Sibeprenlimab, which neutralizes a PRoliferation inducing ligand (APRIL), as a new approach to treating IgA nephropathy

INTRODUCTION

Immunoglobulin A (IgA) nephropathy is a common immune-mediated kidney disease leading to high blood pressure and may progress to kidney failure. None of the present treatments are disease-modifying or prolong life. The levels of A Proliferation Inducing Ligand (APRIL) are raised in subjects with IgA nephropathy. Sibeprenlimab is a humanized IgG2 monoclonal antibody that binds to, and neutralizes, APRIL.

AREAS COVERED

A phase 2 clinical trial of intravenous sibeprenlimab (VIS649) in IgA nephropathy: NCT04287985. The primary efficacy endpoint was the change from baseline in 24-h protein-to-creatinine ratio at 12 months, and this was reduced by sibeprenlimab. Sibeprenlimab also caused clinical remission in some subjects, stabilized estimated glomerular filtration rate (eGFR), and reduced galactose deficient IgA1, IgA, IgM, and IgG levels without causing any infections or other adverse events.

EXPERT OPINION

Sibeprenlimab is a promising new approach to treating IgA nephropathy. The pharmaceutical company behind sibeprenlimab is also developing it for subcutaneous use, which would have advantages over intravenous use. As IgA nephropathy is a long-term progressive disease, key questions that need to be answered, over a long-time course, with sibeprenlimab are (i) whether its safety is maintained, and (ii) whether it improves clinical outcomes.

More failure with solanezumab - this time in preclinical Alzheimer's disease

INTRODUCTION

There is no cure for Alzheimer's disease, which is the sixth leading cause of death in the U.S.A.. Lecanemab is anti-Aβ monoclonal antibody approved for the treatment of early Alzheimer's disease but is only marginally effective. Other antibodies are being developed including solanezumab.

AREAS COVERED

A phase 3 clinical trial of solanezumab in preclinical Alzheimer's disease. In the A4 study, solanezumab did not reduce the decline in cognition or function and had no effect on brain amyloid burden.

EXPERT OPINION

After the poor results in the EXPEDITION series of trials, the development of solanezumab should have been terminated. The rationale for undertaking the A4 trial was questionable, and the lack of benefit was probable. The controversial approval of two anti-Aβ monoclonal antibodies (aducanumab, lecanemab) for the treatment of Alzheimer's disease by the US Food and Drug Administration (FDA), despite a high incidence of amyloid-related imagining abnormalities (ARIA), may be fueling this continuation of clinical development of agents such as solanezumab. The lesson from the A4 trial is that more careful/realistic consideration needs to be given before embarking on further phase 3 trials with anti-Aβ monoclonal antibodies.

Bempedoic acid as treatment for subjects at cardiovascular risk who are statin-intolerant

INTRODUCTION

Atherosclerotic cardiovascular disease is the leading cause of death globally. LDL cholesterol is a key risk factor for cardiovascular disease.  The most common group of medicines for lowering LDL cholesterol are the statins, as they reduce the risk of cardiovascular events.  However, some subjects are statin-intolerant and remain at high risk.

AREAS COVERED

CLEAR Outcomes; a phase 3 clinical trial of bempedoic acid, an ATP citrate lyase (ACL) inhibitor, in subjects who do not tolerate statins or are unable to take the recommended dose. It enrolled subjects with prior cardiovascular events (secondary prevention) and at high risk (primary prevention). The primary endpoint was a composite of major adverse cardiovascular events, and this occurred in less subjects in the bempedoic acid than the placebo group.

EXPERT OPINION

Bempedoic acid is suitable for use as monotherapy in the prevention of cardiovascular events in statin intolerant subjects, and it has a good safety profile in most subjects.However, the effects of bempedoic acid in lowering LDL cholesterol and cardiovascular events are modest.  This suggests that more benefits may ensue ifbempedoic acid was used in combination with other lipid lowering agents to cause larger decreases in LDL cholesterol.

Continuous subcutaneous levodopa-carbidopa for the treatment of advanced Parkinson's disease: is it an improvement on other delivery?

INTRODUCTION

Parkinson's disease (PD) is the second most common neurodegenerative disease and is growing in prevalence and disability. The standard treatment for PD is oral levo-dopa (LD) with carbidopa (CD). As PD progresses, despite higher doses of LD/CD, plasma levels of LD fluctuate, and may be associated with motor fluctuations and dyskinesia.

AREAS COVERED

The development of two new subcutaneous preparations of LD/CD (ND0612 and ABBV-951) for the treatment of motor fluctuations in PD is described in detail. Both reduce motor fluctuations and dyskinesia with minor infusion site adverse events. A third subcutaneous preparation, DIZ102, is in early-stage development.

EXPERT OPINION

The premise for using continuous release LD in advanced PD is that steady state levels of LD will prevent motor fluctuations/dyskinesia, but this is not the whole story, and will limit the benefits of subcutaneous continuous release LD. With its present pump system ND0612 cannot be used as monotherapy, whereas ABBV-951 can be. Having to combine with oral LD/CD will complicate the use of ND0612. Both ND0612 and ABBV-951 only cause modest reductions in OFF time. It is not clear whether these subcutaneous preparations will have more benefits than the intestinal gel, which also reduces OFF time and dyskinesia.

Retatrutide showing promise in obesity (and type 2 diabetes)

INTRODUCTION

Obesity is a major risk factor for cardiovascular disease, diabetes, osteoarthritis, and some cancers. Retatrutide stimulates Glucagon-like peptide 1 (GLP-1), Glucose-dependent insulinotropic polypeptide (GIP) receptors, and glucagon receptors, and is being developed for the treatment of obesity and type 2 diabetes.

AREAS COVERED

A phase 2 clinical trial of retatrutide (LY3437943) in the treatment of obesity. The primary end point was percentage change in weight from baseline to 24 weeks, which ranged from -7.2% to -~18% as the dose of retatrutide increased from 1 mg to 12 mg. The most frequent adverse events were gastrointestinal (nausea, diarrhea, vomiting).

EXPERT OPINION

The results for retatrutide in phase 2 for obesity (and diabetes) are mostly encouraging. Consistent with being a GLP-1 receptor agonist, heart rate was increased by up to 6.7 beats/min by retatrutide, which may be detrimental and offset some of the benefits of weight loss. Presumably, retatrutide is being developed as a challenger to the recently developed weight loss medicines; semaglutide and/or tirzepatide. Thus, comparator studies are needed between retatrutide and these drugs, but none are ongoing and, in my opinion, this lack is a major omission in the development of retatrutide.

Is sotatercept, which traps activins and growth differentiation factors, a new dawn in treating pulmonary arterial hypertension (PAH)?

INTRODUCTION

Although the prevalence of pulmonary arterial hypertension (PAH) is low, mortality is high. In PAH, there is a down-regulation of the bone morphogenic protein receptor type 2 (BMPR2) pathway leading to a prominence of the up-regulation pathway that is mediated by activins growth differentiation factors acting at the receptor type IIA (ActRIIA). Sotatercept is an ActRIIA fusion protein. STELLAR was a phase 3 study of sotatercept for the treatment of PAH.

AREAS COVERED

STELLAR. The primary endpoint of STELLAR was change from baseline at 24 weeks in the 6-minute walking distance, which was increased by 34.4 meters by sotatercept, compared to one meter in the placebo group. Epistaxis/nosebleed, telangiectasia, and dizziness were more common with sotatercept than placebo.

EXPERT OPINION

By targeting the remodeling in PAH, sotatercept is providing a new approach to the treatment of PAH and has potential to slow or reverse cardiovascular remodeling in other conditions e.g. left heart failure. However, the development of sotatercept for the treatment of PAH still requires consideration of the appropriate dose, and longer-term assessment of the benefits and safety. If sotatercept becomes available for self-administration, it will be of interest, to assess whether this affects adherence and benefits.

Follow-up descriptive study of how proportioning marks between coursework and examination affects the performance of students in nursing

BACKGROUND

There has been little attention to how the allocation of marks affects the academic performance of students in courses. Our previous study showed that students in nursing had much lower marks in exams than coursework (tutorials and case study) in a pharmacology course. It is not known whether this applies to nursing students in other courses and/or with different types of coursework. The purpose of this study was to analyse how the allocation of marks to examination and different coursework affected the performance of students in nursing in a bioscience course.

METHODS

For the 379 completing students in a nursing degree undertaking a first-year first semester bioscience course, a descriptive study was undertaken of (i) the marks for the exam and two coursework components (individually undertaken laboratory skills, and a team/group project on health communication), with the marks being compared by Students t-test, (ii) any association between these marks was determined by regression line analysis, and (iii) modelling was undertaken to determine the effects of changing the allocation of marks on passing and failing rates.

RESULTS

Students in nursing who completed a bioscience course had much lower marks in the exam than the coursework. Regression line analysis of the marks in the exam versus combined coursework showed (a) a poor line fit and (b) the correlation coefficient was moderate (r = 0.51), for the individual laboratory skills vs. exam was moderate (r = 0.49), but only weak for the group project on health communication vs. exam (r = 0.25). A high percentage of students passed the course (97%). Modelling showed that increasing the marks for the exam decreased the number of students passing the course to as few as 57%.

CONCLUSIONS

The allocation of marks determines the percentage of students in nursing who pass courses, regardless of the type of coursework. The students in nursing in the bioscience course, who pass the course based on marks from coursework, but not the examination component, may not have the necessary knowledge to continue their program of study. Thus, requiring students in nursing to pass exams should be given further consideration.

Is retatrutide (LY3437943), a GLP-1, GIP, and glucagon receptor agonist a step forward in the treatment of diabetes and obesity?

INTRODUCTION

Despite there being a wide range of medicines available for the treatment of type 2 diabetes, the high rate of mortality, suggests treatment needs to be improved. Only a few medicines have shown long-term effectiveness in obesity, and new medicines are urgently needed.

AREAS COVERED

A multiple-ascending dose phase 1b clinical trial of a new drug retatrutide (LY3437943), which in addition to stimulating Glucagon-like peptide 1 (GLP-1) and Glucose-dependent insulinotropic polypeptide (GIP) receptors, stimulates glucagon receptors, in subjects with type 2 diabetes. Retatrutide was relatively safe and pharmacokinetics support once-weekly dosing.

EXPERT OPINION

The role of stimulating glucagon receptors in the treatment of type 2 diabetes and/or obesity is poorly defined and needs to be clarified. Although retatrutide may be superior to the GLP-1 receptor agonist dulaglutide in reducing plasma glucose and body weight, this is not a meaningful comparison, as another GLP-1 receptor agonist (semaglutide) is more potent than dulaglutide at this and may have similar efficacy to retatrutide. Retatrutide also needs to be compared to another Eli Lilly and Company drug, the combined GLP-1 and GIP receptor agonist, tirzepatide. The safety of retatrutide needs to be determined in larger and longer trials.

A new role for an old drug: acetazolamide in decompensated heart failure

INTRODUCTION

Mortality from heart failure remains high. Many subjects who have been hospitalized with acute decompensated heart failure leave hospital with residual congestion, despite treatment with loop diuretics. In an attempt to improve this, the Acetazolamide in Decompensated heart failure with Volume OveRload (ADVOR) trial was undertaken, where acetazolamide was added to the loop diuretic bumetanide.

AREAS COVERED

This article discusses ADVOR. The primary endpoint of ADVOR was the reversal of congestion, which was increased by adding acetazolamide to bumetanide. However, acetazolamide did not shorten hospital stay or the composite of rehospitalisation and death after three months.

EXPERT OPINION

The limitations of ADVOR include that acetazolamide did not improve quality of life and that the testing was in white subjects only. During the hospital stay for decompensation, medicines that inhibit the angiotensin and mineralocorticoid systems were increased, which suggests that the treatment for heart failure was not ideal on hospitalization. As the death rates in ADVOR were lower than in previous studies, this suggests that the overall treatment of decompensated/heart failure is improving. However, in the author's opinion, although the addition of acetazolamide is a small improvement in the treatment of acute decompensated heart failure with volume overload, more options need to be considered.

Are there advantages of daprodustat over erythropoiesis-stimulating agents (ESAs) in treating anemia associated with chronic kidney disease (CKD)?

Anemia is common in CKD and increases the risk of developing heart disease. Although ESAs relieve the symptoms of anemia, they have adverse effects and do not reduce the adverse outcomes associated with anemia. This evaluation is of the phase 3 ASCEND clinical trials of the hypoxia-inducible factor (HIF) prolyl hydroxylase inhibitor daprodustat versus ESAs in subjects with CKD undergoing dialysis or not. Daprodustat was non-inferior to ESAs in increasing hemoglobin, and in the incidence of cardiovascular events and adverse effects. Daprodustat is effective in subjects who are hyporesponsive to ESAs, and this is one circumstance when daprodustat may be preferred to ESAs. However, to become a widely used medicine in subjects with CKD responsive to ESAs, daprodustat needs to be well tolerated, used by a high percentage of subjects over a long time, and be superior to ESAs in improving clinical outcomes. As this may not be the case, there is not a strong basis for recommending daprodustat over ESAs. The other 'dustats' (roxadustat, vadadustat) have also not been shown to be superior to the ESAs, and none have been approved by the FDA to date.

Adding liraglutide to diet and exercise to maintain weight loss - is it worth it?

INTRODUCTION

Obesity is a major risk factor for cardiovascular disease, diabetes, osteoarthritis, and some cancers. Weight loss is an obvious management for this, but a major problem is that after weight loss, many people regain weight.

AREAS COVERED

In the following evaluation of S-LITE (NCT04122716, Combined effects of GLP-1 analogue and exercise on maintenance of weight loss after very-low calorie diet), the author gives emphasis to the prevention of weight regain by liraglutide, not the effects of exercise. In S-LITE, liraglutide (with or without exercise) was effective in reducing weight regain in subjects with obesity.

EXPERT OPINION

The subjects with obesity in S-LITE were limited by the enrollment criteria, and the findings of S-LITE cannot be generalized. The increased heart rate with liraglutide did not occur when liraglutide was combined with exercise, and this suggests that liraglutide should probably not be used alone, but only with exercise to maintain weight loss. As the only presently available medicine to have been shown to be effective against weight regain, liraglutide should probably be preferred to other weight-loss medicines in this circumstance. However, without clear evidence that liraglutide treatment for obesity prevents diabetes and/or reduces cardiovascular risk, it is difficult to justify using it.

Quantitative study of lecture attendance and the association between this attendance and academic outcomes for nursing and nonnursing students in an introductory pathophysiology course

Since the availability of lecture recordings, there have been limited studies of any associations between face-to-face lecture attendance and academic outcomes. The aims of the study, in an introductory pathophysiology course, where lecture recordings were available, were 1) to quantify lecture attendance and any associations between academic outcomes and lecture attendance, and 2) to determine why students do or do not attend lectures. Data were analyzed for the whole cohort before separating the nursing (∼60%) and nonnursing students. Of 288 enrolled students, 205 consented to sign the attendance register, and 139 to undertake the online survey. Lecture attendance was higher (41%) before the midsemester exam than afterwards (24%), P < 0.001, due to higher attendance by the nursing than nonnursing students. Students who attended ≥50% of lectures consistently got higher academic outcomes than those that attended <50%, e.g., examinations, 11 percent points higher. Pearson's or Spearman's correlation coefficients for students from both the sign-in and survey showed that there were positive associations between lecture attendance and academic outcomes, which were mainly weak for nursing students (P ≤ 0.05), with no association for nonnursing students. From the survey, most students who attended lectures did so because they considered they learned more by attending lectures, whereas not liking the lecture time was the most common reason for not attending lectures. In conclusion, even though students have access to lecture recordings, lecture attendance is still a determinant of academic outcomes for some students of pathophysiology.

Do we need bamlanivimab? Is etesevimab a key to treating Covid-19?

Introduction

Treatments for subjects with Covid-19 are required. One approach is neutralizing monoclonal antibodies. Bamlanivimab and etesevimab are monoclonal antibodies to SARS-CoV-2.

Areas Covered

This evaluation is of the phase 3 BLAZE-1 clinical trial, which was of bamlanivimab plus etesevimab in adult ambulatory participants with a risk factor for, and mild to moderate, Covid-19 illness. The primary outcome was Covid 19 related hospitalization of ≥ 24 hours or death from any cause by day 29, and this occurred in 2.1% subjects in the bamlanivimab/etesevimab group, compared to 7.0% in the placebo group.

Expert Opinion

In the pandemic, the attempts by the FDA to shorten approval processes for medicines and by journals to make information available in a timely manner are admirable. However, these shortened processes made negotiating the details of BLAZE-1 and producing accurate and critical appraisals difficult. It seems to me that if there are any benefits of bamlanivimab alone in Covid-19, they are not clear-cut. Bamlanivimab has limited effects against the beta and gamma variants and is not effective against the delta variant. Thus, the benefits of bamlanivimab/etesevimab in the phase 3 of the BLAZE-1 may be solely due to etesevimab, and this needs to be tested.

Still grasping at straws: donanemab in Alzheimer's disease

INTRODUCTION

Alzheimer's disease is the leading cause of disability and poor health, takes a huge emotional and financial burden on family caregivers, and is costly. Donanemab (LY3002813) is a new monoclonal antibody that uniquely targets Aβ(p3-42), a pyroglutamate form of Amyloid-β (Aβ) exclusively found in plaques.

AREAS COVERED

The phase 2 trial of donanemab in participants with early symptomatic Alzheimer's disease, TRAILBLAZER-ALZ. Donanemab reduced cerebral plaque but not tau load and only marginally improved the primary outcome of cognition and activities of daily living (p = 0.04) without altering individual measures of these.

EXPERT OPINION

In TRAILBLAZER-ALZ, anticholinesterase use was given at the beginning but not the end of the trial, and thus, it is not known whether changes in this or other medicines were involved in the outcome with donanemab. Tau load (measured with flortuacipir PET) may be a biomarker of cognition but was not altered by donanemab. As there is no clear evidence that removing cerebral amyloid plaques with Aβ antibodies, such as donanemab, improves cognition and the activities of daily living in Alzheimer's disease, clinical trials with these agents should be abandoned, and more time and money should spend on further investigating the underlying cause of Alzheimer's disease.

Finerenone - are we there yet with a non-steroidal mineralocorticoid receptor antagonist for the treatment of diabetic chronic kidney disease?

Introduction: Chronic kidney disease occurs in 40% of subjects with diabetes and increases the risk of cardiovascular death three-fold, compared to having diabetes alone. The non-steroidal mineralocorticoid receptor antagonist finerenone protects against chronic kidney disease in animal models.Areas covered: This evaluation is of a phase 3 trial of finerenone; Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (FIDELIO-DKD). In FIDELIO-DKD, finerenone reduced the primary composite outcome of kidney failure, a sustained decrease of at least 40% in eGFR over four weeks, or death from renal causes, from 21.1% to 17.8%, with a good safety profile.Expert opinion: Finerenone is an effective mineralocorticoid receptor antagonist for the treatment of diabetic chronic kidney disease. Recently, glucagon-like peptide 1 (GLP-1) receptor agonists and sodium-glucose cotransporters 2 (SGLT-2) inhibitors have been added to the list of medicines for use in subjects with this condition. Although finerenone has a different mechanism of action to these medicines, it will need to be tested and shown to be effective in presence of these medicines in diabetic kidney disease, prior to widespread use.

Will evinacumab become the standard treatment for homozygous familial hypercholesterolemia?

Introduction: Homozygous Familial Hypercholesterolemia (HoFH) is a very severe genetic form of hypercholesterolemia. Lacking LDL receptors in the liver, subjects with HoFH have raised plasma levels of LDL cholesterol, and up to 100 times higher risk of premature atherosclerotic cardiovascular disease than the general population.Areas covered: This evaluation is of a phase 3 trial of evinacumab; Evinacumab Lipid Studies in Patients with Homozygous Familial Hypercholesterolemia (ELIPSE HoFH). Evinacumab is a human monoclonal antibody inhibitor of angiopoietin-like protein 3 (ANGPTL3). In ELIPSE HoFH, evinacumab reduced LDL cholesterol by 47.1 ± 4.6%, HDL cholesterol by 30.4%, and triglycerides by 50.4 ± 7.7%.Expert opinion: Evinacumab is not the ideal treatment for HoFH as it does not reduce LDL cholesterol levels to treatment targets while increasing HDL cholesterol. Although the incidence of adverse effects with evinacumab was low in ELIPSE HoFH, further studies are necessary to clarify its effects on liver enzymes and clinical cardiovascular outcomes. Evinacumab is a candidate to become the standard treatment for HoFH, as it may be better tolerated and/or more efficacious than the presently available specific treatment (lomitapide). However, the widespread use of evinacumab to treat high triglycerides or LDL cholesterol is unlikely due to evinacumab decreasing HDL cholesterol.

Remdesivir, a remedy or a ripple in severe COVID-19?

Introduction

In clinical trial for the Ebola virus, the broad-spectrum anti-viral agent remdesivir was shown to have a good safety profile. Remdesivir is now being tested in severe COVID-19.

Areas covered

The Gilead Sciences SIMPLE trial suggests that the short-term use of remdesivir probably does not increase mortality dramatically or have serious short-term toxicity when used to treat severe COVID-19. The Adaptive COVID-19 treatment trials (ACTT1) trial showed that remdesivir may shorten recovery and decrease mortality in severe COVID-19 without increasing adverse effects.

Expert opinion

It seems to me that we have learnt very little from the SIMPLE trial, and this would be predicted from a trial that has no control or placebo group. The results of ACTT1 were reported early after an interim analysis showed that a higher than expected number of recoveries had occurred. There was an indication that remdesivir may be reducing mortality, but this was no statistical significance. The trial is continuing, and the final data are eagerly awaited to determine whether remdesivir is a game-changing remedy or a ripple in the ongoing search for a medicine for the treatment of COVID-19.

Does lopinavir measure up in the treatment of COVID-19?

Introduction

Lopinavir in combination with ritonavir is approved for the treatment of HIV and has recently been subject to a clinical trial in severe COVID-19.

Areas covered

This evaluation is of LOTUS China (the Lopinavir Trial for Suppression of SARS-Cov-2 in China), which was a randomized trial in hospitalized subjects with COVID-9 in a respiratory sample and pneumonia. As, in severe COVID-19, lopinavir/ritonavir had no beneficial effects but increased gastrointestinal adverse effects, this combination should not be used at this stage of COVID-19.

Expert opinion

In my opinion, the rationale for undertaking a trial of lopinavir/ritonavir in COVID-19 was poor. The analysis of a modified intention to treat group analysis in LOTUS China may have introduced bias. After LOTUS China, there is probably no future for lopinavir in the treatment of severe COVID-19, but some clinical trials for prevention or in various stages of COVID-19 have recently started or are ongoing. The major limitation of these trials is that as lopinavir does not inhibit COVID-19, it is unlikely to prevent infection, reduce viral load, or reduce the severity. However, these trials may be worthwhile in finally determining whether lopinavir has any role in preventing or treating COVID-19.

Grasping at straws: the failure of solanezumab to modify mild Alzheimer's disease

INTRODUCTION

The amyloid-beta (Aβ) cascade hypothesis is that reducing Aβ levels in the brain will be beneficial in the treatment of Alzheimer's disease. Solanezumab is a humanized analog of a murine antibody that selectively targets the central domain of the soluble form of Aβ. In the EXPEDITION 1 and 2 Phase 3 clinical trials, solanezumab was shown to be ineffective in subjects with mild-to-moderate Alzheimer's disease, and to have no effect on brain Aβ burden. Areas covered: This evaluation considers the secondary analysis of (EXPEDITION 1 and 2), which led to the EXPEDITION 3 trial of solanezumab in subjects with mild Alzheimer's disease, and the results of EXPEDITION 3. Expert opinion: The secondary analysis of EXPEDITION 1 and 2 was limited to mild Alzheimer's disease, and showed improvements on some scales, but not others. This analysis did not report data on Aβ burden. In my opinion, this was a questionable basis to undertake a further phase trial with solanezumab. The EXPEDITION 3 trial of solanezumab in subjects with mild Alzheimer's disease was terminated early for ineffectiveness. With hindsight, solanezumab should have been discontinued after EXPEDITION 1 and 2, especially as it had not been shown to reduce Aβ burden.

Do glucagon-like peptide-1 receptor (GLP-1R) agonists have potential as adjuncts in the treatment of type 1 diabetes?

INTRODUCTION

Glucagon-like peptide-1 (GLP-1) is produced by the gut, stimulates insulin secretion from the pancreatic β-cells, and inhibits glucagon secretion from the α-cells. The GLP-1 receptor (GLP-1R) agonists are used in the treatment of type 2 diabetes (T2DM).

AREAS COVERED

This review covers the clinical trials of the GLP-1R agonists (exenatide and liraglutide) and their potential as adjunct treatment in type 1 diabetes mellitus (T1DM).

EXPERT OPINION

GLP-1R agonists are unable to increase insulin secretion, in subjects with T1DM, who are C-peptide negative. Also, the GLP-1R agonists either have no effect or cause a small inhibition of glucagon secretion in subjects with T1DM. There is no evidence that the GLP-1R agonists cause a major reduction in HbA1c, or have a major effect on hypo- or hyperglycemia in subjects with TD1M. The main beneficial effect of the GLP-1R agonists is probably the modest weight loss, which may underlie the reduction in dose of insulin used. Given that the GLP-1R agonists cause gastrointestinal adverse effects, and with reduced insulin doses, increase the risk of ketosis, it seems to me that the risk with these agents may outweigh any benefit in T1DM, and that they have little potential as adjuncts in the treatment of T1DM.

What have we learnt from the clinical outcomes trials with the cetrapibs?

PURPOSE OF REVIEW

The current review considers what we have learnt from the clinical outcome trials with the cetrapibs; the inhibitors of cholesteryl ester transfer protein that increase HDL cholesterol levels; torcetrapib, dalcetrapib, evacetrapib and anacetrapib.

RECENT FINDINGS

Although an off-target increase in blood pressure may have contributed to the failure of torcetrapib in Investigation of Lipid Level Management to Understand its Impact in Atherosclerotics Events, recent evidence shows that torcetrapib also increased atherogenic apoproteins, and this may have contributed to its failure. Evacetrapib and anacetrapib also increase atherogenic apoproteins. This may have contributed to lack of effect of evacetrapib in Assessment of Clinical Effects of Cholesteryl Ester Transfer Protein Inhibition with Evacetrapib in Patients at a High Risk for Vascular Outcomes. The success of anacetrapib in Randomized Evaluation of the Effects of Anacetrapib through Lipid Modification is more likely to have been due to lowering LDL cholesterol than to increasing HDL cholesterol. The lack of potency in increasing HDL cholesterol was initially considered as a reason for the failure of dalcetrapib in dal-OUTCOMES, but recent genomic studies suggest that dalcetrapib may be effective in subjects with a particular genotype, and this is being clinically tested.

SUMMARY

Collectively, these clinical outcome trials do not support raising HDL cholesterol by inhibiting cholesteryl ester transfer protein, as a mechanism for improving cardiovascular outcomes, in the total population of subjects with coronary artery disease.

Cardiovascular outcomes trial with anacetrapib in subjects with high cardiovascular risk - are major benefits REVEALed?

INTRODUCTION

The actions of the cholesteryl ester transfer protein (CETP) inhibitors (torcetrapib, dalcetrapib and evacetrapib) include increasing high-density lipoprotein (HDL) cholesterol, but they do not reduce cardiovascular outcomes in subjects with high cardiovascular risk. Anacetrapib also inhibits CETP, increases HDL cholesterol and lowers low-density lipoprotein (LDL) cholesterol. Areas covered: This evaluation is of the REVEAL (Randomized Evaluation of the Effects of Anacetrapib through Lipid Modification) trial, which was a cardiovascular outcomes trial with anacetrapib in subjects with high cardiovascular risk. Consideration is given as to whether increasing HDL cholesterol, lowering LDL cholesterol or other mechanisms/factors underlying the positive outcome with this CETP inhibitor. Expert opinion: After three years, the REVEAL trial with anacetrapib, demonstrated cardiovascular benefits, but not a reduction in coronary artery deaths. The reductions were not significant in years one and two. Thus, in my opinion, the benefits of anacetrapib were not major, and may not apply in 'real' world populations where adherence to medicines is lower than in REVEAL. Also, lowering LDL cholesterol and off-target mechanisms of anacetrapib may have contributed to any beneficial and/or toxic effects. Anacetrapib has a good safety profile.

Sgemaglutide in type 2 diabetes - is it the best glucagon-like peptide 1 receptor agonist (GLP-1R agonist)?

INTRODUCTION

Glucagon-like peptide-1 (GLP-1) is produced by the gut, and in a glucose-dependent manner stimulates insulin secretion while inhibiting glucagon secretion, reduces appetite and energy intake, and delays gastric emptying. The GLP-1R agonist semaglutide has recently been registered to treat type 2 diabetes. Area covered: This review is of semaglutide in type 2 diabetes, and considers which properties of this GLP-1R agonist, may be responsible for its clinical outcome benefits . Expert opinion: The pharmacokinetics of semaglutide make it ideal for once-weekly dosing. SUSTAIN 6 (Trial to Evaluate Cardiovascular and Other Long-term Outcomes With Semaglutide in Subjects With Type 2 Diabetes) showed that semaglutide 0.5 or 1 mg subcutaneously once-weekly reduced cardiovascular outcomes in subjects with type 2 diabetes and cardiovascular disease or risk, mean age 65 years, baseline HbA1c 8.7% and mean body weight of 92 kg. Although, semaglutide may be a useful drug in this population, it increased retinopathy to a small extent and this needs further investigation. Also, it is not known whether semaglutide will improve cardiovascular outcomes in other populations including those with lower ages, HbA1c values, and body weights similar to those included in the unsuccessful clinical outcome trials with the GLP-1R agonists, lixisenatide and exenatide.

Pilot study, in a rental retirement village, of an "AdherenceCheck" on the management of medicines by the older-aged

Background The older-aged living in a low socioeconomic, rental, retirement village have a low adherence to medicines and a poor understanding of their illnesses. MedsChecks are commonly used in Australian pharmacies in an attempt to improve the management of medicines. There is no published evidence that MedsChecks, or similar brief/single, interventions improve the management of medicines in the older-aged. Objective The objective of our study was to determine the effect of an AdherenceCheck, which is similar to a MedsCheck, but is performed in the home of the older-aged, had on the ongoing management of medicines by the older-aged living independently. Both a MedsCheck and an AdherenceCheck involves forming an individual Action Plan. Setting Rental retirement village. Method After interviewing the older-aged in the village about their management of medicines, they were given an AdherenceCheck and an Action Plan. Six months later their management of medicines and the Action Plan were (re-)evaluated. Main outcome measure Present and ongoing adherence to medicines. Results Only 15 of the original 23 participants completed the study. The AdherenceCheck with Action Plan did not significantly change the adherence to medicines of these older-aged living in the rental retirement village. Pre- to post-AdherenceCheck, there was a reduction in the percentage of participants with a good knowledge of their illnesses, and thus a corresponding significant increase in the percentage with no knowledge of their illnesses, and this may have been age related. Only 11 of the 15 participants remembered receiving an Action Plan, as part of the AdherenceCheck, and 7 of these considered that the Action Plan helped them manage their medicines. Conclusion An AdherenceCheck may not improve the management of medicines by the older-aged living in a rental retirement village. As there are no peer-reviewed publications as to whether the commonly used MedsChecks, which have some similarities to the AdherenceCheck, improve the management of medicines, it is suggested that these MedsChecks should also be formally evaluated.

Sitagliptin and other 'gliptins'--why prescribe them?

INTRODUCTION

In 2008, the Federal Drug Administration (FDA) required all new glucose-lowering therapies to show cardiovascular safety, and this applies to the dipeptidyl peptidase (DPP)-4 inhibitors ('gliptins'). At present, there is contradictory evidence on whether the gliptins increase hospitalizations for heart failure.

AREAS COVERED

This is an evaluation of the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS) in high risk cardiovascular subjects with type 2 diabetes [1]. TECOS demonstrated non-inferiority for sitagliptin over placebo for the primary outcome, which was cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina. There was no difference in the rate of hospitalization for heart failure between sitagliptin and placebo.

EXPERT OPINION

Despite the results of TECOS, debate over the effects of sitagliptin on the rates of hospitalizations for heart failure continues with some recent studies suggesting increased rates. Recently, empagliflozin (an inhibitor of sodium-glucose cotransporter 2) has been shown to reduce cardiovascular outcomes in subjects with type 2 diabetes, including the rates of hospitalization for heart failure. In our opinion, these positive findings with empagliflozin suggest that it should be prescribed in preference to the gliptins, including sitagliptin, unless any positive cardiovascular outcomes are reported for the gliptins.

Ongoing poor management of medicines in the older-aged living independently in a rental retirement village

BACKGROUND

In a low socioeconomic status, small, rental retirement village, we have shown the older-aged managed their medicines poorly (Doggrell and Kairuz in J Pharm Pract Res 42:208-212, 2012).

OBJECTIVE

As the number of participants was only 25, and the population in the rental retirement village turns over regularly; our objective was to determine whether the findings were consistent and ongoing.

METHODS

We returned to the rental retirement villages after 1 and 2 years, and reassessed the management of medicines, using the same semi-structured interview method. Main outcome measure The perception of present and ongoing adherence.

RESULTS

Although similar numbers (23-25) participated in the studies in 2011-2013, the actual participants changed with only three being interviewed on three occasions. Nevertheless, the findings over the 3 years were similar: <50 % of the participants were adherent at the time of the study and unlikely to have problems in the next 6-12 months; only 50 % had a good knowledge of their illnesses.

CONCLUSION

The management of medicines by the older-aged living in a low socioeconomic, rental retirement village is poor, and this finding is ongoing and consistent. This supports the need for extra assistance and resources for the older-aged, living in rental retirement villages, to manage their medicines.

Comparator clinical trials of surrogate endpoints with albiglutide are in HARMONY

Evaluation of: Ahrén B, Johnson SL, Stewart M et al. HARMONY 3: 104-Week randomized, double-blind, placebo- and active-controlled trial assessing the efficacy and safety of albiglutide compared with placebo, sitagliptin, and glimepiride in patients with type 3 diabetes taking metformin. Diabetes Care 2014;37:2141-8 and Rosenstock J, Fonseca VA, Grass JL et al. Advancing basal insulin replacement in type 2 diabetes inadequately controlled with insulin glargine plus oral agents: a comparison of adding albiglutide, a weekly GLP-1 receptor agonist, versus thrice-daily prandial insulin lispro. Diabetes Care 2014;37:2317-25. Agonists of glucagon-like peptide-1 (GLP-1) receptors are used in the treatment of Type 2 diabetes. Albiglutide is a new long-acting GLP-1 receptor agonist being developed for once weekly use. This is an evaluation of two clinical trials in the HARMONY clinical trials series. HARMONY 3 compares albiglutide with sitagliptin and glimepiride in subjects with Type 2 diabetes poorly controlled with metformin, and HARMONY 6 compares albiglutide with insulin lispro in subjects poorly controlled with slow/medium release preparations of insulin. Both studies showed that albiglutide lowered HbA1c and had advantages over its comparator drugs. However, questions remain about the safety of albiglutide. Albiglutide is not being used in subjects with a history of thyroid cancer because it is not known whether this is a rare adverse effect with albiglutide. Also, the safety of albiglutide in subjects with Type 2 diabetes and high cardiovascular risk is unknown.

After 10 Years of Clinical Trials with Liraglutide in Diabetes, What do we Know About its Effects on Clinical Cardiovascular Outcomes?

Type 2 diabetes remains an escalating world-wide problem, despite a range of treatments. The revelation that insulin secretion is under the control of a gut hormone, glucagon-like peptide 1 (GLP-1), led to a new paradigm in the management of type 2 diabetes. Liraglutide is a long acting GLP-1 receptor agonist used in the treatment of type 2 diabetes. The review considers the clinical trials with liraglutide. There are many comparator trials between liraglutide and other medicines for the treatment of type 2 diabetes, and these trials have shown that liraglutide lowers HbA1c and body weight, and is well tolerated. A large cardiovascular safety trial with liraglutide is presently being undertaken. After 10 years of clinical trials with liraglutide, we do not know whether liraglutide has cardiovascular safety in subjects with type 2 diabetes and high cardiovascular risk. Although this is not a requirement for registration by the Food and Drug Administration (FDA), in my opinion, they should reconsider this. We also do not presently know whether liraglutide has any beneficial effects on clinical cardiovascular outcomes.

Do interventions by allied health professionals discussing adherence to insulin improve this adherence?

It is assumed that interventions to improve the adherence to insulin by allied health professionals discussing adherence to insulin will improve this adherence. However, there is little evidence to support this, as interventions by a pharmacist or nurse educator have not been shown conclusively to improve adherence to insulin.

The association between the measurement of adherence to anti-diabetes medicine and the HbA1c

BACKGROUND

Adherence to medicines is important in subjects with diabetes, as nonadherence is associated with an increased risk of morbidity and mortality. However, it is not clear whether there is an association between adherence to medicines and glycaemic control, as not all studies have shown this. One of the reasons for this discrepancy may be that, although there is a standard measure of glycaemic control i.e. HbA1c, there is no standard measure of adherence to medicines. Adherence to medicines can be measured either qualitatively by Morisky or non-Morisky methods or quantitatively using the medicines possession ratio (MPR).

AIMS OF THE REVIEW

The aims of this literature review are (1) to determine whether there is an association between adherence to anti-diabetes medicines and glycaemic control, and (2) whether any such association is dependent on how adherence is measured. Methods A literature search of Medline, CINAHL and the Internet (Google) was undertaken with search terms; 'diabetes' with 'adherence' (or compliance, concordance, persistence, continuation) with 'HbA1c' (or glycaemic control).

RESULTS

Twenty-three studies were included; 10 qualitative and 12 quantitative studies, and one study using both methods. For the qualitative methods measurements of adherence to anti-diabetes medicines (non-Morisky and Morisky), eight out of ten studies show an association with HbA1c. Nine of ten studies using the quantitative MPR, and two studies using MPR for insulin only, have also shown an association between adherence to anti-diabetes medicines and HbA1c. However, the one study that used both Morisky and MPR did not show an association. Three of the four studies that did not show a relationship, did not use a range of HbA1c values in their regression analysis. The other study that did not show a relationship was specifically in a low income population.

CONCLUSIONS

Most studies show an association between adherence to anti-diabetes medicines and HbA1c levels, and this seems to be independent of method used to measure adherence. However, to show an association it is necessary to have a range of HbA1c values. Also, the association is not always apparent in low income populations.

Canagliflozin - something new for type 2 diabetes, but is it safe and efficacious?

INTRODUCTION

Inhibition of the sodium-glucose cotransporter 2 (SGLT2), to promote the excretion of glucose, is a new paradigm in the treatment of type 2 diabetes.

AREAS COVERED

Canagliflozin is an SGLT2 inhibitor, which has been the subject of two recent clinical trials, which are evaluated.

EXPERT OPINION

Studies with canagliflozin, in subjects with type 2 diabetes, have shown that its use is associated with reductions in HbA1c and body weight and small reductions in blood pressure and triglycerides, while increasing high-density lipoprotein cholesterol and low-density lipoprotein cholesterol. As monotherapy in Japanese subjects, or in comparison with glimepiride in CANTATA-SU (CANagliflozin Treatment and Trial Analysis versus SUlphonylurea), canagliflozin causes a low incidence of hypoglycemia, and this is an advantage over glimepiride. However, one of the disadvantages with canagliflozin, which was also highlighted in CANTATA-SU, is that canagliflozin can cause urogenital infections, which are not observed with other antidiabetic drugs. The Federal Drug Administration has recently approved canagliflozin for use in type 2 diabetes, while directing that a clinical outcome safety trial be undertaken. We are concerned that canagliflozin has been approved for use in type 2 diabetes prior to a clinical outcome study of efficacy being undertaken and without the outcome of further safety testing.

Comparative studies of how living circumstances influence medication adherence in ≥65 year olds

BACKGROUND

Resources to help the older aged (≥65 year olds) manage their medicines should probably target those in greatest need. The older-aged have many different types of living circumstances. There are different locations (urban, rural), different types of housing (in the community or in retirement villages), different living arrangements (living alone or with others), and different socioeconomic status (SES) circumstances. However, there has been limited attention to whether these living circumstances affect adherence to medicines in the ≥65 year olds.

AIM OF THE REVIEW

The aim was to determine whether comparative studies, including logistic regression studies, show that living circumstances affect adherence to medicines by the ≥65 year olds.

METHODS

A literature search of Medline, CINAHL and the Internet (Google) was undertaken.

RESULTS

Four comparative studies have not shown differences in adherence to medicines between the ≥65 year olds living in rural and urban locations, but one study shows lower adherence to medicines for osteoporosis in rural areas compared to metropolitan, and another study shows greater adherence to antihypertensive medicines in rural than urban areas. There are no comparative studies of adherence to medicines in the older-aged living in indigenous communities compared to other communities. There is conflicting evidence as to whether living alone, being unmarried, or having a low income/worth is associated with nonadherence. Preliminary studies have suggested that the older-aged living in rental, low SES retirement villages or leasehold, middle SES retirement villages have a lower adherence to medicines than those living in freehold, high SES retirement villages.

CONCLUSIONS

The ≥65 year olds living in rural communities may need extra help with adherence to medicines for osteoporosis. The ≥65 year olds living in rental or leasehold retirement villages may require extra assistance/resources to adhere to their medicines. Further research is needed to clarify whether living under certain living circumstances (e.g. living alone, being unmarried, low income) has an effect on adherence, and to determine whether the ≥65 year olds living in indigenous communities need assistance to be adherent to prescribed medicines.

Cardiac safety concerns for domperidone, an antiemetic and prokinetic, and galactogogue medicine

INTRODUCTION

Domperidone is a dopamine D2-receptor antagonist developed as an antiemetic and prokinetic agent. Oral domperidone is not approved in the United States, but it is used in many countries to treat nausea and vomiting, gastroparesis and as a galactogogue (to promote lactation). The US Food and Drug Administration (FDA) have issued a warning about the cardiac safety of domperidone.

AREAS COVERED

The authors undertook a review of the cardiac safety of oral domperidone.

EXPERT OPINION

The data from preclinical studies are unambiguous in identifying domperidone as able to produce marked hERG channel inhibition and action potential prolongation at clinically relevant concentrations. The compound's propensity to augment instability of action potential duration and action potential triangulation are also indicative of proarrhythmic potential. Domperidone should not be administered to subjects with pre-existing QT prolongation/LQTS, subjects receiving drugs that inhibit CYP3A4, subjects with electrolyte abnormalities or with other risk factors for QT-prolongation. With these provisos, it is possible that domperidone may be used as a galactogogue without direct risk to healthy breast feeding women, but more safety information should be sought in this situation. Also, more safety information is required regarding risk to breast feeding infants before domperidone is routinely used in gastroparesis or gastroesphageal reflux in children.