Ueda2016 symposium -managing t2 dm with no compromise - khaled el hadidy

Managing T2DM
with no compromise
BY
DR. Khaled El Sayed El Hadidy. MD
Professor of Internal Medicine.
Head of Internal Medicine Department.
Head of Diabetes and Endocrinology Unit.
Beni - Suef University.
UEDA ( IDF member )

Multiple Pathophysiological Failures Contribute to
Hyperglycaemia: The ‘Ominous Octet’
Islet α-cell
Increased
lipolysis
Increased
glucose
reabsorption
Increased glucagon
secretion
Increased
hepatic glucose
production
Neurotransmitter dysfunction
Decreased
glucose uptake
Islet β-cell
Decreased incretin effect
Impaired insulin
secretion
Hyper-
Adapted from DeFronzo RA. Diabetes 2009;58:773–795. Wolters Kluwer Health
Hyper-
glycemia
2

HbA1c=haemoglobin A1c; OAD, oral antidiabetic drugs.
Jacob AN, et al. Diabetes Obes Metab. 2007; 9:386–393;
Kahn SE, et al. N Engl J Med. 2006; 355: 2427–2443;
Wright AD, et al. J Diabetes Complications. 2006; 20: 395–401.
Decreasing HbA1c is associated with increased risks
of hypoglycaemia and weight gain
Weight gain
and
hypoglycaemia
Bodyweight
HbA1c
Plasmaglucose

Consequences of hypoglycaemia
Hypoglycaemia
Cardiovascular
complications3
Weight gain
by defensive eating5
Coma3
Increased risk
of car accident6
Hospitalisation
costs4
Loss of
consciousness3
Increased risk
of seizures3
Death2,3
Increased risk
of dementia1
1Whitmer RA, et al. JAMA. 2009; 301: 1565–1572; 2Bonds DE, et al. Br Med J. 2010; 340: b4909;
3Barnett AH. 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.
.
Reduced
quality of life7

Mechanisms ( Hypoglycemia -------------- CVS )

CVD=cardiovascular disease; DM=diabetes mellitus; HDL-C=high-density lipoprotein cholesterol; HTN=hypertension;
IGT=impaired glucose tolerance; IR=insulin resistance; LDL-C=low-density lipoprotein cholesterol; TG=triglyceride.
Eckel RH, Grundy SM, Zimmet PZ.
The metabolic syndrome. Lancet. 2005; 365: 1415 428.
Weight Gain and Co-morbidities
Weight gain
Hyperinsulinaemia and IR
Dyslipidemia
TG 
small dense LDL-C 
Apo-B 
HDL-C 
HTN
Prothrombotic state
PAI-1 , Factor VII 
Fibrinogen 
IGT and DM
Proinflammatory state
CVD

L L L
GLP-1 GLP-1 GLP-1
InsulinGlucagon
Slowed gastric
emptying
Early
Satiety
Inactive
GLP-1
DPP-4
enzyme
(DPP-4
inhibitor)
GLP-1

Guidelines recommend the combination
ADA
/EASD
& AACE
24 hours glycemic control with once daily dose
Ideal Criteria of OAD* in treatment of T2DM Patients
in order to get High Glycemic Control with Confidence (1/2) :
Why Saxagliptin / Metformin XR
can be an Ideal FDC# in management of T2DM patients ?
Diabetes Care, Diabetologia. 19 April 2012
Garber AJ, et al. Endocr Pract 2013;19(2):327-336.
Jadzinsky et al – Diabetes, Obesity & metabolism (2009)
Fonseca V, Zhu T, Kayaker C, et al. Diabetes, Obesity and Metabolism 2012; 14 (4): 365–371.
Full Prescribing Information
* OAD: Oral Antidiabetic
# FDC: Fixed dose combination
**HbA1c: Haemoglobin A1c
##: Fasting plasma glucose
***: Postprandial plasma glucose
Well studied in diabetes type 2 patients with established
cardiovascular disease & high cardiovascular risk patients.
4 years sustained Efficacy (Evidence based)
3.3% A1c reduction from baseline 10%
Comparable efficacy to Sulphonylurea without
risk of hypoglycemia

Healthy eating, weight control, increased physical activity & diabetes education
Metformin
high
low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
high
low risk
gain
edema, HF, fxs
low
Thiazolidine-
dione
intermediate
low risk
neutral
rare
high
DPP-4
inhibitor
highest
high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-
dione
+
SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-i
GLP-1-RA
high
low risk
loss
GI
high
GLP-1 receptor
agonist
Sulfonylurea
high
moderate risk
gain
hypoglycemia
low
SGLT2
inhibitor
intermediate
low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor
agonist
+
SGLT-2
Inhibitor
+
SU
TZD
Insulin§
Metformin
+
Metformin
+
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono-
therapy
Efficacy*
Hypo risk
Weight
Side effects
Costs
Dual
therapy†
Efficacy*
Hypo risk
Weight
Side effects
Costs
Triple
therapy
or
or
DPP-4
Inhibitor
+
SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
injectable
therapy‡
GLP-1-RAMealtime Insulin
HbA1c
≥9%
Me ormin
intolerance or
contraindica on
Uncontrolled
hyperglycemia
(catabolic features,
BG ≥300-350 mg/dl,
HbA1c ≥10-12%)
Insulin (basal)
+
or
or
or
Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0American Diabetes Association Standards of Medical Care in Diabetes. Approaches to Glycemic Treatment. Diabetes Care 2016; 39 (Suppl. 1)
MANAGE EARLY AND TIGHTLY

Metformin
high
low risk
neutral/loss
low
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
high
low risk
gain
edema, HF, fxs
low
Thiazolidine-
dione
intermediate
low risk
neutral
rare
high
DPP-4
inhibitor
highest
high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-
dione
+
SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-i
GLP-1-RA
high
low risk
loss
GI
high
GLP-1 receptor
agonist
Sulfonylurea
high
moderate risk
gain
hypoglycemia
low
SGLT2
inhibitor
intermediate
low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor
agonist
+
SGLT-2
Inhibitor
+
SU
TZD
Insulin§
Metformin
+
Metformin
+
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono-
therapy
Efficacy*
Hypo risk
Weight
Side effects
Costs
Dual
therapy†
Efficacy*
Hypo risk
Weight
Side effects
Costs
Triple
therapy
or
or
DPP-4
Inhibitor
+
SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
Metformin
+
Combination
injectable
therapy‡
Figure 2A. An -hyperglycemic
therapy in T2DM:
Avoidance of hypoglycemia
or
or
or
Insulin (basal)
+
Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0American Diabetes Association Standards of Medical Care in Diabetes. Approaches to Glycemic Treatment. Diabetes Care 2016; 39 (Suppl. 1)

Metformin
high
low risk
neutral/loss
low
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
high
low risk
gain
edema, HF, fxs
low
Thiazolidine-
dione
intermediate
low risk
neutral
rare
high
DPP-4
inhibitor
highest
high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-
dione
+
SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-i
GLP-1-RA
high
low risk
loss
GI
high
GLP-1 receptor
agonist
Sulfonylurea
high
moderate risk
gain
hypoglycemia
low
SGLT2
inhibitor
intermediate
low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor
agonist
+
SGLT-2
Inhibitor
+
SU
TZD
Insulin§
Metformin
+
Metformin
+
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono-
therapy
Efficacy*
Hypo risk
Weight
Side effects
Costs
Dual
therapy†
Efficacy*
Hypo risk
Weight
Side effects
Costs
Triple
therapy
or
or
DPP-4
Inhibitor
+
SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
Metformin
+
Combination
injectable
therapy‡
Insulin (basal)
+
or
or
or
Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0
Figure 2B. An -hyperglycemic
therapy in T2DM:
Avoidance of weight gain American Diabetes Association Standards of Medical Care in Diabetes. Approaches to Glycemic Treatment. Diabetes Care 2016; 39 (Suppl. 1)

Secondary failure of metformin monotherapy is increased when initial HbA1C is ≥8%
Figure shows a Kaplan–Meier plot of secondary failure of metformin monotherapy by categories of HbA1C at metformin initiation
adjusted for age and diabetes duration at initiation and the percent per year (95% CIs) experiencing secondary failure.
Brown JB, et al. Diabetes Care 2010;33:501‒6

16
• RAZ I. Guideline Approach to therapy in patients with Newly diagnosed type 2 diabetes. Diabetes Care 2013; 36
(suppl 2 ) (suppl 2 ): S 139 – S 144

Specific reasons why early combination therapy
may be beneficial in Type 2 diabetes
Rationale for early combination therapy in Type 2 diabetes
 Early, robust lowering of HbA1C
 Avoidance of clinical inertia associated with a stepwise approach to therapy
 Potential for early combination therapy to improve β-cell function
 Initiation of a therapeutic intervention with a complimentary mechanism of action
 Potential to use less than maximal doses of individual agents, minimizing side effects
11 Confidential. Contains unpublished data. For training purpose only. Not to be distributed. 732HQ12NP149Zinman B. Am J Med 2011;124:S19‒34.

ADA
/EASD
& AACE
2013
Comparable efficacy to Sulphonylurea
without risk of hypoglycemia
Ideal Criteria of OAD* in treatment of T2DM Patients
in order to get High Glycemic Control with Confidence (1/2) :

19
Muscle/Fat
…in response to ↑ insulin release:
↑ peripheral glucose uptake
Liver
…in response to ↓ glucagon release:
↓ hepatic glucose output
Pancreas
↓ glucagon release
from  cells
↑ insulin release
from  cells
…in response to ↑ GLP-1 concentrations:
 
Muscle/Fat
Improves insulin sensitivity and
↑ glucose uptake and utilization
Liver
↓ glucose output by the liver
Pancreas
Insulin secretion remains unchanged
while fasting insulin levels and
day-long plasma insulin response
may decrease
Muscle/Fat
…in response to ↑ insulin release:
↑ peripheral glucose uptake
Liver
…in response to ↓ glucagon release:
↓ hepatic glucose output
Muscle/Fat
Improves insulin sensitivity and
↑ glucose uptake and utilization
Liver
↓ glucose output by the liver
Pancreas
Insulin secretion remains unchanged
while fasting insulin levels and
day-long plasma insulin response
may decrease
GLP=glucagon-like peptide; DPP=dipeptidyl peptidase.
1. Verspohl EJ. Pharmacol Ther 2009;124:113-138.
Saxagliptin Metformin XR
Gut
Decreases (↓) intestinal
glucose absorption
Gut
Decreases (↓) intestinal
glucose absorption
Lower levels of the incretin hormone
GLP-1 are released from the gut
in patients with type 2 diabetes
Saxagliptin increases (↑) incretin
concentrations in the bloodstream
Gut
Saxagliptin inhibits DPP-4 enzyme
activity
DPP-4
Enzymes
S
Lower levels of the incretin hormone
GLP-1 are released from the gut
in patients with type 2 diabetes
Saxagliptin increases (↑) incretin
concentrations in the bloodstream
Gut
Saxagliptin inhibits DPP-4 enzyme
activity
DPP-4
Enzymes
S
Pancreas
↓ glucagon release
from  cells
↑ insulin release
from  cells
…in response to ↑ GLP-1 concentrations:
 
Once-a-Day Saxagliptin/Metformin XR :
Complementary & synergistic mechanism of action

Saxagliptin/ Met XR
Saxagliptin/ Met XR

ADA
/EASD
& AACE
2013
Ideal Criteria of OAD* in treatment of T2DM Patients in order to get
High Glycemic Control with Confidence (1/2) :
Why Saxagliptin / Metformin XR can be an Ideal FDC# in
management of T2DM patients ?

ADA
/EASD
& AACE
2013

26 Moses RG, et al. A randomized controlled trial of the efficacy and safety of saxagliptin as add-on therapy in patients with type 2 diabetes and
inadequate glycaemic control on metformin plus a sulphonylurea. Diabetes, Obesity and Metabolism 2014;16(5):443-450.
Saxagliptin/ Met XR + SU
Saxagliptin/ Met XR

27
Bioequivalence of Kombiglyze XR with coadminstered saxagliptin and metformin hydrochloride extended release tablets has been demonstrated
Gummesson A, et al Clin Drug Investig. 2014 Nov;34(11):763-72”
Göke B et al. Int J Clin Pract. 2010;64(12):1619-1631. Onglyza [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; December 2011.
Stenlof K, Raz I, Neutel J, et al. Current Medical Research & Opinion 2010 ;26 (10): 2355-2363.
Goke trial
Glycemic control without risk of hypoglycemia

28
The between-group mean difference was -0.37 % (95 % CI -0.55 to -0.19; post hoc P<0.0001).
Barnett AH, et al. EASD 2011:243; Charbonnel B, et al. ADA 2011:1108-P.
3 folds
reduction in
A1C
2 folds
reduction in
A1C
Saxagliptin- Add-On to Insulin
Saxa/Metformin XR
Saxagliptin
Saxagliptin

ADA
/EASD
& AACE
2013
Why Saxagliptin / Metformin XR can be an Ideal FDC# in
management of T2DM patients ?

Diabetes Is Associated With
Increased Risk of CV Disease
• Diabetes confers an increased risk for MI, stroke, and PAD1–3
• It is not clear whether diabetes should be considered a cause or a
comorbidity of heart failure4
– Diabetes is associated with an increased risk of developing HF in patients with
other causes (eg, acute MI) and is believed to promote diastolic dysfunction
• Diabetes is associated with a 2- to 3-fold increase in the risk of CV and all-
cause mortality5
CV = cardiovascular; MI = myocardial infarction; PAD = peripheral artery disease; CHD = coronary heart disease; HF = heart failure.
1. Emerging Risk Factors Collaboration. Lancet. 2010;375:2251–2222. 2. American Diabetes Association. Diabetes Care. 2003;26:3333–3341. 3. American Diabetes Association. Diabetes Care.
2014;37:S14–S80. 4. McMurray JJV et al. Lancet Diabetes Endocrinol. 2014; DOI 10.1016/S2213-8587(14)70031-2. 5. Gregg EW et al. Ann Int Med. 2007;147:149–156.

SAXAGLIPTIN
5 mg/d
PLACEBO
Follow up Visits
Q 6 months
Final Visit
Documented Type 2 DiabetesN = 16,492
Primary EP
CV Death, MI,
Ischemic Stroke
Duration
Event driven (n=1040)
Median duration 2.1y
Age ≥40 y ….. Established CV Disease or Age ≥55y M / 60y F ….. ≥ 1 CVD RF.
Major Secondary EP: CV death, MI, ischemic stroke, or hosp.
for heart failure, unstable angina, or coronary revascularization
RANDOMIZED 1:1 DOUBLE BLIND
All other DM Rx per treating MD
SaxagliptinAssessmentofVascularOutcomesRecorded
inPatientswithDM-TIMI53
2.5 mg/d if eGFR ≤ 50 ml/min
Scirica BM, Bhatt DL, Braunwald E, et al…. Raz I. NEJM 2013 at www.NEJM.org.
TIMI STUDY GROUP / HADASSAH MEDICAL ORG
HbA1c ≥6.5%

Primary Composite Endpoint *
CV Death, MI, or Stroke
•Kaplan-Meier Rates K-M event rates are presented after 2 yrs. HR: hazard ratio; K-M: Kaplan-Meier; Pbo: placebo; Saxa: saxagliptin
Scirica BM, et al. N Engl J Med. 2013.10.1056/NEJMoa1307684.
Days
7983
8071
7761
7836
7267
7313
4855
4920
851
847
Placebo
Saxagliptin
8212
8280
PatientsWithEndpoints(%)
14
12
10
8
6
4
2
0
0 180 360 540 720 900
HR 1.00; 95% CI, 0.89–1.12
(P≤0.001 non-inferiority)
(P=0.99 superiority) Saxagliptin: 7.3%*
Rate/100 person-yrs – 3.7%
Placebo: 7.2%*
Saxagliptin met the primary safety objective demonstrating
non-inferiority but, didn’t meet the criteria for the superiority

Major Secondary Endpoint*
*K-M event rates are presented after 2 yrs. Composite of CV death, MI, stroke, and hosp for HF, UA, or coronary revascularization.
Days
7843
7880
7502
7539
6926
6963
4602
4660
813
817
Placebo
Saxagliptin
8212
8280
14
12
10
8
6
4
2
0
0 180 360 540 720 900
HR 1.02; 95% CI 0.94-1.11
P=0.66
Saxagliptin: 12.8%*
Placebo: 12.4%*
PatientsWithEndpoints(%)
No significant differences were observed between saxagliptin and placebo
CVD, MI, Ischemic Stroke, or
Hospitalization for Unstable Angina, Coronary Revascularization, or CHF (%)

Individual Components
of the Composite Endpoints
*K-M event rates are presented after 2 yrs.
Saxagliptin Placebo
n (%)* n (%)*
Efficacy endpoint (N = 8,280) (N = 8,212) HR (95% CI) P value
CV death 269 (3.2) 260 (2.9) 1.03 (0.87–1.22) 0.72
MI 265 (3.2) 278 (3.4) 0.95 (0.80–1.12) 0.52
Ischemic stroke 157 (1.9) 141 (1.7) 1.11 (0.88–1.39) 0.38
Hosp for UA 97 (1.2) 81 (1.0) 1.19 (0.89–1.60) 0.24
Hosp for HF 289 (3.5) 228 (2.8) 1.27 (1.07–1.51) 0.007
Hosp for
coronary revasc. 423 (5.2) 459 (5.6) 0.91 (0.80–1.04) 0.18

Adjudicated Causes of CV Death
*Event rates are presented after 2 yrs.
Although more frequently Hospitalized HF., there was no imbalance in deaths
due to heart failure between saxagliptin and placebo
3.2
0.5
0.3 0.3
1.6
0.2
0.4
2.9
0.5
0.2
0.4
1.3
0.2
0.4
0
0.5
1
1.5
2
2.5
3
3.5
4
Onglyza™ (%)
(n = 8,280)
Placebo n (%)
(n = 8,212)
CerebrovascularAcute MI Presumed
CV death
HF Sudden
cardiac death
Any CV death Other
Adjudicated Causes of CV Death1
%ofpatients

Risk of Hospitalization for HF
According to Baseline NT-proBNP
HospitalizationforHF(%)
HR 1.04
95% CI 0-26.3
P=0.98
HR 1.82
95% CI 0.9-4.1
P=0.12
HR 0.94
95% CI 0.6-1.6
P=0.82
HR 1.31
95% CI 1.0-1.6
P=0.021
0.7% 0.7% 1.1%
0.3%
2.2% 2.0%
10.9%
8.9%
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0% N = 3076
Q1
(5 - 64)
N = 3076
Q2
(65 - 140)
N = 3076
Q3
(141 - 332)
N = 3073
Q4
(333 - 46,627)
Quartiles of NT-proBNP (pg/mL)
# of HHF events/1000 pt-years 0 5 1 10
P for interaction = 0.46
Saxagliptin Placebo
Scirica BM, et al. American Heart Association Scientific Sessions. November 2013.
NT-proBNP: N-terminal pro-brain natriuretic peptide; HHF: hospitalization for heart failure

 Hospitalization for heart failure was the only component of the 2ry composite
endpoint increased with Saxagliptin vs. placebo early during the first 6 months of
therapy, However;
 This increase in risk was highest among patients with elevated levels of natriuretic
peptides, previous heart failure, or chronic kidney disease
 Difference between the 2 treatment groups stabilised after 6 - 9 months.
 No evidence that subjects treated with saxagliptin had a more complicated course while
hospitalised
 No evidence of clinically detectable fluid overload (i.e., no increase in oedema or
weight gain) for the overall study population.
 No clinically significant change in biomarkers at 2 years/EOT for
 NT-proBNP
 hs-TNT
 hs-CRP
Investigators’ Conclusions Hospitalization for Heart Failure
hs TNT; High-sensitivity cardiac troponin
NT-proBNP ; N-terminal pro-brain natriuretic peptide.

No Evidence of Increased Risk of hHF for
`(DPP-4i Relative to SU) or for (Saxagliptin Relative to Sitagliptin)
*Reference category for HR; HR<1 indicates lower risk for
DPP-4i or saxagliptin
DPP-4i SU
Patients Events Patients Events
DPP-4i vs. SU
No baseline
CVD
82,019 35 82,019 58 0.59 (0.38,0.89)
Baseline CVD 27,259 200 27,259 202 0.95 (0.78, 1.15)
SAXA SITA
Patients Events Patients Events
SAXA vs. SITA
No baseline
CVD
43,402 23 43,402 24
0.99 (0.56,
1.75)
Baseline CVD 13,042 82 13,042 87
0.95 (0.70,
1.28)
0.2 1 5
Hazard Ratio
(95% CI)
Favors SAXA Favors SITA
Favors DPP-4i Favors SU
0.2 1 5
American Diabetes Association 75th Scientific Sessions,
Boston, MA, 5–9 June2015 3340-0615-AZ-DL-0617 FU et al. 2015. ADA abstract accepted

Conclusions
 No evidence of increased risk for hospitalization for heart failure with DPP-4i
treatment compared with SU treatment
Among patients without prior CVD, DPP-4i treatment was associated with
statistically significant lower risk for hospitalization for heart failure compared with
SU treatment.
DPP-4i treatment was associated with statistically significant lower risk of
cardiovascular events across a range of cardiovascular outcomes compared with
SU treatment among patients without prior CVD.
DPP-4i treatment was associated with statistically significant lower risk of
cardiovascular events on the composite measure of all CV events in both the no
prior CVD and prior CVD strata.
These results were robust across multiple sensitivity analyses.
 No evidence of an increased risk of hospitalization for heart failure compared with
sitagliptin.
No evidence was found of statistically significant differences in cardiovascular
risk between saxagliptin and sitagliptin on any cardiovascular outcome, including
the composite outcome.
These results were robust across multiple sensitivity analyses.
American Diabetes Association 75th Scientific Sessions, Boston, MA, 5–9 June2015 3340-0615-AZ-DL-0617
FU et al. 2015. ADA abstract accepted

ADA
/EASD
& AACE
To Conclude regarding
Saxagliptin/Metformin XR Combination

Ueda2016 symposium -managing t2 dm with no compromise - khaled el hadidy

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