Search Images Maps Play YouTube News Gmail Drive More »
Sign in
Screen reader users: click this link for accessible mode. Accessible mode has the same essential features but works better with your reader.

Patents

  1. Advanced Patent Search
Publication numberUS20050203001 A1
Publication typeApplication
Application numberUS 11/072,941
Publication dateSep 15, 2005
Filing dateMar 4, 2005
Priority dateMar 5, 2004
Also published asUS8324156, US8729016, US8962554, US20080175907, US20090253614, US20090318331, US20140206612
Publication number072941, 11072941, US 2005/0203001 A1, US 2005/203001 A1, US 20050203001 A1, US 20050203001A1, US 2005203001 A1, US 2005203001A1, US-A1-20050203001, US-A1-2005203001, US2005/0203001A1, US2005/203001A1, US20050203001 A1, US20050203001A1, US2005203001 A1, US2005203001A1
InventorsEhud Arbit, Michael Goldberg, Shingai Majuru
Original AssigneeEmisphere Technologies, Inc.
Export CitationBiBTeX, EndNote, RefMan
External Links: USPTO, USPTO Assignment, Espacenet
Oral insulin therapies and protocol
US 20050203001 A1
Abstract
Methods for treating impaired glucose tolerance and early and late stage diabetes in mammals, for prophylactically sparing β-cell function, aiding in preventing β-cell death, preventing the onset of overt diabetes in a mammal with type 2 diabetes, treating the current level of glycemic control dysfunction of a mammal with impaired glucose tolerance or diabetes, comprising orally administering insulin and a delivery agent that facilitates insulin absorption from the gastrointestinal tract at the time of or shortly before mealtime, e.g., within about 10 minutes prior to ingestion of a meal, on a chronic basis. The methods also comprise, in addition to administering a rapid-acting insulin to provide a first insulin peak, administering a slow acting insulin to provide a second insulin peak occurring at a later time but of a longer duration. These methods achieve improved glycemic control without the risks of hypoglycemia, hyperinsulinemia and weight gain and the need for frequent blood glucose monitoring that are normally associated with insulin therapy.
Images(42)
Previous page
Next page
Claims(87)
1. A method of treating a diabetic patient, comprising:
orally administering to an early stage type II diabetic patient, at a time from about 30 minutes prior to ingestion of a meal to concurrently with ingestion of a meal, a dose of a therapeutically effective amount of unmodified insulin with from about 20 to about 600 mg of a pharmaceutically acceptable delivery agent that facilitates absorption of said insulin from the gastrointestinal tract, said dose contained in one or more pharmaceutically acceptable tablets, to provide a time to maximum plasma concentration of insulin at a time point from about 15 to about 20 minutes after oral administration of said dose, said dose being sufficient to compensate for the lack of a first phase insulin response which occurs endogenously in a non-diabetic subject in response to an ingested meal.
2. The method of claim 1, further comprising administering said dose such that said patient obtains a first peak plasma insulin concentration substantially from said administered dose and a second phase insulin response to said meal substantially from endogenous insulin release.
3. A method of treating a patient with type I diabetes or late stage type II diabetes, comprising:
orally administering to said patient, at the time of or shortly prior to ingestion of a meal, a unit dose of from about 10 Units to about 600 Units (from about 0.4 mg to about 23 mg) of unmodified insulin with from about 20 to about 600 mg of a pharmaceutically acceptable delivery agent that facilitates absorption of said insulin from the gastrointestinal tract to provide a time to maximum plasma concentration of insulin at a time point from about 15 to about 20 minutes after oral administration of said dose, said dose being sufficient to compensate for the lack of a first phase insulin response which occurs endogenously in a non-diabetic subject in response to an ingested meal, and
administering to said patient a separate dose of insulin in an effective amount to replace a second phase insulin response to a meal which occurs a non-diabetic subject substantially from endogenous insulin release.
4. The method of claim 3, further comprising orally administering said dose such that said patient obtains a first peak plasma insulin concentration substantially from said administered dose and administering said separate dose such that said patient obtains a second phase insulin response to said meal substantially from said administered separate dose.
5. The method of claim 3, further comprising, instead of the step of administering to said patient a separate dose of insulin, the step of administering to said patient an effective amount of an agent that causes the patient to secrete sufficient insulin to provide a second phase insulin response similar to a second phase insulin response to a meal which occurs in a non-diabetic subject substantially from endogenous insulin release.
6. The method of claim 5, further comprising orally administering said dose such that said patient obtains a first peak plasma insulin concentration substantially from said administered dose and administering said separate dose such that said patient obtains a second phase insulin response to said meal substantially from endogenous insulin release.
7. The method of claim 3, wherein administration to said patient takes place from about 30 minutes prior to ingestion of one meal daily to concurrently with ingestion of one meal daily.
8. The method of claim 3, wherein administration to said patient takes place at least once daily at a time point chosen from among the group consisting of at bedtime, in the morning and preprandial to one meal from about 30 minutes prior to ingestion of a meal to concurrently with ingestion of the meal.
9. The method of claim 3 wherein chronic administration to said patient is for at least two consecutive weeks.
10. A method of treating pre-diabetic patients, early stage type 2 patients and/or late stage type 2 diabetic patients comprising:
orally administering to the mammal on a chronic basis a pharmaceutical formulation comprising a therapeutically effective dose of insulin and a delivery agent that facilitates absorption of insulin from the gastrointestinal tract,
discontinuing said chronic administration, and
obtaining, as a result of said chronic administration, an improved effect as compared to baseline levels before said chronic administration, said improved effect selected from the group consisting of improved glucose tolerance, improved glycemic control, improved glucose homeostasis, spared β-cell function, prevention of β-cell death or dysfunction, reduction in systemic hyperinsulinemia, delay in the onset of overt or insulin dependent diabetes, reduction in the incidence of a disease state associated with chronic dosing of insulin, improved insulin utilization and insulin sensitivity, and improved insulin secretion capacity.
11. The method of claim 10 wherein said improved effect is improved glucose tolerance as demonstrated by better endogenous capacity of the mammal to handle sugar load as measured by blood glucose concentration, following a sugar load, that is reduced by a statistically significant amount as compared with baseline blood glucose concentration, following a glucose load, prior to said chronic administration.
12. The method of claim 11 wherein said statistically significant amount is a mean of about 15%.
13. The method of claim 10 wherein said improved effect is improved glycemic control as measured by fasting blood glucose concentration that is reduced by a statistically significant amount as compared with baseline fasting blood glucose concentration prior to treatment.
14. The method of claim 13 wherein said statistically significant amount is a mean of about 19%.
15. The method of claim 10 wherein said improved effect is improved glucose tolerance, further comprising the step of achieving said improved glucose tolerance without any statistically significant weight gain by said patient over said period of chronic administration.
16. The method of claim 15 wherein said improved effect is improved glucose tolerance, further comprising the step of achieving said improved glucose tolerance without any statistically significant risk of hypoglycemia in said mammal over said period of chronic administration.
17. The method of claim 10 wherein said improved effect is improved glucose tolerance, further comprising the step of achieving said improved glucose tolerance without any statistically significant risk of hyperinsulinemia in said mammal over said period of chronic administration.
18. The method of claim 10 wherein said improved effect is improved glucose tolerance, further comprising the step of achieving said improved glucose tolerance without the need for monitoring said patient's blood glucose concentrations or HbA1c levels over said period of chronic administration.
19. The method of claim 10 wherein said improved effect is improved glycemic control as measured by serum fructosamine level that is reduced by a statistically significant amount as compared with baseline serum fructosamine level prior to treatment.
20. The method of claim 19 wherein said statistically significant amount is a mean of about 9%.
21. The method of claim 10 wherein said improved effect is improved HbA1c levels as measured by an HbA1c concentration that is reduced by a statistically significant amount as compared with baseline HbA1c concentration prior to treatment.
22. The method of claim 10 wherein said improved effect is improved glycemic control, further comprising the step of achieving said improved glycemic control without any statistically significant weight gain by said patient over said period of chronic administration.
23. The method of claim 10 wherein said improved effect is improved glycemic control, further comprising the step of achieving said improved glycemic control without any statistically significant risk of hypoglycemia in said mammal over said period of chronic administration.
24. The method of claim 10 wherein said improved effect is improved glycemic control, further comprising the step of achieving said improved glycemic control without any statistically significant risk of hyperinsulinemia in said mammal over said period of chronic administration.
25. The method of claim 10 wherein said improved effect is improved glycemic control, further comprising the step of achieving said improved glycemic control without the need for monitoring said patient's blood glucose concentrations or HbA1c levels over said period of chronic administration.
26. The method of claim 10 wherein said improved effect is improved insulin utilization and insulin sensitivity as measured by HOMA (Homeostasis Model Assessment) that is reduced by a statistically significant amount as compared with baseline HOMA (Homeostasis Model Assessment) prior to treatment.
27. The method of claim 10 wherein said improved effect is improved insulin secretion capacity as measured by a Stumvoll first-phase insulin secretion capacity index as compared with a baseline Stumvoll first-phase insulin secretion capacity index prior to treatment.
28. The method of claim 10 wherein administration to said patient takes place from about 30 minutes prior to ingestion of one meal daily to concurrently with ingestion of one meal daily.
29. The method of claim 10 wherein administration to said patient takes place at least once daily at a time point chosen from among the group consisting of at bedtime, in the morning and preprandial to one meal from about 30 minutes prior to ingestion of a meal to concurrently with ingestion of the meal.
30. The method of claim 10 wherein administration to said patient takes place at least twice daily at time points chosen from among the group consisting of at bedtime, in the morning and preprandial to at least one meal at from about 30 minutes prior to ingestion of a meal to concurrently with ingestion of the meal.
31. The method of claim 10 wherein administration to said patient takes place at least three times daily at time points chosen from among the group consisting of at bedtime, in the morning and preprandial to at least one meal at from about 30 minutes prior to ingestion of a meal to concurrently with ingestion of the meal.
32. The method of claim 10 wherein administration to said patient takes place at least four times daily at time points chosen from among the group consisting of at bedtime, in the morning and preprandial to at least one meal at from about 30 minutes prior to ingestion of a meal to concurrently with ingestion of the meal.
33. The method of claim 10 wherein administration to said patient takes place at bedtime and preprandial to three meals at from about 30 minutes prior to ingestion of a meal to concurrently with ingestion of the meal.
34. The method of claim 10 wherein chronic administration to said patient is for at least two consecutive weeks.
35. The method of claim 3 wherein the second pharmaceutical formulation is administered at least once orally.
36. The method of claim 3 wherein the second pharmaceutical formulation is administered at least once subcutaneously.
37. The method of claim 10, wherein said method achieves a therapeutically effective reduction in blood glucose after treatment of said patient, and provides a ratio of portal vein to peripheral blood insulin concentration from about 2:1 to about 6:1.
38. The method of claim 10, wherein administration of said oral dose provides a maximum blood glucose concentration reduction caused by said dose of insulin after about 30 minutes after oral administration.
39. The method of claim 10, wherein the amount of insulin contained in said dose is from about 10 Units (0.4 mg) to about 600 Units (23 mg).
40. The method of claim 10, wherein the amount of insulin contained in said dose is from about 100 Units (3.8 mg) to about 450 Units (15.3 mg).
41. The method of claim 10, wherein the amount of insulin contained in said dose is from about 200 Units (5.75 mg) to about 350 Units (13.4 mg).
42. The method of claim 10, wherein said delivery agent is of the formula or a pharmaceutically acceptable salt thereof,
wherein
X is hydrogen or halogen;
R is substituted or unsubstituted C1-C3 alkylene, substituted or unsubstituted C1-C3 alkenylene, substituted or unsubstituted C1-C3 alkyl(arylene), substituted or unsubstituted C1-C3 aryl(alkylene).
43. The method of claim 42, wherein X is a halogen, or wherein R=C3, or both.
44. The method of claim 43, wherein said halogen is chlorine.
45. The method of claim 10, wherein chronic administration to said patient is for at least two consecutive weeks.
46. A method for treating a patient in accordance with the patient's stage of development of diabetes mellitus, comprising:
(a) identifying a patient's stage of diabetes along a continuum of development of diabetes as one of prediabetic stage, early stage type 2 diabetes, late stage type 2 diabetes and type 1 diabetes; and
(b) recommending a treatment to said patient that includes an oral insulin treatment appropriate to said patient's stage along the continuum of development of diabetes.
47. The method of claim 46 wherein said patient is at the prediabetic stage along said continuum of development of diabetes, and said treatment is administration to said patient on a chronic basis a pharmaceutical formulation comprising a therapeutically effective dose of insulin and a delivery agent that facilitates absorption of insulin from the gastrointestinal tract, at least once daily at a time point chosen from among the group consisting of at bedtime, in the morning and preprandial to one meal from about 30 minutes prior to ingestion of a meal to concurrently with ingestion of the meal.
48. The method of claim 47 wherein administration to said patient is at bedtime.
49. The method of claim 46 wherein said patient is at the early diabetic stage along said continuum of development of diabetes, and said treatment is administration to said patient on a chronic basis a pharmaceutical formulation comprising a therapeutically effective dose of insulin and a delivery agent that facilitates absorption of insulin from the gastrointestinal tract, at least twice daily at time points chosen from among the group consisting of at bedtime and preprandial to at least one meal at from about 30 minutes prior to ingestion of a meal to concurrently with ingestion of the meal.
50. The method of claim 49 wherein administration to said patient is at bedtime.
51. The method of claim 49 wherein administration to said patient is at bedtime and preprandial all meals.
52. The method of claim 46 wherein said patient is at the late diabetic stage along said continuum of development of diabetes, and said treatment is administration to said patient on a chronic basis a pharmaceutical formulation comprising a therapeutically effective dose of insulin and a delivery agent that facilitates absorption of insulin from the gastrointestinal tract, at least three times daily at time points chosen from among the group consisting of at bedtime and preprandial to at least one meal at from about 30 minutes prior to ingestion of a meal to concurrently with ingestion of the meal.
53. The method of claim 52 wherein administration to said patient is at bedtime and preprandial all meals.
54. The method of claim 52 further comprising administering to the mammal on a chronic basis a therapeutically effective dose of a second pharmaceutical formulation comprising an intermediate-acting and/or a long-acting insulin.
55. The method of claim 54 wherein the second pharmaceutical formulation is administered at least once a day orally.
56. The method of claim 54 wherein the second pharmaceutical formulation is administered at least once a day subcutaneously.
57. The method of claim 54 wherein the pharmaceutical formulation and the second pharmaceutical formulation provide two different activity rates in order to simulate the endogenous biphasic release of insulin to an ingested meal in a non-diabetic subject.
58. An oral solid dosage form comprising a dose of unmodified insulin and an effective amount of a delivery agent that facilitates the absorption of the insulin from the gastrointestinal tract and an excipient, one or more of said dosage forms upon administration to a diabetic patient at a time from about 30 minutes prior to ingestion of a meal to concurrently with ingestion of a meal providing a therapeutically effective reduction in blood glucose after oral administration and a time to maximum plasma concentration of insulin at a time point from about 15 to about 20 minutes after oral administration, said total dose being sufficient to replace an endogenous first phase insulin response to an ingested meal in a non-diabetic subject.
59. The oral dosage form of claim 58, wherein said dosage form is a tablet.
60. A substantially homogeneous oral tablet comprising a therapeutically effective dose of insulin, a delivery agent that facilitates absorption of insulin from the gastrointestinal tract and an excipient suitable for tableting, said tablet upon administration to a diabetic patient at a time from about 30 minutes prior to ingestion of a meal to concurrently with ingestion of a meal providing a therapeutically effective reduction in blood glucose after oral administration.
61. The substantially homogeneous oral tablet of claim 60, further comprising per dosage unit a dose of insulin within the range of from about 10 Units (about 2 mg) to about 600 Units (about 23 mg), a delivery agent that facilitates absorption of insulin from the gastrointestinal tract within the range of from about 20 mg to about 600 mg, and at least one pharmaceutically acceptable excipient, such that an effective dose comprising one or more of said tablets upon administration to a diabetic mammal providing a therapeutically effective reduction in blood glucose of said mammal.
62. The tablet of claim 60, wherein said delivery agent is of the formula or a pharmaceutically acceptable salt thereof,
wherein
X is hydrogen or halogen;
R is substituted or unsubstituted C1-C3 alkylene, substituted or unsubstituted C1-C3 alkenylene, substituted or unsubstituted C1-C3 alkyl(arylene), substituted or unsubstituted C1-C3 aryl(alkylene).
63. The tablet of claim 62, wherein X is a halogen, or wherein R=C3, or both.
64. The tablet of claim 63, wherein said halogen is chlorine.
65. The tablet of claim 60, wherein said delivery agent is 4-[(4-chloro, 2-hydroxybenzoyl)amino]butanoic acid.
66. The tablet of claim 60, which provides a maximum plasma insulin concentration at from about 5 minutes to about 25 minutes after oral administration.
67. The tablet of claim 60, which provides a maximum blood glucose concentration reduction caused by said dose of insulin after about 30 minutes after oral administration.
68. The tablet of claim 60, wherein the amount of insulin contained in said tablet is from about 100 Units (3.8 mg) to about 450 Units (15.3 mg).
69. The tablet of claim 60, wherein the amount of delivery agent contained in said tablet is from about 20 mg to about 600 mg.
70. The tablet of claim 60, wherein the ratio of Insulin [Units] to delivery agent [mg] ranges from 10:1 [Units/mg] to 1:10 [Units/mg].
71. The tablet of claim 58, wherein said delivery agent is of the formula or a pharmaceutically acceptable salt thereof,
wherein
X is hydrogen or halogen;
R is substituted or unsubstituted C1-C3 alkylene, substituted or unsubstituted C1-C3 alkenylene, substituted or unsubstituted C1-C3 alkyl(arylene), substituted or unsubstituted C1-C3 aryl(alkylene).
72. The tablet of claim 58, wherein X is a halogen, or wherein R=C3, or both.
73. The tablet of claim 58, wherein said halogen is chlorine.
74. The tablet of claim 58, wherein said delivery agent is 4-[(4-chloro, 2-hydroxybenzoyl)amino]butanoic acid.
75. The tablet of claim 58, which provides a maximum plasma insulin concentration at from about 5 minutes to about 25 minutes after oral administration.
76. The tablet of claim 58, which provides a maximum blood glucose concentration reduction caused by said dose of insulin after about 30 minutes after oral administration.
77. The tablet of claim 58, wherein the amount of insulin contained in said tablet is from about 100 Units (3.8 mg) to about 450 Units (15.3 mg).
78. The tablet of claim 58, wherein the amount of delivery agent contained in said tablet is from about 20 mg to about 600 mg.
79. The tablet of claim 58, wherein the ratio of Insulin [Units] to delivery agent [mg] ranges from 10:1 [Units/mg] to 1:10 [Units/mg].
80. The method of claim 1, wherein said delivery agent is of the formula or a pharmaceutically acceptable salt thereof,
wherein
X is hydrogen or halogen;
R is substituted or unsubstituted C1-C3 alkylene, substituted or unsubstituted C1-C3 alkenylene, substituted or unsubstituted C1-C3 alkyl(arylene), substituted or unsubstituted C1-C3 aryl(alkylene).
81. The method of claim 80, wherein X is a halogen, or wherein R=C3, or both.
82. The method of claim 81, wherein said halogen is chlorine.
83. The method of claim 1, wherein said delivery agent is 4-[(4-chloro, 2-hydroxybenzoyl)amino]butanoic acid.
84. The method of claim 3, wherein said delivery agent is of the formula or a pharmaceutically acceptable salt thereof,
wherein
X is hydrogen or halogen;
R is substituted or unsubstituted C1-C3 alkylene, substituted or unsubstituted C1-C3 alkenylene, substituted or unsubstituted C1-C3 alkyl(arylene), substituted or unsubstituted C1-C3 aryl(alkylene).
85. The method of claim 84, wherein X is a halogen, or wherein R=C3, or both.
86. The method of claim 85, wherein said halogen is chlorine.
87. The method of claim 3, wherein said delivery agent is 4-[(4-chloro, 2-hydroxybenzoyl)amino]butanoic acid.
Description
    CROSS REFERENCE TO RELATED APPLICATIONS
  • [0001]
    This application claims the benefit of U.S. Provisional Patent Applications No. 60/550,401, filed Mar. 5, 2004, No. 60/561,102, filed Apr. 9, 2004, No. 60/574,096, filed May 24, 2004, and No. 60/576,912, filed Jun. 4, 2004, and is a continuation-in-part of International Application No. PCT/US04/06943, filed Mar. 5, 2004.
  • FIELD OF THE INVENTION
  • [0002]
    This invention relates to the oral delivery of insulin in a therapeutically effective amount to the bloodstream as part of a therapeutic regimen for the treatment of diabetes. This invention also relates to oral administration of compositions of insulin and a delivery agent that facilitates insulin transport in a therapeutically effective amount to the bloodstream for the treatment of diabetes. The present invention is also directed to therapies and protocols for administration of oral pharmaceutical dosage forms of insulin on a chronic basis to pre-diabetics, including those with impaired glucose tolerance and/or insulin resistance, to early stage diabetics, and to late stage diabetics. The present invention further relates to methods for reducing adverse effects and the incidence of diseases that are associated with systemic hyperinsulinemia and hyperglycemia, especially to the β-cells of the pancreas.
  • BACKGROUND OF THE INVENTION
  • [0003]
    Proteins, peptides and other biological molecules (“biological macromolecules”, namely biological polymers such as proteins and polypeptides) are increasingly being use in many diverse areas of science and technology. For example, proteins are employed as active agents in the fields of pharmaceuticals, vaccines and veterinary products. Unfortunately, the use of biological macromolecules as active agents in pharmaceutical compositions is often severely limited by the presence of natural barriers of passage to the location where the active agent is required. Such barriers include the skin, lipid bi-layers, mucosal membranes, severe pH conditions and digestive enzymes.
  • [0004]
    There are many obstacles to successful oral delivery of biological macromolecules. For example, biological macromolecules are large and are amphipathic in nature. More importantly, the active conformation of many biological macromolecules may be sensitive to a variety of environmental factors, such as temperature, oxidizing agents, pH, freezing, shaking and shear stress. In planning oral delivery systems comprising biological macromolecules as an active agent for drug development, these complex structural and stability factors must be considered. In addition, in general, for medical and therapeutic applications, where a biological macromolecule is being administered to a patient and is expected to perform its physiologic action, delivery vehicles can be used to facilitate absorption through the gastro-intestinal tract. These delivery vehicles must be able to release active molecules at a rate that is consistent with the needs of the particular patient or the disease process.
  • [0005]
    One specific biological macromolecule, the hormone insulin, contributes to the normal regulation of blood glucose levels through its release by the pancreas, more specifically by the β-cells of a major type of pancreatic tissue (the islets of Langerhans), so that the glucose can be used as a source of energy. Insulin secretion is a regulated process that, in normal subjects, provides stable concentrations of glucose in blood during both fasting and feeding. In healthy humans, insulin is secreted from the pancreas into the portal vein, which carries the insulin to the liver. The liver utilizes and/or metabolizes a large portion of the insulin that it receives from the portal circulation. In very basic terms, the liver plays a key role in the metabolism of glucose as follows: in the presence of excess insulin, excess glucose, or both, the liver modulates the production of glucose released into the blood; and, in the absence of insulin or when the blood glucose concentration falls very low, the liver manufactures glucose from glycogen and releases it into the blood. The liver acts as a key blood glucose buffer mechanism by keeping blood glucose concentrations from rising too high or from falling too low.
  • [0006]
    Blood glucose concentration is the principal stimulus to insulin secretion in healthy humans. The exact mechanism by which insulin release from the pancreas is stimulated by increased glucose levels is not fully understood, but the entry of glucose into the β-cells of the pancreas is required. Glucose enters the pancreatic β-cells by facilitated transport and is then phosphorylated by glucokinase. Expression of glucokinase is primarily limited to cells and tissues involved in the regulation of glucose metabolism, such as the liver and the pancreatic β-cells. The capacity of sugars to undergo phosphorylation and subsequent glycolysis correlates closely with their ability to stimulate insulin release. It is noted that not all tissues are dependent on insulin for glucose uptake. For example, the brain, kidneys and red blood cells are insulin independent tissues, while the liver, adipose and muscle are insulin dependent tissues.
  • [0007]
    When evoked by the presence of glucose (e.g., after a solid meal is ingested) in a non-diabetic individual, insulin secretion is biphasic: shortly after ingesting food, the pancreas releases the stored insulin in a burst, called a first phase insulin response, and then approximately 15-20 minutes later outputs further insulin to control the glycemic level from the food. The first phase insulin response reaches a peak after 1 to 2 minutes and is short-lived, whereas a second phase of secretion has a delayed onset but a longer duration. Thus, secretion of insulin rises rapidly in normal human subjects as the concentration of blood glucose rises above base levels (e.g., 100 mg/100 ml of blood), and the turn-off of insulin secretion is also rapid, occurring within minutes after reduction in blood glucose concentrations back to the fasting level.
  • [0008]
    In healthy human subjects, insulin secretion is a tightly regulated process that maintains blood concentrations of glucose within an acceptable range regardless of whether or not the subject has ingested a meal (i.e., fasting and fed states). Insulin facilitates (and increases the rate of) glucose transport through the membranes of many cells of the body, particularly skeletal muscle and adipose tissue. Insulin has three basic effects: the enhanced rate of glucose metabolism, the promotion of increased glycogen stores in muscle and adipose tissue, and decreased circulating blood glucose concentration.
  • [0009]
    Diabetes Mellitus (“diabetes”) is a disease state in which the pancreas does not release insulin at levels capable of controlling blood glucose and/or in which muscle, fat and liver cells respond poorly to normal insulin levels because of insulin resistance. Diabetes thus can result from a dual defect of insulin resistance and “burn out” of the β-cells of the pancreas. Diabetes is classified into two types: Type 1 and Type 2. Approximately 5 to 10% of diagnosed cases of diabetes are attributed to Type 1, and approximately 90% to 95% are attributed to Type 2.
  • [0010]
    Type 1 diabetes is diabetes that is insulin dependent and usually first appears in young people. In Type 1 diabetes, the islet cells of the pancreas stop producing insulin mainly due to autoimmune destruction, and the patient must self-inject the missing hormone. For type 1 diabetics, insulin therapy is essential and is intended to replace the absent endogenous insulin with an exogenous insulin supply.
  • [0011]
    Type 2 diabetes is commonly referred to as adult-onset diabetes or non-insulin dependent diabetes and may be caused by a combination of insulin resistance (or decreased insulin sensitivity) and, in later stages, insufficient insulin secretion. This is the most common type of diabetes in the Western world. Close to 6% of the adult population of various countries around the world, including the United States, have Type 2 diabetes, and about 30% of these patients will need exogenous insulin at some point during their lifespans due to secondary pancreatic exhaustion and the eventual cessation of insulin production. For type 2 diabetics, therapy has consisted first of oral antidiabetic agents, which increase insulin sensitivity and/or insulin secretion, and only then insulin if, and when, the oral agents fail.
  • [0012]
    Diabetes is the sixth leading cause of death in the United States and accounted for more than 193,000 deaths in 1997. However, this figure is an underestimate because complications resulting from diabetes are a major cause of morbidity in the population. Diabetes is associated with considerable morbidity and mortality in the form of cardiovascular disease, stroke, digestive diseases, infection, metabolic complications, ophthalmic disorders, neuropathy, kidney disease and failure, peripheral vascular disease, ulcerations and amputations, oral complications, and depression. Thus, diabetes contributes to many deaths that are ultimately ascribed to other causes.
  • [0013]
    The main cause of mortality with Diabetes Mellitus is long term micro- and macro-vascular disease. Cardiovascular disease is responsible for up to 80% of the deaths of type 2 diabetic patients, and diabetics have a two- to four-fold increase in the risk of coronary artery disease, equal that of patients who have survived a stroke or myocardial infarction. In other words, heart disease, high blood pressure, heart attacks and strokes occur two to four times more frequently in adult diabetics than in adult non-diabetics. This increased risk of coronary artery disease combined with an increase in hypertensive cardiomyopathy manifests itself in an increase in the risk of congestive heart failure. These vascular complications lead to neuropathies, retinopathies and peripheral vascular disease. Diabetic retinopathy (lesions in the small blood vessels and capillaries supplying the retina of the eye, i.e., the breakdown of the lining at the back of the eye) is the leading cause of blindness in adults aged 20 through 74 years, and diabetic kidney disease, e.g., nephropathy (lesions in the small blood vessels and capillaries supplying the kidney, which may lead to kidney disease, and the inability of the kidney to properly filter body toxins), accounts for 40% of all new cases of end-stage renal disease (kidney failure). Furthermore, diabetes is also the leading cause for amputation of limbs in the United States. Diabetes causes special problems during pregnancy, and the rate of congenital malformations can be five times higher in the children of women with diabetes.
  • [0014]
    Poor glycemic control contributes to the high incidence of these complications, and the beneficial effects of tight glycemic control on the chronic complications of diabetes are widely accepted in clinical practice. However, only recently has it been firmly established that elevated blood glucose levels are a direct cause of long-term complications of diabetes. The Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study both showed that control of blood glucose at levels as close to normal as possible prevents and retards development of diabetic retinopathy, nephropathy, neuropathy and microvascular disease.
  • [0015]
    Insulin resistance (or decreased insulin sensitivity) is also prevalent in the population, especially in overweight individuals, in those with risk of diabetes (i.e., pre-diabetic, wherein blood glucose levels are higher than normal but not yet high enough to be diagnosed as diabetes) and in individuals with type 2 diabetes who produce enough insulin but whose tissues have a diminished ability to adequately respond to the action of insulin. When the liver becomes insulin-resistant, the mechanism by which insulin affects the liver to suppress its glucose production breaks down, and the liver continues to produce glucose, even under hyperinsulinemic conditions (elevated plasma insulin levels). This lack of suppression can lead to a hyperglycemia (elevated blood glucose levels), even in a fasting state.
  • [0016]
    In order to compensate and to overcome the insulin resistance, the pancreatic β-cells initially increase their insulin production such that insulin resistant individuals often have high plasma insulin levels. This insulin is released into the portal vein and presented to the liver constantly or almost constantly. It is believed that the liver's constant exposure to high levels of insulin plays a role in increased insulin resistance and impaired glucose tolerance. After a period of high demand placed on the pancreatic β-cells, the cells start to decompensate and exhaust, and insulin secretion, or insulin secretory capacity, is reduced at later stages of diabetes. It is estimated that, by the time an individual is diagnosed with type 2 diabetes, roughly 50% of the β-cells have already died due to increased demand for insulin production.
  • [0017]
    Insulin resistance plays an important role in the pathogenesis of hyperglycemia in type 2 diabetes, eventually inducing the development of diabetic complications. Furthermore, insulin resistance ostensibly plays a role in the pathogenesis of macrovascular disease, cardiovascular diseases and microvascular disease. See, for example, Shinohara K. et al., Insulin Resistance as an Independent Predictor of Cardiovascular Mortality in Patients With End-Stage Renal Disease, J. Am. Soc. Nephrol., Vol. 13, No. 7, July 2002, pp. 1894-1900. Research currently shows that insulin resistance reaches a maximum and then plateaus. Once the insulin resistance plateaus, it is believed to not get appreciably worse, but can improve.
  • [0018]
    Diabetes or insulin resistance can be diagnosed in many ways, as is known to those in the art. For example, the initial diagnose may be made from a glucose tolerance test (GTT), where a patient is given a bolus of glucose, usually orally, and then the patient's blood glucose levels are measured at regular time intervals for approximately 2 hours, or as many as 6 hours in the case of an extended GTT. Another method of testing for diabetes or insulin resistance is a test of the patients fasting or postprandial glucose. Other tests, such as Glycosolated Hemoglobin, often reported as Hemoglobin A1c (HbA1c) can be used to assess blood glucose over 2-3 months.
  • [0019]
    Several methods to assess insulin resistance are currently available, including the euglycemic-hyperinsulinemic clamp, fasting plasma insulin, homeostasis model assessment (HOMA) of insulin resistance (HOMA-IR), the fasting glucose-to-insulin ratio method and quantitative insulin sensitivity check index (QUICKI). Except for the euglycemic-hyperinsulinemic clamp method, the others are surrogate indices and are indirect methods of assessing insulin resistance. For example, the HOMA-IR is calculated from fasting plasma glucose (FPG) and fasting immunoreactive insulin (FIRI) with the formula HOMA-IR=FIRI in mU/1×FPG in mg/dl/405. In addition, the reciprocal index of homeostasis model assessment (1/HOMA-IR) is also calculated. Similarly, QUICKI is derived from logarithmic-transformed FPG and insulin levels as calculated from FPG and FIRI levels with the formula QUICKI=1/(log [FIRI in mU/l]+log [FPG in mg/dl]).
  • [0020]
    Several oral hypoglycemic agents have been developed for specifically improving a patient's insulin resistance, such as thiazolidinediones, which make the patient more sensitive to insulin, and biguanides, which decrease the amount of glucose made by the liver, and these are currently available clinically for patients with diabetes and insulin resistance. In addition, sulfonylureas stimulate the pancreas to make more insulin, alpha-glucosidase inhibitors slow the absorption of the starches eaten by an individual, meglitinides stimulate the pancreas to make more insulin, and D-phenylalanine derivatives help the pancreas make more insulin quickly. Present treatment of insulin resistance involves sensible lifestyle changes, including weight loss to attain healthy body weight, 30 minutes of accumulated moderate-intensity physical activity per day and diet control, including increased dietary fiber intake and regulation of blood sugar levels and of caloric intake. In addition, Metformin, which has been used successfully for some time to treat diabetes because it increases insulin sensitivity, is also being studied as a treatment.
  • [0021]
    The aim of insulin treatment of diabetics is typically to administer enough insulin such that the patient will have normal carbohydrate metabolism throughout the day. Because the pancreas of a diabetic individual does not secrete sufficient insulin throughout the day, in order to effectively control diabetes through insulin therapy, a long-lasting insulin treatment, known as basal insulin, must be administered to provide the slow and steady release of insulin that is needed to control blood glucose concentrations and to keep cells supplied with energy when no food is being digested. Basal insulin is necessary to suppress glucose production between meals and overnight, and preferably mimics the patient's normal pancreatic basal insulin secretion over a 24-hour period. Thus, a diabetic patient may administer a single dose of a long-acting insulin each day subcutaneously, with an action lasting about 24 hours.
  • [0022]
    Furthermore, in order to effectively control diabetes through insulin therapy by dealing with post-prandial rises in glucose levels, a bolus, fast-acting treatment must also be administered. The bolus insulin, which has generally been administered subcutaneously, provides a rise in plasma insulin levels at approximately 1 hour after administration, thereby limiting hyperglycemia after meals. Thus, these additional quantities of regular insulin, with a duration of action of, e.g., 5-6 hours, may be subcutaneously administered at those times of the day when the patient's blood glucose level tends to rise too high, such as at meal times. Alternative to administering basal insulin in combination with bolus insulin, repeated and regular lower doses of bolus insulin may be administered in place of the long-acting basal insulin, and bolus insulin may be administered postprandially as needed.
  • [0023]
    The problem of providing bioavailable unmodified human insulin, in a useful form, to an ever-increasing population of diabetics has occupied physicians and scientists for almost 100 years. Many attempts have been made to solve some of the problems of stability and biological delivery of this peptide. Because insulin is a peptide drug (MW approx. 6000 Da) that is not absorbed intact in the gastrointestinal tract, it ordinarily requires parenteral administration such as by subcutaneous injection. Thus, most diabetic patients self-administer insulin by subcutaneous injections, often multiple times per day. However, the limitations of multiple daily injections, such as pain, inconvenience, frequent blood glucose monitoring, poor patient acceptability, compliance and the difficulty of matching postprandial insulin availability to postprandial glucose-control requirements, are some of the shortcomings of insulin therapy.
  • [0024]
    Currently, regular subcutaneously injected insulin is recommended to be dosed at 30 to 45 minutes prior to mealtime. As a result, diabetic patients and other insulin users must engage in considerable planning of their meals and of their insulin administrations relative to their meals. Unfortunately, intervening events that may take place between administration of insulin and ingestion of the meal may affect the anticipated glucose excursion. Furthermore, there is also the potential for hypoglycemia if the administered insulin provides a therapeutic effect over too great a time, e.g., after the rise in glucose levels that occur as a result of ingestion of the meal has already been lowered.
  • [0025]
    Despite studies demonstrating the beneficial effects of tight glycemic control on chronic complications of diabetes, clinicians do not often recommend aggressive insulin therapy, particularly in the early stages of the disease, and this is widely accepted in clinical practice. The unmet challenge of achieving tight glycemic control is due, in part, to the shortcomings of frequent blood glucose monitoring, the available subcutaneous route of insulin administration and the fear of hypoglycemia. In addition to the practical limitations of multiple daily injections discussed above, the shortcomings of the commonly available subcutaneous route of insulin administration have resulted in the generally inadequate glycemic control believed to be associated with many of the chronic complications (comorbidities) associated with diabetes. Thus, while intensive insulin therapy may reduce many of the complications of diabetes, the treatment also increases the risk of hypoglycemia and often results in weight gain, as reported in Diabetes Care, Volume 24, pp. 1711-21 (2001).
  • [0026]
    In addition, hyperinsulinemia (elevated blood concentrations of insulin) can also occur, such as by the administration of insulin in a location (and manner) that is not consistent with the normal physiological route of delivery. Insulin circulates in blood as the free monomer, and its volume of distribution approximates the volume of extracellular fluid. Under fasting conditions, the concentration of insulin in portal blood is, e.g., about 2-4 ng/mL, whereas the systemic (peripheral) concentration of insulin is, e.g., about 0.5 ng/mL, in normal healthy humans, translating into, e.g., a 5:1 ratio. In human diabetics who receive insulin via subcutaneous injection, the portal vein to periphery ratio is changed to about 0.75:1. Thus, in such diabetic patients, the liver does not receive the necessary concentrations of insulin to adequately control blood glucose, while the peripheral circulation is subjected to higher concentrations of insulin than are found in healthy subjects. Elevated systemic levels of insulin may lead to increased glucose uptake, glycogen synthesis, glycolysis, fatty acid synthesis, cortisol synthesis and triacylglycerol synthesis, leading to the expression of key genes that result in greater utilization of glucose.
  • [0027]
    One aspect of the physiological response to the presence of insulin is the stimulation of glucose transport into muscle and adipose tissue. It has been reported that hyperglycemia and/or hyperinsulinemia is related to vascular diseases associated with diabetes. Impairment to the vascular system is believed to be the reason behind conditions such as microvascular complications or diseases, such as retinopathy, neuropathy (impairment of the function of the autonomic nerves, leading to abnormalities in the function of the gastrointestinal tract and bladder and loss of feeling in lower extremities) and nephropathy, or macrovascular complications or diseases, such as cardiovascular disease, etc.
  • [0028]
    In the field of insulin delivery, where multiple repeated administrations are required on a daily basis throughout the patient's life, it is desirable to create compositions of insulin that do not alter physiological clinical activity and that do not require injections. Oral delivery of insulin is a particularly desirable route of administration, for safety and convenience considerations, because it can minimize or eliminate the discomfort that often attends repeated hypodermic injections. It has been a significant unmet goal in the art to imitate normal insulin levels in the portal and systemic circulation via oral administration of insulin.
  • [0029]
    Oral delivery of insulin may have advantages beyond convenience, acceptance and compliance issues. Insulin absorbed in the gastrointestinal tract is thought to mimic the physiologic route of insulin secreted by the pancreas because both are released into the portal vein and carried directly to the liver before being delivered into the peripheral circulation. Absorption into the portal vein maintains a peripheral-portal insulin gradient that regulates insulin secretion. In its first passage through the liver, roughly 60% of the insulin is retained and metabolized, thereby reducing the incidence of peripheral hyperinsulinemia, a factor linked to complications in diabetes.
  • [0030]
    However, insulin exemplifies the problems confronted in the art in designing an effective oral drug delivery system for biological macromolecules. Insulin absorption in the gastrointestinal tract is prevented presumably by its molecular size and its susceptibility for enzymatic degradation. The physicochemical properties of insulin and its susceptibility to enzymatic digestion have precluded the design of a commercially viable oral or alternate delivery system.
  • [0031]
    Emisphere Technologies, Inc. has developed compositions of insulin that are orally administrable, e.g., absorbed from the gastrointestinal tract in adequate concentrations, such that the insulin is bioavailable and bioactive following oral administration and provide sufficient absorption and pharmacokinetic/pharmacodynamic properties to provide the desired therapeutic effect, i.e., cause a reduction of blood glucose, as disclosed in U.S. patent application Nos. 10/237,138, 60/346,746, 60/347,312, 60/368,617, 60/374,979, 60/389,364, 60/438,195, 60/438,451, 60/578,967, 60/452,660, 60/488,465, 60/518,168, 60/535,091 and 60/540,462, as well as in International Patent Application Publications Nos. WO 03/057170, WO 03/057650 and WO 02/02509 and International Patent Application No. PCT/US04/00273, all assigned to Emisphere Technologies, Inc., all of which are incorporated herein by reference.
  • [0032]
    The novel drug delivery technology of Emisphere Technologies, Inc. is based upon the design and synthesis of low molecular weight compounds called “delivery agents.” When formulated with insulin, the delivery agent, which is in a preferred embodiment sodium N-[4-(4-chloro-2 hydroxybenzoyl)amino]butyrate (4-CNAB), enables the gastrointestinal absorption of insulin. It is believed that the mechanism of this process is that 4-CNAB interacts with insulin non-covalently, creating more favorable physical-chemical properties for absorption. Once across the gastrointestinal wall, insulin disassociates rapidly from 4-CNAB and reverts to its normal, pharmacologically active state. 4-CNAB is not intended to possess any inherent pharmacological activity and serves only to increase the oral bioavailability of insulin by facilitating the transport of insulin across the gastrointestinal wall. The pharmacology of insulin is the desired therapeutic effect and is well characterized.
  • [0033]
    Insulin/4-CNAB capsules were evaluated by Emisphere Technologies, Inc. in a nonclinical program that included pharmacological screening, pharmacokinetic and metabolic profiles, and toxicity assessments in rats and monkeys. These studies in rats and monkeys showed that 4-CNAB is absorbed rapidly following oral administration and that, over the range tested, insulin absorption increased with increasing doses of 4-CNAB. Similarly, for a fixed oral dose of 4-CNAB, insulin absorption increased with increasing doses of insulin. Preclinical pharmacokinetic studies in rats and monkeys showed that both insulin and 4-CNAB were absorbed and eliminated rapidly following oral administration. Receptor binding screening assays revealed that 4-CNAB possessed no inherent pharmacological activity and serves only to facilitate the oral bioavailability of insulin.
  • [0034]
    Toxicology studies were also conducted in rats and monkeys to assess the potential toxicity of 4-CNAB, alone or in combination with insulin. Based on the 14-day oral repeated dose toxicity studies, the NOAEL (No-Adverse Effect Level) was estimated to be 500 mg/kg in Sprague-Dawley rats, and 400 mg/kg in rhesus monkeys. In the 90-day oral repeated dose toxicity studies, NOAELs of 250 mg/kg and 600 mg/kg were observed in rats and monkeys, respectively. Four genotoxicity studies have also been conducted with 4-CNAB, with no positive findings. Developmental and reproductive toxicology studies have not yet been conducted.
  • [0035]
    Oral insulin/4-CNAB capsules were also evaluated by Emisphere Technologies, Inc. in clinical human studies for safety, pharmacokinetics, pharmacodynamics, and the effect of food on the absorption of insulin/4-CNAB. In these studies, 4-CNAB was shown to enhance the gastrointestinal absorption of insulin following oral administration in diabetic patients and healthy subjects. Oral administration of Insulin/4-CNAB capsules resulted in rapid absorption (tmax ˜20-30 minutes) of both insulin and 4-CNAB, and the insulin absorbed orally in combination with 4-CNAB was pharmacologically active, as demonstrated by a reduction of blood glucose in healthy and diabetic subjects and by a blunting of postprandial glucose excursion in diabetic patients. These studies suggest that oral administration of a formulation of insulin/4-CNAB is well-tolerated and reduces blood glucose concentrations in both healthy subjects and diabetic patients.
  • [0036]
    Whereas traditional subcutaneous insulin dosing shifts the point of entry of insulin into the systemic circulation from the natural site (the portal vein), the oral dosing method developed by Emisphere Technologies, Inc. is thought to mimic natural physiology, namely, the ratio of concentration of insulin in the portal circulation to that in the systemic circulation approaches the normal physiological ratio, e.g., from about 2:1 to about 6:1. The effect of this route of dosing is two fold. First, by targeting the liver directly, a greater control of glucose may be achieved. Various studies have shown that intraportal delivery of insulin can yield a comparable control of glucose at infusion rates lower than those required by peripheral administration. Because the orally-administered insulin will undergo substantial (˜50%) first-pass metabolism prior to entering the systemic circulation, a lower plasma concentration and total exposure is achieved compared to an subcutaneous equivalent dose. This may, in turn, alleviate any detrimental effects of insulin on non-target tissues.
  • [0037]
    Thus, the oral insulin formulations of Emisphere Technologies, Inc. provide an advantage over subcutaneously administered insulin that is currently the state of the art, beyond the benefit of ease of administration, pain-free administration, and the potential for improved patient compliance. Because subcutaneously administered insulin is delivered peripheral to the GI tract and portal vein, and absorption of large biomolecules from the subcutaneous space is generally more prolonged, the first-phase insulin response is not well-replicated by subcutaneous insulin administration. By administration of the oral insulin formulations of the present invention, the plasma levels of insulin that occur upon the first (acute) phase of insulin secretion by the pancreas can be simulated by rapid, direct absorption from the GI tract.
  • [0038]
    In normal physiology, first-phase insulin secretion takes place 5 to 20 minutes after the start of a meal, and this effect has a well-known impact on prandial glucose homeostasis. The first phase of insulin secretion, while of short duration, has an important role in priming the liver to the metabolic events ahead (meal). The loss of first-phase insulin secretion is a characteristic feature of Type 2 diabetic patients in the early stages of the disease, and it is also observed in prediabetic states, namely individuals with impaired glucose tolerance. In the absence of first-phase insulin secretion, the stimulatory effect of glucagon on gluconeogenesis is not suppressed and may contribute to the development of prandial hyperglycemia. In the basal state as well as in the prandial phase, plasma glucose concentrations are correlated with hepatic glucose output. Therefore, restoration of first-phase insulin secretion at the time of meal ingestion should suppress prandial hepatic glucose output and subsequently improve the blood glucose profile.
  • [0039]
    Several approaches have been undertaken to prove this hypothesis. However, the therapeutic regimens were either too dangerous for a long-term treatment (such as intravenous administration of regular human insulin) or pharmacologically unsuitable (fast-acting insulin analogues). In addition, restoration of first phase insulin response appears to be difficult in patients with a long-standing history of diabetes who have lost most or all of their endogenous insulin secretion capacity. Furthermore, certain short acting insulin formulations, because of the speed with which the insulin provides a blood glucose lowering effect, may, between the time of administration of insulin and the time of ingestion of the meal, contribute to a lowering of blood glucose to a level that could range from subclinical hypoglycemia to more undesirable effects.
  • [0040]
    The rapid onset and the short duration of action of oral Insulin/4-CNAB following single dose administration in humans suggests that oral Insulin/4-CNAB may be well-suited for supplementation of first phase insulin secretion in subjects with type 2 diabetes. In a previous study, as set forth in International Patent Application No. PCT/US04/00273, patients with type 2 diabetes were administered a single doses of Insulin (300 U)/4-CNAB (400 mg) at or shortly before bedtime. Substantial decrease in insulin, C-peptide, and fasting blood glucose levels were observed. Insulin sensitivity, as assessed with the HOMA-model, was also significantly improved. This suggests that even a short-term treatment with pre-prandial Insulin/4-CNAB may be able to improve insulin sensitivity and, thereby, metabolic control.
  • [0041]
    It is, therefore, desirable to provide a pharmaceutical compositions of insulin that can be administered closer to as meal than previously known and to provide a protocol for insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes, which treatment can be administered orally multiple times daily, such as at or shortly prior to mealtime and/or at or shortly prior to bedtime, has a short duration of action, and has positive and long lasting effects on the patient's glucose tolerance, glycemic control, insulin secretory capacity and insulin sensitivity, but does not increase the risk of hypoglycemia, hyperinsulinemia and weight gain that are normally associated with insulin therapy treatments.
  • SUMMARY OF THE INVENTION
  • [0042]
    It is an object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes to provide therapeutic effects to the patient greater than or unseen in current parenteral insulin therapy.
  • [0043]
    It is another object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes to provide positive therapeutic effects on the patient's glucose tolerance and glycemic control.
  • [0044]
    It is an object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes to provide long lasting therapeutic effects on the patient's glucose tolerance and glycemic control.
  • [0045]
    It is another object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes to improve the patient's endogenous capacity to handle sugar load.
  • [0046]
    It is additionally an object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early or late stage diabetes to provide for the patient an improved glucose profile, a decrease in glucose excursion or a decreased AUC of blood glucose, measured following a glucose load such as a meal or oral glucose tolerance test.
  • [0047]
    It is a further object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes to provide for the patient a decreased fasting blood glucose concentration when compared with the patient's own baseline level prior to starting the treatment.
  • [0048]
    It is still another object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes to provide for the patient a decreased serum fructosamine level.
  • [0049]
    It is yet another object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes to improve the insulin utilization of the patient's body.
  • [0050]
    It is yet another object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes to improve the insulin sensitivity of the patient's body.
  • [0051]
    It is still a further object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes to improve the insulin secretion capacity of the patient's body.
  • [0052]
    It is yet a further object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes without the negative side effects currently seen in parenteral insulin therapy.
  • [0053]
    It is another object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes without inducing hypoglycemia.
  • [0054]
    It is a further object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes without inducing hyperinsulinemia.
  • [0055]
    In yet another object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes without the weight gain commonly associated with parenteral insulin therapy.
  • [0056]
    It is yet a further object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with early stage or late stage diabetes that reduces the need for frequent monitoring of blood sugar levels currently needed with current insulin therapy regimens.
  • [0057]
    It is another object of the present invention to provide a therapeutic insulin treatment for patients with impaired glucose tolerance or with diabetes from its earliest stages to its latest stages.
  • [0058]
    It is a further object of the present invention to provide a method of reversing impaired glucose tolerance or diabetes by administration of a therapeutic insulin treatment.
  • [0059]
    It is another object of the present invention to provide a therapeutic insulin treatment for patients who are failing dual or multiple therapy with sulfonureas and insulin sensitizers.
  • [0060]
    It is an object of the present invention to provide pharmaceutical compositions for oral administration comprising insulin and a delivery agent that facilitates insulin transport in a therapeutically effective amount to the bloodstream, which compositions are therapeutically and quickly effective.
  • [0061]
    It is another object of the present invention to provide therapeutically effective pharmaceutical compositions comprising insulin and a delivery agent for oral administration to patients with impaired glucose tolerance or with early stage or late stage diabetes to provide longer lasting therapeutic effects on the patient's glucose tolerance and glycemic control without the risks of hypoglycemia, hyperinsulinemia and weight gain that are normally associated with insulin therapy treatments.
  • [0062]
    It is a further object of the present invention to provide compositions for oral administration of insulin and a delivery agent that facilitates insulin transport in a therapeutically effective amount to the bloodstream for the treatment of diabetes, for the treatment of impaired glucose tolerance, for the purpose of achieving glucose homeostasis, for the treatment of early stage diabetes, for the treatment of late stage diabetes, and/or to serve as replacement therapy for type I diabetic patients to provide longer lasting effects on the patient's glucose tolerance and glycemic control without the risks of hypoglycemia, hyperinsulinemia and weight gain that are normally associated with insulin therapy treatments.
  • [0063]
    It is still a further object of the present invention to provide methods of treating mammals with impaired glucose tolerance, early stage diabetes or late stage diabetes, for achieving glucose homeostasis in mammals, for prophylactically sparing pancreatic β-cell function, for preventing β-cell death or dysfunction, for long term protection of a mammal from developing overt or insulin dependent diabetes, for delaying the onset of overt or insulin dependent diabetes in a mammal that has impaired glucose tolerance or early stage diabetes, and for reducing the incidence and/or severity of systemic hyperinsulinemia associated with chronic dosing of insulin or of one or more disease states associated with chronic dosing of insulin.
  • [0064]
    In accordance with these and other objects, the invention provides a method for treating a mammal with impaired glucose tolerance or with early or late stage diabetes, and of achieving glucose homeostasis in mammals, comprising orally administering to a mammal a therapeutically effective dose of a pharmaceutical formulation comprising insulin such that the mammal achieves improved glucose tolerance and glycemic control as compared with baseline levels prior to treatment.
  • [0065]
    The invention also provides a method for treating a mammal with impaired glucose tolerance or with early or late stage diabetes, comprising orally administering to a mammal a therapeutically effective dose of a pharmaceutical formulation comprising insulin such that the mammal achieves improved glucose tolerance and glycemic control as compared with baseline levels prior to treatment without any statistically significant weight gain by the mammal over the treatment period.
  • [0066]
    The invention also provides a method for treating a mammal with impaired glucose tolerance or with early or late stage diabetes, comprising orally administering to a mammal a therapeutically effective dose of a pharmaceutical formulation comprising insulin such that the mammal achieves improved glucose tolerance and glycemic control as compared with baseline levels prior to treatment without any statistically significant risk of hypoglycemia in the mammal over the treatment period.
  • [0067]
    The invention also provides a method for treating a mammal with impaired glucose tolerance or with early or late stage diabetes, comprising orally administering to a mammal a therapeutically effective dose of a pharmaceutical formulation comprising insulin such that the mammal achieves improved glucose tolerance and glycemic control as compared with baseline levels prior to treatment without any statistically significant risk of hyperinsulinemia in the mammal over the treatment period.
  • [0068]
    In certain preferred embodiments, the improved glucose tolerance is demonstrated by better endogenous capacity of the mammal to handle sugar load as measured by blood glucose concentration, following a sugar load, that is reduced by a statistically significant amount as compared with baseline blood glucose concentration, following a glucose load, prior to treatment. Preferably, the statistically significant amount is a mean of about 10-20%, preferably about 15%.
  • [0069]
    In certain preferred embodiments, the improved glucose tolerance is demonstrated by better endogenous capacity of the mammal to handle sugar load as measured by an AUC of blood glucose excursion, following a glucose load, that is reduced by a statistically significant amount as compared with AUC of blood glucose excursion, following a glucose load, prior to treatment. Preferably, the statistically significant amount is a mean of about 10-30%, preferably about 20%.
  • [0070]
    In certain preferred embodiments, the improved glycemic control is demonstrated by decreased fasting blood glucose levels as measured by fasting blood glucose concentration that is reduced by a statistically significant amount as compared with baseline fasting blood glucose concentration prior to treatment. Preferably, the statistically significant amount is a mean of about 10-30%, preferably about 19%.
  • [0071]
    In certain preferred embodiments, the improved glycemic control is demonstrated by decreased serum fructosamine levels, as measured by serum fructosamine assay, that is reduced by a statistically significant amount as compared with baseline serum fructosamine levels prior to treatment. Preferably, the statistically significant amount is a mean of about 5-20%, preferably about 9%.
  • [0072]
    In certain preferred embodiments, the improved glycemic control is demonstrated by improved HbA1c levels after treatment compared with baseline levels prior to treatment. Preferably, the improved HbA1c levels are measured by a statistically significant decline in HbA1c levels. More preferably, administration of the pharmaceutical formulation of the present invention can preferably be made to a mammal with impaired glucose tolerance or with early or late stage diabetes having an HbA1c level ranging from normal to elevated prior to treatment. In one embodiment, the mammal may have an HbA1c level preferably of less than about 8.0 prior to treatment.
  • [0073]
    In certain further preferred embodiments, the improved glucose tolerance and glycemic control are achieved without the need for monitoring the mammal's blood glucose concentrations or HbA1c levels over the treatment period.
  • [0074]
    In certain preferred embodiments, the mammal achieves improved insulin utilization and insulin sensitivity after the treatment as compared with baseline levels prior to treatment. Preferably, the improved insulin utilization and insulin sensitivity are measured by a statistically significant decline in HOMA (Homeostasis Model Assessment).
  • [0075]
    In certain preferred embodiments, the mammal achieves improved insulin secretion capacity after the treatment as compared with baseline levels prior to treatment. Preferably, the improved insulin secretion capacity is measured by a statistically significant decline in Stumvoll first-phase insulin secretion capacity index.
  • [0076]
    The invention is also directed in part to an oral solid dosage form comprising a dose of insulin that achieves a therapeutically effective reduction in blood glucose after oral administration to a human diabetic patient, and which maintains a physiological (portal/peripheral) gradient, and in certain embodiments provides a ratio of portal vein insulin concentration to peripheral blood insulin concentration from about 2.5:1 to about 6:1, and preferably from about 4:1 to about 5:1.
  • [0077]
    The invention is further directed in part to an oral dosage form comprising a therapeutically effective amount of insulin, said dosage form upon pre-prandial oral administration to diabetic patients causing the post prandial blood glucose concentration in said patients to be reduced for the first hour after oral administration relative to a post-prandial blood glucose concentration without treatment or following subcutaneous insulin administration or other standard treatment regimen.
  • [0078]
    The invention is further directed in part to an oral dosage form comprising a therapeutically effective amount of insulin, said oral dosage form upon pre-prandial oral administration provides a mean plasma glucose concentration which does not vary by more than about 40% (and more preferably not more than 30%) for the first hour after oral administration, relative to a mean baseline (fasted) plasma glucose concentration in said patients, where a meal is eaten by said patients within about one half hour of oral administration of said dosage form.
  • [0079]
    In certain preferred embodiments, the administration of the oral insulin formulation of the present invention achieves a reduction in blood glucose concentration in human diabetic patients comparable to a subcutaneous insulin injection in those patients, while providing a lower (e.g., 20% or greater) total exposure of insulin to the peripheral blood circulation under acute, sub-acute and chronic conditions as compared to the peripheral blood insulin exposure achieved via subcutaneous injection.
  • [0080]
    The present invention provides methods of treating mammals with impaired glucose tolerance, early stage diabetes and late stage diabetes; for achieving glucose homeostasis; for reducing the incidence and/or severity of systemic hyperinsulinemia associated with chronic dosing of insulin. It is believed that the present invention also provides methods for reducing the incidence and/or severity of one or more disease states associated with chronic dosing of insulin; for prophylactically sparing β-cell function or for preventing β-cell death or dysfunction, in a mammal which has impaired glucose tolerance or early stage diabetes mellitus; and for long-term protection from developing overt or insulin dependent diabetes, or for delaying the onset of overt or insulin dependent diabetes, in a mammal which has impaired glucose tolerance or early stage diabetes.
  • [0081]
    In a preferred embodiment of the invention, such methods comprise orally administering a therapeutically effective dose of a pharmaceutical formulation comprising insulin and a delivery agent that facilitates the absorption of the insulin from the gastrointestinal tract, to provide a therapeutically effective reduction in blood glucose and a plasma insulin concentration, to provide a therapeutically effective reduction and/or control in blood glucose concentration and a plasma insulin concentration that is reduced relative to the plasma insulin concentration provided by a therapeutically equivalent dose of subcutaneously injected insulin. The determination of insulin concentration obtained in patients who have been administered subcutaneous insulin are well known to those skilled in the art.
  • [0082]
    In a preferred embodiment, administration of the pharmaceutical formulation takes place multiple times daily, preferably at bedtime and preprandially during the day time, e.g., preprandially for breakfast, lunch and dinner. More preferably, administration of the pharmaceutical formulation is at or shortly prior to bedtime and concurrently with or shortly prior to ingestion of a meal, i.e., within about 15 minutes or less of ingestion of the meal.
  • [0083]
    In another preferred embodiment of the invention, the oral pharmaceutical formulation will be administered about once daily to about four times daily, preprandially and/or at bedtime, depending upon the extent of the patient's impaired glucose tolerance and need for exogenous glycemic control. If the patient has a need for fasting glycemic control, the oral pharmaceutical formulation will be administered only at or shortly prior to bedtime. If the patient has a need for post-prandial glycemic control, the oral pharmaceutical formulation will be administered preprandially for all meals. If the patient has a need for comprehensive glycemic control, the oral pharmaceutical formulation will be administered preprandially for all meals and at or shortly prior to bedtime.
  • [0084]
    Preferably, the dosage form of the present invention will be administered for at least one day, more preferably on a chronic basis, and can be administered for the life of the patient. Most preferably, the dosage form of the present invention will be administered on a chronic basis, e.g., for at least about two weeks.
  • [0085]
    Preferably, the therapeutic insulin treatment of the present invention will be administered to patients having some form of impaired glucose tolerance. This can range from insulin resistance seen in pre-diabetics and early stage Type 2 diabetics to failure of insulin production by the pancreas seen in Type 1 diabetes and late stage Type 2 Diabetes. In certain embodiments, the resulting improved insulin utilization or insulin sensitivity of the patient's body is measured by HOMA (Homeostasis Model Assessment). In certain embodiments, the resulting improved insulin secretion capacity of the patient's body is measured by Stumvoll first-phase insulin secretion capacity index.
  • [0086]
    Further, the therapeutic insulin treatment of the present invention can be administered to a mammal with an HbA1c ranging from normal to elevated levels. More particularly, the treatment can be administered to anyone in the range of normal glycemic control to impaired glycemic control to late stage type 2 diabetes or type 1 diabetes. In certain embodiments, the resulting improved glycemic control in the patient's body is measured by a reduced serum fructosamine concentration. Preferably the average decline will be about 8.8% after at least two weeks of treatment with the present invention.
  • [0087]
    In preferred embodiments of the oral dosage forms of the invention described above, the oral dosage form is solid, and is preferably provided incorporated within a gelatin capsule or is contained in a tablet.
  • [0088]
    In certain preferred embodiments, the dose of unmodified insulin contained in one or more dosage forms is from about 50 Units to about 600 Units (from about 2 to about 23 mg), preferably from about 100 Units (3.8 mg) to about 450 Units (15.3 mg) insulin, more preferably from about 200 Units (7.66 mg) to about 350 Units (13.4 mg), and still more preferably about 300 Units (11.5 mg), based on the accepted conversion of factor of 26.11 Units per mg.
  • [0089]
    In certain preferred embodiments of the invention, the dosage forms begin delivering insulin into the systemic circulation via the portal vein (via absorption through the mucosa of the gastrointestinal tract) to achieve peak levels within about 30 minutes or less.
  • [0090]
    In certain preferred embodiments, the dosage forms of the invention provide a tmax for insulin at from about 5 minutes to about 30 minutes, and more preferably at from about 10 minutes to about 25 minutes after oral administration to diabetic patients. In certain preferred embodiments of the invention, the dosage forms begin delivering insulin into the systemic circulation to produce a peak plasma insulin concentration at about 10 to about 20 minutes post oral administration and in further preferred embodiments, a peak plasma insulin concentration at about 10 minutes to about 15 minutes post oral administration to patients who ingested the dosage at about 0 or about 10 minutes prior to ingestion of a meal.
  • [0091]
    The invention is also directed in part to an oral dosage form comprising a dose of unmodified insulin that achieves a therapeutically effective control of post prandial blood glucose after oral administration to human diabetic patients in tablet form at or shortly before mealtime, the oral solid dosage form providing an insulin tmax at a time point from about 10 minutes to about 15 minutes after oral administration to said patients, at least about 30% of the blood glucose concentration reduction caused by said dose of insulin occurring within about less than 1 hour after oral administration of said dosage form. In preferred embodiments of this invention, the oral dosage form is a tablet.
  • [0092]
    In certain preferred embodiments, the composition provides a tmax for maximum control of glucose excursion at about 0.25 to about 1.5 hours, more preferably at about 0.75 to about 1.25 hours, after oral administration. In certain preferred embodiments, the tmax for post-prandial glucose control occurs preferably at less than about 120 minutes, more preferably at less than about 80 minutes, and still more preferably at about 45 minutes to about 60 minutes, after oral administration of the composition.
  • [0093]
    In certain preferred embodiments, the pharmaceutical composition contained in one or more dosage forms comprises from about 5 mg to about 800 mg of delivery agent, preferably about 20 mg to about 600 mg, more preferably from about 30 mg to about 400 mg, even more preferably from about 40 mg to about 200 mg, most preferably about 40 mg, 80 mg or 160 mg. In certain embodiments, the composition provides a peak plasma delivery agent concentration Cmax from about 3,000 to about 15,000 ng/mL, and a tmax at about 10 minutes to about 35 minutes. More preferably, the composition provides a peak plasma delivery agent concentration within about 15 minutes to about 35 minutes after oral administration and more preferably within about 20 minutes after oral administration to fed diabetic patients.
  • [0094]
    For purposes of the present invention, a preferred delivery agent is identified via chemical nomenclature as 4-[(4-chloro, 2-hydroxybenzoyl)amino]butanoic acid. In certain preferred embodiments, the delivery agent is a sodium salt, preferably monosodium salt. Alternatively, the same compound is identified by the alternative nomenclature monosodium N-(4-chlorosalicyloyl)-4-aminobutyrate, or by the short name “4-CNAB”.
  • [0095]
    The following terms will be used throughout the application as defined below:
  • [0096]
    Patient—refers to any mammal in whom there is determined to be.
  • [0097]
    Diabetic patient—refers to a mammal with a form of pre-diabetes or diabetes, either diagnosed or undiagnosed, and/or with a condition that would respond to an anti-diabetic and/or insulin treatment.
  • [0098]
    Mammal—includes but is not limited to rodents, aquatic mammals, domestic animals such as dogs and cats, farm animals such as sheep, pigs, cows and horses, and preferably humans.
  • [0099]
    Diabetes or Diabetes Mellitus—is deemed to encompass type 1 and type 2 diabetes mellitus, unless specifically specified otherwise.
  • [0100]
    Overt Diabetes—is deemed to encompass type 1 and type 2 diabetes mellitus that is insulin dependent.
  • [0101]
    Early stage diabetes—refers to a condition of impaired glycemic control, absent treatment, wherein the function of the islet cells of the pancreas still exist, although in an impaired state, also including impaired glucose tolerance (IGT) and impaired fasting blood glucose (IFG), e.g., the patient's endogenous insulin production is insufficient to provide a first phase insulin response following ingestion of a meal but is sufficient to provide a second phase insulin response following ingestion of a meal.
  • [0102]
    Late stage diabetes—refers to a condition of impaired glycemic control, absent treatment, wherein the islet cells of the pancreas are approaching or have reached total failure, e.g., the patient's endogenous insulin production is insufficient to provide a first or a second phase insulin response following ingestion of a meal.
  • [0103]
    Treatment—when used herein with respect to diabetes is deemed to include prevention of diabetes, delay of the onset of diabetes, delay of worsening of diabetic conditions and delay of progression from an earlier stage of diabetes to a later stage of diabetes, unless specifically specified otherwise.
  • [0104]
    Delivery agent—refers to carrier compounds or carrier molecules that are effective in the oral delivery of therapeutic agents, and may be used interchangeably with “carrier”.
  • [0105]
    Therapeutically effective amount of insulin—refers to an amount of insulin included in the dosage forms of the invention which is sufficient to achieve a clinically relevant control of blood glucose concentrations in a human diabetic patient either in the fasting state or in the fed state effective, during the dosing interval.
  • [0106]
    Effective amount of delivery agent—refers to an amount of the delivery agent that has been shown to deliver the drug following oral administration by measurement of pharmacokinetic and/or pharmacodynamic endpoints.
  • [0107]
    Organic solvents—refers to any solvent of non-aqueous origin, including liquid polymers and mixtures thereof. Organic solvents suitable for the present invention include: acetone, methyl alcohol, methyl isobutyl ketone, chloroform, 1-propanol, isopropanol, 2-propanol, acetonitrile, 1-butanol, 2-butanol, ethyl alcohol, cyclohexane, dioxane, ethyl acetate, dimethylformamide, dichloroethane, hexane, isooctane, methylene chloride, tert-butyl alchohol, toluene, carbon tetrachloride, or combinations thereof.
  • [0108]
    Peptide—refers to a polypeptide of small to intermediate molecular weight, usually 2 or more amino acid residues and frequently but not necessarily representing a fragment of a larger protein.
  • [0109]
    Protein—refers to a complex high polymer containing carbon, hydrogen, oxygen, nitrogen and usually sulfur and composed of chains of amino acids connected by peptide linkages. Proteins in this application refer to glycoproteins, antibodies, non-enzyme proteins, enzymes, hormones and sub-units of proteins, such as peptides. The molecular weight range for proteins includes peptides of 1000 Daltons to glycoproteins of 600 to 1000 kiloDaltons.
  • [0110]
    Reconstitution—refers to dissolution of compositions or compositions in an appropriate buffer or pharmaceutical composition.
  • [0111]
    Unit-Dose Forms—refers to physically discrete units suitable for human and animal subjects and packaged individually as is known in the art. It is contemplated for purposes of the present invention that dosage forms of the present invention comprising therapeutically effective amounts of insulin may include one or more unit doses (e.g., tablets, capsules, powders, semisolids (e.g. gelcaps or films), liquids for oral administration, ampoules or vials for injection, loaded syringes) to achieve the therapeutic effect. It is further contemplated for the purposes of the present invention that a preferred embodiment of the dosage form is an oral dosage form.
  • [0112]
    The term “multiple dose” means that the patient has received at least two doses of the drug composition in accordance with the dosing interval for that composition.
  • [0113]
    The term “single dose” means that the patient has received a single dose of the drug composition or that the repeated single doses have been administered with washout periods in between.
  • [0114]
    Unless specifically designated as “single dose” or at “steady-state” the pharmacokinetic parameters disclosed and claimed herein encompass both single dose and multiple-dose conditions.
  • [0115]
    Unmodified insulin—refers to insulin prepared in any pharmaceutically acceptable manner or from any pharmaceutically acceptable source which is not conjugated with an oligomer such as that described in U.S. Pat. No. 6,309,633 and/or which not has been subjected to amphiphilic modification such as that described in U.S. Pat. Nos. 5,359,030; 5,438,040; and/or 5,681,811, which patents are hereby incorporated by reference in their entireties.
  • [0116]
    The phrase “equivalent therapeutically effective reduction” as used herein means that a maximal reduction of blood glucose concentration achieved by a first method of insulin administration (e.g. via oral administration of insulin in a patient(s)) is not more than 20%, and preferably not more than 10% and even more preferably not more than 5% different from a maximal reduction of blood glucose concentration after administration by a second method (e.g., subcutaneous injection) in the same patient(s) or a different patient requiring the same reduction in blood glucose level. The phrase may also mean the dose required to approximate normoglycemia by any method of administration, normoglycemia being defined as variability from a subject's baseline blood glucose of not more than 20%, preferably 10%, more preferably 5%, in the fasted state.
  • [0117]
    The term “meal” as used herein means a standard, ADA and/or a mixed meal.
  • [0118]
    The term “mean”, when preceding a pharmacokinetic value (e.g., mean tmax), represents the arithmetic mean value of the pharmacokinetic value unless otherwise specified.
  • [0119]
    The term “mean baseline level” as used herein means the measurement, calculation or level of a certain value that is used as a basis for comparison, which is the mean value over a statistically significant number of subjects, e.g., across a single clinical study or a combination of more than one clinical study.
  • [0120]
    The term “Cmax” as used herein is the highest plasma concentration of the drug or delivery agent observed within the sampling interval.
  • [0121]
    The term “tmax” as used herein is the time post-dose at which Cmax is observed.
  • [0122]
    The term “AUC” as used herein means area under the plasma concentration-time curve, as calculated by the trapezoidal rule over the complete sample collection interval.
  • [0123]
    The term “AUC(0-last)” as used herein means the area under the plasma concentration-time curve using linear trapezoidal summation from time zero (dosing) to the time of the last quantifiable concentration post-dose.
  • [0124]
    The term “AUC(0-t)” as used herein means the area under the plasma concentration-time curve using linear trapezoidal summation from time zero (dosing) to time t post-dose, where t is any quantifiable time point.
  • [0125]
    The term “AUC(0-inf)” as used herein means an estimate of the area under the plasma concentration-time curve from time zero (dosing) to infinity.
  • [0126]
    The term “CL/F” as used herein means the apparent total body clearance calculated as Dose/AUC(0-inf), uncorrected for absolute bioavailability.
  • [0127]
    The term “Vd/F” as used herein means the apparent volume of distribution calculated as (CL/F)/Kel, uncorrected for absolute bioavailability.
  • [0128]
    The term “Eb” as used herein means the maximum observed effect (baseline subtracted) prior to intervention for hypoglycemia.
  • [0129]
    The term “Emax” as used herein means the maximum observed effect (baseline subtracted).
  • [0130]
    Kel is the terminal elimination rate constant calculated by linear regression of the terminal linear portion of the log concentration vs. time curve.
  • [0131]
    The term “t1/2” as used herein means the terminal half-life calculated as ln(2)/Kel.
  • [0132]
    The term “BMI” as used herein means the body mass index, calculated as weight in kg divided by the squared height in m.
  • [0133]
    The term “Bioavailability” as used herein means the degree or ratio (%) to which a drug or agent is absorbed or otherwise available to the treatment site in the body relative to a parenteral route. This is calculated by the formula Relative Bioavailability ( % ) = Dose SC Dose Oral × AUC Oral AUC SC × 100
  • [0134]
    The term “Biopotency” as used herein means the degree or ratio (%) to which a drug or agent is effective relative to a parenteral route. This is calculated by the formula Relative Biopotency ( % ) = Dose SC Dose Oral × AUC Oral AUC SC × 100
  • [0135]
    The term “nighttime” or “bedtime” as used herein means a time before the patient goes to sleep and is not limited to clock time or cycles of light and dark, and alternately refers to a time during a day or night of longest fast, a period without external glucose source.
  • [0136]
    For the purposes of the present specification, as used herein, the phrase administered “at nighttime” or “at or shortly before (prior to) bedtime” means administered less than about 3 hours, preferably less than about 2 hours and more preferably less than about 1 hour prior to a prolonged period of sleep, or relative physical and/or mental inactivity, and fast, e.g., overnight. Whereas overnight typically means from the late night (p.m.) hours to the early morning (a.m.) hours, it could mean any period of a sleep-wake cycle during which a person obtains his/her necessary period of sleep. For the purposes of the present specification, administration should also occur at least about one hour, preferably at least about 1.5 hours, more preferably at least about 2 hours and still more preferably at least about 2 to about 3 hours after the last meal of the day.
  • [0137]
    For the purposes of the present specification, as used herein, the phrase administered “at mealtime” or “at or shortly before (prior to) ingestion of a meal” means administered within about 30 minutes prior to the meal. For the purposes of the present specification, the administration is preferably within about 25 minutes, more preferably within about 20 minutes, even more preferably within about 15 minutes, still more preferably within about 10 minutes, further more preferably within about 5 minutes of ingestion of the meal, and most preferably administered concurrently with ingestion of the meal (within about 0 minutes).
  • [0138]
    As used herein and in the appended claims, the singular forms “a,” “an,” and “the,” include plural referents unless the context clearly indicates otherwise. Thus, for example, reference to “a molecule” includes one or more of such molecules, “a reagent” includes one or more of such different reagents, reference to “an antibody” includes one or more of such different antibodies, and reference to “the method” includes reference to equivalent steps and methods known to those of ordinary skill in the art that could be modified or substituted for the methods described herein.
  • [0139]
    Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which the invention belongs. Although any methods, compositions, reagents, cells, similar or equivalent to those described herein can be used in the practice or testing of the invention, the preferred methods and materials are described herein. All publications mentioned herein are incorporated herein, including all figures, graphs, equations, illustrations, and drawings, to describe and disclose specific information for which the reference was cited in connection with.
  • [0140]
    The publications discussed above are provided solely for their disclosure before the filing date of the present application. Nothing herein is to be construed as an admission that the invention is not entitled to antedate such disclosure by virtue of prior invention. Throughout this description, the preferred embodiment and examples shown should be considered as exemplars, rather than as limitations on the present invention.
  • BRIEF DESCRIPTION OF THE DRAWINGS
  • [0141]
    FIG. 1 shows a plot of the arithmetic means of postprandial blood glucose excursions for all subjects.
  • [0142]
    FIG. 2 shows a plot of 4-CNAB plasma concentrations (ng/mL) vs. time (arithmetic means).
  • [0143]
    FIG. 3 shows a plot of the postprandial blood glucose excursion (blood glucose concentration (SuperGL) (mg/dl) vs. time) for Type 2 Diabetic subject no. 116 after oral or subcutaneous administration of insulin or insulin/4-CNAB 30 minutes prior to a standard meal (meal at time=0).
  • [0144]
    FIG. 4 shows a plot of the postprandial blood glucose excursion (blood glucose concentration (SuperGL) (mg/dl) vs. time) for Type 2 Diabetic subject no. 117 after oral or subcutaneous administration of insulin or insulin/4-CNAB 30 minutes prior to a standard meal (meal at time=0).
  • [0145]
    FIG. 5 shows a plot of insulin plasma concentrations (pmol/l) vs. time (arithmetic means).
  • [0146]
    FIG. 6 shows a plot of C-peptide plasma concentrations (nmol/l) vs. time (arithmetic means).
  • [0147]
    FIG. 7 shows a plot of insulin plasma concentration (pmol/l) vs. time for Type 2 Diabetic subject no. 116 after oral or subcutaneous administration of insulin or insulin/4-CNAB 30 minutes prior to a standard meal (meal at time=0).
  • [0148]
    FIG. 8 shows a plot of insulin plasma concentration (pmol/l) vs. time for Type 2 Diabetic subject no. 117 after oral or subcutaneous administration of insulin or insulin/4-CNAB 30 minutes prior to a standard meal (meal at time=0).
  • [0149]
    FIG. 9 is a bar graph showing the effect of nighttime dosing of insulin and 4-CNAB on blood glucose concentration.
  • [0150]
    FIG. 10 is a bar graph showing the effect of nighttime dosing of insulin and 4-CNAB on blood C-peptide concentration.
  • [0151]
    FIG. 11 is a bar graph showing the effect of nighttime dosing of insulin and 4-CNAB on blood insulin concentration.
  • [0152]
    FIG. 12 is a plot of Preliminary Mean+/−SD % Change in Baseline Blood Glucose (SuperGL) Following Oral Administration of Insulin/4-CNAB Tablets to Fed of Fasted Type 2 Diabetic Patients.
  • [0153]
    FIG. 13 is a plot of Preliminary Mean+/−SD % Change in Blood Glucose (SuperGL) Following Oral Administration of Insulin/4-CNAB Tablets to Type 2 Diabetic Patients with a Standard Meal.
  • [0154]
    FIG. 14 is a plot of Preliminary Mean+/−SD % Change in Blood Glucose (SuperGL) Following Oral Administration of Insulin/4-CNAB Tablets to Type 2 Diabetic Patients with or without a Meal.
  • [0155]
    FIGS. 15-22 are plots of Preliminary Percent Change in Blood (SuperGL) Glucose for Subjects 101-108, respectively.
  • [0156]
    FIG. 23 is a plot of Preliminary Mean+/−SD Plasma Glucose Change (%) Following Oral Tablet Administration of Insulin/4-CNAB to Type 2 Diabetic Patients with or without a Meal.
  • [0157]
    FIG. 24 is a plot of Preliminary Mean+/−SD Plasma Glucose concentration Following Oral Administration of Insulin/4-CNAB Tablets to Type 2 Diabetic Patients with or without a Meal.
  • [0158]
    FIG. 25 is a plot of Preliminary Mean+/−SD Blood (SuperGL) Glucose concentration Following Oral Administration of Insulin/4-CNAB Tablets to type 2 diabetic patients with or without a Meal.
  • [0159]
    FIGS. 26-33 are plots of Preliminary Blood (SuperGL) Glucose concentrations for Subjects 101-108, respectively.
  • [0160]
    FIG. 34 is a plot of Mean+/−SD Serum Insulin Concentration Following a Single Oral Administration of Insulin/4-CNAB Tablets to Fasted or Fed Type 2 Diabetic Patients.
  • [0161]
    FIG. 35 is a plot of Mean+/−SD Serum Insulin Concentration Following a Single Oral Administration of Insulin/4-CNAB Tablets to Fasted or Fed Type 2 Diabetic Patients.
  • [0162]
    FIGS. 36-43 are plots of Serum Insulin Concentration Following a Single Oral Administration of Insulin/4-CNAB Tablets to Fasted Type 2 Diabetic Patients Subjects 101-108, respectively.
  • [0163]
    FIG. 44 is a plot of Mean+/−SD Plasma 4-CNAB Concentration Following a Single Oral Tablet Administration of Insulin/4-CNAB to Fed or Fasted Type 2 Diabetic Patients.
  • [0164]
    FIG. 45 is a plot of Mean+/−SD Plasma C-Peptide Concentration Following a Single Oral Administration of Insulin/4-CNAB Tablets to Fed or Fasted Type 2 Diabetic Patients.
  • [0165]
    FIG. 46 is a prior art graph showing mean change in plasma glucose concentration from baseline for administration of placebo, glipizide, nateglinide, and glipizide plus nateglinide.
  • [0166]
    FIG. 47 is a curve showing preliminary Mean (n=6 or 7, SD) Blood (SuperGL) Glucose Following Oral Glucose Tolerance Test on Day 0 and Day 15 Following 14 Days of Daily QID Administration of 300 U Insulin/I 60 mg 4-CNAB OR 200 mg 4-CNAB alone.
  • [0167]
    FIGS. 48A and 48B are curves showing preliminary Mean and Individual Fasting Blood Glucose Prior to Oral Glucose Tolerance Test at Screening and on Day 15 Following 14 Days of Daily QID Administration of 300 U Insulin/160 mg 4-CNAB to Type 2 Diabetic Subjects (48A) and 200 mg 4-CNAB Alone to Type 2 Diabetic Subjects (48B).
  • [0168]
    FIGS. 49A and 49B are curves showing preliminary Mean and Individual Blood Glucose AUC0-240 min Following Oral Glucose Tolerance Test At Screening and on Day 15 Following 14 Days of Daily QID Administration of 300 U Insulin/160 mg 4-CNAB to Type 2 Diabetic Subjects (49A) and 200 mg 4-CNAB Alone to Type 2 Diabetic Subjects (49B).
  • [0169]
    FIGS. 50A and 50B are curves showing preliminary Mean and Individual Blood Glucose 2 Hours Following Oral Glucose Tolerance Test at Screening and on Day 15 Following 14 Days of Daily QID Administration of 300 U Insulin/160 mg 4-CNAB to Type 2 Diabetic Subjects (50A) and 200 mg 4-CNAB Alone to Type 2 Diabetic Subjects (50B).
  • [0170]
    FIG. 51 is a curve showing preliminary Mean (SD, n=6 or 7) Plasma Insulin Concentration Following OGTT at Baseline and on Day 15 Following 14 Days of Daily QID Oral Doses of 300 U Insulin/160 mg 4-CNAB OR 200 mg 4-CNAB alone.
  • [0171]
    FIGS. 52A and 52B are curves showing preliminary Mean and Individual Plasma Insulin AUC0-240 min Following Oral Glucose Tolerance Test At Screening and on Day 15 Following 14 Days of Daily QID Administration of 300 U Insulin/160 mg 4-CNAB to Type 2 Diabetic Subjects (52A) and 200 mg 4-CNAB Alone to Type 2 Diabetic Subjects (52B).
  • [0172]
    FIGS. 53A and 53B are bar graphs showing preliminary Mean and Fasting Blood Glucose and Plasma Insulin Prior to Oral Glucose Tolerance Test At Screening and on Day 15 Following 14 Days of Daily QID Administration of 300 U Insulin/160 mg 4-CNAB to Type 2 Diabetic Subjects (53) and 200 mg 4-CNAB Alone to Type 2 Diabetic Subjects (53B).
  • [0173]
    FIGS. 54A and 54B are bar graphs showing preliminary Mean Blood Glucose and Plasma Insulin 2 Hours Following Oral Glucose Tolerance Test at Screening and on Day 15 Following 14 Days of Daily QID Administration of 300 U Insulin/160 mg 4-CNAB to Type 2 Diabetic Subjects (54A) and 200 mg 4-CNAB Alone to Type 2 Diabetic Subjects (54B).
  • [0174]
    FIG. 55 is a curve showing preliminary Mean (N=6 or 7, SD) Blood Glucose Concentration Following Daily Mealtime Doses of Oral 300 U Insulin/160 mg 4-CNAB OR 200 mg 4-CNAB Alone to Type 2 Diabetic Subjects.
  • [0175]
    FIG. 56 is a curve showing preliminary Mean (N=6 or 7, SD) Blood Glucose Concentration Following Daily Mealtime Doses of Oral 300 U Insulin/160 mg 4-CNAB OR 200 mg 4-CNAB Alone to Type 2 Diabetic Subjects.
  • [0176]
    FIG. 57 is a curve showing preliminary Mean (N=6 or 7, SD) Blood Glucose Concentration Following Daily Mealtime Doses of Oral 300 U Insulin/160 mg 4-CNAB OR 200 mg 4-CNAB Alone to Type 2 Diabetic Subjects.
  • [0177]
    FIG. 58 is a curve showing preliminary Mean (n=6 or 7, SD) Plasma Insulin Concentration on Days 0 (baseline), 1 and 14 Following Daily QID Doses of Oral 300 U Insulin/160 mg 4-CNAB OR 200 mg 4-CNAB alone.
  • [0178]
    FIGS. 59A and 59B are curves showing preliminary Serum Fructosamine on Days 0 and 15 Following 14 Days of Daily QID Administration of 300 U Insulin/160 mg 4-CNAB to Type 2 Diabetic Subjects (59A) and 200 mg 4-CNAB alone (control) to Type 2 Diabetic Subjects (59B).
  • DETAILED DESCRIPTION OF THE INVENTION
  • [0179]
    Because insulin entry into the bloodstream produces a decrease in blood glucose levels, oral absorption of insulin may be verified by observing the effect on a subject's blood glucose following oral administration of the composition. In a preferred embodiment of the invention, the oral dosage forms of the invention facilitate the oral delivery of insulin, and after insulin is absorbed into the bloodstream, the composition produces a maximal decrease in blood glucose in treated type 2 diabetic patients from about 5 to about 60 minutes after oral administration. In another embodiment of the present invention, the pharmaceutical composition produces a maximal decrease in blood glucose in treated type 2 diabetic patients from about 10 to about 50 minutes post oral administration. More particularly, the pharmaceutical composition produces a maximal decrease in blood glucose in treated type 2 diabetic patients within about 20 to about 40 minutes after oral administration.
  • [0180]
    The magnitude of the decrease in blood glucose produced by insulin absorbed into the bloodstream following entry into the gastrointestinal tract varies with the dose of insulin. In certain embodiments of the invention, type 2 diabetic diabetic patients show a maximal decrease in blood glucose by at least 10% within one hour post oral administration. In another embodiment, type 2 diabetic diabetic patients show a maximal decrease in blood glucose by at least 20% within one hour post oral administration, alternatively, at least 30% within one hour post oral administration.
  • [0181]
    Normal levels of blood glucose vary throughout the day and in relation to the time since the last meal. One goal of the present invention is to provide oral compositions of insulin that facilitate achieving close to normal levels of blood glucose throughout the 24-hour daily cycle. In a preferred embodiment of the invention, the pharmaceutical composition includes insulin or an insulin analog as the active agent and a delivery agent in an amount effective to achieve a fasting blood glucose concentration from about 90 to about 115 mg/dl. In another preferred embodiment of the invention, the pharmaceutical composition includes insulin or an insulin analog as the active agent and a delivery agent in an amount effective to achieve a fasting blood glucose concentration from about 95 to about 110 mg/dl, more preferably, the subject manifests fasting blood glucose concentrations at about 100 mg/dl.
  • [0182]
    In the time after a meal is consumed, blood glucose concentration rises in response to digestion and absorption into the bloodstream of carbohydrates derived from the food eaten. The present invention provides oral compositions of insulin that prevent or control very high levels of blood glucose from being reached and/or sustained. More particularly, the present invention provides compositions which facilitate achieving normal levels of blood glucose after a meal has been consumed, i.e., post-prandial. In a preferred embodiment of the invention, the pharmaceutical composition includes insulin as the active agent and a delivery agent in an amount effective to achieve a post-prandial blood glucose concentration from about 130 to about 190 mg/dl. In another preferred embodiment of the invention, the pharmaceutical composition includes insulin or an insulin analog as the active agent and a delivery agent in an amount effective to achieve a post-prandial blood glucose concentration from about 150 to about 180 mg/dl, more preferably, the subject manifests fasting blood glucose concentrations at less than about 175 mg/dl.
  • [0183]
    The present invention provides pharmaceutical compositions for oral administration which includes insulin or an insulin analog as the active agent and a delivery agent in an amount effective to achieve pre-prandial (before a meal is consumed) blood glucose concentration from about 90 to about 125 mg/dl. In a preferred embodiment, the present invention provides pharmaceutical compositions for oral administration which includes insulin or an insulin analog as the active agent and a delivery agent in an amount effective to achieve pre-prandial blood glucose concentration from about 100 to about 115 mg/dl.
  • [0184]
    The present invention provides pharmaceutical compositions for oral administration which include insulin as the active agent and a delivery agent in an amount effective to achieve blood glucose concentrations within the normal range during the evening period from about 70 to about 120 mg/dl. In a preferred embodiment, the present invention provides pharmaceutical compositions for oral administration which include insulin or an insulin analog as the active agent and a delivery agent in an amount effective to achieve blood glucose concentrations at about 4 hours after bed time from about 80 to about 120 mg/dl.
  • [0185]
    In general, the present invention provides a method of administering insulin and pharmaceutical compositions useful for administering insulin such that the insulin is bioavailable and biopotent. The delivery agent enables insulin to be orally absorbable through the mucosa of the stomach and facilitates the absorption of insulin administered therewith (either in the same dosage form, or simultaneously therewith), or sequentially (in either order, as long as both the delivery agent and insulin are administered within a time period which provides both in the same location, e.g., the stomach, at the same time). Following oral administration of the pharmaceutical compositions of the present invention, the delivery agent passes though the mucosal barriers of the gastrointestinal tract and is absorbed into the blood stream where it can be detected in the plasma and/or blood of subjects. The level of delivery agent in the bloodstream as measured in the plasma and/or blood is dose-dependent.
  • [0186]
    By virtue of the present invention, the ratio of portal (unmodified) insulin concentration to systemic (unmodified) insulin concentration approaches in human diabetic patients approaches that which is obtained in normal healthy humans. The chronic administration of oral dosage forms of the present invention result in a higher portal insulin concentration and lower systemic insulin concentration over time than that obtained with an equi-effective dose of insulin administered subcutaneously (i.e., which provide similar control of blood glucose levels). Transient peaks in insulin levels that may occur by virtue of the oral administration of insulin in accordance with the present invention is not believed to be associated with vascular diseases.
  • [0187]
    By virtue of the chronic administration of oral dosage forms of the present invention instead of equi-effective subcutaneous doses of insulin, lower levels of hyperinsulinemia are obtained, e.g., systemic insulin concentrations are at least about 20% lower when compared to a comparably effective subcutaneous dose of insulin. Therefore, the present invention provides a method for reducing the incidence and/or severity of systemic hyperinsulinemia associated with chronic dosing of insulin, and it is believed that the present invention also provides a method for reducing the incidence and/or severity of one or more disease states associated with chronic dosing of insulin.
  • [0188]
    By virtue of the chronic administration of oral dosage forms of the present invention, the patient achieves improved glucose tolerance and glycemic control as compared with baseline levels prior to treatment, even without any statistically significant increase in weight, risk of hypoglycemia or risk of hyperinsulinemia over the treatment period. Further, by virtue of the chronic administration of oral dosage forms of the present invention, the patient achieves improved insulin utilization, insulin sensitivity insulin secretion capacity and HbA1c levels as compared with baseline levels prior to treatment.
  • [0189]
    It is also believed that the chronic administration of oral dosage forms of the present invention to replace the endogenous insulin production in a mammal with impaired glucose tolerance or early stage diabetes mellitus will result in prophylactically sparing the function of the mammal's β-cells or will prevent death or dysfunction of the mammal's β-cells, and will thereby provide long-term protection to the mammal from developing overt or insulin dependent diabetes, or will delay the onset of overt or insulin dependent diabetes in the mammal.
  • [0190]
    The preferred pharmaceutical compositions of the invention comprise a combination of insulin and a delivery agent in a suitable pharmaceutical carrier or excipient as understood by practitioners in the art. The means of delivery of the pharmaceutical composition can be, for example, a capsule, compressed tablet, pill, solution, freeze-dried, powder ready for reconstitution or suspension suitable for administration to the subject.
  • [0191]
    Thus, in certain preferred embodiments of the present invention, the oral insulin formulations of the invention may be administered to a patient at meal time, and preferably slightly before (e.g., about 10-30 minutes before) ingestion of a meal, such that the peak plasma insulin concentrations are attained at or about the time of peak blood glucose concentrations resulting from the meal. As a further advantage in certain preferred embodiments, the administration of a relatively short-acting insulin (e.g., such as the insulin used to prepare the capsules administered in the clinical studies reported in the appended examples) will further result in plasma insulin levels returning to baseline levels within about 4 hours (and preferably within about 3 hours or less) after oral administration of the insulin formulations of the present invention.
  • [0192]
    As used herein, “insulin” refers to insulin from a variety of sources. Naturally occurring insulin and structurally similar bioactive equivalents (insulin analogues including short acting and analogues with protracted action) can be used. Insulin useful in the invention can be may be obtained by isolating it from natural source, such as different species of mammal. For example, animal insulin preparations extracted from bovine or porcine pancreas can be used. Insulin analogues, fragments, mimetics or polyethylene glycol (PEG)-modified derivatives of these compounds, derivatives and bioequivalents thereof can also be used with the invention.
  • [0193]
    The insulin used in the present invention may be obtained by chemically synthesizing it using protein chemistry techniques such as peptide synthesis, or by using the techniques of molecular biology to produce recombinant insulin in bacteria or eukaryotic cells. The physical form of insulin may include crystalline and/or amorphous solid forms. In addition, dissolved insulin may be used. Other suitable forms of insulin, including, but not limited to, synthetic forms of insulin, are described in U.S. Pat. Nos. 4,421,685, 5,474,978, and 5,534,488, the disclosure of each of which is hereby incorporated by reference in its entirety.
  • [0194]
    The most preferred insulin useful in the pharmaceutical compositions and methods of the present invention is human recombinant insulin optionally having counter ions including zinc, sodium, calcium and ammonium or any combination thereof. Human recombinant insulin can be prepared using genetic engineering techniques that are well known in the art. Recombinant insulin can be produced in bacteria or eukaryotic cells. Functional equivalents of human recombinant insulin are also useful in the invention. Recombinant human insulin can be obtained from a variety of commercial sources. For example, insulin (Zinc, human recombinant) can be purchased from Calbiochem (San Diego, Calif.). Alternatively, human recombinant Zinc-Insulin Crystals: Proinsulin Derived (Recombinant DNA Origin) USP Quality can be obtained from Eli Lilly and Company (Indianapolis, Ind.). All such forms of insulin, including insulin analogues (including but not limited to Insulin Lispro, Insulin Aspart, Insulin Glargine, and Insulin Detemir) are deemed for the purposes of this specification and the appended claims are considered to be encompassed by the term “insulin.” The present invention also provides compositions of recombinant human zinc insulin and a delivery agent as a drug for oral administration of insulin in humans.
  • [0195]
    In other preferred embodiments of the invention, the insulin is a modified insulin, such as that conjugated with an oligomer such as that described in U.S. Pat. No. 6,309,633 and/or which not has been subjected to amphiphilic modification such as that described in U.S. Pat. Nos. 5,359,030; 5,438,040; and/or 5,681,811. The conjugated (modified) insulin may be incorporated into the oral formulations of the present invention in addition to or in the absence of any of the types of insulin described above, as well as with other insulin analogues. In such embodiments, the oral formulations include the modified insulin either with or without a pharmaceutically acceptable delivery agent that facilitates absorption of said insulin from the gastrointestinal tract.
  • [0196]
    The total amount of insulin to be used can be determined by those skilled in the art. It is preferable that the oral dosage form comprise a therapeutically effective amount of insulin, i.e., a pharmacologically or biologically effective amount, or an amount effective to accomplish the purpose of insulin. The dose of insulin administered should preferably be in such an amount that, upon oral administration, it results in a measurable and statistically significant reduction in blood glucose levels in normal healthy human subjects.
  • [0197]
    However, the amount can be less than a pharmacologically or biologically effective amount when the composition is used in a dosage unit form, such as a tablet, because the dosage unit form may contain a multiplicity of delivery agent/biologically or chemically active agent compositions or may contain a divided pharmacologically or biologically effective amount. The total effective amounts can then be administered in cumulative units containing, in total, pharmacologically, biologically or chemically active amounts of biologically or pharmacologically active agent.
  • [0198]
    It has been found that the use of the presently disclosed delivery agent provides extremely efficient delivery of insulin. Preferred insulin doses contained in one or more dosage forms, when dosed in combination with the delivery agents described herein, are about 50 to about 600 insulin Units USP (from about 2 to about 23 mg), preferably from about 100 Units (3.8 mg) to about 450 Units (15.3 mg), more preferably from about 200 Units (7.66 mg) to about 350 Units (13.4 mg), and still more preferably about 300 Units (11.5 mg), based on the accepted conversion of factor of 26.11 Units per mg.
  • [0199]
    Presently, different forms of typically subcutaneously-administered insulin preparations have been developed to provide different lengths of activity (activity profiles), often due to ingredients administered with insulin, ranging from short or rapid activity (e.g., solutions of regular, crystalline zinc insulin for injection; semilente insulin (prompt insulin zinc suspension); intermediate activity (e.g., NPH (isophane insulin suspension; lente (insulin zinc suspension; lente is a mixture of crystallized (ultralente) and amorphous (semilente) insulins in an acetate buffer); and slow activity (ultralente, which is extended insulin zinc suspension; protamine zinc). Short-acting insulin preparations that are commercially available in the U.S. include regular insulin and rapid-acting insulins. Regular insulin has an onset of action of 30-60 minutes, peak time of effect of 1.5 to 2 hours, and a duration of activity of 5 to 12 hours. Rapid acting insulins, such as aspart (Humalog®)/lispro (Novolog®), have an onset of action of 10-30 minutes, peak time of effect of 30-60 minutes, and a duration of activity of 3 to 5 hours. Intermediate-acting insulins, such as NPH (neutral protamine Hagedorn) and Lente insulins (insulin zinc suspension), have an onset of action of 1-2 hours, peak time of effect of 4 to 8 hours, and a duration of activity of 10 to 20 hours. In the case of long-acting insulins, Ultralente insulin has an onset of action of 2-4 hrs, peak time of effect of 8-20 hours, and a duration of activity of 16 to 24 hours, while Glargine insulin has an onset of action of 1 to 2 hours, a duration of action of 24 hours but no peak effect.
  • [0200]
    There are over 180 individual insulin preparations available world-wide. Approximately 25% of these are soluble insulin (unmodified form); about 35% are basal insulins (mixed with NPH or Lente insulins, increased pI, or isoelectric point (insulin glargine), or acylation (insulin detemir); these forms have reduced solubility, slow subcutaneous absorption and long duration of action relative to soluble insulins); about 2% are rapid-acting insulins (e.g., which are engineered by amino-acid change, and have reduced self-association and increased subcutaneous absorption); and about 38% pre-mixed insulins (e.g., NPH/soluble/rapid-acting insulins; these preparations have the benefit, e.g., of reduced number of daily injections). In many cases, regimens that use insulin in the management of diabetes combine long-acting and short-acting insulin.
  • [0201]
    It is contemplated that the oral insulin formulations of the present invention, which include insulin preferably together with a pharmaceutically acceptable delivery agent that facilitates absorption of said insulin from the gastrointestinal tract, may be utilized in combination therapy to include an insulin that has rapid action, intermediate action, and/or slow action, as described above, in order to provide effective basal insulin levels in the diabetic patient. The rate of action of the insulin may be caused by virtue of its solubility, and/or by virtue of its half-life, etc. Thus, in alternative embodiments, the oral formulations of the present invention may be designed to provide the intermediate activity which is found with, e.g., a subcutaneously administered NPH insulin, or a slow action which is found with protamine zinc insulin. In each case, the oral formulations of the invention, which preferably include a pharmaceutically acceptable delivery agent which facilitates absorption of the insulin (as described herein) provide effective control of blood glucose levels, albeit for different time periods and with different plasma glucose time curves.
  • [0202]
    Intermediate-acting and long-acting insulin may be prepared using methodologies known to those skilled in the art to provide a continuous level of insulin, similar to the slow, steady (basal) secretion of insulin provided by the normal pancreas. For example, Lantus®, from Aventis Pharmaceuticals Inc., is a recombinant human insulin analog that is a long-acting, parenteral blood-glucose-lowering agent whose longer duration of action (up to 24 hours) is directly related to its slower rate of absorption. Lantus® is administered subcutaneously once a day, preferably at bedtime, and is said to provide a continuous level of insulin, similar to the slow, steady (basal) secretion of insulin provided by the normal pancreas. The activity of such a long-acting insulin results in a relatively constant concentration/time profile over 24 hours with no pronounced peak, thus allowing it to be administered once a day as a patient's basal insulin. Such long-acting insulin has a long-acting effect by virtue of its chemical composition, rather than by virtue of an addition to insulin when administered.
  • [0203]
    In a preferred embodiment, administration of the pharmaceutical formulation comprising long-acting insulin is once or twice a day. In a preferred embodiment, administration of the dosage form providing short-acting insulin effect can be once, twice, three times, four times or more than four times daily, and can be at nighttime, in the morning and/or preprandially. In a more preferred embodiment, administration of the dosage form is preferably at nighttime or morning and three times preprandially, and more preferably is at nighttime and preprandially for breakfast, lunch and dinner. Preferably, the insulin formulations are administered to such human patients on a chronic basis, e.g., for at least about 2 weeks.
  • [0204]
    In other embodiments of the invention, the oral formulations include an insulin conjugated with an oligomer such as that described in U.S. Pat. No. 6,309,633 and/or which not has been subjected to amphiphilic modification such as that described in U.S. Pat. Nos. 5,359,030; 5,438,040; and/or 5,681,811. The conjugated (modified) insulin may be incorporated into the oral formulations of the present invention in addition to or in the absence of any of the types of insulin described above, as well as with other insulin analogues. In such embodiments, the oral formulations preferably include the modified insulin together with a pharmaceutically acceptable delivery agent which facilitates absorption of said insulin from the gastrointestinal tract.
  • [0205]
    Oral administrable drugs currently available for management of type 2 diabetes fall into two general categories: those that increase insulin supply (sulfonylureas, other secretagogues and insulin itself) and those that decrease insulin resistance or improve its effectiveness (biguanides, thiazolidinediones). See The Medical Letter, Volume 1, Issue 1, September 2002, Treatment Guidelines, Drugs for Diabetes. Oral sulfonylurea secretagogues include the first and second generation insulin secretagogues which are believed to interact with ATP-sensitive potassium channels in the beta cell membrane to increase secretion of insulin. The more commonly used second-generation agents (glyburide, glipizide, and glimepiride), which are more potent than the first-generation drugs (acetohexamide, chlorpropamide, tolbutamide, and tolazamide), are similar to each other in efficacy, but differ in dosage and duration of action.
  • [0206]
    Typically, such secretagogues are useful for increasing insulin levels sufficiently to achieve desired basal insulin levels in patients with early stages of type II diabetes, who are still able to produce their own insulin. However, it is unlikely that such secretagogues would be useful for increasing insulin levels sufficiently to achieve desired basal insulin levels in patients with later stages of type II diabetes, who have very little pancreatic function left and produce very little insulin endogenously. In such patients, the basal insulin levels are achieved, e.g., via the use of subcutaneous injections of insulin (such as a long-acting insulin, for example Lantus®).
  • [0207]
    In certain embodiments of the present invention, the oral insulin formulations include one or more of the various types of secretagogues mentioned above in addition to a type of insulin as described above. For example, with respect to the first generation sulfonylureas, tolbutamide (Orinase®) has an onset of action of one (1) hour and a duration of action of 6-12 hours, and is usually given in a dose of 1000 mg to 2000 mg in divided daily doses (maximum daily dose, 3000 mg/day). Tolazamide (Tolinase®) has an onset of action of 4-6 hours and a duration of action of 10-14 hours, and is usually given in a dose of 250 mg to 500 mg either once or in divided daily doses (1000 mg/day). Acetohexamide (Dymelor®) has an onset of action of one (1) hour and a duration of action of 10-14 hours, and is usually given in a dose of 500 mg to 750 mg either once or in divided daily doses (maximum daily dose 1500 mg/day). Chlorpropamide (Diabinese®) has an onset of action of one hour and a duration of action of 72 hours, and is usually given in a dose of 250 mg to 375 mg once a day (maximum daily dose, 750 mg/day).
  • [0208]
    With respect to the second generation sulfonylureas, glyburide (DiaBeta®); Micronase®; Glynase®) has an onset of action of 1.5 hours and a duration of action of 18-24 hours. It is usually given in a dose of 5 to 20 mg either once or in divided daily doses (maximum daily dose, 20 mg/day). Glipizide (Glucotrol®) has an onset of action of one hour and a duration of action of 10-24 hours. It is usually given in a dose of 10 to 20 mg either once or in divided daily doses (maximum daily dose, 40 mg/day). Glimepiride (Amaryl®) has an onset of action of 2 hours and a duration of action of 18-28 hours. It is usually administered in a dose of 1 to 4 mg once a day (maximum daily dose, 8 mg/day). Lastly, gliclazide (Diamicron®) is usually administered in a dose of 40 to 80 mg per day (maximum daily dose, 320 mg).
  • [0209]
    Oral non-sulfonylurea secretagogues, such as repaglinide and nateglinide, although structurally different from the sulfonylureas, also bind to ATP-sensitive potassium channels on beta-cells and increase insulin release. See The Medical Letter, Volume 1, Issue 1, September 2002, Treatment Guidelines, Drugs for Diabetes. Both repaglinide and nateglinide are rapidly absorbed, resulting in plasma levels of insulin that peak within 30 to 60 minutes and return to baseline before the next meal. These drugs must be taken before each meal; if a meal is missed, the drug should be omitted. Repaglinide and nateglinide are much more expensive than sulfonylureas, but repaglinide may be a useful alternative to a sulfonylurea in patients with renal impairment (because it is cleared primarily by hepatic metabolism) or in patients who eat sporadically. Hypoglycemia may be slightly less frequent with nateglinide and repaglinide than with sulfonylureas, but data are limited. Nateglinide (Starlix®) stimulates pancreatic insulin secretion within 20 minutes of oral administration. Following oral administration immediately prior to a meal, nateglinide is rapidly absorbed with a mean peak plasma drug concentration (Cmax) generally occurring within one hour (tmax) after dosing. When nateglinide is dosed three times daily before meals, there is a rapid rise in plasma insulin, with peak levels approximately one (1) hour after dosing and a fall to baseline by four (4) hours after dosing. Nateglinide is usually administered in a dose of 60 to 120 mg three times daily before meals (maximum daily dose, 360 mg/day). When given with or after meals, the extent of nateglinide absorption (AUC) remains unaffected. However, there is a delay in the rate of absorption characterized by a decrease in Cmax and a delay in time to peak plasma concentration (tmax). Similarly, repaglinide (Prandin®) is rapidly and completely absorbed from the gastrointestinal tract following oral administration. After single and multiple oral doses in healthy subjects or in patients, peak plasma drug levels (Cmax) occur within 1 hour (tmax). Repaglinide is usually administered in a dose of 1 to 4 mg three times a day before meals (maximum daily dose, 16 mg/day). When repaglinide was given with food, the mean tmax was not changed, but the mean Cmax and AUC (area under the time/plasma concentration curve) were decreased 20% and 12.4%, respectively.
  • [0210]
    In addition, long-term administration of specific inhibitors of dipeptidyl peptidase IV (DP IV), so as to enhance circulating active potent insulin secretagogues glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) levels, has been shown to improve glucose tolerance and beta-cell glucose responsiveness and to reduce hyperinsulinemia in the Vancouver diabetic fatty (VDF) rat model of type 2 diabetes. [Long-term treatment with dipeptidyl peptidase IV inhibitor improves hepatic and peripheral insulin sensitivity in the VDF Zucker rat: a euglycemic-hyperinsulinemic clamp study. Diabetes 2002 September; 51(9):2677-2683. Pospisilik J A, Stafford S G, Demuth H U, McIntosh C H, Pederson R A.] Upon release into the circulation, GIP and GIP-1 are rapidly cleaved and inactivated by the enzyme DP IV.
  • [0211]
    With respect to anti-diabetic drugs currently available for management of type 2 diabetes that decrease insulin resistance or improve its effectiveness, biguanides, which decrease the amount of glucose made by the liver, and thiazolidinediones, which make the patient more sensitive to insulin, are oral hypoglycemic agents that are currently used clinically for improving insulin resistance. Biguanides, such as Metformin (Glucophage® and Glucophage® XR by Bristol-Myers Squibb Company of Princeton, N.J.), which is the only biguanide available for therapeutic use, decreases hepatic glucose production (gluconeogenesis), decreases intestinal absorption of glucose and improves insulin sensitivity by increasing peripheral glucose uptake and utilization. There is no fixed dosage of Glucophage® for the management of hyperglycemia, and dosage must be individualized based upon effectiveness and tolerance, while not exceeding the maximum recommended daily dose of 2550 mg in adults and 2000 mg in pediatric patients, once or in divided doses. In general, clinically significant results are not seen at doses below 1500 mg per day. However, a lower recommended starting dose and gradually increased dosage is advised in order to minimize gastrointestinal symptoms.
  • [0212]
    Thiazolidinediones improve sensitivity to insulin in muscle and adipose tissue and inhibit hepatic gluconeogenesis, and thus depend on the presence of insulin for their action. The two currently approved thiazolidinedione compounds are pioglitazone (Actos® by Takeda Pharmaceuticals America, Inc. of Lincolnshire, L) and rosiglitazone (Avandia® by GlaxoSmithKline of Research Triangle Park, N.C.). Actos® also improves hepatic sensitivity to insulin and improves dysfunctional glucose homeostasis. Actos® is first measurable in serum, following oral administration in the fasting state, within 30 minutes, with peak concentrations observed within 2 hours. Food slightly delays the time to peak serum concentration to 3 to 4 hours but does not alter the extent of absorption. Actos® is usually given once daily without regard to meals, and dosage must be individualized based upon HbA1c for a period of time adequate to evaluate changes in HbA1c. Monotherapy dosage in patients not adequately controlled with diet and exercise may be initiated at 15 mg or 30 mg and can be increased incrementally up to 45 mg (maximum dose 45 mg per day). Avandia® reaches peak plasma concentrations within about 1 hour after dosing, and administration with food results in no change in overall exposure (AUC) but results in a 28% decrease in maximum plasma concentrations and a delay of the time to reach peak plasma concentrations to about 1.75 hours after dosing. Dosage of Avandia® must be individualized, and Avandia® may be administered either at a starting dose of 4 mg as a single daily dose or divided and administered twice a day with or without food. For patients who respond inadequately, as determined by reduction in fasting blood glucose, the dose may be increased to 8 mg daily (maximum dose 8 mg per day).
  • [0213]
    In certain preferred embodiments of the invention, the oral formulations of the invention provide two forms of insulin having different activity rates in order to simulate the biphasic release of insulin in non-diabetic humans. For example, such oral formulations may include a rapid-acting form of insulin together with a slow acting form of insulin so as to provide a first peak of insulin which occurs rapidly and is short-lived, followed by a second peak of insulin which occurs at a later time, but which preferably has a longer duration.
  • [0214]
    In further alternatively preferred embodiments of the invention, the oral formulations of the invention include a rapid-acting form of insulin together with a secretagogue that promotes the secretion of insulin from the beta-cells at a time and to an extent which mimics the second phase release of insulin in non-diabetic humans.
  • [0215]
    In alternatively preferred embodiments of the invention, the methods of insulin administration of the invention provide two separate forms of insulin having different activity rates in order for the regimen to simulate the biphasic release of insulin in non-diabetic humans. For example, the oral formulations may include a rapid-acting form of insulin so as to provide a first peak of insulin which occurs rapidly and is short-lived. Such fast-acting effect may be provided by the delivery agent that facilitates the absorption of insulin from the gastrointestinal tract. The slow acting form of insulin provides a second peak of insulin that occurs at a later time but that preferably has a longer duration. Such slower acting insulin may be provided by a separate dosage form, which may be administered orally or subcutaneously.
  • [0216]
    In further embodiments of the present invention, the oral dosage forms described herein are orally administered as described herein in combination with an additional therapy to treat diabetes, impaired glucose tolerance, or to achieve glucose homeostasis, said additional therapy comprising, for example, an additional drug such as a sulfonylurea, a biguanide (such as Metformin), an alpha-glucosidase, insulin delivered via a different pathway (e.g., parenteral insulin), and/or an insulin sensitizer such as thiazolidinedione.
  • [0217]
    In further embodiments of the invention, the oral dosage forms described herein reduce the likelihood of hypoglycemic events. Hypoglycemia usually results from a mismatch between insulin levels and degree of glycemia, e.g., when the administration of insulin and the ingestion of the meal are not timed such that the insulin peak occurs at peak glycemia, and administration of insulin shortly before a meal is more practical for a patient and is also safer, because glucose is ingested soon thereafter. The risk of hypoglycemia is lowered mainly due to the portal-physiologic route of administration of oral insulin. One cannot hyperinsulinize the liver, because, even under hyperinsulinemic condition, the uptake of glucose by the liver will be unchanged. Unlike the peripheral tissue, the pancreas will not sequester additional glucose but rather will only cease producing endogenous insulin. Second, the brief peak of insulin that results from the oral composition described herein shows that, even if insulin were to reach high peripheral levels, the peak quickly drops precipitously.
  • [0218]
    In addition, further embodiments of the oral dosage forms described herein avoid the risk of hypoglycemic events that may occur in certain short acting insulin formulations, which may, between the time of administration of insulin and the time of ingestion of the meal, contribute to a lowering of blood glucose to a level that could range from undesirable to clinically hypoglycemic. In the oral dosage forms disclosed herein, dosing closer to a meal eliminated the dip in blood glucose levels, which was precarious by itself. The effect seems to have also translated to lowering of the subsequent glucose excursion.
  • [0219]
    In preferred embodiments of the dosage forms described herein, in the absence of a delivery agent, the dose of insulin is not sufficiently absorbed when orally administered to a human patient to provide a desirable therapeutic effect but said dose provides a desirable therapeutic effect when administered to said patient by another route of administration. Previous disclosures by Emisphere Technologies, Inc. solved the problem of oral absorption of insulin by providing delivery agents that facilitate transport of insulin through the gut wall and into the bloodstream where the insulin can perform its biological function. As a result, effective oral drug delivery methods are provided to increase the oral bioavailability and absorption of insulin, which is currently administered parenterally.
  • [0220]
    The invention is thus directed to an methods involving oral administration of a dosage form comprising insulin together with a pharmaceutically acceptable delivery agent that serves to render the insulin orally absorbable through the gastrointestinal mucosa, the delivery agent being present in an amount effective to facilitate the absorption of said insulin, such that a therapeutically effective amount of said dose of insulin is absorbed from the gastrointestinal tract of human diabetic patients. This allows the oral dosage form to be dosed much closed to a meal than was previously taught.
  • [0221]
    In preferred embodiments, the oral dosage forms of the present invention comprise a mixture of insulin and a delivery agent, e.g., monosodium N-(4-chlorosalicyloyl)-4-aminobutyrate (4-CNAB), a novel compound discovered by Emisphere Technologies, Inc., or separately containing insulin and the delivery agent.
  • [0222]
    In other preferred embodiments, the delivery agents used in the invention have the following structure:
    wherein X is one or more of hydrogen, halogen, hydroxyl or C1-C3 alkoxy, and R is substituted or unsubstituted C1-C3 alkylene, substituted or unsubstituted C1-C3 alkenylene.
  • [0223]
    In certain preferred embodiments, the delivery agents of the invention preferably have the following structure:
    wherein X is halogen, and R is substituted or unsubstituted C1-C3 alkylene, substituted or unsubstituted C1-C3 alkenylene.
  • [0224]
    In a preferred embodiment of the present invention, the pharmaceutical composition includes a delivery agent wherein X is chlorine and R is C3 alkylene. In another preferred embodiment of the present invention, the pharmaceutical composition includes the compound 4-[(4-chloro, 2-hydroxybenzoyl)amino]butanoic acid as a delivery agent for the oral delivery of insulin, preferably the monosodium salt thereof. In preferred embodiments, the oral dosage forms of the present invention comprise a mixture of insulin and a delivery agent, e.g., monosodium N-(4-chlorosalicyloyl)-4-aminobutyrate (4-CNAB), a novel compound discovered by Emisphere Technologies, Inc., or separately containing insulin and the delivery agent.
  • [0225]
    The delivery agents may be in the form of the carboxylic acid or salts thereof. Suitable salts include, but are not limited to, organic and inorganic salts, for example alkali-metal salts, such as sodium, potassium and lithium; alkaline-earth metal salts, such as magnesium, calcium or barium; ammonium salts; basic amino acids, such as lysine or arginine; and organic amines, such as dimethylamine or pyridine. Preferably, the salts are sodium salts. The salts may be mono- or multi-valent salts, such as monosodium salts and di-sodium salts. The salts may also be solvates, including ethanol solvates, and hydrates.
  • [0226]
    Other suitable delivery agents that can be used in the present invention include those delivery agents described U.S. Pat. Nos. 5,650,386, 5,773,647, 5,776,888, 5,804,688, 5,866,536, 5,876,710, 5,879,681, 5,939,381, 5,955,503, 5,965,121,5,989,539, 5,990,166, 6,001,347, 6,051,561, 6,060,513, 6,090,958, 6,100,298, 5,766,633, 5,643,957, 5,863,944, 6,071,510 and 6,358,504, the disclosure of each of which is incorporated herein by reference. Additional suitable delivery agents are also described in International Publications Nos. WO 01/34114, WO 01/21073, WO 01/41985, WO 01/32130, WO 01/32596, WO 01/44199, WO 01/51454, WO 01/25704, WO 01/25679, WO 00/50386, WO 02/02509, WO 00/47188, WO 00/07979, WO 00/06534, WO 98/25589, WO 02/19969, WO 00/59863, WO 95/28838, WO 02/19969, WO 02/20466, WO 02/069937 and WO 02/070438, the disclosure of each of which is incorporated herein by reference.
  • [0227]
    Salts of the delivery agent compounds of the present invention may be prepared by methods known in the art. For example, sodium salts may be prepared by dissolving the delivery agent compound in ethanol and adding aqueous sodium hydroxide.
  • [0228]
    The compounds described herein may be derived from amino acids and can be readily prepared from amino acids by methods known by those with skill in the art based upon the present disclosure and the methods described in International Publications Nos. WO 96/30036, WO 97/36480, WO 98/34632 and WO 00/07979, and in U.S. Pat. Nos. 5,643,957 and 5,650,386, the disclosure of each of which is incorporated herein by reference. For example, the compounds may be prepared by reacting the single amino acid with the appropriate acylating or amine-modifying agent, which reacts with a free amino moiety present in the amino acid to form amides. Protecting groups may be used to avoid unwanted side reactions as would be known to those skilled in the art.
  • [0229]
    The delivery agents may also be prepared by the methods of International Patent Publications Nos. WO 02/02509 and WO 03/057170, the disclosure of each of which is incorporated herein by reference.
  • [0230]
    The delivery agents may also be prepared by alkylation of the appropriate salicylamide according to the methods of International Publication No. WO 00/46182, the disclosure of which is incorporated herein by reference. The salicylamide may be prepared from salicylic acid via the ester by reaction with sulfuric acid and ammonia.
  • [0231]
    In addition, polyamino acids and peptides comprising one or more of these compounds may be used. An amino acid is any carboxylic acid having at least one free amine group and includes naturally occurring and synthetic amino acids. Poly amino acids are either peptides (which are two or more amino acids joined by a peptide bond) or are two or more amino acids linked by a bond formed by other groups which can be linked by, e.g., an ester or an anhydride linkage. Peptides can vary in length from dipeptides with two amino acids to polypeptides with several hundred amino acids.
  • [0232]
    The delivery agent compound may be purified by recrystallization or by fractionation on one or more solid chromatographic supports, alone or linked in tandem. Suitable recrystallization solvent systems include, but are not limited to, ethanol, water, heptane, ethyl acetate, acetonitrile, methanol and tetrahydrofuran and mixtures thereof. Fractionation may be performed on a suitable chromatographic support such as alumina, using methanol/n-propanol mixtures as the mobile phase; reverse phase chromatography using trifluoroacetic acid/acetonitrile mixtures as the mobile phase; and ion exchange chromatography using water or an appropriate buffer as the mobile phase. When anion exchange chromatography is performed, preferably a 0-500 mM sodium chloride gradient is employed.
  • [0233]
    Following oral administration of the pharmaceutical compositions of the present invention, the delivery agent passes though the mucosal barriers of the GI tract and is absorbed into the blood stream where it can be detected in the plasma of subjects. The delivery agent facilitates the absorption of the drug (active agent) administered therewith (either in the same dosage form, or simultaneously therewith), or sequentially (in either order, as long as both the delivery agent and the drug are administered within a time period which provides both in the same location, e.g., the stomach, at the same time). The mechanism by which 4-CNAB facilitates the gastrointestinal absorption of insulin has not yet been fully elucidated. The current working hypothesis is that 4-CNAB interacts with insulin non-covalently, creating more favorable physicochemical properties for absorption. This working hypothesis is provided for explanation purposes only and is not intended to limit the present invention or the appended claims in any way.
  • [0234]
    The amount of delivery agent in the present composition is a delivery effective amount and can be determined for any particular delivery agent/insulin combination by methods known to those skilled in the art. The amount of delivery agent necessary to adequately deliver the therapeutic amount of insulin into the blood stream of a subject needing the therapeutic effect of insulin may vary depending on one or more of the following; the chemical nature of insulin; the chemical structure of the particular delivery agent; the nature and extent of interaction between insulin and delivery agent; the nature of the unit dose, i.e., solid, liquid, tablet, capsule or suspension; the concentration of delivery agent in the GI tract; the feeding state of the subject; the diet of the subject; the health of the subject and the ratio of delivery agent to insulin. In certain preferred embodiments of the invention, the amount of the delivery agent preferred for the pharmaceutical composition and contained in one or more dosage forms is from about 1 mg to about 2,000 mg, more preferably from about 5 mg to about 800 mg, more preferably about 20 mg to about 600 mg, even more preferably from about 30 mg to about 400 mg, still more preferably from about 40 mg to about 200 mg, most preferably about 40 mg, 80 mg or 160 mg.
  • [0235]
    The time it takes for the delivery agent to reach a peak in the bloodstream (tmax) may depend on many factors such as the following: the nature of the unit dose, i.e., solid, liquid, tablet, capsule, suspension; the concentration of delivery agent in the GI tract; the feeding state of the subject; the diet of the subject; the health of the subject and the ratio of delivery agent to the active agent. The delivery agents of the present invention are rapidly absorbed from the gastrointestinal tract when orally administered in an immediate release dosage form, preferably in tablet form, and preferably provide a peak plasma delivery agent concentration within about 5 minutes to about 40 minutes after oral administration, and preferably at about 10 minutes to about 35 minutes after oral administration. In a preferred embodiment of the invention, wherein the pharmaceutical composition includes the compound 4-CNAB as the delivery agent for insulin, the composition provides a peak plasma delivery agent concentration within about 25 minutes to about 35 minutes after oral administration to fasting diabetic patients and within about 15 minutes to about 25 minutes after oral administration to fed diabetic patients.
  • [0236]
    In certain preferred embodiments of the invention, a peak plasma concentration (Cmax) of the delivery agent achieved after oral administration is preferably from about 10 to about 250,000 ng/ml, after oral administration, preferably from about 100 to about 125,000 ng/ml, and preferably the peak plasma concentration of the delivery agent is from about 1,000 to about 50,000 ng/ml, after oral administration. More preferably, the peak plasma concentration of the delivery agents of the present invention is from about 3,000 to about 15,000 ng/ml after oral administration.
  • [0237]
    In a preferred embodiment of the invention, wherein the pharmaceutical composition includes the compound 4-CNAB as the delivery agent and insulin as the active agent, the composition provides a peak plasma 4-CNAB concentration within about 0.1 to about 3 hours after oral administration. In certain preferred embodiments where the pharmaceutical composition includes the compound 4-CNAB as the delivery agent and insulin as the active agent, the peak plasma concentration of delivery agent attained is from about 8,000 to about 37,000 ng/ml.
  • [0238]
    Since the amount of delivery agent required to deliver a particular active agent is variable and the amount of active agent required to produce a desired therapeutic effect is also a variable, the ratio of active agent to delivery agent may vary for different active agent/delivery agent combinations. In certain preferred embodiments of the invention where the oral pharmaceutical composition includes insulin as the active agent and the delivery agent is the compound 4-CNAB, the amount of the delivery agent included in the pharmaceutical composition may be from about 20 mg to about 600 mg of said delivery agent.
  • [0239]
    The optimum ratio of insulin to delivery agent can vary depending on the delivery agent and the formulation. Optimizing the ratio of insulin to delivery agent is within the knowledge of one skilled in the art. In certain preferred embodiments of the invention, the pharmaceutical composition includes insulin as the active agent and the delivery agent is the monosodium salt of 4-CNAB, the ratio of insulin [Units] to delivery agent [mg] ranges from 10:1 [Units/mg] to 1:10 [Units/mg], preferably, the ratio of insulin [Units] to delivery agent [mg] ranges from 5:1 [Units/mg] to 0.5:1 [Units/mg].
  • [0240]
    Preferred insulin doses in a single administration are about 5 to about 1000 insulin units USP, preferably from about 50 to about 400, more preferably from about 150 to about 400, and still more preferably from about 150 to about 300 units.
  • [0241]
    Absorption of insulin can be detected in subjects treated with the pharmaceutical compositions of the present invention by monitoring the plasma levels of insulin after treatment. The time it takes for an active agent to reach a peak in the bloodstream (tmax) may depend on many factors such as the following: the nature of the unit dose, i.e., solid, liquid, tablet, capsule, suspension; the concentration of active agent and delivery agent in the GI tract; the feeding state of the subject; the diet of the subject; the health of the subject and the ratio of active agent to the delivery agent.
  • [0242]
    In a preferred embodiment of the invention, wherein the pharmaceutical composition includes the compound 4-CNAB as the delivery agent and insulin as the active agent, the composition provides a peak plasma insulin concentration from about 0.1 to about 1 hour after oral administration. In another embodiment, the composition provides a peak plasma insulin concentration from about 0.2 to about 0.6 hours after oral administration. In a preferred embodiment, the composition provides a peak plasma insulin concentration from about 0.3 to about 0.4 hours after oral administration. In another embodiment, the composition provides a peak plasma insulin concentration within about 1 hour after oral administration. In certain preferred embodiments, the pharmaceutical composition comprises insulin and the compound 4-CNAB as a delivery agent to facilitate the oral delivery of insulin, and after insulin is absorbed into the bloodstream, the plasma insulin levels in treated patients peak at about 20 minutes post oral administration with a second peak at about 105 minutes.
  • [0243]
    The effect of absorption of insulin is manifested in human patients treated with the pharmaceutical compositions of the present invention by observing reductions in C-peptide concentration following oral treatment. For example, in one embodiment of the invention, the pharmaceutical composition comprises insulin and the compound 4-CNAB as a delivery agent to facilitate the oral delivery of insulin, and, after insulin is absorbed into the bloodstream, the composition produces a maximal decrease in C-peptide concentration in treated patients from about 80 and about 120 minutes post oral administration. More particularly, the composition produces a maximal decrease in C-peptide concentration in treated patients from about 90 and about 110 minutes post oral administration.
  • [0244]
    In previous patent applications, such as those enumerated above that have been incorporated herein by reference, Emisphere Technologies, Inc. disclosed structures of various delivery agents, comparisons of their effectiveness of absorption and effectiveness of delivery, the preparation of the preferred delivery agent 4-CNAB, its preparation for human studies, and data regarding previous non-clinical and clinical studies involving the delivery agent 4-CNAB.
  • [0245]
    The delivery agent may be used directly by mixing with the unmodified insulin prior to administration, either in dry powder form or wet granulated together. To this mixture, other pharmaceutically acceptable excipients may be added. The mixture may be then tableted or placed into gelatin capsules containing a unit dose of the active agent and the delivery agent. Alternatively, the delivery agent/insulin mixture may be prepared as an oral solution or suspension. The delivery agent and insulin do not need to be mixed together prior to administration, such that, in certain embodiments, the unit dose of insulin (with or without other pharmaceutically acceptable excipients) is orally administered without the delivery agents of this invention, and the delivery agent is separately orally administered (with or without other pharmaceutically acceptable excipients) before, after, or simultaneously with the insulin.
  • [0246]
    In certain preferred embodiments, the oral dosage forms of the present invention are solid. The insulin in dry powder form is stable, and in certain preferred embodiments is simply mixed in a desirable ratio with the delivery agent. The dry powder mixture may then be filled into gelatin capsules, with or without optional pharmaceutical excipients. Alternatively, the insulin in dry powder form may be mixed with the delivery agent together with optional pharmaceutical excipients, and the mixture may be tableted in accordance with standard tableting procedures known to those having ordinary skill in the art.
  • [0247]
    The dosage forms of the present invention may be produced by first dissolving insulin and the delivery agent into one solution or separate solutions. The solvent will preferably be an aqueous solution, but organic solvents or aqueous organic solvent mixtures may be used when necessary to solubilize the delivery agent. If two solutions are used, the proportions of each necessary to provide the correct amount of either insulin or delivery agent are combined and the resulting solution may be dried, by lyophilization or equivalent means. In one embodiment of the invention, the oral dosage form may be dried and rehydrated prior to oral administration.
  • [0248]
    The administration mixtures may be prepared, e.g., by mixing an aqueous solution of the delivery agent with an aqueous solution of insulin just prior to administration. Alternatively, the delivery agent and insulin can be admixed during the manufacturing process. The solutions may optionally contain additives such as phosphate buffer salts, citric acid, acetic acid, gelatin, and gum acacia.
  • [0249]
    In preferred embodiments of the oral dosage forms of the invention described above, the oral dosage form is solid, and is preferably provided incorporated within a gelatin capsule or is contained in a tablet.
  • [0250]
    Stabilizing additives may be incorporated into the delivery agent solution. With some drugs, the presence of such additives promotes the stability and dispersibility of the agent in solution. The stabilizing additives may be employed at a concentration ranging from about 0.1 and 5% (W/V), preferably about 0.5% (W/V). Suitable, but non-limiting, examples of stabilizing additives include gum acacia, gelatin, methyl cellulose, polyethylene glycol, carboxylic acids and salts thereof, and polylysine. The preferred stabilizing additives are gum acacia, gelatin and methyl cellulose.
  • [0251]
    The oral dosage forms of the present invention, containing a mixture of the active agent, e.g., insulin and the delivery agent, e.g., 4-CNAB or separately containing the active agent and the delivery agent, may include additional materials known to those skilled in the art as pharmaceutical excipients. Any excipient or ingredient, including pharmaceutical ingredients or excipients. Such pharmaceutical excipients include, for example, the following: Acidifying agents (acetic acid, glacial acetic acid, citric acid, fumaric acid, hydrochloric acid, diluted hydrochloric acid, malic acid, nitric acid, phosphoric acid, diluted phosphoric acid, sulfuric acid, tartaric acid); Aerosol propellants (butane, dichlorodifluoro-methane, dichlorotetrafluoroethane, isobutane, propane, trichloromonofluoromethane); Air displacements (carbon dioxide, nitrogen); Alcohol denaturants (denatonium benzoate, methyl isobutyl ketone, sucrose octacetate); Alkalizing agents (strong ammonia solution, ammonium carbonate, diethanolamine, diisopropanolamine, potassium hydroxide, sodium bicarbonate, sodium borate, sodium carbonate, sodium hydroxide, trolamine); Anticaking agents (see glidant); Antifoaming agents (dimethicone, simethicone); Antimicrobial preservatives (benzalkonium chloride, benzalkonium chloride solution, benzelthonium chloride, benzoic acid, benzyl alcohol, butylparaben, cetylpyridinium chloride, chlorobutanol, chlorocresol, cresol, dehydroacetic acid, ethylparaben, methylparaben, methylparaben sodium, phenol, phenylethyl alcohol, phenylmercuric acetate, phenylmercuric nitrate, potassium benzoate, potassium sorbate, propylparaben, propylparaben sodium, sodium benzoate, sodium dehydroacetate, sodium propionate, sorbic acid, thimerosal, thymol); Antioxidants (ascorbic acid, acorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene, hypophosphorous acid, monothioglycerol, propyl gallate, sodium formaldehyde sulfoxylate, sodium metabisulfite, sodium thiosulfate, sulfur dioxide, tocopherol, tocopherols excipient); Buffering agents (acetic acid, ammonium carbonate, ammonium phosphate, boric acid, citric acid, lactic acid, phosphoric acid, potassium citrate, potassium metaphosphate, potassium phosphate monobasic, sodium acetate, sodium citrate, sodium lactate solution, dibasic sodium phosphate, monobasic sodium phosphate); Capsule lubricants (see tablet and capsule lubricant); Chelating agents (edetate disodium, ethylenediaminetetraacetic acid and salts, edetic acid); Coating agents (sodium carboxymethyl-cellulose, cellulose acetate, cellulose acetate phthalate, ethylcellulose, gelatin, pharmaceutical glaze, hydroxypropyl cellulose, hydroxypropyl methylcellulose, hydroxypropyl methylcellulose phthalate, methacrylic acid copolymer, methylcellulose, polyethylene glycol, polyvinyl acetate phthalate, shellac, sucrose, titanium dioxide, carnauba wax, microcystalline wax, zein); Colorants (caramel, red, yellow, black or blends, ferric oxide); Complexing agents (ethylenediaminetetraacetic acid and salts (EDTA), edetic acid, gentisic acid ethanolmaide, oxyquinoline sulfate); Desiccants (calcium chloride, calcium sulfate, silicon dioxide); Emulsifying and/or solubilizing agents (acacia, cholesterol, diethanolamine (adjunct), glyceryl monostearate, lanolin alcohols, lecithin, mono- and di-glycerides, monoethanolamine (adjunct), oleic acid (adjunct), oleyl alcohol (stabilizer), poloxamer, polyoxyethylene 50 stearate, polyoxyl 35 caster oil, polyoxyl 40 hydrogenated castor oil, polyoxyl 10 oleyl ether, polyoxyl 20 cetostearyl ether, polyoxyl 40 stearate, polysorbate 20, polysorbate 40, polysorbate 60, polysorbate 80, propylene glycol diacetate, propylene glycol monostearate, sodium lauryl sulfate, sodium stearate, sorbitan monolaurate, soritan monooleate, sorbitan monopalmitate, sorbitan monostearate, stearic acid, trolamine, emulsifying wax); Filtering aids (powdered cellulose, purified siliceous earth); Flavors and perfumes (anethole, benzaldehyde, ethyl vanillin, menthol, methyl salicylate, monosodium glutamate, orange flower oil, peppermint, peppermint oil, peppermint spirit, rose oil, stronger rose water, thymol, tolu balsam tincture, vanilla, vanilla tincture, vanillin); Glidants and/or anticaking agents (calcium silicate, magnesium silicate, colloidal silicon dioxide, talc); Humectants (glycerin, hexylene glycol, propylene glycol, sorbitol); Plasticizers (castor oil, diacetylated monoglycerides, diethyl phthalate, glycerin, mono- and di-acetylated monoglycerides, polyethylene glycol, propylene glycol, triacetin, triethyl citrate); Polymers (e.g., cellulose acetate, alkyl celloloses, hydroxyalkylcelloloses, acrylic polymers and copolymers); Solvents (acetone, alcohol, diluted alcohol, amylene hydrate, benzyl benzoate, butyl alcohol, carbon tetrachloride, chloroform, corn oil, cottonseed oil, ethyl acetate, glycerin, hexylene glycol, isopropyl alcohol, methyl alcohol, methylene chloride, methyl isobutyl ketone, mineral oil, peanut oil, polyethylene glycol, propylene carbonate, propylene glycol, sesame oil, water for injection, sterile water for injection, sterile water for irrigation, purified water); Sorbents (powdered cellulose, charcoal, purified siliceous earth); Carbon dioxide sorbents (barium hydroxide lime, soda lime); Stiffening agents (hydrogenated castor oil, cetostearyl alcohol, cetyl alcohol, cetyl esters wax, hard fat, paraffin, polyethylene excipient, stearyl alcohol, emulsifying wax, white wax, yellow wax); Suspending and/or viscosity-increasing agents (acacia, agar, alginic acid, aluminum monostearate, bentonite, purified bentonite, magma bentonite, carbomer 934p, carboxymethylcellulose calcium, carboxymethylcellulose sodium, carboxymethycellulose sodium 12, carrageenan, microcrystalline and carboxymethylcellulose sodium cellulose, dextrin, gelatin, guar gum, hydroxyethyl cellulose, hydroxypropyl cellulose, hydroxypropyl methylcellulose, magnesium aluminum silicate, methylcellulose, pectin, polyethylene oxide, polyvinyl alcohol, povidone, propylene glycol alginate, silicon dioxide, colloidal silicon dioxide, sodium alginate, tragacanth, xanthan gum); Sweetening agents (aspartame, dextrates, dextrose, excipient dextrose, fructose, mannitol, saccharin, calcium saccharin, sodium saccharin, sorbitol, solution sorbitol, sucrose, compressible sugar, confectioner's sugar, syrup); Tablet binders (acacia, alginic acid, sodium carboxymethylcellulose, microcrystalline cellulose, dextrin, ethylcellulose, gelatin, liquid glucose, guar gum, hydroxypropyl methylcellulose, methycellulose, polyethylene oxide, povidone, pregelatinized starch, syrup); Tablet and/or capsule diluents (calcium carbonate, dibasic calcium phosphate, tribasic calcium phosphate, calcium sulfate, microcrystalline cellulose, powdered cellulose, dextrates, dextrin, dextrose excipient, fructose, kaolin, lactose, mannitol, sorbitol, starch, pregelatinized starch, sucrose, compressible sugar, confectioner's sugar); Tablet disintegrants (alginic acid, microcrystalline cellulose, croscarmellose sodium, corspovidone, polacrilin potassium, sodium starch glycolate, starch, pregelatinized starch); Tablet and/or capsule lubricants (calcium stearate, glyceryl behenate, magnesium stearate, light mineral oil, polyethylene glycol, sodium stearyl fumarate, stearic acid, purified stearic acid, talc, hydrogenated vegetable oil, zinc stearate); Tonicity agent (dextrose, glycerin, mannitol, potassium chloride, sodium chloride); Vehicle: flavored and/or sweetened (aromatic elixir, compound benzaldehyde elixir, iso-alcoholic elixir, peppermint water, sorbitol solution, syrup, tolu balsam syrup); Vehicle: oleaginous (almond oil, corn oil, cottonseed oil, ethyl oleate, isopropyl myristate, isopropyl palmitate, mineral oil, light mineral oil, myristyl alcohol, octyldodecanol, olive oil, peanut oil, persic oil, seame oil, soybean oil, squalane); Vehicle: solid carrier (sugar spheres); Vehicle: sterile (bacteriostatic water for injection, bacteriostatic sodium chloride injection); Viscosity-increasing (see suspending agent); Water repelling agent (cyclomethicone, dimethicone, simethicone); and Wetting and/or solubilizing agent (benzalkonium chloride, benzethonium chloride, cetylpyridinium chloride, docusate sodium, nonoxynol 9, nonoxynol 10, octoxynol 9, poloxamer, polyoxyl 35 castor oil, polyoxyl 40, hydrogenated castor oil, polyoxyl 50 stearate, polyoxyl 10 oleyl ether, polyoxyl 20, cetostearyl ether, polyoxyl 40 stearate, polysorbate 20, polysorbate 40, polysorbate 60, polysorbate 80, sodium lauryl sulfate, sorbitan monolaureate, sorbitan monooleate, sorbitan monopalmitate, sorbitan monostearate, tyloxapol). This list is not meant to be exclusive, but instead merely representative of the classes of excipients and the particular excipients which may be used in oral dosage forms of the present invention.
  • [0252]
    The stability of insulin has been well documented, and temperature, pH and moisture are some of the factors that affect the stability of insulin formulations. Likewise, the influence of pharmaceutical excipients on the stability of insulin has been well documented. The present specification discloses oral pharmaceutical formulations in tablet form that exhibit evidence of sufficient stability to warrant long term storage at room temperature, as demonstrated by a stability-indicating High Performance Liquid Chromatography (HPLC) assay methodology. Some of the factors that are believed to contribute to insulin stability in this formulation are:
      • reduced surface area exposure to atmospheric conditions (only the outside surface of the tablet is exposed, while the inner tablet core is not);
      • formulation of the tablet to provide an “insulin-friendly” local pH, perhaps in part due to the presence of dicalcium phosphate; and
      • low moisture content (anhydrous excipients were used whenever possible, and 4-CNAB is not hygroscopic (residual moisture content<0.5%) below 75% RH and has moisture content below 0.5% w/w).
  • [0256]
    There are several ways to assess the stability of insulin. One way is an HPLC stability-indicating assay: This method determines the amount of intact insulin molecules present in a sample, but does not determine whether these molecules are in a bioactive conformation, which is necessary in order to have an effective product. Other methods are measurement of related substances (impurities) by HPLC and assessing the bioactivity of the product, which could be an in vivo assay or an in vitro predictor of in vivo performance.
  • [0257]
    Following administration, the insulin present in the dosage unit form is absorbed into the circulation. The circulating levels of the insulin itself can be measured directly. Similarly, levels of 4-CNAB delivery agent in the blood can be measured. The bioavailability of the insulin is readily assessed by measuring a known pharmacological activity in blood, e.g., decreased blood glucose. Further physiologic effects of the insulin can be measured using tests, for example, measurement of plasma C-peptide concentration as a measure of endogenous insulin production.
  • [0258]
    In addition, a fructosamine assay can be performed to determine the measure of the diabetic patient's glycemic control over the previous period of two to three weeks. Fructosamine is formed by a non-enzymatic reaction between glucose and amino acid residues of proteins, and serum fructosamine levels are elevated in diabetic patients with elevated blood glucose concentration. Whereas blood glucose concentration is a short-term indicator of diabetes control, fructosamine is a short- to medium-term indicator of diabetes control that correlates well with both fasting and mean blood glucose over a 2-week period.
  • [0259]
    In the present invention, the methods for treating a mammal with impaired glucose tolerance or with early or late stage diabetes comprise orally administering to the mammal a pharmaceutical formulation that includes a therapeutically effective amount of insulin or an insulin analog and a delivery agent in an amount effective to facilitate the absorption of the insulin from the gastrointestinal tract. It is preferred that the administration be on a chronic basis, e.g., for at least two weeks, and be preprandially and at bedtime such that, after two weeks of treatment, the mammal achieves improved glucose tolerance and glycemic control, as well as improved insulin utilization, insulin sensitivity, insulin secretion capacity and HbA1c levels, as compared with baseline levels prior to treatment.
  • [0260]
    Improved glucose tolerance can be demonstrated by better endogenous capacity of the mammal to handle sugar load as measured by blood glucose concentration, following a sugar load, that is reduced by a statistically significant amount as compared with baseline blood glucose concentration, following a glucose load, prior to treatment. Preferably, the statistically significant reduction in blood glucose concentration is a mean of about 10-20%, preferably about 15%.
  • [0261]
    Improved glucose tolerance and better endogenous capacity of the mammal to handle sugar load can also be measured by an AUC of blood glucose excursion, following a glucose load, that is reduced by a statistically significant amount as compared with AUC of blood glucose excursion, following a glucose load, prior to treatment. Preferably, the statistically significant reduction in AUC of blood glucose excursion is a mean of about 10-30%, preferably about 20%.
  • [0262]
    Improved glycemic control can be demonstrated by decreased fasting blood glucose levels as measured by fasting blood glucose concentration that is reduced by a statistically significant amount as compared with baseline fasting blood glucose concentration prior to treatment. Preferably, the statistically significant reduction in fasting blood glucose concentration is a mean of about 10-30%, preferably about 19%.
  • [0263]
    Improved glycemic control can also be demonstrated by decreased serum fructosamine concentrations, as measured by serum fructosamine assay, that is reduced by a statistically significant amount as compared with baseline serum fructosamine concentrations prior to treatment. Preferably, the statistically significant reduction in serum fructosamine concentrations is a mean of about 5-20%, preferably about 9%.
  • [0264]
    Improved glycemic control can also be demonstrated by improved HbA1c levels after treatment compared with baseline levels prior to treatment. Preferably, the improved HbA1c levels are measured by a statistically significant decline in HbA1c levels. When treating a mammal with impaired glucose tolerance or with early or late stage diabetes, administration of the pharmaceutical formulation of the present invention can preferably be made to a mammal having an HbA1c level ranging from normal to elevated prior to treatment. In one embodiment, the mammal may have an HbA1c level preferably of less than about 8.0 prior to treatment.
  • [0265]
    Improved insulin utilization and insulin sensitivity of the patient's body can be measured by a statistically significant decline in HOMA (Homeostasis Model Assessment), and the improved insulin secretion capacity of the patient's body is measured by Stumvoll first-phase insulin secretion capacity index.
  • [0266]
    In preferred embodiments of the invention, by virtue of the chronic administration of oral dosage forms of the present invention, the patient achieves improved glucose tolerance and glycemic control as compared with baseline levels prior to treatment even without any statistically significant increase in weight, any statistically significant increase in risk of hypoglycemia or any statistically significant increase in risk of hyperinsulinemia in the mammal over the treatment period, and without the need for monitoring the mammal's blood glucose concentrations or HbA1c levels. Further, by virtue of the chronic administration of oral dosage forms of the present invention, the patient achieves improved insulin utilization, insulin sensitivity insulin secretion capacity and HbA1c levels as compared with baseline levels prior to treatment.
  • [0267]
    It is preferred that the administration of the oral pharmaceutical formulation will be about once daily to about four or more times daily, preprandially and/or at bedtime. In one embodiment of the invention, administration of the pharmaceutical formulation takes place once daily, either at bedtime or preprandially for one meal during the day time, e.g., for breakfast, lunch or dinner. In another embodiment, administration of the pharmaceutical formulation takes place multiple times daily, preferably at bedtime and preprandially for one meal during the day time, e.g., for breakfast, lunch or dinner. In a further embodiment, administration of the pharmaceutical formulation takes place multiple times daily, preferably at bedtime and preprandially for more than one meal during the day time. Administration of the pharmaceutical formulation can also be is at or shortly prior to bedtime and concurrently with or shortly prior to ingestion of each meal, i.e., within about 15 minutes or less of ingestion of each meal.
  • [0268]
    Preferably, the insulin formulations are administered to such human patients on a chronic basis, e.g., for at least about two weeks. The dosage form of the present invention can be administered for at least one day, for one week, for two weeks, for longer periods, for alternating on-off time periods, or for the life of the patient.
  • [0269]
    It is believed that the frequency of administration of the oral pharmaceutical formulation, on a daily basis (i.e., how often during one day-night period) and on a chronic basis (i.e., for how many days), will depend upon the patient's position along a “diabetes continuum”, i.e., the extent of the patient's impaired glucose tolerance, the patient's stage of diabetes and the patient's need for exogenous glycemic control. This continuum ranges from normal glycemic control, to simple impaired glucose tolerance and insulin resistance seen in pre-diabetics or early stage type 2 diabetics, to failure of insulin production by the pancreas seen in type 1 diabetics and late stage type 2 diabetics. This can also be measured by the patient's HbA1c concentration, ranging from normal to elevated levels.
  • [0270]
    For example, if the patient has a need for fasting glycemic control, the oral pharmaceutical formulation should preferably be administered only at or shortly prior to bedtime. If the patient has some need for post-prandial glycemic control, the oral pharmaceutical formulation should preferably be administered preprandially for some meals. If the patient has a need for total post-prandial glycemic control, the oral pharmaceutical formulation should preferably be administered preprandially for all meals. If the patient has a need for comprehensive glycemic control, the oral pharmaceutical formulation should preferably be administered preprandially for all meals and at or shortly prior to bedtime.
  • [0271]
    Similarly, it is also believed that depending upon the patient's position along the “diabetes continuum”, the oral insulin formulations of the present invention may be utilized in combination therapy, and may also include an additional treatment, either oral or subcutaneously administered, such as an anti-diabetic drug or insulin that has rapid action, intermediate action and/or slow action. It is believed that, in certain preferred embodiments of the present invention, the oral dosage forms described herein can be orally administered as described herein in combination with an additional yet separate therapy to treat diabetes or impaired glucose tolerance or to achieve glucose homeostasis, such as an additional drug such as sulfonylurea, a biguanide, an alpha-glucosidase, insulin delivered via a different pathway (e.g., parenteral insulin), an insulin sensitizer such as thiazolidinedione, and/or an insulin secretagogue.
  • [0272]
    In alternatively preferred embodiments of the invention, the additional treatment may comprise a second form of insulin, so as to provide the patient with two separate forms of insulin having different activity rates in order for the regimen to simulate the biphasic release of insulin in non-diabetic humans. For example, the oral formulations may include a rapid-acting form of insulin so as to provide a first insulin peak that occurs rapidly and is short-lived, and the fast-acting effect may be provided by the delivery agent that facilitates the absorption of insulin from the gastrointestinal tract. The slow acting form of insulin provides a second insulin peak that occurs later but has a longer duration. Such slower acting insulin may be provided by the same oral formulation as the rapid-acting insulin or by a separate dosage form that may be administered orally or subcutaneously.
  • [0273]
    It is further believed that the particular combination therapy and its frequency of administration, on a daily basis and on a chronic basis, will depend upon the patient's position along the “diabetes continuum”. For example, if the patient has a need for fasting glycemic control, the oral pharmaceutical formulation should be administered only at or shortly prior to bedtime. If the patient has some need for post-prandial glycemic control, the oral pharmaceutical formulation should be administered preprandially for meals. If the patient has a need for basal insulin, as in late stage type 2 diabetes or type 1 diabetes, the supplemental slow-acting insulin or anti-diabetic drug should be administered daily. If the patient has a need for comprehensive glycemic control, the oral pharmaceutical formulation should preferably be administered preprandially for all meals and at or shortly prior to bedtime in combination with the slow-acting insulin or anti-diabetic drug.
  • [0274]
    It is also believed that the invention provides a method of achieving glucose homeostasis in mammals, comprising orally administering to a mammal a pharmaceutical formulation comprising a therapeutically effective amount of insulin or an insulin analog and a delivery agent in an amount effective to facilitate the absorption of the insulin from the gastrointestinal tract. It is preferred that the administration be on a chronic basis, e.g., for at least two weeks, and be preprandially and at bedtime such that, after two weeks of treatment, the mammal achieves improved glucose tolerance and glycemic control as compared with baseline levels prior to treatment.
  • [0275]
    It is further believed that the chronic administration of the oral dosage forms of the present invention will reduce the incidence and/or severity of systemic hyperinsulinemia associated with chronic dosing of insulin or of one or more disease states associated with chronic dosing of insulin in a mammal that has impaired glucose tolerance or early stage diabetes.
  • [0276]
    The chronic administration of oral dosage forms of the present invention result in a higher portal insulin concentration and lower systemic insulin concentration over time than that obtained with an equi-effective dose of insulin administered subcutaneously (i.e., which provide similar control of blood glucose levels). Transient peaks in insulin levels that may occur by virtue of the oral administration of insulin in accordance with the present invention are not believed to be associated with vascular diseases. By virtue of the chronic administration of oral dosage forms of the present invention instead of equi-effective subcutaneous doses of insulin, lower levels of hyperinsulinemia are obtained, e.g., systemic insulin concentrations are at least about 20% lower when compared to a comparably effective subcutaneous dose of insulin.
  • [0277]
    The present invention thus provides methods for reducing the incidence and/or severity of systemic hyperinsulinemia associated with chronic dosing of insulin, and it is believed that the present invention also provides a method for reducing the incidence and/or severity of one or more disease states associated with chronic dosing of insulin.
  • [0278]
    Such methods also comprise orally administering a therapeutically effective dose of a pharmaceutical formulation comprising insulin and a delivery agent that facilitates the absorption of the insulin from the gastrointestinal tract, to provide a therapeutically effective reduction and/or control in blood glucose concentration and a plasma insulin concentration that is reduced relative to the plasma insulin concentration provided by a therapeutically equivalent dose of subcutaneously injected insulin. Such methods also achieve a reduction in blood glucose concentration in human diabetic patients comparable to a subcutaneous insulin injection in those patients, while providing a lower (e.g., 20% or greater) total exposure of insulin to the peripheral blood circulation under acute, sub-acute and chronic conditions as compared to the peripheral blood insulin exposure achieved via subcutaneous injection. The determinations of blood or insulin concentration obtained in patients who have been administered subcutaneous insulin are well known to those skilled in the art.
  • [0279]
    It is still further believed that the chronic administration of oral dosage forms of the present invention to replace the endogenous insulin production in a mammal with impaired glucose tolerance or early stage diabetes mellitus will result in prophylactically sparing the function of the mammal's β-cells or will prevent death or dysfunction of the mammal's β-cells, and will thereby provide long-term protection to the mammal from developing overt or insulin dependent diabetes, or will delay the onset of overt or insulin dependent diabetes in the mammal. The rationale for this belief is as follows.
  • [0280]
    A two year observational study with SC insulin therapy initiated early in type 2 diabetic patients, as reported in Kalfhaus J and Berger M, Insulin Treatment With Preprandial Injections of Regular Insulin in Middle-Aged Type 2 Diabetic Patients: A Two Years Observational Study, Diabetes Metab, Volume 26, pp. 197-201 (2000), showed that a subcutaneous insulin treatment regimen is safe (with a very low incidence of hypoglycemia), and highly effective in terms of establishing long-term metabolic control by the preservation of β-cell function. Insulin/4-CNAB may have the potential to show similar or even better results, because, as an oral therapy, it will be much more easily accepted by patients.
  • [0281]
    The clinical studies with oral insulin in type 2 diabetic patients reported previously by Emisphere Technologies, Inc. and herein demonstrated a hypoglycemic effect of short duration, probably indicating that the half-life of systemic circulating insulin provided by oral administration is short to affect peripheral glucose disposal. It was hypothesized that orally administered insulin as set forth herein may, however, due to its portal delivery, have a more profound effect on hepatic glucose production, which is responsible for the fasting blood glucose levels.
  • [0282]
    In a non-diabetic individual, during times of fasting, such as during sleeping hours or between meals, the pancreas is able to store insulin for future use and is given a rest from secretion. In a diabetic or insulin resistant patients, the pancreas continues to secrete insulin without allowing a proper insulin store to be achieved. It is believed that one of the first defects of the pancreas in insulin resistance and type 2 diabetes is this defect in insulin storage.
  • [0283]
    In type 2 diabetics, blood glucose levels are often elevated after an overnight fast, presumably because of unrestrained glucose production by the liver as a result of a combination of insulin resistance and insufficient insulin secretion, which is the hallmark of the diabetes disease. Elevated blood glucose levels can lead to a vicious cycle to perpetuate the severity of a diabetic's condition because, if blood glucose concentration is elevated for an extended period of time, a corresponding “wear and tear” on the cells in the pancreas that secrete insulin to regulate blood glucose levels is possible. It is believed that hyperglycemia is toxic to the β-cells of the pancreas. Current literature shows that patients in the United States with type 2 diabetes are being diagnosed 8-10 years after the diabetic process has begun. The current American Diabetes Association guideline for diagnosing diabetes is two consecutive fasting blood glucose levels above 110 mg/dL. It is believed that, by the time of diagnosis, a diabetic patient has already lost function of about 50% of his islet cells.
  • [0284]
    In insulin resistant and early stage diabetic patients, the first phase insulin response is lost or impaired, depending on the stage of the disease. In addition, this lack of rest by the pancreas, especially the β-cells, can cause these cells to become dysfunctional or die from exhaustion. Thus, if a treatment were to spare insulin producing cell function, this “rest” to the cells may provide for long-term protection to develop overt diabetes.
  • [0285]
    In a study reported in International Patent Application No. PCT/US04/00273 and also discussed below, it was shown that administration of exogenous insulin at nighttime had an effect on hepatic glucose production and hence FBG (free blood glucose), thereby presumably allowing the patients' β-cells to rest and produce less insulin to achieve the same glycemic level. The suggested clinical implication is that, if nighttime oral insulin treatment were to be given alone, it is likely to spare β-cell function. This significance is supported by several reported studies that have shown that, by intervening “aggressively” with insulin at early stages of the disease (such as at the impaired glucose tolerance stage) by giving insulin even for a short time such as two week duration, the resulting rest to the β-cells may provide long term protection from developing overt diabetes. It is thus believed that a boost of exogenous insulin at nighttime can also be useful through the progression of the diabetes from a healthy state, to a pre-diabetic state and finally to a diabetic state.
  • [0286]
    It is believed that therapy can be initiated at an early stage to prophylactically spare β-cell function and aid in preventing β-cell death and the progression to overt diabetes. Many factors may be taken into account when therapy becomes necessary or desirable including, but not limited to: defects in GTT indicating signs of insulin resistance, reactive hypoglycemia, or early β-cell dysfunction, elevated fasting or postprandial blood glucose levels, family history for diabetes, obesity, HbA1c above approximately 6.5 or an elevation of HbA1c of more than about 10% over patient's past values, even if still within normal ranges. In accordance with the present invention, it is believed that a mammal at this early stage can be treated, prophylactically sparing β-cell function, aiding in preventing β-cell death and/or the progression to overt diabetes, by administering one time daily an effective dose of a pharmaceutical formulation, preferably an oral formulation, comprising insulin (as described herein) at nighttime, in the morning or preprandially, preferably at nighttime or in the morning. Preferably, the insulin formulation is administered to such human patients on a chronic basis, e.g., for at least about two weeks.
  • [0287]
    It is believed that, as the diabetes progresses, the patient may no longer be able to control his blood glucose at breakfast, even with the once a day dose as described above. This progression can be diagnosed using any method known in the art including but not limited to noting: further defects in the GTT, elevated fasting or postprandial blood glucose levels, HbA1c above approximately 6.5 or an elevation of HbA1c of more than about 10% over patient's past values, even if still within normal ranges, or no noticeable decrease in patients elevated HbA1c as described above despite treatment. In accordance with the present invention, it is believed that a mammal at this early stage of impaired glucose tolerance or early stage diabetes mellitus can be treated, prophylactically sparing remaining β-cell function, aiding in preventing β-cell death and/or the progression to overt diabetes and treating the current level of glycemic control dysfunction, by administering an effective dose of a pharmaceutical formulation, preferably an oral formulation, twice daily comprising insulin (as described herein) at nighttime, in the morning and/or preprandially, preferably at nighttime or morning and preprandially, more preferably at nighttime and preprandial for breakfast. Preferably, the insulin formulation is administered to such human patients on a chronic basis, e.g., for at least about two weeks.
  • [0288]
    Alternatively, it is believed that, even at this stage of impaired glucose tolerance or early stage diabetes, the patient can be treated, prophylactically sparing remaining β-cell function, aiding in preventing β-cell death and/or the progression to overt diabetes and treating the current level of glycemic control dysfunction, by administering an effective dose of a pharmaceutical formulation, preferably an oral formulation, three times daily comprising insulin (as described herein) preprandially or postprandially. This treatment regime can be carried through to later stages of the diabetes. Preferably, the insulin formulation is administered to such human patients on a chronic basis, e.g., for at least about two weeks.
  • [0289]
    It is believed that, as the diabetes progresses even further, the patient may no longer be able to control his blood glucose at lunch, even with the twice a day dose as described above. This progression can be diagnosed using any method known in the art including but not limited to noting: further defects in the GTT or defects in a lunchtime GTT, elevated fasting or postprandial blood glucose levels, HbA1c above approximately 6.5 or an elevation of HbA1c of more than about 10% over patient's past values, even if still within normal ranges, or no noticeable decrease in patients elevated HbA1c as described above despite treatment. In accordance with the present invention, it is believed that a mammal at this stage of impaired glucose tolerance or diabetes mellitus can be treated, prophylactically sparing remaining β-cell function, aiding in preventing β-cell death and/or the progression to overt diabetes and treating the current level of glycemic control dysfunction, by administering an effective dose of a pharmaceutical formulation, preferably an oral formulation, three times daily comprising insulin (as described herein) at nighttime, in the morning and/or preprandially, preferably at nighttime or morning and twice preprandially, more preferably at nighttime and preprandial for breakfast and lunch. Preferably, the insulin formulation is administered to such human patients on a chronic basis, e.g., for at least about two weeks.
  • [0290]
    It is believed that, as the diabetes progresses yet further, the patient may no longer be able to control his blood glucose at dinner, even with the three times a day dose as described above. This progression can be diagnosed using any method known in the art including but not limited to noting: further defects in the GTT, or defects in a dinnertime GTT, elevated fasting or postprandial blood glucose levels, HbA1c above 6.5 or an elevation of HbA1c of more than about 10% over patients past values, even if still within normal ranges, or no noticeable decrease in patients elevated HbA1c as described above, even with treatment. In accordance with the present invention, it is believed that a mammal at this stage of impaired glucose tolerance or diabetes mellitus can be treated, prophylactically sparing remaining β-cell function, and/or aiding in preventing β-cell death and treating the current level of glycemic control dysfunction, by administering an effective dose of a pharmaceutical formulation, preferably an oral formulation four times daily comprising insulin (as described herein) at nighttime, in the morning and/or preprandially, preferably at nighttime or morning and three times preprandially, more preferably at nighttime and preprandially for breakfast, lunch and dinner. Preferably, the insulin formulation is administered to such human patients on a chronic basis, e.g., for at least about two weeks.
  • [0291]
    It is believed that, as the diabetes progresses still further, the patient may no longer be able to control his blood glucose endogenously at all, even with the four time a day dose as described above. In accordance with the present invention, it is believed that a mammal at this stage of diabetes mellitus can be treated, prophylactically sparing any remaining β-cell function, and/or aiding in preventing β-cell death and treating the current level of glycemic control dysfunction, by administering an effective dose of a pharmaceutical formulation, preferably oral, comprising long-acting insulin; and an effective dose of a pharmaceutical formulation, preferably an oral formulation, four times daily comprising insulin (as described herein) at nighttime, in the morning and/or preprandially, preferably at nighttime or morning and three times preprandially, more preferably at nighttime and preprandially for breakfast, lunch and dinner. Preferably, the insulin formulations are administered to such human patients on a chronic basis, e.g., for at least about two weeks.
  • [0292]
    It is believed that, if it is determined that the pancreas has ceased to function, in accordance with the present invention, a mammal at this stage of diabetes mellitus can be treated by administering an effective dose of a pharmaceutical formulation, preferably oral, comprising long-acting insulin; and an effective dose of a pharmaceutical formulation, preferably an oral formulation, three or four times daily comprising insulin (as described herein) at nighttime, in the morning and/or preprandially, preferably nighttime, or in the morning and three preprandially, preferably at nighttime and three times preprandially. If three times a day dosing is chosen, it is believed that in addition to the long acting formulation described above, an effective dose of a pharmaceutical formulation of should be dosed, preferably preprandially. Preferably, the insulin formulations are administered to such human patients on a chronic basis, e.g., for at least about two weeks.
  • [0293]
    In another embodiment of the invention, a continuum of development of diabetes is identified comprising a pre-diabetic stage, an early stage diabetes and late stage diabetes, and the invention comprises identifying a patient's stage along the continuum of development of diabetes. A preferred embodiment of the invention comprises a method for treating a patient in accordance with his/her stage of development of diabetes comprising: identifying a patient's stage along the continuum of development of diabetes, devising a course of treatment for that patient in accordance with his stage along the continuum of development of diabetes and administering the treatment to the patient.
  • [0294]
    In order that this invention may be better understood, the following examples are set forth. These examples are for the purpose of illustration only and are not to be construed as limiting the scope of the invention in any manner.
  • EXAMPLE 1
  • [0000]
    Comparison Between Oral Insulin and SC Short Acting Postprandial Blood Glucose Excursions
  • [0295]
    A randomized, 3-period crossover, double-blind, double-dummy study was conducted in order to compare the effect (i.e., the postprandial pharmacokinetic and pharmacodynamic profiles) of an oral insulin formulation with that of subcutaneously administered short acting insulin on postprandial blood glucose excursions in type 2 diabetic subjects without any antidiabetic medication.
  • [0296]
    A primary objective of this study was to compare the effect of an oral insulin formulation (300 U insulin combined with 400 mg 4-CNAB in 2 capsules, each capsule containing 150 U insulin/200 mg 4-CNAB) with that of 12 U subcutaneous (SC) injected short acting insulin [Humalog® injection 100 U/ml from Eli Lilly and Company] on postprandial blood glucose excursions. The postprandial blood glucose excursions were assessed after a standardized breakfast intake.
  • [0297]
    Fifteen male subjects between 35 and 70 years old, inclusive, with type 2 diabetes mellitus as defined by the American Diabetes Association (1998 Diabetes care, 21: S5-S19) for more than one year were chosen. Subjects included in the study had BMI<36 kg/m2, had stable glycemic control (HbA1C<11%), were off all oral hypoglycemic agents 24 hours prior to each study dosing day and off any investigational drug for at least four (4) weeks prior to Visit 1, refrained from strenuous physical activity beginning 72 hrs prior to admission and through the duration of the study, and were confined to the clinical research unit as required by the protocol. Subjects maintained a constant body weight (+/−2 kg).
  • [0298]
    All patients received the same oral and SC injection treatments in a randomized sequence. At visit 1, each patient was randomized to one of six possible treatment sequences (see Table 1). On four separate occasions, patients received one of the four possible treatments prior to a standardized breakfast: 300 U oral Insulin/400 mg 4-CNAB (2 capsules, each capsule containing 150 U Insulin/200 mg 4-CNAB), 150 U oral Insulin/200 mg 4-CNAB (one capsule), 12 U SC short-acting insulin (Humalog®), and no supplemental insulin (placebo). During the first three treatment periods, 300 U oral, 12 U SC and placebo insulin were administered in random order and under blinded conditions (double-dummy technique). During the fourth treatment period, the patients received 150 U oral insulin in an open fashion. The overall study design is illustrated in Table 1 below.
    TABLE 1
    Overall Study Design
    Randomization
    Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Visit 8*)
    Screening Session 1 Session 2 Session 3 Final Screening Session 4 Final
    Visit Visit*)
    300 U oral insulin or 12 U SC or 150 U
    placebo oral

    *)For all patients, Visits 7 and 8 were combined (i.e., final examination was performed at Visit 7, immediately after finishing experimental procedures).
  • [0299]
    The SC insulin dose of 12 U was selected to fall within a range typical for type 2 diabetic patients. The oral dose of 300 U insulin (in combination with 400 mg 4-CNBA) had been shown to be effective in Example 5 above. The oral dose of 150 U insulin (in combination with 200 mg 4-CNBA) was chosen to investigate whether or not an effect on hepatic glucose production could be achieved also by a lower insulin dose.
  • [0300]
    The time point of study drug administration (SC injection: 15 minutes prior to meal intake; oral administration: 30 minutes prior to meal intake) was selected in order to match the PK and PD properties of the administered insulin formulations with the postprandial rise of blood glucose. The wash-out period between the first three treatment sessions was 1-20 days. The duration of each session was approximately 8-9 hours, and all experiments were performed after an overnight fast of approx. 12 hours.
  • [0301]
    At Visit 1 (screening visit), the patients came to the clinical research unit in a fasted state (i.e., not having had any caloric intake for at least 12 hours). The patients' physical statistics, medical history and social habits recorded, and a physical examination performed. Not more than 14 days later, at Visit 2, each patient was randomized to one of six treatment sequences shown in Table 2 below and received either one of the two active treatments (300 U oral Insulin/400 mg 4-CNAB or 12 U short-acting SC insulin) or no supplemental insulin (placebo). Thirty minutes after oral and fifteen minutes after SC drug administration, the patients ate a standardized breakfast, and postprandial blood glucose concentrations were monitored for six hours. Serial blood samples were also collected in regular intervals for measurement of plasma insulin, 4-CNAB, and C-peptide concentrations. The study patients were released from the institute at the end of the treatment session.
  • [0302]
    At Visits 3 and 4, the study patients returned to the clinical unit to receive the alternative treatments in conjunction with the test meal according to their treatment sequence. All experimental procedures and measurements were identical with those of the preceding treatment days. A final examination (Visit 5) was performed after Visit 4, preferably immediately after the experimental procedures were completed, but no longer than fourteen days after Visit 4.
  • [0303]
    The patients were invited to attend a fourth treatment session (Visit 7) with a single oral administration of 150 U Insulin/200 mg 4-CNAB thirty minutes prior to a test meal. All experimental procedures and measurements were the same as on the preceding treatment days. Patients attended a screening (Visit 6), no more than twenty days prior to the additional session, as well as a final examination (Visit 8), preferably immediately after the experimental procedures of Visit 7 were completed, but no longer than fourteen days thereafter. Visits 7 and 8 were generally combined (i.e., for all patients final examination was performed at Visit 7, immediately after completion of experimental procedures).
  • [0304]
    The patients were randomly assigned to one of the following treatment sequences:
    TABLE 2
    Treatments Administered
    Treatment Treatment Period
    Sequence 1 (Visit 2) 2 (Visit 3) 3 (Visit 4) 4 (Visit 7)
    1 300 U Oral  12 U SC Placebo 150 U Oral
    2 300 U Oral Placebo  12 U SC 150 U Oral
    3  12 U SC 300 U Oral Placebo 150 U Oral
    4  12 U SC Placebo 300 U Oral 150 U Oral
    5 Placebo  12 U SC 300 U Oral 150 U Oral
    6 Placebo 300 U Oral  12 U SC 150 U Oral
  • [0305]
    According to the double-dummy technique, each patient received on the first three treatment sessions (Visits 2-4), in addition to his scheduled treatment administration (oral or SC), the alternative administration (SC or oral) as placebo preparation. On sessions without supplemental insulin, both treatments (oral and SC) were placebo preparations. On the last treatment session (Visit 7), all patients received in an open fashion one oral dose of 150 U Insulin/200 mg 4-CNAB.
  • [0306]
    Based on the six sequences shown above, the following treatments were administered during the study:
  • [0307]
    Sequence 1:
      • Visit 2: Two insulin capsules 30 minutes, one SC placebo injection 15 minutes before meal.
      • Visit 3: Two placebo capsules 30 minutes, one SC insulin injection 15 minutes before meal
      • Visit 4: Two placebo capsules 30 minutes, one SC placebo injection 15 minutes before meal
      • Visit 7: One insulin capsule 30 minutes before meal
  • [0312]
    Sequence 2:
      • Visit 2: Two insulin capsules 30 minutes, one SC placebo injection 15 minutes before meal.
      • Visit 3: Two placebo capsules 30 minutes, one SC placebo injection 15 minutes before meal
      • Visit 4: Two placebo capsules 30 minutes, one SC insulin injection 15 minutes before meal
      • Visit 7: One insulin capsule 30 minutes before meal
  • [0317]
    Sequence 3:
      • Visit 2: Two placebo capsules 30 minutes, one SC insulin injection 15 minutes before meal.
      • Visit 3: Two insulin capsules 30 minutes, one SC insulin injection 15 minutes before meal
      • Visit 4: Two placebo capsules 30 minutes, one SC placebo injection 15 minutes before meal
      • Visit 7: One insulin capsule 30 minutes before meal
  • [0322]
    Sequence 4:
      • Visit 2: Two placebo capsules 30 minutes, one SC insulin injection 15 minutes before meal.
      • Visit 3: Two placebo capsules 30 minutes, one SC placebo injection 15 minutes before meal
      • Visit 4: Two insulin capsules 30 minutes, one SC placebo injection 15 minutes before meal
      • Visit 7: One insulin capsule 30 minutes before meal
  • [0327]
    Sequence 5:
      • Visit 2: Two placebo capsules 30 minutes, one SC placebo injection 15 minutes before meal.
      • Visit 3: Two placebo capsules 30 minutes, one SC insulin injection 15 minutes before meal
      • Visit 4: Two insulin capsules 30 minutes, one SC placebo injection 15 minutes before meal
      • Visit 7: One insulin capsule 30 minutes before meal
  • [0332]
    Sequence 6:
      • Visit 2: Two placebo capsules 30 minutes, one SC placebo injection 15 minutes before meal.
      • Visit 3: Two insulin capsules 30 minutes, one SC placebo injection 15 minutes before meal
      • Visit 4: Two placebo capsules 30 minutes, one SC insulin injection 15 minutes before meal
      • Visit 7: One insulin capsule 30 minutes before meal
  • [0337]
    The 4-CNAB used for the capsules was manufactured under GMP compliance. The Insulin used to prepare the capsules was Zinc-Insulin Crystals Human: Proinsulin Derived (Recombinant DNA Origin) USP Quality obtained from Eli Lilly and Company (Indianapolis, Ind.). The Insulin/4-CNAB capsules contained 150 Insulin Units USP and 200 mg 4-CNAB. The insulin/4-CNAB capsules were prepared by AAI Pharma Inc., Wilmington N.C.
  • [0338]
    Insulin/4-CNAB capsules were provided in HDPE bottles, each of which contained 40 capsules and a polyester coil. Each bottle had a heat-induction seal and a child-resistant cap, and were stored frozen at or less than minus 10° C. On the day of dosing, the appropriate number of capsules was removed from the freezer and brought to room temperature (between 15 and 30° C.) for about one hour. Capsules were used within four hours of dispensing, and unopened bottles were not left at room temperature for more than four hours.
  • [0339]
    The subjects ingested the meal thirty minutes after oral insulin administration. Blood glucose concentrations were monitored for six hours after glucose ingestion, and serial blood samples were collected in regular intervals for measurement of insulin concentration, 4-CNAB concentration, C-peptide, and blood glucose, providing information for pharmacokinetic and pharmacodynamic determinations. Blood glucose concentrations were determined immediately after sample collection and documented. All experiments were identical in their sample collections and monitoring period for all visits. The experimental procedure after the meal intake lasted for six hours (+1 hour baseline period for stabilization of blood glucose concentrations at the desired preprandial blood glucose level).
  • [0340]
    During each treatment session, blood samples were collected for determination of plasma concentrations of 4-CNAB, insulin and C-peptide, and for blood glucose concentration. Sampling started 1 hour before intake of the test meal and continued until 6 hours thereafter. Blood samples were drawn via a venous cannula and collected related to the start of the test meal at time point 0. The timing of scheduled samples could be adjusted according to clinical needs or needs for pharmacokinetic data. The duration of each session was approximately 8-9 hours. All experiments were performed after an overnight fast of approximately 12 hours.
  • [0341]
    The studies started in the morning. A 17-gauge PTFE catheter was inserted into an arm vein for blood sampling for measurement of blood glucose, and for plasma insulin, 4-CNAB and C-peptide concentrations. The line was kept patent with 0.15-mol/L (0.9%) sterile saline.
  • [0342]
    At time-point-15, exogenous insulin was administered by oral insulin administration or by subcutaneous injection at two of the three experimental days. At time point 0, subjects ingested a standardized breakfast at every study day (visits 2-4 and 7). The oral treatments (Insulin/4-CNAB capsules and placebo capsules) were administered 30 minutes, and the injections (short-acting insulin and placebo solution) 15 minutes, before start of meal intake. The pharmacodynamic response elicited was studied by measurements of blood glucose concentrations in 5 minute intervals for another six hours, and no food intake was allowed during this period, although water was consumed as desired.
  • [0343]
    Blood samples for blood glucose determination (0.25 mL per sample) were taken at −1 min (baseline), 5 minutes after start of meal intake and thereafter in 5 minute intervals until 120 minutes, 10 minute intervals until 240 minutes, and 15 minute intervals until 360 minutes after start of meal intake (45 samples per session). Blood glucose concentrations were measured immediately after sample collection using an automated GOD method (Super GL Ambulance Glucose Analyzer, Ruhrtal Labortechnik, Delecke-Möhnesee, Germany).
  • [0344]
    Blood samples for determination of 4-CNAB plasma concentrations (2 mL in sodium heparin tube) were drawn 10, 20, 30, 40, 60, 90, 120, 240 and 360 minutes after start of meal intake (9 samples per session). Blood samples for determination of insulin and C-peptide plasma concentrations (5 mL in sodium heparin tube) were drawn at −60 and −30 minutes, at time 0 (start of meal intake), and after 10, 20, 30, 40, 50, 60, 75, 90, 105, 120, 150, 180, 210, 240, 300, and 360 minutes (19 samples per session). Plasma concentrations of insulin were determined by a GLP-validated microparticle enzyme immunoassay (MEIA).
  • [0345]
    In case of a hypoglycemia (defined as blood glucose concentrations below 60 mg/dl), a blood glucose concentration of 60 mg/dl was maintained by means of a variable-rate intravenous infusion of 20% glucose. The glucose infusion rate was adopted, if necessary, in relation to the blood glucose concentrations measured to maintain this blood glucose level. In case of blood glucose values exceeding 350 mg/dl for more than 60 minutes, the experiments were aborted and the subject was treated with additional s.c. insulin to normalize his blood glucose concentrations.
  • [0346]
    Blood samples for the determination of plasma concentrations of insulin, 4-CNAB and C-peptide were collected at defined intervals, as discussed above. Plasma samples were stored at approximately −20° C. (4-CNAB at −70° C.) until determination by immunoassay is performed. After the end of the sampling period, the study subjects were released from the clinic.
  • [0347]
    Inter-subject variability for selected pharmacodynamic and pharmacokinetic parameters was assessed. Incidence of postprandial hypoglycemia was assessed for each subject and across the study population.
  • [0348]
    Blood glucose excursions (i.e., differences between pre-prandial and postprandial blood glucose concentrations) registered after the ingestion of the meal were used to evaluate pharmacodynamic parameters of the two insulin administration routes and compared with the same data obtained for the study day without any supplemental insulin. From these measurements, the area under the glucose infusion rate versus time curve from 0-6 hours (and other time intervals), the maximal blood glucose excursion (Cmax) and time to the maximal blood glucose excursion (tmax) were analyzed.
  • [0349]
    For pharmacodynamic assessment, the following parameters were calculated: Maximal blood glucose excursion (BGmax), time to BGmax (tBG max ), Area under the blood glucose excursion curve in defined time-intervals (AUCBG 0-1h, AUCBG 0-2h, AUCBG 0-3h, AUCBG 0-4h, AUCBG 0-6h), maximal absolute blood glucose concentrations (BGabsmax), time to BGabsmax (tBGabsmax).
  • [0350]
    For pharmacokinetic assessment the following parameters were calculated: Maximal plasma insulin concentrations (INSmax), time to INSmax (tINS max ), Area under the glucose infusion rates in defined time-intervals (AUCIns 0-1h, AUCIns 0-2h, AUCIns 0-3h, AUCIns 0-4h, AUCIns 0-6h) and maximum reduction of C-peptide concentrations.
  • [0351]
    Plasma insulin concentrations were subjected to appropriate pharmacokinetic analyses. Parameters determined include Cmax, tmax, and the area under the plasma concentration versus time curve from the time of dosing until a return to the baseline measurement (AUC0-t′), where t′ is the time that the level of plasma insulin concentration returns to the baseline. In addition, other pharmacokinetic parameters, such as t1/2, elimination rate constant (λz) and partial AUC values, were calculated, if considered appropriate, for each individual subject enrolled within the study.
  • [0000]
    Pharmacodynamics
  • [0352]
    As measurement of a pharmacodynamic effect of oral Insulin/4-CNAB capsules, the blood glucose excursions measured over 6 hours were considered, and the area under the blood glucose excursion vs. time curve in the first two hours after start of meal intake (AUC0-2h) was defined as primary pharmacodynamic endpoint.
  • [0353]
    From the blood samples taken, the individual blood glucose concentrations were determined, and summary concentration vs. time tables were prepared and profiles were plotted, as set forth in Tables 3-20 below.
    TABLE 3
    Patient Number 101
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA
    −105 NA NA NA
    −90 NA NA NA
    −75 NA NA NA
    −60 134 149 140
    −45 135 152 141
    −30 130 150 144
    −16 124 146 139
    −1 127 0 144 0 140 0
    5 126 −1 144 0 134 −6
    10 123 −4 141 −3 116 −24
    15 121 −6 142 −2 138 −2
    20 127 0 148 4 136 −4
    25 129 2 158 14 145 5
    30 139 12 164 20 166 26
    35 140 13 169 25 171 31
    40 150 23 179 35 183 43
    45 153 26 179 35 198 58
    50 163 36 184 40 195 55
    55 170 43 185 41 209 69
    60 178 51 186 42 206 66
    65 185 58 193 49 211 71
    70 204 77 193 49 222 82
    75 215 88 197 53 223 83
    80 218 91 213 69 225 85
    85 221 94 210 66 224 84
    90 225 98 210 66 222 82
    95 225 98 204 60 229 89
    100 231 104 211 67 231 91
    105 231 104 209 65 214 74
    110 229 102 199 55 231 91
    115 226 99 202 58 223 83
    120 215 88 208 64 204 64
    130 207 80 201 57 202 62
    140 211 84 182 38 192 52
    150 208 81 173 29 175 35
    160 188 61 164 20 177 37
    170 176 49 153 9 165 25
    180 169 42 141 −3 169 29
    190 157 30 126 −18 154 14
    200 148 21 130 −14 162 22
    210 142 15 117 −27 155 15
    220 141 14 116 −28 160 20
    230 141 14 114 −30 159 19
    240 134 7 105 −39 155 15
    255 132 5 101 −43 135 −5
    270 131 4 95 −49 131 −9
    285 117 −10 91.7 −52.3 128 −12
    300 118 −9 86.1 −57.9 123 −17
    315 105 −22 83.6 −60.4 114 −26
    330 105 −22 83 −61 118 −22
    345 101 −26 78.3 −65.7 113 −27
    360 99.9 −27.1 83.8 −60.2 110 −30
  • [0354]
    TABLE 4
    Patient Number 102
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA
    −105 NA NA NA
    −90 NA NA NA
    −75 NA NA NA
    −60 135 149 164
    −45 147 157 181
    −30 139 161 169
    −16 144 164 177
    −1 146 0 151 0 172 0
    5 157 11 157 6 177 5
    10 154 8 155 4 178 6
    15 152 6 158 7 180 8
    20 154 8 167 16 167 −5
    25 159 13 164 13 174 2
    30 175 29 160 9 184 12
    35 182 36 179 28 184 12
    40 191 45 184 33 199 27
    45 206 60 167 16 208 36
    50 202 56 177 26 217 45
    55 209 63 175 24 223 51
    60 217 71 168 17 234 62
    65 239 93 188 37 252 80
    70 247 101 188 37 239 67
    75 241 95 194 43 260 88
    80 246 100 194 43 279 107
    85 249 103 213 62 271 99
    90 255 109 196 45 255 83
    95 253 107 211 60 275 103
    100 261 115 197 46 256 84
    105 258 112 214 63 279 107
    110 276 130 209 58 264 92
    115 270 124 201 50 270 98
    120 275 129 198 47 270 98
    130 265 119 199 48 281 109
    140 266 120 190 39 295 123
    150 271 125 186 35 254 82
    160 252 106 194 43 275 103
    170 254 108 188 37 259 87
    180 249 103 184 33 251 79
    190 243 97 172 21 252 80
    200 247 101 171 20 247 75
    210 243 97 180 29 248 76
    220 244 98 170 19 227 55
    230 245 99 170 19 231 59
    240 233 87 163 12 226 54
    255 225 79 162 11 222 50
    270 218 72 153 2 223 51
    285 219 73 158 7 212 40
    300 213 67 147 −4 212 40
    315 210 64 129 −22 205 33
    330 210 64 145 −6 196 24
    345 204 58 105 −46 199 27
    360 199 53 130 −21 204 32
  • [0355]
    TABLE 5
    Patient Number 103
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA NA
    −105 NA NA NA NA
    −90 NA NA NA NA
    −75 NA NA NA NA
    −60 162 172 177 170
    −45 144 177 175 167
    −30 146 174 179 165
    −16 139 162 166 164
    −1 137 0 169 0 162 0 160 0
    5 135 −2 167 −2 166 4 159 −1
    10 135 −2 165 −4 159 −3 159 −1
    15 137 0 161 −8 164 2 160 0
    20 150 13 166 −3 159 −3 167 7
    25 161 24 170 1 175 13 174 14
    30 180 43 168 −1 179 17 188 28
    35 172 35 186 17 184 22 188 28
    40 187 50 198 29 188 26 202 42
    45 190 53 203 34 190 28 201 41
    50 216 79 203 34 194 32 209 49
    55 207 70 214 45 199 37 215 55
    60 218 81 219 50 200 38 214 54
    65 223 86 224 55 201 39 203 43
    70 222 85 228 59 209 47 225 65
    75 216 79 205 36 205 43 226 66
    80 229 92 229 60 204 42 214 54
    85 228 91 233 64 196 34 217 57
    90 226 89 250 81 193 31 214 54
    95 238 101 246 77 190 28 219 59
    100 227 90 244 75 189 27 209 49
    105 235 98 248 79 186 24 217 57
    110 233 96 231 62 179 17 216 56
    115 220 83 249 80 172 10 222 62
    120 225 88 254 85 172 10 214 54
    130 204 67 245 76 157 −5 217 57
    140 215 78 249 80 156 −6 216 56
    150 215 78 246 77 146 −16 199 39
    160 222 85 248 79 151 −11 194 34
    170 220 83 257 88 147 −15 200 40
    180 212 75 250 81 144 −18 199 39
    190 204 67 248 79 144 −18 192 32
    200 193 56 235 66 145 −17 188 28
    210 168 31 240 71 129 −33 187 27
    220 188 51 205 36 127 −35 188 28
    230 189 52 222 53 116 −46 181 21
    240 178 41 217 48 112 −50 185 25
    255 189 52 204 35 112 −50 175 15
    270 151 14 192 23 108 −54 163 3
    285 142 5 181 12 106 −56 157 −3
    300 135 −2 178 9 101 −61 155 −5
    315 135 −2 170 1 101 −61 148 −12
    330 122 −15 161 −8 99.8 −62.2 140 −20
    345 111 −26 164 −5 96.6 −65.4 136 −24
    360 104 −33 157 −12 92.8 −69.2 136 −24
  • [0356]
    TABLE 6
    Patient Number 104
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA NA
    −105 NA NA NA NA
    −90 NA NA NA NA
    −75 NA NA NA NA
    −60 164 166 149 184
    −45 164 137 135 180
    −30 165 177 139 178
    −16 163 135 168 185
    −1 164 0 157 0 173 0 183 0
    5 161 −3 154 −3 182 9 172 −11
    10 161 −3 151 −6 178 5 173 −10
    15 159 −5 118 −39 190 17 169 −14
    20 164 0 150 −7 195 22 192 9
    25 163 −1 163 6 193 20 202 19
    30 170 6 164 7 208 35 213 30
    35 177 13 171 14 208 35 214 31
    40 179 15 176 19 214 41 220 37
    45 185 21 184 27 218 45 224 41
    50 196 32 195 38 193 20 235 52
    55 189 25 207 50 211 38 251 68
    60 203 39 224 67 213 40 229 46
    65 206 42 214 57 216 43 262 79
    70 211 47 228 71 213 40 267 84
    75 223 59 240 83 198 25 267 84
    80 232 68 220 63 210 37 267 84
    85 220 56 238 81 207 34 263 80
    90 212 48 248 91 198 25 271 88
    95 213 49 242 85 189 16 282 99
    100 218 54 265 108 191 18 284 101
    105 205 41 250 93 183 10 259 76
    110 207 43 253 96 194 21 276 93
    115 208 44 246 89 188 15 281 98
    120 207 43 244 87 188 15 256 73
    130 204 40 238 81 179 6 240 57
    140 209 45 250 93 185 12 228 45
    150 220 56 249 92 164 −9 239 56
    160 220 56 241 84 165 −8 252 69
    170 216 52 246 89 153 −20 251 68
    180 220 56 218 61 145 −28 252 69
    190 225 61 228 71 152 −21 256 73
    200 228 64 213 56 162 −11 268 85
    210 224 60 203 46 160 −13 264 81
    220 230 66 217 60 155 −18 237 54
    230 218 54 218 61 151 −22 271 88
    240 226 62 211 54 150 −23 252 69
    255 227 63 195 38 138 −35 234 51
    270 215 51 196 39 135 −38 227 44
    285 218 54 176 19 128 −45 225 42
    300 213 49 175 18 131 −42 218 35
    315 206 42 171 14 132 −41 195 12
    330 200 36 160 3 129 −44 201 18
    345 188 24 159 2 133 −40 195 12
    360 172 8 156 −1 130 −43 184 1
  • [0357]
    TABLE 7
    Patient Number 105
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA NA
    −105 NA NA NA NA
    −90 NA NA NA NA
    −75 NA NA NA NA
    −60 131 114 111 125
    −45 111 108 112 114
    −30 116 109 110 98.6
    −16 109 106 105 84.2
    −1 99.1 0 107 0 106 0 93.1 0
    5 95.5 −3.6 105 −2 102 −4 96.1 3
    10 96.8 −2.3 99.9 −7.1 99.7 −6.3 95.2 2.1
    15 108 8.9 92.1 −14.9 104 −2 92.8 −0.3
    20 111 11.9 112 5 107 1 99.6 6.5
    25 137 37.9 107 0 120 14 118 24.9
    30 149 49.9 118 11 119 13 120 26.9
    35 157 57.9 120 13 120 14 119 25.9
    40 156 56.9 126 19 133 27 117 23.9
    45 176 76.9 119 12 130 24 102 8.9
    50 178 78.9 136 29 133 27 144 50.9
    55 184 84.9 119 12 126 20 151 57.9
    60 186 86.9 133 26 137 31 160 66.9
    65 179 79.9 133 26 138 32 160 66.9
    70 182 82.9 157 50 140 34 147 53.9
    75 185 85.9 155 48 138 32 161 67.9
    80 190 90.9 156 49 130 24 162 68.9
    85 178 78.9 167 60 141 35 147 53.9
    90 181 81.9 154 47 134 28 161 67.9
    95 164 64.9 155 48 147 41 159 65.9
    100 162 62.9 156 49 146 40 161 67.9
    105 152 52.9 168 61 147 41 159 65.9
    110 139 39.9 168 61 139 33 165 71.9
    115 133 33.9 168 61 138 32 158 64.9
    120 120 20.9 178 71 148 42 157 63.9
    130 112 12.9 171 64 132 26 156 62.9
    140 106 6.9 159 52 137 31 159 65.9
    150 97.3 −1.8 153 46 135 29 158 64.9
    160 102 2.9 146 39 117 11 143 49.9
    170 101 1.9 147 40 119 13 145 51.9
    180 109 9.9 143 36 108 2 132 38.9
    190 116 16.9 138 31 93.7 −12.3 132 38.9
    200 113 13.9 127 20 85.1 −20.9 127 33.9
    210 108 8.9 132 25 77.6 −28.4 119 25.9
    220 109 9.9 132 25 70.3 −35.7 117 23.9
    230 101 1.9 113 6 67.4 −38.6 109 15.9
    240 90.6 −8.5 110 3 62.5 −43.5 102 8.9
    255 79.6 −19.5 123 16 64.5 −41.5 94.1 1
    270 75 −24.1 95.7 −11.3 68.3 −37.7 92.9 −0.2
    285 71.4 −27.7 81.1 −25.9 72.8 −33.2 82.3 −10.8
    300 70.9 −28.2 87.9 −19.1 66.9 −39.1 76.2 −16.9
    315 68 −31.1 85.4 −21.6 67.6 −38.4 74.1 −19
    330 68.7 −30.4 80.4 −26.6 66.9 −39.1 69.2 −23.9
    345 68.9 −30.2 74.5 −32.5 73.7 −32.3 69.9 −23.2
    360 69.1 −30 80.4 −26.6 72.5 −33.5 71 −22.1
  • [0358]
    TABLE 8
    Patient Number 106
    Treatment
    Oral Oral SC 12 U
    150 U Insulin/ 300 U Insulin/ Short-acting
    200 mg 4-CNAB 400 mg 4-CNAB insulin Placebo
    Time Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
    (min) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l)
    −60 65 0.82 42 0.71 24 0.51 24 0.69
    −30 55 0.86 30 0.74 19 0.49 24 0.58
    0 62 0.71 48 0.61 26 0.55 32 0.66
    10 46 0.75 48 0.66 38 0.61 39 0.68
    20 38 0.76 27 0.58 52 0.75 71 0.81
    30 82 0.88 33 0.57 69 0.76 90 0.93
    40 106 1.00 42 0.68 39 0.74 122 1.12
    50 123 1.33 55 0.74 63 0.77 136 1.32
    60 118 1.39 78 0.82 58 0.72 130 1.63
    75 94 1.44 53 0.77 BLQ* 0.51* 155 1.76
    90 127 1.42 121 1.22 BLQ* 0.43* 173 1.96
    105 123 1.90 62 1.05 BLQ  0.34 166 2.30
    120 140 2.10 73 1.09 13 0.32 159 2.40
    150 155 2.30 88 1.36 17 0.35 97 1.91
    180 121 2.50 146 1.58 26 0.46 108 1.73
    210 84 1.98 135 2.10  12* 0.44* 104 1.75
    240 112 2.00 137 2.20 31 0.50 90 1.90
    300 87 1.68 51 1.30 BLQ* 0.41* 22 0.84
    360 35 0.88 30 0.70 BLQ  0.31 18 0.57
  • [0359]
    TABLE 9
    Patient Number 107
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA NA
    −105 NA NA NA NA
    −90 NA NA NA NA
    −75 NA NA NA NA
    −60 145 140 147 139
    −45 145 136 154 138
    −30 142 151 147 141
    −16 129 141 145 136
    −1 123 0 130 0 140 0 128 0
    5 120 −3 125 −5 141 1 131 3
    10 114 −9 140 10 139 −1 128 0
    15 114 −9 136 6 141 1 124 −4
    20 119 −4 142 12 141 1 126 −2
    25 140 17 144 14 147 7 127 −1
    30 141 18 156 26 152 12 140 12
    35 151 28 162 32 159 19 142 14
    40 155 32 164 34 149 9 152 24
    45 163 40 164 34 154 14 164 36
    50 166 43 172 42 158 18 165 37
    55 174 51 167 37 154 14 170 42
    60 174 51 170 40 160 20 171 43
    65 176 53 171 41 164 24 176 48
    70 186 63 172 42 168 28 173 45
    75 183 60 188 58 164 24 187 59
    80 175 52 187 57 162 22 184 56
    85 181 58 175 45 169 29 184 56
    90 181 58 197 67 170 30 185 57
    95 179 56 189 59 166 26 185 57
    100 174 51 180 50 169 29 184 56
    105 176 53 192 62 165 25 183 55
    110 175 52 187 57 165 25 180 52
    115 175 52 183 53 167 27 183 55
    120 182 59 189 59 160 20 185 57
    130 178 55 181 51 154 14 186 58
    140 167 44 183 53 157 17 182 54
    150 156 33 190 60 141 1 174 46
    160 152 29 182 52 133 −7 170 42
    170 148 25 173 43 130 −10 170 42
    180 149 26 169 39 128 −12 170 42
    190 146 23 162 32 121 −19 170 42
    200 149 26 150 20 120 −20 168 40
    210 146 23 137 7 115 −25 162 34
    220 141 18 127 −3 112 −28 155 27
    230 147 24 140 10 107 −33 149 21
    240 140 17 126 −4 102 −38 147 19
    255 139 16 113 −17 101 −39 135 7
    270 138 15 115 −15 98.6 −41.4 120 −8
    285 136 13 106 −24 97.9 −42.1 111 −17
    300 127 4 102 −28 99.2 −40.8 104 −24
    315 120 −3 97 −33 100 −40 98.3 −29.7
    330 117 −6 100 −30 98.8 −41.2 94.4 −33.6
    345 111 −12 99.5 −30.5 101 −39 95.5 −32.5
    360 108 −15 88.5 −41.5 95.8 −44.2 92.1 −35.9
  • [0360]
    TABLE 10
    Patient Number 108
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA NA
    −105 NA NA NA NA
    −90 NA NA NA NA
    −75 NA NA NA NA
    −60 150 148 150 162
    −45 146 148 154 163
    −30 147 147 151 156
    −16 154 151 151 158
    −1 144 0 129 0 147 0 150 0
    5 142 −2 122 −7 151 4 151 1
    10 139 −5 123 −6 148 1 152 2
    15 142 −2 118 −11 146 −1 151 1
    20 164 20 119 −10 148 1 158 8
    25 170 26 113 −16 155 8 179 29
    30 200 56 133 4 166 19 200 50
    35 205 61 137 8 172 25 210 60
    40 212 68 168 39 177 30 227 77
    45 213 69 179 50 184 37 221 71
    50 223 79 196 67 184 37 219 69
    55 215 71 189 60 186 39 219 69
    60 222 78 200 71 194 47 238 88
    65 231 87 197 68 194 47 242 92
    70 238 94 207 78 209 62 239 89
    75 238 94 214 85 219 72 256 106
    80 256 112 214 85 213 66 257 107
    85 262 118 222 93 220 73 244 94
    90 268 124 211 82 222 75 252 102
    95 277 133 208 79 228 81 256 106
    100 273 129 223 94 219 72 251 101
    105 280 136 228 99 226 79 249 99
    110 281 137 220 91 222 75 246 96
    115 277 133 212 83 226 79 244 94
    120 270 126 214 85 231 84 241 91
    130 284 140 208 79 220 73 244 94
    140 294 150 213 84 227 80 241 91
    150 298 154 214 85 235 88 255 105
    160 252 108 225 96 231 84 264 114
    170 293 149 227 98 233 86 257 107
    180 286 142 214 85 224 77 252 102
    190 281 137 211 82 232 85 252 102
    200 288 144 213 84 234 87 255 105
    210 270 126 204 75 232 85 230 80
    220 254 110 198 69 219 72 234 84
    230 244 100 193 64 212 65 218 68
    240 236 92 184 55 202 55 208 58
    255 225 81 172 43 197 50 198 48
    270 212 68 171 42 158 11 195 45
    285 207 63 161 32 149 2 179 29
    300 189 45 153 24 141 −6 170 20
    315 178 34 147 18 128 −19 159 9
    330 168 24 139 10 123 −24 152 2
    345 158 14 133 4 113 −34 142 −8
    360 140 −4 121 −8 103 −44 134 −16
  • [0361]
    TABLE 11
    Patient Number 109
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA NA
    −105 NA NA NA NA
    −90 NA NA NA NA
    −75 NA NA NA NA
    −60 171 187 171 179
    −45 182 195 171 179
    −30 176 193 170 169
    −16 172 185 168 177
    −1 172 0 175 0 166 0 173 0
    5 170 −2 170 −5 170 4 171 −2
    10 171 −1 170 −5 166 0 171 −2
    15 174 2 171 −4 165 −1 171 −2
    20 187 15 164 −11 179 13 177 4
    25 195 23 180 5 188 22 186 13
    30 206 34 190 15 201 35 199 26
    35 210 38 193 18 209 43 202 29
    40 234 62 202 27 216 50 220 47
    45 237 65 211 36 208 42 221 48
    50 239 67 213 38 211 45 225 52
    55 246 74 196 21 200 34 227 54
    60 258 86 208 33 213 47 233 60
    65 255 83 199 24 220 54 247 74
    70 256 84 221 46 223 57 249 76
    75 256 84 232 57 226 60 243 70
    80 258 86 233 58 227 61 239 66
    85 266 94 241 66 226 60 226 53
    90 266 94 230 55 217 51 230 57
    95 273 101 245 70 220 54 228 55
    100 275 103 252 77 218 52 236 63
    105 280 108 256 81 206 40 233 60
    110 275 103 262 87 184 18 242 69
    115 264 92 249 74 189 23 235 62
    120 262 90 240 65 191 25 225 52
    130 250 78 247 72 195 29 228 55
    140 256 84 251 76 196 30 219 46
    150 253 81 267 92 195 29 213 40
    160 253 81 267 92 187 21 224 51
    170 244 72 268 93 188 22 211 38
    180 257 85 265 90 190 24 206 33
    190 267 95 262 87 171 5 195 22
    200 273 101 256 81 166 0 197 24
    210 285 113 239 64 173 7 189 16
    220 280 108 245 70 148 −18 185 12
    230 268 96 234 59 153 −13 178 5
    240 255 83 232 57 148 −18 177 4
    255 246 74 211 36 135 −31 164 −9
    270 232 60 231 56 132 −34 154 −19
    285 224 52 222 47 131 −35 153 −20
    300 219 47 225 50 118 −48 146 −27
    315 214 42 222 47 117 −49 143 −30
    330 192 20 212 37 111 −55 137 −36
    345 189 17 211 36 111 −55 127 −46
    360 181 9 210 35 107 −59 119 −54
  • [0362]
    TABLE 12
    Patient Number 110
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA NA
    −105 NA NA NA NA
    −90 NA NA NA NA
    −75 NA NA NA NA
    −60 142 142 151 141
    −45 141 138 148 141
    −30 143 141 117 143
    −16 136 140 144 141
    −1 131 0 121 0 141 0 139 0
    5 128 −3 84.8 −36.2 133 −8 135 −4
    10 135 4 80 −41 129 −12 134 −5
    15 138 7 68.8 −52.2 132 −9 144 5
    20 144 13 79.2 −41.8 134 −7 150 11
    25 149 18 73.9 −47.1 145 4 162 23
    30 154 23 75.8 −45.2 147 6 176 37
    35 149 18 73.9 −47.1 147 6 181 42
    40 158 27 80 −41 145 4 191 52
    45 156 25 87.3 −33.7 146 5 191 52
    50 168 37 88.4 −32.6 151 10 188 49
    55 162 31 93.5 −27.5 144 3 189 50
    60 164 33 113 −8 151 10 190 51
    65 156 25 110 −11 156 15 186 47
    70 160 29 120 −1 155 14 189 50
    75 169 38 130 9 156 15 194 55
    80 165 34 135 14 161 20 199 60
    85 170 39 142 21 164 23 199 60
    90 170 39 142 21 158 17 196 57
    95 176 45 139 18 156 15 197 58
    100 171 40 139 18 161 20 191 52
    105 176 45 137 16 155 14 196 57
    110 185 54 137 16 159 18 185 46
    115 172 41 142 21 136 −5 189 50
    120 180 49 143 22 135 −6 197 58
    130 186 55 151 30 144 3 188 49
    140 186 55 138 17 119 −22 188 49
    150 191 60 144 23 116 −25 180 41
    160 181 50 142 21 113 −28 170 31
    170 186 55 145 24 102 −39 159 20
    180 183 52 146 25 104 −37 158 19
    190 181 50 148 27 95.9 −45.1 160 21
    200 177 46 139 18 90.1 −50.9 158 19
    210 171 40 139 18 83.4 −57.6 153 14
    220 154 23 134 13 83.8 −57.2 146 7
    230 130 −1 127 6 81.8 −59.2 142 3
    240 126 −5 126 5 82.4 −58.6 137 −2
    255 127 −4 111 −10 78.9 −62.1 133 −6
    270 122 −9 109 −12 78.8 −62.2 129 −10
    285 122 −9 103 −18 80.9 −60.1 124 −15
    300 130 −1 99 −22 79 −62 120 −19
    315 124 −7 99 −22 79.9 −61.1 117 −22
    330 123 −8 97 −24 77.7 −63.3 115 −24
    345 113 −18 96 −25 79.7 −61.3 109 −30
    360 104 −27 92.1 −28.9 80.4 −60.6 104 −35
  • [0363]
    TABLE 13
    Patient Number 111
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA NA
    −105 NA NA NA NA
    −90 NA NA NA NA
    −75 NA NA NA NA
    −60 109 110 134 129
    −45 117 113 132 127
    −30 118 112 142 127
    −16 122 120 141 126
    −1 106 0 109 0 138 0 118 0
    5 112 6 96.2 −12.8 138 0 127 9
    10 124 18 90.5 −18.5 138 0 128 10
    15 108 2 80.6 −28.4 135 −3 127 9
    20 108 2 92.1 −16.9 138 0 136 18
    25 114 8 106 −3 149 11 142 24
    30 119 13 110 1 147 9 144 26
    35 121 15 127 18 161 23 NA
    40 129 23 120 11 165 27 160 42
    45 154 48 144 35 174 36 165 47
    50 144 38 146 37 166 28 168 50
    55 147 41 134 25 181 43 183 65
    60 156 50 157 48 137 −1 183 65
    65 154 48 161 52 155 17 176 58
    70 146 40 154 45 165 27 183 65
    75 153 47 161 52 165 27 191 73
    80 150 44 147 38 150 12 184 66
    85 160 54 159 50 147 9 183 65
    90 152 46 142 33 135 −3 191 73
    95 153 47 160 51 119 −19 189 71
    100 153 47 146 37 142 4 194 76
    105 150 44 149 40 133 −5 195 77
    110 151 45 143 34 147 9 191 73
    115 160 54 137 28 134 −4 188 70
    120 160 54 146 37 77.6 −60.4 180 62
    130 163 57 145 36 117 −21 176 58
    140 155 49 134 25 131 −7 167 49
    150 164 58 143 34 134 −4 183 65
    160 152 46 151 42 135 −3 176 58
    170 156 50 129 20 145 7 165 47
    180 149 43 118 9 152 14 183 65
    190 154 48 153 44 147 9 154 36
    200 147 41 148 39 145 7 154 36
    210 139 33 148 39 152 14 161 43
    220 138 32 137 28 142 4 145 27
    230 133 27 150 41 119 −19 130 12
    240 142 36 152 43 144 6 131 13
    255 147 41 133 24 138 0 121 3
    270 133 27 122 13 118 −20 118 0
    285 134 28 124 15 112 −26 111 −7
    300 121 15 118 9 108 −30 114 −4
    315 96.7 −9.3 120 11 99.6 −38.4 108 −10
    330 110 4 111 2 97.4 −40.6 107 −11
    345 107 1 107 −2 95.1 −42.9 106 −12
    360 105 −1 108 −1 91.6 −46.4 105 −13
  • [0364]
    TABLE 14
    Patient Number 112
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA NA
    −105 NA NA NA NA
    −90 NA NA NA NA
    −75 NA NA NA NA
    −60 108 112 120 117
    −45 108 108 117 116
    −30 92.6 111 117 116
    −16 101 105 109 112
    −1 99.3 0 86.6 0 104 0 110 0
    5 96.7 −2.6 76.6 −10 106 2 107 −3
    10 96.7 −2.6 74.3 −12.3 103 −1 107 −3
    15 98.4 −0.9 60.1 −26.5 101 −3 111 1
    20 93.3 −6 81.1 −5.5 98 −6 120 10
    25 96 −3.3 84.6 −2 101 −3 128 18
    30 103 3.7 84.9 −1.7 109 5 132 22
    35 109 9.7 95 8.4 111 7 134 24
    40 108 8.7 99.1 12.5 109 5 141 31
    45 118 18.7 106 19.4 107 3 138 28
    50 125 25.7 101 14.4 112 8 137 27
    55 129 29.7 107 20.4 100 −4 137 27
    60 137 37.7 107 20.4 NA 144 34
    65 140 40.7 111 24.4 117 13 144 34
    70 143 43.7 116 29.4 108 4 137 27
    75 146 46.7 120 33.4 109 5 137 27
    80 151 51.7 121 34.4 102 −2 144 34
    85 147 47.7 120 33.4 99.9 −4.1 137 27
    90 143 43.7 132 45.4 104 0 136 26
    95 139 39.7 133 46.4 105 1 140 30
    100 143 43.7 129 42.4 112 8 141 31
    105 147 47.7 134 47.4 110 6 138 28
    110 148 48.7 127 40.4 105 1 143 33
    115 145 45.7 125 38.4 110 6 141 31
    120 141 41.7 138 51.4 108 4 141 31
    130 139 39.7 130 43.4 99.2 −4.8 136 26
    140 134 34.7 121 34.4 96.2 −7.8 144 34
    150 124 24.7 119 32.4 100 −4 147 37
    160 91 −8.3 129 42.4 87.6 −16.4 143 33
    170 90.3 −9 129 42.4 92.9 −11.1 114 4
    180 96.8 −2.5 143 56.4 83.5 −20.5 111 1
    190 96.6 −2.7 139 52.4 85.7 −18.3 113 3
    200 100 0.7 126 39.4 86.1 −17.9 124 14
    210 88.9 −10.4 108 21.4 84.1 −19.9 119 9
    220 96.6 −2.7 111 24.4 87.7 −16.3 120 10
    230 96.7 −2.6 118 31.4 96.1 −7.9 120 10
    240 97.3 −2 121 34.4 101 −3 120 10
    255 90.4 −8.9 115 28.4 104 0 110 0
    270 86.2 −13.1 109 22.4 102 −2 109 −1
    285 79.4 −19.9 111 24.4 102 −2 96.2 −13.8
    300 75.3 −24 105 18.4 97.9 −6.1 96.5 −13.5
    315 72.1 −27.2 105 18.4 93.6 −10.4 94.8 −15.2
    330 81.4 −17.9 103 16.4 87.7 −16.3 91.8 −18.2
    345 83.7 −15.6 101 14.4 84.1 −19.9 85.9 −24.1
    360 78.8 −20.5 95.6 9 82.6 −21.4 82.7 −27.3
  • [0365]
    TABLE 15
    Patient Number 113
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA NA
    −105 NA NA NA NA
    −90 NA NA NA NA
    −75 NA NA NA NA
    −60 110 144 174 115
    −45 108 139 174 113
    −30 103 136 171 106
    −16 103 130 164 115
    −1 99.2 0 129 0 168 0 111 0
    5 98.8 −0.4 123 −6 168 0 102 −9
    10 98.8 −0.4 120 −9 168 0 107 −4
    15 96.1 −3.1 125 −4 153 −15 100 −11
    20 97.5 −1.7 123 −6 164 −4 104 −7
    25 102 2.8 122 −7 168 0 113 2
    30 112 12.8 128 −1 174 6 108 −3
    35 119 19.8 129 0 184 16 116 5
    40 128 28.8 144 15 184 16 123 12
    45 127 27.8 144 15 188 20 131 20
    50 138 38.8 156 27 179 11 132 21
    55 146 46.8 153 24 188 20 129 18
    60 156 56.8 156 27 201 33 131 20
    65 159 59.8 185 56 224 56 139 28
    70 166 66.8 183 54 219 51 141 30
    75 168 68.8 187 58 228 60 136 25
    80 165 65.8 197 68 236 68 148 37
    85 168 68.8 194 65 223 55 157 46
    90 163 63.8 195 66 231 63 167 56
    95 169 69.8 188 59 222 54 168 57
    100 171 71.8 199 70 229 61 162 51
    105 170 70.8 200 71 229 61 187 76
    110 171 71.8 204 75 233 65 176 65
    115 174 74.8 212 83 238 70 177 66
    120 173 73.8 206 77 237 69 199 88
    130 176 76.8 215 86 232 64 190 79
    140 186 86.8 220 91 234 66 178 67
    150 195 95.8 219 90 241 73 198 87
    160 199 99.8 207 78 269 101 187 76
    170 204 104.8 218 89 241 73 184 73
    180 210 110.8 224 95 245 77 195 84
    190 223 123.8 221 92 236 68 178 67
    200 225 125.8 226 97 243 75 176 65
    210 220 120.8 227 98 224 56 164 53
    220 216 116.8 241 112 220 52 180 69
    230 219 119.8 222 93 213 45 176 65
    240 211 111.8 224 95 210 42 184 73
    255 215 115.8 228 99 192 24 179 68
    270 221 121.8 228 99 187 19 187 76
    285 218 118.8 231 102 179 11 168 57
    300 218 118.8 218 89 174 6 165 54
    315 211 111.8 210 81 170 2 152 41
    330 209 109.8 210 81 164 −4 170 59
    345 204 104.8 201 72 167 −1 156 45
    360 198 98.8 200 71 154 −14 147 36
  • [0366]
    TABLE 16
    Patient Number 114
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA
    −105 NA NA NA
    −90 NA NA NA
    −75 NA NA NA
    −60 141 140 142
    −45 144 138 154
    −30 138 140 156
    −16 133 138 157
    −1 94 0 132 0 135 0
    5 70.4 −23.6 131 −1 151 16
    10 65.9 −28.1 125 −7 143 8
    15 67.9 −26.1 126 −6 142 7
    20 79.6 −14.4 136 4 157 22
    25 90.4 −3.6 141 9 172 37
    30 98.9 4.9 148 16 172 37
    35 110 16 155 23 154 19
    40 125 31 157 25 205 70
    45 127 33 152 20 200 65
    50 135 41 156 24 161 26
    55 144 50 149 17 204 69
    60 143 49 142 10 225 90
    65 162 68 156 24 200 65
    70 172 78 143 11 212 77
    75 189 95 140 8 224 89
    80 199 105 138 6 223 88
    85 190 96 134 2 179 44
    90 194 100 130 −2 222 87
    95 186 92 126 −6 226 91
    100 186 92 123 −9 203 68
    105 177 83 115 −17 207 72
    110 177 83 112 −20 177 42
    115 178 84 114 −18 218 83
    120 185 91 108 −24 225 90
    130 195 101 119 −13 204 69
    140 195 101 120 −12 185 50
    150 193 99 123 −9 194 59
    160 185 91 127 −5 167 32
    170 183 89 127 −5 195 60
    180 176 82 111 −21 155 20
    190 166 72 93 −39 159 24
    200 169 75 73 −59 150 15
    210 167 73 65.5 −66.5 159 24
    220 164 70 57.9 −74.1 161 26
    230 153 59 65.1 −66.9 142 7
    240 136 42 54.1 −77.9 136 1
    255 134 40 80.7 −51.3 131 −4
    270 127 33 67.7 −64.3 137 2
    285 117 23 65.9 −66.1 130 −5
    300 111 17 68.2 −63.8 128 −7
    315 112 18 70.5 −61.5 119 −16
    330 112 18 82 −50 119 −16
    345 108 14 84 −48 115 −20
    360 111 17 87.1 −44.9 114 −21
  • [0367]
    TABLE 17
    Patient Number 115
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA
    −105 NA NA NA
    −90 NA NA NA
    −75 NA NA NA
    −60 136 175 176
    −45 136 170 176
    −30 135 166 174
    −16 136 169 170
    −1 126 0 168 0 174 0
    5 123 −3 165 −3 180 6
    10 111 −15 161 −7 175 1
    15 105 −21 161 −7 179 5
    20 104 −22 162 −6 169 −5
    25 103 −23 162 −6 175 1
    30 114 −12 170 2 191 17
    35 122 −4 168 0 189 15
    40 135 9 203 35 219 45
    45 143 17 203 35 228 54
    50 147 21 193 25 235 61
    55 168 42 184 16 249 75
    60 172 46 194 26 231 57
    65 171 45 194 26 251 77
    70 173 47 199 31 274 100
    75 183 57 198 30 284 110
    80 196 70 203 35 275 101
    85 184 58 204 36 286 112
    90 206 80 212 44 286 112
    95 200 74 212 44 283 109
    100 204 78 210 42 281 107
    105 213 87 214 46 287 113
    110 217 91 221 53 298 124
    115 210 84 230 62 291 117
    120 222 96 230 62 300 126
    130 218 92 222 54 308 134
    140 217 91 214 46 302 128
    150 224 98 202 34 302 128
    160 239 113 183 15 302 128
    170 233 107 160 −8 281 107
    180 235 109 149 −19 276 102
    190 239 113 122 −46 278 104
    200 238 112 112 −56 271 97
    210 243 117 98.6 −69.4 270 96
    220 236 110 97.7 −70.3 268 94
    230 231 105 89.9 −78.1 260 86
    240 236 110 84.4 −83.6 253 79
    255 239 113 73.5 −94.5 254 80
    270 234 108 64.2 −104 249 75
    285 224 98 68.5 −99.5 237 63
    300 217 91 73 −95 230 56
    315 208 82 78.9 −89.1 223 49
    330 206 80 77.7 −90.3 218 44
    345 194 68 80.1 −87.9 216 42
    360 184 58 77.6 −90.4 196 22
  • [0368]
    TABLE 18
    Patient Number 116
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA NA
    −105 NA NA NA NA
    −90 NA NA NA NA
    −75 NA NA NA NA
    −60 113 107 106 117
    −45 117 104 115 115
    −30 117 98.3 110 118
    −16 105 92.2 102 117
    −1 112 0 72.2 0 108 0 111 0
    5 111 −1 57.4 −14.8 107 −1 124 13
    10 111 −1 44.7 −27.5 105 −3 105 −6
    15 116 4 41.7 −30.5 105 −3 113 2
    20 119 7 50.7 −21.5 107 −1 131 20
    25 137 25 61.8 −10.4 127 19 130 19
    30 160 48 79.4 7.2 131 23 NA
    35 169 57 112 39.8 141 33 NA
    40 197 85 125 52.8 155 47 166 55
    45 216 104 136 63.8 156 48 165 54
    50 219 107 136 63.8 164 56 205 94
    55 220 108 153 80.8 159 51 222 111
    60 233 121 154 81.8 192 84 206 95
    65 248 136 163 90.8 181 73 212 101
    70 242 130 157 84.8 179 71 205 94
    75 239 127 165 92.8 176 68 199 88
    80 244 132 182 109.8 170 62 NA
    85 252 140 186 113.8 177 69 203 92
    90 260 148 186 113.8 165 57 203 92
    95 263 151 187 114.8 165 57 194 83
    100 244 132 188 115.8 163 55 200 89
    105 241 129 184 111.8 175 67 184 73
    110 248 136 178 105.8 158 50 188 77
    115 248 136 172 99.8 157 49 181 70
    120 235 123 177 104.8 162 54 174 63
    130 219 107 180 107.8 150 42 172 61
    140 205 93 156 83.8 138 30 169 58
    150 175 63 134 61.8 127 19 157 46
    160 167 55 132 59.8 112 4 136 25
    170 171 59 117 44.8 105 −3 138 27
    180 151 39 115 42.8 89.2 −18.8 130 19
    190 119 7 108 35.8 73.3 −34.7 111 0
    200 104 −8 97.5 25.3 62.3 −45.7 93.8 −17.2
    210 91 −21 98.5 26.3 57.8 −50.2 85.7 −25.3
    220 94.2 −17.8 94.5 22.3 53.6 −54.4 74 −37
    230 91.6 −20.4 83.8 11.6 73.2 −34.8 75.9 −35.1
    240 86.4 −25.6 78.7 6.5 77.8 −30.2 73.5 −37.5
    255 81 −31 80.3 8.1 73.1 −34.9 70.5 −40.5
    270 80.8 −31.2 75 2.8 72.9 −35.1 73.1 −37.9
    285 77.7 −34.3 78.7 6.5 69.3 −38.7 71.1 −39.9
    300 77.8 −34.2 79.4 7.2 75 −33 70.8 −40.2
    315 71.4 −40.6 76.2 4 77.7 −30.3 69.1 −41.9
    330 74.5 −37.5 76.2 4 77.1 −30.9 72.3 −38.7
    345 78.5 −33.5 75.8 3.6 75.8 −32.2 73.3 −37.7
    360 78.5 −33.5 76.8 4.6 85.6 −22.4 75.9 −35.1
  • [0369]
    TABLE 19
    Patient Number 117
    Treatment
    Oral 150 U Insulin/ Oral 300 U lnsulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    Time glucose excursion glucose excursion glucose excursion glucose excursion
    (min) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA NA NA
    −105 NA NA NA
    −90 NA NA NA
    −75 NA NA NA
    −60 160 133 145
    −45 161 139 140
    −30 157 135 146
    −16 156 135 140
    −1 142 0 134 0 138 0
    5 139 −3 134 0 140 2
    10 125 −17 132 −2 141 3
    15 119 −23 130 −4 138 0
    20 125 −17 136 2 141 3
    25 129 −13 147 13 160 22
    30 146 4 155 21 170 32
    35 157 15 165 31 179 41
    40 172 30 168 34 193 55
    45 182 40 166 32 191 53
    50 199 57 163 29 207 69
    55 203 61 175 41 213 75
    60 221 79 170 36 221 83
    65 215 73 184 50 220 82
    70 230 88 184 50 222 84
    75 222 80 178 44 234 96
    80 227 85 196 62 237 99
    85 227 85 191 57 238 100
    90 216 74 181 47 250 112
    95 221 79 187 53 254 116
    100 228 86 179 45 258 120
    105 229 87 184 50 267 129
    110 226 84 180 46 269 131
    115 226 84 173 39 270 132
    120 230 88 165 31 269 131
    130 228 86 176 42 267 129
    140 231 89 176 42 270 132
    150 232 90 175 41 268 130
    160 223 81 155 21 255 117
    170 213 71 137 3 249 111
    180 209 67 124 −10 255 117
    190 220 78 118 −16 259 121
    200 228 86 121 −13 263 125
    210 237 95 129 −5 260 122
    220 223 81 139 5 256 118
    230 214 72 137 3 249 111
    240 214 72 138 4 242 104
    255 218 76 136 2 233 95
    270 225 83 133 −1 228 90
    285 217 75 124 −10 214 76
    300 211 69 123 −11 209 71
    315 194 52 119 −15 202 64
    330 191 49 109 −25 184 46
    345 187 45 123 −11 178 40
    360 169 27 118 −16 165 27
  • [0370]
    TABLE 20
    Patient Number 118
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
    200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin Placebo
    Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
    glucose excursion glucose excursion glucose excursion glucose excursion
    Time (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)
    −120 NA
    −105 NA
    −90 NA
    −75 NA
    −60 175
    −45 181
    −30 181
    −16 184
    −1 190 0
    5 193 3
    10 191 1
    15 185 −5
    20 184 −6
    25 185 −5
    30 190 0
    35 202 12
    40 201 11
    45 210 20
    50 215 25
    55 227 37
    60 214 24
    65 228 38
    70 233 43
    75 239 49
    80 218 28
    85 211 21
    90 224 34
    95 223 33
    100 233 43
    105 225 35
    110 226 36
    115 226 36
    120 225 35
    130 215 25
    140 212 22
    150 214 24
    160 214 24
    170 205 15
    180 201 11
    190 192 2
    200 189 −1
    210 188 −2
    220 176 −14
    230 179 −11
    240 177 −13
    255 167 −23
    270 148 −42
    285 138 −52
    300 136 −54
    315 136 −54
    330 136 −54
    345 125 −65
    360 129 −61
  • [0371]
    Based upon individual blood glucose excursion data, the mean time data (with standard deviation) of the blood glucose excursions per treatment were calculated. Table 21 below presents the mean time profiles (with standard deviation) of the blood glucose excursions per treatment.
    TABLE 21
    Statistics on Blood Glucose Excursions (mg/dL) versus Time
    Treatment
    Oral 150 U Oral 300 U SC 12 U
    Insulin/200 mg Insulin/400 mg Short-acting
    4-CNAB 4-CNAB insulin Placebo
    Time MEAN STD Mean STD Mean STD Mean STD
     −1 min 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
     5 min −1.88 2.85 −10.28 9.82 0.83 3.90 1.26 7.21
     10 min −0.94 6.82 −14.32 12.79 −2.02 4.12 −1.34 7.73
     15 min −0.90 6.60 −20.80 15.85 −1.83 6.65 0.67 6.27
     20 min 5.17 9.34 −13.10 12.28 2.00 7.99 6.36 8.95
     25 min 14.45 13.65 −7.73 15.37 8.78 8.34 15.98 10.94
     30 min 25.78 19.53 0.96 16.45 13.94 10.32 25.04 12.13
     35 min 30.03 19.59 9.65 20.71 20.22 11.84 27.17 13.77
     40 min 38.70 25.11 19.44 22.26 25.61 14.29 42.09 16.75
     45 min 46.62 28.06 27.22 23.02 25.39 14.72 44.27 15.74
     50 min 53.20 28.13 34.15 25.35 25.17 14.72 50.21 17.62
     55 min 53.78 28.10 36.32 26.55 25.23 18.21 59.15 20.77
     60 min 61.53 29.36 45.12 25.43 28.61 22.60 60.68 20.18
     65 min 62.95 33.22 47.66 26.40 34.27 20.98 64.92 20.20
     70 min 65.28 31.71 53.43 25.78 34.80 23.89 67.21 21.48
     75 min 67.03 29.53 60.82 26.01 35.18 24.69 73.09 24.03
     80 min 71.62 31.52 63.58 28.07 34.76 27.55 72.98 23.59
     85 min 72.78 33.07 65.35 27.24 34.84 28.91 70.15 23.72
     90 min 72.45 35.93 66.43 27.65 31.73 28.64 74.27 23.37
     95 min 73.95 38.85 65.43 26.86 30.77 32.19 77.04 24.40
    100 min 72.03 33.65 68.82 31.37 31.89 29.45 73.86 24.91
    105 min 71.70 36.28 70.05 28.56 30.43 34.39 74.98 24.90
    110 min 72.53 36.31 68.66 29.11 28.94 29.69 74.21 27.63
    115 min 69.95 34.89 66.82 25.86 27.78 30.69 75.51 26.02
    120 min 67.62 33.17 68.74 26.84 24.39 38.20 73.09 27.51
    130 min 64.20 33.66 69.66 26.29 23.58 29.38 69.92 30.50
    140 min 64.12 36.90 67.05 29.96 21.13 29.04 65.21 34.05
    150 min 61.81 39.39 69.82 27.52 18.24 30.41 63.09 33.30
    160 min 52.45 36.58 69.89 26.44 14.70 33.22 60.04 35.19
    170 min 56.14 43.50 66.58 29.68 8.18 31.08 54.62 33.10
    180 min 53.43 43.74 63.05 29.07 2.46 32.61 52.51 34.37
    190 min 52.50 46.66 65.51 25.89 −5.92 35.08 47.62 36.83
    200 min 51.87 49.16 61.24 30.87 −7.98 38.93 47.20 38.33
    210 min 43.86 50.96 56.55 34.19 −11.50 40.57 42.43 37.39
    220 min 44.02 46.33 54.32 35.95 −16.28 38.64 38.04 37.33
    230 min 39.06 45.66 51.03 30.63 −18.03 36.67 34.38 38.38
    240 min 35.81 43.81 47.56 33.31 −19.99 37.25 30.18 36.50
    255 min 34.03 45.16 38.68 38.20 −23.24 34.66 21.01 37.12
    270 min 25.78 44.25 37.74 39.55 −30.94 31.16 17.26 38.00
    285 min 22.66 44.50 32.02 39.22 −33.17 29.93 9.15 34.35
    300 min 17.62 42.95 27.00 37.62 −36.51 27.14 5.46 33.57
    315 min 9.72 42.22 22.73 34.64 −38.84 23.55 −1.79 31.13
    330 min 6.50 39.10 19.07 34.40 −40.00 22.81 −3.87 30.70
    345 min 2.29 37.43 15.57 31.59 −42.37 22.24 −7.80 29.53
    360 min −3.60 36.03 10.60 31.52 −42.68 21.48 −12.44 26.69
  • [0372]
    Based upon individual blood glucose excursion data, the mean time profiles (with standard deviation) of the blood glucose excursions per treatment were plotted. FIG. 1 shows a plot of the arithmetic means of postprandial blood glucose excursions (mg/dL) vs. time for all subjects. As indicated in FIG. 1, mean blood glucose excursions of the different treatments reach their maxima between 1 and 2 hours after start of meal intake and then return towards baseline. The time to maximal glucose excursion (median) was 1.3 hours for SC 12 U short-acting insulin, 1.7 hours for placebo, 1.8 hours for oral 150 U Insulin/200 mg 4-CNAB, and 2.2 hours for oral 300 U Insulin/400 mg 4-CNAB.
  • [0373]
    The lowest overall excursions were achieved with the 12 U SC short-acting insulin injection. Compared to both oral insulin treatments and placebo, blood glucose excursions after SC injection are markedly lower during the period from 45 to 360 minutes and, after crossing the baseline at about 180 minutes, values become increasingly negative until 360 minutes after meal intake.
  • [0374]
    After oral 300 U Insulin/400 mg 4-CNAB, a sharp decline from baseline can be seen until −20.8 mg/dL at 15 minutes, followed by a return to baseline at 30 minutes. Thus, during approximately the first hour, the dose of 300 U oral Insulin/400 mg 4-CNAB led to lower excursions even when compared to injection. Thereafter, rise and subsequent decline of the curve follows the pattern seen for oral 150 U Insulin/200 mg 4-CNAB dosage and no treatment (placebo). No differences could be seen between 150 U oral Insulin/200 mg 4-CNAB and no treatment (placebo).
  • [0375]
    Based on the profiles, the derived parameters, AUC0-1h, AUC0-2h, AUC0-3h, AUC0-4h, AUC0-6h and Cmax were calculated, as presented in Table 22 below.
    TABLE 22
    Treatment
    Oral 150 U Oral 300 U SC 12 U
    Insulin/ Insulin/ Short-
    200 mg 400 mg acting
    4-CNAB 4-CNAB insulin Placebo
    Parameter Mean STD Mean STD Mean STD Mean STD
    AUC0-1 h 24.5 15.2 6.9 15.0 13.1 8.5 25.3 9.1
    (h * mg/dL)
    AUC0-2 h 94.3 46.3 69.8 38.0 44.9 32.8 97.8 28.5
    (h * mg/dL)
    AUC0-3 h 154.1 74.1 138.2 60.4 61.4 57.5 160.2 54.0
    (h * mg/dL)
    AUC0-4 h 200.1 105.9 195.2 81.4 50.0 83.6 202.1 84.9
    (h * mg/dL)
    AUC0-6 h 233.9 164.3 250.8 140.6 −21.1 119.4 214.2 143.7
    (h * mg/dL)
    Cmax (mg/dL) 90.5 38.1 85.8 28.3 50.7 25.8 88.3 27.7
  • [0376]
    This data indicates that AUC0-1h is lowest following the 300 U oral Insulin/400 mg 4-CNAB dosage. Up to 2 hours and 3 hours, the AUCs are still smaller than the AUCs of 150 U oral Insulin/200 mg 4-CNAB and no treatment (placebo), but larger than the AUCs of 12 U SC short-acting insulin. However, for 4 hours and 6 hours, no difference can be seen between the oral applications and no treatment. For 150 U oral Insulin/200 mg 4-CNAB, all AUCs are more or less equal to those obtained under no treatment. Mean maximum blood glucose excursions (Cmax) after both oral insulin administrations and after no treatment are similar and clearly higher than Cmax after the SC injection.
  • [0377]
    FIGS. 3 and 4 show the blood glucose concentration vs. time curves for subjects 116 and 117, respectively. Subject 116 was chosen because he was a Type II diabetic in an early stage of the disease i.e., was able to produce his own insulin, and the glucose curve for subject 116 shown in FIG. 3 paralleled that of healthy (normal) non-diabetic humans. By contrast, subject 117 was a type II diabetic in an advanced stage of the disease, i.e., having very little pancreatic function left and producing very little endogenous insulin. Accordingly, as shown in the glucose curve of FIG. 4 for subject 117, it took much longer to lower the glucose level for this subject back to a level found in healthy (normal) non-diabetic humans.
  • [0378]
    The test results can be summarized as follows: When Cmax and AUCs for 3 hours and more are considered, no statistically significant differences of the oral treatments compared to no treatment (placebo) could be established. On the other hand, both oral treatments differ significantly from SC insulin injection, with oral treatments leading to higher mean values.
  • [0379]
    With regard to the primary endpoint AUC0-2h, a single oral dose of 300 U Insulin/400 mg 4-CNAB, administered 30 minutes prior to a standardized test meal, caused a statistically significant reduction of postprandial blood glucose excursions in comparison to no treatment (placebo). However, the effect was significantly lower than after SC injection of 12 U short-acting insulin. The effect of 150 U oral Insulin/200 mg 4-CNAB was not significantly different from no treatment (placebo).
  • [0000]
    Pharmacokinetics
  • [0380]
    From the blood samples taken, the individual plasma concentrations of 4-CNAB, insulin and C-peptide were also determined, and summary concentration vs. time tables were prepared and profiles were plotted, as set forth in Tables 23-40 for insulin and C-peptide concentrations below.
    TABLE 23
    Patient Number 101
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Short-
    200 mg 4-CNAB 400 mg 4-CNAB acting insulin Placebo
    Time Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
    (min) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l)
    −60 63 0.73 134 0.97 72 0.85
    −30 78 0.80 66 0.76 95 0.90
    0 277 0.76 112 0.90 74 0.81
    10 334 0.81 111 0.98 105 0.98
    20 159 0.85 140 1.13 136 1.15
    30 222 1.19 280 1.58 229 1.53
    40 202 1.17 339 1.66 281 1.71
    50 222 1.27 281 1.73 322 1.96
    60 311 1.70 270 1.66 338 2.20
    75 311 1.95 349 1.98 352 2.30
    90 339 2.10 384 2.20 430 2.50
    105 386 2.40 397 2.30 349 2.50
    120 433 2.70 501 2.60 441 2.90
    150 452 2.90 395 2.70 299 2.60
    180 285 2.60 252 2.30 192 2.30
    210 220 2.20 186 1.88 273 2.60
    240 165 2.10 93 1.32 175 2.20
    300 95 1.42 68 0.93 98 1.51
    360 102 1.14 43 0.71 67 0.86
  • [0381]
    TABLE 24
    Patient Number 102
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Short-
    200 mg 4-CNAB 400 mg 4-CNAB acting insulin Placebo
    Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
    Time (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l)
    −60 44 0.78 30 0.55 51 0.71
    −30 35 0.69 23 0.50 47 0.76
    0 52 0.68 48 0.59 45 0.69
    10 68 0.72 60 0.62 67 0.76
    20 54 0.70 50 0.60 66 0.75
    30 113 0.93 41 0.85 128 0.93
    40 169 1.16 212 1.22 153 1.13
    50 250 1.47 163 1.14 264 1.47
    60 256 1.50 153 1.15 282 1.61
    75 336 2.00 300 1.71 322 1.88
    90 362 2.20 128 1.53 556 2.70
    105 343 2.40 267 1.73 602 2.80
    120 344 2.50 209 1.72 763 3.20
    150 213 2.30 162 1.61 488 3.10
    180 142 1.83 139 1.52 416 3.00
    210 135 2.10 219 1.70 281 2.70
    240 95 1.49 108 1.38 213 2.20
    300 83 1.28 70 1.01 140 1.61
    360 83 1.24 56 0.88 86 1.35
  • [0382]
    TABLE 25
    Patient Number 103
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Short-
    200 mg 4-CNAB 400 mg 4-CNAB acting insulin Placebo
    Time Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
    (min) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l)
    −60  70 0.88 35 1.11 77 1.01  58 1.01
    −30  70 0.83 79 1.09 65 1.00  25 0.97
    0  68 0.85 95 0.97 61 0.94  78 1.00
    10  82 0.90 73 1.13 84 1.05  80 1.16
    20 101 0.99 84 1.17 81 1.07 120 1.26
    30 132 1.12 147 1.41 150 1.25 152 1.44
    40 174 1.38 178 1.46 191 1.41  73* 1.59
    50 253 1.69 180 1.63 208 1.52 196 1.77
    60 275 1.74 237 1.84 249 1.68 271 1.87
    75 350 2.40 305 1.99 291 1.94 274 2.20
    90 483 2.80 271 2.30 343 2.10 278 2.50
    105 530 3.60 173 2.40 301 2.20  96* 2.50
    120 558 3.90 227 2.70 318 2.20 320 2.70
    150 596 4.30 260 2.70 211 2.10 292 2.80
    180 469 4.80 288 2.90 148 1.82 256 3.00
    210 410 4.40 164 3.00 100 1.55 224 2.90
    240 304 3.90 126 2.10 68 1.33 122 2.40
    300 167 2.50 119 1.90 74 1.12  93 1.74
    360  93* 2.10 122 1.88 61 1.00  44* 1.43
  • [0383]
    TABLE 26
    Patient Number 104
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Short-
    200 mg 4-CNAB 400 mg 4-CNAB acting insulin Placebo
    Time Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
    (min) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l)
    −60  22 0.48 BLQ 0.52 27 0.55 23 0.52
    −30  23 0.51 15 0.47 BLQ BLQ 14 0.47
    0  62 0.59 47 0.50 25 0.53 31 0.60
    10  95 0.83 35 0.53 24 0.54 53 0.73
    20 130 1.14 61 0.77 84 0.78 100 0.94
    30  94 0.99 56 0.72 71 0.76 73 0.92
    40  50* 0.95 BLQ BLQ 112 0.83 89 1.05
    50 108 1.11 64 0.82 124 0.98 14 1.23
    60 141 1.34 65 1.04 114 0.94 98 1.37
    75 135 1.39 113 1.23 82 0.90 22 1.65
    90 115 1.36 129 1.18 51 0.91 117 1.67
    105  83 1.45 142 1.75 85 1.07 117 1.70
    120 107 1.54 162 2.00 82 0.94 98 1.80
    150 117 1.57 158 2.30 54 0.83 74 1.46
    180 116 1.58 118 2.00 32 0.75 44 1.43
    210  94 1.53 89 1.96 42 0.71 64 1.64
    240 122 1.63 77 1.76 27 0.61 56 1.38
    300  48 1.41 35 1.19 14 0.47 40 1.01
    360  43 1.01 28 0.91 19 0.43 23 0.78
  • [0384]
    TABLE 27
    Patient Number 105
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Short-
    200 mg 4-CNAB 400 mg 4-CNAB acting insulin Placebo
    Time Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
    (min) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l)
    −60  44 0.95 36 0.79 23 0.72  23 0.76
    −30  40 1.04 39 0.85 19 0.72  23 0.73
    0  38 1.01 76 0.82 25 0.70  22 0.71
    10  48 1.03 114 0.83 40 0.76  42 0.83
    20  53 1.03 61 0.79 38 0.75  43 0.77
    30 146 1.65 98 1.01 106 1.10 100 1.12
    40 165 1.78 95 1.19 120 1.10 135 1.30
    50 193 1.83 97 1.05 122 1.11 144 1.18
    60  49* 2.60* 111 1.22 119 1.24 148 1.43
    75 360 3.20 149 1.57 159 1.62 239 2.00
    90  245* 3.70 148 1.68 170 1.75 283 2.30
    105 498 3.80 233 2.00 197 2.20 289 2.50
    120 430 4.30 232 2.10 193 1.81 321 2.60
    150 188 3.00 286 2.40 207 2.30 260 2.80
    180 244 3.10 281 2.50 135 1.99 213 2.60
    210 121 3.20 229 2.50 40 1.28  134* 2.40
    240 103 1.90 169 2.40 18 0.83  84 1.97
    300  28 1.26 48 1.29 14 0.74  32 1.11
    360  25 0.91 34 0.92 BLQ 0.58  25 0.86
  • [0385]
    TABLE 28
    Patient Number 106
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Short-
    200 mg 4-CNAB 400 mg 4-CNAB acting insulin Placebo
    Time Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
    (min) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l)
    −60 65 0.82 42 0.71 24 0.51 24 0.69
    −30 55 0.86 30 0.74 19 0.49 24 0.58
    0 62 0.71 48 0.61 26 0.55 32 0.66
    10 46 0.75 48 0.66 38 0.61 39 0.68
    20 38 0.76 27 0.58 52 0.75 71 0.81
    30 82 0.88 33 0.57 69 0.76 90 0.93
    40 106 1.00 42 0.68 39 0.74 122 1.12
    50 123 1.33 55 0.74 63 0.77 136 1.32
    60 118 1.39 78 0.82 58 0.72 130 1.63
    75 94 1.44 53 0.77 BLQ* 0.51* 155 1.76
    90 127 1.42 121 1.22 BLQ* 0.43* 173 1.96
    105 123 1.90 62 1.05 BLQ  0.34 166 2.30
    120 140 2.10 73 1.09 13 0.32 159 2.40
    150 155 2.30 88 1.36 17 0.35 97 1.91
    180 121 2.50 146 1.58 26 0.46 108 1.73
    210 84 1.98 135 2.10  12* 0.44* 104 1.75
    240 112 2.00 137 2.20 31 0.50 90 1.90
    300 87 1.68 51 1.30 BLQ* 0.41* 22 0.84
    360 35 0.88 30 0.70 BLQ  0.31 18 0.57
  • [0386]
    TABLE 29
    Patient Number 107
    Treatment
    Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Short-
    200 mg 4-CNAB 400 mg 4-CNAB acting insulin Placebo
    Time Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
    (min) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l) (pmol/l) (nmol/l)
    −60 42 0.76  43 0.73 38 0.70 36 0.74
    −30 43 0.77  43 0.74 46 0.77 40 0.75
    0 134 0.85  98 0.94 52 0.81 53 0.84
    10 86 0.84 163 1.30 103 1.08 83 1.01
    20 145 1.28 143 1.35 135 1.22 70 0.92
    30 153 1.37 221 1.55 220 1.46 138 1.26
    40 163 1.37 217 1.58 184 1.48 258 1.48
    50 214 1.63 190 1.60 184 1.49 235 1.49
    60 245 1.95 210 1.86 219 1.66 203 1.78
    75 306 2.30 263 2.10 330 2.10 326 2.10
    90 306 2.50 268 2.20 260 2.10 455 2.50
    105 251 2.40 261 2.20 273 2.20 346 2.50
    120 275 2.70 269 2.50 253 2.10 386 2.80
    150 229 2.50  40* 2.30* 159 2.00 280 2.60
    180 172 2.30 148 2.00 111 1.67 237 2.50
    210 87 1.97 114 1.75 86