E m e r g i n g T r e a t m e n t s a n d T e c h n o l o g i e s
`O R I G I N A L
`A R T I C L E
`
`The Effect of Liraglutide, a Long-Acting
`Glucagon-Like Peptide 1 Derivative, on
`Glycemic Control, Body Composition, and
`24-h Energy Expenditure in Patients
`With Type 2 Diabetes
`
`1
`HELLE HARDER, MSC
`LENE NIELSEN, MSCODONT
`
`2
`
`2
`TU D.T. THI, MSC
`ARNE ASTRUP, MD, DRMEDSCI
`
`1
`
`OBJECTIVE — Glucagon-like peptide (GLP)-1 is a gut hormone that exerts incretin effects
`and suppresses food intake in humans, but its therapeutic use is limited due to its short half-life.
`This was a randomized, double-blind, parallel-group, placebo-controlled trial investigating the
`effect of the long-acting GLP-1 derivative liraglutide (NN2211) on glycemic control, body
`weight, body composition, and 24-h energy expenditure in obese subjects with type 2 diabetes.
`
`RESEARCH DESIGN AND METHODS — Thirty-three patients (mean ⫾ SD) aged
`60.0 ⫾ 9.5 years, with HbA1c 7.5 ⫾ 1.2% and BMI 36.6 ⫾ 4.1 kg/m2, were randomized to
`treatment with a single daily subcutaneous dose of 0.6 mg liraglutide (n ⫽ 21) or placebo (n ⫽
`12) for 8 weeks. In addition to weight and glycemic parameters, body composition was assessed
`by dual-energy X-ray absorptiometry (DEXA) scanning and 24-h energy expenditure in a respi-
`ratory chamber.
`
`RESULTS — After 8 weeks, liraglutide reduced fasting serum glucose (liraglutide, ⫺1.90
`mmol/l, and placebo, 0.27 mmol/l; P ⫽ 0.002) and HbA1c (liraglutide, ⫺0.33%, and placebo,
`0.47%; P ⫽ 0.028) compared with placebo. No change in body weight was detected (liraglutide,
`⫺0.7 kg, and placebo, ⫺0.9 kg; P ⫽ 0.756). There was a nonsignificant trend toward a decrease
`in total fat mass (liraglutide, ⫺0.98%, and placebo, ⫺0.12%; P ⫽ 0.088) and toward an increase
`in lean body mass (liraglutide, 1.02%, and placebo, 0.23%; P ⫽ 0.118) in the liraglutide group
`compared with the placebo group. Twenty-four-hour energy expenditure was unaffected by the
`treatment (liraglutide, ⫺12.6 kJ/h, and placebo, ⫺13.7 kJ/h; P ⫽ 0.799).
`
`CONCLUSIONS — Eight weeks of 0.6-mg liraglutide treatment significantly improved gly-
`cemic control without increasing weight in subjects with type 2 diabetes compared with those on
`placebo. No influence on 24-h energy expenditure was detected.
`
`Diabetes Care 27:1915–1921, 2004
`
`G lucagon-like peptide (GLP)-1 has
`
`several effects that make it a poten-
`tial candidate molecule for the
`treatment of type 2 diabetes. GLP-1 is a
`
`peptide hormone secreted from the L-cells
`in the lower gut, i.e., the distal jejunum,
`ileum, and colon/rectum, in response to
`ingestion of carbohydrates, lipids, and
`
`● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
`
`From the 1Department of Human Nutrition, LMC, The Royal Veterinary and Agricultural University, Fred-
`eriksberg, Denmark; and 2Novo Nordisk, Bagsvaerd, Denmark.
`Address correspondence and reprint requests to Arne Astrup, Research Department of Human Nutrition,
`LMC, The Royal Veterinary and Agricultural University, Rolighedsvej 30, DK-1958 Frederiksberg, Denmark.
`E-mail: ast@kvl.dk.
`Received for publication 8 January 2004 and accepted in revised form 15 May 2004.
`H.H. left the Department of Human Nutrition at The Royal Veterinary and Agricultural University to take
`a position at Novo Nordisk in September 2003.
`Abbreviations: AUC, area under the curve; DEXA, dual-energy X-ray absorptiometry; GLP, glucagon-like
`peptide; HOMA, homeostasis model assessment; OHA, oral hypoglycemic agent; VAS, visual analog score.
`A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion
`factors for many substances.
`© 2004 by the American Diabetes Association.
`
`mixed meals (1–3). GLP-1 stimulates
`postprandial insulin secretion and acts as
`an incretin hormone, thus potentiating
`glucose-stimulated insulin release. The
`incretin effect refers to the increased insu-
`lin response elicited by oral glucose com-
`pared with the response resulting from an
`isoglycemic intravenous infusion (4). In
`addition, GLP-1 has a suppressive effect
`on glucagon release and hepatic glucose
`output (5).
`Treatment of hyperglycemia in type 2
`diabetic patients with GLP-1 has received
`much attention, but additional therapeu-
`tic indications could be envisioned.
`Within the last few years, the ability of
`GLP-1 to decrease appetite and energy in-
`take has been established (6). A reduced
`food intake would support weight reduc-
`tion attempts in patients with type 2 dia-
`betes. The appetite-reducing effect might
`partly be related to the ability of GLP-1 to
`decrease gastric emptying and reduce gas-
`tric motility (2). The mechanisms in-
`volved in the regulation of appetite and
`food intake are, however, complex and
`not fully understood; this also applies for
`the mechanisms mediating the anorectic
`effects of GLP-1. Furthermore, GLP-1 re-
`ceptors have been found in various tis-
`sues, such as pancreas, stomach,
`intestine, brain, and heart (7). The ano-
`rectic effect of GLP-1 has been shown in
`both healthy lean and obese people as
`well as in type 2 diabetic patients (6,8 –
`12). This effect has been reported from
`studies (13,14) of up to 2 days in dura-
`tion. In addition, obese subjects have
`been shown (10) to have an attenuated
`GLP-1 release in response to meals. A
`study (15) in obese type 2 diabetic sub-
`jects with continuous infusion of GLP-1
`using insulin pumps demonstrated that,
`aside from a glucose-lowering effect,
`GLP-1 also exhibited weight-reducing
`properties. After 6 weeks, GLP-1–treated
`subjects experienced a significant weight
`
`DIABETES CARE, VOLUME 27, NUMBER 8, AUGUST 2004
`
`1915
`
`MPI EXHIBIT 1085 PAGE 1
`
`

`

`Effects of liraglutide in type 2 diabetes
`
`loss of 1.9 kg compared with baseline; the
`weight loss was, however, not significant
`when compared with placebo (15).
`It is estimated that ⬎80% of type 2
`diabetic patients are obese, and even more
`might be overweight, with abdominal fat
`accumulation, and hence benefit from
`weight loss. It would be desirable if pe-
`ripherally administered GLP-1 was able
`to reduce energy intake and thereby in-
`duce weight loss. A major disadvantage is
`that native GLP-1 has a very short half-life
`in plasma due to rapid degradation by
`⬍1.5 min af-
`dipeptidyl-peptidase IV (t0.5
`ter intravenous injection) (16), which is
`why modifications are needed for clinical
`use. Liraglutide (NN2211) is a long-
`acting GLP-1 derivative developed for the
`treatment of type 2 diabetes. Liraglutide
`⫽ 13 h) suit-
`has a prolonged action (t0.5
`able for once-daily injection. The mecha-
`nism of protraction is a combination of
`albumin binding and self-association, re-
`sulting in slow absorption from subcutis,
`stability against dipeptidyl-peptidase IV,
`and a long plasma half-life. The aim of the
`present study was to examine if liraglutide
`administered subcutaneously once daily
`for 8 weeks in obese type 2 diabetic sub-
`jects would decrease body weight and to-
`tal fat mass and have an effect on 24-h
`energy expenditure, in addition to im-
`provement of glycemic control.
`
`RESEARCH DESIGN AND
`METHODS — Thirty-five type 2 dia-
`betic patients (age 60.0 ⫾ 9.5 years
`[mean ⫾ SD]) were recruited from the
`investigators’ own patient files and/or ad-
`vertisement in local newspapers and
`screened medically for their eligibility for
`the trial. Inclusion criteria were 1) diet
`treated and/or subjects in monotherapy
`with sulfonylurea or repaglinide (No-
`voNorm); 2) HbA1c for diet-treated sub-
`jects of 7–12%, both inclusive; 3) HbA1c
`for sulfonylurea-treated subjects ⱕ10%;
`and 4) BMIⱖ27 kg/m 2. The key exclu-
`sion criteria were 1) New York Heart As-
`sociation class III and IV heart failure, 2)
`uncontrolled hypertension (systolic
`blood pressure ⱖ180 mmHg and/or dia-
`stolic blood pressure ⱖ105 mmHg), 3)
`serum creatinine ⬎150 ␮mol/l, and 4)
`alanine aminotransferase three or more
`times the upper-normal range. Twenty
`patients were treated with sulfonylureas,
`3 with NovoNorm, and 12 with diet only.
`The protocol (file no. 02-024/01) was ap-
`proved by the Ethical Committee of Fre-
`
`deriksberg and Copenhagen. The trial
`was performed in accordance with the
`Helsinki II Declaration. Written consent
`was obtained from each participant be-
`fore beginning the study.
`The study was double blind and pla-
`cebo controlled with two parallel arms.
`The subjects attended a screening visit to
`assess their eligibility. Eligible subjects on
`oral hypoglycemic agents (OHAs) were
`asked to discontinue current OHA treat-
`ment for a 2-week washout period before
`the start of dosing. Eligible subjects were
`randomized to receive a single daily dos-
`ing of liraglutide (0.6 mg) or placebo for 8
`weeks (long term). The trial product was
`administered as a subcutaneous injection
`in the abdomen or in the thigh in the
`morning using a NovoPen (1.5 with No-
`vofine 30-gauge 0.3- to 8-mm needle) as
`the dispensing device. The 24-h energy
`expenditure was measured in a respira-
`tory chamber before the intervention pe-
`riod (baseline) and again after 3 days on
`liraglutide or placebo. The 24-h energy
`expenditure was performed after 3 days
`(short term) only to avoid confounding
`due to possible weight loss later in the
`intervention period. Thus, no long-term
`energy expenditure assessment was done.
`To assess appetite and spontaneous en-
`ergy intake, three meal tests were con-
`ducted through the intervention period.
`Two were carried out following each re-
`spiratory chamber visit, and the third one
`was conducted at the end of the interven-
`tion period (8 weeks). Subjective appetite
`ratings were assessed by visual analog
`scores (VASs) in connection with the
`fixed-energy breakfast meal (17). Sponta-
`neous energy intake was assessed in con-
`nection to an ad libitum lunch meal 4 h
`after the fixed-energy breakfast meal.
`Body composition (assessed by dual-
`energy X-ray absorptiometry [DEXA]
`scan) was evaluated at baseline and after 8
`weeks (end of intervention).
`
`Analytical determinations
`HbA1c was analyzed using a high-
`performance liquid chromatography,
`ion-exchange chromatography assay
`(normal range 4.3–5.8%; Tosoh). Serum
`concentrations of liraglutide, insulin, and
`C-peptide were analyzed by enzyme-
`linked immunosorbent assay methods.
`Serum concentration of glucose was mea-
`sured using an enzymatic glucose oxidase
`method (normal range [fasting] 3.9 – 6.6
`mmol/l). Plasma glucagon was analyzed
`
`by MDS Pharma Services, Switzerland,
`using a radioimmunoassay (Linco Re-
`search, St. Charles, MO). Standard labo-
`ratory analyses were performed by a
`central laboratory (if not otherwise stat-
`ed): Capio Diagnostik, Copenhagen,
`Denmark. Homeostasis model assess-
`ment (HOMA) analysis: An estimate of
`␤-cell function (HOMA-S) and of insulin
`resistance (HOMA-R) was calculated by
`HOMA: ␤-cell function (%) ⫽ 20 ⫻ in-
`sulin/(glucose ⫺ 3.5) and insulin resis-
`tance ⫽ insulin/(22.5 ⫻ elnglucose) (18).
`
`Meal test
`A venflon catheter was inserted in an an-
`tecubital arm vein. After a 10-min rest,
`fasting blood samples were taken. Imme-
`diately thereafter the subjects took a sin-
`gle dose of either liraglutide or placebo,
`then the standard breakfast meal consist-
`ing of 2.5 MJ (carbohydrate 50 E%, pro-
`tein 13 E%, and fat 37 E%) was served
`and consumed within 30 min. Paraceta-
`mol (15 mg/kg) dissolved in 150 ml of
`water was administered to the subjects at
`initiation of the breakfast meal for assess-
`ment of the gastric emptying rate. Blood
`samples were collected regularly over the
`240 min after starting the meal for analy-
`sis of plasma paracetamol, glucose, insu-
`lin, glucagon, C-peptide, and lipid
`profile. Ratings for appetite were made on
`100-mm VASs, with the text expressing
`the most positive and the most negative
`rating anchored at each end. VAS was
`used to assess satiety, hunger, fullness,
`prospective food consumption, and
`thirst. The ratings were recorded immedi-
`ately before the meal and throughout a
`4-h period after the meal.
`An ad libitum lunch meal consisting
`of carbohydrate 49.5 E%, protein 13.3
`E%, and fat 37.2 E% was served ⬃4.5 h
`after completion of the breakfast meal.
`The lunch meal should be completed
`within 30 min. To reduce participants’
`awareness of the amount of food being
`consumed, food was served in excess. The
`quantity of food and fluid consumed was
`measured, and the total energy intake was
`calculated.
`
`DEXA scan
`Body composition was assessed before
`treatment by DEXA scan in all subjects
`and again after the 8-week intervention
`period. A dual-energy X-ray absorptiom-
`eter (Lunar Radiation, Madison, WI) was
`used. All scans were performed in the
`
`1916
`
`DIABETES CARE, VOLUME 27, NUMBER 8, AUGUST 2004
`
`MPI EXHIBIT 1085 PAGE 2
`
`

`

`Table 1—Baseline characteristics of patients
`
`n
`Demographics
`Men/women
`Age (years)
`Anthropometrics
`BMI (kg/m2)
`Diabetes
`Duration (years)
`HbA1c (%)
`Fasting plasma glucose (mmol/l)
`Previous diabetes treatment
`Diet
`OHA
`Data are means ⫾ SD or n (%).
`
`Liraglutide
`
`21
`
`11/10
`59.9 ⫾ 11.0
`
`36.8 ⫾ 4.6
`
`4.5 ⫾ 6.4
`7.4 ⫾ 1.0
`10.7 ⫾ 2.4
`
`4 (19)
`17 (81)
`
`Placebo
`
`12
`
`1/11
`60.1 ⫾ 6.7
`
`36.1 ⫾ 3.4
`
`3.3 ⫾ 3.4
`7.7 ⫾ 1.6
`10.4 ⫾ 2.8
`
`7 (58)
`5 (42)
`
`slow mode on fasting subjects. The fol-
`lowing parameters were assessed: lean tis-
`sue mass, fat mass, and total body weight.
`
`Respiratory chamber
`The 24-h energy expenditure was mea-
`sured in an open-circuit indirect calorim-
`etry respiratory chamber as described
`elsewhere (19). The measurement started
`at 9:00 A.M. and continued for 24 h. Basic
`metabolic rate was measured during the
`last hour of the stay. Subjects arrived at
`the department at 10:00 P.M. the evening
`before the examination and stayed in the
`chamber overnight. This procedure was
`chosen for the subject to adapt to the
`chamber, thereby minimizing stress dur-
`ing the 24-h measurement period. During
`the 24-h stay, subjects followed a stan-
`dard protocol, including two periods of
`10 min of bicycle exercise (75 watts) and
`two periods of walking back and forth in
`the chamber (with a total distance of
`182.5 m each time).
`
`Safety assessments
`Adverse events, hematology, blood chem-
`istry, and urine values were monitored
`throughout the study period. In addition,
`electrocardiograms and blood pressure
`were measured. Subjects were also sup-
`plied with a diary and asked to record
`information on home measurements of
`blood glucose, any changes in concomi-
`tant medication, concomitant illness, and
`hypoglycemic episodes.
`
`Statistical analysis
`All statistical tests were two sided at a 5%
`significance level. The model used was an
`
`ANOVA with treatment as a fixed factor
`and baseline value as a covariate. The
`main comparison was after 8 weeks of
`treatment (long-term assessment). In ad-
`dition, the end points were assessed after
`2– 4 days of treatment (short-term assess-
`ment) and for the period between the long
`and short terms. The latter was only done
`for the within-group comparison. This
`model was applied to all efficacy end
`points. Safety end points were summa-
`rized by descriptive statistics (number of
`observations, mean, SE, minimum, and
`maximum) or listed.
`
`RESULTS — Thirty-five patients were
`randomized. Thirty-three patients com-
`pleted the intervention, 21 assigned to the
`liraglutide group and 12 to the placebo
`group. One subject was withdrawn from
`the trial due to claustrophobia and one
`subject due to difficulties with blood
`drawing, both of whom withdrew before
`the trial drug was administered. There
`was an unbalanced distribution of sex in
`the two treatment groups. However, this
`uneven distribution has been analyzed
`and no statistical significant effect was
`seen. Clinical characteristics of the en-
`rolled patients are shown in Table 1.
`
`Total body weight and body
`composition
`After 8 weeks, no significant difference in
`total body weight change was observed
`between liraglutide and placebo treat-
`ments (liraglutide, ⫺0.7 kg, and placebo,
`⫺0.9 kg; P ⫽ 0.756) (Fig. 1 and Table 2).
`Although nonsignificant, the results from
`the DEXA scan indicated that fat mass (as
`
`Harder and Associates
`
`a percentage) decreased (liraglutide,
`⫺1.0%, and placebo, ⫺0.1%; P ⫽ 0.088)
`and that lean tissue mass increased after
`treatment with liraglutide compared with
`placebo (liraglutide, 1.0%, and placebo,
`0.2%; P ⫽ 0.118) (Table 2).
`
`Glycemic control and lipids
`Table 2 shows changes from baseline
`within each group and a comparison of
`changes from baseline between groups.
`Liraglutide improved glycemic control,
`and this effect was significant after the
`first week and persisted throughout the
`study period (difference in fasting serum
`glucose between liraglutide and placebo
`after 8 weeks: 2.17 mmol/l [95% CI
`⫺3.50 to ⫺0.83], P ⫽ 0.002). At the end
`of the study, liraglutide showed a signifi-
`cant decrease in HbA1c level compared
`with placebo (⫺ 0.80% [⫺ 1.50 to
`⫺0.09], P ⫽ 0.028). Liraglutide treat-
`ment suggested an improved ␤-cell func-
`tion compared with placebo as indicated
`by increased HOMA-S (liraglutide,
`17.2%, and placebo, ⫺15.2%; P ⫽
`0.015), whereas insulin resistance
`(HOMA-R) was not affected (liraglutide,
`⫺1.9, and placebo, ⫺0.8, P ⫽ 0.530).
`Liraglutide had no effect on lipid param-
`eters compared with placebo (data not
`shown).
`
`Meal tests
`The absolute area under the curve (AUC)
`for serum glucose was significantly sup-
`pressed in the liraglutide group compared
`with placebo both after 3 days (short
`term) (liraglutide, ⫺530.6 mmol 䡠 l⫺1 䡠
`min⫺1, and placebo, ⫺113.9; P ⫽ 0.002)
`and after 8 weeks (long term) of treatment
`(liraglutide, ⫺554.7, and placebo, 11.5;
`P ⫽ 0.004). No difference was detected
`for the incremental AUC for serum glu-
`cose in either the short term (liraglutide,
`0.23 mmol/l, and placebo, ⫺0.20
`mmol/l; P ⫽ 0.441) or the long term (li-
`raglutide, ⫺0.05 mmol/l, and placebo,
`⫺0.84 mmol/l; P ⫽ 0.128). Gastric emp-
`tying was unaffected as measured by
`mean change in postprandial plasma
`paracetamol concentrations after both 3
`days’ and 8 weeks’ treatment. Neither
`short- nor long-term treatment with lira-
`glutide changed the subjective appetite
`sensations during the meal test according
`to the VAS. Food intake during the ad
`libitum lunch meal after 3 days and 8
`weeks of treatment was not affected by
`liraglutide compared with placebo (short
`
`DIABETES CARE, VOLUME 27, NUMBER 8, AUGUST 2004
`
`1917
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`MPI EXHIBIT 1085 PAGE 3
`
`

`

`Effects of liraglutide in type 2 diabetes
`
`Figure 1—Mean body weight (A), fasting serum
`glucose (B), and HbA1c (C) over 8 weeks in type 2
`diabetic patients treated with liraglutide 0.6 mg/kg
`versus placebo for 8 weeks.
`
`CONCLUSIONS — This clinical trial
`of 8 weeks’ treatment with subcutaneous
`liraglutide in patients with type 2 diabetes
`shows that 0.65 mg liraglutide, self-
`administered once daily before breakfast
`for 8 weeks, compared with placebo im-
`proves glycemic control by decreasing
`fasting glucose by 2.2 mmol/l and HbA1c
`by 0.8% in this group of relatively well-
`controlled type 2 diabetic patients, with-
`out inducing weight gain. Weight gain
`associated with improved glycemic con-
`trol is common in treatment with sulfo-
`nylureas, insulin, or thiazolidinediones
`and often occurs when HbA1c levels are
`significantly reduced. This effect has been
`reported in the intensively treated cohorts
`of the Diabetes Control and Complica-
`tions Trial (20) and the U.K. Prospective
`Diabetes Study (21). Weight gain is an
`undesirable effect as it is often associated
`with increased insulin resistance, espe-
`cially if the additional fat is deposited in
`the abdominal region (22). In the present
`study, we failed to see any weight loss
`produced by liraglutide, and in accor-
`dance with this observation there were no
`detectable effects on appetite sensation,
`gastric emptying, or energy intake at the
`ad libitum test meals in connection with
`administration of liraglutide. However,
`there was a trend to a reduction in fat
`mass, which results from a daily negative
`energy balance of a magnitude that would
`not be picked up by the meal tests or the
`appetite sensations. The trend in reduc-
`tion of fat mass suggests that liraglutide
`actually may have the potential to induce
`weight loss, and we speculate that larger
`doses and a longer study period might be
`required to produce an effect on appetite
`and weight loss (23). Further studies are
`needed to fully elucidate the weight pro-
`file of liraglutide. Preclinical studies in
`nondiabetic animals have shown a poten-
`tial for lowering food intake and body
`weight with liraglutide. In one study, a
`dose of 0.2 mg/kg has been shown to
`markedly decrease food intake and body
`weight in normal-weight and obese rats
`(24). Doses of liraglutide needed in rats
`are larger than in humans, also for blood
`glucose lowering (25).
`In addition, treatment with lira-
`
`term: liraglutide, 5 g, and placebo, ⫺1 g,
`P ⫽ 0.883; long term: liraglutide, 21 g,
`and placebo, 7 g, P ⫽ 0.766).
`
`treatment did not differ significantly be-
`tween the groups (P ⫽ 0.548).
`
`Twenty-four-hour energy
`expenditure
`Liraglutide had no short-term effect on
`energy balance as the mean change in
`24-h energy expenditure from before to
`after 3 days’ treatment did not differ sig-
`nificantly between the groups (lira-
`glutide, ⫺12.6 kJ/h, and placebo, ⫺13.7
`kJ/h; P ⫽ 0.799). The substrate oxidation
`was not affected by treatment with lira-
`glutide as the change in 24-h nonprotein
`respiratory quotient from before to after
`
`Safety assessments
`Eight weeks’ treatment with the subcuta-
`neous injection of liraglutide (single daily
`dose of 0.65 mg) was well tolerated. No
`hypoglycemic episodes occurred during
`the study. In the liraglutide group, 76%
`(16 of 21) of the subjects reported adverse
`events, whereas 58% (7 of 12) of the pla-
`cebo-treated subjects reported adverse
`events. Nausea and diarrhea were the
`most frequent events; however, these
`were transient episodes.
`
`1918
`
`DIABETES CARE, VOLUME 27, NUMBER 8, AUGUST 2004
`
`MPI EXHIBIT 1085 PAGE 4
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`

`

`Table 2—Body weight, body composition, and glycemic control parameters before and after 8 weeks’ intervention
`
`Variable
`
`Liraglutide
`
`Placebo
`
`P
`
`Harder and Associates
`
`n
`Weight (kg)
`Before
`After
`Change
`Waist circumference (cm)
`Before
`After
`Change
`Fat mass (kg)
`Before
`After
`Change
`Lean mass (kg)
`Before
`After
`Change
`Fat mass (%)
`Before
`After
`Change
`Lean mass (%)
`Before
`After
`Change
`Fasting serum glucose (mmol/l)
`Before
`After
`Change
`HbA1c (%)
`Before
`After
`Change
`Fructosamine (␮mol/l)
`Before
`After
`Change
`Insulin (pmol/l)
`Before
`After
`Change
`C-peptide (nmol/l)
`1.64 ⫾ 0.39
`1.48 ⫾ 0.13
`Before
`1.53 ⫾ 0.35
`1.52 ⫾ 0.13
`After
`⫺0.09 (⫺0.41 to 0.23)
`0.02 (⫺0.22 to 0.26)
`Change
`Data are means ⫾ SE or mean change values (95% CI). All change values are adjusted for differences in baseline values between groups.
`
`21
`
`106.9 ⫾ 2.9
`104.8 ⫾ 3.0
`⫺0.7 (⫺1.6 to 0.3)
`
`114.6 ⫾ 2.0
`114.0 ⫾ 2.0
`⫺0.5 (⫺1.6 to 0.6)
`
`41.4 ⫾ 2.3
`39.8 ⫾ 2.1
`⫺1.0 (⫺1.8 to ⫺0.3)
`
`59.6 ⫾ 2.5
`60.2 ⫾ 2.6
`0.7 (⫺0.1 to 1.6)
`
`39.5 ⫾ 1.8
`38.5 ⫾ 1.7
`⫺1.0 (⫺1.6 to ⫺0.4)
`
`57.0 ⫾ 1.8
`58.1 ⫾ 1.6
`1.0 (0.5 to 1.6)
`
`10.7 ⫾ 0.5
`8.8 ⫾ 0.5
`⫺1.9 (⫺2.7 to ⫺1.1)
`
`7.37 ⫾ 0.21
`7.07 ⫾ 0.24
`⫺0.33 (⫺0.75 to 0.09)
`
`298.5 ⫾ 10.9
`272.8 ⫾ 9.0
`⫺25.0 (⫺41.2 to ⫺8.9)
`
`124.8 ⫾ 14.2
`118.7 ⫾ 16.7
`⫺7.8 (⫺38.1 to 22.5)
`
`12
`
`98.0 ⫾ 3.8
`96.0 ⫾ 4.0
`⫺0.9 (⫺2.2 to 0.4)
`
`108.6 ⫾ 2.0
`107.8 ⫾ 2.4
`⫺1.1 (⫺2.6 to 0.4)
`
`39.3 ⫾ 1.9
`38.6 ⫾ 2.0
`⫺0.7 (⫺1.7 to 0.4)
`
`49.7 ⫾ 1.9
`49.5 ⫾ 2.1
`0.2 (⫺1.4 to 1.1)
`
`42.7 ⫾ 1.2
`42.4 ⫾ 1.0
`⫺0.1 (⫺0.9 to 0.7)
`
`54.1 ⫾ 1.2
`54.5 ⫾ 1.1
`0.2 (⫺0.6 to 1.0)
`
`10.4 ⫾ 0.8
`10.7 ⫾ 1.0
`0.3 (⫺0.8 to 1.3)
`
`7.68 ⫾ 0.47
`8.10 ⫾ 0.47
`0.47 (⫺0.09 to 1.03)
`
`293.8 ⫾ 18.6
`313.4 ⫾ 16.1
`18.3 (⫺3.1 to 39.6)
`
`147.2 ⫾ 53.4
`122.8 ⫾ 48.7
`⫺21.5 (⫺61.6 to 18.5)
`
`0.756
`
`0.505
`
`0.590
`
`0.259
`
`0.088
`
`0.118
`
`0.002
`
`0.028
`
`0.003
`
`0.581
`
`0.592
`
`glutide did not result in any hypoglyce-
`mic episodes. Therapy with sulfonylureas
`and insulin is associated with the risk of
`hypoglycemia (26), whereas the insulino-
`tropic action of GLP-1 is attenuated as
`ambient glucose levels fall. This glucose-
`dependent mode of action is mediated by
`intracellular signaling mechanisms de-
`
`pendent on a high ATP-to-ADP ratio,
`which is generated by the glucose-
`glycolysis signaling pathway (27,28).
`Thus, treatment with the long-acting
`GLP-1 derivative potentially conveys a
`low risk of drug-related hypoglycemia.
`This glucose-dependent mechanism has
`been confirmed for liraglutide in a glu-
`
`cose-ramp study (29), where liraglutide
`only enhanced insulin secretory response
`under graded glucose infusion when
`plasma glucose was ⬎6 mmol/l. In the
`present study, the placebo-corrected fast-
`ing plasma glucose was reduced by 2.2
`mmol/l to an average of 8.8 mmol/l, and a
`corresponding signifi cant placebo-
`
`DIABETES CARE, VOLUME 27, NUMBER 8, AUGUST 2004
`
`1919
`
`MPI EXHIBIT 1085 PAGE 5
`
`

`

`Effects of liraglutide in type 2 diabetes
`
`corrected reduction in HbA1c of 0.8% was
`seen. In the liraglutide group, a relatively
`modest decrease of 0.33% in HbA1c from
`baseline was detected, which is most
`likely due to one or more of the following
`circumstances. First, the effect on HbA1c
`is most likely underestimated because af-
`ter only 8 weeks’ treatment steady-state
`levels on HbA1c are not achieved, together
`with the short prerandomization washout
`period. Second, the subjects in the lira-
`glutide group were relatively well con-
`trolled at baseline, with an HbA1c of
`7.4%, limiting the potential for observing
`further substantial absolute reductions in
`HbA1c. Third, the preponderance of
`OHA-treated subjects in the liraglutide
`group might also have led to an underes-
`timation of the effect of liraglutide on gly-
`cemic control; compared with oral
`antidiabetic drug–treated patients who
`have their treatment substituted, diet-
`treated patients would be expected to im-
`prove their glycemic control more when
`commencing drug treatment. Finally, the
`above-mentioned circumstances, to-
`gether with the potentially suboptimal
`dose of liraglutide, might have led to an
`underestimation of liraglutide’s true effi-
`cacy on glycemic control in the present
`trial.
`In addition to the overall improve-
`ment in glycemic control noted with lira-
`glutide in both sulfonylurea-treated and
`oral hypoglycemic agent–naive patients,
`liraglutide lowered the absolute AUC for
`glucose significantly in the postprandial
`period, which was maintained over the 8
`weeks. This is in accordance with previ-
`ous long-term studies (15,30), which
`have shown that administration of subcu-
`taneous injections of native GLP-1 before
`meals through periods of up to several
`weeks can reduce the mean blood glucose
`levels in patients with type 2 diabetes with
`suboptimal blood glucose control. How-
`ever, the incremental AUC for glucose
`was unaffected by liraglutide treatment
`compared with placebo. This is not in
`agreement with another liraglutide study,
`in which a single injection of liraglutide
`(10 ␮g/kg) was administered at 11:00 P.M.
`and a standardized mixed meal served at
`11:30 A.M. the next day. In this study,
`both absolute and incremental AUCs for
`glucose were markedly and significantly
`reduced by 23 and 27%, respectively, by
`liraglutide treatment (31). However, the
`dose was higher than in the present study,
`which might explain this discrepancy.
`
`In the present study, the liraglutide
`did not increase the postprandial insulin
`response significantly (data not shown)
`and did not improve insulin sensitivity as
`indicated by unchanged HOMA-R, but
`suppressed the postprandial glucagon re-
`sponse. ␤-Cell function seemed to im-
`prove after liraglutide treatment because
`HOMA-S increased significantly com-
`pared with placebo. Early and progress-
`ing decline in ␤-cell function is a key
`feature of type 2 diabetes and will even-
`tually lead to insulin deficiency. A study
`(15) with native GLP-1 found similar ef-
`fects on ␤-cell function after 6 weeks’
`treatment, which suggests that GLP-1 has
`a sustained ␤-cell–improving effect.
`This trial clearly shows that 8 weeks’
`treatment with the long-acting GLP-1 de-
`rivative liraglutide improves glycemic
`control in subjects with type 2 diabetes.
`Despite significant improved glycemic
`control, body weight was maintained
`during treatment with liraglutide. Appe-
`tite and food intake were unaffected, but a
`tendency toward a favorable change in
`body composition was observed. There-
`fore, we speculate that a higher dose
`might produce significant loss of fat mass.
`Treatment with liraglutide had no ther-
`mogenic effect, as 24-h energy expendi-
`ture was unaffected after 3 days’ treatment
`(short term). Adverse events were mainly
`mild and related to the gastrointestinal
`system. No episodes of hypoglycemia
`were observed.
`
`Acknowledgments — This study was finan-
`cially supported by Novo Nordisk.
`
`References
`1. Nauck MA, Holst JJ, Willms B, Schmiegel
`W: Glucagon-like peptide 1 (GLP-1) as a
`new therapeutic approach for type 2-dia-
`betes. Exp Clin Endocrinol Diabetes 105:
`187–195, 1997
`2. Holst JJ: Glucagonlike peptide 1: a newly
`discovered
`gastrointestinal
`hormone.
`Gastroenterology 107:1848 –1855, 1994
`3. Kreymann B, Williams G, Ghatei MA,
`Bloom SR: Glucagon-like peptide-1 7-36:
`a physiological incretin in man. Lancet
`2:1300 –1304, 1987
`4. Unger RH, Eisentraut AM: Entero-insular
`axis. Arch Intern Med 123:261–266, 1969
`5. Larsson H, Holst JJ, Ahren B: Glucagon-
`like peptide-1 reduces hepatic glucose
`production indirectly through insulin and
`glucagon in humans. Acta Physiol Scand
`160:413– 422, 1997
`
`6. Flint A, Raben A, Astrup A, Holst JJ: Glu-
`cagon-like peptide 1 promotes satiety and
`suppresses energy intake in humans.
`J Clin Invest 101:515–520, 1998
`7. Drucker DJ: Glucagon-like peptides. Dia-
`betes 47:159 –169, 1998
`8. Naslund E, Barkeling B, King N, Gutniak
`M, Blundell JE, Holst JJ, Rossner S, Hell-
`strom PM: Energy intake and appetite are
`suppressed by glucagon-like peptide-1
`(GLP-1) in obese men. Int J Obes Relat
`Metab Disord 23:304 –311, 1999
`9. Naslund E, Gutniak M, Skogar S, Rossner
`S, Hellstrom PM: Glucagon-like peptide 1
`increases the period of postprandial sati-
`ety and slows gastric emptying in obese
`men. Am J Clin Nutr 68:525–530, 1998
`10. Ranganath LR, Beety JM, Morgan LM,
`Wright JW, Howland R, Marks V: Atten-
`uated GLP-1 secretion in obesity: cause or
`consequence? Gut 38:916 –919, 1996
`11. Naslund E, Gryback P, Backman L, Jacob-
`sson H, Holst JJ, Theodorsson E, Hell-
`strom PM: Distal small bowel hormones:
`correlation with fasting antroduodenal
`motility and gastric emptying. Dig Dis Sci
`43:945–952, 1998
`12. Gutzwiller JP, Drewe J, Goke B, Schmidt
`H, Rohrer B, Lareida J, Beglinger C: Glu-
`cagon-like peptide-1 promotes satiety
`and reduces food intake in patients with
`diabetes mellitus type 2. Am J Physiol 276:
`R1541–R1544, 1999
`13. Toft-Nielsen MB, Madsbad S, Holst JJ:
`Continuous subcutaneous infusion of
`glucagon-like peptide 1 lowers plasma
`glucose and reduces appetite in type 2 di-
`abetic patients. Diabetes Care 22:1137–
`1143, 1999
`14. Nauck MA, Sauerwald A, Ritzel R, Holst
`JJ, Schmiegel W: Influence of glucagon-
`like peptide 1 on fasting glycemia in type
`2 diabetic patients treated with insulin af-
`ter sulfonylurea secondary failure. Diabe-
`tes Care 21:1925–1931, 1998
`15. Zander M, Madsbad S, Madsen JL, Holst
`JJ: Effect of 6-week course of glucagon-
`like peptide 1 on glycaemic control, insu-
`lin sensitivity, and beta-cell function in
`type 2 diabetes: a parallel-group study.
`Lancet 359:824 – 830, 2002
`16. Knudsen LB, Agerso H, Bjenning S, Bre-
`genholt S, Carr RD, Godtfredsen C, Holst
`JJ, Huusfeldt PO, Larsen MO, Larsen PJ,
`Nielsen PF, Ribel U, Rolin B, Romer J,
`Sturis J, Wilken M, Kristensen P: GLP-1
`derivatives as novel compounds for the
`treatment of type 2 diabetes: selection of
`NN2211 for clinical development. Drugs
`of the Future 26:677– 685, 2001
`17. Flint A, Raben A, Blundell JE, Astrup A:
`Reproducibility, power and validity of vi-
`sual analogue scales in assessment of ap-
`petite sensations in single test meal
`studies. Int J Obes Relat Metab Disord 24:
`38 – 48, 2000
`
`1920
`
`DIABETES CARE, VOLUME 27, NUMBER 8, AUGUST 2004
`
`MPI EXHIBIT 1085 PAGE 6
`
`

`

`Harder and Associates
`
`18. Matthews DR, Hosker JP, Rudenski AS,
`Naylor BA, Treacher DF, Turner RC: In-
`sulin resistance and beta-cell
`function
`from fasting plasma glucose and insulin
`concentrations in man. Diabetologia 28:
`412– 419, 1985
`19. Toubro S, Sorensen TI, Ronn B, Chris-
`tensen NJ, Astrup A: Twenty-four-hour
`energy expenditure: the role of body com-
`position, thyroid status, sympathetic ac-
`tivity, and family membership.
`J Clin
`Endocrinol Metab 81:2670 –2674, 1996
`20. Diabetes Control and Complications Trial
`Research Group: The effect of intensive
`treatment of diabetes on the development
`and progression of long-term complica-
`tions in insulin-dependent diabetes mel-
`litus. N Engl J Med 329:977–986, 1993
`21. United Kingdom Prospective Diabetes
`Study Group: United Kingdom Pros-
`pective Diabetes Study 24: a 6-year,
`randomized, controlled trial comparing
`sulfonylurea,
`insulin, and metformin
`therapy in patients with newly diagnosed
`type 2 diabetes that coul