin exhibits a half-life of more than 18 h under physiological conditions when injected subcutaneously, for example, greater than 20 h, greater than 22 h or greater than 24 h. In a "prolonged action profile" mode it is defined as an average time until the loss of glucose control of at least 20 hours, where the average time until the loss of glucose control can be determined as described in the Example Clinical 1 in the present description.

In one embodiment, the insulin-type compound used in the present invention has 1) a sufficiently prolonged action and / or half-life profile in most subjects and optionally 2) a relatively flat and stable form of the activity profile so as not to cause undue increase in insulin action when used with a short dosage interval. An indication of the duration of action in clinical use can be obtained under experimental conditions such as by using the euglycemic glucose clamp procedure (L. Heinemann and JH Anderson-Jr. Measurement of insulin absorption and insulin action. Diabetes Technol Ther 6 (5): 698-718, 2004), which is used in Clinical Example 1. An indication of the flat nature of the activity profile in clinical use can be obtained under experimental conditions as described in Clinical Example 1 or Example Clinical 2. An indication of the stability of the activity profile in clinical use can be obtained under experimental conditions as described in Clinical Example 1 or Clinical Example 2.

In one embodiment, the first insulin-type compound does not have a relatively high peak activity profile. This peak is defined as the maximum value in a curve when glucose infusion is plotted against time since drug administration. An indication of the peak activity profile in clinical use can be obtained under experimental conditions as described in Clinical Example 1 or Clinical Example 2. Preferably, the first and / or the second insulin of insulin type induces a deviation in a subject Maximum mean insulin concentration (AUCF%) in a 24-hour period of <18, for example, <17, <16, <15, <14, <13, <12, <11, <10, <9 , <8, <7, <6, <5, <4, <3, <2, <1, <0.5, <0.1. The maximum deviation of the average insulin concentration (AUCF%) can be determined by any suitable means known in the art (see, for example, Heise et al., Poster eAs D 2011).

In one embodiment, the first and / or the second insulin of the insulin type preferably provides a stable and evenly distributed glucose reduction effect in the dosage range. For example, the glucose infusion rate (GIR) in a 24-hour dosing interval (tau) quantified by calculating the AUC ratio for the subareas under the GIR profiles for the four 6-hour measurement intervals ( GIR AUC ratio: AUCGiR, o-6h, ss / AUCGiR, T, ss; AUCGiR, ⁶ -i ² h, ss / AUCGiR, T, ss; AUCGiR, i ² -i ⁸ h, ss / AUCGiR, T , ss; AuCGiR, i8-24h, ss / AUCGiR, T, ss) should be close to the 25: 25: 25: 25% distribution (preferably 6 8%, for example, 64%, 63%, 62%, 61 %, 60.5% or 60.1%).

In addition, the fluctuation in GIR in a dosage range is preferably as small as possible. The fluctuation in GIR can be assessed by AUC ^{fg ir, t} : which estimates how much an individual's GIR profile deviates from its average GIR in 24 h). Preferably, AUC ^{fg ir, t} is <58 (for example, <57, <56, <55, <54, <53, <52, <51 or <50). The fluctuation in GIR (AUC ^{fg ir, t} ) can be evaluated by any suitable method known in the art. However, in one modality, GIR (AUC ^{fg ir, t} ) is evaluated according to the method described in Heise et al., 2012, Diabetes, Obesity and Metabolism, 14 (9): 859-64.

In another group of parental insulin analogs, the amino acid residue at position B30 has been removed. A specific example of this group of parental insulin analogs is human insulin des (B30).

In another group of parental insulin analogs, the amino acid residue at position B28 is Asp. A specific example of this group of parental insulin analogs is human insulin AspB28 (or otherwise indicated as AspB28).

In another group of parental insulin analogs, the amino acid residue at position B28 is Lys and the amino acid residue at position B29 is Pro. A specific example of this group of parental insulin analogs is human insulin LysB28ProB29.

In another group of parental insulin analogs the amino acid residue at position B30 is Lys and the amino acid residue at position B29 is any encodable amino acid except Cys, Met, Arg and Lys. An example is an insulin analogue where the amino acid residue at position B29 is Thr and the amino acid residue at position B30 is Lys. A specific example of this group of parental insulin analogs is the human insulin ThrB29LysB30.

In another group of parental insulin analogs, the amino acid residue at position B3 is Lys and the amino acid residue at position B29 is Glu. A specific example of this group of parental insulin analogs is the human insulin LysB3GluB29.

In one embodiment, parental insulin is selected from the group consisting of human insulin; human insulin des (B1); human insulin des (B30); human insulin GlyA21; human insulin GlyA21 des (B30); human insulin AspB28; porcine insulin; human insulin LysB28ProB29; human insulin GlyA21ArgB31ArgB32; and human insulin LysB3GluB29.

Details concerning the preparation, formulation, pharmacology and other relevant characteristics for human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) are set forth in WO 2005/012347.

The combination of the present invention may further comprise one or more additional first insulin-type compounds.

The one or more additional insulin-like compounds may be any one or more of the first insulin-type compounds presented above.

Second insulin type compound

The combination of the present invention comprises a second insulin type compound that is faster acting than the second insulin type compound.

The second insulin-type compound is a fast-acting insulin.

The term "rapid-acting insulin" means that the insulin-like compound has an insulin action that has an effect in a very short period of time - that is, the appearance of the action is within 30 minutes and the maximum effect is within 1-3 hours.

In the combination of the invention, the fast-acting insulin is the IAsp. IAsp is a human insulin in which the naturally occurring amino acid at position B28 is replaced with Asp (human insulin AspB28). The IAsp is sold under the trade name of NovoRapid® (Novo Nordisk A / S).

Other rapid-acting insulin analogs are described in WO2007 / 074133.

The combination of the present invention may further comprise one or more additional second insulin type compounds.

The one or more additional insulin-like compounds may be any one or more of the second insulin-type compounds presented above.

In a preferred embodiment, the additional rapid-acting insulin is selected from the group consisting of human insulin LysB28ProB29 and human insulin LysB3GluB29.

Hydrophobicity

For some embodiments, the first insulin-type compound has a general hydrophobicity that is essentially similar to that of human insulin.

For some embodiments, the first insulin-type compound has a hydrophobic index, k'rel, which is in the range of about 0.02 to about 10, from about 0.1 to about 5; from about 0.5 to about 5; or from about 0.5 to about 2.

Solubility

For some embodiments, the first insulin-type compound is soluble at physiological pH values.

For some embodiments, the second insulin-type compound is soluble at physiological pH values.

When it is indicated that an insulin-type compound according to the invention is "soluble at physiological pH values" it means that the insulin derivative can be used to prepare injectable insulin compositions that dissolve completely at physiological pH values. Such favorable solubility may be due to the inherent properties of the insulin-like compound alone or be a result of a favorable interaction between the insulin derivative and one or more ingredients contained in the vehicle.

Therefore, in one embodiment, the invention relates to a pharmaceutical composition comprising a first insulin type compound that is soluble at physiological pH values and / or a second insulin type compound that is soluble at physiological pH values.

Therefore, in one embodiment, the invention relates to a pharmaceutical composition comprising a first insulin type compound that is soluble at physiological pH values and a second insulin type compound that is soluble at physiological pH values.

In another embodiment, the invention relates to a pharmaceutical composition comprising a first insulin-like compound that is soluble at pH values in the range of about 6.5 to about 8.5 and / or a second insulin-like compound that It is soluble at pH values in the range of about 6.5 to about 8.5.

Some preferred modalities

For some embodiments of the present invention, the combination of the present invention is used in conjunction with another of one or more pharmaceutically active agents.

For some embodiments of the present invention, the combination of the present invention is used in conjunction with one or more antidiabetic drugs, such as one or more orally administered antidiabetic drugs.

For some embodiments of the present invention, the combination of the present invention is used to treat a subject who is at least 20 years old.

For some embodiments of the present invention, the combination of the present invention is used to treat a subject whose body mass index is not greater than 35 kg / m2.

For some embodiments of the present invention, the combination of the present invention is used to treat a subject whose body mass index is approximately 25 kg / m2.

For some embodiments of the present invention, the combination of the present invention is used to treat a subject whose initial HbA ¹ c level before treatment is greater than 7%, such as about 8% or 9%.

For some embodiments of the present invention, the combination of the present invention is used to treat a subject who has suffered a duration of diabetes for at least 1 year, such as at least 5 years, such as at least 10 years.

For some embodiments of the present invention, the combination of the present invention is capable of achieving an initial HbA ¹ c level for the subject of no more than 7% after 26 weeks of treatment.

For some embodiments of the present invention, the combination of the present invention is capable of reducing the increase in PG (plasma glucose) more than with the use of an equivalent dosage of IGlar. For some embodiments of the present invention, the combination of the present invention is capable of achieving an increase in PG (plasma glucose) by more than about 50%.

For some embodiments of the present invention, the combination of the present invention is capable of achieving long-acting basal coverage with additional prandial coverage of one meal per day.

For some embodiments of the present invention, the combination of the present invention is capable of achieving superior control of postprandial glucose deviations compared to an equivalent dose of IGlar without compromising the control of FPF (fasting plasma glucose).

For some embodiments of the present invention, the combination of the present invention is capable of achieving an improvement in glycemic control and reducing the increase in prandial plasma glucose at dinner.

For some embodiments of the present invention, the combination of the present invention is greater than IGlar at an equivalent dose in achieving a greater proportion of subjects up to a target of HbA1c <7% without confirmed hypoglycemia.

For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and the second insulin type compound are supplied together.

For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and the second insulin type compound are supplied together in the same formulation. For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and / or the second insulin type compound are delivered by injection.

For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and the second insulin type compound are delivered by injection.

For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and the second insulin type compound are supplied together by injection.

For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and the second insulin type compound are supplied together by injection and in the same formulation.

For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and / or the second insulin type compound are delivered by injection using insulin pen devices.

For some embodiments of the present invention, with the combination of the present invention, the first insulin-like compound and the second insulin-like compound are delivered by injection through the use of insulin pen-type devices.

For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and the second insulin type compound are delivered together by injection using insulin pen devices.

For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and the second insulin type compound are supplied together by injection and in the same formulation by the use of an insulin pen device.

For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and / or the second insulin type compound are delivered by injection by using FlexPen® or Flex-Touch®.

For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and the second insulin type compound are delivered by injection through the use of FlexPen® or FlexTouch®.

For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and the second insulin type compound are supplied together by injection using FlexPen® or FlexTouch®.

For some embodiments of the present invention, with the combination of the present invention, the first insulin type compound and the second insulin type compound are delivered together by injection and in the same formulation by using a FlexPen® or a FlexTouch® .

FlexPen® and / or FlexTouch® are trademarks of Novo Nordisk A / S.

The insulin derivative described in WO2005 / 012347 can be formulated with fast-acting insulin analogs as described in WO2007 / 074133.

The first compound is insulin - human insulin N ^EB29 - (N ^° - (HOOC (CH ²⁾ 14CO) - ^and -L-Glu) des (B30) and the second compound of insulin is Asp B28 human insulin together with pharmaceutically acceptable carriers and additives.

In some cases herein, human insulin N ^EB29 - (N ^° - (HOOC (CH ²⁾ 14CO) - ^and -L-Glu) des (B30) is called Degludec, degludec insulin, LysB29 human insulin or Ideg ( N ^g -hexadecandioyl- ^and -Glu) des (B30).

In some cases in the present description, human insulin AspB28 is called IDegAsp or DegludecPlus. Other combinations

In one embodiment, the combination of the present invention is used alone in the treatment of the patient.

In one embodiment, the combination of the present invention is used in conjunction with one or more other combinations according to the present invention, or its components.

In one embodiment, the combination of the present invention is used together with one or more other pharmaceutically active agents.

In one embodiment, the combination of the present invention is used together with one or more antidiabetic drugs. In one embodiment, the combination of the present invention is used together with one or more antidiabetic drugs administered orally.

In one embodiment, the combination of the present invention is used together with one or more antidiabetic drugs, such as one or more of sulfonylurea, biguanide, alpha-glucosidase inhibitor, thiazolidinedione, DPP4 inhibitor, glinide, metformin and a GLP agonist. -one.

Formulations

The first insulin type compound according to the present invention and the second insulin type compound according to the present invention can be mixed if necessary in a ratio of approximately 90/10%; approximately 85/15%, approximately 80/20%, approximately 70/30%, approximately 60/40%, approximately 50/50%, approximately 40/60%, approximately 30/60% or approximately 10/90%. In another embodiment, the first insulin type compound according to the present invention and the second insulin type compound according to the present invention may be mixed if necessary in a ratio of 40% or more of the first to 60% or less of the second insulin-like compound, from more than 50% or more of the first to less than 50% of the second insulin-like compound, or from about 70% or more of the first to about 30% or less of the second insulin-like compound,

In another embodiment, the invention relates to a pharmaceutical composition which is a solution containing from about 120 nmol / ml to about 2400 nmol / ml, from about 400 nmol / ml to about 2400 nmol / ml, from about 400 nmol / ml at about 1200 nmol / ml, from about 600 nmol / ml to about 2400 nmol / ml, or from about 600 nmol / ml to about 1200 nmol / ml of a first insulin-like compound of the present invention and / or a second compound insulin type.

In the combination of the present invention, each of the insulin-like compounds may be in an amount of about 0.01 to about 5 U / Kg, typically from about 0.03 to about 3 U / Kg.

In one embodiment of the present invention the concentration of the pharmaceutical composition is 100 U / ml.

In one embodiment of the present invention the concentration of the pharmaceutical composition is 200 U / ml.

In one embodiment the naturally occurring insulin, the insulin analogue or the derivative is formulated together with a pharmaceutically acceptable carrier and / or carrier and / or diluent and / or excipient.

In the present description a pharmaceutical composition containing a naturally occurring insulin, an insulin analogue, or a derivative of a naturally occurring insulin or an insulin analogue is called an "insulin composition." To make use of the present invention an insulin composition can be administered parenterally to patients in need of such treatment. Parenteral administration can be performed by injection, such as subcutaneous, intramuscular or intravenous injection, by means of a syringe, optionally a pen-type syringe. In one embodiment the administration is by injection s.c. In one modality the administration is by injection i.m. In one mode the administration is by injection i.v. Alternatively, parenteral administration can be performed by means of an infusion pump. Other options are to administer the insulin composition by nasal or pulmonary route, preferably in compositions, powders or liquids, specifically designed for the purpose.

Injectable insulin compositions can be prepared using conventional pharmaceutical industry techniques that involve dissolving and mixing the ingredients as appropriate to provide the desired final product. Therefore, according to a procedure, a natural insulin, an analogue or a derivative is dissolved in an amount of water that is somewhat smaller than the final volume of the composition to be prepared. An isotonic agent, a preservative and a buffer are added as required and the pH value of the solution is adjusted - if necessary - with the use of an acid, for example, hydrochloric acid, or a base, for example, hydroxide of aqueous sodium as needed. Finally, the volume of the solution is adjusted with water to provide the desired concentration of the ingredients.

The buffer is typically selected from the group consisting of sodium acetate, sodium carbonate, citrate, glycylglycine, histidine, glycine, lysine, arginine, sodium dihydrogen phosphate, disodium hydrogen phosphate, sodium phosphate and tris (hydroxymethyl) -aminomethane , bicin, tricine, malic acid, succinate, maleic acid, fumaric acid, tartaric acid, aspartic acid or mixtures thereof. Each of these specific buffers constitutes a useful alternative in the embodiments of the invention.

In a further embodiment of the invention the formulation further comprises a pharmaceutically acceptable preservative that can be selected from the group consisting of phenol, o-cresol, m-cresol, p-cresol, methyl p-hydroxybenzoate, propyl p-hydroxybenzoate, 2 -phenoxyethanol, butyl p-hydroxybenzoate, 2-phenylethanol, benzyl alcohol, chlorobutanol, and thiomersal, bronopol, benzoic acid, imidaurea, chlorohexidine, sodium dehydroacetate, chlorocresol, ethyl p-hydroxybenzoate, benzethonium 3 (chlorphenesine) chlorphenoxypropane-1,2-diol) or mixtures thereof. In a further embodiment of the invention, the preservative is present in a concentration of 0.1 mg / ml to 20 mg / ml. In a further embodiment of the invention, the preservative is present in a concentration of 0.1 mg / ml to 5 mg / ml. In a further embodiment of the invention, the preservative is present in a concentration of 5 mg / ml to 10 mg / ml. In a further embodiment of the invention, the preservative is present in a concentration of 10 mg / ml to 20 mg / ml. Each of these specific preservatives constitutes an alternative embodiment of the invention. The use of a preservative in pharmaceutical compositions is well known to experts. For convenience, reference is made to Remington: The Science and Practice of Pharmacy, 19th edition, 1995.

In a further embodiment of the invention the formulation further comprises an isotonic agent that may be selected from the group consisting of a salt (for example, sodium chloride), an alcoholic sugar or sugar, an amino acid (for example, L-glycine, L- histidine, arginine, lysine, isoleucine, aspartic acid, tryptophan, threonine), an alditol (for example, glycerol (glycerin), 1,2-propanediol (propylene glycol), 1,3-propanediol, 1,3-butanediol) polyethylene glycol ( for example, PEG400), or mixtures thereof. Any sugar such as mono-, di-, or polysaccharides, or water-soluble glucans may be used, including, for example, fructose, glucose, mannose, sorbose, xylose, maltose, lactose, sucrose, trehalose, dextran, pululane, dextrin , cyclodextrin, soluble starch, hydroxyethyl starch and Na carboxymethyl cellulose. In one embodiment the sugar additive is sucrose. Alcoholic sugar is defined as a C4-C8 hydrocarbon having at least one -OH group and includes, for example, mannitol, sorbitol, inositol, galactitol, dulcitol, xylitol and arabitol. In one embodiment, the alcohol sugar additive is mannitol. The sugars or alcoholic sugars mentioned above may be used individually or in combination. There is no fixed limit for the amount used, provided that sugar or alcoholic sugar is soluble in the liquid preparation and does not adversely affect the stabilizing effects achieved with the use of the methods of the invention. In one embodiment, the concentration of sugar or alcoholic sugar is between about 1 mg / ml and about 150 mg / ml. In a further embodiment of the invention the isotonic agent is present in a concentration of 1 mg / ml to 50 mg / ml. In a further embodiment of the invention the isotonic agent is present in a concentration of 1 mg / ml to 7 mg / ml. In a further embodiment of the invention the isotonic agent is present in a concentration of 8 mg / ml to 24 mg / ml. In a further embodiment of the invention the isotonic agent is present in a concentration of 25 mg / ml to 50 mg / ml. Each of these specific isotonic agents constitutes an alternative embodiment of the invention. The use of an isotonic agent in pharmaceutical compositions is well known to experts.

For convenience, reference is made to Remington: The Science and Practice of Pharmacy, 19th edition, 1995. Typical isotonic agents are sodium chloride, mannitol, dimethyl sulfone and glycerol and typical preservatives are methyl phenol, m-cresol, methyl p-hydroxybenzoate and benzyl alcohol.

Examples of suitable buffers are sodium acetate, glycylglycine, HEPES (4- (2-hydroxyethyl) -1-piperazinethanesulfonic acid), TRIS (2-amino-2-hydroxymethyl-1,3-propanediol), and sodium phosphate.

A composition for nasal administration can be prepared, for example, as described in European Patent No. 272097 (granted to Novo Nordisk A / S).

Compositions containing insulin can be used in the treatment of conditions that are sensitive to insulin. Therefore, they can be used in the treatment of type 1 diabetes, type 2 diabetes and hyperglycemia, for example, as it is sometimes observed in seriously injured people and people who have undergone major surgery. The optimal dose level for any patient will depend on a variety of factors that include the effectiveness of insulin, the analogue or the specific derivative employed, age, body weight, physical activity, and the patient's diet, of a possible combination with other drugs, and the severity of the condition to be treated. It is recommended that those skilled in the art determine the dosage regimen for each individual patient in a manner similar to that of known insulin compositions, however taking into account the present teachings related to dosage ranges.

When appropriate, insulin compositions may be used in combination with other types of insulin, for example, insulin analogues with a faster onset of action. Examples of such insulin analogs are described, for example, in European patent applications that have Nos. EP 214826 (Novo Nordisk A / S), EP 375437 (Novo Nordisk A / S) and EP 383472 (Eli Lilly & Co.).

Use as medicine

The present invention is used in the treatment of type 1 or 2 diabetes. In one embodiment diabetes mellitus is type 2 diabetes, which fails with oral antidiabetic treatment.

In one embodiment the invention relates to instructions for use comprising a description of a method as defined in the present description.

Brief description of the drawings

Figure 1 shows a graph.

Figure 2 shows a graph.

Modalities of the invention

The invention will be further summarized in the following paragraphs:

1. A combination comprising at least a first insulin type compound and a second insulin type compound to treat type 1 or type 2 diabetes in a subject in need thereof where the administration of insulin would be beneficial for said subject; wherein said first insulin-like compound is human insulin LysB29 (Nehexadecandioyl-y-Glu) des (B30) and said second insulin-like compound is human insulin AspB28; wherein said combination is administered once daily in an amount to achieve beneficial glycemic control in said subject as determined by HbA ¹ c levels in said subject after administration of said combination in the largest meal of the day for said subject; wherein said beneficial glycemic control by said combination comprises decreasing HbA ¹ c levels in said subject to 7.0% or less after administration of said combination in the largest meal of the day.

2nd. A combination to achieve glycemic control according to the previous paragraph where said patient determines which is the biggest meal of the day.

2b A combination to achieve glycemic control according to any of the preceding paragraphs where the biggest meal of the day for said patient is not necessarily dinner.

2 C. A combination to achieve glycemic control according to any of the preceding paragraphs where in the larger meal it comprises or consists of during said meal as well as up to approximately 30 minutes before the first food intake and up to approximately 30 minutes after the last food intake of that food.

3. A combination to achieve glycemic control in accordance with paragraph 1 wherein said combination achieves long-term glycemic control in said subject.

4. A combination to achieve glycemic control according to any of the preceding paragraphs where the combination is capable of causing the subject to have less nocturnal hypoglycemia compared to an equivalent dose of IGlar.

5. A combination to achieve glycemic control according to any of the preceding paragraphs where the combination is capable of causing the subject to have less total hypoglycemia compared to an equivalent dose of IGlar.

6. A combination to achieve glycemic control according to any of the preceding paragraphs where said subject suffers from type II diabetes.

7. A combination to achieve glycemic control according to any of the preceding paragraphs wherein said first insulin type compound is present in said combination in an amount greater than the second insulin type compound.

8. A combination to achieve glycemic control according to any of the preceding paragraphs wherein said first insulin-type compound is present in said combination in a molar amount of more than about 55%, or more than about 60%, or more than about 65%, or more than about 70%, or more than about 75% or more than about 80% based on the molar amount of the second insulin-like compound in said combination.

9. A combination to achieve glycemic control according to any of the preceding paragraphs wherein said first insulin-type compound is present in said combination in a molar amount of about 70% or more, based on the molar amount of the second insulin type compound in said combination.

10. A combination to achieve glycemic control according to any of the preceding paragraphs wherein said first insulin-type compound is present in said combination in a molar amount of about 70%, based on the molar amount of the second compound insulin type in said combination.

11. A combination to achieve glycemic control according to any of the preceding paragraphs wherein said first insulin-type compound is present in said combination in a molar amount of approximately 85%, based on the molar amount of the second compound insulin type in said combination.

12. A combination to achieve glycemic control according to any of the preceding paragraphs wherein said second insulin-type compound is present in said combination in a molar amount of less than about 55%, or less than about 40%, or less than about 35%, or less than about 30%, or less than about 25%, or less than about 20% based on the molar amount of the first insulin-like compound in said combination.

13. A combination to achieve glycemic control according to any of the preceding paragraphs wherein said second insulin-type compound is present in the combination in a molar amount of about 30% or less, based on the molar amount of the first insulin type compound in said combination.

14. A combination to achieve glycemic control according to any of the preceding paragraphs wherein said second insulin-type compound is present in the combination in a molar amount of about 15%, based on the molar amount of the first compound insulin type in said combination. 15. A combination to achieve glycemic control according to any of the preceding paragraphs wherein said second insulin-type compound is present in the combination in a molar amount of about 30%, based on the molar amount of the first compound insulin type in said combination. 16. A combination to achieve glycemic control according to any of the preceding paragraphs wherein said combination comprises a pharmaceutically acceptable carrier and / or vehicle and / or a diluent and / or excipient.

17. A combination to achieve glycemic control according to any of the preceding paragraphs wherein said first insulin type compound and the second insulin type compound are in the same formulation.

18. A combination to achieve glycemic control in accordance with any of the preceding paragraphs wherein said beneficial glycemic control by said combination comprises decreasing HbA ¹ c levels in said subject at approximately 7 % or less after administration of said combination in the largest meal of the day in a period of approximately 26 weeks.

19. A combination to achieve glycemic control according to any of the preceding paragraphs wherein said beneficial glycemic control by said combination comprises decreasing HbA ¹ c levels in said subject to approximately 7% or less after administration of said combination in the largest meal of the day in a period of less than approximately 26 weeks.

20. The use of a combination as defined in any of the preceding paragraphs in the preparation of a medicament to achieve beneficial glycemic control in a subject.

21. A use according to paragraph 20 wherein said subject suffers from type II diabetes.

22. A combination or method or use to achieve glycemic control according to any of the preceding paragraphs wherein said combination is administered in an amount of approximately 0.4 U / kg. Abbreviations

The following abbreviations have been used in the description and examples:

Aad: Alpha-aminoadipic acid (homoglutamic acid)

Bzl: Bn: benzyl

DIEA: N, N-diisopropylethylamine

DMF: N, N-dimethylformamide

IDA: Iminodiacetic Acid

Sar: Sarcosine (N-methylglycine)

tBu: tert-butyl

TSTU: O- (N-succinimidyl) -1,1,3,3-tetramethyluronium tetrafluoroborate

THF: Tetrahydrofuran

EtOAc: Ethyl Acetate

DIPEA: Diisopropylethylamine

HOAt: 1-Hydroxy-7-azabenzotriazole

ASD: triethylamine

Su: succinimidil = 2,5-dioxo-pyrrolidin-1-yl

TFA: trifluoroacetic acid

DCM: dichloromethane

DMSO: dimethylsulfoxide

TLC: Thin Layer Chromatography

RT: room temperature

hGlu: homoglutamic acid

a-Asp: Form L of -HNCH (CO-) CH ² COOH

P-Asp: Form L of -HNCH (COOH) CH ² CO-a-Glu: Form L of -HNCH (CO-) CH ² CH ² COOH

Y-Glu: Form L of -HNCH (COOH) CH ² CH ² CO-a-hGlu: Form L of -HNCH (CO-) CH ² CH ² CH ² COOH

6-hGlu: Form L of -HNCH (COOH) CH ² CH ² CH ² CO-P-Ala: -NH-CH ² -CH ² -COOH

Sar: sarcosine (N-methylglycine)

Degludec: human insulin N ^EB29 - (N ^a - (HOOC (CH ² ) 14CO) - ^and -L-Glu) des (B30)

AspB28: human insulin analogue that has Asp in position B28

IDegAsp: combination of human insulin N ^EB29 - (N ^a - (HOOC (CH ² ) 14CO) - ^and -L-Glu) des (B30) and AspB28 DegludecPlus: combination of human insulin N ^EB29 - (N ^a - (HOOC ( CH ² ) 14CO) - ^and -L-Glu) des (B30) and AspB28 OAD: oral antidiabetic

The present invention is further illustrated by the following examples, which, however, should not be construed as limiting the scope of protection.

EXAMPLES

Introduction

To investigate the clinical effect of any insulin product, a clinical trial should be performed under conditions that represent the mode of use of the invention. Clinical trials investigating compounds for the treatment of diabetes for the purpose of obtaining approval and registration are subject to the guidelines provided by the regional authorities (the European guideline serves as an example: Note for the Guide on clinical investigations of medicinal products in the treatment of diabetes mellitus, EMEA, London, 2002). An example of an insulin-like product with a prolonged duration of action is the human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) corresponding to the human insulin N ^EB29 - (Na- (HOOC (CH ² ) ^{i 4} CO) - ^and -L-Glu) des (B30) (Example 1 in WO 2005/012347). Sometimes this compound is called human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30).

In the Examples of the present invention (Clinical Examples 4 and 5), the combination of human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) and lAsp was investigated with respect to the clinical effect with administration to different meal hours

It was surprisingly discovered that a beneficial glycemic control (as defined in the present description) can be achieved by administering the combination of the present invention at the same time or around the time of the largest meal, typically from a little before, such as about 30 minutes before, or until a little later, such as about 30 minutes later.

Preparative Examples 1 to 37 are derived from EP2275439 and are presented for informational purposes as they provide background information related to the present invention.

Clinical Examples 1 to 4 are derived from PCT / EP2011 / 068870 and are presented for informational purposes as they provide background information related to the present invention.

In the Examples of Pharmacological Studies, trials (I), (II) and (III) are presented. These assays are useful for determining properties about insulin type compounds. The results are presented for some insulin type compounds that are suitable for use as the first insulin type compounds in the combination of the present invention.

In the Example of Hydrophobicity Studies, hydrophobicity data are presented for some insulin-like compounds that are suitable for use as the first insulin-like compounds in the combination of the present invention.

Preparative examples

Preparative Example 1

Synthesis of human insulin N ^EB29 - (N ^a - (HOOC (CH ² ) ^{and 4} CO) - ^and -Glu) des (B30)

A method of preparing this compound is described in example 1 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 2

Synthesis of human insulin N ^g B29- (N ^a - (HOOC (CH2) 16CO) - ^Y -Glu) des (B30)

A method of preparing this compound is described in example 2 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 3

Synthesis of human insulin N ^EB29 - (N ^a - (HOOC (CH ² ) ^{and 6} CO) - ^and -Glu-N- ( ^and -Glu)) des (B30)

A method of preparing this compound is described in example 3 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 4

Synthesis of human insulin N ^EB29 - (N ^a - (HOOC (CH ² ) ^{and 4} CO) - ^and -L-Glu) des (B30)

A method of preparing this compound is described in example 4 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 5

Synthesis of human insulin N ^EB29 - (N ^a - (HOOC (CH ² ) ^{and 6} CO) - ^and -L-Glu) des (B30)

A method of preparing this compound is described in example 5 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 6

Synthesis of human insulin N ^EB29 - (N- (L-Asp-OC (CH ² ) ^{and 6} CO) - ^and -L-Glu) des (B30)

A method of preparing this compound is described in example 6 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 7

Synthesis of human insulin N ^EB29 - (N- (L-Glu-OC (CH ² ) ^{and 4} CO- ^and -L-Glu) des (B30)

A method of preparing this compound is described in example 7 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 8

Synthesis of human insulin N ^EB29 - (N- (L-Glu-OC (CH ² ) ^{and 4} CO-) des (B30)

A method of preparing this compound is described in example 8 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 9

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ^{and 6} CO-aL-Glu) -N- (PL-Asp) des (B30)

A method of preparing this compound is described in example 9 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 10

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ^{and 5} CO- ^and -L-Glu) des (B30)

A method of preparing this compound is described in example 10 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 11

Synthesis of human insulin N ^EB29 - (N- (Gly-OC (CH ² ) ^1st CO- ^and -L-Glu) des (B30)

A method of preparing this compound is described in example 11 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 12

Synthesis of human insulin N ^EB29 - (N- (L-Sar-OC (CH ² ) ¹³ CO- ^and -L-Glu) des (B30)

A method of preparing this compound is described in example 12 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 13

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ¹⁶ CO-aL-Asp) -N- (PL-Asp) des (B30)

A method of preparing this compound is described in example 13 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 14

Synthesis of human insulin N ^EB29 - (N- (Gly-OC (CH ² ) ¹⁴ CO- ^and -L-Glu) des (B30)

A method of preparing this compound is described in example 14 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 15

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ¹⁴ CO-pL-Asp) des (B30)

A method of preparing this compound is described in example 15 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 16

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ¹⁶ CO-pL-Asp) des (B30)

A method of preparing this compound is described in example 16 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 17

Synthesis of human insulin N ^EB29 - (N- (Gly-OC (CH ² ) ¹⁶ CO- ^and -L-Glu) des (B30)

A method of preparing this compound is described in example 17 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 18

Synthesis of human insulin N ^EB29 - (N- (HOOC (CH ² ) ¹⁴ CO- ^e -L-LysCO-) des (B30)

A method of preparing this compound is described in example 18 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 19

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ¹⁶ CO-aL-Glu) des (B30)

A method of preparing this compound is described in example 19 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 20

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ^{and 6} CO-aL-Asp) des (B30)

A method of preparing this compound is described in example 20 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 21

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ¹⁵ CO-pL-Asp) des (B30)

A method of preparing this compound is described in example 21 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 22

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ¹⁶ CO-yD-Glu) des (B30)

A method of preparing this compound is described in example 22 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 23

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ¹⁶ CO- ⁸ -L-Aad) des (B30)

A method of preparing this compound is described in example 23 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 24

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ¹³ CO-pL-Asp) des (B30)

A method of preparing this compound is described in example 24 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 25

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ^rs CO-pL-Glu) des (B30)

A method of preparing this compound is described in example 25 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 26

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ¹⁴ CO-pD-Asp) des (B30)

A method of preparing this compound is described in example 26 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 27

Synthesis of human insulin N ^EB29 - (N-HOOC (CH ² ) ¹⁶ CO-pD-Asp) des (B30)

A method of preparing this compound is described in example 27 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 28

Synthesis of human insulin N ^eB29 - (N-HOOC (CH ² > ^m CO-IDA) des (B30)

A method of preparing this compound is described in example 28 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 29

Synthesis of human insulin N ^EB29 - [N- (HOOC (CH ² ) ¹⁶ CO) -N- (carboxymethyl) -p-Ala] of

A method of preparing this compound is described in example 29 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 30

Synthesis of human insulin N ^EB29 - [N- (HOOC (CH ² ) ^{and 6} CO) -N- (2-carboxyethyl) -Gly] des (B30)

A method of preparing this compound is described in example 30 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 31

Synthesis of human insulin N ^EB29 - [N- (HOOC (CH ² ) ^{and 4} CO) -N- (carboxyethyl) -Gly] des (B30)

A method of preparing this compound is described in example 31 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 32

Synthesis of human insulin N ^EB29 - [N- (HOOC (CH ² ) ¹⁴ CO) -N- (carboxymethyl) -p-Ala] des (B30)

A method of preparing this compound is described in example 32 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 33

Synthesis of human insulin N ^EB29 - [N ^a - (HOOC (CH ² ) ⁿ ) NHCO (CH ² ) ³ CO) - ^and -L-Glu] des (B30)

A method of preparing this compound is described in example 33 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 34

Synthesis of human insulin N ^EB29 - [Na- (HOOC (CH ² ) ⁿ ) NHCO (CH ² ) ² CO) - ^and -L-Glu] des (B30)

A method of preparing this compound is described in example 34 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 35

Synthesis of human insulin N ^EB29 - [Na- (HOOC (CH ² ) ¹⁶ CO)] - Gly- ^and -L-Glu des (B30)

A method of preparing this compound is described in example 35 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 36

Synthesis of human insulin N ^EB29 - [N- (HOOC (CH ² ) ¹⁴ CO) -N- (2-carboxyethyl) -p-Ala] des B30

A method of preparing this compound is described in example 36 of patent application WO2005 / 012347, which is incorporated herein by reference.

Preparative Example 37

Synthesis of human insulin N ^EB2 9- [N- (HOOC (CH ² ) ¹⁶ CO) -N- (2-carboxyethyl) -p-Ala] des B30

A method of preparing this compound is described in example 37 of patent application WO2005 / 012347, which is incorporated herein by reference.

Pharmacological studies

Essay (I)

Insulin receptor binding of insulin derivatives of the invention

The affinity of the insulin-like compounds for use in the present invention by the human insulin receptor was determined by a microtiter plate antibody capture assay with SPA test (proximity scintillation assay). The SPA-PVT antibody binding microspheres, anti-mouse reagent (Amersham Biosciences, Catalog No. PRNQ0017) were mixed with 25 ml of binding buffer (100 mm HEPES pH 7.8; 100 mm sodium chloride, 10 mM MgSO4, 0.025% Tween-20). The mixture of reagents for a single Packard Optiplate plate (Packard No. 6005190) is composed of 2.4 ml of a purified recombinant human insulin receptor diluted 1: 5000 - exon 11, an amount of a human insulin stock solution in A14 Tyr with [125I] corresponding to 5000 cpm per 100 ml of reagent mixture, 12 ml of a 1: 1000 dilution of F12 antibody, 3 ml of SPA microspheres and binding buffer for a total of 12 ml. A total of 100 ml was then added and a series of dilutions were made from suitable samples. Then 100 ml of reagent mixture was added to the dilution series and the samples were incubated for 16 hours while stirring gently. The phases were then separated by centrifugation for 1 min and the plates were counted in a Topcounter instrument. Binding data were adjusted using the non-linear regression algorithm in the GraphPad Prism 2.01 program (GraphPad Software, San Diego, CA).

Preparation of monoclonal antibodies mmlR

Specific antibodies (F12) were produced by monoclonal technique: RBF mice were immunized by subcutaneous injection of 50 mg of purified mlR in FCA followed by two injections with 20 mg of mlR in FIA. Mice with high response were intravenously boosted with 25 mg of mlR and spleens were harvested after 3 days. Splenic cells were fused with the Myeloma Fox cell line (Kohler, G & Milstein C. (1976), European J. Immunology, 6: 511-19; Taggart RT et al. (1983), Science 219: 1228-30) . Supernatants were screened for antibody production in a specific mlR ELISA. Positive wells were cloned and tested in Western blotting.

Table 1

Essay (II)

Potency of the insulin derivatives of the invention with respect to human insulin

Male Sprague Dawley rats weighing 238-383 g were used on the experimental day for the caliper experiment. Rats had free access to food under controlled environmental conditions and were fasted overnight (after 3 pm) before the clamp experiment.

Experimental protocol

The rats were acclimatized in animal facilities for at least 1 week before the surgical procedure. Approximately 1 week before the clamp experiment, Tygon catheters were inserted under anesthesia with halothane in the jugular vein (for infusion) and the carotid artery (for blood sampling) and externalized and fixed in the back of the neck. Veterinary streptocillin was provided to the rats (Boehringer Ingelheim; 0.15 ml / rat, i.m.) after surgery and these were placed in an animal care unit (25 ° C) during the recovery period. To obtain analgesia, Anorphin (0.06 mg / rat, sc) was administered during anesthesia and Rimadyl (1.5 mg / kg, sc) was administered after complete recovery of anesthesia (2-3 h) and again once a day for 2 days.

The clamp technique used was adapted from (1). At 7 am on the experimental day the rats that fasted overnight (after 3 pm the previous day) were weighed and connected to the sampling syringes and infusion system (Harvard 22 Basic pumps, Harvard, and Perfectum hypodermic glass syringe, Aldrich) and then placed in individual holding cages where they rested for approx. 45 min before the start of the experiment. The rats were able to move freely in their usual bed throughout the experiment and had free access to drinking water. After a baseline period of 30 min during which plasma glucose levels were measured at 10 min intervals, the insulin derivative to be tested and human insulin (a dose level per rat, n = 6-7 per level of dose) were infused (iv) at a constant rate for 300 min. Plasma glucose levels were measured at 10 min intervals and the 20% aqueous glucose infusion was adjusted accordingly to maintain euglycemia. Samples of resuspended erythrocytes from each rat were combined and returned in volumes of approximately © ml by the carotid catheter.

On each experimental day, samples of the solutions of the individual insulin derivatives to be tested and the human insulin solution were taken before and at the end of the clamp experiments and the concentrations of the peptides were confirmed by HPLC. Plasma concentrations of rat C-peptide and insulin as well as the insulin derivative to be tested and human insulin were measured at relevant time points before and at the end of the studies. The rats were sacrificed at the end of the experiment with the use of an overdose of pentobarbital.

Test compounds and doses: Insulin type compounds for use in the present invention to be tested were diluted from a stock solution containing 97 mM insulin derivative in 5 mM phosphate pH 7.7. The final concentration in the ready-to-use solution was 0.45 mM insulin derivative, 5 mM phosphate, 100 mM sodium chloride, 0.007% polysorbate 20. The pH was 7.7 and the infusion rate i.v. It was 15 and 20 pmolmin'1 kg'1.

A stock solution of human insulin that was used as a reference compound was formulated in a similar medium and infused via i.v. at 6, 15 or 30 pmolmin'1 kg'1.

Both stock solutions were stored at -20 ° C and thawed overnight at 4 ° C before use. The solutions were gently turned several times 15 min before transferring them to the infusion syringes.

Table 2

Essay (III)

Determination in pigs of T50% of the insulin derivatives of the invention

T ⁵⁰ % is the time in which 50% of an injected amount of the derivative labeled in A14 Tyr with [125I] of an insulin-like compound to be tested for use in the present invention has disappeared from the injection site as measured with a radiation meter and external.

The principles of laboratory animal care were followed, non-diabetic female pigs LYYD, free of specific pathogens, descendants of the Danish Landrace, Yorkshire and Duroc (Holmenlund, Haarloev, Denmark) cross-breeding were used for pharmacokinetic and pharmacodynamic studies. The pigs were conscious, they were 4-5 months old and weighing 70-95 kg. The animals were fasted overnight for I8 h before the experiment.

Formulated preparations of insulin-like compounds for use in the present invention labeled in TyrA14 with 125I were injected by s.c. in pigs as described above (Ribel, U., Jorgensen, K, Brange, J, and Henriksen, U. The pig as a model for subcutaneous insulin absorption in man. Serrano-Rios, M and Lefébvre, PJ 891-896 1985. Amsterdam; New York; Oxford, Elsevier Science Publishers. 1985 (Congress Act)).

At the beginning of the experiments a 60 nmol dose of insulin-like compounds for use in the present invention (test compound) and a 60 nmol dose of insulin detemir (both labeled with 125I in Tyr A14) were injected in two separate sites on the neck of each pig.

The disappearance of the radioactive label from the injection site sc. was monitored with the use of a modification of the traditional external gamma radiation counting method (Ribel, U. Subcutaneous absorption of insulin analogues. Berger, M. and Gries, FA 70-77 (1993). Stuttgart; New York, Georg Thime Verlag (Minutes of Congress). With this modified method it was possible to continuously measure the disappearance of the radioactivity of a subcutaneous reservoir for several days with the use of a portable wireless device (Scancys Laboratorieteknik, V ^ rl ⁰ se, DK-3500, Denmark). The measurements were made at intervals of 1 min, and the counted values were corrected for background activity.

In Table 3, the "test / detemir" column shows the T50% found for each of the compounds tested ("test") and the T50% found for insulin detemir ("detemir") in the same experiment.

Table 3

Hydrophobicity studies

Hydrophobicity data of the insulin type compounds of the invention.

The hydrophobicity (hydrophobic index) of insulin-like compounds with respect to human insulin, k'rel, was measured on a Lichrosorb RP18 HPLC column (5 mm, 250x4 mm) by isocratic elution at 40 ° C with the use of mixtures from A) 0.1 M sodium phosphate buffer, pH 7.3, containing 10% acetonitrile, and B) 50% acetonitrile in water as eluents. Elution was monitored by monitoring the UV absorption of the eluate at 214 nm. The downtime, t ⁰ , was found by injecting 0.1 mM sodium nitrate. The retention time for human insulin, thumana, was adjusted to at least 2t0 by varying the relationship between solutions A and B. k 'rel— (tderivadoto) / (thumana-to). The k'rel values found for a series of insulin derivatives according to the invention are provided in Table 4.

Table 4

Clinical studies - clinical examples 1-4

Clinical example 1

Clamp of equilibrium status - Investigation of the activity profile and duration of action of the human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30).

Methodology

The research was conducted as a two-period, single-blind, double-blind, randomized, cross ^- sectional trial to compare the activity profiles of human insulin LysB29 (N ^e- hexadecandioyl- ^and -Glu) des (B30) and insulin glargine (IGlar ) in subjects with type 1 diabetes.

The subjects were randomized to different administration sequences of multiple subcutaneous doses (sc) once daily of human insulin LysB29 (N ^e- hexadecandioyl- ^and -Glu) des (B30) and IGlar. The doses were 0.57 U / kg or 0.85 U / kg of human insulin LysB29 (N ^e -hexadecandioyl- ^and -Glu) des (B30) and 0.4 U / kg or 0.6 U / kg IGlar . Subjects were treated for 8 days for each dosage period. There was a period of pharmacological rest that lasted 10-20 days between the two dosage periods.

On the last day of each dosing period, the subjects received a controlled intravenous infusion of soluble human glucose and insulin (Actrapid®) for 8-4 hours prior to the administration of the test drug to keep the blood glucose concentration stable at a level 100 mg / dL (5.5 mmol / L), that is, an euglycemic clamp was started with a target blood glucose level of 100 mg / dL (5.5 mmol / L). The euglycemic clamp was terminated at 42 hours after dosing but earlier if blood glucose levels increased to concentrations above 200 mg / dl (11.1 mmol / L) without glucose infusion during the last 30 min.

Blood samples for the measurement of human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) serum / IGlar in plasma, and blood glucose were taken before dosing and up to 146 hours after dosing .

Standard safety assessments were performed.

Number of subjects

21 subjects completed the trial.

Diagnosis and main criteria for inclusion

Men or women with type 1 diabetes (> 12 months) aged 18-69 years (included), with glycosylated hemoglobin (HbA ¹ c) <10% and treated normally with insulin (<1.2 U / kg / day ). Subjects must have been treated with insulin> 12 months and have a body mass index (BMI) of 18-28 kg / m2 (included) and a fasting C-peptide <0.3 nmol / L.

Test product, dose and mode of administration

Multiple doses of 0.57 U / kg or 0.85 U / kg of human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30), 600 nmol / ml, human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30), supplied in 3 ml FlexPen® cartridge (100 DU / ml) with the use of NovoFine® 30G needles, 8 mm.

Treatment duration

Multiple doses of human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) and IGlar were administered with the use of two different dosage periods of 8 days duration (optionally 1-5 days) at intervals of 10 -20 days.

Reference therapy, dose and mode of administration

Multiple doses (0.4 U / lg or 0.6 U / kg) of IGlar (Lantus®), 100 lU / ml, 600 nmol / ml supplied in 3.0 ml with 3 ml Optiset® cartridges and injected via sc on the thigh with the use of PenFine® 31G, 8 mm.

Evaluation criteria - Effectiveness

Pharmacodynamics:

- Glucose infusion rate (GIR) during a 42-hour euglycemic forceps during the 8th and last day of dosing.

- Blood glucose concentrations.

Pharmacokinetics:

- Concentrations of human insulin LysB29 (N ^e -hexadecandioyl- ^and -Glu) des (B30) serum / IGlar in plasma for 144 hours after a single dose of human insulin LysB29 (N ^e -hexadecandioyl- ^and -Glu) des (B30 ) or IGlar. Main valuation criteria:

- AUCGIR (0-24h), the area under the curve (AUC) of the GIR curve from 0 to 24 hours

Fundamental secondary assessment criteria:

- Blood glucose level during the euglycemic clamp period

- Pharmacokinetics (tmax, terminal half-life)

Demography of the trial population

The 35 male and 7 female subjects with type 1 diabetes had an average age of 40 years, respectively, the average weight was 75 kg, the average HbA1c was 7.8%, and they had a mean duration of diabetes of 21 years. Fundamental results

- AUCGIR (0-24h) for human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30), did not capture the total insulin action, since pronounced levels of GIR were still present at the time point of 24 hours. GIR levels at 24 hours were approximately 2.0 and 3.0 mg / kg / min for human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) after the low or high dose, respectively . The corresponding values for insulin glargine were approximately 0.8 and 1.8 mg / kg / min.

- The mean GIRmax was higher for IGlar (5.6 and 4.2 mg / kg / min) than for human insulin LysB29 (N ^e- hexadecandioyl- ^and -Glu) des (B30) (4.68 and 4.02 mg / kg / min, respectively), after the highest dose but GIRmax was the same after the lowest doses (3.07 mg / kg / min).

- The average GIR time to GIRmax was longer for human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) (13.2 hours and 6.1 for low and high doses respectively) than for IGlar (5 , 0 and 4.1 hours for low and high doses, respectively)

- The mean peak with respect to the lower value ranges was lower for human insulin LysB29 (N ^e -hexadecandioyl- ^and -Glu) des (B30) than after insulin glargine. Values were 1.0 and 0.7 mg / kg / min after the low and high dose, respectively. For insulin glargine the corresponding values were 1.6 and 1.1 mg / kg / min.

- The average time to loss of glucose control was longer for human insulin LysB29 (N ^e -hexadecandioyl- ^and -Glu) des (B30) than for glargine at both dose levels. This occurred after approximately 40 hours after the low dose of human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) and no significant loss of glucose control was observed (defined as an increase in glucose in blood of more than about 10 mg / dl) at the time point of 42 hours after the high dose of human insulin LysB29 (N ^e -hexadecandioyl- ^and -Glu) des (B30). After dosing insulin glargine there was a loss of glucose control after approximately 24 hours and 26 hours when the low and high dose was administered, respectively.

- The average time to maximum concentration (Cmax) was shorter for insulin glargine than for human insulin LysB29 (N £ -hexadecandioyl- ^and -Glu) des (B30). For insulin glargine the values were 7.2 and 6.4 hours while the values for human insulin LysB29 (N £ -hexadecandioyl- ^and -Glu) des (B30) were 9.2 and 10.1 hours after intermediate and high dose, respectively.

- The mean terminal half-life was 25.2 hours (95% CI 23 to 28 hours) for human insulin LysB29 (N £ -hexadecandioyl- ^and -Glu) des (B30) and 13.9 hours (95% CI 13 to 15) for IGlar.

Fundamental Security Results

In general, the administration of multiple doses of human insulin LysB29 (N ^e- hexadecandioyl- ^and -Glu) des (B30) and IGlar, respectively, was well tolerated in subjects with type 1 diabetes.

Fundamental Conclusions

The human insulin LysB29 (N ^e -hexadecandioyl- ^and -Glu) des (B30) appeared to have a flatter and longer action profile and a longer duration of action compared to IGlar as evidenced by the characteristics of the GIR profile . The data show that human insulin LysB29 (N ^e- hexadecandioyl- ^and -Glu) des (B30) has a GIRmax less than a comparable dose, a longer time to GIRmax at both dose levels and a smaller peak with respect to the range of values Lower. The duration of action of the human insulin LysB29 (N ^e -hexadecandioyl- ^and -Glu) des (B30) in the present circumstances was approximately 40 hours or more. The data shows that human insulin LysB29 (N ^e -hexadecandioyl- ^and -Glu) des (B30) has the ability to control blood glucose for a longer period. The conclusions based on the activity data (pharmacodynamics) are supported by the pharmacokinetic data (longer time to Cmax and higher average terminal half-life).

Clinical example 2

Investigation of the clinical effect of human insulin LysB29 (N ^e -hexadecandioyl- ^and -Glu) des (B30) administered once daily with varying intervals.

Methodological elements and fundamental results

The trial was designed to assess the viability, efficacy, safety and tolerability of human insulin LysB29 (N ^e -hexadecandioyl- ^and -Glu) des (B30) (600 nmol / ml) for the treatment of subjects with type 2 diabetes once daily with variable injection intervals (flexible injection). The treatment consisted of the administration of insulin with or without metformin and / or sulfonylurea and / or pioglitazone, in subjects with type 2 diabetes who failed treatment with insulin or treatment with oral antidiabetics (OAD) or the combination of treatment with insulin and OAD. The viability of the variable injection intervals (i.e., flexible injection) with human insulin LysB29 (Nehexadecandioyl-y-Glu) des (B30) was investigated by having the participating subjects injected in the morning (between waking up and breakfast) on Mondays, Wednesdays and Fridays, while Tuesdays, Thursdays, Saturdays and Sundays were injected at night (between nighttime meal and bedtime) as shown in Table 5.

Table 5

Main goal

To assess glucose control with respect to HbA1c after 26 weeks of treatment with human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) once daily with varying injection intervals (flexible injection), insulin Human LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) once a day provided with the night meal or insulin glargine once a day provided at the same time each day (according to the approved label), all in combination with metformin and / or sulfonylurea and / or pioglitazone in subjects with type 2 diabetes who failed treatment with insulin or treatment with oral antidiabetics (OAD) or the combination of treatment with insulin and OAD.

Materials and methods

The trial was conducted in subjects with type 2 diabetes, previously treated with one or more of the oral antidiabetic agents: metformin, sulfonylurea, pioglitazone or with any treatment with basal insulin or the combination of the specified OADs and any treatment with basal insulin. At the time of randomization, subjects continued their treatment with OAD (if any), while adding, initiating or switching to basal insulin human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) once a day with variable injection intervals or human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) once a day with the night meal or insulin glargine once a day at the same time each day (from agreement with the label).

[0226] A total of 687 subjects with type 2 diabetes, 56 years of age, average diabetes duration of 10.6 years, average BMI of 29.6 kg / m2, average FPG of 8.9 mmol / L, and mean HbA ¹ c of 8.4% were randomized (1: 1: 1) to receive human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) once daily provided with varying injection intervals (229 subjects) or human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) once a day provided with the night meal (228 subjects) or insulin glargine once a day (230 subjects), alone or in combination with metformin and / or SU and / or pioglitazone, during a treatment period of 26 weeks.

Specific combinations of OAD and insulin treatment before randomization can be seen in Table 12.

The types of insulin used before randomization to the insulin products of the study are shown in Table 6.

Table 7 shows the OADs used before and during the experiment.

Table 6 - Insulin at the time of screening - Summary - Complete analysis group

IDeg OD FF IDeg OD IGlar OD Total N (%) N (%) N (%) N (%) Number of subjects 229 228 230 687 Baseline insulin 96 (41.9) 96 (42.1) 96 (41.7 ) 288 (41.9) IDet 19 (8.3) 21 (9.2) 21 (9.1) 61 (8.9) IGlar 43 (18.8) 41 (18.0) 30 (13.0 ) 114 (16.6) Insulin NPH 34 (14.8) 34 (14.9) 45 (19.6) 113 (16.4) Bolus insulin 1 (0.4) 1 (0.1) IAsp 1 (0.4) 1 (0.1) Premix 1 (0.4) 1 (0.1) N: Number of subjects

%: Proportion of subjects

Subjects can use more than one type of insulin within each group

NPH insulin: Hagedorn neutral protamine

Table 7 - Type of OAD treatment at the beginning and end of the trial

IDeg IGlar

Start End of test Start End of test Test (weeks) N (%) N (%) N (%) N (%) 3668 (26) FF

Biguanide 207 (90.4) 206 (90.0) 211 (91.7) 212 (92.2) Metformin 207 (90.4) 206 (90.0) 211 (91.7) 212 (92.2)

DPP-4 inhibitor 1 (0.4) 1 (0.4) Sitagliptin 1 (0.4) 1 (0.4) Glinide 10 (4.4) 10 (4.4) 8 (3.5) 7 (3.0) Repaglinide 10 (4.4) 10 (4.4) 8 (3.5) 7 (3.0) Sulfonylurea 159 (69.4) 156 (68.1) 157 (68.3) 155 (67.4) Glibenclamide 55 (24.0) 54 (23.6) 57 (24.8) 55 (23.9) Gliclazide 43 (18.8) 41 (17.9) 39 (17.0) 39 (17.0) Glimepiride 56 (24.5) 56 (24.5) 54 (23.5) 54 (23.5) Glipizide 5 (2.2) 5 (2.2) 7 (3.0) 7 (3.0)

Thiazolidinedione 13 (5.7) 12 (5.2) 17 (7.4) 16 (7.0) Pioglitazone 13 (5.7) 12 (5.2) 16 (7.0) 15 (6.5) Rosiglitazone 1 (0.4) 1 (0.4)

3668 (26)

Biguanide 205 (89.9) 205 (89.9)

Metformin 205 (89.9) 205 (89.9)

Glinide 14 (6.1) 13 (5.7)

Repaglinide 14 (6.1) 13 (5.7)

Sulfonylurea 136 (59.6) 136 (59.6)

Glibenclamide 51 (22.4) 50 (21.9)

Gliclazide 37 (16.2) 37 (16.2)

Glimepiride 44 (19.3) 44 (19.3)

Glipizide 4 (1.8) 4 (1.8)

Glyburide 1 (0.4)

Thiazolidinedione 17 (7.5) 17 (7.5)

Glinide 14 (6.1) 13 (5.7)

Repaglinide 14 (6.1) 13 (5.7)

Sulfonylurea 136 (59.6) 136 (59.6)

Gliclazide 37 (16.2) 37 (16.2)

Glimepiride 44 (19.3) 44 (19.3)

Glipizide 4 (1.8) 4 (1.8)

Glyburide 1 (0.4)

Thiazolidinedione 17 (7.5) 17 (7.5)

Pioglitazone 17 (7.5) 17 (7.5)

Ideg - human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30)

IGlar - insulin glargine,

FF: Fixed Injection

End of trial: the last trial visit of a subject excluding the follow-up visit

IGlar (3579, 3672, 3586, 3668) and Sita (3580)

A subject can be treated with more than one OAD

Efficacy results

HbA1c

HbA1c at the end of the test and the change in HbA1c with respect to the initial value at the end of the test are given in Table 8.

The confidence interval of the contrast between treatments when comparing human insulin LysB29 (N ^e- hexadecandioyl- ^and -Glu) des (B30) provided with varying injection intervals with the other treatment groups was within the non-inferiority limit 0, 4), which is within the non-inferiority limit accepted by the FDA (Guide for the Diabetes Mellitus industry: Development of drugs and therapeutic biological products for treatment and prevention, Preliminary guide, Department of health and human services of the Administration Center of food and drugs for drug research and evaluation (CDER) February 2008) Therefore, the group that received human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) provided with variable injection intervals it was similar to the other two treatment groups with respect to the mean changes in HbA ¹ c with respect to the initial value at the end of the treatment

(Table 8 and Table 9).

Table 8

Table 9

Hypoglycemia

Only six severe hypoglycemic events were reported during the trial cf. Table 10

Table 10

Insulin dose

Table 11

Conclusions

It was surprisingly found that with the use of human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30), which has a prolonged duration of action and a profile of activity without peaks and stable, subjects with type 2 diabetes they were sufficiently regulated with once-daily dosing administered with varying injection intervals alone or in combination with OAD treatment.

In subjects with type 2 diabetes who fail treatment with OAD and / or insulin, a 26-week treatment with human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) provided flexibly (with injection intervals variables) with or without metformin and / or sulfonylurea and / or pioglitazone, resulted in comparable glycemic control (not lower) and an incidence of hypoglycemic episodes comparable to that observed for human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) provided with the night meal and glycemic control and the incidence of hypoglycemic episodes observed for insulin glargine provided once a day at the same time each day (according to the approved label).

Clinical example 3

Investigation of the clinical effect of human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) administered once daily with varying intervals.

Methodological elements and fundamental results

The trial was designed to assess the viability, efficacy, safety and tolerability of human insulin LysB29 (N ^e -hexadecandioyl- ^and -Glu) des (B30) (600 nmol / ml) for the treatment of subjects with type 1 diabetes once daily with variable injection intervals (flexible injection). The treatment consisted of the administration of basal insulin human insulin (LysB29 (N ^g- hexadecandioyl- ^and -Glu) des (B30) or insulin glargine) in combination with separate injections of bolus insulin (human insulin AspB28). The viability of the variable injection intervals (i.e., flexible injection) with human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) was investigated by causing the participating subjects to be injected in the morning (between waking and breakfast) on Mondays, Wednesdays and Fridays, while Tuesdays, Thursdays, Saturdays and Sundays were injected at night (between nighttime food and bedtime) as shown in Table 12.

Table 12

Main goal

To assess glucose control with respect to HbA1c after 26 weeks of treatment with human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) once daily with varying injection intervals (flexible injection), insulin Human LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) once a day provided with the night meal or insulin glargine once a day provided at the same time each day (according to the approved label), all in combination with human insulin AspB28 in subjects with type 1 diabetes.

Materials and methods

The trial was conducted in subjects with type 1 diabetes, previously treated with insulin for at least 12 months. At the time of randomization, subjects switched to basal insulin human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) once daily with variable injection intervals or human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) once a day with night food or insulin glargine once a day at the same time each day (according to the label) all in combination with human insulin AspB28.

A total of 490 subjects with type 1 diabetes, 56 years old, average diabetes duration of 10.6 years, average BMI of 29.6 kg / m2, average FPG of 8.9 mmol / L, and HbA ¹ c average of 8.4% were randomized (1: 1: 1) to receive human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) once daily provided with variable injection intervals (164 subjects) or human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) once a day provided with the night meal (165 subjects) or insulin glargine once a day, provided according to the label, (161 subjects) during a treatment period of 26 weeks.

Specific insulin treatment before randomization can be seen in Table 6. The types of insulin used before randomization to the study's insulin products are shown in Table 7.

Efficacy results

HbA1c

HbA1c at the end of the test and the change in HbA1c with respect to the initial value at the end of the test are given in Table 13. The confidence interval of the contrast between treatments when comparing human insulin LysB29 (N ^e -hexadecandioyl- ^and - Glu) des (B30) provided with variable injection intervals with the other treatment groups was within the non-inferiority limit of 0.4 (Table 14).

Table 13

Table 14

Table 15 shows the hypoglycemic events reported during the trial.

Table 15

Insulin dose

Table 16

Conclusions

It was surprisingly discovered that with the use of human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30), which has a prolonged duration of action and a stable and peak activity profile, subjects with diabetes Type 1 was regulated sufficiently with a single unit of administration administered with variable injection rates in combination with insulin symbol.

In the subjects under test 1, the 26-week treatment with insulin ana L and s B 29 (N g - hexadecandioil - and - G lu) des (B 30) provided in a flexible manner (with interim human injections) sp. In comparison with what has been observed for Nahuman insuli L and S B 29 (N g - hexadecandioyl - and - G lu) from (B 30) provided with the non-nocturnal control of glycemic control and the inclusion of hypoglycemic episodes observed for insulin glargine. o r c i o n a d a u n a v e z a l dí a a l a m i s m a h o r a c a d a d í a (d e a c u e r d o c o n la e t i q u e t a a p r or b a d a).

E j e m p l o c l í n i c o 4

E l e m e n t o s m e t o d o l o g i c o s y r e s u l t a d o s f u n d a m e n t a l e s

E lensayosedise ñ ó paraevaluarlaviabilid ad, efficacy, safety andtolerabilid addelprodudedecombin aci or ndeinsulinahumana L ys B 29 (N g - hexadecandioil - and - G lu) des (B 30) einsulinahumana A sp B 28 (600 nmol / ml) for treatment of the treatment of the unit of the test 1 unit It is related to a meal with the exchange option for another time of injection of the human insulin product L ys B 29 (N-hexadecandioil-y-G lu) des (B 30) einsulinahumana A sp B 28 a different community. E l t r a t a m i e n t o c o n s i s t i o e n a d m i n i s t r a t i o n d e l p r o d u c t o d e c o m b i n a t i o n d e i n s u l i n a h u m a n a L and s B 29 (N g - h e x a d e c a n d i o i l - and - G l u) d e s (B 30) e i n s u l i n a h u m a n a A s p B 28 e n u n a c o m i d e i n s u l i n a h u m a n a A s p 28 p r o p o r c i o n a d a c o n r e l a t i o n a l a s c o m i t s r e s t a n t e s q u e r e q u i e r e n i n s u l i n e n s u j e t o s c o n d i a b e t e s t i p o 1.

Main goal

E valuarelcontroldelagl ucosa related to H b A 1 c after 26 weeks of treatment c with a product of the human cyl or human insulin L and s B 29 (N g - hexadecandioil - y - G lu) des (B 30) einsulinahumana A sp B 28 with the combination of the jointly used by the group. í aaotro) oinsulinadetemirunave Zald í to (conlaopci or ndeoptimizaradosveces ald í aensujetosnocontrolad osdemanera or optimum), ambosbrazosdetratamie ntoencombinaci nconlainsulinahumana or Ph 28 conlascomidasrestante squerequiereninsulina ipo ensujetoscondiabetest 1.

Materials and methods

E l e n s a y o s e r e a l i z o e n s u j e t o s c o n d i a b e t e s t i p o 1 d i a g n o s t i c a d a a l m e n o s u n yyy a n t e s d e i n g r e s a r a l e n s a y o c t 1 a n a 10% E n e l m o m e n t o d e l a a l e a t o r i z a c i o n, l o s s u j e t o s s e a s i g n a r o n a c u a l q u i e r a d e d o s p r o d u c t o s d e i n s u l i n a b a s a l:

1. l c o m b i n a t i o n d e i n s u l i n a h u m a n L and s B 29 (N e - h e x a d e c a n d i o i l - and - G l u) d and s (B 30) and i n s u l i n a h u m a n to A s p B 28 u n to v and z to l d t a c o n c u a l q u i and r c o m i t (h o r d e i n e c t i o n v e r a b l e d e u n d t a a o t r o) or

2. i n s u l i n a d e t e m i r u n a v e z a l d í a (o d o s v e c e s a l d í a) a l a m i s m a h o r a c a d a d d a (d e a c u e r d o c o n l a e t i q u e t a). A m b o s g r u p o s d e t r a t a m i e n t o r e c i b i e r o n i n s u l i n a h u m a n a A s p B 28 c o m o i n s u l i n a a l a h o r a d e l a c o m i d a e n l a s c o m i d a s e

A total of 548 subjects with testimony or 1, aged 41 years, mean duration of diabetes 17 years, average BMI of 26.4 kg / m 2, FPG average of 10.5 mmol / L, and H b A 1c average of 8, 3% They were randomized (2: 1 in favor of the human insulin combination L ys B 29 (N e - hexadecandioil - and - G lu) des (B 30) and human insulin A sp B 28 during a 26-week treatment period.

R e s u l t a d o s d e e f i c a c i a

H b A 1 c

The interval of confidence of the contractor during the comparisons when comparing human rainsulina L and s B 29 (N e-hexadecandioil - and - G lu) des (B 30) and human insulin A sp B 28 with the other group of treatment was within the limit of the lowest half, four times the changes in both groups. b A 1 crespectoalvaluinici alalfinaldeltratamien to (T hela 17 dean to static statistics).

Table 17

Hypoglycemia

Hypoglycemic episodes were recorded during the trial according to the definitions of the American Diabetes Association, cf. Table 18

Table 18

Insulin dose

Table 19

Conclusions

It was surprisingly discovered that the basal component of the combination product, human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30), which has a prolonged duration of action and a stable and stable activity profile, allowed that the subjects were sufficiently regulated with the dosage once a day even when the injection intervals varied as a result of changing the food in which the injection of the combination product was administered.

[0254] In subjects with type 1 diabetes, 26-week insulin treatment with human insulin LysB29 (N ^e- hexadecandioyl- ^and -Glu) des (B30) combined with human insulin AspB28 provided once daily in relation to a meal selected (with the option of varying the time of injection to a different meal from one day to another) resulted in a blood glucose control comparable (not less) than insulin detemir provided twice a day according to the label, both treatments were combined with human insulin AspB28 for the remaining meals. The combination of human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) resulted in a lower use of insulin and a lower incidence of hypoglycemic episodes compared to that observed for insulin detemir.

Clinical studies - clinical example 5

Investigation of the clinical effect of IDegAsp (human insulin LysB29 (N ^g -hexadecandioyl- ^and -Glu) des (B30) and human insulin AspB28) administered in the larger meal.

Introduction

In this detailed clinical study, IDegAsp (insulin degludec / aspartic insulin) is administered to patients with type 2 diabetes at the largest meal of the day. The results presented in this description are from a Phase 3 trial, controlled and randomized. In the present description the analysis is based on real measurements. However, in some places the estimated rates are analyzed (for example, those obtained from an adequate statistical model.

Definition of the analysis groups

The following analysis groups were defined according to the ICH-E9 guide:

- Complete analysis group (FAS): included all randomized subjects. In exceptional cases, FAS subjects could be eliminated. In such cases, the removal should be justified and documented. The statistical evaluation of the FAS followed the principle of intention to treat and the subjects contributed to the evaluation "as randomized".

- Protocol analysis group (PP): included the subjects without any significant violation of the protocol that may have affected the main assessment criteria. On the other hand, the subjects must have been exposed to the product under investigation or to their comparator for more than 12 weeks and must have a valid evaluation necessary to obtain the main evaluation criterion. The subjects in the PP group contributed to the evaluation "as they were treated".

- Safety analysis group: included all subjects who received at least one dose of the product under investigation or their comparator. The subjects in the safety set contributed to the evaluation "as they were treated".

Randomized subjects who were lost for follow-up and where information on exposure to the product under investigation or their comparator was not available after randomization were treated as unexposed. All OADs were considered products that are not under investigation.

Before the data was released for statistical analysis, a blind review of all the data was performed to identify deviations from the protocol that could potentially have affected the results. This review was conducted without revealing the trial product that was assigned to the subjects. The masking of the test products was maintained for all participants in the definition of the analysis groups until the data was released for statistical analysis. In addition, the statistician identified the extreme and outliers during the programming and review of the data in accordance with ICH-E930, with the use of a false randomization. Subjects who were exposed to the trial products <12 weeks and who did not have a valid HbA ¹ c assessment after randomization were excluded from the PP analysis, as were the subjects who violated the selection criteria in the trial. The decision to exclude any subject or observation from the statistical analysis was the joint responsibility of the blind members of the study group. The subjects or observations to exclude and the reason for its exclusion should be documented and signed by all parties, before the release of the database. The documentation was stored along with the rest of the trial documentation.

Statistic analysis

Main Valuation Criteria

The main assessment criterion was the change in HbA1c (%) with respect to the initial value after 26 weeks of treatment.

Statistic analysis

The change in HbA1c with respect to the initial value after 26 weeks of treatment was analyzed with the use of a variance analysis method (ANOVA) with treatment, antidiabetic therapy at the time of screening and sex as fixed factors, and age and HbA ^1c Initial as covariates. Antidiabetic therapy at the time of screening was a factor with the following two levels: 1. SU and / or glinides and 2: Others.

The model was adjusted to all data simultaneously (all treatment groups) and from this model the relevant differences between treatments were calculated.

The non-inferiority was considered confirmed if the upper limit of the bilateral 95% CI was less than or equal to 0.4% or equivalent if the p-value for the unilateral test of H ^or : D> 0.4% against H ^a : D <0.4%, was less than or equal to 2.5%, where D is the average difference between treatments (product under investigation minus the comparator).

If the non-inferiority was confirmed, the superiority of the product under investigation over the comparator should be investigated. The superiority was considered confirmed if the upper limit of the bilateral 95% CI, which was calculated with the use of FAS, was below 0%. In this case the PP analysis was considered as support.

Sensitivity analysis

The following sensitivity analyzes were performed only with the use of FAS.

All observed HbA ^ic measurements available after randomization at the programmed measurement times were also analyzed in a mixed linear model with the use of an unstructured residual covariance matrix (if possible). This approach depends on the assumption that data is randomly lost according to the taxonomy defined by Rubin (1976 Biometrika vol 63 (3) pp 581-592). The results were compared with the results of the LOC ^f method to treat the lost data. Any marked difference related to the differences between treatments between the random data loss approach and the LOCF approach should be discussed in the CTR.

The change in HbA ^1c with respect to the initial value was further analyzed with the use of a model with only treatment as a fixed factor and initial HbA ^1c as a covariate to assess the sensitivity of the results for the inclusion / exclusion of fixed and covariate factors.

Secondary Confirmation Criteria

Since the non-inferiority was confirmed for the main valuation criterion, a series of secondary confirmation valuation criteria were tested to confirm the superiority of the product under investigation over the comparator.

Secondary confirmation assessment criteria are provided below along with the indication of the test for superiority. The order of the evaluation criteria defined the sequence of tests.

1. Increase in prandial PG at dinner after 26 weeks of treatment (90 minutes after the start of dinner as measured by SMPG)

- The superiority was considered confirmed if the 95% CI for the difference between treatments (product under investigation minus the comparator) was completely below zero.

2. Respondent without hypoglycemic episodes (HbA ^1c <7.0% at the end of the trial and no severe or minor episode during the last 12 weeks of treatment that only includes exposed subjects for at least 12 weeks)

- The superiority was considered confirmed if the 95% CI for the odds ratio (product under investigation / comparator) was completely above one.

3. Number of severe or minor nocturnal hypoglycemic episodes (00: 01-05: 59 a.m.) emerging from treatment

- The superiority was considered confirmed if the 95% CI for the relative risk (product under investigation / comparator) was completely below one.

4. Change in body weight with respect to the initial value after 26 weeks of treatment

- The superiority was considered confirmed if the 95% CI for the difference between treatments (product under investigation minus the comparator) was completely below zero.

Increase in prandial plasma glucose at dinner

The increase in prandial PG at the dinner of the day (in which insulin was injected) was obtained from the SMPG profile of 9 points as the difference between the PG values available before dinner and 90 minutes after dinner. The assessment criterion after 26 weeks of treatment was analyzed with the use of an ANOVA method with treatment, antidiabetic therapy at the time of screening and sex as fixed factors, and age and increase of PG at baseline as covariates.

Respondent without hypoglycemic episodes

The responder without hypoglycemic episodes is a dichotomous assessment criterion (responder / nonresponder) that is defined based on whether a subject has met the ADA HbA1c objective at the end of the trial (HbA- ^ic <7%) without hypoglycemic episodes severe or minor emergent treatment during the last 12 weeks of treatment. Severe hypoglycemic episodes are defined according to the ADA classification while minor hypoglycemic episodes (PG <3.1 mmol / L) constitute an additional group. A hypoglycemic episode is defined as emerging from treatment if the onset of the episode is on or after the first day of exposure to randomized treatment and not later than 7 days after the last day of randomized treatment. The assessment criterion was defined only for subjects who had been exposed to the product under investigation or their comparator for at least 12 weeks.

Responders' analysis was based on a logistic regression model with the use of treatment, antidiabetic therapy at the time of screening and sex as fixed factors, and age and initial HbA ^1c as covariates.

Number of severe or minor nocturnal hypoglycemic episodes emerging from treatment

This criteria for assessing the count is defined as the sum of the severe and minor nocturnal hypoglycemic episodes emerging from the treatment. Any episode that had an hour of appearance between 00:01 and 05:59 a.m. (both included) was considered nocturnal.

The amount of nocturnal hypoglycemic episodes was analyzed with the use of a negative binomial regression model with a logarithmic link function and the logarithm of the period of time in which a hypoglycemic episode was considered emergent treatment as an exposure variable. The model included treatment, antidiabetic therapy at the time of screening and sex as fixed factors and age as covariate.

Change in body weight with respect to initial value

The change in body weight with respect to the initial value after 26 weeks of treatment was analyzed with the use of an ANOVA method with treatment, antidiabetic therapy at the time of screening and sex as fixed factors, and age and initial body weight as covariates.

Secondary backup assessment criteria

HbA ^1c response assessment criteria

Dichotomous assessment criteria (responders / non-responders) were defined based on whether a subject met a specific objective - for example, at least the ADA HbA1c objective (HbA ^1c <7%). Another example of an objective is the HbA1c objective of the International Diabetes Federation (HbA ^1c at 6.5%).

Additional dichotomous assessment criteria were defined based on whether the treatment objectives were achieved at the end of the trial without hypoglycemic episodes in the last 12 weeks of treatment considering severe episodes only, and severe and minor episodes as a whole. The assessment criteria were defined only for subjects who had been exposed for at least 12 weeks.

The response assessment criteria were analyzed separately based on a logistic regression model with the use of treatment, antidiabetic therapy at the time of screening and sex as fixed factors, and age and initial HbA ^ic as covariates.

Fasting plasma glucose

The change in FPG with respect to the initial value was analyzed with the use of an ANOVA method with treatment, antidiabetic therapy at the time of screening and sex as fixed factors, and age and initial FPG as covariates.

Self-Measured Plasma Glucose

Self-measured plasma glucose was measured in terms of the 9-point SMPG profiles and the 1-point SMPG profiles used for insulin dose adjustments.

9 point profile (SMPG)

The 9-point profile (SMPG) included measurements before and 90 minutes after the start of breakfast, lunch, and the main night meal, measurements before bedtime and at 4 a.m., and before breakfast the next day.

The evaluation criteria of the 9-point profiles (SMPG) were

• 9 point profile (SMPG)

• 9 point profile average (SMPG)

• 9 point profile fluctuation (SMPG)

• Increases in prandial PG

• Changes between nighttime SMPG measurements

The average of the 9-point profile (SMPG) is defined as the area below the profile divided by the measurement time and is calculated using the trapezoidal method. The fluctuation in the 9-point profile (SMPG) is defined as where T, PG (t) and PG denote the length of the profile, the value of PG at time t and the average of the profile, respectively. The prandial PG increase for each meal was obtained from the 9-point profile (SMPG) as the difference between the PG values available 90 minutes after the meal and before the meal. The average increase in prandial PG in all meals was obtained as the average of all increases in available meals. The change between night PGs was evaluated considering the differences between the available PG values before bedtime, at 4 a.m. and the value before breakfast the next day: (value of PG at 4 am minus the value of PG before bedtime), (value of PG before breakfast less value of PG before bedtime) and (value of PG before breakfast less PG value at 4 am).

A mixed effect model was adjusted to the 9-point profile data (SMPG). The model included treatment, time, interaction between treatment and time, antidiabetic therapy at the time of screening and sex as fixed factors, age as covariate and subject as random effect. From the model, the average profile per treatment and the relevant differences between treatments were calculated and explored.

The mean and fluctuation in the 9-point profile (SMPG), the increase in prandial PG and the night PG assessment criteria were analyzed separately with the use of an ANOVA method with treatment, antidiabetic therapy at the time of screening and sex as fixed factors, and age and relevant initial value as covariates. The fluctuation in the 9-point profile (SMPG) was transformed logarithmically before analysis.

Security Assessment Criteria

The following safety assessment criteria were evaluated:

• EA

• Laboratory analysis

• clinical evaluations

Hypoglycemic episodes

Subjects recorded hypoglycemic episodes in their trial journals throughout the trial. The information collected included the PG before treating the episode and if the subject was able to treat himself / herself.

Information about the last meal and dose was also collected. This information was used to classify an episode according to the ADA definition (severe, documented symptomatic, asymptomatic, probable and relative symptomatic).

A hypoglycemic episode was defined as emerging from treatment if the episode appeared on or after the first day of exposure to randomized treatment and not later than 7 days after the last day of randomized treatment.

Abstracts of the hypoglycemic episodes emerging from the treatment were performed by presenting the following:

• the number of subjects with at least one episode

• the percentage of subjects with at least one episode

• the number of episodes and the episode rate per 100 PYE

• summaries separated by severity:

- all episodes

- night episodes that use both the definition of the ADA and the additional minor category.

The night period was considered as the period between 00:01 and 05:59 a.m. (both included). A hypoglycemic episode that had an hour of appearance during this period was considered nocturnal.

The number of hypoglycemic episodes was analyzed with the use of a negative binomial regression model with a logarithmic link function and the logarithm of the period of time in which a hypoglycemic episode was considered emergent treatment as an exposure variable. The model included treatment, antidiabetic therapy at the time of screening and sex as fixed factors, and age as covariate. To the extent that the data allowed, separate analyzes were performed for severe episodes and severe or minor episodes, considering all episodes and night episodes separately.

Additional test information

The following tabulated information presents additional information on the specific test performed.

Table 20

Treatment regimen

IDegAsp IGlar

OD OD OD

Injection time Larger meal3 According to label1 Initial dose 10 U 10 U

Flexpen® Solostar® device

Additional antidiabetic therapy <2 OAD2 <2 OAD2

1) Before breakfast or before bedtime (once a day at the same time each day)

2) SU / glinides and DPP-IV inhibitors were interrupted at the time of randomization

3) The subjects choose the injection time at the time of randomization

T a b l a 21

P r i n c i p a l e s c r i t e r i o s d e r e c l u t a m i e n t o

D i a g n o s t i c o D i a b e t e s t i p o 2 D u r a n t e> 6 m e s e s

U s o d i a r i o d e V i r g e n p a r a la

i n s u l i n a i n s u l i n a

T r a t a m i e n t o p r e v i o 1 o m á s O A D D u r a n t e> 3 m e s e s

H b A 1 c 7 - 10%

Í n d i c e d e m a s a

<35 k g / m 2

c o r p o r a l

E d to d> 20 years

T a b l a 22

E j e c u c i o n d e l e n s a y o

T a b l a 25

N u m e r o d e s u j e t o s e n g r u p o s d e a n á l i s i s

T a b l a 26

R e s u l t a d o s p a r a e l E j e m p l o C l í n i c o 5

L o s r e s u l t a d o s p a r a e l E j e m p l o 5 s e p r e s e n t a n e n l a s F i g u r a s a d j u n t a s. L o s r e s u l t a d o s s e a n a l i z a n m á s a d e l a n t e e n l a p r e s e n t e d e s c r i p c i o n.

H b A 1c - C r i t e r i o d e v a l o r a c i o n p r i n c i p a l

The estimated mean reduction in HbA1c was -1.61% - points with IDegAsp and - 1.33% - points with IGlar, with an estimated average difference (IDegAsp-IGlar) of - 0.28% - points, [- 0, 46; - 0.10] 95% CI after 26 weeks of treatment; See Table 28.

Table 28

HbA1c (%) after 26 weeks of treatment - Primary statistical analysis - Complete FAS N analysis group Estimated SE 95% CI HbA1c (%)

LSMedia

IDegAsp OD 147 147 6.81 0.08

IGlar OD 149 149 7.09 0.08

Change in value

initial

LSMedia

IDegAsp OD 147 147 -1.61 0.08

IGlar OD 149 149 -1.33 0.08

Contrast between treatments

IDegAsp OD - IGlar OD -0.28 [-0.46; -0.10] N = Number of subjects contributing to the analysis, CI = Confidence interval,

SE = Standard error of the mean

The response and the change with respect to the initial value in the response after 26 weeks of treatment are analyzed with the use of an ANOVA method with treatment, antidiabetic treatment at the time of screening and sex as fixed effects, and age and initial response as covariates .

The lost data is imputed with the use of extrapolation from the last observation.

The primary efficacy analysis was based on the FAS and the PP analysis group, where the PP analysis was considered as supporting evidence. The result of the analysis with the use of the PP analysis group supported the result of the primary analysis; See Table 29.

The results of the primary analysis were also supported by two additional sensitivity analyzes, one based on a simple model, which includes only initial HbA1c as a covariate, and one based on a repeated measurement model.

Table 29

HbA1c (%) after 26 weeks of treatment - Statistical sensitivity analysis - PP PP N analysis group Estimated SE 95% CI HbA1c (%)

LSMedia

IDegAsp OD 141 141 6.70 0.07

IGlar OD 140 140 6.95 0.07

Change from initial value

LSMedia

IDegAsp OD 141 141 -1.71 0.07

IGlar OD 140 140 -1.46 0.07

Contrast between treatments

HbA1c <= 6.5%

LSMedia, Probabilities

IDegAsp OD 147 147 0.84

IGlar OD 149 149 0.38

Ratio of probabilities of

treatments

IDegAsp OD / IGlar OD ________________________________________________ 2.20 __________ [1.20; 4.02] N = Number of subjects contributing to the analysis, CI = Confidence interval

The binary valuation criterion is analyzed in a logistic regression model with the use of a logit link.

The model includes treatment, antidiabetic treatment at the time of screening and sex, as fixed effects, and age and initial HbA ¹ c as covariates.

The lost data is imputed with the use of extrapolation from the last observation.

End of the trial: the last visit to a subject at the end of the trial excluding the follow-up visit.

In line with this, the estimated probability of achieving the HbA ^{ic target} at 6.5% at the end of the trial was also approximately twice as high with IDegAsp as with IGlar, given that the lower 95% CI limit for the ratio of Estimated probabilities (IDegAsp / IGlar probability ratio: 2.20 [1.20; 4.02] ^{ic of 95%} ) was> 1, see Table 31.

Subjects that achieve HbA1c objectives without hypoglycemia

Overall, a proportion of subjects treated with IDegAsp (43.3%) numerically higher than with IGlar (25.0%) achieved the HbA ¹ c target <7% without confirmed hypoglycemic episodes during the last 12 weeks of treatment; See Table 32.

Table 32

Respondent for HbA1c at the end of the trial without hypoglycemia - Summary - Complete analysis group IDegAsp OD IGlar OD Total _______________________________ N_________ (%) _______ N_________ (%) _______ N_________ (%) Number of subjects 147 149 296

HbA1c <7.0% without hypoglycemia

confirmed

Visit 28 (Week 26) (LOCF)

N 141 (100.0) 140 (100.0) 281 (100.0) Yes 61 (43.3) 35 (25.0) 96 (34.2) No 80 (56.7) 105 (75.0 ) 185 (65.8)

Visit 28 (Week 26) (LOCF)

N 141 (100.0) 140 (100.0) 281 (100.0) Yes 36 (25.5) 22 (15.7) 58 (20.6) No 105 (74.5) 118 (84.3 ) 223 (79.4) N = Number of subjects

Respondent for HbA ¹ c without hypoglycemia: subject that meets the objective of HbA1c at the end of the trial without emerging hypoglycemia of the treatment during the last 12 weeks of treatment. The assessment criterion is defined only for subjects exposed for at least 12 weeks of treatment. End of the trial: the last visit to a subject at the end of the trial excluding the follow-up visit. Confirmed hypoglycemia: subject unable to treat himself / herself and / or who has a registered PG <3.1 mmol / L (56 mg / dl)

The proportion of subjects achieving HbA ¹ c <7% at the end of the trial without episodes of confirmed hypoglycemia was specified as a secondary confirmation assessment criterion.

Statistical analysis confirmed that IDegAsp was higher than IGlar in terms of a greater proportion of subjects achieving HbA ¹ c <7% without confirmed hypoglycemic episodes, given that the lower limit of the 95% CI for Estimated odds ratio (IDegAsp / IGlar) was> 1. The estimated probability of achieving this objective was approximately twice as high with IDegAsp compared to IGlar (odds ratio 2.21 [1.25; 3.92] ^{ic of 95%} ); See Table 33.

Table 33

HbA ^ic <7.0% at the end of the trial without confirmed hypoglycemia - Statistical confirmation analysis - Complete analysis group

FAS N Estimated 95% CI HbA1c <7.0% without hypoglycemia

confirmed <7.0%

LSMedia, Probabilities

IDegAsp OD 147 141 1.09

IGlar OD 149 140 0.49

Ratio of probabilities of

treatments

HbA1c <7.0% without confirmed hypoglycemia

HbA1c <7.0% without hypoglycemia 2.21 [1.25; 3.92] confirmed <7.0%

IDegAsp OD / IGlar

OD

N = Number of subjects contributing to the analysis, CI = Confidence interval. The assessment criterion is analyzed in a logistic regression model with the use of a logit link, which includes treatment, antidiabetic treatment at the time of screening and sex as fixed effects, and age and initial HbA1c as covariates. Lost data is imputed with the use of LOCF. HbAlc <7.0% without hypoglycemia: A subject exposed for at least 12 weeks, who meets the objective of HbAlc without hypoglycemia during the last 12 weeks of treatment or within 7 days from the last randomized treatment. End of the trial: the last visit to a subject at the end of the trial excluding the follow-up visit. Confirmed hypoglycemia: subject unable to treat himself / herself and / or having a registered PG <3.1 mmol / L (56 mg / dl) .________________________ The estimated probability (IDegAsp / IGlar) of achieving the strictest objective of HbA ^1c at 6.5% without episodes of confirmed hypoglycemia was 1.78 [0.90; 3.51] ^{95% ic} . No statistically significant difference was observed between the treatment groups since the 95% CI for the estimated odds ratio (IDegAsp / IGlar) included the value 1.

In accordance with the previously planned statistical analyzes, the proportion of subjects that achieved the objective of HbA ^1c <7% or HbA ^1c at 6.5% without severe hypoglycemia was analyzed. No episodes of severe hypoglycemia were reported for this trial.

The following primary statistical analysis for HbA1c at Week 26 confirms the superiority of the combination of the present invention.

Table 34

Estimated Difference Group [CI of 95

analysis %]

FAS -0.28 [-0.46; -0.10]

Table 34 contains an extract from Table 28.

Summary of Clinical Example 5

In this example, IDegAsp is administered to patients with type 2 diabetes inadequately controlled with oral drugs. The results presented in this description are from a Phase 3 trial, controlled and randomized.

Background and objectives

Insulin degludec (Ideg) is a new basal insulin that forms multiple soluble hexamers after sc injection, which results in an ultra-prolonged and consistent glucose reduction effect. Insulin degludec / aspartic insulin (IDegAsp) is a soluble coformulation of IDeg (70%) and aspartic insulin (30%) that provides insulin coverage both at mealtime and at baseline. The efficacy and safety of IDegAsp in adult insulin insulin adults with inadequately controlled type 2 diabetes was investigated. with oral antidiabetic drugs (OAD) in a treatment trial to an open, 26-week objective, Phase 3.

Materials and methods

Participants (mean: 60.5 years of age; HbA ^1c 8.4%; fasting plasma glucose [FPG] 9.0 mmol / L; BMI 25.1 kg / m ² ; duration of diabetes 11.7 years ) were randomized to injections once a day of IDegAsp (n = 147) or insulin glargine (IGlar; n = 149), with / without up to 2 OAD (excluding sulfonylureas, dipeptidyl peptidase 4 inhibitors and glinides).

The IDegAsp was injected before the largest meal of the day according to the criteria of each participant (and was maintained throughout the trial); IGlar was injected at the same time each day according to the label. The doses of both insulins were adjusted for an FPG <5 mmol / L.

Results

After 26 weeks, the average HbA ^1c was 7.0% with IDegAsp and 7.3% with IGlar.

The analysis of the change in HbA ^1c with respect to the initial value at the end of the trial showed that IDegAsp was higher than IGlar (estimated difference between treatments (ETD) IDegAsp-IGlar: -0.28% -points [-0.46; -0 , 10] ^{95% ic} , p <0.001). At the end of the trial, a higher proportion of subjects achieved HbA ^1c <7.0% with IDegAsp (58.5%) vs. IGlar (40.3%). The mean FPG was similar for IDegAsp and IGlar (5.7 vs. 5.6 mmol / L; ETD IDegAsp-IGlar: 0.15 mmol / L [-0.29; 0.60], p = NS).

No severe hypoglycemia was reported.

Confirmed hypoglycemia (PG <3.1 mmol / L) was reported for 44% of the subjects in both groups; IDegAsp was associated with a numerically lower confirmed hypoglycemia rate (27%) than IGlar (estimated rate ratio (ERR) IDegAsp / IGlar: 0.73 [0.50; 1.08] p = NS).

A significantly higher proportion of subjects achieved HbA ^1c <7.0% at the end of the trial (without confirmed hypoglycemia in the last 12 weeks of treatment) with IDegAsp compared to IGlar (43% vs. 25%; odds ratio 2, 21 [1.25; 3.92], p = 0.003).

The confirmed nocturnal hypoglycemia rate (confirmed hypoglycemia with onset between 00: 01-05: 59 h) was numerically lower (in 25%) with IDegAsp than with IGlar (RR: 0.75 [0.34; 1.64], p = NS).

The average daily doses of insulin were similar between the groups at the end of the trial (IDegAsp: 28 U; IGlar: 29 U) as well as increases in body weight with respect to the initial value (0.7 kg for both groups). The total rates of adverse events were similar between groups without a pattern or specific grouping of treatment.

conclusion

The IDegAsp dosed once daily with the largest meal of the day provided superior long-term glycemic control with an IGG-like FPG at a numerically lower rate of total and nocturnal hypoglycemia. Therefore, superior glycemic control was achieved with once-daily administration of IDegAsp vs. IGlar in subjects with type 2 diabetes inadequately controlled with oral drugs.

Analysis and general conclusions

Background Information

Insulin analogs have been developed that more closely mimic endogenous insulin secretion compared to human insulin preparations and are now an established part of diabetes control. IDegAsp is the first ready-to-use soluble insulin comprising both a basal insulin component (IDeg) and a bolus insulin component (IAsp). In the present trial, virgin subjects for insulin with type 2 diabetes mellitus inadequately controlled with OAD alone, were selected to investigate the use of IDegAsp for initiation of insulin treatment since IDegAsp offers baseline ultraprolonged action with prandial coverage Additional one meal.

The trial was conducted to confirm the efficacy and safety of treatment with IDegAsp OD as monotherapy or in combination with up to 2 OAD, when glucose levels are no longer controlled with OAD alone in subjects with type 2 diabetes mellitus. The main objective was confirm the efficacy of IDegAsp OD 6 OAD in glycemic control with respect to the change in HbA1c with respect to the initial value after 26 weeks of treatment. The Initial characteristics were similar in the two treatment arms and approximately 93 % of the subjects completed the trial.

As in any open trial, there may be a risk of underlying report bias. In general, researchers are likely to be more alert when they treat subjects with a new medical entity such as IDegAsp, and subjects may also have more doubts about a new treatment. This could influence the report of ^e A and hypoglycemia.

Blood glucose control

IDegAsp was superior to IGlar in terms of HbA1c reduction with a clinically relevant difference of 0.28% - points after 26 weeks of treatment. After 26 weeks of treatment, the mean HbA1c observed was reduced to 7.0% in IDegAsp compared with 7.3% in the IGlar group. The estimated reduction in HbA1c was -1.61% -points with IDegAsp and -1.33% -points with IGlar. The estimated probability of achieving the ADA objective of HbA ¹ c <7% with or without confirmed hypoglycemia was approximately twice as high with IDegAsp compared to IGlar, which highlights the fact that treatment with the combination of a basal insulin Ultra-extended action with additional prandial coverage in the main meal provides superior glucose control without compromising safety. In addition, the estimated probability of achieving the HbA ¹ c ID of <c% 6.5% was also approximately twice as high with IDegAsp compared to IGlar. The reduction of FPG was similar in both treatment groups after 26 weeks of treatment but was achieved with a lower risk of confirmed nocturnal and total hypoglycemic episodes in subjects receiving IDegAsp.

Both treatments with IDegAsp and IGlar resulted in total reductions in SMPG profiles and treatment with IDegAsp resulted in a minor prandial increase in main nighttime food and all meals compared to IGlar. The superior glucose reduction effect of IDegAsp observed after the main night meal reflects the benefit of prandial coverage of IDegAsp. There were no more hypoglycemic events in the group with IDegAsp compared to the group with IGlar after the main night meal. This supports the advantage of letting patients choose the dosing time depending on when they consume their largest meal. That IDegAsp is superior in the control of deviations of postprandial glucose compared to IGlar without compromising the control of FPG, suggests that the ratio of insulin degludec to aspartic insulin of IDegAsp is adequate for this group of subjects.

Insulin dose and dose adjustment

The initiation of IDegAsp at 10 U OD seemed safe only with some hypoglycemic episodes reported during the first 4 weeks of insulin administration.

The average daily doses of insulin followed the same pattern in the groups with IDegAsp and IGlar throughout the trial. After 26 weeks of treatment, the average insulin doses were 28 U (0.41 U / kg) and 29 U (0.41 U / kg) in the groups with IDegAsp and IGlar, respectively.

The doses of all subjects in both treatment groups were adjusted based on SMPG before breakfast regardless of the time of injection. Subject compliance and close adherence to the dose adjustment algorithm were indicated in both treatment groups given that the mean differences between the prescribed dose and the actual dose and between the dose of the dose adjustment algorithm and the prescribed dose , respectively, were close to 0 U (the average difference [prescribed dose - dose adjustment algorithm dose] was between -2 U and -1 U) throughout the trial.

The prandial component of IDegAsp resulted in lower glucose values after nighttime meal and at bedtime, thereby reducing the need for basal insulin coverage at night, so the baseline component of IDegAsp (70 % insulin degludec) is adequate to achieve the same average FPG values as with IGlar.

Hypoglycemia

The observed rate of confirmed hypoglycemic episodes was numerically lower with IDegAsp compared to IGlar.

One of the major concerns of subjects with diabetes mellitus is the risk of hypoglycemic episodes that occur during sleep. Treatment with IDegAsp resulted in a numerically lower confirmed night hypoglycemic episode rate compared to IGlar while maintaining a superior glucose reduction effect after 26 weeks of treatment. The more stable and flat action profile of the baseline component of IDegAsp makes it possible for subjects to reach the glycemic target without compromise it d. No information is reported about severe hypoglycemia or onacturnaseveradurant eesteensayoenning or a treatment group.

N o h u b o a g r u p a m i e n t o d e e p i s o d i o s h i p o g l u c é m i c o s o b s e r v a d o s e n n i n g u n p u n t o d e t i e m p o d u r a n t e e l e n a y o. S e g u r i d a d y t o l e r a b i l i d a d

Claims (8)

i. U n a c o m b i n a t i o n q u e c o m p r e n d e a l m e n o s u n p r i m e r c o m p u e s t o d e t i p o i n s u l i n a y u n s e g u n d c o m p u e s t o d e t i p o i n s u l i n a p a r e l u s e n e l t r a t a m i e n t o d e l a d i a b e t e s t i p o 1 or l a d i a b e t e s t i p o 2 e n u n s u j e t o q u e lo n e c e s i t a d o n d e l a a d m i n i s t r a t i o n d e i n s u l i n a s e r t a b e n e f i c i o s a p a r a d i c h o s u j e t o; e n d n d e d i c h o p r i m e r c o m p h o s t o r t i p or i n s u l i n e s l a i n s u l i n a h u m a n L and s B 29 (N s - h e x a d e c a n d i o i l - and - G l u) d and s (B 30) and d i c h o s e c o n d c o m p h o s t o r t i p or i n s u l i n e s l a i n s u l i n a h u m a n to A s p B28; e n d o n d e d i c h a c o m b i n a t i o n s e a d m i n i s t r u n a v e z a l d t e n u n a c a n t i t y p r a l o g r a r u n c o n t r o l b e n e f i c i o s o d e l a g l u c e m i e n d i c h o s u j e t o c o m o s e d e t e r m i n a p o r l o s n i v e l e s d e H b A 1c e n d i c h o s u j e t o d e s p u e s d e l a a d m i n i s t r a t i o n u n a v e z a l d t a d e d i c h a c o m b i n a t i o n e n l a c o m i d a m s g r a n d e d e l d t a p a r a d i c h o s u j e t o; e n d n d e d i c h o c o n t r o l b e n e f i c i o s o f l g l u c e p i to p o r d i c h a c o m b i n a t i o n c o m p r e n d e d i s m i n u i r l o s n i v e l e s d e H b A 1c e n d i c h o s u j and t or 7, 0% or m and n or s d e s p h o s o f a to d m i n i s t r a t i o n u n to v and z to l d t a d e d i c h a c o m b i n a t i o n e n l c o m i d a m s g r a n d e d e l d y. 2. U nacombinación nparaelusoeneltratami entodeladiabetestipo 1 otipo 2delodoconclara 1 claim ^{whereincomponent to the commandocomprendeoconsistenstand during this first} 30 minutes before the first rains of the ramp for 30 minutes. 3. U n a c o m b i n a t i o n p a r e l u s e n e l t r a t a m i e n t o d e l a d i a b e t e s t i p o 1 o t i p o 2 o f a c u e r d o c o n c u a l q u i e r a d e l a s r e i v i n d i c a t i o n e s a n t e r i o r e s e n d o n d e l c o m b i n a t i o n e s c a p a z d e p r o v o c a r q u e e l s u j e t o t e n g a m e n o s h i p o g l u c e m i a t o t a l e n c o m p a r a t i o n c o n u n a d o s i s e q u i v a l e n t e d e I G l to r. 4. U n a c o m b i n a t i o n p r e l u s i n e l t r a t a m i e n t o f l a d i a b e t e s t i p or 1 or t i p o 2 d e a c h e r d or c o n c u a l q u i e r o f a s r e i v i n d i c a t i o n s a n t e r i o r e s e n d n d e d i c h o s u j e t o p a d e c e d e d i a b e t e s t i p or 2. 5. U n a c o m b i n a t i o n p r e l u s i n e l t r a t a m i e n t o f l a d i a b e t e s t i p or 1 or t i p o 2 d e a c h e r d or c o n c u a l q u i e r o f a s r e i v i n d i c a t i o n s a n t e r i o r e s e n d n d e d i c h o p r i m e r c o m p h o s t o r t i p or i n s u l i n e s t to p r e s e n t e e n d i c h a c o m b i n a t i o n e n u n a c a n t i t d M o r q u e e l s e c o n d c o m p h o s t o r t i p or i n s u l i n a. 6. U n a c o m b i n a t i o n p a r e l u s e n e l t r a t a m i e n t o d e l a d i a b e t e s t i p o 1 o t i p o 2 o f a c u e r d o c o n c u a l q u i e r r e i v i n d i c a t i o n a n t e r i o r e n d o n d e e l s e g u n d c o m p u e s t o d e t i p o i n s u l i n e s t a p r e s e n t e e n d i c h a c o m b i n a t i o n e n u n a c a n t i d a d m o l a r d e m e n o s d e 55% e n b a s e a l a c a n t i d a d m o l a r d e l p r i m e r c o m p u e s t o d e t i p o i n s u l i n e n d i c h a c o m b i n a t i o n.

8. U n a c o m b i n a t i o n p a r e l u s e n e l t r a t a m i e n t o d e l a d i a b e t e s t i p o 1 o t i p o 2 o f a c u e r d o c o n c u a l q u i e r a d e l a s r e i v i n d i c a t i o n e s a n t e r i o r e s e n d o n d e d i c h o c o n t r o l b e n e f i c i o s o d e l a g l u c e m i a p o r d i c h a c o m b i n a t i o n c o m p r e n d e d i s m i n u i r l o s n i v e l e s d e H b A 1c e n d i c h o s u j e t o 7, 0% or m e n o s d e s p u e s d e l a a d m i n i s t r a t i o n d e d i c h a c o m b i n a t i o n e n l a c o m i d a m s g r a n d e d e l d t e n u n p e r t o d e 26 s e m a n a s.