BARCELONA – The glucagon-like peptide-1 receptor agonist (GLP-1 RA) liraglutide added onto metformin with or without basal insulin effectively reduced hemoglobin A1c and fasting plasma glucose levels in children with type 2 diabetes in the 52-week ELLIPSE study.
Sara Freeman/MDedge News
Dr. Timothy Barrett
The primary endpoint of the trial, which was the mean change in HbA1c from baseline to 26 weeks, was met, with a greater percentage point decrease with liraglutide (Victoza) than placebo (–0.64 vs. +0.42), with an estimated treatment difference of –1.06 percentage points (P less than .001). At the end of the study, the percentage point changes were –0.50 and +0.80, with a between-group difference of –1.30 in favor of liraglutide.
“Those of us working in pediatric practice are seeing an increasing demand for our clinical services in children with type 2 diabetes,” study investigator Timothy Barrett, PhD, MBBS, observed at the annual meeting of the European Association for the Study of Diabetes. This reflects the increasing prevalence of type 2 diabetes in this age group and is most likely linked to the rising rates of obesity and overweight that have been reported widely in young people in recent years, he added.
“Unfortunately, we look with envy upon our adult physician colleagues, and the range of treatments they have available to treat type 2 diabetes in adults.” In pediatrics, the only licensed treatments that have been available until recently were metformin and insulin, with the latter being an “illogical treatment to treat those with obesity-related diabetes.” The study’s findings, however, support liraglutide as another option to consider, said Dr. Barrett, a pediatric endocrinologist and professor of pediatrics and child health based at the University of Birmingham, England.
“Liraglutide at doses of up to 1.8 mg/day when added to metformin, and basal insulin if required, does seem to offer an additional treatment option for children and young people with type 2 diabetes who require improved glycemic control after they’ve reached a maximum dose of metformin,” he said.
ELLIPSE (Evaluation of Liraglutide in Pediatrics with Diabetes) was a multicenter, randomized, parallel group, placebo-controlled trial to assess the efficacy and safety of liraglutide as an add-on treatment to metformin, with or without basal insulin, in 134 overweight or obese children and adolescents (aged 10-17) with type 2 diabetes.
For inclusion, patients had to be able to complete the trial before their 18th birthday, and have an HbA1c of at least 7% if being treated with diet and exercise, or 6.5% or higher if already being treated with metformin, with or without insulin. Body mass index had to be above the 85the percentile for their age and sex.
Of 307 children and adolescents screened at 84 centers in 25 countries, 135 were randomized and 134 were treated between 2012 and 2018. Screening took place over a period of 2 weeks, after which time those eligible for the trial underwent a 3- to 4-week period where their dose of metformin was titrated if needed followed by an 8-week maintenance period. Only after that was randomization to liraglutide or placebo done, with the GLP-1R started at a subcutaneous dose of 0.6 mg and titrated up to 1.2 or 1.8 mg over 3 days to achieve a fasting plasma glucose (FPG) of less than 6.1 mmol/L (110 mg/dL). However, not all patients were escalated to the top dose, Dr. Barrett noted.
The mean age of patients in the trial was 14.5 years; about 60% of patients were female. The duration of diabetes was about 1.9 years and the average body weight and BMI a respective 91 kg and 33 kg/m2.
Over the course of the study, FPG fell by 1.06 mmol/L at week 26 and 1.03 mmol/L at week 52 in the liraglutide group but rose in the placebo group by 0.80 and 0.78 mmol/L, respectively. The estimated treatment difference was –1.88 (P = .002) and –1.81 at 26 an 52 weeks, respectively.
What was “a really gratifying to see,” said Dr. Barrett, was that the proportion of children and young people achieving a glycemic target of an HbA1c of less than 7% by the end of the double-blind treatment period was significantly higher in the liraglutide than placebo group, at 63.7% and 36.5%, respectively.
Most of the adverse effects seen in the study were gastrointestinal symptoms, including nausea, vomiting, and diarrhea, in about 20% of liraglutide-treated patients, compared with roughly 10% of placebo-treated patients. “This is really reflected in the adult studies as well, and many of these were thankfully transient.”
As for hypoglycemia, Dr. Barrett reported that there was a higher rate in liraglutide- than placebo-treated patients (45.5% vs. 25% for any event), although there were no severe episodes in the liraglutide group and one in the placebo group. Almost a third (31%) of hypoglycemic episodes were asymptomatic, versus 17.6% for the placebo group.
“This is the first successfully completed phase 3 trial showing efficacy of a noninsulin agent, in this case, for children who do not get managed solely on metformin monotherapy,” Dr. Barrett said.
The Food and Drug Administration has approved liraglutide for use in pediatric patients 10 years or older with type 2 diabetes, based in part on results of the ELLIPSE results, Novo Nordisk announced in June. The trial results were published prior to the EASD meeting (Tamborlane WV et al. N Engl J Med. 2019 Aug 15;381:637-46).
Novo Nordisk initiated and funded the trial, and most of the investigators reported receiving funds from the company outside the submitted work. Dr Barrett disclosed being a consultant to and/or receiving honoraria from AstraZeneca, Novo Nordisk and Servier.
SOURCE: Barrett T et al. EASD 2019. Abstract 84.