dienogest for pain induced endometriosis
DESCRIPTION
Vissane is a new drug for treatment of endometriosis : how effective it is ??: this talk may help in illustrating thisTRANSCRIPT
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Dienogest For Treatment of Endometriosis
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Declaration
• No conflict of interest at all with this product or the manufacturing company
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Why this talk?
• To update our knowledge• A real breakthrough in management of
endometriosis
• To share
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Treatment of Endometriosis
• Treatment could be surgical or medical • Combined• There is no permanent cure !!!
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Q1: What is the problem
• Endometriosis has high rate of recurrence up to 60% within 5 years of surgery
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Ideal Goal
• As stated by the ASRM, “Endometriosis should be viewed as a chronic disease that requires a life-long management plan with the goal of maximizing the use of medical treatment and avoiding repeated surgical procedures.” Fertil & Steril, 2008
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Q2: How to prevent recurrence?
• GnRH agonist• Progestin• others
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GnRHa
• Effective • Severe hypoestrogenic state• Limited to 6 month• Bone loss
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Progestins
• effective in endometriosis only at high doses• This may increase the likelihood of adverse
effects, such as weight gain and androgenic effects
• may elevate the risk of CVS adverse events
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Dienogest (Visanne)
• is a synthetic oral progestogen with unique pharmacological properties
• highly selective for the progesterone receptor
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Unique
• strong progestational effects • moderate antigonadotrophic effects
•no androgenic, glucocorticoid or mineralocorticoid activity.
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Administration
• 2mg once-daily• Can start at any day of menstrual cycle• Must be continued regardless of vag. Bleeding
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Dose
• it appears that at a dose of 2 mg dienogest per day, ovulation is inhibited but ovarian hormone production is not completely suppressed.
• Thus, compared to other endometriosis treatments, estrogen-deficiency related side effects are expected to be of low intensity with 2 mg dienogest.
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For How Long?
• Based on Its relatively short half-life of 10 hours means that there is no risk of accumulation after repeated dosing.
• Suggested for long term treatment
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License
• An EU marketing authorisation application for the use of dienogest to treat endometriosis was granted by The Netherlands in December 2009.
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Where is the evidence?
• There are a number of studies comparing dienogest treatment with buserelin (double-dummy), and triptorelin (open-label), and one longer-term study.
• Some of these studies have been carried out in Japanese, not European, women.
• None of these were sponsored by Bayer.
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Pivotal study
• The safety and efficacy of dienogest 2mg daily for 12 weeks was assessed in 198 women with endometriosis and pain above 30mm on a visual analogue scale (VAS), in a randomised, placebo-controlled study. (Strowitzki et al, 2010)
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Results
• Reductions on the VAS in endometriosis-associated pelvic pain (the primary endpoint) were 27.4mm with dienogest and 15.1mm with placebo, (mean difference in core of 12.3mm; 95% CI 6.4 to 18.1, p<0.0001).
• 168 women have continued with a further 52 weeks of dienogest treatment
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Long term study
• open-label extension study of dienogest for up to 52 additional weeks, providing an overall treatment period of up to 65 weeks. (~ 5 yrs)
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Results
• The 52-week extension study results showed a progressive reduction in the frequency of and improvements in endometriosis-associated pelvic pain scores.
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Surrogate outcomes
• During the long-term study, laboratory parameters, vital signs, and body weight remained stable or underwent minimal changes.
• Adverse effects considered potentially treatment-related developed in 16.1% of women, including breast discomfort (4.2%), nausea (3.0%), and irritability (2.4%).
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SE
• The most commonly reported treatment-related adverse event was metrorrhagia (71.9%), followed by headaches (18.5%) and constipation (10.4%). None of the treatment-related adverse events was rated as serious
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Comparison with leuprorelin
• Dienogest 2mg/day (n=124) was compared with leuprorelin 3.75mg/4 weeks (n=128) in a randomised 24- week study.
• Improvements in VAS scores of endometriosis-associated pelvic pain were similar in both groups (reductions of 47.5mm with dienogest and 46.0 with leuprorelin)
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Comparison with intranasal buserelin
• In Japan, a Phase III, randomized, double-blind, multicenter, controlled trial was conducted to compare the efficacy and safety of DNG with intranasal buserelin acetate in patients with endometriosis.
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VAS at 24 ws
• In both groups the change was large enough to be clinically relevant. For the objective symptoms, the change was from 3.8±2.1 to 1.9±1.9 in the dienogest group and from 3.7±2.0 to 1.5±1.3 in the buserelin group (difference of mean change -0.35, 9% CI -0.75 to 0.05).
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Moreover
• The study demonstrated that DNG causes less bone mineral density loss, resulting in the use on a commercial basis for endometriosis patients in Japan from 2008. (Momoeda et al, 2009)
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Comparison with triptorelin
• Dienogest 2mg/day (n=59) was compared with triptorelin 3.75mg/4 weeks (n=61) in an open-label 16-week study. Patients had undergone an operative laparoscopy and drug treatment was used as consolidation therapy.
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Results
• No reappearance of endometrial tissue was achieved in 25% of patients in each group.
• 86.2% of patients treated with dienogest and 80% of patients treated with triptorelin were satisfied with treatment.
• Fifteen patients in the dienogest group and 12 in the triptorelin group had spontaneous pregnancies in the 12 months following the end of treatment, p=0.71
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Potential benefits over existing technologies
• Dienogest appears to be safe and effective when taken for up to 2 years. Current treatments are limited to shorter treatment intervals.
• Dienogest is an oral therapy• Treatment of endometriosis with dienogest is
not inferior to that with GnRH agonists.
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Contraindications (CVS & liver)
• DVT• Arterial and cardiovascular disease, past or
present (e.g. myocardial infarction, cerebrovascular accident, ischemic heart disease)
• Presence or history of severe hepatic disease as long as liver function values have not returned to normal
• Presence or history of liver tumours (benign or malignant)
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Limitations
• Uterine bleeding may be aggravated with the use of Visanne®.
• Longer-term treatment (up to a year) is required before a positive effect on the number and duration of days/ episodes of bleeding or spotting (a reduction) can be seen.
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Ovulation inhibition
• doses ≥1 mg dienogest per day inhibited ovulation. However, follicular maturation processes evident by a rise in serum estradiol levels were not completely suppressed even with the highest dose of 2 mg dienogest.
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Share : Meta-analysis
Absolute reduction in VAS
Mean Difference (IV, Fixed, 95% CI)
-1.60 [-9.17, 5.97]
Proportion of women experienced improvement in VAS
Odds Ratio (M-H, Fixed, 95% CI)
1.26 [0.27, 5.80]
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SE
Alopecia Odds Ratio (M-H, Fixed, 95% CI)
0.60 [0.17, 2.09]
Migraine Odds Ratio (M-H, Fixed, 95% CI)
0.52 [0.13, 2.13]
Sleep disorder Odds Ratio (M-H, Fixed, 95% CI)
0.20 [0.04, 0.93]
Vaginal dryness Odds Ratio (M-H, Fixed, 95% CI)
0.22 [0.05, 1.06]
Hot flushes Odds Ratio (M-H, Fixed, 95% CI)
0.40 [0.25, 0.65]
Abnormal genital Bleeding Odds Ratio (M-H, Fixed, 95% CI)
8.41 [3.60, 19.63]
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Others
Decreased Libido Odds Ratio (M-H, Fixed, 95% CI)
0.65 [0.21, 2.05]
Depression Odds Ratio (M-H, Fixed, 95% CI)
0.56 [0.20, 1.56]
weight gain Odds Ratio (M-H, Fixed, 95% CI)
1.76 [0.56, 5.53]
Headache Odds Ratio (M-H, Fixed, 95% CI)
0.62 [0.40, 0.95]
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More to Share: RCTs
• Dienogest in endometriosis associated Infertility: Visanne for 3 month Then clomid vs clomid alone
• Dienogest associated menstrual irregularities: Visanne with Cycloprogenova for the first 3 month vs Visanne alone
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Conclusion
• DNG represents a promising new medication for safe and effective long-term management of pain of endometriosis.