Insulin icodec of Novo Nordisk is a novel long-acting insulin analogue that exhibits an extended duration of action, providing a promising treatment option for individuals with diabetes. It has been reported that the incorporation of fatty acid moieties into insulin icodec plays a crucial role in its prolonged action, as these fatty acid chains facilitate the formation of stable hexameric structures, thereby delaying insulin absorption and promoting sustained release. Yet, the underlying biophysics still is elusive of the roles of the three site-specific mutations (Y14A\_E, Y37B\_H, F46B\_H) of insulin icodec in its prolonged activity. Thus, through a comprehensive structural and biophysical analysis of the insulin (both native and icodec) structures bound to its receptor, this article delves deep into the biophysics underlying the molecular design of insulin icodec, and identified a delicate biophysical mechanism through which two missense mutations of insulin icodec (Y37B\_H and F46B\_H) contribute to its prolonged duration of action. Overall, this structural and biophysical investigation provides valuable insights into the mechanisms underlying the relationship between three site-specific mutations and prolonged duration of action of insulin icodec, while understanding these modifications at a structural and biophysical level can aid in the rational design of future long-acting insulin analogues, offering further enhanced therapeutic options for diabetic patients.

Insulin therapy is a cornerstone in the management of diabetes, yet the pursuit of optimizing its pharmacokinetic profile remains a focal point in diabetes research. For instance, insulin icodec of Novo Nordisk is a novel long-acting insulin analogue that exhibits an extended duration of action, providing a promising once-weekly treatment option for diabetic patients. However, designing insulin analogues with lower receptor affinity than that of insulin icodec could still produce a further extended duration of action than that of insulin icodec through the suppression of receptor-mediated internalization of insulin analogues. In this study, therefore, I present the design of a novel series of insulin analogues engineered towards lower binding affinity to the insulin receptor compared to that of insulin icodec. Through computational structural biophysics-based rational design strategies, this article aims to further extend the duration of action while maintaining therapeutic efficacy of insulin analogues. Utilizing homology molecular modeling and structural biophysics-based binding affinity calculations, this article puts forward a set of insulin analogues with lower binding affinity to insulin receptor than that of insulin icodec from a structural and biophysical point of view. Overall, this article calls for subsequent in vitro and in vivo evaluations of the efficacy and prolonged action of the engineered insulin analogues to pharmacokinetically test whether these analogues acutally surpass that of insulin icodec as hopeful candidates for next-generation insulin analogue therapies with improved duration of action and enhanced control of blood glucose levels for diabetic patients in future.

There are far more options to treat diabetes now, than about 15-20 years ago. Among the newer agents, glucagon-like peptide 1 receptor agonists (GLP-1RA), dipeptidyl peptidase-4 inhibitors (DPP-4i) and sodium-glucose cotransporter 2 inhibitors (SGLT-2i), are in common use. While their benefits extend far beyond the management of hyperglycemia, some pose concerns, and challenges to the anesthesia providers. Retained gastric contents due to slow gastric emptying is a significant drawback of GLP-1RA. It benefits the patient in losing weight; however, increases the risk of aspiration and can surprise an unsuspecting anesthesia provider. National associations have issued statements in an effort the mitigate the risk. Recommendations range from withholding of GLP-1RA for a predefined period of time, gastric ultrasound to evaluate the gastric contents and modification of anesthesia management especially with regards to the airway and cancellation of a scheduled (elective) surgery/procedure. SGLT-2i are known to increase the risk of euglycemic ketoacidosis. Duration of preprocedural withholding of SGLT-2i varies with the drug. Use of both GLP-1RA and SGLT-2i extends beyond the treatment of diabetes. While SGLT-2i are being extensively used to treat obesity, they are also used in the management of heart failure. A new insulin formulation of basal insulin that can be administered once weekly to achieve similar blood sugar control as once daily formulation has become available in some countries. Labelled as icodec, this is as yet not approved by the FDA because of severe hypoglycemia concerns. Imeglimin is a variant of metformin with unique mechanisms of action. It is approved for clinical use for type 2 diabetes in Japan and India. Another, as yet investigational product is IcoSema, a once-weekly combination of insulin icodec plus semaglutide. A discussion of all aspects of these drugs is warranted.