Saxagliptin

Saxagliptin is used as monotherapy or in combination with other drugs for the treatment of type 2 diabetes. It does not appear to decrease the risk of heart attacks or strokes. One study showed a 3.5% risk of hospitalization for heart failure compared to 2.8% in a placebo-controlled group. Like other DPP-4 inhibitors, it has relatively modest HbA1c lowering ability, is associated with a relatively low risk of hypoglycemia, and does not cause weight gain.{{cite journal | vauthors = Scirica BM, Bhatt DL, Braunwald E, Steg PG, Davidson J, Hirshberg B, Ohman P, Frederich R, Wiviott SD, Hoffman EB, Cavender MA, Udell JA, Desai NR, Mosenzon O, McGuire DK, Ray KK, Leiter LA, Raz I | display-authors = 6 | title = Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus | journal = The New England Journal of Medicine | volume = 369 | issue = 14 | pages = 1317–1326 | date = October 2013 | pmid = 23992601 | doi = 10.1056/nejmoa1307684 | hdl-access = free | s2cid = 5080046 | hdl = 10044/1/40070 }}{{cite journal | vauthors = Ali S, Fonseca V | title = Saxagliptin overview: special focus on safety and adverse effects | journal = Expert Opinion on Drug Safety | volume = 12 | issue = 1 | pages = 103–109 | date = January 2013 | pmid = 23137182 | doi = 10.1517/14740338.2013.741584 | s2cid = 12634714 }}

Saxagliptin improved mean HbA1c levels (relative to placebo) in a 24-week trial in people with type 2 diabetes.{{cite journal | vauthors = Dhillon S, Weber J | title = Saxagliptin | journal = Drugs | volume = 69 | issue = 15 | pages = 2103–2114 | date = October 2009 | pmid = 19791828 | doi = 10.2165/11201170-000000000-00000 | s2cid = 243454677 }} Combination therapy with saxagliptin and metformin was more effective than saxagliptin or metformin monotherapy. When the relative benefits of increasing the dose of a sulfonylurea or adding saxagliptin were assessed in a study of 768 patients, combination treatments were shown to have a significantly greater impact on fasting blood glucose than increasing the tested glibenclamide dose alone.{{cite journal |title=New Drugs: Saxagliptin |journal=Australian Prescriber |date=June 2011 |issue=34 |pages=89–91 |url=http://www.australianprescriber.com/magazine/34/3/89/91 |access-date=2011-06-17 |archive-date=2014-02-02 |archive-url=https://web.archive.org/web/20140202230031/http://www.australianprescriber.com/magazine/34/3/89/91 |url-status=usurped }}

In those taking sulphonylureas there is an increased risk of low blood sugar.{{cite journal | vauthors = Salvo F, Moore N, Arnaud M, Robinson P, Raschi E, De Ponti F, Bégaud B, Pariente A | display-authors = 6 | title = Addition of dipeptidyl peptidase-4 inhibitors to sulphonylureas and risk of hypoglycaemia: systematic review and meta-analysis | journal = BMJ | volume = 353 | pages = i2231 | date = May 2016 | pmid = 27142267 | pmc = 4854021 | doi = 10.1136/bmj.i2231 }}

3 adverse reactions were seen higher in saxagliptin vs placebo.

Table 1: Adverse Reactions (Regardless of Investigator Assessment of Causality) in Placebo-Controlled Trials* Reported in ≥ 5% of Patients Treated with ONGLYZA (saxagliptin tablets) 5 mg and More Commonly than in Patients Treated with Placebo.{{cite web | publisher = RxList | title = Onglyza | url = http://www.rxlist.com/onglyza-drug.htm | access-date = 2012-01-31}}

• The 5 placebo-controlled trials include two monotherapy trials and one add-on combination therapy trial with each of the following: metformin, thiazolidinedione, or glyburide. Table shows 24-week data regardless of glycemic rescue.

In February 2012, Bristol-Myers/Astra Zeneca distributed additional safety information on saxagliptin use in South Africa. The package insert is to be edited for South Africa. Contraindications will now include a history of sensitivity to saxagliptin (or another DPP4 inhibitor) as well as pancreatitis. Spontaneously reported adverse events in South Africa have included anaphylaxis, angioedema and acute pancreatitis.{{medcn|date=April 2021}}

In a cardiovascular outcomes trial, saxagliptin treatment let to a small increase in the risk of being hospitalized for heart failure. Saxagliptin may cause joint pain that can be severe and disabling.{{cite web|title=DPP-4 Inhibitors for Type 2 Diabetes: Drug Safety Communication - May Cause Severe Joint Pain|url=https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-warns-dpp-4-inhibitors-type-2-diabetes-may-cause-severe-joint-pain|website=U.S. Food and Drug Administration (FDA)|access-date=1 September 2015|date=2015-08-28}} Saxagliptin may increase the risk of heart failure.{{cite web | title=FDA Drug Safety Communication: FDA adds warnings about heart failure risk to labels of type 2 diabetes medicines containing saxagliptin and alogliptin | website=U.S. Food and Drug Administration (FDA) | date=12 January 2017 | url=https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-adds-warnings-about-heart-failure-risk-labels-type-2-diabetes | access-date=11 August 2020}}

Both monotherapy and combination therapy with other agents was generally well tolerated in clinical trials.

An association of the DPP-IV inhibitor class with pancreatic problems has been proposed, mainly based on case reports associated with the DPP-IV inhibitor sitagliptin and several incretin mimetics including exenatide. A 2013 study of the DPP-4 inhibitor sitagliptin reported found "worrisome changes in the pancreases of the rats that could lead to pancreatic cancer".{{cite journal | vauthors = Matveyenko AV, Dry S, Cox HI, Moshtaghian A, Gurlo T, Galasso R, Butler AE, Butler PC | display-authors = 6 | title = Beneficial endocrine but adverse exocrine effects of sitagliptin in the human islet amyloid polypeptide transgenic rat model of type 2 diabetes: interactions with metformin | journal = Diabetes | volume = 58 | issue = 7 | pages = 1604–1615 | date = July 2009 | pmid = 19403868 | pmc = 2699878 | doi = 10.2337/db09-0058 }} A second paper by the same authors reported an increase in precancerous lesions in the pancreases of organ donors who had taken GLP-1 inhibitors.{{cite journal | vauthors = Butler AE, Campbell-Thompson M, Gurlo T, Dawson DW, Atkinson M, Butler PC | title = Marked expansion of exocrine and endocrine pancreas with incretin therapy in humans with increased exocrine pancreas dysplasia and the potential for glucagon-producing neuroendocrine tumors | journal = Diabetes | volume = 62 | issue = 7 | pages = 2595–2604 | date = July 2013 | pmid = 23524641 | pmc = 3712065 | doi = 10.2337/db12-1686 }} In response to these reports, the United States FDA and the European Medicines Agency each undertook independent reviews of all clinical and preclinical data related to the possible association of DPP-IV inhibitors with pancreatic cancer. In a joint letter to the New England Journal of Medicines, the agencies stated that "Both agencies agree that assertions concerning a causal association between incretin-based drugs and pancreatitis or pancreatic cancer, as expressed recently in the scientific literature and in the media, are inconsistent with the current data. The FDA and the EMA have not reached a final conclusion at this time regarding such a causal relationship. Although the totality of the data that have been reviewed provides reassurance, pancreatitis will continue to be considered a risk associated with these drugs until more data are available; both agencies continue to investigate this safety signal."{{cite journal | vauthors = Egan AG, Blind E, Dunder K, de Graeff PA, Hummer BT, Bourcier T, Rosebraugh C | title = Pancreatic safety of incretin-based drugs--FDA and EMA assessment | journal = The New England Journal of Medicine | volume = 370 | issue = 9 | pages = 794–797 | date = February 2014 | pmid = 24571751 | doi = 10.1056/NEJMp1314078 | doi-access = free }}

Lawsuits have been filed in which plaintiffs who developed pancreatic cancer claim that DPP-IV inhibitors or incretins had a causative role in the development of their cancers.{{cite web | url = http://www.jpml.uscourts.gov/sites/jpml/files/MDL-2452-Initial_Transfer-07-13.pdf | title = IN RE: INCRETIN MIMETICS PRODUCTS LIABILITY LITIGATION | access-date = 2013-08-26 | date = August 26, 2013 | work = USJP | publisher = United States Judicial Panel on Multidistric Litigation}}

The synthesis of saxagliptin by Bristol-Myers Squibb by the amide coupling of N-Boc-3-hydroxyadamantylglycine (2) and methanoprolineamide (3) with EDC. The former is commercially available, whereas the latter is available as the N-Boc analog. The prolineamide moiety is subsequently dehydrated with trifluoroacetic anhydride to give the cyanide as the trifluoracetate ester, which is hydrolyzed. Removal of the Boc protecting group, followed by neutralization gives the desired product (1):{{cite journal | journal = Org. Process Res. Dev. | doi = 10.1021/op900226j | title = Preparation of Saxagliptin, a Novel DPP-IV Inhibitor | year = 2009 | pages = 1169–1176 | vauthors = Scott AS, Gregory SJ, Sergei K, Shelly AR, Truc V, Robert EW | volume = 13| issue = 6 }}

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Saxagliptin is part of a class of diabetes medications called dipeptidyl peptidase-4 (DPP-4) inhibitors.

DPP-4 is an enzyme that breaks down incretin hormones. As a DPP-4 inhibitor, saxagliptin slows down the breakdown of incretin hormones, increasing the level of these hormones in the body. It is this increase in incretin hormones that is responsible for the beneficial actions of saxagliptin, including increasing insulin production in response to meals and decreasing the rate of gluconeogenesis in the liver.{{cite web | title = Onglyza | url = http://diabetes.emedtv.com/onglyza/onglyza.html | archive-url = https://web.archive.org/web/20210614085426/http://diabetes.emedtv.com/onglyza/onglyza.html | archive-date = 14 June 2021 | work = eMedTV | publisher = Clinaero, Inc. | author1 = Emedtv }}

Dipeptidyl peptidase-4's role in blood glucose regulation is thought to be through degradation of GIP{{cite journal | vauthors = Mentlein R, Gallwitz B, Schmidt WE | title = Dipeptidyl-peptidase IV hydrolyses gastric inhibitory polypeptide, glucagon-like peptide-1(7-36)amide, peptide histidine methionine and is responsible for their degradation in human serum | journal = European Journal of Biochemistry | volume = 214 | issue = 3 | pages = 829–835 | date = June 1993 | pmid = 8100523 | doi = 10.1111/j.1432-1033.1993.tb17986.x | doi-access = free }} and the degradation of GLP-1.{{cite journal | vauthors = Ahrén B, Landin-Olsson M, Jansson PA, Svensson M, Holmes D, Schweizer A | title = Inhibition of dipeptidyl peptidase-4 reduces glycemia, sustains insulin levels, and reduces glucagon levels in type 2 diabetes | journal = The Journal of Clinical Endocrinology and Metabolism | volume = 89 | issue = 5 | pages = 2078–2084 | date = May 2004 | pmid = 15126524 | doi = 10.1210/jc.2003-031907 | doi-access = }}

Because incretin hormones are more active in response to higher blood sugar levels (and are less active in response to low blood sugar), the risk of dangerously low blood sugar (hypoglycemia) is low with saxagliptin monotherapy. {{cn|date=January 2025}}

A New Drug Application for saxagliptin in the treatment of type 2 diabetes was submitted to the FDA in June 2008. It was based on a drug development program with 8 randomized trials: 1 phase 2 dose-ranging (2.5–100 mg/d) study; 6 phase 3, 24-week controlled trials with additional controlled follow-up from 12 to 42 months, double-blinded throughout; and one 12-week mechanism-of-action trial with a 2-year follow-up period.{{cite journal | vauthors = Frederich R, Alexander JH, Fiedorek FT, Donovan M, Berglind N, Harris S, Chen R, Wolf R, Mahaffey KW | display-authors = 6 | title = A systematic assessment of cardiovascular outcomes in the saxagliptin drug development program for type 2 diabetes | journal = Postgraduate Medicine | volume = 122 | issue = 3 | pages = 16–27 | date = May 2010 | pmid = 20463410 | doi = 10.3810/pgm.2010.05.2138 | s2cid = 10975424 }} The FDA approved saxagliptin with brand name Onglyza on July 31, 2009.{{cite news | author = Telegram | title = FDA approves diabetes drug from two area manufacturers | url = http://www.telegram.com/article/20090802/NEWS/908020328/1002 | publisher = Worcester Telegram & Gazette Corp. | date = 2 August 2009 | access-date = 2009-08-02 | archive-date = 2009-08-07 | archive-url = https://web.archive.org/web/20090807002844/http://www.telegram.com/article/20090802/NEWS/908020328/1002 | url-status = dead }}

Saxagliptin was licensed for use throughout the European Union by the European Medicines Agency on December 1, 2009.{{cite web | title = Assessment report for ONGLYZA | work = European Medicines Agency | date = | url = https://www.ema.europa.eu/en/documents/variation-report/onglyza-h-c-1039-x-0004-epar-assessment-report-extension_en.pdf }}

Bristol-Myers Squibb announced on 27 December 2006 that Otsuka Pharmaceutical Co. has been granted exclusive rights to develop and commercialize the compound in Japan. Under the licensing agreement, Otsuka will be responsible for all development costs, but Bristol-Myers Squibb retains rights to co-promote saxagliptin with Otsuka in Japan.{{cite press release

| title = Bristol-Myers Squibb and Otsuka Pharmaceutical Co., Ltd. Announce Exclusive Licensing Agreement for Diabetes Compound Saxagliptin in Japan

| publisher = Bristol-Myers Squibb | date = December 27, 2006 | access-date = 2006-12-27

| url = http://investor.bms.com/phoenix.zhtml?c=106664&p=irol-newsArticle&ID=944899&highlight=

}} Further, on 11 January 2007 it was announced that Bristol-Myers Squibb and AstraZeneca would work together to complete development of the drug and in subsequent marketing.{{cite news |agency=Associated Press |title=AstraZeneca teams with Bristol-Myers on diabetes drugs |url=http://www.delawareonline.com/apps/pbcs.dll/article?AID=/20070111/BUSINESS/70111024/-1/NLETTER02 |publisher=Delaware News-Journal |date=11 January 2007 |access-date=2007-01-11 |url-status=dead |archive-url=https://web.archive.org/web/20070930160341/http://www.delawareonline.com/apps/pbcs.dll/article?AID=%2F20070111%2FBUSINESS%2F70111024%2F-1%2FNLETTER02 |archive-date=September 30, 2007 }}

{{reflist}}

• {{cite web| url = https://druginfo.nlm.nih.gov/drugportal/rn/361442-04-8 | publisher = U.S. National Library of Medicine| work = Drug Information Portal | title = Saxagliptin }}
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