Onglyza® (saxagliptin) Achieves Primary Safety Endpoint, Demonstrating No Increased Risk for Cardiovascular Death, Heart Attack or Stroke in SAVOR Cardiovascular Outcomes Trial
• SAVOR provides information on cardiovascular safety for Onglyza in the wake of past questions about cardiovascular safety of type 2 diabetes treatments • SAVOR is the largest cardiovascular outcomes trial to study a diverse population of type 2 diabetes patients at high risk for cardiovascular events • Onglyza did not meet the primary efficacy endpoint of superiority to placebo • In additional analyses, patients treated with Onglyza had improved glycemic control over two years
AstraZeneca and Bristol-Myers Squibb Company today announced the full results of the SAVOR clinical trial in 16,492 adult patients with type 2 diabetes at high risk for cardiovascular events. In this study, Onglyza® (saxagliptin) met the primary safety objective, demonstrating no increased risk for the primary composite endpoint of cardiovascular death, non-fatal myocardial infarction (MI) or non-fatal ischemic stroke, when added to a patient’s current standard of care (with or without other anti-diabetic therapies), as compared to placebo. Onglyza did not meet the primary efficacy endpoint of superiority to placebo for the same composite endpoint. Patients treated with Onglyza experienced improved glycemic control and reduced development and progression of microalbuminuriaover two years as assessed in exploratory analyses.1
The major secondary composite endpoint of cardiovascular death, non-fatal MI, non-fatal ischemic stroke or hospitalization for heart failure, unstable angina or coronary revascularization was balanced across the two arms. One component of the composite secondary endpoint, hospitalization for heart failure, occurred more in the Onglyza group compared to placebo. Rates of pancreatitis were low and balanced between Onglyza and placebo. Overall rates of malignancy were balanced, and the observed rates of pancreatic cancer were lower in the Onglyza group than in the placebo group. More patients in the Onglyza group reported at least one hypoglycemic event compared to placebo. Results were presented on Monday, September 2nd, 2013 during a Hot Line session at the ESC Congress 2013 in Amsterdam, Netherlands, and published in The New England Journal of Medicine.2
In the past, questions have been raised about the safety of many diabetes treatments, in particular regarding their impact on the risk of cardiovascular death, heart attack or stroke. Led by the academic research organizations TIMI Study Group and Hadassah University Medical Center and conducted at more than 700 sites worldwide,SAVOR (Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus) was a randomized, double-blind, placebo-controlled trial of 16,492 patients (including 981 Canadian patients) designed to evaluate the cardiovascular safety and efficacy of Onglyza(saxagliptin) in adults with type 2 diabetes at risk for cardiovascular death, heart attack and stroke, compared to placebo.2
“No other DPP-4 inhibitor and few other anti-hyperglycemic agents have been studied as extensively as Onglyza to address the question of cardiovascular safety. This trial hasanswered important questions about the cardiovascular safety of this widely-prescribed medication. The AstraZeneca/Bristol-Myers Squibb Diabetes Alliance is proud to be a part of this major global study that had significant Canadian participation,” says Dr. Alex Romanovschi, Medical Advisor, AstraZeneca Canada.
“With the scale of this study we have shown leadership in diabetes patient care and expect that the results will be welcomed by the diabetes community. We’re very pleased that we’ve been able to reinforce the safety profile of Onglyza – from a cardiovascular perspective as well as questions related to pancreatic events,” says Dr. Awny Farajallah, Canada Country Medical Director and Vice-President Medical, Bristol-Myers Squibb Canada.
In the study, the primary composite endpoint of cardiovascular death, non-fatal MI or non-fatal ischemic stroke occurred in 613 patients (7.3%) in the Onglyzagroup vs. 609 patients (7.2%) in the placebo group (Hazard Ratio [HR]: 1.00; 95% Confidence Interval [CI]: 0.89, 1.12; non-inferiority p-value < 0.001; superiority p-value = 0.99). The major secondary endpoint, consisting of the primary composite endpoint and hospitalization for heart failure, unstable angina or coronary revascularization, occurred in 1,059 patients (12.8%) in the Onglyza(saxagliptin) group vs. 1,034 patients (12.4%) in the placebo group (HR: 1.02; 95% CI: 0.94, 1.11; p-value = 0.66). Hospitalization for heart failure, a component of this secondary composite endpoint, occurred at a greater rate in the Onglyza group (3.5%) than in the placebo group (2.8%) (HR: 1.27; 95% CI: 1.07, 1.51; p-value = 0.007). The pre-specified secondary endpoint of all-cause mortality occurred in 420 patients (4.9%) in the Onglyzagroup compared to 378 patients (4.2%) in the placebo group (HR: 1.11; 95% CI: 0.96, 1.27; p-value = 0.15).2
Study physicians were allowed to actively manage patients’ glucose through concomitant use of other anti-diabetic drugs and dose titration. Fewer patients in the Onglyzagroup required the addition or increase of any new anti-diabetic medication compared to placebo (1,938 patients [23.7%] vs. 2,385 patients [29.3%], respectively; HR: 0.77; 95% CI: 0.73, 0.82; p-value < 0.001) or the initiation of insulin therapy for more than three months (454 patients [5.5%] vs. 634 patients [7.8%], respectively; HR: 0.70; 95% CI: 0.62, 0.79; p-value < 0.001).2 Patients in the Onglyzagroup had greater reductions in blood sugar levels both from baseline and compared to those in the placebo group, with mean reductions in glycosylated hemoglobin (HbA1c) levels of 0.5% at two years of treatment in the Onglyzagroup vs. 0.2% in the placebo group (p-value < 0.001). More patients in the Onglyza group achieved or maintained goal HbA1c of less than seven percent compared to those in the placebo group at two years (40.0% vs. 30.3%; p-value < 0.001).2
A total of 1,264 patients (15.3%) in the Onglyzagroup reported at least one hypoglycemic event compared to 1,104 (13.4%) in the placebo group (p-value < 0.001), which included patients with both major (177 patients [2.1%] vs. 140 patients [1.7%]; p-value = 0.047) and minor (1,172 patients [14.2%] vs. 1,028 patients [12.5%]; p-value = 0.002) events for the Onglyzaand placebo groups, respectively. Hospitalization for hypoglycemia was infrequent and similar between groups (0.6% vs. 0.5%; p-value = 0.33).2
Patients in the Onglyza group experienced reduced development and progression of microalbuminuria, and were more likely to have an improved albumin:creatinine ratio at two years (372 patients [11.1%] in the Onglyzagroup vs. 295 patients [9.2%] in the placebo group), and less likely to have a worsening ratio (414 patients [12.4%] in the Onglyzagroup vs. 457 patients [14.2%] in the placebo group), compared to placebo.1
A number of pre-specified safety endpoints for diabetes treatments were evaluated (pancreatitis, cancer, liver abnormalities, renal abnormalities, thrombocytopenia, lymphocytopenia, infections, hypersensitivity or skin reactions, bone fractures and hypoglycemia).2
All suspected cases of pancreatitis were independently reviewed and adjudicated by a committee of medical experts external to the sponsors and investigators. Pancreatitis occurred infrequently and the number of patients with acute or chronic pancreatitis was similar between the treatment groups (24 [0.3%] in the Onglyza(saxagliptin) group vs. 21 [0.3%], in the placebo group; p-value = 0.77). Definite/possible acute pancreatitis occurred in 22 patients (0.3%) in the Onglyza group vs. 16 patients (0.2%) in the placebo group (p-value = 0.42); definite acute pancreatitis in 17 patients (0.2%) vs. nine patients (0.1%) (p-value = 0.17); and chronic pancreatitis in two patients (< 0.1%) vs. six patients (0.1%)(p-value = 0.18), respectively. There were five cases of pancreatic cancer in the Onglyzagroup and 12 cases in the placebo group (p-value = 0.095). Renal abnormalities were observed more frequently in the Onglyzagroup compared to the placebo group (5.8% vs. 5.1%, respectively; p-value = 0.04). The incidence of the other pre-specified safety endpoints was balanced between the two groups.2
The study included 16,492 adult patients (including 981 Canadian patients) with type 2 diabetes, 8,280 of whom were randomized to receive Onglyzaand 8,212 of whom were randomized to receive placebo. Recruitment included patients with type 2 diabetes and baseline HbA1c levels of 6.5% to 12%2on any diabetes treatment including diet, insulin and/or oral therapy (excluding GLP-1 agonists and DPP-4 inhibitors) who were at elevated risk for cardiovascular events according to two categories:3
- Patients ≥ 40 years of age with established cardiovascular disease, defined as ischemic heart disease, peripheral vascular disease or ischemic stroke.
- Males ≥ 55 years of age and females ≥ 60 years of age with at least one of the following risk factors: dyslipidemia, hypertension or current smoking, but without established cardiovascular disease.
Further grouping was based on renal function, including patients with normal/mild (eGFR > 50 mL/min), moderate (30 - 50 mL/min) or severe (eGFR < 30 mL/min) renal impairment.3
The primary safety objective was to establish that the upper bound of the 95% confidence interval for the estimated risk ratio comparing the incidence of the composite endpoint (cardiovascular death, non-fatal MI or non-fatal ischemic stroke) observed with Onglyzato that observed in the placebo group was less than 1.3. The primary efficacy objective was to determine, as a superiority assessment, whether treatment with Onglyza compared to placebo when added to current background therapy would result in a reduction in the composite endpoint of cardiovascular death, non-fatal MI or non-fatal ischemic stroke in patients with type 2 diabetes. Secondary efficacy objectives included a reduction in the primary composite endpoint together with hospitalization for heart failure, coronary revascularization or unstable angina pectoris, and reduction of all-cause mortality. Secondary safety objectives included the evaluation of safety and tolerability by assessment of overall adverse events and adverse events of special interest.4
Patients were randomized between May 2010 and December 2011. The median follow-up was 2.1 years and maximum follow-up was 2.9 years.2
Onglyza belongs to a class of medicines called DPP-4 inhibitors (dipeptidyl peptidase-4 inhibitors). It is used to improve blood sugar levels in adult patients with type 2 diabetes, when used in combination with: metformin; a sulfonylurea; metformin and a sulfonylurea, or; insulin (with or without metformin) – when diet and exercise and metformin, sulfonylurea, metformin and a sulfonylurea or insulin (with or without metformin) alone have failed to adequately control blood sugar levels.14 Onglyza is contraindicated in patients with a history of hypersensitivity reaction (e.g., anaphylaxis or angioedema) to saxagliptin, another DPP-4 inhibitor or to any ingredient in Onglyza. Onglyza is also contraindicated in patients with diabetic ketoacidosis, diabetic coma/precoma or Type I diabetes mellitus.14 These conditions should be treated with insulin. A full Product Monograph can be found at www.bmscanada.caand www.astrazeneca.caor by contacting Bristol-Myers Squibb Canada at 1-866-463-6267.
About Diabetes in Canada
In 2012, diabetes was estimated to affect more than 370 million people worldwide. The prevalence of diabetes is projected to reach more than 550 million by 2030.5 Type 2 diabetes accounts for approximately 90% to 95% of all cases of diagnosed diabetes in adults.6 According to the Canadian Diabetes Association, there are more than nine million Canadians who are living with diabetes or pre-diabetes – and approximately 90 per cent of people with diabetes have type 2 diabetes.7 Type 2 diabetes is a chronic disease8 characterized by insulin resistance and dysfunction of beta cells in the pancreas, leading to elevated glucose levels.9 Over time, this sustained hyperglycemia contributes to further progression of the disease.10 Significant unmet needs still exist, as many patients remain inadequately controlled on their current glucose-lowering regimen.11
The major cause of death and complications in patients with type 2 diabetes is cardiovascular disease.12 As many as 80% of patients with type 2 diabetes will develop and possibly die from a cardiovascular event.13
About the AstraZeneca / Bristol-Myers Squibb Diabetes Alliance
Dedicated to addressing the global burden of diabetes by advancing individualized patient care, AstraZenecaand Bristol-Myers Squibb are working in collaboration to research, develop and commercialize a versatile portfolio of innovative treatment options for diabetes and related metabolic disorders that aim to provide treatment effects beyond glucose control. Find out more about the Alliance and our commitment to meeting the needs of health care professionals and people with diabetes at www.astrazeneca.comor www.bms.com.
About AstraZeneca Canada
AstraZeneca is a global, innovation-driven biopharmaceutical business with a primary focus on the discovery, development and commercialization of prescription medicines for gastrointestinal, cardiovascular, neuroscience, respiratory and inflammation, oncology and infectious disease. AstraZeneca operates in over 100 countries and its innovative medicines are used by millions of patients worldwide. AstraZeneca’s Canadian headquarters are located in Mississauga, Ontario. For more information, please visit the company's website at www.astrazeneca.ca.
About Bristol-Myers Squibb Canada
Bristol-Myers Squibb Canada is an indirect wholly-owned subsidiary of Bristol-Myers Squibb Company, a global biopharmaceutical company whose mission is to discover, develop and deliver innovative medicines that help patients prevail over serious diseases. For more information, please visit www.bmscanada.ca.
Kerry Buck, Manager, Corporate Communications, AstraZeneca Canada Inc.,
(905) 803-4823, [email protected]
Monica Flores, Senior Manager, Corporate and Business Communications, Bristol-Myers Squibb Canada, (514) 333-3845, [email protected]
1. Scirica BM, et al. N EnglJ Med. 2013.10.1056/NEJMoa1307684
2. SAVOR Primary Results Supplemental Appendix. Updated August 6, 2013.
3.Mosenzon O, et al. Baseline characteristics of patient population in the Saxagliptin Assessment of Vascular Outcomes Recorded in patients with diabetes mellitus. Diabetes Metab Res Rev. 2013; 29(5):417.
4. Scirica BM, et al. The design and rationale of the Saxagliptin Assessment of Vascular Outcomes Recorded in patients with diabetes mellitus–Thrombolysis in Myocardial Infarction (SAVOR-TIMI) 53 Study. Am Heart J. 2001; 162(5):818-825e6.
5. International Diabetes Federation. IDF Diabetes Atlas Update 2012. Available at: http://www.idf.org/diabetesatlas/5e/Update2012. Accessed August 1, 2013.
6. Centers for Disease Control and Prevention. National Diabetes Factsheet 2011. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed August 1, 2013.
7. “Diabetes Facts,” Canadian Diabetes Association, accessed August 23, 2013, http://www.diabetes.ca/diabetes-and-you/what/facts/.
8. World Health Organization. Media Centre – Diabetes. 2011. Available at: http://www.who.int/mediacentre/factsheets/fs312/en/. Accessed August 1, 2013.
9. Kahn SE. The relative contributions of insulin resistance and beta-cell dysfunction to the pathophysiology of type 2 diabetes. Diabetologia. 2003;46:3-19.
10. Kahn SE. Clinical review 135: The importance of β-cell failure in the development and progression of type 2 diabetes. J Clin Endocrinol Metab. 2001;86(9):4047-4058.
11. Cheung B, Lond, Edin et al. Diabetes Prevalence and Therapeutic Target Achievement in the United States, 1999-2006. American Journal of Medicine. 2009;122:443-453.
12. Duckworth W, Abraira C, Moritz T, et al; for VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009;360(2):129-139.
13. Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation. 2007;115(1):114-126
14. Onglyza® Product Monograph. AstraZeneca Canada Inc./Bristol-Myers Squibb Canada. April 30, 2013.Back to Public Notices