Design and Development of the Selective
`DPP-4 Inhibitor Sitagliptin
`
`AstraZeneca Exhibit 2177
`Mylan v. AstraZeneca
`IPR2015-01340
`
`Page 1 of 45
`
`
`DPP-4 Inhibitor Sitagliptin
`
`AstraZeneca Exhibit 2177
`Mylan v. AstraZeneca
`IPR2015-01340
`
`Page 1 of 45
`
`
`
`Incretin-Based Therapies: A Glucose-Dependent
`Mechanism for Diabetes Therapy1–4
`Release of active incretins by the intestinea
`
`Inactive
`
`Food
`
`GLP-1
`
`+
`
`GIP
`
`Glucose-dependent
` Glucagon from alpha cells
`
`Glucose-dependent
` Insulin from beta cells
`
` Hepatic glucose production
`
` Peripheral glucose uptake
`
`DPP-4
`enzyme
`
`Sitagliptin
`
`GLP-1
`
`GIP
`
`DPP-4 Inhibitors:
`• Oral therapy
`• Low risk of
`hypoglycemia
`• No weight gain
`• Potentiation of GIP
`
` Blood glucose in fasting and postprandial states
`
`DPP-4=dipeptidyl peptidase-4; GIP=glucose-dependent insulinotropic peptide; GLP-1=glucagon-like peptide-1.
`aIncretin hormones GLP-1 and GIP are released by the intestine throughout the day, and their levels increase in response to a meal.
`1. Kieffer TJ et al. Endocr Rev. 1999;20(6):876–913. 2. Ahrén B. Curr Diab Rep. 2003;3(5):365–372. 3. Drucker DJ. Diabetes Care. 2003;26(10):2929–2940. 4. Holst JJ. Diabetes Metab Res
`Rev. 2002;18(6):430–441.
`
`Page 2 of 45
`
`
`
`6-Week Infusion of GLP-1 in Subjects With
`Type 2 Diabetes1
`
`3
`
`8-hour glucose profile
`
`Week 0
`Week 6
`
`9.5
`
`HbA1c
`p =0.003
`
`p =0.4
`
`9
`
`8.9
`
`9.2
`
`9.1
`
`14%
`
`7.9
`
`Saline
`(n=9)
`
`GLP-1
`(n=10)
`
`8.5
`
`8
`
`7.5
`
`7
`
`Percent
`
`Saline infusion
`
`P <.0001
`
`GLP-1 infusion
`
`0
`
`2
`
`4
`Hours
`
`6
`
`8
`
`20
`
`15
`
`10
`
`5 0
`
`20
`
`15
`
`10
`
`5 0
`
`Plasma glucose (mmol/L)
`
`GLP-1=glucagon-like peptide-1.
`20 patients with inadequately controlled type 2 diabetes treated with continuous subcutaneous infusion of saline (n=10) or GLP-1 (n=10) for 6 weeks.
`1. Zander M et al. Lancet. 2002;359:824–830.
`
`Page 3 of 45
`
`
`
`4
`
`GLP-1 Is Rapidly Degraded and Has Limited Clinical Use
`Exendin-4 (Exenatide/Byetta): A GLP-1 Mimetic With Enhanced Stability
`Amino Acid Sequences1
`GLP-1(7-36)amide
`HAEGTFTSDVSSYLEGQAAKEFIAWLVKGR-NH2
`Exendin-4
`HGEGTFTSDLSKQMEEEAVRLFIEWLKNGGPSSGAPPPS
` Exendin-4 shares 53% amino
`acid identity with GLP-12
` Exendin-4 and GLP-1 have
`similar binding affinity at the
`GLP-1 receptor3
` Exendin-4 is resistant to
`proteolytic cleavage4
`
`GLP-1=glucagon-like peptide-1.
`1. Chen Y et al. J Biol Chem. 1997;272:4108–4115.
`2. Eng J et al. J Biol Chem. 1992;267:7402-7405.
`3. Goke R et al. J. Biol. Chem. 1993;268:19650–19655.
`4. Drucker D. Diabetes Care. 2003; 26:2929–2940.
`
`Gila Monster (H. suspectum)
`
`Page 4 of 45
`
`
`
`DPP-4 Inactivates GLP-1 and GIP
`
`5
`
`DPP-4 cleavage of GLP-11
`t1/2 ~2 min
`7 36
`HA–
`
`Agonist, active
`= GLP-1active
`DPP-4
`9 36
`
`Inactive
`
`Double staining for DPP-4 and GLP-1
`in the human ileum2
`
`Red:
`DPP-4–positive capillaries
`Green:
`GLP-1–positive L cell
`
` DPP-4 inhibitors provide an oral approach to incretin-based therapy.3
`
`DPP-4=dipeptidyl peptidase-4; GIP=glucose-dependent insulinotropic peptide; GLP-1=glucagon-like peptide-1.
`1. Drucker DJ. Diabetes Care. 2003; 26:2929–2940.
`2. Hansen L et al. Endocrinology. 1999;140:5356–5363.
`3. Deacon CF et al. Diabetes. 1995;44:1126–1131.
`
`Page 5 of 45
`
`
`
`6
`
`The DPP-4 Enzyme
` Cell surface serine dipeptidase;
`member of the prolyl
`oligopeptidase family1,2
` Cleaves the N-terminal dipeptide
`from peptides with proline or
`alanine in the penultimate
`position3,4
` Widely expressed1
` Shed into the circulation in
`a soluble form lacking the
`transmembrane region2
` Identical to CD26, a marker
`for activated T cells1-3
`
`DPP-4=dipeptidyl peptidase-4.
`1. Šedo A et al. Biochim Biophys Acta. 2001;550:107–116.
`2. Lambeir A et al. Crit Rev Clin Lab Sci. 2003;40:209-294.
`3. Cordero O et al. Cancer Immunol Immunother. 2009;58:1723–1747.
`4. Rasmussen HB et al. Nat Structural Biol. 2002;10:19–25.
`
`Page 6 of 45
`
`
`
`7
`
`Validation of DPP-4 as a Target for Diabetes
`
` DPP-4 inhibition stabilizes active GLP-1 and GIP in pigs.1,2
` Metabolic phenotype of Dpp-4–/– mice is as follows3:
`– Healthy and fertile
`– Improved metabolic function: increased active GLP-1
` DPP-4 inhibitors stabilize GLP-1 and GIP and lower prandial and fasting glucose in
`humans.4,5
`
`O
`
`CN
`
`N
`
`HN
`
`N
`
`HO
`
`CH3
`
`O
`
`H3C
`
`O
`
`CN
`
`N
`
`HN
`
`NH
`
`N
`
`NC
`
`O
`
`N
`
`H2N
`
`Valine pyrrolidide
`Ki = 400 nM
`
`Novartis DPP728
`Ki = 5 nM
`1996
`
`NH2
`S
`Probiodrug P32/98
`Ki = 220 nM
`1997
`
`LAF237 (vildagliptin)
`Ki = 19 nM
`1998
`
`DPP-4=dipeptidyl peptidase-4; GIP=glucose-dependent insulinotropic peptide; GLP-1=glucagon-like peptide-1.
`1. Deacon CF et al. Diabetes. 1998;47:764–769; 2. Deacon CF et al. Diabetes. 2001;50:1588–1597; 3. Marguet D et al. Proc Natl Acad Sci U S A. 2000;97:6874–6879; 4. Ahrén B et
`al. Diabetes Care. 2002;25:869–875; 5. Herman GA et al. J Clin Endocrinol Metab. 2006;91:4612–4619.
`
`Page 7 of 45
`
`
`
`Inhibition of DPP-4 Increases Plasma Levels
`of Active GLP-1 in Anesthetized Pigs1
`
`8
`
`GLP-1 infusion
`
`Glucose
`
`DPP-4
`inhibitora
`
`GLP-1 infusion
`
`Glucose
`
`Total GLP-1
`Intact GLP-1
`
`500
`
`400
`
`300
`
`200
`
`100
`
`0
`
`GLP-1, pmol/L
`
`0
`
`20
`
`40
`
`60
`
`80
`
`100
`120
`Minutes
`
`140
`
`160
`
`180
`
`200
`
`220
`
`DPP-4=dipeptidyl peptidase-4; GLP-1=glucagon-like peptide-1.
`aValine-pyrrolidide; 300 µmol/kg.
`1. Deacon C et al. Diabetes. 1998;47:764–769
`
`Page 8 of 45
`
`
`
`9
`
`DPP-4 Inhibition: Potential Issues
` Stabilization of substrates other than GLP-1 and GIP1
`– GLP-1 and GIP are well-validated in vivo substrates
`– Other potential substrates identified in vitro
` Nonselective inhibition1,2
`– DPP-4 is a member of an emerging protease family
` Potential role for DPP-4 (CD26) in T-cell activation1,2
`– Early nonselective inhibitors were reported to attenuate T-cell
`activation.
`– This effect suggested a potential role for catalytic activity.
`
`DPP-4=dipeptidyl peptidase-4; GIP=glucose-dependent insulinotropic peptide; GLP-1=glucagon-like peptide-1.
`1. Drucker DJ. Diabetes Care. 2007;30:1335–1343.
`2. Lankas GK et al Diabetes. 2005;54: 2988–2994.
`
`Page 9 of 45
`
`
`
`DPP-4 Cleaves Multiple Glucagon Family
`Peptides In Vitro1
`
`10
`
`GHRH(1-29)
`GLP-1
`Glucagon
`PACAP271
`PACAP381
`VIP
`
`100
`
`80
`
`60
`
`40
`
`20
`
`Conversion, %
`
`kcat/KM (M-1.s-1)
`Substrate
`3.00E+06
`GHRH(1-44)
`2.00E+06
`GHRH(1-29)
`1.00E+06
`GRP (1st)
`6.40E+05
`GRP (2nd)
`6.10E+05
`GH(1-43)
`7.30E+05
`PACAP38
`4.20E+05
`GLP-1
`2.50E+05
`PHM
`2.30E+05
`GIP
`1.50E+05
`Oxyntomodulin
`8.60E+04
`GLP-2
`4.60E+04
`PACAP27
`2.40E+04
`Glucagon
`1.20E+04
`Secretin
`1.6e+3
`VIP
`DPP-4=dipeptidyl peptidase-4; GH=growth hormone; GHRH=growth hormone-releasing hormone; GIP=glucose-dependent insulinotropic peptide; GLP-1=glucagon-like peptide-1;
`GLP-2=glucagon-like peptide-2; GRP=gastrin-releasing peptide; PHM=peptide histidine methionine; VIP=vasoactive intestinal peptide.
`1. Zhu L et al. J Biol Chem. 2003;278:22418–22423.
`
`0
`
`0
`
`20
`
`40
`
`80
`60
`Time, min
`
`100
`
`120
`
`Page 10 of 45
`
`
`
`Non-Incretin In Vitro Substrates of DPP-4: In Vitro
`Cleavage of GHRH Does Not Predict In Vivo Biology1
`
` Preclinical data: chronic infusion of a potent, selective DPP-4 inhibitor
`achieving >98% DPP-4 inhibition does not increase IGF-1 in pigs
`
`11
`
`GHRH (n=4, 0.0025 mg/kg/h for 48 h, then saline at 2 mL/h for 24 h)
`Desfluorositagliptin (n=4, 0.236 mg/kg/h for 72 h)
`Saline (n=2, 2 mL/h for 72 h)
`
`GHRH
`
`Saline
`DPP-4 inhibitor
`
`250
`
`200
`
`150
`
`100
`
`50
`
`0
`
`–50
`
`–100
`
`Plasma IGF-1, ng/mL
`
`–30
`
`–20
`
`–10
`
`0
`
`10
`
`30
`20
`Time, h
`
`40
`
`50
`
`60
`
`70
`
`80
`
`DPP-4=dipeptidyl peptidase-4; GHRH=growth hormone-releasing hormone; IGF-1=insulinlike growth factor-1.
`1. Faidley TD et al. Exp Biol Med. 2006;231:1373–1378.
`
`Page 11 of 45
`
`
`
`DPP-4 Inhibitors Require GIP and GLP-1 Receptors
`for Acute Improvement of Glucose Tolerance in Mice
`
`Saline
`DPP-4 Inhibitor
`
`Val-Pyr
`LAF-237
`SYR106124
`TP8211
`
`GIPR-/-
`
`*
`
`**
`
`*
`
`0.6
`
`0.3
`Insulin
`60
`30
`0
`Time (minutes)
`
`90 120
`
`DIRKO
`
`0.6
`
`0.3
`Insulin
`60
`30
`0
`Time (minutes)
`
`90 120
`
`20
`
`15
`
`10
`
`05
`
`-30
`
`20
`15
`10
`
`05
`
`-30
`
`Wildtype
`
`*** ***
`
`***
`
`**
`
`90 120
`
`0.9
`0.6
`0.3
`Insulin
`60
`30
`0
`Time (minutes)
`GLP-1R-/-
`
`***
`
`***
`
`***
`
`*
`
`0.9
`0.6
`0.3
`
`Insulin
`60
`30
`0
`Time (minutes)
`
`90 120
`
`20
`
`15
`
`10
`
`05
`
`-30
`
`20
`
`15
`
`10
`
`05
`
`-30
`
`Blood Glucose (mM)
`
`Blood Glucose (mM)
`
`* / ** / *** P<0.05
`Hansotia T, et al. Diabetes. 2004 May;53(5):1326-1335.
`Copyright © 2004. The American Diabetes Association. Reprinted with permission from the American Diabetes Association.
`
`Page 12 of 45
`
`
`
`13
`
`MRL DPP-4 Inhibitor Program:
`In-Licensed Isoleucyl Thiazolidide (P32/98): October 20001
`
` Moderately potent, reversible DPP-4 inhibitor in phase 1
` Preclinical toxicology study findings in dogs:
`• Acute gastrointestinal toxicity
`• Anemia, thrombocytopenia
`• Mortality
` Development discontinued
`– Basic research and preclinical studies designed to elucidate
`mechanism of toxicity
`CH3
`O
`
`H3C
`
`N
`
`NH2
`
`S
`
`threo isoleucyl thiazolidide (Ile-Thz)
`
`1. Lankas GK et al. Diabetes. 2005;54:2988–2994.
`
`DPP-4=dipeptidyl peptidase-4; MRL=Merck Research Laboratories.
`
`Page 13 of 45
`
`
`
`Preclinical Profiles of threo- and allo-
`Isoleucyl Thiazolidide1
`
`14
`
`H3C
`
`CH3
`
`O
`
`N
`
`S
`
`NH2
`threo-Ile-Thz
`
`H3C
`
`CH3
`
`O
`
`N
`
`S
`
`NH2
`allo-Ile-Thz
`
`1
`
`human DPP-4
`
`Relative Velocity
`
` Mechanism: competitive, reversible
` Similar Ki values (~195 nM)
` Clean in counterscreening at 100 M
` Same efficacy in mouse OGTT
` Similar PK and metabolic profile
`allo-diastereomer ~10-fold more
`potent in preclincial toxicities
`
`0.1
`1
`10
`log (inhibitor, mM)
`threo, Ki = 201 nM
`allo, Ki = 188 nM
`DPP-4=dipeptidyl peptidase-4; IC50= half maximal inhibitory concentration; Ile-Thz=isoleucyl thiazolidide; OGTT=oral glucose tolerance test; PK=pharmacokinetics.
`1. Lankas GK et al. Diabetes. 2005;54:2988–2994.
`
`0
`
`0.01
`
`100
`
`Page 14 of 45
`
`
`
`Residual Proline-Selective DPP Activity in Dpp-4–/– Mice Is
`Differentially Inhibited by allo- and threo-Ile-Thz1
`
`15
`
`Human data:
`
`threo-Ile-Thz
`allo-Ile-Thz
`
`DPP-4
`420
`460
`
`IC50, nM
`DPP-8
`2,180
`220
`
`DPP-9
`1,600
`320
`
`Mouse data:
`• Fluorescent enzyme activity assay: Gly-Pro-AMC + DPP Gly-Pro + AMC*
`• DPP-4 activity was 10- to 25-fold lower in DPP-4 KO vs WT in multiple tissues
`• DPP-4 KO IC50: 730 nM (threo) compared to 90 nM (allo)
`• WT IC50: same for threo and allo isomers
`
`AMC=amino-4-methylcoumarin; AMC*=fluorescent AMC; DPP=dipeptidyl peptidase-4; IC50= half maximal inhibitory concentration; Ile-Thz=isoleucyl thiazolidide; KO=knockout; WT=wild-type.
`1. Lankas GK et al. Diabetes. 2005;54:2988–2994.
`
`Page 15 of 45
`
`
`
`Potential for Nonselective Inhibition:
`The DPP-4 Peptidase Family1
`Specificity
`
`16
`
`Function
`Unknown
`
`NH2-Xaa-Pro~Yaa--
`
`Unknown
`
`Unknown
`
`GLP-1/GIP cleavage
`
`DPP-9
`
`DPP-8
`
`FAP
`
`DPP-4
`
`DPP-6
`
`DPP-4
`Gene
`Family
`
`Other
`Proline-Specific
`Peptidases
`
`PEP
`QPP/DPPII
`Unknown
`APP
`Unknown
`Prolidase
`Unknown
`APP=aminopeptidase P; DPP=dipeptidyl peptidase; FAP= fibroblast activation protein; GIP=glucose-dependent insulinotropic peptide; GLP-1=glucagon-like peptide-1; PEP=prolyl endopeptidase;.
`QPP=quiescent cell proline dipeptidase.
`1. Drucker DJ. Diabetes Care. 2007;30:1335–1343.
`
`Unknown
`
`Unknown
`
`Catalytically inactive
`--Xaa-Pro~Yaa--
`NH2-Xaa-Pro~Yaa--
`NH2-Xaa~Pro-Yaa----
`NH2-Xaa~Pro-COOH
`
`Page 16 of 45
`
`
`
`17
`
`Selectivity of threo- and allo-Ile-Thz
`IC50, allo, nM2
`IC50, threo, nM2
`320
`1600
`220
`2170
`ND
`ND
`460
`420
`Not catalytically active
`> 100000
`> 100000
`
`DPP-9
`
`DPP-8
`
`FAP
`
`DPP-4
`
`DPP-6
`
`DPP-4
`Gene
`Family1
`
`Other
`Proline-Specific
`Enzymes
`
`PEP
`QPP/DPPII
`APP
`Prolidase
`
`14,000
`> 100000
`> 100000
`
`18,000
`> 100000
`> 100000
`
`1. Drucker DJ. Diabetes Care. 2007;30:1335–1343.
`2. Lankas GK et al. Diabetes. 2005;54: 2988–2994.
`
`APP=aminopeptidase P; DPP=dipeptidyl peptidase; FAP= fibroblast activation protein; IC50= half maximal inhibitory concentration;
`Ile-Thz=isoleucyl thiazolidide; ND=not determined; PEP=prolyl endopeptidase; QPP=quiescent cell proline dipeptidase.
`
`Page 17 of 45
`
`
`
`18
`
`Toxicity of Isoleucinyl Thiazolidide Inhibitors1
`Hypothesis
` Toxicity from off-target activity (DPP-8, DPP-9, or QPP)
`
`Strategy
` Identify selective inhibitors of DPP-4, DPP-8, DPP-9, and
`QPP
` Test in comparative toxicity studies
`– 2-week rat toxicity study (10, 30, 100 mg/kg PO)
`– Single-dose dog tolerability study (10 mg/kg PO)
`
`DPP=dipeptidyl peptidase; PO=by mouth; QPP=quiescent cell proline dipeptidase.
`1. Lankas GK et al. Diabetes. 2005;54:2988–2994.
`
`Page 18 of 45
`
`
`
`Identification of Selective DPP-4 Inhibitors1
`
`19
`
`F
`
`F
`
`NH2
`
`O
`
`N
`
`N
`
`N
`
`N
`
`CF3
`
`DPP-4 Selective
`Enzyme
`
`O
`
`NS
`O
`
`O
`
`N
`
`NH2
`
`S
`
`I
`
`Me
`
`Me
`
`O
`
`N
`
`NH2
`
`DPP-8/9 Selective
`
`QPP Selective
`IC50, nM
`DPP-8/9 Selective
`QPP Selective
`DPP-4 Selective
`55
`11,000
`>100,000
`DPP9
`38
`22,000
`69,000
`DPP8
`>100,000
`>100,000
`>100,000
`FAP
`27
`30,000
`1900
`DPP-4
`>100,000
`63,000
`>100,000
`PEP
`19
`14,000
`>100,000
`QPP/DPPII
`>100,000
`>100,000
`>100,000
`APP
`>100,000
`>100,000
`>100,000
`Prolidase
`APP=aminopeptidase; DPP=dipeptidyl peptidase; FAP= fibroblast activation protein; IC50= half maximal inhibitory concentration; PEP=prolyl endopeptidase; QPP=quiescent cell proline dipeptidase.
`1. Lankas GK et al. Diabetes. 2005;54:2988–2994.
`
`Page 19 of 45
`
`
`
`20
`
`Comparative Toxicity Studies1
`2-Week Rat Study at 10, 30 100 mg/kg/day; Acute dog toxicity at 10 mg/kg
`2-Week Rat
`QPP
`DPP-8/9
`DPP-4
`Toxicity
`Selective
`Selective
`Selective
`Alopecia
`
`Thrombocytopenia
`
`Anemia
`
`Enlarged spleen
`
`Mortality
`
`Acute Dog Toxicity
`Bloody diarrhea
`
`Nonselective
`
`
`
`
`
`
`
`
`Conclusion: Inhibition of DPP-8 and/or DPP-9 resulted in multiorgan
`toxicities in rats and dogs.
`
`DPP=dipeptidyl peptidase; QPP=quiescent cell proline dipeptidase.
`1. Lankas GK et al. Diabetes. 2005;54:2988–2994.
`
`Page 20 of 45
`
`
`
`21
`
`100
`
`Inhibition of DPP-8/9 Attenuated T-Cell Proliferation
`In Vitro, While Selective DPP-4 Inhibition Did Not1
`
`Superantigen Stimulated
`100
`90
`80
`70
`60
`50
`40
`30
`20
`10
`0
`–10
`–20
`–30
`0.0001
`
`Inhibition, %
`
`IC50, μM
`QPP
`DPP-8 DPP-9
`
`DPP-4
`
`0.0005
`
`>100
`
`>100
`
`86
`
`<0.004
`
`0.310
`
`0.004
`
`0.011
`
`30
`
`14
`
`0.038
`
`0.055
`
`DPP-4
`selective
`
`DPP-4
`nonselective
`
`DPP-8/9
`selective
`
`DPP-4 Nonselective
`DPP-8/9 Selective
`DPP-4 Selective
`
`1
`0.01
`Compound, μM
`• Similar results in
`PHA-stimulated assay
`
`DPP=dipeptidyl peptidase; IC50= half maximal inhibitory concentration; PHA=phytohemagglutinin; QPP=quiescent cell proline dipeptidase.
`1. Lankas GK et al. Diabetes. 2005;54:2988–2994.
`
`Page 21 of 45
`
`
`
`22
`
`Identification of Sitagliptin: 20011
`
`Sitagliptin (MK-0431)
`
`Enzyme
`DPP-4
`DPP-8
`DPP-9
`Quiescent cell prolyl peptidase (QPP, DPP-II)
`Fibroblast activation protein (FAP) (seprase)
`Prolyl endopeptidase
`Aminopeptidase P
`
`DPP=dipeptidyl peptidase; IC50= half maximal inhibitory concentration.
`1. Kim D et al. J Med Chem. 2005;48:141–151.
`
`F
`
`F
`
`F
`
`NH2
`
`O
`
`N
`
`N
`
`N
`
`N
`
`CF3
`
`IC50, nM
`18
`48,000
`>100,000
`>100,000
`>10,000
`>10,000
`>10,000
`
`Page 22 of 45
`
`
`
`Proposed Structural Basis for Selectivity
`of Sitagliptin
`DPP-4 Crystal Structure1
`
`DPP-8 Homology Model1
`
`23
`
`R125
`
`S209
`
`E205
`E206
`
`S630
`
`K174
`
`S739
`
`E259
`E260
`
`R358
`
`H435
`
`Y547
`
`F357
`
`Y653
`
` Homology modeling indicates DPP-8 pocket lacking key residues Ser209, Phe357,
`and Arg3582
` DPP-9 model similar2
`
`1. Data on file, MSD.
`2. Rummey C et al. Proteins. 2007;66:160–171.
`
`DPP=dipeptidyl peptidase.
`
`Page 23 of 45
`
`
`
`DPP-4 Inhibitors
`
`24
`
`O
`
`CN
`
`N
`
`HN
`
`Vildagliptin2
`
`N
`
`O
`
`N
`
`HO
`
`N
`N
`
`N
`
`F
`F
`
`F
`
`F
`
`F
`
`F
`Sitagliptin1
`
`O
`
`N
`
`O
`
`N
`
`N
`
`NH2
`
`N
`
`N N
`
`O
`
`N
`
`N
`
`N
`
`N
`
`O
`
`Linagliptin5
`
`O
`
`N
`
`N
`
`N
`Alogliptin3
`
`N
`
`O
`Saxagliptin4
`
`N
`
`DPP-4=dipeptidyl peptidase-4.
`1. Kim D et al. J Med Chem. 2005;48:141–151. 2. Villhauer EB et al. J Med Chem. 2003;46:2774–2789. 3. Feng J et al. J Med Chem. 2007;50:2297–2300.
`4. Augeri DJ et al. J Med Chem. 2005;48(15):5025–5037. 5. Thomas L et al. J Pharmacol Exp Ther. 2008;325:175–182.
`
`Page 24 of 45
`
`
`
`Sitagliptin Is Designed for Binding to the
`DPP-4 Active Site (X-ray structure)1
`
`25
`
`H126
`
`H740
`
`R125
`
`Y662
`
`S630
`
`E205
`E206
`
`S209
`
`R358
`
`Y547
`
`F357
`
`1. Data on file, MSD.
`
`DPP-4=dipeptidyl peptidase-4.
`
`Page 25 of 45
`
`
`
`Vildagliptin in the DPP-4 Active Site
`(X-ray structure)1
`
`26
`
`R125
`
`E205
`E206
`
`H126
`
`S209
`
`R358
`
`H740
`
`S630
`
`Y547
`
`F357
`
`1. Data on file, MSD.
`
`DPP-4=dipeptidyl peptidase-4.
`
`Page 26 of 45
`
`
`
`Sitagliptin and Vildagliptin in the DPP-4
`Active Site (X-ray structure)1
`
`27
`
`H740
`
`Yellow: sitagliptin
`Green: vildagliptin
`
`S630
`
`R125
`
`E205
`
`E206
`
`H126
`
`S209
`
`R358
`
`Y547
`
`F357
`
`1. Data on file, MSD.
`
`DPP-4=dipeptidyl peptidase-4.
`
`Page 27 of 45
`
`
`
`DPP-4/Inhibitor Binding: Structural Studies Show
`All DPP-4 Inhibitors Bind to Active Site of DPP-4
`
`Sitagliptin
`
`Linagliptin
`
`Saxagliptin
`Metabolite
`
`1. Data on file, MSD.
`
`Alogliptin
`
`Saxagliptin
`
`Vildagliptin
`
`Page 28 of 45
`
`
`
`DPP-4 Inhibitor Pharmacokinetics in Humans:
`Sitagliptin Has an Elimination Half-Life Consistent With
`Once-Daily Dosing
`
`29
`
`3
`Saxagliptin
`Active metabolite
`
`3.1
`
`2.5
`
`14
`
`12
`
`10
`
`02468
`
`2
`
`Sitagliptin
`12.5
`
`14
`
`12
`
`10
`
`02468
`
`1
`Vildagliptin
`
`3.5
`
`2×/day
`
`1×/day
`
`1×/day
`
`DPP-4=dipeptidyl peptidase-4.
`
`14
`
`12
`
`10
`
`02468
`
`Half-Life, h
`
`Dosing:
`
`1. Galvus EU-SPC 2011.
`2. JANUVIA EU-SPC 2011.
`3. Onglyza EU-SPC 2011.
`
`Page 29 of 45
`
`
`
`DPP-4 Activity Is Inhibited by 97% Over
`24 Hours With Sitagliptin 100 mg1,a
`Single-dose study in healthy subjects (n=6)
`
`100
`
`30
`
`Sitagliptin 100 mg qd
`
`0 1 2
`
`4
`
`6
`
`8
`
`12
`16
`Hours Postdose
`
`24
`
`80
`
`60
`
`40
`
`20
`
`0
`
`DPP-4 Inhibition, %a
`
`DPP-4=dipeptidyl peptidase-4; qd=once daily.
`aDPP-4 inhibition corrected for sample assay dilution.
`1. Alba M et al. Curr Med Res Opin. 2009;25:2507–2514.
`
`Page 30 of 45
`
`
`
`A Single Dose of Sitagliptin Increased Active
`GLP-1 and GIP Over 24 Hours
`Crossover single-dose study in patients with type 2 diabetes
`Active GIP1
`Active GLP-11
`Placebo
`OGTT
`OGTT
`OGTT
`OGTT
`24 h (n=19)
`2 h (n=55)
`2 h (n=55)
`24 h (n=19)
`
`Sitagliptin 25 mg
`
`Sitagliptin 200 mg
`
`31
`
`
`
`
`
`
`
`0000
`
`
`
`
`70707070
`
`
`
`60606060
`
`
`
`50505050
`
`
`
`40404040
`
`
`
`30303030
`
`
`
`20202020
`
`
`
`10101010
`
`
`
`0000
`
`(P<0.001 treatment
`vs placebo)
`
`GIP, pM
`
`26
`
`2626
`
`28
`
`2828
`
`2
`
`22
`
`0
`
`00
`
`30
`
`3030
`25
`
`2525
`20
`
`2020
`15
`
`1515
`10
`
`1010
`
`55
`
`05
`
`GLP-1, pM
`
`GIP=glucose-dependent insulinotropic peptide; GLP-1=glucagon-like peptide-1; OGTT=oral glucose tolerance test.
`1. Herman GA et al. J Clin Endocrinol Metab. 2006;91:4612–4619. Copyright © 2006, The Endocrine Society.
`2. JANUVIA EU-SPC 2011.
`
`
`
`
`4444
`
`
`
`6666
`
`
`
`24242424
`24
`6
`4
`
`2424
`
`66
`
`44
`Hours Postdose
`Hours Postdose
`The recommended dose of sitagliptin is 100 mg once daily for appropriate patients.2
`
`
`
`
`
`
`
`2222
`
`
`
`
`
`
`
`26 2826 2826 2826 28
`
`Page 31 of 45
`
`
`
`DPP-4 Inhibition Increases Insulin, Decreases Glucagon,
`and Reduces Glycemic Excursion After a Glucose Load1
`Crossover single-dose study in patients with type 2 diabetes
`40
`Placebo
`
`32
`
`30
`
`20
`
`10
`
`0
`
`µU/mL
`
`75
`70
`65
`60
`55
`50
`
`pg/mL
`
`P<0.05 for both dose comparisons to placebo for AUC
`0
`1
`2
`3
`Time, h
`AUC=area under the curve; DPP-4=dipeptidyl peptidase-4.
`1. Herman GA et al. J Clin Endocrinol Metab. 2006;91:4612–4619.
`
`4
`
`Sitagliptin 25 mg
`
`Sitagliptin 200 mg
`
`Glucose
`Drug
`Glucose
`Dose
`Load
`
`~26%
`
`0
`
`1
`
`P<0.001 for both dose comparisons to placebo for AUC
`2
`3
`4
`5
`6
`Time, h
`
`17.8
`15.5
`13.3
`11.1
`8.9
`6.7
`
`mmol/L
`
`22
`%
`
`14
`%
`
`Insulin
`Drug
`Dose
`
`Glucose
`Load
`
`P<0.05 for both dose comparisons to placebo for AUC
`0
`1
`2
`3
`Glucagon
`
`4
`
`Page 32 of 45
`
`
`
`33
`
`Sitagliptin Monotherapy Significantly Lowers
`HbA1c With Once-Daily Dosing1
`24-Week Study
`Inclusion criteria: HbA1c 7%–10% not on OAHA for ≥8 weeks
`All patients – treated population
`Prespecified subgroup analysis
`by baseline HbA1c
`<8% 8%–9% ≥9%
`
`8.4
`
`n=130
`
`n=62
`
`n=37
`
`–0.57
`
`–0.8
`
`0.0
`–0.2
`–0.4
`–0.6
`–0.8
`–1.0
`–1.2
`–1.4
`–1.6
`–1.52
`Progressively greater reductions
`in HbA1c with higher baselines
`
`Placebo-Subtracted
`
`ΔHbA1c, %
`
`ΔHbA1c (week 24) =
`–0.79% (P<0.001)
`
`Placebo (n=244)a
`Sitagliptin 100 mg (n=229)a
`
`8.0
`
`7.6
`
`7.2
`
`HbA1c, %
`
`0
`
`6
`
`18
`
`24
`
`12
`Weeks
`
`OAHA=oral antihyperglycemic agent.
`an-value at week 24.
`1. Aschner P et al. Diabetes Care. 2006;29:2632–2637.
`
`Page 33 of 45
`
`
`
`Addition of Sitagliptin or Glipizide in Patients Inadequately
`Controlled on Metformin: Study Design1,2
`
`34
`
` Multinational, randomized, double-blind study compared sitagliptin with glipizide in patients with
`T2DM with inadequate glycemic control on metformin
` Noninferiority design (for primary hypothesis at week 52)
`
`Continue/start
`metformin
`monotherapy
`
`Week –2:
`Eligible if HbA1c
`≥6.5% to ≤10%
`
`Glipizide: 5 mg/day increased to 20 mg/day
`(held if premeal fingerstick glucose <6.1 mmol/L
`or hypoglycemia)
`
`Day 1
`Randomization
`Metformin monotherapy run-
`in period
`
`Screening
`period
`
`Double-blind treatment period:
`glipizide or sitagliptin 100 mg qd
`
`Week 104
`
`Single-blind
`placebo
`
`Week 52
`Primary End Point
`Metformin (stable dose ≥1,500 mg/day)
`
` Mean glipizide titrated dose was 9.2 mg/day for the per-protocol population
`
`qd=once daily; T2DM=type 2 diabetes mellitus.
`1. Nauck MA et al. Diabetes Obes Metab. 2007;9(2):194–205.
`2. Seck T et al. Int J Clin Pract. 2010;64(5):562–576.
`
`Page 34 of 45
`
`
`
`35
`
`8.2
`
`8.0
`
`Change in HbA1cFrom Baseline (±SE), %
`
`Sitagliptin Was Noninferior to Glipizide in Reducing HbA1c
`at Week 52 (Primary End Point)1
`Per-Protocol Population
`LS mean change from baseline
`at 52 weeks (for both groups): –0.7%
`Sulfonylureaa + metformin (n=411 at 52 weeks)
`Sitagliptinb + metformin (n=382 at 52 weeks)
`
`7.8
`
`7.6
`
`7.4
`
`7.2
`
`7.0
`
`6.8
`
`6.6
`
`6.4
`
`6.2
`
`Achieved primary
`hypothesis of
`noninferiority to
`sulfonylurea
`
`0
`
`6
`
`12
`
`18
`
`24
`Weeks
`
`30
`
`38
`
`46
`
`52
`
`LS=least-squares; SE=standard error.
`aSpecifically glipizide ≤20 mg/day; bSitagliptin 100 mg/day with metformin (≥1,500 mg/day).
`Adapted from Nauck MA, Meininger G, Sheng D, et al, for the Sitagliptin Study 024 Group. Efficacy and safety of the dipeptidyl peptidase-4 inhibitor, sitagliptin, compared with the
`sulfonylurea, glipizide, in patients with type 2 diabetes inadequately controlled on metformin alone: a randomized, double-blind, non-inferiority trial. Diabetes Obes Metab.
`2007;9(2):194–205 with permission from Blackwell Publishing Ltd., Boston, MA.
`1. Nauck MA et al. Diabetes Obes Metab. 2007;9(2):194–205.
`
`Page 35 of 45
`
`
`
`36
`
`Summary and Conclusion
` Incretins are rapidly degraded by DPP-4.
`– DPP-4 inhibition increases the concentration of active incretins, thereby
`increasing insulin release and decreasing circulating glucagon levels in a
`glucose-dependent manner.
` Highly-selective DPP-4 inhibitors have not been associated with
`preclinical toxicity.
` Sitagliptin has a favorable PK/PD profile.
` Sitagliptin monotherapy and combination therapy with metformin
`provided substantial and statistically significant glucose-lowering
`efficacy.
`
`DPP-4=dipeptidyl peptidase-4; PK=pharmacokinetic; PD=pharmacodynamic.
`
`Page 36 of 45
`
`
`
`JANUVIA™ (sitagliptin, MSD)
`JANUMET™ (sitagliptin/metformin, MSD)
`
`Page 37 of 45
`
`
`
`38
`
`JANUVIA™ (sitagliptin, MSD):
`Indications
` For patients with type 2 diabetes mellitus, JANUVIA is indicated to improve glycaemic control
`as monotherapy in patients inadequately controlled by diet and exercise alone and for whom
`metformin is inappropriate due to contraindications or intolerance; as dual oral therapy in
`combination with metformin when diet and exercise plus metformin alone do not provide
`adequate glycaemic control; in combination with a sulphonylurea when diet and exercise plus
`maximal tolerated dose of a sulphonylurea alone do not provide adequate glycaemic control
`and when metformin is inappropriate due to contraindications or intolerance; in combination
`with a PPARγ agonist (ie, a thiazolidinedione) when use of a PPARγ agonist is appropriate
`and when diet and exercise plus the PPARγ agonist alone do not provide adequate
`glycaemic control; as triple oral therapy in combination with a sulphonylurea and metformin
`when diet and exercise plus dual therapy with these agents do not provide adequate
`glycaemic control; and in combination with a PPARγ agonist and metformin when use of a
`PPARγ agonist is appropriate and when diet and exercise plus dual therapy with these
`agents do not provide adequate glycaemic control. JANUVIA is also indicated as add-on to
`insulin (with or without metformin) when diet and exercise plus stable dose of insulin do not
`provide adequate glycaemic control.
`
`Page 38 of 45
`
`
`
`39
`
`JANUVIA™ (sitagliptin, MSD):
`Selected Safety Information
` JANUVIA is contraindicated in patients who are hypersensitive to any component of this
`product.
` JANUVIA should not be used in patients with type 1 diabetes or for the treatment of diabetic
`ketoacidosis.
` There have been postmarketing reports of acute pancreatitis in patients taking JANUVIA.
`Patients should be informed of the characteristic symptom of acute pancreatitis: persistent,
`severe abdominal pain. Resolution of pancreatitis has been observed after discontinuation of
`JANUVIA (with or without supportive treatment), but very rare cases of necrotizing or
`haemorrhagic pancreatitis and/or death have been reported. If pancreatitis is suspected,
`JANUVIA and other potentially suspect medicinal products should be discontinued.
` When sitagliptin was added to a sulphonylurea or to insulin, the incidence of hypoglycaemia
`was increased over that of placebo. To reduce the risk of hypoglycaemia, a lower dose of
`sulphonylurea or insulin may be considered.
` As the experience is limited, patients with moderate to severe renal impairment should not be
`treated with JANUVIA.
` JANUVIA is not recommended for use in children below 18 years of age due to a lack of data
`on its safety and efficacy. JANUVIA should not be used during pregnancy or during breast-
`feeding.
` Postmarketing reports of serious hypersensitivity reactions in patients treated with JANUVIA
`have been reported including anaphylaxis, angioedema, and exfoliative skin conditions
`including Stevens-Johnson syndrome. Onset of these reactions occurred within the first 3
`months after initiation of treatment with JANUVIA, with some reports occurring after the first
`dose. If a hypersensitivity reaction is suspected, discontinue JANUVIA, assess for other
`potential causes for the event, and institute alternative treatment for diabetes.
`
`Page 39 of 45
`
`
`
`40
`
`JANUVIA™ (sitagliptin, MSD):
`Selected Safety Information (continued)
` In clinical studies as monotherapy and in combination with other agents, drug-related
`adverse reactions reported, in excess (>0.2% and difference >1 patient) of placebo in
`double-blind studies included decreased blood glucose, headache, somnolence, diarrhoea,
`dry mouth, nausea, flatulence, constipation, upper abdominal pain, vomiting, hypoglycaemia,
`influenza, peripheral oedema, and dizziness. Adverse events (reported regardless of causal
`relationship to medicinal product) occurring in at least 5% and more commonly in patients
`treated with sitagliptin included upper respiratory tract infection and nasopharyngitis.
`Additional adverse experiences, occurring more frequently (not reaching the 5% level but
`occurring >0.5%) with JANUVIA than in the control group included osteoarthritis and pain in
`extremity. For additional adverse experience information, see the product circular.
` No dosage adjustment is required based on age. Age did not have a clinically meaningful
`impact on the pharmacokinetics of sitagliptin based on a population pharmacokinetic analysis
`of phase I and phase II data. Elderly subjects (65 to 80 years) had approximately 19% higher
`plasma concentrations of sitagliptin compared to younger subjects. Care should be exercised
`in patients ≥75 years of age (limited safety data available).
` Before initiating therapy, please consult the full prescribing information.
`
`Page 40 of 45
`
`
`
`41
`
`JANUMET™ (sitagliptin/metformin, MSD):
`Indications
`
` For patients with type 2 diabetes mellitus: JANUMET is indicated as an adjunct to
`diet and exercise to improve glycaemic control in patients inadequately controlled
`on their maximal tolerated dose of metformin alone or those already being treated
`with the combination of sitagliptin and metformin. JANUMET is indicated in
`combination with a sulphonylurea or a PPARγ agonist (triple combination therapy)
`as an adjunct to diet and exercise in patients inadequately controlled on their
`maximal tolerated dose of metformin and a sulphonylurea or a PPARγ agonist,
`respectively. JANUMET is also indicated as an add-on to insulin (triple combination
`therapy) as an adjunct to diet and exercise to improve glycaemic control in patients
`when stable dose of insulin and metformin alone do not provide adequate glycaemic
`control.
`
`Page 41 of 45
`
`
`
`42
`
`JANUMET™ (sitagliptin/metformin, MSD):
`Selected Safety Information
` JANUMET is contraindicated in patients with hypersensitivity to any component of this
`product; diabetic ketoacidosis, diabetic pre-coma; moderate or severe renal impairment
`(creatinine clearance <60 ml/min); acute conditions with the potential to alter renal function,
`(eg, dehydration, severe infection, shock, contrast agents); acute or chronic disease that may
`cause tissue hypoxia (eg, cardiac or respiratory failure, recent myocardial infarction, shock)
`hepatic impairment; and acute alcohol intoxication or alcoholism; and in patients who are
`lactating.
` JANUMET should not be used in patients with type 1 diabetes and must not be used for the
`treatment of diabetic ketoacidosis.
` There have been postmarketing reports of acute pancreatitis in patients taking sitagliptin.
`Patients should be informed of the characteristic symptom of acute pancreatitis: persistent,
`severe abdominal pain. Resolution of pancreatitis has been observed after discontinuation of
`sitagliptin (with or without supportive treatment), but very rare cases of necrotizing or
`haemorrhagic pancreatitis and/or death have been reported. If pancreatitis is suspected,
`JANUMET and other potentially suspect medicinal products should be discontinued.
` Serum creatinine concentrations should be determined at least once a year in patients with
`normal renal function and at least 2 to 4 times a year in patients with serum creatinine levels
`at or above the upper limit of normal and in elderly patients.
` Patients receiving JANUMET in combination with a sulphonylurea or with insulin may be at
`risk of hypoglycaemia. Therefore, a reduction in the dose of the sulphonylurea or insulin may
`be necessary.
`
`Page 42 of 45
`
`
`
`43
`
`JANUMET™ (sitagliptin/metformin, MSD):
`Selected Safety Information (continued)
` Temporarily discontinue JANUMET in patients undergoing surgery or radiologic studies
`involving intravascular administration of iodinated contrast materials and in those with
`intercurrent serious conditions or infection.
` Promptly evaluate a patient who develops laboratory abnormalities or clinical illness for
`evidence of ketoacidosis or lactic acidosis. If acidosis occurs, discontinue JANUMET
`immediately and initiate appropriate corrective measures.
` JANUMET is not recommended for use in children below 18 years of age due to a lack of
`data on its safety and efficacy. JANUMET should not be used during pregnancy or during
`breast-feeding.
` Postmarketing reports of serious hypersensitivity reactions in patients treated with sitagliptin
`have been reported including anaphylaxis, angioedema, and exfoliative skin conditions
`including Stevens-Johnson syndrome. Onset of these reactions occurred within the first
`3 months after initiation of treatment with sitagliptin, with some reports occurring after the first
`dose. If a hypersensitivity reaction is suspected, discontinue JANUMET, assess for other
`potential causes of the event, and institute alternative treatment for diabetes.
`
`Page 43 of 45
`
`
`
`44
`
`JANUMET™ (sitagliptin/metformin, MSD):
`Selected Safety Information (continued)
` In clinical studies of sitagliptin added to metformin alone or in combination with other agents
`(ie, triple combination), drug-related adverse reactions reported in excess (>0.2% and
`difference >1 patient) of placebo in double-blind studies included decreased blood glucose,
`headache, somnolence, diarrhoea, nausea, constipation, upper abdominal pain, vomiting,
`dry mouth, hypoglycaemia, and peripheral oedema. In monotherapy studies with sitagliptin,
`adverse reactions considered as drug-related in excess (>0.2% and difference >1 patient) of
`placebo included headache, hypoglycaemia, constipation, and dizziness. Adverse events
`(reported regardless of causal relationship to medicinal product) occurring in at least 5% and
`more commonly in patients treated with sitagliptin included upper respiratory tract infection
`and nasopharyngitis. Adverse reactions identified from clinical trial and postmarketing data
`with metformin included metallic taste, nausea, vomiting, diarrhoea, abdominal pain, and loss
`of appetite. For additional adverse experience information, see the product circular. Before
`initiating therapy, please consult the full prescribing information.
` No dose adjustment is required based
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