Human insulin and porcine insulin in the treatment of diabetic children: comparison of metabolic control and insulin antibody production.

Semisynthetic human insulin and highly purified porcine insulin were compared in a double blind crossover study in 21 diabetic children. Glycosylated haemoglobin values at the end of four month treatment periods were higher after treatment with human insulin than after treatment with porcine insulin (mean 15.7% (SD 2.3%) v 14.2% (2.3%); p less than 0.01). Higher fasting blood glucose concentrations occurred during treatment with human insulin than with porcine insulin (mean 12.0 (SD 2.1) v 11.0 (2.4) mmol/1; mean 216 (SD 38) v 198 (43) mg/100 ml; p less than 0.05), but there were no significant differences at other time points during the day. The incidence of hypoglycaemia was similar for both treatment groups. Concentrations of antibody reactive with porcine and human insulins were similar for the two treatment groups, although greater fluctuation was observed in the amount of antibody reactive with human insulin. Semisynthetic human insulin is safe and effective in diabetic children, although further work is needed to devise regimens which achieve optimal blood glucose control.     

Effects of fully synthetic human insulin in comparison to porcine insulin in normal subjects

Fully synthetic human insulin (CGP 12'831) was compared to porcine insulin in identical and non-identical formula by intravenous insulin tolerance tests in 12 volunteers. The half-lives of the three insulins tested did not differ (t 1/2: 5.5 +/- 0.2 minutes), though acid porcine insulin exhibited lower serum peak values. The hypoglycemic effects of the three insulins were identical. Human insulin produced a significantly smaller decrease in serum potassium (2p less than 0.01). The secretion of serum C-peptide was less inhibited by human insulin (2p less than 0.05). The counter-regulatory hormonal response of cortisol and growth hormone was lower after hypoglycemia induced by human insulin (2p less than 0.05). It is suggested that the hormonal effects of hypoglycemia are modified by insulin and depend in part on the molecular structure of insulin.     

Effects of fully synthetic human insulin in comparison to porcine insulin in normal subjects

Fully synthetic human insulin (CGP 12'831) was compared to porcine insulin in identical and non-identical formulation by intravenous insulin tolerance tests in 12 volunteers. The half-lives of the three insulins tested did not differ (t 1/2: 5.5 +/- 0.2 minutes), though acid porcine insulin exhibited lower serum peak values. The hypoglycemic effects of the three insulins were identical. Human insulin produced a significantly smaller decrease in serum potassium (2p less than 0.01). The secretion of serum C-peptide was less inhibited by human insulin (2p less than 0.05). The counter-regulatory hormonal response of cortisol and growth hormone was lower after hypoglycemia induced by human insulin (2p less than 0.05). It is suggested that the hormonal effects of hypoglycemia are modified by human insulin and depend in part on the molecular structure of insulin.     

Autoantibodies against human insulin.

Sera from 680 non-diabetic subjects with suspected autoimmune disease were screened for 13 different antibodies. Of the 582 sera found to contain these antibodies, nine bound insulin in an IgG specific enzyme linked immunosorbent assay (micro ELISA). Four of the sera bound human, porcine, and bovine insulins and five bound exclusively human insulin. "Cold" human, porcine, and bovine insulins each displaced, in a dose dependent manner, the four sera which bound all three insulins, but only human insulin displaced the remaining five, porcine and bovine insulins having little or no effect in concentrations up to 1000 U/1. These observations point to the existence of autoantibodies specifically against human insulin in some subjects with established autoimmunity.     

Responder strain-specific enhancement of endothelial and mononuclear cell Ia in delayed hypersensitivity reactions in (strain 2 X strain 13)F1 guinea pigs

This study was undertaken to test the hypothesis that preferential responder strain-specific Ia expression can be detected in delayed hypersensitivity (DH) skin reactions. Seven adult (strain 2 X strain 13)F1 and two strain 13 guinea pigs were sensitized with poly-L glutamic acid-lysine (GL), poly-L glutamic acid-tyrosine (GT), and bovine insulin in complete Freund's adjuvant, and were skin tested with GL, GT, PPD, bovine insulin, porcine insulin (which has the same B chain as bovine insulin), and saline. Strain 2 guinea pigs react with bovine insulin A chain, GL, and PPD but not with GT or the bovine insulin B chain, whereas strain 13 guinea pigs react with bovine insulin B chain, GT, and PPD but not with GL or bovine insulin A chain. The (2 X 13)F1 animals had positive DH responses to GT, GL, PPD, and bovine insulin. At 24 hr, areas of induration were measured and the test sites and draining lymph nodes were biopsied. Cryostat sections were stained with monoclonal antibodies to strain 2 Ia, strain 13 Ia, and Ia framework determinants with immunoperoxidase. Stained dermal and subdermal inflammatory cells and vessels were counted on coded slides. In GT tests, there was more staining of dermal and subdermal cells and vessels for strain 13 Ia than strain 2 Ia (p less than 0.02). In bovine insulin tests there was more staining of dermal cells and vessels for strain 13 than strain 2 Ia (p less than 0.05). In GL tests there was more staining on dermal vessels and subdermal cells and vessels of strain 2 Ia than strain 13 Ia (p less than 0.05). There was much greater staining of strain 2 Ia of dermal cells and vessels in GL tests compared with strain 2 Ia staining in GT and bovine insulin tests (p less than 0.02, cells; p less than 0.01, vessels). No significant differences between strain 2 and strain 13 Ia expression were found in PPD, porcine insulin tests, saline controls, or in lymph nodes that drained sensitization sites from animals in which GL and GT had been injected on different sides. Anti-Ia framework expression generally correlated with the greater parental strain Ia in each reaction. These findings and previous observations in experimental allergic encephalomyelitis suggest that responder type Ia may be selectively found in vivo on mononuclear and endothelial cells in sites of T cell-mediated hypersensitivity reactions.     

World Health Organization International Standards for highly purified human, porcine and bovine insulins

The 4th International Standard (IS) for Insulin, established in 1958, consists of a mixture of relatively impure bovine and porcine insulins and is not suitable as a standard for the assay of highly purified single-species insulins presently used in the treatment of diabetes. Preparations of human, bovine and porcine crystalline insulins, representative of current highly purified therapeutic insulins, have now been studied in an international collaborative study carried out by twenty-three laboratories in fifteen countries. In the collaborative study described here, each of the three preparations was found to be suitable for use as a standard for insulin for bioassay and each was established by WHO in 1986 as an international standard. The 4th IS of Insulin bovine/porcine (code numbered 58/6) has been discontinued. Insulin preparations should now be calibrated in terms of International Units defined by the standard for the appropriate species: the International Standard for Insulin, Human, the International Standard for Insulin, Bovine, or the International Standard for Insulin, Porcine.     

Very pure porcine insulin in clinical practice.

In a one-year follow-up study the insulin dose in diabetic patients using very pure porcine insulin was compared with that in patients using conventional preparations. The dose of insulin used to obtain diabetic control was reduced by 7% in 108 patients treated solely with very pure porcine insulin from the start of insulin treatment when compared with 108 matched patients who had received conventional insulins. In 117 patients whose treatment had been changed from conventional bovine or bovine-porcine insulin to very pure porcine insulin the dose was reduced by 9%. A further 511 patients receiving conventional insulins were examined for local cutaneous or subcutaneous abnormalities at insulin injection sites. Lipoatrophy was found in 49 of these patients (10%), but not in patients using very pure porcine insulin. The results confirm that very pure porcine insulin reduces the insulin dose needed to maintain diabetic control and may resolve or prevent local reactions such as lipoatrophy. Long-term advantages in reduced antigenicity to insulin and contaminating peptides remain to be established.     

Association of specific immune response to pork and beef insulin with certain HLA-DR antigens in type 1 diabetes.

To test the association of HLA-DR antigens with high-responder and low-responder status to either beef or pork insulin, insulin antibodies in diabetic sera were separated into those with average low and those with average high affinity and their insulin-binding capacities for each insulin determined. Significantly less binding of pork insulin by the high affinity antibodies occurred in the group of patients with DR3 antigens compared with those with DR4 antigens (p less than 0.01) and DR3/4 antigens (p less than 0.01). The difference in the binding capacity of beef insulin by the high affinity antibodies between the groups with DR3 and DR4 antigens was less pronounced but still significant. The high-responder status of DR3/4 antigens to pork insulin suggests that the gene or genes associated with HLA-DR4, and responsible for a high response to pork insulin, are dominant to genes associated with HLA-DR3 and a low response. If extended to human insulin and different HLA-DR and HLA-B antigen patterns, these finding should help in the therapeutic selection of the appropriate insulin and thus reduce the induction of an anti-insulin response in patients with diabetes.     

Diet fat composition alters membrane phospholipid composition, insulin binding, and glucose metabolism in adipocytes from control and diabetic animals

The present study was designed to determine if diet fat-induced alteration in the fatty acid composition of the adipocyte plasma membrane alters insulin binding and the insulin responsiveness of glucose metabolism in control and diabetic states. Normal (control) and diabetic (streptozotocin-induced) rats were fed high fat semipurified diets providing a high or low polyunsaturated to saturated fatty acid (P/S) ratio. Feeding a high P/S diet increased the polyunsaturated fatty acid content of major membrane phospholipids of the adipocyte plasma membrane from both normal and diabetic animals. The diabetic state was associated with an elevated content of linoleic acid and a reduced level of arachidonic acid consistent with reduced delta 6-desaturation. Feeding the high P/S diet to diabetic animals increased membrane linoleic acid content and prevented the decrease observed in the arachidonic acid of membrane phospholipids. The high P/S diet was associated with increased insulin binding in nondiabetic animals but did not change the amount of insulin bound by cells from diabetic animals. Significantly (p less than 0.05) increased rates of insulin-stimulated glucose transport and lipogenesis (glucose incorporation into lipids) were observed in control animals fed the high as compared to the low P/S diet. The rates of insulin-stimulated glucose transport, oxidation, and lipogenesis were lower (p less than 0.05) for cells from diabetic as compared to control animals. However, feeding a high P/S diet significantly improved rates for all three of these functions (p less than 0.05). It is concluded that diet-induced alterations in membrane composition may provide a mechanism for improving the cellular response to insulin in cells from diabetic animals.     

Interval between insulin injection and eating in relation to blood glucose control in adult diabetics.

In a survey of 225 diabetics treated with insulin 24 (10.6%) claimed never to have received advice concerning the interval between insulin injection and eating. Of the remainder, 67 (33%) admitted disregarding advice and using shorter intervals. There was a significant (p less than 0.01) difference between the reported frequencies of clinical hypoglycaemia in patients using different intervals. The effects on glucose control of intervals between insulin injection and breakfast of zero, 15, 30, and 45 minutes were studied for periods of one week in 11 patients with type I diabetes who were receiving twice daily injections of monocomponent porcine insulins and high fibre, high carbohydrate diets, using standard home blood glucose monitoring techniques to measure blood glucose concentrations each morning. The delay of 45 minutes resulted in the lowest frequency of hypoglycaemia and the most acceptable pattern of glucose concentrations measured one and two hours after breakfast and before lunch. Combining results obtained at these three times, the mean increment in blood glucose concentration was smaller after allowing a delay of 45 minutes than after delays of zero (p less than 0.001), 15 (p less than 0.03), and 30 (NS) minutes. A delay of 30 minutes resulted in smaller mean increments in blood glucose concentration than did delays of zero (p less than 0.001) and 15 (NS) minutes. These results suggest that this aspect of diabetic management may be neglected, with important consequences for blood glucose control. An increase in delay between insulin injection and eating to 45 minutes would be a simple and safe way of improving blood glucose control in at least the 37% of the diabetic population surveyed in this study who currently allow less than 15 minutes.     

What happens to defaulters from a diabetic clinic?

The annual rate at which patients defaulted from follow up at the Wolverhampton diabetic clinic between 1971 and 1981 was 4.1% overall and 3.5% in white patients. In 1982 a study was started to discover what happened to white patients, born after 1919, who defaulted from the hospital clinic. There were 162 defaulters, of whom 19 had died. Of the remaining 143 patients, 19 were attending another hospital diabetic clinic, 22 had moved out of the area, and 28 refused to participate in the study. Seventy four agreed to participate: 39 were treated with diet, 15 with oral hypoglycaemic agents, and 20 with insulin. They were matched for sex, age, treatment, and duration of diabetes with patients attending the clinic. Non-insulin dependent defaulters were significantly more overweight at diagnosis (40% v 25%; p less than 0.05) and remained more obese. They developed significantly higher diastolic blood pressure (94 v 86 mm Hg; p less than 0.02) and higher haemoglobin A1 (HbA1) concentrations (11.7% v 8.4%; p less than 0.01). They had significantly more neuropathy at reassessment (15 v 6 out of 54; p less than 0.05) and a greater incidence of new retinopathy (p less than 0.02), which correlated with their higher diastolic blood pressures (p less than 0.01) and HbA1 concentration (p less than 0.02). In defaulters who were treated with insulin only the prevalence of neuropathy was significantly different from that in controls (p less than 0.05). Defaulters received minimal medical supervision and suffered greater morbidity than regular attenders at the clinic.     

Analytical biotechnology of recombinant peptides and proteins: I. determination of the purity, composition, and structure of human, porcine, and bovine insulins

A method for analysis of the type, purity, and possible structural modifications of insulins of bovine, porcine, and human origin was proposed. It is based on a combination of narrow-bore reversed-phase HPLC and mass spectrometry. The hydrolysis of insulins with highly specific Glu-protease V8 fromStaphylococcus aureus followed by peptide mapping of the hydrolysis products and mass spectrometry of the isolated fragments helps rapidly and reliably localize and identify substitutions of amino acid residues in insulin structure by using insulin samples of less than 1 nmol.     

Analytical biotechnology of recombinant peptides and proteins. I. Analysis of the purity, composition and structure of human, porcine and bovine insulins

A method for analysis of the type, purity, and possible structural modifications of insulins of bovine, porcine, and human origin was proposed. It is based on a combination of narrow-bore reversed-phase HPLC and mass spectrometry. The hydrolysis of insulins with highly specific Glu-protease V8 from Staphylococcus aureus followed by peptide mapping of the hydrolysis products and mass spectrometry of the isolated fragments helps rapidly and reliably localize and identify substitutions of amino acid residues in insulin structure by using insulin samples of less than 1 nmol.     

Double blind clinical and laboratory study of hypoglycaemia with human and porcine insulin in diabetic patients reporting hypoglycaemia unawareness after transferring to human insulin.

OBJECTIVES--To compare awareness of hypoglycaemia and physiological responses to hypoglycaemia with human and porcine insulin in diabetic patients who reported loss of hypoglycaemia awareness after transferring to human insulin. DESIGN--Double blind randomised crossover study of clinical experience and physiological responses during slow fall hypoglycaemic clamping with porcine and human insulin. SETTING--Clinical investigation unit of teaching hospital recruiting from diabetes clinics of five teaching hospitals and one district general hospital. SUBJECTS--17 patients with insulin dependent diabetes mellitus of more than five years'' duration who had reported altered hypoglycaemia awareness within three months of transferring to human insulin. MAIN OUTCOME MEASURES--Glycaemic control and frequency of hypoglycaemic episodes during two months'' treatment with each insulin. Glucose thresholds for physiological and symptomatic responses during clamping. RESULTS--Glycaemic control did not change with either insulin. 136 hypoglycaemic episodes (eight severe) were reported with human insulin and 149 (nine severe) with porcine insulin (95% confidence interval -4 to 2.5, p = 0.63). 20 episodes of biochemical hypoglycaemia occurred with human insulin versus 18 with porcine insulin (-0.8 to 1, p = 0.78). During controlled hypoglycaemia the mean adrenaline response was 138 nmol/l/240 min for both insulins; neurohormonal responses were triggered at 3.0 (SE 0.2) versus 3.1 (0.2) mmol/l of glucose for adrenaline and 2.5 (0.1) versus 2.5 (0.1) mmol/l for subjective awareness. CONCLUSIONS--These data suggest that human insulin per se does not affect the presentation of hypoglycaemia or the neurohumoral, symptomatic, and cognitive function responses to hypoglycaemia in insulin dependent diabetic patients with a history of hypoglycaemia unawareness.     

Human insulin

The two human insulins of clinical importance are (a) semisynthetic human insulin prepared from pork pancreas by enzymatically substituting threonine for alanine-the last amino acid in the beta chain-thereby transforming pork insulin in vitro to human insulin; and (b) biosynthetic human insulin synthesized biotechnologically in Escherichia coli-K12. Using this latter technique, it is possible to produce mass quantities of highly purified insulin for the treatment of insulin-dependent diabetics, avoiding the problems inherent in supplies of insulin produced from animal pancreas. It has been suggested that to avoid confusion the two human insulins should be called semisynthetic human insulin of pork origin and biosynthetic human insulin of E. coli origin, respectively. These insulins have four advantages over highly purified animal insulins: (a) they induce lower titers of circulating insulin antibodies; (b) their subcutaneous injection is associated with fewer skin reactions; (c) they are absorbed more rapidly from the injection site; and (d) less degradation occurs at the site of injection. These data indicate that newly diagnosed insulin-dependent diabetes, particularly in children, should be treated with either of the two human insulins. The warranty against inadequate supplies of insulin offered by biosynthetic human insulin makes the use of pork insulins unnecessary and beef insulins totally useless.     

Isolation and amino acid sequence of insulins and C-peptides of European bison (Bison bonasus) and fox (Alopex lagopus)

Insulins and C-peptides were extracted and purified from bison and fox pancreatic glands. The insulins were reduced and pyridylethylated, and the derived A- and B-chains separated by HPLC. Amino acid sequence determinations of the pyridylethylated A- and B-chains proved bisontine insulin to be identical to bovine insulin and fox insulin to be identical to dog and porcine insulin. Bisontine C-peptide proved to be identical to bovine C-peptide. The isolated fox C-peptide comprises 23 amino acid residues and probably represents a major tryptic fragment of a larger C-peptide. The fox C-peptide fragment is identical to the dog C-peptide (9-31) except for residue 3 (residue 11 in the dog C-peptide), which is aspartic acid as compared with glutamic acid in the dog C-peptide.     

Plasma 6-keto-PGF1 alpha, thromboxane B2 and PGE2 during diabetic ketoacidosis

In 10 patients admitted to hospital with diabetic ketoacidosis plasma prostanoids 6-keto-PGF alpha, thromboxane B2 and PGE2 were studied before treatment and following recovery. During ketoacidosis the median plasma 6-keto-PGF1 alpha and PGE2 were significantly increased compared to those of a normal reference group: 5.2 pg/ml and 3.9 pg/ml versus 1.7 pg/ml and 0.4 pg/ml (p less than 0.01 and p less than 0.05). In response to therapy both prostanoids decreased significantly towards a normal level, 6-keto-PGF1 alpha: 0.5 pg/ml p less than 0.01 and PGE2: 0.08 p less than 0.05 respectively. The changes in plasma 6-keto-PGF1 alpha were negatively correlated to changes in pH, rho: -0.7788 p = 0.0135, whereas the changes in PGE2 were positively correlated to serum creatinine at admittance, rho: 0.6976, p = 0.0368 and to the amount of intravenous fluid and insulin used during treatment, rho: 0.7500 p = 0.0126 and rho: 0.8424, p = 0.0023 respectively. Plasma thromboxane B2 concentrations were not elevated and did not change after treatment of the ketoacidosis.     

Transfer from porcine insulin to human insulin in insulin-dependent diabetes mellitus: effects on insulin binding to IgG and glycemic control

Thirty type I diabetic patients who were treated for at least 2 years with a combination of regular and lente monocomponent porcine insulins were allocated in a double-blind study to either continued porcine insulin treatment or a transfer to the corresponding semi-synthetic human insulins. Insulin binding to IgG measured by an immunoelectrophoretic method, was followed at 3-month intervals for 1 year, and did not change after the transfer. The glycemic control, as assessed by hemoglobin A1 levels, tended to deteriorate in the human insulin group during the first 3 months of the trial and then return to the baseline level. It is concluded that a transfer from highly purified porcine insulin to human insulin apparently does not change the insulin binding to IgG in already sensitized patients.     

Urinary dopamine, noradrenaline and adrenaline in type 2 diabetic patients with and without nephropathy

We measured the urinary excretions of dopamine, noradrenaline and adrenaline, their conjugated metabolites, urinary excretion of sodium and creatinine clearance simultaneously in 21 patients with Type 2 (non-insulin-dependent) diabetes and 6 normal subjects. The mean (+/- SEM) value for urinary excretion of dopamine (52.4 +/- 8.8 micrograms/day) in diabetic patients with nephropathy (Group C, n = 12) was significantly lower (P less than 0.01) than in the normal subjects (Group A, 179.7 +/- 15.5 micrograms/day) and in diabetic patients without nephropathy (Group B, n = 9, 131.5 +/- 16.5 micrograms/day). The mean values for the urinary excretions of noradrenaline and adrenaline were also significantly lower (P less than 0.01) in Group C than in Groups A and B. In addition, the mean urinary excretion of conjugated metabolite of dopamine in Group C was significantly lower (P less than 0.05) than in Group A. There was a trend toward the observation that the mean 24-h urinary excretion of sodium in Group C (121.6 less than 12.9 mEq) was lower as compared with that in Group A (140.8 +/- 8.9 mEq) or B (150.7 +/- 17.9 mEq). A multiple regression analysis revealed that the 24-h urinary excretion of dopamine correlated significantly with creatinine clearance, systolic (P less than 0.01) and diastolic (P less than 0.05) blood pressures. The results indicate that synthesis or secretion of renal dopamine might decrease with a progression of diabetic nephropathy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dogfish insulin. Primary structure, conformation and biological properties of an elasmobranchial insulin

Insulin from an elasmobranch, the spiny dogfish (Squalus acanthias) has been purified to near homogeneity by means of acid-ethanol extraction and salt precipitation. The amino acid sequences of the performic-acid-oxidised A and B chains have been determined and exhibit some unusual features. The A chain contains a total of 22 amino acids; only the insulin from coypu (a member of the Rodentia suborder, Hystricomorpha), has previously been reported to contain an extension past the A21 asparagine. The B10 histidine, which is involved in the formation of the insulin hexamers in higher vertebrates through the co-ordination of zinc, is present in this elasmobranch insulin. Several substitutions relative to bovine insulin occur in the proposed receptor binding region (A5Gln leads to His, B21Glu leads to Pro, B22Arg leads to Lys, B25Phe leads to Tyr). In spite of these substitutions, the maximal response in the rat epididymal fat cell assay is the same for bovine and dogfish insulins; the concentration required to produce the half-maximal response is, however, approximately threefold greater for dogfish insulin than that of bovine insulin. The use of interactive computer graphics model-building predicts that the dogfish insulin can attain a three-dimensional structure very similar to that of bovine insulin; circular dichroic spectra are presented which support the model-building studies.