Francesca Porcellati - PDF Free Download

XX Congresso Nazionale AMD Razionali e Benefici dell Aggiunta del GLP-1 RA Short-Acting all Insulina Basale Francesca Porcellati Dipartimento di Medicina Interna, Sezione di Medicina Interna, Endocrinologia e Metabolismo, Università degli Studi di Perugia. Genova, 15 Maggio 215

Exploring Combination Options of Basal Insulin and GLP-1 Receptor Agonist in Type 2 DM An Initial Call to Action!. Efforts should be directed to explore the potential role of GLP-1 receptor agonists in combination with insulin Rosenstock J and Fonseca V, Diabetes Care 27

Total hyperglycemia (%) Total hyperglycemia (%) Combination of Basal insulin with a GLP-1 Receptor Agonist Addressing FPG and PPG Contributions by A1C Level 1 8 24 22 21 21 2 Postprandial Hyperglycemia Fasting or Basal Hyperglycemia 6 4 2 A1C 76 78 79 79 8 <8. 8. <8.5 8.5 <9. 9. <9.5 9.5 On Baseline OADs, Fasting Hyperglycemia dominates over a wide range of A1C levels 1 8 6 58 59 58 57 52 4 2 42 41 42 43 48 Postprandial Increments Persist Following Titration of Basal Insulin A1C <6.5 6.5 <7. 7. <7.5 7.5 <8. 8. Courtesy of J. Rosenstock Riddle M, et al. Diabetes Care 211

GLP-1 RAs in Combination with Basal Insulin: the Rationale An attractive therapeutic option as both components may address complementary targets and underlying mechanisms without hypoglycemia and weight gain associated with intensification of the insulin regimen. Do All GLP-1 Receptor Agonists Interact Equally with Basal Insulin?

GLP-1 Receptor Agonists: Structures and Pharmacokinetics Lixisenatide H G E G T F T S D L S K Q M E E E A V R L F I Exenatide H G E G T F T S D L S K Q M E E E A V R L F I Native GLP-1 H A E G T F T S D V S S Y L E G Q A A K E F I E W L K N G G P S S E A P P S K K K K K K E W L K N G G P S S E A P P S K A W L V K E R E Short acting DPP4 DPP4 H A E G T GLP-1 F T S D V S S Q G E L Y A A K E F I A W L V R E R E Albiglutide Dulaglutide Long acting T F T G E A H S D V S S Y L E G Q A Liraglutide Exenatide-LAR E R E R V L W A I F K E A16-carbon fatty acid E Meier JJ. 212 Nature Reviews Endocrinology; 8: 728-742

Short- and Long-acting GLP-1 RAs Short-acting GLP-1 RAs Long-acting GLP-1 RAs Meier JJ Nat Rev Endocrinol 212

Comparison of Short-Acting versus Long-Acting GLP-1 Receptor Agonists Parameters Short acting GLP-1 RAs Long acting GLP-1 RAs Compounds Exenetide Lixisenatide Albiglutide Dulaglutide Exenatide-LAR Liraglutide Half-life 2-5 h 12 h-several days Effects Fasting blood glucose levels Modest reduction Strong reduction Postprandial hyperglycemia Strong reduction Modest reduction Fasting insulin secretion Modest stimulation Strong stimulation Postprandial insulin secretion Reduction Modest stimulation Glucagon secretion Reduction Reduction Gastric empting rate Deceleration No effects Blood pressure Reduction Reduction Heart rate No effect or small increase Modest increase Body weight reduction 1-5 Kg 2-5 Kg Induction of nausea 2 5%, attenuates slowly (weeks to many months) 2 4%, attenuates quickly ( ~ 4 8 weeks) Abbreviations: GLP 1-R, glucagon-like peptide 1 receptor ; LAR, long-acting release. Meier J Nat. Rev. Endocrinol 8:728-42, 212

Glucose (mg/dl) Comparative Effects of Lixisenatide and Liraglutide on Postprandial Glucose Excursions and Insulin Levels Insulin free (µiu/ml) lixisenatide Day-1 Day-28 liraglutide Day-1 Day-28 9 Glucose 7 6 Insulin 6 5 3 4 3 2-3 45 6 9 12 Meal 451 kcal 18 21 27 Time (minutes) 3 6 9 15 Meal 451 kcal 21 27 Time (minutes) Kapitza C., et al. Diabetes, Obesity and Metabolism 213 January 31.

AUC :3-4:3 (h μiu/ml) AUC :3-4:3 (h ng/ml) AUC :3-4:3 (h pg/ml) Relative Effects of Lixisenatide and Liraglutide on postprandial Insulin, C-peptide and Glucagon Levels Insulin C-peptide Glucagon 1-1 -2-3 -4-5 -6-7 -64.2 5.3 p <.1 2 1-1 -2-3 -4-5 -6-5.3 1.4 p <.1-5 -1-15 -2-25 -3-35 -4-45 -5-46.7-25.3 p <.32 Lixisenatide (n = 75) Liraglutide (n = 68) Data shown are changes from baseline in each parameter at 28 days Kapitza C, et al. Diabetes Obes Metab 15:642-9, 213

Use of Twice-Daily Exenatide in Basal Insulin Treated Patients with Type 2 Diabetes -1.74% vs -1.4% [CI, 1.22% Difference -.69% [CI -.93% to -.46%] P.1 8.5% Optimized Glargine + Placebo Optimized Glargine + Exenatide N= 261 8.3% N= 122 7.4% N= 137 6.7% Buse J B et al. Ann Intern Med 211;154:13-112

ΔHbA 1c (%) Minor hypoglycaemia (events/patient/year) ΔWeight (kg) Combination of Insulin Glargine with Exenatide HbA 1c Hypoglycemia Weight -.2 -.4 -.6 -.8-1 -1.2-1. 1.6 1.4 1.2 1.8.6 1.4 1.2 1.5 -.5-1 1. -1.4-1.6-1.8-1.7.4.2-1.5-2 -1.8 Insulin glargine + exenatide ± OADs (n=137) Insulin glargine + placebo ± OADs (n=122) Two cases of severe hypoglycemia in the placebo group Buse J, et al. Ann Intern Med 211;154:13 12.

Twice Daily Exenatide in Combination with Insulin Glargine : Changes in PG Profiles after 3 weeks Plasma glucose (mmol/l) Glucose Profiles (SMBG) 12 1 8 ** 6 ** ** ** ** * 3. h *p<.1 **p<.1 Pre- Glargine + Postexenatide Postplacebo Pre- Glargine + Buse JB, et al. Ann Intern Med 211;154:13 112.

Lixisenatide GetGoal clinical trial programme Study Objectives # of pts ClinicalTrials.gov Identifier GetGoal-Mono GetGoal-Mono Japan Efficacy and safety of monotherapy (1- or 2-step dose increase) Safety and efficacy of monotherapy in Asian patients (1- or 2-step dose increase) 361 NCT68871 69 NCT95255 GetGoal-M Efficacy and safety in combination with MET 68 NCT712673 GetGoal-M-Asia Efficacy and safety in combination with MET (+ SU) 391 NCT1169779 GetGoal-F1 Efficacy and safety in combination with MET (1 or 2-step dose increase) 482 NCT763451 GetGoal-S Efficacy and safety in combination with SU (+ MET) 859 NCT71383 GetGoal-P Efficacy and safety in combination with pioglitazone (+ MET) 484 NCT763815 GetGoal-X Efficacy and safety head-to-head vs exenatide (+ MET) 634 NCT7731 GetGoal-L Efficacy and safety in combination with basal insulin (+ MET) 496 NCT715624 GetGoal-L Asia Efficacy and safety in combination with basal insulin (+ SU) 311 NCT866658 GetGoal-Duo 1 GetGoal-Duo 2 Efficacy and safety in combination with insulin glargine + MET (± TZDs) Efficacy and safety in combination with insulin glargine in comparison with glulisine (QD or TID) ± MET 446 NCT975286 855 In progress NCT1768559

Lixisenatide Added to Background Insulin: Change in HbA1c at Week 24 (primary endpoint) HbA1c change from baseline (%) Lixisenatide 2μg QD.2.1. GetGoal-Duo 1 1 GetGoal-L 2 GetGoal-L Asia 3.11 Placebo -.1 -.2 -.3 -.4 -.4 -.38 -.5 -.6 -.7 -.8 -.9 -.71 * -.74 ** -.77 * Baseline HbA1c (%) 7.6 8.4 8.5 Background therapy Study duration (wk) Titrated glargine + MET ± TZD 24 Basal insulin ± MET 24 Basal insulin ± SU 24 *p<.1 vs placebo; **p<.1 vs placebo; following 12 week run-in period; MET, metformin; SU, sulphonylurea; TZD, thiazolidinedione; QD, once daily *p<.1 vs placebo; **p<.1 vs placebo; following 12 week run-in period; MET: metformin; SU: sulphonylurea; TZD: thiazolidinedione; QD: once daily. 1. Riddle MC, et al. Diabetes Care. 213;36:2497 253; 2. Riddle MC, et al. Diabetes Care. 213;36:2489 2496; 3. Seino Y, et al. Diabetes Obes Metab. 212;14:91 917.

PPG change from baseline (mmol/l) Lixisenatide Added to Background Insulin: Secondary Endpoints Body weight change from baseline (kg) Lixisenatide 2μg QD Placebo Change in 2-hr PPG Change in Body Weight GetGoal- Duo 1 3 GetGoal-L 1 GetGoal-L Asia 2 GetGoal- Duo 1 3 GetGoal-L 1 GetGoal-L Asia 2 1-1 -2-3 -4-5 -6-7 -8-3.9.8 Baseline PPG ~13. (234 mg/dl) -5.54-1.72 ~16. (288 mg/dl) -7.96 -.14 17.8 (32.4 mg/dl) 1.5 1.5 -.5-1 -1.5-2 ***.3 1.2-1.8 * -.5 -.38 NS.6 *P<.1 versus placebo; **P<.1 versus placebo; ***P <.1; NS = not significant; MET, metformin; SU, sulfonylurea; TZD, thiazolidinedione; QD, once daily 1. Riddle MC, et al. Diabetes Care 213;36:2489 96. 2. Seino Y, et al. Diabetes Obes Metab 212;14:91 7. 3. Riddle MC, et al. Diabetes Care 213;36:2497 53.

% of patients Lixisenatide Added to Background Insulin: Hypoglycemia Lixisenatide 2μg QD Placebo Symptomatic hypoglycemia Severe hypoglycemia GG-L GG-Duo1 GG-L GG-Duo1 1 8 1 8 27.7% 91 6 6 21.6% 4 4 2 27,7% 21,6% n=328 n=167 22,4% 13,5% n=223 n=223 2 1,2% % n=328 n=167,4% % n=223 n=223 Safety population Safety population Symptomatic documented hypoglycemia o 3.3 mmol/l (6 mg/dl) Riddle M. et al. Diabetes Care 213; DOI: 1.2337/dc12-2454; Riddle M. et al. Diabetes care 213; DOI: 1.2337/dc12-2462.

Lixisenatide vs Liraglutide on top of basal insulin Meier JJ et al, Diabetes Care 215

Lixisenatide vs Liraglutide on Top of Basal Insulin: Postprandial Glucose Levels Meier JJ et al, Diabetes Care 215

Lixisenatide vs Liraglutide on Top of Basal Insulin: Gastric Empting Meier JJ et al, Diabetes Care 215

Hourly mean heart rate (bpm) Lixisenatide vs Liraglutide on Top of Basal Insulin: Heart Rate Hourly mean heart rate (bpm) Increases in HR were significantly greater with liraglutide 1.2 and 1.8 mg than with lixisenatide (9.3 and 9.2 bpm vs 3.3 bpm, respectively; P<.1) Baseline Week 8 9 85 Lixisenatide 2 mg (baseline) Liraglutide 1.2 mg (baseline)) Liraglutide 1.8 mg (baseline) 9 85 * * Lixisenatide 2 mg (Week 8) Liraglutide 1.2 mg (Week 8) Liraglutide 1.8 mg (Week 8) * * * 8 8 * * * * * * * 75 75 7 7 65 65 Time of lixisenatide / liraglutide injection 6 6 Hourly timepoint Statistical tests compared treatment arms at each timepoint at Week 8. bpm, beats per minute. *P<.5 for liraglutide 1.2 mg vs lixisenatide 2 μg; P<.5 for liraglutide 1.8 mg vs lixisenatide 2 μg. Hourly timepoint Meier JJ et al, Diabetes Care 215

Lixisenatide vs Liraglutide on Top of Basal Insulin: Safety findings Lixisenatide 2µg (N=48) Liraglutide 1.2mg (N=47) Liraglutide 1.8mg (N=47) Gastrointestinal AEs 17 (35.4%) 21 (44.7%) 22 (46.8%) Amylase (mean change, week 8) 2.98 ± 4. 8.1 ± 4. 5.68 ± 4.13 Lipase (mean change, week 8) 6.97 ± 7.11 21.12 ± 7.16 2.76 ± 7.38 Number (%) of patients experiencing symptomatic hypoglycemia Number (%) of patients experiencing severe symptomatic hypoglycemia 14 (29.2) 9 (19.1) 1 (21.3) 1 (2.1) Lixisenatide resulted in: Fewer reports of gastrointestinal adverse events Lower increases in levels of pancreatic enzymes (amylase and lipase) More frequent symptomatic hypoglycemia Meier JJ et al, Diabetes Care 215

Baseline FPG Level Influences the Therapeutic Effects of Lixisenatide GetGoal-L FPG at baseline Group 1 FPG 6.7 mmol/l (12 mg/dl) Group 2 FPG > 6.7 to 8.9 mmol/l Group 3 FPG 16 mg/dl (16 mg/dl) Basal insulin + lixisenatide vs Basal insulin + placebo Efficacy measurements HbA 1c Body weight 2-hour PPG after a standardized breakfast SMPG Basal insulin dose Symptomatic hypoglycaemia FPG=fasting plasma glucose; HbA 1c =glycated haemoglobin; PPG=postprandial plasma glucose; SMPG=self-monitored plasma glucose; mitt=modified intent-to-treat; LOCF=last observation carried forward; LS=least squares; ANCOVA=analysis of covariance.

Baseline FPG Level Influences the Therapeutic Effects of Lixisenatide Mean difference with placebo ± SE at week 24 -.5 -.6 HbA 1c (%) -.3 -.3 Weight (kg) Post Breakfast SMPG (mmol/dl) -1-1.5-1.8-1. -1. * * -1.6-2 *** -2.2-2.5-3 -3.5 FPG < 6.7 mmol/l FPG 6.7 to 8.9 mmol/l FPG 8.9 mmol/l -2.9 ** ** -4 Placebo adjusted changes by FPG tertiles SMPG: Self Monitored Plasma Glucose * P <.5 ** P <.1 *** P <.1 Vidal J, et al. EASD, 213

Efficacy of Lixisenatide According to Baseline b-cell Function Characteristic Low HOMA-b index (n=49) High HOMA-b index (n=49) p-value Mean age, years (SD) 56.5 (9.7) 54.7 (9.4).25 Sex, male/female, % 47.8/52.2 41.2/58.8.5 Race (%) Asian Black/African American White Other 25.1 3.1 68.4 3.5 9.6 4.5 83.7 2.2 <.1 Mean BMI, kg/m 2 (SD) 29.9 (5.7) 34.9 (6.9) <.1 Mean known diabetes duration, years (SD) 8.7 (6.4) 6.4 (4.9) <.1 Mean duration of OAD therapy, years (SD) Metformin at baseline, % Sulfonylurea at baseline, % 4.7 (4.3) 85.7 32.2 4.1 (4.1) 92.5 16.5.263.7 <.1 Mean HbA 1c, % (SD) 8.3 (.9) 7.9 (.8) <.1 Mean PPG, mg/dl (SD) 318 (74) 267 (68) <.1 Mean FPG, mg/dl (SD) 176 (4) 158 (35) <.1 Post hoc analysis data extracted from the intent-to-treat populations of three GetGoal trials: GetGoal-M, GetGoal-S, GetGoal-P Bonadonna R et al., ADA, 214

Mean FPG (mg/dl) Mean HbA 1c (%) Mean PPG (mg/dl) Lixisenatide is Effective Regardless b-cell Function (HOMA-b) 8.5 8 7.5 7 8.3 * =.95 7.4 7.9 7.1 4 318 * * 3 =.85 = -123 2 195 267 * = -91 176 Baseline Endpoint 6.5 6 1 Low index (n=49) High index (n=49) Low index (n=49) High index (n=49) 25 2 15 176 = -22 * 154 158 * 144 = -14 1 5 * (p <.1) Low index (n=49) High index (n=49) Bonadonna R et al., ADA, 214

The Evaluation of Lixisenatide in Acute Coronary Syndrome Introduction - John McMurray, MD, PhD 8 th June, 215 ELIXA Design and Baseline Eldrin F. Lewis, MD, MPH Results Part 1 Matthew C. Riddle, MD Results Part 2 Marc A. Pfeffer, MD, PhD ELIXA in Perspective Hertzel C. Gerstein, MD, MSc, FRCPC Panel Discussion/Question-and- Answer Period

... the Ideal Partners... Basal insulin therapy Simple to initiate Controls nocturnal and FPG Decreases hepatic glucose production Often started when residual endogenous insulin is compromised Less hypoglycemia risk Weight gain ~1-3 kg Achieves A1C targets in ~5-6% Short-acting GLP-1 RAs Rx Simple to use Controls PPG and some FPG Decreases gastric emptying Efficay regardless the presence of residual endogenous insulin No increase of hypoglycemia Weight loss ~1-3 kg Achieves A1C targets in ~4-6% Complementary and potentially synergistic effects

Combination Option of Basal Insulin and Short Acting GLP-1 receptor agonists in Type 2 DM an obvious approach that theoretically could restore physiology through pharmacology..

The Challenge of Diabetes Thank you for your attention

Combination Option of Basal Insulin and Short Acting GLP-1 receptor agonists in Type 2 DM an obvious approach that theoretically could restore physiology through pharmacology..

... the Ideal Partner... Basal insulin therapy Simple to initiate Controls nocturnal and FPG Decreases hepatic glucose production Often started when residual endogenous insulin is compromised Less hypoglycemia risk Weight gain ~1-3 kg Achieves A1C targets in ~5-6% Short-acting GLP-1 RAs Rx Simple to use Controls PPG and some FPG Decreases gastric emptying Efficay regardless the presence of residual endogenous insulin No increase of hypoglycemia Weight loss ~1-3 kg Achieves A1C targets in ~4-6% Complementary and potentially synergistic effects

Effects of Lixisenatide on HbA1c in Patients with Different Degrees of b-cell Function Mean change in HbA 1c (%) C-peptide/glucose quartile 1 4 (low high), Q1 Q2 Q3 Q4 -,2 -,4 p=.766 -,6 -,8.7-1,.9 1..9-1,2 Mean change from baseline to endpoint in C-peptide/glucose ratio (nmol/mg).14.16.17.6 Meier JJ et al., 213 Diabetologia (EASD abstract)

Effects of Lixisenatide on HbA1c in Patients with Different Degrees of b-cell Function Mean change in PPG (mg/dl) C-peptide/glucose quartile 1 4 (low high), * * * * Q1 Q2 Q3 Q4-2, p=.1-4, -6, -8, -1, 85. 86.7-12, 111.4-14, 135.3-16, Mean change from baseline to endpoint in C-peptide/glucose ratio (nmol/mg).14.16.17.6 Meier JJ et al., 213 Diabetologia (EASD abstract)