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Introducing FORXIGA
FORXIGA, a first-in-class SGLT2 inhibitor, removes excess glucose via an insulin-independent mechanism of action and provides: Significant and sustained HbA1c reductions15 Additional benefits of weight loss15 and a reduction in blood pressure1,5 Low incidence of hypoglycaemia1 In one 10 mg tablet a day5* Add on for patients uncontrolled on metformin who need the additional benefit of weight loss and have normal or only mildly impaired renal function
*In patients with severe hepatic impairment, a starting dose of 5 mg is recommended. If well tolerated, the dose may be increased up to 10 mg. 1. Bailey CJ, et al. Lancet 2010;375:222333; 2. Bailey CJ, et al. Diabetes 2011;60(Suppl. 1):988-P; 3. Nauck MA, et al. Diabetes Care 2011;34:201522; 4. Nauck MA, et al. Diabetes 2011;60(Suppl. 1):Poster 40-LB; 5. FORXIGA. Summary of product characteristics. Bristol-Myers Squibb/AstraZeneca EEIG, 2012.
Overview
Current challenges in Type 2 diabetes The role of the kidney in Type 2 diabetes FORXIGA (dapagliflozin) Mechanism of action Efficacy and safety profile Dosing and administration
8.1% of the adult population in Europe suffer from diabetes1 By 2030, the prevalence of diabetes in Europe is forecast to rise to 9.5% of the adult population1
*Comparative prevalence. 1. The International Diabetes Federation. Diabetes Atlas, 5th edition (2011). Available at: http://www.idf.org./diabetesatlas/5e/europe. Last accessed May 2012.
Despite advances in treatment, a significant proportion of patients with Type 2 diabetes still fail to reach target HbA1c levels
Percentage of patients not achieving glycaemic goals in Europe
CODE-2 study (19981999)1 Target HbA1c level: 6.5%
100
31% 69%
Failed to reach target Achieved target
80
60
40
20
France (n=750)
Spain (n=743)
CODE-2, Cost of Diabetes in Europe - Type 2. 1. Liebl A, et al. Diabetologia 2002;45:S238; 2. De Pablos-Velasco P, et al. Diabetologia 2010;53(Suppl. 1):1012-P.
Overweight
Obese
50
25
0
<23 <2323.9 <2424.9 <2526.9 <2728.9 <2930.9 <3132.9 <3334.9 35
BMI (kg/m2)
*Results are from two different studies. The first study is from a cohort of 27,983 US male health professionals, 4075 years of age in 1986 who completed biennial questionnaires sent out in 1986, 1988, 1990 and 1992 (follow-up: 19871922). The second study is from a cohort of 114,281 US female registered nurses, 3055 years of age in 1976 who completed questionnaires (follow-up: 19761990). BMI, body mass index. Adapted from: 1. Chan J, et al. Diabetes Care 1994;17:9619; 2. Colditz GA, et al. Ann Intern Med 1995;122:4816.
Controlling multiple parameters is essential for effective treatment of patients with Type 2 diabetes
HbA1c
Weight Blood pressure Lipids
Reductions in glycaemic control (HbA1c) and other parameters that are sustained over time can benefit the health of patients with Type 2 diabetes15
1. Stratton IM, et al. BMJ 2000;321:40512; 2. Pi-Sunyer FX. Postgrad Med 2009;121:94107; 3. Williamson DF, et al. Diabetes Care 2000;23:1499504; 4. Patel A, ADVANCE Collaborative Group. Lancet 2007;370:82940; 5. Pyrl K, et al. Diabetes Care 1997;20:61420.
Glucose uptake ~250 g/day: Brain ~125 g/day Rest of the body ~125 g/day
1. Wright EM. Am J Physiol Renal Physiol 2001;280:F1018; 2. Gerich, JE. Diabetes Obes Metab 2000;2:34550.
Glucose uptake >250 g/day: Brain ~125 g/day Rest of the body >125 g/day
Above the renal threshold for glucose (~200 mg/dL), glucose is excreted in the urine (glucosuria)
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Proximal tubule
SGLT2 Glucose
Glucose filtration
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SGLT, sodium-glucose co-transporter. 1. Wright EM. Am J Physiol Renal Physiol 2001;280:F1018; 2. Lee YJ, et al. Kidney Int Suppl 2007;106:S2735; 3. Hummel CS, et al. Am J Physiol Cell Physiol 2011;300:C1421.
Insulin-independent mechanism
SGLT2 inhibition
Insulin release
Sulphonylureas GLP-1R agonists* DPP4 inhibitors* Meglitinides
Pancreas
Insulin replacement
Insulin
Glucose utilisation
*In addition to increasing insulin secretion, which is the major mechanism of action, GLP-1 agonists and DPP4 inhibitors also act to decrease glucagon secretion. DDP4, dipeptidyl peptidase-4; GLP-1R, glucagon-like peptide-1 receptor. 1. Washburn WN. J Med Chem 2009;52:178594; 2. Bailey CJ. Curr Diab Rep 2009;9:3607; 3. Srinivasan BT, et al. Postgrad Med J 2008;84:52431; 4. Rajesh R, et al. Int J Pharma Sci Res 2010;1:13947.
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Proximal tubule
FORXIGA
SGLT2 Glucose
Glucose filtration
Increased urinary excretion of excess glucose (~70 g/day, corresponding to 280 kcal/day*)
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1. List JF, et al. Diabetes Care 2009;32:6507; 2. Bailey CJ, et al. Lancet 2010;375:222333; 3. Bailey CJ, et al. Diabetes 2011;60(Suppl. 1):988-P.
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FORXIGA is indicated in adults with Type 2 diabetes to improve glycaemic control as...
Add-on combination therapy In combination with a monotherapy of metformin, a monotherapy of sulphonylureas or a treatment with insulin ( oral antidiabetic drugs) when these, together with diet and exercise, do not provide adequate glycaemic control Monotherapy When diet and exercise alone do not provide adequate glycaemic control in patients for whom use of metformin is considered inappropriate due to intolerance
The use of FORXIGA with pioglitazone is not recommended. FORXIGA has not been studied in combination with DPP4 inhibitors or GLP-1 analogues. FORXIGA. Summary of product characteristics. Bristol-Myers Squibb/AstraZeneca EEIG, 2012.
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FORXIGA: A Comprehensive Phase III clinical development programme with 40% of patients from Europe
Phase III N=5693 Monotherapy n=840 Monotherapy n=558 Low dose n=282 Add-on combination n=2369 Add-on to metformin n=546 Add-on to SU n=596 Add-on to pioglitazone* n=420 Add-on to insulin n=807 Comparator n=2050 Add-on to metformin compared with SU n=814 FORXIGA 5 mg combined with metformin XR n=598 FORXIGA 10 mg combined with metformin XR n=638 Special studies n=434 DXA body composition n=182 Moderate renal impairment n=252 Large CV outcomes trial planned as postmarketing commitment
*The use of FORXIGA with pioglitazone is not recommended; metformin extended release (XR) is not approved or available in all European countries; FORXIGA should not be used in patients with moderate to severe renal impairment (CrCl <60 mL/min or eGFR <60 mL/min/1.73 m2). CrCl, creatinine clearance; CV, cardiovascular; DXA, dual-energy X-ray absorptiometry; eGFR, estimated glomerular filtration rate; SU, sulphonylurea.
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FORXIGA: Significant reductions in HbA1c compared with placebo at the 24-week primary endpoint
FORXIGA 10 mg + metformin 24 weeks Placebo + metformin 0.30%
(n=134)
0.54%
difference p<0.0001
Changes reported for Week 24 are adjusted for baseline values and are based on last observation carried forward (LOCF). A Phase III, multicentre, randomised, double-blind, placebo-controlled, parallel-group, 24-week clinical study to evaluate the efficacy and safety of FORXIGA 10 mg + metformin (1500 mg/day) versus placebo + metformin (1500 mg/day) in adult patients with Type 2 diabetes who had inadequate glycaemic control (HbA1c 7% and 10%) on metformin alone. Primary endpoint: HbA1c reduction at 24 weeks. Bailey CJ, et al. Lancet 2010;375:222333.
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Placebo + metformin
(Mean baseline HbA1c 8.13%)
+0.02%
(95% Cl, 0.20 to 0.23%; n=28)
0.80%
difference
0.78%
(95% Cl, 0.97 to 0.60%; n=57)
Data are mean change from baseline after adjustment for baseline value. Data after rescue are excluded. Analyses were obtained by longitudinal repeated measures analyses. CI, confidence interval. Bailey CJ, et al. Diabetes 2011;60(Suppl. 1):988-P.
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FORXIGA also had the additional benefit of weight loss over time
24 weeks (LOCF analysis)1 2.0 Adjusted mean change from baseline body weight (kg) 1.0 0.0 0.9 kg -1.0 -2.0 1.7 kg -3.0 -4.0 2.9 kg
(n=133) (n=136)
FORXIGA 10 mg + metformin
Placebo + metformin
+1.4 kg
(n=73)
3.1 kg
difference
2.0 kg
difference p<0.0001
(n=95)
In a separate dedicated weight loss study, weight loss in patients treated with FORXIGA came from fat mass reduction3
Data are mean change from baseline after adjustment for baseline value (mean baseline weight: FORXIGA 86.3 kg, placebo 87.7 kg). 24-week data are based on LOCF analysis excluding data after rescue; 102-week data are based on longitudinal repeated measures analysis and include data after rescue. 1. Bailey CJ, et al. Lancet 2010;375:222333; 2. Bailey CJ, et al. Diabetes 2011;60(Suppl. 1):988-P; 3. Bolinder J, et al. J Clin Endocrinol Metab 2012;97:102031.
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0 Adjusted mean change from baseline HbA1c (%) -0.1 -0.2 -0.3 -0.4 -0.5 -0.6
0.52%
(95% Cl, 0.60 to 0.44%) n=400 Mean baseline HbA1c 7.69%
0.52%
(95% Cl, 0.60 to 0.44%)
n=401 Mean baseline HbA1c 7.74%
Data are adjusted mean change from baseline and 95% CI derived from analysis of covariance using the full analysis set and LOCF values. A Phase III, multicentre, randomised, double-blind, parallel-group, 52-week, glipizide-controlled non-inferiority study to evaluate the efficacy and safety of FORXIGA 10 mg + metformin (1500 mg/day) versus glipizide + metformin (1500 mg/day) in patients with inadequate glycaemic control (HbA1c >6.5% and 10%) on metformin alone. Nauck MA, et al. Diabetes Care 2011;34:201522.
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0.14%
(95% Cl, 0.25 to 0.03%; n=208)
0.32%
(95% Cl, 0.42 to 0.21%; n=233)
12
18
26
34
42
52
65
78
91
104
Study week
Data are adjusted mean change from baseline and 95% CI derived from a repeated measures mixed model. 1. Nauck MA, et al. Diabetes Care 2011;34:201522; 2. Nauck MA, et al. Diabetes 2011;60(Suppl. 1):Poster 40-LB.
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p<0.0001
40.8% (n=401)
23
2.0 1.5 1.0 0.5 0.0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -3.5 -4.0
+1.36 kg
(95% Cl, 0.88 to 1.84 kg; n=211)
5.06 kg difference
(95% Cl, 5.73 to 4.4 kg)
FORXIGA 10 mg + metformin
(n=400) Mean baseline weight 88.4 kg
3.70 kg
(95% Cl, 4.16 to 3.24 kg; n=234)
12 18
26
34
42
52 Study week
65
78
91
104
Data are adjusted mean change from baseline and 95% CI derived from a repeated measures mixed model. 1. Nauck MA, et al. Diabetes Care 2011;34:201522; 2. Nauck MA, et al. Diabetes 2011;60(Suppl. 1):Poster 40-LB.
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FORXIGA 10 mg
Control groups
(n=949)
4.4 mmHg
(n=949)
126 mmHg 129 mmHg 77 mmHg 79 mmHg
FORXIGA is not indicated for the management of high blood pressure. Mean seated systolic and diastolic blood pressure were based on a placebo-controlled, pooled analysis from the 24-week, short-term, double-blind treatment period, including data after rescue. N is the number of subjects with non-missing baseline and Week 24 (LOCF) values in the randomised full analysis set. Change in blood pressure was primarily assessed as safety or exploratory efficacy endpoints in the Phase III clinical programme; therefore, the background antihypertensive medications were not controlled. 1. FORXIGA. Summary of product characteristics. Bristol-Myers Squibb/AstraZeneca EEIG, 2012; 2. BMS/AZ data on file.
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Volume depletion Thirst Constipation Hyperhidrosis Back pain Dysuria Polyuria Dyslipidaemia Haematocrit increased Nocturia Blood creatinine increased Blood urea increased
Gastrointestinal disorders Skin and subcutaneous tissue disorders Musculoskeletal and connective tissue disorders Renal and urinary disorders Investigations
SU, sulphonylurea; UTI, urinary tract infection. FORXIGA. Summary of product characteristics. Bristol-Myers Squibb/AstraZeneca EEIG, 2012.
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*In a prespecified pooled analysis of 12 placebo-controlled studies. FORXIGA. Summary of product characteristics. Bristol-Myers Squibb/AstraZeneca EEIG, 2012.
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Serious events occurred in <0.2% of patients and were comparable between groups
FORXIGA is not recommended for initiation of therapy in patients who are volume depleted. Temporary interruption of Forxiga is recommended for patients who develop volume depletion until the depletion is corrected. FORXIGA. Summary of product characteristics. Bristol-Myers Squibb/AstraZeneca EEIG, 2012.
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Cardiovascular safety
FORXIGA is not associated with an increase in cardiovascular risk in patients with Type 2 diabetes*
2.5
2.0
Hazard ratio 0.82 (95% CI 0.58, 1.15) 1.99 % per patient per year 1.64% per patient per year
1.5
1.0
0.5
0.0
FORXIGA
Control
*In a meta-analysis of cardiovascular events in 19 double-blind clinical studies of FORXIGA 2.510 mg adjudicated by an independent committee. Cardiovascular death, stroke, myocardial infarction or hospitalisation for unstable angina.
FORXIGA. Summary of product characteristics. Bristol-Myers Squibb/AstraZeneca EEIG, 2012.
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In patients with severe hepatic impairment, a starting dose of 5 mg is recommended. If well tolerated, the dose may be increased to 10 mg No known drugdrug interactions with other commonly prescribed Type 2 diabetes treatments
FORXIGA. Summary of product characteristics. Bristol-Myers Squibb/AstraZeneca EEIG, 2012.
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*eGFR calculated with Modification of Diet in Renal Disease Formula. FORXIGA. Summary of product characteristics. Bristol-Myers Squibb/AstraZeneca EEIG, 2012.
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Summary
FORXIGA, a first-in-class SGLT2 inhibitor, removes excess glucose via an insulin-independent mechanism of action and provides: Significant and sustained HbA1c reductions15 Additional benefits of weight loss15 and a reduction in blood pressure1,5 Low incidence of hypoglycaemia1 In one 10 mg tablet a day5* Add on for patients uncontrolled on metformin who need the additional benefit of weight loss and have normal or only mildly impaired renal function
*In patients with severe hepatic impairment, a starting dose of 5 mg is recommended. If well tolerated, the dose may be increased up to 10 mg. 1. Bailey CJ, et al. Lancet 2010;375:222333; 2. Bailey CJ, et al. Diabetes 2011;60(Suppl. 1):988-P; 3. Nauck MA, et al. Diabetes Care 2011;34:201522; 4. Nauck MA, et al. Diabetes 2011;60(Suppl. 1):Poster 40-LB; 5. FORXIGA. Summary of product characteristics. Bristol-Myers Squibb/AstraZeneca EEIG, 2012.
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