What’s New on the Horizon: Outline of Talk Diabetes Medication Update „ Newly released and upcoming medications: the incretins, DPP-IV inhibitors, and what’s coming „ Revised ADA/EASD and AACE guidelines: focus on potency , safety , cost „ Update on insulin therapeutic regimens: self- titration regimens and creative simplified bolus mealtime dosing

Michael Shannon, MD Providence Endocrinology, Olympia WA

The Diabetes Toolbox 2010 What’s New and What’s Coming

Drug Class (First in Class) FDA Approval „ Incretins: GLP-1 agonists and analogs Insulin 1922 (first use) „ Incretins: DPP-IV inhibitors Sulfonylurea (chlorpropamide) 1958 „ Bile acid sequestrants: colesevelam Biguanides (metformin) 1995 „ Sodium-Glucose Transport Proteins-2 (SGLT- Alpha-glucosidase inhibitor (acarbose) 1995 2) inhibitors: Dapagliflozin Thiazolidinedione (troglitazone) 1997 Meglitinide (repaglinide) 1997 Incretins (exenatide) 2005 DPP-IV Inhibitors (sitagliptin) 2006

Glucagon-Like Peptide-1 GLP-1 Agonists and DPP-IV Inhibitors

„ Glucagon-like peptide-1 is an incretin, a gut Intestinal Mixed GLP-1 hormone that increases the release of insulin Meal Release „ Many effects of GLP-1: Active GLP-1 „ Increases i nsuli n sensiti vit y „ Inhibits glucagon release DPP4 „ Inhibits gastric emptying t1/2 = 1-2 min Rapid Inactivation „ Increases satiety and decreases food intake „ Native GLP-1 improves glucose control but Inactive the short half-life limits its use (needs pump) GLPGLP--11

1 GLP-1 Agonists and Analogs GLP-1 Inhibitors: Exenatide

„ Exenatide: GLP-1 receptor agonist (BID) „ Modification of GLP-1 to prevent degrading „ Liraglutide: GLP-1 analog (QD) „ Modest benefit in HbA1c 0.7-1.1% „ Under development: „ Significant nausea (52% vs 8% for insulin) and „ Once-weekly exenatide long-acting release (LAR) emesis; RJ Hei ne et al , A nn Int Med 200 5 „ Taspoglutide „ Some weight loss as well (see further slide) „ Lixisenatide „ Significant heterogeneity in response in „ Others in various stages clinical experience (some all-stars, some fail) „ Safety warnings about pancreatitis, kidneys

Liraglutide GLP-1 Inhibitors: Exenatide LAR

„ Approved January 2010; once-daily injection „ Sustained release form of exenatide that will „ Associated with similar modest decrease in likely be given once-weekly HbA1c of 0.7% - 1.1% with slightly more „ Similar A1c benefit to twice-daily exenatide reduction in one trial (LEAD-6) and similar weight reduction with somewhat „ Less renal limitations than exenatide less nausea (26% vs 50%) „ Possible association with pancreatitis and there „ Device not finalized; path to approval not yet is suggestion of rare thyroid tumors in rats so clear special warnings for medullary thyroid cancer

DPP-IV Inhibitors Colesevelam

„ Sitagliptin (Januvia) and saxagliptin (Onglyza) „ Bile acid sequestrant, initially approved to lower „ Associated with modest decrease in HbA1c of LDL cholesterol; trade name Welchol 0.6% - 0.8%; can be dosed with ESRD „ Approved for DM2 in 2008; modest efficacy of „ Miiinimal sid e eff ects ( possibl e more mi nor 040.4-05%0.5% infections) „ Previously required a large number of pills, now „ Both are pregnancy Category B – unclear why approved in powdered suspension „ Minimal long-term safety data – possible off- „ Modest efficacy, probably best suited for target interactions with diverse DPP-IV targets patients needing small LDL and A1c reductions

2 SGLT-2 Inhibitors Final Thoughts on New Therapies

„ Sodium-glucose cotransporter-2 is a protein that „ None of these have been in wide use for long aids in glucose reabsorption from the kidney „ Lessons of rosiglitazone: hemoglobin A1c is „ Inhibition of this protein leads to increased a surroggpate endpoint, not the true g oal of care glucosuria – in early studies appears to reduce A1c and body weight, with possible side effect „ None of these have any microvascular or of increased UTIs and yeast infections macrovascular endpoints (trials underway) „ All of these drugs cost upwards of $6/day „ Several in development (dapagliflozin, remogliflozin, sergliflozin), none near release „ Hence their place in ADA/EASD paradigm

ADA/EASD DM2 Algorithm ADA/EASD DM2 Algorithm

Tier 1: Well validated core therapies „ Updated in 2009 based on clinical trials and collective Lifestyle + Metformin Lifestyle + Metformin clinical judgment and experience of authors At diagnosis: + + Basal insulin Intensive insulin „ Evaluates glucose reductions, non-glycemic effects Lifestyle + Lifestyle + Metformin that could reduce diabetic complications, safety, Metformin + Sulfonylurea tol erabilit y, ease of use, and cost of each i nt erventi on STEP 1 STEP 2 STEP 3 Tier 2: Less well validated therapies „ Provides treatment algorithm with intervention tiers Lifestyle + Metformin Lifestyle + Metformin + + Pioglitazone Pioglitazone + Sulfonylurea

Lifestyle + Metformin + Lifestyle + Metformin GLP-1 agonist + Basal insulin

DM Nathan et al, Diabetes Care 2009 DM Nathan et al, Diabetes Care 2009

Diabetes Interventions by Tiers Comments on Treatment Choices

„ Tier 1 Interventions (‘well-validated core’) „ Tier 2 options may be considered when weight loss is Lifestyle changes with diet and exercise (1.0-2.0)* major goal (exenatide) or when hypoglycemia is Metformin (1.0-2.0) major concern (pioglitazone and exenatide, not rosi) Insulin (1.5-3.5) „ α-Glucosidase inhibitors, glinides, pramlintide, and Sulfonylureas (1. 0-20)2.0) DPP-4 inhibitors appropriate for selected patients „ Tier 2 Interventions (‘less well-validated’ core) Thiazolidinediones (pioglitazone) (0.5-1.4) „ Starting or intensifying insulin preferred to third oral GLP-1 agonists (exenatide) (0.5-1.0) „ Algorithm is cautious in use of newer treatments „ Others (less A1c lowering, less evidence, or costlier): α-Glucosidase inhibitors (0.5-0.8), Glinides (0.5-1.5) Pramlintide (0.5-1.0), DPP-IV inhibitors (0.5-0.8)

DM Nathan et al, Diabetes Care 2009 DM Nathan et al, Diabetes Care 2009

3 A Broader Toolbox Doesn’t Improve AACE Algorithm All Outcomes „ Released by American Association of Clinical Endocrinologists in October 2009 „ Diabetes is a progressive disease „ Stated by AACE to include a variety of choices „ More choices can decrease ability to based on first -line, second-line, and third -line int ensif y care (SS I yengar, 2000) therapies as well as secondary factors (weight, risk of hypoglycemia) „ Use algorithms as a guideline (joint ADA-EASD consensus statement) „ Emphasizes wider choices „ Ends up somewhat overwhelming algorithm „ Individual patients may have specific needs that require tailoring algorithms

HW Rodbard et al, Endocrine Practice 2009

Diabetes Toolbox: A Critical Look Indications for Insulin Therapy Drug Class A1C% Cost/Mo Sulfonylureas (glimepiride, etc) 1.2-2.0 4-12 „ Severe hyperglycemia at diagnosis or at a Metformin 1.2-2.0 4-12 later point despite aggressive treatment Thiazolidediones (pio 45 qday) 080.8-141.4 245 „ To meet ggylycemic goals - hyperg ly caemia despite maximum doses of oral agents GLP-1 agonist (exenatide 10 bid) 0.8-1.2 271 „ Decompensation of other organ systems that DPP-IV (sitagliptin 100 qday) 0.6-0.8 193 limits use of other oral agents Human Insulin No limit ~25 „ Early cost-effective potent treatment Insulin Analogs (vials) No limit ~80 Insulin Analogs (pens) No limit ~100 Drugstore.com

Creative Regimens for Insulin Basal Insulin Self-Titration

„ Empowering through „ Clinical trial data suggests that patients can basal self-titration self-titrate once-daily basal insulin with regimens excellent success (compared with clinicians) „ Customizing meal „ Lowering fasting glucose dosing based on „ Lowering hemoglobin A1c patient real-world „ Minimal hypoglycemia visualization, “the „ This is seen both with basal insulin glargine sandwich rule” and detemir in published clinical trials

4 Simpler Bolus Meal Dosing Conclusion

„ Not every patient has to move to carb counting „ There are interesting new therapies available „ For Olympia, “carb counting for loggers” and on the horizon, but all still have limited „ 5 units for meal less than a sandwich long-term safety and hard endpoint data „ 10 units for a sandwich-sized meal „ The new ADA/EASD guid eli nes support fi rst - „ 15 units for more than a sandwich line use of metformin and then either „ Can substitute burrito or Hawaiian lunch plate sulfonylureas or basal insulin „ This is not full carbohydrate counting, but „ Creative approaches with self-titration basal leads patient to grasp insulin-food connection regimens and mealtime dosing can be designed

Questions and Appreciation

Thanks to Mindy Nichols and WADE for the opportunity to speak today

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