Ueda2016 symposium -managing t2 dm with no compromise - khaled el hadidy
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Transcript of Ueda2016 symposium -managing t2 dm with no compromise - khaled el hadidy
Managing T2DM with no compromise
BYDR. Khaled El Sayed El Hadidy. MD
Professor of Internal Medicine.Head of Internal Medicine Department.
Head of Diabetes and Endocrinology Unit.Beni - Suef University.UEDA ( IDF member )
Multiple Pathophysiological Failures Contribute to Hyperglycaemia: The ‘Ominous Octet’
Islet α-cell
Increased
lipolysis
Increased
glucose
reabsorption
Increased glucagon
secretion
Increased
hepatic glucose
production
Neurotransmitter dysfunction
Decreased
glucose uptake
Islet β-cell
Decreased incretin effectImpaired insulin
secretion
Hyper-
Adapted from DeFronzo RA. Diabetes 2009;58:773–795. Wolters Kluwer Health
Hyper-
glycemia
2
HbA1c=haemoglobin A1c; OAD, oral antidiabetic drugs.
Jacob AN, et al. Diabetes Obes Metab. 2007; 9:386–393;
Kahn SE, et al. N Engl J Med. 2006; 355: 2427–2443;
Wright AD, et al. J Diabetes Complications. 2006; 20: 395–401.
Decreasing HbA1c is associated with increased risks
of hypoglycaemia and weight gain
Weight gain
and
hypoglycaemia
Body w
eig
ht
HbA1c
Pla
sma
glu
cose
Consequences of hypoglycaemia
Hypoglycaemia
Cardiovascular
complications3
Weight gain
by defensive eating5
Coma3
Increased risk
of car accident6
Hospitalisation
costs4
Loss of
consciousness3
Increased risk
of seizures3
Death2,3
Increased risk
of dementia1
1Whitmer RA, et al. JAMA. 2009; 301: 1565–1572; 2Bonds DE, et al. Br Med J. 2010; 340: b4909;
3Barnett AH. Curr Med Res Opin. 2010; 26: 1333–1342; 4Jönsson L, et al. Value Health. 2006; 9: 193–198;
5Foley JE, Jordan J. Vasc Health Risk Manag. 2010; 6: 541–548; 6Begg IS, et al. Can J Diabetes. 2003; 27: 128–140; 7McEwan P, et al. Diabetes Obes Metab. 2010; 12: 431–436.
.
Reduced
quality of life7
Mechanisms ( Hypoglycemia -------------- CVS )
CVD=cardiovascular disease; DM=diabetes mellitus; HDL-C=high-density lipoprotein cholesterol; HTN=hypertension;
IGT=impaired glucose tolerance; IR=insulin resistance; LDL-C=low-density lipoprotein cholesterol; TG=triglyceride.
Eckel RH, Grundy SM, Zimmet PZ.
The metabolic syndrome. Lancet. 2005; 365: 1415 428.
Weight Gain and Co-morbidities
Weight gain
Hyperinsulinaemia and IR
Dyslipidemia
TG
small dense LDL-C
Apo-B
HDL-C
HTNProthrombotic state
PAI-1 , Factor VII
Fibrinogen
IGT and DM
Proinflammatory state
CVD
L L L
GLP-1 GLP-1 GLP-1
InsulinGlucagon
Slowed gastric
emptying
Early
Satiety
Inactive
GLP-1
DPP-4
enzyme
(DPP-4
inhibitor)
GLP-1
Guidelines recommend the combinationADA
/EASD
& AACE
24 hours glycemic control with once daily dose
Ideal Criteria of OAD* in treatment of T2DM Patientsin order to get High Glycemic Control with Confidence (1/2) :
Why Saxagliptin / Metformin XR
can be an Ideal FDC# in management of T2DM patients ?
Diabetes Care, Diabetologia. 19 April 2012 Garber AJ, et al. Endocr Pract 2013;19(2):327-336.
Jadzinsky et al – Diabetes, Obesity & metabolism (2009)
Fonseca V, Zhu T, Kayaker C, et al. Diabetes, Obesity and Metabolism 2012; 14 (4): 365–371.
Full Prescribing Information
* OAD: Oral Antidiabetic
# FDC: Fixed dose combination
**HbA1c: Haemoglobin A1c
##: Fasting plasma glucose
***: Postprandial plasma glucose
Well studied in diabetes type 2 patients with established cardiovascular disease & high cardiovascular risk patients.
4 years sustained Efficacy (Evidence based)
3.3% A1c reduction from baseline 10%
Comparable efficacy to Sulphonylurea without risk of hypoglycemia
Healthy eating, weight control, increased physical activity & diabetes education
Metformin high low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin +
Metformin +
Metformin +
Metformin +
Metformin +
high low risk
gain
edema, HF, fxs
low
Thiazolidine- dione
intermediate low risk
neutral
rare
high
DPP-4 inhibitor
highest high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin +
Metformin +
Metformin +
Metformin +
Metformin +
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-dione
+ SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-i
GLP-1-RA
high low risk
loss
GI
high
GLP-1 receptor agonist
Sulfonylurea
high moderate risk
gain
hypoglycemia
low
SGLT2 inhibitor
intermediate low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor agonist
+
SGLT-2 Inhibitor +
SU
TZD
Insulin§
Metformin +
Metformin +
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono- therapy
Efficacy* Hypo risk
Weight
Side effects
Costs
Dual therapy†
Efficacy* Hypo risk
Weight
Side effects
Costs
Triple therapy
or
or
DPP-4 Inhibitor
+ SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin +
Combination injectable therapy‡
GLP-1-RA Mealtime Insulin
HbA1c≥9%
Me orminintoleranceorcontraindica on
Uncontrolledhyperglycemia
(catabolicfeatures,BG≥300-350mg/dl,HbA1c≥10-12%)
Insulin (basal)
+
or
or
or
Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0 American Diabetes Association Standards of Medical Care in Diabetes. Approaches to Glycemic Treatment. Diabetes Care 2016; 39 (Suppl. 1)
Guidelines recommend the combination
MANAGE EARLY AND TIGHTLY
Healthy eating, weight control, increased physical activity & diabetes education
Metformin high low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin +
Metformin +
Metformin +
Metformin +
Metformin +
high low risk
gain
edema, HF, fxs
low
Thiazolidine- dione
intermediate low risk
neutral
rare
high
DPP-4 inhibitor
highest high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin +
Metformin +
Metformin +
Metformin +
Metformin +
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-dione
+ SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-i
GLP-1-RA
high low risk
loss
GI
high
GLP-1 receptor agonist
Sulfonylurea
high moderate risk
gain
hypoglycemia
low
SGLT2 inhibitor
intermediate low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor agonist
+
SGLT-2 Inhibitor +
SU
TZD
Insulin§
Metformin +
Metformin +
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono- therapy
Efficacy* Hypo risk
Weight
Side effects
Costs
Dual therapy†
Efficacy* Hypo risk
Weight
Side effects
Costs
Triple therapy
or
or
DPP-4 Inhibitor
+ SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin +
Combination injectable therapy‡
GLP-1-RA Mealtime Insulin
Figure2A.An -hyperglycemictherapyinT2DM:Avoidanceofhypoglycemia
or
or
or
Insulin (basal)
+
Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0 American Diabetes Association Standards of Medical Care in Diabetes. Approaches to Glycemic Treatment. Diabetes Care 2016; 39 (Suppl. 1)
Healthy eating, weight control, increased physical activity & diabetes education
Metformin high low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin +
Metformin +
Metformin +
Metformin +
Metformin +
high low risk
gain
edema, HF, fxs
low
Thiazolidine- dione
intermediate low risk
neutral
rare
high
DPP-4 inhibitor
highest high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin +
Metformin +
Metformin +
Metformin +
Metformin +
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-dione
+ SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-i
GLP-1-RA
high low risk
loss
GI
high
GLP-1 receptor agonist
Sulfonylurea
high moderate risk
gain
hypoglycemia
low
SGLT2 inhibitor
intermediate low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor agonist
+
SGLT-2 Inhibitor +
SU
TZD
Insulin§
Metformin +
Metformin +
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono- therapy
Efficacy* Hypo risk
Weight
Side effects
Costs
Dual therapy†
Efficacy* Hypo risk
Weight
Side effects
Costs
Triple therapy
or
or
DPP-4 Inhibitor
+ SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin +
Combination injectable therapy‡
GLP-1-RA Mealtime Insulin
Insulin (basal)
+
or
or
or
Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0
Figure2B.An -hyperglycemictherapyinT2DM:Avoidanceofweightgain American Diabetes Association Standards of Medical Care in Diabetes. Approaches to Glycemic Treatment. Diabetes Care 2016; 39 (Suppl. 1)
Secondary failure of metformin monotherapy is increased when initial HbA1C is ≥8%
Figure shows a Kaplan–Meier plot of secondary failure of metformin monotherapy by categories of HbA1C at metformin initiation
adjusted for age and diabetes duration at initiation and the percent per year (95% CIs) experiencing secondary failure.
Brown JB, et al. Diabetes Care 2010;33:501‒6
16
• RAZ I. Guideline Approach to therapy in patients with Newly diagnosed type 2 diabetes. Diabetes Care 2013; 36
(suppl 2 ) (suppl 2 ): S 139 – S 144
Specific reasons why early combination therapy may be beneficial in Type 2 diabetes
Rationale for early combination therapy in Type 2 diabetes
Early, robust lowering of HbA1C
Avoidance of clinical inertia associated with a stepwise approach to therapy
Potential for early combination therapy to improve β-cell function
Initiation of a therapeutic intervention with a complimentary mechanism of action
Potential to use less than maximal doses of individual agents, minimizing side effects
11 Confidential. Contains unpublished data. For training purpose only. Not to be distributed. 732HQ12NP149Zinman B. Am J Med 2011;124:S19‒34.
Guidelines recommend the combination
ADA
/EASD
& AACE
2013
24 hours glycemic control with once daily dose
Diabetes Care, Diabetologia. 19 April 2012 Garber AJ, et al. Endocr Pract 2013;19(2):327-336.
Jadzinsky et al – Diabetes, Obesity & metabolism (2009)
Fonseca V, Zhu T, Kayaker C, et al. Diabetes, Obesity and Metabolism 2012; 14 (4): 365–371.
Full Prescribing Information
* OAD: Oral Antidiabetic
# FDC: Fixed dose combination
**HbA1c: Haemoglobin A1c
##: Fasting plasma glucose
***: Postprandial plasma glucose
Well studied in diabetes type 2 patients with established cardiovascular disease & high cardiovascular risk patients.
4 years sustained Efficacy (Evidence based)
3.3% A1c reduction from baseline 10%
Comparable efficacy to Sulphonylurea without risk of hypoglycemia
Ideal Criteria of OAD* in treatment of T2DM Patientsin order to get High Glycemic Control with Confidence (1/2) :
Why Saxagliptin / Metformin XR
can be an Ideal FDC# in management of T2DM patients ?
19
Muscle/Fat
…in response to ↑ insulin release:
↑ peripheral glucose uptake
Liver
…in response to ↓ glucagon release:
↓ hepatic glucose output
Pancreas
↓ glucagon release from cells
↑ insulin releasefrom cells
…in response to ↑ GLP-1 concentrations:
Muscle/Fat
Improves insulin sensitivity and ↑ glucose uptake and utilization
Liver
↓ glucose output by the liver
Pancreas
Insulin secretion remains unchanged while fasting insulin levels and day-long plasma insulin response may decrease
Muscle/Fat
…in response to ↑ insulin release:
↑ peripheral glucose uptake
Liver
…in response to ↓ glucagon release:
↓ hepatic glucose output
Muscle/Fat
Improves insulin sensitivity and ↑ glucose uptake and utilization
Liver
↓ glucose output by the liver
Pancreas
Insulin secretion remains unchanged while fasting insulin levels and
day-long plasma insulin response may decrease
GLP=glucagon-like peptide; DPP=dipeptidyl peptidase.
1. Verspohl EJ. Pharmacol Ther 2009;124:113-138.
Saxagliptin Metformin XR
Gut
Decreases (↓) intestinal glucose absorption
Gut
Decreases (↓) intestinal glucose absorption
Lower levels of the incretin hormoneGLP-1 are released from the gut in patients with type 2 diabetes
Saxagliptin increases (↑) incretinconcentrations in the bloodstream
Gut
Saxagliptin inhibits DPP-4 enzyme activity
DPP-4Enzymes
S
Lower levels of the incretin hormone GLP-1 are released from the gut in patients with type 2 diabetes
Saxagliptin increases (↑) incretinconcentrations in the bloodstream
Gut
Saxagliptin inhibits DPP-4 enzyme activity
DPP-4Enzymes
S
Pancreas
↓ glucagon release from cells
↑ insulin releasefrom cells
…in response to ↑ GLP-1 concentrations:
Once-a-Day Saxagliptin/Metformin XR : Complementary & synergistic mechanism of action
# FDC: Fixed dose combination
Saxagliptin/ Met XR
Saxagliptin/ Met XR
Guidelines recommend the combination
ADA
/EASD
& AACE
2013
24 hours glycemic control with once daily dose
Diabetes Care, Diabetologia. 19 April 2012 Garber AJ, et al. Endocr Pract 2013;19(2):327-336.
Jadzinsky et al – Diabetes, Obesity & metabolism (2009)
Fonseca V, Zhu T, Kayaker C, et al. Diabetes, Obesity and Metabolism 2012; 14 (4): 365–371.
Full Prescribing Information
* OAD: Oral Antidiabetic
# FDC: Fixed dose combination
**HbA1c: Haemoglobin A1c
##: Fasting plasma glucose
***: Postprandial plasma glucose
Well studied in diabetes type 2 patients with established cardiovascular disease & high cardiovascular risk patients.
4 years sustained Efficacy (Evidence based)
3.3% A1c reduction from baseline 10%
Comparable efficacy to Sulphonylurea without risk of hypoglycemia
Ideal Criteria of OAD* in treatment of T2DM Patientsin order to get High Glycemic Control with Confidence (1/2) :
Why Saxagliptin / Metformin XR
can be an Ideal FDC# in management of T2DM patients ?
22
Saxagliptin/Met XR
Guidelines recommend the combination
ADA
/EASD
& AACE
2013
24 hours glycemic control with once daily dose
Ideal Criteria of OAD* in treatment of T2DM Patients in order to get High Glycemic Control with Confidence (1/2) :
Why Saxagliptin / Metformin XR can be an Ideal FDC# in
management of T2DM patients ?
Diabetes Care, Diabetologia. 19 April 2012 Garber AJ, et al. Endocr Pract 2013;19(2):327-336.
Jadzinsky et al – Diabetes, Obesity & metabolism (2009)
Fonseca V, Zhu T, Kayaker C, et al. Diabetes, Obesity and Metabolism 2012; 14 (4): 365–371.
Full Prescribing Information
* OAD: Oral Antidiabetic
# FDC: Fixed dose combination
**HbA1c: Haemoglobin A1c
##: Fasting plasma glucose
***: Postprandial plasma glucose
Well studied in diabetes type 2 patients with established cardiovascular disease & high cardiovascular risk patients.
4 years sustained Efficacy (Evidence based)
3.3% A1c reduction from baseline 10%
Comparable efficacy to Sulphonylurea without risk of hypoglycemia
24
Guidelines recommend the combination
ADA
/EASD
& AACE
2013
24 hours glycemic control with once daily dose
Ideal Criteria of OAD* in treatment of T2DM Patients in order to get High Glycemic Control with Confidence (1/2) :
Diabetes Care, Diabetologia. 19 April 2012 Garber AJ, et al. Endocr Pract 2013;19(2):327-336.
Jadzinsky et al – Diabetes, Obesity & metabolism (2009)
Fonseca V, Zhu T, Kayaker C, et al. Diabetes, Obesity and Metabolism 2012; 14 (4): 365–371.
Full Prescribing Information
* OAD: Oral Antidiabetic
# FDC: Fixed dose combination
**HbA1c: Haemoglobin A1c
##: Fasting plasma glucose
***: Postprandial plasma glucose
Well studied in diabetes type 2 patients with established cardiovascular disease & high cardiovascular risk patients.
4 years sustained Efficacy (Evidence based)
3.3% A1c reduction from baseline 10%
Comparable efficacy to Sulphonylurea without risk of hypoglycemia
Why Saxagliptin / Metformin XR
can be an Ideal FDC# in management of T2DM patients ?
26 Moses RG, et al. A randomized controlled trial of the efficacy and safety of saxagliptin as add-on therapy in patients with type 2 diabetes and
inadequate glycaemic control on metformin plus a sulphonylurea. Diabetes, Obesity and Metabolism 2014;16(5):443-450.
Saxagliptin/ Met XR + SU
Saxagliptin/ Met XR
27
Bioequivalence of Kombiglyze XR with coadminstered saxagliptin and metformin hydrochloride extended release tablets has been demonstrated Gummesson A, et al Clin Drug Investig. 2014 Nov;34(11):763-72”
Göke B et al. Int J Clin Pract. 2010;64(12):1619-1631. Onglyza [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; December 2011.
Stenlof K, Raz I, Neutel J, et al. Current Medical Research & Opinion 2010 ;26 (10): 2355-2363.
Goke trial
Glycemic control without risk of hypoglycemia
28
The between-group mean difference was -0.37 % (95 % CI -0.55 to -0.19; post hoc P<0.0001).
Barnett AH, et al. EASD 2011:243; Charbonnel B, et al. ADA 2011:1108-P.
3 folds reduction in
A1C
2 folds reduction in
A1C
Saxagliptin- Add-On to Insulin
Saxa/Metformin XRSaxagliptin
Saxagliptin
Guidelines recommend the combination
ADA
/EASD
& AACE
2013
24 hours glycemic control with once daily dose
Ideal Criteria of OAD* in treatment of T2DM Patients in order to get High Glycemic Control with Confidence (1/2) :
Why Saxagliptin / Metformin XR can be an Ideal FDC# in
management of T2DM patients ?
Diabetes Care, Diabetologia. 19 April 2012 Garber AJ, et al. Endocr Pract 2013;19(2):327-336.
Jadzinsky et al – Diabetes, Obesity & metabolism (2009)
Fonseca V, Zhu T, Kayaker C, et al. Diabetes, Obesity and Metabolism 2012; 14 (4): 365–371.
Full Prescribing Information
* OAD: Oral Antidiabetic
# FDC: Fixed dose combination
**HbA1c: Haemoglobin A1c
##: Fasting plasma glucose
***: Postprandial plasma glucose
Well studied in diabetes type 2 patients with established cardiovascular disease & high cardiovascular risk patients.
3.3% A1c reduction from baseline 10%
Comparable efficacy to Sulphonylurea without risk of hypoglycemia
Diabetes Is Associated With Increased Risk of CV Disease
• Diabetes confers an increased risk for MI, stroke, and PAD1–3
• It is not clear whether diabetes should be considered a cause or a comorbidity of heart failure4
– Diabetes is associated with an increased risk of developing HF in patients with other causes (eg, acute MI) and is believed to promote diastolic dysfunction
• Diabetes is associated with a 2- to 3-fold increase in the risk of CV and all-cause mortality5
CV = cardiovascular; MI = myocardial infarction; PAD = peripheral artery disease; CHD = coronary heart disease; HF = heart failure.
1. Emerging Risk Factors Collaboration. Lancet. 2010;375:2251–2222. 2. American Diabetes Association. Diabetes Care. 2003;26:3333–3341. 3. American Diabetes Association. Diabetes Care.
2014;37:S14–S80. 4. McMurray JJV et al. Lancet Diabetes Endocrinol. 2014; DOI 10.1016/S2213-8587(14)70031-2. 5. Gregg EW et al. Ann Int Med. 2007;147:149–156.
SAXAGLIPTIN5 mg/d
PLACEBO
Follow up Visits
Q 6 months
Final Visit
Documented Type 2 DiabetesN = 16,492
Primary EP CV Death, MI,
Ischemic Stroke
Duration
Event driven (n=1040)
Median duration 2.1y
Age ≥40 y ….. Established CV Disease or Age ≥55y M / 60y F ….. ≥ 1 CVD RF.
Major Secondary EP: CV death, MI, ischemic stroke, or hosp.
for heart failure, unstable angina, or coronary revascularization
RANDOMIZED 1:1 DOUBLE BLIND
All other DM Rx per treating MD
SaxagliptinAssessment of Vascular Outcomes Recorded in Patients with DM -TIMI 53
2.5 mg/d if eGFR ≤ 50 ml/min
Scirica BM, Bhatt DL, Braunwald E, et al…. Raz I. NEJM 2013 at www.NEJM.org.
TIMI STUDY GROUP / HADASSAH MEDICAL ORG
HbA1c ≥6.5%
Primary Composite Endpoint *
CV Death, MI, or Stroke
•Kaplan-Meier Rates K-M event rates are presented after 2 yrs. HR: hazard ratio; K-M: Kaplan-Meier; Pbo: placebo; Saxa: saxagliptin
Scirica BM, et al. N Engl J Med. 2013.10.1056/NEJMoa1307684.
Days
79838071
77617836
72677313
48554920
851847
PlaceboSaxagliptin
82128280
Pat
ien
ts W
ith
En
dp
oin
ts (
%)
14
12
10
8
6
4
2
0
0 180 360 540 720 900
HR 1.00; 95% CI, 0.89–1.12
(P≤0.001 non-inferiority)
(P=0.99 superiority)Saxagliptin: 7.3%*
Rate/100 person-yrs – 3.7%
Placebo: 7.2%*
Rate/100 person-yrs – 3.7%
Saxagliptin met the primary safety objective demonstrating
non-inferiority but, didn’t meet the criteria for the superiority
TIMI STUDY GROUP / HADASSAH MEDICAL ORG
Major Secondary Endpoint*
*K-M event rates are presented after 2 yrs. Composite of CV death, MI, stroke, and hosp for HF, UA, or coronary revascularization.
Scirica BM, et al. N Engl J Med. 2013.10.1056/NEJMoa1307684.
Days
78437880
75027539
69266963
46024660
813817
PlaceboSaxagliptin
82128280
14
12
10
8
6
4
2
0
0 180 360 540 720 900
HR 1.02; 95% CI 0.94-1.11
P=0.66
Saxagliptin: 12.8%*
Rate/100 person-yrs – 6.6%
Placebo: 12.4%*
Rate/100 person-yrs – 6.5%
Pat
ien
ts W
ith
En
dp
oin
ts (
%)
No significant differences were observed between saxagliptin and placebo
CVD, MI, Ischemic Stroke, or Hospitalization for Unstable Angina, Coronary Revascularization, or CHF (%)
TIMI STUDY GROUP / HADASSAH MEDICAL ORG
Individual Components
of the Composite Endpoints
*K-M event rates are presented after 2 yrs.
Scirica BM, et al. N Engl J Med. 2013.10.1056/NEJMoa1307684.
Saxagliptin Placebo n (%)* n (%)*
Efficacy endpoint (N = 8,280) (N = 8,212) HR (95% CI) P value
CV death 269 (3.2) 260 (2.9) 1.03 (0.87–1.22) 0.72
MI 265 (3.2) 278 (3.4) 0.95 (0.80–1.12) 0.52
Ischemic stroke 157 (1.9) 141 (1.7) 1.11 (0.88–1.39) 0.38
Hosp for UA 97 (1.2) 81 (1.0) 1.19 (0.89–1.60) 0.24
Hosp for HF 289 (3.5) 228 (2.8) 1.27 (1.07–1.51) 0.007
Hosp for coronary revasc. 423 (5.2) 459 (5.6) 0.91 (0.80–1.04) 0.18
TIMI STUDY GROUP / HADASSAH MEDICAL ORG
Adjudicated Causes of CV Death
*Event rates are presented after 2 yrs.Scirica BM, et al. N Engl J Med. 2013.10.1056/NEJMoa1307684.
Although more frequently Hospitalized HF., there was no imbalance in deaths due to heart failure between saxagliptin and placebo
3.2
0.50.3 0.3
1.6
0.20.4
2.9
0.5
0.20.4
1.3
0.20.4
0
0.5
1
1.5
2
2.5
3
3.5
4
Onglyza™ (%) (n = 8,280)
Placebo n (%)(n = 8,212)
CerebrovascularAcute MI Presumed CV death
HF Sudden cardiac death
Any CV death Other
Adjudicated Causes of CV Death1
% o
f p
atie
nts
Risk of Hospitalization for HF According to Baseline NT-proBNP
Ho
spit
aliz
atio
n f
or
HF
(%)
HR 1.0495% CI 0-26.3
P=0.98
HR 1.8295% CI 0.9-4.1
P=0.12
HR 0.9495% CI 0.6-1.6
P=0.82
HR 1.3195% CI 1.0-1.6
P=0.021
0.7% 0.7% 1.1%0.3%
2.2% 2.0%
10.9%
8.9%
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%N = 3076
Q1(5 - 64)
N = 3076
Q2(65 - 140)
N = 3076
Q3(141 - 332)
N = 3073
Q4(333 - 46,627)
Quartiles of NT-proBNP (pg/mL)
# of HHF events/1000 pt-years 0 5 1 10
P for interaction = 0.46
Saxagliptin Placebo
Scirica BM, et al. American Heart Association Scientific Sessions. November 2013.
NT-proBNP: N-terminal pro-brain natriuretic peptide; HHF: hospitalization for heart failure
Hospitalization for heart failure was the only component of the 2ry composite endpoint increased with Saxagliptin vs. placebo early during the first 6 months of therapy, However;
This increase in risk was highest among patients with elevated levels of natriuretic peptides, previous heart failure, or chronic kidney disease
Difference between the 2 treatment groups stabilised after 6 - 9 months.
No evidence that subjects treated with saxagliptin had a more complicated course while hospitalised
No evidence of clinically detectable fluid overload (i.e., no increase in oedema or weight gain) for the overall study population.
No clinically significant change in biomarkers at 2 years/EOT for
NT-proBNP
hs-TNT
hs-CRP
Investigators’ Conclusions Hospitalization for Heart Failure
hs TNT; High-sensitivity cardiac troponin
NT-proBNP ; N-terminal pro-brain natriuretic peptide.
No Evidence of Increased Risk of hHF for
`(DPP-4i Relative to SU) or for (Saxagliptin Relative to Sitagliptin)
*Reference category for HR; HR<1 indicates lower risk for DPP-4i or saxagliptin
DPP-4i SU
Patients Events Patients Events
DPP-4i vs. SU
No baseline CVD
82,019 35 82,019 58 0.59 (0.38,0.89)
Baseline CVD 27,259 200 27,259 202 0.95 (0.78, 1.15)
SAXA SITA
Patients Events Patients Events
SAXA vs. SITA
No baseline CVD
43,402 23 43,402 240.99 (0.56,
1.75)
Baseline CVD 13,042 82 13,042 870.95 (0.70,
1.28)
0.2 1 5
Hazard Ratio(95% CI)
Favors SAXA Favors SITA
Favors DPP-4i Favors SU
0.2 1 5
American Diabetes Association 75th Scientific Sessions,
Boston, MA, 5–9 June2015 3340-0615-AZ-DL-0617 FU et al. 2015. ADA abstract accepted
Conclusions No evidence of increased risk for hospitalization for heart failure with DPP-4i
treatment compared with SU treatment
Among patients without prior CVD, DPP-4i treatment was associated with
statistically significant lower risk for hospitalization for heart failure compared with
SU treatment.
DPP-4i treatment was associated with statistically significant lower risk of
cardiovascular events across a range of cardiovascular outcomes compared with
SU treatment among patients without prior CVD.
DPP-4i treatment was associated with statistically significant lower risk of
cardiovascular events on the composite measure of all CV events in both the no
prior CVD and prior CVD strata.
These results were robust across multiple sensitivity analyses.
No evidence of an increased risk of hospitalization for heart failure compared with
sitagliptin.
No evidence was found of statistically significant differences in cardiovascular
risk between saxagliptin and sitagliptin on any cardiovascular outcome, including
the composite outcome.
These results were robust across multiple sensitivity analyses.
American Diabetes Association 75th Scientific Sessions, Boston, MA, 5–9 June2015 3340-0615-AZ-DL-0617
FU et al. 2015. ADA abstract accepted
Guidelines recommend the combinationADA
/EASD
& AACE
24 hours glycemic control with once daily dose
Diabetes Care, Diabetologia. 19 April 2012 Garber AJ, et al. Endocr Pract 2013;19(2):327-336.
Jadzinsky et al – Diabetes, Obesity & metabolism (2009)
Fonseca V, Zhu T, Kayaker C, et al. Diabetes, Obesity and Metabolism 2012; 14 (4): 365–371.
Full Prescribing Information
* OAD: Oral Antidiabetic
# FDC: Fixed dose combination
**HbA1c: Haemoglobin A1c
##: Fasting plasma glucose
***: Postprandial plasma glucose
Well studied in diabetes type 2 patients with established cardiovascular disease & high cardiovascular risk patients.
4 years sustained Efficacy (Evidence based)
3.3% A1c reduction from baseline 10%
Comparable efficacy to Sulphonylurea without risk of hypoglycemia
To Conclude regarding
Saxagliptin/Metformin XR Combination
Thanks