J O U R N A L O F T H E R O Y A L S O C I E T Y O F M E D I C I N E
`
`V o l u m e 9 7
`
`J u n e 2 0 0 4
`
`GLP-1: target for a new class of antidiabetic agents?
`
`C Mark B Edwards PhD MRCP
`
`J R Soc Med 2004;97:270–274
`
`In 1998 a large highly powered trial, the UK Prospective
`Diabetes Study (UKPDS), demonstrated that in type 2
`diabetes several clinical endpoints were improved by better
`diabetic
`control. A 0.9% decrease
`in glycosylated
`haemoglobin (HbA1c) over ten years was associated with
`a 25% reduction in microvascular complications (P=0.0099)
`and a
`less
`impressive 16% reduction in myocardial
`infarction (P=0.052).1 With this evidence base, the pressure
`is on for physicians to improve the HbA1c of people with
`diabetes.
`
`CURRENT ANTIDIABETIC DRUGS
`
`Therapies currently available for type 2 diabetes are limited,
`and all have drawbacks. Metformin, which reduced
`mortality and morbidity in obese people with type 2
`diabetes in the UKPDS, is widely used as therapy for such
`patients.2 Contraindications are renal failure, heart failure
`and liver dysfunction but these are relative: in one study a
`quarter of patients treated with it had contraindications,3
`and many clinicians use metformin despite moderate renal
`dysfunction (e.g. creatinine less than 150 mmol/L), chronic
`stable heart
`failure or mild liver dysfunction when
`transaminases are less than three times normal. A rare
`side-effect is lactic acidosis, probably avoidable if the drug is
`not used in severe renal or liver failure.4 In addition, many
`patients cannot tolerate the gastrointestinal side-effects.5
`The other compounds commonly used to treat type 2
`diabetes are sulphonylureas. These drugs have likewise been
`least microvascular).1
`shown to improve morbidity (at
`However,
`sulphonylureas
`carry a
`substantial
`risk of
`hypoglycaemia,6 particularly in elderly patients and those
`with poor renal function. The rate of major hypoglycaemic
`events in the UKPDS was 1–1.4% per year. In addition,
`sulphonylureas caused weight gain of 1.7–2.6 kg.1 Metfor-
`min and sulphonylureas are commonly prescribed in
`combination; however, in the UKPDS, the group in whom
`metformin was added to a sulphonylurea had a 96% higher
`rate of diabetes-related death than those treated with
`sulphonylureas alone.2 Although the metformin-sulphonyl-
`urea group was small and this statistical analysis was not a
`primary endpoint of the study, concern remains regarding
`the combination.7 Two new sulphonylurea-like drugs,
`
`REVIEWARTICLES
`
`nateglinide and repaglinide, bind to the sulphonylurea
`receptor and stimulate insulin secretion. Their action is
`short-lasting and hypoglycaemic episodes are less trouble-
`some than with established sulphonylureas; however, their
`usefulness alone appears limited to early type 2 diabetes
`and, even then, they may be less effective than established
`agents in reducing HbA1c.8,9
`The alpha-glucosidase inhibitor acarbose delays intestinal
`carbohydrate absorption. It appears less efficacious than
`antidiabetic drugs10
`other
`and has not proved as
`successful—not least because of its gastrointestinal side-
`effects. In contrast, the thiazolidinediones are increasingly
`prescribed. Rosiglitazone and pioglitazone are peroxisome-
`proliferator-activated receptor gamma (PPARg) agonists
`which alter transcription of
`several genes
`involved in
`carbohydrate and lipid metabolism. These agents decrease
`insulin resistance11
`and seem to be
`as potent
`as
`sulphonylureas or metformin.12,13 Unfortunately, thiazoli-
`dinediones induce weight gain and can cause fluid retention
`and are thus contraindicated in heart failure. In recent NICE
`guidelines thiazolidinediones are recommended only in
`combination with metformin or sulphonylureas, in patients
`who either cannot tolerate a combination of the latter two
`drugs through side-effects or have a contraindication to one
`of
`them.
`In reality,
`clinicians
`are
`starting to use
`thiazolidinediones outside the NICE guidelines and even
`beyond the terms of the UK drug licence, particularly as
`triple therapy with sulphonylureas and metformin. There is
`very little published information on the safety or efficacy of
`triple therapy; glycaemic control does seem to improve,
`though at the expense of more hypoglycaemic events,
`weight gain and oedema.14
`
`GLP-1
`
`for type 2 diabetes have
`treatments
`the current
`All
`important limitations, so the search is on for alternatives.
`Glucagon-like peptide-1 (GLP-1)
`analogues
`seem an
`attractive possibility.
`With oral ingestion of glucose, plasma concentrations
`of insulin are about twice those induced by intravenous
`infusion of an equivalent dose of glucose.15 GLP-1 and GIP
`(glucose-dependent insulinotropic peptide) are responsible
`for most of the differences between these two values,
`known as the incretin effect.16 GLP-1 has a physiological
`role in the incretin effect in some species though not
`
`270
`
`Hillingdon Hospital, Uxbridge UB8 3NN, UK
`
`E-mail: c.m.b.edwards@imperial.ac.uk
`
`MPI EXHIBIT 1082 PAGE 1
`
`MPI EXHIBIT 1082 PAGE 1
`
`

`

`J O U R N A L O F T H E R O Y A L S O C I E T Y O F M E D I C I N E
`
`V o l u m e 9 7
`
`J u n e 2 0 0 4
`
`all.17–19 When infused in people with type 2 diabetes, GIP
`appears ineffective.20 By contrast, GLP-1 decreases glucose
`levels,20,21 stimulates insulin secretion, decreases glucagon,
`delays gastric emptying, reduces food intake, stimulates
`beta-cell neogenesis, may enhance insulin sensitivity,22 and
`may inhibit beta-cell apoptosis.23 Its effect
`is glucose-
`dependent, lessening though probably not removing the risk
`of hypoglycaemia.24,25 Thus, GLP-1 has several potential
`advantages over current treatments for type 2 diabetes.
`‘Proof of principle’ for GLP-1 as a therapeutic agent was
`demonstrated by regular subcutaneous injections26 and by
`intravenous27 or subcutaneous infusion.28,29 The circulating
`half-life of GLP-1 is about one minute,30 making it an
`unlikely diabetic agent, but several strategies have been
`explored to utilize the principle.
`GLP-1 is broken down by the enzyme dipeptidyl
`peptidase IV (DPP IV).31,32 Mice lacking this enzyme
`(DPP IV knockout) show better glucose tolerance, higher
`GLP-1 levels and greater insulin sensitivity than their non-
`knockout equivalents,33
`and less obesity and insulin
`resistance when fed a high fat diet.34 Various DPP IV
`antagonists and DPP IV resistant analogues of GLP-1 are
`under investigation.
`
`DPP IV ANTAGONISTS
`
`P32/98, NVP-DPP728 and FE 999011 are DPP IV
`antagonists. Treatment of Zucker fatty rats (a model of
`type 2 diabetes) with P32/98 for three months caused
`sustained improvement in glucose tolerance,35 and mice fed
`a standard or high-fat diet had better glycaemic control after
`eight weeks of NVP-DPP728.36 P32/98 stimulated islet
`neogenesis and beta-cell survival in rats with streptozotocin-
`induced diabetes, suggesting possible usefulness in type 1 or
`late type 2 diabetes.37 Administration of FE 999011 to
`Zucker rats for seven days delayed the onset of diabetes.38
`Published work with DPP IV in man is limited. Twice
`or three times daily oral treatment with NVP-DPP728 for
`four weeks reduced HbA1c by 0.5%.39 Fasting, post-
`prandial and mean 24-hour glucoses were all reduced, but
`body weight was unchanged. The medication was generally
`well tolerated in this patient group, although one out of a
`group of sixty-five developed transient nephrotic syndrome
`and was withdrawn from the study.39 Pharmacokinetic
`assessment of NVP-DPP728 and its daughter compound
`NVP-LAF237 in monkeys indicates that NVP-LAF237 is
`suitable for once daily administration and this seems a better
`therapeutic option, though both products are currently in
`phase II clinical testing.40
`DPP IV is not specific to GLP-1 and breaks down
`several other peptides including neuropeptide Y, peptide
`YY and GIP as well as chemokines such as macrophage-
`derived chemokine and eotaxin.41 Whether increases in the
`
`half-lives of some or all of these compounds will cause side-
`effects awaits further evaluation.
`
`GLP-1 ANALOGUES
`
`Long-acting GLP-1 receptor agonists such as exendin-4 and
`liraglutide (NN2211) are also under therapeutic investiga-
`tion. Exendin-4, isolated from the salivary gland of the Gila
`monster (Heloderma suspectum [Figure 1]), has 53% sequence
`homology to GLP-1 and is a high-affinity GLP-1 receptor
`agonist.42 Exendin-4 has a longer duration of action than
`GLP-1: it improved glycaemic control in diabetic mice, rats
`and baboons and decreased food intake and body weight in
`Zucker rats.43,44 Exendin-4 stimulated beta-cell replication
`tolerance,45
`and neogenesis,
`improving
`glucose
`and
`stimulated
`non-insulin-secreting
`pancreatic
`cells
`into
`producing insulin.46 The beta-cell neogenesis may occur
`via increased expression of the homeodomain protein IDX-
`1,47 the lack of which results
`in failure of pancreas
`development.48 Interestingly, transgenic mice processing
`excess exendin-4 exhibited improved glucose tolerance and
`ate less food in the short term but had normal beta-cell mass
`and islet histology.49 Injection of exogenous exendin-4 to
`streptozotocin treated newborn rats increased beta-cell
`mass
`though glucose-stimulated insulin secretion was
`unaltered.50 Exendin-4 increased beta-cell mass and delayed
`the onset of diabetes when administered in the prediabetic
`state to two rodent models of diabetes.51,52
`Intravenous infusion of exendin-4 in healthy volunteers
`was well tolerated at one dose but doubling of the dose
`caused postprandial nausea in some and trebling caused
`vomiting in most.53 The half-life of intravenous exendin-4
`
`Figure 1 The Gila monster (Heloderma suspectum) (courtesy of
`Dr Mark Seward, www.drseward.com)
`
`271
`
`MPI EXHIBIT 1082 PAGE 2
`
`MPI EXHIBIT 1082 PAGE 2
`
`

`

`J O U R N A L O F T H E R O Y A L S O C I E T Y O F M E D I C I N E
`
`V o l u m e 9 7
`
`J u n e 2 0 0 4
`
`was about 30 minutes. It decreased fasting and postprandial
`glucose and reduced food intake by 19%.53 Exendin-4
`seems
`not
`to
`affect
`insulin
`sensitivity
`in
`healthy
`volunteers.54
`More data are available for exendin-4 (exenatide is the
`synthetic peptide)
`than for
`the DPP IV antagonists.
`Exenatide is insulinotropic in healthy volunteers and people
`with type 2 diabetes.55 Subcutaneous injection of exenatide
`prevented any postprandial rise in glucose for 300 minutes
`in people with diabetes whether on diet, oral antidiabetic
`agents or insulin.56 This effect seemed partly due to delayed
`gastric emptying and glucagon suppression. Exenatide
`decreased fasting glucose with a maximum effect 3–4 hours
`after subcutaneous injection, seemingly via insulin stimula-
`tion. Though no individuals withdrew from these studies
`there were slightly more gastrointestinal side-effects in the
`treatment groups.56
`Subcutaneous injection of exenatide, in patients on no
`other antidiabetic therapy57 or as an additive treatment to
`metformin or sulphonylureas,58 caused a drop in HbA1c of
`0.8% and 0.6%, respectively. However, there was no
`control group in the first study57 and neither study showed
`a change in body weight. Serious side-effects were rare;
`reported nausea declined over time and hypoglycaemia
`occurred only in patients also taking sulphonylureas. There
`was no difference between twice daily and three times daily
`dosing,58 but once daily was
`insufficient.57 Exenatide
`therapy is
`likely to require twice daily subcutaneous
`injections, although a long-acting preparation is under
`investigation.59
`Liraglutide is an acylated derivative of GLP-1 with an
`aminoacid substitution at position 34 protecting it from
`DPP IV degradation and increasing the half-life to about
`14 hours in pigs.60 Twice daily subcutaneous injections of
`liraglutide for ten days reduced body weight in normal and
`obese rats,61 and a similar protocol
`in ob/ob and db/db
`diabetic mice for two weeks improved glycaemic control
`and increased beta-cell mass (though only significantly in the
`db/db mice).62 Twice daily injections of liraglutide for six
`weeks caused weight loss in normal rats.63
`Subcutaneous liraglutide has a half life of 11–15 hours in
`healthy volunteers.64 Subcutaneous injection of liraglutide
`at night to people with type 2 diabetes decreased fasting
`glucose the next morning as well as postprandial glucose
`12.5 hours later, seemingly at least partly via delayed gastric
`emptying, glucagon suppression and stimulation of
`in-
`sulin.65 The two patients with the highest concentrations of
`liraglutide developed nausea and one was unable to eat the
`meal. Liraglutide was more potent during hyperglycaemia
`when administered before a graded glucose infusion in
`people with type 2 diabetes.66 No long-term studies are
`published to date. Exenatide and liraglutide are both the
`subjects of continued clinical trials.
`
`Another method for protection of GLP-1 from
`degradation by DPP IV is via drug affinity complex
`technology. A preparation in which CJC-1131 binds GLP-
`1 to albumin in vivo gives better glycaemic control in mice.
`No human data are available, though the product is in
`phase II trials.67 DPP IV inactivates GLP-1 by removal of
`the N-terminal dipeptide His(7)-Ala(8).32 Several GLP-1
`analogues with longer half-lives have been assessed,
`particularly those with substitutions or
`insertions of
`aminoacids at positions 7, 8 or 9.68–72 To date there are
`no publications of the effects of these compounds in people
`with type 2 diabetes.
`
`CONCLUSIONS
`
`The range of drugs against diabetes is growing but is still
`inadequate. DPP IV antagonists and GLP-1 analogues have
`advantages over current therapies, particularly in terms of
`hypoglycaemia risk and potential weight loss. NVP-LAF237
`appears the most advantageous DPP IV antagonist. It is an
`oral agent, seemingly without side-effects. However, the
`likely increase in other products of DPP IV inhibition,
`together with multiple daily dosing, reduces its potential
`impact. More clinical data are available for the GLP-1
`analogue exenatide. Exenatide causes weight loss and may
`result in beta-cell restoration, but it seems to produce
`nausea and has to be injected.
`Therapy for diabetes will probably not alter radically in
`the next few years unless long-term data demonstrate other
`advantages over metformin and insulin. However, since the
`number of people with diabetes is increasing rapidly, agents
`modulating GLP-1 are likely to be licensed, with second or
`third generation molecules possibly playing a major role in
`combating the world-wide burden of diabetes in the 21st
`century.
`
`REFERENCES
`
`1 UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-
`glucose control with sulphonylureas or
`insulin compared with
`conventional treatment and risk of complications in patients with
`type 2 diabetes (UKPDS 33). Lancet 1998;352:837–53
`2 UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive
`blood-glucose control with metformin on complications in overweight
`patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854–65
`3 Emslie-Smith AM, Boyle DI, Evans JM, Sullivan F, Morris AD, for the
`DARTS/MEMO collaboration. Contraindications to metformin therapy
`in patients with type 2 diabetes—a population-based study of adherence
`to prescribing guidelines. Diabetic Med 2001;18:483–8
`4 Edwards CM, Barton MA, Snook J, David M, Mak VH, Chowdhury
`TA. Metformin-associated lactic acidosis in a patient with liver disease.
`Quart J Med 2003;96:315–16
`5 Bailey CJ, Turner RC. Metformin. N Engl J Med 1996;334:574–9
`6 Lebovitz HE, Melander A. Sulphonylureas: basic aspects and clinical
`uses. In: Alberti KGMM, Defronzo RA, Keen H, Zimmet P, eds.
`International Textbook of Diabetes Mellitus, 1st edn. Oxford: Alden Press,
`1992:745–72
`
`272
`
`MPI EXHIBIT 1082 PAGE 3
`
`MPI EXHIBIT 1082 PAGE 3
`
`

`

`J O U R N A L O F T H E R O Y A L S O C I E T Y O F M E D I C I N E
`
`V o l u m e 9 7
`
`J u n e 2 0 0 4
`
`Lancet
`
`7 Nathan DM. Some answers, more controversy, from UKPDS. United
`Kingdom Prospective Diabetes Study. Lancet 1998;352:832–3
`8 Dornhorst
`A.
`Insulinotropic meglitinide
`analogues.
`2001;358:1709–16
`9 Saloranta C, Hershon K, Ball M, Dickinson S, Holmes D. Efficacy and
`safety of nateglinide in type 2 diabetic patients with modest fasting
`hyperglycemia. J Clin Endocrinol Metab 2002;87:4171–6
`10 Coniff RF, Shapiro JA, Seaton TB, Bray GA. Multicenter, placebo-
`controlled trial comparing acarbose (BAY g 5421) with placebo,
`tolbutamide, and tolbutamide-plus-acarbose in non-insulin-dependent
`diabetes mellitus. Am J Med 1995;98:443–51
`11 Nolan JJ, Ludvik B, Beerdsen P, Joyce M, Olefsky J. Improvement in
`glucose tolerance and insulin resistance in obese subjects treated with
`troglitazone. N Engl J Med 1994;331:1188–93
`12 Lebovitz HE, Dole JF, Patwardhan R, Rappaport EB, Freed MI,
`Rosiglitazone Clinical Trials Study Group. Rosiglitazone monotherapy
`is effective in patients with type 2 diabetes. J Clin Endocrinol Metab
`2001;86:280–8
`13 Aronoff S, Rosenblatt S, Braithwaite S, Egan JW, Mathisen AL,
`Schneider RL. Pioglitazone hydrochloride monotherapy improves
`glycemic control in the treatment of patients with type 2 diabetes:
`a 6-month randomized placebo-controlled dose–response study.
`The Pioglitazone 001 Study Group. Diabetes Care 2000;23:1605–11
`14 Yale JF, Valiquett TR, Ghazzi MN, Owens-Grillo JK, Whitcomb RW,
`Foyt HL. The effect of a thiazolidinedione drug, troglitazone, on
`glycemia in patients with type 2 diabetes mellitus poorly controlled
`with sulfonylurea
`and metformin. A multicenter,
`randomized,
`Ann
`Intern Med
`double-blind,
`placebo-controlled
`trial.
`2001;
`134:737–45
`15 Creutzfeldt W, Ebert R. New developments in the incretin concept.
`Diabetologia 1985;28:565–73
`16 Nauck MA, Bartels E, Orskov C, Ebert R, Creutzfeldt W. Additive
`insulinotropic effects of exogenous synthetic human gastric inhibitory
`polypeptide and glucagon-like peptide-1-(7-36) amide infused at near-
`physiological insulinotropic hormone and glucose concentrations. J Clin
`Endocrinol Metab 1993;76:912–17
`17 Scrocchi LA, Brown TJ, MaClusky N, et al. Glucose intolerance but
`normal satiety in mice with a null mutation in the glucagon-like
`peptide 1 receptor gene. Nat Med 1996;2:1254–8
`18 Edwards CM, Todd JF, Mahmoudi M, et al. Glucagon-like peptide 1
`has a physiological role in the control of postprandial glucose in
`exendin 9-39. Diabetes
`humans:
`studies with
`the
`antagonist
`1999;48:86–93
`19 Edwards CM, Edwards AV, Bloom SR. Cardiovascular and pancreatic
`endocrine responses to glucagon-like peptide-1(7-36) amide in the
`conscious calf. Exp Physiol 1997;82:709–16
`20 Nauck MA, Heimesaat MM, Orskov C, Holst JJ, Ebert R, Creutzfeldt
`W. Preserved incretin activity of glucagon-like peptide 1 [7-36 amide]
`but not of synthetic human gastric inhibitory polypeptide in patients
`with type-2 diabetes mellitus. J Clin Invest 1993;91:301–7
`21 Gutniak M, Orskov C, Holst JJ, Ahren B, Efendic S. Antidiabetogenic
`effect of glucagon-like peptide-1 (7-36)amide in normal subjects and
`patients with diabetes mellitus. N Engl J Med 1992;326:1316–22
`22 Drucker DJ. Minireview: the glucagon-like peptides. Endocrinology
`2001;142:521–7
`23 Farilla L, Bulotta A, Hirshberg B, et al. Glucagon-like peptide 1
`inhibits cell apoptosis and improves glucose responsiveness of freshly
`isolated human islets. Endocrinology 2003;144:5149–58
`24 Nathan DM, Schreiber E, Fogel H, Mojsov S, Habener
`JF.
`Insulinotropic action of glucagonlike peptide-I-(7-37) in diabetic and
`nondiabetic subjects. Diabetes Care 1992;15:270–6
`25 Edwards CM, Todd JF, Ghatei MA, Bloom SR. Subcutaneous
`glucagon-like peptide-1 (7-36) amide is insulinotropic and can cause
`Clin
`Sci
`(Lond)
`hypoglycaemia
`in
`fasted
`healthy
`subjects.
`1998;95:719–24
`
`26 Todd JF, Edwards CM, Ghatei MA, Mather HM, Bloom SR.
`Subcutaneous glucagon-like peptide-1 improves postprandial glycaemic
`control over a 3-week period in patients with early type 2 diabetes.
`Clin Sci (Lond) 1998;95:325–9
`27 Rachman J, Barrow BA, Levy JC, Turner RC. Near-normalisation of
`diurnal glucose concentrations by continuous
`administration of
`glucagon-like
`peptide-1
`(GLP-1)
`in
`subjects with NIDDM.
`Diabetologia 1997;40:205–11
`28 Zander M, Madsbad S, Madsen JL, Holst JJ. Effect of 6-week course of
`glucagon-like peptide 1 on glycaemic control, insulin sensitivity, and
`beta-cell function in type 2 diabetes: a parallel-group study. Lancet
`2002;359:824–30
`29 Meneilly GS, Greig N, Tildesley H, Habener JF, Egan JM, Elahi D.
`Effects of 3 months of continuous subcutaneous administration of
`glucagon-like peptide 1 in elderly patients with type 2 diabetes.
`Diabetes Care 2003;26:2835–41
`30 Deacon CF, Pridal L, Klarskov L, Olesen M, Holst JJ. Glucagon-
`like peptide 1 undergoes differential tissue-specific metabolism in
`the anesthetized pig. Am J Physiol Endocrinol Metab 1996;271:
`E458–64
`31 Mentlein R, Gallwitz B, Schmidt WE. Dipeptidyl-peptidase IV
`hydrolyses gastric inhibitory polypeptide, glucagon-like peptide-1(7-
`36)amide, peptide histidine methionine and is responsible for their
`degradation in human serum. Eur J Biochem 1993;214:829–35
`32 Deacon CF, Johnsen AH, Holst JJ. Degradation of glucagon-like
`peptide-1 by human plasma in vitro yields an N-terminally truncated
`peptide that is a major endogenous metabolite in vivo. J Clin Endocrinol
`Metab 1995;80:952–7
`33 Marguet D, Baggio L, Kobayashi T, et al. Enhanced insulin secretion
`and improved glucose tolerance in mice lacking CD26. Proc Natl Acad
`Sci USA 2000;97:6874–9
`34 Conarello SL, Li Z, Ronan J, et al. Mice lacking dipeptidyl peptidase IV
`are protected against obesity and insulin resistance. Proc Natl Acad Sci
`USA 2003;100:6825–30
`35 Pospisilik JA, Stafford SG, Demuth HU, et al. Long-term treatment
`with the dipeptidyl peptidase IV inhibitor P32/98 causes sustained
`improvements
`in
`glucose
`tolerance,
`insulin
`sensitivity,
`hyperinsulinemia, and beta-cell glucose responsiveness in VDF (fa/
`fa) Zucker rats. Diabetes 2002;51:943–50
`36 Reimer MK, Holst JJ, Ahren B. Long-term inhibition of dipeptidyl
`peptidase IV improves glucose tolerance and preserves islet function in
`mice. Eur J Endocrinol 2002;146:717–27
`37 Pospisilik JA, Martin J, Doty T, et al. Dipeptidyl peptidase IV inhibitor
`treatment
`stimulates beta-cell
`survival
`and islet neogenesis
`in
`streptozotocin-induced diabetic rats. Diabetes 2003;52:741–50
`38 Sudre B, Broqua P, White RB, et al. Chronic inhibition of circulating
`dipeptidyl peptidase IV by FE 999011 delays the occurrence of diabetes
`in male zucker diabetic fatty rats. Diabetes 2002;51:1461–9
`39 Ahren B, Simonsson E, Larsson II, et al. Inhibition of dipeptidyl
`peptidase IV improves metabolic control over a 4-week study period in
`type 2 diabetes. Diabetes Care 2002;25:869–75
`40 Villhauer EB, Brinkman JA, Naderi GB,
`et al.
`J-[[3-hydroxy-l-
`adamantyl)amino]acetyl]-2-cyano-(S)-pyrrolidine: a potent, selective,
`and orally bioavailable dipeptidyl peptidase IV inhibitor with
`antihyperglycemic properties. J Med Chem 2003;46:2774–89
`41 Mentlein R. Dipeptidyl-peptidase IV (CD26)—role in the inactivation
`of regulatory peptides. Regul Pept 1999;85:9–24
`42 Thorens B, Porret A, Buhler L, Deng SP, Morel P, Widmann C.
`Cloning and functional expression of the human islet GLP-1 receptor.
`Demonstration that exendin-4 is an agonist and exendin-(9-39) an
`antagonist of the receptor. Diabetes 1993;42:1678–82
`43 Young AA, Gedulin BR, Bhavsar S, et al. Glucose-lowering and
`insulin-sensitizing actions of exendin-4: studies in obese diabetic (ob/
`ob, db/db) mice, diabetic fatty Zucker rats, and diabetic rhesus
`monkeys (Macaca mulatta). Diabetes 1999;48:1026–34
`
`273
`
`MPI EXHIBIT 1082 PAGE 4
`
`MPI EXHIBIT 1082 PAGE 4
`
`

`

`J O U R N A L O F T H E R O Y A L S O C I E T Y O F M E D I C I N E
`
`V o l u m e 9 7
`
`J u n e 2 0 0 4
`
`44 Szayna M, Doyle ME, Betkey JA, et al. Exendin-4 decelerates food
`intake, weight gain, and fat deposition in Zucker rats. Endocrinology
`2000;141:1936–41
`45 Xu G, Stoffers DA, Habener JF, Bonner-Weir S. Exendin-4 stimulates
`both beta-cell replication and neogenesis, resulting in increased beta-
`cell mass and improved glucose tolerance in diabetic rats. Diabetes
`1999;48:2270–6
`46 Zhou J, Wang X, Pineyro MA, Egan JM. Glucagon-like peptide 1 and
`exendin-4 convert pancreatic AR42J cells into glucagon- and insulin-
`producing cells. Diabetes 1999;48:2358–66
`47 Stoffers DA, Kieffer TJ, Hussain MA, et al. Insulinotropic glucagon-
`like peptide 1 agonists
`stimulate expression of homeodomain
`protein IDX-1 and increase islet size in mouse pancreas. Diabetes
`2000;49:741–8
`48 Jonsson J, Carlsson L, Edlund T, Edlund H. Insulin-promoter-factor 1
`is required for pancreas development in mice. Nature 1994;371:606–9
`49 Baggio L, Adatia F, Bock T, Brubaker PL, Drucker DJ. Sustained
`expression of exendin-4 does not perturb glucose homeostasis, beta-
`cell mass, or food intake in metallothionein–preproexendin transgenic
`mice. J Biol Chem 2000;275:34471–7
`50 Tourrel C, Bailbe D, Meile MJ, Kergoat M, Portha B. Glucagon-like
`peptide-1
`and
`exendin-4
`stimulate
`beta-cell
`neogenesis
`in
`streptozotocin-treated
`newborn
`rats
`resulting
`in
`persistently
`improved glucose homeostasis at adult age. Diabetes 2001;50:1562–70
`51 Wang Q, Brubaker PL. Glucagon-like peptide-1 treatment delays the
`db/db mice. Diabetologia
`onset
`of
`diabetes
`in
`8 week-old
`2002;45:1263–73
`52 Stoffers DA, Desai BM, DeLeon DD, Simmons RA. Neonatal exendin-
`4 prevents the development of diabetes in the intrauterine growth
`retarded rat. Diabetes 2003;52:734–40
`53 Edwards CM, Stanley SA, Davis R, et al. Exendin-4 reduces fasting and
`postprandial glucose and decreases energy intake in healthy volunteers.
`Am J Physiol Endocrinol Metab 2001;281:E155–61
`54 Vella A, Shah P, Reed AS, Adkins AS, Basu R, Rizza RA. Lack of effect
`of exendin-4 and glucagon-like peptide-1-(7,36)-amide on insulin
`action in non-diabetic humans. Diabetologia 2002;45:1410–15
`55 Egan JM, Clocquet AR, Elahi D. The insulinotropic effect of acute
`exendin-4 administered to humans: comparison of nondiabetic state to
`type 2 diabetes. J Clin Endocrinol Metab 2002;87:1282–90
`56 Kolterman OG, Buse JB, Fineman MS, et al. Synthetic exendin-4
`(exenatide)
`significantly reduces postprandial and fasting plasma
`glucose in subjects with type 2 diabetes. J Clin Endocrinol Metab
`2003;88:3082–9
`57 Egan JM, Meneilly GS, Elahi D. Effects of 1-mo bolus subcutaneous
`administration of exendin-4 in type 2 diabetes. Am J Physiol Endocrinol
`Metab 2003;284:E1072–9
`58 Fineman MS, Bicsak TA, Shen LZ, et al. Effect on glycemic control of
`exenatide (synthetic exendin-4) additive to existing metformin and/or
`sulfonylurea treatment in patients with type 2 diabetes. Diabetes Care
`2003;26:2370–7
`
`59 Gedulin B, Smith P, Prickett K, et al. Dose-response for 2-day
`glycemic improvement following a single injection of long-acting-
`release exenatide (synthetic exendin-4) in diabetic fatty zucker (ZDF)
`rats. Diabetes 2003;52(suppl. 1):A109
`60 Knudsen LB, Nielsen PF, Huusfeldt P, et al. Potent derivatives of
`glucagon-like peptide-1 with pharmacokinetic properties suitable for
`once daily administration. J Med Chem 2000;43:1664–9
`61 Larsen PJ, Fledelius C, Knudsen LB, Tang-Christensen M. Systemic
`administration of the long-acting GLP-1 derivative NN2211 induces
`lasting and reversible weight loss in both normal and obese rats.
`Diabetes 2001;50:2530–9
`62 Rolin B, Larsen MO, Gotfredsen CF, et al. The long-acting GLP-1
`derivative NN2211 ameliorates glycemia and increases beta-cell mass
`in diabetic mice. Am J Physiol Endocrinol Metab 2002;283:E745–52
`63 Bock T, Pakkenberg B, Buschard K. The endocrine pancreas in non-
`diabetic rats after short-term and long-term treatment with the long-
`acting GLP-1 derivative NN2211. APMIS 2003;111:1117–24
`64 Elbrond B,
`et
`al. Pharmacokinetics,
`Jakobsen G, Larsen S,
`pharmacodynamics,
`safety,
`and tolerability of
`a
`single-dose of
`NN2211, a long-acting glucagon-like peptide 1 derivative, in healthy
`male subjects. Diabetes Care 2002;25:1398–404
`65 Juhl CB, Hollingdal M, Sturis J, et al. Bedtime administration of
`NN2211, a long-acting GLP-1 derivative, substantially reduces fasting
`and postprandial glycemia in type 2 diabetes. Diabetes 2002;51:424–9
`66 Chang AM, Jakobsen G, Sturis J, et al. The GLP-1 derivative NN2211
`restores beta-cell sensitivity to glucose in type 2 diabetic patients after
`a single dose. Diabetes 2003;52:1786–91
`67 Kim JG, Baggio LL, Bridon DP,
`al. Development
`et
`and
`characterization of a glucagon-like peptide 1-albumin conjugate: the
`ability to activate the glucagon-like peptide 1 receptor in vivo. Diabetes
`2003;52:751–9
`68 Deacon CF, Knudsen LB, Madsen K, Wiberg FC, Jacobsen O, Holst
`JJ. Dipeptidyl peptidase IV resistant analogues of glucagon-like
`peptide-1 which have extended metabolic stability and improved
`biological activity. Diabetologia 1998;41:271–8
`69 Burcelin R, Dolci W, Thorens B. Long-lasting antidiabetic effect of a
`dipeptidyl peptidase IV-resistant analog of glucagon-like peptide-1.
`Metabolism 1999;48:252–8
`70 Doyle ME, Greig NH, Holloway HW, Betkey JA, Bernier M, Egan
`JM. Insertion of an N-terminal 6-aminohexanoic acid after the 7 amino
`acid position of glucagon-like peptide-1 produces a long-acting
`hypoglycemic agent. Endocrinology 2001;142:4462–8
`71 Naslund E, Skogar S, Efendic S, Hellstrom PM. Glucagon-like peptide-
`1 analogue LY315902: effect on intestinal motility and release of
`insulin and somatostatin. Regul Pept 2002;106:89–95
`72 Green BD, Gault VA, Mooney MH,
`et al. Novel dipeptidyl
`peptidase
`IV resistant
`analogues of glucagon-like peptide-1(7-
`in vitro conferring
`36)amide have preserved biological activities
`in
`vivo.
`J Mol
`Endocrinol
`improved
`glucose-lowering
`action
`2003;31:529–40
`
`274
`
`MPI EXHIBIT 1082 PAGE 5
`
`MPI EXHIBIT 1082 PAGE 5
`
`