WC 500029819
WC 500029819
WC 500029819
This module reflects the initial scientific discussion for the approval of Mixtard. For information
on changes after approval please refer to module 8.
1. Introduction
Diabetes mellitus is a group of metabolic diseases characterised by hyperglycaemia resulting from
defects in insulin secretion, insulin action, or both. Acute, life-threatening consequences of diabetes
are hypoglycaemia, and hyperglycaemia with ketoacidosis or non-ketotic hyperosmolar syndrome.
Long-term complications of diabetes include retinopathy with potential loss of vision, nephropathy
leading to renal failure, and peripheral neuropathy causing foot ulcers, gastrointestinal, genitourinary,
and sexual dysfunction. The disease is also accompanied by an increased incidence of atherosclerotic
cardiovascular, peripheral vascular and cerebrovascular disease.
Type 1 diabetes, which usually is of childhood or adolescence onset, accounts for 5 to 10% of
diagnosed diabetes; it is characterised by loss of insulin production due to destruction of pancreatic ß
cells as a result of an autoimmune response or idiopathic causes. Patients with type 1 diabetes depend
on exogenous insulin for survival.
Type 2 diabetes, which usually is of adult onset, is by far the more common form of diabetes. In the
Western World, it constitutes approximately 90% of all cases of diabetes. Type 2 diabetes is
characterised by impaired insulin secretion, insulin resistance, increased hepatic glucose output and
lipid disorders. Patients with type 2 diabetes generally do not require insulin treatment for survival,
although a substantial number (20-30%) of patients need insulin to achieve acceptable metabolic
control.
Marketing authorisation for this human insulin has been obtained for the treatment of patients with
diabetes mellitus. The active substance of Mixtard is insulin human manufactured by recombinant
DNA technology in Saccharomyces cerevisiae.
Mixtard is a dual-acting, biphasic formulation consisting of a premix of soluble fast-acting insulin
human and isophane long-acting insulin in the proportions:
Mixtard 10: 10% soluble and 90% isophane
Mixtard 20: 20% soluble and 80% isophane
Mixtard 30: 30% soluble and 70% isophane
Mixtard 40: 40% soluble and 60% isophane
Mixtard 50: 50% soluble and 50% isophane
Mixtard is intended for marketing in dose strengths of 40 IU/ml and 100 IU/ml in vials, Penfill,
InnoLet, NovoLet and FlexPen presentations. Mixtard is presented in 10 ml vials, 3 ml cartridges
(Penfill) and in multidose pre-filled pens (InnoLet, NovoLet and FlexPen). Two strengths exist in vial
presentations: 100 IU/ml and 40 IU/ml. Only one strength exists in the other presentations: 100 IU/ml.
All 100 IU/ml presentations have identical compositions.
The Penfill presentation is a cartridge that is designed to be inserted in a durable device. The
cartridges should only be used with devices and needles that are compatible with the Penfill products.
The InnoLet presentation is a multi-dose pre-filled pen that delivers a maximum of 50 units per dose in
increments of 1 unit. The device is equipped with an end-of-content mechanism that ensures that the
adjusted dose does not exceed the remaining content of the 3 ml cartridge after a multiple use. The device
is targeted for use by geriatric patients with impaired dexterity and/or vision.
The NovoLet presentation is a multidose pre-filled pen delivering 2-78 units per dose in increments of 2
units.
The FlexPen presentation is also a multidose pre-filled pen delivering 1-60 units per dose in increments
of 1 unit. For patients, the FlexPen device represents an improvement over the NovoLet device in terms of
automatic zeroing and delivery of dosage in single unit increments.
Methods of analysis developed by the applicant are fully described with relevant validations.
Development Genetics
Insulin human is produced using a genetically modified strain of Saccharomyces cerevisiae. The strain
carries a plasmid which codes for the expression of a single amino acid chain insulin precursor
attached to a pre-pro leader region of the yeast mating factor (MFα1) gene.
The plasmid is constructed based on the yeast 2µ plasmid. The yeast transformant used to produce the
insulin precursor is a transformant of Saccharomyces cerevisiae carrying the expression plasmid
described above. The applicant has presented the complete DNA sequence of the plasmid. The
sequencing presented is assembled from published sequences and in-house sequence determinations as
relevant. The gene has also been fully characterised from isolated plasmids from long-term production
scale fermentation and cell bank (Original Mother Culture (OMC)).
Constructional stability has been investigated in production strain, prolonged and very long term
fermentation and cell bank (OMC).
Cell bank system
The cell bank system consists of Original Mother Culture (OMC), New Mother Culture (NMC), MCB
and WCB. Satisfactory details of the preparation of the different types of cell banks have been
provided and a clear description given of the numbering and origin of the various cell banks and their
sublots.
Production of active substance
The encoded product of secretion during fermentation is a single chain insulin precursor consisting of
the first 29 amino acid residues of the insulin B chain linked with three amino acids to the insulin A
chain. This single chain precursor is converted enzymatically to an insulin methyl ester, which is
subsequently hydrolysed to yield insulin human, consisting of two chains (A and B) linked together
• In vivo studies
The effect on blood glucose in diabetic rats after subcutaneous administration was studied in diabetic rats
which received by a single subcutaneous injection either insulin human, semi-synthetic insulin or vehicle.
The effect on blood glucose was measured by blood sampling. Insulin human (rDNA) and semi-synthetic
insulin showed dose and time dependent antidiabetic effect.
In a few studies, Mixtard 30, insulin human was used as reference substance in order to show the
additional effect of dual-acting insulin aspart 30. The hypoglycaemic effect in the pig of SC injection of
dual-acting insulin aspart 30 and Mixtard 30, insulin human was compared.
In this study the blood glucose lowering effect of Mixtard 30 was confirmed.
Toxicokinetics
Toxicokinetic studies were done during the 52 weeks repeated dose toxicity studies in the rat and the dog
and the Segment II test (teratogenicity studies) in the pregnant rabbit. They demonstrated linearity of
the plasma levels of insulin human with the dose, the Cmax, occurred 1-5 hours after administration of
either type of insulin. The plasma levels and AUCs of insulin human remained directly related to dose
throughout the 52 weeks of treatment and that the rate of elimination did not increase with time.
Toxicology
Some experiments where Mixtard 30 was used as reference substance for the testing of dual-acting
insulin aspart have been performed. Some other studies confirmed the lack of local toxicity and tried
to evaluate the possible immunogenicity of the product.
• Single dose toxicity studies.
Mice and Rats were given a single dose of insulin human subcutaneous at dosage up to 4000 U/kg. In
higher dosage groups insulin human was compared to semi-synthetic insulin human. Apart from few
sporadic hypoglycaemic reactions on the day of dosing, no treatment related signs were seen. No
significant difference between insulin human and semi-synthetic insulin human was observed.
• Repeated doses toxicity.
The subacute toxicity was examined in rats and dogs during a 4 weeks SC study in Wistar Rats and a 13
weeks SC study in Beagle Dogs.
In the rat the highest dose of 200 IU/kg caused hypoglycaemic deaths. In surviving rats only a few
signs were seen. In samples taken approximately 20 hours after administration, higher dosage of both
insulins lowered plasma concentration of protein. A slightly lowered urea and increased blood glucose
were observed as well. These findings are in accordance with other studies on insulin (Andersen et al,
1983 and Hansen et al, 1986). The observations in the dogs were attributed to the hypoglycaemic state
of the animals and not due to toxic effect of insulin human.
human was administrated subcutaneously for 1 year to Sprague Dawley Rats. At necropsy there was an
increased incidence of mammary gland cysts and mammary tumours were found at microscopic
examination. The incidence of total number of mammary tumours as well as fibroadenomas and
adenocarcinomas were, however, not significant from the control group. There were no other treatment-
related effects in any organ, including the pituitary.
In the dog study, beagle dogs were given insulin human subcutaneous for 13 weeks. Both dogs given 1
U/kg daily and 3 U/kg daily showed peripheral vasodilatation. Ocular discharge and quiet behaviour were
seen in dogs at 3 U/kg daily only. Body weight and food consumption were slightly increased. All these
After dinner
EXC(0-4h, dinner) (mmol/l×min) 13 13.0 6.4
Cmax (glu, dinner) (mmol/l) 13 15.0 3.4
tmax (glu, dinner) (min) 13 118 46
After breakfast
EXC(0-4h, breakfast) (mmol/l⋅min) 13 23.6 5.5
Cmax (glu, breakfast) (mmol/l) 13 17.4 3.5
tmax (glu, breakfast) (min) 13 133 31
After lunch
EXC(19-23h, lunch) (mmol/l×min) 13 16.9 8.5
Cmax (glu ,lunch) (mmol/l) 13 14.9 3.5
tmax (glu, lunch) (min) 13 128 40
The pharmacodynamic parameters are listed in Table 4.
• Bioavailability
No studies of absolute bioavailability could be performed as biphasic insulin human cannot be injected
intravenously.
• Distribution
No formal distribution studies were performed with biphasic insulin human. Insulin is not bound to
plasma proteins unless circulating antibodies directed against insulin are present.
• Elimination
Metabolism
Metabolism of biphasic insulin human was not formally investigated. Biphasic insulin human is
absorbed as standard human insulin. From previously published data it is known that insulin is
catabolised by various proteases. The degradation products are not active.
Parameter Mixtard 30 a
Mixtard 30
N Mean (SEM)
_______________________________________________________________________________________
The statistical analysis of the results concerning HbA1c (using an analysis of variance – ANOVA)
showed that, with regard to treatment effect, there was no significant difference between type 1 and
type 2 diabetic patients. Demographic and prognostic variables had a significant effect on HbA1c
levels at 12 weeks but there was no treatment interaction. ANOVA analysis with adjustment for rate of
hypoglycaemic events was in agreement with the results of the primary analysis. No statistically
significant treatment interaction was observed.
The efficacy of Mixtard, insulin human has been assessed with the following secondary endpoints:
Mean 8-point blood glucose profiles at baseline and after 12 weeks of treatment with Mixtard 30,
insulin human. The results are shown in Figure 2. An analysis (ANOVA) on the measurements of the
blood pressure measurements at 12 weeks is shown in Table 11.
Figure 2: Mean 8 point blood glucose profiles at baseline and after 12 weeks – Study 038/D,
UK
Mean Eight-point BG profiles,
at Baseline and 12 Weeks
13
12
Blood glucose (mmol / l )
11
10
5
BB B90 BL L90 BD D90 BE 2 AM
Time
BHI 30 Bl BHI 30 Week 12
Note: Bl = Baseline
ANA/DCD/038/D-UK/15AUG02/fig6_bhi.sas/fig6_bhi.cgm
Table 11: Results of the statistical analysis (ANOVA) performed blood glucose levels taken
at 8 different periods after 12 weeks – study 038/D, UK
Mixtard 30
Time of Day N Mean (SEM)
Before breakfast 143 8.24 (0.27)
Breakfast + 90 min. 142 11.4 (0.36)
Before lunch 143 7.57 (0.27)
Lunch + 90 min. 142 9.97 (0.27)
Before dinner 143 8.72 (0.29)
Dinner + 90 min. 142 10.2 (0.32)
Bedtime 142 9.10 (0.30)
2 am 135 8.12 (0.25)
Severity:
Mild adverse events 58 (38%) 115
Moderate adverse events 32 (21%) 52
Severe adverse events 6 (4%) 7
The majority of the reported events were mild to moderate in severity and considered unlikely to be
related to treatment.
Serious adverse reactions
An adverse reaction (or event) is considered serious when at any dose it results in death, requires
inpatient hospitalisation or prolongation of existing hospitalisation, results in persistent or significant
disability/incapacity or is life-threatening. No such serious adverse reactions were reported in phase I
and II trials. In the Mixtard 30, insulin human treated group, 8 patients reported a total of 9 serious
experiences (hypoglycaemia (twice in the same patient), urinary tract infection, bundle branch block,
cranial nerve lesion, pancreatic adenocarcinoma, neuropathy, uterine carcinoma, angina pectoris). In
all of the cases, causal association with Mixtard 30, insulin human treatment was considered to be
unlikely related to the product.
No deaths were reported in Mixtard 30, insulin human treated patients.
Among all subjects exposed to Mixtard 30, insulin human, three cancers were reported (pancreatic
adenocarcinoma, uterine carcinoma, renal carcinoma). In all of the cases, causal relation to treatment
was considered unlikely.
3.5
3.0
Episodes/Subject Year
2.5
2.0 BHI 30
1.5
1.0
0.5
0.0
0-2 2-4 4-6 6-8 8-10 10-12 12-14 14-16 16-18 18-20 20-22 22-24
N indicates number of subjects with major episode(s) in each Time interval
E indicates number of major episodes in each Time interval
66 subjects on BHI 30 treatment had no minor episodes.
ANA/DCD/038/D-UK/15AUG02/fmintod.sas/fig7_bhi.cgm
Insulin antibodies
Levels of insulin antibodies specific to human insulin remained unchanged throughout the 12-week
treatment period..
Increase in cross-reactive antibody levels did not influence change in glycosylated haemoglobin
(HbA1c) nor did it correlate with dose of insulin, indicating that the increase in levels of cross-reactive
insulin antibodies did not have a negative effect on efficacy. The increase in antibody levels did not
result in any adverse events (including allergic reactions) that could be specifically linked to the
antibody. Two cases of potentially hypersensitivity reactions with probable or possible relation to
treatment were reported (the two patients treated with biphasic insulin human 30/70 experienced a rash
and an injection site reaction).
Laboratory findings
Thirteen laboratory test abnormalities (five in the Mixtard 30, insulin human group) were reported.
None of these were considered clinically relevant and primarily involved small increases in serum
triglycerides or serum cholesterol levels.
Since the report from Teuscher and Berger (Hypoglycaemia unawareness in diabetics transferred from
beef/porcine insulin to human insulin. Lancet 1987, ii.382-5) there has been focus on diminished
awareness of hypoglycaemia after changing from animal insulin to human insulin. A review of clinical
and epidemiological studies prepared by the applicant could not support this hypothesis, neither could
an update of this paper including literature research up to May 1997.
The most common reactions were hyper- and hypoglycaemia, injection site reaction and pain,
therapeutic response decreased, allergic reaction and rash or pruritus.
A total of 29 serious adverse reaction reports associated with fast-acting administration were classified
as serious unlisted. Of these a total of three cases of toxic epidermal necrolysis/Stevens Johnson
syndrome have been reported. As of 30 August 2000, a total of 6 cases of epidermal
necrolysis/Stevens Johnson syndrome/erythema multiforme have been reported in association with
insulin human. In 5 of these cases concomitant medication provided a more likely explanation than
insulin human .
In the last PSUR (1999-2000) concerning fast-acting insulin, the Company received 20 reports of
impaired liver function (9 of these being serious). All these cases occurred in Japan. No reports on
impaired liver function were received from other countries. Such reports have already been published
(especially increased liver enzymes in patients with non-insulin dependant diabetes mellitus) and they
are generally associated with overweight. According to evidence from three studies liver enzyme
increases are most likely related to diabetes mellitus non insulin-dependent/treatment with oral
antidiabetic agents but not to insulin. Many of the reports involved semisynthetic, - but not genetically
engineered insulin. The hypothesis of an idiosyncratic reaction was ruled out by the Company since no
other signs of hypersensitivity were observed and no eosinophile granulocytes were found in the
biopsies.
During the reporting period, two changes have been made in the summary of product characteristics
for safety reasons: a more detailed description of the symptoms of hypo- and hyperglycaemia and a
more detailed description of possible generalised hypersensitivity reactions. Apart from these
amendments, no regulatory or manufacturer actions have been taken for safety reasons.
Based on the review of the safety data from the extensive post marketing experience, no new safety
issue to be included in the product information was identified. The most frequent adverse reactions are
hypo- or hyperglycaemia. The safety profile of Mixtard is well characterised.
Quality
The quality of this product is considered to be acceptable when used in accordance with the conditions
defined in the SPC. Physicochemical and biological aspects relevant to the uniform clinical
performance of the product have been investigated and are controlled in a satisfactory way.
Viral Safety and Batch to Batch consistency have been documented and the relevant tests will be
performed according to the agreed specifications