Session 10: Drugs. GLP-1 receptor agonists

Transcription

1 Session 10: Drugs GLP-1 receptor agonists Dr. Manel Mata La Mina Primary Health Care Centre. Barcelona. Catalonian Institute of Health. Grup DAP_Cat, Barcelona Research Support Unit. IDIAP-Jordi Gol. CIBERDEM. RedGDPS (Spanish Network of Primary Care Groups for the Study of Diabetes)

2 Dr. Manel Mata Session 10: Drugs GLP-1 receptor agonists Conflict of interest disclosure: Honoraria from AstraZeneca, GlaxoSmithKline, Eli Lilly, Novo Nordisk and Sanofi for the participation in advisory boards and lectures about the treatment of diabetes.

3 Session 10: Drugs GLP-1 receptor agonists Agenda - Mechanism of action and benefits - GLP-1ra in the algorithms - GLP-1ra as alternative to basal insulin - GLP-1ra as alternative to prandial insulin added to basal insulin - Adverse Effects. Cardiovascular and pancreatic safety - Key factors when choosing a GLP-1ra - Messages to take home

4 The ideal drug for type 2 diabetes Metformin is the recommended first line agent Safe Efficacious Durable control Well tolerated Low risk of hypoglycaemia Weight neutral or weight loss Reduction of long term complications GLP-1ra are a good option in the second and third steps

5 GLP-1 is released by the small intestine after meal ingestion and enhances glucose-stimulated insulin secretion (incretin action ) Kerr Saraiva F & Sposito AC. Cardiovasc Diabetol. 2014;13(142)

6 Pleiotropic effects of GLP-1 and GLP-1ra Kerr Saraiva F & Sposito AC. Cardiovasc Diabetol. 2014;13(142)

7 GLP-1ra different effects based on the duration of their action in the receptor Exenatide BID Lixisenatide Dulaglutide Exenatide LAR Albiglutide Liraglutide Madsbad S. Diabetes Obes Metab. 2016;18(4):317-32

8 GLP-1 receptor agonists Favorable effects Adverse effects HbA1c Nausea Weight Diarrhea Satiety Vomiting Blood Pressure Heart Rate No Hypoglycaemia Pancreatitis Neutral or CVD Pancreas cancer (?) Brand Name Injection Frequency Usual Dose Clinical Trial Program Exenatide BID Byetta Twice daily 10 μg AMIGO Lixisenatide Lyxumia Once daily 20 mg GetGoal Liraglutide Victoza Once daily mg LEADER Exenatide LAR Bydureon Once weekly 2 mg DURATION Albiglutide Eperzan Once weekly 50 mg HARMONY Dulaglutide Trulicity Once weekly 1.5 mg AWARD

9 GLP-1ra in the algorithm of T2DM treatment

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11 Need for personalized care: the benefits versus risks of diabetes therapy must be assessed for each patient

12 ADA/EASD Position Statement A patient-centered approach Based on: Preferences, needs and values of the patient Shared decisions Resources and support

13 Patients preferences related to the effects of T2DM treatment Monthly willingess to pay in Denmark N=270 WTP for Beneficial Attributes WTP to avoid detrimental attributes Bøgelund M et al. Curr Med Res Opin 2011;27(11):

14 45-50% of T2DM patients are obese 50-75% of T2DM patients have metabolic syndrome

15 Weight and antidiabetic drugs GLP-1ra SGLT-2i Metformin AGi DPP-4i Glitazones Glinides Sulfonylureas Insulin

16 The consequences of hypoglycaemia Death 2,3 Coma 3 Hospitalisation costs 4 Cardiovascular complications 3 Increased risk of dementia 1 Hypoglycaemia Weight gain due to defensive eating 5 Reduced quality of life 7 Loss of consciousness 3 Increased risk of car accident 6 Increased risk of seizures 3 1 Whitmer RA, et al. JAMA. 2009;301: ; 2 Bonds DE, et al. BMJ. 2010;340:b4909; 3 Barnett AH. Curr Med Res Opin. 2010;26: ; 4 Jönsson L, et al. Value Health. 2006;9: ; 5 Foley JE, Jordan J. Vasc Health Risk Manag. 2010;6: ; 6 Cox DJ. Am J Med Sci. 2013;345:263-5; 7 McEwan P, et al. Diabetes Obes Metab. 2010;12:

17 T2DM treatment choice Risks vs Benefits Benefits HbA1c reduction Reduced complications Safety Hypoglycaemia Weight gain Specific adverse effects Long-term side effects Cost

18 Annual cost of antidiabetic drugs in Spain ArGLP-1 ISGLT-2 IDPP-4 Pioglitazona Inh. α-glucosidases Repaglinida Sulfonilureas Metformina

19 % patients Evolution of new antidiabetic drugs in Catalunya (Spain) from 2007 to ,2 DPP4i 10 6, ,6 5,6 5,8 5,7 4,9 5,2 5,5 3,9 4 3,3 3,7 3,2 2,6 1,5 1,2 0,6 0,1 0,4 0,5 0,7 0,9 Glinides Glitazones GLP1ra

20 2014

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23 GLP-1ra in the 2015 Nice guideline Second Intensification of drug treatment (triple therapy)

24 GLP-1ra in the 2015 Nice guideline Stop if no efficacy (HbA1c+weight loss)

25 GLP1ra vs oral antidiabetic drugs

26 GLP-1ra vs DPP4i in patients treated with Metformin Exenatide LAR vs Sitagliptin 1 Liraglutide vs Sitagliptin 2 Dulaglutide vs Sitagliptin 3 Albiglutide vs Sitagliptin 4 mean HbA1c from baseline (%) Exe 1/w 1.5 Sita 1/d 0.9 Lira 1.8 1/d 1.5 Sita 1/d 0.9 Dula 1.5 1/w Weight 1.6 (kg): Hypos (%) : Sita 1/d 0.4 Albi 1/w 0.6 Sita 1/d Bergenstal et al. Lancet. 2010;376: Pratley et al. Int J Clin Pract. 2011;65: Nauck M et al. Lancet 2014; 384 (9951): Ahrén B, et al. Diabetes Care 2014; 37(8):2141-8

27 GLP1ra vs basal insulin

28 GLP-1ra vs basal insulin in patients treated with Met SU mean HbA1c from baseline (%) Daily Liraglutide 1 LEAD 5 Lira Glargine Weekly Exenatide 2 DURATION 3 Exe Glargine Weekly Albiglutide 3 HARMONY 4 Albi Glargine Weekly Dulaglutide 4 AWARD 2 Dula Glargine Weight 1.6(kg): Hypos (%): Russell-Jones D et al. Diabetologia 2009; 52: Diamant M et a. Diabetes Care. 2012; 35(4): Weissman PN, et al. Diabetologia 2014;57: Georgino F et al. Diabetes Care. 2015;38(12):

29 DURATION-3: 79% of patients treated with Once Weekly Exenatide lost weight and reduced HbA1c vs 31% with Glargine Weight change from baseline (kg) % 63% 0% 5% 12 79% 4% 31% 1% HbA 1c (%) change from baseline Exenatida semanal Insulina glargina Modified ITT population, N=448. Diamant M, et al. Lancet. 2010;375:

30 GLP1ra vs prandial insulin in patients on basal insulin

31 Consider GLP1 ra

32 GLP-1ra vs prandial insulin in patients on basal insulin mean HbA1c from baseline (%) Daily Exenatide vs Lispro 1 EXE 2/d 1.13 Lispro 3/d 1.10 Albiglutide vs Lispro 2 ALBI 1/sem 0.82 Lispro 3/d 0.66 Liraglutide vs Aspart 3 Weight 1.6(kg): Major hypos : LIRA 1/d 0.74 Aspart 1/d 0.39 Lixisenatide vs Glulisine 4 LIXI 1/d 0.6 Glulisine 3/d Diamant M, et al,. Diabetes Care. 2014;37(10): Rosenstock J et al. Diabetes Care 2014; 37(8): Mathieu C et al. Diabetes Obes Metab. 2014;16(7): Rosenstock J et al. Poster ADA 2015; Boston, USA

33 GLP-1ra Gastrointestinal Adverse Effects Pancreatitis and pancreas cancer Cardiovascular Safety

34 GLP1ra Adverse Effects Adverse reactions Albi glutide Place bo Dula glutide 1.5 Place bo Lira glutide 1.8 Place bo Exe natide LAR Place bo Lixi senatide Diarrhea Nausea Vomiting Place bo Injectionsite reactions Heart rate increase (bpm) Ref +2 3 Ref +1 2 Ref 0 Ref 0 Ref No increase in hypoglycaemias Small increase in pancreatitis Risk of pancreas cancer (?)

35 Incretins and Pancreatitis Meta-analysis 55 Randomized trials (N=33,350) 0.11% vs 0.11% (OR 1.11; 0.57 to 2.17) 5 Observational studies (N=320,289) 0.47% vs 0.47% (OR 0.98; 0.69 to 1.38) 1.11 (0.57 to 2.17) Conclusions The available evidence suggests that the incidence of pancreatitis among patients using incretins is low and that the drugs do not increase the risk of pancreatitis. Li L et al. BMJ. BMJ 2014;348:g2366 doi: /bmj.g2366 (Published 14 April 2014)

36 Both agencies agree that assertions concerning a causal association between incretin-based drugs and pancreatitis or pancreatic cancer, as expressed recently in the scientific literature and in the media, are inconsistent with the current data. Although the totality of the data that have been reviewed provides reassurance, pancreatitis will continue to be considered a risk associated with these drugs until more data are available; both agencies continue to investigate this safety signal. Egan AG et al. NEJM 2014; 370(9) Pub Online 27 february 2014

37 ELIXA: Lixisenatide vs placebo in T2DM with a recent coronary event*, mean follow up 2 years. Cumulative incidence (%) Primary endpoint HR (95% CI): (0.886, 1.168) Secondary Variable Heart Failure Hospitalization RR 0,96 Placebo Lixisenatide 0 Number at risk Placebo 3034 Lixisenatide Months * AMI or Unestable Angina in the previous 180 days

38 4/3/16: Novo Nordisk announces that Liraglutide reduces CVD 29/4/16: Novo Nordisk announces that Semaglutide reduces CVD

39 GLP1ra choice based on: Head to Head studies? Efficacy Tolerability Patient convenience? Frequency of injection Device

40 Review of head-to-head comparisons of GLP-1ra Effects on HbA1c HbA1c reduction Liraglutide **** Dulaglutide **** Exenatide OW *** Exenatide BID ** Lixisenatide ** Albiglutide ** Madsbad S. Diabetes Obes Metab. 2016;18(4):317-32

41 Review of head-to-head comparisons of GLP-1ra Effects on Weight Weight reduction Liraglutide **** Dulaglutide *** Exenatide OW *** Exenatide BID *** Lixisenatide *** Albiglutide * Madsbad S. Diabetes Obes Metab. 2016;18(4):317-32

42 GLP1ra Adverse effects in Head to Head studies Gastrointestinal AE Exenatide BID **** Liraglutide **** Dulaglutide **** Exenatide OW *** Lixisenatide ** Albiglutide * Trujillo JM et al. Ther Adv Endocrinol Metab Feb;6(1):19-28

43 Daily GLP 1ra Weekly GLP 1ra Exenatide BID, Byetta Exenatide LAR, Bydureon Liraglutide, Victoza Albiglutide, Eperzan Eperzan TM Lixisenatide, Lyxumia Dulaglutide, Trulicity

44 How to select a GLP-1ra? Use in clinical practice should be customized for individual patients, based on clinical profile and patient preferences HbA1c reduction Weight loss Postprandial effect GI effects Site reactions Frequency injection Device Exenatide BID BID +++ Lixisenatide OD +++ Liraglutide OD +++ Exenatide LAR OW + Albiglutide OW ++ Dulaglutide OW ++++

45 Messages to take home GLP 1ra reduce HbA1c, weight, blood pressure and probably cardiovascular events, but are of limited use in primary care mainly because of its high cost GLP 1ra are preferable in the second and third steps of treatment in obese patients as an alternative to basal or prandial insulin with fewer injections, no need of blood glucose monitoring or dose adjustments Adverse gastrointestinal effects (mainly nausea) are frequent but are usually well tolerated and improve spontaneously after several weeks. Don t use them in patients with history of pancreatitis, gastroparesia or severe renal failure GLP 1ra use in clinical practice should be customized to individual patients, based on their clinical profile and patients preferences

46 Thanks for your attention

47 CV Outcome trials in Type 2 Diabetes ORIGIN Insulin glargine Sanofi (6/ 12) Insulin DPP4 SAVOR TIMI 53 Saxagliptin AZ/BMS (6/ 13) EXAMINE Alogliptin Takeda (12/ 13) TECOS Sitagliptin Merck (12/ 14) LEADER Liraglutide Novo (1/ 16) CAROLINA Linagliptin BI/Lilly (9/ 18) FREEDOM CVO ITCA650 Servier (7/ 17) REWIND Dulaglutide Lilly (4/ 19) MK Omarigliptin MercK (12/ 20) SGLT2 GLP1 SUSTAIN 6 Semaglutide Novo (1/ 16) ELIXA Lixisenatide Sanofi (5/ 14) EXSCEL Exenatide LAR Amylin (3/ 17) CANVAS (interim) Canagliflozin J&J 200 events (subm: 1/ 12) EMPA REG OUTCOME Empagliflozin BI/Lilly (8/ 15) CANVAS (final) Canagliflozin 500 events J&J (/4 17) Ertugliflozin MSD (04/ 20) C SCADE 8 Empagliflozin BI/Lilly (3/ 18) DECLARE Dapagliflozin BMS/AZ (04/ 19)

48 Cardiac effects of GLP-1 and GLP-1ra Ussher JR, Drucker DJ Circ Res. 2014;114(11):

49 GLP1ra vs. DPP4i: HbA1c and weight changes Weight (kg) Bergenstal et al. Lancet. 2010;376: Pratley et al. Int J Clin Pract. 2011;65:

50 Harmony 8: Albiglutide vs Sitagliptin in Renal Impaired Mean (SD) HbA1c (%) Model-Adjusted Albiglutide a Change (N=246) From Sitagliptina Baseline in HbA (N=240) 1c At Week 26 by Severity of Renal Impairment (ITT-LOCF) Mild Moderate Severe 9, , ml/min/1.73 m 2 0,0 8,5 n = n = n = n = n = n = 69 0, Albiglutide 8,0 63 7,5 0,4 0,31 Sitagliptin 57 7,0 0,6 51 6,5 0,8 0,80 0,67 0,61 0, ,0 1, ,2 1,08 Weeks Mean Change From Baseline in HbA 1c, % Number of patients at each a Based point: on analysis of covariance (ANCOVA) Albiglutide Sitagliptin HbA 1c, a % Albiglutide Sitagliptin Model adjusted LS mean change from baseline Treatment difference (albiglutide vs. sitagliptin) (CI 95%) P value for superiority a Efficacy data through week 26 in the safety population using an LOCF analysis Mean (SD) HbA1c mmol/mol 0.32 ( 0.49, 0.15) Leiter LA, et al. Diabetes Care 2014;37: Adapted from Leiter LA, et al. Diabetes Care 2014;37: [Supplement]]

51 Dulaglutide vs sitagliptin vs placebo AWARD-5 trial: 1098 T2DM patients on metformin, 52 weeks HbA1c Weight DU DU Sita Placebo P, 0.001, superiority vs. sitagliptin; P, 0.001, superiority vs. placebo; #, *P, 0.05 vs.sitagliptin and placebo, respectively; ##, **P, vs. sitagliptin and placebo, respectively. Nauck M, et al. Diabetes Care. 2014;37(8):

52 LEAD-5; N=581, 26 weeks HbA1c Triple therapy GLP-1 RA vs Basal insulin Gla -1.1 AE Lira Gla* Lira -1.3 Any hypo 27.4% 28.9% Major hypo 6 0 Diarrhoea 10.0% 1.3% Nausea 13.9% 1.3% *Mean daily dose: 24 UI/day Weight Gla +1.6 Lira -1.8 Russell-Jones D, et al. Diabetologia. 2009;52:

53 HbA1c Triple therapy GLP-1 RA vs Basal insulin DURATION-3; N=415, 84 weeks AE ExeW Gla* Hypos** 12% 40% Hypos*** 36% 56% Diarrhoea 12% 6% Nausea 15% 1% * Mean daily dose: 35 UI/d ** Symptomatic in patients on Met *** Symptomatic in patients on SU+Met Weight Gla -1.0 Exe -1.2 Gla +2.4 Exe -2.1 Diamant M, et al. Diabetes Care. 2012;35(4):683 9.

54 Triple therapy GLP1ra vs Insulin HbA 1c % Glar Albi Hypos 27,4% 17,5% Nausea 3,7% 9,9% Albiglutide (N =496) Glargine* (N =239) Difference: 0.11 (-0.04, 0.27) P no inferiority (margin 0.3)= P superiority = ,67-0, Weight KG ,57-1,06 *Mean daily dose: 30UI Weissman PN, et al. Diabetologia 2014;57:

55 Dulaglutide vs insulin Glargine (AWARD 2) add-on to Metformin ± glimepiride, 78 weeks N=810, 78 weeks Glargine, Dulaglutide 0.75 and 150 mg HbA1c Dula 1.5 Glargina* Hypos 54.4% 69.1% Major Hipos 2 2 Diarrhea 10.6% 5.7% Nausea 15.4% 1.5% * Mean daily dose: 29 UI Weight Georgino F et al. Diabetes Care. 2015;38(12):

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57 Review of head-to-head comparisons of GLP-1ra Effects on HbA1c Trujillo JM et al. Ther Adv Endocrinol Metab 2015; 6(1):19-28

58 Review of head-to-head comparisons of GLP-1ra Effects on Weight Trujillo JM et al. Ther Adv Endocrinol Metab 2015; 6(1):19-28