The AMPLITUDE-O phase 3 trial showed that investigational drug efpeglenatide (Sanofi/Hanmi Pharmaceutical) — an exendin-based glucagon-like peptide-1 (GLP-1) receptor agonist — was safe and reduced the risk of worsening renal and cardiovascular outcomes in patients with type 2 diabetes at high cardiovascular risk.

That is, in patients with type 2 diabetes and a high prevalence of cardiovascular and kidney disease with a high A1c and moderate use of a sodium-glucose cotransporter-2 (SGLT2) inhibitor, subcutaneous efpeglenatide (4 or 6 mg/week) significantly and safely reduced cardiovascular and renal outcomes, said study investigator Naveed Sattar, MD.

Sattar, of the University of Glasgow, UK, summarized the results during a symposium at the virtual American Diabetes Association (ADA) 81st Scientific Sessions. The study was simultaneously published online in the New England Journal of Medicine.

AMPLITUDE-O was a cardiovascular outcome trial (CVOT) in more than 4000 high-risk patients with type 2 diabetes followed for a mean of 1.8 years.

Compared with patients who received placebo, those who received either dose of efpeglenatide had a:

• 27% lower risk of a major adverse cardiovascular events (MACE), defined as nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular or undetermined causes.

• 21% lower risk of expanded MACE (MACE, coronary revascularization, or hospitalization for unstable angina).

• 32% lower risk of a composite renal outcome (decrease in kidney function or macroalbuminuria).

• 27% lower risk of MACE or noncardiovascular death.

And “these effects were independent of baseline SGLT2 inhibitors, estimated glomerular filtration rate (eGFR), or metformin use,” Sattar pointed out.

New and Important Findings, but Sanofi No Longer Developing Drug

In an email to Medscape Medical News, the trial’s primary investigator, Hertzel C. Gerstein, MD, pointed out several new and important findings of the drug and study compared with CVOTs of seven other GLP-1 receptor agonists.

The trial included more patients (32%) with renal disease (eGFR 25-60 mL/min) than the other trials.

There were enough patients taking SGLT2 inhibitors at baseline (15%) to show no difference in the effect of a GLP-1 receptor agonist in the presence/absence of an SGLT2 inhibitor.

So this is the first clearly positive GLP-1 receptor agonist CVOT with an exendin-4–based GLP-1 receptor agonist showing that the GLP-1 receptor agonist class is cardioprotective whether or not it is based on a human or animal GLP-1 structure.

And there was a significant reduction in MACE or noncardiovascular death.

“This would be good for people with type 2 diabetes and either cardiovascular or renal disease at high risk for cardiovascular and/or renal outcomes,” said Gerstein, professor of medicine at McMaster University in Hamilton, Ontario, Canada.

However, the trial sponsor, Sanofi, is no longer developing the drug. The company returned the rights back to Hanmi, which had started this line of research. “Hopefully” Hanmi or another company will develop the drug further, said Gerstein.  

Sicker Patients Than in 7 Other GLP-1 Agonist CVOTs

Efpeglenatide — like two other drugs in the class, exenatide and lixisenatide — is an exendin-based GLP-1 agonist. (Exendin-4 is a peptide found in the saliva of the Gila monster lizard.) In contrast, liraglutide, dulaglutide, albiglutide, and semaglutide are human-analog GLP-1 agonists.

A meta-analysis of the seven CVOTs of these other drugs in this class reported, among other things, that “overall, GLP-1 agonist treatment reduced MACE by 12%” (Lancet Diabetes Endocrinol. 2019;7:776-785).

Amanda I. Adler, MD, PhD, professor of diabetic medicine and health policy, University of Oxford, UK, and the assigned independent commenter at the symposium, cited many things “the investigators did well.”

Compared with the CVOTs of the other GLP-1 receptor agonists — ELIXA (lixisenatide), LEADER (liraglutide), SUSTAIN-6 (semaglutide), EXSCEL (exenatide), Harmony Outcomes (albiglutide), REWIND (dulaglutide), and PIONEER 6 (oral semaglutide) — patients in the AMPLITUDE-O trial were sicker, she noted.

AMPLITUDE-O participants had the longest duration of diabetes (15 years), lowest mean eGFR of 72 ml/min/1.73 m², highest A1c (8.9%), and highest percentage of insulin use (62%), she noted. 

The study was primarily a safety and noninferiority trial, she pointed out, although a series of superiority analyses were prespecified that would be conducted if the drug was found to be noninferior to placebo for the primary outcome of 3-point MACE.

It was good that patients were stratified according to SGLT2 inhibitor use — into current user, likely future user, and not likely future user — although “likely future user” may have misclassified some patients.

The various stakeholders — patients, regulators, doctors, payers, statisticians, and the marketing department of any company providing the drug — would want to know more, such as quality of life, long-term effects, and cost, she observed.

Meta-Analysis of 8 CVOTs Shows Stronger Class Benefit

Sattar presented an eight-trial meta-analysis (an update of the seven-trial meta-analysis that included data from AMPLITUDE-O), which showed patients with type 2 diabetes who received GLP-1 agonists had a decreased rate of the 3-component MACE and decreased individual components (stroke more so than myocardial infarction) — regardless of the structure of these drugs (exenatide or human analogs).

The updated meta-analysis also showed that, overall, GLP-1 agonists decreased all-cause mortality and possibly reduced the risk of heart failure hospitalization (perhaps linked to atherosclerotic benefits) as well as renal dysfunction.

There was no increase in risk of severe hypoglycemia, retinopathy, or pancreatic adverse effects.

AMPLITUDE-O: Design and Findings

AMPLITUDE-O included 4076 adults with type 2 diabetes from 344 sites in 28 countries who were screened from May 2018 to April 2019.

Participants also had cardiovascular disease or kidney disease (eGFR, 25-60 mL/min) plus at least one other cardiovascular risk factor.

They were randomized 1:1:1 to receive subcutaneous efpeglenatide (4 or 6 mg/week) or placebo.

Patients were a mean age of 65, most (87%) were White, and 33% were female.

They had a mean A1c of 8.9%. Most (90%) had a history of cardiovascular disease and 31% had current kidney disease.

MACE occurred in 189 participants (7.0%) assigned to efpeglenatide and 125 participants (9.2%) assigned to receive placebo (3.9 vs 5.3 events/100 person-years) (hazard ratio [HR], 0.73; 95% CI, 0.58 – 0.92; P < .001 for noninferiority; P = .007 for superiority).

The composite renal outcome event (decreased kidney function or macroalbuminuria) occurred in 353 participants (13.0%) assigned to receive efpeglenatide and in 250 participants (18.4%) assigned to receive placebo (HR, 0.68; 95% CI, 0.57 – 0.79; P < .001).

Diarrhea, constipation, nausea, vomiting, or bloating occurred more frequently with efpeglenatide than placebo. 

The study was funded by Sanofi. Sattar has reported being on advisory panels for Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Merck, Novartis, Novo Nordisk, Pfizer, and Sanofi, and receiving research support from Boehringer Ingelheim. Gerstein has reported being a member of advisory panels for Novo Nordisk, Pfizer, and Sanofi, and a consultant for Abbott, Covance, Eli Lilly, Kowa, and Sanofi. He reported receiving research support from AstraZeneca, Eli Lilly, Merck, Novo Nordisk, and Sanofi, and having other relationships with Boehringer Ingelheim, DKSH, Eli Lilly, Sanofi, and Zuellig Pharma. Adler has reported no relevant financial relationships.

ADA 2021 Scientific Sessions. Presented June 26, 2021.

N Engl J Med. Published online June 28, 2021. Full Text

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