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Effects of Lixisenatide Versus Liraglutide (Short- and Long-Acting

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Effects of Lixisenatide Versus Liraglutide (Short- and Long-Acting EMERGING THERAPIES: DRUGS AND REGIMENS Diabetes Care Volume 43, September 2020 2137 Daniel R. Quast,1 Nina Schenker,1 Effects of Lixisenatide Versus Bjorn¨ A. Menge,1 Michael A. Nauck,1 Liraglutide (Short- and Long- Christoph Kapitza,2 and Juris J. Meier1 Acting GLP-1 Receptor Agonists) on Esophageal and Gastric Function in Patients With Type 2 Diabetes Diabetes Care 2020;43:2137–2145 | https://doi.org/10.2337/dc20-0720 OBJECTIVE Short-acting glucagon-like peptide 1 receptor agonists (GLP-1 RAs) decelerate gastric emptying more than long-acting GLP-1 RAs. Delayed gastric emptying is a risk factor for gastroesophageal reflux disease. We aimed to measure esophageal reflux and function as well as gastric emptying and acid secretion during treatment with short-acting (lixisenatide) and long-acting (liraglutide) GLP-1 RAs. RESEARCH DESIGN AND METHODS A total of 57 subjects with type 2 diabetes were randomized to a 10-week treatment with lixisenatide or liraglutide. Changes from baseline in the number of reflux episodes during 24-h pH registration in the lower esophagus, lower esophagus sphincter pressure, gastric emptying (13C-sodium octanoate acid breath test), and gastric acid secretion (13C-calcium carbonate breath test) were analyzed. RESULTS Gastric emptying half-time was delayed by 52 min (D 95% CI 16, 88) with lixisenatide 1Diabetes Division, Department of Medicine I, St (P 5 0.0065) and by 25 min (3, 46) with liraglutide (P 5 0.025). There was no Josef-Hospital Bochum, Ruhr-University Bochum, Bochum, Germany difference in the number of reflux episodes (mean 6 SEM 33.7 6 4.1 vs. 40.1 6 5.3 2Profil, Neuss, Germany P 5 for lixisenatide and liraglutide, respectively, 0.17) or the extent of gastro- Corresponding author: Juris J. Meier, juris.meier@ esophageal reflux (DeMeester score) (35.1 6 6.7 vs. 39.7 6 7.5, P 5 0.61), with ruhr-uni-bochum.de similar results for the individual GLP-1 RAs. No significant changes from baseline in Received 2 April 2020 and accepted 9 June 2020 other parameters of esophageal motility and lower esophageal sphincter function Clinical trial reg. no. NCT02231658, clinicaltrials were observed. Gastric acidity decreased significantly by 220.7% (240.6, 20.8) .gov (P 5 0.042) with the GLP-1 RAs. This article contains supplementary material on- line at https://doi.org/10.2337/figshare.12490601. CONCLUSIONS © 2020 by the American Diabetes Association. Lixisenatide exerted a more pronounced influence on gastric emptying after Readers may use this article as long as the work is breakfast than liraglutide. Neither lixisenatide nor liraglutide had significant effects properly cited, the use is educational and not for profit, and the work is not altered. More infor- on esophageal reflux or motility. Gastric acid secretion appears to be slightly mation is available at https://www.diabetesjournals reduced by GLP-1 RAs. .org/content/license. 2138 Reflux and GI Motility in GLP-1 RAs Diabetes Care Volume 43, September 2020 Glucagon-like peptide 1 receptor ago- (16). However, the effect of GLP-1 RA to be measured in the current study (in- nists (GLP-1 RAs) can be categorized into treatment on gastroesophageal reflux cluding history of GERD or overt gastro- long-acting (e.g., liraglutide, exenatide and esophageal motility has not yet paresis), as judged by the investigator. once weekly, dulaglutide, albiglutide, been determined. Furthermore,clinically relevant impairment semaglutide) and short-acting (e.g., ex- Therefore, in the current study the of hepatic, renal, or cardiac function as enatide b.i.d. [unretarded], lixisenatide) effects of a short- and a long-acting GLP-1 indicated by alanine aminotransferase, bil- compounds (1). Both subclasses of GLP-1 RA (lixisenatide and liraglutide, respec- irubin, and/or alkaline phosphatase greater RAs differ markedly from each other tively) on gastroesophageal reflux, esoph- than threefold the upper limit of normal at with respect to their pharmacokinetic ageal motility, gastric emptying, and gastric screening, estimated glomerular filtration and pharmacodynamic properties (2,3). acid secretion were compared over 10 rate ,60 mL/min/1.73 m2 (estimate ac- Mainly, short-acting GLP-1 RAs lead to weeks of treatment. cording to the MDRD study equation) at short-lived peaks of drug concentrations screening, clinically relevant electrocardio- after subcutaneous injection, the dura- RESEARCH DESIGN AND METHODS gram findings, or symptoms of heart failure tion of which are several hours, with Study Design (New York Heart Association class III–IV) as ensuing troughs with near-zero drug The current study was a randomized, judged by the investigator were defined as concentrations (4). Long-acting GLP-1 bicentric, investigator-blinded, parallel- exclusion criteria. Smokers or participants RAs provide circulating drug concentra- group study in subjects with type 2 di- not able or willing to refrain from smoking tions that are constantly elevated, with abetes. The study was performed at the were not included. minor fluctuations over a 24-h or 7-day Diabetes Division, St Josef-Hospital, and period (5,6). Consequently, premeal ad- at Profil. Informed consent was obtained Safety Assessment ministration of short-acting GLP-1 RAs from all participants. Patients were ran- Monitoring of adverse events included elicits a significant delay of gastric emp- domized using the program RANCODE symptomatic and severe hypoglycemic tying even after prolonged treatment Professional 3.6 (idv Datenanalyse & episodes and gastrointestinal disorders periods (weeks/months), thereby pri- Versuchsplanung, Gauting, Germany). using a structured questionnaire that marily reducing postprandial glucose el- The randomization and blinding process will be published separately. Laboratory evations (7). In contrast, long-acting GLP-1 is described in detail in Supplementary monitoring included pancreatic, renal, RAs initially delay gastric emptying, but Material. The study was approved by the and hepatic parameters. Laboratory anal- their pharmacokinetic profile leads to ethics committee of Ruhr-University Bo- ysis was performed at MLM Medical desensitization for this effect over a pe- chum (registration no. 14-5177 FF), and Laboratories Moenchengladbach GmbH riod of weeks to months, known as investigations were carried out in accor- and the laboratory of St Josef-Hospital. tachyphylaxis (8). Therefore, during lon- dance with the principles of the Decla- Study Procedures ger-term treatment, long-acting GLP-1 ration of Helsinki as revised in 2008. RAs influence postprandial glucose rises Screening Visit predominantly by their effects on insulin Study Population At a screening visit, participants had their and glucagon secretion and have greater The study included male and female medical history taken and underwent a effects on fasting plasma glucose due to patients aged 18–70 years with a range clinical examination. In addition, the fol- greater exposure during the night hours of BMI of 18–40 kg/m2 (inclusive) who lowing anthropometric variables were as- (7). Earlier studies with acute intrave- had been diagnosed with type 2 diabetes sessed: age, height, weight, heart rate, nous infusion of native human GLP-1 for at least 3 months. Treatment with a blood pressure, and waist and hip circum- have also indicated an inhibition of gas- stable regimen of metformin and/or a ference. Venous blood samples were tric acid secretion, but whether this is sulfonylurea or metformin plus thiazoli- taken in the fasting state for the measure- also the case with GLP-1 RAs has not yet dinedione for at least 1 month or treat- ment of standard hematological and clin- been determined (9). ment with a stable regimen of insulin ical chemistry variables. Delayed gastric emptying and gastric with or without additional oral antidia- Interventions distension are well-established risk fac- betes drug treatment (metformin, sulfo- After screening, participants were ran- tors in the pathophysiology of gastro- nylureas, thiazolidinediones) for at least domized to receive either lixisenatide or esophageal reflux disease (GERD) (10). 1 month was obligatory. liraglutide. Participants randomized to Thus, delayed gastric emptying may tem- Exclusion criteria included contraindi- lixisenatide were administered 10 mg porarily increase the intragastric content cations (including known or suspected once daily for 1 week, followed by a of both solids and acidic liquids, thereby hypersensitivity) to GLP-1 RAs, current 20-mg once-daily maintenance dose for increasing the likelihood of reflux into the use of GLP-1 RAs or inhibitors of dipep- the remainder of the trial. Participants lower esophagus (11). Several studies tidyl-peptidase 4, intake of medication randomized to receive liraglutide were have reported higher frequencies of that may influence gastric acid secretion administered 0.6 mg once daily for week GERD symptoms in people with type 2 or gastrointestinal motility, decompen- oneafter initiation and 1.2 mg once daily diabetes (12–14). So far, little informa- sated glycemic control (HbA1c $10%), for week two, followed by 1.8 mg once tion is available on the effects of GLP-1 preexisting significant concomitant dis- daily for the remaining period of the RAs on the incidence of GERD (15). eases (except those typically associated trial. In both groups, the GLP-1 RA was Treatment with GLP-1 RAs may theoret- with type 2 diabetes, e.g., arterial hyper- administered 30 min before breakfast. ically further increase the incidence of tension, dyslipidemia), or prominent dia- Subjectswereaskedtoattendtheclin- gastroesophageal reflux in these patients betes complications affecting parameters ical unit in the morning in the fasting care.diabetesjournals.org Quast and Associates 2139 condition (only still water was allowed test (13C-CC-BT) has been designed to for Windows (GraphPad Software, San after 8:00 P.M. the evening before the estimate gastric acid secretion in a non- Diego, CA) (www.graphpad.com), and Sta- visit) for screening and all other exper- invasive manner (23). Study medication tistica (data analysis software system), imental visits. was injected 1 h before ingestion of the version 13.5 for Windows (TIBCO Soft- ; Experimental Visits tracer.
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