Management of diabetes with risk factors getting to goal in glycemic control Dr Mahir Khalil Jallo

1. Management of Diabetes with Risk Factors:
Getting to Goal in Glycemic Control
Dr Mahir Khalil Jallo
Associate Professor of Medicine
Senior consultant – Diabetes & Endocrinology
Gulf Medical University Hospital & Research Centre
Member of AACE – ESE – EASD
PRIMARY CARE S E M I N A R
SHARJAH UAE 25 May 2012

2. Objectives:
• Epidemiology of Diabetes in UAE.
• Recent ADA-EASD Position Statement:
Management of Hyperglycemia in T2DM.
• Cardiovascular Risks of Diabetes.
• Role of DPP4 Inhibitor in Diabetic Care.
• Hypoglycemia and its Consequences.
• Diabetes & Ramadan.

3. Objectives:
• Epidemiology of Diabetes in UAE.
• Recent ADA-EASD Position Statement:
Management of Hyperglycemia in T2DM.
• Cardiovascular Risks of diabetes.
• Role of DPP4 Inhibitor in Diabetic Care.
• Hypoglycemia and its consequences.
• Diabetes & Ramadan.

5. Key Messages
• Diabetes is a huge and growing problem with high
and escalating costs to the society.
• Diabetes has reached epidemic proportions.
• It is a complex multifactorial disease.
• Management requires a complex multifactorial
approach.

6. Diabetes and weight in the US

7. Prevalence of Type 2 Diabetes by
Ethnicity
Pima Indian
Asian Indian Fiji
Mauritius
Hispanic US
Black US
White US
Polynesian Cook
Polynesian Wallis
Bantu
China
0 10 20 30 40 50 60
Prevalence (%)

8. The Top 10s
(number of people with diabetes)

9. The Top 10s
(prevalence %)

11. The Global Burden
 366 million people have diabetes in 2011 ..by 2030 this will have risen to
552 million
 The number of people with type 2 diabetes is increasing in every country
 80% of people with diabetes live in low-and middle-income countries
 The greatest number of people with diabetes are between 40 to 59 years of
age
 183 million people (50%) with diabetes are undiagnosed
 Diabetes caused 4.6 million deaths in 2011
 Diabetes caused at least USD 465 billion dollars in healthcare expenditures
in 2011 .. 11% of total healthcare expenditures in adults (20-79 years)
 78,000 children develop type 1 diabetes every year

12. Undiagnosed Diabetes

13. Deaths due to Diabetes
• 4.6 million
deaths due to
diabetes in 2011
• 8.2% of all-
cause mortality
• 48% in people
under 60

14. The Benefits of Good Glucose Control in
Type 2 DM

15. The UK Prospective
Diabetes Study

16. UK Prospective Diabetes Study
Does an intensive glucose control
policy reduce the risk of complications
of diabetes?

17. Actual Therapy
Conventional Policy Intensive Policy
accept < 15 mmol/L aim for < 6 mmol/L
100
die t alone
additional non-intens ive
proportion of patient s
80 pharm acological therapy
60
intens ive
40 pharm acological
therapy
20 die t alone
0
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
Ye ars from random isation

18. Aggregate Clinical Endpoints
Relative Risk
& 95% CI
RR p 0.5 1 2
Any diabetes related endpoint 0.88 0.029
Diabetes related deaths 0.90 0.34
All cause mortality 0.94 0.44
Myocardial infarction 0.84 0.052
Stroke 1.11 0.52
Microvascular 0.75 0.0099
Favours Favours
intensive conventional

19. Progression of Retinopathy
Two step change in Early Treatment Diabetic Retinopathy Study (ETDRS) sca
Relative Risk
& 99% CI
RR p 0.5 1 2
0 - 3 years 1.03 0.78
0 - 6 years 0.83 0.017
0 - 9 years 0.83 0.012
0 - 12 years 0.79 0.015
Favours Favours
intensive conventional

20. Microalbuminuria
Urine albumin >50 mg/L
Relative Risk
& 99% CI
RR p 0.5 1 2
Baseline 0.89 0.24
Three years 0.83 0.043
Six years 0.88 0.13
Nine years 0.76 0.00062
Twelve years 0.67 0.000054
Fifteen years 0.70 0.033 <
Favours Favours
intensive conventional

21. Glucose Control Study Summary
The intensive glucose control policy maintained a lower HbA1c
by mean 0.9 % over a median follow up of 10 years from
diagnosis of type 2 diabetes with reduction in risk of:
12% for any diabetes related endpoint p=0.029.
25% for microvascular endpoints p=0.0099.
16% for myocardial infarction p=0.052.
24% for cataract extraction p=0.046.
21% for retinopathy at twelve years p=0.015.
33% for albuminuria at twelve years p=0.000054

22. Conclusion
The UKPDS has shown that intensive
blood glucose control reduces the risk of
diabetic complications.. the greatest effect
being on microvascular complications

23. Early control has lasting benefits
10 year follow-up analysis
Treatment with
Sulphonylureas
and insulin

24. Objectives:
• Epidemiology of Diabetes in UAE.
• Recent ADA-EASD Position Statement:
Management of Hyperglycemia in T2DM.
• Cardiovascular Risks of diabetes.
• Role of DPP4 Inhibitor in Diabetic Care.
• Hypoglycemia and its consequences.
• Diabetes & Ramadan.

25. Managing Diabetes
Blood pressure
Cholesterol
Micro albuminuria
Glycaemia

26. OMINOUS OCTET
Decreased
Incretin Effect
Decreased Insulin
Secretion Increased
Lipolysis
Islet–a cell
ETIOLOGY OF T2DM
Impaired Insulin Increased Lipolysis
Secretion
Hyperglycemia
Increased Decreased Glucose
HGP Uptake
DEFN75-3/99
HYPERGLYCEMI
Increased
A Glucose
Reabsorption
Increased
Glucagon
Secretion Increased
HGP Decreased Glucose
Uptake
Neurotransmitter
Dysfunction

27. Type 2 Diabetes Medication Choices
Experience and Potency
Efficacy as monotherapy: %
Medication Route Year
 in HgbA1c
Insulin s.c. 1921 2.5
Sulfonylureas Oral 1946 1.5
Glinides Oral 1997 1.0-1.5
Metformin Oral 1995 1.5
a-glucosidase inhibitors Oral 1995 0.5-0.8
TZDs Oral 1999 0.8-1.0
GLP analogue s.c. 2005 0.6
DPP-IV Inhibitors Oral 2006 0.5-0.8
Amylin analogue s.c. 2005 0.6
Colesevelam Oral 2008 0.5
Bromocriptine mesylate Oral 2009 0.2-0.4

28. Mechanisms of Action of Pharmacologic Agents
for Diabetes
Improving Outcomes in Patients With Type 2 Diabetes Mellitus: Practical Solutions for Clinical Challenges
James R. Gavin, III, MD, PhD; Mark W. Stolar, MD; Jeffrey S. Freeman, DO; Craig W. Spellman, DO, PhD
JAOA • Vol 110 • No 5suppl6 • May 2010 • 2-14

29. Type 2 Diabetes Medication Choices and Potency
• Higher baseline A1C levels predict
greater drop in A1C
• Shorter duration of diabetes predicts
greater drop in A1C with any oral agent
• All oral agents require presence of
some endogenous b cell function.. as
they work by either increasing insulin
sensitivity or augmenting b cell insulin
release
Sherifali et.al. Diabetes Care. 2010; 33: 1859-1864

30. ADA-EASD Position Statement: Management of
Hyperglycemia in T2DM
• Glycemic targets
• HbA1c < 7.0% (mean PG 150-160 mg/dl [8.3-8.9 mmol/l])
- Pre-prandial PG <130 mg/dl (7.2 mmol/l)
- Post-prandial PG <180 mg/dl (10.0 mmol/l)
• Individualization is key:
 Tighter targets (6.0 - 6.5%) – younger.. Healthier.
 Looser targets (7.5 - 8.0%+) – older.. Comorbidities.
hypoglycemia prone, etc.
• Avoidance of hypoglycemia
PG = plasma glucose Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]

31. ADA-EASD Position Statement: Management of
Hyperglycemia in T2DM
 Achieve and Maintain near normoglycemia, A1c <7.0
 Initiate Therapy with Lifestyle and Metformin
 Rapid addition of medications.. and transition to new
regimens when targets are not achieved
 Early addition of insulin therapy in patients who do not
met target goals
Nathan, Diabetes Care 2008;31:1-11

32. Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]
(Adapted with permission from: Ismail-Beigi F, et al. Ann Intern Med 2011;154:554)

33. Diabetes Care, Diabetologia. 19 April 20
T2DM Antihyperglycemic Therapy: General Recommendations ahead of print]
[Epub

34. Diabetes Care, Diabetologia. 19 April 20
T2DM Antihyperglycemic Therapy: General Recommendations ahead of print]
[Epub

35. Diabetes Care, Diabetologia. 19 April 20
T2DM Antihyperglycemic Therapy: General Recommendations ahead of print]
[Epub

36. Diabetes Care, Diabetologia.
19 April 2012 [Epub ahead of print]

37. Patient Preference: Efficacy
sulfonylurea
DPP4
inhibitor
GLP1
metformin TZD
α-
glucosidase
inhibitors
glinide

38. Patient Preference: Cost
TZD
DPP4
metformin sulfonylurea inhibitor
GLP1
α-glucosidase
inhibitor

39. Patient Preference: Weight
sulfonylurea
DPP4 α-
metformin inhibitor glucosidase
GLP1 inhibitor
TZD

40. Patient Preference:
Hypoglycemia Avoidance
DPP4
inhibitor
GLP1
sulfonylurea
metformin TZD
glinide
α-
glucosidase
inhibitor

41. Factors to Consider when Choosing
Pharmacological Agent(s) for Diabetes
• Current A1C
• Duration of diabetes
• Potential Hypoglycemia
• Body weight (BMI.. abdominal obesity)
• Age of patient
• Co-morbidities
• Cost of medication
• Convenience

42. Objectives:
• Epidemiology of Diabetes in UAE.
• Recent ADA-EASD Position Statement:
Management of Hyperglycemia in T2DM.
• Cardiovascular Risks of diabetes.
• Role of DPP4 Inhibitor in Diabetic Care.
• Hypoglycemia and its consequences.
• Diabetes & Ramadan.

43. Cardiovascular risks
140
Age adjusted CVD death rate per
non diabetic
120 diabetic
10,000 person years
100
80
60
40
20
0
none one only two only all three
(from cholesterol, hypertension and smoking)

44. Level of established risk factors of CHD in type 2
diabetic compared with non-diabetic populations
80 Men
70
Women
60
Difference (%)
50
40
30
20
10
0
-10

45. Survival of diabetic (1059) and non-diabetic (1378)
subjects with and without prior MI in Finland
100
80
60
Non-diabetic no MI
%
Non-diabetic with MI
40 Diabetic no MI
Diabetic with MI
20
0
1 2 3 4 5 6 7 8
years
Haffner SM et al. NEJM 98;339:229-34

46. The Benefits of Tight Glucose Control in
Type 2 DM
Is the Lower always the Better ???

47. ACCORD..ADVANCE and VADT Trials
• ACCORD - Action to Control Cardiovascular Risk in Diabetes
• ADVANCE - Action in Diabetes to Prevent Vascular Disease
• VADT - Veterans Administration Diabetes Trail
ACCORD Study Group, NEJM 2008, 358:2545-2559.
ADVANCE Collaborative Group, NEJM 2008, 358:2560-2572.
VADT Study Diabetes Obesity and Metabolism, 2008

48. ACCORD.. ADVANCE and VADT Trials
Does Intensive Glucose Control
Reduce Risk for Cardiovascular Disease
in Type 2 Diabetes?
ACCORD Study Group, NEJM 2008, 358:2545-2559.
ADVANCE Collaborative Group, NEJM 2008, 358:2560-2572.
VADT Study Diabetes Obesity and Metabolism, 2008

49. ACCORD, ADVANCE and VADT
Study Design
ACCORD ADVANCE VADT
Major Endpoints CV death, CV death, CV death,
Non-fatal Non-fatal Non-fatal
MI/Stroke MI/Stroke, MI/Stroke, CHF
macrovacs event macrovacs event
Study RCT RCT RCT
design Glucose Glucose Glucose
Intensive vs Intensive vs Intensive vs
Standard Arm Standard Arm Standard Arm
2x2 2x2 2x1
BP control Perindopril All received BP
+/-fenofibrate +indamide and Lipid Rx
v placebo v placebo

50. ACCORD, ADVANCE and VADT
Demographics
ACCORD ADVANCE VADT
# Participants 10,251 11,140 1,791
population North America Europe /Asia US
Male 62% 58% 97%
Age group 40-79 >55 yrs >40yrs
mean age 62.2 66 60.5
Non-Hispanic White 27% Hispanic, 37% Asian 38% Hispanic,
Ethnic Representation African Am African Am,
Native Am

51. Outcomes
ACCORD.. ADVANCE and VADT
ACCORD* ADVANCE VADT
A1C (%) 6.4 vs.7.5 † 6.4 vs. 7.0 † 6.9 vs. 8.4 †
(Intensive vs. Std)
Nonfatal MI (%) 3.6 vs 4.6% † 2.7 vs.2.8 6.3 vs. 6.1
(Intensive vs. Std)
CV Death (%) 2.6 vs. 1.8 † 4.5 vs. 5.2 2.1 vs.1.7
(Intensive vs. Std) (1.35 Hazard Ratio)
Microvascular - nephropathy ↓ 21% -
retinopathy ↓ 5% NS
Take home ↓ risk MIs, but Glucose control has no Glucose control
↑ risk death in impact on CV events, has no impact on
intensive arm but ↓ Microvascular risk CV events
*ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial halted intensive glucose group (2/6/08)
† significant difference between intensive and standard group

52. Adverse Outcomes:
ACCORD.. ADVANCE and VADT
Intensive vs Std ACCORD* ADVANCE VADT
Severe Hypoglycemia 3.0 vs 1.0 0.7 vs 0.4 -
(% per yr)
Hypoglycemia requiring 4.6 vs 1.5 1.8 vs 0.6 2.3 vs 1.1
assistance (% per year)
Weight Gain > 10Kg 27.8 % vs 14.1% 0.0 vs -1.0 -
Wt gain (Kg) 3.5 0.7 6.8
Intensive group
Increased Mortality No No No
Rosigliatzone?

53. Hazard Ratios for the Primary Outcome and Death from Any
Cause in Pre-specified Subgroups: ACCORD Study
Prior
CVD
Age
<65
A1c
>8.1
N Engl J Med 358;24, 2008

54. ACCORD.. ADVANCE and VADT
Lessons Learned
• Intensive glucose control does not reduce CVD
mortality in T2DM.. and may increase risk,
especially in patients with pre-existing CHD
• Aggressive A1c targets (<6.5%) were associated
with a 3-fold increased risk hypoglycemia

55. ACCORD, ADVANCE, and VADT
Lessons Learned- Continued
• Intensive control associated with reduced risk for
nephropathy in ADVANCE.
• To reach and maintain A1c targets of <6.5
required frequent adjustments of multiple anti-
diabetic medications
• Aggressive Targets (<6.5) are probably reasonable
for healthy patients to reduce risk micro-vascular
complications

56. Risks of Hypos
ACCORD ADVANCE
HbA1c, % 6.4 vs. 7.5* 6.5 vs. 7.3*
Death from any cause,% 5.0 vs. 4.0* 8.9 vs. 9.6
Death from cardiovascular event, 2.6 vs. 1.8* 4.5 vs. 5.2
%
Nonfatal MI, % 3.6 vs. 4.6* 2.7 vs. 2.8
Major/severe hypoglycemia, % 10.5 vs. 3.5* 2.7 vs. 1.5*
Weight gain, kg 3.5 vs. 0.4* 0.0 vs. -1.0*
Summary of ACCORD & ADVANCE
*p≤0.05

57. Objectives:
• Epidemiology of Diabetes in UAE.
• Recent ADA-EASD Position Statement:
Management of Hyperglycemia in T2DM.
• Cardiovascular Risks of diabetes.
• Role of DPP4 Inhibitor in Diabetic Care.
• Hypoglycemia and its consequences.
• Diabetes & Ramadan.

58. The Incretin System
• The missing link in diabetes and
metabolic syndrome?

59. Incretins
• Messengers exist to stimulate insulin release
and prepare vasculature for glucose/insulin
combination
• Glucagon-like peptede -1 (GLP-1)
• Glucose-dependent insulinotropic
polypeptide (GIP)

60. Insulin and Glucagon Regulate Normal
Glucose Homeostasis
Glucagon (a-cell)
Fasting state Pancreas Fed state
Insulin
(b-cell)
Glucose output Glucose uptake
Muscle
Blood glucose
Blood glucose
Liver Adipose
tissue
Porte D Jr, Kahn SE. Clin Invest Med. 1995;18:247-54. Adapted with permission from Kahn CR, Saltiel AR. In: Kahn CR et al, eds.
Joslin’s Diabetes Mellitus. 14th ed. Lippincott Williams & Wilkins; 2005:145-68.

61. Role of Incretin System in Glucose
Homeostasis Glucose-
dependent Glucose
insulin uptake by
Ingestion (GLP-1 & GIP) peripheral
of food tissue
Pancreas
Release of b-cells
GI tract active incretins a-cells Normoglycaemia
GLP-1 & GIP
 Hepatic
Glucose- glucose
dependent production
DPP-4  glucagon
inactivates (GLP-1)
GLP-1 & GIP
Adapted from Drucker DJ. Cell Metab. 2006;3:153-65.

62. Food Promotes
Insulin secretion
Inhibits Inhibits background
gastric emptying Glucagon secretion
Increases
Hypo-dependent
Glucagon secretion
GIP GLP-1
Vasodilates
perfusing beds Reduces
appetite
Inhibits
gluconeogenesis

63. Food Promotes
Inhibits Insulin secretion
gluconeogenesis Inhibits background
Glucagon secretion
Increases
Hypo-dependent
Glucagon secretion
GIP GLP-1
Vasodilates
perfusing beds Reduces
DPP-IV appetite

64. The Incretin System and Glucose
Homeostasis
– Glucagon-like peptide-1 (GLP-1) and glucose-dependent
insulinotropic polypeptide (GIP) are incretins secreted from
enteroendocrine cells postprandially that participate in regulation
of glucose homeostasis1,2
– The incretins enhance glucose-dependent insulin secretion,
suppress postprandial glucagon secretion from pancreatic a-cells,
slow gastric emptying, reduce food intake and promote weight
loss3
– The incretins are normally inactivated by dipeptidyl peptidase 4
(DPP-4)4
1. Mosjov S, et al. J Clin Invest. 1987;79:616-9.
2. Kreymann B, et al. Lancet. 1987;2:1300-4.
3. Drucker DJ. J Clin Invest. 2007;117(1):24-32.
4. Kieffer TJ, et al. Endocrinology. 1995;136(8):3585-96.

65. GLP-1 and GIP are the Two Major
Incretins
GLP-1 GIP
– Produced by K cells in the proximal
– Produced by intestinal L cells1 gut6
– Stimulates glucose-dependent insulin – Stimulates glucose-dependent insulin
release2-4 release2-4
– Suppresses hepatic glucose output by – Minimal effects on gastric emptying;
inhibiting glucagon secretion in a no significant effects on satiety or body
weight2-4
glucose-dependent manner2-4
– Potentially enhances b-cell
– Inhibition of gastric emptying; proliferation and survival in islet cell
reduction of food intake and body lines2-4
weight2-4 – In contrast to GLP-1, does not retain its
– Enhances b-cell proliferation and insulinotropic activity in type 2
diabetics7
survival in animal models and
– The contribution of endogenous GIP to
isolated human islets2-4 the therapeutic efficacy of DPP-4
– Half-life 11.4 ± 1.0 minutes5 inhibitors uncertain4
– Half-life 7.3 ± 1.0 minutes8
1. Kieffer TJ, et al. Endocr Rev. 1999;20(6):876-913; 2. Drucker DJ. Cell Metab. 2006;3:153-65; 3. Dunning BE and Gerich JE.
Endo Rev. 2007;28(3):253-83; 4. Drucker DJ. J Clin Invest. 2007;117(1):24-32; 5. Schjoldager BT, et al. Dig Dis Sci.
1989;34(5):703-8; 6. Buchan AM, et al. Histochemistry. 1978;56(1):37-44; 7. Nauck MA, et al. J Clin Invest. 1993;91(1):301-7; 8.
Deacon CF, et al. J Clin Endocrinol Metab. 2000;85(10):3575-81.

66. Sites of Action of GLP-1
Brain
Neuroprotection
Gastric emptying
Heart Appetite
Stomach
Cardioprotection
Cardiac output
Glucose production Pancreas
GI tract
Insulin biosynthesis
b-cell proliferation
b-cell apoptosis
Liver Insulin Insulin secretion
sensitivity
Glucagon secretion
Muscle
Adapted from Drucker DJ. Cell Metab. 2006;3:153-65.

67. The Incretin Effect in Type 2 Diabetes
 The incretins may be responsible for up to 70% of postprandial insulin
secretion
 The incretin effect is severely reduced or absent in patients with type 2
diabetes
 The loss of GIP action is probably a consequence of diabetes
 GLP-1 secretion is also impaired, but its insulinotropic and glucagon-
suppressive actions are preserved
 The reduced incretin effect is believed to contribute to impaired
regulation of insulin and glucagon secretion in diabetic patients
 Enhancement of incretin action may therefore represent a therapeutic
solution
Holst JJ, et al. Mol Cell Endocrinol. 2009;297(1-2):127-36.

68. Potential Strategies for Incretin-
based Therapies
– GLP-1 continuous infusion
– Agents that mimic GLP-1 action (GLP-1 analogues)
– Agents that prevent GLP-1 degradation (DPP-4 inhibitors)

69. Continuous Infusion of GLP-1 Decreases
Fasting Glucose as well as HbA1c
Compared to saline, patients treated with GLP-1 showed fasting and 8-hour mean plasma glucose that was
decreased by 4.3 mmol/l and 5.5 mmol/l (P<0.0001), and HbA1c that was decreased by 1.3% (P=0.003)
Patients assigned saline Patients assigned GLP-1
Week 0 Week 1 Week 6
25 25
Glucose concentration in
Glucose concentration in
20 20
plasma (mmol/L)
plasma (mmol/L)
15 15
10 10
5 5
0 0
0 2 4 6 8 0 2 4 6 8
Time (hr) Time (hr)
20 patients with type 2 diabetes were alternately assigned continuous subcutaneous infusion of GLP-1 (N=10) or saline (N=10) for 6
weeks. The primary endpoints were HbA1c concentration, 8-h profile of glucose concentration in plasma and b-cell function.
Adapted from Zander M, et al. Lancet. 2002;359(9309):824-30.

70. The GLP-1 Receptor Agonist Exenatide
Improve Glycaemic Control
Exenatide LAR offers the potential of 24-hour glycaemic control
and weight reduction in type 2 diabetes
Placebo Exenatide LAR Exenatide LAR
(N=14) 0.8 mg (N=16) 2.0 mg (N=15)
13 10 *P<0.05 vs placebo
Mean (±SE) fasting plasma
Mean D: Mean D:
Mean (±SE) HbA1C (%)
12
glucose (mmol/l)
11 +1.0±0.7 9 +0.4±0.3%
10
8
9
8 -2.4±0.9* 7 -1.4±0.3%*
7 -2.2±0.5* -1.7±0.3%*
6 6
0 3 6 9 12 15 0 3 6 9 12 15
Time (weeks) Time (weeks)
 Patients receiving 2.0 mg exenatide LAR had significant reductions in body weight
(-3.8 ± 1.4 kg) (P < 0.05)
Randomised, placebo-controlled phase 2 study in which exenatide long-acting release (LAR) was administered
subcutaneously once weekly for 15 weeks to subjects with type 2 diabetes suboptimally controlled with metformin
(60%) and/or diet and exercise (40%).
Adapted from Kim D, et al. Diabetes Care. 2007;30:1487-93.

71. DPP-4 Inhibitors

72. DPP-4 Inhibitors Inhibit Breakdown of GLP-1
and GIP, Improving Incretin Activity
Glucose-
dependent Glucose
insulin uptake by
(GLP-1 & GIP) peripheral
Ingestion tissue
of food
Pancreas
 Blood glucose
Release of
GI tract a-cells
in fasting and
active incretins
b-cells postprandial
GLP-1 & GIP
states
DPP-4
inhibitors
 Hepatic
Glucose- glucose
DPP-4 dependent
inactivates production
 glucagon
GLP-1 & GIP (GLP-1)
• When plasma glucose levels are high, GLP-1 and GIP provoke an increase in insulin release from b-cells
• The action of GLP-1 on a-cells results in a decrease in glucagon secretion
Adapted from Drucker DJ. Cell Metab. 2006;3:153-65.

73. DPP-4 Inhibitors Approved or Pending for Approval
Compound
Sitagliptin1
Vildagliptin2
Saxagliptin3
Linagliptin
Alogliptin3
Sitagliptin + metformin4-6
Vildagliptin + metformin7-9
Saxagliptin + metformin XR
1. Januvia, Summary of Product Characteristics, EMEA, 4 Nov 2008. 2. Jalra, Summary of Product Characteristics, EMEA,
12 Jan 2009. 3. Ahrèn B. Expert Opin. Emerging Drugs. 2008;13(4):593-607. 4. Janumet, Summary of Product
Characteristics, EMEA, 18 Feb 2009. 5. Efficib, Summary of Product Characteristics, EMEA, 18 Feb 2009. 6. Velmetia,
Summary of Product Characteristics, EMEA, 18 Feb 2009. 7. Eucreas, Summary of Product Characteristics, EMEA, 18 Feb
2009. 8. Icandra, Summary of Product Characteristics, EMEA, 4 Mar 2009. 9. Zomarist, Summary of Product Characteristics,
EMEA, 12 Jan 2009.
SU, sulphonylurea; MF, metformin; TZD, thiazolidinedione

74. Mechanism of action: Summary
– Incretin hormones stimulate insulin release in a
glucose-dependent manner1-3
– GLP-1 has a major contribution in suppressing
postprandial glucagon secretion from pancreatic a-
cells3-5
– The incretin hormone GLP-1 plays a major role in
reducing postprandial glucose excursions3-5
– The incretin effect is diminished in type 2 diabetes6
1. Drucker DJ. Cell Metab. 2006;3:153-65; 2. Dunning BE and Gerich JE. Endo Rev. 2007;28(3):253-83; 3. Drucker DJ. J Clin
Invest. 2007;117(1):24-32; 4. Mosjov S, et al. J Clin Invest. 1987;79:616-9; 5. Kreymann B, et al. Lancet. 1987;2:1300-4; 6. Nauck
M, et al. Diabetologia. 1986;29:46-52; 7. Ahrèn B. Expert Opin Emerging Drugs. 2008;13(4):593-607.

75. Clinical Profile of DPP-4 Inhibitors
 Efficacy
 Safety Profile

76. Efficacy

77. Sitagliptin
Summary of Clinical Trials
Baseline Change in Total
Monotherapy/combination Duration HbA1c HbA1c number of
(weeks) (%) (%) patients Reference
Monotherapy 12 7.7 -0.39−0.56* 555 Curr Med Res Opin 2007;23:1329-39
Monotherapy 12 7.9 -0.38−0.77* 743 Int J Clin Pract 2007;61:171-180
Monotherapy 18 8.1 -0.48−0.60* 521 Diabetologia 2006;49:2564-71
Monotherapy 24 8.0 -0.79−0.94* 741 Diabetes Care 2006; 29:2632-7
Monotherapy 52 7.5 -0.67 1172 Diabet Obes Metab 2007;9:194-205
Metformin 18 7.7 -0.73 273 Diabet Obes Metab 2008;10:959-69
Metformin 24 8.0 -0.65* 701 Diabetes Care 2006;29:2638-43
Metformin 24 8.8 -1−2.1 1091 Diabetes Care 2007;30:1979-87
Metformin 52 7.5 -0.67 1172 Diabet Obes Metab 2007;9:194-205
Metformin 104 8.6 -1.4−1.7 587 Diabetologa 2008;51(Suppl 1):S36
Thiazolidinedione 24 8.1 -0.70* 353 Clin Ther 2006;28:1556-68
Sulphonylurea 24 8.3 -0.74* 441 Diabet Obes Metab 2007;9:733-45
Metformin + sulphonylurea 24 8.3 -0.89* 222 Diabet Obes Metab 2007;9:733-45
Metformin + thiazolidinedione 18 8.8 -0.9 277 Diabetologa 2008;51(Suppl 1):S365
*Placebo-adjusted change. Note that the studies are different and therefore not comparable; doses of compounds are not shown and may vary
in different studies. Change in HbA1c shows change from baseline except when asterisk is shown.
Ahrèn B. Expert Opin Emerging Drugs 2008; 13(4): 593-607.

78. Vildagliptin
Summary of Clinical Trials
Baseline Change in Total
Monotherapy/com
Duration HbA1c HbA1c number of
bination
(weeks) (%) (%) patients Reference
Monotherapy 4 7.2 -0.38* 37 J Clin Endocrinol Metab 2004;89:2078-84
Monotherapy 12 8.0 -0.6* 98 Horm Metab Res 2006;387:423-38
Monotherapy 24 8.4 -0.5−0.9* 354 Diabets Res Clin Pract 2007;76:132-8
Monotherapy 24 8.4 -0.8−0.9 632 Horm Metab Res 2007;39:218-23
Monotherapy 24 8.7 -1.1 786 Diabetes Care 2007;30:217-23
Monotherapy 52 6.6 -0.30 131 Diabetes Obes Metab 2008;10:1114-24
Metformin 24 8.4 -0.7-1.1* 544 Diabetes Care 2007;30:890-5
Metformin 24 8.4 -0.9 576 Diabet Obes Metab 2008;10:82-90
Metformin 52 7.8 -1.1* 107 Diabetes Care 2004;27:2874-80
Metformin 52 7.3 -0.44 2789 Diabetes Obes Metab 2009;11:157-66
Thiazolidinedione 24 8.7 -0.8−1.1* 463 Diabet Obes Metab 2007;9:166-74
Sulphonylurea 24 8.5 -0.6−0.7* 515 Diabetes Obes Metab 2008;10:1047-56
*Placebo-adjusted change. Note that the studies are different and therefore not comparable; doses of compounds are not shown and may
vary in different studies. Change in HbA1c shows change from baseline except when asterisk is shown.
Ahrèn B. Expert Opin Emerging Drugs 2008; 13(4): 593-607.

79. Saxagliptin
Summary of Clinical Trials
Baseline Change in Total
Monotherapy/comb
Duration HbA1c HbA1c number of
ination
(weeks) (%) (%) patients Reference
Monotherapy 12 7.9 -0.45−0.63* 338 Diabet Obes Metab 2008;10:376
Poster presented at 68th ADA, June
Monotherapy 24 7.9 -0.54−0.43 401 2008, San Francisco, CA, USA.
Poster presented at AADE. August 6
Metformin 24 8.0 -0.83−0.72* 733 - 9, 2008 Washington, DC, USA.
Poster presented at EASD.
Thiazolidinedione 24 8.3 -0.66−0.94 565 September 7-11, 2008 Rome, Italy.
Poster presented at EASD.
Sulphonylurea 24 8.4 -0.54−0.64 768 September 7-11, 2008 Rome, Italy
Initial combination Poster presented at ICE 2008, Rio de
24 9.5 -2.53−2.49 1306 Janeiro, Brazil.
with metformin
*Placebo-adjusted change. Note that the studies are different and therefore not comparable; doses of compounds are not shown and may vary
in different studies. Change in HbA1c shows change from baseline except when asterisk is shown.

80. Saxagliptin
Phase 2 Dose-ranging Study
Significant Reduction from Baseline in HbA1c in All Treatment Arms for Saxagliptin vs Placebo*
Mean baseline HbA1c (%)
8.0 7.7 7.9 8.0 7.9 7.8
0
-0.2 -
Adjusted mean change
-0.4 -
in HbA1c (%)
-0.6 -
-0.8 -
* * *
-1.0 - *
*
-1.2 - *P<0.007 vs placebo
-1.4 - Placebo 2.5 mg 5 mg 10 mg 20 mg 40 mg
(N=67) (N=55) (N=47) (N=63) (N=54) (N=52)
Saxagliptin dose
12-week, multicentre, randomised, parallel-group, double-blind, placebo-controlled trial conducted at 152 out-patient US study centres
in 338 (low-dose cohort) and 85 (high-dose cohort) drug-naive patients with type 2 diabetes and inadequate glycaemlc control
(baseline HbA1c ≥6.8 and ≤9.7%). Following a 2-week washout, patients received saxagliptin 2.5, 5, 10, 20 or 40 g once daily, or
placebo, for 12 weeks. The test for log-linear trend across the treatment groups (the primary endpoint) did not demonstrate a
statistically significant dose-response relationship after 12 weeks of treatment.
Adapted from Rosenstock J, et al. Diabetes, Obesity and Metab. 2008;10:376-386.

81. Efficacy
Both drugs added to baseline metformin therapy
Vildagliptin Sitagliptin
0.4 Mean 0.4 Mean
baseline baseline
Mean change from baseline HbA1C (%)
0.2 HbA1c:8.3% 0.2 HbA1c: 8.1%
0.0 0.0
-0.2 -1.1% -0.2
0.67%
-0.4 (p<0.001) -0.4 p<0.001
-0.6 -0.6
-0.8 -0.8
-1.0 -1.0
-1.2 -1.2
0 4 8 12 16 20 24 0 4 8 12 16 20 24
Time (weeks of treatment)

82. Efficacy
Both drugs added to baseline metformin therapy
Vildagliptin Saxagliptin
0.4 Mean 0.4 Mean
baseline baseline
Mean change from baseline HbA1C (%)
0.2 HbA1c:8.3% 0.2 HbA1c: 8.2%
0.0 0.0
-7.2%
-0.2 -1.1% -0.2
P<0.0001
-0.4 (p<0.001) -0.4
-0.6 -0.6
-0.8 -0.8
-1.0 -1.0
-1.2 -1.2
0 4 8 12 16 20 24 0 4 8 12 16 20 24
Time (weeks of treatment)

83. Explaining the differences?
• Unlikely mediated through insulin
– Insulin levels are lower in vildagliptin than
sitagliptin
– No comparisons with Saxa available
• Also

84. DPP-4s and Glucagon
Meal
20
Vildagliptin 100 mg (n=16)
10 Placebo (n=16)
0
Delta Glucagon (ng/L)
−10
−20
*
−30 *
−40
* *
−50
* * * *
*
−60
17:00 20:00 23:00 02:00 05:00 08:00
Time

85. Effect on Glucagon
• 1x head to head
comparison of Sita
and Vilda
• Vilda maintains
better 24-hour
control glucose
control with very
similar insulin, but
much better
Glucagon control
Vildagliptin Sitagliptin

86. Safety Profile

87. Risk of hypos with agents
14 fold reduction 6.5 fold reduction
Ferrannini E, et al Diabetes, Obesity and Metabolism Nauck MA, et al. Diabetes Obes Metab. 2007;9(2):194-205.
2009;11:157–166.

88. Vildagliptin: similar efficacy to glimepiride when added to metformin at 52
weeks (interim analysis) – no weight gain and low incidence of hypoglycemia
Add-on treatment to metformin (~1.9 g mean daily) Number of Severe events
Patients with
hypoglycemic (grade 2 and
≥1 hypos (%)
7.5 Events suspected grade 2)
n= 1389 1383 1389 1383 1389 1383
7.3 554
600 12
Mean HbA1c (%)
20 10
16.2
NI: 97.5% 500 10
7.1 16
Incidence (%)
No. of events
No. of events
CI (0.02, 0.16)
400 8
12
6.9 300 6
–0.5%
8
200 4
6.7
–0.4% 4 100 2
1.7 39
0
6.5 0 0 0
–8 –4 0 4 8 12 16 20 24 28 32 36 40 44 48 52 56
Time (weeks) 91.0
90.5
Body weight (kg)
90.0
Vildagliptin 50 mg twice daily + metformin 89.5
Glimepiride up to 6 mg once daily + metformin −1.8 kg
89.0
difference
Duration: 52 weeks 88.5
Add-on to metformin: vildagliptin vs glimepiride
88.0
87.5
–8 –2 12 22 32 42 52
Safety population Time (weeks)
CI=confidence interval; hypo=hypoglycemia; NI=non-inferiority
Ferrannini E et al. Diabetes Obes Metab 2009;11:157–66
Data on file, Novartis Pharmaceuticals

89. Vildagliptin plus metformin: similar efficacy to glimepiride plus metformin –
with lower incidence of hypoglycemia after 104 weeks
Duration: 104 weeks Hypoglycemiaa
Add-on to metformin: vildagliptin vs glimepiride
Patients with ≥1 hypos (%) Number of hypo events Number of severe eventsb Discontinuations due to hypos
n= 1553 1546 n= 1553 1546 n= 1553 1546 n= 1553 1546
20 900 838 16 15 14 13
18.2
18 800 14 12
16 700 12 10
14 600
Incidence (%)
No. of events
No. of events
No. of events
12 10
8- 500 14- 8
10 8
fold 400 fold 6
8 6
6 300
4 4
4 200
2.3 59 2 2
2 100 0 0
0 0 0 0
Vildagliptin 50 mg bid + metformin Glimepiride up to 6 mg qd + metformin
Mean HbA1cc
• Adjusted mean change in HbA1c was comparable between vildagliptin and glimepiride treatment:
‒ 0.1% for both
• Primary objective of non-inferiority was met:
‒ 97.5% CI= (-0.00, 0.17); non-inferiority margin 0.3%
aSafety
population; bAny episode requiring the assistance of another party; cPer protocol population
Matthews DR et al. Diabetes Obes Metab 2010;12:780–9

90. Vildagliptin plus metformin: similar efficacy to glimepiride plus
metformin, with no weight gain after 104 weeks
Duration: 104 weeks Change in body weight1
Add-on to metformin:
vildagliptin vs glimepiride Change from BL to EP (BL mean
~89 kg)
N = 1.5 1539 1520
1.2
1.0
Adjusted mean change
-1.5 kg
in body weight (kg)
0.5 difference
P <0.001
0.0
-0.3
Vildagliptin 50 mg bid + metformin
-0.5
Glimepiride up to 6 mg qd + metformin
Mean HbA1c2
 Adjusted mean change in HbA1c was comparable between vildagliptin and glimepiride treatment:
−0.1% (0.0%) for both
 Primary objective of non-inferiority was met:
– 97.5% CI= (-0.00, 0.17); upper limit 0.3%
1Intent-to-treat
population 2Per protocol population.
BL=baseline; EP=week 104 end point; HbA1c=haemoglobin A1c.
Matthews DR, et al. Diabetes Obes Metab. 2010; 12: 780–789.

91. Saxagliptin
Phase 2 Dose-ranging Study: Safety and Tolerability
Adverse Events* in Double-blind Treatment Period in Low-
dose Cohort
Placebo SAXA 2.5 mg SAXA 5 mg SAXA 10 mg SAXA 20 mg SAXA 40 mg
N 67 55 47 63 54 52
AE*, N (%) 53 (79.1) 44 (80.0) 36 (76.6) 49 (78.8) 47 (87.0) 39 (75.0)
Serious AE 1 (1.5) 1 (1.8) 0 1 (1.6) 1 (1.9) 0
Discontinuations due to AEs 1 (1.5) 0 1 (2.1) 1 (1.6) 1 (1.9) 2 (3.8)
Headache 6 (9.0) 8 (14.5) 4 (8.5) 10 (15.9) 6 (11.1) 5 (9.6)
URI 4 (6.0) 6 (10.9) 3 (6.4) 6 (9.5) 6 (11.1) 0
UTI 5 (7.5) 6 (10.9) 2 (4.3) 4 (6.3) 5 (9.3) 2 (3.8)
Nasopharyngitis 5 (7.5) 0 2 (4.3) 5 (7.9) 3 (5.6) 6 (11.5)
Arthralgia 2 (3.0) 6 (10.9) 3 (6.4) 3 (4.8) 5 (9.3) 2 (3.8)
Nausea 5 (7.5) 1 (1.8) 2 (4.3) 2 (3.2) 2 (3.7) 5 (9.6)
Cough 3 (4.5) 4 (7.3) 3 (6.4) 1 (1.6) 3 (5.6) 3 (5.8)
Confirmed hypoglycaemia 0 0 0 0 0 0
*Hypoglycaemia events excluded.
12-week, multicentre, randomised, parallel-group, double-blind, placebo-controlled trial conducted at 152 out-patient US study centres
in 338 (low-dose cohort) and 85 (high-dose cohort) drug-naive patients with type 2 diabetes and inadequate glycaemic control.
Following a 2-week washout, patients received saxagliptin 2.5, 5, 10, 20 or 40 g once daily, or placebo, for 12 weeks.
SAXA, saxagliptin; AE, adverse event; URI, upper respiratory tract infection; UTI, urinary tract infection.
Rosenstock J, et al. Diabetes, Obesity and Metab. 2008;10:376-86.

92. Saxagliptin
Add-on to Metformin: Safety and Tolerability
Most Common (≥5%) AEs During 24-Week Treatment Period
Placebo + MET All SAXA + MET
(N=179) (N=564)
Total patients with AEs* (%) 116 (64.8) 413 (74.3)
Adverse event, N (%)
Nasopharyngitis 14 (7.8) 49 (8.7)
Headache 13 (7.3) 45 (8.0)
Diarrhoea 20 (11.2) 40 (7.1)
URI 9 (5.0) 37 (6.6)
Influenza 13 (7.3) 34 (6.0)
UTI 8 (4.5) 29 (5.1)
Back pain 12 (6.7) 24 (4.3)
Pain in extremity 10 (5.6) 17 (3.0)
*Hypoglycaemia events based upon the saxagliptin predefined list of hypoglycaemia events are excluded.
 Incidence of hypoglycaemia was 5.7% for all saxagliptin+metformin groups vs 5.0% for
placebo+metformin
 Mean change from baseline in body weight at week 24 was -1.4 kg, -0.9 kg and -0.5 kg for saxagliptin
2.5, 5 and 10 mg groups, respectively, vs -0.9 kg for placebo + MET
SAXA, saxagliptin; MET, metformin; URI, upper respiratory tract infection; UTI, urinary tract infection.
Ravichandran S, et al. Saxagliptin added to metformin improves glycemic control in T2DM patients. Poster presented at AADE.
August 6-9, 2008 Washington, DC, USA.

93. Guidelines for Use of DPP-4
Inhibitors in Clinical Practice

94. DPP-4 inhibitors
• Dependent on presence of endogenous
GLP-1
• Excellent for use in early diabetes as add-on
to metformin
• May have additional cardiovascular benefits
by reducing Glucagon & Improving
perfusion

95. Guidelines on Clinical Use of DPP-4 Inhibitors
Summary of Recommendations by Various Organisations
Organisation Recommendations/Considerations
ESC/EASD1 • No specific recommendations
ADA/EASD2 • Not as first- second-tier agents, although may be appropriate choices in selected patients
• According to the ACE/AACE roadmap, DPP-4 inhibitors can be considered as initial
ACE/AACE3 therapy when initial HbA1c is between 6% and 7% or as combination therapies when initial
HbA1c is between 7-9
• DPP-4 inhibitors have shown significant benefits in reducing post-meal plasma glucose
IDF4
excursions and lowering HbA1c
• Consider as second-line therapy instead of a sulphonylurea when blood glucose control
remains or becomes inadequate with metformin or if metformin not tolerated
• If a trial of metformin in combination with a sulfonylurea does not adequately control blood
NICE (UK)5
glucose (HbA1c ≤7.5%) and human insulin is unacceptable or inappropriate
• May be preferable in certain patient populations (e.g. problems with weight gain or
thiazolidinedione therapy
1. Rydén L, et al. Eur Heart J. 2007;28(1):88-136.
2. Nathan DM, et al. Diabetes Care. 2009;32(1):193-203.
3. American Association of Clinical Endocrinologists. Available at:
http://www.aace.com/meetings/consensus/odimplementation/roadmap.pdf. Accessed on 12 Feb 2009.
4. International Diabetes Foundation. Available at: http://www.idf.org/webdata/docs/Guideline_PMG_final.pdf. Accessed 26 Jan 2009.
5. National Institute for Clinical Excellence (UK). http://www.nice.org.uk/nicemedia/pdf/T2DDraftGudeline.pdf. Accessed 26 Jan 2009.

96. Objectives:
• Epidemiology of Diabetes in UAE.
• Recent ADA-EASD Position Statement:
Management of Hyperglycemia in T2DM.
• Cardiovascular Risks of diabetes.
• Role of DPP4 Inhibitor in Diabetic Care.
• Hypoglycemia and its consequences.
• Diabetes & Ramadan.

97. Hypoglycaemia
“The major limiting factor to achieving
intensive glycaemic control for people
with type 2 diabetes”
Briscoe VJ, et al. Clin Diab 2006;24:115-121.

98. What is a hypo?
• Any blood sugar that is lower than usual
• Relative reduction in glucose to the tissues
• Historically at a value of around 4mmol/l
• Patients can experience symptoms at
11mmol if they usually run at 15mmol

99. Definition of hypoglycaemia
• Plasma glucose <3.9mmol/l based on
activation of counter-regulatory responses
• In clinical trials threshold ranges between 3-
3.9 mmol/l
• Others “classify” into “mild” and “severe”
Result: difficult to pinpoint exact incidence!
Briscoe VJ, Davis SN. Clin Diabetes 2006;24:115-21.

100. Hypoglycaemia in type 2 diabetes
• Hypoglycaemia symptoms are common in
type 2 diabetes (38% of patients)1
• Associated with:
– Reduced quality of life
– Reduced treatment satisfaction
– Reduced therapy adherence
– More common at HbA1c < 7%
1. Diabetes, Obesity and Metabolism 2008 Jun;10 Suppl 1:25-32.

101. Clinical consequences of hypoglycaemia
• Hospital admissions:
– In a prospective study1 of well-controlled elderly
T2D patients, 25% of hospital admissions for
diabetes were for severe hypos
• Increased mortality:
– 9% in a study2 of severe SU-associated
hypoglycaemia
• Road accidents caused by hypos3:
– 45 serious events per month
1. Diab Nutr Metab 2004;17(1):23-26.
2. Horm Metab Res Suppl 1985;15:105-111.
3. BMJ 2006;332:812.

102. Hypoglycaemia
• Hypoglycaemia event triggers
– Parasympathetic stimulation
– Adrenaline release (comparable with Acute MI)
– Electrophysiology changes (dysrythmias)
– Increased peripheral systolic BP
– Reduced central diastolic BP

103. Hypoglycaemias
• Acutely hypoglycaemias may cause
– Irritability
– Impaired judgement
– Confusion
– Convulsions
• All due to reduced cerebral perfusion

104. Longer term damage
• Most likely mediated through damage to the
Glycocalyx
• Literally “sugar coating”
• On lining of platelets and endothelium
• Reduces friction of blood flow
• Barrier for loss of fluid and protein through
vessel wall.

105. Hypoglycaemia
• Recurrent hypoglycaemia associated with
increased risk of
– Falls
– Dementia
– Increased sudden cardiac death
– Myocardial infarction
– Heart failure
– Stroke (both large and small vessel)

106. Frequency of Recurrent hypos
• Hypoglycaemia = 7% of patients/year
• Severe hypoglycaemia = 0.35/patient/year
• Risk is the same with insulin and SU
• Risk of all hypos is similar between type 1
and type 2 diabetes
• Elderly patients at greatest risk

107. The consequences of hypoglycaemia
Hospitalisation
Coma3 costs4
Death2,3 Cardiovascular
complications3
Increased risk Weight gain
Hypoglycaemia
of dementia1 by defensive eating
Reduced Loss of
quality of consciousness3
life7
Increased risk Increased risk
of car accident6 of seizures3
1Whitmer RA, et al. JAMA. 2009; 301: 1565–1572; 2Bonds DE, et al. Br Med J. 2010; 340: b4909;
3BarnettAH. Curr Med Res Opin. 2010; 26: 1333–1342; 4Jönsson L, et al. Value Health. 2006; 9: 193–198;
5Foley JE, Jordan J. Vasc Health Risk Manag. 2010; 6: 541–548; 6Begg IS, et al. Can J Diabetes. 2003; 27: 128–140; 7McEwan P, et al. Diabetes Obes
Metab. 2010; 12: 431–436.

108. Hypoglycemia as a cause for cardiovascular events -
Mechanisms
Desouza CV, et al.
Diabetes Care. 2010;
33:1389–394

109. Potential mechanisms of
hypoglycaemia-induced mortality
• Cardiac arrhythmias due to abnormal cardiac
repolarization in high-risk patients (IHD,
cardiac autonomic neuropathy)
• Increased thrombotic tendency/decreased
thrombolysis
• Cardiovascular changes induced by
catecholamines
– Increased heart rate
– Silent myocardial ischaemia
– Angina and myocardial infarction

110. Effect of experimental hypoglycaemia
on QT interval
A B
QTc= 456 ms QTc= 610 ms
HR= 66 bpm HR= 61 bpm
5.0mM 2.5mM
International Diabetes Monitor 2009; 21(6): 234-241.

111. Why are they missed
• Patients are not asked!
• Symptoms are misdiagnosed
• Patients are ill-informed
• Therefore patients do not report symptoms
• Even after Severe hypoglycaemia patients
often don’t report it

112. Objectives:
• Epidemiology of Diabetes in UAE.
• Recent ADA-EASD Position Statement:
Management of Hyperglycemia in T2DM.
• Cardiovascular Risks of diabetes.
• Role of DPP4 Inhibitor in Diabetic Care.
• Hypoglycemia and its consequences.
• Diabetes & Ramadan.

113. Hypoglycaemia During Ramadan

114. (4.7 fold)
(7.5 fold)

115. Hypoglycemia in Sulphonylurea -Treated
Subjects with Type 2 Diabetes
Undergoing Ramadan Fasting:
A Five-Country Observational Study
Current Medical Research & Opinion Vol. 27, No. 6, 2011, 1237-1242

116. Results
• Symptomatic hypoglycemia was 40% in occupied
Palestine and 10% in Saudi Arabia
• Over all symptomatic hypoglycemic events were
recorded in 271 subjects (19.7%)
• Headache represent 14.5%, sweating 10.2%,
tremors 8.5% and palpitation 7%.
Current Medical Research & Opinion Vol. 27, No. 6, 2011, 1237-1242

117. Incidence of symptomatic hypoglycemia
during Ramadan by countries
Countries N of Patients
Occupied Palestine 40%
Malaysia 24%
United Arab Emirates 18%
India 13%
Saudi Arabia 10%
Current Medical Research & Opinion Vol. 27, No. 6, 2011, 1237-1242

118. Hypoglycaemias in Ramadan
• 52 patients preparing for Ramadan
• Currently poorly controlled (HbA1c >8.5%)
• Minimum Metformin 2g/day
• Randomised to receive
– Gliclazide 160mg bd
– Vildagliptin 50mg bd
• All given educational program
Devendra et al 2009

119. Results
• Hypos were more common in gliclazide
group 61.5 vs 7.7% (p < 0.001)
• One Severe hypo in gliclazide arm
• HbA1c – Similar reductions
Int J Clin Pract, 2009

120. • Main aim
– To determine the incidence of hypoglycaemic events in 100 Muslim patients with T2D fasting
during Ramadan, who are treated with dual therapy of metformin plus vildagliptin or metformin
plus sulphonylurea (SU)
• Primary objectives
– the incidence of hypoglycaemic events defined as:
• Any reported symptoms by the patient and/or any blood glucose measurement of less than
3.9 mmol/L (also defined as mild or Grade 1 hypoglycaemia)
• The need for third party assistance (also defined as severe or Grade 2 hypoglycaemia);
• Secondary objectives
– the change in weight;
– the change in HbA1c levels; and
– the treatment adherence during Ramadan.

121. VECTOR: Results - Hypoglycaemic events (HE)
Mean between-group difference in patients who experienced at
least one HE was –41·7% (p = 0·0002)

122. VECTOR: HbA1c
The between group difference was −0·6% (p = 0·0262)
(7·7% to 7·2%) (7·2% vs 7·3%)

123. :Adherence
Only 1 patient in the Vildagliptin group missed at least one
dose, compared with 10 patients in the SU group.
p = 0·0204

124. VECTOR study
Vildagliptin in Fasting Ramadan T2DM pts
Hypoglycemia in SU group = 41.7 %
No hypoglycemia in Vildagliptin group
Median total dose after Ramadan adjustment, mg/day
Vildagliptin = 100 ; Gliclazide = 80*
*Different formulations of gliclazide were used: conversion factor used: 80mg
standard formulation = 30mg modified release formulation
Mohamed Hassanein etal, Vildagliptin in Muslim patients fasting during RamadanCurrent Medical Research & Opinion Volume 27, Number 7 July 2011

125. Cardiovascular endpoints
Study Author Year DPP-4 SU CV events on
DPP-4 SU
Nauck et al 2007 Sita Glipizide n.r. n.r.
Seck et al 2010 Sita Glipizide n.r. n.r.
Ferrannini et al 2009 Vilda Glimepiride 12/1389 22/1383
Matthews et al 2010 Vilda Glimepiride n.r. n.r.
Filosof & Gautler 2010 Vilda Gliclazide 7/501 12/494

126. Cardiovascular endpoints
Study Author Year DPP-4 SU CV events on
DPP-4 SU
Nauck et al 2007 Sita Glipizide n.r. n.r.
Seck et al 2010 Sita Glipizide n.r. n.r.
Ferrannini et al 2009 Vilda Glimepiride 12/1389 22/1383
Matthews et al 2010 Vilda Glimepiride n.r. n.r.
Filosof & Gautler 2010 Vilda Gliclazide 7/501 12/494
19/1902 36/1877
Relative Risk 0.53 (95% CI 0.30-0.91) p=0.029 by χ2 test
(Nauck et al, EASD 2010)

127. Take Home Message
• The DPP-4 inhibitors appear to have great potential for
the treatment of type 2 diabetes.
• They do not lower glucose to a greater extent than
existing therapies .. but they offer many potential
advantages:
1. The ability to achieve sustainable reductions in
HbA1c.
2. Well-tolerated agent .
3. Low risk of hypoglycemia.. Safe during Ramadan.
4. No weight gain
5. Can be administered as a once-daily oral dose.
• Choose the right patient.