Steven Edelman, MD: Current State of Postprandial Glucose Control

Steven Edelman, MD

As the number of diabetic patients, both pediatric and adult, continues to rise, many endocrinologists are looking forward optimistically in hopes that new therapies will help improve quality of life for their patients.

With multiple products in development, deciding which treatment option fits best into the lives of patients is often about providing insulin in as quick and efficient as possible. While injectable insulin is still a popular treatment choice, the recent announcement of enrollment beginning for a pediatric trial examining insulin human (Afrezza) inhalation powder in children ages 4 through 7 has captured the attention of many throughout the field.

Steven Edelman, MD, clinical professor of medicine at UC San Diego School of Medicine who also helped lead previous trials examining inhaled insulin, recently took part in a Q&A with MD Magazine® to discuss the potential of inhaled insulin going forward.

MD Mag: How do new insulin therapies, specifically for children, alter the current landscape of therapy?

Edelman: Well, most pediatric patients have type 1 diabetes. One of the biggest unmet needs in any individual with type 1 diabetes — no matter what age — is that we need a insulin that has a rapid onset and a rapid offset of action because this will reduce the post-meal spikes and also helps tremendously with a reduction in delayed hypoglycemia.

The current insulins — even the faster acting analogs — they take too long to get into the system, they peak late, and they also hang around for a long time. So, when someone with type 1 diabetes, even in the pediatric age group which is no exception, experience unexpected highs and unexpected lows it can be very frustrating. Our current injectable fast acting insulins just don't work fast enough and they hang around for too long.

MD Mag: What kind of relief does an inhalable insulin give parents compared to other, injectable forms of fast-acting insulin?

Edelman: It is important to say they inhaled insulin is not approved yet by the FDA in the pediatric population but studies are underway. I think it would give them a little bit more comfort that their loved ones will be safer for a greater period of time during the day and night. Of course there's no guarantee that hyper- and hypoglycemia will be avoided, but if you connect any patient —especially pediatric, they're running around a lot more and you can't watch all the time — with a continuous glucose monitor that you can share in real time their glucose numbers, such as the Dexcom and the Eversense. When you have less highs, it negates the need for a correction dose, which when given does not always bring the glucose into a good range. Sometimes the blood sugar is higher than it was when you gave the correction and other times you crash and get a low and that's in part because of the unpredictable nature of subcutaneously injected insulin.

MD Mag: Is there any other therapies that deliver fast-acting insulin available for children, either available or development?

Edelman: Well, it’s (inhaled insulin) definitely ahead of anything else, but there is fast-acting aspart. Now, fast-acting aspart is a little bit faster than aspart and gets out of the system a little bit faster than the regular aspart, a faster acting injected insulin. It really doesn't have the same pharmacokinetics and pharmacokinetics as inhaled insulin, marketing name is Afrezza.

Now, in the development areas. Lilly and Adocia each have their own ultra-rapid acting analogs that are injectable and some of the preliminary data looks like they are definitely faster on and off then other currently available insulins on the market. I'm not quite sure how close they are compared to Afrezza but they are injectable which means you can put them into an insulin pump and you can put them into a hybrid or closed loop artificial pancreas which is nice. This obviously cannot be down with inhaled insulin such as Afrezza.