沙格列汀的作用机制培训课件.ppt

1、沙格列汀的作用机制沙格列汀的作用机制肠促胰岛激素简史1902-首次观察到藏到对胰岛分泌的影响1,21932-首次确定肠促胰岛素31964-证实仓促胰岛素效应1,4,51966-首次描述DPP-4 61973-GIP被确定为一种人类长促胰岛素11986-证实了长促胰岛素在2型糖尿病患者中的作用71995-DPP-4被确定为一种灭活GIP和GLP-1的酶 9,101987-GLP-1被确定为一种人类长促胰岛素Creutzfeldt W.Regul Pept.2005;128:87-91.Bayliss WM et al.J Phystol.1902;28:325-353.La Barre J.Bu

2、ll Acad R.Med Belg.1932;120:620-634.McIntyre N et al.Lancet.1964;41:20-21.Elrick H et al.J Clin Endocr.1964;24:1076-1082.Hopsu-Havu VK,Glenner GG.Histochemle.1966;7(3):197-201.Nauck M et al.Diabetologia.1986;29:46-52.Kreymann B et al.Lancet.1987;2:1300-1304.Kieffer TJ et al.Endocrinology.1995;136;33

3、85-3596.Deacon CF et al.J Clin Endocrinol Metab.1995;80:952-957.2沙格列汀的作用机制静脉血浆葡萄糖(mmol/L)时间(分钟)C-肽(nmol/L)115.500.00.51.01.52.0时间(分钟)016012018002口服葡萄糖 静脉注射葡萄糖*平均值 SE;n=6;*P0.05;01-02=葡萄糖输注时间肠促胰素效应的发现与静脉注射葡萄糖相比，口服葡萄糖增强了-细胞反应Nauck J.Clin Endocrinol Metab.1986;63:492-8.检测8名健康对照受试者口服葡萄糖（50 g）和静脉注射葡萄糖的反应

4、与静脉注射葡萄糖相比，口服葡萄糖后，患者的血清C肽水平更高，由此证实了肠促胰素效应016012018002肠促胰素效应3沙格列汀的作用机制Nauck et al.Diabetologia.19862型糖尿病患者肠促胰岛素效应减弱口服葡萄糖静脉注射葡萄糖Time(min)Insulin(mU/l)806040200180601200Time(min)Insulin(mU/l)806040200180601200肠促胰岛素效应非糖尿病组(n=8)2型糖尿病组(n=14)4沙格列汀的作用机制Role of Incretin System in Glucose Homeostasis Normogly

5、caemia Glucose uptake by peripheral tissueAdapted from Drucker DJ.Cell Metab.2006;3:153-65.Hepatic glucose productionGlucose-dependent insulin(GLP-1&GIP)Glucose-dependent glucagon(GLP-1)Pancreas-cells-cellsRelease ofactive incretinsGLP-1&GIPDPP-4inactivates GLP-1&GIPGI tractIngestion of food5沙格列汀的作用

6、机制GLP-1和GIP 是两类主要的肠促胰素GLP-1（胰高糖素样肽-1）GIP（葡萄糖依赖的促胰岛素释放多肽）主要合成部位L 细胞(回肠和结肠)K 细胞(十二指肠和空肠)2型糖尿病患者中分泌是否 餐后胰高糖素是否 食物摄入是 否延缓胃排空是 否促进细胞增殖是是促进胰岛素生物合成是是Drucker DJ.Diabetes Care.2003;26:2929-2940.6沙格列汀的作用机制The Incretin Effect is Reduced in Type 2 DiabetesAdapted from Nauck M,et al.Diabetologia.1986;29:46-52.Or

7、al glucose(50g)IV glucose(variable)Responses to an oral glucose load of 50 g and intravenous glucose infusion were measured in 14 type 2 diabetic patients and 8 healthy control subjects.Responses to glucose load in type 2 diabetics and healthy subjectsControl subjects(N=8)Type 2 diabetic patients(N=

8、14)Oral glucose(50g)IV glucose(variable)Venous plasma glucose(mmol/l)Time(min)Time(min)010151201800160051015512018001600202Venous immunoreactiveinsulin(mU/l)(nmol/l)020406080020406080000.10.30.40.60.50.20.10.30.40.60.50.2*Venous plasma glucose(mmol/l)*P0.05 to the respective value after the oral loa

9、dTime(min)Time(min)120180601201806002020101(nmol/l)Venous immunoreactiveinsulin(mU/l)7沙格列汀的作用机制Incretin hormone changesIn patients with type 2 diabetes,levels of GLP-1 released in response to glucose are reduced and GIP activity is decreased8沙格列汀的作用机制Continuous Infusion of GLP-1 Decreases Fasting Gl

10、ucose as well as HbA1cAdapted from Zander M,et al.Lancet.2002;359(9309):824-30.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(P0.0001),and HbA1c that was decreased by 1.3%(P=0.003)Patients assigned saline(N

11、=9)Patients assigned GLP-1(N=10)Glucose concentration in plasma(mmol/L)008246082462520151050252015105Week 0Week 1Week 6Time(hr)Time(hr)Glucose concentration in plasma(mmol/L)9沙格列汀的作用机制Exogenous GlucoseDependent Insulinotropic Polypeptide Worsens Postprandial Hyperglycaemia in Type 2 DiabetesAdapted

12、from Chia CW,et al.Diabetes.2009;58(6):1342-9.GIP given at supraphysiological levels still has an early,short-lived insulinotropic effect in type 2 diabetesTime(min)GIPPlacebo455256528018038080-20Insulin(mg/mL)Glucose(mg/dL)45525656040200Time(min)19011015023028018038080-201401902406040200When compar

13、ed with placebo,exogenous GIP infusion not only did not lower postprandial glucose but further worsened hyperglycaemia during late postprandial period(120360 min)in patients with type 2 diabetes(N=22)Changes in insulinChanges in glucose*P0.05 vs placebo10沙格列汀的作用机制在2型糖尿病的治疗中，针对GLP-1的药物更有价值u肠促胰岛素的效应在2

14、型糖尿病患者中减弱u在2型糖尿病患者中GIP水平正常甚至略微升高，但其作用很小-GIP抵抗GIP的促胰岛素分泌作用的减弱可能是遗传因素和环境因素共同作用引起的u2型糖尿病患者中，GLP-1水平降低，但其作用未受损 开发提高GLP-1 水平的药物具有重要的临床意义Nauck.MA et al.J Clin Invest 1993,91:301-30711沙格列汀的作用机制Sites of Action of GLP-1BrainGlucose productionNeuroprotectionAppetiteLiverStomachGastric emptyingGI tractInsulin

15、biosynthesis-cell proliferation-cell apoptosisInsulin secretionGlucagon secretionMuscleHeartCardioprotectionCardiac outputInsulinsensitivityAdapted from Drucker DJ.Cell Metab.2006;3:153-65.Pancreas12沙格列汀的作用机制GLP-1在人体的作用促进饱腹感，降低食欲细胞:餐后胰高血糖素分泌肝脏:胰高血糖素减少肝糖输出胃:有助于调节胃排空细胞:促进血糖依赖性胰岛素分泌进食后，小肠开始分泌GLP-1Adapt

16、ed from:Flint A,et al.J Clin Invest.1998;101:515-20.Holst JJ.TEM.2005;10:229-35.Lovshin JA,Drucker DJ.Nat Rev Endocrinol.2009;5:262-9.细胞 工作负荷细胞 反应13沙格列汀的作用机制胰高血糖素样肽-1(GLP-1)进食后由肠道L细胞分泌 GLP-1在进食后数分钟内开始分泌，对食物中脂类和碳水化合物的反应最为明显Kieffer TJ,et al.Endocr Rev.1999;20:876-913 Drucker DJ.Curr Pharm Des.2001;7:1

17、399-412.Drucker DJ.Mol Endocrinol.2003;17:161-71.在人体和动物体内在动物体内和体外研究中促进葡萄糖刺激的胰岛素分泌抑制胰高血糖素的释放延缓胃排空减少食物的摄入量 增强胰岛素基因的转录可能通过以下途径增加 细胞数量-刺激新生细胞的形成-抑制细胞凋亡uGLP-1通过其受体（GLP-1R）发挥作用GLP-1R在胰岛细胞上表达，受刺激后，可激活cAMP，以及蛋白激酶A依赖性或非依赖性的作用14沙格列汀的作用机制2型糖尿病(n=10)Adapted from:Nauck MA,et al.Diabetologia.1993;36:741-4.-300601

18、20180240270180900安慰剂*GLP-1葡萄糖(mg/dL)安慰剂GLP-13002001000*GLP-1安慰剂-30060120180240胰岛素(pmol/L)20100*GLP-1安慰剂-30060120180240胰高血糖素(pmol/L)时间(分钟)平均值(SE);*P0.05GLP-1以葡萄糖依赖性方式增加胰岛素的分泌15沙格列汀的作用机制T2DM中胰岛细胞对葡萄糖的敏感性降低AGRarg=2-5分钟对精氨酸的平均急性胰高糖素反应；PG50=对AGRarg的抑制达最大值的一半时所需的血糖水平T2DM=2型糖尿病;*健康者平均年龄 1829岁 NGT*(n=8)T2DM

19、(n=8)180-150-120-90-60-30-0100200300400500600700AGRarg(pg/mL)血糖水平(mg/dL)PG50Ward WK,et al.J Clin Invest.1984;74:13181328.Dunning B,et al.Diabetologia.2005;48:1700171316沙格列汀的作用机制 糖尿病前期胰高糖素异常J J Holst,Diabetologia(2009)52:17141723Bo Ahren,European Journal of Endocrinology(1997)137 127131糖尿病前期状态的病理生理学1

20、7沙格列汀的作用机制胰高血糖素受体敲除小鼠血糖水平降低70010001600200024000.02.55.07.510.0*Time of DayBlood Glucose(mM)GR-/-GR+/+RW Gelling et al.PNAS 100:1438-1443,2003血糖(随意饲养)血糖时间(天)18沙格列汀的作用机制T2DM是胰岛素分泌不足和胰高糖素分泌增加致高血糖 Mller WA,et al.N Engl J Med.1970;283:109115碳水化合物膳食胰高糖素时间(分钟)7510012515060060120180240pg/mL胰岛素050100150U/mL0

21、血糖100200300400mg/dL正常葡萄糖耐量2型糖尿病正常葡萄糖耐量2型糖尿病正常葡萄糖耐量2型糖尿病19沙格列汀的作用机制GLP-1降低1型糖尿病患者的胰高糖素和血糖水平Creutzfeldt WO,et al.Diabetes Care.1996;19:580-6.*GLP-1P .001PlaceboGLP-1 or PlaceboPlaceboGLP-1P .001 *GLP-1 or Placebo20沙格列汀的作用机制GLP-1抑制胰高糖素分泌并非由胰岛素介导uGLP-1抑制胰岛 细胞功能无残留的1型糖尿病患者的胰高血糖素分泌u在2型糖尿病中，在不足以导致可测出胰岛素分泌的

22、血糖水平下，GLP-1能抑制胰高血糖素的分泌l没有证据显示其他非肠促胰素类降糖药物对人胰高糖素分泌起作用Jesper Gromada Endocrine Reviews 28(1):8411621沙格列汀的作用机制GLP-1在体内快速降解1 2 330GLP-1 Des-HA-GLP-1(失活)GLP-1被二肽基肽酶-4（DPP-4）降解失活半衰期1-2分钟1 23 30DPP-4提高 GLP-1作用的治疗方法:模拟 GLP-1作用的药物(肠促胰岛素类似物)1)DPP-4 酶抑制剂Mentlein et al.Eur J Biochem.1993;Gallwitz et al.Eur J Bi

23、ochem.1994 22沙格列汀的作用机制DPP4抑制剂作用机理食物摄入胃胃肠道肠增加和延长GLP-1对细胞的影响:细胞：胰腺胰岛素释放净效应：血糖细胞:增加和延长GLP-1和GIP对细胞的作用：DPP4抑制剂胰高血糖素分泌Drucker和Nauck,2006;Idris和Donnelly,2007;Barnett,2006肠促胰岛素23沙格列汀的作用机制临床药效学:稳定状态下，血浆中不同剂量的DPP-4 活性CV181002(MAD in T2DM),data are means-100-80-60-40-2002004812162024Time post-dose(h)Plasma DP

24、P4 activity(%change from baseline).Placebo(n=7)2.5 mg(n=6)5 mg(n=5)血 浆 DPP4 活 性(自基线的变化%)24沙格列汀的作用机制b-Cell Stimulation by Saxagliptin in Patients with T2DStudy schemaSAXA:saxagliptin;PBO,placebo;BMI:body mass index;T2D:type 2 diabetes.n=156n=46SAXA5 mgPBOScreeningSingle-blind lead-in2 weeksDouble-bli

25、ndtreatment12 weeksInclusion Treatment nave T2D 18-70 years old HbA1c 6-8%BMI 40 kg/m2 Fasting C-peptide1 ng/mLDiet&exerciseplaceboSubjects wereprovided with:Meters tomonitor glucose Blood glucose self-monitoring instructionn=20n=16RandomisationAdapted from Henry R,et al.Poster presented at EASD.Sep

26、 27-Oct 1,2009.Vienna,Austria.422HQ09NP10126沙格列汀的作用机制入选标准u2型糖尿病病人u筛选访视时，糖化血红蛋白 6.0%和 8.0%u空腹 C-肽 浓度 1.0 ng/mLu未服用药物的患者uBMI 40 kg/m2u男性 和 女性,18 和 70 岁.女性必须是不在哺乳期和妊娠期Source:CV181041 3.3.1研究 04127沙格列汀的作用机制有效性终点u主要有效性终点主要有效性终点是在肠内给糖的高糖钳夹试验中静脉-口服高糖钳夹试验，180-480分钟，胰岛素分泌率曲线下面积在12周时自基线变化的百分比。如果没有12周的测量值，将采用1

27、2周前基线后的最后一次测量值。u次要有效性终点次要有效性终点是在静脉高糖钳夹试验中（120-180分钟），胰岛素分泌率曲线下面积在12周时自基线变化的百分比。如果没有12周的测量值，将采用12周前基线后的最后一次测量值。Source:CV181041 3.5.1.1研究 04128沙格列汀的作用机制b-Cell Stimulation by Saxagliptin in Patients with T2DMethodsSAXA:saxagliptin;PBO:placebo;IV:intravenous.*Glucose infusion to achieve and maintain hyp

28、erglycaemia=280 mg/dL from 0-480 min.At 480 min,infusion adjusted to maintain hyperglycaemia=450 mg/dL.Arginine 5 g(10%solution,50 mL IV over 30 sec)administered at 505 min.Samples drawn at protocol-specified intervals.Sequential IV-Oral hyperglycaemic clamp and arginine stimulation testPlasma gluco

29、se(mg/dL)4001005052004503002804805151801200-30Time(min)75 g oralglucosechallengeStartglucoseinfusion*SAXAorPBOIV hyperglycaemic clampIV-Oral hyperglycaemic clampArgininestimulation testSamplesGlucoseInsulinGlucagonGLP-1GIP0Adapted from Henry R,et al.Poster presented at EASD.Sep 27-Oct 1,2009.Vienna,

30、Austria.T2D:type 2 diabetes422HQ09NP10129沙格列汀的作用机制基线和12周(LOCF)时，高糖钳夹试验中，在空腹（0-180分钟）和OGTT后（180-480分钟）状态的胰岛素分泌率Source:CV181041 Figure 7.1(App.5.3.4)研究 041胰岛素分泌率平均值 (pmol/kg*min)分钟胰岛素分泌率平均值 (pmol/kg*min)分钟10沙格列汀 5mg安慰剂1030沙格列汀的作用机制主要和次要有效性终点Source:CV181041 Table 7.1研究 041有效性终点(12 周)沙格列汀 5 mgn=20安慰剂n=1

31、6静脉-口服钳夹试验中胰岛素分泌(pmol/kg)(180-480 分钟)病例数1615 基线平均值(SE)2817.73687.0 12 周 LOCF平均值3303.13564.3 校正后自基线的几何平均值的变化%a15.9-2.2 校正后与安慰剂的差异%b18.5 与安慰剂对照的P-值*0.0350*静脉钳夹试验中胰岛素分泌(pmol/kg)(120-180分钟)病例数1815 基线几何平均值446.3593.5 24周 LOCF几何平均值552.1563.1 校正后自基线的几何平均值的变化%a22.6-4.1 校正后与安慰剂的区别%b27.9 与安慰剂对照的P-值*0.0204*估值=1

32、00*exp(校正后自基线的自然对数平均值的变化)-1估值=100*exp(校正后沙格列汀5mg 和安慰剂间自然对数平均值变化的差异)-1在alpha=0.05水平有意义时，比较沙格列汀5mg 和安慰剂31沙格列汀的作用机制b-Cell Stimulation by Saxagliptin in Patients with T2DInsulin secretion rates in the postprandial stateSAXA 5 mg(n=16)PBO(n=15)30-101020Geometric mean%changefrom baseline-200-*Values are g

33、eometric means;Adjusted%change from baseline,geometric mean and 95%CI(represented by bar)SAXA:saxagliptin;PBO:placebo;T2D:type 2 diabetes;LOCF,last observation carried forward.-2.2-12.49.315.94.229.0Insulin secretion rate during IV-Oral hyperglycaemic clamp:adjusted%change from baseline at Week 12(L

34、OCF)Insulin secretion rate(pmol/kg)*Baseline28183687Week 12(LOCF)33033564Adjusted%difference PBO(95%CI):18.5(1.3,38.7)P=0.035Adapted from Henry R,et al.Poster presented at EASD.Sep 27-Oct 1,2009.Vienna,Austria.422HQ09NP10132沙格列汀的作用机制b-Cell Stimulation by Saxagliptin in Patients with T2DInsulin secre

35、tion rates in the fasting state40-101020-200-*Values are geometric means;Adjusted%change from baseline,geometric mean and 95%CI(represented by bar)SAXA:saxagliptin;PBO:placebo;T2D:type 2 diabetes;LOCF,last observation carried forward.-4.1-17.411.222.67.240.4Insulin secretion rate during IV hyperglyc

36、aemic clamp:adjusted%change from baseline at Week 12(LOCF)Insulin secretion rate(pmol/kg)*Baseline446594Week 12(LOCF)552563Adjusted%difference PBO(95%CI):27.9(4.2,57.1)P=0.02030-SAXA 5 mg(n=18)PBO(n=15)Geometric mean%changefrom baselineAdapted from Henry R,et al.Poster presented at EASD.Sep 27-Oct 1

37、,2009.Vienna,Austria.422HQ09NP10133沙格列汀的作用机制b-Cell Stimulation by Saxagliptin in Patients with T2D Insulin secretion following IV arginineInsulin secretion in first 5 minutes following IV arginineSAXA 5 mgPBOAcute insulin response,mU/mL(n=16)(n=14)Baseline,median(Q1,Q3)164(107,203)204(175,268)Week 1

38、2,median(Q1,Q3)172(136,228)185(147,208)Change from baseline*,median(Q1,Q3)24.0(-5.8,71.5)-21.7(-52.3,5.3)*LOCF:last observation carried forward.P value vs PBO=0.074(Kruskal-Wallis test)SAXA:saxagliptin;PBO:placebo;IV,intravenous;T2D:type 2 diabetes.Adapted from Henry R,et al.Poster presented at EASD

39、.Sep 27-Oct 1,2009.Vienna,Austria.Insulin secretion following IV arginine:changes from baseline at Week 12422HQ09NP10134沙格列汀的作用机制静脉-口服高糖钳夹试验中，胰高糖素曲线下面积12周(LOCF)时自基线的变化Source:CV181041 Section 7.4.3.1(App.5.6.3)研究 041单位:pg*min/mL沙格列汀 5 mgn=20安慰剂n=16统计学结果 病例数1714 基线平均值(SE)14279(1228.2)11177(880.2)12周 L

40、OCF 平均值(SE)11571(1112.7)12965(1272.5)自基线变化的平均值(SE)-2708(864.9)1788(1247.5)校正后自基线的变化 平均值(SE)-2191(957.8)1161(1061.9)95%双侧检验的可信区间-4153,-229-1014,3336与安慰剂的不同a 平均值(SE)b-3352(1473.8)95%双侧检验的可信区间-6371,-333 p-值0.0308a 沙格列汀5 mg与安慰剂自基线变化的差异 b 估值=沙格列汀 5 mg校正后平均值变化 安慰剂校正后平均值变化35沙格列汀的作用机制Henry et al.Diabetes,Ob

41、esity and Metabolism 2011;13:850-858.沙格列汀单剂治疗降低胰高糖素水平沙格列汀降低胰高糖素水平达 15.4%胰高血糖素pg/ml75g口服葡萄糖测试沙格列汀5mg:基线沙格列汀5mg:12周36沙格列汀的作用机制SAXA:saxagliptin;PBO:placebo;T2D:type 2 diabetes.b-Cell Stimulation by Saxagliptin in Patients with T2D GLP-1 and GIP concentrations during IV-Oral hyperglycaemic clamp360Time(

42、min)Mean active GLP-1 concentrations(pmol/L)0270 300420480GLP-1SAXA 5 mg-Week 12PBO-Week 12PBO-BaselineSAXA 5 mg-Baseline5432124021018075 g oralglucose challenge360Time(min)Mean active GIP concentrations(pmol/L)0270 300420480GIPSAXA 5 mg-Week 12PBO-Week 12PBO-BaselineSAXA 5 mg-Baseline80604020102402

43、1018075 g oralglucose challenge305070Adapted from Henry R,et al.Poster presented at EASD.Sep 27-Oct 1,2009.Vienna,Austria.Active GLP-1 and GIP concentrations during IV-Oral hyperglycemic clamp at baseline and Week 12(LOCF)422HQ09NP10137沙格列汀的作用机制A1C Changes from Baseline at Week 12(LOCF)Source:CV1810

44、41 Section 7.4.4(App.5.7.1)Study 041Unit:PercentSAXA 5 mgn=20PBOn=16Summary Statistics n1816 Baseline mean(SE)6.94(0.117)6.59(0.144)Week 12 LOCF mean(SE)6.77(0.155)6.64(0.167)Mean from baseline(SE)-0.17(0.133)0.05(0.094)Adjusted from baseline Mean(SE)-0.14(0.118)0.02(0.125)95%two-sided CI-0.38,0.10-

45、0.23,0.2838沙格列汀的作用机制Fasting Plasma Glucose Changes from Baseline at Week 12(LOCF)Source:CV181041 Section 7.4.1.5(App.5.7.2)Study 041Mean Change from Baselinewith 95%CI39沙格列汀的作用机制Glucose AUC During OGTT Changes from Baseline at Week 12(LOCF)Study 041Mean Change from Baselinewith 95%CISAXA 5 mgPBOn=1615Baseline Mean(mgmin/dL)5910850473Source:CV181041 Section 7.4.1.3(App.5.4.7)40沙格列汀的作用机制