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Sokolov V, Yakovleva T, Penland RC, Boulton DW, Tang W. Effectiveness of dapagliflozin as an insulin adjunct in type 1 diabetes: a semi-mechanistic exposure-response model. Front Pharmacol 2023; 14:1229255. [PMID: 37954838 PMCID: PMC10634426 DOI: 10.3389/fphar.2023.1229255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/04/2023] [Indexed: 11/14/2023] Open
Abstract
Introduction: Dapagliflozin-induced improvement of glycemic control in patients with inadequately controlled type 1 diabetes (T1D) is complicated by the delicate balance between blood glucose and exogenous insulin. In this work, we developed a semi-mechanistic population exposure-response model using pooled patient-level data to characterize the joint effect of dapagliflozin and insulin on average daily glucose concentrations and glycated hemoglobin (HbA1c) levels in patients with T1D. Methods: A non-linear mixed-effects model was developed in Monolix (Lixoft, France) and R software (R Project, www.r-project.org) using pooled patient-level data from phase 2 and phase 3 trials (NCT01498185, NCT02460978, NCT02268214). Results: Because of the apparent lack of association between bolus insulin dose and glucose concentrations measured by continuous glucose monitoring the model was able to capture the quantitative link between basal, but not bolus, insulin dose and plasma glucose. Even so, this association remained flat, with a 50% decrease in the basal insulin dose from pretreatment level, resulting in ∼5% increase in glucose exposure. Therefore, dapagliflozin efficacy was not significantly affected by the insulin dose adjustment, with 24-week HbA1c reduction on 10-mg dapagliflozin treatment changing from -0.5 [95% CI: -0.55, -0.45] to -0.42 [95%CI: -0.48, -0.36] after adjustment. At the same time, the analysis revealed ∼2-fold steeper slope of glucose-HbA1c relationship in dapagliflozin-treated patients vs. control group, suggesting the presence of additional dapagliflozin treatment-related benefits, not explained by the dapagliflozin-mediated ∼4% increase in plasma hemoglobin levels. Finally, the efficacy of 5 and 10-mg doses, represented by the mean HbA1c reduction at week 24 of dapagliflozin treatment, was shown to be notably greater than the 1- and 2.5-mg doses. Discussion: This research is an attempt to deconvolute and reconstruct dapagliflozin-HbA1c dose-response relationship in T1D by accounting for the drug's action on both daily insulin dose and plasma glucose on a subject-level. While the model is able to adequately capture the observed data, it also revealed that the variability in CGM is poorly approximated by the variability in insulin dose alone. Furthermore, the slope of CGM/HbA1c relationship may differ depending on the population and treatment scenarios. As such, a deeper dive into the physiological mechanisms is required to better quantify the intricate network of glycemic response under dapagliflozin treatment.
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Affiliation(s)
- Victor Sokolov
- M&S Decisions LLC, Moscow, Russia
- STU “Sirius”, Sochi, Russia
| | | | - Robert C. Penland
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Waltham, MA, United States
| | - David W. Boulton
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, MD, United States
| | - Weifeng Tang
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, MD, United States
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Barton-Maxwell V. A Case Report of LADA in the Primary Care Setting. J Nurse Pract 2023. [DOI: 10.1016/j.nurpra.2023.104539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Hossain MF, Khan NA, Rahman A, Chowdhury MFI, Bari S, Khan MA, Masud UW, Zakia UB, Paul SP, Tasnim N. Empagliflozin Ameliorates Progression From Prediabetes to Diabetes and Improves Hepatic Lipid Metabolism: A Systematic Review. Cureus 2022; 14:e28367. [PMID: 36168335 PMCID: PMC9506669 DOI: 10.7759/cureus.28367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 11/05/2022] Open
Abstract
Diabetes mellitus (DM) and hepatic steatosis are two of the most common metabolic syndromes that affect the health of people globally. Empagliflozin (EMPA) is a promising drug of choice for the diabetic population. Recent studies have shown its beneficial effects not only on diabetic patients but also on patients suffering from cardiac, hepatic, neurological, or pancreatic anomalies. In this paper, we systematically searched electronic databases to compile literature that focuses on EMPA’s effect on the prediabetic population, diabetic population, and hepatic lipid metabolism. We focus on the mechanism of EMPA, specifically by which it increases insulin sensitivity and fat browning and reduces fat accumulation. Overall, we hypothesized that by its effect on weight loss and reducing inflammatory markers and insulin resistance (IR), EMPA decreases the rate of prediabetes to diabetes conversion. We concluded that by improving hepatic and serum triglyceride, decreasing visceral fat, and its positive impact on hepatic steatosis, the drug improves hepatic lipid metabolism. Further research should be done on this matter.
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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.
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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.)
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Buzzetti R, Tuomi T, Mauricio D, Pietropaolo M, Zhou Z, Pozzilli P, Leslie RD. Management of Latent Autoimmune Diabetes in Adults: A Consensus Statement From an International Expert Panel. Diabetes 2020; 69:2037-2047. [PMID: 32847960 PMCID: PMC7809717 DOI: 10.2337/dbi20-0017] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/09/2020] [Indexed: 02/07/2023]
Abstract
A substantial proportion of patients with adult-onset diabetes share features of both type 1 diabetes (T1D) and type 2 diabetes (T2D). These individuals, at diagnosis, clinically resemble T2D patients by not requiring insulin treatment, yet they have immunogenetic markers associated with T1D. Such a slowly evolving form of autoimmune diabetes, described as latent autoimmune diabetes of adults (LADA), accounts for 2-12% of all patients with adult-onset diabetes, though they show considerable variability according to their demographics and mode of ascertainment. While therapeutic strategies aim for metabolic control and preservation of residual insulin secretory capacity, endotype heterogeneity within LADA implies a personalized approach to treatment. Faced with a paucity of large-scale clinical trials in LADA, an expert panel reviewed data and delineated one therapeutic approach. Building on the 2020 American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) consensus for T2D and heterogeneity within autoimmune diabetes, we propose "deviations" for LADA from those guidelines. Within LADA, C-peptide values, proxy for β-cell function, drive therapeutic decisions. Three broad categories of random C-peptide levels were introduced by the panel: 1) C-peptide levels <0.3 nmol/L: a multiple-insulin regimen recommended as for T1D; 2) C-peptide values ≥0.3 and ≤0.7 nmol/L: defined by the panel as a "gray area" in which a modified ADA/EASD algorithm for T2D is recommended; consider insulin in combination with other therapies to modulate β-cell failure and limit diabetic complications; 3) C-peptide values >0.7 nmol/L: suggests a modified ADA/EASD algorithm as for T2D but allowing for the potentially progressive nature of LADA by monitoring C-peptide to adjust treatment. The panel concluded by advising general screening for LADA in newly diagnosed non-insulin-requiring diabetes and, importantly, that large randomized clinical trials are warranted.
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Affiliation(s)
- Raffaella Buzzetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Tiinamaija Tuomi
- Division of Endocrinology, Abdominal Center, Helsinki University Hospital, Institute for Molecular Medicine Finland FIMM and Research Program for Clinical and Molecular Metabolism, University of Helsinki, and Folkhälsan Research Center, Helsinki, Finland
- Lund University Diabetes Center, University of Lund, Malmo, Sweden
| | - Didac Mauricio
- Department of Endocrinology & Nutrition, CIBERDEM, Hospital de la Santa Creu i Sant Pau & Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Autonomous University of Barcelona, Barcelona, Spain
| | - Massimo Pietropaolo
- Division of Endocrinology, Diabetes and Metabolism, Diabetes Research Center, Baylor College of Medicine, Houston, TX
| | - Zhiguang Zhou
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University and Key Laboratory of Diabetes Immunology, Central South University, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Changsha, Hunan, China
| | - Paolo Pozzilli
- Unit of Endocrinology and Diabetes, Department of Medicine, Campus Bio-Medico University, Rome, Italy
- Blizard Institute, Barts and The London School of Medicine and Dentistry, University of London, London, U.K
| | - Richard David Leslie
- Blizard Institute, Barts and The London School of Medicine and Dentistry, University of London, London, U.K.
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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.
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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
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