Cross-Matches for Bioequivalence Evaluation Division using Needle Free Jet Injector (Comfort-In) and conventional Pen type syringe.

Transcription

1 Cross-Matches for Bioequivalence Evaluation Division using Needle Free Jet Injector (Comfort-In) and conventional Pen type syringe. Dr. EunJig, Lee Dr. DongYeobp, Shi Copyright c 2013 Yonsei University Severance Hospital : licensee Mika Medical Co. All rights reserved. This Edition is published by Yonsei University Severance Hospital though Mika Medical Co.

2 1. SELECTION OF SUBJECTION OR EX -CLUSION CRITEIA AND SURVEY ITEM FOR SCREENING A. Selection criteria (normal people) - Men and women over the age of 20 and under 50 as of the research registration date (the date of receiving the written consent) - Body-mass index (Weight/Height 2): More than 18 kg/m2 and less than 28 kg/m2 - Blood pressure: systole under 160 mmhg & diastole under 90 mmhg - A person who is expected to benefit from the trial or be able to complete the trial successfully by appropriate medical judgment - A person who voluntarily wishes to participate in the clinical trial and agreed to a written consent B. Exclusion criteria (normal people) - A woman of childbearing age, or pregnant, the lactation, or does not use a reliable method of contraception, or does not agree to continue contraception for the duration of the clinical period. - If first-degree relatives of subjects with type II diabetes - A person with a severe disease affecting the progress of the clinical trial (heart disease, liver disease, etc.) - A person who takes chronic medications other than oral contraceptives or thyroid hormone replacement therapy - Mental patients or patients with drug and alcohol addiction or who does not understand the purpose and methods of the clinical trial - A person who have participated in another clinical trial within 30 days before committing to the trial - If the researcher of the clinical trial deems that a person is incapable of performing the clinical trial C. Inspection items for screening Check basic items of subjects (gender, age, a history of alcohol ingestion alcohol and smoking, etc.), clinical pathology (blood and urine) selection and exclusion criteria, a medical history (diabetes, anamnesis, associated disease, etc.) concomitant medications, vital signs, physical examination D. How to recruit: internal medicine call patients of Severance Hospital and public announcement

3 E. A number of subjects: 22 normal people F. Calculation basis - The study conducted by Engwerda EE et al (Diabetes Care, 2011) on aerosol syringe and pen-type insulin infusion effects found that from (n = 18), the time to maximal glucose infusion rate was reported to be 51 ± 3 minutes and (mean ± SE) and 105 ± 11 minutes (mean ± SE), respectively. - When considering a 95% confidence interval, the difference (δ) by the two devices was 26.6 basal 81.4 minutes. A significant level (α): 0.05 / calibration (1-β): 80%/ drop-out rate: 10% / calibration of both devices/ we applied 46.7, the standard deviation of 12.7 and 46.7 that we obtained from the standard error. - The target number of subjects for a cross-tabulation analysis is n = 19.0 (19 people), assuming the difference of the two devices as 26.6 using the following formula: - With the assumption of 10% as the drop-out rate, the test subjects are 22 normal people (19/0.9 = 21.1). G. Using drug Insulin : Aspart (Novo Nordisk) 2. PROJECT PROTO- COL A. Clinical Test Period The clinical trial involved a crossover design; after screening, subjects are admitted to the hospital on the first visit, Wash Out, and admit to the hospital on their second visit. A subject participates in the primary and secondary tests through admitted to the hospital. (1) The screening period (registration date -30 days basal -1 day) Written consent of subjects: Explain thoroughly about the purpose and process of the clinical trial, the possibility of adverse reactions, compensation regulations, and obtain a written consent from subjects who wish to participate in the trial (registration date) Conformity assessment of subject: Make a decision whether a subject will participate in the clinical trial according to selection criteria and exclusion criteria Basic survey: Weight, height, a history of alcohol ingesting and smoking of subjects Medical history: Medical history of the past and comorbidities Check concomitant medications, physical examination, vital signs, pregnancy test, clinical pathology, and training of subjects (2) Primary Test Admit to the hospital in the morning/ Check for concomitant medications after screening

4 Relax for 30 minutes, collect blood 10 minutes prior to the test and at the time of the test and measure the concentration of blood glucose, and input the mean average as the basal blood glucose of the target. Reschedule a test date if fasting blood glucose measurement (normal range 60 basal 110 mg/dl) deviates Randomized numbering: A group is assigned according to assign tags if selected as a subject Position measurement: Supine Insert a venous catheter between forearm and back of the hands for blood collection Insert a catheter to supply 20 % Dextrose to the antecubital vein of the other side of the arm. Administer insulin to the abdomen using aerosol or pen-type syringes through randomization and initiate the Euglycemic clamp test: 0.2 unit/kg (weight) If insulin is administered using an aerosol syringe (a pen-type) in the primary test, the pen-type (the aerosol syringe) will be used in the next test. Pain measurement after insulin administration Euglycemic clamp technique: After insulin is administered, maintain the basal blood glucose level (about 90mg/dL) through 20 % dextrose glucose infusion rate while checking blood glucose concentration (Defronzo RA et al, 1979). Eight hours of implementation Measuring glucose concentration: Collect blood samples at a 5-minute interval up to 4 hours after insulin administration, and at a 10-minute interval up to 8 hours after 4 hours Measuring insulin concentration: Collect blood samples at a 10-minute interval up to 1 hour after insulin administration, and at a 30-minute interval up to 8 hours after 1 hour Relax for more than 30 minutes after the clamp test and administer sugar orally to prevent hypoglycemia (3) Wash Out Allow at least one week interval after the primary test; for women subjects, the interval time may be up to 8 weeks considering their menstruation cycle. (4) Secondary Test Check for concomitant medications and adverse reactions during Wash Out The same as the primary test B. Application of the Euglycemic Clamp Technique The Euglycemic Clamp Technique was first developed by DeFronzo et al. (1979), which is also known to be the most standard method to date for measuring and evaluating in vivo insulin sensitivity and resistance. We can compare time-based the pharmacological glucose reinforcing effect of the administered insulin through injection of glucose by hour that continues euglycemia after external administration of insulin

5 preparations using the glucose infusion methods and formulas presented in the technique. Endogenous insulin secretion of a subject in the hunger state after fasting overnight is almost suppressed, maintaining the basal blood glucose while minimum generation of new hepatic glucose and consumption of glucose in vivo are achieving equilibrium. In this condition, insulin preparations administered externally is absorbed into the blood, circulating the whole body, thereby increasing glucose absorption from insulin sensitivity organs (muscle, liver, and fat); this will decrease glucose in subjects and danger of hypoglycemia if there is no glucose administered externally. Hence, if infusion rate of the 20% dextrose solution is adjusted to maintain the basal blood glucose of the subject while measuring the subject's blood glucose at a minute interval, the amount of glucose infusion can be observed and recorded by time for 8 hours, which the pharmacological effect of the insulin administered diminishes, without hypoglycemia. Endogenous basal insulin, which is secreted in a small amount from subjects can be suppressed to near 0 instantly after external insulin administration; therefore, the blood glucose change of the subject is due to the pharmacological effect; if the basal blood glucose can be maintained during the test time by glucose infusion, we can say the administering GIR reflects the hypoglycemic effect, which is the pharmacological effect of insulin. Glucose infusion formula according to the Euglycemic Clamp Technique Si = SVi + SMi Si: setting of infusion pump at time i SVi: setting needed for volume component SMi: setting needed for metabolic component SVi = (Gd-Gi)x10x(0.19xBwt) x P.F. (x 60) Ginf x 15 Gd: desired plasma glucose concentration (mg/dl) Gi: actual plasma glucose concentration at time i (mg/dl) x 10: glucose concentration ( mg/dl mg/l) 0.19 x Bwt: glucose space in liters Ginf: glucose concentration in infusate (mg/ml) 15: infusion rate (ml ml/min) x 60: infusion rate (ml/min ml/hr) SMi: SM1-2 x FMi x FMi-1 FMi-1 = Gb/Gi Gb: basal glucose concentration (mg/dl) Gd = Gb = ~90mg/dl SMi = SMi-2 x (Gb/Gi) x (Gb/Gi-1) initial Si = 0 mg /kg /min Si = Glucose Infusion Rate (GIR, mg/kg/min) 3. ITEMS FOR OBS- ERVATION AND CL-

6 INICAL TRIAL, AND HOW TO PERFORM OBSERVATION TESTS A. Primary evaluation variable: The difference of the time to maximal glucose infusion rate (T-GIRmax) when the Euglycemic Clamp method is used by infusing insulin to normal people using aerosol or pen-type syringes. T-GIRmax: The pharmacodynamic meaning, which refers to the point where the lowering effect of the glucose concentration is at the maximum level B. Secondary evaluation variable: Phamacodynamic Measure the following variables for the insulin infusion effects conducted by aerosol and pen-type insulin syringes: Maximum glucose infusion speed (C- GIRmax): Maximum glucoselowering effect, the total dose of glucose (GIRtot), glucose 50 % consumption time (T-GIR50%): Duration of insulin action, Phamacokinetic, measure the number of aerosol and pen-type insulin syringes, the time to maximal insulin concentration (T-INSmax), maximum insulin concentration (C-INSmax), total insulin concentration (INStot), the time to 50% of insulin concentration (T-INS50%), pain measurement Comparison of the pain felt by the subject when insulin is infused by aerosol and pen-type insulin syringes C. Stability evaluation variable: Cutaneous side effects when insulin is infused by aerosol and pen-type insulin syringes D. How to inspect (1) Glucose concentration Collect blood samples two times baseline, at a 5-minute interval up to 4 hours after insulin administration and at a 10-minute interval after 4 hours (74 times in total); measure instantly after collecting blood samples using a portable glucose meter; collect about 1cc blood sample using the inserted catheter. (2) Insulin concentration Collect blood samples 1 time baseline, at a 10-minute interval up to 1 hour after insulin administration and at a 30-minute interval after 1 hour (21 times in total); collect about 4cc blood sample using the inserted catheter. Collect in the Lithium-heparin tube and put into cold storage; keep plasma frozen (-20 ) through centrifugation and analyze plasma insulin concentration. (3) Pain measurement VAS

7 Immediately after administration, present 0-10 points VAS (Visual Analog Scale) for survey responses (4) Cutaneous side effects (Visual observation) 4. TEST RESULT A. Progress and schedule After recruiting 22 normal people that meet the target number, we implemented the Euglycemic Clamp inspection to 20 subjects, 2 times each, by January 31, 2013, besides (considering 10% drop out rate) two drop outs and completed the analysis. B. Analysis result (1) The basis of the clinical information The information of the 20 subjects is as (Table 1) <TABLE 1> The information of the subjects (N=20) CHECK LIST RESULT (AVE.±STANDARD DEVIATION) TOTAL NUMBER 20 SEX (MALE : FEMALE) 8:12 AGE 27.2±6.6 BMI (Kg/m2) 22.9±2.2 Hb (g/dl) 15.4 ± 1.6 Albumin (g/dl) 4.7 ± 0.5 TOTAL bilirubin (mg/dl) 1.1±0.4 TOTAL PROTEIN (g/dl) 7.2±0.4 ALT (IU/L) 16.6±2.9 AST (IU/L) 15.7±6.4 BUN (mg/dl) 12.6±3.7 Cr (mg/dl) 1.0±0.0 URIC-ACID (mg/dl) 5.3±1.1 FASTING GLUCOSE (mg/dl) 89.5±5.2 DIASTATIC HEMOGLOBIN (%) 5.5±0.5 - No difference in the clinical indicator between 10 subjects randomized as the first group to administer using aerosol and pen-type syringes (Table 2-4).

8 <TABLE2> The information of the subjects : Sex and Age (N=20) <TABLE3> The information of the subjects : Alcohol, Smoking (N=20)

9 <TABLE4> The information of Glucose at Screening (N=20) (2) The Euglycemic Clamp inspection result -We implemented the Euglycemic Clamp inspection one-time, a total of two, the insulin administration method in cross-over after administering pen-type and aerosol insulin to the 20 subjects (8 male, 12 female); and randomized 11 subjects, respectively to pen-type and aerosol insulin groups by insulin type. - The result of Euglycemic Clamp inspection for pen-type and aerosol insulin is as Table 5. - The aerosol insulin showed a significant reduction compared to the pen-type in the time to maximal glucose infusion rate (T-GIRmax), which is the primary evaluation variable. - The time to maximal insulin concentration (T-INSmax) show a significant decrease when insulin is administered via the aerosol syringe compared to pen-type syringe, while the maximal insulin concentration (C- INSmax) showed a significant increase when insulin is administered via the aerosol type syringe. - The maximum glucose infusion speed (C-GIRmax) did not demonstrate a significant difference between pen-type and aerosol insulin. - The aerosol-type insulin showed a rapid increase in serum insulin concentration and glucose-lowering effect compared to the pen-type when

10 the same fast-acting insulin was administered. (Figure 1) <TABLE5> Comparison result of Pen type and Needle free injector about Pain Measurement, Pharmacodynamic and pharmacokinetic indicators

11 <Pigure 1> Insulin concentration rate and glucose infusion speed of Jet injector and Pen-type (3) Pain measurement The pain inspection via the VAS scoring after administering insulin showed no difference among the pain felt by subjects when insulin was administered using the pen-type and aerosol-type syringes (1.85±2.08 vs. 1.60±0.88, P=0.514) (Table 5). CONCLUSION (4) Safety evaluation - No significant adverse reactions were found during the test, except a slight headache from one subject - No difference in the vital signs before and after the test concerning pen-type and aerosol-type first dose administration The aerosol-type insulin infusion method showed an increase in the plasma concentration of the fast-acting insulin and glucose-lowering effects appear more quickly when compared with the pen-type insulin injection method; no difference in pain and severe adverse reactions.