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DPP-4 Inhibitors
SGLT-2 Inhibitors
Insulin
Decreased
Incretin Effect
Increased
Impaired Lipolysis
Insulin Secretion
Islet -cell
Increased
Decreased Glucose
HGP
Neurotransmitter Uptake
Dysfunction
From DeFronzo, Diabetes: 2009
Type 2 Diabetes: A Progressive Disease
Type 2
Normal IGT Diabetes
Complications Disability
Death
Number
of Cases HR (95% CI) I2 (95% CI)
Coronary heart disease* 26,505
2.00 (1.83–2.19) 64 (54–71)
Coronary death 11,556 2.31 (2.05–2.60) 41 (24–54)
Nonfatal MI 14,741 1.82 (1.64–2.03) 37 (19–51)
Stroke subtypes*
Ischemic stroke 3,799 2.27 (1.95–2.56) 1 (0–20)
Hemorrhagic stroke 1,183 1.56 (1.19–2.05) 0 (0–26)
1.84 (1.59–2.13) 33 (12–48)
Unclassified stroke 4,973
1 2 4
Long-acting GLP-1 RAs ~1.5 No Loss 1, injected GI, ? pancreatitis, ?MTC, ?ARF
Islet -cell
SGLT-2
inhibitors
GLP-1 RA
DPP-4 inhibitors
Increased Increased Glucose
Glucagon Secretion Reabsorption
Metformin TZDs
Increased
Bromocryptine
Decreased Glucose
HGP
Neurotransmitter Uptake
Dysfunction
From DeFronzo, Diabetes: 2009
Properties of Established Anti-
Hyperglycemic Agents
Class Mechanism Advantages Disadvantages Cost
Biguanides • Activates AMP- • Extensive experience • Gastrointestinal Low
(Metformin) kinase • No hypoglycemia • Lactic acidosis
• Hepatic • Weight neutral • B-12 deficiency
glucose production • ? CVD events • Contraindications
Kidney
Kidney Liver and kidney Bile (mostly
Elimination (mostly
(mostly unchanged) Active metabolite unchanged)
unchanged)
Renal Dose
Adjustments Yes Yes Yes No
Required
Food effect No No No No
Efficacy of DPP-4 Inhibitor Therapy Added
to Metformin
Sitagliptin Saxagliptin Linagliptin Alogliptin
BL A1C (%)
≥7–≤10
7.7
≥7–≤10
8.1
≥7–≤10
≥7–≤10
≥7–≤10
8.0
7.7
7.7
8.1
—
n=701
n=743 n=743 n=527
n=701
n=743
n=273
n=273
Sitagliptin 100 mg Saxagliptin 5 mg
n=190 Rosiglitazone Saxagliptin 10 mg
Placebo Linagliptin 5 mg
Saxagliptin 2.5 mg Alogliptin 12.5–25 mg
1. Charbonnel. Diabetes Care. 2006;29:2638‐43. 2. Raz et al. Curr Med Res Opin. 2008;24:537‐50.
3. Scott et al. Diabetes Obes Metab. 2008;10:959‐69. 4. DeFronzo et al. Diabetes Care. 2009;32:1649‐55.
5. Taskinen et al. Diabetes Obes Metab. 2011;13:65‐74. 6. Nauck et al. Int J Clin Pract. 2009;63:46‐55.
14
DPP-4 Inhibitors vs Sulfonylureas Added to
Metformin – 2-Year Results
ALO (25 mg)1,a LINA (5 mg)2,b SAXA (5 mg)3,c SITA (100 mg)4,d
GLIP1,3,4 GLIM2
P = .01 Noninferiority vs SU
DPP-4i SU DPP-4i SU
ALO1,a −0.9e +1.0 1.4 23.2
LINA2,b −1.4e +1.3 7e 36
1. Del Prato et al. Diabetes Obes
SAXA3,c
Metab. 2014;16:1239‐46.
−1.5 +1.3 3.5 38.4
2. Gallwitz et al. Lancet. 2012;380:475‐83. SITA4,d −1.6 +0.7 5 34
3. Göke et al. Int J Clin Pract. 2013;67:307‐16.
4. Seck et al. Int J Clin Pract. 2010;64:562‐76.
5. Nauck et al. Diabetes Obes Metab. 2007;9:194‐205.
GLP-1 Receptor Agonists
GLP-1 RA
His Gly Glu Gly Thr Phe Thr Ser Asp Leu
Ser
Lys
Phe Leu Arg Val Ala Glu Glu Glu Met Gln
Ile
His Ala Glu Gly Thr Phe Thr Ser Asp
Glu
Ser
analogues Analogues[4]
Ala
Lys Ala Ala Gln Gly Glu Leu Tyr Ser
Ser Pro Pro Pro
Glu
Phe
Ile Ala Trp Leu Val Lys Gly Arg Gly
1. Christensen M, et al. Idrugs. 2009;12:503-513. 2. Ratner RE, et al. Diabet Med. 2010;27:1024-1032.
3. Stewart M, et al. ADA 2008, poster 522-p. 4. Glaesner, et al. Diabetes Metab Res Rev. 2010;26:287-296. 5. Meier JJ. Nat Rev Endocrinol. 2012;8:728-
742.
GLP-1 RA Administration and Devices
*
Dulaglutide
Automatic Injection
Hidden needle
*Not FDA approved
1. BYETTA Prescribing Information.
2. Victoza Summary of Product Characteristics.
3. Eperzan Summary of Product Characteristics.
4. Lyxumia Summary of Product Characteristics.
5. BYDUREON Prescribing Information.
Short-Acting vs. Long-acting GLP-1 RAs:
Pharmacokinetic Differences
Liraglutide3 13 h 8–12 h
Dulaglutide4 90 h 24–48 h
Short-acting Long-acting
b
a
a,b c
a a
1. DeFronzo RA, et al. Diabetes Care. 2005;28:1092-1100; 2. Bergenstal RM, et al. Lancet. 2010;376:431-439;
3. Pratley RE, et al. Lancet. 2010;375(9724):1447-1456; 4. Nauck M, et al. Diabetes Care. 2014;37(8):2149-2158;
5. Leiter LA, et al. Diabetes Care. 2014;37(10):2723-2730.
SGLT-2 Inhibition
Insulin-Independent Reversal of Glucotoxicity
Tubular
Proximal Lumen
Tubule
Insulin sensitivity
3Na+
in muscle1,2
ATP
2K+
SGLT-2 Insulin sensitivity
GLUT-2 in liver2
Na+/ 3Na+
Glucose
Gluconeogenesis2,3
ATP
Glucose 2K+
SGLT-1
GLUT-1 Glucose
Na+ Improved β-cell
function4,5
Glucose
GLUT-2, glucose transporter 2.
1. DeFronzo RA, et al. Diabetes Obes Metab. 2012;14(1):5-14; 2. Merovci A, et al. J Clin Invest. 2014;124(2):509-514;
3. Marsenic O. Am J Kidney Dis. 2009;53(5):875-883; 4. Ferrannini E, et al. J Clin Invest. 2014;124(2):499-508;
5. Polidori D, et al. Diabetologia. 2014;57(5):891-901.
SGLT2 Inhibitors: FDA-Approved Agents
vs SU
Δ Weight, Hypoglycemia,
kg % of patients
Agent
SGLT-2 SGLT-2
Inhibitor
SU SU
Inhibitor
1. Cefalu WT, et al. Lancet. 2013;382(9896):941-950; 2. Nauck MA, et al. Diabetes Care. 2011;34(9):2015-2022;
3. Ridderstråle M, et al. Lancet Diabetes Endocrinol. 2014;2(9):691-700.
Outline
Overview of new classes of diabetes drugs
Rationale for CVOTs in diabetes
Cardiovascular safety of new diabetes drugs:
evidence to date
Thiazolidinediones
DPP-4 Inhibitors
SGLT-2 Inhibitors
Insulin
● 25 Trials Ongoing/Completed
● 8 classes of medications
● >200,000 planned participants
2008
FDA guidance
DPP-4 Inhibitors
SGLT-2 Inhibitors
Insulin
20
Placebo
358 events
15 16% RRR
Events HR 0.84 (0.72–0.98)
(%) P = 0.027
10
Pioglitazone
301 events
5
0
0 6 12 18 24 30 36
Time from randomization (months)
*Excluding silent MI
Dormandy JA et al. Lancet. 2005;366:1279-89.
PROactive: HF Hospitalization and
Mortality
N = 5238
Pioglitazone Placebo
n (%) n (%) P
HF leading to hospital
admission* 149 (5.7) 108 (4.1) 0.007
*Non-adjudicated
Pioglitazone
95%
Cumulative
Event-Free 9.0%*
Survival
90% Placebo
Probability
HR 0.76
85% 11.8%*
95% CI, 0.62 to 0.93
P=0.007 *cumulative event rates
80%
‐0 20 40 60
Months in Trial
Kernan WN et al. N Engl J Med, published on-line Feb 17, 2016 DOI: 10.1056/NEJMoa1506930
Summary: Thiazoladinedione
Cardiovascular Outcomes Trials
DPP-4 Inhibitors
SGLT-2 Inhibitors
Insulin
EXAMINE2
0.96
Alogliptin Median (upper boundary
ACS CV death,
follow-up of 1-sided
A1c 6.5–11.0% nonfatal MI, or repeated CI 1.16)
1.5 years nonfatal stroke
n=5,380 Placebo p=0.315
TECOS3 0.98
CV death, (95% CI 0.88, 1.09)
Median
Sitagliptin nonfatal MI, or p=0.645
CVD follow-up
nonfatal stroke, or
A1c 6.5–8.0% (superiority)
3 years UA requiring
n=14,735 hospitalization
Placebo
0.99
CV death, (95% CI 0.89, 1.10)
nonfatal MI, or p=0.84
Randomization Year 1 Year 2 Year 3 nonfatal stroke (superiority)
Median Duration of Follow-up
. Scirica BM, et a. NEJM. 2013;369:1317-1326; 2. White W, et al. NEJM. 2013;369:1327-1335; 3. Green JB, et al. NEJM, 2015
Cardiovascular Outcomes Trials for DPP-4
Inhibitors
Saxagliptin Alogliptin Sitagliptin
(SAVOR-TIMI 53 Trial1) (EXAMINE Trial2) (TECOS Trial3)
N=16,492 N=5380 N=14,671
14 24
12 15 Placebo
10 18
Patients, %
Placebo Placebo
8 10 Sitagliptin
12
6 Saxagliptin Alogliptin
4 Hazard ratio: 1.00 Hazard ratio: 0.96 5 Hazard ratio: 0.98
6 (95% CI: 0.89, 1.08)
2 (95% CI: 0.89–1.12) (upper boundary of one-
P < 0.001 (noninferiority) sided repeated 95% CI: 1.16) P=0.65
0 0 0
0 180 360 540 720 900 0 6 12 18 24 30 0 4 8 12 18 24 30 36 42 48
Days Months Months
Composite of CV death, MI, or Composite of CV death, nonfatal MI, Composite of CV death, nonfatal
ischemic stroke or nonfatal stroke. MI, nonfatal stroke, or
hospitalization for unstable angina
0 1 2
Test for heterogeneity for 3 trials: Favors Favors
p=0.877, I2=0% Treatment Placebo
*Lower Confidence Limit not given for EXAMINE trial; MACE = major adverse cardiac events.
1. Scirica BM, et al. N Engl J Med. 2013;369:1317–1326. 2. White WB, et al. N Engl J Med. 2013;369:1327–
1335. 3. Green JB, et al. N Engl J Med. 2015;373(3):232–242.
SAVOR-TIMI 53, EXAMINE, and TECOS:
Hospitalization for Heart Failure
0 1 2
*Statistically significant increase in hospitalizations for heart failure associated with saxagliptin use in SAVOR-TIMI.
1. Scirica BM, et al. N Engl J Med. 2013;369:1317–1326. 2. White WB, et al. N Engl J Med. 2013;369:1327–1335.
Summary: DPP-4 Inhibitor
Cardiovascular Outcomes Trials
No benefit is apparent
DPP-4 Inhibitors
SGLT-2 Inhibitors
Insulin
Placebo
(n=2333)
Randomised and
Screening Empagliflozin 10 mg
treated
(n=11531)
(n=7020)
(n=2345)
P<0.001
Event, %
6
P=0.002 Placebo
Event, %
5
4 Hazard ratio, 0.65 (95% CI, 0.50–0.85)
3
2 Empagliflozin
1
0
0 6 12 18 24 30 36 42 48
Month
aCumulative incidence of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke.
N=7020 patients with T2DM at high risk of cardiovascular events.
Zinman B, et al. N Engl J Med. 2015;373(22):2117-2128.
EMPA-REG Outcomes Trial: CV Death,
MI and Stroke
Patients with event/analysed
Empagliflozin Placebo HR (95% CI) p-value
1. Zinman B, et al. N Engl J Med. 2015;373:2117-2128; 2. Barnett AH, et al. Lancet Diabetes Endocrinol. 2014;2:369-384.
Neal B et al. N Engl J Med. 2017 Jun 12.
Baseline Demographics and Disease
History
DPP-4 Inhibitors
SGLT-2 Inhibitors
Insulin
15
Patients with event (%)
10
5
Lixisenatide: 406/3034 = 13.4%
Placebo: 399/3034 = 13.2%
0 12 24 36
Months
Number at risk
Placebo 3034 2759 1566 476
Lixisenatide 3034 2785 1558 484
Lixisenatide Placebo HR
Outcome n=3034 n=3034 (95% CI)
Primary outcome
(CV death, nonfatal MI, nonfatal stroke, or 13.4% 13.2% 1.02 (0.89–1.17)
hospitalization for UA)
15 15 15
Hazard ratio, 0.85
Hazard ratio, 0.78 (95% CI, 0.74–0.97)
(95% CI, 0.66–0.93) P=0.02
10
Placebo 10 P=0.007 10
Placebo Placebo
5
Liraglutide 5 5
Liraglutide
Liraglutide
0 0 0
0 6 12 18 24 30 36 42 48 54 0 6 12 18 24 30 36 42 48 54 0 6 12 18 24 30 36 42 48 54
Months Since Randomization
aComposite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke.
The cumulative incidences were estimated with the use of the Kaplan–Meier method, and the hazard ratios with the use of the Cox proportional-
hazard regression model. The data analyses are truncated at 54 months, because less than 10% of the patients had an observation time beyond 54
months. CI: confidence interval; ESRD: end-stage renal disease; HR: hazard ratio.
Presented at the American Diabetes Association 76th Scientific Sessions, Session 3-CT-SY24. June 13 2016, New Orleans, LA, USA.
SUSTAIN 6: Primary and Secondary
Outcomes With Semaglutide
DPP-4 Inhibitors
SGLT-2 Inhibitors
Insulin
Day-to-day
variability Coefficient of variation 20% Coefficient of variation 80%
(AUCGIR,0–24h)
AUCGIR, area under the curve for glucose infusion rate; IGlar U100, insulin glargine U100
Insulin glargine image data on file; Jonassen et al. Pharm Res. 2012;29:2104–14; Heise et al. Expert Opin Drug Metab Toxicol 2015;11:1193–
201; Heise et al. Diabetes Obes Metab 2012;14:859–64
DEVOTE: Time to First 3-point MACE
12
356 patients
IGlar U100 Rate:
Insulin degludec 4.71/100 PYO
Patients with an event
10
325 patients
8
HR: 0.91
(%)
6 [0.78; 1.06]95% CI
Non-inferiority confirmed
4 Rate: p<0.001
4.29/100 PYO
2
0
0 3 6 9 12 15 18 21 24 27 30
Time to first EAC-confirmed event (months)
Insulin degludec (N) 3818 3765 3721 3699 3611 3563 3504 2851 1767 811 217
IGlar U100 (N) 3819 3758 3703 3655 3595 3530 3472 2832 1742 811 205
Full analysis set; Cox regression analysis accounting for treatment. Analysis includes events between
randomization date and follow-up date. Patients without an event are censored at the time of last contact (phone
or visit)
EAC, Event Adjudication Committee; N, number of patients at risk; PYO, patient-years of observation
DPP-4 Inhibitors
SGLT-2 Inhibitors
Insulin
e
ARB +
a b c d Neprilysin f g
ARB ACE inhibitor Beta blocker MRA inhibitor Empagliflozin Liraglutide
0%
% Decrease in mortality
-10%
-20%
-30%
-40%
Study
duration 38 41 10-12 21-24 27 36 46
(months)
ACE, acetylcholinesterase; ARB, Angiotensin II Receptor Blocker; HF, heart failure; MRA, Mineralocorticoid receptor antagonist
aSOLVD Treatment; bCHARM Alternative; cCOPERNICUS and MERIT-HF; dRALES and EMPHASIS-HF, ePARADIGM, fEMPA-REG OUTCOME, gLEADER
DPP-4i, dipeptidyl peptidase-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1 RA, glucagon-like peptide-1 receptor agonist; GU, genitourinary; HbA1c, glycosylated hemoglobin; HF,
heart failure; SU, sulfonylurea; SGLT2-i, sodium-glucose co-transporter 2 inhibitor; TZD, thiazolidinedione.
American Diabetes Association. Diabetes Care 2016;39(Suppl. 1):S52-S59.
ADA Glycemic Treatment
Recommendations for T2DM 2017
Summary
Completed long-term CV safety trials have demonstrated no increased
risk of CV events associated with newer antihyperglycemic agents
DPP-4 inhibitors not associated with an increased overall risk