b asal i nsulin and c ardiovascular and o ther o utcomes in d ysglycemia t he origin t rial i...
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BASAL INSULIN AND CARDIOVASCULAR AND OTHER OUTCOMES IN DYSGLYCEMIATHE ORIGIN TRIAL INVESTIGATORSNEJM JULY 26, 2012: 367;4Charles Wang
4th Year PharmD Candidate
University of Georgia College of Pharmacy
8/27/2012
OVERVIEW
ORIGIN Trial Outcome Reduction with Initial Glargine
InterventionTested if sufficient basal insulin to normalize
fasting plasma glucose levels may reduce cardiovascular events.
Funding Sanofi BioPharma Norge
Study Dates September 2003 – December 2011
BACKGROUND
Diabetes is a chronic metabolic disease in which a person has high blood glucose levels.
It involves either the body not producing enough insulin or because the cells do not respond to the insulin that is produced.
Globally, as of 2012, an estimated 346 million people have type 2 diabetes.
Diabetes has many complications: Cardiovascular disease Ischemic heart disease Stroke Peripheral vascular disease Diabetic retinopathy, nephropathy, and neuropathy
BACKGROUND
Elevated blood glucose indicates that there is not enough endogenous insulin to regulate the glucose levels or to overcome underlying insulin resistance
Correction of this deficiency may reduce cardiovascular outcomes.
United Kingdom Prospective Diabetes Study (UKPDS) 15% reduction in myocardial infarction 13% reduction in death among people with a new-
onset type 2 diabetes Normalizing fasting plasma glucose levels may safely
reduce incident CV outcomes Exogenous insulin may slow the decline in pancreatic
function with time
BACKGROUND
Insulin glargine Brand name: Lantus Long acting basal insulin Consists of microcrystals that slowly release
insulin Usually given once daily “peakless” profile according to package insert
Formulated at an acidic pH of 4 Water soluble at that pH Physiologic pH (~7.4) causes the insulin to come out of
solution that forms hexamers Hexamers slows dissociation into insulin monomers
which is the physiologically active unit of insulin. Do not mix Lantus with any other insulin
Precipitates out of solution and reduces effectiveness
DESIGN
Trial tested the effects of titrated basal insulin glargine versus standard of care and of n-3 fatty acid supplements versus placebo on cardiovascular outcomes
Study Design Used 2-by-2 factorial design Double-blinded Randomized 537 cardiology, diabetes, or other clinical sites 40 countries
DESIGN
Insulin Glargine Standard of Care
N-3 fatty-acid supplements
Insulin Glargine +N-3 fatty-acid supplements
Standard of Care +N-3 fatty-acid supplements
Placebo Insulin Glargine +Placebo
Standard of Care +Placebo
INCLUSION CRITERIA
Impaired Glucose Tolerance PPG ≥ 140 < 200 mg/dL FPG < 126 mg/dL
OR Impaired Fasting Glucose without DM FPG ≥ 110 and < 126 PPG must be <200 mg/dL
OR early type 2 diabetes FPG ≥ 126 mg/dL or a PPG ≥ 200 or a previous
diagnosis of DM and either: No pharmacologic treatment for at least 10 weeks
prior to screening or An A1c of < 150% of the upper limit for the laboratory
(<9% if 6%)
INCLUSION CRITERIA OR taking one oral antidiabetic drugs for at least 10
weeks at the time of screening and <8.5% A1c Men or women ≥ 50 years old Must be at risk for cardiovascular disease
Prior MI Prior Stroke Prior coronary, carotid, or peripheral arterial
revascularization Angina with documented ischemic changes Microalbuminuria or clinical albuminuria
A:C ratio > 30 mg/mg LV hypertrophy At least 50% stenosis on angiography of a coronary,
carotid, or lower extremity artery Ankle/brachial index <0.9
EXCLUSION CRITERIA
Type 1 diabetes Requiring insulin treatment Known anti-GAD Ab positivity in the past
Autoimmune antibodies differentiates between types of diabetes
HgA1c >150% of upper limit (≥9%) CABG within 4 years of screening SrCr > 2.0 mg/dL ALT or AST > 2.5 times upper limit of normal Chronic or recurrent treatment of systemic
corticosteroids or niacin treatment Heart Failure of NYHA Class III or IV Prior heart transplant or awaiting heart transplant
METHODS
12,537 participants 2-by-2 factorial design Follow up for 7 years 6,264 in the Insulin Glargine Group 6,273 in the Standard Care Group In the insulin group, participants added an
evening injection to their control regimen and increased the dose at least once weekly Targeting a FPG level of 95 mg/dL
Those without a diabetes diagnosis Reduced dose of insulin by 10 units per day and
stopped any metformin by the last visit
METHODS
Those in the Standard Care arms were treated on the basis of the investigator’s best judgment and local guidelines
Also, those that did not have a diabetes diagnosis and were not using glucose lowering drugs were scheduled for a Glucose Tolerance Test and retested if it did not establish a diagnosis of diabetes.
BASELINE CHARACTERISTICS
BASELINE CHARACTERISTICS
BASELINE CHARACTERISTICS
BASELINE CHARACTERISTICS
OUTCOMES
Co-primary Outcomes Death from cardiovascular causes, nonfatal
myocardial infarction, or nonfatal stroke A revascularization procedure (cardiac, carotid,
or peripheral) or hospitalization for heart failure Other outcomes
Microvascular events Incident cases of diabetes in participants without
baseline diabetes All-cause mortality New or recurrent cancers Hypoglycemic episodes Weight
RESULTS
RESULTS
RESULTS
HAZARD RATIO
Used when presenting results with survival analysis data Should not be considered the same as relative risk ratio
A hazard is the rate at which events happen Probability=length of time x hazard The hazard ratio is an expression of the hazard or
chance of events occurring in the treatment arm as a ratio of the hazard of the events occurring in the control arm
Assume proportional hazard Risk does not depend on time A hazard ration of 2 means that the treatment will cause
the patient to progress more quickly, that a person that has not progressed has twice the chance of having progressed to a certain point when compared to someone in the control group.
RESULTS
Coprimary Outcomes No significant difference in either outcome MI, Stroke, or death from CV causes
HR: 1.02; 95%CI 0.94-1.11; P=0.63 Revascularization or Hospitalization for CHF
HR: 1.04; 95%CI 0.97-1.11; P=0.27
Other Outcomes All-outcome death
HR: 0.98; 95%CI 0.9 to 1.08; P=0.7 Microvascular Events
HR: 0.97; 95%CI 0.90 to 1.05; P 0.43
RESULTS
1,456 participants without diabetes at randomization, (737 assigned to Lantus and 719 assigned to standard care) Lantus Group were 28% less likely to develop
diabetes OR:0.72; 95%CI, 0.58 to 0.91; P=0.006
No significant difference of incidence of cancer HR: 1.00; 95%CI, 0.88 to 1.13; P=0.97
Incidence of first episode of severe hypoglycemia 1 per 100 person-years in Lantus 0.31 per 100 person years in standard care P=<0.001
RESULTS
Weight Changes +1.6 kg in Lantus Group -0.5 kg in standard of care group
AUTHOR’S CONCLUSION
When used to target normal fasting plasma glucose levels for more than 6 years, insulin glargine had a neutral effect on cardiovascular outcomes and cancers
Reduced new-onset diabetes Increased hypoglycemia events Modest increase in weight
STRENGTHS
Very large sample size Long follow up duration and high rate of
follow-up and treatment adherence 6.2 year average follow up time
Well distributed baseline Large and diverse data collection
LIMITATIONS
Only included relatively controlled diabetics Did not include patients currently on insulin No standard, standard care, thus allowing
each physician to determine course of care. Guideline-suggested degrees of glycemic control
Did not test more intense versus less intense glucose control
DISCUSSION
Metformin was used in 47% of the insulin-glargine group Cardioprotective effect of metformin might have
mitigated cardiovascular harm of insulin. 60% of standard care was also on [
Patients that were not diagnosed with diabetes had a reduced incidence of developing diabetes in the Lantus group. Most likely due to the masking of the
hyperglycemia by residual Lantus.