1
|
Jiang X, Yu KS, Nam DH, Oh J. A Population Pharmacokinetic Study to Compare a Novel Empagliflozin L-Proline Formulation with Its Conventional Formulation in Healthy Subjects. Pharmaceuticals (Basel) 2024; 17:522. [PMID: 38675482 PMCID: PMC11054906 DOI: 10.3390/ph17040522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/06/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
Empagliflozin is a sodium-glucose cotransporter 2 (SGLT2) inhibitor that is commonly used for the treatment of type 2 diabetes mellitus (T2DM). CKD-370 was newly developed as a cocrystal formulation of empagliflozin with co-former L-proline, which has been confirmed to be bioequivalent in South Korea. This study aimed to quantify the differences in the absorption phase and pharmacokinetic (PK) parameters of two empagliflozin formulations in healthy subjects by using population PK analysis. The plasma concentration data of empagliflozin were obtained from two randomized, open-label, crossover, phase 1 clinical studies in healthy Korean subjects after a single-dose administration. A population PK model was constructed by using a nonlinear mixed-effects (NLME) approach (Monolix Suite 2021R1). Interindividual variability (IIV) and interoccasion variability (IOV) were investigated. The final model was evaluated by goodness-of-fit (GOF) diagnostic plots, visual predictive checks (VPCs), prediction errors, and bootstrapping. The PK of empagliflozin was adequately described with a two-compartment combined transit compartment model with first-order absorption and elimination. Log-transformed body weight significantly influenced systemic clearance (CL) and the volume of distribution in the peripheral compartment (V2) of empagliflozin. GOF plots, VPCs, prediction errors, and the bootstrapping of the final model suggested that the proposed model was adequate and robust, with good precision at different dose strengths. The cocrystal form did not affect the absorption phase of the drug, and the PK parameters were not affected by the different treatments.
Collapse
Affiliation(s)
- Xu Jiang
- Department of Pharmacology, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea;
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, College of Medicine, Seoul National University and Hospital, Seoul 03080, Republic of Korea;
- Department of Biomedical Sciences, College of Medicine, Seoul National University, Seoul 03080, Republic of Korea
| | - Dong Hyuk Nam
- Department of Chemical Research Laboratory, Chong Kun Dang Research Institute, Chong Kun Dang Pharmaceutical Corporation, Yongin 16995, Republic of Korea;
| | - Jaeseong Oh
- Department of Pharmacology, College of Medicine, Jeju National University, Jeju 63243, Republic of Korea
- Clinical Research Institute, Jeju National University Hospital, Jeju 63243, Republic of Korea
| |
Collapse
|
2
|
Yao X, Zhou J, Song L, Ren Y, Hu P, Liu D. A model-based meta analysis study of sodium glucose co-transporter-2 inhibitors. CPT Pharmacometrics Syst Pharmacol 2023; 12:487-499. [PMID: 36890732 PMCID: PMC10088079 DOI: 10.1002/psp4.12934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/31/2022] [Accepted: 01/26/2023] [Indexed: 03/10/2023] Open
Abstract
Type 2 diabetes mellitus (T2DM) agent sodium-glucose co-transporter 2 (SGLT2) inhibitors show special benefits in reducing body weight and heart failure risks. To accelerate clinical development for novel SGLT2 inhibitors, a quantitative relationship among pharmacokinetics, pharmacodynamics, and disease end points (PK/PD/end points) in healthy subjects and patients with T2DM was developed. PK/PD/end point data in published clinical studies for three globally marketed SGLT2 inhibitors (dapagliflozin, canagliflozin, and empagliflozin) were collected according to pre-set criteria. Overall, 80 papers with 880 PK, 27 PD, 848 fasting plasma glucose (FPG), and 1219 hemoglobin A1c (HbA1c) data were collected. A two-compartmental model with Hill's equation was utilized to capture PK/PD profiles. A novel translational biomarker, the change of urine glucose excretion (UGE) from baseline normalized by FPG (ΔUGEc ) was identified to bridge healthy subjects and patients with T2DM with different disease statuses. ΔUGEc was found to have a similar maximum increase with different half-maximal effective concentration values of 56.6, 2310, and 841 mg/mL·h for dapagliflozin, canagliflozin, and empagliflozin respectively. ΔUGEc will change FPG based on linear function. HbA1c profiles were captured by indirect response model. Additional placebo effect was also considered for both end points. The PK/ΔUGEc /FPG/HbA1c relationship was validated internally using diagnostic plots and visual assessment and further validated externally using the fourth globally approved same-in-class drug (ertugliflozin). This validated quantitative PK/PD/end point relationship offers novel insight into long-term efficacy prediction for SGLT2 inhibitors. The novelty identified ΔUGEc could make the comparison of different SGLT2 inhibitors' efficacy characteristics easier, and achieve early prediction from healthy subjects to patients.
Collapse
Affiliation(s)
- Xueting Yao
- Drug Clinical Trial Center, Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing, China.,Center of Clinical Medical Research, Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing, China
| | - Jiawei Zhou
- Division of Pharmacotherapy and Experimental Therapeutics, School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ling Song
- Drug Clinical Trial Center, Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing, China.,Center of Clinical Medical Research, Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing, China
| | - Yupeng Ren
- Johnson & Johnson Pharmaceuticals (Shanghai) Ltd., Shanghai, China
| | - Pei Hu
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital & Chinese Academy of Medical Sciences, Beijing, China
| | - Dongyang Liu
- Drug Clinical Trial Center, Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing, China.,Center of Clinical Medical Research, Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing, China
| |
Collapse
|
3
|
Rao L, Ren C, Luo S, Huang C, Li X. Sodium-glucose cotransporter 2 inhibitors as an add-on therapy to insulin for type 1 diabetes mellitus: Meta-analysis of randomized controlled trials. Acta Diabetol 2021; 58:869-880. [PMID: 33651228 PMCID: PMC8187227 DOI: 10.1007/s00592-021-01686-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
AIMS The aim was to systematically review the efficacy and safety of sodium-glucose cotransporter inhibitor (SGLT2i) as an adjunct to insulin at different follow-up durations in randomized, double-blind clinical trials in patients with type 1 diabetes. METHODS We conducted a search on Medline, Embase, and the Cochrane Library for relevant studies published before May 2020. According to the duration of follow-up, the subgroup analysis included four periods: 1-4, 12-18, 24-26, and 52 weeks. In the five trials included both 24-26 and 52 weeks of follow-up, we compared the efficacy by the placebo-subtracted difference and changes in SGLT2i groups. RESULTS Fifteen trials including 7109 participants were analyzed. The combination of SGLT2i and insulin improved hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), daily insulin dose, body weight, and blood pressure, which varied greatly by different follow-ups. Compared with %HbA1c at 24-26 weeks, placebo-subtracted differences and changes in the SGLT2i groups slightly increased. SGLT2i plus insulin treatment showed no difference in the occurrence of urinary tract infections (UTIs), hypoglycemia, or severe hypoglycemia but increased the risk of genital tract infections (GTIs) in a duration-dependent manner. SGLT2i treatment was associated with a significantly higher rate of ketone-related SAEs and diabetic ketoacidosis (DKA) at 52 weeks. CONCLUSION SGLT2i as an add-on therapy to insulin improved glycemic control and body weight and decreased the required dose of insulin without increasing the risk of hypoglycemia. However, after 6 months the benefits of SGLT2is on glycemic control may weaken and the risks of GTIs and DKA increased.
Collapse
Affiliation(s)
- Lunwen Rao
- Huangdu Community Health Service Center, Jiading District, Anting TownShanghai, China
| | - Chenhong Ren
- Postgraduate Training Basement of Jinzhou Medical University, Taihe Hospital, Hubei University of Medical, Shiyan, China
- Department of Endocrinology, Taihe Hospital, Hubei University of Medical, Shiyan, 442000, China
| | - Shan Luo
- Department of Endocrinology, Taihe Hospital, Hubei University of Medical, Shiyan, 442000, China
| | - Chenghu Huang
- Department of Endocrinology, The People's Hospital of Bishan District, Bishan, Chongqing, 402760, China.
| | - Xuefeng Li
- Department of Endocrinology, Taihe Hospital, Hubei University of Medical, Shiyan, 442000, China.
| |
Collapse
|
4
|
Johnston CK, Eudy-Byrne RJ, Elmokadem A, Nock V, Marquard J, Soleymanlou N, Riggs MM, Liesenfeld KH. A Model-Informed Drug Development (MIDD) Approach for a Low Dose of Empagliflozin in Patients with Type 1 Diabetes. Pharmaceutics 2021; 13:pharmaceutics13040485. [PMID: 33918261 PMCID: PMC8066500 DOI: 10.3390/pharmaceutics13040485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 11/16/2022] Open
Abstract
In clinical trials, sodium-glucose co-transporter (SGLT) inhibitor use as adjunct to insulin therapy in type 1 diabetes (T1D) provides glucometabolic benefits while diabetic ketoacidosis risk is increased. The SGLT2 inhibitor empagliflozin was evaluated in two phase III trials: EASE-2 and EASE-3. A low, 2.5-mg dose was included in EASE-3 only. As the efficacy of higher empagliflozin doses (i.e., 10 and 25 mg) in T1D has been established in EASE-2 and EASE-3, a modeling and simulation approach was used to generate additional supportive evidence on efficacy for the 2.5-mg dose. We present the methodology behind the development and validation of two modeling and simulation frameworks: M-EASE-1, a semi-mechanistic model integrating information on insulin, glucose, and glycated hemoglobin; and M-EASE-2, a descriptive model informed by prior information. Both models were developed independently of data from EASE-3. Simulations based on these models assessed efficacy in untested clinical trial scenarios. In this manner, the models provide supportive evidence for efficacy of low-dose empagliflozin 2.5 mg in patients with T1D, illustrating how pharmacometric analyses can support efficacy assessments in the context of limited data.
Collapse
Affiliation(s)
- Curtis K. Johnston
- Metrum Research Group, Tariffville, CT 06081, USA; (C.K.J.); (R.J.E.-B.); (A.E.); (M.M.R.)
| | - Rena J. Eudy-Byrne
- Metrum Research Group, Tariffville, CT 06081, USA; (C.K.J.); (R.J.E.-B.); (A.E.); (M.M.R.)
| | - Ahmed Elmokadem
- Metrum Research Group, Tariffville, CT 06081, USA; (C.K.J.); (R.J.E.-B.); (A.E.); (M.M.R.)
| | - Valerie Nock
- Boehringer Ingelheim International GmbH, 55216 Ingelheim, Germany;
| | - Jan Marquard
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT 06877, USA; (J.M.); (N.S.)
| | - Nima Soleymanlou
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT 06877, USA; (J.M.); (N.S.)
| | - Matthew M. Riggs
- Metrum Research Group, Tariffville, CT 06081, USA; (C.K.J.); (R.J.E.-B.); (A.E.); (M.M.R.)
| | | |
Collapse
|
5
|
Saha S, Saha S. The comparison of efficacy and safety between different doses of empagliflozin in insulin-treated type 1 diabetes mellitus patients: a systematic review and meta-analysis protocol. J Diabetes Metab Disord 2020; 19:545-550. [PMID: 32550206 PMCID: PMC7270238 DOI: 10.1007/s40200-020-00544-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The proposed review aims to compare the efficacy and safety profile of empagliflozin 25 mg with its lower dosages and placebo, respectively, in insulin-treated type 1 diabetes mellitus (T1DM) patients. METHODS Double-blinded randomized controlled trials comparing the above outcomes will be searched primarily in three electronic databases (PubMed, Embase, and Scopus) and eligible trials will be included in the proposed review. Then, from the trials recruited in the review, data of the study design, participants, interventions compared, and outcomes of interest will be extracted. Subsequently, the trials' risk of bias will be assessed using the Cochrane Collaboration's tool. The meta-analysis will be conducted with a fixed-effect or a random-effect model to estimate the mean differences (weighted or standardized) and risk ratios for the efficacy and safety-related comparable outcome data, respectively. Statistical heterogeneity will be assessed by the p-value of chi-squared statistics and I2 statistics and explained by subgroup analysis and meta-regression. Publication bias will be assessed by funnel plots and Egger's test. The sensitivity analysis will repeat the meta-analysis for respective outcomes using assumptions alternative to that used in the preliminary meta-analysis and by dropping each study at a time. RESULTS A narrative reporting will ensue if a meta-analytic comparison is not possible. CONCLUSIONS Based on the contemporary literature, the proposed review will synthesize the evidence on how the efficacy and safety profile of high dose empagliflozin varies with its lower doses and placebo, respectively, in insulin-treated T1DM patients.
Collapse
Affiliation(s)
- Sumanta Saha
- National Institute for Research in Tuberculosis, Chennai, India
| | | |
Collapse
|
6
|
Perkins BA, Soleymanlou N, Rosenstock J, Skyler JS, Laffel LM, Liesenfeld K, Neubacher D, Riggs MM, Johnston CK, Eudy‐Byrne RJ, Elmokadem A, George JT, Marquard J, Nock V. Low-dose empagliflozin as adjunct-to-insulin therapy in type 1 diabetes: A valid modelling and simulation analysis to confirm efficacy. Diabetes Obes Metab 2020; 22:427-433. [PMID: 31858718 PMCID: PMC7064984 DOI: 10.1111/dom.13945] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/06/2019] [Accepted: 12/16/2019] [Indexed: 12/15/2022]
Abstract
AIM To confirm the observed reduction in HbA1c for the 2.5 mg dose in EASE-3 by modelling and simulation analyses. MATERIALS AND METHODS Independent of data from EASE-3 that tested 2.5 mg, we simulated the effect of a 2.5 mg dose through patient-level, exposure-response modelling in the EASE-2 clinical study. A primary semi-mechanistic model evaluated efficacy considering clinical insulin dose adjustments made after treatment initiation that potentially limited HbA1c reductions. The model was informed by pharmacokinetic, insulin dose, mean daily glucose and HbA1c data, and was verified by comparing the simulations with the observed HbA1c change in EASE-3. One of two empagliflozin phase 3 trials in type 1 diabetes (EASE-3 but not EASE-2) included a lower 2.5 mg dose. A placebo-corrected HbA1c reduction of 0.28% was demonstrated without the increased risk of diabetic ketoacidosis observed at higher doses (10 mg and 25 mg). Since only one trial included the lower dose, we aimed to confirm the observed reduction in HbA1c for the 2.5 mg dose by modelling and simulation analyses. RESULTS The simulated 26-week mean HbA1c change was -0.41% without insulin dose adjustment and -0.29% at 26 weeks with insulin dose adjustment. A simplified (descriptive) model excluding insulin dose and mean daily glucose confirmed the -0.29% HbA1c change that would have been observed had the EASE-2 population received a 2.5 mg dose for 26/52 weeks. CONCLUSIONS The HbA1c benefit of low-dose empagliflozin directly observed in the EASE-3 trial was confirmed by two modelling and simulation approaches.
Collapse
Affiliation(s)
- Bruce A. Perkins
- Lunenfeld‐Tanenbaum Research InstituteMount Sinai Hospital, TorontoOntarioCanada
- Division of Endocrinology and MetabolismUniversity of TorontoTorontoONCanada
| | | | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical CityDallasTexasUnited States
| | - Jay S. Skyler
- Diabetes Research InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUnited States
| | - Lori M. Laffel
- Joslin Diabetes CenterHarvard Medical SchoolBostonMassachusettsUnited States
| | | | | | | | | | | | | | | | - Jan Marquard
- Boehringer Ingelheim International GmbHIngelheimGermany
| | - Valerie Nock
- Boehringer Ingelheim Pharma GmbH & Co KGBiberachGermany
| |
Collapse
|
7
|
Rosenstock J, Marquard J, Laffel LM, Neubacher D, Kaspers S, Cherney DZ, Zinman B, Skyler JS, George J, Soleymanlou N, Perkins BA. Empagliflozin as Adjunctive to Insulin Therapy in Type 1 Diabetes: The EASE Trials. Diabetes Care 2018; 41:2560-2569. [PMID: 30287422 DOI: 10.2337/dc18-1749] [Citation(s) in RCA: 210] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/20/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the safety and efficacy of empagliflozin 10- and 25-mg doses plus a unique lower dose (2.5 mg) as adjunct to intensified insulin in patients with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS The EASE (Empagliflozin as Adjunctive to inSulin thErapy) program (N = 1,707) included two double-blind, placebo-controlled phase 3 trials: EASE-2 with empagliflozin 10 mg (n = 243), 25 mg (n = 244), and placebo (n = 243), 52-week treatment; and EASE-3 with empagliflozin 2.5 mg (n = 241), 10 mg (n = 248), 25 mg (n = 245), and placebo (n = 241), 26-week treatment. Together they evaluated empagliflozin 10 mg and 25 mg, doses currently approved in treatment of type 2 diabetes, and additionally 2.5 mg on 26-week change in glycated hemoglobin (primary end point) and weight, glucose time-in-range (>70 to ≤180 mg/dL), insulin dose, blood pressure, and hypoglycemia. RESULTS The observed largest mean placebo-subtracted glycated hemoglobin reductions were -0.28% (95% CI -0.42, -0.15) for 2.5 mg, -0.54% (-0.65, -0.42) for 10 mg, and -0.53% (-0.65, -0.42) for 25 mg (all P < 0.0001). Empagliflozin 2.5/10/25 mg doses, respectively, reduced mean weight by -1.8/-3.0/-3.4 kg (all P < 0.0001); increased glucose time-in-range by +1.0/+2.9/+3.1 h/day (P < 0.0001 for 10 and 25 mg); lowered total daily insulin dose by -6.4/-13.3/-12.7% (all P < 0.0001); and decreased systolic blood pressure by -2.1/-3.9/-3.7 mmHg (all P < 0.05). Genital infections occurred more frequently on empagliflozin. Adjudicated diabetic ketoacidosis occurred more with empagliflozin 10 mg (4.3%) and 25 mg (3.3%) but was comparable between empagliflozin 2.5 mg (0.8%) and placebo (1.2%). Severe hypoglycemia was rare and frequency was similar between empagliflozin and placebo. CONCLUSIONS Empagliflozin improved glycemic control and weight in T1D without increasing hypoglycemia. Ketoacidosis rate was comparable between empagliflozin 2.5 mg and placebo but increased with 10 mg and 25 mg. Ketone monitoring for early ketoacidosis detection and intervention and lower empagliflozin doses may help to reduce this risk.
Collapse
Affiliation(s)
| | - Jan Marquard
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Lori M Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Dietmar Neubacher
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Stefan Kaspers
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - David Z Cherney
- Division of Nephrology, Department of Medicine, and Department of Physiology, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, and Division of Endocrinology and Metabolism, University of Toronto, Toronto, Canada
| | - Jay S Skyler
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Jyothis George
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, and Division of Endocrinology and Metabolism, University of Toronto, Toronto, Canada
| |
Collapse
|
8
|
Ellenbroek JH, Arioglu Inan E, Michel MC. A systematic review of urinary bladder hypertrophy in experimental diabetes: Part 2. Comparison of animal models and functional consequences. Neurourol Urodyn 2018; 37:2346-2360. [DOI: 10.1002/nau.23786] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/03/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Johanne H. Ellenbroek
- Department of Internal Medicine; Leiden University Medical Centre; Leiden The Netherlands
| | | | - Martin C. Michel
- Department of Pharmacology; Johannes Gutenberg University; Mainz Germany
| |
Collapse
|