Developing a Treatment for Post-Bariatric Hypoglycemia
Transcript of Developing a Treatment for Post-Bariatric Hypoglycemia
![Page 1: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/1.jpg)
December 9, 2016
Developing a Treatment for Post-Bariatric Hypoglycemia
![Page 2: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/2.jpg)
Forward-Looking Statements
This presentation and the oral commentary contain “forward-looking” statements that involve substantial risks and uncertainties. All statements other than statements of historical facts, including statements regarding our future financial condition, timing for and outcomes of clinical results, business strategy and plans and objectives for future operations, are forward looking statements. These forward-looking statements include terminology such as “believe,” “will,” “may,” “estimate,” “continue,” “anticipate,” “contemplate,” “intend,” “target,” “project,” “should,” “plan,” “expect,” “predict,” “could,” “potentially” or the negative of these terms Forward looking statements are our current statements regarding our intentions, beliefs, projections, outlook, analyses or current expectations concerning, among other things, our ongoing and planned clinical development, the timing of and our ability to initiate or enroll clinical trials, and our ability to make regulatory filings and obtain and maintain regulatory approvals for Sarasar, Bestatin, PEG IFN Lambda and our other product candidates, our intellectual property position, the potential safety, efficacy, reimbursement, convenience clinical and pharmaco-economic benefits of our product candidates, commercial opportunities, including potential market sizes and segments, our ability to commercialize, expectations regarding clinical trial data and FDA outcomes, our results of operations, cash needs, spending of the proceeds from this offering, financial condition, liquidity, prospects, growth and strategies, the industry in which we operate and the trends that may affect the industry or us.
Forward-looking statements involve known and unknown risks, uncertainties, assumptions and other factors that may cause our actual results, performance or achievements to be materially different from any future results, performance or achievements expressed or implied by the forward-looking statements. Forward-looking statements represent our beliefs and assumptions only as of the date of this presentation. Except as required by law, we assume no obligation to update these forward-looking statements publicly, or to update the reasons why actual results could differ materially from those anticipated in the forward-looking statements, even if new information becomes available in the future.
© 2016 Eiger Biopharmaceuticals, Inc., all rights reserved. Sarasar is a registered trademark of Merck Sharp & Dohme Corp. Bestatin is a trademark of Nippon Kayaku Co., Ltd. All other trademarks belong to their respective owners. 2
![Page 3: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/3.jpg)
8:00 AM Welcome David Cory - Corporate Highlights and Pipeline - HDV program update / next steps
8:15 AM PBH: Defining the Problem Mary-Elizabeth Patti, MD
Joslin Diabetes Center
8:30 AM Pharmacologic Approaches to PBH Marzieh Salehi, MD Cedars-Sinai
8:45 AM Exendin 9-39 in PBH Colleen Craig, MD - Review of IV / SC Data Stanford / Eiger - Interim Results of MAD Study - Novel Liquid Formulation - Next Steps
9:05 PM Panel Discussion and Q&A All
Agenda
3
![Page 4: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/4.jpg)
Post-Bariatric Hypoglycemia (PBH): A Challenging Clinical Syndrome
Mary-Elizabeth Patti, MD Investigator and Adult Endocrinologist Research Division Director, Hypoglycemia Clinic Joslin Diabetes Center Harvard Medical School
4
![Page 5: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/5.jpg)
• Bariatric surgery increasing worldwide - 193,000 bariatric procedures in the US in 2015 and growing*
• Post-prandial hyperinsulinemia and hypoglycemia - Neuroglycopenia – seizures, loss of consciousness, and even death - Disability – impaired ability to work, drive, perform daily activities - Asymptomatic hypoglycemia is substantial
• Impacts ~5-10% of gastric bypass patients: Orphan Disease
- ~ 60,000 gastric bypass procedures in US in 2015 - ~ Up to 3,000 new patients annually in US (estimated incidence)** - ~ 30,000 current patients in US (estimated prevalence)**
• No approved therapy; high unmet medical need
Post-Bariatric Hypoglycemia (PBH) Complication of Bariatric Surgery
* ASMBS 2015, **Market research estimates 5
![Page 6: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/6.jpg)
Common Bariatric Procedures in US
Normal Anatomy
Adjustable Gastric Band
(AGB)
Roux-en-Y Gastric Bypass
(RYGB)
Vertical Sleeve Gastrectomy
(VSG)
ASMBS 2015: 193,000 procedures per year in US
10% 27% 52%
6
![Page 7: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/7.jpg)
Gastric Bypass is Highly Effective for Sustained Weight Loss and Remission of Type 2 Diabetes
Sjostrom L et al. N Engl J Med 2007; 357:741-752
Banding C
hang
e in
Wei
ght (
%)
Years
0
-10
-20
-30
15 10 8 6 4 0 1 2 3
Control
Vertical-Banded Gastroplasty
Gastric Bypass
7
![Page 8: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/8.jpg)
Healthy Range
70-100 mg/dL
Diabetes
> 126 mg/dL
Hypoglycemia (low blood glucose)
< 54 mg/dL
Blood Glucose Levels Are Tightly Regulated
8
![Page 9: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/9.jpg)
Food Intake & Absorption or ↑ Glucose
Pancreas
Liver
Glucose Uptake into Muscle & Other TIssues
Glycogen Synthesis
Lowering of Blood Glucose
GLP1
Insulin Release
Blood Glucose Levels Are Tightly Regulated After Meals
Stomach
9
![Page 10: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/10.jpg)
GLP1
Insulin Release
Glycogen Breakdown
Liver Glucagon
Low Blood Glucose
Raises Blood
Glucose
Counterregulatory hormones: cortisol, catecholamines, GH, neural input
Blood Glucose Levels Are Tightly Regulated
Pancreas
Stomach
10
![Page 11: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/11.jpg)
Whipple’s triad required to diagnose hypoglycemia
• Symptoms of hypoglycemia
• Low plasma glucose at time of symptoms
(< 54 mg/dL*)
• Relief of symptoms by raising glucose
Allen O. Whipple Surgeon
* ADA/EASD Hypo Study Group, Diabetes Care, Nov 2016
How Do We Diagnose Hypoglycemia?
11
![Page 12: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/12.jpg)
Adrenergic Tremor Palpitations Anxiety
Cholinergic Sweating Hunger Paresthesias
• These symptoms are often nonspecific! • Overlap with “dumping syndrome”
- Occurring post-meals in bariatric patients
Neuroglycopenia Impaired cognition Seizures ↓ Consciousness
Hypoglycemia Symptoms
12
![Page 13: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/13.jpg)
Adrenergic Tremor Palpitations Anxiety
Cholinergic Sweating Hunger Paresthesias
Neuroglycopenia Impaired cognition Seizures ↓ Consciousness
Hypoglycemia Symptoms
• Brain requires glucose for normal functioning • Hypoglycemia Unawareness: A Threat to Safety
- loss of adrenergic or cholinergic warning symptoms with repeated hypoglycemia - abrupt onset of neuroglycopenia - can result in serious falls, motor vehicle accidents, seizures, loss of consciousness
13
![Page 14: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/14.jpg)
Post-Bariatric Hypoglycemia is Increasingly Recognized
• Mainly after gastric bypass, but also sleeve gastrectomy • PBH can be mild, moderate or severe
• Mild / moderate can be managed with diet modification – Avoid easily digested carbohydrates (simple carbohydrates) – Focus on defined quantities of complex carbohydrates only – Frequent small meals – No liquids with meals – Snack before activity – Avoid alcohol – Carry glucose tablets at all times
14
![Page 15: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/15.jpg)
• Low plasma glucose levels at time of neuroglycopenia – with inappropriately high insulin levels
• Symptoms resolve with glucose administration
• Typical onset 2-3+ years after surgery
• Usually 1-3 hours after meals
• Normal glucose and insulin response to prolonged fasting
• Loss of consciousness, seizures, strokes, falls, disability
• Unresponsive to dietary management
Severe PBH Occurs in a Subset of Patients
15
![Page 16: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/16.jpg)
Roller Coaster of Post-Bypass Glycemia Continuous Glucose Monitoring Reveals Spikes and Troughs
Patient Glucose Chart
16
![Page 17: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/17.jpg)
Time (min) 0 20 40 60 80 100 120
Glu
cose
(mg/
dL)
60
80
100
120
140
160
180
200
OW MOb
GB + NG Post-bypass hypoglycemia patients with neuroglycopenia GB Post-bypass, NO symptoms of hypoglycemia OW Obese, matched to patients’ current BMI MOb Morbidly obese, matched to patients’ pre-op BMI
Goldfine & Patti, JCEM 2007
GB Alters Post-Prandial Glucose Patterns
17
![Page 18: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/18.jpg)
Time (min) 0 20 40 60 80 100 120
Glu
cose
(mg/
dL)
60
80
100
120
140
160
180
200
GB OW MOb
GB + NG Post-bypass hypoglycemia patients with neuroglycopenia GB Post-bypass, NO symptoms of hypoglycemia OW Obese, matched to patients’ current BMI MOb Morbidly obese, matched to patients’ pre-op BMI
Goldfine & Patti, JCEM 2007
GB Alters Post-Prandial Glucose Patterns
18
![Page 19: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/19.jpg)
Time (min) 0 20 40 60 80 100 120
Glu
cose
(mg/
dL)
60
80
100
120
140
160
180
200
GB+NG (PBH) GB OW MOb
GB + NG Post-bypass hypoglycemia patients with neuroglycopenia GB Post-bypass, NO symptoms of hypoglycemia OW Obese, matched to patients’ current BMI MOb Morbidly obese, matched to patients’ pre-op BMI
Goldfine & Patti, JCEM 2007
GB Alters Post-Prandial Glucose Patterns
19
![Page 20: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/20.jpg)
Time (min) 0 20 40 60 80 100 120
Glucose (mg/dL)
60
80
100
120
140
160
180
200
Higher Levels of Insulin In Post-GB Patients with Neuroglycopenia
p (ANOVA) = 0.06
GB+NG GB OW MOb
Goldfine & Patti, JCEM 2007
0 20 40 60 80 100 120
Insulin (µU/mL)
0
50
100
150
200
250
300 GB+NG GB OW MOb
Time (min)
20
![Page 21: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/21.jpg)
Time (min) 0 20 40 60 80 100 120
0
100
200
300 GLP-1
GLP-1 Levels are Increased in PBH
Goldfine & Patti, JCEM 2007
*
*
*
*
p (ANOVA) = 0.03 pm
ol /
L
GB+NG GB OW MOb
Food Intake & Absorption
GLP-1
Intestine
Pancreas
GLP1
Insulin 21
![Page 22: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/22.jpg)
Food Intake in Post-Bariatric Patient
• Accelerated Intestinal Delivery
• Rapid ↑ Plasma Glucose
Chronic Intestinal & Neural Adaptation
• Dysregulated Enteroendocrine Cell Secretion • ↑ Secretion of incretin hormones e.g. GLP-1 • Altered Gut Microbiota • ↑ Bile Acids • Altered Intestinal Metabolism • β-Cell Trophic Hormones • Insulin-independent glucose disposal
↑ Postprandial Insulin
Secretion
Severe Hypoglycemia
Patti & Goldfine, Lancet Diab & Endo, 2016 22
![Page 23: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/23.jpg)
Method of Diagnosis Prevalence Hospitalization 0.1 - 1%a
Clinical recognition 0.4 - 6.6%b
Symptoms (survey) 33%c
OGTT glucose < 50 mg/dL 10 - 33%d
MMTT glucose < 55 mg/dL 29%e
CGMS (sensor glucose < 55 mg/dL) 75%e
Duration CGMS (sensor glucose < 60 mg/dL) 30 - 71 minf
Prevalence of PBH is Significant
aMarsk, Gribsholt, Sarwar, Lee; bKellogg, Gribsholt; cLee; dPigeyre, Goldfine, Papamargatis; eKefurt, fHalperin, Abrahamsson, Kefurt 23
![Page 24: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/24.jpg)
PBH: A Debilitating Disorder Summary
• Bariatric surgery is now recommended in treatment guidelines as an option for obesity and type 2 diabetes*
• RYGB and VSG are most common bariatric surgeries • Post-prandial hyperinsulinemia and hypoglycemia
- Impacts a significant % of RYGB patients - Neuroglycopenia, disability - Asymptomatic hypoglycemia is substantial
• Prevalence of post-bariatric hypoglycemia is significant
• Pharmacological treatment for PBH is needed *2016 Diabetes Surgery Summit (DSSI) guidelines
24
![Page 25: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/25.jpg)
Joslin Allison Goldfine Ping Li Ali Bajwa CRC Nurses & Staff Christopher Mulla Rohit Kulkarni Susan Bonner-Weir Gordon Weir Franco Folli Stefano La Rosa Jonathan Dreyfuss Hui Pan Emmy Suhl Joanne Rizzotto Patients!
Thank you to…
Surgery Edward Mun Daniel Jones Ben Schneider Douglas Hanto Mark Callery David Lautz Jim Moser
Pathology Jeffrey Goldsmith Eric Yee Radiology Elisa Franquet Gerald Kolodny George Watts
External Colleagues Jens Holst University of Copenhagen
Jean-Claude Reubi University of Geneva
Clary Clish Broad Institute
Funding NIDDK-SBIR (with Xeris)
AZ/BMS/Amylin Medimmune
Harvard School of Engineering Eyal Dassau Alejandro Laguna Frank Doyle
25
![Page 26: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/26.jpg)
Pharmacological Approaches to Hypoglycemia after Gastric Bypass
Surgery
Marzieh Salehi, MD Director of the Clinical & Translational Research Center Cedars-Sinai Medical Center
26
![Page 27: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/27.jpg)
Adapted: McIntyre N, et al; Lancet 1964; 41:20-1
Blood glucose Plasma insulin
Time (min)
Blo
od G
luco
se (m
g/dL
)
Intravenous Intrajejunal
Plas
ma
Insu
lin (
pmol
/L)
-30 -15 0 15 30 45 60 75 90 105 120 135 -30 -15 0 15 30 45 60 75 90 105 120 135
300
250
200
150
100
50
0
300
250
200
150
100
50
0
Time (min)
incretin effect ü GI hormones (GLP-1 / GIP) ü Neural factors ü Direct nutrient effect
Insulin Secretion is Greater With Oral Compared to IV Glucose
27
![Page 28: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/28.jpg)
0 3 0 6 0 9 0 1 2 0 1 5 0 1 8 0
3 .0
4 .5
6 .0
7 .5
9 .0
1 0 .5
T im e (m in )
Blo
od
glu
co
se
(m
mo
l/l)
A s y m p to m a tic -G B (2 9 )C o n tro ls (1 1 )
S y m p to m a tic -G B (3 6 )
0 3 0 6 0 9 0 1 2 0 1 5 0 1 8 00
4 0 0
8 0 0
1 2 0 0
1 6 0 0
T im e (m in )
Ins
uli
n (
pm
ol/
l)
Increased incretin effect after GB ü Gut hormones (mainly GLP-1) ü Neural factors ü Direct nutrient stimuli
Postprandial insulin secretion after RYGB is exaggerated in post-RYGB hypoglycemia
Salehi, et al; JCEM 2014 28
![Page 29: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/29.jpg)
• Frequent meals low in glycemic index
• Adding protein and fat to all meals and snacks
• Modification of source of carbohydrate - fructose instead of glucose
• Uncooked starch (Extend bar)
• Not effective in all patients with post-RYGB hypoglycemia
• Generally combined with other therapeutic options
Dietary Modification First Line Intervention
29
![Page 30: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/30.jpg)
• Pharmacological Treatments (approved for other indications) – Acarbose – Somatostatin analogues – Diazoxide (symptom relief) – Calcium Channel Blockers (symptom relief) – GLP-1 receptor analogue (liraglutide)
• Investigational Pharmacological Treatments – XOMA 358 – GLP-1 receptor antagonist (Exendin 9-39)
Pharmacological Approaches No FDA Approved Rx
30
![Page 31: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/31.jpg)
N=8
Acarbose (alpha-glucosidase inhibitor) Insulin secretion is reduced as a result of lower carbohydrate absorption
Valderas, et al; Obes Surg 2012 31
![Page 32: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/32.jpg)
Glucose Starch Sucrose Maltose
• Differential effect of on carbohydrate absorption • GI side effects (abdominal gas, bloating, and diarrhea)
Acarbose
Jenkins, et al; Diabetes 1981 32
![Page 33: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/33.jpg)
0 60 120 180 240 300 0 60 120 180 240 300
• Suppress insulin secretion both fasting and post-meal • Reduce GLP-1 secretion • Suppress glucagon and growth hormone (counter-regulatory hormones) • Limited by GI side effects (diarrhea) and cost
Case report: Hypoglycemia after RYGB compared with non-surgical controls (n=8)
Octreotide (100mcg) or placebo Before oral glucose ingestion
Glu
cose
(pm
ol/L
)
Insu
lin (p
mol
/L)
Somatostatin Analogues
Myint, et al; Euro J Endocrinol 2012
Time (min) Time (min)
33
![Page 34: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/34.jpg)
0 3 0 6 0 9 0 1 2 0 1 5 0 1 8 0
3 .0
4 .5
6 .0
7 .5
9 .0
1 0 .5
T im e (m in )
Blo
od
glu
co
se
(m
mo
l/l)
A s y m p to m a tic -G B (2 9 )C o n tro ls (1 1 )
S y m p to m a tic -G B (3 6 )
0 3 0 6 0 9 0 1 2 0 1 5 0 1 8 00
4 0 0
8 0 0
1 2 0 0
1 6 0 0
T im e (m in )
Ins
uli
n (
pm
ol/
l)
Increased incretin effect after GB ü Gut hormones (mainly GLP-1)
Post-prandial insulin secretion after RYGB is exaggerated in post-RYGB hypoglycemia
Salehi, et al; JCEM 2014 34
![Page 35: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/35.jpg)
0 3 0 6 0 9 0 1 2 0 1 5 0 1 8 00
7 0
1 4 0
2 1 0
T im e (m in )
GL
P-1
(p
g/m
L)
N o n -s u rg ic a l c o n tro ls
A s y m p to m a tic -R Y G BH y p o g ly c e m ic -R Y G B
L-Cell (ileum)
Proglucagon
GLP-1 [7-37]
GLP-1 [7-36NH2]
Salehi, et al; JCEM 2014
Hypoglycemic patients have larger GLP-1 response compared to those without
GLP-1 levels post-meal are greater after RYGB compared to non-surgical controls
35
![Page 36: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/36.jpg)
Accentuated GLP-1 action contributes to enhanced insulin
secretion after GB in general, and to a greater extent in
patients with hypoglycemia
36
![Page 37: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/37.jpg)
0.5 pmol/kg/min exendin 9-39 500 pmol/kg/min exendin 9-39
Pla
sma
Insu
lin (p
mol
/L)
Pla
sma
Glu
cose
(pm
ol/L
)
Glucose Insulin
0.5 pmol/kg/min exendin 9-39 500 pmol/kg/min exendin 9-39
Exendin 9-39 is a Potent GLP-1r Antagonist GLP-1-induced insulin response is suppressed by Exendin 9-39
1:1000 dose ratio
Edwards et al; Diabetes 1999 37
![Page 38: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/38.jpg)
Exendin 9-39: 500 pmol/kg/min IV
Insulin Glucose
Edwards et al; Diabetes 1999
Endogenous GLP-1 is important in regulation of glucose tolerance
GLP-1-induced insulin secretion is confounded by hyperglycemia
38
![Page 39: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/39.jpg)
2 0
4 0
6 0
8 0(%
)
*
G L P -1 - in d u c e d IS R(p o s tp ra n d ia l)
G B C O N
Salehi, et al; Diabetes 2011
GLP-1-stimulated insulin response to meal ingestion is larger in GB subjects
MTT: Fixed glucose 240-250 mg/dL
39
![Page 40: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/40.jpg)
3 0
5 5
8 0
1 0 5
1 3 0
1 5 5
1 8 0
In tra v e n o u s E x -9 o r s a lin e in fu s io n
M e a l
S a lin eE x -9
Blo
od
glu
co
se
(m
g/d
l) H yp o g ly c em ic -G B
In tra v e n o u s E x -9 o r s a lin e in fu s io n
M e a l
S a lin eE x -9
A s ym p tom a tic -G B
-120 -90 -60 -30 0 30 60 90 120 150 1800
300
600
900
1200
1500
1800
Time (min)
Insu
lin (p
mol
/l)
-120 -90 -60 -30 0 30 60 90 120 150 180Time (min)
-120 -90 -60 -30 0 30 60 90 120 150 180Time (min)
Blocking GLP-1r Corrected GB-related Hypoglycemia Through Reduction of Insulin Secretion
In tra v e n o u s E x -9 o r s a lin e in fu s io n
M e a l
S a lin eE x -9
C o n tro lsHypoglycemia-GB Asymptomatic-GB Controls
Blo
od g
luco
se (m
g/dL
) In
sulin
(pm
ol/L
)
Salehi, et al; Gastroenterology 2014 40
![Page 41: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/41.jpg)
• Medical nutrition therapy remains the first line of treatment
• No approved pharmacological therapy for RYGB-related hypoglycemia • Current treatments are suboptimal
• Exendin 9-39 targets underlying pathogenic factor:
à Increased GLP-1 contribution to insulin secretion
ü Intravenous infusion of Exendin 9-39 has been shown to correct
hypoglycemia in meal studies
ü Phase 2 studies with Exendin 9-39 in PBH underway (Eiger)
Summary
41
![Page 42: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/42.jpg)
Exendin 9-39 in
Post-Bariatric Hypoglycemia
COL L E EN M. CRA I G , M .D .
Division of Endocrinology, Metabolism & Gerontology Stanford University School of Medicine
Director, Clinical Development
Eiger BioPharmaceuticals
42
![Page 43: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/43.jpg)
Byetta (exenatide)
Bydureon (exenatide er) GLP-1 Agonist
Exendin 9-39 Well-characterized GLP-1 Antagonist
Exendin 9-39
GLP-1 Antagonist
31-amino-acid fragment of exenatide, a GLP-1 agonist
43
![Page 44: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/44.jpg)
Exendin 9-39 Blocks the GLP-1 Receptor Prevents Dysregulated Secretion of Insulin
44
![Page 45: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/45.jpg)
Study # Patients Duration of dosing Dose Status
Phase 1 Continuous IV infusion
8 Single dose 0.03 mg/kg bolus
+ 0.35 mg/kg
Complete In press: Diabetologia
Phase 2a SAD
SC injection 8 Single dose 0.1 – 0.3 mg/kg
Complete Oral presentation 2016 ADA
Manuscript in draft
Phase 2a MAD SC injection
11 (completed
to date)
Up to 3 days
BID dosing 0.05 - 0.4 mg/kg In progress
3 Clinical Studies of Exendin 9-39 at Stanford 27 Patients Dosed
Over 300 patients are reported to have received exendin 9-39 as an investigational agent worldwide.
45
![Page 46: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/46.jpg)
Exendin 9-39: Phase 1b IV Infusion Study Crossover Design, Placebo-controlled Trial
46
![Page 47: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/47.jpg)
Day 1 OGTT
Day 2 OGTT
Screening & Randomization
Washout 24 hr – 7 day
Ran
dom
izat
ion
Inclusion Criteria: 1) Whipple’s triad 2) Hyperinsulinemia (> 3 uU/mL)
Endpoints: 1°: Prevention of hypoglycemia (≤ 50 mg/dL) 2°: Improvement in symptom score
N = 8
Exendin 9-39: Phase 1b IV Infusion Study Crossover Design, Placebo-controlled Trial
OGTT = oral glucose tolerance test 47
![Page 48: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/48.jpg)
0
50
100
150
200
250
0 30 60 90 120 150 180
Mea
n G
luco
se (m
g/dL
)
Time (minutes)
Placebo (n=8)
Hypoglycemia
Placebo IV Infusion All patients became hypoglycemic
Rapid decline
High peak
All subjects required rescue with IV dextrose
48
![Page 49: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/49.jpg)
0
50
100
150
200
250
0 30 60 90 120 150 180
Mea
n G
luco
se (m
g/dL
)
Time (minutes)
IV Ex-9 (n=8)
Placebo (n=8)
* *
Hypoglycemia
Exendin 9-39: 100% Reversal of Hypoglycemia Phase 1b IV Infusion Study
Hypoglycemia prevented
* P < 0.01
Reduced rate of glucose decline
IV Exendin 9-39 (n=8)
Peak magnitude unchanged
In press: Diabetologia
No patients required rescue with IV dextrose
Dose = 0.38 mg/kg
49
![Page 50: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/50.jpg)
Severity ranked 5-point scale: • 0=none • 5=severe ** **
Subjects surveyed every 30 min for presence of: • Autonomic symptoms • Neuroglycopenia • Malaise
Composite Scores
** P < 0.001
Improved Symptoms of Hypoglycemia Exendin 9-39 Phase 1b IV Infusion Study
Edinburgh Hypoglycemia Symptom Scoring
)
50
Overall Glucose Rise Glucose Fall Placebo 26.5 8.1 24.0 IV Exendin (9-39 4.5 3.1 3.9
0
5
10
15
20
25
30
Sym
ptom
Sco
re
![Page 51: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/51.jpg)
Exendin 9-39: Phase 2a SC SAD Study Single-Ascending Dose Study
51
![Page 52: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/52.jpg)
SC Exendin 9-39 with OGTT Baseline OGTT
Ran
dom
izat
ion
Endpoints: 1°: Prevention of hypoglycemia (≤ 50 mg / dL) 2°: Improvement in hypoglycemia symptom score Pharmacokinetic profile Safety & Tolerability
N=8
Exendin 9-39: Phase 2a SC SAD Study
OGTT = oral glucose tolerance test 52
![Page 53: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/53.jpg)
0
50
100
150
200
250
0 60 120 180
Mea
n G
luco
se (m
g/dL
)
Time (minutes)
Baseline (n=8)
Hypoglycemia
Baseline OGTT: All Patients Became Hypoglycemic Phase 2a SAD SC Exendin 9-39 Study
All subjects required rescue
Rapid decline
High peak
53
![Page 54: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/54.jpg)
Exendin 9-39: All Doses Therapeutic Phase 2a SAD SC Study
0
50
100
150
200
250
0 60 120 180
Mea
n G
luco
se (m
g/dL
)
Time (minutes)
SC Ex-9 (n=8)
Baseline (n=8)
Hypoglycemia
**
* P < 0.05
*
** P < 0.01
Hypoglycemia prevented
Rate of glucose decline reduced
Peak statistically unchanged
Presented at 2016 ADA Manuscript in draft
No patients required rescue with IV dextrose
54
![Page 55: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/55.jpg)
Edinburgh Hypoglycemia Symptom Scoring
**
*
Exendin 9-39 Reduced Symptoms of Hypoglycemia Phase 2a SAD SC Study
Overall Glucose Rise Glucose Fall Baseline 21.6 11.4 17.5 SC Exendin (9-39) 14.6 12.3 4.0
0
5
10
15
20
25
Sym
ptom
Sco
re
* P < 0.01 ** P < 0.001
55
![Page 56: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/56.jpg)
Exendin 9-39: Phase 2a SC MAD Study Multiple-Ascending Dose Study
56
![Page 57: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/57.jpg)
OGTT = oral glucose tolerance test
N =
16
DAY 4 PK + Safety
Baseline
OGTT DAY 1 SC inj
DAY 2 SC inj
DAY 3 OGTT + SC inj
Purpose: • To evaluate the efficacy, safety, and PK profile of multi-ascending doses of SC
exendin 9-39 after up to 3 days of treatment • To determine the lowest effective dose
Exendin 9-39: Phase 2 SC MAD Study Multiple-Ascending Dose Study
0.4 mg/kg
0.3 mg/kg
0.2 mg/kg
0.1 mg/kg
0.05 mg/kg Bro
ader
spe
ctru
m o
f dos
es
57
![Page 58: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/58.jpg)
Dose (mg/kg) 0.05 0.1 0.2 0.3 0.4
# Patients 3 3 1 2 2
% Increase Nadir 11 ± 18 4 ± 5 26 41 ± 17 31 ± 3
Mea
n %
Incr
ease
in
Glu
cose
Nad
ir
Therapeutic Increase in Glucose Nadir For Patients Dosed ≥ 0.2 mg/kg
0
10
20
30
40
0.05 mg/kg 0.1 mg/kg 0.2 mg/kg 0.3 mg/kg 0.4 mg/kg
All patients required rescue
All dose levels reduced magnitude of hypoglycemia
58
![Page 59: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/59.jpg)
Exendin 9-39 Prevented Severe Hyperinsulinemia Fasting Insulin, Fasting Glucose Not Raised: a Targeted Therapeutic Approach
Insu
lin (µ
U/m
L)
Time (min) A
UC
insu
lin (µ
U/m
L m
in)
0
5000
10000
15000
20000
25000
30000
35000
Baseline SC Ex-9
51% reduction in peak insulin
0
50
100
150
200
250
300
350
400
0 30 60 90 120 150 180
baseline SC-ex
59
![Page 60: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/60.jpg)
Exendin 9-39 Improved Symptoms of Hypoglycemia For Patients Dosed ≥ 0.2 mg/kg
Overall Glucose Rise Glucose Fall Baseline 16 12 13 SC-Ex-9 9 8 6
0
5
10
15
20
Sym
ptom
Sco
re
Edinburgh Hypoglycemia Symptom Scoring
0 1 2 3 4 5 6 7 8
Autonomic Neuroglycopenic
Baseline
SC Ex-9
*
* P < 0.05
Sym
ptom
Sco
re
60
![Page 61: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/61.jpg)
Dog
Pla
sma
of E
xend
in
9-39
(ng/
mL)
Time (h)
800
600
400
200
0 0 2 4 6 8 10 12 14 16 18 20 22 24
Novel Liquid Formulation: Improved Exposure Compared to Original Lyophilized Formulation
To be evaluated in planned Phase 1 PK study in healthy humans To be tested in remaining patients in ongoing MAD study
3x higher Cmax; potential opportunity for lower dosing
Data will inform dosing for planned Phase 2 study
Liquid formulation 0.72 mg/kg Lyophilized powder 0.72 mg/kg
0.72 mg/kg dose in dog = 0.38 mg/kg dose in human 61
![Page 62: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/62.jpg)
Phase 2a SC Exendin 9-39 MAD Study Summary
• Exendin 9-39 SC administered in doses ranging from 0.05 - 0.4 mg/kg
• All doses administered were well-tolerated - Headache and nausea were reported
• All doses reduced the magnitude of post-prandial hypoglycemia
• All doses reduced the presence and severity of symptoms of hypoglycemia • Novel liquid formulation appears to increase Cmax by 3x
- Potential opportunity for lower dosing
62
![Page 63: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/63.jpg)
Exendin 9-39 Clinical and Regulatory Path to Registration
2015
N=8
N=8
SC Injection SAD
Study
SC SAD Oral Preso
IV Infusion Study
IV Manuscript in Press: Diabetologia
N=16
SC Injection MAD Study
Dosing Now
ADA June 2016
US & EU Orphan Designation
File Eiger IND
2016 2017
Phase 1 PK
Study
Phase 2 Study
Dosing with new liquid formulation planned
63
![Page 64: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/64.jpg)
Acknowledgements
Stanford University McLaughlin Lab Tracey McLaughlin Li-fen Liu Dalia Perelman Marilyn Tan Cindy Lamendola Roger Luong Thi Nguyen Kathryn Weaver Elizabeth Colbert University of Copenhagen Carolyn Deacon Jens Holst Lene Albaek Washington University David Gibson
Eiger BioPharmaceuticals Stanford TRAM Pilot program Dean Felsher Joanna Lilienthal Stanford SPARK program Daria Mochly-Rosen Kevin Grimes KL2 Mentored Career Development Award NIH KL2 TR 001083
64
![Page 65: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/65.jpg)
Q & A
Developing a Treatment for Post-Bariatric Hypoglycemia
![Page 66: Developing a Treatment for Post-Bariatric Hypoglycemia](https://reader034.fdocuments.in/reader034/viewer/2022051600/627f868329343411c31f315b/html5/thumbnails/66.jpg)
Clinical Data and News Flow Phase 2 Results Across All Programs
2016
Lonafarnib: LOWR HDV – 2 Interim (EASL 2016)
Exendin 9-39: SC SAD Study Data (ADA 2016)
Lonafarnib: LOWR HDV EOT Data (AASLD 2016)
Exendin 9-39: SC MAD Interim Data
Lonafarnib: LOWR HDV EOF Data (EASL 2017)
Exendin 9-39: SC MAD Final Data
Lonafarnib: HDV Agency Meeting
Ubenimex: Lymphedema ULTRA Study
Ubenimex: PAH LIBERTY Study
2017
66
þþþþ