Long-term Safety and Tolerability of Dasiglucagon, a Stable-in-Solution Glucagon Analog

Jessica Castle1, Mikael Elander2, Sean O’Halloran3 1. Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Sam Jackson Park Road, Portland, OR 97239, USA. 2. Zealand Pharma A/S, Smedeland 36, DK-2600 Glostrup, Copenhagen, Denmark. 3. Covance Laboratories Ltd, Otley Road, Harrogate, North Yorkshire, HG3 1PY, England.

Introduction Findings Discussion of Findings

Several groups are developing fully integrated dual-hormone artificial The principal effect of glucagon is to increase blood glucose through increased Chronic administration of dasiglucagon to rats and dogs was not associated with organ toxicity. The findings pancreas systems, which deliver insulin and glucagon in response to glycogenolysis and gluconeogenesis in the liver. Glucagon also has known physiological are consistent with exaggerated pharmacological effects. changes in glucose to maintain euglycemia. These systems hold the effects on other organ systems (see figure below). All findings in the chronic toxicity potential to transform management of type 1 diabetes, but in order to studies with dasiglucagon can be explained from these physiological effects. Dasiglucagon 1. Diarrhea in dogs - diarrhea is not a prominent finding in humans administered glucagon or dasiglucagon. be realized these systems require a stable-in-solution glucagon analog is therefore considered a specific glucagon receptor (GCGR) agonist with no observed off- 2. Increased heart/kidney weight – caused by increased work load following an increase in heart rate and GFR. suitable for chronic use. Dasiglucagon is a stable glucagon analog target effects. Unlikely to be of clinical relevance at the doses administered with a dual-hormone AP system. comprised of 29 amino acids, with 7 amino acid substitutions 3. Increased glycogen content in the liver – found after administration of glucagon to normoglycemic animals. compared to native glucagon. Dasiglucagon has been specifically Unlikely to be relevant for treatments where the goal is euglycemia. designed to overcome the problems with fibril formation and Freezing absences: a sleep-like state with slow instability in solution seen with marketed glucagon products. movement was noted in rats. Rat specific findings, not relevant for humans ↓ bodyweight gain in dogs (≤30%)1 1. Hyaline droplets in cortical tubules is a male rat specific finding caused by accumulation of α2µ globulin. Aim 2. Chronic progressive nephropathy is a rodent specific age-related finding.

The 26- and 39-week toxicity studies with dasiglucagon were Findings where pathogenesis is unclear 1 conducted to support the chronic use of dasiglucagon including use in ↑ heart weight in rats/dogs (≤ 25%) 1. Freezing absences in rats: Possibly related to nausea seen in humans following glucagon administration. Similar an integrated dual-hormone artificial pancreas system with insulin for ↑ kidney weight in findings were noted for glucagon in a comparative study. rats/dogs (≤ 58%)1 the treatment of type 1 diabetes. ↓ incidence of hyaline 2. Increased incidence of hyaline/granular casts in dogs: exacerbation of a background lesion in dogs possibly droplets in cortical associated with the increased workload caused by increased GFR. Methods tubules of male rats ↑ incidence/severity of Clinical implications Rats and dogs were dosed s.c. daily for 26 and 39 weeks, chronic progressive respectively, in 4 groups of 20 rats with 0 (vehicle), 0.5, 2, or 8 nephropathy in rats The chronic toxicity studies in rats and dogs do not raise any safety concerns for long- ↑ incidence of term clinical use of dasiglucagon. The physiological effects on heart kidney, intestinal mg/kg/day; 4 groups of 4 beagle dogs with 0, 0.02, 0.1, or 0.3 hyaline/granular casts in mg/kg/day. Delayed toxicity and recovery for any findings noted within dogs and liver function can be monitored via standard biomarkers in clinical trials. the treatment period was evaluated following a 4-week treatment-free period in both studies.

Assessment of toxicity was based on clinical observations, food Conclusions consumption, body weight measurements, ophthalmic observations, Diarrhea noted in dogs ECG measurements (dogs only), hematology, clinical chemistry, • Chronic administration of dasiglucagon was well tolerated with exposure at NOAEL exceeding human urinalysis, macroscopic pathology and histopathology. Blood samples exposure (AUC) at the expected maximum daily dose of 0.6 mg/day by 22 and 3 in rats and dogs, were collected for exposure evaluations in Week 1 and Week 39 of the respectively dosing phase and for ADA evaluations in Week 1 and Week 39 of the • All findings were consistent with the known physiological effects of glucagon dosing phase and Week 4 of the recovery phase. Samples for analysis • All findings showed full or partial recovery following a 4-week treatment free period of plasma glucose and insulin concentrations were taken post dose in Week 26/39. • These findings support long-term human testing of dasiglucagon in dual-hormonal artificial pancreas systems

↑ liver weight in rats/dogs (≤ 97%) 1 ↓ plasma cholesterol (≤ 58%)1 , ↑ triglycerides (≤ 207%)1 , ↑ AST (≤ 82%)1 and ↑ ALT (≤ 50%)1 in rats. ↑ plasma cholesterol (≤ 63%)1, ↑ triglycerides (≥ 56%)1 and ↑ ALP (≥230%) 1 in dogs. ↑ accumulation of glycogen in hepatocytes in rats/dogs ↑ plasma glucose and insulin in rats/dogs © Zealand Pharma 2018 1: Change compared to controls