selecting glp-1 ra treatment...2017/06/07 · a recent national diabetes audit showed that 35.2% of...
TRANSCRIPT
Selecting GLP-1 RA Treatment
Dr Felicity Kaplan
March 2017
Objectives
• Review the progressive nature of type 2 diabetes
• Understand the need for timely treatment intensification
• Examine the place of GLP-1 receptor agonists (GLP-1 RA) in guidelines
• Compare the attributes of different GLP-1 RA products available in the
UK
100
0
0
HbA1c
ß-cell function
Lifestyle Monotherapy Dual therapy
Insulin ±oral drugs for lowering blood glucose
Time (years)
8
>15
5
6
7
9
0
10
T2D=Type 2 diabetes mellitus.
Data from Heine RJ et al. BMJ. 2006; 333: 1200‒1204.
Progressively declining beta cell function in T2D
“waiting for failure”
New drug treatments in the last 10 years
GLP-1 RA
(once weekly)
Dulaglutide15
GLP-1 RA
(once weekly)
Albiglutide14
Biosimilar glargine11
Insulin + GLP-1 RA
fixed combination12
SGLT2-i + metformin
fixed combination13
2006 2007 2008 2009 2010 2011 2013 2012 2014 2015
SGLT2
Inhibitors
Dapagliflozin8
GLP-1 RA
(once weekly)
Exenatide QW7
DPP-4-i + metformin
fixed combination3
DPP-4-i
Sitagliptin4
GLP-1 RA
(once daily)
Lixisenatide10
Insulin
degludec 200
units/ml9
GLP-1 RA
(once daily)
Liraglutide6
Insulin
glargine 300
units/ml5
Insulin lispro
200 units/ml1
(renewal; first
authorisation 1996)
GLP-1 RA
(twice daily)
Exenatide
BID2
1. Humalog 200 units/ml Summary of Product Characteristics. 2. Byetta Summary of Product Characteristics. 3. Eucreas Summary of Product Characteristics. 4. Januvia Summary of Product
Characteristics. 5. Toujeo Summary of Product Characteristics. 6. Victoza Summary of Product Characteristics. 7. Bydureon Summary of Product Characteristics. 8. Forxiga Summary of Product
Characteristics. 9. Tresiba Summary of Product Characteristics. 10. Lyxumia Summary of Product Characteristics. 11. Abasaglar Summary of Product Characteristics. 12. Xultophy Summary of
Product Characteristics. 13. Xigduo Summary of Product Characteristics. 14. Eperzan Summary of Product Characteristics. 15. Trulicity Summary of Product Characteristics.
Date of Marketing Authorisation in the UK
Despite the addition of new treatment options, many
patients with type 2 diabetes are not meeting their treatment
goals
• Many patients are not meeting their outcome goals on oral therapy2,
increasing the risk of complications3
A recent national diabetes audit showed that
35.2% of patients with type 2 diabetes have
HbA1c >58mmol/mol (7.5%)1
1. Health & Social Care Information Centre (HSCIC). National Diabetes Audit ‒ 2012‒2013: Report 1, Care Processes and Treatment Targets. October 2014. Available at:
http://www.hscic.gov.uk/catalogue/PUB14970/nati-diab-audi-12-13-care-proc-rep.pdf [Last Accessed: December 2015]. 2. Casagrande S et al. Diabetes Care 2013; 36(8): 2271‒2279.
3. Inzucchi SE et al. Diabetes Care. 2015; 38: 140–149.
35.2%
The treatment intensification challenge
• How long do people with type 2 diabetes wait for therapy intensification
despite an HbA1c ≥58 mmol/mol (7.5%)?
• 50% of patients may be uncontrolled on oral therapy for an average of 5
years before moving onto an injectable2
1. Khunti K et al. Diabetes Care 2013; 36: 3411–3417. 2. Rubino A et al. Diabetic Medicine 2007; 24: 1412–1418.
HbA1c ≥58 mmol/mol (7.5%) Time to next intensification (median)1
On 1x OAD
On 2x OADs
1.9 years
7.2 years
The potential reward for improved control
Every 1% reduction in HbA1c REDUCED
RISK
Deaths from diabetes
Microvascular
complications
Amputation or death
from peripheral
vascular disorders
1%
43%
37%
Fatal or non-fatal MI
21%
14%
Data from Stratton IM et al. BMJ 2000; 321: 405‒412.
Delayed initiation of GLP-1 RAs in the UK – IMS localised data
The NICE guideline 28 recommends initiation of GLP-1 RA therapy in combination with metformin and sulphonylurea when
triple therapy with metformin and two other oral medications is not effective, or tolerated or contraindicated, fails to maintain
an HbA1c ≤58 mmol/mol (≤7.5%, or other higher level agreed with the patient) and the patient meets one of the following
criteria
• a BMI of 35 kg/m2 or higher (adjust accordingly for people from black, Asian and other minority ethnic groups) and specific
psychological or other medical problems associated with obesity or
• a BMI lower than 35 kg/m2 and for whom insulin therapy would have significant occupational implications or weight loss
would benefit other significant obesity-related comorbidities
1. National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. NICE guideline 28. London: NICE; December 2015 (http://www.nice.org.uk/guidance/ng28) [Last
Accessed: January 2016]. 2. Data on File. IMS data May 2015, HbA1C level before starting GLP-1 Receptor Agonist Therapy. Eli Lilly and Company; 2015.
% P
atie
nts
at th
is le
ve
l b
efo
re
sta
rtin
g G
LP
-1 R
A T
he
rap
y*2
HbA1c (%)
3% 3%
9%
13% 12%
16%
11%
33%
0%
5%
10%
15%
20%
25%
30%
35%
<7.0 ≥7.0
<7.5
≥7.5
<8.0
≥8.0
<8.5
≥8.5
<9.0
≥9.0
<9.5
≥9.5
<10.0
≥10.0
*n=14,623
In the UK 72% of patients are initiated on a GLP-1 receptor agonist at an HbA1c of ≥8.5%2
• Challenges with insulin
selection and titration
• Burdensome patient
counselling requirements
• Avoidance of patient burden
• Concern over hypoglycaemic
risk (insulin-specific)
• Lifestyle and employment
restrictions
• Fear of hypoglycaemia
(insulin-specific)
• Anxiety about injecting
• Concern about weight gain
Attitudes toward the initiation of insulin may delay escalation to other
injectable therapies1
1. Korytkowski M. Int J Obes Relat Metab Disord. 2002; 26(Suppl3): S18‒24.
Clinicians People with type 2 diabetes
Why is there a delay in initiating injectable therapy?
Despite the potential for improved glycaemic control, many people with type 2 diabetes are
reluctant to start injectable therapy1
GLP-1 RAs offer the following benefits:
1. Garcia-Perez L et al. Diabetes Ther 2013; 4: 175–194. 2. Freeman JS. J Am Osteopath Assoc. 2011; 111(2 suppl 1): eS15-eS20. 3. Byetta Summary of Product Characteristics. 4. Victoza
Summary of Product Characteristics. 5. Bydureon Summary of Product Characteristics.
Development of GLP-1 RAs over time has allowed the option of less
frequent injections for patients
20063 20094 20115
Twice daily Once daily Once weekly
HbA1c reductions2 Low risk of hypoglycaemia2 Potential for weight loss2
Treatment intensification with GLP-1 RAs may be
an attractive option for people with type 2 diabetes
SU + TZD or DPP-4-i or
SGLT2-i or GLP-1 RA or insulin
TZD + SU or DPP-4-i or
SGLT2-i or GLP-1 RA or insulin
DPP-4-i or SU or TZD or SGLT2-i
or insulin
SGLT2-i + SU or TZD or insulin
GLP-1 RA + SU or TZD
or insulin
Insulin + TZD or DPP-4-i +
SGLT2-i or GLP-1 RA
Metformin +
3-drug
combinations
The guidelines highlight where GLP-1 RAs can be used in combination:
Strategy progression after 3 months of unsuccessful glycaemic control (HbA1c target)
ADA=American Diabetes Association; EASD=European Association for the Study of Diabetes; DPP-4-I=Dipeptidyl peptidae-4 inhibitor; SGLT2-I=Sodium-glucose transporter 2 inhibitor; GLP-1
RA=Glucagon-like peptide-1 receptor agonist; SU=Sulphonylurea; TZD=Thiazolidinedione.
Inzucchi SE et al. Diabetes Care 2015; 38: 140‒149.
Initial drug
monotherapy
Metformin (or SU if metformin
not tolerated)
Combination
injectable therapy
Metformin +
Basal insulin + mealtime
insulin or GLP-1 RA
2-drug
combinations
Metformin +
SU
TZD
DPP-4-i
SGLT2-i
GLP-1 RA
Insulin (usually basal)
ADA/EASD Joint Position Statement:
NICE NG28: algorithm for blood glucose lowering therapy in
adults with type 2 diabetes
1. National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. NICE guideline 28. London: NICE; December 2015 (http://www.nice.org.uk/guidance/ng28) [Last
Accessed: January 2016]. Reproduced with permission.
NICE NG28: algorithm for blood glucose lowering therapy in
adults with type 2 diabetes
1. National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. NICE guideline 28. London: NICE; December 2015 (http://www.nice.org.uk/guidance/ng28) [Last
Accessed: January 2016]. Reproduced with permission.
*Reduction in HbA1c
**Not licensed for weight loss
ADA, Standards of Medical Care in Diabetes, section 7. Approaches to Glycemic Treatment Diabetes Care 2015; 38(Suppl. 1): S41–S48.
Potential dual therapy options for people with type 2 diabetes are displayed. It is not
meant to denote any specific preference.
Additional selection criteria
Metformin +
SU TZD DPP-4-i SGLT2-i GLP-1 RA
Efficacy* High High intermediate intermediate High
Hypo risk Moderate Low Low Low Low
Weight** Gain Gain Neutral Loss Loss
Side effects Hypoglycaemia Oedema, HF Rare GU, dehydration GI
Cost Low Low High High High
Blood pressure PPG
Treatment attributes of various drug choices for type
2 diabetes
Dose Dosing
frequency
Change in
HbA1c
Change in
weight (kg)
Exenatide1 10 μg Twice daily − 0.8% − 2.8
Liraglutide2
1.2 mg Once daily
− 1.3% − 2.6
1.8 mg − 1.3% − 2.8
Lixisenatide3 20 μg Once daily − 0.8% − 3.0
Exenatide4 2 mg Once weekly − 1.5% − 2.3
Trulicity®5 1.5 mg Once weekly − 1.4% − 2.9
Albiglutide6 30 mg Once weekly − 0.9% − 1.2
1. DeFronzo RA et al. Diabetes Care 2005; 28: 1092‒1100. 2. Nauck M et al. Diabetes Care 2009; 32: 84‒90. 3. Rosenstock J et al. Diabetes Care 2013; 36: 2945‒2951. 4. Bergenstal RM et al.
Lancet 2010; 376: 431‒439. 5. Dungan KM et al. Lancet 2014; 384: 1349‒1357. 6. Ahrén B et al. Diabetes Care 2014; 37: 2141‒2148.
Different GLP-1 RAs as add-on to metformin–
data derived from clinical trials
GLP-1 RAs as part of triple therapy –
data derived from clinical trials
Dose Background therapy Change in HbA1c
Change in weight
(kg)
Exenatide BID1 10 μg Metformin + SU -0.8% -1.6 kg
Exenatide QW2,3 2 mg
Oral antihyperglycaemic drugs -1.3% -2.7 kg
Included patients treated with metformin, SU,
TZD alone or in combination -2.0% -4.1 kg
Liraglutide4
1.2 mg Metformin + TZD (rosiglitazone) -1.5% -1.0 kg
1.8 mg Metformin + TZD (rosiglitazone) -1.5% -2.0 kg
Metformin + glimepiride -1.3% -1.8%
Lixisenatide5 20 μg Metformin + SU -0.9% -1.8 kg
Trulicity®6 1.5 mg Metformin + SU -1.1% -1.9 kg
Metformin + TZD (pioglitazone) -1.5% -1.3 kg
Albiglutide7 30 mg Metformin + glimepiride -0.6% -0.4 kg
Metformin + SU -0.7% -1.1 kg
1. Kendall D et al. Diabetes Care 2005; 28: 1083–1091. 2. Buse J et al. Diabetes Care 2010; 33: 1255–1261. 3. Buse J et al. Lancet 2013: 381: 117–124. 4. Victoza Summary of Product
Characteristics. Novo Nordisk Ltd. 5. Rosenstock J et al. Journal of Diabetes and its complications 2014; 28: 386–392. 6. Trulicity Summary of Product Characteristics. 7. Eperzan Summary of
Product Characteristics.
Indication in type 2 diabetes
Guidance on use
In renal
impairment In the elderly + insulin
Exenatide
BID1
In combination with: metformin, SU, TZD or metformin
+ SU, metformin + TZD in adults who have not
achieved adequate glycaemic control on maximally
tolerated doses of these oral therapies
Mild
Moderate (approach
dose
escalation
conservatively)
Use with caution
also indicated as
adjunctive therapy to
basal insulin +/- metformin
and/or pioglitazone in
adults who have not
achieved adequate
glycaemic control with
these agents
Exenatide
QW2
In combination with: metformin, SU, TZD or metformin
+ SU, metformin + TZD in adults who have not
achieved adequate glycaemic control on maximally
tolerated doses of these oral therapies
Mild only
No dose adjustment
required; consideration
to renal function with
older age
Not reported
Liraglutide3
To achieve glycaemic control as:
Monotherapy when diet and exercise alone do not
provide adequate glycaemic control in patients for
whom use of metformin is considered inappropriate
due to intolerance or contraindications
Combination therapy
In combination with oral glucose-lowering medicinal
products and/or basal insulin when these, together
with diet and exercise, do not provide adequate
glycaemic control (see sections 4.4 and 5.1 for
available data on the different combinations)
Mild-
moderate
No dose adjustment
required
Can be used in
combination with basal
insulin
Lixisenatide4
To achieve glycaemic control in combination with oral
glucose-lowering medicinal products and/or basal
insulin when these, together with diet and exercise, do
not provide adequate glycaemic control
Mild-
moderate
No dose adjustment
required
Can be used in
combination with basal
insulin
1. Byetta Summary of Product Characteristics. 2. Bydureon Summary of Product Characteristics. 3. Victoza Summary of Product Characteristics. 4. Lyxumia Summary of Product Characteristics.
Different GLP-1 RAs: licensed indications and
special populations
Indication in type 2 diabetes
Guidance on use
In renal
impairment In the elderly + insulin
Trulicity®1
To improve glycaemic control as:
Monotherapy when diet and exercise alone do not
provide adequate glycaemic control in patients for
whom the use of metformin is considered
inappropriate due to intolerance or contraindications
Add-on therapy in combination with other glucose-
lowering medicinal products including insulin, when
these, together with diet and exercise, do not provide
adequate glycaemic control
Mild-
moderate
No dose adjustment
required; ≥75 years
consider 0.75 mg dose
Can be used in
combination with insulin
Albiglutide2
To improve glycaemic control as:
Monotherapy when diet and exercise alone do not
provide adequate glycaemic control in patients for
whom use of metformin is considered inappropriate
due to contraindications or intolerance
Add-on combination therapy in combination with
other glucose-lowering medicinal products including
basal insulin, when these, together with diet and
exercise, do not provide adequate glycaemic control
Mild-
moderate
No dose adjustment
required
Can be used in
combination with insulin
1. Trulicity Summary of Product Characteristics. 2. Eperzan Summary of Product Characteristics.
Different GLP-1 RAs: licensed indications and
special populations
a: 60 minutes before 2 main meals (6 hours apart)
b: any time of day, independent of meals
1. Byetta Summary of Product Characteristics. 2. About the Byetta pen. Available at: https://www.byetta.com/getting-started-on-byetta/about-the-byetta-pen. [Last accessed: April 2016]. 3. Victoza Summary of
Product Characteristics. 4. Lyxumia Summary of Product Characteristics. 5. Bydureon Summary of Product Characteristics. 6. Bydureon Frequently Asked Questions. Available at:
https://www.bydureon.com/using-bydureon/bydureon-faqs.html. [Last accessed: April 2016]. 7. Trulicity Summary of Product Characteristics. 8. Eperzan Summary of Product Characteristics. 9. European
Medicines Agency. Eperzan Assessment Report. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Public_assessment_report/human/002735/WC500165119.pdf. [Last accessed:
April 2016].
Dose Need to
reconstitute
Needle
included
Hidden
needle
Needle
gauge
Exenatide BIDa,1,2 10μg NO ✗ ✗ 29, 30 or
31
Liraglutide QoDb,3 1.2mg
NO ✗ ✗ 32
Liraglutide QoDb,3 1.8mg
Lixisenatide QoDb,4 20μg NO ✗ ✗ 29 to 32
Exenatide QWb,5,6 2 mg YES ✔ ✗ 23
Trulicity® QWb,7 1.5 mg NO ✔ ✔ 29
Albiglutide QWb,8,9 30mg YES ✔ ✗ 29
Different GLP-1 RAs, different devices and practical
considerations
Dulaglutide offers significant HbA1c reduction in a
ready-to-use pen with once-weekly dosing1
Trulicity is indicated in adults with type 2 diabetes mellitus to
improve glycaemic control as:
Monotherapy 0.75 mg once weekly
When diet and exercise alone do not provide adequate
glycaemic control in patients for whom the use of metformin is
considered inappropriate due to intolerance or contraindications.
Add-on therapy 1.5 mg once weekly
In combination with other glucose-lowering medicinal products
including insulin, when these, together with diet and exercise, do
not provide adequate glycaemic control. For potentially
vulnerable populations, such as patients ≥ 75 years, 0.75 mg
once weekly can be considered as a starting dose
Trulicity 1.5 mg demonstrated statistically superior HbA1c reduction in phase III clinical trials vs metformin,
exenatide BID, insulin glargine, and sitagliptin. Trulicity 1.5mg demonstrated statistically noninferior HbA1c reduction
vs liraglutide 1.8 mg in 1 phase III trial.
1. Trulicity Summary of Product Characteristics
In a post-hoc analysis of patients from Award 1, Trulicity achieved
HbA1c reductions >2% in the subgroup of patients with a baseline
HbA1c ≥8.5%1
In the UK 72% of patients are initiated on a GLP-1 receptor agonist at an HbA1c of ≥8.5%*2
*Patients had their HbA1c recorded in the 6 months prior to initiation of GLP-1 therapy
1. Bain S et al. Poster presented at the PCDS 2015; 5–6 November, Birmingham 2. Data on File. IMS data May 2015, HbA1C level before starting GLP-1 Receptor Agonist Therapy. Eli Lilly and
Company; 2015.
HbA1c reduction
Trulicity 1.5 mg
(n=191; baseline 7.4% [57.4 mmol/mol])
Exenatide BID
(n=192; baseline 7.3% [56.3 mmol/mol])
Placebo
(n=92; baseline 7.3% [56.3 mmol/mol])
Trulicity 1.5 mg
(n=88; baseline 9.7% [82.5 mmol/mol])
Exenatide BID
(n=84; baseline 9.8% [83.6 mmol/mol])
Placebo
(n=49; baseline 9.6% [81.4 mmol/mol])
†P≤0.001 vs placebo
‡P<0.001 vs exenatide
Comparisons are
within each baseline
HbA1c cohort
-1.16%
-0.17%
-0.64%
0
-1.6
-1.2
-0.8
-0.4
-2.0
<8.5% (69.4 mmol/mol)
-2.4
†‡
†
-1.86%
-0.76%
0
-1.6
-1.2
-0.8
-0.4
-2.0
≥8.5% (69.4 mmol/mol)
-2.4 †‡ -2.37%
Hb
A1c c
han
ge f
rom
baselin
e ±
SE
(%
, L
S m
ean
)
Hb
A1c c
han
ge f
rom
baselin
e ±
SE
(%
, L
S m
ean
) H
bA
1c c
han
ge fro
m b
aselin
e ±
SE
(mm
ol/m
ol, L
S m
ean
)
0
-08
-06
-04
-02
-24
-26
-10
-12
-14
-16
-18
-20
-22
Hb
A1c c
han
ge fro
m b
aselin
e ±
SE
(mm
ol/m
ol, L
S m
ean
)
0
-08
-06
-04
-02
-24
-26
-10
-12
-14
-16
-18
-20
-22
Hypoglycaemia with Trulicity 1.5 mg
Please be aware: Patients receiving Trulicity in combination with a sulphonylurea or prandial insulin may have an
increased risk of hypoglycaemia. The risk may be lowered by reducing the dose of sulphonylurea or insulin.1
*Documented symptomatic hypoglycaemia and blood glucose 3.9 mmol/L.1
0
0.2 Rate
of sym
pto
ma
tic h
yp
og
lyca
em
ia (
ep
iso
de
s/p
atien
t/ye
ar)
1.67
3.02
0.12 0.29
AWARD-6 Without background sulphonylurea
Add-on to metformin
AWARD-2 With background sulphonylurea
Add-on to metformin and a sulphonylurea
Rates of documented symptomatic hypoglycaemia*
1.8
1.0
1.2
1.4
1.6
0.6
0.8
0.4
2
2.2
2.4
2.6
2.8
3
3.2
0.19
0.75
AWARD-1 Add-on to metformin
and pioglitazone
Trulicity 1.5 mg (n=273)
Insulin glargine (n=262)
Trulicity 1.5 mg (n=299)
Liraglutide (n=300)
Trulicity 1.5 mg (n=279)
Exenatide BID (n=276)
Trulicity Summary of Product Characteristics.
Incidence of nausea was comparable with Trulicity
1.5 mg and liraglutide 1.8 mg in a head-to-head trial1
Pa
tie
nts
(%
)
50
10
20
30
40
0 0 2 8 12 20 26 1
Time (weeks)
4
Trulicity 1.5 mg
(n=299)
Liraglutide
0.6 mg 1.2 mg
1.8 mg titrated over
the first 3 weeks of
treatment (n=300)
1. Dungan KM et al. Lancet. 2014; 384(9951): 1349‒1357.
Pancreatic safety
The recommended dose for Trulicity is 1.5 mg when prescribed as add-on therapy. In AWARD-1, AWARD-2, AWARD-4 and AWARD-5, additional groups
received Trulicity 0.75 mg, which is the recommended dose for monotherapy or can be considered as a starting dose in potentially vulnerable populations such as
patients ≥75 years of age.
Trulicity Summary of Product Characteristics.
Acute pancreatitis
• Use of GLP-1 associated with a risk of pancreatitis
• Pancreatitis has been reported with Trulicity. The incidence of acute
pancreatitis in phase 2 and 3 clinical studies was 0.07% for Trulicity
compared to 0.14% for placebo and 0.19% for comparators with or
without additional background antidiabetic therapy
*Needles included in list price
**Cost refers to the maintenance dose of 20 micrograms once daily5
All figures have been rounded to 2 decimal places
1. Liraglutide MIMS. Available at: http://www.mims.co.uk/drugs/diabetes/oral-and-parenteral-hypoglycaemics/victoza. [Last Accessed: February 2016]. 2. Exenatide QW MIMS. Available at:
http://www.mims.co.uk/drugs/diabetes/oral-and-parenteral-hypoglycaemics/bydureon. [Last Accessed: February 2016]. 3. Albiglutide MIMS. Available at: http://www.mims.co.uk/drugs/diabetes/oral-
and-parenteral-hypoglycaemics/eperzan. [Last Accessed: February 2016]. 4. Exenatide BD MIMS. Available at: http://www.mims.co.uk/drugs/diabetes/oral-and-parenteral-hypoglycaemics/byetta.
[Last Accessed: February 2016]. 5. Lixisenatide MIMS. Available at: http://www.mims.co.uk/drugs/diabetes/oral-and-parenteral-hypoglycaemics/lyxumia. [Last Accessed: February 2016].
List price and cost per day of GLP-1 receptor
agonists
• We need to take a proactive approach in the management of glycaemic control in type 2
diabetes
• Despite the introduction of new therapies, clinical inertia results in many patients not
meeting their glycaemic goals
• GLP-1 RAs offer the potential for glycaemic control with a low risk of hypoglycaemia and
the potential for weight loss – NICE recommends after 3 oral agents1
• Choice of GLP-1 treatment should be based on:1
– the person's individual clinical circumstances, preferences and needs in addition to effectiveness
– safety, tolerability
– available licensed indications or combinations, and cost
– if 2 drugs in the same class are appropriate, choose the option with the lowest acquisition cost
1. National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. NICE guideline 28. London: NICE; December 2015 (http://www.nice.org.uk/guidance/ng28) [Last
Accessed: January 2016].
Summary
Dulaglutide has received positive opinion from the CHMP; however, there is no guarantee it will receive regulatory
approval and become commercially available in your affiliate.
UKDUA00278(2) December 2016
The latest update to the NICE type 2 diabetes guideline (NG28) now recommends that treatment choice should take individual needs into account1
• The choice of drug treatment should consider:
– the person's individual clinical circumstances, preferences and needs in addition to effectiveness
– safety, tolerability
– available licensed indications or combinations, and cost
– if 2 drugs in the same class are appropriate, choose the option with the lowest acquisition cost
NICE guideline 28 also updates and replaces the single technology appraisals for liraglutide (TA203) and exenatide (TA248)1
• Therefore there is no longer mandatory funding for liraglutide and exenatide once-weekly
1. National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. NICE guideline 28. London: NICE; December 2015 (http://www.nice.org.uk/guidance/ng28) [Last
Accessed: January 2016].
NICE Guideline
1. National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. NICE guideline 28. London: NICE; December 2015 (http://www.nice.org.uk/guidance/ng28) [Last
Accessed: January 2016].
Patient preference and needs The choice of drug treatment should consider the person’s
individual clinical circumstances, individual preferences and needs, safety,
cost (if 2 drugs in the same class are appropriate, choose the option with
the lowest acquisition cost), licensed indications or combinations available
in addition to effectiveness of the drug treatment(s) in terms of metabolic
response (NICE NG28)1
Both the Trulicity molecule and the pen were
designed with these patients in mind
The Patient Trulicity
Clinical profile
Has type 2 diabetes* and:
• currently on oral medications only
• HbA1c between 7.5% and 9.0%
• weight is a clinical concern
Efficacy evaluated in phase III clinical
trials in this patient population1‒7
Body weight change evaluated as
secondary endpoint1‒7
Lifestyle considerations
Wants to succeed, but:
• struggles to fit changes into a busy life
• disappointed about not reaching goals
An extended half-life for
once-weekly dosing1
Solubility to avoid the need
for reconstitution8,9
Needs to start an injectable therapy for
the first time, but like many patients is
reluctant to do so
Ready-to-use pen10
No need to see or touch needle10
Once-weekly dosing1
1. Trulicity Summary of Product Characteristics. 2. Wysham C et al. Diabetes Care. 2014; 37(8): 2159‒2167. 3. Giorgino F et al. Diabetes Care. 2015; 38: 2241‒2249. 4. Umpierrez G et al. Diabetes
Care. 2014; 37: 2168‒2176. 5. Blonde L et al. Lancet. 2015; 385: 2057‒2066. 6. Nauck M et al. Diabetes Care. 2014; 37(8): 2149‒2158. 7. Dungan KM et al. Lancet. 2014; 384(9951): 1349‒1357.
8. Barrington P et al. Diabetes Obesity and Metabolism 2011; 13: 426‒433. 9. Data on File. Wolfgang Glaesner interview. Eli Lilly and Company; 2014. 10. Trulicity Instructions for use.
*hypothetical patient
Patient-centred attributes: Results of the dulaglutide
molecular design1
• Once-weekly subcutaneous administration
• Soluble, ready-to-use formulation
• Reduced renal clearance
• Low potential for immunogenicity
1. Trulicity Summary of Product Characteristics.
GLP-1
analogue
Linker
Modified
IgG4-Fc
domain
Ready-to-use pen designed with the patient in mind
1. Trulicity Instructions for use. 2. Matfin G et al. J Diabetes Sci Technol. 2015; 9(5): 1071‒1079.
The Trulicity pen is ready-to-use1
• No reconstitution or priming required
• Pre-attached, hidden 29-gauge needle
• Each pen contains a fixed dose of Trulicity
Automatic dose delivery at the push of a button1
Administration that 99% of patients found easy2
Beta cells: Enhances
glucose-dependent
insulin secretion
GLP-1 secreted upon
the ingestion of food
Promotes satiety and
reduces appetite
Stomach:
Slows gastric emptying
Alpha cells:
Postprandial
glucagon secretion
1. Nauck MA et al. Diabetologia 1986; 29: 46‒52. 2. Drucker DJ. Diabetes 1998; 47: 159‒169. 3. Flint A et al. J Clin Invest 1998; 101: 515‒520. 4. Larsson H et al. Acta Physiol Scand 1997; 160:
413‒422. 5. Nauck MA et al. Diabetologia 1996; 39: 1546‒1553.
GLP-1 secreted upon
the ingestion of food
Liver:
Glucagon reduces
hepatic glucose output
GLP-1 effects in humans: Understanding the
glucoregulatory role of incretins1–5
Different GLP-1 RAs: safety
Very common (≥1 in 10) AEs
Exenatide BID1 • Hypoglycaemia (with metformin + SU/ with SU)
• Nausea, vomiting, diarrhoea
Exenatide QW2 • Hypoglycaemia (with SU)
• Nausea, diarrhoea
Liraglutide3 • Nausea, diarrhoea
Lixisenatide4 • Hypoglycaemia (with SU and/or basal insulin)
• Headache
• Nausea, vomiting, diarrhoea
Trulicity®5 • Hypoglycaemia (with insulin, glimepiride, metformin or metformin + glimepiride)
• Nausea, vomiting, diarrhoea, abdominal pain
Albiglutide6 • Hypoglycaemia (when used in combination with insulin or sulphonylurea)
• Diarrhoea, nausea
• Injection site reactions
1. Byetta Summary of Product Characteristics. 2. Bydureon Summary of Product Characteristics. 3. Victoza Summary of Product Characteristics. 4. Lyxumia Summary of Product Characteristics. 5. Trulicity
Summary of Product Characteristics. 6. Eperzan Summary of Product Characteristics.
Significant HbA1c reduction across 6 clinical trials
Trulicity Summary of Product Characteristics.
The recommended dose for Trulicity is 1.5 mg when prescribed as add-on therapy. In AWARD-1, AWARD-2, AWARD-4 and AWARD-5, additional
groups received Trulicity 0.75 mg, which is the recommended dose for monotherapy or can be considered as a starting dose in potentially vulnerable
populations such as patients ≥75 years of age.
HbA
1c c
hange fro
m b
aselin
e ±
SE
(%
, LS
mean)
0
-0.2
-0.4
-0.6
-0.8
-1.0
-1.2
-1.4
-1.6
-1.8
Monotherapy
-1.10%*
-0.56% -0.71%*
-0.39%
-1.36%
-1.51%*
-0.99%
0.46%
-1.08%*
-0.63%
-1.64%*
-1.41%
Trulicity 0.75 mg (n=270; baseline 7.58%
[59.3 mmol/mol])
Metformin (n=268; baseline 7.60%
[59.6 mmol/mol])
Trulicity 1.5 mg (n=304; baseline 8.12%
[65.3 mmol/mol])
Sitagliptin (n=315; baseline 8.09%
[64.9 mmol/mol])
Trulicity 1.5 mg (n=299; baseline 8.06%
[64.6 mmol/mol])
Liraglutide 1.8 mg (n=300; baseline 8.05%
[64.5 mmol/mol])
Trulicity 1.5 mg (n=279; baseline 8.10%
[65.0 mmol/mol])
Exenatide BID (n=276; baseline 8.07%
[64.7 mmol/mol])
Placebo (n=141; baseline 8.06%
[64.6 mmol/mol])
Trulicity 1.5 mg (n=273; baseline 8.18%
[65.9 mmol/mol])
Insulin glargine (n=262; baseline 8.10%
[65.0 mmol/mol])
Trulicity 1.5 mg (n=295; baseline 8.46%
[69.0 mmol/mol])
Insulin glargine (n=296; baseline 8.53%
[69.7 mmol/mol])
AWARD-3
(26 weeks)
Dual therapy
AWARD-5
(52 weeks)
Triple therapy
AWARD-1
(26 weeks)
Insulin
AWARD-4
(26 weeks)
AWARD-6
(26 weeks)
AWARD-2
(52 weeks)
HbA
1c c
hange fro
m b
aselin
e ±
SE
(mm
ol/m
ol, L
S m
ean)
0
-2
-4
-6
-8
-10
-12
-14
-16
-18
-2.0
-1.42%†
*P<.025 , superiority vs active comparator
†P<.001, noninferiority vs active comparator
Indicates likely first
injectable options
Weight change with Trulicity across phase III clinical trials
Trulicity Summary of Product Characteristics.
Trulicity is not indicated for weight loss; weight change was a secondary endpoint in clinical trials. The recommended dose for Trulicity is 1.5 mg when prescribed as add-on therapy. In AWARD-1, AWARD-2, AWARD-4 and AWARD-5, additional
groups received Trulicity 0.75 mg, which is the recommended dose for monotherapy or can be considered as a starting dose in potentially
vulnerable populations such as patients ≥75 years of age.
Change in b
ody
weig
ht
(kg)
3.0
2.0
1.0
0
-1.0
-2.0
-3.0
-4.0
-2.22
-1.36*
-3.03†
-1.53
-2.90*
-3.61
-1.30 -1.07
+1.24 +1.44
-1.87†
-0.87†
*P<.05 vs active comparator
†P<.001 vs active comparator
Trulicity 0.75 mg
(n=270)
Metformin
(n=268)
Trulicity 1.5 mg
(n=304)
Sitagliptin
(n=315)
Trulicity 1.5 mg
(n=299)
Liraglutide 1.8 mg
(n=300)
Trulicity 1.5 mg
(n=279)
Exenatide BID
(n=276)
Placebo
(n=141)
Trulicity 1.5 mg
(n=273)
Insulin glargine
(n=262)
Trulicity 1.5 mg
(n=295)
Insulin glargine
(n=296)
Weight change at prespecified primary time-point
+2.33
Monotherapy
AWARD-3
(26 weeks)
Dual therapy
AWARD-5
(52 weeks)
Triple therapy
AWARD-1
(26 weeks)
Insulin
AWARD-4
(26 weeks)
AWARD-6
(26 weeks)
AWARD-2
(52 weeks)
Indicates likely first
injectable options
HbA1c reduction with Trulicity 1.5 mg once-weekly was
noninferior to liraglutide 1.8 mg once daily in a head-to-head
trial1,2
Data presented are mean values at 26 weeks.
LS = least squares; SE = standard error.
1. Trulicity Summary of Product Characteristics. 2. Dungan KM et al. Lancet. 2014; 384(9951): 1349‒1357.
Trulicity 1.5 mg
(n=299; baseline
HbA1c: 8.1% [65.0
mmol/mol])
HbA
1c C
ha
nge
fro
m B
ase
line ±
SE
(%
, L
S M
ea
n)
-0.8
-0.6
-0.4
-0.2
-1.2
0
-1.6
-1.4
-1.0
-1.36% -1.42%
HbA
1c C
ha
nge
from
Ba
se
line ±
SE
(mm
ol/m
ol, L
S M
ea
n)
-16
-14
-12
-10
-8
-6
-4
-2
0
P<.0001
Non-inferiority vs liraglutide
-18
-1.8 -20
Liraglutide 1.8 mg
(n=300; baseline
HbA1c: 8.1% [65.0
mmol/mol])