Evidence-based clinical use of insulin premixtures

Brazil is expected to have 19.6 million patients with diabetes by the year 2030. A key concept in the treatment of type 2 diabetes mellitus (T2DM) is establishing individualized glycemic goals based on each patient’s clinical characteristics, which impact the choice of antihyperglycemic therapy. Targets for glycemic control, including fasting blood glucose, postprandial blood glucose, and glycated hemoglobin (A1C), are often not reached solely with antihyperglycemic therapy, and insulin therapy is often required. Basal insulin is considered an initial strategy; however, premixed insulins are convenient and are equally or more effective, especially for patients who require both basal and prandial control but desire a more simplified strategy involving fewer daily injections than a basal-bolus regimen. Most physicians are reluctant to transition patients to insulin treatment due to inappropriate assumptions and insufficient information. We conducted a nonsystematic review in PubMed and identified the most relevant and recently published articles that compared the use of premixed insulin versus basal insulin analogues used alone or in combination with rapid-acting insulin analogues before meals in patients with T2DM. These studies suggest that premixed insulin analogues are equally or more effective in reducing A1C compared to basal insulin analogues alone in spite of the small increase in the risk of nonsevere hypoglycemic events and nonclinically significant weight gain. Premixed insulin analogues can be used in insulin-naïve patients, in patients already on basal insulin therapy, and those using basal-bolus therapy who are noncompliant with blood glucose self-monitoring and titration of multiple insulin doses. We additionally provide practical aspects related to titration for the specific premixed insulin analogue formulations commercially available in Brazil.

Oligonucleotide Adsorption Affects Phase Transition but Not Interdigitation of diC14-Amidine Bilayers

Oligonucleotides have been extensively used in basic research of gene expression and function, vaccine design, and allergy and cancer therapy. Several oligonucleotide-based formulations have reached the clinical trial phase and one is already on the market. All these applications, however, are dependent on suitable carriers that protect oligonucleotides against degradation and improve their capture by target cells. The cationic lipid diC14-amidine efficiently delivers nucleic acids to mammalian cells. It was recently shown that diC14-amidine bilayers present an interdigitated phase which strongly correlates with a potent fusogenic activity at low temperatures. Interdigitated phases correspond to very ordered gel phases where the two bilayer leaflets are merged; they usually result from perturbations at the interfacial region such as modifications of the polar headgroup area or dehydration of the bilayer. Interdigitation has been described for asymmetric lipids or mixed-chain lipids of different chain lengths and for lipids with large effective headgroup sizes. It has also been described for symmetric lipids under pressure modifications or in the presence of alcohol, glycerol, acetonitrile, polymyxin B, or ions like thiocyanate. Surprisingly, the role of polyelectrolytes on membrane interdigitation has been only poorly investigated. In the present work, we use dynamic light scattering (DLS), differential scanning calorimetry (DSC), and electron spin resonance (ESR) to explore the effect of a small single-stranded oligonucleotide (ODN) polyelectrolyte on the structure and colloid stability of interdigitated diC14-amidine membranes.