Diabetes drug found no better than placebo at treating nonalcoholic fatty liver disease: But randomized, double-blind clinical trial suggests better way to conduct future trials

A diabetes medication described in some studies as an effective treatment for nonalcoholic fatty liver disease (NAFLD) works no better than a placebo, report researchers at University of California San Diego School of Medicine, after conducting the first randomized, double-blind, controlled clinical trial of sitagliptin, an oral antihyperglycemic marketed by Merck & Co. under the name Januvia.

 

Januvia (sitagliptin)

Writing in the Journal of Hepatology, a multidisciplinary team headed by study senior author Rohit Loomba, MD, professor of medicine in the Division of Gastroenterology and director of the NAFLD Translational Research Unit at UC San Diego School of Medicine, found that sitagliptin was not significantly better than a placebo in reducing liver fat, as measured by magnetic resonance imaging-proton density fat fraction (MRI-PDFF) and other technologies.

The team included Claude Sirlin, MD, professor and vice chair (translational research) of radiology at UC San Diego School of Medicine, and Richard Ehman, MD, professor of radiology at Mayo Clinic. The labs, led by Sirlin and Ehman, invented and validated the advanced noninvasive imaging techniques applied in this study.

NAFLD is the accumulation of fat in the livers of people who drink little or no alcohol. It is the leading cause of chronic liver disease in the United States. Roughly one-quarter of Americans -- an estimated 100 million adults and children -- have NAFLD, which can progress to a more serious form called nonalcoholic steatohepatitis, which in turn can develop into cirrhosis, liver cancer and liver failure.

Currently, there are no approved, specific therapies for NAFLD. However, it is commonly associated with diabetes, which has prompted researchers to test diabetes medications, such as metformin, rosiglitazone and liraglutide, as potential treatments.

Sitagliptin is another possibility. In clinical trials conducted in patients with type 2 diabetes, sitagliptin has been shown to be effective in improving glycemic (blood sugar) control, cholesterol, lipoproteins and other health measures compared to placebo.

"But human trials of sitagliptin have been limited to date because they have lacked important tools like a placebo arm and allocation concealment (in which researchers do not know what the next treatment allocation will be, further preventing selection bias in testing)," said Loomba.

In the new study, 50 NAFLD patients with pre-diabetes or early diabetes were randomized into two groups: one received a 100 milligram oral dose of sitagliptin daily for 24 weeks, the other received a placebo. Primary outcome was assessed by changes to liver fat measured by MRI-PDFF, conducted by the Liver Imaging Group in the Department of Radiology at UC San Diego Health.

At end-of-treatment, Loomba and colleagues found no significant differences between sitagliptin and placebo across a range of measures. Neither study group experienced any adverse effects.

While the study did not support earlier findings that sitagliptin was an effective treatment for NAFLD, Loomba said it provided new evidence that clinical trials with patients at higher risk of diabetes do not necessarily need a liver biopsy to be efficiently screened for potential therapeutic agents.

"Biopsies present their own complications, such as possible pain and infection," said Loomba. "MRI-PDFF, and magnetic resonance elastography (a non-invasive imaging technique that measures the stiffness of soft tissues) proved to be accurate, quantitative, and useful over the study duration in measuring the state and progression of disease. These technologies should be further investigated in clinical trials, especially those of longer duration."

Sitagliptin Promising Addition for Preventing Acute GVHD

In continuation of my updates on sitagliptin 

For patients undergoing myeloablative allogeneic hematopoietic stem cell transplantation, sitagliptin combined with tacrolimus and sirolimus results in a low incidence of grade II to IV acute graft-versus-host disease (GVHD) by day 100, according to a study published in the Jan. 7 issue of the New England Journal of Medicine.

Sherif S. Farag, M.D., Ph.D., from the Indiana University School of Medicine in Indianapolis, and colleagues conducted a phase 2 clinical trial to examine the reduction in incidence of grade II to IV acute GVHD from 30 percent to no more than 15 percent by day 100 with sitagliptin plus tacrolimus and sirolimus. Thirty-six patients received myeloablative conditioning followed by mobilized peripheral-blood stem cell transplants from matched related or unrelated donors.

The researchers found that by day 100, acute GVHD occurred in two of 36 patients. The incidence of grade II to IV GVHD and of grade III or IV GVHD was 5 and 3 percent, respectively. At one year, nonrelapse mortality was zero. The one-year cumulative incidence of relapse was 26 percent, and for chronic GVHD, it was 37 percent. At one year, GVHD-free, relapse-free survival was 46 percent. Toxic effects were similar to those seen in patients undergoing allogeneic stem cell transplantation.

"Inhibition of dipeptidyl peptidase 4 should be further investigated in randomized trials that compare sitagliptin with current standard GVHD prophylaxis regimens," the authors write.

https://en.wikipedia.org/wiki/Sitagliptin

Dapagliflozin more effective than sitagliptin for adult patients with type 2 diabetes

Dapagliflozin more effective than sitagliptin for adult patients with type 2 diabetes: 

In continuation of my update on dapagliflozin and sitagliptin

The study also demonstrated significant reductions in total body weight and fasting plasma glucose (FPG) levels in patients taking dapagliflozin added to sitagliptin (with or without metformin), with results maintained throughout the duration of the study extension.

Patients were actively questioned at each study visit for signs, symptoms or events suggestive of genital infections and urinary tract infections. These events were more frequent with the dapagliflozin treatment group compared to the placebo treatment group, and were generally mild to moderate in intensity, with most patients responding to standard treatment.

"Type 2 diabetes is a complex disease that often requires patients to take multiple treatments to control their blood sugar levels, with DPP4 inhibitors being some of the most widely prescribed therapies," said Serge Jabbour, M.D., Division Director of Endocrinology, Thomas Jefferson University. "In this study, dapagliflozin, in addition to diet and exercise, resulted in reduced blood sugar levels when added to sitagliptin, a DPP4 inhibitor. These findings add to our understanding of the effect of dapagliflozin in combination with commonly prescribed type 2 diabetes treatments."

Bristol-Myers Squibb Company and AstraZeneca today announced results from a Phase 3 clinical study that showed the investigational compound dapagliflozin 10 mg demonstrated significant reductions in blood sugar levels (glycosylated hemoglobin levels, or HbA1c) compared with placebo at 24 weeks when either agent was added to existing sitagliptin therapy (with or without metformin) in adult patients with type 2 diabetes.

More..

FDA Approves Jentaduet ((sitagliptin and metformin hydrochloride (HCl) )...

In continuation of my update on sitagliptin and metformin hydrochloride (HCl)

U.S. Food and Drug Administration (FDA) approved JANUMET^® XR    ((sitagliptin and metformin hydrochloride (HCl) ) extended-release) tablets, a new treatment for type 2 diabetes that combines sitagliptin, which is the active component of JANUVIA^® (sitagliptin), with extended-release metformin. JANUMET XR provides a convenient once-daily treatment option for healthcare providers and patients who need help to control their blood sugar.

More..

First combination drug to treat type 2 diabetes and high cholesterol receives FDA approval

In continuation of my update on Simvastin

The U.S. Food and Drug Administration recently approved Juvisync (sitagliptin and simvastatin), a fixed-dose combination (FDC) prescription medication that contains two previously approved medicines in one tablet for use in adults who need both sitagliptin and simvastatin.....

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Dulaglutide Fares Well in New Trials

Eli Lilly and Co.'s potential once-weekly treatment for type 2 diabetes fared better than three other drugs in lowering blood sugar levels, according to initial results from some late-stage research.

The Indianapolis drugmaker said that two doses of its injectable drug dulaglutide (see structure) delivered statistically superior reductions in blood sugar levels when compared to twice-daily injections of exenatide and the oral treatments metformin and sitagliptin. Lilly will present more details from the studies at scientific meetings next year and in 2014.

Lilly said it will submit the drug to regulators for approval next year. It said timing in the United States will depend on the completion of Food and Drug Administration requirements for an assessment of the drug's cardiovascular risk.

Dulaglutide Fares Well in New Trials 

FDA Expands Indication of Invokamet (canagliflozin/metformin HCl) to Include First-Line Treatment of Type 2 Diabetes

In continuation of my updates on INVOKANA® (canagliflozin) and metformin hydrochloride,

Janssen Pharmaceuticals, Inc. (Janssen), announced the U.S. Food and Drug Administration (FDA) has approved Invokamet, a fixed-dose combination therapy of INVOKANA® (canagliflozin) and metformin hydrochloride, for first-line treatment of adults with type 2 diabetes. With this new approval, Invokamet may now be prescribed in adults with type 2 diabetes who are not already being treated with canagliflozin or metformin and may benefit from dual therapy.

 metformin    canagliflozin

Invokamet, the first combination of a sodium glucose co–transporter 2 (SGLT2) inhibitor and metformin available in the United States, was previously approved by the FDA in August 2014 as an adjunct to diet and exercise to improve blood glucose control in adults with type 2 diabetes not adequately controlled by either canagliflozin or metformin, or who are already being treated with both medications separately.

“Physicians increasingly try to achieve greater initial blood sugar control by using dual therapy at the outset, versus single-agent therapy alone, especially for patients with higher A1C levels,” said John Anderson, M.D.*, Frist Clinic, Nashville, Tenn. “Invokamet combines two effective, complementary medicines—canagliflozin and metformin—into one convenient pill, to lower A1C significantly more than metformin alone.”

A1C is a measure of average blood glucose over the past two to three months; the American Diabetes Association recommends most adults with type 2 diabetes maintain A1C levels of 7 percent or less.[2]

The new Invokamet indication aligns with recent type 2 diabetes treatment guidelines, which recommend dual therapy for patients with higher A1C levels. Specifically, guidelines recommend dual therapy for patients who have an initial A1C level of 7.5 percent or higher;[3] and for those who have an initial level below 7.5 percent and do not achieve an A1C treatment goal after about three months on single therapy, often metformin.3,[4] In addition, dual or triple therapy is recommended as first-line therapy in asymptomatic patients with an initial A1C level above 9 percent.3

Studies have demonstrated that administration of Invokamet results in the same levels and effects of canagliflozin and metformin in the body as co-administration of corresponding doses of both drugs as individual tablets. Canagliflozin works with the kidneys to help adults with type 2 diabetes lose some sugar through the process of urination, and metformin decreases the production of glucose in the liver and improves the body's response to insulin. Invokamet should not be used in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis.1

Invokamet is available in four dose strengths, in tablets containing canagliflozin 50 milligrams (mg) or 150 mg, and metformin 500 mg or 1000 mg. The recommended dosing is twice daily. The prescribing information for Invokamet also contains a boxed warning for lactic acidosis, a rare, but serious complication that can occur due to metformin accumulation.1

“The available doses of Invokamet allow physicians to tailor therapy for individual patient needs and offer an alternative for people living with type 2 diabetes who may be able to reduce the number of pills they take each day,” said Paul Burton, M.D., Ph.D., Vice President, Medical Affairs, Janssen. “This expansion marks an important milestone as we continue to study Invokamet and INVOKANA®—the number-one prescribed SGLT2 inhibitor with more than 8 million prescriptions to date—for the treatment of type 2 diabetes.”

Phase 3 Study Supports Expanded Indication

The expanded indication for Invokamet was based largely on a 26-week, double-blind, active-controlled, multicenter Phase 3 study in 1,186 adults with type 2 diabetes inadequately controlled with diet and exercise, and who had not been treated previously with any glucose-lowering medications. The participants were assigned randomly to one of five treatment groups: metformin hydrochloride extended release (MET), canagliflozin 100 mg (CANA100), canagliflozin 300 mg (CANA300), canagliflozin 100 mg + MET (CANA100/MET), or canagliflozin 300 mg + MET (CANA300/MET). The mean baseline A1C across all groups was 8.8 percent. The primary endpoint was the change in A1C. A report on the study findings was published in Diabetes Care in March 2016.[5]

After 26 weeks, participants in the CANA100/MET and CANA300/MET groups had significantly greater decreases in A1C compared to those in the CANA100, CANA300 and MET groups: 1.77 percent and 1.78 percent vs. 1.37 percent, 1.42 percent and 1.3 percent, respectively (p-values for all differences between the combination therapies vs. individual therapies less than 0.001). Additionally, significantly more participants in the CANA100/MET and CANA300/MET groups compared to the MET group achieved the goal of reducing A1C to less than 7 percent: 47 percent and 51 percent vs. 38 percent, respectively (p less than 0.05 for both combination groups vs. MET).1

Other Phase 3 Studies of Canagliflozin-Metformin Therapy

The co-administration of canagliflozin—INVOKANA®—and metformin has been evaluated in six other Phase 3 clinical studies that enrolled 4,732 patients with type 2 diabetes and who were already taking glucose-lowering medications. The studies showed that the combination of INVOKANA® and metformin lowered blood sugar and, in pre-specified secondary endpoints, was associated with significant reductions in body weight and systolic blood pressure.

In two studies comparing INVOKANA® plus metformin to current standard treatments plus metformin—one studying sitagliptin and the other studying glimepiride—INVOKANA® dosed at 300 mg provided greater reductions in A1C levels and body weight than either comparator. The overall incidence of adverse events was similar with INVOKANA® and the comparators.

Results from the Phase 3 studies showed that INVOKANA® was generally well tolerated, and the most common adverse events include genital yeast infections, urinary tract infections, and changes in urination. The most common adverse reactions due to initiation of metformin, as noted in the prescribing information for that medication, are diarrhea, nausea, vomiting, flatulence, asthenia, indigestion, abdominal discomfort, and headache. Hypoglycemia does not occur in patients receiving metformin alone under usual circumstances of use. INVOKANA® can increase the risk of hypoglycemia when combined with insulin or a medication that increases insulin levels (e.g., a sulfonylurea). Therefore, a lower dose of insulin or insulin-raising medication may be required to minimize the risk of hypoglycemia when used in combination with Invokamet.

About Type 2 Diabetes

Of the approximately 29 million people who have diabetes in the United States, 90 to 95 percent of them have type 2 diabetes, which is chronic and affects the body's ability to metabolize sugar (glucose), and is characterized by the inability of pancreatic beta cell function to keep up with the body's demand for insulin

Semaglutide found to be effective against type 2 diabetes

In continuation of my update on Semaglutide

Semaglutide is safe and effective for the treatment of type 2 diabetes, according to a review published online May 13 in Diabetes, Obesity and Metabolism.

Panagiotis Andreadis, M.D., from the Aristotle University of Thessaloniki in Greece, and colleagues conducted a systematic literature review to identify randomized controlled trials comparing semaglutide with placebo or other antidiabetic agents. The primary outcome was measured change in HbA1c from baseline.

Six placebo-controlled and seven active-controlled studies were identified. The researchers found that subcutaneous semaglutide (0.5 and 1 mg) reduced HbA1c by 1.01 percent (95 percent confidence interval [CI], 0.56 to 1.47) and 1.38 percent (95 percent CI, 1.05 to 1.70), respectively, compared to placebo. Compared to other antidiabetic agents (sitagliptin, exenatide, liraglutide, dulaglutide, and insulin glargine), both doses of semaglutide demonstrated superior glycemic efficacy. There was a beneficial effect on body weight (mean difference versus placebo −4.11 kg; 95 percent CI, −4.85 to −3.37 for semaglutide 1 mg) and systolic blood pressure with semaglutide. There was increased incidence of nausea, vomiting, and diarrhea with semaglutide. Compared to placebo, the odds ratio for diabetic retinopathy was 1.32 (95 percent CI, 0.98 to 1.77).

"Semaglutide is a potent once-weekly glucagon-like peptide 1 receptor agonist, reducing significantly HbA1c, body weight, and systolic blood pressure. However, it is associated with increased incidence of gastrointestinal adverse events," the authors write.

Several authors disclosed financial ties to pharmaceutical companies, including Novo Nordisk, the manufacturer of semaglutide.

Ref : https://onlinelibrary.wiley.com/doi/10.1111/dom.13361

FDA Approves Rybelsus (semaglutide), the First Oral GLP-1 Analog Treatment for Adults with Type 2 Diabetes

In continuation of my updates on Semaglutide

Novo Nordisk today announced that the U.S. Food and Drug Administration (FDA) has approved Rybelsus (semaglutide) tablets 7 mg or 14 mg for adults with type 2 diabetes that along with diet and exercise may improve blood sugar (glucose).  Rybelsus is the first and only glucagon-like peptide-1 (GLP-1) analog in a pill and a new option for adults with type 2 diabetes who are not achieving their A1C goal with current antidiabetic treatment.

Type 2 diabetes is a global public health issue that impacts more than 28 million people in the U.S. alone.2 Despite existing treatment options, many adults with type 2 diabetes have poorly managed blood sugar that can increase the risk of developing serious diabetes-related complications.

"GLP-1 receptor agonists are effective medications for people with type 2 diabetes but have been underutilized in part because they have, until now, only been available as an injectable treatment," said Vanita R. Aroda, MD, Director of Diabetes Clinical Research, Brigham and Women's Hospital, Boston, MA and a PIONEER clinical trial investigator. "The availability of an oral GLP-1 receptor agonist represents a significant development and primary care providers, specialists and patients alike may now be more receptive to the use of a GLP-1 therapy to help them achieve their blood sugar goals."

The approval of Rybelsus is based on results from 10 PIONEER clinical trials, which enrolled 9,543 participants and included head-to-head studies of Rybelsus vs. sitagliptin, empagliflozin and liraglutide 1.8 mg.4 In the trials, Rybelsus reduced A1C and, as a secondary endpoint, showed reductions in body weight. The most common adverse reactions in the PIONEER trials, reported in ≥5% of patients, were nausea, abdominal pain, diarrhea, decreased appetite, vomiting and constipation. The types and frequency of the adverse reactions were similar across trials.

"People living with type 2 diabetes deserve more innovation, research and support to help them achieve their individual A1C goals," said Todd Hobbs, vice president and U.S. chief medical officer of Novo Nordisk. "With Rybelsus, we have the opportunity to expand use of effective GLP-1 receptor agonist therapy by providing adults with type 2 diabetes an oral medication which was previously only available as an injection to help with managing their blood sugar."

Rybelsus is approved for once-daily use in two therapeutic doses, 7 mg and 14 mg, and will be available in the U.S. beginning in Q4 2019. Initial supply of Rybelsus will come from manufacturing facilities in Denmark; however, future supply for Rybelsus will come from manufacturing facilities in the U.S. In 2015, Novo Nordisk made a strategic investment to build a new manufacturing facility in Clayton, NC to prepare for the future demand for Rybelsus. Additionally, earlier this year Novo Nordisk acquired a tableting and packaging facility in Durham, NC to meet anticipated supply needs for Rybelsus.

Novo Nordisk is working with health insurance providers with a goal of ensuring broad insurance coverage and patient access to the product. A savings card program will be available at the time of launch for eligible commercially-insured patients to keep out of pocket costs down to as little as $10 a month.

The U.S. FDA is still reviewing Novo Nordisk's new drug application (NDA) for Rybelsus seeking an additional indication to reduce the risk of major adverse cardiovascular events (MACE) such as heart attack, stroke, or cardiovascular death in adults with type 2 diabetes and established cardiovascular disease (CVD). A decision is expected in Q1 2020.

Rybelsus is currently under review by several regulatory agencies around the world, including the European Medicines Agency and the Japanese Pharmaceuticals and Medical Devices Agency.

https://en.wikipedia.org/wiki/Semaglutide

Novo Nordisk Receives FDA Approval of Ozempic (semaglutide) Injection For the Treatment of Adults with Type 2 Diabetes

Novo Nordisk today announced that the U.S. Food and Drug Administration (FDA) approved its New Drug Application (NDA) for Ozempic (semaglutide) injection 0.5 mg or 1 mg, a once-weekly glucagon-like peptide (GLP-1) receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes.¹ Ozempic is administered once weekly, on the same day each week, and can be taken any time of the day, with or without meals.

The approval of Ozempic is based on the results from a Phase 3a clinical trial program. In people with type 2 diabetes, Ozempic showed clinically meaningful and statistically significant reductions in A1c compared with placebo, sitagliptin and exenatide extended-release.¹ As a secondary endpoint in the trials, treatment with Ozempic resulted in reductions in body weight. The most common adverse reactions reported in ≥5% of patients treated with Ozempic are: nausea, vomiting, diarrhea, abdominal pain and constipation.¹

"The Ozempic approval builds on Novo Nordisk's commitment to offering healthcare professionals a range of treatments that effectively addresses the complex needs of diabetes management and fits their patients' lifestyles," said Todd Hobbs, vice president and U.S. chief medical officer of Novo Nordisk. "We are grateful to the many adults with type 2 diabetes who participated in the studies, as well as the clinical trial investigators. Thanks to their collective contributions, Novo Nordisk is able to bring once-weekly Ozempic to the type 2 diabetes community."

Ozempic is approved for use in two therapeutic doses, 0.5 mg and 1 mg, and will be launched in the Ozempic pre-filled pen.¹

The global Phase 3a clinical trial program for Ozempic comprised eight clinical trials involving more than 8,000 adults with type 2 diabetes, including a two-year cardiovascular outcomes trial that evaluated safety in adults with type 2 diabetes at high risk of cardiovascular events.¹

"Type 2 diabetes is a serious condition that affects more than 28 million people in the U.S., and despite advancements in treatment, some people with type 2 diabetes do not achieve their A1c goals," said Helena Rodbard, MD, FACP, MACE, medical director, Endocrine and Metabolic Consultants, Rockville, MD, and past president of the American Association of Clinical Endocrinologists. "The approval of semaglutide offers healthcare professionals an important new treatment option to help adults with type 2 diabetes meet their A1c goals."

Novo Nordisk expects to launch Ozempic in the U.S. in Q1 2018, with a goal of ensuring broad insurance coverage and patient access to the product. Ozempic will be priced at parity to current market-leading weekly GLP-1 receptor agonists and will be offered with a savings card program to reduce co-pays for eligible commercially-insured patients. Additionally, as part of the access strategy, Novo Nordisk is working with appropriate health insurance providers to establish innovative contracting solutions.

Semaglutide is currently under review by the European Medicines Agency and the Japanese Pharmaceuticals and Medical Devices Agency.

Novo Nordisk Receives FDA Approval of Ozempic (semaglutide) Injection For the Treatment of Adults with Type 2 Diabetes