Glufast® (Mitiglinide) 10mg

授權

112/04/12 2

The total number of patients of Diabetes mellitus was 1,110,941 (547,051 males and 563,890 females), accounting for 4.90% more of the total population (DOH)

112/04/12 3

Glycaemic targets for the management of type 2 diabetes

1. Nathan DM, et al. Diabetologia. 2009;52:17-30. 2. IDF. European Guidelines. 2007. 3. American College of Endocrinology. Endocr Pract. 2007;13 (Suppl. 1):1-68. 4. NICE clinical guideline 87. May 2009. 5. Matthaei S et al. German Diabetes Association guidelines. 2008.

Organisation HbA1c (%) FPG (mg/L) PPG (mg/L)

ADA-EASD1 <7 70-130 <180

IDF-Europe2 <6.5 <100 <140

AACE3 ≤6.5 <110 <140

NICE4 <6.5* — <153FPG: Fasting plasma glucose; PPG: Postprandial glucose; ADA: American Diabetes Association, IDF: International Diabetes

Federation; AACE: American Association of Clinical Endocrinologists; NICE: National Institute of Clinical Excellence;

*<7.5% for people receiving two or more oral glucose-lowering drugs or those requiring insulin.

Lowering blood glucose is critical to type 2 diabetes management inorder to decrease the risk of macro- and microvascular complications

This approach should be tailored according to individual needs

4

%

TADE 2002-2006

Goal Attainment in Taiwan

3

2117

32

24 25

31

25

31

35

1.34.1

0

10

20

30

40

A1C<7 BP<130/80 LDL-C <100 A+B+C

TADE 2002 TADE 2004 TADE 2006

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Oxidative stress

LDL oxidation

Antioxidant consumption

F VIIa

Hypertriglyceridaemia

Endothelium

Endothelial dysfunction

Atherosclerosis

Breakfast Lunch Dinner

Hyperglycaemia

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餐後高血糖

Morris NJ, et al. Diabetologia 44(suppl.2):S14-S21, 2001Hanefeld M, et al. Eur Heart J 25:10-16: 2004

餐後高血糖直接相關於第 1 型及第 2 型糖尿病的心臟血管疾病。 在葡萄糖耐受不良 (IGT) 的藥物研究更顯示，降低餐後高血糖， 可以減少 35% 的心血管疾病的風險。

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異常血糖 (Dysglycemia) 與心血管疾病的自然病程之相關性

( 證據等級 : 高 )

Brunner EJ, et al. Diabetes Care 29: 26-31, 2006Pan CY, et al. Diabetes Res Clin Pract 61:183-90, 2003

英國進行的一項長達 33 年的追蹤研究發現，經過口服葡萄糖耐受 測試 2 小時後的血糖偏高者，未來心臟血管疾病的死亡率明顯偏高。

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餐後高血糖的控制目標 ( 證據等級 : 高 ; 建議強度 : 強烈 )

• 目前糖尿病血糖控制的主要指標是糖化血色素。• 2009 年美國糖尿病學會的建議，當餐前血糖控制於 70

mg/dL 至 130 mg/dL 時，如果 HbA1c 仍高於 7.0 % 時，餐後1 至 2 小時的血糖，應加強監測，並控制於 180 mg/dL 以下，應可改善其 A1C 數值。

• IDF 建議應將餐後 2 小時血糖控制於 140 mg/dl 以下，以期降低糖尿病長期慢性之併發症。

• 本指引建議餐後 2 小時血糖控制於 140 mg/dl 以下。

Ceriello A, Circulation 106:1211–1218, 2002Standards of medical care in diabetes. Diabetes Care 32:S13-S53, 2009Guideline for management of postmeal blood glucose. IDF, 2007.

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餐後高血糖的控制目標 ( 證據等級 : 高 ; 建議強度 : 強烈 )

• 妊娠型糖尿病 (gestational diabetes mellitus, GDM) 的患者，以 SMBG (Self-Monitoring Blood Glucose) 時，餐後 1 小時及 2 小時的血糖，更需分別低於 155mg/dL及 130 mg/dL ，方可降低妊娠期間孕婦及胎兒的風險。

Standards of medical care in diabetes. Diabetes Care 32:S13-S53, 2009

Monnier L, et al. Diabetes Care 26:881–885,2003Gerich JE. Arch Intern Med 163:1306,2003

餐前與餐後血糖濃度隨著 A1C 增加，皆會上升，而餐前與餐後血糖差異程度也會增大

Monnier L, et al. Diabetes Care 26:881–885,2003Gerich JE. Arch Intern Med 163:1306,2003

餐後血糖在 A1C 低於 8.5%時，相較於空腹血糖，對於 A1C 有較多貢獻度

100

50

Rela

tive c

ontr

ibuti

on (

%)

<7.3

7.3―8.4 8.5―9.2 9.3―10.2 >10.2 HbA1c (%) quintiles

70%

30%Fasting

Postprandial

Chemical Structure of Meglitinide and its analogs

Meglitinide

Repaglinide Mitiglinide Nateglinide

Malaisse WJ. Treat Endocrinol 2003;2(6):401-404

Glufast® (Mitiglinide) 10mg

Fast !! Strong !!

Physiological insulin secretion

Glufast®: 速效型胰島素分泌促進劑

• 每日 10 ~ 20mg t.i.d , 餐前 5 分鐘內 ( 或隨餐 ) 服用(Tmax: 14 分鐘 ; t1/2:72 分鐘 )

• 肝 (major) 、腎臟代謝• 由腎臟排除及膽汁排除

Glufast® 僅 < 25% 經 CYP 代謝途徑，藥物交互作用少。 極少有活性代謝物，可適用於腎功能不全患者

CO2HNH

H

H

O

UGT1A3UGT1A9

葡萄糖醛酸化作用(glucuronidation)

約 74 ％

Mitiglinide

CYP 2C9

氧化＜ 25 ％

Hydroxy-

5α-Hydroxy-

5β-Hydroxy-

4α-Hydroxy-

4β-Hydroxy-

3aβ-Hydroxy-

O Gluc.

NH

H

H

O

O

葡萄糖醛酸結合體

Glufast® 可快速刺激 early-phase 胰島素分泌

Mechanism of Glufast Glufast SUSU

receptor

Pancreas

Insulin

BloodInsulinlevel

Administration

Glufast

SU

Insulin

Pancreatic beta cell

SU receptor

Time

Pancreatic beta cell

Glufast® : 15 分鐘迅速刺激 early-phase 胰島素分泌達最大高峰

Mitiglinide has 1000 fold higher affinity to SUR1 (IC50=4 nM), than to SUR2A (IC50=3 μM) and SUR2B

(IC50=5 μM)

Beta Cell Cardiomyocyte Smooth Muscle Cell

Reimann F, et al. Bri J Pharmacol 2001;132:1542-1548

Mitiglinide inhibits Kir6.2/SUR currents at two site:

A low affinity site on Kir6.2, a high affinity site on SUR

Glufast® is safe to heart

Glufast

SUR2ASUR1

Pancreatic beta cell

Pancreas Heart

Glufast selectively binds to SU receptor(SUR1) in pancreas beta cells. Glufast dose not bind to SU receptor (SUR2A) in heart.

Glufast acts pancreas beta cells only,not act on heart.

Pancreatic β cell

Expression organMitiglinide

IC50 （ mol/L ）KATP channel

Cardiac muscle

Smooth muscle

3.8×10-9

3.2×10-6

4.6×10-6

SUR1/Kir6.2

SUR2A/Kir6.2

SUR2B/Kir6.2

Reimann, F. et al.: Britsh Journal of Pharmacology, 132: 1542, 2001.

Glufast® 長期使用顯著降低 HbA1c 1-1.5%

低血糖症狀發生率與 Placebo 相似

組 對象病例數

發現病例數

發生率(%)

p=0.650

χ 2 檢定

Placebo 2.93102

Glufast 10mg 102 2 2.0

Data on Japan Kissei file

Glufast® 適合於年長 ( ＞ 60 歲 ) 及初始病友 (A1C ＜8%)

The Journal International Medical Research 2009; 37:812-821

A Randomized, Double-blind, Placebo-control, Metformin Add-on Study to Evaluate the Efficacy and Safety of Mitiglinide in Patients with Type 2 Diabetes Mellitus

九醫學中心 :台大、北榮、長庚、三總、新光、馬偕、慈 濟、中國、彰基

Taiwan Glufast® clinical study

Study Design—Metformin Add-on

8 weeks run-in period

Metformin monotherapy

500mg t.i.d.

Glufast 10mg + metformin

2 tablets, t.i.d. 500mg, t.i.d.

Glufast 10mg + metformin

1 tablet, t.i.d. 500mg, t.i.d.

Placebo + metformin

1 tablet, t.i.d. 500mg, t.i.d.

4 weeks

12 weeksRandomization

Titration-up: FPG > 140mg/dL

Placebo + metformin

2 tablets, t.i.d. 500mg, t.i.d.

Titration-down if FPG < 70mg/dL

Glufast® : 顯著降低 HbA1c

For patients with measurements at both baseline and week 16

HbA1c Mean Change with 95% CI

Glufast-0.91

Glufast-0.96

Placebo-0.22

Placebo-0.22

-1.4

-1.2

-1

-0.8

-0.6

-0.4

-0.2

0

ITT Population (p<0.0001) PP Population (p<0.0001)

(%

)

71

65

61

57

Glufast® : 顯著降低 2h-PPG

2 hour-PPG Mean Change with 95% CI

Glufast-55.12

Glufast-45.03

Placebo-15.25

Placebo-11.31

-70

-60

-50

-40

-30

-20

-10

0

Week 8 (p<0.0001) Week 16 (p<0.0001)

(mg/

dL)

68

67

69

64

Weight gain 與 Placebo 組無差異

Weight Mean Change with 95% CI

Glufast-0.49

Glufast-0.21

Glufast-0.54

Glufast-0.41Placebo

-0.59

Placebo-1.14

Placebo-0.89

Placebo-0.58

-1.6

-1.2

-0.8

-0.4

0

Week 4(p=0.5169)

Week 8(p=0.0779)

Week 12(p=0.0762)

Week 16(p=0.1905)

(kg)

72 72

71 69 71 67 71 65

33

AEs occurred during treatment period

Variable

GlufastN= 73n(%)

PlaceboN= 72n(%) P-value*

- AE number 105 88

- AE incidence rate 42 (57.53%) 36 (50.00%) 0.4069

- Maximum Severity: Mild 31 ( 42.47) 23 ( 31.94) 0.2300 Moderate 8 ( 10.96) 11 ( 15.28) 0.4710 Severe 3 ( 4.11) 2 ( 2.78) 1.0000

- Drug-related AE incidence rate 10 ( 13.70) 6 ( 8.33) 0.4276 Diarrhea 3 ( 4.11) 3 ( 4.17) 1.0000 Increased Appetite 3 ( 4.11) 0 ( 0.00) 0.2448 Sweating 3 ( 4.11) 0 ( 0.00) 0.2448Note: N= the number of patients in the analysis population. n= the number of patients with the event. (%)= n/N*100.

-A patient with multiple occurrences of an AE under one treatment is counted only once in the AE category for that treatment.

*p-value from the comparsion of event incidence between treatment group by using Fisher's exact test

AE incidence rate of possible hypoglycemia symptoms

Conclusions

• In both ITT and PP analysis, statistically significant reduction on HbA1c and FPG after 4, 8, 12 and 16 weeks Mitiglinide treatment, compared to placebo.

• In both ITT and PP analysis, statistically significant reduction on 1-hour PPG and 2-hour PPG after 8 and 16 weeks Mitiglinide treatment, compared to placebo.

• No statistical difference on body weight.

Efficacy and safety of Glufast in diabetic patients on maintenance hemodialysis

2010 Endocrine Journal 57(7): 579-586

Baseline and medications

Follow: 24 weeks

Average Glufast® dose: 20±8.6mg

Dose Adjustment of Mitiglinide at Patients on Hemodialysis

Initial dose: Age < 70 y/o: 5mg tid AC

Age ≥ 70 y/o: 2.5 mg tid AC The dose was doubled stepwise to ascertain

the safety of the drug Final average dose: 20.0 ± 8.6 mg/day (0.35 ±

0.14 mg/Kg/day)

Abe M, et al. Endocrine Journal 2010;57(7): 579-586

Significantly reduce in HbA1c & GA

Significantly reduce in FPG

Adverse effects

• None of the patients exhibited significant adverse effects such as symptomatic hypoglycemia or liver dysfunction.

• Only ALP level was significantly decreased at the end of the study compared with baseline levels.

Effective in reducing TG

Mitiglinide is more Safe in Patients on Hemodialysis than Repaglinide and Nateglinide

• Repaglinide is metabolized in the liver by the cytochrome P450 enzymes, principally CYP2C8 and CYP3A4, and its metabolites have insulin secretion properties.

• Nateglinide is predominantly metabolized by cytochrome P450 isoenzymes CYP2C9 (70%) and CYP3A4 (30%), and its metabolites have insulin secretion properties.

• Mitiglinide is metabolized in the kidney and liver, and predominantly metabolized to glucuronic acid conjugate (74%) and hydroxide (<25%), these metabolites have little insulin secretory activity

Mitiglinide decreases the postprandial generation of oxidative stress and inflammation in type 2 diabetic patients

Assaloni R, et al. Diabetologia 2005;48:1919-1924

45

NameDuration

(hr)代謝

Nateglinide(Starlix®)

2-6 肝代謝， 16 ％原型由腎排出

Repaglinide(NovoNorm®)

2-6 完全肝代謝，膽汁排出

Meglitinides

CKD stage 3/4 CKD stage 5

商品名（學名）

Glufast 10mg（ Mitiglinide ）

Starlix 120mg（ Nateglinide ）

製劑

　　　　　　　　　　　

用法、用量餐前或隨餐

1 次 10mg 　適度增減餐前

1 次 120mg

體內動態Ｔ max 10mg ： 14 分鐘 0.5~1.9 小時Ｔ 1/2 10mg ： 72 分鐘 1.5 小時

主要代謝路徑 　葡萄糖醛酸結合（ 74% ） , 2C9<25%

CYP 2C9(70%) , 3A4(30%)

組織選擇性 　對心肌 ： 約 1000 倍　對平滑肌： 約 1000 倍

　　對心肌 ： 約 50 倍　　對平滑肌： 約 300 倍

代謝物 極少具活性 主要代謝物具活性對洗腎病人的給藥 可給藥 禁止 (in Japan)

健保價 NT$ 4.76 NT$ 5.5

Glufast vs Starlix

（有切割線）30mg 錠

Nateglinide switch to Glufast®

6.8

6.6

6.4 6.4

6.0

6.2

6.4

6.6

6.8

7.0

7.2

7.4

轉換前 1 個月後 2 個月後 3 個月後

mean±SE

HbA

1C（

％）

＊： P<0.05

＋： P<0.1

＊＊

＋

N=12

加藤　光敏等人：第 49 屆日本糖尿病學會年次學術集會，東京（ 2006 年 5月）

對　象：第 2 型糖尿病病人 56 例方　法：對正在接受其他經口降血糖藥處方，或對 Drug Naïve 的第 2 型糖尿病病人，轉換為 Glufast 30mg/ 天或改採新處方副作用：並未發現

Brand name Novonorm (1mg) Starlix (120mg) Glufast (10mg)Product name Repaglinide Nateglinide Mitiglinide

Recommended dose 0.5-4 mg tid; max.:16mg 60-180 mg tid 10-20 mg tid

Administration time Before meal, 15-30 min

Before meal,1-30 min

Before meal,隨餐服用

Tmax 0.5-1 hr 0.25-1 hr 14 mins

T 1/2 1-1.8 hr 1.25-2.9 hr 72 minsMetabolite enzyme CYP 3A4 、

CYP 2C8 CYP 2C9 (70%) 、CYP 3A4(30%)

CYP 2C9 ＜ 25%UGT 1A9, 1A3 (74%)

Drug-drug interaction Gemfibrozil, macrolide, cyclosporine, -conazole, CCB, atorvastatin, simvastatin

Warfarin, Phenytoin, Rosuvastatin, Fluvastatin

No significant interaction

Dose reduction with CYP3A4 inhibitors

Yes No No

Metabolites in urine 8-10 % 80-83 % 93 % (inactive)Metabolites in feces 80-90 % 8-12 % 7 %CKD stage 3,4 or Kidney transplant Initiate at 0.5mg

(GFR ＜ 40mL/min/1.73m2

Initiate at low dose: 60mg No dose adjustment necessary

Dialysis Dosing Initiate at low dose Avoid Initiate at low doseSafety - hypoglycemia - GI intolerance

 16-31 %3

2-5 %

 5.5 %3.2 %

 6.1 %1

1.4 %Efficacy - HbA1C

(0.25-4 mg tid, 12 wks)3

-1.7 %(120 mg tid, 24 weeks)3- 0.7 %

(5~10 mg tid, 52 weeks)- 1.5 %

Weight gain (0.5~4mg tid, 16weeks)4

+1.8Kg(60-120mg tid, 16weeks)+0.7Kg

(10~20mg tid, 16 weeks)5體重無影響

BNHI price 4.98 6.5 4.87

Daily cost 7.47 ~ 79.68 9.75~29.25 3.65 ~ 29.22

Glinide 比較

Dosage and administration

• 10 mg / tab

• 3 times/day

• Just before meal ( 隨餐服用 )

Step1 Step2 Step3

Lift chopsticks

Take Glufast

Immediatelyhave a meal

（ 1 ）肝功能障礙的病人　　　

（ 2 ）腎功能障礙的病人　　　

（ 3 ）下列病人或狀態

1 ）貧血性心臟疾病的病人

2 ）腦下垂體功能衰竭或腎上腺功能衰竭的病人

3 ）腹瀉、嘔吐等腸胃障礙的病人

4 ）營養不良狀態、飢餓狀態、或餐飲攝取量不足或衰弱狀態

5 ）激烈肌肉運動

6 ）攝取過量酒精者

7 ）高齡者

Glufast® 可給藥者

Conclusion

服用 15 分鐘內快速刺激 early-phase 胰島素分泌達最大高峰

以 glucuronidation 代謝為主，與其他藥物交互作用極少 無活性代謝物，適合於腎功能不全及洗腎糖尿病友使用，

安全性高 與其他 glinide 產品比較，病友最不影響體重 年長糖尿病友最安全的選擇 : 快速、短效、低血糖發生率

低，肝、腎功能不全皆可使用。