developments in the treatment of t2dm dr john clark
TRANSCRIPT
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Developments in the Treatment of T2DM
Dr John Clark
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Diabetes Prevalence
0
1 million
2 million
3 million
1995 2000 2013
Type 1Type 2
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Audit of West Suffolk Hospital In-Patients
One day (23/9/12)
440 in-patients, in total, in WSH that day
75 known to have Diabetes
17% of in-patients are Diabetic (1 in 6)
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Glycaemic ControlGlycaemic Control Drugs to use Drugs to use (prior to 2010)(prior to 2010)
Drug of choiceDrug of choice MetforminMetformin
Next StageNext Stage MetforminMetformin + + SulphonylureaSulphonylurea oror MetforminMetformin + + PioglitazonePioglitazone
Next StageNext Stage Metformin Metformin + + Pioglitazone + SUPioglitazone + SU
Final StageFinal Stage MetforminMetformin + + basal insulinbasal insulin
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New DevelopmentsNew Developments
The incretin effect and GLP-1 The incretin effect and GLP-1
Treatments Treatments A) DPP-4 InhibitorsA) DPP-4 Inhibitors
Treatments Treatments B) GLP-1 Agonists B) GLP-1 Agonists
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Oral glucose load (50 g) iv. glucose infusion
Pla
sma g
luco
se (
mm
ol/L)
–10 –5 60 120 180
10
Time (min)
5
0
15
Plasma glucose
The Incretin Effect
• Insulin response is greater following oral glucose than i.v. glucose, despite similar plasma glucose concentration
Insulin response
Insu
lin (
mU
/L)
80
60
40
20
–10 –5 60 120 1800
Time (min)
Incretineffect
Healthy volunteers (n=8); i.v.: intravenousNauck et al. Diabetologia 1986;29:46–52
Date of preparation: August 2009UK/LR/0809/0384
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The Incretin Effect is Reduced in Subjects with Type 2 Diabetes
Nauck MA, et al. Diabetologia 1986;29:46–52. *P ≤.05 compared with respective value after oral load.
Time (min)
Intravenous GlucoseOral Glucose
0
20
40
60
80
Ins
uli
n (
mU
/L)
0 30 60 90 120 150 180
** *
** **
Control subjects
0
20
40
60
80
0 30 60 90 120 150 180
Time (min)
**
*
Subjects with type 2 diabetes
Ins
uli
n (
mU
/L)
The Incretin Effect accounts for ~ 60% of total Insulin release following a meal
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Studies of the entero-insular axis following pancreas transplantation in man: neural or
hormonal control?Clark JDA, Wheatley T, Brons IG, Bloom SR, Calne RY.
Department of Medicine and Surgery, Addenbrooke's Hospital, Cambridge, UK.
Diabetic Medicine. 1989 Dec,6, 813-7.
To study the role of hormonal and neural factors in the control of the entero-insular axis, the responses to oral and intravenous glucose were investigated in 5 patients who had received a combined kidney and paratopic pancreas transplant
As the incretin effect was preserved, despite
a denervated pancreas, hormonal rather than neural factors may be more important in mediating increased insulin secretion after oral carbohydrate. The normal GIP response is compatible with its proposed role as an insulinotropic hormone.
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Incretin EffectIncretin Effect
Larger insulin response toLarger insulin response to ora oral rather than IV l rather than IV glucose. Why?glucose. Why?
Oral glucose stimulates release of Oral glucose stimulates release of GLP-1GLP-1 from from
small intestinesmall intestine
GLP-1 GLP-1 augments insulin releaseaugments insulin release from B cells of from B cells of
pancreaspancreas
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What is glucagon-like peptide-1 (GLP-1)?
Lys
His Ala Thr Thr SerPheGlu Gly Asp
Val
Ser
SerTyrLeuGluGlyAlaAla GlnLys
Phe
Glu
Ile Ala Trp Leu GlyVal Gly Arg
• A 31 amino acid peptide
• Cleaved from proglucagon in L-cells in the GI tract
• Secreted in response to meal ingestion
GI: gastrointestinalDrucker & Nauck. Lancet 2006;368:1696–705
Date of preparation: August 2009UK/LR/0809/0384
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GLP-1: Effects in HumansGLP-1: Effects in Humans
Promotes satiety and reduces appetite
-cells:Enhances glucose-
dependent insulin secretion
GLP-1: Glucagon-like peptide 1Adapted from Flint A, et al. J Clin Invest. 1998;101:515-520; Adapted from Larsson H, et al. Acta Physiol Scand. 1997;160:413-422; Adapted from Nauck MA, et al. Diabetologia. 1996;39:1546-1553; Adapted from Drucker DJ. Diabetes. 1998;47:159-169.
Stomach: Helps regulate
gastric emptying
GLP-1 secreted upon the ingestion of food
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Native GLP-1 is rapidly degraded by DPP-4 (Di-Peptidyl Peptidase-4)
Human ileum, GLP-1-producingL-cells
Capillaries,DPP-4
Double immunohistochemical staining for DPP-4 (red) and GLP-1 (green) in the human ileum
Hansen et al. Endocrinology 1999;140:5356–63
Date of preparation: August 2009UK/LR/0809/0384
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The family of incretin-based The family of incretin-based therapiestherapies
Human GLP-1 analogues, liraglutide
Exendin-basedtherapies,
exenatide + lixisenatide
GLP-1 receptor agonists
DPP-4 inhibitors, sitagliptin vildagliptin saxagliptinlinagliptin
Incretin-basedtherapies
Date of preparation: August 2009UK/LR/0809/0384
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DPP-4 Inhibitors (Gliptins)DPP-4 Inhibitors (Gliptins)
OralOral
Weight neutralWeight neutral
Minimal hypoglycaemiaMinimal hypoglycaemia
NICE – must lower HbA1c by 0.5% within 6/12NICE – must lower HbA1c by 0.5% within 6/12
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Mr K S age 65
Type 2 Diabetes for 10 years
Gradual increase in OHA dosage
June 2010 HbA1c 7.8%
Metformin 500mg bd + glipizide 10mg bd
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Mr K S
June 2010 - Add in Sitagliptin 100 mg od
October 2010 - HbA1c 7.4%
Glipizide reduced to 2.5 mg am, 5 mg pm.
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Do Exenatide/Liraglutide/Lixisenatide Do Exenatide/Liraglutide/Lixisenatide Work?Work?
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Exenatide vs. Insulin Glargine Exenatide vs. Insulin Glargine
Reductions in HbAReductions in HbA1c1c
-1.1% -1.1%
-1.5
-1.0
-0.5
0.0
% C
ha
ng
e i
n H
bA
1c
HbA1c <7% HbA1c <6.5%
46% 48%
32%
25%
0
10
20
30
40
50
60
% P
ati
en
ts A
ch
iev
ing
H
bA
1c t
arg
ets
Exenatide
Insulin glargine
ITT population; Mean ± SE shown.Heine RJ et al. Ann Intern Med. 2005;143:559-569.
(n=275)
(n=260)
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Exenatide vs. Insulin GlargineExenatide vs. Insulin GlargineChange in Body WeightChange in Body Weight
Exenatide (n = 275) Insulin glargine (n = 260)
Time (weeks)
Ch
an
ge
in
bo
dy
we
igh
t (k
g)
0 2 4 8 12 18 26
-3
-2
-1
0
1
2
**
**
**
+1.8 kg
-2.3 kg
4.1 kg
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HbAHbA1c1c and weight loss: and weight loss: from LEAD trials 1–6from LEAD trials 1–6
% patients
Weig
ht
loss
Weig
ht
gain
HbA1c decrease HbA1c increase
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LEAD-2. ITT, LOCF. n=232
Glimepiride 4 mg
51%
32%
HbAHbA1c1c and weight change: and weight change: sulphonylurea sulphonylurea
HbA1c decrease
Weig
ht
loss
Weig
ht
gain
HbA1c increase
5%
12%
Data on file Composite Endpoint,Novo Nordisk
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LEAD-1. ITT, LOCF. n=224
Pioglitazone
10%15%
49% 26%
HbAHbA1c1c and weight change: and weight change: thiazolidinedionethiazolidinedione
ITT, intention-to-treat; LOCF, last observation carried forward
HbA1c decrease
Data on file, Composite Endpoint, Novo Nordisk
HbA1c increase
Weig
ht
loss
Weig
ht
gain
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LEAD-5. ITT, LOCF. n=224
Glargine 24 IU
63% 10%
2%25%
HbAHbA1c1c and weight change and weight change: : glargineglargine
HbA1c decrease
Weig
ht
loss
Weig
ht
gain
HbA1c increase
Data on file Composite Endpoint, Novo Nordisk
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LEAD-6. ITT, LOCF. n=196
Exenatide 10 μg BD
5%14%
9%72%
HbAHbA1c1c and weight change and weight change: : exenatideexenatide
HbA1c decrease
Weig
ht
loss
Weig
ht
gain
HbA1c increase
Data on file Composite Endpoint, Novo Nordisk
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LEAD-2. ITT, LOCF. n=231
Liraglutide 1.2 mg
72% 13%
4%10%
HbAHbA1c1c and weight change: and weight change: liraglutide liraglutide 1.2 mg1.2 mg
HbA1c decrease
Weig
ht
loss
Weig
ht
gain
HbA1c increase
Data on file Composite Endpoint,Novo Nordisk
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Comparison : shifting the paradigmComparison : shifting the paradigm
Pioglitazone
Glimepiride 4 mg
Exenatide 10 μg BID
Lixisenatide 20ug od
Glargine 24 IU
25%
72%
72%
72%
Liraglutide 1.2 mg
32%
15%
HbA1c decrease HbA1c increase
Weig
ht
gain
Weig
ht
loss
Data on file Composite Endpoint, Novo Nordisk
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Diabetes Clinic Diabetes Clinic (1/9/10)(1/9/10)
Weight HbA1c ExenatideWeight HbA1c Exenatide NJ 120 – 92kg 8.5 – 6.1 1yearNJ 120 – 92kg 8.5 – 6.1 1year
JH 117 – 96kg 7.8 – 6.0 6 monthsJH 117 – 96kg 7.8 – 6.0 6 months
NT 123 – 112kg 9.2 – 7.3 6 monthsNT 123 – 112kg 9.2 – 7.3 6 months
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NICE Guidance NICE Guidance 20102010
(must satisfy all criteria)(must satisfy all criteria)
HbA1c > 7.5%HbA1c > 7.5% Already on OHAsAlready on OHAs Weight related health problemsWeight related health problems BMI > 35BMI > 35
By 6 months must achieve both targets By 6 months must achieve both targets weight loss of 3% weight loss of 3% drop in HbA1c of 1%drop in HbA1c of 1%
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312 patients initiated on Exenatide since May 2008
207 patients completed 6 months treatment by December 2010
WSH Audit 2011
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WSH Outcome Data: Passed v Failed @ 6 months
Passed @ 6/12(184)
HbA1c Weight (Kg) BMI
Baseline 9.6SD 1.5(7.4 to 14.0)
119.8SD 20.9(75.2 to 185.6)
41.5SD 7.2(26.0 to 84.8)
Change at 6/12
-1.6SD 1.6(-7.1 to +3.5)
-6.8SD 5.4(-25.6 to +5.6)
-2.4SD 1.9(-9.3 to +1.9)
P value P < 00001 P < 0.0001 P < 0.0001
Failed @ 6/12(23)
HbA1c Weight (Kg) BMI
Baseline 9.3(6.2 to 12.9)SD 1.6
126.4(80.2 to 183.7)SD 25.1
43.2(33.8 to 59.1)SD 7.9
Change at 6/12
-0.3(-5.4 to +3.3)SD 1.6
-6.2(-16.7 to +1.3)SD 5.1
-2.1(-5.0 to +0.4)SD 1.7
P value P = 0.35 P < 0.0001 P = 0.0014
P value (pass v non-pass)
P = 0.0004 P = 0.57 P = 0.50
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WSH Data: Exenatide success @ 6/12Insulin v Non-Insulin Group
Total on Insulin (86)
HbA1c Weight (Kg)
BMI P value
Baseline 9.5SD 1.3(8.2 to 10.8)
118.7SD 17.9(100.8 to 136.6)
41.7 SD 6.2(35.5 to 37.9)
Change at 6/12
-1.6 SD 1.4(-3.0 to -0.2)
-7.3 (6.2%)SD 5.2(-12.5 to -2.1)
-2.6 SD 1.9(-4.5 to -0.7)
P <0.0001
Non-insulin (98)
HbA1c Weight (Kg)
BMI P value
Baseline 9.7SD 1.6(8.1 to 11.3)
120.8SD 23.2(97.6 to 144.0)
41.3SD 8.0(33.3 to 49.3)
Change at 6/12
-1.6 SD 1.7
(-3.3 to 0.1)
-6.5 (5.4%)SD 5.5(-12.0 to -1.0)
-2.2SD 1.9(-4.1 to -0.3)
p < 0.0001
P value P = 0.83 P = 0.32 P = 0.23
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New Drug - DapagliflozinNew Drug - Dapagliflozin
Blocks reabsorption of glucose in Blocks reabsorption of glucose in kidneyskidneys
Increased urinary glucose lossIncreased urinary glucose loss Oral medication 5-10mg once dailyOral medication 5-10mg once daily
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DapagliflozinDapagliflozinBenefitsBenefits
HbA1c drops by 0.5-1.0%HbA1c drops by 0.5-1.0% Weight loss of 2-3 kg over 6 monthsWeight loss of 2-3 kg over 6 months Low risk of hypos (not reliant on Low risk of hypos (not reliant on
insulin)insulin) Additive effect when combined with Additive effect when combined with
other diabetic treatments, including other diabetic treatments, including insulin. insulin.
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DapagliflozinDapagliflozinSide-effectsSide-effects
Urinary tract infectionUrinary tract infection PolyuriaPolyuria Genital fungal infectionGenital fungal infection
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Bariatric SurgeryBariatric Surgery
30 Kg weight loss30 Kg weight loss 50% achieve HbA1c < 6.5%50% achieve HbA1c < 6.5% High rate of High rate of remissionremission of diabetes of diabetes But no long term studiesBut no long term studies
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Summary of TargetsSummary of Targets
HbA1c < 7.5 % (Metformin)HbA1c < 7.5 % (Metformin)
BP 140 / 80 or less (ACE-I or BP 140 / 80 or less (ACE-I or ARB)ARB)
Cholesterol < 4.0 (Statin)Cholesterol < 4.0 (Statin)
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Glycaemic ControlGlycaemic Control Drugs to use Drugs to use
Drug of choice MetforminDrug of choice Metformin
Next Stage Metformin with Sulphonylurea Next Stage Metformin with Sulphonylurea or Pioglitazoneor Pioglitazone or or
Sita/Vilda/Saxa/LinaSita/Vilda/Saxa/Lina
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Glycaemic ControlGlycaemic Control Drugs to use Drugs to use
Next Stage Metformin with GLP-1 Next Stage Metformin with GLP-1 injection injection
Final Stage Metformin with basal Final Stage Metformin with basal Insulin Insulin
Consider Dapagliflozin Consider Dapagliflozin
Last resort Bariatric surgery Last resort Bariatric surgery
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Glycaemic ControlGlycaemic Control Drugs to use Drugs to use
Drug of choice MetforminDrug of choice Metformin
Next Stage Metformin with Sulphonylurea Next Stage Metformin with Sulphonylurea or Pioglitazoneor Pioglitazone or or Sita/Vilda/Saxa/LinagliptinSita/Vilda/Saxa/Linagliptin
Next Stage Metformin with Exenatide/Liraglutide/Lixisenatide Next Stage Metformin with Exenatide/Liraglutide/Lixisenatide
Final Stage Metformin with basal Insulin Final Stage Metformin with basal Insulin
Consider Dapagliflozin Consider Dapagliflozin
Last resort Bariatric surgery Last resort Bariatric surgery
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WSH COST DATAExenatide Success @ 6/12Insulin v Non-Insulin Group
Extra Cost for Exenatide (per person , per month)
Reduction in Cost @ 6 months
Baseline £68.24
On Insulin (86)@ 6/12
£33.90 £34.34
Non-insulin (98)@ 6/12
£54.80 £13.44