Chief of Endocrinology East Orange General Hospital

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2 Targeting the Incretins System: Can it Improve Our Ability to Treat Type 2 Diabetes? Darshi Sunderam, MD Darshi Sunderam, MD Chief of Endocrinology East Orange General Hospital

3 Age-adjusted Percentage of US Adults Who Were Obese or Had Diagnosed Diabetes Obesity (BMI 30 kg/m2) No Data <14.0% % % % >26.0% Diabetes No Data <4.5% % % % >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System. Accessed October 30, 2008.

4 Diabetes is Costly $132 Billion for Total Excess U.S. Cost Attributable to Diabetes in 2002 Costs in Millions of Dollars Indirect Costs $39,180 $54,215 Institutional Care Medication and Supplies $17,516 Outpatient Care $20,130 American Diabetes Association. Diabetes Care 2003;26:

5 and Deadly New Cases 4,100 Amputations 230 (60% of non-traumatic amputations annually) Blindness 55 (#1 cause) Kidney Failure 120 (#1 cause) Deaths >60% due to CVD Derived from NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005.

6 ADA Criteria for the Diagnosis of Diabetes Diabetes Care,January 2010; 33:S62-S69S69 HbA1C 6.5% OR FPG 126 mg/dl. Fasting is defined as no caloric intake for at least 8 h OR 2-h plasma glucose 200 mg/dl using 75 g glucose load OR Random plasma glucose 200 mg/dl with classic symptoms of hyperglycemia or hyperglycemic crisis

7 Change in Nomenclature and Testing Pre-diabetes = Increased Risk for Diabetes HbA1C of % FPG 100 mg/dl to 125 mg/dl 2-h 75-g OGTT 140 mg/dl to 199 mg/dl

8 Goal of HbA1C What is Safe? Lower HbA1C decreases microvascular complications DM1 and DM2 But, is tight control dangerous in type 2 diabetes with cardiovascular risks?

9 Pathophysiology

10 Natural History of Type 2 Diabetes

11 β-cell Dysfunction Begins 10 Years Prior to Diagnosis of Type 2 Diabetes

12 Introduction to Incretin Therapy in T2DM

13 Functional Definition of an Incretin Intestinal Secretion of Insulin

14 Measuring the Incretin Effect: OGTT and Matched IV Infusion

15 Key Characteristics of Incretin Hormones Differ in Patients with Type 2 Diabetes

16 The Incretin Effect in Type 2 Diabetes

17 GLP-1: Effects in Humans After food ingestion Stimulates glucose- Suppresses glucagon dependent secretion insulin secretion Slows gastric emptying GLP-1 is secreted from L-cells of the jejunum and ileum Leads to a reduction of food intake Improves insulin sensitivity That in turn Long-term effects in animal models: Increase of β-cell mass and improved β-cell function Drucker. Curr Pharm Des Drucker. Mol Endocrinol. 2003

18 GLP-1 Secretion and Metabolism DPP-4 Mixed meal eaten GLP-1 released into bloodstream and rapidly degraded by DPP-4 Remaining GLP-1 enters pancreas Remaining GLP-1 affects other systems >50% of secreted GLP-1 is degraded before it reaches the general circulation Stimulates insulin secretion Suppresses glucagon secretion Slows gastric emptying Enhances satiety and reduces food intake Kieffer TJ, Habener JF. Endocr Rev. 1999;20:

19 Incretin-Based Therapy

20 Therapeutic Effect of GLP-1 in People with Type 2 Diabetes Glucose (mmol/l) C-peptide (nmol/l) Glucagon (pmol/l) GLP-1 infusion GLP-1 infusion GLP-1 infusion * * * * * * * * * * * * * * *P<0.05 GLP-1 Saline Time (min) Nauck et al. Diabetologia * Time (min) 5 * * * * Time (min)

21 Available Incretin Agents and Their Effect on A1C and Glucose Levels

22 GLP-1 enhancement GLP-1 secretion is impaired in Type 2 diabetes Natural GLP-1 has extremely short half-life Add GLP-1 analogues with longer half-life: Exenatide (Byetta) Liraglutide (Victoza) Exenatide QW (Bydurion) Injectables Block DPP-4, the enzyme that degrades GLP-1: Sitagliptin (Januvia) Saxagliptin (Onglyza) Vildagliptin (Tradjenta) Oral agents Drucker. Curr Pharm Des. 2001; Drucker. Mol Endocrinol. 2003

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26 Incretin Mimetic Drugs: Safety Issues CV Events Meta-analysis of 12 randomized, controlled trials weeks duration Exenatide (5-10 µg bid) vs comparator (placebo or insulin) Patient characteristics at baseline (mean) Age 56 y; BMI = kg/m²; A1C = 8.3%-8.4 % CV event incidence (unadjusted) Exposure-adjusted incidence (per 1000 patient-years) Exenatide (n=2279) 1063 patientyears Comparator (n=1629) 780 patientyears RR (95% CI) 2.0% 2.6% 0.69 ( ) ( ) Shen L, et al. Diabetes. 2009;58(suppl 1):A96.

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30 Comparison of GLP-1 Receptor Agonists and DPP-4 Inhibitors Effects/Parameters GLP-1 receptor agonists DP-4 inhibitors Route of administration Subcutaneous injection Oral Dosing/timing of administration Once or twice daily Once daily Insulin secretion Enhanced Enhanced HbA1c reduction -0.6% to -1.9% -0.5% to -0.8% Postprandial hyperglycemia Reduced Reduced Glucagon secretion Suppressed Suppressed Body Weight Reduced Neutral Appetite Suppressed No effect Gastric emptying Slowed significantly No Effect Hypoglycemia Low rates Low Rates GI AE's Nausea, diarrhea No significant GI AE's CVD risk factors Improved (with weight loss) No consistent change

31 ADA/EASD Consensus Guidelines Treatment Algorithm Tier 1: Well-validated core therapies At Diagnosis: Lifestyle + Metformin Lifestyle + Metformin + Basal insulin Lifestyle + Metformin + Sulfonylurea Lifestyle + Metformin + Intensive insulin STEP 1 STEP 2 STEP 3 Tier 2: Less well validated therapies Lifestyle + Metformin + Pioglitazone No hypoglycemia Edema/CHF Bone loss Lifestyle + Metformin + GLP-1 agonist No hypoglycemia Weight loss Nausea/vomiting Lifestyle + Metformin + Pioglitazone + Sulfonylurea Lifestyle + Metformin + Basal insulin Reproduced with permission from Nathan DM, et al. [published online ahead of print October 22, 2008] Diabetes Care. Accessed October 30, 2008.

32 Summary Type 2 diabetes is a progressive disease with multiple pathogenic defects Therapeutic approaches based on pathophysiology with multiple agents early in the disease state GLP-1 increases insulin secretion, decreases glucagon secretion in a glucose dependent manner GLP-1 has an effect on beta cell, liver, alpha cell, gut and brain. GLP-1 analogs provide long acting GLP-1 activity improve glycemia with weight loss Reduce blood pressure with improved lipid profile DP-4 inhibitors prolong activity of native GLP-1 Improve glycemia and weight neutral GLP-1 analogs and DP-4 inhibitors are effective alone and in

33 Remember Multiple pathogenic abnormalities At diagnosis only 20% of Beta Cell function is left Early diagnosis and aggressive treatment Protect remaining Beta Cell

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