Diabetes & Metabolism
`Volume , Supplement , April , Pages S-S
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`B. Vergès
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`, B. Charbonnel
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`After the LEADER trial and SUSTAIN-6, how do we
`explain the cardiovascular benefits of some GLP-1
`receptor agonists?
`Abstract
`Recent cardiovascular outcome trials – the
`LEADER with liragutide and SUSTAIN-6 with semaglutide –
`have shown significant reductions of major cardiovascular (CV) events with these glucagon-like
`peptide (GLP)-1 receptor agonists. Progressive separation of the
`treatment and placebo curves,
`starting clearly between 12 and 18 months of the trial period, and significant reductions in the risk of
`myocardial infarction and stroke, indicate that the beneficial
`CV effects observed with GLP-1 receptor
`agonists could be due to an antiatherogenic effect. So far, the reasons for such an effect of GLP-1
`receptor agonists have not been entirely clear, although several hypotheses may be proposed. As the
`reductions in
`glycated haemoglobin and systolic blood pressure (SBP) in these trials were modest, and
`both trials lasted only a short period of time, reductions in
`hyperglycaemia and SBP are unlikely to be
`involved in the beneficial
`CV effects of GLP-1 receptor agonists. On the other hand, their effect on
`lipids and, in particular, the dramatic decrease in postprandial
`hypertriglyceridaemia may explain
`their beneficial CV actions. Reduction of body weight, including a significant decrease in
`visceral fat in
`patients using GLP-1 receptor agonists, may also have beneficial CV effects by reducing chronic
`proatherogenic inflammation. In addition, there are in-vitro data showing a direct anti-inflammatory
`effect with these agents that could also be involved in their beneficial CV effects. Moreover, studies in
`humans have shown significant beneficial effects on
`ischaemic myocardium after a very short
`treatment period, suggesting a direct effect of GLP-1 receptor agonists on myocardium, although the
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`precise mechanism remains unclear. Finally, as a reduction in insulin resistance has been associated
`with a decrease in CV risk, it cannot be ruled out that the lowering of insulin resistance induced by
`GLP-1 receptor agonists might also be involved in their beneficial CV actions.
`Introduction
`Glucagon-like peptide (GLP)-1 receptor agonists are effective hypoglycaemic agents that are widely
`used. In recent years, considerable data have suggested that GLP-1 receptor agonists may have effects
`beyond their glucose-lowering actions, including a possible cardioprotective effect [1], [2]. Some
`animal studies showed that GLP-1 receptor agonists could reduce the size of myocardial infarction
`(MI) [3], [4] while, in humans, limited studies have reported reduced MI size after administration of
`these drugs, suggesting beneficial effects on the ischaemic heart [5], [6], [7]. Furthermore, the
`Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) trial
`and the Trial to Evaluate Cardiovascular and Other Long-term Outcomes with Semaglutide in Subjects
`with Type 2 Diabetes (SUSTAIN-6) have recently provided clear evidence of cardiovascular (CV)
`benefit with these GLP-1 receptor agonists. Both studies were conducted in patients with type 2
`diabetes mellitus (T2DM) and a history of previous CV events (82–83%) or high CV risk (17–18%) [8],
`[9]. In the LEADER trial, 3.5 years of treatment with liraglutide 1.8 mg/day was associated with a
`significant 13% reduction in the primary outcome (time to first major CV event: CV death, non-fatal
`MI, non-fatal stroke; p = 0.01), and a significant 14% reduction in MI (fatal and non-fatal; p = 0.046),
`22% reduction in CV-related death (p = 0.007) and 15% reduction in total mortality (p = 0.02; Table 1)
`[8]. In SUSTAIN-6, 2 years of treatment with semaglutide, a long-acting GLP-1 receptor agonist
`administered once a week, resulted in a significant 26% reduction in the primary outcome (time to
`first major CV event: CV death, non-fatal MI, non-fatal stroke; p = 0.02), 39% reduction in non-fatal
`stroke (p = 0.04) and 35% reduction in revascularization procedures (p = 0.003; Table 1) [9].
`There are some similarities, but also some differences, between the results of these two trials (Table
`1). One major similarity was the significant reduction in major CV outcomes with liraglutide.
`However, the significant reduction in CV death and total mortality in LEADER was not observed in
`SUSTAIN-6. This difference could be due to both the shorter duration of SUSTAIN-6 and its smaller
`number of included patients, leading to considerably fewer deaths compared with the LEADER trial
`(122 vs 497, respectively). A notable difference between the two trials was the significant reduction in
`non-fatal stroke in SUSTAIN-6, but not in LEADER. Although the reasons for this discrepancy are still
`unknown, it may be supposed that the greater reduction in systolic blood pressure in SUSTAIN-6
`compared with LEADER (-2.6 mmHg vs -1.2 mmHg, respectively) is perhaps part of the explanation.
`Nevertheless, further studies are needed to clarify the dramatic effect of semaglutide on stroke. It is
`important to note that, in LEADER, the curves for liraglutide and placebo diverged at between 12 and
`18 months, which is similar to what is observed in clinical prospective trials of statins, whereas in
`SUSTAIN-6, the curves for semaglutide and placebo diverged progressively throughout the study.
`While this suggests that the decrease in major CV events observed with GLP-1 receptor agonists could
`be due to an antiatherogenic effect, so far, the reasons behind this beneficial effect have not been
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`entirely elucidated, although several hypotheses may be considered. Thus, the present review
`discusses the potential mechanisms that might explain the CV benefits of GLP-1 receptor agonists
`summarized in Fig. 1.
`Section snippets
`Effects of liraglutide on fasting lipids
`Significant variations in lipid parameters are observed in type 2 diabetes mellitus (T2DM) patients
`treated with GLP-1 receptor agonists. In a 3.5-year open-label study, exenatide b.i.d. reduced low-
`density lipoprotein (LDL) cholesterol by 6% and triglycerides (TGs) by 12%, while increasing high-
`density lipoprotein (HDL) cholesterol by 24% [10]. Five-year data from the DURATION study showed a
`significant reduction in LDL cholesterol (-9.8%) and TGs (-12%), and a significant increase in HDL…
`Reduction of hyperglycaemia
`In LEADER, the mean HbA level with liraglutide was 0.4% lower than with placebo whereas, in
`SUSTAIN-6, the mean HbA level was 0.7% lower with semaglutide 0.5 mg and 1% lower with
`semaglutide 1 mg than with placebo [8], [9]. Previous prospective studies have shown that the
`reduction in hyperglycaemia needs time to induce a significant decrease in CV events [26]. For
`instance, in the United Kingdom Prospective Diabetes Study (UKPDS), a significant reduction in MI was
`observed only in the…
`Anti-inflammatory actions of GLP-1
`Several in-vitro and animal studies have shown anti-inflammatory effects with both GLP-1 and GLP-1
`receptor agonists [30], [31], [32], [33], [34]. Exendin-4 directly reduced lipopolysaccharide (LPS)-
`induced secretion of cytokines [tumour necrosis factor (TNF)-
`, interleukin (IL)-1
` and IL-10] in
`human monocytes from non-diabetic individuals, effects that were blocked by coadministration of the
`GLP-1 receptor antagonist exendin-(9-39), suggesting that GLP-1 had a direct effect on the immune…
`Effect on weight loss
`In addition to their effects on blood glucose control, GLP-1 receptor agonists have demonstrated
`positive effects on body weight. A meta-analysis of 27 trials showed significant mean weight loss with
`GLP-1 receptor agonists vs placebo: exenatide 2 mg/week: -1.62 kg; exenatide 20 
`g: -1.37 kg;
`liraglutide 1.2 mg: -1.01 kg; and liraglutide 1.8 mg: -1.51 kg [41]. Another meta-analysis of 18 trials
`involving T2DM patients reported a mean body weight decrease of -2.8 kg with GLP-1 receptor
`agonists vs…
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`Effects of native GLP-1
`Several studies have shown a beneficial effect of native GLP-1 on the heart [51]. GLP-1 in vitro
`increased intracellular cyclic AMP in rat cardiomyocytes [52] while, in murine cardiomyocytes, GLP-1
`protected cells against apoptosis induced by staurosporine, palmitate or ceramide, a cytoprotective
`effect mainly mediated by phosphatidylinositol 3-kinase (PI3K) and partially dependent on
`extracellular signal-regulated kinase (ERK) 1/2 [53]. In wild-type mouse hearts subjected to ischaemia
`–…
`GLP-1 and endothelium function
`In several in-vitro studies, GLP-1 induced endothelial-dependent relaxation [74], [75], an effect that is
`NO-dependent [75]. Also, in-vitro GLP-1 decreased reactive oxygen species (ROS) generation and
`subsequently reduced VCAM-1 mRNA levels in human umbilical vein endothelial cells (HUVECs)
`exposed to advanced glycation end-products (AGEs) [76], while several human studies reported
`beneficial effects with GLP-1 on endothelium function. In healthy non-diabetic subjects, GLP-1
`infusion enhanced…
`GLP-1 receptor agonists and insulin resistance
`Several human studies using the euglycaemic – hyperinsulinaemic clamp test have clearly shown that
`GLP-1 receptor agonists can significantly improve insulin sensitivity, which appears to be only partly
`mediated by weight reduction, so suggesting a direct effect [90], [91], [92]. This is reinforced by in-
`vitro studies showing that GLP-1 receptor agonists can enhance the insulin-signaling pathway [93],
`[94]. It is well established that insulin resistance is associated with increased CV risk [95], …
`Reduction in hypoglycaemia?
`Hypoglycaemia is associated with an increased risk of CV events [98] and, as GLP-1 receptor agonists
`are known to reduce the risk of hypoglycaemia compared with insulin and sulphonylureas, it seems
`plausible that this effect could be linked to their CV benefits. However, this is actually unlikely
`because, although fewer hypoglycaemic events were observed in patients using liraglutide in the
`LEADER trial [8], the rate of hypoglycaemia in patients using semaglutide was similar to that with a…
`Are CV effects similar in all GLP-1 receptor agonists?
`As the prospective Evaluation of Lixisenatide in Acute Coronary Syndrome (ELIXA) trial failed to show
`any reduction of major CV events with lixisenatide in T2DM patients after acute coronary syndrome,
`it must be acknowledged that the CV effects are not the same in all GLP-1 receptor agonists [99].
`While the reason(s) behind these discrepancies still need to be fully elucidated, it is likely that the
`different CV effects are due to differences in pharmacokinetics [100]. Lixisenatide has a very…
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`Conclusion
`In conclusion, the LEADER trial and SUSTAIN-6 have clearly demonstrated, in T2DM patients at high
`CV risk, the beneficial CV actions of the GLP-1 receptor agonists liraglutide and semaglutide, most
`probably due to antiatherogenic effects. So far, the reasons behind this benefit are not entirely clear.
`Nevertheless, several hypotheses have been proposed, including the reduction of postprandial lipids,
`of body weight and visceral fat, and of chronic inflammation, as well as the possible direct…
`Disclosure of interest
`During the past 5 years, B. Charbonnel has received fees for consultancy, speaking, travel or
`accommodation from AstraZeneca, Boehringer-Ingelheim, Janssen, Lilly, Merck-Sharpe & Dohme,
`Novartis, Novo-Nordisk, Sanofi, Takeda.
`During the past 5 years, B. Vergès received consulting fees and honoraria for lectures from
`AstraZeneca/Bristol-Myers Squibb, Bayer Pharma, Kowa, Lilly, Merck Sharp Dohme, Novartis, Novo
`Nordisk, Sanofi, Servier and Takeda.…
`References (101)
`Exenatide reduces infarct size and improves cardiac function in a porcine model of
`ischemia and reperfusion injury
`Five-year efficacy and safety data of exenatide once weekly: long-term results from the
`DURATION-1 randomized clinical trial
`Reductions in lipids and CV risk markers in patients with type 2 diabetes treated with
`liraglutide: a meta-analysis
`Exenatide suppresses postprandial elevations in lipids and lipoproteins in individuals with
`impaired glucose tolerance and recent onset type 2 diabetes mellitus
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`
`Diabetes Metab ()
`
`Ł. Bułdak et al.
`
`Pharmacol Rep PR ()
`
`A.J. Scheen et al.
`
`Diabetes Metab ()
`
`R.S. Rosenson et al.
`
`J Lipid Res ()
`View more references
`
`, Molecular Metabolism
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`Show abstract
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`Effects of reducing blood pressure on cardiovascular outcomes and mortality in patients
`with type 2 diabetes: Focus on SGLT2 inhibitors and EMPA-REG OUTCOME
`Reduction in cardiovascular and all-cause mortality in the EMPA-REG OUTCOME trial: A
`critical analysis
`Effects of glucose-lowering agents on vascular outcomes in type 2 diabetes: a critical
`reappraisal
`Exenatide (a GLP-1 agonist) expresses anti-inflammatory properties in cultured human
`monocytes/macrophages in a protein kinase A and B/Akt manner
`Antidiabetic agents: Potential anti-inflammatory activity beyond glucose control
`Modulation of oxidative stress, inflammation, and atherosclerosis by lipoprotein-
`associated phospholipase A2
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`Cardiovascular protection by SGLT2 inhibitors – Do anti-inflammatory mechanisms play a
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`Sodium Glucose Transporter, Type 2 (SGLT2) Inhibitors (SGLT2i) and Glucagon-Like
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`Cardiovascular outcome studies in type 2 diabetes: Comparison between SGLT2 inhibitors
`and GLP-1 receptor agonists
`…When comparing the three CVOTs having tested a GLP-1RA, significant reductions in CV events occurred with
`those medications that induced the largest reduction not only in HbA1c, but also in body weight and systolic
`blood pressure, i.e. liraglutide and semaglutide. Thus, even if a small effect due to differences in glucose/HbA1c
`cannot be excluded [69], it seems more likely that the reductions in MACEs with GLP-1RAs are mainly driven by
`nonglycaemic effects of these drugs [11,70]. However, it also appears likely that traditional risk factor modification
`alone cannot explain the overall benefits observed within a rather short time frame of two (SUSTAIN 6) to four
`(LEADER) years.…
`Myocardial Infarction Subtypes in Patients With Type 2 Diabetes Mellitus and the Effect of
`Liraglutide Therapy (from the LEADER Trial)
`…However, there were some numeric differences in MI subtypes between the treatment groups, and the lack of
`power in our study to examine MI subtypes may obscure genuine differences (a type II error). The mechanisms
`underlying the CV benefits of liraglutide shown in the LEADER trial have not been fully elucidated, but because of
`the effects on a composite end point of atherosclerotic events, it has been suggested that it could be due to an
`antiatherogenic effect.5 Several mechanistic hypotheses for such an effect have been proposed, including the
`favorable effects of liraglutide on weight, lipid profiles, systolic blood pressure, and anti-inflammatory
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`Cardiovascular outcomes in diabetic kidney disease: insights from recent clinical trials
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`…Several studies have shown that GLP-1 RA induces major reductions in postprandial hyperlipidemia, a
`meaningful component of diabetic dyslipidemia that is known to be atherogenic.47–49 Additionally, several
`preclinical and clinical studies have shown evidence of direct and indirect effects (through lower body weight and
`better glucose control) of GLP-1 RA on reducing inflammation, which could contribute to its beneficial CV
`actions.50–52 Interestingly, studies in humans also seem to suggest a direct effect of GLP-1 RA in the heart,
`specifically in ischemic conditions.…
`