Treatment of patients with diabetes with insulin and pramlintide (an amylin analogue) is more effective than treatment with insulin only. However, because mixtures of insulin and pramlintide are unstable and have to be injected separately, amylin analogues are only used by 1.5% of people with diabetes needing rapid-acting insulin. Here, we show that the supramolecular modification of insulin and pramlintide with cucurbituril-conjugated polyethylene glycol improves the pharmacokinetics of the dual-hormone therapy and enhances postprandial glucagon suppression in diabetic pigs. The co-formulation is stable for over 100 h at 37 °C under continuous agitation, whereas commercial formulations of insulin analogues aggregate after 10 h under similar conditions. In diabetic rats, the administration of the stabilized co-formulation increased the area-of-overlap ratio of the pharmacokinetic curves of pramlintide and insulin from 0.4 ± 0.2 to 0.7 ± 0.1 (mean ± s.d.) for the separate administration of the hormones. The co-administration of supramolecularly stabilized insulin and pramlintide better mimics the endogenous kinetics of co-secreted insulin and amylin, and holds promise as a dual-hormone replacement therapy.
Subscribe to Journal
Get full journal access for 1 year
only $8.25 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
All data supporting the results in this study are available within the article and its Supplementary information. The broad range of raw datasets acquired and analysed (or any subsets thereof), which would require contextual metadata for reuse, are available from the corresponding author on reasonable request.
Diabetes: Key Facts (World Health Organization, 2017).
Borm, A. K. et al. The effect of pramlintide (amylin analogue) treatment on bone metabolism and bone density in patients with type 1 diabetes mellitus. Horm. Metab. Res. 31, 472–475 (1999).
Gottlieb, A. et al. Pramlintide as an adjunct to insulin therapy improved glycemic and weight control in people with type 1 diabetes during treatment for 52 weeks. Diabetes 49, A109 (2000).
Ryan, G. J., Jobe, L. J. & Martin, R. Pramlintide in the treatment of type 1 and type 2 diabetes mellitus. Clin. Ther. 27, 1500–1512 (2005).
Edelman, S. et al. A double-blind, placebo-controlled trial assessing pramlintide treatment in the setting of intensive insulin therapy in type 1 diabetes. Diabetes Care 29, 2189–2195 (2006).
Jones, M. C. Therapies for diabetes: pramlintide and exenatide. Am. Fam. Physician 75, 1831–1835 (2007).
Rodriguez, L. M. et al. The role of prandial pramlintide in the treatment of adolescents with type 1 diabetes. Pediatr. Res. 62, 746–749 (2007).
Weinzimer, S. A. et al. Effect of pramlintide on prandial glycemic excursions during closed-loop control in adolescents and young adults with type 1 diabetes. Diabetes Care 35, 1994–1999 (2012).
Grunberger, G. Novel therapies for the management of type 2 diabetes mellitus: part 1. pramlintide and bromocriptine-QR. J. Diabetes 5, 110–117 (2013).
Hay, D. L. et al. Amylin: pharmacology, physiology, and clinical potential. Pharmacol. Rev. 67, 564–600 (2015).
Wang, H. et al. Rationally designed, nontoxic, nonamyloidogenic analogues of human islet amyloid polypeptide with improved solubility. Biochemistry 53, 5876–5884 (2014).
Ratner, R. et al. Adjunctive therapy with pramlintide lowers HbA1c without concomitant weight gain and increased risk of severe hypoglycemia in patients with type 1 diabetes approaching glycemic targets. Exp. Clin. Endocrinol. Diabetes 113, 199–204 (2005).
Whitehouse, F. et al. A randomized study and open-label extension evaluating the long-term efficacy of pramlintide as an adjunct to insulin therapy in type 1 diabetes. Diabetes Care 25, 724–730 (2002).
Ratner, R. E. et al. Amylin replacement with pramlintide as an adjunct to insulin therapy improves long-term glycaemic and weight control in type 1 diabetes mellitus: a 1-year, randomized controlled trial. Diabet. Med. 21, 1204–1212 (2004).
Hampp, C. et al. Use of antidiabetic drugs in the U.S., 2003–2012. Diabetes Care 37, 1367–1374 (2014).
Martin, C. The physiology of amylin and insulin: maintaining the balance between glucose secretion and glucose uptake. Diabetes Educ. 32, 101S–104S (2006).
Heptulla, R. A. et al. The role of subcutaneous pramlintide infusion in the treatment of adolescents with type 1 diabetes. Diabetes 54, A110–A111 (2005).
Want, L. L. & Ratner, R. Exenatide and pramlintide: new therapies for diabetes. Int. J. Clin. Pract. 60, 1522–1523 (2006).
Mathieu, C. et al. Insulin analogues in type 1 diabetes mellitus: getting better all the time. Nat. Rev. Endocrinol. 13, 385–399 (2017).
Holleman, F. & Hoekstra, J. B. L. Insulin lispro. N. Engl. J. Med. 337, 176–183 (1997).
Gast, K. et al. Rapid-acting and human insulins: hexamer dissociation kinetics upon dilution of the pharmaceutical formulation. Pharm. Res. 34, 2270–2286 (2017).
Riddle, M. C. et al. Fixed ratio dosing of pramlintide with regular insulin before a standard meal in patients with type 1 diabetes. Diabetes Obes. Metab. 17, 904–907 (2015).
Haidar, A. et al. Insulin-plus-pramlintide artificial pancreas in type 1 diabetes—randomized controlled trial. Diabetes 67(Suppl. 1), 210-OR (2018).
Riddle, M.C. et al. Control of postprandial hyperglycemia in type 1 diabetes by 24-hour fixed-dose coadministration of pramlintide and regular human insulin: a randomized, two-way crossover study. Diabetes Care 41, 2346–2352 (2018).
Manning, M. C. et al. Stability of protein pharmaceuticals: an update. Pharm. Res. 27, 544–575 (2010).
Mitragotri, S., Burke, P. A. & Langer, R. Overcoming the challenges in administering biopharmaceuticals: formulation and delivery strategies. Nat. Rev. Drug Discov. 13, 655–672 (2014).
Yang, C., Lu, D. & Liu, Z. How PEGylation enhances the stability and potency of insulin: a molecular dynamics simulation. Biochemistry 50, 2585–2593 (2011).
Guerreiro, L. H. et al. Preparation and characterization of PEGylated amylin. AAPS PharmSciTech 14, 1083–1097 (2013).
Sisnande, T. et al. Monoconjugation of human amylin with methylpolyethyleneglycol. PLoS ONE 10, e0138803 (2015).
Veronese, F. M. & Mero, A. The impact of PEGylation on biological therapies. BioDrugs 22, 315–329 (2008).
Webber, M. J. et al. Supramolecular PEGylation of biopharmaceuticals. Proc. Natl Acad. Sci. USA 113, 14189–14194 (2016).
Hirotsu, T. et al. Self-assembly PEGylation retaining activity (SPRA) technology via a host–guest interaction surpassing conventional PEGylation methods of proteins. Mol. Pharm. 14, 368–376 (2017).
Bush, M., Bouley, N. & Urbach, A. R. Charge-mediated recognition of N-terminal tryptophan in aqueous solution by a synthetic host. J. Am. Chem. Soc. 127, 14511–14517 (2005).
Heitmann, L. M. et al. Sequence-specific recognition and cooperative dimerization of N-terminal aromatic peptides in aqueous solution by a synthetic host. J. Am. Chem. Soc. 128, 12574–12581 (2006).
Rajgariah, P. & Urbach, A. R. Scope of amino acid recognition by cucurbituril. J. Incl. Phenom. Macro. 62, 251–254 (2008).
Reczek, J. J. et al. Multivalent recognition of peptides by modular self-assembled receptors. J. Am. Chem. Soc. 131, 2408–2415 (2009).
Yin, H. & Wang, R. Applications of cucurbit[n]urils (n = 7 or 8) in pharmaceutical sciences and complexation of biomolecules. Isr. J. Chem. 58, 188–198 (2018).
Walker, S. et al. The potential of cucurbit[n]urils in drug delivery. Isr. J. Chem. 51, 616–624 (2011).
Kuok, K. I. et al. Cucurbituril: an emerging candidate for pharmaceutical excipients. Ann. NY Acad. Sci. 1398, 108–119 (2017).
Berthon, G. Handbook of Metal–Ligand Interactions in Biological Fluids: Bioinorganic Chemistry (Marcel Dekker, 1995).
Waters, R. S. et al. EDTA chelation effects on urinary losses of cadmium, calcium, chromium, cobalt, copper, lead, magnesium, and zinc. Biol. Trace Elem. Res. 83, 207–221 (2001).
Hvidt, S. Insulin association in neutral solutions studied by light scattering. Biophys. Chem. 39, 205–213 (1991).
Fineberg, S. E. et al. Immunological responses to exogenous insulin. Endocr. Rev. 28, 625–652 (2007).
Woods, R. J. et al. Intrinsic fibrillation of fast-acting insulin analogs. J. Diabetes Sci. Technol. 6, 265–276 (2012).
da Silva, D. C. et al. Amyloidogenesis of the amylin analogue pramlintide. Biophys. Chem. 219, 1–8 (2016).
Like, A. A. & Rossini, A. A. Streptozotocin-induced pancreatic insulitis: new model of diabetes mellitus. Science 193, 415–417 (1976).
Gedulin, B. R., Rink, T. J. & Young, A. A. Dose-response for glucagonostatic effect of amylin in rats. Metabolism 46, 67–70 (1997).
Knadler, M. P. et al. Addition of 20-kDa PEG to insulin lispro alters absorption and decreases clearance in animals. Pharm. Res. 33, 2920–2929 (2016).
Zou, L., Braegelman, A. S. & Webber, M. J. Dynamic supramolecular hydrogels spanning an unprecedented range of host–guest affinity. ACS Appl. Mater. Interfaces 11, 5695–5700 (2019).
Chinai, J. M. et al. Molecular recognition of insulin by a synthetic receptor. J. Am. Chem. Soc. 133, 8810–8813 (2011).
Wu, K. K. & Huan, Y. Streptozotocin-induced diabetic models in mice and rats. Curr. Protoc. Pharmacol. 40, 5.47.1–5.47.14 (2008).
Maikawa, C. L. et al. Stable monomeric insulin formulations enabled by supramolecular PEGylation of insulin analogues. Adv. Ther. 3, 1900094 (2019).
This work was funded in part by a NIDDK R01 (the National Institutes of Health grant no. R01DK119254), a Pilot and Feasibility funding from the Stanford Diabetes Research Center (NIH grant no. P30DK116074) and the Stanford Child Health Research Institute, as well as a Research Starter Grant from the PhRMA Foundation. C.L.M. was supported by the NSERC Postgraduate Scholarship and the Stanford Bio-X Bowes Graduate Student Fellowship. A.A.A.S. was funded by grant no. NNF18OC0030896 from the Novo Nordisk Foundation and the Stanford Bio-X Program, as well as by the Danish Council of Independent Research (grant no. DFF5054-00215). The authors thank the Stanford Animal Diagnostic Lab and the Veterinary Service Centre staff for their technical assistance.
E.A.A., B.A.B., D.M.M., C.L.M. and G.A.R. are inventors on a patent filing (provisional application no. 62/804,357) describing the work reported in this manuscript.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Maikawa, C.L., Smith, A.A.A., Zou, L. et al. A co-formulation of supramolecularly stabilized insulin and pramlintide enhances mealtime glucagon suppression in diabetic pigs. Nat Biomed Eng 4, 507–517 (2020). https://doi.org/10.1038/s41551-020-0555-4
Angewandte Chemie International Edition (2021)
Science Translational Medicine (2021)
Quantitative self-assembly of photoactivatable small molecular prodrug cocktails for safe and potent cancer chemo-photodynamic therapy
Nano Today (2021)
Advanced Drug Delivery Reviews (2021)