Tag Archives: liraglutide

Are These Two Diabetes Drugs Better Than the Others?

Better living through chemistry

Empagliflozin is a pill. Liraglutide is a once-daily subQ injection.

The two drugs in question are empagliflozin (aka Jardiance) and liraglutide (aka Victoza). Both are used to treat type 2 diabetes, not type 1.

A major problem we have with most diabetes drugs is that while they do lower blood sugars, we don’t have much evidence on whether they actually prolong life and prevent bad outcomes like heart attacks, strokes, cancer, blindness, kidney failure, amputations, and serious infections. It gets even more complicated. For instance, a given drug may eventually be proven to prolong life by a year via prevention of death from heart disease, while at the same time increasing the risk of spending that last year bedridden from a stroke.

It’s extremely difficult and costly to suss out these issues. It requires large clinical trials wherein half of the PWDs (people with diabetes) are treated with a particular drug, and the other half are treated with “standard therapy.” Five or 10 years later you compare clinical endpoints between the two groups. A couple studies have done this recently.

A blogger I follow, Larry Husten, wrote the following:

But it was the secondary goal of these trials that led to the transformation of the field. Baked into the trial design was the provision that if they were able to establish noninferiority then the trial investigators were permitted to test for superiority. The second phase began when Empa-Reg became the first trial to convincingly show a clear benefit, including a reduction in cardiovascular death and a reduction in hospitalization for heart failure. with empagliflozin (Jardiance, Merck). Then, more recently, the LEADER trial showed a significant reduction in cardiovascular events with liraglutide (Victoza, Novo Nordisk). In both trials nearly all the patients had significant established cardiovascular disease—precisely the population that cardiologists are likely to see.

Click the embedded links above for more details. Even better, read the original research reports if you have the time and knowledge. I support my family with a full-time job taking care of patients, so it will be a while (if ever) before I can dig into this further. (When my book sales make me independently wealthy, I’ll have more time for this!)

diabetic diet, low-carb Mediterranean Diet, low-carb, Conquer Diabetes and Prediabetes

Analyzing clinical reports requires a good grasp of logic, statistics, and basic science

Are the LEADER and Empa-Reg trials valid? Yeah, maybe. In an ideal world, other investigators would try to replicate the results with additional clinical trials. Are the published results free of fraud and bias? I don’t know.

Because we don’t know the long-term effects of many of our diabetes drugs, I favor doing as much as possible to control blood sugars with diet, exercise, and weight management.

Stay tuned for future developments.

Steve Parker, M.D.

PS: Just because one drug in a class of drugs reduces bad clinical outcomes, it doesn’t mean all drugs in the class do.

PPS: If it’s hard for you to pronounce empagliflozin and liraglutide, some of my books don’t even have them.

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Diabetes Drug Now Sold As Weight-Loss Aid

It’s liraglutide, which has been available to treat diabetes in the U.S. since 2009. It’s sold as Victoza. Click for my brief review of the drug class for diabetics. The weight-loss preparation will be sold in the U.S. as Saxenda and it’s a higher dose than is used for just diabetes.

Click for the CBS News report on Saxenda. A snippet:

One clinical trial that involved patients without diabetes found that patients taking Saxenda had an average weight loss of 4.5 percent after one year. Of the people treated with the drug, 62 percent lost at least 5 percent of their body weight. Meanwhile, only 34 percent of those given an inactive placebo had the same result.

Another clinical trial that included patients with type 2 diabetes found that patients had an average weight loss of almost 4 percent after one year. Of those given Saxenda, 49 percent lost at least 5 percent of their body weight, compared to 16 percent of those who were given a placebo treatment.

Click for the FDA’s press release.

Oh, by the way. You have to inject it daily under the skin (subcutaneous). And if you were hoping for a shortcut to weight loss, this ain’t it. You’re still supposed to follow a reduced-calorie diet and exercise regularly.

I’d try the  Low-Carb Mediterranean Diet first if I had diabetes.

Steve Parker, M.D.

PS: Full prescribing information.

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FDA Approves Exenatide for Once Weekly Use

Once-weekly injection of exenatide, sold in the U.S. as Bydureon, has been approved for use by the U.S. Food and Drug Administration.  It’s main competitors are Byetta (exenatide  injected twice daily) and Victoza  (liraglutide).  Byetta  and Bydureon are made by the same company, Amylin Pharmaceuticals.  Bydureon apparently is a slow-release formulation of exenatide.

Victoza is the one that celebrity chef Paula Deen endorsed about a month ago, around the same time she revealed she’s had type 2 diabetes for three years.  Victoza’s injected once daily.

The New York Times has a January 27, 2012, article on Bydureon, focusing on business and investing.  The new drug is expected to retail for $4,200 (USD) a year. 

Click for complete prescribing information.

Click for a press release approved by Amylin.

David Mendosa is excited about Bydureon.

These drugs are in a class called GLP-1 receptor agonists, which mimic the effect of glucagonlike peptide- 1, a hormone that increases insulin secretion by the pancreas when blood sugar levels are high.  They are prescribed as adjuncts to diet and exercise in adults with type 2 diabetes.

Steve Parker, M.D.

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Drug Review: GLP-1 Analogues (exenatide, liraglutide, albiglutide, dulaglutide, lixisenatide)

GLP-1 analogues available in the U.S. are exenatide (sold as Byetta and Bydureon), liraglutide (sold as Victoza), albiglutide (Tanzeum), dulaglutide (Trulicity), and lixisenatide (Adlyxin).  They are sometimes referred to as GLP-1 receptor agonists.  They are not considered first-choice drugs, but instead are typically used in combination with other drugs, in conjuction with diet and exercise.

Remember that drug names vary by country and manufacturer.  This is a brief review only; consult your physician or pharmacist for full details.

Fun Fact for the diabetic version of  Trivial Pursuit:

Exenatide  (Byetta and Bydureon) is a synthesized version of a protein initially discovered in the saliva of a lizard, the Gila monster.

How do they work?

It’s complicated.

First off, you need to know that a small intestine hormone, glucagon-like peptide-1 (GLP-1), is produced in response to a meal.  This hormone increases insulin secretion by pancreas beta cells, suppresses glucagon after meals, inhibits emptying of the stomach, and inhibits appetite. Other effects are suppression of glucose production by the liver, and improved glucose uptake by tissues outside the liver.  All this tends to lower blood sugar levels after meals.

The problem is that GLP-1 is quickly destroyed by an enzyme called DPP-4.  We have available to us now chemicals similar to GLP-1, called GLP-1 analogues, that bind to the GLP-1 receptors and are resistant to degradation by the enzyme DPP-4.  They essentially act like GLP-1, and they hang around longer.

GLP-1 levels, by the way, are decreased in type 2 diabetes.

The action of GLP-1 is dependent on blood sugar levels.  If blood glucose is not elevated, GLP-1 doesn’t go to work.  From a practical viewpoint, this means that GLP-1-based therapies rarely cause hypoglycemia.

We know little about long-term outcomes with these drugs, such as diabetic complications, health-related quality of life, or mortality.

Uses

Exenatide (Byetta)  is FDA-approved for adults with type 2 diabetes who are not adequately controlled with metformin, sulfonylurea, or a thiazolidinedione (or a combination of these agents).  So it’s an add-on drug, not approved for use by itself.  In October, 2011, the FDA extended approval as an add-on therapy to insulin glargine (for example, Lantus in the U.S.), with or without metformin and/or a thiazolidinedione (TZD), in conjunction with diet and exercise for adults with type 2 diabetes who are not achieving adequate glycemic control on insulin glargine alone.

Once-weely exenatide (Bydureon) was FDA-approved in January, 2012.  Use with insulin has not been studied and is not recommended.  Don’t use along with Byetta.  Surprisingly, I found nothing in the drug package insert Feb.2, 2012, regarding whether it can be used with other diabetes drugs.  See comments in the preceding paragraph regarding standard twice-daily exenatide.  I suspect Bydureon can be used with metformin, sulfonylurea, thiazolidinedione, and insulin glargine (Lantus), but the package insert is not at all clear.

Liraglutide is FDA-approved for treatment of type 2 diabetes but is not recommended as initial therapy, although it does seem to be approved for use by itself.  It has been used alone and also in combination with metformin, sulfonylurea, and/or thiazolidinediones.  It’s not approved for use with insulin therapy.

Albiglutide is a once-weekly subcutaneous injection for type 2 diabetes. It was FDA-approved in 2014. It’s not recommended as initial drug therapy, although it is approved for use by itself. It can be used in combination with metformin, sulfonylurea, thiazolidinediones, and/or insulin.

Dulaglutide is also a once-weekly injection for adults with type 2 diabetes, approved by the FDA in2014.  It’s not a first-line drug, but can be used by itself or with metformin, glimiperide (and presumably other sulfonylureas), pioglitazone, and insulin lisper (e.g., Humalog, a rapid-acting insulin).

Lixisenatide is a daily injection for adults with type 2 diabetes. It can be used alone or in combination with metformin, sulfonylurea, thiazolidinedione (e.g., pioglitazone), or long-acting insulin (insulin glargine). Clinical trials did not include short-acting insulin.

You can assume none of these have been tested for safety in pregnant or nursing mothers.

Dosing

They are available only as subcutaneous injections.  Exenatide is twice daily, starting at 5 mcg within 60 minutes prior to a meal.  After one month, the dose may be increased to 10 mcg twice daily.

Extended-release exenatide (Bydureon): 2 mg subcutaneous injection every seven days.

Liraglutide is a once daily subcutaneous injection starting at 0.6 mg, increasing to 1.2 mg after one week.  It is given without regard to meals.  Maximum dose is 1.8 mg/day.

Albiglutide is started at 30 mg subcutaneously every seven days and may be increased to 50 mg if needed.

Start dulaglutide at 0.75 mg weekly, increasing to 1.5 mg weekly if needed.

Lixisenatide starts at 10 mcg daily for 14 days then increases to 20 mcg daily.

Side Effects

GLP-1 analogues tend to cause nausea, vomiting, and diarrhea in as many as four in 10 users.  The nausea typically improves over time.  Compared with Byetta, Bydureon seems to cause less nausea.  They tend to cause weight loss.  These drugs might cause pancreatitis, which is life-threatening.  When used with insulin or an insulin secretagogue (like sulfonylureas or meglitinides), hypoglycemia may occur.

Hypoglycemia is rare when GLP-1 analogues are used as the sole diabetes drug, but still possible (0-5% risk?). When it happens, it’s rarely severe.

Liraglutide, albiglutide, and dulaglutide might cause thyroid cancer or thyroid tumors.   

Don’t use if you have . . .

… severe kidney impairment (exenatide), end-stage renal disease (lixisenatide),Multiple Endocrine Neoplasia syndrome (liraglutide), Multiple Endocrine Neoplasia syndrome type 2 (albiglutide, dulaglutide), or family history of medullary thyroid cancer (liraglutide, albiglutide, dulaglutide), or personal history or medullary thyroid cancer (albiglutide, dulaglutide).

Use GLP-1 analogues with caution or avoid entirely if you have a history of pancreatitis or gastroparesis. Don’t use dulaglutide if you have pre-existing severe gastrointestinal disease.

Use liraglutide with caution in patients with kidney or liver impairment. Dulaglutide is risky in the setting of liver impairment.

Don’t use any of these to treat diabetic ketoacidosis.

Steve Parker, M.D.

Last modification date: July 29, 2016

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New Drug for Type 2 Diabetes: Victoza (liraglutide)

Reuters reported on January 25, 2009, the U.S. Food and Drug Administration’s recent approval of liraglutide (brand name: Victoza).

It joins Byetta (exenatide) as the second  GLP-1 (glucagon-like peptide-1) analog available in the U.S.  Both are injections and work by stimulating the release of insulin by pancreas beta cells when blood sugar is too high. 

The FDA indicated liraglutide is not generally a first-choice drug for diabetes.

It’s always good to have options.

Steve Parker, M.D.

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