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Therapeutics Bulletin Therapeutics Bulletin October 2018 Please see Important Safety Information throughout. Please see accompanying Prescribing Information, including Boxed Warning. Table of contents Introduction Introduction page 2 Diabetes is a complex disease that has the potential to negatively influence the health of patients if left untreated. Type 2 Diabetes and Cardiovascular Disease page 3 Currently, about 30 million people in the United States have diabetes (including about 7 million undiagnosed Introduction to Victoza® page 4 cases), which represents about 9.4% of the U.S. population. Approximately 90-95% of those cases are patients with LEADER Trial page 5 type 2 diabetes. Almost 34% of the population has pre- diabetes (based on elevated fasting glucose or A1C levels), Additional features page 10 meaning they are at risk for developing type 2 diabetes.1 Complications associated with type 2 diabetes can lead to Summary page 10 increased emergency room visits, hospitalizations, and even death.1 For these reasons, treatment of type 2 diabetes and References page 12 its associated complications is an important topic of study. Among other complications, patients with type 2 diabetes often experience cardiovascular disease (CVD). One therapy used to treat type 2 diabetes is Victoza® (liraglutide) injection 1.2 mg or 1.8 mg a human glucagon- PUBLISHER ASSISTANT ART DIRECTOR like peptide-1 (GLP-1) analog that was approved by the Gene Conselyea John Salesi U.S. Food and Drug Administration on January 25, 2010, WRITER/EDITOR PROJECT MANAGER as an adjunct to diet and exercise, to improve glycemic Jaelithe Russ Aubrey Feeley control in adults with type 2 diabetes. On August 27, 2017, Francine Pozzolano The U.S. Food and Drug Administration approved Victoza® ART DIRECTOR (liraglutide) injection to reduce the risk of major adverse Ari Mihos SALES Ron Gordon cardiovascular (CV) events including non fatal myocardial infarction (MI), non fatal stroke, or CV death, in adults with type 2 diabetes and established CV disease.2 The landmark LEADER trial demonstrated that Victoza® significantly reduced the risk of major adverse cardiovascular events, a three component composite 630 Madison Avenue endpoint consisting of cardiovascular death, non-fatal 2nd Floor MI, or non-fatal stroke, by 13% vs placebo (hazard ratio, Manalapan, NJ 07726 0.87; 95% confidence interval, 0.78-0.97; p=0.01) with an absolute risk reduction (ARR) of 1.9%.2 This bulletin ©2018 American Medical Communications, Inc, Manalapan, NJ 07726. 18061 provides information on the connection between type 2 diabetes and CVD; indications, use, and safety information for Victoza®; and the LEADER trial. Important Safety Information Contraindications Warnings and Precautions • Victoza® is contraindicated in patients with a personal or • Risk of Thyroid C-cell Tumors: Patients should be family history of MTC or in patients with MEN 2, and in referred to an endocrinologist for further evaluation if patients with a prior serious hypersensitivity reaction to serum calcitonin is measured and found to be elevated Victoza® or to any of the product components. Serious or thyroid nodules are noted on physical examination or hypersensitivity reactions including anaphylactic reactions neck imaging. and angioedema have been reported with Victoza®. 2 Victoza® Product Bulletin Background on disease Type 2 diabetes Selected Important Safety Information According to the American Diabetes Association, “Diabetes is a complex, chronic illness requiring continuous medical care with multifactorial risk-reduction WARNING: RISK OF THYROID C-CELL TUMORS strategies beyond glycemic control.”3 Patients with type • Liraglutide causes dose-dependent and treat- 2 diabetes often present with multiple, related health ment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats concerns. Nearly half of patients with type 2 diabetes are ® above the target A1C of <7% 4 and approximately 85% and mice. It is unknown whether Victoza causes are also classified as obese or overweight.5 In addition, thyroid C-cell tumors, including medullary thyroid studies have shown that adults with type 2 diabetes are carcinoma (MTC), in humans, as the human rele- up to four times more likely to develop cardiovascular vance of liraglutide-induced rodent thyroid C-cell disease, which is the number one leading cause of tumors has not been determined. morbidity and mortality in patients with diabetes.6,7 • Victoza® is contraindicated in patients with a Residual CV risk personal or family history of MTC and in patients Some of the key factors in diabetes care include lifestyle with Multiple Endocrine Neoplasia syndrome type 3 2 (MEN 2). Counsel patients regarding the potential changes, monitoring, glycemic control, and medication . ® The addition of high-dose statins to type 2 diabetes risk for MTC with the use of Victoza and inform care can also reduce the risk of vascular complications.8 them of symptoms of thyroid tumors (eg, a mass However, when patients are treated with the optimal in the neck, dysphagia, dyspnea, persistent hoarse- standards of CV risk reduction and diabetes care, including ness). Routine monitoring of serum calcitonin or intensive therapy and multifactorial management, there using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with is still a residual risk (around 14% with high-dose statin ® treatment) for CVD.9 Victoza . The Treating to New Targets (TNT) study was designed to Indications and Limitations of Use investigate whether the benefits of high-dose intensive Victoza® (liraglutide) injection 1.2 mg or 1.8 mg is indicat- atorvastatin therapy could be achieved in patients ed as an adjunct to diet and exercise to improve glycemic with CHD and diabetes. 1,501 patients with diabetes control in adults with type 2 diabetes mellitus, and to and CHD, with LDL cholesterol levels of <130 mg/dl, reduce the risk of major adverse cardiovascular (CV) events were randomized to double-blind therapy with either (CV death, non-fatal myocardial infarction, or non-fatal atorvastatin 10 (n = 753) or 80 (n = 748) mg/day. While the stroke) in adults with type 2 diabetes mellitus and estab- study did show clinical benefit, even with high-dose statin lished CV disease. treatment 14% of the patients studied experienced CV • Victoza® is not a substitute for insulin and should not be 3,9,10 events. used in patients with type 1 diabetes mellitus or diabetic ketoacidosis. Ultimately, there is a need to consider the residual CV risk • Concurrent use with prandial insulin has not been when treating patients with type 2 diabetes. studied. Warnings and Precautions (cont’d) • Pancreatitis: Acute pancreatitis, including fatal and nonfatal hemorrhagic or necrotizing pancreatitis, has been observed in patients treated with Victoza® post-marketing. Observe patients carefully for signs and symptoms of pancreatitis (persistent severe abdominal pain, sometimes radiating to the back with or without vomiting). If pancreatitis is suspected, discontinue Victoza® promptly and if pancreatitis is confirmed, do not restart. Victoza® has been studied in a limited number of patients with a history of pancreatitis. It is unknown if patients with a history of pancreatitis are at a higher risk for development of pancreatitis on Victoza®. Please see additional Important Safety Information throughout. Please see accompanying Prescribing Information, including Boxed Warning. Victoza® Product Bulletin 3 Clinical Background For patients with type 2 diabetes and established CVD, Mechanism of Action2 Victoza® (liraglutide) injection 1.2 mg or 1.8 mg is a GLP-1 RA Liraglutide is an acylated human Glucagon-Like Peptide-1 therapy approved to improve glycemic control and reduce (GLP-1) receptor agonist with 97% amino acid sequence the risk of major adverse cardiovascular events.2 homology to endogenous human GLP-1(7-37). GLP-1(7-37) represents <20% of total circulating endogenous GLP-1. Victoza® is a glucagon−like peptide−1 (GLP−1) receptor Like GLP-1(7-37), liraglutide activates the GLP-1 receptor, a agonist that can help manage CVD risk for adult patients membrane-bound cell-surface receptor coupled to adenylyl with type 2 diabetes and established CVD. It is indicated cyclase by the stimulatory G-protein, Gs, in pancreatic beta as an adjunct to diet and exercise to improve glycemic cells. Liraglutide increases intracellular cyclic AMP (cAMP) control in adults with type 2 diabetes mellitus, and to leading to insulin release in the presence of elevated reduce the risk of major adverse cardiovascular events glucose concentrations. This insulin secretion subsides (cardiovascular death, non-fatal myocardial infarction, or as blood glucose concentrations decrease and approach non-fatal stroke) in adults with type 2 diabetes mellitus euglycemia. Liraglutide also decreases glucagon secretion and established cardiovascular disease.2 Victoza® is also a in a glucose-dependent manner. The mechanism of blood first-line treatment option. glucose lowering also involves a delay in gastric emptying. Limitations of Use: Common adverse reactions2 • Not for treatment of type 1 diabetes mellitus or diabetic Table 1 shows common adverse reactions, excluding ketoacidosis. hypoglycemia, associated with the use of Victoza®. These • Has not been studied in combination with prandial adverse reactions occurred more commonly with Victoza® insulin. than with placebo and occurred in at least 5% of patients treated with Victoza®. Table 1: Adverse reactions reported in ≥ 5% of Victoza®-treated patients2 Placebo Liraglutide 1.2 mg Liraglutide 1.8 mg N = 661 N = 645 N = 1024 Adverse Reaction (%) (%) (%) Nausea 5 18 20 Diarrhea 4 10 12 Headache 7 11 10 Nasopharyngitis 8 9 10 Vomiting 2 6 9 Decreased appetite 1 10 9 Dyspepsia 1 4 7 Upper Respiratory Tract Infection 6 7 6 Constipation 1 5 5 Back Pain 3 4 5 Important Safety Information (cont’d) Warnings and Precautions (cont’d) • Never Share a Victoza® Pen Between Patients, even • Renal Impairment: Acute renal failure and worsening if the needle is changed. Pen-sharing poses a risk for of chronic renal failure, which may sometimes require transmission of blood-borne pathogens.
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