New Frontiers and Advances in Oral Therapy for Type 2 Diabetes Focus on DPP-4 Inhibition and...

New Frontiers New Frontiers andand Advances Advances inin

Oral Therapy Oral Therapy forfor Type 2 Type 2 DiabetesDiabetes

Focus on DPP-4 Inhibition and Focus on DPP-4 Inhibition and Incretin-Based Therapy (IBT)Incretin-Based Therapy (IBT)

Program ChairmanProgram ChairmanCharles Faiman, MD, FRCPC,MACECharles Faiman, MD, FRCPC,MACE

Past ChairmanPast ChairmanConsultant StaffConsultant Staff

Department of Endocrinology, Diabetes and MetabolismDepartment of Endocrinology, Diabetes and MetabolismCleveland Clinic FoundationCleveland Clinic Foundation

Investigations • Innovation • Clinical ApplicationInvestigations • Innovation • Clinical Application

CME-certified symposium CME-certified symposium jointly jointly sponsored by the University of sponsored by the University of Massachusetts Medical School Massachusetts Medical School and CMEducation Resources, and CMEducation Resources, LLCLLC

Commercial Support: Commercial Support: Sponsored Sponsored by an independent educational by an independent educational grant grant from Bristol-Myers Squibb from Bristol-Myers Squibb and AstraZeneca Partnershipand AstraZeneca Partnership

Faculty disclosures: Faculty disclosures: Listed in Listed in program syllabusprogram syllabus

Welcome and Program Overview Welcome and Program Overview

Program FacultyProgram Faculty

Program ChairmanProgram ChairmanCharles Faiman, MD, Charles Faiman, MD, FRCPC,MACEFRCPC,MACEPast ChairmanPast ChairmanConsultant StaffConsultant StaffDepartment of Endocrinology, Department of Endocrinology, Diabetes Diabetes and Metabolismand MetabolismCleveland Clinic Foundation Cleveland Clinic Foundation

Samir Malkani, MDSamir Malkani, MDDirector, Adult Diabetes Clinic, Director, Adult Diabetes Clinic, University CampusUniversity CampusUMass Memorial Medical CenterUMass Memorial Medical CenterClinical Associate Professor of Clinical Associate Professor of MedicineMedicineUniversity of Massachusetts University of Massachusetts Medical Medical SchoolSchoolUMASS Memorial Medical CenterUMASS Memorial Medical CenterWorcester, MAWorcester, MA

Alexander Turchin, MD, MSAlexander Turchin, MD, MSAssistant ProfessorAssistant ProfessorHarvard Medical SchoolHarvard Medical SchoolBrigham and Women's HospitalBrigham and Women's HospitalBoston, MABoston, MA

Derek LeRoith, MD, PhD, Derek LeRoith, MD, PhD, FACPFACPChief, Division of Endocrinology, Chief, Division of Endocrinology, Diabetes and Bone DiseaseDiabetes and Bone DiseaseDirector, Metabolism Institute,Director, Metabolism Institute,Mount Sinai School of MedicineMount Sinai School of MedicineNew York, NYNew York, NY

Type 2 Diabetes 2010:Type 2 Diabetes 2010:New FrontiersNew Frontiers

New Frontiers New Frontiers andand Advances Advances inin

Oral Therapy Oral Therapy forfor Type 2 Diabetes Type 2 Diabetes




Number of People with Diabetes Number of People with Diabetes (20-79 (20-79 years)years)

2010 and 20302010 and 2030

Country/TerritoryCountry/Territory 2010 Millions2010 Millions

India 50.8

China 43.2

United States 26.8

Russian Federation 9.6

Brazil 7.6

Germany 7.5

Pakistan 7.1

Japan 7.1

Indonesia 7.0

Mexico 6.8

Country/TerritoryCountry/Territory 2030 Millions2030 Millions

India 87.0

China 62.6

United States 36.0

Pakistan 13.8

Brazil 12.7

Indonesia 12.0

Mexico 11.9

Bangladesh 10.4

Russian Federation 10.3

Egypt 8.6

IDF Diabetes Atlas, 4IDF Diabetes Atlas, 4thth ed. International Diabetes Federation, 2009 ed. International Diabetes Federation, 2009

At a Glance: WorldAt a Glance: World

At a GlanceAt a Glance 20102010 20302030

Total world population (billions) 7.0 8.4

Adult population (20-79 yrs, billions) 4.3 5.6

Diabetes (20-79 Years)

Global prevalence (%) 6.6 7.8

Comparative prevalence (%) 6.4 7.7

Number of people with diabetes (millions) 285 438

IGT (20-79 years)

Global prevalence (%) 7.9 8.4


Number of people with IGT (millions) 344 472

Number of People with Diabetes Number of People with Diabetes by Age Group, 2010 and 2030by Age Group, 2010 and 2030

Mill

ions

Mill

ions

Number of People with Impaired Glucose Number of People with Impaired Glucose Tolerance by Age Group, 2010 and 2030Tolerance by Age Group, 2010 and 2030

Mill

ions

Mill

ions

North America and Caribbean Region North America and Caribbean Region


Total population (millions) 477 555

Adult population (20-79 yrs, millions) 320 390

Diabetes (20-79 Years)

Regional prevalence (%) 11.7 13.6


Number of people with diabetes (millions) 37.4 53.2

IGT (20-79 years)

Regional prevalence (%) 11.4 12.6


Number of people with IGT (millions) 36.6 49.1

North America and Caribbean Region North America and Caribbean Region


Type 1 diabetes (0-14 years)

Number of children with type 1 diabetes (thousands)

96.7

Number of newly-diagnosed cases per year (thousands)

14.7

Diabetes mortality (20-79 years)

Number of deaths, male (thousands) 141.0

Number of deaths, female (thousands) 172.2

Health expenditure for diabetes (USD)

Total health expenditure, R=2 (billions) 214.2 288.7

Highest PrevalenceHighest PrevalenceDiabetes Diabetes

► Pacific Island - 43%Pacific Island - 43%

► Arab Gulf States (U.A.E.) - 19%Arab Gulf States (U.A.E.) - 19%

► U.S.A. / CanadaU.S.A. / Canada

- Natives- Natives

- Blacks / Hispanics- Blacks / Hispanics

Costs for DM Care: 2010Costs for DM Care: 2010

► United States United States $198 billion$198 billion

► World World $376 billion$376 billion

Definition of DiabetesDefinition of Diabetes

IndicatorIndicator AmericanAmerican(mg/dL)(mg/dL)

SISI(mmo/L)(mmo/L)

Glucose – FastingNormalNormal 65 - 9965 - 99 3.6 – 5.53.6 – 5.5

DMDM >> 126 126 >> 7.0 7.0

Random (with symptoms) DMDM >> 200 200 > > 11.111.1

GTT (2 hr.) DMDM >> 200 200 > > 11.111.1

HbA1c DMDM >> 6.5% 6.5%

Definition of Impaired Glucose ToleranceDefinition of Impaired Glucose Tolerance

IndicatorIndicator mg/dLmg/dL mmo/Lmmo/L

Fasting glucose 100 – 125100 – 125 >>5.6 – 6.95.6 – 6.9

Glucose tolerance test 140 – 199140 – 199 7.8 – 11.07.8 – 11.0

HbA1c 5.7% – 6.4%5.7% – 6.4%

Types Of DiabetesTypes Of Diabetes

► Type 1 (Juvenile-Onset)Type 1 (Juvenile-Onset)

► Type 2 (Adult-Onset)Type 2 (Adult-Onset)

► Other types including:Other types including:

- Gestational diabetes- Gestational diabetes

- MODY (maturity onset diabetes of the - MODY (maturity onset diabetes of the young)young)

- LADA (latent auto-immune diabetes of - LADA (latent auto-immune diabetes of adults)adults)

- Others- Others

Cause of Type 1 DMCause of Type 1 DM

► Auto-immune destruction ofAuto-immune destruction of

insulin-producing insulin-producing ββ--cells cells inin

the pancreasthe pancreas

Cause of Type 2 DMCause of Type 2 DM

► Insulin resistance (genetics)Insulin resistance (genetics)

- aggravated by obesity- aggravated by obesity

- aggravated by lack of exercise- aggravated by lack of exercise

► ““Exhaustion” of insulin-producing Exhaustion” of insulin-producing ββ--cellscells

Major Metabolic Defects Major Metabolic Defects in Type 2 Diabetesin Type 2 Diabetes

► Peripheral insulin resistance Peripheral insulin resistance in muscle and fatin muscle and fat

► Decreased pancreatic Decreased pancreatic insulin secretioninsulin secretion

► Increased hepatic glucose Increased hepatic glucose outputoutput

Haffner SM, et al. Haffner SM, et al. Diabetes CareDiabetes Care, 1999, 1999

Development and Progression Development and Progression of Type 2 Diabetes*of Type 2 Diabetes*

RelativeActivity

Glucose

Years from Diabetes Diagnosis–10 –5 0 5 10 15 20 25 30

-10 -5 0 5 10 15 20 25 30

*Conceptual representation. NGT=normal glucose tolerance; IGT=impaired glucose tolerance; IFG=impaired fasting glucose.Adapted from Ferrannini E. Presentation at 65th ADA in Washington, DC, 2006.; and Ramlo-Halsted et al. Prim Care. 1999;26:771–789.

NGT Insulin IGT/ IFG Type 2 Diabetes Resistance

Postprandial glucose

Fasting glucose

Insulin resistance —hepatic and peripheral

Insulin level

Beta-cell function

Functional Defects in ß-Cells in the Functional Defects in ß-Cells in the Development of DiabetesDevelopment of Diabetes

► Progressive decrease in Progressive decrease in -cell insulin -cell insulin secretion in response to nutrientssecretion in response to nutrients● First manifested as a decrease in First manifested as a decrease in

early or acute insulin secretion early or acute insulin secretion (decreased first phase insulin (decreased first phase insulin secretion)secretion)

► Loss of normal minute-by-minute Loss of normal minute-by-minute pulsatile insulin secretion and daily pulsatile insulin secretion and daily ultradian rhythm of secretionultradian rhythm of secretion

► Decreases in insulin processing with Decreases in insulin processing with increased proinsulin:insulin ratioincreased proinsulin:insulin ratio

Type 2 Diabetes: Pathogenesis in a Type 2 Diabetes: Pathogenesis in a Nutshell Nutshell (cont.)(cont.)

► Type 2 diabetes has been considered a Type 2 diabetes has been considered a PROGRESSIVE diseasePROGRESSIVE disease● -cell dysfunction first leads to impaired -cell dysfunction first leads to impaired

glucose tolerance, which in some glucose tolerance, which in some individuals progresses to type 2 diabetesindividuals progresses to type 2 diabetes

● -cell dysfunction starts long before -cell dysfunction starts long before blood glucose rises and worsens after blood glucose rises and worsens after diabetes developsdiabetes develops

► Hyperglycemia may cause additional Hyperglycemia may cause additional defects defects in insulin secretion and insulin action in insulin secretion and insulin action (glucotoxicity(glucotoxicity))

Buchanan TA. Buchanan TA. Clin TherClin Ther. 2003;25(suppl B):B32-B46.. 2003;25(suppl B):B32-B46.DeFronzo RA. DeFronzo RA. Med Clin North AmMed Clin North Am. 2004;88:787-835. . 2004;88:787-835. Kahn SE. Kahn SE. J Clin Endocrinol MetabJ Clin Endocrinol Metab. 2001;86:4047-4058.. 2001;86:4047-4058.

0

UKPDS: Progressive Deterioration in UKPDS: Progressive Deterioration in Glycemic Control Over TimeGlycemic Control Over Time

IntensiveConventional

Time from randomization (y)

63 9 12 15

Med

ian

A1C

(%

)

A1C

Years from diagnosis

-ce

ll fu

nctio

n (%

)

100

80

60

40

20

0

UKPDS Group. Lancet. 1998;352:837-853.

-12 -10 -8 -6 -4 -2 0 2 4 6

Holman RR. Diabetes Res Clin Pract. 1998;40(suppl):S21-S25.

9

8

7

60

Mechanisms Responsible for Changes Mechanisms Responsible for Changes in Insulin Levelsin Insulin Levels

► Normal Normal -cell adaptation to insulin -cell adaptation to insulin resistanceresistance● Increased secretion from each cellIncreased secretion from each cell● Increased Increased -cell mass-cell mass

► Impaired Impaired -cell adaptation in type 2 -cell adaptation in type 2 diabetes result ofdiabetes result of● Decreased secretion from each cellDecreased secretion from each cell● Reduced Reduced -cell mass-cell mass

Potential Causes for DecliningPotential Causes for DecliningInsulin SecretionInsulin Secretion

Glucotoxicity Lipotoxicity

-cell

ApoptosisInsulinSecretion

Prentki M et al. Prentki M et al. Diabetes.Diabetes. 2002;51(suppl 3):s405-s413. 2002;51(suppl 3):s405-s413.

Abnormalities of Abnormalities of αα-Cell -Cell Function in Type 2 DiabetesFunction in Type 2 Diabetes

► Elevated glucagon levelsElevated glucagon levels

► Loss of insulin-induced suppressionLoss of insulin-induced suppression

► Loss of glucose-induced suppressionLoss of glucose-induced suppression

► Increased stimulatory effect of Increased stimulatory effect of argininearginine

Dunning BE et al. Dunning BE et al. Diabetologia. Diabetologia. 2005;48:1700-1713.2005;48:1700-1713.

SummarySummary

► Islets can adapt to insulin resistanceIslets can adapt to insulin resistance

► Failure of adaptation results in impaired Failure of adaptation results in impaired glucose tolerance and eventually, type 2 glucose tolerance and eventually, type 2 diabetesdiabetes

► Failure appears to be due to reduced Failure appears to be due to reduced insulin secretion per islet and a reduction insulin secretion per islet and a reduction in the in the number of isletsnumber of islets

► Increased glucagon contributes to Increased glucagon contributes to hyperglycemia in type 2 diabeteshyperglycemia in type 2 diabetes

Global Cardiometabolic Risk*Global Cardiometabolic Risk*

Gelfand EV Gelfand EV et alet al, 2006; Vasudevan AR , 2006; Vasudevan AR et alet al, 2005, 2005 * working definition* working definition

Differentiating Type 1 Vs. Type 2 DMDifferentiating Type 1 Vs. Type 2 DM

► Presentation with ketoacidosisPresentation with ketoacidosis

► Age at onsetAge at onset

► Testing for C-peptide levelsTesting for C-peptide levels

► Testing for antibodiesTesting for antibodies - GAD-65- GAD-65 - IA2- IA2 - Insulin- Insulin - Islet-cell- Islet-cell

► Trial of oral agentsTrial of oral agents

Other Kinds of DiabetesOther Kinds of Diabetes

► LADA (latent autoimmune disease of LADA (latent autoimmune disease of adults)adults)

► MODY (maturity-onset diabetes of the MODY (maturity-onset diabetes of the young)young)

► Gestational diabetesGestational diabetes

► Stress-inducedStress-induced

► Post-transplantPost-transplant

Complications of DiabetesComplications of Diabetes

► Small Blood VesselSmall Blood Vessel - eye (retina) – blindness- eye (retina) – blindness

- kidney failure – dialysis- kidney failure – dialysis

► Large Blood VesselLarge Blood Vessel - heart attacks- heart attacks

- strokes- strokes

- peripheral vascular : amputations- peripheral vascular : amputations

► NeuropathyNeuropathy

► Erectile dysfunction (both vascular and nerve Erectile dysfunction (both vascular and nerve damage)damage)

Avoiding Complications - IAvoiding Complications - I

► Diet / exerciseDiet / exercise

► ‘‘Girth’ controlGirth’ control

► Sugar controlSugar control

► Lipid (cholesterol) controlLipid (cholesterol) control

► Blood pressure controlBlood pressure control

Avoiding Complications - IIAvoiding Complications - II

► Self-monitoring glucoseSelf-monitoring glucose

► Visits to PCP – endocrinologist: goals Visits to PCP – endocrinologist: goals

► Eye examsEye exams

► Podiatry examsPodiatry exams

► Periodic blood / urine lab testingPeriodic blood / urine lab testing

Standards of CareStandards of CareAmerican Diabetes AssociationAmerican Diabetes Association

► Glycemia: HbAGlycemia: HbA1c1c <7.0%, <7.0%,

FPG 90-130 mg/dL, PP <180 mg/dLFPG 90-130 mg/dL, PP <180 mg/dL

► Blood Pressure: <130/80 mm HgBlood Pressure: <130/80 mm Hg

► Lipids: LDL <100 mg/dL; TG <150 Lipids: LDL <100 mg/dL; TG <150

mg/dLmg/dL

► YearlyYearly● Dilated eye exam; urinary protein; Dilated eye exam; urinary protein;

foot exam; flu shotfoot exam; flu shot

► OtherOther● Aspirin usage; pneumococcal vaccineAspirin usage; pneumococcal vaccine

AACE goalsHbA1c 6.5% FPG 110 mg/dL PP 140 mg/dL

NCEPLDL ≤70 mg/dL

FPG – fasting plasma glucosePP - Postprandial

ADA. ADA. Diabetes CareDiabetes Care. 2009;32(suppl 1);S13-S61. . 2009;32(suppl 1);S13-S61.

Oral Drugs for Rx DM2Oral Drugs for Rx DM2

► Metformin (glucophage)Metformin (glucophage)

► Sulfonylureas (glyburide, glipizide, Sulfonylureas (glyburide, glipizide, glimepiride)glimepiride)

► Thiazolidinediones (actos, avandia)Thiazolidinediones (actos, avandia)

► DPP-IV inhibitors (januvia, onglyza)DPP-IV inhibitors (januvia, onglyza)

► Glucosidase inhibitors (acarbose, miglitol)Glucosidase inhibitors (acarbose, miglitol)

► Others: colesevelam ; bromocriptineOthers: colesevelam ; bromocriptine

Injectables For RX DM2Injectables For RX DM2

► Pramlintide (Symlin)Pramlintide (Symlin)

► Exenatide (Byetta) / liraglutide (Victoza)Exenatide (Byetta) / liraglutide (Victoza)

► InsulinsInsulins

NativeNative - Regular (short-acting)- Regular (short-acting)

- Isophane (NPH : intermediate)- Isophane (NPH : intermediate)

- Mixtures- Mixtures

AnaloguesAnalogues - Glargine / Detemir (long-acting)- Glargine / Detemir (long-acting)

- Humalog, Novolog, Apidra (rapid)- Humalog, Novolog, Apidra (rapid)

- Mixtures- Mixtures

ConclusionsConclusions

► No specific drugs or regimens No specific drugs or regimens seem to have a seem to have a necessarily adverse effect on cardiovascular necessarily adverse effect on cardiovascular event rates despite expressed concerns about event rates despite expressed concerns about certain drugscertain drugs

► A1C goalA1C goal should be individualizedshould be individualized• <6.5% if healthy, and short duration diabetes and long life <6.5% if healthy, and short duration diabetes and long life

expectancyexpectancy

• <7% average patient<7% average patient

• <7.5-8% medically complex, clinical cardiovascular disease, <7.5-8% medically complex, clinical cardiovascular disease, failed failed to achieve lower target with lifestyle, metformin and adequate to achieve lower target with lifestyle, metformin and adequate doses doses of insulinof insulin

► The futureThe future: : continuing surveillance of newer continuing surveillance of newer classes of drugs for adverseclasses of drugs for adverse – or beneficial – – or beneficial – cardiovascular effectscardiovascular effects

Future Rx DM2Future Rx DM2

► Longer acting GLP-1 analoguesLonger acting GLP-1 analogues

► More DPP-IV inhibitorsMore DPP-IV inhibitors

► More TZD’sMore TZD’s

► Newer drug classes : e.g., SGLT2-Newer drug classes : e.g., SGLT2-inhibitorsinhibitors

NOTE : NOTE : FDA requires longer duration studies in FDA requires longer duration studies in DM2 to better understand risk / benefit before DM2 to better understand risk / benefit before approvalapproval

Prevention of DMPrevention of DM

► TYPE 1TYPE 1 - Immune modulation- Immune modulation

► TYPE 2TYPE 2 - Diet/exercise- Diet/exercise - Drugs: Metformin- Drugs: Metformin TZD’sTZD’s Glucosidase inhibitorsGlucosidase inhibitors Others?Others?

Today’s ProgramToday’s Program

► Evolving science & medicine of Evolving science & medicine of incretin-based therapyincretin-based therapy

► Options, strategies and combinationsOptions, strategies and combinations

► Practice – focused overviewPractice – focused overview

► T2DM Rx in 2010 – where are we?T2DM Rx in 2010 – where are we?

Stamp Out Diabetes!Stamp Out Diabetes!

The Current Armamentarium of Oral The Current Armamentarium of Oral Agents for Type 2 Diabetes Mellitus—Agents for Type 2 Diabetes Mellitus—

Sequencing Oral Therapy Sequencing Oral Therapy

When and Where Do We Start? When When and Where Do We Start? When Do We Add? How Do The Guidelines Do We Add? How Do The Guidelines

Guide Us?Guide Us?


Samir Malkani, MDSamir Malkani, MDDirector, Adult Diabetes Clinic, University CampusDirector, Adult Diabetes Clinic, University Campus

UMass Memorial Medical CenterUMass Memorial Medical CenterClinical Associate Professor of MedicineClinical Associate Professor of Medicine

University of Massachusetts Medical SchoolUniversity of Massachusetts Medical SchoolUMASS Memorial Medical CenterUMASS Memorial Medical Center

Worcester, MAWorcester, MA

0

1

2

3

4

5

6

7

1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06

Year

Per

cen

t w

ith

Dia

bet

es

0

2

4

6

8

10

12

14

16

18

20

Nu

mb

er w

ith

Dia

bet

es (

Mil

lio

ns)Percent with Diabetes

Number with Diabetes

Number and Percentage of U.S. Number and Percentage of U.S. Population with Diagnosed Diabetes, Population with Diagnosed Diabetes,

1958-2008 1958-2008

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

19951995

U.S. Population with Diagnosed Diabetes, U.S. Population with Diagnosed Diabetes, 1995-2008 1995-2008


20012001


20082008

Too fatToo thin


Natural History of Type 2 DiabetesNatural History of Type 2 Diabetes

Insulin resistance

Years of diabetesYears of diabetes

Beta-cell failure Insulin output

Fasting glucose

50100

200

300

Glu

cose

(m

g/dL

)G

luco

se (

mg/

dL)

Post-meal glucose

DiabetesDiabetes

0

100

200

300

–10 –5 0 5 10 15 20 25 30Rel

ativ

e R

elat

ive

-ce

ll-c

ell

func

tion

(%)

func

tion

(%)

At risk for diabetes

The Importance of ß-Cell Failure in the Development The Importance of ß-Cell Failure in the Development and Progression of Type 2 Diabetesand Progression of Type 2 Diabetes

FIG. 7. Model for the relationship between cell dysfunction and deterioration of glucose tolerance. As cell function declines, glucose tolerance deteriorates so that the criteria for impaired fasting glucose and/or impaired glucose tolerance are reached.Subsequently, with a further loss of cell function, diabetes developsbased on either or both the fasting and 2-h glucose levels

The Journal of Clinical Endocrinology & Metabolism, September 2001, 86(9):4047–4058The Journal of Clinical Endocrinology & Metabolism, September 2001, 86(9):4047–4058

Steven E Kahn

HbA1c Trend with Time - UKPDSHbA1c Trend with Time - UKPDS

06

7

8

9

0 3 6 9 12 15

HbA

1c (%

)

Years from randomisation

Conventional

Intensive

6.2% upper limit of normal range

Targets for Glycemia ControlTargets for Glycemia Control

Recommendations for glycemia control from the American Diabetes Association and the Recommendations for glycemia control from the American Diabetes Association and the American Association of Clinical Endocrinologists. *The glycated hemoglobin (HbA1c) goal for American Association of Clinical Endocrinologists. *The glycated hemoglobin (HbA1c) goal for patients in general is less than 7.0%, while the HbA1c goal for selected patients is as close to patients in general is less than 7.0%, while the HbA1c goal for selected patients is as close to normal (normal (<<6.0%) as possible without significant hypoglycemia. 6.0%) as possible without significant hypoglycemia. Sources:Sources: American Diabetes American Diabetes Association.Association. Diabetes Care. 2010;33(suppl 1):S11-S61; ACE/AACE Diabetes Road Map Task Diabetes Care. 2010;33(suppl 1):S11-S61; ACE/AACE Diabetes Road Map Task Force. Endocr Pract. 2007;13:260-268.Force. Endocr Pract. 2007;13:260-268.

Dietary TherapyDietary Therapy

► Best implemented by a registered dietitian Best implemented by a registered dietitian experienced in behavioral modificationexperienced in behavioral modification

► Individualized diet based on weight, lipids, Individualized diet based on weight, lipids, lifestylelifestyle● Total carbohydrates 45-65% of daily energy Total carbohydrates 45-65% of daily energy

intakeintake• Avoid sugars, increase complex Avoid sugars, increase complex

carbohydrates, 50 gram of fiber dailycarbohydrates, 50 gram of fiber daily● Fat <30% calories (<7% saturated)Fat <30% calories (<7% saturated)

► Dietary therapy alone can reduce A1C by Dietary therapy alone can reduce A1C by 0.25-3% or more0.25-3% or more

Diabetes Care, 2010. 33 (Supp 1) S11-S48Diabetes Care, 2010. 33 (Supp 1) S11-S48

Physical ActivityPhysical Activity

► Perform at least 150 minutes of Perform at least 150 minutes of moderate-intensity* aerobic physical moderate-intensity* aerobic physical activity per weekactivity per week

► In the absence of contraindications, In the absence of contraindications, perform resistance training three perform resistance training three times a weektimes a week

Diabetes Care, 2010. 33 (Supp 1) S11-S48Diabetes Care, 2010. 33 (Supp 1) S11-S48

* 50-70% of max heart rate

Patient Education in Diabetes Mellitus:Patient Education in Diabetes Mellitus:10 Content Areas10 Content Areas

Diabetes Self-Management

Education

Diabetes Disease Process

Physical Activity

UtilizingMedication

MonitoringBlood Glucose

Preventing,Detecting & Treating Acute Complications

Preventing,Detecting & Treating

Chronic Complications

Goal setting forHealth &

Daily Living

IntegratingPsychosocial Adjustment

To Daily Living

Promoting Care prior to and during

Pregnancy

Nutritional Management

Funnell et. al. Diabetes Care 2010:33 (Suppl1) S89-96

MedicationMedication RouteRoute YearYear Efficacy as monotherapy: % Efficacy as monotherapy: % in HgbA1cin HgbA1c

Insulin s.c.s.c. 19211921 2.52.5

Sulfonylureas OralOral 19461946 1.51.5

Glinides OralOral 19971997 1.0-1.51.0-1.5

Metformin OralOral 19951995 1.51.5

-glucosidase inhibitors OralOral 19951995 0.5-0.80.5-0.8

TZDs OralOral 19991999 0.8-1.00.8-1.0

GLP analogue s.c.s.c. 20052005 0.60.6

DPP-IV Inhibitors OralOral 20062006 0.5-0.80.5-0.8

Amylin analogue s.c.s.c. 20052005 0.60.6

Colesevelam OralOral 20082008 0.50.5

Bromocriptine mesylate OralOral 20092009 0.2-0.40.2-0.4

Type 2 Diabetes Medication ChoicesType 2 Diabetes Medication ChoicesExperience and PotencyExperience and Potency

MedicationMedication RouteRoute YearYear Efficacy as monotherapy: Efficacy as monotherapy: % % in HgbA1c in HgbA1c

Insulin s.c.s.c. 19211921 2.52.5

Sulfonylureas OralOral 19461946 1.51.5

Glinides OralOral 19971997 1.0-1.51.0-1.5

Metformin OralOral 19951995 1.51.5

-glucosidase inhibitors OralOral 19951995 0.5-0.80.5-0.8

TZDs OralOral 19991999 0.8-1.00.8-1.0

GLP analogue s.c.s.c. 20052005 0.60.6

DPP-IV Inhibitors OralOral 20062006 0.5-0.80.5-0.8

Amylin analogue s.c.s.c. 20052005 0.60.6

Colesevelam OralOral 20082008 0.50.5

Bromocriptine mesylate OralOral 20092009 0.2-0.40.2-0.4

Type 2 Diabetes Medication ChoicesType 2 Diabetes Medication ChoicesExperience and PotencyExperience and Potency

Mechanisms of Action of Pharmacologic Mechanisms of Action of Pharmacologic Agents for Diabetes Agents for Diabetes

Improving Outcomes in Patients With Type 2 Diabetes Mellitus: Practical Solutions for Clinical ChallengesJames R. Gavin, III, MD, PhD; Mark W. Stolar, MD; Jeffrey S. Freeman, DO; Craig W. Spellman, DO, PhDJAOA • Vol 110 • No 5suppl6 • May 2010 • 2-14

Oral Medications for Type 2 DiabetesOral Medications for Type 2 DiabetesDrug Initial Dose Maximum Dose Usual Dose

Biguanide

Metformin 500 mg bid 2550 mg/d 500-1000 mg bid

Metformin XR 500 mg/d 2000 mg/d 1500-2000 mg/d

Sulfonylurea

Glimepiride 1-2 mg/d 8 mg/d 4 mg/d

Glipizide 2.5-5 mg/d 40 mg/d 10-20 mg/d

Glipizide SR 2.5-5 mg/d 20 mg/d 5-20 mg/d

Glyburide 2.5-5 mg/d 20 mg/d 5-10 mg/d

Glyburide Micronized 0.75-3 mg/d 12 mg/d 3-12 mg/d

Thiazolidinedione

Pioglitazone 15-30 mg/d 45 mg/d 15-45 mg/d

Rosiglitazone 4 mg/d 8 mg/d 4-8 mg/d

-Glucosidase inhibitor

Acarbose 25 mg tid 100 mg tid 25-100 mg tid

Miglitol 25 mg tid 100 mg tid 25-100 mg tid

Metiglinide

Repaglinide 0.5 mg before meals 4 mg before meals 0.5-4 mg before meals

Nateglinide 60-120 mg tid before meals 120 mg tid before meals 60-120 mg tid before meals

DPP4 Inhibitor

Sitagliptin 100 mg/d 100 mg/d 100 mg/d

Saxagliptin 2.5 mg/d 5 mg/d 5 mg/d

Bile Acid Sequestrants

Colesevelam 375 mg/day 375 mg/day 375 mg/day

Adapted from: Annals of Internal Medicine, March 2010 “In the Clinic”Adapted from: Annals of Internal Medicine, March 2010 “In the Clinic”

Type 2 Diabetes Medication ChoicesType 2 Diabetes Medication Choices and Potency and Potency

► Higher baseline A1C levels predict Higher baseline A1C levels predict greater drop in A1Cgreater drop in A1C

► Shorter duration of diabetes predicts Shorter duration of diabetes predicts greater drop in A1C with any oral greater drop in A1C with any oral agentagent

► All oral agents require presence of All oral agents require presence of some endogenous some endogenous cell function, as cell function, as they work by either increasing they work by either increasing insulin sensitivity or augmenting insulin sensitivity or augmenting cell insulin releasecell insulin release

Sherifali et.al. Diabetes Care. 2010; 33: 1859-1864Sherifali et.al. Diabetes Care. 2010; 33: 1859-1864

Percentage of Individuals with A1C>7%Percentage of Individuals with A1C>7%NHANES surveysNHANES surveys

Hoerger TJ et. al. Diabetes Care. 2008; 31:81-86Hoerger TJ et. al. Diabetes Care. 2008; 31:81-86

Metformin - Drug ProfileMetformin - Drug Profile

Advantages

No hypoglycemiaNo hypoglycemia

Weight lossWeight loss

Cardiovascular benefitCardiovascular benefit

Reduces LDL-C (approx 10 mg/dL), Reduces LDL-C (approx 10 mg/dL), reduces TGreduces TG

Disadvantages

Diarrhea is commonDiarrhea is common

Contraindicated in renal impairment, Contraindicated in renal impairment, liver failure, advanced cardiac failureliver failure, advanced cardiac failure

Risk of lactic acidosis not increased Risk of lactic acidosis not increased in meta-analyses and systematic in meta-analyses and systematic reviewsreviews

Concomitant use with other drugs Can be used as monotherapy and Can be used as monotherapy and with all classes including insulinwith all classes including insulin

Sulfonylureas - Drug ProfileSulfonylureas - Drug Profile

AdvantagesPotent glucose lowering effect

Favorable adverse effect profile

Disadvantages

Hypoglycemia, more with Glyburide

Glyburide contraindicated in renal impairment

?Glyburide impairs ischemic preconditioning in heart (UKPDS did not reveal increased cardiac risk)

Concomitant use with other drugsCan be used as monotherapy and with all classes including insulin

Repaglinide and Nateglinide: Drug Profiles Repaglinide and Nateglinide: Drug Profiles

Advantages

Less hypoglycemia than sulfonylureas

Favorable adverse effect profile

Disadvantages

Less potent than sulfonylureas; target mainly post-prandial glucose

Nateglinide less potent than Repaglinide

Concomitant use with other drugs

Can be used with all classes including insulin

TZDs - Drug ProfileTZDs - Drug Profile

Advantages

No hypoglycemia

May be useful in nonalcoholic fatty liver disease

Disadvantages

Increased fracture risk

Weight gain

Edema and exacerbation of CHF Rosiglitazone increases LDL-C (10mg/dL), TG (15-50mg/dL) and possible increase in MI


Can be used with other classes including insulin. Increased fluid retention and weight gain with insulin

Alpha Glucosidase Inhibitor (AGI) - Alpha Glucosidase Inhibitor (AGI) - Drug ProfileDrug Profile

AdvantagesNo hypoglycemiaNo hypoglycemia

Weight neutralWeight neutral

Disadvantages

Targets only postprandial Targets only postprandial glucoseglucose

GI side effectsGI side effects


Can be used as Can be used as monotherapy and with all monotherapy and with all classes including insulinclasses including insulin

DPP4 Inhibitors – Drug ProfileDPP4 Inhibitors – Drug Profile

Advantages

Weight neutralWeight neutral

Favorable adverse effect profileFavorable adverse effect profile

No hypoglycemiaNo hypoglycemia

Disadvantages

Limited track recordLimited track record

Nasopharyngitis, upper Nasopharyngitis, upper respiratory infectionsrespiratory infections

Rare pancreatitisRare pancreatitis


Can be used as monotherapy Can be used as monotherapy and with SU, TZD, metformin and with SU, TZD, metformin (some have been studied with (some have been studied with insulin)insulin)

Colesevelam - Drug ProfileColesevelam - Drug Profile

AdvantagesNo hypoglycemiaNo hypoglycemia

Reduces LDL-C (approx 10 mg/dL), Reduces LDL-C (approx 10 mg/dL),

Disadvantages

Constipation is commonConstipation is common

Increase in triglyceridesIncrease in triglycerides

Malabsorption of fat soluble vitaminsMalabsorption of fat soluble vitamins

Concomitant use with other drugs Can be used as combination therapy Can be used as combination therapy with metorminwith metormin

ADA/EASD GuidelinesADA/EASD Guidelines

ADA/EASD: ADA/EASD: Considerations for the GuidelinesConsiderations for the Guidelines

1.1. Use of information from clinical trials that address the Use of information from clinical trials that address the efficacy and safety of different modalities of efficacy and safety of different modalities of treatmenttreatment Paucity of high quality evidence was an impedimentPaucity of high quality evidence was an impediment

2.2. Clinical judgment of the panel participantsClinical judgment of the panel participants

3.3. Extrapolation of UKPDS data that glucose lowering of Extrapolation of UKPDS data that glucose lowering of drugs (metformin, sulfonylureas, insulin) predicted drugs (metformin, sulfonylureas, insulin) predicted decrease in complications. decrease in complications.

4.4. Nonglycemic effects of medication, such as effect on Nonglycemic effects of medication, such as effect on CV risk, lipids, hypertension or insulin resistanceCV risk, lipids, hypertension or insulin resistance

5.5. Safety, side effects, ease of use and expenseSafety, side effects, ease of use and expense

ADA Algorithm for Management of ADA Algorithm for Management of DiabetesDiabetes

Diabetes Care. 2009, 32:193-203Diabetes Care. 2009, 32:193-203

At diagnosis:Lifestyle

+Metformin

Lifestyle+Metformin+

Pioglitazone(No hypoglycemia, edema,

CHF, bone loss)


Sulfonylurea


Intensive insulin


Basal Insulin


GLP1 (No hypoglycemia, wt loss,

Nausea/vomiting)


Pioglitazone+

Sulfonylurea


Basal Insulin

Tier 2: less well-validatedtherapies

Tier 1: Well-validated core therapies

Step 1Step 1 Step 2Step 2 Step 3Step 3

Amylin agonists, GlinidesDPP-4 inhibitors may be appropriate in selected patients

*Useful when hypoglycemia is to be avoided

Review

Annals of Internal Medicine

Systematic Review: Comparative Effectiveness and Safety of Oral Medications for Type 2 Diabetes MellitusShari Bolen, MD, MPH; Leonard Feldman, MD; Jason Vassy, MD, MPH; Lisa Wilson, BS, ScM; Hsin-Chieh Yeh, PhD;Spyridon Marinopoulos, MD, MBA; Crystal Wiley, MD, MPH; Elizabeth Selvin, PhD; Renee Wilson, MS; Eric B. Bass, MD, MPH; and Frederick L. Brancati, MD, MHS

Background: As newer oral diabetes agents continue to emerge on the market, comparative evidence is urgently required to guide appropriate therapy.Purpose: To summarize the English-language literature on the benefits and harms of oral agents (second-generation sulfonylureas, biguanides, thiazolidinediones, meglitinides, and -glucosidase inhibitors) in the treatment of adults with type 2 diabetes mellitus.Conclusions: Compared with newer, more expensive agents (thiazolidinediones, glucosidase inhibitors, and meglitinides), older agents (second-generation sulfonylureas and metformin) have similar or superior effects on glycemic control, lipids, and other intermediate end points. Large, long-term comparative studies are needed to determine the comparative effects of oral diabetes agents on hard clinical end points.Ann Intern Med. 2007;147:386-399. www.annals.org

http://www.annals.org/

Figure 4 Events per 1000 patient-years for representative endpoints. Black bars indicate excess risk of events in diabetes patients relative to nondiabetic subjects;19,75,85,86 gray bars indicate excess risk of events in patients treated with specific glucose- lowering medications relative to diabetic patients on other agents;2,25,41,54,60,61,74 and white bars indicate the decreased risk of events in patients undergoing intensive glucose control policies. Foley RN et al. J Am Soc Nephrol. 2005;16(2):489-495; b = 19Haffner SM et al. N Engl J Med.1998;339(4)229-234; c = 75Noel RA et al. Diabetes Care. 2009;32(5):834-838;d = 86Trautner C et al. Diabetes Care. 1997;20(7):1147-1153; e = 60,61HamptonT. JAMA. 2007;297(15):1645 and Meier C et al. Arch Intern Med. 2008;168(8):820-825; f = 41Lago RM et al. Lancet. 2007;370(9593):1129-1136; g = 25Patel A et al. N Engl J Med. 2008;358(24):2560-2572; h = 2Nissen SE, Wolski K. N Engl J Med. 2007;356(24)2457-2471; i = 54Glucophage [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2006; j = 74Dore DD et al.

Type 2 Diabetes: Assessing the Type 2 Diabetes: Assessing the Relative Risks andRelative Risks andBenefits of Glucose-lowering Benefits of Glucose-lowering MedicationsMedications

Richard M. Bergenstal, MD, Clifford Richard M. Bergenstal, MD, Clifford J. Bailey, PhD David M. Kendall, MDJ. Bailey, PhD David M. Kendall, MDInternational Diabetes Center, International Diabetes Center, Minneapolis, Minn; Diabetes Research, Minneapolis, Minn; Diabetes Research, Life and Health Sciences, Aston Life and Health Sciences, Aston University, Birmingham, UK.University, Birmingham, UK.The American Journal of Medicine The American Journal of Medicine (2010) 123, 374.(2010) 123, 374.

Type 2 Diabetes: Assessing the Relative Type 2 Diabetes: Assessing the Relative Risks and Benefits of Glucose-lowering Risks and Benefits of Glucose-lowering

MedicationsMedications

► Glucose-lowering medications have a favorable risk-Glucose-lowering medications have a favorable risk-benefit profile benefit profile

► The most common adverse event is hypoglycemia, The most common adverse event is hypoglycemia, particularly among patients receiving sulfonylureas or particularly among patients receiving sulfonylureas or insulin.insulin.

► Metformin-associated lactic acidosis, exenatide-Metformin-associated lactic acidosis, exenatide-associated pancreatitis, and sitagliptin-associated associated pancreatitis, and sitagliptin-associated hypersensitivity reactions appear to be rare.hypersensitivity reactions appear to be rare.

► Increased risks of congestive heart failure and bone Increased risks of congestive heart failure and bone fractures in thiazolidinedione-treated patients, and fractures in thiazolidinedione-treated patients, and reports of increased cardiovascular events in reports of increased cardiovascular events in rosiglitazone-treated patients remain an issue.rosiglitazone-treated patients remain an issue.

Richard M. Bergenstal, MD, Clifford J. Bailey, PhD David M. Kendall, MDRichard M. Bergenstal, MD, Clifford J. Bailey, PhD David M. Kendall, MDInternational Diabetes Center, Minneapolis, Minn; Diabetes Research, Life and International Diabetes Center, Minneapolis, Minn; Diabetes Research, Life and

Health Sciences, Aston University, Birmingham, UK.Health Sciences, Aston University, Birmingham, UK.

Figure 2. Kaplan–Meier Estimates of the Cumulative Incidence of Monotherapy Failure at 5 Years.Treatment was considered to have failed if a patient had a confirmed or adjudicated level of fasting plasma glucose of more than 180 mg per deciliter. Risk reduction is listed for comparisons of pairwise groups from a baseline co variate adjusted Cox proportional hazards model. Gray’s estimates of cumulative incidence adjusted for all deaths were smaller than Kaplan–Meier estimates of treatment failure: 10% in the rosiglitazone group, 15% in the metformin group, and 25% in the glyburide group. I bars indicate 95% CIs.

Cu

mu

lative Incid

ence o

f Mo

no

therap

y Failu

re

Hazard ratio (95% CI)Rosiglitazone vs. metformin, 0.68 (0.55–0.85);

P<0.001Rosiglitazone vs. glyburide, 0.37 (0.30–0.45);

P<0.001

Rosiglitazone 1393 1207 1078 957 844 324

Metformin 1397 1205 1076 950 818 311

Glyburide 1337 1114 958 781 617 218

Years1 2 3 4 5

Glyburide

Metformin

Rosiglitazone

10

20

30

40

Glycemic Durability of Rosiglitazone, Glycemic Durability of Rosiglitazone, Metformin, or Glyburide MonotherapyMetformin, or Glyburide Monotherapy

N Engl J Med 2006;355:2427 43 N Engl J Med 2006;355:2427 43

Steven E. Kahn, M.B., Ch.B., Steven M. Haffner, M.D., Mark A. Heise, Ph.D., William H. Herman, M.D., M.P.H., Rury R. Steven E. Kahn, M.B., Ch.B., Steven M. Haffner, M.D., Mark A. Heise, Ph.D., William H. Herman, M.D., M.P.H., Rury R. Holman, F.R.C.P., Nigel P. Jones, M.A., Barbara G. Kravitz, M.S., John M. Lachin, Sc.D., M. Colleen O’Neill, B.Sc., Holman, F.R.C.P., Nigel P. Jones, M.A., Barbara G. Kravitz, M.S., John M. Lachin, Sc.D., M. Colleen O’Neill, B.Sc.,

Bernard Zinman, M.D., F.R.C.P.C., and Giancarlo Viberti, M.D., F.R.C.P., for the ADOPT Study Group *Bernard Zinman, M.D., F.R.C.P.C., and Giancarlo Viberti, M.D., F.R.C.P., for the ADOPT Study Group *

AACE/ACE: AACE/ACE: Considerations for the GuidelinesConsiderations for the Guidelines

1.1. Minimizing risk and severity of hypoglycemiaMinimizing risk and severity of hypoglycemia2.2. Minimizing weight gainMinimizing weight gain3.3. Inclusion of all major classes of FDA-approved Inclusion of all major classes of FDA-approved

glycemic medicationsglycemic medications4.4. Selection of therapy stratified by hemoglobin A1C Selection of therapy stratified by hemoglobin A1C

(A1C) and based on documented A1C lowering (A1C) and based on documented A1C lowering potentialpotential

5.5. Consideration of both fasting and postprandial Consideration of both fasting and postprandial glucose levels as end pointsglucose levels as end points

6.6. Consideration of total cost of therapy to individual Consideration of total cost of therapy to individual and society and society

- includes cost of medication, glucose monitoring, - includes cost of medication, glucose monitoring, hypoglycemic events, drug adverse events, and hypoglycemic events, drug adverse events, and treatment of complicationstreatment of complications

LIFESTYLE MODIFICATION

A1C 6.5-7.5% A1C 7.6-9.0% A1C >9%

Monotherapy Dual Therapy

Triple Therapy

Dual Therapy

MET +

GLP-1 or DPP4

TZD

Glinide or SU

TZD + GLP-1 or DPP4

MET +Colesevelam

AGI

MET DPP4GLP1

TZDAGI

Triple Therapy

MET +

GLP1 or DPP4

+

TZD

Glinides or SU

Insulin + other agents

MET +

GLP1 or DPP4 or TZD

SU or

Glinides

MET +

GLP1 or

DPP4+TZD

GLP1 or

DPP4 +SU

TZD

MET +

GLP1 or

DPP4 +SU

TZD

GLP1 or

DPP4+TZD

Triple Therapy

Drug naïve, No symptoms

Symptoms or under treatment

Adapted from AACE December 2009 update with permission

ADA/ EASD CriteriaADA/ EASD Criteria► Evidence basedEvidence based► Recognize that beta Recognize that beta

cell failure is cell failure is progressive, and progressive, and eventually insulin will eventually insulin will be required, so be required, so recommends this recommends this transition earlytransition early

► Greater emphasis on Greater emphasis on direct medication costs direct medication costs and efficacyand efficacy

► Emphasis on one or Emphasis on one or two drug regimens, two drug regimens, minimizes use of minimizes use of multiple drugsmultiple drugs

AACE/ ACE CriteriaAACE/ ACE Criteria► Attempts to provide a Attempts to provide a

place and place and recommendation for all recommendation for all FDA approved drugsFDA approved drugs

► Greater emphasis on Greater emphasis on hypoglycemia hypoglycemia avoidanceavoidance

► Recognizes that people Recognizes that people may want choices, so may want choices, so allows a wide variety allows a wide variety of choices and of choices and combinations for combinations for individual situationsindividual situations

AACE/ACE Diabetes AlgorithmAACE/ACE Diabetes Algorithm

Alexander, G. C. et al. Arch Intern Med 2008;168:2088-2094.Alexander, G. C. et al. Arch Intern Med 2008;168:2088-2094.

National Trends in Use of Different National Trends in Use of Different Therapeutic Drug Classes to Treat Diabetes, Therapeutic Drug Classes to Treat Diabetes,

1994-20071994-2007

Leading Diabetes Medications Leading Diabetes Medications by Treatment Classby Treatment Class

Alexander, G. C. et al. Arch Intern Med 2008;168:2088-2094.Alexander, G. C. et al. Arch Intern Med 2008;168:2088-2094.

Complex Physiology Complex ManagementComplex Physiology Complex Management

Insulin resistance

Years of diabetesYears of diabetes

Beta-cell failure

Insulin output

0

100

200

300

–10 –5 0 5 10 15 20 25 30Rel

ativ

e R

elat

ive

-ce

ll-c

ell

func

tion

(%)

func

tion

(%)

At risk for diabetes

Fasting glucose

50100

200

300

Glu

cose

(m

g/dL

)G

luco

se (

mg/

dL) Post-meal glucose

LifestyleLifestyle InsulinInsulinSFU, glitinides, exenatide

Metformin, TZDs, AGIs, DPP4 Metformin, TZDs, AGIs, DPP4 AGI: alpha glucosidase inhibitorSFU: sulfonylurea

Factors to Consider when Choosing Factors to Consider when Choosing Pharmacological Agent(s) for DiabetesPharmacological Agent(s) for Diabetes

► Current A1CCurrent A1C

► Duration of diabetesDuration of diabetes

► Body weight (BMI, abdominal Body weight (BMI, abdominal obesity)obesity)

► Age of patientAge of patient

► Co-morbiditiesCo-morbidities

► Cost of medicationCost of medication

► Convenience Convenience

Considerations when Choosing a Considerations when Choosing a Drug Within a ClassDrug Within a Class

► Adverse effects are not “class-Adverse effects are not “class-specific”specific”● Phenformin vs. MetforminPhenformin vs. Metformin● Troglitazone vs. Rosiglitazone vs. Troglitazone vs. Rosiglitazone vs.

PioglitazonePioglitazone

► Drugs within a class may not be Drugs within a class may not be equally effectiveequally effective

LIFESTYLE MODIFICATION

MET DPP4 GLP1 TZD AGI

MET +

GLP-1 or DPP4

TZD

Glinide or SU

TZD + GLP-1 or DPP4

MET +Colesevelam

AGI

MET +

GLP1 or

DPP4 +SU

TZD

GLP1 or

DPP4+TZD

Insulin + other agents

MonotherapyMonotherapy

Dual TherapyDual Therapy

Triple TherapyTriple Therapy

symptomatic orsevere hyperglycemia

The Role of Incretin The Role of Incretin Mimetics in Treating Type 2 Mimetics in Treating Type 2

DiabetesDiabetes





Case PresentationCase Presentation

► 50-year-old patient with type 2 50-year-old patient with type 2 diabetes on glyburide 5 mg/d and diabetes on glyburide 5 mg/d and metformin 1000 bid presents with a metformin 1000 bid presents with a random blood sugar of 240 mg/dL random blood sugar of 240 mg/dL and HbA1c 8.0%and HbA1c 8.0%● Weight 250 lb Ht 5’9” BMI 36.9 Weight 250 lb Ht 5’9” BMI 36.9

What would be the best therapeutic What would be the best therapeutic option to treat this patient’s option to treat this patient’s

diabetes?diabetes?

1. Add pioglitazone 30 mg/d1. Add pioglitazone 30 mg/d

2. Add insulin glargine 10 units qhs2. Add insulin glargine 10 units qhs

3. Start nateglinide 120 mg tid3. Start nateglinide 120 mg tid

4. Start sitagliptin 100 mg/d4. Start sitagliptin 100 mg/d

5. Start exenatide 5 mcg bid5. Start exenatide 5 mcg bid

1. Add pioglitazone 30 mg/d1. Add pioglitazone 30 mg/d

2. Add insulin glargine 10 units qhs2. Add insulin glargine 10 units qhs

3. Start nateglinide 120 mg tid3. Start nateglinide 120 mg tid

4. Start sitagliptin 100 mg/d4. Start sitagliptin 100 mg/d

5. Start exenatide 5 mcg bid5. Start exenatide 5 mcg bid

What would be the best therapeutic What would be the best therapeutic option to treat this patient’s option to treat this patient’s

diabetes?diabetes?

David M. Nathan, MDDavid M. Nathan, MDThe New England Journal of MedicineThe New England Journal of Medicine

““A host of medications that are already A host of medications that are already available are effective as monotherapy or in available are effective as monotherapy or in combination with metformin or one of the combination with metformin or one of the TZDs (the approved uses of sitagliptin). The TZDs (the approved uses of sitagliptin). The fact that these medications achieve better fact that these medications achieve better glycemic control than sitagliptin suggests glycemic control than sitagliptin suggests the need for caution in approving a new the need for caution in approving a new medication that has received limited medication that has received limited testingtesting.”.”

Perspectives February 1, 2007Perspectives February 1, 2007

Nathan DM et al. Nathan DM et al. Diabetes CareDiabetes Care. 2006;29:1963-1972.. 2006;29:1963-1972.

A Consensus Statement From the American A Consensus Statement From the American Diabetes Association and the European Diabetes Association and the European Association for the Study of Diabetes Association for the Study of Diabetes

Adapted from Nathan DM et al. Adapted from Nathan DM et al. Diabetes CareDiabetes Care. 2006;29:1963-1972. . 2006;29:1963-1972.

Management of Hyperglycemia in T2DMManagement of Hyperglycemia in T2DM

Diagnosis

Lifestyle intervention + Metformin

No Yes*A1C≥7%

No Yes*A1C≥7%

Add basal insulin*- most effective

Add sulfonylurea- least effective

Add glitazone- no hypoglycemia

Intensify insulin* Add glitazone* Add basal insulin* Add sulfonylurea*

No Yes*A1C≥7% No Yes*A1C≥7%

Add basal or intensify insulin*

Intensive insulin + metformin ± glitazone

No Yes*A1C≥7% No Yes*A1C≥7%

Algorithm OverviewAlgorithm Overview

► The algorithm takes into account the The algorithm takes into account the characteristics of the individual interventions, characteristics of the individual interventions, their synergies, and expense their synergies, and expense

► The goal is to achieve and maintain glycemic The goal is to achieve and maintain glycemic levels as close to the nondiabetic range as levels as close to the nondiabetic range as possible and to change interventions at as possible and to change interventions at as rapid a pace as titration of medications allowsrapid a pace as titration of medications allows

► Pramlintide, exenatide, Pramlintide, exenatide, αα-glucosidase -glucosidase inhibitors, and the glinides are not included in inhibitors, and the glinides are not included in this algorithm, owing to their generally lower this algorithm, owing to their generally lower overall glucose-lowering effectiveness, limited overall glucose-lowering effectiveness, limited clinical data, and/or relative expense. clinical data, and/or relative expense.

● These may, however, be appropriate choices in selected These may, however, be appropriate choices in selected patients patients

ADOPT: A Diabetes Outcome Progression ADOPT: A Diabetes Outcome Progression Trial—Safety ProfileTrial—Safety Profile

Data from Kahn SE et al. Data from Kahn SE et al. N Engl J Med.N Engl J Med. 2006;355:2427-2443. 2006;355:2427-2443.

** PP≤0.01 vs RSG≤0.01 vs RSG†† PP≤0.05 vs RSG≤0.05 vs RSG

Selected EventsSelected EventsRSG RSG

(N=1456)(N=1456)n (%)n (%)

METMET(N=1454)(N=1454)

n (%)n (%)

SU SU (N=1441)(N=1441)

n (%)n (%)

Gastrointestinal 335 (23.0) 557 (38.3)* 316 (21.9)

Edema 205 (14.1) 104 (7.2)* 123 (8.5)*

Hypoglycemia 142 (9.8) 168 (11.6) 557 (38.7)*

MI, fatal 2 (0.1) 2 (0.1) 3 (0.2)

MI, non-fatal 25 (1.7) 21 (1.4) 15 (1.0)

CHF 22 (1.5) 19 (1.3) 9 (0.6)†

Stroke 16 (1.1) 19 (1.3) 17 (1.2)

Change in weight observed in study: RSG +0.7 kg/year; MET -0.3 kg/year; SU 0.2 kg/yearChange in weight observed in study: RSG +0.7 kg/year; MET -0.3 kg/year; SU 0.2 kg/year

Incidence of Selected Adverse EventsIncidence of Selected Adverse Events

ADOPT—ImplicationsADOPT—Implications

► Current oral agent therapy is associated Current oral agent therapy is associated with significant adverse eventswith significant adverse events

► Weight gain, edema, lactic acidosis, GI side Weight gain, edema, lactic acidosis, GI side effects, and hypoglycemia are significant effects, and hypoglycemia are significant problemsproblems

► GLP-1 agonists cause significant weight GLP-1 agonists cause significant weight lossloss

► DPP-4 inhibitors have no associated weight DPP-4 inhibitors have no associated weight gain or complicationsgain or complications

Relationship Between Weight Gain in Relationship Between Weight Gain in Adulthood and Risk of T2DMAdulthood and Risk of T2DM

Data from Willett WC et al. Data from Willett WC et al. N Engl J MedN Engl J Med. 1999;341:427.. 1999;341:427.

0

1

2

3

4

5

6

Rela

tive R

isk

Rela

tive R

isk

Weight Change (kg)Weight Change (kg)-10-10 -5-5 00 55 1010 1515 2020

MenMen

WomenWomen

Weight Gain and Glycemic ControlWeight Gain and Glycemic Control

► Weight gain seems to be inseparable Weight gain seems to be inseparable from glycemic control with many from glycemic control with many antidiabetic treatments, including antidiabetic treatments, including sulfonylureas, insulin, and sulfonylureas, insulin, and thiazolidinediones, which have an thiazolidinediones, which have an estimated 2 kg weight gain for every estimated 2 kg weight gain for every 1% decrease in HbA1C 1% decrease in HbA1C

Buse J et al. Clin Ther. 2007;29:139-153.

Clinical Role of GLP-1Clinical Role of GLP-1——MimeticsMimetics

► Overweight patients with type 2 Overweight patients with type 2 diabetes requiring initial treatmentdiabetes requiring initial treatment

► Overweight patients with type 2 Overweight patients with type 2 diabetes on metformin, sulfonylurea, diabetes on metformin, sulfonylurea, or combinationor combination

► Addition to thiazolidinediones to Addition to thiazolidinediones to avoid weight gainavoid weight gain

*P*P≤0.05≤0.05Data from Nauck M et al. Data from Nauck M et al. Diabetologia.Diabetologia. 1986;29:46-52. 1986;29:46-52.

8080

6060

4040

2020

00

Insu

lin (

mU

/L)

Insu

lin (

mU

/L)

0 30 60 90 120 150 180Time (min)Time (min)

Control subjectsControl subjects

8080

6060

4040

2020

00

Insu

lin (

mU

/L)

Insu

lin (

mU

/L)

0 30 60 90 120 150 180Time (min)Time (min)

T2DM patientsT2DM patients

**** ** ** ** ** **

** ****

Intravenous glucoseIntravenous glucoseOral glucoseOral glucose

Reduced Incretin Effect in Patients Reduced Incretin Effect in Patients With T2DMWith T2DM

Summary of GLP-1Summary of GLP-1——Effects in HumansEffects in Humans

Flint A et al. Flint A et al. J Clin InvestJ Clin Invest. 1998;101:515-520. 1998;101:515-520. . Larsson H et al. Larsson H et al. Acta Physiol ScandActa Physiol Scand. . 1997;160:413-422. Nauck MA et al. 1997;160:413-422. Nauck MA et al. Diabetologia.Diabetologia. 1996;39:1546-1553. 1996;39:1546-1553. Drucker DJ. Drucker DJ. DiabetesDiabetes. . 1998;47:159-169.1998;47:159-169.

StomachStomach Regulates gastric emptying

Central nervous systemCentral nervous system Promotes satiety and Promotes satiety and reduction of appetitereduction of appetite

LiverLiver Glucagon reduces Glucagon reduces

hepatic glucose outputhepatic glucose output

αα cell cell Glucagon Glucagon secretion secretion

post-mealpost-meal

ββ cell cellEnhances secretion of Enhances secretion of glucose-dependent insulinglucose-dependent insulin

PotentialPotential increase in increase in ββ--cell masscell mass

Glucose-dependent Effects of GLP-1 Infusion Glucose-dependent Effects of GLP-1 Infusion on Insulin and Glucagon Levels in T2DM on Insulin and Glucagon Levels in T2DM

PatientsPatients

Adapted from Nauck MA et al. Adapted from Nauck MA et al. DiabetologiaDiabetologia. 1993;36:741-744. . 1993;36:741-744.

GlucoseGlucose

GlucagonGlucagon

**PP<0.05<0.05Patients with T2DM Patients with T2DM (N=10)(N=10)

mm

ol/

Lm

mo

l/L 15.015.0

12.512.510.010.0

7.57.55.05.0

250250

200200

150150

100100

5050

mg

/dL

mg

/dL**

** ** ** ** ** **p

mo

l/L

pm

ol/

L 250250200200150150100100

5050

4040

3030

2020

1010

00

mU

/Lm

U/L

** **

When glucose levels When glucose levels approach normal values,approach normal values,insulin levels decrease.insulin levels decrease.

** **** ** ** **

InfusionInfusion

MinutesMinutes

pm

ol/

Lp

mo

l/L 2020

1515

1010

55

00 6060 120120 180180 240240

When glucose levels When glucose levels approach normal approach normal values, glucagon levels values, glucagon levels rebound.rebound.

** ** ** **

pm

ol/L

pm

ol/L

2020

1515

1010

55

PlaceboPlacebo

GLP-1GLP-1

InsulinInsulin

2.52.500

00

00 00

00

––3030

Exenatide: HbA1C and Body Weight Exenatide: HbA1C and Body Weight ReductionsReductions

Kendall D. ADA. 2005.Kendall D. ADA. 2005.

Two-year data for 82-wk cohort (N=146)Two-year data for 82-wk cohort (N=146)

Mean ± SEMean ± SE

0.00.0 0.50.5 1.01.0 1.51.5 2.02.0

-1.5-1.5

-1.0-1.0

-0.5-0.5

0.00.0

Duration of Treatment (Years)Duration of Treatment (Years)

Placebo-Placebo-controlledcontrolled Open-label ExtensionsOpen-label Extensions

Baseline A1C: 8.2%Baseline A1C: 8.2%

ΔΔ A1C (%) A1C (%)

0.00.0 0.50.5 1.01.0 1.51.5 2.02.0

-6-6

-4-4

-2-2

00

Placebo-Placebo-controlledcontrolled Open-label ExtensionsOpen-label Extensions

Baseline weight: 100 kgBaseline weight: 100 kg

Duration of Treatment (Years)Duration of Treatment (Years)

ΔΔ Body Weight (kg) Body Weight (kg)

-1.2±0.1%-1.2±0.1%-5.5±0.5 kg-5.5±0.5 kg

Preliminary Analysis for Subjects Treated for 2 Years

Effect of Exenatide vs Insulin Glargine in Pts Effect of Exenatide vs Insulin Glargine in Pts with Suboptimally Controlled T2DM on HbA1C with Suboptimally Controlled T2DM on HbA1C

ITT population; Mean ± SE shownITT population; Mean ± SE shown WeekWeek

00 1212 2626

Insulin glargine, mean dose at endpoint = 25.0 U/day Insulin glargine, mean dose at endpoint = 25.0 U/day

0.00.0

6.56.5

7.07.0

7.57.5

8.08.0

8.58.5

A1

CA

1C

(%)

(%)

Exenatide, 10 Exenatide, 10 g BID g BID

Adapted from Heine R et al. Adapted from Heine R et al. Ann Intern MedAnn Intern Med. 2005;143:559-569.. 2005;143:559-569.

7.1%7.1%

8.2%8.2%

Change in Body WeightChange in Body Weight——Time Course Time Course

+1.8 kg

-2.3 kg

ITT population; Mean ± SE shown; *P<0.0001, exenatide vs insulin glargine at same time point

Adapted from Heine R et al. Ann Intern Med. 2005;143:559-569.

Difference of 4.1 kgbetween groups

WeekWeek

0 12 26

-3

-2

-1

0

1

2

Change in B

ody W

eig

ht

(kg)

Change in B

ody W

eig

ht

(kg)

2 4 8 18

*

**

**

*

Insulin glargine

Exenatide

*P<0.0001

Effects of Exenatide and Placebo Effects of Exenatide and Placebo on Body Weight on Body Weight

Adapted from Zinman B et al. Adapted from Zinman B et al. Ann Intern MedAnn Intern Med. 2007;146:477-485. . 2007;146:477-485.

**PP <0.01: <0.01: ††PP <0.001 <0.001

**

††

00 88 1616

-2.0-2.0

-1.5-1.5

0.50.5

1.01.0

1212

Cha

nge

in B

ody

Wei

ght

(kg)

Cha

nge

in B

ody

Wei

ght

(kg)

44

ExenatideExenatide

PlaceboPlacebo

††††

-2.5-2.5

-1.0-1.0

-0.5-0.5

0.00.0

WeeksWeeks

88

Patients With T2DM Treated With a TZD with or Without MetforminPatients With T2DM Treated With a TZD with or Without Metformin

Liraglutide Is a Long-acting Liraglutide Is a Long-acting Human GLP-1 IncretinHuman GLP-1 Incretin

Knudsen LB et al. Knudsen LB et al. J Med ChemJ Med Chem. 2000;43:1664-1669; Degn KB et al. . 2000;43:1664-1669; Degn KB et al. DiabetesDiabetes. 2004;53:1187-1194. . 2004;53:1187-1194.

Changes in HbA1c From Baseline for Changes in HbA1c From Baseline for Liraglutide 1.8 mg vs Comparator and PlaceboLiraglutide 1.8 mg vs Comparator and Placebo

Data originally presented as Marre M et al. Data originally presented as Marre M et al. DiabetesDiabetes. 2008;57(suppl 1):A4 (LEAD 1); Nauck MA et al. . 2008;57(suppl 1):A4 (LEAD 1); Nauck MA et al. DiabetesDiabetes. . 2008;57(suppl 1):A15 (LEAD 2); Garber A et al. 2008;57(suppl 1):A15 (LEAD 2); Garber A et al. LancetLancet. 2009;373:473-481 (LEAD 3); Zinman B et al. . 2009;373:473-481 (LEAD 3); Zinman B et al. DiabetologiaDiabetologia. . 2008;51(suppl 1): A898 (LEAD 4); Russell-Jones D et al. 2008;51(suppl 1): A898 (LEAD 4); Russell-Jones D et al. DiabetesDiabetes. 2008;57(suppl 1):A159 (LEAD 5). . 2008;57(suppl 1):A159 (LEAD 5).

Body Weight Change: Liraglutide 1.8 mg Body Weight Change: Liraglutide 1.8 mg vs Comparator and Placebovs Comparator and Placebo


Liraglutide Consistently Reduces Liraglutide Consistently Reduces Systolic Blood PressureSystolic Blood Pressure


Outline of LEAD 6 Study DesignOutline of LEAD 6 Study Design

Buse JB et al. Buse JB et al. Diabetes CareDiabetes Care. 2010 Mar 23. . 2010 Mar 23.

LEAD 6 14-week Extension: Shifting Patients LEAD 6 14-week Extension: Shifting Patients to Liraglutide Improves HbA1c Controlto Liraglutide Improves HbA1c Control


LEAD 6 14-week Extension: Shifting Patients LEAD 6 14-week Extension: Shifting Patients to Liraglutide Improves FPG Controlto Liraglutide Improves FPG Control


Potential Roles of GLP-1 MimeticsPotential Roles of GLP-1 Mimetics

► Once-weekly injection of exenatide-Once-weekly injection of exenatide-LAR in overweight patients with LAR in overweight patients with T2DM who require initial therapy or T2DM who require initial therapy or combination with other oral agentscombination with other oral agents

► Potential treatment for overweight Potential treatment for overweight nondiabetic patientsnondiabetic patients

► Potential treatment of overweight, Potential treatment of overweight, insulin-treated patients with T2DMinsulin-treated patients with T2DM

Exenatide LAR 15-Week Study in Exenatide LAR 15-Week Study in T2DM: ResultsT2DM: Results

Kim D. Kim D. Diabetes CareDiabetes Care. 2007;30:1487-1493.. 2007;30:1487-1493.

*Blood glucose*Blood glucose

Baseline HbA1C (mean ± SD) 8.5 ± 1.2%Baseline HbA1C (mean ± SD) 8.5 ± 1.2% Baseline fasting BG 9.9 ± 2.3 mmol/LBaseline fasting BG 9.9 ± 2.3 mmol/L

**No vomiting notedNo vomiting noted No severe hypoglycemia or withdrawal due to adverse events observedNo severe hypoglycemia or withdrawal due to adverse events observed

Exenatide LAR 15-Week Study in T2DM: Exenatide LAR 15-Week Study in T2DM: ResultsResults——Safety and TolerabilitySafety and Tolerability

ReactionReaction PlaceboPlacebo Exenatide Exenatide 0.8 mg/wk0.8 mg/wk

Exenatide Exenatide 2 mg/wk2 mg/wk

Nausea (mild–moderate) * 15%15% 19%19% 27%27%

Injection site bruising 0%0% 13%13% 7%7%

Injection-site pruritus 15%15% 6%6% 7%7%

% patients with exenatide antibodies

67% of all exenatide LAR-treated 67% of all exenatide LAR-treated patientspatients

Weight change -0.04 kg-0.04 kg -0.03 kg-0.03 kg -3.8 kg-3.8 kg

Kim D. Kim D. Diabetes CareDiabetes Care. 2007;30:1487-1493.. 2007;30:1487-1493.

Will the DPP-4 Inhibitors Replace Will the DPP-4 Inhibitors Replace GLP-1 Mimetics?GLP-1 Mimetics?

► DPP-4 inhibitors have similar action to DPP-4 inhibitors have similar action to GLP-1 agonists but do not result in GLP-1 agonists but do not result in weight loss; therefore, for patients in weight loss; therefore, for patients in whom weight loss is needed, GLP-1 whom weight loss is needed, GLP-1 agonists are indicated.agonists are indicated.

► Lack of weight loss with DPP-4 inhibition Lack of weight loss with DPP-4 inhibition is thought to be due to lesser increase in is thought to be due to lesser increase in GLP-1 levels (3x) compared with that of GLP-1 levels (3x) compared with that of GLP-1 mimetic (10x) or due to lack of GLP-1 mimetic (10x) or due to lack of PYY* activation by DPP-4PYY* activation by DPP-4

*PPY = peptide YY (intestinal satiety hormone)*PPY = peptide YY (intestinal satiety hormone)

Sitagliptin: Mechanism of ActionSitagliptin: Mechanism of Action

Release ofRelease ofactive incretinsactive incretinsGLP-1 and GIPGLP-1 and GIP Blood glucose

in fasting and postprandial states

Ingestion Ingestion of foodof food

GlucagonGlucagon(GLP-1)(GLP-1)

Hepatic glucose production

GI tract

DPP-4 enzyme

InactiveInactiveGLP-1GLP-1

Incretin hormones GLP-1 and GIP are released by the intestine throughout the Incretin hormones GLP-1 and GIP are released by the intestine throughout the day, and their levels day, and their levels in response to a meal in response to a meal

InsulinInsulin(GLP-1and(GLP-1and

GIP)GIP)

Glucose-Glucose-dependentdependent

Glucose- Glucose- dependendependentt

PancreasPancreas

InactiveInactiveGIPGIP

GLP-1=glucagon-like peptide-1; GIP=glucose-dependent insulinotropic polypeptide.

Beta cells

Alpha cells

Glucose uptake by peripheral tissue

Sitagliptin: Mechanism of Action Sitagliptin: Mechanism of Action (cont)(cont)

Release ofRelease ofactive incretinsactive incretinsGLP-1 and GIPGLP-1 and GIP Blood glucose

in fasting and postprandial states

Ingestion Ingestion of foodof food

GlucagonGlucagon(GLP-1)(GLP-1)

Hepatic glucose production

GI tract

DPP-4 enzyme

InactiveInactiveGLP-1GLP-1

XSitagliptin(DPP-4

inhibitor)

Incretin hormones GLP-1 and GIP are released by the intestine Incretin hormones GLP-1 and GIP are released by the intestine throughout the day, and their levels throughout the day, and their levels in response to a meal in response to a meal

InsulinInsulin(GLP-1and(GLP-1and

GIP)GIP)

Glucose-dependent

Glucose Glucose dependendependentt

PancreasPancreas

InactiveInactiveGIPGIP

GLP-1=glucagon-like peptide-1; GIP=glucose-dependent insulinotropic polypeptide.

Concentrations of the active intact hormones are increased by sitagliptin,Concentrations of the active intact hormones are increased by sitagliptin,thereby increasing and prolonging the actions of these hormonesthereby increasing and prolonging the actions of these hormones

Beta cells

Alpha cells

Glucose uptake by peripheral tissue

Role of DPP-4 InhibitorsRole of DPP-4 Inhibitors

► Approved as single agents or in Approved as single agents or in combination with a glitazone, combination with a glitazone, sulfonylurea, or metforminsulfonylurea, or metformin

► Sitagliptin approved to be used in Sitagliptin approved to be used in combination with insulincombination with insulin

Saxagliptin: Difference from Placebo inSaxagliptin: Difference from Placebo inAdjusted Mean Change from Baseline in HbA1cAdjusted Mean Change from Baseline in HbA1c

Rosenstock J et al. Rosenstock J et al. Curr Med Res OpinCurr Med Res Opin. 2009;25:2401-2411; . 2009;25:2401-2411; Hollander P et al. Hollander P et al. J Clin EndocrinolJ Clin Endocrinol MetabMetab. 2009;94:4810-4819; DeFronzo RA et al. . 2009;94:4810-4819; DeFronzo RA et al. Diabetes CareDiabetes Care. 2009;32:1649-1655.. 2009;32:1649-1655.

Sitagliptin Provides Significant and Sitagliptin Provides Significant and ProgressivelyProgressively Greater Reductions in A1C Greater Reductions in A1C

Inclusion Criteria: 7%–10%Inclusion Criteria: 7%–10%

Reductions are placebo-subtractedReductions are placebo-subtractedAdapted from Raz I et al. and Aschner P et al. ADA 2006.Adapted from Raz I et al. and Aschner P et al. ADA 2006.

Baseline A1CBaseline A1C (%)(%)

Mean (%)Mean (%)

Red

uctio

n in

A1C

(%

)R

educ

tion

in A

1C (

%)

Red

uctio

n in

AR

educ

tion

in A

1c1c

(%)

(%

)

<8%<8% 8<9%8<9% >>9%9%

7.37 8.407.37 8.40 9.489.48

<8%<8% 8<9%8<9% >>9%9%

7.397.39 8.368.36 9.589.58

n=96n=96

n=70n=70

n=27n=27

n=130n=130

n=62n=62

n=37n=37

18-Week Study18-Week Study

With Progressively Higher Baseline A1CWith Progressively Higher Baseline A1C

Sitagliptin 100 mg qd

Placebo-controlled Sitagliptin Add-on to Placebo-controlled Sitagliptin Add-on to Glimepiride or Glimepiride/MetforminGlimepiride or Glimepiride/Metformin

Placebo

Phase BPhase B

Sitagliptin 100 mg qd

ScreeningScreeningPeriod Period

Single-blindSingle-blindPlaceboPlacebo

Stratum 1 Glim (≥4 mg/day) alone

Stratum 2 Glim + MF (≥1500 mg/day)

Week 24Week 24

RANDOMIZATION

Week 80Week 80Week 0Week 0

441 Randomized patients with T2DM age 18–78 yrs

Continue/startContinue/startregimen of regimen of glimepirideglimepiride± metformin± metformin

Week-2 Week-2 eligible ifeligible if

A1C 7.5%–10%A1C 7.5%–10%

Double-blindDouble-blind

Placebo

Hermansen K et al. Diabetes Obes Metab. 2007;9:733-745.

Study—Design and Patients

Summary of Conclusions (24 weeks)Summary of Conclusions (24 weeks)

► Sitagliptin significantly improved A1C when Sitagliptin significantly improved A1C when added to:added to:● Overall cohort: Sitagliptin reduced A1C by Overall cohort: Sitagliptin reduced A1C by

0.7% (0.7% (PP<0.001)<0.001)● Stratum 1: Glimepiride = -0.6%Stratum 1: Glimepiride = -0.6%● Stratum 2: Glimepiride + Metformin = -Stratum 2: Glimepiride + Metformin = -

0.9%0.9%

► Hypoglycemia rates were similar to those Hypoglycemia rates were similar to those observed for other AHA when added to SFUobserved for other AHA when added to SFU● Sitagliptin + glimepiride = 7.5%Sitagliptin + glimepiride = 7.5%● Sitagliptin + glimepiride + metformin = Sitagliptin + glimepiride + metformin =

16.4%16.4%Hermansen K et al. Hermansen K et al. Diabetes Obes MetabDiabetes Obes Metab. 2007;9:733-745. . 2007;9:733-745.

Saxagliptin: Drug InteractionsSaxagliptin: Drug Interactionsand Use in Specific Populationsand Use in Specific Populations

► Drug interactions: Drug interactions: Because ketoconazole, a strong CYP3A4/5 inhibitor, Because ketoconazole, a strong CYP3A4/5 inhibitor, increased saxagliptin exposure, the dose should be limited to 2.5 mg increased saxagliptin exposure, the dose should be limited to 2.5 mg when coadministered with a strong CYP3A4/5 inhibitor (eg, atazanavir, when coadministered with a strong CYP3A4/5 inhibitor (eg, atazanavir, clarithromycin, indinavir, itraconazole, ketoconazole, nefazodone, clarithromycin, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, saquinavir, and telithromycin)nelfinavir, ritonavir, saquinavir, and telithromycin)

► Patients with renal impairment: Patients with renal impairment: Saxagliptin dose is 2.5 mg/d for patients Saxagliptin dose is 2.5 mg/d for patients with moderate or severe renal impairment, or with ESRD requiring with moderate or severe renal impairment, or with ESRD requiring hemodialysis (CrCl ≤50 mL/min). Saxagliptin should be administered hemodialysis (CrCl ≤50 mL/min). Saxagliptin should be administered following hemodialysis. Saxagliptin has not been studied in patients following hemodialysis. Saxagliptin has not been studied in patients undergoing peritoneal dialysis. Assessment of renal function is undergoing peritoneal dialysis. Assessment of renal function is recommended prior to initiation of saxagliptin and periodically thereafterrecommended prior to initiation of saxagliptin and periodically thereafter

► Pregnant and nursing women: Pregnant and nursing women: There are no adequate and well-controlled There are no adequate and well-controlled studies in pregnant women. Saxagliptin, like other antidiabetic studies in pregnant women. Saxagliptin, like other antidiabetic medications, should be used during pregnancy only if clearly needed. It medications, should be used during pregnancy only if clearly needed. It is not known whether saxagliptin is secreted in human milk. Because is not known whether saxagliptin is secreted in human milk. Because many drugs are secreted in human milk, caution should be exercised many drugs are secreted in human milk, caution should be exercised when saxagliptin is administered to a nursing woman.when saxagliptin is administered to a nursing woman.

► Pediatric patients: Pediatric patients: Safety and effectiveness of saxagliptin have not been Safety and effectiveness of saxagliptin have not been established.established.

OnglyzaOnglyza ® ® (saxagliptin) [package insert]. Princeton, NJ; Bristol-Myers Squibb; 2009. (saxagliptin) [package insert]. Princeton, NJ; Bristol-Myers Squibb; 2009.

Addition of Sitagliptin to InsulinAddition of Sitagliptin to Insulin——Effect on HbA1c at 24 WeeksEffect on HbA1c at 24 Weeks

► Sitagliptin change from baseline in A1C Sitagliptin change from baseline in A1C at Week 24 -0.59 (at Week 24 -0.59 (PP<0.001)<0.001)

► Placebo change from baseline -0.03Placebo change from baseline -0.03

Why DPP-4 Inhibitors?Why DPP-4 Inhibitors?

► Excellent in patients with mild Excellent in patients with mild hyperglycemia requiring insulin hyperglycemia requiring insulin secretagogue secretagogue

► No contraindication in heart failure and no No contraindication in heart failure and no risk of edema or lactic acidosisrisk of edema or lactic acidosis

► Can be used in renal insufficiency without Can be used in renal insufficiency without risk of hypoglycemia or lactic acidosisrisk of hypoglycemia or lactic acidosis

► No weight gainNo weight gain

► Immediate activity without causing Immediate activity without causing hypoglycemiahypoglycemia

Should DPP-4 Inhibitors Should DPP-4 Inhibitors Be First-line Agents?Be First-line Agents?

► If If ββ-cell-sparing effect shown in rats proves to -cell-sparing effect shown in rats proves to be true in humans, DPP-4 inhibitors could be true in humans, DPP-4 inhibitors could become the preferred first-line agentsbecome the preferred first-line agents

► Appropriate for patients with mild elevation Appropriate for patients with mild elevation of glucose with contraindications to other of glucose with contraindications to other agents that cause hypoglycemiaagents that cause hypoglycemia

► Should be considered early in overweight Should be considered early in overweight patientspatients

► Should be considered in patients with heart Should be considered in patients with heart failurefailure

► Strongly considered in patients with renal Strongly considered in patients with renal failurefailure

30

35

40

45

50

55

60

65

70

75

80

Sitagliptin Improved Markers of Sitagliptin Improved Markers of ββ-Cell -Cell Function Function —— 24-week Monotherapy Study 24-week Monotherapy Study

Proinsulin/insulin ratio

Aschner P et al. ADA. 2006.

P<0.001*

*P value for change from baseline compared to placebo

Hatched = BaselineSolid = Week 24

∆ from baseline vs pbo=0.078(95% CI -0.114, -0.023)

Placebo Sitagliptin 100 mg

Rat

io (

pm

ol/L

/pm

ol/L

)

HOMA-β

P<0.001*

∆ from baseline vs pbo=13.2 (95% CI 3.9, 21.9)

Placebo Sitagliptin 100 mg0.3

0.35

0.4

0.45

0.5

0.55

GLP-1 Improves GLP-1 Improves ββ-cell Mass in Fatty -cell Mass in Fatty Zucker Diabetic RatsZucker Diabetic Rats

Weeks

Control

β-cell Mass (mg) β-cell Proliferation (%) β-cell Apoptosis (%)

GLP-1-treated

16

12

8

4

0Control GLP-1-

treatedControl GLP-1-

treated

P<0.05P<0.01

P<0.001

2.5

2.0

1.5

0.5

0

1.0

30

20

10

0

Adapted from Farilla L et al. Endocrinology. 2002;143:4397-4408.

Beta

-Cell

Mass

(m

g)

Beta

-Cell

Mass

(m

g)

Pro

lifera

ting B

eta

Cells

(%

)Pro

lifera

ting B

eta

Cells

(%

)

Apopto

tic

Beta

Cells

(%

)A

popto

tic

Beta

Cells

(%

)

ConclusionsConclusions——GLP-1 MimeticsGLP-1 Mimetics

► GLP-1 mimetics are important new therapeutic GLP-1 mimetics are important new therapeutic options that have important roles in current therapy options that have important roles in current therapy and major potential future rolesand major potential future roles

► GLP-1 mimetics have excellent glucose-lowering GLP-1 mimetics have excellent glucose-lowering efficacy and are associated with significant weight efficacy and are associated with significant weight lossloss

► Combination with glitazones prevents glitazone-Combination with glitazones prevents glitazone-induced weight gaininduced weight gain

► Long-acting GLP-1 mimetics will increase their Long-acting GLP-1 mimetics will increase their acceptance acceptance

► ββ-cell preservation, if proven in humans, may make -cell preservation, if proven in humans, may make these mimetics early treatment options in the these mimetics early treatment options in the futurefuture

► Use in patients with glucose intolerance or simple Use in patients with glucose intolerance or simple obesity for weight reduction needs further obesity for weight reduction needs further evaluationevaluation

ConclusionsConclusions——DPP-4 InhibitorsDPP-4 Inhibitors

► DPP-4 inhibitors have a major role in diabetes DPP-4 inhibitors have a major role in diabetes managementmanagement

► Ability to use in renal insufficiency, heart failure, and Ability to use in renal insufficiency, heart failure, and hepatic disease markedly increases therapeutic hepatic disease markedly increases therapeutic options for our patientsoptions for our patients

► Quick onset of action and lack of hypoglycemia may Quick onset of action and lack of hypoglycemia may make these first-line agents in hospitalized patientsmake these first-line agents in hospitalized patients

► Excellent agents for the growing population of Excellent agents for the growing population of patients requiring modest glucose loweringpatients requiring modest glucose lowering

► Efficacy is enhanced with increased baseline HbA1CEfficacy is enhanced with increased baseline HbA1C

► New data support efficacy with sulfonylureas, which New data support efficacy with sulfonylureas, which will greatly enhance the usefulness of DPP-4 inhibitorswill greatly enhance the usefulness of DPP-4 inhibitors

► May be used as single agents or in combination with May be used as single agents or in combination with metformin, glitazones, sulfonylurea, or insulinmetformin, glitazones, sulfonylurea, or insulin

Future Management Directions in Future Management Directions in DM2DM2

► Longer – acting incretin mimeticsLonger – acting incretin mimetics

► Other DPP-IV inhibitorsOther DPP-IV inhibitors

► Other agents - e.g., SGLT-2 inhibitorsOther agents - e.g., SGLT-2 inhibitors

► Newer insulin formulations (oral / inhaled)Newer insulin formulations (oral / inhaled)

► Weight (“girth”) control - medical / Weight (“girth”) control - medical / surgical surgical

► DM2 prevention - action in the pre-DM2 prevention - action in the pre-diabetes (impaired tolerance) phasediabetes (impaired tolerance) phase

SGLT-2 Inhibitors – Useful Adjuncts?SGLT-2 Inhibitors – Useful Adjuncts?

► Mechanism of action - Mechanism of action - sodium-glucose transporter sodium-glucose transporter inhibition – prevents glucose reabsorption in the inhibition – prevents glucose reabsorption in the proximal tubal resulting in glucose loss (analogous to proximal tubal resulting in glucose loss (analogous to the apparently benign condition of renal glycosuria). the apparently benign condition of renal glycosuria). Not insulin dependent. Effective in DM2 and DM1. Not insulin dependent. Effective in DM2 and DM1.

► Studies to date - Studies to date - monotherapy and as add on to monotherapy and as add on to metformin, SU’s, TZD’s, DPP-IV inhibitors & insulin – metformin, SU’s, TZD’s, DPP-IV inhibitors & insulin – most studies preliminarymost studies preliminary

► Route - Route - oral, daily (contraindicated with severe CKD)oral, daily (contraindicated with severe CKD)► Efficacy - Efficacy - HbA1c reduction ~ 0.7-0.8% : weight loss – HbA1c reduction ~ 0.7-0.8% : weight loss –

1-2 kg1-2 kg► Side effects - Side effects - small(?) increase in U.T.I.’s & genital small(?) increase in U.T.I.’s & genital

moniliasis. No hypoglycemia with monotherapy. moniliasis. No hypoglycemia with monotherapy. See See LancetLancet 2010;375: 2196-98 & 2223-33 2010;375: 2196-98 & 2223-33

Stamp Out Diabetes!Stamp Out Diabetes!

Sequencing Oral Therapy in Type 2 Sequencing Oral Therapy in Type 2 Diabetes: DPP-4 Inhibitors as Monotherapy Diabetes: DPP-4 Inhibitors as Monotherapy or Combination Therapy with Metformin, or Combination Therapy with Metformin, Sulfonylureas, and TZDs—Constructing Sulfonylureas, and TZDs—Constructing

Outcome-Optimizing Oral Regimens Outcome-Optimizing Oral Regimens

Aligning Oral Therapy with Appropriate Patient Aligning Oral Therapy with Appropriate Patient Subgroups and Clinical SituationsSubgroups and Clinical Situations

Alexander Turchin, MD, MSAlexander Turchin, MD, MSAssistant Professor, Harvard Medical SchoolAssistant Professor, Harvard Medical School

Brigham and Women's HospitalBrigham and Women's HospitalBoston, MABoston, MA


► DPP-4 inhibitors as monotherapy or DPP-4 inhibitors as monotherapy or combination therapy with metformin, combination therapy with metformin, sulfonylureas, and TZDs - constructing sulfonylureas, and TZDs - constructing outcome-optimizing oral regimensoutcome-optimizing oral regimens

► Aligning oral therapy with appropriate patient Aligning oral therapy with appropriate patient subgroups: how to choose and what to subgroups: how to choose and what to choose - a systematic, guideline-consistent choose - a systematic, guideline-consistent approach based on clinical evidenceapproach based on clinical evidence

TopicsTopics

DPP-IV InhibitorsDPP-IV InhibitorsSitagliptin (Januvia)Saxagliptin (Onglyza)[Vildagliptin][Alogliptin]

• Glucose-dependent stimulation of insulin secretionGlucose-dependent stimulation of insulin secretion• Reduction of gastric emptyingReduction of gastric emptying• Reduction of inappropriate glucagon secretionReduction of inappropriate glucagon secretion• Beta-cell proliferation / regenerationBeta-cell proliferation / regeneration

Adapted from: Nauck MA et al. (2009). Diabetes Care 32(S2):S223Adapted from: Nauck MA et al. (2009). Diabetes Care 32(S2):S223

Risks & BenefitsRisks & Benefits

DPP-IVinhibitors

EFFICACY↓A1c 0.7%

(up to 1.5% if starting A1c higher)

COST$200 / month*

* Source – drugstore.com

SIDE EFFECTS (common)

- none

SIDE EFFECTS (putative)

- Pancreatitis- Pharyngitis

CONTRAINDICATIONS- h/o pancreatitis

► DPP-4 is found on the surface of lymphocytesDPP-4 is found on the surface of lymphocytes► It inhibits breakdown of multiple cytokines and It inhibits breakdown of multiple cytokines and

hormones including many involved in immune hormones including many involved in immune cell regulationcell regulation

BUTBUT► Meta-analysis of 12 Phase IIb / III trials involving Meta-analysis of 12 Phase IIb / III trials involving

3,415 patients on sitagliptin vs. 2,724 patients 3,415 patients on sitagliptin vs. 2,724 patients on placebo showed incidence of infections on placebo showed incidence of infections 34.5% vs. 32.9% (NS)34.5% vs. 32.9% (NS)

► Incidence of nasopharyngitis was 7.1% vs. 5.9% Incidence of nasopharyngitis was 7.1% vs. 5.9% (NS) (NS)

Risks: ImmunodeficiencyRisks: Immunodeficiency

From: Williams-Herman, D et al. (2008). BMC End Dis 8(14)From: Williams-Herman, D et al. (2008). BMC End Dis 8(14)

► 88 cases of pancreatitis in patients on 88 cases of pancreatitis in patients on sitagliptin have been reported to the FDA sitagliptin have been reported to the FDA by 09/2009by 09/2009

BUTBUT ► Retrospective study of 786,656 patients Retrospective study of 786,656 patients

including patients with h/o chronic including patients with h/o chronic pancreatitis and other pancreatitis risk pancreatitis and other pancreatitis risk factorsfactors

► 15,826 patients on sitagliptin15,826 patients on sitagliptin► Incidence of pancreatitis increased in Incidence of pancreatitis increased in

patients with diabetes; no difference for patients with diabetes; no difference for sitagliptinsitagliptin

Risks: PancreatitisRisks: Pancreatitis

From: Garg R et al. (2010). Diabetes Care online 08/03/10

The Rest - DailyThe Rest - Daily

SulfonylureasThiazolidinediones

(TZD)Metformin

-1.5%

HypoglycemiaHypoglycemiaWeight gainWeight gain

$4§

EfficacyEfficacy (A1c)(A1c)

CostCost**

(1 month)(1 month)

Side effectsSide effects

-1.0% -1.5%

$250 $4§

CHFCHFWeight gainWeight gainBone lossBone loss

GIGI

* Source – drugstore.com if not specified otherwise

All are approved as monotherapy or in combination with each All are approved as monotherapy or in combination with each otherother

§ Wal-Mart

The Rest – with MealsThe Rest – with Meals

Glinidesα-

glucosidase inhibitors

-1.5%

HypoglycemiaWeight gain

$100

EfficacyEfficacy (A1c)(A1c)

CostCost**

(1 month)(1 month)

Side Side effectseffects

GI

* Source – drugstore.com if not specified otherwise

All are approved as monotherapy or in combination with each otherAll are approved as monotherapy or in combination with each other

-0.7%

$200

ADA Consensus AlgorithmADA Consensus Algorithm

At diagnosis: lifestyle + metformin

lifestyle + metformin

+ basal insulin


+ sulfonylurea


+ pioglitazone

lifestyle + metformin +

GLP-1 agonist

lifestyle + metformin + sulfonylurea

+ basal insulin

lifestyle + metformin +

intensive insulin

Less well validated therapies

Adapted from: Nathan DM et al. (2009). Diabetes Care 32(1):193

ACE / AACE AlgorithmACE / AACE Algorithm

Patient Preference: EfficacyPatient Preference: Efficacy

metformin

sulfonylurea

TZD

glinide

DPP4 inhibitor

α -glucosidase inhibitors

Patient Preference: CostPatient Preference: Cost

metformin sulfonylurea

α-glucosidase

inhibitor

TZD

DPP4 inhibitor

Patient Preference: WeightPatient Preference: Weight

metforminDPP4

inhibitor

α -glucosidase inhibitor

TZD

sulfonylurea

Patient Preference: Patient Preference: Hypoglycemia AvoidanceHypoglycemia Avoidance

metformin

DPP4 inhibitor

TZD

α -glucosidase inhibitor

sulfonylurea

glinide

Questions?Questions?

Alexander Turchin, MD, MSAlexander Turchin, MD, [email protected]@partners.org


Cardiovascular, Metabolic, and Renal Cardiovascular, Metabolic, and Renal Considerations: Optimizing Efficacy and Considerations: Optimizing Efficacy and

Safety of DPP-4 Inhibitor Therapy in Safety of DPP-4 Inhibitor Therapy in High Risk PatientsHigh Risk Patients

Evidence-Based Therapy for T2D in Patients with CV Evidence-Based Therapy for T2D in Patients with CV

and/or Renal Risk Factors or Dysfunctionand/or Renal Risk Factors or Dysfunction

Derek LeRoith, MD, PhD, FACPDerek LeRoith, MD, PhD, FACP

Chief, Chief, Division of Endocrinology, Diabetes and Bone DiseaseDivision of Endocrinology, Diabetes and Bone DiseaseDirector, Metabolism Institute,Director, Metabolism Institute,

Mount Sinai School of MedicineMount Sinai School of MedicineNew York, NYNew York, NY


No A1C threshold is apparent– Finnish study by Kuusisto et al;UKPDS epidemiologic analysis; EPIC-Norfolk Study

Impaired glucose tolerance (IGT) and postprandial hyperglycemia are CV risk factors– Funagata Diabetes Study,;Honolulu Heart Program; DECODE Study; Rancho Bernardo Study

Mortality in Multiple Risk Factor Mortality in Multiple Risk Factor Intervention Trial (MRFIT)Intervention Trial (MRFIT)

Risk FactorRisk Factor Diabetes Diabetes (n = 5163)(n = 5163)

No DiabetesNo Diabetes(n = 342,815)(n = 342,815)

Relative Relative Risk*Risk*

CVD 85.1385.13 22.8822.88 3.03.0

CHD 65.9165.91 17.0317.03 3.23.2

Stroke 6.726.72 1.751.75 2.82.8

Other CVD 12.9912.99 4.084.08 2.32.3

Other 160.13160.13 53.2053.20 2.52.5

*Age-adjusted rate per 10,000 person-years. Relative risk adjusted for age, race, income, systolic BP, and smoking. Savage PJ. Ann Intern Med. 1996;124:123-126.

““Ticking Clock” Hypothesis: Glucose Ticking Clock” Hypothesis: Glucose Abnormalities Increase CV Risk, Even Before Dx Abnormalities Increase CV Risk, Even Before Dx

DMDMNurses’ Health Study, N = 117,629 women, aged 30–55 years; Nurses’ Health Study, N = 117,629 women, aged 30–55 years;

follow-up 20 years (1976–1996)follow-up 20 years (1976–1996)

Hu FB et al. Hu FB et al. Diabetes CareDiabetes Care. 2002;25:1129-34.. 2002;25:1129-34.

Relative Relative risk of MI risk of MI

or or stroke*stroke*

No diabetesNo diabetesBefore Before

diabetesdiabetesdiagnosisdiagnosis

After After diabetesdiabetesdiagnosidiagnosi

ss

Diabetes Diabetes atat

baselinebaseline

*Adjusted*Adjustedn = 1508 diabetes at baselinen = 1508 diabetes at baselinen = 5894 new-onset diabetesn = 5894 new-onset diabetes

High Risk of Cardiovascular Events High Risk of Cardiovascular Events in Type 2 Diabetesin Type 2 Diabetes

Cardiovascular Cardiovascular deathsdeaths

0

5

10

15

20

25

30

35

40

45

50

7-y

ear

inci

dence

of

7-y

ear

inci

dence

of

card

iovasc

ula

r events

(%

)ca

rdio

vasc

ula

r events

(%

)

Myocardial Myocardial infarctioninfarction

StrokeStroke - +

No diabetes

Type 2 diabetes

Prior myocardial infarctionPrior myocardial infarction - + - + - + - + - +

Haffner, NEJM 1998, 229-234Haffner, NEJM 1998, 229-234

DCCT/EDIC: Incidence of DCCT/EDIC: Incidence of Any CVD EventAny CVD Event

0.00

0.02

0.04

0.06

0.08

0.10

0.12

Cum

ula

tive inci

dence

Cum

ula

tive inci

dence

10 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

42%42%Risk reductionRisk reduction

PP=0.02=0.02

DCCT=Diabetes Control and Complications Trial.EDIC=Epidemiology of Diabetes Interventions and Complications.

DCCT/EDIC Study Research Group. DCCT/EDIC Study Research Group. N Engl J MedN Engl J Med. 2005;353:2643-2653.. 2005;353:2643-2653.

Years since entry into studiesYears since entry into studies

Conventional treatmentEDIC A1C mean 8.2%

Intensive treatmentEDIC A1C mean 8.0%

EDIC observation

20 years 20 years

After median 8.5 years post-trial follow-up

Aggregate Endpoint 1997 2007

Any diabetes related endpoint RRR: 12% 9% P: 0.029 0.040

Microvascular disease RRR: 25% 24% P: 0.0099 0.001

Myocardial infarction RRR: 16% 15% P: 0.052 0.014

All-cause mortality RRR: 6% 13% P: 0.44 0.007

RRR = Relative Risk Reduction, P = Log Rank

Legacy Effect of Earlier Glucose Legacy Effect of Earlier Glucose ControlControl

10-Year Follow-up of Intensive Glucose Control in Type 2 Diabetes. N Eng J Med 2008; 359

Cardiovascular Safety: Exenatide Cardiovascular Safety: Exenatide BIDBID

► Meta-analysis of clinical trials for exenatide twice dailyMeta-analysis of clinical trials for exenatide twice daily● No increased risk of CV events No increased risk of CV events ● Relative risk (95% CI) = 0.69 (0.46 - 1.04) versus pooled Relative risk (95% CI) = 0.69 (0.46 - 1.04) versus pooled

comparatorscomparators

► Retrospective, comparative analysis of large health Retrospective, comparative analysis of large health insurance databaseinsurance database

● Exenatide-treated (n = 21754) versus non-exenatide-Exenatide-treated (n = 21754) versus non-exenatide-treated (n = 361771)treated (n = 361771)

● Significantly lower risk of CV event for exenatide-treated Significantly lower risk of CV event for exenatide-treated patientspatients• Hazard ratio (95% CI) = 0.81 (0.68-0.95); P = .011Hazard ratio (95% CI) = 0.81 (0.68-0.95); P = .011• Lower risk despite greater inherent CV risk due to higher rates Lower risk despite greater inherent CV risk due to higher rates

of hyperlipidemia, hypertension, obesity, and prior CADof hyperlipidemia, hypertension, obesity, and prior CAD

Shen L, et al. Diabetes. 2009;58(suppl 1):366-OR.Best JH, et al. Presented at the ADA 70th Scientific Sesions; 712-P.

Cardiovascular Safety: LiraglutideCardiovascular Safety: Liraglutide

► US FDA analyses of clinical trial data identified no US FDA analyses of clinical trial data identified no excess risk of CV events versus comparators excess risk of CV events versus comparators (active or placebo)(active or placebo)

► Liraglutide Effect and Action in Diabetes: Evaluation Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) trial of Cardiovascular Outcome Results (LEADER) trial ● Designed to assess CV safety and satisfy FDA Designed to assess CV safety and satisfy FDA

guidelines for T2DM treatmentsguidelines for T2DM treatments● Scheduled to begin Autumn 2010Scheduled to begin Autumn 2010

FDA briefing materials – liraglutide. http://www.fda.gov/ohrms/dockets/ac/09/briefing/FDA briefing materials – liraglutide. http://www.fda.gov/ohrms/dockets/ac/09/briefing/2009-4422b2-01-FDA.pdf; Update on FDA Advisory Committee meeting on2009-4422b2-01-FDA.pdf; Update on FDA Advisory Committee meeting onliraglutide for the treatment of type 2 diabetes. liraglutide for the treatment of type 2 diabetes. http://www.novonordisk.com/include/asp/exe_news_attachment.pdf?shttp://www.novonordisk.com/include/asp/exe_news_attachment.pdf?sAttachmentGUID=1c87137d-806f-41bc-832a-e5a74aa86164; AttachmentGUID=1c87137d-806f-41bc-832a-e5a74aa86164; LEADER trial press release. LEADER trial press release. http://press.novonordisk-us.com/index.php?s=43&item=250.http://press.novonordisk-us.com/index.php?s=43&item=250.

CV Safety With DPP-4 Inhibitors: CV Safety With DPP-4 Inhibitors: SitagliptinSitagliptin

► Over 10,000 patients with T2DM, treated with Over 10,000 patients with T2DM, treated with sitagliptin 100 mg/day or placebo (non-exposed), sitagliptin 100 mg/day or placebo (non-exposed), up to 2 years.up to 2 years.

► The patients were from trials using sitagliptin as The patients were from trials using sitagliptin as monotherapy, or in combination with metformin, monotherapy, or in combination with metformin, sulfonylurea, pioglitazone or insulin.sulfonylurea, pioglitazone or insulin.

► Incidence rates of adverse events in the Cardiac Incidence rates of adverse events in the Cardiac Disorders Systems Order Class was ~4% per 100 Disorders Systems Order Class was ~4% per 100 Patient years, in both the sitagliptin and non-Patient years, in both the sitagliptin and non-exposed patients.exposed patients.

Williams-Herman D, et al.BMC Endocr Disord. 2010 Apr 22;10:7.Williams-Herman D, et al.BMC Endocr Disord. 2010 Apr 22;10:7.

Cardiovascular Safety in Cardiovascular Safety in Saxagliptin Clinical TrialsSaxagliptin Clinical Trials

Wolf R, et al. ADA 69th Scientific Sessions. Wolf R, et al. ADA 69th Scientific Sessions. Late Breaking Abstract Handout. 2009;8-LB:LB3.Late Breaking Abstract Handout. 2009;8-LB:LB3.

Data from 8 randomized, double-blind, phase 2b/3 trialsData from 8 randomized, double-blind, phase 2b/3 trialsaa

Major adverse cardiovascular events (MACE)Major adverse cardiovascular events (MACE)bb

Acute cardiovascular events (ACE)Acute cardiovascular events (ACE)cc

a Saxagliptin exposure: n = 3356 (3758 patient-years);

comparator exposure: n = 1251 (1293 patient-years).

b Stroke, myocardial infarction, cardiovascular death.

c Includes revascularization.

0 0.5 1 1.5 2

0.44(0.24, 0.82)

0.59 (0.35, 1.00)

MACE

ACE

Cox Proportional Hazard Ratio(95% confidence interval)

Event typeEvent type

SaxagliptinSaxagliptinn (%)n (%)

ComparatComparatoror

n (%)n (%)

ACEACE 38 (1.1)38 (1.1) 23 (1.8)23 (1.8)

MACEMACE 23 (0.7)23 (0.7) 18 (1.4)18 (1.4)

All deathsAll deaths 10 (0.3)10 (0.3) 12 (1.0)12 (1.0)

CV deathsCV deaths 7 (0.2)7 (0.2) 10 (0.8)10 (0.8)

Insulin secretionGlucagon secretion

Gastric emptying

Appetite

CardioprotectionCardiac output

Insulin biosynthesis cell proliferation cell apoptosis

Neuroprotection

Glucose production

Insulin sensitivity

Brain

Heart

GI tract

Liver

Muscle

Stomach

GLP-1

Drucker D. J. Cell Metabolism 2006

Summary of Incretin Actions on Different Target Tissues

Position StatementPosition Statementaa Regarding ACCORD, Regarding ACCORD, ADVANCE, and VADT ResultsADVANCE, and VADT Results

► Clinical implication = individualized goals and Clinical implication = individualized goals and carecare

► General A1C goal of < 7%General A1C goal of < 7%● For microvascular disease preventionFor microvascular disease prevention● Reasonable for macrovascular risk reduction, pending Reasonable for macrovascular risk reduction, pending

more evidencemore evidence

► A1C goals closer to normal for some patientsA1C goals closer to normal for some patients● Short diabetes duration, long life expectancy, no Short diabetes duration, long life expectancy, no

significant CVDsignificant CVD● Levels reached without significant adverse treatment Levels reached without significant adverse treatment

effectseffects

► Less stringent goals for some patientsLess stringent goals for some patients● History of severe hypoglycemia, limited life expectancy, History of severe hypoglycemia, limited life expectancy,

advanced micro- or macrovascular complications, advanced micro- or macrovascular complications, extensive comorbid conditions, long-standing diabetes extensive comorbid conditions, long-standing diabetes with difficulty achieving glycemic goalswith difficulty achieving glycemic goals

aAuthored by the American Diabetes Association, American College of Cardiology Foundation, and American Heart Association.

Skyler JS, et al. Diabetes Care. 2009;32:187-192.

Risk of Hypoglycemia in Type 2 DMRisk of Hypoglycemia in Type 2 DM

► Hypoglycemia associated with use of sulfonylureas Hypoglycemia associated with use of sulfonylureas and insulin.and insulin.

► Severe hypoglycemia is clinically evident, however, Severe hypoglycemia is clinically evident, however, mild to moderate hypoglycemia maybe asymptomatic mild to moderate hypoglycemia maybe asymptomatic and remain unreported.and remain unreported.

► When unreported, asymptomatic hypoglycemia maybe When unreported, asymptomatic hypoglycemia maybe detrimental to patients.detrimental to patients.

► Asymptomatic hypoglycemia maybe more prevalent in Asymptomatic hypoglycemia maybe more prevalent in older patients.older patients.

Chico A et al Diabetes Care 26: 1153-1157. 2003Chico A et al Diabetes Care 26: 1153-1157. 2003

Matyka K et al Diabetes Care 20: 135-141. 1997.Matyka K et al Diabetes Care 20: 135-141. 1997.

Monami M, et al. Eur J Endocrinol. 2009;160:909-917.Monami M, et al. Eur J Endocrinol. 2009;160:909-917.Buse JB, et al. Lancet. 2009;374:39-47.Buse JB, et al. Lancet. 2009;374:39-47.

aHypoglycemia requiring third-party assistance.

Kim.McFarland.IMNE

I think there's a graphic - as in the next slide - that will workDo we need an explanation as to why the risk of hypoglycemia is lower?

Risk Factors and Consequences of Risk Factors and Consequences of Hypoglycemia in Type 2 DiabetesHypoglycemia in Type 2 Diabetes

► Risk factorsRisk factors11

● Use of insulin secretagogues and insulin Use of insulin secretagogues and insulin therapytherapy

● Missed or irregular mealsMissed or irregular meals● Advanced ageAdvanced age● Duration of diabetesDuration of diabetes● Impaired awareness of hypoglycemiaImpaired awareness of hypoglycemia

► ConsequencesConsequences2,32,3

● Suboptimal glycemic controlSuboptimal glycemic control● Other health effectsOther health effects

1. Amiel SA et al. 1. Amiel SA et al. Diabet MedDiabet Med. 2008;25:245–254.. 2008;25:245–254.2. Landstedt-Hallin L et al. 2. Landstedt-Hallin L et al. J Intern MedJ Intern Med. 1999;246:299–307.. 1999;246:299–307.3. Cryer PE. 3. Cryer PE. J Clin InvestJ Clin Invest. 2007;117:868–870.. 2007;117:868–870.

Hypoglycemia May Be a Barrier to Hypoglycemia May Be a Barrier to Glycemic Control in Patients With Type 2 Glycemic Control in Patients With Type 2

DiabetesDiabetes► Hypoglycemia is an important limiting Hypoglycemia is an important limiting

factor in glycemic management and may factor in glycemic management and may be a significant barrier to treatment be a significant barrier to treatment adherenceadherence

► Fear of hypoglycemia is an additional Fear of hypoglycemia is an additional barrier to controlbarrier to control● A study in patients with type 2 diabetes A study in patients with type 2 diabetes

showed increased fear of hypoglycemia as showed increased fear of hypoglycemia as the number of mild/moderate and severe the number of mild/moderate and severe hypoglycemic events increasedhypoglycemic events increased

Amiel SA et al. Amiel SA et al. Diabet MedDiabet Med. 2008;25:245–254.. 2008;25:245–254.

Current Treatments Increase Current Treatments Increase Risk of HypoglycemiaRisk of Hypoglycemia

pp<0.05 glibenclamide <0.05 glibenclamide vs. rosiglitazonevs. rosiglitazone

Pat

ient

s w

ith h

ypog

lyca

emia

** (

%)

Pat

ient

s w

ith h

ypog

lyca

emia

** (

%)

1010

3939

00

55

1010

1515

2020

2525

3030

3535

4040

4545

RosiglitazoneRosiglitazone MetforminMetformin GlibenclamideGlibenclamide

1212

Hyp

ogly

caem

ia, e

vent

s/pa

tient

/yea

r*H

ypog

lyca

emia

, eve

nts/

patie

nt/y

ear*

00

55

1010

2020

GlargineGlargine NPHNPH

*All symptomatic hypoglycaemic events*All symptomatic hypoglycaemic events

1515

** Patients self-reporting (unconfirmed) hypoglycaemia** Patients self-reporting (unconfirmed) hypoglycaemia

Riddle Riddle et al. Diabetes Care et al. Diabetes Care 2003;26:3080; Kahn 2003;26:3080; Kahn et al et al (ADOPT). (ADOPT). NEJM NEJM 2006;355:2427–432006;355:2427–43

Hypoglycemia Risk Hypoglycemia Risk With GLP-1 Receptor AgonistsWith GLP-1 Receptor Agonists

► Meta-analysisMeta-analysis● 15 trials with exenatide BID or liraglutide versus active 15 trials with exenatide BID or liraglutide versus active

comparators or placebocomparators or placebo● Low risk of hypoglycemia Low risk of hypoglycemia exceptexcept in combination with in combination with

SUsSUs

► Significantly less minor hypoglycemia with liraglutide than Significantly less minor hypoglycemia with liraglutide than with exenatide in head-to-head comparisonwith exenatide in head-to-head comparison● Liraglutide or exenatide + MET and/or SULiraglutide or exenatide + MET and/or SU● Major hypoglycemiaMajor hypoglycemiaaa: 2 events in patients treated with : 2 events in patients treated with

exenatide + SUexenatide + SU

Monami M, et al. Eur J Endocrinol. 2009;160:909-Monami M, et al. Eur J Endocrinol. 2009;160:909-917.917.Buse JB, et al. Lancet. 2009;374:39-47.Buse JB, et al. Lancet. 2009;374:39-47.

aHypoglycemia requiring third-party assistance.

Hypoglycemia Risk With Hypoglycemia Risk With DPP-4 InhibitorsDPP-4 Inhibitors

Monami M, et al. Nutr Metab Cardiovasc Dis. Monami M, et al. Nutr Metab Cardiovasc Dis. Published online June 8, 2009; doi:10.1016/j.numecd.2009.03.015.Published online June 8, 2009; doi:10.1016/j.numecd.2009.03.015.

Hypoglycemia risk similar to placeboHypoglycemia risk similar to placebo

Act

ive

Act

ive

Co

mp

arat

ors

Co

mp

arat

ors

Pla

ceb

o-C

on

tro

lled

Pla

ceb

o-C

on

tro

lled

Tri

als

Tri

als

VildagliptinVildagliptinMonotherapyMonotherapyAdd-on to SU/InsulinAdd-on to SU/Insulin

SitagliptinSitagliptinMonotherapyMonotherapyAdd-on to SU/InsulinAdd-on to SU/Insulin

DPP-4 InhibitorsDPP-4 InhibitorsSulfonylureasSulfonylureasThiazolidinedionesThiazolidinediones

0.01 0.10 1.0 10.0

Any Hypoglycemia (Mantel-Haenzel Odds Ratio With Any Hypoglycemia (Mantel-Haenzel Odds Ratio With 95% CI)95% CI)aa

a Logarithmic scale.

Age-related Decline in Renal Function Age-related Decline in Renal Function in Patients with Type 2 diabetesin Patients with Type 2 diabetes

Dosing GLP-1 Receptor Agonists in Dosing GLP-1 Receptor Agonists in Renal InsufficiencyRenal Insufficiency

Degree of Renal Degree of Renal InsufficiencyInsufficiency Exenatide BIDExenatide BID LiraglutideLiraglutide

Mild (GFR > 50 mL/min) No changeNo change

Use with caution due to Use with caution due to limited clinical limited clinical experience in this experience in this population. No dose population. No dose adjustment adjustment recommended.recommended.

Moderate (GFR ≥ 30-50 mL/min)

Use caution during Use caution during initiation or dose escalationinitiation or dose escalation


Severe (GFR < 30 mL/min)

•Should not be used in Should not be used in patients with severe renal patients with severe renal impairment or end-stage impairment or end-stage renal diseaserenal disease

•Use with caution in Use with caution in patients with renal patients with renal transplantationtransplantation


Byetta (exenatide) [prescribing information]. http://pi.lilly.com/us/byetta-pi.pdf.Byetta (exenatide) [prescribing information]. http://pi.lilly.com/us/byetta-pi.pdf.Victoza (liraglutide) [prescribing information]. Victoza (liraglutide) [prescribing information]. http://www.victoza.com/pdf/PI_(1_Column_Format).pdf.http://www.victoza.com/pdf/PI_(1_Column_Format).pdf.

Dosing DPP-4 Inhibitors in Dosing DPP-4 Inhibitors in Renal InsufficiencyRenal Insufficiency

Degree of Renal Degree of Renal InsufficiencyInsufficiency SitagliptinSitagliptin SaxagliptinSaxagliptin

Mild (GFR > 50 mL/min)

100 mg per day100 mg per day 5mg per day5mg per day

Moderate (GFR ≥ 30-50 mL/min)

50 mg per day50 mg per day No adjustmentNo adjustment

Severe (GFR < 30 mL/min)

25 mg per day25 mg per day 2.5 mg per day2.5 mg per day

Saxagliptin and Sitagliptin Saxagliptin and Sitagliptin in Elderly Patientsin Elderly Patients

SaxagliptinSaxagliptin

5 mg/day vs placebo5 mg/day vs placeboSitagliptinSitagliptin

100 mg/day vs placebo100 mg/day vs placeboaa

Participants

•Patients ≥ 65 yearsPatients ≥ 65 yearsbb

•Monotherapy and Monotherapy and combination therapycombination therapy

•N = 274N = 274

•Patients ≥ 65 yearsPatients ≥ 65 years•MonotherapyMonotherapy•N = 206N = 206

A1C change (relative to placebo)

- 0.55%- 0.55% - 0.7%- 0.7%

AEs Similar to placeboSimilar to placebo Similar to placeboSimilar to placebo

Hypoglycemia None reportedNone reported Similar to placeboSimilar to placebo

a a Except in cases of dose adjustment for renal Except in cases of dose adjustment for renal insufficiency.insufficiency.b b Pooled analysis of clinical trial data.Pooled analysis of clinical trial data.

Barzilai N, et al. Diabetes. 2009;58(suppl 1):587-P.Barzilai N, et al. Diabetes. 2009;58(suppl 1):587-P.Maheux P, et al. Presented at the 2009 European Maheux P, et al. Presented at the 2009 European Association for the Study of Diabetes Meeting. Present Association for the Study of Diabetes Meeting. Present No. 766.No. 766.

Case Studies in Oral Therapeutics Case Studies in Oral Therapeutics for Type 2 Diabetes—Clinical for Type 2 Diabetes—Clinical

Decisions and Real World Decisions and Real World OutcomesOutcomes





► 47-year-old male with type 2 diabetes 47-year-old male with type 2 diabetes mellitus diagnosed 5 years ago, returns for a mellitus diagnosed 5 years ago, returns for a follow-up visit.follow-up visit.

► He reports feeling well. For exercise, he walks He reports feeling well. For exercise, he walks his dog daily for about a mile. He feels he his dog daily for about a mile. He feels he could “do better with his diet”; he has seen a could “do better with his diet”; he has seen a nutritionist and diabetes educator, but says nutritionist and diabetes educator, but says he lacks motivation. he lacks motivation.

Case Study #1Case Study #1

► On exam he has a BMI of 36, Pulse 74, On exam he has a BMI of 36, Pulse 74, BP 130/80. Rest of the exam is normal BP 130/80. Rest of the exam is normal

► His current meds are metformin 1000 mg His current meds are metformin 1000 mg bid, glyburide 10 mg bid, lisinopril 10 mg bid, glyburide 10 mg bid, lisinopril 10 mg daily, simvastatin 40 mg daily, and ASA 81 daily, simvastatin 40 mg daily, and ASA 81 mg daily.mg daily.

► Downloaded meter reveals BG testing Downloaded meter reveals BG testing about once daily; BG range 55-320, about once daily; BG range 55-320, average 162 mg/dl.average 162 mg/dl.

► A1C 7.8 %, serum creatinine 1.1 mg/dl , A1C 7.8 %, serum creatinine 1.1 mg/dl , LDL-C 66 mg/dlLDL-C 66 mg/dl


What is your recommendation for What is your recommendation for him?him?

1.1. Add basal insulinAdd basal insulin

2.2. Stop glyburide and start basal Stop glyburide and start basal bolus insulin treatmentbolus insulin treatment

3.3. Add pioglitazone (Actos) 45 mg Add pioglitazone (Actos) 45 mg dailydaily

4.4. Add sitagliptin (Januvia) 100 mg Add sitagliptin (Januvia) 100 mg dailydaily

5.5. Do not change drug therapy and Do not change drug therapy and refer back to the diabetes refer back to the diabetes educatoreducator

6.6. Add exenatide (Byetta) bidAdd exenatide (Byetta) bid


► 67-year-old woman with DM-2, 67-year-old woman with DM-2, hypertension, obesity, rheumatoid arthritis hypertension, obesity, rheumatoid arthritis and COPD presents with A1c of 7.6%. Her and COPD presents with A1c of 7.6%. Her BMI is 34.2 and she is looking to lose BMI is 34.2 and she is looking to lose weight. She tried metformin previously but weight. She tried metformin previously but did not tolerate due to side effects.did not tolerate due to side effects.

► Candidate for DPP-IV monotherapyCandidate for DPP-IV monotherapy

► Alternatives: Alternatives: αα-glucosidase inhibitor-glucosidase inhibitor

► Other optionsOther options


► 82-year-old man with hypertension, 82-year-old man with hypertension, hypercholesterolemia, ischemic hypercholesterolemia, ischemic cardiomyopathy and NYHA class III heart cardiomyopathy and NYHA class III heart failure presents with a newly diagnosed failure presents with a newly diagnosed DM-2 and A1c of 7.4%. DM-2 and A1c of 7.4%.

► Candidate for DPP-IV monotherapyCandidate for DPP-IV monotherapy




► 59-year-old man with DM-2 treated with 59-year-old man with DM-2 treated with metformin, hypertension, dyslipidemia, prostate metformin, hypertension, dyslipidemia, prostate cancer and osteoporosis presents with A1c of cancer and osteoporosis presents with A1c of 7.9%. He was previously taking glyburide but had 7.9%. He was previously taking glyburide but had several episodes of severe hypoglycemia (had to several episodes of severe hypoglycemia (had to be assisted in treatment) and discontinued it 3 be assisted in treatment) and discontinued it 3 months ago. He has a hectic work schedule months ago. He has a hectic work schedule (marketing executive) and is not always able to (marketing executive) and is not always able to have meals at regular times.have meals at regular times.

► Candidate for DPP-IV as 2Candidate for DPP-IV as 2ndnd line agent (after line agent (after metformin)metformin)




► 52-year-old man with no past medical 52-year-old man with no past medical history presents with newly diagnosed DM-history presents with newly diagnosed DM-2. His A1c is 9.1%. He is adamant in 2. His A1c is 9.1%. He is adamant in refusing to consider injectable medications.refusing to consider injectable medications.

► Candidate for DPP-IV as 3Candidate for DPP-IV as 3dd line agent (after line agent (after metformin + sulfonylurea and / or TZD)metformin + sulfonylurea and / or TZD)

► Alternatives: Alternatives: αα--glucosidase inhibitorglucosidase inhibitor



73-year-old African-American female - T2DM for the past 5 73-year-old African-American female - T2DM for the past 5 yearsyears

PM History:PM History: GI intolerance with metforminGI intolerance with metforminLongstanding hypertensionLongstanding hypertensionMI at age 65, ejection fraction 40%MI at age 65, ejection fraction 40%

Meds: Meds: Glimepiride 4 mg, Aspirin 325 mg, Metoprolol 50 mgGlimepiride 4 mg, Aspirin 325 mg, Metoprolol 50 mgRosuvastatin 10mg, Furosemide 20mg, Lisinopril Rosuvastatin 10mg, Furosemide 20mg, Lisinopril

10mg daily10mg daily

Vitals:Vitals: BMI 29, BP 130/80 BMI 29, BP 130/80

Bloods:Bloods: TCHOL 193, LDL 70, HDL 58, TG 81TCHOL 193, LDL 70, HDL 58, TG 81FPG 127 mg/dl, A1C 7.5%FPG 127 mg/dl, A1C 7.5%Creatinine 1.4 mg/dl, GFR 49 ml/minCreatinine 1.4 mg/dl, GFR 49 ml/min

What’s the next step in managing her diabetes? What’s the next step in managing her diabetes?


What’s the next step in managing her diabetes?What’s the next step in managing her diabetes?

The following should not be used in this The following should not be used in this patient, patient, exceptexcept one class: one class:

A. A. MetforminMetforminB. B. SulfonylureasSulfonylureasC. C. ThiazolidinedionesThiazolidinedionesD. D. Incretin mimetics/ DPP-IV inhibitorsIncretin mimetics/ DPP-IV inhibitorsE. E. InsulinInsulin


What are some of the major risk factors in What are some of the major risk factors in treating Type 2 diabetic patients?treating Type 2 diabetic patients?

1. 1. Cardiovascular diseaseCardiovascular disease

2. 2. Renal FailureRenal Failure

3. 3. AgingAging

4. 4. HypoglycemiaHypoglycemia


New Frontiers and Advances in Oral Therapy for Type 2 Diabetes Focus on DPP-4 Inhibition and...

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