Safety, tolerability, pharmacokinetics, and pharmacodynamics of macimorelin in healthy adults: Results of a single-dose, randomized controlled study

OBJECTIVE

Macimorelin is an orally active ghrelin receptor agonist indicated for the diagnosis of adult growth hormone (GH) deficiency in the United States. This phase 1 study evaluated the safety, tolerability, pharmacokinetics, and pharmacodynamics of single ascending doses of macimorelin (including a supratherapeutic dose to be used in a thorough QT trial) in healthy adults.

DESIGN

Participants were randomized to receive macimorelin 0.5, 1.0, or 2.0 mg/kg or placebo in 1 of 3 sequential ascending-dose cohorts. Blood samples for pharmacokinetic and pharmacodynamic assays were collected pre-dose and at specified time points over a 24-h period. Pharmacokinetic parameters assessed included area under the concentration-time curve (AUC), maximum concentration (C_max) of macimorelin in plasma, time to C_max (t_max), and terminal elimination half-life (t_1/2). Pharmacodynamic assessments evaluated levels of GH, adrenocorticotropic hormone, thyroid-stimulating hormone, cortisol, and prolactin. Safety was assessed based on treatment-emergent adverse events (TEAEs), vital signs, 12‑lead electrocardiograms, and laboratory parameters.

RESULTS

A total of 28 healthy adults were enrolled and completed the study. Macimorelin AUC and C_max showed less than dose-proportional increases following administration of 0.5 and 1.0 mg/kg. Mean t_1/2 was 3.51 h for macimorelin 0.5 and 1.0 mg/kg and 8.29 h for macimorelin 2.0 mg/kg; median t_max occurred at 0.5 to 0.75 h. GH levels increased after dosing, with a t_max of 0.75 h to 1.0 h. Mean GH C_max was similar with the macimorelin 0.5- and 1.0-mg/kg doses (31.9 and 37.8 ng/mL, respectively) and was ~50% lower with macimorelin 2.0 mg/kg (18.4 ng/mL). Transient increases were observed in adrenocorticotropic hormone, cortisol, and prolactin, which were not dose related. A total of 19 TEAEs were reported in 35.7% (10/28) of participants; all TEAEs were mild or moderate and resolved. A total of 12 drug-related TEAEs were reported in 8 participants. Headache was the most common drug-related TEAE. All doses of macimorelin prolonged mean QTcF by 10 to 11 ms. There were no clinically meaningful changes in vital signs or laboratory parameters.

CONCLUSIONS

Single-dose administration of macimorelin 0.5 to 2.0 mg/kg was well tolerated. Macimorelin exposure was less than dose-proportional over the dose range studied. Administration of macimorelin stimulated GH production, with the greatest increases observed in the macimorelin 0.5- and 1.0-mg/kg groups.

Efficacy, Safety, and Mechanistic Insights of Cotadutide, a Dual Receptor Glucagon-Like Peptide-1 and Glucagon Agonist

CONTEXT

Cotadutide is a dual receptor agonist with balanced glucagon-like peptide-1 and glucagon activity.

OBJECTIVE

To evaluate different doses of cotadutide and investigate underlying mechanisms for its glucose-lowering effects.

DESIGN/SETTING

Randomized, double-blind, phase 2a study conducted in 2 cohorts at 5 clinical trial sites.

PATIENTS

Participants were 65 adult overweight/obese patients with type 2 diabetes mellitus; 63 completed the study; 2 were withdrawn due to AEs.

INTERVENTION

Once-daily subcutaneous cotadutide or placebo for 49 days. Doses (50-300 µg) were uptitrated weekly (cohort 1) or biweekly (cohort 2).

MAIN OUTCOME MEASURES

Co-primary end points (cohort 1) were percentage changes from baseline to end of treatment in glucose (area under the curve from 0 to 4 hours [AUC0-4h]) post-mixed-meal tolerance test (MMTT) and weight. Exploratory measures included postprandial insulin and gastric emptying time (GET; cohort 2).

RESULTS

Patients received cotadutide (cohort 1, n = 26; cohort 2, n = 20) or placebo (cohort 1, n = 13; cohort 2, n = 6). Significant reductions were observed with cotadutide vs placebo in glucose AUC0-4h post MMTT (least squares mean [90% CI], -21.52% [-25.68, -17.37] vs 6.32% [0.45, 12.20]; P < 0.001) and body weight (-3.41% [-4.37, -2.44] vs -0.08% [-1.45, 1.28]; P = 0.002). A significant increase in insulin AUC0-4h post MMTT was observed with cotadutide (19.3 mU.h/L [5.9, 32.6]; P = 0.008) and GET was prolonged on day 43 with cotadutide vs placebo (t½: 117.2 minutes vs -42.9 minutes; P = 0.0392).

CONCLUSION

These results suggest that the glucose-lowering effects of cotadutide are mediated by enhanced insulin secretion and delayed gastric emptying.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03244800.

[Study of the quality of codification of diagnoses and procedures under DRG conditions]

A system based on Diagnosis Related Groups was introduced in Germany and is mandatory for hospitals from 2004. Hospitals, health care providers and the Medical Service of Social Security-Health Insurance (MDK) face a common effort. Proper codification of diagnoses and procedures is essential. The Medical Service in the State of Hessen, the Techniker Krankenkasse and the Burgerhospital Frankfurt am Main combined forces to assess codification under the DRG system.

GOALS

The partners cooperated to assess actual codification and to identify starting points for improvement.

METHODS

A random sample was taken from all in-patient cases (all departments) over a 6-month-period (n = 309). Codification or coding was checked according to German Coding Rules (Deutsche Kodierrichtlinien) from the complete hospital records. Different codification, or coding, was discussed between MDK and Hospital doctors.

RESULTS

The actual data revealed overcoding in 34 per cent of diagnoses and in 15 per cent of procedures. Undercoding was present in 9 per cent of diagnoses and in 2 per cent of procedures. The DRG grouping changed in 68 cases (22 per cent) after scrutiny by the Medical Service (MDK). The case-mix index (CMI) calculated from relative weights as coded by the hospital was 0.84. The case-mix index calculated from coding by MDK was 0.81. The CMI calculated from effective weights was 0.77 (hospital) and 0.75 (MDK).

DISCUSSION

Causes of faulty coding and possible remedies are presented.

CONCLUSIONS

Further systematic reviews are required to develop the DRG System and identify faulty trends.

[Vessels of the brachial plexus]

The blood supply of brachial plexus is described by means of lightened injected specimens of older human fetus. The following arteries have direct branches to brachial plexus: the aortic arch/brachiocephalica trunk, subclavia a., thyrocervical trunk, ascending cervical a., transverse cervical a., suprascapular a., and the acromial network. Secondary branches leave them that partly anastomose and also return from distal to proximal. The blood supply is luxurious.

The involution of the ageing human thymic epithelium is independent of puberty. A morphometric study

One hundred and thirty-six thymuses completely removed at autopsy from persons suffering a sudden death were examined by stereological and morphometrical methods. Adding biopsy material from immunologically healthy cardiac patients we obtained relative volumes from 204 persons ranging in age from 1 month to 107 years. The size of the human thymus remains unchanged during ageing under normal physiological conditions (median: 19.5 cm3). Individual maximum size (range: 5-70 cm3) is reached in the first year of life. Early histological changes are in the enlargement of the perivascular space, the Hassall's bodies, and the connective tissue. This begins in the first year of life, reaches a maximum from 10 to 25 years, then declines again. Adipose tissue replaces the lymphocytic perivascular space and the connective tissue only. This occurs extensively after the age of 15 years. When defined by the silver impregnation technique, the volumes of the thymic epithelium (cortex and medulla), show a continuous involution from the first year to the end of life. The curve can be approximated to simple negative logarithmic functions. The velocity and nature of involution of the thymic epithelium do not change under the influence of the changing hormonal balance due to puberty. Since important thymic functions (T lymphopoiesis and T-cell differentiation) are located in the epithelial space, the age-related involution of the human thymus is not related to puberty.

Adherence of mycoplasmas: phenomena and possible role in the pathogenesis of disease

Mycoplasma pneumoniae attaches to a variety of surfaces. Adherence to inert surfaces such as glass requires an intact energy metabolism. Interaction with sheep erythrocytes occurs via a binding protein on the mycoplasma surface. The protein reacts with a receptor containing sialic acid. Adherence to other erythrocytes may involve different mechanisms. Different results have been reported on interaction with tissue cells. The various mechanisms probably cooperate and thereby facilitate the colonization of the human respiratory tract.

Dysuria in women

Only 46% of 84 women with dysuria were found to have significant bacteriuria while 8% had gonorrhea, 1% had herpes progenitalis and 17% had monilia and Trichomonas vaginitis. The remainder were considered to have the urethral syndrome. Neither pyuria, microscopic bacteriuria, nor any single subjective or objective datum definitively predicted cystitis at the initial visit. Therefore, we advise formulating the problem as "dysuria" at the initial evaluation even though one treats with an antimicrobial. The initial workup should include a routine urinalysis, gram stain of the urinary sediment, urine culture, an examination of the urethra and labia as well as a urethral culture. Complete pelvic examination is useful in documenting gonorrhea, herpes progenitalis or vaginitis. If the pelvic examination is deferred and the initial urine culture is negative, reevaluation of the dysuria should include a pelvic examination.