NZ734595B2 - Treatment of pediatric type 2 diabetes mellitus patients with lixisenatide - Google Patents
Treatment of pediatric type 2 diabetes mellitus patients with lixisenatideInfo
- Publication number
- NZ734595B2 NZ734595B2 NZ734595A NZ73459516A NZ734595B2 NZ 734595 B2 NZ734595 B2 NZ 734595B2 NZ 734595 A NZ734595 A NZ 734595A NZ 73459516 A NZ73459516 A NZ 73459516A NZ 734595 B2 NZ734595 B2 NZ 734595B2
- Authority
- NZ
- New Zealand
- Prior art keywords
- lixisenatide
- treatment
- patients
- patient
- study
- Prior art date
Links
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- 239000011691 vitamin B1 Substances 0.000 description 1
- 235000019154 vitamin C Nutrition 0.000 description 1
- 239000011718 vitamin C Substances 0.000 description 1
- 150000003700 vitamin C derivatives Chemical class 0.000 description 1
- 235000019165 vitamin E Nutrition 0.000 description 1
- 239000011709 vitamin E Substances 0.000 description 1
- 150000003712 vitamin E derivatives Chemical class 0.000 description 1
- 150000003722 vitamin derivatives Chemical class 0.000 description 1
- 230000001755 vocal Effects 0.000 description 1
- 239000011800 void material Substances 0.000 description 1
- 230000003442 weekly Effects 0.000 description 1
- HCHKCACWOHOZIP-UHFFFAOYSA-N zinc Chemical compound [Zn] HCHKCACWOHOZIP-UHFFFAOYSA-N 0.000 description 1
- 239000011701 zinc Substances 0.000 description 1
- 229910052725 zinc Inorganic materials 0.000 description 1
- 229910000368 zinc sulfate Inorganic materials 0.000 description 1
- 229960001763 zinc sulfate Drugs 0.000 description 1
- OENHQHLEOONYIE-JLTXGRSLSA-N β-Carotene Chemical compound CC=1CCCC(C)(C)C=1\C=C\C(\C)=C\C=C\C(\C)=C\C=C\C=C(/C)\C=C\C=C(/C)\C=C\C1=C(C)CCCC1(C)C OENHQHLEOONYIE-JLTXGRSLSA-N 0.000 description 1
Classifications
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K2300/00—Mixtures or combinations of active ingredients, wherein at least one active ingredient is fully defined in groups A61K31/00 - A61K41/00
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/13—Amines
- A61K31/155—Amidines (), e.g. guanidine (H2N—C(=NH)—NH2), isourea (N=C(OH)—NH2), isothiourea (—N=C(SH)—NH2)
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K38/00—Medicinal preparations containing peptides
- A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
- A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
- A61K38/22—Hormones
- A61K38/26—Glucagons
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K38/00—Medicinal preparations containing peptides
- A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
- A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
- A61K38/22—Hormones
- A61K38/28—Insulins
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
- A61K47/02—Inorganic compounds
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
- A61K47/06—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite
- A61K47/08—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite containing oxygen, e.g. ethers, acetals, ketones, quinones, aldehydes, peroxides
- A61K47/10—Alcohols; Phenols; Salts thereof, e.g. glycerol; Polyethylene glycols [PEG]; Poloxamers; PEG/POE alkyl ethers
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
- A61K47/06—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite
- A61K47/16—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite containing nitrogen, e.g. nitro-, nitroso-, azo-compounds, nitriles, cyanates
- A61K47/18—Amines; Amides; Ureas; Quaternary ammonium compounds; Amino acids; Oligopeptides having up to five amino acids
- A61K47/183—Amino acids, e.g. glycine, EDTA or aspartame
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K9/00—Medicinal preparations characterised by special physical form
- A61K9/0012—Galenical forms characterised by the site of application
- A61K9/0019—Injectable compositions; Intramuscular, intravenous, arterial, subcutaneous administration; Compositions to be administered through the skin in an invasive manner
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K9/00—Medicinal preparations characterised by special physical form
- A61K9/0012—Galenical forms characterised by the site of application
- A61K9/0053—Mouth and digestive tract, i.e. intraoral and peroral administration
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- A—HUMAN NECESSITIES
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- A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
- A61P3/00—Drugs for disorders of the metabolism
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- A—HUMAN NECESSITIES
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- A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
- A61P3/00—Drugs for disorders of the metabolism
- A61P3/08—Drugs for disorders of the metabolism for glucose homeostasis
- A61P3/10—Drugs for disorders of the metabolism for glucose homeostasis for hyperglycaemia, e.g. antidiabetics
-
- Y10S514/866—
Abstract
The present invention refers to lixisenatide for use in pediatrics. Specifically, the use of lixisenatide to treat Type 2 diabetes mellitus (T2DM) in pediatric patients, where the treatment may be used as an add-on therapy in conjunction with the administration of known T2DM medicament Metformin.
Description
TREATMENT OF PEDIATRIC TYPE 2 DIABETES US PATIENTS WITH
LIXISENATIDE
Description
It is to be understood that if any prior art publication is referred to herein, such
reference does not constitute an ion that the publication forms a part of
the common general knowledge in the art in New Zealand or any other country.
Subject of the present invention is desPro36 Exendin-4(1-39)-Lys 6-NH 2
(AVE0010, lixisenatide) or/and a pharmaceutically able salt thereof, for
use in pediatrics. Yet r subject of the present invention is a
pharmaceutical combination for use in pediatrics, said combination
comprising (a) lixisenatide or/and a pharmaceutically able salt thereof,
and (b) metformin or/and a pharmaceutically acceptable salt thereof.
Yet r aspect is a method for treatment of a pediatric patient, said
method comprising administering lixisenatide or/and a pharmaceutically
acceptable salt thereof, optionally in ation with metformin, to a
pediatric t in need thereof.
In a healthy person the release of insulin by the pancreas is strictly coupled
to the concentration of blood glucose. An increased level of blood glucose, as
appears after meals, is rapidly counterbalanced by a respective increase in
insulin secretion. In fasting condition the plasma insulin level drops to a basal
value which is sufficient to ensure the continuous supply of glucose to insulinsensitive
organs and tissues and to keep the hepatic glucose production at a
low level at night.
In contrast to type 1 diabetes, there is not generally a lack of insulin in type 2
diabetes mellitus but in many cases, particularly in progressive cases, the
treatment with insulin is regarded as the most suitable therapy, if required in
combination with orally administered iabetic drugs.
An increased glucose level in the blood over several years without l
symptoms represents a significant health risk. It could clearly be shown by
the large-scale DCCT study in the USA (The Diabetes Control and
Complications Trial Research Group (1993) N. Engl. J. Med. 329, 977-986)
18464995_1 ters) P43144NZ00
that chronically increased levels of blood glucose are a main reason for the
development of diabetes complications. Examples for diabetes complications
are micro and macrovascular damages that possibly manifest themselves in
retinopathies, nephropathies or neuropathies and lead to ess, renal
failure and the loss of extremities and are accompanied by an increased risk
of cardiovascular diseases. It can thus be concluded that an improved
therapy of diabetes primarily has to aim keeping blood glucose in the
physiological range as closely as possible.
A particular risk exists for oven/veight patients suffering from type 2 diabetes
mellitus, e.g. patients with a body mass index (BMI) 2 30 kg/mz. In these
patients the risks of diabetes p with the risks of oven/veight, leading e.g.
to an increase of cardiovascular diseases compared to type 2 diabetes
us patients being of a normal weight.
Until recently, type 2 diabetes mellitus (T2DM) was almost exclusively an
adult disease. ding with the increasing prevalence of obesity in
children, the incidence of T2DM in children and adolescents has markedly
increased to the point that it ts for as many as one third of all the new
cases of T2DM sed in adolescent.
Children/adolescents with T2DM are usually diagnosed over the age of 10
years, in middle to late puberty, when due to physiological changes in the
GH/lGF-1 axis insulin resistance develops. Like in adults, the incidence of
type 2 diabetes in children/adolescents is highest in some ethnic populations
(e.g. American Indians, African an, Asian/pacific Islander and
Hispanics) (Canadian Diabetes Association Clinical Practice ines
_xpert Committee, Type 2 es in Children and cents, 2008
Clinical ce Guidelines, 8162—8167).
iabetes is a therapeutic area for which the EMA Paediatric Working Party
considers that research and development of medicinal products for children
should be med. Type 2 diabetes may have an earlier and more
aggressive course in pediatric patients; therefore, they are likely to be at
higher risk for developing cations and need the best le ic
l in the early stage of their e.
T2DM in children differs from adults in a number of ways that have an
important impact on potential treatment. Puberty appears to play a major role
in the development of type 2 diabetes in children. During y, there is
increased resistance to the action of insulin, resulting in hyperinsulinemia.
Growth hormones have been considered as candidates for causing insulin
resistance during y. The mean growth e levels increase
transiently during puberty coincidental with the decrease in insulin .
Given this information, it is not surprising that the peak age at presentation of
type 2 diabetes in children coincides with the usual age of mid-puberty. In an
individual who has a genetic position for insulin resistance,
compounded with environmental risk re, the additional burden of
insulin resistance during puberty may tip the balance from a state of
compensated hyperinsulinemia with normal glucose tolerance to inadequate
insulin secretion and glucose intolerance that continues beyond puberty
(American Diabetes ation, Diabetes Care 2000, 23(3): 381-389).
in the US, about 12% of type 2 pediatric diabetes mellitus patients received
metformin monotherapy and about 34 % received insulin monotherapy
Dombrowsky and Barrett, Type II Diabetes Mellitus in en: Analysis of
Drevalence Based on the Pediatric Heath Information System (PI-t8)
Database, American College of Clinical Pharmacology Annual Meeting
September 22nd — 24th 2013, Bethesda, Maryland). In many pediatric type 2
diabetes mellitus patients, progression of the disease is rapid, and control of
hyperglycaemia may become insufficient even at maximal tolerated doses of
metformtn.
-lowever there are no reported studies describing the efficacy of GLP-1
analogs in the pediatric population.
Metformin is a biguanide hypoglycemic agent used in the treatment of non—
insulin-dependent diabetes mellitus (type 2 diabetes mellitus) not responding
to dietary modification. Metformin es glycemic control by improving
n sensitivity and decreasing intestinal absorption of glucose. Metformin
is usually administered orally. However, control of type 2 diabetes mellitus in
obese patients by metformin may be insufficient. Thus, in these patients,
additional measures for controlling type 2 diabetes mellitus may be required.
Metformin is the ational nonproprietary name of 1,1—dimethylbiguanide
(CAS number 657-24—9).
The compound desPro35Exendin-4(1-39)~Lys6—NH2(AVEOO1O, lixisenatide) is
a derivat've of Exendin—4. AVEOO1O is disclosed as SEQID NO:93 in
wo 156:
SEQ ID NO: 1: lix'senatide (44 amino acids)
H—G—E—G-T—F-T—S—D-L—S~K—Q-M—E-E-E—A-V—R—L-F—I-f3—W—L-K—N—G—G—P-S—S-G—
A-P-P~S-K-K-K-K—-<—K—NH2
SEQ | NO: 2: exendin-4 (39 am'no acids)
H-G—E-G—T-F-T-S- )-L—S-K—Q—M-E~ 3~E-A-V-R—L-F—I-E—W—L-K—N—G—G—P—S—S-G—
A—P—P—P—S—NHZ
Exendins are a group of peptides which can lower blood glucose
concentration. The Exendin ue natide is characterised by C-
terminal truncation of the native Exendin—4 sequence. Lixisenatide comprises
six C-terminal lysine residues not present in Exendin-4.
Lixisenatide is also termed des-38—proline—exendin—4(Heloderma suspecfum)-
(1 —39)-peptidylpenta—L—lysyl-L—lysinamide (CAS number 3203673).
The aim of the present ion can be seen in the improvement of anti-
diabetic treatment in en and adolescents suffering from diabetes
mellitus, in particular from type 2 diabetes me litus.
In Examples 1 and 2 of the present 'on, after a standardized liquid
breakfast in ’12 pediatric patients with Type 2 Diabetes mellitus (TZDM) with a
mean HbA1C of 8.65% and mean body weight of 84.7 kg, a non-significant
decrease in plasma glucose cted plasma glucose AUCO;30h_4;30h and
plasma glucose AUCo;3oh_ 430),) was observed with single doses of Iixisenatide
and 10 pg compared to placebo. In contrast, single doses of lixisenatide 5
and 10 pg icantly reduced plasma glucose (corrected plasma glucose
AUC0;30h-4;30h and plasma glucose AUC0;30h4;30h) compared to placebo in
12 adult patients with T2DM. Lixisenatide exposure was r for both dose
groups in the evaluable pediatric patients, s in adult patients, the
Iixisenatide exposure dose-proportionally increased. In pediatric patients, the
exposure was similar to that in adults for Iixisenatide 5 pg, but lower for
lixisenatide 10 pg. Single doses of lixisenatide 5 and 10 pg were safe and
well tolerated in both, pediatric and adult patients in this study of short
duration.
In conclusion, Examples 1 and 2 demonstrated able pharmacokinetic
(PK) and pharmacodynamic (PD) profiles in pediatric and adults patients at a
dose of 5 pg, as well as no unexpected safety results.
Examples 1 and 2 of the present invention confirm that adult patients have a
different pathophysiology compared with children and cents. The
response to a standardized liquid breakfast ed in pediatric type 2
diabetes mellitus patients from that of adult patients. In the pediatric control
population (placebo group), the peak insulin concentration was observed
about one hour after the test meal (Figure 12), followed by a rapid decline. In
the adult control population (placebo group), the andial insulin peak
was broader. The peak insulin concentration was observed about 2 hours
after the test meal e 11). A similar difference was observed in the
postprandial C-peptide concentration (Figures 13 and; 14).
In line with these findings, differences were identified in the effects of
natide in the ric patients compared with the effects obtained in the
adult patient population. The described differences in time course of
postprandial insulin and ide secretion found in the placebo groups
were also observed under Iixisenatide.
RECTIFIED SHEET (RULE 91) lSA/EP
The exposure of lixisenatide in pediatric patients lixisenatide was smaller
than in adults at doses of 10 pg es 15 and 16). The reduction of
postprandial plasma glucose (PPG) by treatment with lixisenatide was
smaller than in adult patients, and, due to the small number of patients, not
significant (Figures 5 to 8).
Surprisingly, at a dose of 5 pg, lixisenatide exhibited a larger reduction in
plasma glucacon level than in adult patients (Figures 9 and 10).
In summary, the results of Example 2 indicate ences in the
pathophysiology of pediatric type 2 diabetes mellitus patients and adult
patients. The fact that lixisenatide can reduce postprandial plasma glucose,
postprandial glucagon and insulin secretion in pediatric patients tes that
natide is effective in the treatment of this patient group.
Example 3 of the present invention describes a randomized, double-blind,
placebo-controlled, dose escalation, study on safety, cokinetics and
pharmacodynamics of lixisenatide in pediatric patients with type 2 diabetes
not adequately controlled with metformin and/or basal insulin.
A first aspect of the present invention is lixisenatide or/and a
pharmaceutically acceptable salt thereof, for use in pediatrics.
Another aspect of the present invention is a pharmaceutical combination for
use in rics, said combination comprising
(a) lixisenatide or/and a pharmaceutically acceptable salt thereof, and
(b) min or/and a pharmaceutically acceptable salt thereof.
Yet another aspect of the present ion is a ceutical combination
for use in pediatrics, said combination comprising
(a) lixisenatide or/and a ceutically acceptable salt thereof,
(b) metformin or/and a pharmaceutically acceptable salt thereof, and
(c) a basal insulin or/and a pharmaceutically acceptable salt thereof.
RECTIFIED SHEET (RULE 91) ISA/EP
Yet another aspect of the present invention is a pharmaceutical combination
for use in pediatrics, said combination comprising
(a) lixisenatide or/and a pharmaceutically acceptable salt thereof, and
(b) a basal n or/and a pharmaceutically able salt thereof.
As used herein, "to be treated according to the present invention", ”treatment
according to the present invention", or "pediatric treatment according to the
present invention" relates to the treatment of pediatric patients, as d
herein, by (i) lixisenatide or/and a pharmaceutically acceptable salt thereof,
or (ii) the pharmaceutical combination as described .
The patient in need of the pediatric treatment according to the t
invention by may have an age of at least 10 years.
The patient in need of the pediatric treatment according to the present
invention as described herein may have an age of less than 18 years.
It is preferred that the patient in need of the pediatric treatment according to
the present invention as described herein may have (a) an age of at least 10
years, and (b) and age of less than 18 years.
The patient in need of the pediatric treatment according to the present
ion as described herein may suffer from type 2 es mellitus.
The pediatric patient to be treated according to the present ion may be
a subject suffering from type 2 diabetes mellitus, wherein type 2 diabetes
mellitus is not adequately controlled by treatment with metformin
monotherapy, for instance with a dose of at least 1.0 g/day metformin or at
least 1.5 g/day metformin for 3 months, or/and a dose of at the maximum 2.0
g/day min for 3 months.
The pediatric patient to be treated according to the t invention may be
a subject suffering from type 2 es mellitus, wherein type 2 diabetes
mellitus is not adequately controlled by treatment with a basal insulin or/and
metformin, for instance with a dose of at least 1.0 g/day metformin or at least
1.5 g/day min for 3 months, or/and a dose of at the maximum 2.0 g/day
metformin for 3 months.
The pediatric patient to be treated according to the present invention may be
a subject ing from type 2 diabetes mellitus, wherein type 2 diabetes
mellitus is not adequately controlled by treatment with a basal insulin
monotherapy.
in the present invention, "not tely controlled" by the ent with
metformin monotherapy (treatment with metformin alone) means that
min monotherapy is not sufficient to remove the symptoms of diabetes
mellitus. In particular, "not adequately controlled" by the treatment with
metformin monotherapy means that the patient does not reach
normoglycemic values in terms of, for example, postprandial plasma glucose
concentration, glucose excursion or/and fasting plasma glucose
concentration.
in the present invention, "not adequately controlled" by the treatment with
metformin or/and a basal insulin means that this therapy alone is not
sufficient to remove the symptoms of diabetes mellitus. In ular, "not
adequately controlled" by the treatment with metformin or/and a basal insulin
means that the patient does not reach normoglycemic values in terms of, for
example, postprandial plasma glucose concentration, glucose excursion
or/and fasting plasma glucose concentration.
In the t invention, "not adequately controlled" by the treatment with a
basal insulin monotherapy (treatment with a basal insulin alone) means that
this therapy alone is not sufficient to remove the symptoms of diabetes
mellitus. in ular, "not tely controlled" by the treatment with a
basal insulin monotherapy means that the patient does not reach
normoglycemic values in terms of, for example, postprandial plasma glucose
tration, glucose ion or/and fasting plasma glucose
concentration.
The term "not adequately controlled" by the treatment with metformin
monotherapy in ular relates to the period before onset of treatment
according to the present invention. It can be diagnosed before onset of the
treatment according to the present ion if monotherapy with metformin
adequately ls the type 2 diabetes mellitus or not. For example, such
diagnosis may be performed within 1 months, within 2 months or within 3
months before onset of the therapy of the present invention.
The term "not adequately controlled" by the treatment with metformin or/and
a basal insulin in particular relates to the period before onset of treatment
according to the present invention. it can be sed before onset of the
treatment according to the present invention if the therapy with metformin
or/and a basal insulin adequately controls the type 2 diabetes mellitus or not.
For example, such sis may be performed within 1 months, within 2
months or within 3 months before onset of the y of the present
invenfion.
The term "not adequately controlled" by the treatment with a basal n
monotherapy in particular relates to the period before onset of treatment
according to the present invention. It can be diagnosed before onset of the
treatment according to the present ion if the therapy with a basal n
monotherapy adequately controls the type 2 diabetes mellitus or not. For
example, such diagnosis may be performed within 1 months, within 2 months
or within 3 months before onset of the therapy of the present invention.
By the treatment according to the present invention, adequate control of type
2 diabetes mellitus may be achieved in pediatric patients not adequately
controlled with metformin monotherapy.
By the treatment according to the present ion, adequate control of type
2 es mellitus may be achieved in pediatric patients not adequately
controlled with metformin or/and a basai insulin.
By the treatment according to the present invention, adequate control of type
2 diabetes mellitus may be achieved in pediatric patients not adequately
controiied with a basai n monotherapy.
The pediatric patient suffering from type 2 diabetes mellitus to be treated
according to the present invention may be obese. A t can be
considered as obese if the body mass index is at least 30 kg/mz. In the
present invention, an obese pediatric t may have a body mass index of
at least 30 kg/m2 or at least 31 kg/mz. It is preferred that that the pediatric
patient has a body mass index of at least 31 kg/mz.
The pediatric patient ing from type 2 diabetes mellitus to be treated
according to the present invention preferabiy does not receive an antidiabetic
treatment by insulin or/and related compounds.
The pediatric patient suffering from type 2 diabetes mellitus to be treated
according to the present invention may suffer from type 2 diabetes mellitus
for at least three months. in particular, in the pediatric patient to be treated,
type 2 diabetes mellitus has been sed for at least three months before
onset of therapy of the present invention.
in the present invention, a ric patient may have a HbAlc value in the
range of 7 % to 10%, or 7% to 9.9%. In particular the pediatric patient to be
treated may have a l—le1C value of at least about 7 %, at least about 7.5 %,
at least about 8 %, at least about 8.5 %, at least about 8.65 %, or at least
about 9 %.
In particular, in a pediatric patient ing metformin monotherapy (in
ular before onset of therapy according to the present invention), a
bAtc value in the range of 7 % to 10% or 7% to 9.9%, or a HbA1C value of
at least about 7 %, at ieast about 7.5 %, at least about 8 %, at least about 8.5
%, at least about 8.65 %, or at least about 9 % tes that the type 2
diabetes mellitus is not adequately controlled by metformin monotherapy.
In particular, in a pediatric patient ing metformin or/and a basal insulin
(in particular before onset of therapy according to the present invention), a
-ibA1c value in the range of 7 % to 10% or 7% to 9.9%, or a -le1c value of
at least about 7 %, at least about 7.5 %, at least about 8 %, at least about 8.5
%, at least about 8.65 %, or at least about 9 % tes that the type 2
diabetes mellitus is not adequately controlled by metformin or/and a basal
insulin.
In particular, in a pediatric patient receiving a basal insulin monotherapy (in
particular before onset of therapy according to the present invention), a
HbA1c value in the range of 7 % to 10% or 7% to 9.9%, or a HbA1C value of
at least about 7 %, at least about 7.5 %, at least about 8 %, at least about 8.5
%, at least about 8.65 %, or at least about 9 % indicates that the type 2
diabetes mellitus is not adequately controlled by a basal insulin monotherapy.
In the present invention, normoglycemic values are blood glucose
concentrations of in particular 60 — 140 mg/dl (corresponding to 3.3 to 7.8
mmol/L). This range refers in ular to biood e concentrations
under fasting conditions and postprandial conditions.
Criteria for a type 2 diabetes mellitus diagnosis include:
- the fasting plasma e concentration (FPG) is 2 7.0 mmol/L (126
mg/dl), or
- the post challenge plasma glucose concentration is > 11.1 mmol/L (200
mg/dl), med as bed by the World -lea|th Organization
(Definition, Diagnosis and Classification of Diabetes Mellitus and its
Complications. Part 1: Diagnosis and Classification of Diabetes Mellitus.
D/NCS/992. Geneva; 1999), using a glucose load containing
the equivalent of 75 g ous glucose dissolved in water, or
- symptoms of diabetes and a casual plasma glucose
2 200 mg/di (11.1 mmol/L).
These criteria are described in the Global lDF/lSPAD Guideline for es
in Childhood and Adolescence (international Diabetes Federation, ISBN 2—
930229—72—1).
The sis of Type 2 Diabetes should not be based on a single plasma
glucose concentration. Diagnosis may require continued observation with
fasting and/or andial blood glucose levels and/or an oral glucose
tolerance test.
According to Craig ( ediatric Diabetes 2014: pl. 20): 4—17), fasting
plasma glucose (FPG) and post nge (postload) e can be
classified as follows:
— FPG < 5.6 mmol/L (100 mg/dL) = normal fasting glucose
concentration.
— FPG 5.6 to 6.9 mmol/_ (100—125 mg/dL) = impaired fasting glucose
concentration.
- FPG 2 7.0 mmol/L (126 mg/dL) = provisional diagnosis of diabetes
(the diagnosis must be confirmed, as described above)
The corresponding categories when the Oral Glucose Tolerance Test
(OGTT) is used are as s:
- Two hour postload glucose < 7.8 mmol/L (140 mg/dL) = normal
glucose tolerance.
- Two hour postload glucose 7.8 to <11.1mmol/L (140—200 mg/dL) =
impaired glucose tolerance.
— Two hour postload glucose 2 11.1 mmol/L (200 mg/dL) = provisional
diagnosis of diabetes (the diagnosis must be confirmed, as described
above).
Impaired glucose tolerance (IGT) and impaired fasting glucose concentration
(IFG) are intermediate stages in the natural history of disordered
ydrate lism between normal glucose tasis and
In the present invention, normoglycemic glucose concentrations can include
impaired glucose concentrations, as described herein.
In the present invention, normoglycemic values of fasting plasma e are
blood glucose concentrations of in particular < 5.6 mmol/L or < 7.0 mmol/L.
In the present invention, normoglycemic values of postprandial plasma
glucose, as defined herein, are blood glucose concentrations of in ular
<7.8 mmol/L or < 11.1 mmol/L.
The ric patient to be treated according to the present invention may
have a 2 hours postprandial plasma e concentration of at least 11.1
, at least 12 mmol/L, or at least 13 mmol/L. These plasma glucose
concentrations exceed normoglycemic concentrations.
In particular, in a pediatric patient receiving metformin monotherapy (in
particular before onset of therapy according to the present ion), a 2
hours postprandial plasma concentration of at least 11.1 mmol/L, at least 12
mmol/L or at least 13 mmol/L indicates that the type 2 diabetes mellitus is not
adequately controlled by metformin monotherapy.
In particular, in a pediatric patient receiving metformin or/and a basal n
(in particular before onset of therapy according to the present invention), a 2
hours postprandial plasma concentration of at least 11.1 mmoI/L, at least 12
mmol/= or at least 13 mmol/L indicates that the type 2 diabetes mellitus is not
adequately controlled by metformin or/and a basal insulin.
In particular, in a pediatric patient receiving a basal insulin monotherapy (in
particular before onset of therapy according to the present invention), a 2
hours postprandial plasma concentration of at least 11.1 mmol/L, at least 12
mmol/L or at least 13 mmol/L indicates that the type 2 diabetes mellitus is not
tely controlled by a basal insulin monotherapy.
“Postprandial” is a term that is well known to a person skilled in the art of
diabetology. The term “postprandial” describes in particular the phase after
an ingestion of a meal or/and exposure to glucose under experimental
conditions. In a healthy person this phase is characterised by an increase
and subsequent decrease in blood glucose concentration. The postprandial
phase typically ends up to 2 h after a meal or/and exposure to glucose.
Determination of postprandial plasma glucose is well-known (see, eg. Crapo
et al., Diabetes, 1977, 26(12):1178—1183). A typical standardized ast
suitable for exposure to glucose under experimental conditions in a meal test
is described in the Appendix of e 2.
The pediatric patient to be treated according to the invention may have a
glucose excursion of at least 3 mmol/L, at least 3.5 mmol/L or at least 3.65
mmol/L. In the t invention, the glucose excursion is in particular the
difference of the 2 hours andial plasma glucose concentration and the
plasma glucose concentration prior to a meal test, eg. the plasma glucose
concentration 30 minutes prior to a meal test.
In particular, in a pediatric patient ing metformin monotherapy (in
ular before onset of therapy according to the present invention), a
glucose excursion of at least 3 mmol/L, at least 3.5 mmol/L or at least 3.65
mmol/_ indicates that the type 2 diabetes mellitus is not adequately
contro led by min monotherapy
ln part'cular, in a pediatric patient receiving min or/and a basal insulin
(in particular before onset of y according to the present invention), a
glucose excursion of at least 3 mmol/L, at least 3.5 mmol/_ or at least 3.65
mmol/_ indicates that the type 2 diabetes mellitus is not adequately
contro led by metformin or/and a basal insulin.
In particular, in a pediatric patient receiving a basal insulin erapy (in
particular before onset of therapy according to the present invention), a
glucose excursion of at least 3 mmol/L, at least 3.5 mmol/L or at least 3.65
mmol/L indicates that the type 2 diabetes mellitus is not adequately
controlled by a basal insulin monotherapy.
The pediatric patient to be treated ing to the invention may have a
fasting plasma glucose concentration of at least 8 mmol/L, or at least 8,5
mmol/L. These plasma glucose concentrations exceed normoglycemic
concentrations.
In particular, in a pediatric patient receiving mettormin monotherapy (in
particular before onset of therapy according to the present ion), a
fasting plasma glucose tration of at least 8 mmol/L, or at least 8,5
mmol/ tes that the type 2 diabetes mellitus is not adequately
contro led by metformin erapy.
ln part'cular, in a pediatric patient receiving metformin or/and a basal insulin
(in particular before onset of therapy according to the present invention), a
fasting plasma glucose tration of at least 8 mmol/L, or at least 8,5
mmol/L indicates that the type 2 diabetes mellitus is not adequately
controlled by metformin or/and a basal insulin.
in particular, in a pediatric patient receiving basal insulin monotherapy (in
particular before onset of therapy according to the present invention), a
fasting plasma glucose concentration of at least 8 mmol/L, or at least 8,5
mmoi/L indicates that the type 2 diabetes us is not tely
controlled by basal insulin monotherapy.
The pediatric t to be treated according to the invention may have a C~
peptide plasma concentration of at least 1.2 nmol/. in fasting conditions.
The pediatric patient to be treated ing to the invention may have a
plasma glucagon level of at least 140 ng/L in fasting conditions.
In another aspect of the present ion, (i) lixisenatide or/and a
pharmaceutically acceptable salt thereof, or (ii) the combination as described
herein can be used for improving (i.e. reducing) the 2 hours postprandial
plasma glucose in a pediatric patient suffering from type 2 diabetes mellitus.
Reduction means in particular that the 2 hours postprandial plasma glucose
concentration reaches normoglycemic values or at least approaches these
values.
n another aspect of the present invention, (i) natide or/and a
pharmaceutically acceptable salt thereof, or (ii) the combination as bed
werein can be used for improving (i.e. reducing) the glucose excursion in a
pediatric patient suffering from type 2 diabetes mellitus. ion means in
particular that the glucose excursion reaches normoglycemic values or at
east approaches these values.
n another aspect of the present invention, (i) lixisenatide or/and a
ceutically acceptable salt thereof, or (ii) the combination as described
herein can be used for improving (i.e. reducing) the plasma glucagon
concentration in a pediatric patient suffering from type 2 diabetes us.
Lixisenatide or/and a pharmaceutically acceptable salt thereof, or the
ation of the present invention can be used in the treatment of one or
more of the medical indications described herein, for example in treatment of
type 2 diabetes mellitus patients, as described herein, or for conditions
associated with type 2 diabetes mellitus, such as for the improvement of
glucose excursion, for improvement of the andial plasma e
concentration, or/and for improvement of plasma on concentration.
The plasma glucagon concentration, as used , is in particular the '
postprandial plasma glucagon concentration.
in the present invention, metformin includes pharmaceutically acceptable
salts thereof. The person d in the art knows suitable pharmaceutically
acceptable salts of metformin.
in the present invention, metformin can be administered ing to
commonly known administration protocols of metformin in accordance with
the terms of ing authorization. Metformin can be administered to
patients from 10 years. For example, metformin can be administrated once
daily, twice daily or three times a day. In particular, the metformin dose
applied before the onset of the y as disclosed herein is ued in
combination with lixisenatide or/and a pharmaceutically acceptable salt
thereof, as disclosed herein.
In the present invention, metformin may be administered orally. The skilled
person knows formulations of metformin suitable for treatment of type 2
diabetes mellitus by oral administration. Metformin may be administered to a
pediatric patient in need thereof, in an amount ient to induce a
therapeutic effect. Metformin may be administered in a dose of at least 1.0
g/day or at least 1.5 g/day. Metformin may be administered in a dose of at
the m of 2.0 g/day. The daily metformin dose can be d into 2 or
three separate doses. For oral administration, metformin may be formulated
in a solid dosage form, such as a tablet or pill. Metformin may be formulated
with suitable pharmaceutically acceptable carriers, adjuvants, or/and auxiliary
substances.
In the present invention, lixisenatide or/and a pharmaceutically acceptable
salt may be stered in an add—on therapy to administration of
metformin.
ln the t invention, the terms "add-on", "add-on treatment" and "add—on
therapy" can relate to treatment according to the present invention with
metformin and lixisenatide.
In the present invention, the terms "add-on", "add-on treatment" and n
therapy" can also relate to treatment according to the present invention with
a basal insulin or/and metformin, and lixisenatide.
in the present invention, the terms "add-on" n treatment" and "add-on
therapy" can also relate to ent according to the t invention with
a basal insulin and lixisenatide.
Metformin, natide or/and the basal insulin each may be administered in
a once—a-day-dosage. Metformin, the basal insulin and lixisenatide may be
administered by different administration routes. Metformin may be
administered orally, and lixisenatide and the basal insulin may be
administered parenterally.
in particular, "add—on add—on treatment" and "add—on therapy" mean that
the dose of metformin administered before the onset of the treatment with
lixisenatide or/and a pharmaceutically acceptable salt thereof, as disclosed
herein, is continued in combination with lixisenatide or/and a
ceutically acceptable salt f.
In particular, "add—on", n treatment” and "add-on therapy" mean that
the dose of the basal insulin administered before the onset of the treatment
with natide or/and a ceutically acceptable salt thereof, as
disclosed herein, is continued in combination with lixisenatide or/and the
pharmaceutically acceptabie salt thereof. Alternatively, the dose of the basal
insulin may be reduced in combination with lixisenatide or/and the
pharmaceutically acceptable salt thereof;
in the present invention, lixisenatide includes pharmaceutically acceptable
salts thereof. The person d in the art knows suitable pharmaceutically
acceptable salts of lixisenatide. A preferred pharmaceutically acceptable salt
of lixisenatide employed in the present invention is the acetate salt of
lixisenatide.
In the present invention, lixisenatide or/and the pharmaceutically acceptable
sait thereof may be administered to a pediatric patient in need thereof, in an
amount sufficient to induce a therapeutic effect.
in the present invention, lixisenatide or/and the pharmaceutically acceptable
salt thereof may be formulated with suitable pharmaceutically acceptable
carriers, adjuvants, or/and auxiliary nces.
Lixisenatide or/and a pharmaceutically acceptable salt thereof may be
administered parenterally, e.g. by injection (such as by intramuscular or by
subcutaneous injection). Suitable ion devices, for instance the so—cailed
"pens" comprising a cartridge comprising the active ingredient, and an
injection needle, are known. ixisenatide or/and a pharmaceutically
acceptable salt thereof may be administered in a suitable amount, for
instance in an amount in the range of 5 pg to 10 pg per dose.
In the present invention, lixisenatide or/and a pharmaceutically acceptable
salt thereof may be administered in a daily dose in the range of 5 to 10 pg.
Lixisenatide or/and a pharmaceutically acceptable salt thereof may be
administered by one injection per day. Lixisenatide or/and a pharmaceutically
acceptable salt f may be administered about 30 min before breakfast.
In the present invention, lixisenatide or/and a ceutically acceptable
salt f may be provided in a liquid composition, which ably is an
aqueous formulation. it is preferred that the liquid composition is suitable for
eral administration, in particular for injection. The skilled person knows
such liquid compositions of natide. A liquid composition of the present
invention may have an acidic or a physiologic pH. An acidic pH preferably is
in the range of pH 1 — 6.8, p-l 3.5 - 6.8, or pH 3.5 — 5. A physiologic pH
preferably is in the range of pH 2.5 - 8.5, pH 4.0 - 8.5, or pH 6.0 - 8.5. The pH
may be adjusted by a pharmaceutically acceptable d acid (typically HCI)
or pharmaceutically acceptable diluted base (typically NaOH).
The liquid composition comprising lixisenatide or/and a pharmaceuticaliy
acceptable salt thereof may comprise a suitable preservative. A suitable
preservative may be ed from , m-cresol, benzyl alcohol and p-
hydroxybenzoic acid ester. A preferred preservative is m-cresol.
The liquid composition comprising lixisenatide or/and a pharmaceutically
acceptable salt thereof may comprise a tonicity agent. A suitable tonicity
agent may be ed from glycerol, lactose, ol, mannitol, glucose,
NaCl, calcium or magnesium containing compounds such as CaClz. The
» concentration of glycerol, lactose, sorbitol, mannitol and glucose may be in
the range of 100 — 250 mM. The concentration of NaCl may be up to 150
mM. A preferred tonicity agent is glycerol.
The liquid composition comprising natide or/and a ceutically
acceptable salt thereof may comprise methionine from 0.5 ug/mL to 20
ug/mL, preferably from 1 pg /ml to 5 pg/ml. Preferably, the liquid composition
comprises L—methionine.
In the present invention, the basal insulin includes pharmaceutically
acceptable salts f. The person skilled in the art knows suitable
ceutically acceptable salts.
in the present invention, the basal insulin or/and the pharmaceutically
acceptable salt thereof may be administered to a pediatric patient in need
thereof, in an amount sufficient to induce a eutic effect.
In the t invention, the basal insulin or/and the pharmaceutically
acceptable salt thereof may be ated with suitable pharmaceutically
acceptable carriers, adjuvants, or/and auxiliary substances.
The basal insulin or/and a pharmaceutically acceptable salt thereof may be
administered parenterally, e.g. by injection (such as by intramuscular or by
subcutaneous injection). Suitable injection devices, for instance the led
"pens" comprising a cartridge comprising the active ingredient, and an
injection needle, are known.
A further aspect of the present invention is a method of ric treatment,
said method comprising administering to a patient in need of a pediatric
treatment, lixisenatide or/and a pharmaceutically acceptable salt thereof.
In this method of treatment, the ric t is a patient as bed
herein. In particular, the pediatric patient suffers from type 2 diabetes
mellitus, as described herein. Lixisenatide is prepared as described herein, in
particular as a liquid formulation le for parenteral administration.
Another aspect of the present invention is a method of ric treatment,
said method comprising administering to a patient in need of a pediatric
treatment, a pharmaceutical combination, said combination comprising
(a) lixisenatide or/and a pharmaceutically able salt f, and
(b) metformin or/and a pharmaceutically acceptable salt thereof.
Another aspect of the present invention is a method of pediatric treatment,
said method comprising administering to a patient in need of a pediatric
treatment, a pharmaceutical combination, said combination comprising
(a) natide or/and a pharmaceutically acceptable salt thereof, and
(b) a basal n or/and a pharmaceutically acceptable salt thereof.
Another aspect of the present invention is a method of pediatric treatment,
said method comprising administering to a patient in need of a pediatric
treatment, a pharmaceutical combination, said combination comprising
(a) lixisenatide or/and a pharmaceutically acceptable salt thereof
(b) metformin or/and a pharmaceutically acceptable salt thereof, and
(c) a basal insulin or/and a pharmaceutically acceptable salt f.
in these methods of treatment, the pediatric patient is a patient as described
herein. in particular, the pediatric patient suffers from type 2 diabetes
mellitus, as described herein. Lixisenatide is prepared as described herein, in
particular as a liquid formulation suitable for parenteral stration.
Metformin is prepared as bed herein, in particular for oral
administration. The basal insulin is prepared as described herein, in
particular as a liquid formulation suitable for parenteral administration.
Yet another aspect of the t invention is a method for the improvement
of glucose excursion, for the improvement of the postprandial plasma
glucose concentration, or/and for the improvement of plasma glucagon
concentration, said method comprising administering to a pediatric patient, as
described herein, (i) lixisenatide or/and a pharmaceutically able salt
thereof, or (ii) the combination as described herein.
Yet another aspect of the present invention is the use of lixisenatide or/and a
pharmaceutically acceptable salt thereof, for the manufacture of a
medicament for use in pediatrics (for pediatric treatment). The pediatric
patient is a patient as described herein. in particular, the medicament is for
the treatment of type 2 diabetes mellitus, as described herein. Lixisenatide is
prepared as bed herein, in ular as a liquid formulation suitable for
parenteral administration.
Yet another aspect of the present ion is the use of a pharmaceutical
combination, said combination comprising
(a) lixisenatide or/and a pharmaceutically acceptable salt thereof, and
(b) metformin or/and a pharmaceutically acceptable salt thereof,
for the manufacture of a ment for use in pediatrics (for pediatric
treatment).
Yet another aspect of the present invention is the use of a pharmaceutical
combination, said ation sing
(a) lixisenatide or/and a pharmaceutically acceptable salt f, and
(b) a basal insulin or/and a pharmaceutically acceptable salt thereof,
for the manufacture of a medicament for use in pediatrics (for pediatric
treatment).
Yet another aspect of the present invention is the use of a pharmaceutical
combination, said combination comprising
(a) lixisenatide or/and a pharmaceutically acceptable salt thereof,
(b) metformin or/and a pharmaceutically acceptable salt f, and
(c) a basal insulin or/and a pharmaceutically acceptable salt thereof,
for the manufacture of a medicament for use in pediatrics (for pediatric
treatment).
In these uses, the pediatric patient is a patient as described herein. In particular, the
medicament is for the treatment of type 2 diabetes mellitus, as described herein.
Lixisenatide is prepared as bed herein, in particular as a liquid formulation
suitable for parenteral administration. min is prepared as described herein, in
particularfor oral administration. The basal insulin is prepared as described herein, in
ular as a liquid formulation suitable for parenteral administration.
Yet r aspect of the t invention is the use of (i) Iixisenatide or/and a
pharmaceutically acceptable salt thereof, or (ii) the combination as described herein,
for the manufacture of a medicament for the improvement of glucose ion, for
the improvement of the postprandial plasma glucose concentration, or/and for the
improvement of plasma glucagon concentration, wherein the patient to be treated is a
pediatric patient, as described herein.
The invention is further rated by the following examples and figures.
Figure legends
Figure 1 Graphical study design of Example 1. * Mandatory blood sampling D—30 to
0—25 for laboratory tests (eg, anti—lA2 and anti—GAD autoantibodies, fasting
C—peptide). The following assessments will be done at TPl, TP2, TP3 and E08:
Physical ation and vital signs, ECG and AE assessment (except ing).
Figure 2 3 cartridges for injections
Figure 3 Body mass index (BMI) for age percentiles by gender: Boys, 2 to 20 years
RECTIFIED SHEET (RULE 91) ISA/EP
Figure 4 Body mass index (BMI) for age percentiles by gender: Girls, 2 to 20
years
Figure 5 Mean i SEM plasma glucose per ent group in adult ts
- evaluable PD population
Figure6 Mean i SEM plasma glucose per treatment group in pediatric
patients — evaluable PD population
Figure? Median plasma glucose (mmol/L) per treatment group in adult
patients - evaluable PD population
RECTIFIED SHEET (RULE 91) ISA/EP
Figure 8 Median plasma glucose (mmol/L) per treatment group in pediatric
ts - evaluable PD population
Figure 9 Median glucagon (ng/L) per treatment group in adult patients -
evaluable PD population
Figure 10 Median glucagon (ng/L) per treatment group in pediatric patients -
evaluable PD population
Figure 11 Median plasma insulin (pmol/L) per treatment group in adult
patients - evaluable PD population
Figure 12 Median plasma n (pmol/L) per treatment group in pediatric
patients - evaluable PD population
Figure 13 Median C-peptide L) per treatment group in adult ts -
evaluable PD population
Figure 14 Median C—peptide (nmol/L) per treatment group in pediatric
patients - evaluable PD population
Figure 15 Mean (+ SD) lixisenatide plasma concentrations by treatment (full
PK population, linear scale)
Figure 16 Mean (+SD) lixisenatide plasma concentrations by treatment
(evaluable PK'population, linear scale)
Figure 17 cal study design of Example 3. * o solution and
volume to be injected matching to lixisenatide solution: 50 pl during Weeks 1
and 2 (injector device Tactipen®), 200 pl during Weeks 3 and 4 (green
injector device Delta14®) and 200 u_ during Weeks 5 and 6 (purple injector
device Delta14®)
RECTIFIED SHEET (RULE 91) ISA/EP
t-matter of the present application is described in the following
items:
1. Lixisenatide or/and a pharmaceutically acceptable salt thereof, for use
in pediatrics.
RECTIFIED SHEET (RULE 91) ISA/EP
ixisenatide or/and a pharmaceutically acceptable salt thereof, for use
according to item 1, n lixisenatide or/and the pharmaceutically
acceptable salt f is administered as an add-on y to
metformin or/and a pharmaceutically acceptable salt thereof.
Lixisenatide or/and a pharmaceutically acceptable salt thereof, for use
according to item 2, wherein metformin or/and the pharmaceutically
acceptable salt thereof is prepared for oral administration.
Lixisenatide or/and a pharmaceutically acceptable salt thereof, for use
according to any one of the preceding items, wherein the patient in
need of the pediatric treatment has an age of at least 10 years.
natide or/and a pharmaceutically acceptable salt thereof, for use
according to any one of the ing items, n the patient in
need of the pediatric treatment has an age of less than 18.
Lixisenatide or/and a pharmaceutically acceptable salt thereof, for use
according to any one of the preceding items, wherein the patient in
need of the pediatric treatment suffers from type 2 diabetes mellitus.
_ixisenatide or/and a pharmaceutically acceptable salt thereof, for use
according to item 6, wherein the type 2 diabetes mellitus has been
diagnosed at least three months before onset of therapy.
jixisenatide or/and a pharmaceutically acceptable salt thereof, for use
ing to item 6 or 7, wherein the type 2 diabetes mellitus is not
adequately lled by metformin monotherapy, by basal insulin
monotherapy or by a combination of metformin and a basal insulin.
_ixisenatide or/and a pharmaceutically able salt thereof, for use
according to any one of the preceding items, wherein the patient in
deed of the pediatric treatment is obese.
. _ixisenatide or/and a pharmaceutically acceptable salt thereof, for use
according to any one of the preceding items, wherein the patient in
need of the pediatric treatment has a body mass index of at least 30
kg/m2 or at least 31 kg/mz.
11. Lixisenatide or/and a pharmaceutically acceptable salt thereof, for use
according to any one of the preceding items, wherein lixisenatide is
administered about 30 min before breakfast.
12. Lixisenatide or/and a ceutically acceptable salt thereof, for use
according to any one of the preceding items, wherein at the onset of
treatment with lixisenatide or/and the pharmaceutically acceptable salt
thereof, the t has a fasting plasma glucose concentration of at
least 8 mmol/L or at least 8.5 mmol/L.
13. Lixisenatide or/and a pharmaceutically able salt thereof, for use
according to any one of the preceding items, wherein at the onset of
treatment with lixisenatide or/and the pharmaceutically able salt
thereof, the patient has a 2 hours postprandial plasma glucose
concentration of at least 11.1 mmol/L or at least 12 mmol/L.
14. Lixisenatide or/and a pharmaceutically acceptable salt thereof, for use
ing to any one of the preceding items, wherein at the onset of
treatment with lixisenatide or/and the ceutically acceptable salt
thereof, the patient has a glucose excursion of at least 3 mmol/_,
n the e excursion is the difference of the 2 hours
postprandial plasma glucose concentration and plasma glucose
concentration 30 minutes prior to a meal test.
. _ixisenatide or/and a pharmaceutically acceptable salt thereof, for use
according to any one of the preceding items, wherein at the onset of
treatment with lixisenatide or/and the pharmaceutically acceptable salt
thereof, the patient has a HbA1c value of at least about 7 %, at least
about 7.5 %, at least about 8 %, at least about 8.5 %, at least about
8.65 %, or at least about 9 %.
16. natide or/and a pharmaceutically acceptable salt thereof, for use
according to any one of the preceding items, wherein at the onset of
treatment with lixisenatide or/and the pharmaceutically acceptable salt
thereof, the patient has a plasma glucagon level of at least 140 ng/L.
17. Lixisenatide or/and a pharmaceutically acceptable salt thereof, for use
according to any one of the preceding items, n at the onset of
treatment with lixisenatide or/and the pharmaceutically acceptable salt
thereof, the patient has a ide plasma concentration of at least
1.2 nmol/L.
18. Lixisenatide or/and a pharmaceutically acceptable salt thereof, for use
according to any one of the preceding items, wherein lixisenatide
or/and the pharmaceutically acceptable salt thereof is prepared for
parenteral administration.
19. Lixisenatide or/and a pharmaceutically acceptable salt thereof, for use
according to any one of the preceding items, wherein lixisenatide is
administered in a daily dose selected from the range of 5 pg to 10 pg.
.Lixisenatide or/and a pharmaceutically acceptable salt thereof
ing to any one of the preceding items, for use in the
improvement of glucose excursion, for use in the improvement of the
postprandial plasma glucose concentration, or/and for use in the
improvement of plasma glucagon concentration.
21.A pharmaceutical combination for use in pediatrics, said combination
comprising
(a) natide or/and a pharmaceutically acceptable salt thereof, and
(b) metformin or/and a ceutically acceptable salt thereof.
22.The pharmaceutical combination for use ing to item 21, wherein
lixisenatide or/and the pharmaceutically acceptable salt f is
ed for parenteral administration.
23.The ceutical combination for use according to item 21 or 22,
wherein metformin or/and the pharmaceutically able salt thereof
is prepared for oral administration.
24.The pharmaceutical ation for use according to any one of the
item 21 to 23, wherein the patient in need of the pediatric treatment
suffers from type 2 diabetes mellitus.
.The pharmaceutical combination according to any one of the item 21
to 24, for use in the improvement of glucose excursion, for use in the
improvement of the postprandial plasma glucose concentration, or/and
for use in the ement of plasma glucagon concentration.
26A method of pediatric treatment, said method comprising
administering to a patient in need of a pediatric treatment, lixisenatide
or/and a pharmaceutically acceptable salt thereof.
27.The method according to item 26, wherein natide or/and the
pharmaceutically acceptable salt thereof is prepared for parenteral
administration.
28.The method according to item 26 or 27, further sing
administering metformin or/and a ceutically acceptable salt
thereof to the patient.
29.The method according to item 28, wherein metformin or/and the
pharmaceutically acceptable salt thereof is prepared for oral
administration.
.The method according to any one of the items 26 to 29, wherein the
patient in need of a pediatric treatment suffers from type 2 diabetes
mellitus.
31.Use of natide or/and a pharmaceutically acceptable salt thereof,
for the manufacture of a medicament for use in pediatrics.
Example 1
A randomized, double-blind, placebo controlled trial to assess safety, tolerability,
pharmacokinetics and pharmacodynamics of lixisenatide in paediatric (10 — 17 years
old) and adult patients with type 2 es
A randomized, double-blind, placebo controlled trial to assess
safety, tolerability, cokinetics and codynamics of
lixisenatide in paediatric (10 - 17 years old) and adult patients
with type 2 diabetes.
lNVESTlGATOR/TRIAL LOCATION Multi—center
STUDY 0 BJ ECTIVE(S) Primary objective:
c To investigate the effects of a single subcutaneous
lixisenatide dose of 5 pg and 10 pg as compared to placebo
in reducing postprandial e (PPG) assessed as area
under the plasma glucose concentration curve (AUC) after a
standardized liquid meal (breakfast) in type 2 diabetic
paediatric population (10—17 years old) and adults as controls
ary objectives:
To evaluate in both paediatric and adult populations:
. pharmacokinetic parameters of lixisenatide in plasma after
single subcutaneous ascending doses
0 the maximum PPG excursion, and on the changes in insulin,
C—peptide and glucagon plasma concentrations following a
standardized breakfast
safety and tolerability
Phase I, multicenter, double—blind, randomized, placebo
controlled, single—dose, 3—period, 3-treatment, 6 sequence cross-
over study in paediatric and adult with type 2 diabetic patients
(see Section 6.1 )
The study is double blind with regard to active treatment versus
placebo. The study drug volume (i.e., dose of active drug at 5 pg
and 10 pg or matching o) is not blinded but placebo,
volumes matched to 5 pg and 10 pg in a ratio 1:1.
STUDY POPULATION
Inclusion criteria:
Main ion criteria: 0 Male and female patients with type 2 diabetes mellitus
(T2DM), as defined by WHO (fasting plasma glucose
27 mmol/l (126 mg/dl) or 2 hours postprandial plasma
glucose 211.1 mmol/l (200 ), diagnosed at least
3 months at the time of screening visit, with or without
min (stable dose for at least 4 weeks prior to
randomization)
o HbA1c 2 7% and S 10% at screening
o g C-peptide at screening > 0.6 ng/mL
a ve test for anti-islet cell antibodies (or insulinoma
associated protein (IA2)) and anti-glutamic acid
decarboxylase (GAD) autoantibodies
Paediatric population:
o Male and female 2 10 and < 18 years of age with at least 3
patients below 15 years of age and limited to 3 patients 2 16
years of age, BMI > 85th percentile for age and gender (body
weight > 50 kg)
Adult population:
0 Male and female patients a 18 and S 65 years of age and
with BMI > 25 kg/m2 and S 37 kg/m2
ion criteria:
0 Diabetes other than T2DM
0 Use of antihyperglycaemic nal product(s), other than
metformin
. History of unexplained pancreatitis
0 Personal or family history of ary thyroid cancer (MTC)
or genetic ions that predispose to MTC (eg, multiple
endocrine neoplasia syndromes)
0 Calcitonin 2 20pg/mL (5.9 pmol/L)at screening
Total expected number of patients: 12 paediatric patients and 12 adult patients with type 2 diabetic
patients
lNVESTIGATOR/TRIAL LOCATION Worldwide
STUDY TREATMENT(s)
Compound Dose Form Route of
nvestigational Medicinal Product(s) administration
Cormulation: natide 5 ug in solution for aneous
50 pL injection injection
100 ug/mL
Lixisenatide 10 ug in solution for subcutaneous
100 uL injection injection
100 ug/mL
Lixisenatide is supplied as a sterile aqueous solution for
subcutaneous (5.0.) ion in a 3-mL glass cartridge.
Placebo is supplied as 3—mL aqueous solution (in cartridge).
Both to be ed with the OptiClik® self—injector device.
Route(s) of administration: Thin needles will be used to minimize discomfort.
Dose regimen:
3 treatment periods each lasting 2 days. In each ent
period patients receive a subcutaneously injected single dose of
either 5 ug or 10 pg lixisenatide with 5 ug preceding the 10 pg
dose level or volume matched placebo (50 uL or 100 ML).
IMP will be administered in fasted conditions 30 min before a
standardized, liquid meal (breakfast).
Non lnvestigational Medicinal Product(s) NA
RIMARY ENDPOINT(S) AND MAIN codynamics:
ECONDARY ENDPOINT(S) primary endpoint:
a Plasma glucose: GLU-AUCO:30-4:30h2 area under the curve for
plasma glucose concentration time profile calculated from
time of rdized breakfast start (30 min after IMP
injection=T0.5 until 4 hours later T4.5 subtracting the pre-
meal value T0.5h
Secondary nts:
0 Post Prandial Glucose excursion (PPG0230—430h): maximum
change from time of standardized breakfast start (30 min after
IMP injection=TO.5) until 4 hour later (T45) in postprandial
plasma glucose
o Insulin, ide and glucagon (AUCOflMflOh) : area under
the curve for insulin, C-peptide and on concentrations
time profiles from time of standardized breakfast start (30 min
after lMP injection=TO.5) until 4 hours later (T45)
o Pharmacokinetics: lixisenatide plasma concentration, PK
parameters (Cmax, Tmax, t, AUG)
0 : clinical laboratory, ECG parameters, vital signs, local
tolerability and e events
ASSESSMENT SC Pharmacodynamics:
Blood samples will be taken immediately prior to IMP injection
min before a standardized breakfast, then just prior to the
standardized breakfast, and at 30, 60, 90, 120, 180, and 240 min
thereon for glucose assessments on Day 10f each of the 3
treatment periods for GLU-AUCosmsm.
For secondary endpoints including safety refer to study and
period flow charts.
STATISTICAL CONSIDERATIONS Both overs will be ed separately. Results will be
compared between the two populations descriptively.
Pharmacodynamics:
Analysis of population:
The pharmacodynamic population will consist of patients
randomized and d and having blood samples for reliable
evaluation.
Within each cross—over, the analyses of the primary
pharmacodynamic nt will be performed based on the
pharmacodynamic population. GIU—AUCO:30-4:30h will be analyzed
using a linear mixed model with sequence, period, and treatment
effect and patient-within-sequence as random effect, and the
T05 h plasma e concentration as covariate. The least
square mean differences between treatment groups and the
corresponding 90% confidence interval (CI) will be calculated
within the linear mixed model framework. A significance level of
p< 0.05 will be used.
Secondary codynamic parameters will be analyzed using
the same statistical model as described above with the
corresponding T0.5 h values as covariates.
Pharmacokinetics:
Log- transformed lixisenatide pharmacokinetic parameters
Cmax, AUClast, and AUC will be analyzed using a linear mixed
effect model with fixed terms for sequence, ‘ treatment and
a random term for a patient-within-sequence. Estimates and 90%
CI for the geometric mean ratio of 5 pg lixisenatide and versus
lopg lixisenatide will be obtained by computing estimate and
90% CI for the difference between treatment means within the
linear mixed effects model framework, and then converting to
ratio by the antilog transformation to the original scale.
Safety:
The safety analysis will be based on the review of the individual
values (clinically significant alities) and descriptive
statistics (summary tables and plots if appropriate) by treatment.
Treatment-emergent adverse events ) classified in
system-organ classes and preferred terms then summarized by
number and percentage of patients and number of TEAEs.
Individual clinical laboratory data, vital sign. and ECG data will
be listed and flagged for potentially ally significant abnor-
malities (PCSAs) and for lower and upper clinical laboratory
limits. Frequency of patients with alities and with PCSAs
will be summarized for each type of parameter by treatment.
DURATION OF STUDY PERIOD Screening: D -30 to D -2 prior to inclusion with a minimal period
(per patient) of 25 days
ent Period: 3 Periods each lasting 1 day (up to 2 days if
there is an institutionalization on 0-1 evening ) (discharge in the
oon of Di of each period)
E08: 1 to 6 days after last dosing (DZ to 07 after Period 3)
Total duration: 4 to 7 weeks
1. FLOW CHARTS
1.1 GRAPHICAL STUDY DESIGN
The graphical study design of Example 1 is shown in Figure 1.
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3 LIST OF ABBREVIATIONS
Pharmacokinetic parameter definitions are provided in Section 9.3.5.
AB: Adverse event
ARAC: Allergic Reaction Assessment Committee
ARAC: ic Reaction ment Committee
BMI: Body mass index
CRF: Case Report Form
CV: cardiovascular
ECG: , Electrocardiogram
FSH: Follicle— stimulating hormone
GAD: Glutamic acid decarboxylase
GLP—l; Glucagon—like e— 1
1A2: Insulinoma ated protein
IMP: Investigational Medicinal Product
lXRS: Interactive Voice and Web Response System
MTC: Medullary thyroid cancer
PPG: Postprandal glucose
SD: standard deviation
SEM: standard error of the mean
SU: Sulfonylurea
TZDM: Type 2 diabetes mellitus
4 INTRODUCTION AND RATIONAL IIII
4.1 INTRODUCTION
Lixisenatide is an exendin analog with tic activity on on~like peptide—1(GLP—1)
or. The principal eutic potential of lixisenatide to lower blood glucose in T2DM
patients has been established in clinical studies. Sanofi—aventis is ting global registration
submissions including a Marketing Authorization Application (lVIAA) sion by Centralized
Procedure. in the European Union. A total of 42 clinical studies were conducted or are ongoing,
ing 24 Phase 1 studies, 5 Phase 2 studies and 13 Phase 3 studies.
A large Phase 3 program (the “GetGoal” clinical trial m) ted throughout 48
countries and approximately 900 sites have been initiated to assess the safety and cy of
lixisenatide. The l program has enrolled more than 4500 adult patients with T2DM (more
than 2700 of them receiving lixisenatide). This program includes 10 studies with a duration
ranging fiom 12 to more than 76 weeks. In addition to the GetGoal program, one Phase 3b study
has been completed and a second Phase 3b study and a large placebo—controlled study to evaluate
cardiovascular outcomes during treatment with lixisenatide are ongoing.
In the phase 3 studies that have been completed and ed so far [AVEOOlO Clinical
Investigator’s rochure, latest version]:
o The y of lixisenatide on glycemic control was confirmed
o Lixisenatide was safe and well tolerated:
- As expected for a GLP—1 receptor agonist the most frequent adverse events were
gastrointestinal in nature, mainly nausea, with low rates of vomiting and diarrhea.
Most of these events were transient, mild to moderate in intensity and resolved
spontaneously without sequelae.
— Reported ycemia events were mostly mild to moderate in intensity. The
incidence was similar to placebo when lixisenatide was used in monotherapy. In the
EFC10887 study, in which 70% of the patients were receiving a background ent
with basal insulin in combination with a sulfonylurea (SU), the percentage of patients
with symptomatic hypoglycemia was higher with lixisenatide (42.9%) versus placebo
(23.6%). r, in the. subgroup of patients not treated with a SU, the incidence of
patients with symptomatic hypoglycemia was similar in the placebo and lixisenatide
groups (32.6% with lixisenatide and 28.3% with placebo).
- In a comparative study versus exenatide (10 ug twice daily), significantly fewer
patients treated with lixisenatide 20 ug once daily experienced symptomatic
hypoglycemia events (5.0% in the lixisenatide arm vs 14.6% in the exenatide arm).
Lixisenatide also offered better gastrointestinal tolerability with fewer patients
experiencing nausea or vomiting.
There have been no paediatric clinical trials conducted as of today with lixisenatide.
More detailed information is provided in the Clinical lnvestigator’s Brochure (1).
4.2 RATIONALE
4.2.1 Study rationale
Until recently, TZDM was almost exclusively an adult disease. ding with the sing
prevalence of y in children, the incidence of TZDM in children and cents has
markedly increased to the point that it accounts for as many as one third of all the new cases of
TZDM diagnosed in adolescent.
en/adolescents with TZDM are usually diagnosed over the age of 10 years, in middle to late
puberty, when due to physiological changes in the GH/IGF—l axis insulin ance develops.
Like in adults, the incidence of type 2 diabetes in children/adolescents-is highest in some ethnic
populations (e, g. American Indians, African American, Asian/pacific Islander and Hispanics) (2).
Diabetes is a therapeutic area for which the aEMA Paediatric Working Party considers that
research and development of medicinal ts for en should be performed. Type 2
diabetes may have an earlier and more aggressive course in paediatric patients; therefore, they are
likely to be at higher risk for ping complications and need the best possible glycemic
control in the early stage of their disease.
As of today, mettOrmrn is commonly ed as the first pharmacotherapy in managing TZDM in
children above 10 years and in adolescent in addition to diet and exercise (5, 6, 7). This drug has
indeed shown to be safe and effective in randomized controlled trials d out in this population
(8) Nevertheless, in many patients, progression is rapid, and control of hyperglycaemia may
become insufficient even at maximal tolerated doses of metformin.
Therefore, we propose to evaluate pharmacokinetics, pharmacodynamics and safety / efficacy of
lixisenatide in a paediatn'c population.
4.2.2 Population to be studied
The population to be studied comprises patients with diabetes mellitus type 2 on diet and exercise,
With or Without a stabletreatment of metformin, with an
age of 10 to 17 years for the paediatric
populationhand 18 to 65 years for the adult population. BMI will be either > 25 kg/m2 (adults) or
BMI > 85 tile for age and gender (paediatric population).
4.2.3 Design rationale and risk assessment
The cross—over, blinded and randomized design allows enhancing the ivity to assess true
effects by analyzing for differences between lixisenatide and placebo within each participant,
while avoiding influence of between patient variability.
Subjects with diabetes mellitus type 2 with a background metformin therapy (with stable dose
:2 10 % for at least 4 weeks prior to randomization) can be included and their metformin therapy
will not be changed throughout the study. As insulin releasing treatments (e. g. sulfonylureas)
require long wash out periods, subjects on insulin agogues will not be asked to participate.
A dose of 10 ug results in mean peak plasma concentrations of about 50 pg/mL about 2 hours
after injection (1).
In a phase I study, single doses of 1ixisenatide from 3 ug lower PPG in TZDM patients but at least
ug lixisenatide caused a clear ation of the rise in plasma glucose induced by a
standardized liquid meal stered 1 hour after dosing (Study AV 4 0010A/01—016, see details
in the Clinical Investigator’s brochure (1)).
The elimination half life for 1iXisenatide administered to adult TZDM patients is around 3 to 4
hours. The quick disappearance of lixisenatide from the circulation when absorption is te
enables short wash—out periods of 1 day. As a consequence the end—of—study visit can occur within
a week.
Lixisenatide has been studied in subjects with type 2 diabetes mellitus, and has a record of safety
and bility which allow further single dose ments. The most common e effects
upon single dose administration in patients with type 2 diabetes mellitus were headache, nausea,
and injection site reactions. As GLP—1 mediated insulin release is depending on plasma glucose
concentration, and decreases to absence with lower glucose concentration, the risk for
hypoglycemia is very limited.
Hospitalization and close supervision of participants by professional staff members in the research
unit on Day 1 ensure maximum protection against uences of unforeseen adverse .
4.2.4 Dose, Regimen, and Treatment on Rationale
The maximum dose evaluated in the g phase 111 program is 20 pg QD with a preceding
starting dose of 10 ug. In this planned study (PKD11475) the dose of 5 ug corresponds to 50 % of
the starting dose in adults. Randomization will assure that in any patient the first lixisenatide
treatment will be at a dose level of 5 ug.
Since pharmacodynamic effects of lixisenatide such as lowering ofPPG after a test meal could be
demonstrated even after the very first dose, a single—dose study is considered appropriate to
compare pharmacodynamic effects between adult and paediatric populations.
4.2.5 Specific parameters rationale
1 Postprandial plasma glucose after a standardized breakfast
natide is known to exert glucoregulatory effects, including enhancement of glucose~
dependent insulin secretion, reduction of glucagon secretion, reduction of food intake, and
slowing of gastric emptying. After a meal, the gastrointestinal tract regulates the rate at which
carbohydrate and nutrients are absorbed and it is known to release regulatory peptides that
ate insulin secretion fiom pancreas. Although the rate of c emptying does not affect
insulin secretion directly, it regulates the delivery of nts to the small intestine and, therefore,
has a major impact on the, timing and ude of the blood e excursion, thereby
modulating insulin secretion indirectly.
Therefore, beside the assessment of postprandial plasma glucose (primary endpoint) after a
standardized meal, study ives include the evaluation of the effects of lixisenatide on
secretion of insulin, glucagon and C—peptide.
4.2.5.2 Specific safety parameters
Amylase and lipase: Because some cases of acute pancreatitis have been reported with marketed
GLP—l agonists (7), patients with amylase and lipase above 3 times the upper limit of normal at
screening will be excluded from the study, and amylase and lipase will be monitored.
STUDY OBJECTIVES
.1 PRIMARY
0 To investigate the effects of a single subcutaneous lixisenatide dose of 5 ug and 10 ng as
compared to o in reducing postprandial glucose (PPG) assessed as area under the
plasma glucose concentration curve (AUC) after a standardized liquid meal (breakfast) in
type 2 diabetic paediatric population (10-17 years old) and adults as controls.
.2 SECONDARY
To te in both paediatric and adult populations:
0 Pharmacokinetic parameters of lixisenatide in plasma after single subcutaneous ascending
doses
0 The maximum PPG ion, and on the changes in insulin, sulin, C—peptide and
glucagon plasma concentrations following a standardized breakfast
0 Safety and tolerability.
6 STUDY DESIGN
6.1 DESCRIP“ION OF THE PROTOCOL
Graphical study design/flow charts — please refer to flow charts in Section 1.
This is a phase I, multicenter, double-blind, randomized, placebo controlled, single-dose, 3~
, 3—treatment, 6 sequence cross-over study in paediatric and adult with type 2 diabetic
patients.
The study is double blind with regard to active treatment versus placebo. The study drug volume
(i.e., dose of active drug at 5 pg and 10 pg or matching placebo) is not blinded.
There are 3 treatment periods l~7 days apart, each period lasting only one day (Day 1) with an
early start in the morning up to the beginning of the afternoon. However, ing to the
possibilities of the igational site and at the ience of patient, the period may start on
ay —1 (afternoon/evening) for all examinations and tests to be done before the IMP
administration and before the standardized breakfast (liquid meal). After the dinner on Day—1,
patients should stay in fasted conditions for at least 8 hours (food and drink are not allowed
except water) up to the standardized breakfast test meal.
In each treatment period, the patients Will receive a subcutaneously injected single dose of either 5
pg or 10 pg natide With 5 pg preceding the 10 pg dose level or volume matched placebo (50
pL or 100 pL) before a standardized test meal.
There are 6 sequences with 3 treatment s, lixisenatide 5 pg, lixisenatide 10 pg, placebo—
controlled group (volume of 50 pL or 100 pL) as described in Table l
Table 1 - ization schedule per study population (children/adults)
Sequence Number Period 1 Period 2 Period 3
of Treatment Treatment ent
patients
1 2 o
(100 pL)
Le. 10 Units*
2 2 Placebo
(50 lJL)
i.e. 5 Units*
3 2 Placebo
(50 lJL)
i.e. 5 Units*
4 2 Placebo
(100 pL)
i.e. 10 Units*
2 Placebo
(50 IJL)
La 5 Units*
6 2 o
(100 pL)
Le. 10 Units*
* Number of Units indicated in the Opticlick® device
6.1.1 Screening period
Overall, the screening period can start on Day —30 up Day —2 before the start of the treatment
period. However, laboratory blood sampling must be performed from Day ~30 to Day —25 to get .
the results (ie, A and anti—1A2 antibodies) before Day 1.
Patients with type 2 diabetes are screened firstly from Day —30 up to Day -2 (screening phase) and
those meeting all inclusion criteria are candidates for a final selection on Day 1 (or Day —1) at the
study site (inclusion phase). Patients to be enrolled in this study are patients with type 2 diabetes
diagnosed at least 1 year for adults and at least 3 months for paediatric population before the time of
screening visit, and patients who are not treated with antihyperglycaemic medicinal product other
than metformin with a stable dose(:t10%)'for at least 4 weeks prior to randomization (Day 1) (see
Section 7.2).
The first measurements of HbAlc, plasma glucose and C—peptide must be obtained for checking
the inclusion criteria of the patients.
Patients meeting all the inclusion criteria and presenting no exclusion criteria are le for the
treatment period starting on Day 1.
6.1.2 Treatment period
At the convenience of ts and according to the ilities of the igational centre,
patient may be institutionalized in the afternoon or evening on Day —l up to the beginning of the
oon on Day 1.
After the dinner on Day—1 of each treatment period, patients must fast for at least 8 hours (food
and drink are not allowed except water) prior to the IMP administration on Day 1 of each
ent period.
On Day 1 of the treatment period 1, patient will undergo the final inclusion examinations and
ne safety assessments will be evaluated prior to the first D/IP administration and before the
standardized breakfast test meal.
On Day 10f each Period 1, patients will be randomly assigned to one of the six treatment
sequences consisting of a od cross—over, separated by washout periods of at least one day up
to 7 days n each period (see details Section 6.1.1).
An ‘ dent Person’ will be ed at the investigational centre solely for the
administration of NIP, to prevent un-blinding of the clinical team during the conduct of the
study. However, activities which are not prone to any bias should be allowed, e.g. data entry of
forms filled in by the clinical team, checking position of ECG electrodes etc.
One single SC dose of the following treatment will be administered at each period of treatment
0 One 5 ug dose of liXisenatide (50 uL, 5 Units indicated on the Opticlick®)
0 One 10 ug dose of lixisenatide (100 uL, 10 Units indicated on the Opticlick®)
o 50 uL placebo solution (5 Units indicated on the Opticlick®) or
100 uL placebo solution (10 Units indicated on the Opticlick®)
At each treatment period, patients will undergo an 8—point plasma glucose profile, a 7—point
profile of insulin, C—peptide and glucagon, and a 8—point pharmacokinetic profile up to 6.5h after
the MP administration as well as safety assessments before leaving the CR0 or investigational
centre. ‘
6.1.3 —study visit
The end of study visit should be scheduled on 32 to D7 of the Period 3.
Concerning the procedure to be followed in case of premature permanent discontinuation of
treatment with investigational product, please refer to Section 11 .
6.2 DURATION OF STUDY PARTICIPATION
6.2.1 Duration of study participation for each patient
0 Screening duration: 25 (blood sampling for autoantibodies testing) to 30 days
0 3 ent period(s): only 1 day (1 treatment day) to 2 days (if patient will arrive on Day
-1) each
a Wash—out period between each period: at least 1 day up to 7 days
0 End of study: 1 to 6 days after last dosing (D2 to D7 after Period 3)
a Total study duration from screening per t: 4 to 7 weeks at maximum
However, patient ipation could be prolonged in case of safety concerns (see
n10.3.3.l).
6.2.2 Determination of end of cIinicaI triaI (all patients)
The end of the clinical trial is defined as the day the last patient completed his/her last visit
planned in the protocol.
6.3 STUDY COMMITTEES
6.3.1 Allergic Reaction Assessment Committee
Since lixisenatide is a peptide that may potentially generate allergic reactions, an Allergic
Reaction Assessment Committee (ARAC) has been setup. The ARAC is a committee of experts
in the field of allergy, independent from the Sponsor and the igators, implemented to assess
allergic reactions or allergic—like reactions that may occur during the study. The mission of the
ARAC is to adjudicate, in a timely manner, all allergic, or possible allergic events. The ARAC is
blinded regarding the study treatment.
mes transient, injection site reactions, irritant in nature may occur, requiring no
intervention and being of dubious significance. These ons would not be considered to be
allergic reactions.
Virtually all symptoms listed on the CR 4‘ “Allergic Reaction Complementary Form” are possible
adverse reactions that may be allergic in nature and may need to be addressed after medical
nt, excluding another etiology than allergy.
e events that may cOnstitute an allergic reaction (e.g., generalized itch, nasal itch, swelling
at injection site, flushing, hives, swelling at lips, eyes, face, tongue, hands, feet, lump in throat,
difficulty to w, hoarseness, change in pitch of voice, incapacity to speak, ng, chest
tightness, stridor, etc) should be considered to be reported on the Allergic Reaction
Complementary Form.
Adverse events that are obviously not of allergic origin (e. g., local injection site reactions) should
not be ed on the Allergic Reaction Complementary Form.
The ARAC reviews the reported cases and determines the nature of the events, confirms the
allergic nature or alternative diagnosis based on the information reported by the igator. A
detailed charter describes the ARAC procedures.
7 SELECTION OF PATIENTS
7.1 NUMBER OF PATIENTS PLANNED
Twelve (12) paediatric patients and 12 adult diabetic patients are to be enrolled for final
Pharmacodynamics evaluation.
7.2 INCLUSION CRITERIA
Patients meeting all of the following criteria will be considered for enrollment into the study:
Demography
101. Age eligibility for tric population: 2 10 years and <18 years with at least 3 patients
below 15 years and no more than 3 patients aged between 16 and 18 years (see below in
Table 2)
Table 2 — Subset definition for paediatric population
Age range ) Number of paediatric patients (n=12)
Age range 2 10 3 to 10
and <15
Age range 2 15 l to 8
and < 16
Age range 2 16 l to 3
and <18
Age eligibility for adults: 2 18 and S 65 years.
I 02. BMI > 85th percentile for age and gender in children, body weight > 50 kg dix A);
1 BMI > 25 kg/m2 and s 37 kg/m2 for adults
Health status
Male and female patients with type 2 diabetes us, as defined by WHO (fasting plasma
glucose 27 mmol/l (126 mg/dl) or 2 hours postprandial plasma glucose 211.1 mmol/I (200 mg/dl)),
diagnosed for at least 1 year for adults and at least 3 months for paediatric population at the time of
ing visit, with Or without metformin (stable dose i10% for at least 4 weeks prior to
randomization)
I 04. HbAlc 2 7% and E 10% at screening
I 05. Fasting C—peptide at screening > 0.6 ng/mL
I 06. ve test for anti—inSulinoma associated protein (1A2) and anti—glutamic acid
decarboxylase (GAD) autoantibodies
I 07. Menstruating females must have a regnancy (serum beta HCG) test for inclusion
(Tanner Stage 2 3)
I 08. Women of childbearing potential (including ‘seirualxactivev girls).rnust_use a double
ceptive method throughout the study asjudgedby themvestigator, except if she has
undergone sterilization at least 3 months prior to the time of screening or is
postmenopausal. The accepted double contraception methods include use of a highly
effective method of birth control (intrauterine device or hormonal contraception) in
addition to one of the following contraceptive options: (1) condom; (2) diaphragm or
cervical/vault cap; (3) spermicide (CPMP/ICH/286/95, modification)
Note: Menopause is defined as being over 60 years of age, or between 45 and 60 years of
age and being amenorrheic for at least 2 years with plasma FSH level > 30 UI/L.
Regulations
I 09. Adult patient having given written informed consent prior to undertaking any study-related
procedure and for miner’s, provision of Informed Consent Form signed by the t’s
parent(s)/legal representative. In addition, provision of Assent Form signed by minor
patient or Informed Consent Form signed by emancipated or mature minors (defined by
local lows)
I 10. Covered by a health insurance system where applicable, and/or in compliance with the
recommendations of the al laws in force relating to biomedical research. (to be
adapted if needed, country c)
I 11. Not under any administrative or legal ision.
7.3 EXCLUSION CRITERIA
7.3.1 Echusion criteria related to study methodoIogy
E 01. If female, pregnancy (defined as positive urinary ncy test), breast—feeding
E 02. Diabetes other than type 2 diabetes
E 03. History of metabolic acidosis, including diabetic idosis within 1 year prior to
screening
E 04. Hemoglobinopathy or hemolytic anemia
E 05. History of dial infarction, stroke, or heart failure requiring hospitalization within 6
months prior to the time of screening, y or ce of clinically significant diabetic
retinopathy, history or ce of macular edema likely to require laser treatment within
the study period
, 06. Cardiovascular, hepatic, neurological, endocrine disease, active malignant tumor or other
major systemic disease or patients with short life expectancy making implementation of
the protocol or interpretation of the study results difficult (euthyroid patients on
replacement therapy will be included if the dosage of thyroxin is stable for at least three
months prior to screening Visit)
E 07. For adults, uncontrolled or inadequately controlled hypertension at the time of screening
with a g ic or lic blood pressure > 160 mmHg or > 95 man,
respectively
108. For children, abnormal blood pressure levels greater or equal to 90th percentile adjusted
for age, gender and height percentile (Appendix B)
'3 O9. Positive test for insulinoma associated protein (1A2) and ic acid decarboxylase
(G )) autoantibodies
E10. Any clinically significant abnormality fied on physical examination, laboratory tests
or vital signs at the time of screening that in the judgment of the investigator or any sub
investigator would preclude safe completion of the study
E11. Receipt ofblood or plasma products within 3 months prior to the time of screening
*1 12. igator or any sub investigator, pharmacist, study coordinator, other study staff or
relative thereof ly involved in the conduct of the protocol
iii 13. Patients considered by the investigator or any sub investigator as inappropriate for this
study for any reason (e.g. impossibility to meet specific protocol requirements, such as
scheduled visits, being able to do self—inj ections, etc)
E14. Use of other oral or injectable antidiabetic or hypoglycemic agents other than metformin
(e.g., alpha glucosidase inhibitor, exenatide, DPP—IV inhibitors, insulin etc.) within 3
months prior to the time of screening
E 15. Use of systemic glucocorticoids (excluding topical application or inhaled forms) for one
week or more within 3 months prior to the time of screening
.2 16. For children, known allergy to local etics (e. g., Emla® Elamax® cream
, , Ethyl
Chloride)
417. Likelihood of requiring treatment during the screening phase and treatment phase with
drugs not permitted by the clinical study protocol
* 18. Use of any investigational drug within 3 months prior to screening
7.3.2 Exclusion criteria related to the current knowledge of iixisenatide and/or metformin
Exclusion criteria related to lixisenatide:
E 19. Clinically nt y of gastrointestinal disease associated with prolonged nausea and
vomiting, including, but not limited to gastroparesis and gastroesophageal reflux disease
requiring medical treatment, within 6 months prior to the time of screening
.LiJ 20. Any previous treatment with lixisenatide
E21. Allergic on to any GLP—l st in the past (eg. exenatide, liraglutide) or to
metacresol
E 22. History of unexplained pancreatitis, chronic pancreatitis, pancreatectomy, stomach/gastric
surgery, inflammatory bowel disease
* 23. Personal or family history of medullary thyroid cancer (MTC) or c conditions that
predispose to MTC (e.g., le endocrine neoplasia syndromes)
E 24. Known y of drug or alcohol abuse within 6 months prior to the time of screening
E 25. Laboratory findings at the time of screening:
In adults
— ALT > 3 times the upper limit of the normal laboratory range
— Total bilirubin: > 1.5 times the upper limit of the normal laboratory range (except in
case of Gilbert’s syndrome)
— Hemoglobin < 11 g/dL and/or neutrophils < 1,500/mm3 and/or
platelets < 100,000/mm3
In paediatrics:
— ElevatiOnsin blood tests of renal (serum creatinine > 1.0 mg/dL) and]or liver (ALT,
AST and/or bilirubin) >2 times the upper limit of normal (ULN) for age.
— Hemoglobin < 11 g/dL and/or neutrophils < 1,500/mm3 and/or
platelets < 100,000/mm3
In /paediatrics:
— Calcitonin Z 20 pg/mL
— Amylase and/or lipase above 3 times the upper limit
— Positive result on any of the following tests: hepatitis B e (HBs Ag) antigen,
anti—hepatitis C virus (anti—HCV) antibodies, anti—human immunodeficiency virus 1
and 2 antibodies (anti—HIV 1 and anti HIV2 Ab).
E 26. Positive alcohol test.
Exclusion criteria related to the background therapy (i.e. metformin):
E 27. Renal ment in adult defined with creatinine clearance < 60 mL/min using the
Cockcroft— Gault Formula (see Appendix C)
A patient may not be enrolled in this study more than once (i.e. randomized twice).
8 TREATM ENTS
8.1 DIET AND EXERCISE
Lifestyle and diet therapy provided before the time of screening is to be continued during the
study in a similar manner. Dietary and lifestyle counseling should be given by a Registered
Dietitian or other qualified nutrition professional (eg, diabetic educator, etc) and should be
consistent with the recommendations of international or local guidelines (with regard to the
distribution of calories among carbohydrates, proteins, and fats, exercises, etc) for type 2 ic
patients.
At each of 3 treatment periods, adult and paediatric ts will ingest a standardized meal test,
min. after the IMP administration to assess fasting and post—prandial glucose.
For adults and paediatrics, the standardized breakfast meal is a 400 mL drink (Ensure Plus®
Drink, Abbott). It contains 600 kcal and is composed of 53.8% carbohydrate, 16.7% protein and
29.5% fat (see details in Appendix D).
The composition and the quantity of the standardized meal must be identical at each treatment
period.
The standardized meal for all adult and paediatric ts should be ed within a 15 —
minute period.
8.2 INVESTIGATIONAL NAL DRODUCT
8.2.1 Lixisenatidelplacebo
o Lixisenatide pharmaceutical form: Sterile aqueous solution for subcutaneous (s.c.)
injection in a 3-mL glass cartridge, containing the active ingredient 300 ug (i.e. 100
, ol, sodium acetate trihydrate, methionine, meta—cresol, HCL/NaOH and
water for injection.
0 Control drug: matching o, s solution for subcutaneous injection.
0 Route and method of administration: Subcutaneous injection using the pen-type injector
(OptiClik®). Lixisenatide injection will be performed in the clinical unit by a person
experienced with s.c. Administration will be by deep s.c., alternating n the left and
right anterolateral and the left/right posterolateral nal walls. Within a given area,
location should be changed (rotated) at each time to prevent injection site skin reaction.
0 Dose of the lixisenatide investigational medicinal product (MP) per administration: Once
injection in the morning of Day 1 of each period
0 Timing: lixisenatide will be stered at around 07:30 in the morning in fasted
condition (breakfast will be taken 30 minutes after the injection)
o For the correct dosing of Lixisenatide and placebo volume, the units of the ik® pen
have to be settled as described in Table l.
o Lixisenatide IMP will be provided by the sponsor.
8.2.2 Description of the or device OptiClik®
A pen—type injector (OptiClik®) with Optifine 8TM (8 mm X31G) needles from Ypsomed are
provided to each igational centre for the injection of liXisenatide or its o, specifically
labeled for the use of the study (“lixisenatide”) in accordance with applicable regulatory
requirements. Handling procedure of the pen-type in]ector and administration technique of
natideis providedin a specific manual.
Pen—device or cartridges related issues (malfunctions) should be reported to the sponsor or the
Wharehouse by the means of a procedure on product technical complaint (PTC) forms, which is
described in a separate manual.
8.2.3 Dosage schedule
According to the randomization schedule (Section 6.1) the lixisenatide dose per injection or the
placebo volume (Day 1) is to be administered 30 minutes before breakfast and for the correct
dosing, the units of the ik® pen will be administered as follows:
0 5 pg lixisenatide = 05 Units indicated on OptiClik® (= 50 uL)
o 10 pg liXisenatide = 10 Units indicated on OptiClik® (= 100 11L)
0 50 uL (0.05 mL) placebo = 05 Units ted on OptiClik®
o 100 uL (0.10 mL) placebo = 10 Units indicated on OptiClik®
8.3 NONINVESTIGATIONAL M EDICINAL PRODUCTS
The possible background therapy (ie, metformin only) is not considered as non investigational
medicinal product.
8.4 DESCRIPTION OF BLINDING METHODS
The lixisenatide investigational t and o are indistinguishable.
The treatment allocation (on Day 1 of each period) will be -blinded and will be done
according to a randomization list. The treatment codes will be generated according to sanofi-
aventis procedure.
For blinding purposes the on—site administration of natide or its o will therefore be
performed by an independent person who is not a member of the clinical study team at the CRO
or investigational site. This “unblinded” person should not be involved in activities which could
be biased by the knowledge of the treatment assignment (e.g. A3 assessments, access to
pharmacodynamic data). However, activities which are not prone to any bias should be allowed,
e. g. blood sampling, vital signs, ECG recording, etc).
OptiClik® pens will be loaded with either lixisenatide or placebo containing cartridges on—site.
Furthermore lixisenatide or its placebo will be administered at different doses resulting also in
different volumes. The volume to be injected (see Section 8.2.3) must be set on the ik®
pen and is visible to the “unblinded” person responsible for the injection. The “unblinded” person
responsible for administration will set the volume to be injected on the OptiClik® pen shortly
before injection.
The ARAC members will review and cate allergic ons or allergic-like reactions in a
blinded manner.
s collected during the lixisenatide treatment periods only will be analyzed for plasma
trations. Therefore the bioanalyst(s) at sanofi-aventis responsible for the determination of
lixisenatide plasma concentrations will be ded to the randomization code. The results of
these assessments will not be ed to the study nel when the study is ongoing except
for urgent safety issues.
8.5 METHOD OF ASSIGNING PATIENTS TO TREATMENT GROUP
At the screening visit, the procedure for assigning of patient number will start only after the
provision of the written informed consent by the adult patients to be enrolled or the provision of
Informed Consent Form signed by the patient's (s)/lega1 representative of the patient to be
enrolled and also the ion of Assent Form or Informed Consent Form signed by the
paediatric patient (see inclusion criteria 109).
Then, the investigator or designee has to contact the IXRS and has to e some information to
the system (e.g.: date of birth/age of the patient, background oral or inj ectable antidiabetic drugs
other than metformin: yes/no, ..). The Interactive Voice and Web Response System (lXRS) will
ensure that the enrolment for children Wi11be controlled in respect of the obligations to recruit at
least 3 paediatric patients between 10 and 15 years, at least 1 paediatric patient between 15 and 16
years, and no more than 3 paediatric patients above 16 years (inclusion criterion 1 0]).
If criteria are in agreement with the above ent, IXRS will allocate an incremental patient
number ing to the chronological order of inclusion. The patient number will be a 9—digit
patient number combined of 3 ents Ol—XXX), of which the first 3 digits are the
country number (e.g.: for Germany: 276; Mexico: 484; South Africa: 710; UK: 826; US site: 840)
the middle 3 digits are the site number (starting with 001) and the last 3 digits are the patient
incremental number within the site. The patient number remains unchanged during the study and
allows the patient to be identified during the whole study.
On Day 1 of Period 1, the investigator or the designee will contact lXRS and has to provide the
following information to the system: patient number, age, and negative test for anti—GAD and
anti—1A2 antibodies: . If the patient complies with all inclusion/exclusion criteria, this
patient will be considered as randomized. A randomized patient is defined as a patient who is
registered, who complies with all inclusion/exclusion criteria and assigned to his /her treatment kit
number.
The randomization treatment kit number list is ted centrally by sanofi. The randomization
list will be provided by sanofr to the IXRS vendor. The allocation of the treatment kit number to
the patients will be performed by IXRS. Patients will e 1MP according to their
randomization treatment kit number.
The randomization ratio will be 1:1 for the 2 lixisenatide dose levels (5 pg and 10 pg) and 1:1 for
the placebo volumes (50 pL and 100 pL) and 2:1 for each lixisenatide dose versus each placebo
volume.
The administration order of the 3 study drugs (5 pg lixisenatide, 10 pg natide, 100 pL
placebo or 50 pL placebo) as defined by the randomization plan is defined using the centralized
treatment allocation system (IXRS) on Day 1 of the first period after the safety assessments prior
to the first IMP ion. The “independent person” (see Section 6.1.2), will administer the first
study treatment on Day 1 at each study period in the respect of the written information received
by IXRS. The CRO or the investigational site will call IXRS at the end of the last .
Potential replacement patients will have a different identification number (ie, 500 + the number of
replaced patients). Each patient will receive the same treatment sequence (the same order of the
treatment as the withdrawn patient.
Notes: The randomization of a patient should occur as close as possible to the first administration
ofthe IMP. Baseline parameters will be the parameters available the closest before the
randomization.
8.6 PACKAGING AND LABELING
Cartridges (ie, disposable part of OptiClik®) will be used once at each ent period and are
packaged in multiple treatment boxes. Each Box per patient will contain 3 cartridges for injections
(1 cartridge to be used per ent period for a single administration).
A ent box containing three cartridges is shown in Figure 2.
Dispensation scheme is described in the study flow chart (please refer to Section 1.3 and n
1.4 )
RECTIFIED SHEET (RULE 91) ISA/EP
The content of the ng is in accordance with the local regulatory specifications and
requirements.
8.7 STORAGE CONDITIONS AND SHEL‘: LIFE
All study drug boxes will be stored in an appropriate safe and locked room under the
sibility of the Investigator or other authorized persons (e.g., pharmacists), and must be
accessible only to authorized personnel.
Prior to the first use, the investigational products (cartridges) have to be stored between +2°C and
+8°C (between 36°F and 46°F), protected from light, and must not be frozen.
When used, the cartridges should be kept. At each treatment period on Day 1, a new cartridge
should be replaced. One OptiClik® pen per patient will be used for the 3 single injections.
8.8 RANDOMIZATION CODE BREAKING DURING IH- SIUDY
Please refer to Section 9.5.
In case of an adverse event (AS), the code will not be broken except in the stances when
knowledge of the IMP is essential for treating the t. prossible, a contact should be initiated
with the Sponsor’s monitoring team or medical expert before breaking the code.
No code-breaking material is provided to the igators. For each patient, code—breaking could
be performed by the investigator calling the IXRS system.
The code-breaking material is also kept at the entity responsible for the "24 hour alert system";
but this system should be used in very exceptional cases only (i.e., unavailability of IXRS system
or ity to contact investigator and/or site staff). The igators will be ed by the
sanofi—aventis clinical ring team about the availability of the local code—breaking material.
A patient card, including the relevant “24 hour alert system” telephone number will be provided to
every t who participates in the study.
If the blind is broken, the Investigator will document the date of opening and reason for code
breaking in source data.
In case the blind code is broken, the treatment with the lixisenatide (or placebo) investigational
product should be permanently discontinued, and the patient handled according to the procedure
described in Section HA. The Investigator must document the date, time of day and reason for
code breaking. In case of SAE, the instructions for SAE reporting are to be followed (please refer
to Section 10.2.2).
8.9 RESPONSIBILITIES
The igator, the clinical site pharmacist, or other personnel allowed to store and dispense
lixisenatide, its placebo and the or pen Opticiick® red by Investigational medicinal
product) will be responsible for ensuring that the IMP used in the clinical trial is securely
maintained as specified by the Sponsor and in ance with the able regulatory
requirements.
All IVIPs shall be dispensed in accordance with the Investigator’s prescription and it is the
Investigator’s responsibility to ensure that an accurate record of IMP issued and returned is
ined.
Any quality issue d with the receipt or use of lixisenatide and its placebo provided by the
sponsor (deficiency in condition, packaging, appearance, pertaining documentation, labeling,
expiration date, etc.) or OptiCIick® should be promptly notified to the Sponsor, who will initiate a
complaint procedure.
A potential defect in the quality of IL I provided by the sponsor may prompt to initiation of a
recall procedure by the Sponsor. In this case, the Investigator will be sible for promptly
addressing any request made by the Sponsor, in order to recall IMP and eliminate potential
hazards.
Under no circumstances will the Investigator supply natide and its placebo provided by the
Sponsor to a third party, allow the IMP provided by the Sponsor to be used other than as directed
by this clinical trial protocol, or dispose of IMP provided by the Sponsor in any other manner.
8.10 CONCOMITANT TREATMENT
Specific treatments, which are ongoing before the study and/or prescribed or changed during the
study, must be recorded in the CRF and Source ata (please refer to Section 12.2 ).
8.10.1 Concomitant Diabetes y
Patients may be ed with metformin background therapy at a stable dose (210%) for at least 4
weeks prior to randomization). The min dose should be kept unchanged hout the
study. It should be administered according to the approved label.
8.10.2 Prohibited concomitant therapy
The following drugs dy listed as exclusion criteria, see Section 7.3 ) are not permitted during
the study (up to the end—of study visit):
1. Any other any oral or inj ectable antidiabetic or hypoglycemic agents other than metformin
(e. g., alpha glucosidase inhibitor, exenatide, DPP—IV inhibitors, insulin, TZD, SU etc.)
2. Systemic glucocorticoids (excluding topical application or inhaled forms) administered for
one week or more should be discontinued within 3 months prior to the time of screening.
8.10.3 Permitted concomitant therapy
Any therapy other than the prohibited concomitant therapy described above, is d and has to
be recordedin the source data (please refer to 12.2) and the e——.CRF
Note: For oral treatments that are dependent on threshold concentrationsfor efficacy, such as
contraceptives (pill) and otics, patients should be advised to take those treatments at least
1 hour before study drug injection or about 11 hours after study drug injection.
8.11 ENT ACCOUNTABILITY AND ANCE
The independent person designed by the investigational site (see Section 8.4) will document dates,
time and dose of each self injection of lixisenatide and o and the oral daily dose of
metforrnin, if any and will complete the appropriate “Treatment Log Form”.
The Monitoring Team in charge of the study then checks the CRF data by comparing them with
the date and time of IMP.
8.12 RETURN AND/OR DESTRUCTlON OF TREATMENTS
Investigational medicinal product reconciliation must be performed at the site or CRO by the
Pharmacist or other personnel allowed and the monitoring team using ent log forms and
documented on center IMP inventory countersigned by the Pharmacist /Investigator and the
monitoring team.
A written authorization for destruction will be given by the clinical trial team once the IMP
reconciliation is ed. This destruction can be performed at site depending on P
specificities and local requirements or IMP can be returned to the Sponsor for destruction.
9 ASSESSMENT OF INVESTIGATIONAL MEDICINAL PRODUCT
9.1 PHARMACODYNAMICS
All pharmacodynamics parameters Will be med by a Central Laboratory. Detailed
ation on sample drawing, management and analysis will be provided.
0 Plasma glucose concentrations
0 Insulin, C—peptide and glucagon plasma concentrations
(see study and period flow charts for detailed ment schedule)
9.1.1 Assessment methods
Plasma glucose, insulin, C—peptide and glucagon are to be sampled at pre-specified times and
determined by specific validated . The exact time of sample collection must be recorded on
the CRF. l procedures for storage and shipping ofpharmacodynamic samples will be
described in a separate technical manual provided by the l Laboratory.
9.1.2 Pharmacodynamic parameters
9. 1.2. 1 Primary parameter(s)
o GLU— AUC0230 -4230 after each lixisenatide dose (5 ug, 10 ug) compared to placebo
GLU-AUCO:30-4;30hI area under the plasma glucose concentration time profile from time of the
standardized breakfast start (30 min after IMP injection and pre-meal plasma glucose =T05) until
4 hours later (T45) subtracting the pre—meal value. AUC will be calculated using the trapezoidal
rule.
9. 1.2.2 ary parameter(s)
- randial plasma glucose (PPG) excursion after each lixisenatide dose stration
(5 pg, 10 ug) compared to placebo
PPG excursion Will be calculated from the difference between the maximum after the standardized
breakfast and before lunch minus the pre-meal plasma glucose (T05).
- AUCOQO 4:30 of insulin, C—peptide and glucagon concentrations after each lixisenatide dose
(5 pg, 10 ug) compared to placebo:
The area under the concentration time profile from time of standardized breakfast start (30 min
after IIVIP injection and pre-meal plasma glucose =T05) until 4 hours later (T45). AUC will be
calculated using the trapezoidal rule.
9.1.3 Assessment schedule
The assessment timing can be found in the period flow chart (please refer to Section 1.3 and
Section 1.4
Table 3 — Number of samples
Plasma Insulin, C- Glucagon
Glucose peptide
By t/ ing 1 1a 0
By patient per Period 8 7 7
Total by patient 25 22 21
Total for study, n: 24 tsb 600 528 504
a C-peptide only b to be added replacement patients,
— if any
9.2 SAFETY
9.2.1 Baseline demographic characteristics:
Baseline demographic characteristics will consist of:
1. Age (years)
2. Height (cm)
3. Body mass index
4. Gender
. Tanner staging ning only)
The Tanner stages are stages (5 stages) of physical development in children, adolescents,
and adults (9, (10). The stages‘define physical measurements of development based on
external primary and secondary sex characteristics, such as the size of the breasts,
genitalia, and development of pubic hair. Due to natural variation, individuals pass
through the Tanner stages at different rates, ing in particular on the timing of
puberty. The Tanner stages will be used to assist in defining females of childbearing
potential during the ing physical examination. '
6. Diabetes history including :1
— Date of the diagnosis of type 2 diabetes
— ormin co—administered, start date of treatment with metforrnin, daily dose of
netforrnin at Baseline
9.2.2 Safety assessment at baseline and during the study
The tolerability investigations at baseline and during the study will consist of:
1. Physical examination (includes at a minimum: heart and respiratory auscultation;
peripheral arterial pulse; pupil, knee, Achilles, and plantar reflexes; peripheral lymph
nodes and abdomen examination).
Body weight (kg);
3. Body temperature (0C);
Vital signs (heart rate, systolic and diastolic blood pressure measured after 10 s in
supine resting position);
Laboratory tests (in fasting conditions for blood samples):
Hematology: red blood cell count, hematocrit, hemoglobin, white blood cell count with
differential count (neutrophils, eosinophils, basophils, monocytes, and lymphocytes),
Biochemistry:
— Plasma/serum electrolytes: sodium potassium, chloride calcium
— Liver function. AST, ALT, alkaline phosphatase, glutamyl transferase, total
and ated bilirubin
.- Renal function: urea, creatinine
- lism: glucose, albumin, total proteins, total terol, triglycerides
~ Potential muscle toxicity: creatine phosphokinase
— Pancreas: e and lipase
— onin (tyroidc-cell tumor marker) at screening only
Serum B—HCG only at screening in females of reproductive potential (Tanner stage 2 3) ;
Urinary pregnancy test for uating females before each ent period;
Plasma follicle—stimulating hormone (FSH), if applicable, at screening to confirm
postmenopausal status;
Serology tests: hepatitis B antigen, hepatitis C antibodies, anti—HIVl and anti—HIVZ
antibodies;
ll. Urinalysis: proteins,glucose, erythrocytes, ytes, ketone bodies, and pH.
— Qualitative: A dipstick is to be performed on a freshly voided specimen for qualitative
detection using a reagent strip.
— tative: A quantitative measurement for glucose, protein, erythrocytes, and
leucocytes count will be required in the event that the urine sample test is positive for
any of the above parameters by urine dipstick (eg, to confirm any positive dipstick
parameter by a quantitative measurement).
12. Urine drug screen: amphetamines/methamphetamines, barbiturates, benzodiazepines,
cannabinoids, cocaine, and opiates.
13. Alcohol breath test.
14. Adverse , spontaneously reported by the patient or observed by the Investigator, will
be monitored;
. Standard d ECGs are recorded after at least 10 minutes in supine position using an
electrocardiographic device. The electrodes will be positioned at the same place for each
ECG ing throughout the study (attachment sites of the leads Will be marked with an
indelible pen).
Each ECG consists of a lO—second recording of the 12 leads simultaneously, leading to.
o A single l2—lead ECG (25 mm/s, 10mm/mV) printout with heart rate, PR, QRS, QT, QTc
automatic correction evaluation (by the ECG ), ing date, time, initials, and
number of the patient, signature of the research physician, and at least 3 complexes for
each lead. The Investigator’s medical n and automatic values will be ed in the
e-CRF. This printout will be retained at the site.
Warning at each period: Whenever measurements of vital signs, ECG, and blood samples for
pharmacokinetics, pharmacodynamics, or safety coincide, the following order will be respected:
ECG, Vital signs, codynamics, pharmacokinetics, and then safety samples. In order to
respect exact timing of pharmacokinetics samples (refer to flow chart for time Window allowance
for pharmacodynamic and pharmacokinetics samples), the other measurements will be done ahead
of the scheduled time. The assessment schedule should be adapted to the design of the study.
9.2.3 Anti-lixisenatide antibodies
Plasma samples from all patients Will be collected to determine anti-lixisenatide antibodies on
Day 1/ period 1 before the first study drug stration only. Procedures for collection, storage,
and nt will be provided in a separate manual.
Table 4 - Number of plasma samples for ixisenatide antibodies
Anti-lixisenatide antibodies
Total by patient (once D1/P1) 1
Total for patients (n=24) 24
Table 5 - Bioanalytical method
Analyte Anti- Lixisenatide antibodies
Matrix Plasma
Analytical que BIAcore
Lower Limit of Quantification cut—off
Assay Range not relevant
Assay Volume 100 pL
Site of Bioanaiysis Dept. of Disposition, Safety and Animal ch (DSAR), sanofi aventis, urt
Method Reference RPSMPK-DOHO754—BMi—EN-EOi
9.3 PHARMACOKINETICS
9.3.1 Sampling times
The sampling times for blood tion can be found in the period flow chart (please refer to
Section 1.3 and Section 1.4).
9.3.2 Number of pharmacokinetic samples
Table 6 — Number of plasma samples for AVEOO‘iO PK
AVE0010
By patient per period 8
Total by patient (X3 periods) 24
Total for patients n=24 (up to 36) 24* 24: 576 (up to 864)
9.3.3 Sample handling procedure for pharmacokinetic samples
Procedures for collection, storage, and shipment will be provided in a separate manual.
9.3.4 Bioanalytical methods
All iixisenatide plasma samples from patients having ed natide were analyzed as
described in Table 7, with a lower limit of quantification.
Table 7- Summary of bioanalytical method
WWW-—ytebtisenatide
Matrix Plasma
Analytical technique Double-antibody sandwich ELlSA
Lower limit of quantification 5.5 pg/mL
Assay volume 120 uL
Site of bioanalysis Biomarker/Biologicals, DSAR,
sanofi aventis, Frankfurt
Method reference DOH1154
9.3.5 Pharmacokinetic parameters
Lixisenatide plasma concentrations at predefined timepoints will be documented. The
pharmacokinetic parameters will be ated, using non-compartmental methods for lixisenatide
plasma concentrations after single dose. The parameters will include, but may not be limited to
the following.
Table 8 — List of cokinetic parameters and definitions
Parameters Drug/Analyte Matrix Definition/Calculation
Cmax AVEOOlO Plasma Maximum plasma concentration ed
tmax 0 Plasma Time to reach Cmax
Area under the plasma concentration versus time curve calculated usmg the
AUCiast AVE0010 Plasma
trapezoidal method from time zero to the real time
Area under the plasma concentration versus time curve extrapolated to
infinity according to the following equation:
Clast
AUG — AUCiast +
AUC AVEOO1O Plasma 32
(Clasl is the last quantifiable tration, and A; the rate constant of the terminal phase)
Values with a percentage of extrapolation >20% will not be taken into account
in the descriptive statistics
9.4 SAMP-E BLOOD VOLUME
The approximate total sampled blood volume in children is 144 ml (approximate due to ded
blood when catheter is set up at each period). The amount of blood volume per Visit will not exceed 46'
mL (the highest at period 1). The approximate total sampled blood volume in adults is 144 mL
(approximate due to discarded blood when er is set up at each period).
9.5 MEASURES TO PROTECT NG OF THE TRIAL
For the purpose of IMP dispensing and stration and bioanalytical ment of PK and
anti-lixisenatide antibody samples, the following persons will be unblinded (refer to section 8.8
for the IMP dispensing procedure'restricted to the independent on-site person of the
CRO/investigational centre). A copy of the randomization list will be provided only to the
bioanalyst responsible for lixisenatide concentration measurements.
In case of an adverse event, the Investigator should only break the code in exceptional
stances when knowledge of the Investigational Product is essential for treating the patient
(refer to section 8.8).
Nevertheless, for safety reason, the treatment code will be unblinded for reporting to the health
authorities of any suspected cted serious adverse reaction (SUSAR), ie, any serious
adverse event that is both unexpected (per the investigator’s brochure) and reasonably associated ‘
with the use of the IMP according to either the judgment of the Investigator and/or the Sponsor.
The ARAC is blinded for the cation of allergic and allergic~like cases (please also refer to
Section 6.3.1). '
All persons at —aventis and at any CRO involved in the study including laboratory and
eventually pharmacodynamic assessors will be blinded to the randomization code.
PATIENT SAFETY
The Investigator is the primary person responsible for taking all clinically relevant decisions on
safety issues.
Ifjudged necessary, the opinion of a Specialist should be envisaged in a timely manner (eg, acute
renal failure, convulsions, skin rashes, angioedema, cardiac arrest, electrocardiographic
modifications, etc).
In case of derrnatologic lesions, the realization of photographs is strongly ended in
on to quick Dermatologist advice.
.1 ADVERSE EVENT MONITORING
All events will be managed and ed in compliance with all applicable regulations, and
included in the final clinical study .
.2 DEFINITIONS OF ADVERSE EVENTS
.2.1 Adverse event
An adverse event (AB) is any untoward medical occurrence in a patient administered a
pharmaceutical product and which does not necessarily have to have a causal relationship with
this treatment.
0 Mild = no modification of daily activities and does not e mandatory
corrective/symptomatic treatment.
0 Moderate = hinders normal daily activities and/or requires mandatory
corrective/symptomatic treatment.
0 Severe : prevents daily activities and requires mandatory corrective/symptomatic
treatment.
.2.2 Serious adverse event
A serious adverse event (SAE) is any rd medical occurrence that at any dose:
0 Results in death, or
o Is life—threatening, or
Note: The term “life—threatening” in the definition of us” refers to an event in which the
patient was at risk of death at the time of the event; it does not refer to an event which
hypothetically might have caused death if it were more severe.
o Requires inpatient hospitalization or prolongation of existing hospitalization, or
0 s in persistent or significant disability/incapacity, or
o Is a congenital anomaly/birth defect, or
o Is a medically important event:
— Medical and scientific judgment should be exercised in deciding r expedited
ing is appropriate in other situations, such as important medical events that may
not be immediately life—threatening or result in death or hospitalization but may
jeopardize the patient or may require intervention to prevent one of the other outcomes
listed in the ion above.
Note: Examples of such events are intensive treatment in an emergency room or at
home for allergic ospasm, blood dyscrasias, convulsions ALT > 3 x ULN +
total bilirubin > 2 x ULN or asymptomatic ALTincrease > 10 X ULN or development
of drug dependency or drug abuse
Unblinding of SUSAR by the Sponsor is described in Section 9.5.
.3 OBLIGATION OF THE INVESTIGATOR REGARDING SAFETY REPORTING
.3.1 General guidelines for reporting adverse events
All AEs, regardless of seriousness or relationship to D/IP, spanning from the signature of the
informed t form until the end of the study as defined by the protocol, are to be recorded on
the corresponding page(s) or screen(s) of the case report form for included patients. For screen
failed ts, recording in the case report form is only performed in case of SAE occurring
during the screening period or in case ofAE when some screening procedures expose the patient
to safety risks (eg, any substance administered as pretreatment or for phenotyping, invasive tests
performed or chronic treatment interrupted).
Whenever possible, diagnosis or single me should be reported d of symptoms. The
Investigator should specify the date of onset, intensity (see definitions in Section 10.2.1), action
taken with respect to TMP corrective treatment/therapy given, onal igations performed
(eg, in the case of derrnatologic lesions photographs are required), outcome, and Investigator’s
n as to whether there is a reasonable possibility that the AE was caused by the IMP.
In order to ensure the safety of the ts, the Investigator should take appropriate measures to
follow all AEs until clinical recovery is complete and laboratory results have returned to normal,
or until ssion has been stabilized, or until death. This may imply that observations will
continue beyond the last planned visit per protocol, and that additional investigations may be
requested by the monitoring team.
When treatment is prematurely discontinued, the patient’s observations will continue until the end
of the study for that patient as defined by the protocol.
Laboratory, vital signs, or ECG abnormalities are to be recorded as A *s only if:
symptomatic, and/or
requiring either corrective treatment or consultation, and/or
leading to IMP/NIMP discontinuation or modification of dosing, and/or
fulfilling a seriousness criterion, and/or
defined as an AESI.
.3.2 Guidelines for reporting s adverse events
In the case of a SAE, the Investigator must immediately:
These first 4 bullets should be applicable in case of paper case report form used.
ENTER the information d to the serious adverse event in the
appropriate s of the e—CRF; the system will automatically send the notification to the
monitoring team after approval by the igator within the e—CRF or after a standard
delay.
SEND (preferably by fax or e—mail) the photocopy of all examinations carried out and the
dates on which these examinations were performed, to the representative of the monitoring
team whose name, fax number, and e—mail address appear on the clinical trial protocol.
Care should be taken to ensure that the patient’s identity is protected and the patient‘s
identifiers in the clinical trial are properly mentioned on any copy of source document
provided to the r. For laboratory results, include the tory normal ranges.
All r data updates should be recorded in the e—CRF as appropriate, and r
documentation as well as additional information (for laboratory data, concomitant
medication, t status, etc) should be sent (by fax or e—mail) to the monitoring team
within 1 g day of knowledge. In addition, any effort should be made to further
document within the week (7 days) following initial notification any s adverse event
that is fatal or life threatening.
A back—up plan is used (using paper flow) when the e—CRF system does not work.
These next 3 bullets will be applicable in case of e—CRF is used for a %ack—up plan)
SEND ( preferably by fax or e-mail) the signed and dated
corresponding page(s) in the case report form to the representative of the monitoring team
whose name, fax number, and e—mail address appear on the clinical trial protocol.
ATTACH the photocopy of all examinations carried out and the dates on which these
examinations were performed. Care should be taken to ensure that the patient’s identity is
protected and the t’s identifiers in the clinical trial are properly mentioned on any
copy of source documentprovided to the Sponsor. For laboratory results, include the
laboratory normal ranges.
All further documentation should be sent to the monitoring team within 1 working day of
knowledge. In addition, every effort should be made to further document within the week
(7 days) following initial notification any s e event that is fatal or life
ening.
Any SAE brought to the attention of the igator at any time after the end of the study
for the patient and ered by the Investigator to be caused by the MP with a
reasonable possibility, should be reported to the monitoring team.
0.3.3 Guidelines for reporting e events of special interest
”he need for specific monitoring, documentation, and management of AESI are described in this
section.
“:or each defined adverse events of special interest, consider carefully the need to collect
additional specific information that would impact the study and]or the case report form design,
such as:
Preexisting related condition or lifestyle of interest for the adverse event (eg, habits,
cardiovascular risk factor, etc)
Expected list of associated signs and symptoms
Corrective actions (eg, treatment discontinuation, concomitant treatment, etc)
Diagnostic actions (eg, test(s) or procedure(s) results, etc)
Additional descriptive factors
Sequelae
.3.3.1 Reporting of adverse events of l interest with immediate notification
For AESI with immediate cation, the Sponsor is to be informed immediately (ie, within 1
working day), as per SAE notification guidelines described in n 10.3 .2, even if a seriousness
criterion is not met, using the corresponding pages of the case report form (to be sent) or screens
in the e-CRF.
ALT increase 22 x ULN (refer to d decision chart in ix A)
_QTc _>_500 ms
Tn the event of prolongation of QTc interval (automatic measurement) >500 ms, confirmed by
a manual reading by the Investigator or a physician delegated by the Investigator using the
Fridericia formula for correcting QT, the patient should be placed under supervision in a
specialized setting. Investigational medicinal product administration must be stopped and
appropriate blood samples collected. Subsequent ECG monitoring of the patient should then
be med on a r and clinically responsible basis until the QTc interval returns to a
safe value as determined by the Investigator in agreement with the Sponsor.
Pregnancy
~ Pregnancy occurring in a female patient ed in the clinical trial: Pregnancy will
be recorded as an adverse event of special interest with immediate notification in all
cases. It will be qualified as a serious adverse event only if meeting one of the
seriousness criteria.
- In the event of pregnancy, IMP should or must be discontinued.
— Follow—up of pregnancy will be mandatory until its outcome has been determined.
- Symptomatic overdose with IMP
— An overdose (accidental or intentional) with the IMP is an event ted by the
Investigator and defined as at least twice of the intended dose within the intended
therapeutic interval, adjusted according to the tested drug
.3.3.2 Reporting of adverse events of special interest without immediate notification
o Asymptomatic overdose with IMP (Refer to Section 10.3.3.1)
- Symptomatic hypoglycemia (see definition below) with an accompanying plasma glucose
< 60 mg/dL (3.3 mmol/L) or associated with prompt recovery after oral carbohydrate
administration if no plasma glucose measurement is available.
Symptomatic hypoglycemia is defined as an event with clinical symptoms that are considered
to result from a hypoglycemic episode (e.g., sweating, palpitations, hunger, restlessness,
anxiety, fatigue, irritability, headache, loss of concentration, somnolence, psychiatric or visual
disorders, ent sensory or motor s, confusion, convulsions, or coma).
Symptoms with an associated blood glucose ement _>_ 60 mg/dL (3.3 mmol/L) should
not be reported as a hypoglycemia.
Symptomatic hypoglycemia is to be ed as an adverse event. It should be ed in the
CRF on the specific AE form for symptomatic hypoglycemia. Additional information should
be collected on a c symptomatic hypoglycemic event complementary form.
0 Severe symptomatic hypoglycemia
Severe symptomatic hypoglycemia is defined as an event with clinical ms that are
considered to result from hypoglycemia in which the patient required the ance of another
person, because the patient could not treat rself due to acute neurological impairment
directly resulting from the hypoglycemic event, and one of the following:
— The event was associated with a plasma e level below 36 mg/d J (2.0 mmolIL).
— If no blood glucose measurement is available, then the event was associated with
prompt recovery after oral carbohydrate, enous glucose, or glucagon
administration.
The ion of severe symptomatic hypoglycemia includes all es in which
neurological impairment was severe enough to prevent self—treatment and which were thus
thought to place patients at risk for injury to themselves or . Note that “requires
assistance” means that the patient could not help f or herself. Someone being kind that
assists spontaneously the patient when not necessary does not qualify as.“requires assistance.”
Severe symptomatic hypoglycemia will be qualified as an SAE only if it fiilfills SAE criteria.
Suspected Pancreatitis
In case of severe, persistent abdominal pain, which can radiate to the back, often with
teristic positional features, with possible occurrence of nausea, vomiting, fever and
leucocytosis, r measurement of amylase and lipase should be performed. The
diagnosis of pancreatitis may be supposed also if other causes of abdominal pain are
excluded (i.e., gallbladder e, etc) and elevated amylase/lipase is seen and in addition
pancreatic changes are seen on ultrasound and/or CT or MRI (with contrast, as
appropriate).
Pancreatic enzymes (amylase, lipase) must be measured.
9Amylase and lipase values greater than 2-fold ULN should be repeated within 7 days.
-)Amylase and lipase values greater than 3—fold ULN should be repeated Within 48 hours.
If the value remains above 2—fold ULN, it should be repeated weekly until it is less than 2—
fold ULN. e and lipase elevations without associated clinical symptoms should
receive a gastroenterologic evaluation with additional imaging, as appropriate. All the
laboratory or clinical documentations should be collected. As soon as there are signs,
symptoms and results of investigations exploring ted pancreatitis (eg, laboratory
results, imaging reports, gastroenterologist’s evaluations, etc) related to suspected
pancreatitis, the investigator must document and report them on a specific e—CRF form.
With any diagnosis of acute pancreatitis, the investigatidnal ent and other potentially
suspect drugs should be stopped and the patient followed further ally
Allergic or allergic—like reaction
In case a patient experiences an allergic reaction or an allergic—like reaction this has to be
reported as an e event. Additional ation is collected on specific allergic
reaction forms. Allergic, or possible allergic reactions will be adjudicated by the Allergic
on Assessment Committee (ARAC, Section 6.3.1 ).
.3.4 Guidelines for management of specific laboratory abnormalities
Once the patient is included in the al trial, the ing laboratory abnormalities must be
monitored, documented, and managed i. ”
o Neutropenia
o Thrombocytopenia
0 Acute renal insufficiency
o Suspicion of rhabdornyolysis
.4 OBLIGATIONS OF THE SPONSOR
During the course of the study, the Sponsor will report in an expedited manner:
0 All SAEs that are both unexpected and at least ably related to the IVIP (SUSAR), to
the Health Authorities, lRB/IECS as appropriate and to the Investigators.
o All SAEs that are expected and at least reasonably related to the [MIPS to the Health
Authorities, according to local regulations.
11 HANDLING OF PATIENT WITHDRAWAL
The basis of reason for treatment withdrawal should be identified.
11.1 -IST OF TREATMENT WITHDRAWAL CRITERIA
Refer to Section 10.3
Pregnaney lead to permanent treatment discontinuation in all cases (Refer to
Section
11.2 REASONS FOR ENT WITH DRAWAL
ts can withdraw from the treatment if they decide to do so, at any time, and for any reason,
or this may be the Investigator’s on.
11.3 EMENTS OF PATIENTS
A patient who prematurely end his/her treatment study participation after the start of the baseline
period and who received study drug can be replaced in order to obtain as far as possible 12
completed patients per population. In the event of discontinuation due to occurrence of AE, the
replacement will be discussed between the Investigator and the Sponsor. Replacement patients
must meet all inclusion and exclusion criteria.
The replacement patients will have a different t number, by adding 500 to the number of
patient ed.
11.4 FOLLOW-UP URE FOR TREATMENT WITH DRAWAL
All study treatment withdrawals should be recorded by the Investigator on the appropriate case
report form pages or screens for e—CRF when considered as confirmed.
If possible, patients are to be ed using the procedure planned for the end—of—study Visit,
including a pharmacokinetic sample if appropriate.
For any patient who fails to return to the site, the Investigator should make every effort to
recontact the patient (eg, contact the patient’s family or private physician, review available
registries or health care database), and to ine his/her health , including at least his/her
vital . Attempts to contact the patient must be documented in the patient’s records (eg, times
and dates of attempted telephone contact, receipt for sending a registered letter).
Patients Withdrawn fiom the study must not be reincluded in the study. Their inclusion and
treatment numbers must not be reused.
12 STUDY PROCEDURES
12.1 VISIT SCHEDULE
The study consists of a screening period up to 4 weeks followed by a randomized, —blind, 3
crossover treatment periods l~7 days apart. Each period will last one day only (but, if all
examinations and tests to be performed before dosing on Day 1, are not possible, a visit on Day —1
(afternoon) at the ience of patient and the possibilities of the investigational site (e.g., an
institutionalization / an accommodation for one night before Day 1 at each period).
At each treatment period, the patients will receive a subcutaneously injected single dose of either
pg or 10 ug lixisenatide with 5 ug preceding the 10 ug dose level or volume matched placebo
(50 uL or 100 uL). The end—of—study visit is scheduled between Day 2 and Day 7 of the treatment
period 3.
All the in—clinic (Day 1) visits should take place in the morning at approximately the same time.
12.1.1 Screening procedures
Screening procedures will be carried out within 30 days prior to inclusion but blood sampling
should be done at latest on Day --25 to obtain the results before the randomization (Dayl).
For paediatric study population:
At this first contact the study will be explained to the patient’s parents or legal guardian
(hereinafter the “paren ”). The parent will receive verbal information concerning the aims and
methods of the study, its constraints and risks, and the study duration. Written informed consent
must be signed by the parent prior to any investigations. In addition, ion of Assent Form
will be signed by minor patients or Informed Consent Form will be signed by emancipated or
mature minors (defined by local lows).
For adult study population:
The patient will receive ation on the study obj ective(s) and ures fiom the
Investigator. The adult patient will have to sign the informed consent prior to any action related to
the study.
For all patients, the screening visit will include the following investigations (refer to Section 9.2):
1. Demographics: age, sex, race, height, body weight in kg, BMI [Body Mass Index =
weight (in kg)/height (in cm) 21;
2. For paediatric population: tanner g ning only).
3. Relevant medical history ing personal or familial history of medullary thyroid
cancer (MTC) or a c condition that predisposes to MTC, t’s y medical
y, risk factors for pancreatitis [c.g, habits of alcohol consumption (none, 3 2 drinks
/ day or > 2)] and al history;
Physical ation (cardiovascular system, chest and lungs, thyroid, abdomen, nervous
system, skin and mucosae, and musculo—skeletal system);
. History of type 2 diabetes history (date of the diagnosis of diabetes);
Concomitant and previous medication including antidiabetic treatments in the last 3
months prior to study entry start date of treatment with metformin if administered, daily
dose of metforrnin at Baseline (refer to the inclusion criteria 101, Section 7.2) '
1CG (standard l2—lead), Vital signs ements (heart rate, systolic and diastolic blood
pressure measured after 10 minutes rest in supine position);
Body temperature
Urine drug screen: amphetamines/methamphetamines, barbiturates, benzodiazepines,
cannabinoids, cocaine, and opiates;
. l test;
ll. Laboratory tests in fasting condition with hematology and clinical chemistry including
serum test (anti—L42, and anti—GAD), fasting C—peptide, HbAl c, fasting plasma
, antibody
glucose, calcitonin, serologies itis B n, hepatitis C antibodies, anti-HIVl and
anti-HIV2 antibodies), urinalysis, B-HCG blood test solely in females of reproductive
potential (Tanner Stage 2 3), serum FSH (in adult women, if applicable, to confirm
postmenopausal status);
12. Each centre will call IXRS to receive an incremental identification number of their patient
corresponding to his/her order of enrollment in the study (refer to Section 8.5);
Patients who meet all the inclusion criteria and none of the exclusion criteria will be eligible for
the ion visit (Day 1).
12.1.2 Description by type of visit
12.1.2.1 Treatment period 1
Inclusion procedures
The inclusion Visit will be d out on the day of inclusion (Day 1) and will include the
following investigations (refer to Section 9.2):
1. For safety and practical reasons, for tric population, topical application of cream or
other anesthesic local application (e.g.; EMLA®) can be applied on the forearm
approximately 1 hour before the venipuncture at the site where the catheter for blood
ng will be in place for ng pain in patients, especially in children;
Physical examination: medical history, weight, and body temperature;
. ECG and vital signs measurements;
4. Urinary pregnancy test in females with reproductive potential (Tanner stage 2 3);
. Urine drug screen: amines/methamphetamines, barbiturates, benzodiazepines,
cannabinoids, cocaine, and opiates;
6. Alcohol test;
Rechecking of any baseline parameter is to be limited to one time except when the ement
has not been obtained in accurate conditions. The last value should be considered, as the baseline
value and reported in the case report form. If a parameter at baseline is part of specific inclusion
criteria, king is not permitted; one abnormal value is cause for exclusion.
Patients who meet all the inclusion criteria and none of the exclusion criteria will be eligible for
inclusion in the study. Final inclusion and randomization will be performed just before the IMP
administration on Day 1.
'For safety and practical reasons, approximately 15 minutes before blood sampling, an indwelling
catheter may be inserted in a peripheral vein of the forearm in order to obtain blood s.
etween samplings, the catheter will be locked with a mandrel. Heparin use during blood draws is
NOT allowed (to avoid any potential contamination with heparin which may interfere with the
drug/antibody assays). 0.9% saline can be used to flush the collection catheter. Prior to collection
of the blood sample Via an indwelling catheter, 05 mL of blood has to be drawn and discarded to
avoid on.
When the patient is confirmed for the study inclusion, the treatment period will include the
following investigations (refer to n 9.2):
1. According to the procedure described in Section 85, the Pharmacist or the Independent
person will call IXRS to receive the treatment kit number allocation;
2. Blood sampling for anti—lixisenatide antibodies test before the IMP stration;
3. 0.5h before breakfast, self injection of lixisenatide at the dose of 5 pg (5 Units indicated
on OptiClick®) or lOug QD (10 Units indicated on OptiClick®) or placebo (50 uL or 100
uL), under the observation of the medically qualified designee. However, for blinding
purposes the on—site administration of lixisenatide or its placebo will therefore be
performed by an independent person who is not a member of the clinical study team at the
CR0 or investigational site;
4. rdized breakfast (refer to n 8.4 30 minutes after the first
, Appendiij) given
blood codynamic sampling, corresponding to the pre—specified time T0.5h.;
. Blood ng for the evaluation of plasma glucose, insulin, ide- and glucagon
starting between approximately 07:30 and 09:00 (T0 before the study drug administration)
with 7 (8 for plasma e) pre— specified timepoints: T0, T05 (just before breakfast),
Tl, T15, T2 (plasma glucose only), T25, T35, and T45 e ;
6. Blood sampling for PK starting between approximately 07:30 and 09:00 (T0, before the
study drug administration) and at 7 pre— specified timepoints after dosing: T05 (just before
breakfast), Tl, T15, T25, T35, T45 (before lunch) and T65;
7. Vital signs measurements at T25 and T65
8. Physical examination : before discharge (T65);
9. Recording of e events and concomitant medication, if any;
. Patients will be discharged after a complete review of the available safety data by the
Investigator;
11. Patients will be instructed to come back to the study site within 8 days (between Day 2
and Day 8);
12.1.2.2 Treatment periods 2 and 3
The treatment period will include the following investigations (refer to Section 9.2):
l. For safety and practical reasons, for tric population, topical
atch (eg, EMLA®) a
pain inpatients, especially in children.
w, x M . m ;
Recording of adverse events and concomitant medication, if any;
Urine drug screen: amphetamines/methamphetamines, barbiturates, benzodiazepines,
cannabinoids, cocaine, and opiates before IMP administration ;
Alcohol test before IMP administration;
Physical examination including body , body temperature and the respect of the
adherence to study ctions before IMP administration;
ECG and vital signs ements before IMP administration ;
Urinary pregnancy test in females with uctive potential r stage 2 3) before
IMP administration;
0.5h before breakfast, self injection of liXisenatide at the dose of 5 ug (5 Units ted
on OptiClick®) or lOug QD (10 Units indicated on OptiClick®) or placebo (50 uI. or 100
uL), under the observation of the medically qualified designee. However, for blinding
purposes the on—site administration of lixisenatide or its placebo will therefore be
performed by an independent person who is not a member of the clinical study team at the
CRO or investigational site;
Standardized breakfast (refer to n 8.1), given 30 minutes after the first blood
pharrnacodynamic sampling, corresponding to the pie-specified time ;
. Blood sampling for the evaluation ofplasma glucose, insulin, C—peptide- and glucagon
starting between approximately 07:30 and 09:00 (T0 before the study drug administration)
with 7 (8 for plasma glucose) pre— specified timepoints: T0, T05 (just before breakfast),
T1, T15, T2 (plasma glucose only), T25, T35, and T45 (before ;
ll. Blood ng for PK starting approximately between 07:30 and 09:00 (T0, before the
study drug administration) and at 7 pre— specified timepoints after dosing: T05 (just before
breakfast), T1, T15, T25, T35, T45 (before lunch) and T65;
12. Vital signs measurements at T2 and T65
13f“CG and physical examination med at T65 ;
14. Recording of adverse events and concomitant medication, if any;
. Patients will be discharged after a complete review of the available safety data by the
Investigator;
16. At period 3, each centre will call lXRS to inform that all treatments have been
stered (end of the treatment period) for the given patient;
17. Patient will be instructed to come back to the study site within 8 days (between Day 2 and
Day 8); >
Ambulatory peri0d(s)
During the study, patients should immediately contact the Investigator or one of the clinical unit
managers in the event of any ained symptom or any unexpected effect or event occurring
during the study. For this , patients will be informed that they can contact the clinical unit
by telephone 24 hours a day. Patients must give the Investigator a telephone number Where they
can be contacted in an emergency. Patients must carry with them, during ambulatory study
period(s), the t card indicating the patient number and the emergency telephone number
provided by the study site.
12. 1.2.3 End-of-study visit
The —study visit will be performed between 1 to 6 days after last dosing (D2 to )7 afier
Period 3); it will include the following investigations (refer to Section 9.2):
l. Physical examination including body weight;
2 . ECG and vital signs measurements;
3 Laboratory tests in g conditions with hematology and clinical chemistry;
4. Jrinalysis;
’{ecording of adverse events and concomitant medication, if any;
6 . TXRS call for the end of the study for the patient given;
12.1.3 Study restriction(s)
The s of the glycemic index (GI) of carbohydrate eaten the previous night on the glycaemic
response to a standard test meal eaten subsequently in the morning (breakfast) have been
described (ll, 12). As far as possible, recommendation will be given to patient to eat a pasta
course at the dinner preceding Day 1 of each period.
After the dinner on Day—l, patients should stay in fasted conditions for at least 8 hours (food and
drink are not d except water) up to the standardized test meal.
At each site visit, on Day 1 of each period, patients should refrain from drinking alcohol, tea,
coffee, chocolate, quinine, or ne—containing beverages. Consumption of citrus fiuits and
their juices is prohibited during the treatment period (Dayl of each period). Smoking and tobacco
use will not be allowed from 1 day prior to institutionalization throughout the study duration until
the end—of—study Visit. Patients will receive standardized meal test (liquid test for breakfast) (see
Section 8.1).
Patients will be requested to follow a stable lifestyle with no intensive physical ty for the
on of the study until the end~of~study visit.
12.2 DEFINITION OF SOURCE DATA
All evaluations that are reported in the case report form must be supported by appropriately
identified source documentation.
0 Agreement and signature of informed consent mentioning the study identification,
0 Patient identification, last participation in a clinical trial, medical y, associated
diseases, and data d to the studied pathology,
0 Contraception method for women of childbearing potential,
0 Previous and concomitant medication,
0 Study identification,
0 Dates of administration and doses of lixisenatide or placebo,
0 Start date of metformin if patients are treated with, and daily dose at screening,
0 Dates of Visits and assessments including the examination report,
0 Vital signs, height, body weight,
0 laboratory assessments, ECG;
o Pharmacodynamic and cokinetic time points
0 start/end of meals
a ECG records signed and dated,
0 Adverse events and follow—up:
c In case of SAE, the site should file in the source document at least copies of the
hospitalization s (if appropriate) and any relevant examination reports documenting
the follow—up of the SAE. ‘
0 Date of ure study discontinuation (if any) and reason.
Source documentation may be found in the following:
0 Patient’ s identity,
0 Medical history,
0 Nursing notes,
0 Physician’s notes,
0 Patient’s diaries.
o starflend of ECG
13 STATISTICAL CONSIDERATIONS
The material in Section 13 of the clinical trial protocol constitutes the statistical analysis plan for
the study. Should this plan need revision during the study to accommodate clinical trial protocol
amendments or to adapt to unexpected issues in study execution and data that affect planned
es, a statistical analysis plan will be issued prior to database lock.
13..1 DETERMINATION OF SAMP c SI? Illll
Power ation was based on the results of the double—blind, placebo—controlled, single—dose,
study AV £0010/01-016 performed in patients with type 2 diabetes. The following table
(Table ll) summarizes the results of the comparison of single doses of 3 ug and 10 ug
lixisenatide with placebo for the AUCl—Sh of plasma glucose. It can be assumed that the effect of
pg is more pronounced than in 3 pg.
Table 11 - Results from study AVE0010 l 01-016 - Statistical Analysis of Area Under Curve for
plasma Glucose: Pairwise Comparisons Between Dose Groups 3 and 5 pg versus placebo
Dose N Mean difference to Placebo Standard Error
(mg/d1) (mg/dl)
3 pg 4 154 50
pg 4 347 50
Power calculation was performed for a 2-group t—test (Crossover ANOVA) for differences in
means n active treatment and placebo for different standard deviations of 70, 100 and 150
mg.h/dL to take into consideration a possible higher variation in paediatrics than in adults. A type
1 error alpha = 5 % and a roni corrected alpha = 2.5 % was used for the power calculation.
Table 12 - Power ation for Plasma Glucose AUC - alpha = 5 %
Power ation for 12 patients with alpha = 5% for blood glucose AUC
Dose levels
5119 10:19 Spa 10119 5119 10ug
Within—patient 70 70 100 100 150 150
standard deviation
(mg.h/dL)
ence in means 155 350 155 350 155 350
(mg.h/dL)
Power (%) 99 99 92 99 62 99
TotalN 12 12 12 12 12 12
2-sided t-test over ANOVA) for difference of means
Table 13 — alpha = 2.5 %
- Power calculation for Blood Glucose AUC
Power calculation for 12 patients with alpha = 2.5% for plasma e AUC
Dose levels
5119 10119 599 10119 599 10119
Within—patient standard 70 70 100 100 150 150
ion (mg.h/dL)
Difference in means 155 350 155 350 155 350
(m.hg/dL)
Power (%) 99 99 85 99 48 99
Total N 12 12 1'2 12 12 12
H I i i i H
l—test( CrossoerMDAVA) fortitediffrencf‘ means
With a total of 12 patients, a crossover‘design would have 99% power to detect a difference
in the mean corrected plasma glucose—AUC0;30h-4;30h, between lixisenatide and placebo of
19.43 mmol.h/L (350 mg.h/dL) assuming a —standard deviation of 5.55 mmol.h/L (100
mg.h/clL), using a 2—group t—test with a 0.05 two—sided significance level, and 92% power to
detect a difference in means of 8.60 mmol.h/L (155 mg.h/dL). Additional details are provided.
in 16-1—1-protocol [13].
13.2 PATIENT DESCRIPTION
13.2.1 Disposition of patients
A detailed ption of patient accountability including count of patients randomized and treated
(i.e. having a randomization number assigned and who received at least one administration of the
Investigational Medicinal Product (1MP) ), and who discontinued along with the main reason for
discontinuation and who requested treatment discontinuation, will be generated by tion
(paediatric and adult) and ent group within population.
Patient disposition at the end—of—study (EOS) visit will be presented in a g sorted by
population and patient within sequence, including patients’ status (alive or dead) at the end of the
study with the date of last study drug intake, date of last available information and method of
contact, date of ‘TOS visit, reason for discontinuation, and r the blind was broken on site at
time of discontinuation. All withdrawals from the study, taking place on or after IMP
administration, will be fully documented in the body of the CSR.
In case of code broken for medical and accidental reasons on site, a listing of concerned patients
will be provided, specifying the reason (AE/SAE or other), the date and time of code breaking and
the person who broke the code.
A listing of comments on the e—CRF related to igational product compliance and dosing,
safety (adverse events, tory, vital signs and ECG data) or other comments will be provided.
13.2.2 Protocol deviations
During the review of the database, the ance with the protocol will be examined with regard
to inclusion and exclusion criteria, treatment compliance, prohibited therapies, and timing and
availability of planned assessments. Protocol deviations will be identified by the study team
before database lock and listed in the Data Review and Surveillance Report, including missing
data and study drug discontinuations, and classified as important or other deviations.
Individual deviations to inclusion and exclusion criteria as reported by the Investigator will be
listed.
If any, important deviations will be listed by population (paediatric, adult) and patient and/or
described in the body of the al study report.
13.3 ANALYSIS POPULATION
A summary table of count of patients included in each analysis population (pharrnacodynamic,
pharmacokinetic and safety) will be provided by population (paediatric and adult) and by
ent within population. All exclusions from any is populations will be fully
documented in the CSR.
Safety population
All randomized patients d to the IMP (regardless of the amount of treatment administered)
will be ed in the safety population.
Pharmacokinetics population
Two pharmacokinetic (PK) populations will be considered.
-— ‘he full analyses tion including all patients without any major deviations related to
study drug administration, and for whom any pharmacokinetic ters are available.
— he evaluable population including patients from full analyses population who completed
both lixisenatide treatments in compliance with the protocol and having blood samples for
reliable evaluation. ‘
The primary PK population is the evaluable tion. The full analyses population will only be
analyzed if the number of evaluable patients differ by more than 3 (>= 3).
The placebo treatment period can not be ered.
Pharmacodynamic population
Two pharmacodynamic (PD) tions will be considered:
— The full analyses population including all randomized and treated patients without any
important deviation d to IMP administration for whom the primary PD data is
ered sufficient and interpretable.
— The evaluable PD population including patients from the full es population who
completed all 3 treatment s in compliance with the protocol and having blood
s for reliable evaluation.
Patients will be analyzed as treated. The primary PD population is the evaluable population. The
full analyses population will only be analyzed if the number of evaluable patients differ by more
than 3 (>= 3).
13.4 DEMOGRAPHIC AND BASELINE CHARACTERISTICS
13.4.1 t demographic characteristics, medical history and diagnoses
Continuous variables (age, weight, BMI, duration of es, duration of anti—diabetic treatment,
age at onset of diabetes ) and qualitative variables (gender, race, pubertal stage) will be
summarized by descriptive statistics by treatment group within population (paediatric, adult), and
for all patients for the safety tion and for the P ) and/or PK population, if relevant.
All demographic data will be listed.
13.4.2 ne codynamic parameters
The baseline will be the jay 1 pre—dose measurement of each parameter.
13.4.3 Baseline safety parameters
Baseline for safety parameters will be defined as the last available and evaluable parameter value
before and closest to the first closing on Day—l/Day l in each period for vital sign parameters and
for {CG parameters and during screening for laboratory data.
Baseline definitions specific to each type of safety parameter will be detailed in corresponding
Sections 13.8.3.2 to 13.8.5).
13.5 EXTENT OF STUDY TREATMENT EXDOSURE AND COMPLIANCE
A summary table presenting the exposure of treatment (ie, duration of IMP in days, defined by:
end date of administration — start date of stration + 1) will be provided by treatment group
within population, on the safety population.
The following listings will be provided:
0 Details of drug dosing l treatment received, date and time of HVIP intake, route of
administration, intended and actual dose received)
o The patients receiving D/IP fiom specified batch
o Randomization scheme
0 A listing of meal data.
13.6 PRIORICONCOMITANT M EDlCATION/THERAPY
Previous medications and itant treatments will be coded according to the World Health
Organization — Drug Dictionary (W IO—DD, last version available). Patients who took medications
that were stopped before the first 1MP dosing, and/or patients who received concomitant
treatments with the IMP will be listed. In addition, a separate g of the previous anti~diabetic
medication will be provided.
13.7 ANALYSIS OF PHARMACODYNAMIC VARIABLES
13.7.1 Description of pharmacodynamic variable(s
The pharrnacodynamic data will be collected and managed by a Central Laboratory. The
pharmacodynamic parameters will be derived from using plasma glucose, insulin, C—peptide and
glucagon trations.
All the pharmacodynamic analyses will be performed using the evaluable PD population. Ifthe
evaluable PD population differs by more than 3 patients (>=3) then the full analyses tion
will be ed in on.
The paediatric and the adult population will be analyzed separately. Results will be compared
between paediatrics and adults descriptively.
13. 7. 1. 1 Primary variable
The following PD le will be considered as primary:
— (GLU-AUCO;30_4;30h) calculated as the area under the plasma glucose concentration time
curve from time of breakfast start (30 min after IMP injection i.e. T0.5h) until 4 hours
later ) subtracting the pre—meal value T0.5.
The trapezoidal rule will be used to calculate the AUC.
13.7.1.2 Secondary variables
The following les will be used as secondary for codynamic es:
— Post-prandial plasma glucose (PPG) excursion: PPG excursion will be calculated from
the difference betWeen the maximum after the standardized breakfast and before lunch
subtracting the pre—meal plasma glucose (T05).
~ AUC0130 —4:30 of insulin, C—peptide and glucagon concentrations: the area under the
concentration time profile from time of standardized breakfast start (30 min after
injection and pre—meal plasma glucose = T05) until 4 hours later (T45). AUC will be
calculated using the trapezoidal rule.
13.7.2 Primary analysis
GLU—AUCO:30—4:30h will be analyzed using the following analyses of covariance (ANCOVA)
model with treatment (lixisenatide 5 ng and 10 ug and o pooled across both placebo
formulations), sequence (6 ces), period (1, 2 and 3) as fixed effects, and patient-within-
sequence as random effect, and the T05h plasma glucose concentration as covariate using SAS®
PROC MIXED procedure:
GLU—AUC0230—4z30h = Treatment + period + sequence + patient (sequence) + plasma glucose
T05 + error
In case the number of patients in at least one sequence is too small, the model has to be adapted
by removing the sequence effect.
The least square mean differences between treatment groups and the corresponding 90%
confidence interval (CI) will be calculated within the linear mixed model framework. A
significance level ofp< 0.05 will be used. No adjustment for multiplicity will be performed.
13.7.3 ary analysis/analysis of secondary variables
The secondary acodynamic parameters PPG and the AUCs of n, C—peptide, and
glucagon will be analyzed using the same statistical model as described above with the
corresponding T05 h values as covariates.
GLU—AUC0230—4z30h, PPG and the AUCs of insulin, C—peptide and glucagon will be compared
between the paediatric and adult tions descriptively.
Individual and mean (:SEM) profiles of plasma glucose, insulin, C-peptide and glucagon will be
plotted by population and treatment group
Raw data and derived parameters will be listed.
13.8 ANALYSIS OF SAFETY DATA
The safety evaluation will be based upon the review of the individual values (clinically significant
abnormalities), descriptive statistics (summary , graphics) and if needed on statistical
is (appropriate estimations, confidence intervals), following the sanofi—aventis guideline for
reporting e 1 s rizing and reporting Clinical pharmacology trial data”. All
the safety analyses will be performed using the safety population.
For all safety data, the observation period will be divided into three segments:
0 The pre—treatment phase defined as the time between the patients give informed consent
and the first IMP administration.
0 The on—treatinent phase defined as the time from the first IMP administration up to 24
hours after last administration of IMP (included).
0 The reatment phase will be defined as the time after the on—treatment phase.
All analyses will be based on the on—treatment phase.
For the adults a sanofi-aventis specific list of criteria defining “Potentially Clinical Significant
Abnormalities” (PCSAs) will be used for the statistical analysis and presentation of tory
parameters, vital signs and ECG data. The last version for definition of PCSAs available at the
time of se lock will be used. .
13.8.1 Adverse events
Adverse events will be coded according to the Medical ictionary for Regulatory Activities
(MedDRA, last available version).
They will be fied into predefined rd categories according to chronological criteria:
0 Pre—treatment AEs are defined as AEs that occurred, worsened (according to investigator
opinion) or became s during the pre—treatment phase.
0 Treatment emergent AEs (TEAEs) are defined as AEs that occurred or worsened or
became serious during the on—treatment phase.
o Post—treatment AEs are defined as A is that occurred ed or became serious during
the post-treatment phase.
Treatment emergent adverse events will be assigned to the treatment group ed at the time of
the AB onset.
If the start date (or time) of an A 4 is incomplete or missing, then the AB will be considered as a
TEAE unless a partial date (or time) shows it as a pre— or post—treatment event. If a TEAE
develops on one period and worsens in the following period, it will be considered treatment
emergent for both periods.
All A 1s reported in the study will be listed, sorted by population (paediatric, adult) and patient,
onset date and time. heless, the analyses of the AEs will focus on the T *‘Ab‘s.
13.8.1.1 Treatment-emergent adverse events
The following ncy distributions of TEAEs (incidence tables) will be provided for the safety
population by treatment Within population for the total on—treatrnent period:
e Overview ofTEAE: Number and tage of patients with at least one TEAE, severe
TEAEs, s TEAEs, TEAES g to treatment tinuation and, if any occurred,
TEAEs leading to death
a Summary of treatment—emergent adverse events by primary system organ class and
preferred term — Number and percentage of patients with at least one TEAE
a Summary of treatment—emergent adverse events by primary system organ class and
preferred term ~ Number and percentage of patients and the number of events
0 Listing of patients presenting treatment emergent e events by population, treatment,
system organ class and preferred term
13.8.1.2 Deaths, serious, and other significant adverse events
Deaths, serious ABS, and other significant AEs (eg, related to specific laboratory abnormalities)
will be listed dually and described in the study report in detail.
13.8.1.3 Adverse events leading to treatment discontinuation
In case of any occurrences, individual t listings will be generated for all adverse events
g to treatment discontinuation.
13.8.1.4 Allergic reactions
Listings for allergic reactions
Any cases of allergic reaction will be documented as e events with detailed complementary
information. A listing of individual data (separate from the listing of all adverse events) will be
provided, sorted by patient, onset date and time, irrespective of the tion of the on—treatment
phase, including specifically ption of the adverse event, symptoms of the adverse event,
possible etiologies, actions taken, vital signs measurements (at outset, during reaction and at
recovery) and a ption of the allergic or allergic—like event.
The assessment of all these cases by the Allergic Reaction Assessment Committee (ARAC) will
be also listed, including notably Whether the event reported constitutes an allergic reaction, and if
it does, its diagnosis and severity grade.
All cases will be described in detail in the CSR.
Allergic medical history and family medical history
Allergic medical history and family medical history is to be documented for patients with any
occurrence of potential allergic reaction and will be coded according to the MedDRA dictionary
(latest n in use at time of database lock). All details of allergic medical y and of
allergic family medical history will be listed on an individual basis.
13.8.1.5 Pancreatitis
Any cases of pancreatitis Will be documented as adverse events with detailed complementary
information. A listing of individual data (separate from the listing of all adverse events) will be
provided, sorted by patient, onset date and time, irrespective of the definition of the on—treatment
phase, including notably description of the adverse event, values of amylase and lipase,
gastroenterologist’s evaluation and potential causes of the pancreatitis. All cases will be described
in detail in the clinical study report.
13.8.1.6 Hypoglycemia
Symptomatic hypoglycemia will be reported together with all adverse events.
13.8.2 Clinical laboratory evaluations
13.8.2.1 Biochemistry, hematology and coagulation data
Baseline definition
The values to be used as baselines will be the values collected during screening assessments. If
any of the scheduled ne tests are repeated for any patient, the last ked values will be
considered as baselines, provided they were done before the first IMP administration and in the
same conditions (e.g. fasting for glucose).
alities analyses
For parameters with laboratory ranges and/or abnormality criteria, an “on—treatment” analysis will
be performed using all post-baseline ments done during the on—treatment phase, including
all unplanned and rechecked values. Since laboratory assessments Will be performed during
screening and at end-of—study visit (EOS), no on—treatment ements are pre—planned, only
unscheduled values can occur during the on—treatment phase.
Data will be analyzed quantitatively using descriptive statistics, qualitatively by tabulating al
abnormalities using Sponsor or tory criteria.
If appropriate, counts of patients With out—of—normal laboratory range values Will be provided in
summary tables showing shifts from normal and abnormal baselines to post—baseline
alities, presented by population and ent group. The same type of summary tables
will be provided for out—of—normal laboratory range values. These tables are split by
normal/abnormal status and missing value at baseline (if any).
Descriptive statistics and plots
For ALT, AST, ALP, neutrophils, platelets and creatinine, e, lipase raw data and changes
from baseline (percent change for creatinine) to EOS will be ized in ptive statistics,
by population and treatment group.
Listings
All individual data, for planned urinalysis, hematology and biochemistry, including rechecked
values, will be listed by biological function. If any, data from unscheduled laboratory tests will
also be listed. In these gs, individual data will be flagged when lower or higher than the
lower or upper laboratory limits and/or when reaching the absolute limit of the Sponsor or
tory criteria, when defined. A listing of out—of—normal range definitions will also be
provided.
A listing of liver function data for patients experiencing at least one of the following situations
will be provided as an in—text table:
0 ALT >3 ULN and total bilirubin > 2 ULN during the study, with at least one of them being
post first dose, irrespective of the ion of the on~treatment phase
0 Conjugated bilirubin >35% of total bilirubin and total bilirubin >1.5 ULN, on the same
sample post first dose, irrespective of the definition for the on—treatment phase.
If any, a listing d to increase in ALT 2 2 ULN will be provided, ing notably the
information on IMP intake, medical and surgical history, alcohol habits, trigger factors, event
details with ALT values, associated signs and symptoms.
13.8.2.2 Urinalysis
All qualitative urinary test results (dipstick) and results fiom urinary pregnancy test, including
rechecked values, will be listed.
13.8.3 Vital signs
. 1 Blood pressure and heart rate
Heart rate (HR) and systolic and lic blood pressure (SBP and DBP) will be analyzed as raw
parameter value and change from ne (for supine position only), and as orthostatism
parameter (standing—supine parameter values, when applicable).
The values to be used as baseline will be the pre—dose measurement on Day 1 of each period. If
any of the scheduled baseline tests are repeated for any patient, the last ked values will be
considered as ne, provided they were done before 1P administration.
Data will be analyzed quantitatively using descriptive statistics, qualitatively by tabulating clinical
abnormalities using Sponsor or regulatory criteria.
For heart rate and blood pressures, raw data and changes from each baseline to EOS (for supine
position only) will be ized in descriptive statistics, for each type of measurement and by
population and treatment group.
13.8.3.2 Weight and body mass index
The values to be used as nes will be the Day ~l value. Weight will be ed as raw
parameter value and t change from baseline. Individual BMI will be calculated for any
post—baseline weight assessment time point.
For weight, an “on—treatment” analysis will be performed using all post—baseline assessments done
during the on—treatment period, including rechecked values
Individual data for weight and BMI data will be listed.
13.8.4 Electrocardiogram
ECG parameters obtained from automatic reading of lZ—lead ECG are used to support the safety
analysis.
The values to be used as the baseline will be the Day 1 predose value of each period. If any of the
scheduled baseline tests are repeated for any patient, the rechecked values will be considered as
baselines, provided they were done before the first drug stration of the period.
HR, PR—, QRS—, QT, and corrected QT—interval (QTc) will be analyzed as raw parameter value
and change from baseline to EOS.
Data will be analyzed quantitatively using descriptive statistics, qualitatively by tabulating clinical
abnormalities using Sponsor or regulatory criteria.
":or all parameters, raw data and changes from baseline to EOS will be summarized in descriptive
statistics, by population, parameter, population and treatment group.
.ndividual data for all parameters, including rechecked values, will be .
Tn addition, patients with prolonged QTc (>450 ms) and/or change from baseline in QTc >60 ms
will also be listed separately, using all ose timepoints.
A listing of ts with at least one abnormality in qualitative assessment (ie, abnormal ECG)
after the 1st dosing will be also provided.
13.8.5 Other related safety parameters
13.8.5. 1 Anti-A VEOO1O dies
t listing will be provided for anti—lixisenatide antibodies at baseline. If appropriate,
frequency distributions will be provided.
13.9 ANALYSIS OF PHARMACOKINETIC DATA
13.9.1 Pharmacokinetic parameters
The list of pharmacokinetics parameters is listed in Section 9.3.5.
13.9.2 Statistical is
Pharmacokinetic ters of lixisenatide will be summarized by descriptive statistics (such as
mean, geometric mean, median, standard deviation (SD), rd error of the mean (SEM),
coefficient of variation (CV), (minimum, and m) by population and for each treatment
under the sibility ofDrug Disposition, Safety and Animal Research, sanofi. Other statistical
analyses described below will be performed under the responsibility of Biostatistics, sanofi.
The primary analysis will be based on the evaluable population.
Log— transformed lixisenatide pharmacokinetic parameters Cmax, AUClast, and AUC will be
analyzed using a linear mixed effect model with fixed terms for treatment, sequence, period and a
random term for a t—within~sequence. If the number of patients per sequence is too low the
model might be adapted by excluding the sequence . -
Estimates and 90% CI for the geometric mean ratio of 5 pg lixisenatide and versus 10ug
lixisenatide will be ed by computing estimate and 90% CI for the difference between
treatment means within the linear mixed effects model framework, and then converting to ratio by
the antilog transformation to the original scale.
13.10 PHARMACOKINETICIPHARMACODYNAMIC ANALYSIS
If appropriate, an explorative PK/PD analysis of lixisenatide concentrations vs pharrnacodynamics
will be performed.
13.11 INTERIM ANALYSIS
No interim analysis is planned
14 ETHICAL AND REGULATORY STANDARDS
14.1 ETHICAL PRINCIPLES
This clinical trial will be conducted in accordance with the principles laid down by the 18th World
Medical Assembly (Helsinki, 1964) and all applicable amendments laid down by the World
Medical Assemblies, and the ICH guidelines for Good Clinical Practice (GCP).
In compliance with sanofi~aventis public disclosure commitments, this al trial will be
recorded on public registry web sites (eg, clinicaltrialsgov before the enrollment of the first
patient). The registry will contain basic information about the trial sufficient to inform interested
patients (and their healthcare practitioners) on how to enroll in the trial.
14.2 LAWS AND REGULATIONS
This al trial will be conducted in accordance with all ational guidelines, national laws,
and regulations of the country(ies) in which the al trial is performed, as well as any
applicable guidelines for adults and paediatrics.
14.3 IN FORMED CONSENT
The Investigator (according to applicable regulatory requirements), or a person designated by the
Investigator and under the lnvestigator’s responsibility, should fully inform the patient of all
ent s of the clinical trial including the written information giving approval/favorable
opinion by the ethics committee ( RB/IEC) and Health Authorities (according to local
regulations). All participants should be informed to the t extent possible about the study, in
language and terms they are able to understand.
Prior to a t’s participation in the clinical trial, the written informed consent form should be
signed, name filled in, and personally dated by the patient or by the patient’s legally acceptable
representative, and by the person who ted the informed consent discussion. A copy of the
signed and dated written informed t form will be provided to the patient.
For the children participation, local law must be ed in deciding whether one or both
s/guardians consent is required. If only one parent or guardian signs the consent form, the
Investigator must document the reason for only one parent or guardian’s signature.
In addition, participants will assent as detailed below or will follow the Ethics Committee
(IRE/l *C) approved standard practice for pediatric participants at each participating center (age of
assent to be determined by the lRB’s/IEC’s or be consistent with the local requirements):
ipants who can read the Assent Form will do so before writing their name and dating or
signing and dating the form.
Participants who can write but cannot read will have the assent form read to them before writing
their name on the form.
14.4 INSTITUTIONAL REVIEW BOARD/INDEPENDENT ETHICS COMMITTEE (IRB/IEC)
As required by local regulation, the Investigator and/or the Sponsor must submit this al trial
protocol to the riate lRB/IEC and Health Authorities (according to local regulations), and is
required to forward to the respective other party a copy of the written "and dated
approval/favorable opinion of the ethics committee (IRB/IEC) (signed by the chairman with
IRE/EEC composition) and Health ities (according to local regulations).
The clinical trial (study number, clinical trial protocol title and version number), the documents
reviewed (clinical trial ol, informed consent form, investigator’s brochure, Investigator’s
curricula vitae, etc) and the date of the review should be clearly stated on the written IRB/IEC and
Health Authorities (according to local regulations)approval/favorable opinion.
igational medicinal product will not be released at the study site and the Investigator will
not start the study before the written and dated approval/favorable opinion is/are received by the
Investigator and the Sponsor.
During the clinical trial, any amendment or modification to the clinical trial protocol should be
submitted to the RB/IEC and Health Authorities (according to local regulations)before
implementation, unless the change is necessary to eliminate an immediate hazard to the patients,
in which case the IRE/[EC should be ed as soon as possible. It should also be informed of
any event likely to affect the safety of patients or the continued conduct of the clinical trial, in
particular any change in safety. All s to the investigator’s brochure will be sent to the
IRB/IEC.
A progress report is sent to the IRB/IEC and Health Authorities ding to local regulations)at
least annually and a summary of the trial’s e at the end of the clinical trial.
BIBLIOGRAPHIC REFERENCES
Investigator’s Brochure natide, Edition No. 8, 0 1 st April 2011
Centers for Disease Control and Prevention. National diabetes fact sheet United States, 2003:
general information. Available at: http://WWW.cdc.gov/diabetes/pubs/factsheethtm. Accessed
June 6, 2008.
Canadian Diabetes Association. Clinical Practice Guidelines Expert Committee. Canadian
Diabetes Association 2008. Clinical Practice ines for the tion and ment
of es in Canada. an Journal of Diabetes 2008:8161—8167.
http://wvvw.diabetes.ca/files/cngOOS/cpg—2008.pdf
Pinhas—Hamiel 0., Zeitler P. Clinical presentation and treatment of type 2 diabetes in
children. Pediatric Diabetes 2007;8(9): 16—27
American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care
2000; 23(3); 381-389.
[DP Clinical Guidelines Task Force. Global guideline for Type 2 diabetes. Brussels:
International Diabetes tion, 2005
Exenatide (marketed as Byetta) information; http://
.gov/cder/drug/infopage/exenatide/ defaulthtm
Jones KL, Arslanian S, Peterokova VA, Park JS, Tomlinson MJ: Effect of metformin in
ric patients with type 2 diabetes: a randomized controlled trial. Diabetes Care 25:89—94,
Tanner JM, Davies, PS. Clinical longitudinal standards for height and height velocity for
North American children. J r 1985;107(3):3l7~329.
. Tanner JM, Whitehouse RH, Takaishi M. Standards fiom birth to ty for height, weight,
height velocity, and weight velocity: British children, 1965. II. Arch Dis Child.
1966;4l(220):613—635
ll. r TMS, Jenkins D. JA, Ocana A.M, Rao VA, Collier G.C. Second—meal effect: low-
glycemic —index foods eaten at dinner improve subsequent breakfast glycemic response. Am J
CLin Nutr 1988;48:1041-7.
12. Nilsson A, Ostman E, Preston T and Bjorck. Effects of Gi vs content of cereal fibre of the
evening meal on glucose tolearance at a subsequent standardized breakfast. Eur. J Clin
Nutr.2008 62, 712-720.
The body mass index (BMI) for age percentiles by gender is shown in Figures 3-4, also referred to
as Appendix A. Figure 3 shows the body mass for—age percentiles for boys from 2 to 20
years. Figure 4 shows the body mass index-for-age percentiles for girls from 2 to 20 years.
Appendix B Blood pressure levels by gender, age and height
percentile
90m Percentile 01 Blood Pressure in Boy: 2 to 17 Years of Age According to
Height Percentile
600% Systolic BP for Height tile of: 90'1“!» 011110111: BP tor Hal ontlla of:
Age 5!! 251'I 50"I 751* 95" 51'1 26"1 W 751" 95"
' "‘ ‘
2 98 100 102 104 105 55 56 57 53 59
4 102 105 107 109 110 62 63 64 65 66
6 105 108 110 111 113 2 67 69 70 70 71
8 107" 110 112 114 115 71 72 73 74 75
110 113 115 117 118 73 74 75 76 77
7 ' W 77
12 115 117 119 121 123 75' 76 77 78W 78
" " 78 ""
14 120 123125126 128.1 76' 77 79 "86‘”
16 12.5 128 1.30; 133 79 so 81 32 33
_ 132 1
17 128 131 133 134 136 81 112 as 114 85
90"1 Percentile of Blood Pressure in Girls 2 to 17 Years of Age According to
Height Percentile
Age 5'" 259' 50'“ 757' 95“ 91* 26" 5011' 75"! 9511'
2 99 100 102 103 104 57 58 56 59 60
'4 161 103 104 106 107 63 64 65 65 66
6 104 1W16 107 109 110 67 66 69 69 70
' "TV"'1__71'1__'f_”7§'1
8 100 110 111 11112 __. 1113' "1' “70' 173“
1 ' " ‘75 W6
112 114 115""'_””'1'1”6'“ '11"? ‘73 73 "74'
12 116 118' 119 120 121 75 76 76 77 78
14 119 121 122 121 125 77 78 80
1 1 79 1 117911
“16‘ 122 123 125 126 127 79 79 so 81 82
17 1221 121 1 11125 126 128 79 79 30 a1 82
Appendix C Calculation of Creatinine-Clea‘rance by Cockroft and
Gault
Male: Creatinine clearance[mL/min] = 1140 — age lyearsl) x weight [kg]
creatinine [mg/dL] X 72
Female: Creatlnme clearance[mL/min] ——.. . _(”0 _ age D!emD xwe‘‘§3[]_5tk° XOS
nine [mg/dL] x 72
RECTIFIED SHEET (RULE 91) ISA/EP
Appendix D: Meal test (standardized breakfast)
Ensure Plus Next Generation Vanilla
List of ingredients in descending order:
Water, maltodextrin, hydrolized corn starch, sucrose, milk protein isolate, canola
oil,CASElNATES (calcium caseinate, sodium caseinate), corn oil, MINERALS m citrate,
potassium citrate, magnesium chloride, potassium chloride, magnesium phosphate dibasic,
calcium phosphate tribasic, potassium phosphate dibasic, ferrous sulfate, zinc sulfate, manganese
sulfate, cupric sulfate, sodium molybdate, ium iodide, chromium chloride, sodium selenate),
ascorbic acid,
soy protein e, flavoring, soy lecithin, cellulose, NS (choline chloride,
dl—alpha tocopheryl acetate, niacinarnide, calcium pantothenate, xine hydrochloride,
thiamine hydrochloride, riboflavin, Vitamin A palmitate, beta carotene, folic acid, phylloquinone,
, Vitamin D3, eyanocobalamin), sodium carboxymethyl cellulose, gellan gum.
May contain: sodium chloride.
Approximate analysis
Energy EU kcal Keal 300
Energy EU id 1263
LProtein g 12.50
Fat 9 9.84
Carbohydrate g 40.40
Water 9 154.86
”— ‘7
VITAMINS, .
Vitamin A (palmitate) meg RE 175
Vitamin A (palmitate) [U 584
Vitamin A (B—caretene) meg RE 58
Vitamin A otene) lU 584
Vitamin D3 meg 4.0
Vitamin D3 IU 160
Vitamin E iU 6.4
Vitamin K1 meg 24
Vitamin C mg 24
Folic acid meg 80
Vitamin B1 mg 0.40
Vitamin Bz mg 0.54
Vitamin Be mg 0.54
n B12 meg 1.1
Niacin lent 5.2
. mg
Panthothenie acid mg 2.2
Biotin meg 12
Choline mg 110
MINERALS“ '
Sodium mg 184
Potassium mg 320
Chloride mg 220
Calcium mg 120
orus mg 200
Magnesium mg 60
Iron mg 4.2
Zinc mg 3.6
Manganese mg 1.0
Copper mcg 360
Iodine mcg 44
Selenium mcg 17
Chromium mcg 15
Molybdenum mcg 32
Example 2
A randomized, -blind, placebo controlled trial to assess safety, tolerability,
pharmacokinetics and pharmacodynamics of lixisenatide in paediatric (10-17 years
old) and adult patients with type 2 diabetes
Sponsor] Company: Sanofl
Drug substance(s): Lixisenatide (AVEOOiO)
Title of the study: A randomized, double—blind, placebo controlled trial to assess safety, tolerability, cokinetics and
pharmacodynamics of lixisenatide in paediatric (10~17 years old) and adult patients with type 2 es
Study center(s): Six centers from 4 countries (pediatric patients from 4 centers in Mexico, South Africa, and the United States
[US] and adult patients from 2centers in the US and United Kingdom) '
Study period:
Date first patient enrolled: 24/May/2012
Date last patient completed: 04/Mar/2014
Phase of development: Phase 1
Objectives:
Primary objective:
0 To investigate the effects of a single aneous (SC) lixisenatide dose of 5 pg and 10 pg as compared to placebo in
reducing postprandial plasma glucose (PPG) assessed as area under the plasma glucose concentration curve after a
standardized liquid meal (breakfast) in type 2 ic pediatric population (10-17 years old) and adults as controls.
Secondary ives:
To te in both pediatric and adult populations:
. Pharmacokinetic (PK) parameters of lixisenatide in plasma after single SC ascending doses.
9 The maximum PPG excursion, and the changes in n, C-peptide, and glucagon plasma trations following a
standardized breakfast.
a Safety and tolerability
Methodology: Multicenter, double-blind, randomized, o—controlled, single-dose, 3-period, 34treatment, 6-sequence
crossover study in pediatric and adult patients with type 2 diabetes mellitus (TZDM)
Number of patients: Planned: 12 pediatric patients/12 adult patients
Randomized: 12 pediatric patients/13 adult patients
Treated: 12 pediatric patients/12 adult ts
Evaluated:
Overview of study populations
Pediatric patients Adult patients
Number of patients for:
Evaluable codynamics population (N) 9a 12
Full analysis pharmacodynamics population (N) 12 12
Evaluable cokinetics population (N) 81) 10b
Full is pharmacokinetics population (N) 12 12
Safety population (N) 12 12
a Three patients ed: 2 patients had vomiting within 4 hours after the rdized meal test and 1 patient ingested only half of the
standardized meal test.
b Four pediatric and 2 adult patients excluded: lixisenatide plasma concentrations below lower limit of quantification (LLOQ) in all samples
in at least one period or no more than 3 consecutive samples above LLOQ in at least 1 period.
Diagnosis and ia for inclusion:
Male and female patients with T2DM, with or without metformln (at a stable dose for at least 4 weeks prior to randomization);
HbA1c27% and 310% at screening; fasting C—peptide >O.6 ng/mL at screening; negative test for nsulinoma-associated protein
and anti—glutamic acid decarboxylase autoantibodies.
Pediatric population: Male and female patients 210 and <18 years of age with at least 3 patients below 15 years of age and no
more than 3 patients 216 and <18 years of age, body mass index (BMI) >85th percentile for age and gender, and BMI $50 kg/m2
(body weight >50 kg)
Adult population: Male and female patients 218 and 565 years of age, and with BMI >25 kg/m2 and $37 kg/mZ.
Study treatments
igational medicinal product(s): Lixisenatide and placebo
Formulation: Lixisenatide (100 pg/mL) and placebo, provided as ons for injection in a 3-mL glass cartridge
Route(s) of administration: SC injection with pen-type injector lik®)
Dose regimen: In each of the 3 treatment periods, patients were administered, in fasted conditions, a single dose of 5 pg
lixisenatide or 10 pg lixisenatide (with 5 pg ing the 10 pg dose level) or placebo (50 or 100 pL), 30 minutes before a
standardized liquid breakfast.
Duration of treatment: Three treatment periods, each lasting 1 day (up to 2 days in case of institutionalization on the evening of
Day -1).
Duration of observation: Up to 7 weeks for each patient including a screening period of up to 28 days, 3 treatment periods of up
to 2 days ted each by a washout period of 1 to 7 days and an endofstudy visit 1 to 6 days after the last investigational
medicinal product (IMP) administration.
Criteria for evaluation:
Pharmacodynamics:
Primary endpoint:
0 Plasma glucose: corrected plasma glucose-AUCoaomsom area under the curve for plasma glucose concentration-time
profile calculated from time of standardized breakfast start (30 minutes after IMP injection and premeal plasma
glucose=TOH30) until 4 hours later (T4H30) after subtracting the premeal value )
Secondary endpoints:
. cursiono;soh-4;aoh: m change in PPG from time of standardized breakfast start (30 minutes after IMP
injection=TOH30) until 4 hours later (T4H30)
. AUCOZ30h—4I30h of plasma glucose, n, C-peptide, and glucagon: area under the curve for plasma glucose, insulin,
C-peptide or glucagon concentration-time profiles from time of standardized breakfast start (30 minutes after IMP
ion=TOH30) until 4 hours later (T4H30)
Safety: Patients were monitored for safety via adverse events (AEs) reported by the patient or noted by the Investigator,
physical ation, body temperature, standard clinical laboratory evaluations, vital signs, and electrocardiogram (ECG)
ters.
Pharmacokinetics: Lixisenatide plasma tration, PK parameters um plasma concentration observed [Cmax], time
to reach Cmax , area under the plasma concentration versus time curve calculated using the trapezoidal method from time
zero to the real time [AUCIast], area under the plasma concentration versus time curve extrapolated to infinity [AUG], area under
the plasma concentration versus time calculated using the trapezoidal method from time TOH30 to T4H30 [AUCOz30h-4230h1).
PharmacokineticIPharmacodynamic sampling times and bioanalyticai methods:
Blood s for pharmacodynamic (PD) analysis were collected at each treatment period for plasma glucose, glucagon, insulin
and C-peptide assessments: blood samples were taken 30 minutes before a standardized breakfast and prior to dosing (T0), then
immediately prior to the standardized breakfast (TOH30 hours), and thereafter at T1, T1 H30, T2, T2H30, T3H30, and T4H30 (ie,
, 60, 90, 120, 180, and 240 s eakfast) for AUCO:30h-4:30h for plasma glucose, glucagon, insulin, and C-peptide
measurements.
The quantitative is of plasma glucose was assessed using the GIuco-quant GIucose/hexokinase assay for glucose from
Roche Diagnostics, Mannheim, Germany. The range of the method was 3—1000 mg/dL, with i mg/dL as limit of detection (LOD),
3 mg/dL as lower limit of fication (LLOQ), and 1000 mg/dL as upper limit of quantification.
The method for quantitative analysis for human C~peptide was assessed using the Electro Chemiluminescence Immuno Assay
(ECLIA) from Roche Diagnostics, Mannheim, Germany. The range of the method was 0.2-25 ng/mL, with an LLOQ of 0.2 ng/mL
and an LOD of 0.07 ng/mL.
The method for quantitative analysis of glucagon was assessed using the radioimmunoassay (RlA) from Euro-Diagnostica,
Malmd, Sweden. The range of the method was 4.7—150 pmoI/L.
The method for tative analysis of insulin was assessed using the ECLlA assay from Roche Diagnostics Deutschland GmbH,
im, Germany. The range of the method was 1—875 mIU/L, with an LLOQ of 1 mIU/L and an LOD of 0.3 mIU/L.
Blood samples for PK analysis were collected at each treatment period for the determination of lixisenatide plasma concentrations:
blood samples were taken 30 s before a standardized breakfast and prior to dosing (T0), and thereafter at TOH30, T1,
T1 H30, T2H30, T3H30, T4H30, and T6H30.
Lixisenatide plasma concentrations were determined using a validated double—antibody sandwich enzyme-linked immunosorbent
assay method with an LLOQ of 5.5 pg/mL.
Anti-lixisenatide antibody status and, if positive, anti-lixisenatide antibody concentrations were determined using the validated
BlAcore technique with a study-specific, and thus not prospectively determined, cutoff as LLOQ. Blood samples were taken only
on Day 1/Period 1 before the first IMP administration.
Statistical methods:
Pediatric and adult patients were analyzed separately. Results were compared between the 2 populations descriptively.
Pharmacodynamics:
Within each crossover, the analyses of the primary PD endpoint were performed based on the ble PD population, using the
full analysis PD population as supportive analyses. Corrected plasma glucose —tacit was analyzed using a linear
mixed-effect model with sequence, period, and treatment effect as fixed effects, and patient within sequence as random effect,
and the TOHBO plasma glucose concentration as covariate. The least square (LS) mean differences between treatment groups
and the corresponding 95% confidence intervals (Cls) were estimated within the linear mixed model framework. A cance
level of p<0.05 was used.
Secondary PD parameters were analyzed using the same statistical model as described above with the corresponding TOHSO
values as covariates.
Pharmacokinetics:
The statistical analyses of PK ters were done on the evaluable PK population, using the full analysis PK population as
supportive analyses.
Log-transformed natide PK parameters Cmax, t. and 0h-4;30h were analyzed using a linear mixed-effect model with
fixed terms for sequence, treatment and a random term for a t-within-sequence. Estimates and 90% Cls for the geometric
mean ratio of lixisenatide 10 pg versus lixisenatide 5 ug were ed by ing estimate and 90% Cls for the difference
between treatment means within the linear mixed-effects model framework, and then converting to ratio by the antilog
transformation to the original scale.
Safety:
The safety analysis 'was based on the review of the individual values (clinically significant abnormalities) and descriptive statistics
(summary tables and plots if appropriate) by treatment.
Treatment—emergent adverse events (TEAEs) classified in system organ classes (8003) and red terms were summarized
by number and percentage of patients and number of TEAEs. individual clinical laboratory data, vital signs, and ECGrdata were
listed and flagged for potentially clinically significant abnormalities (PCSAs) and for lower and upper clinical laboratory limits.
Frequency of patients with abnormalities and with on-treatment PCSAs were summarized for each type of parameter by treatment.
Population characteristics:
Twelve pediatric and 12 adult patients with T2DM were randomized and treated. One additional adult patient was randomized
but not treated (this t withdrew from the study due to al reasons before the first IMP administration). All patients
were on concomitant metformin therapy during the study.
Demographics and baseline characteristics for ric and adult ts are summarized in the table below.
Demographics, patient, and disease characteristics at baseline in pediatric and adult patients, safety population
Pediatric patients Adult patients
N 12 12
Mean age (years) [min~max] 13.9 [10—17] 51.3 [41—60]
Age group (years) (n, %)
[10—15] 7 (58.3%)
[15—16] 2 (16.7%)
3 (25.0%)
[18-50] 5 (41.7%)
[50—65] 7 (58.3%)
Sex (n [%])
Male 6 (50%) 9 (75%)
Female 6 (50%) 3 (25%)
Race (n [%])
Caucasian/white 1 (8.3%) 6 (50%)
Asian/oriental 1 (8.3%)
Othera 11 (91.7%) 5 (41.7%)
Mean weight (kg) ax] 84.69 [560-1290] 92.58 [747-1353]
Mean BMl (kg/m2) [min-max] 31.42 [22.7-44.1] 31.79 [27.0-36.1]
Duration of diabetes (years): 1.56 [05-79) 4.45 [1 9-20.41
median [min-max]
Duration of metformin treatment (years): 1.56 [0.5-7.6] 2.13 [0.4-7.4]
median [min-max]
Mean HbA1c (%) [min—max] 8.65 [7.09.9] 8.43 [7.2-9.1]
Among 11 pediatric patients, 7 self-reported as Hispanic and 4 self—reported as a group of mixed race in South Africa (the Cape
d). Five adult patients self—reported as Hispanic or Latino.
Pharmacodynamic results:
Primary pharmacodynamic endpoints:
in the pediatric evaluable PD population, the corrected plasma glUCOSG-AU00130h-4230h was decreased by single doses of
lixisenatide 5 and 10 pg compared to placebo, but the differences versus placebo were not statistically significant. For the
primary endpoint (corrected plasma glUCOSe'AUCO:30hA:30h), the LS mean difference between the lixisenatide 5 pg dose and
placebo was -3.92 mmolh/L; 95% Cl: -8.17 to 0.34 mmol.h/L, p=0.0681 (-70.56 mg.h/dL; 95% Cl: -147.15 to 6.04 mg.h/dL).
The L8 mean difference between natide 10 pg and placebo was -1.52 mmol.h/L; 95% Cl: -5.59 to 2.56 mmol.h/L,
p=0.4359 (27.33 L; 95% Cl: -100.75 to 46.10 mg.h/dL) (see tables below).
Pediatric patients - plasma glucose premeal corrected AUC0230h-4230h (mmol.hlL) per treatment group and difference of
lixisenatide 5 pg and 10 pg to placebo - evaluable PD population
Least Square Means (SE)a
Treatment N Corrected plasma Corrected plasma 95% Cl of p-value
group glucose-AUCo:304:aoh giucose-AUCmomon ence
[mmol.h/L] difference to placebo [mmol.h/L]
[mmol.h/L]
o 9 9.63 (3.95)
Lixisenatide 9 5.72 (3.99) -3.92 (1.97) (-8.17; 0.34) 0.0681
Lixisenatide 9 8.11 (4.08) -1.52 (1.89) 0.4359
. (5.59; 2.56)
pg
a SE (standard error)
ric patients - plasma glucose premeal corrected 0h-4:30h (mg.hIdL) per treatment group and difference of
lixisenatide 5 pg and 10 pg to placebo = ble PD population
Least Square Means (SE)a
Treatment N ted plasma Corrected plasma 95% CI of p-value
group giucose-AUCo;3o4;aoh glucose-AUCo;ao4:soh difference
[mg.h/dL] difference to placebo [mg.h/dL]
Placebo 9 173.51 (71.24)
Lixisenatide 9 102.96 (71.81) -70.56 (35.46) (147.15; 6.04) 0.0681
Lixisenatide 9 146.19 (73.44) -27.33 (34.00) (-100.75; 0.4359
pg 46.10)
8 SE (standard error)
In contrast to pediatric patients, in the adult ble PD population, single doses of lixisenatide 5 and 10 pg significantly
reduced PPG assessed as ted plasma e-AUCoaomson compared to placebo. The L8 mean ence between
lixisenatide 5 pg dose and placebo was -8.57 mmolh/L; 95% Cl: -14.91 to -2.23 mmol.h/L, p=0.0104 (~154.41 mg.h/dL;
95% CI: 26.860 to 4.0 21 mg. h/dL). The L8 mean difference n lixisenatide 10 pg and placebo was--15.48 mmol. h/L;
95% Cl: -21. 59 to -.938 mmol. h/L, p<0.0001 (—2.7893 mg.h/dL; 95% CI: -388.96 to 1.68 90 mg.h/dL) (see tables below). The
difference between lixisenatide 10 and 5 pg was not statistically significant.
Adult patients - plasma glucose premeai corrected AUCOz30h-4z30h (mmol.hIL) per treatment group and difference of
Iixisenatide 5 pg and 10 pg to placebo - evaluable PD population
Least Square Means (SE)a
Treatment N Corrected plasma Corrected plasma 95% CI of p-value
group glucose-AUC02304:30h giUCOSB-AUCo:30-4:30h difference
[mmol.h/L] difference to placebo [mmol.h/L]
[mmol.h/L]
Placebo 12 16.60 (2.46)
Lixisenatide 12 8.03 (2.95) -8.57 (3.05) (14.91 ;-2.23) 0.0104
Lixisenatide 12 1.11 (2.85) ~15.48 (2.93) (21.59 ; -9.38) <0.0001
pg
a SE (standard error)
Adult patients - plasma glucose premeai ted AUCO:30h-4:30h (mg.hldL) per treatment group and difference of
Iixisenatide 5 pg and 10 pg to placebo - evaluable PD population
Least Square Means (SE)a
Treatment N » Corrected plasma Corrected plasma 95% CI of p-value
group e-AUCo;3o.4:auh glucose-AUCo;304;3oh difference
[mgh/dL] difference to o [mg.h/dL]
[mg.h/dl_]
Placebo 12 299.01 (44.36)
Lixisenatide 12 144.60 (53.18) ~154.41 ) (268.60 ; -40.21) 0.0104
119
Lixisenatide 12 20.08 (51.37) -278.93 (52.81) (388.96 ; -168.90) <0.0001
pg
a SE (standard error)
Secondary phannacodynamic endpoints:
in the pediatric ble PD population, the results for plasma glucose AUCo:aon4;30h were consistent with those for the primary
endpoint (corrected plasma giucose-AUCaaameon). Single dose of Iixisenatide 5 pg significantly reduced the m PPG
excursion ed to placebo: the LS mean difference n Iixisenatide 5 pg and o was —1.50 mmol/L; 95% Cl: —2.94
to -0.07 mmol/L, p=0.0415'(-27.08 mg/dL; 95% CI: -52.95 to -1.22 . The ence between lixisenatide 10 pg and placebo
was not statistically significant: the LS mean difference was -1.13 mmol/L; 95% CI: —2.50 to 0.25 mmol/L, p=0.1005 (20.30 mg/dL;
95% Cl: -45.09 to 4.50 mg/dL).
In the pediatric ble PD population, the AUCO;30h-4:30h for glucagon, n, and C-peptide were decreased with both
lixisenatide 5 and 10 pg compared to placebo except for insulin that increased with Iixisenatide 5 pg; r, the variability was
high (see tables below). The differences between lixisenatide 5 or 10 pg and placebo were not statistically significant for any of
these endpoints, except the decrease in glucagon with lixisenatide 10 pg. No statistically significant ences between
lixisenatide doses were observed for any ary endpoint in the pediatric evaluable PD population.
In the adult evaluable PD population, the results for plasma glucose AU00130h-4130h were consistent with those for the y
endpoint (corrected plasma giUCOSe‘AUC0230h4:30h). Single doses of Iixisenatide 5 and 10 pg significantly reduced the maximum
PPG excursion during the postprandial period up to 4 hours after the standardized breakfast, compared to placebo. The L8 mean
difference between Iixisenatide 5 pg and placebo was -2.78 mmol/L; 95% Cl: 4.29 to -1.27 mmol/L, p=0.0010 (-50.06 mg/dL;
95% Cl: -77.27 to 22% mg/dL), and the LS mean difference between lixisenatide 10 pg and placebo was -4.32 mmoi/L;
95% CI: -5.77 to -2.87 mmol/L, p<0.0001 (-77.85 mg/dL; 95% CI: 403.95 to -51.76 mg/dL).
In the adult evaluable PD population, the AUC0230h—4230h for glucagon, insulin, and ide were decreased with both atide
and 10 pg compared to placebo, and these decreases were statistically significant with natide 10 pg (see table below). The
decreases in AUCo;30h4:30h for glucagon and C-peptide were not statistically significantly different between lixisenatide doses. The
decrease in AUCosouoaon for insulin with lixisenatide 10 pg compared to lixisenatide 5 pg was statistically significant: the LS mean
difference was -378.97 /L; 95% Cl: -711.56 to 46.38 pmolh/L, p=0.0277 (63.16 mclU.h/mL; 95% Cl: —118.59 to
-7.73 mcth/mL).
Pediatric patients - AUCO:30h-4:30h for plasma glucose, glucagon, insulin, and C-peptide per ent group and difference between
lixisenatide 5 and 10 pg to placebo (SI units) — evaluable PD population
Least Square Means (SE)a
Parameter Treatment group N AUCo;3o-4;30h Difference to 95% CI of p-value
o ence
Plasma
glucose Placebo 9 44.50 (3.91)
(mmol.h/L) Lixisenatide 5 pg 9 40.53 (3.94) -3.97 (1.93) (8.13 ; 0.19) 0.0599
Lixisenatide 10 pg 9 42.94 (4.03) -1.56 (1.85) (5.55 ; 2.43) 0.4147
Glucagon Placebo 9 664.83 )
(ng.h/L) Lixisenatide 5 pg 8 652.63 (22.22) ~12.20 ) (58.05 ,' 33.65) 0.5769
Lixisenatide 10 pg 9 621.48 (20.77) 43.35 (18.30) (83.25 ;—3.45) 0.0356
insulin Placebo 7 1843.81 (297.88)
(pmo|.h/L) Lixisenatide 5 pg 8 1973.88 (243.52) 130.07 (372.42) (668.69 ; 928.83) 0.7321
Lixisenatide 10 pg 8 1602.80 (239.93) -241.01 (365.37) (1024.64 ,' 0.5202
' 542.63)
C—peptide Placebo 8 9.92 (0.56)
(nmol.h/L) Lixisenatide 5 pg 8 9.87 (0.59) 004 (0.80) (1.79 ;1.71) 0.9565
Lixisenatide 10 pg 8 9.21 (0.58) —0.70 (0.74) (2.35 ; 0.94) 0.3631
a SE (standard error)
Pediatric patients - AUCO:30h-4:30h for plasma e, glucagon, insulin, and ide per treatment group and difference between
Iixisenatide 5 and 10 pg to placebo (US units) ~ evaluable PD tion
Least Square Means (SE)a
Parameter Treatment group N AUCO:30-4:30h Difference to 95% CI of p-value
placebo difference
Plasma
glucose Placebo 9 “ 801.63 (70.40)
(mgh/dL) Lixisenatide 5 pg 9 730.11 (70.95) —71.52 (34.71) (146.51; 3.47) 0.0600
natide 10 pg 9 773.58 (72.53) —28.04 (33.29) (99.92; 43.84) 0.4147
Glucagon Placebo 9 664.83 (19.92)
(pg.h/mL) Lixisenatide 5 pg 8 652.63 (22.22) -12.20 (21.35) (58.05; 33.65) 0.5769
Lixisenatide 10 pg 9 621.48 (20.77) 43.35 (18.30) (83.25; ~3.45) 0.0356
Insulin Placebo 7 307.30 (49.65)
h/mL) Lixisenatide 5 pg 8 328.98 (40.59) 21.68 (62.07) (111.45; 154.80) 0.7321
Lixisenatide 10 pg 8 267.13 (39.99) 40.17 ) (170.77; 0.5202
90.44)
C—peptide Placebo 8 29.78 (1.69)
(ng.h/mL) Lixisenatide 5 pg 8 29.65 (1.76) -0.13 (2.41) (5.39; 5.12) 0.9565
Lixisenatide 10 pg 8 27.67 (1.76) -2.11 (2.22) (7.05; 2.82) 0.3631
8 SE (standard error)
Adult patients - AUC0130h-4:30h for plasma e, glucagon, insulin, and ide per treatment group and difference between
lixisenatide 5 and 10 pg to placebo (Si units) - evaluable PD population
Least Square Means (SE)a
Parameter Treatment group N AUCO:30-4:30h . Difference to 95% CI of p-value
placebo difference
Plasma P acebo 12 54.32 (2.46)
glucose
(mmol.h/L) L'xisenatlde 5 pg 12 45.75 (2.95) 857 (3.05) (14.91; -2.23) 0.0104
natide 10 pg 12 38.83 (2.85) —15.48 (2.93) (21.59; 9.38) <0.0001
Glucagon P acebo 12 628.98 (26.47)
(ng.h/L)
L‘xisenatide 5 pg 12 612.44 (27.90) 46.54 (18.48) (55.53; 22.46) 0.3834
L'xisenatide 10 pg 12 575.30 (27.95) 63.68 (18.59) (92.89; . 0.0102
44.46)
Insulin P acebo 12 1276.36 (85.63)
(pmolh/L)
L'xisenatide 5 pg 11 1181.62 —94.74 (124.99) (356.57; ) 0.4579
(103.75)
Lixisenatide 10 pg 12 802.65 (104.20) 473.71 (126.74) (738.96; 0.0014
' ’”' 208.45)
C—peptlde P acebo 12 8.90 (0.48)
(nmol.h/L) natide 5 pg 11 8.42 (0.56) -0.47 (0.64) (1.81; 0.87) 0.4701
Lixisenatide 10 pg 12 6.81 (0.56) —2.09 (0.63) (3.40; 017) 0.0036
a SE (standard error)
Adult patients - AUCO:30h-4:30h for plasma glucose, glucagon, insulin, and C-peptide per treatment group and difference between
lixisenatide 5 and 10 pg to placebo (US units) - evaluable PD tion
Least Square Means (SE)3
Parameter Treatment group N 0-4:30h Difference t0 95% CI of p-value
placebo difference
Plasma Placebo 12 978.50 (44.36
glucose
(mg.h/dL) Lixisenatide 5 pg 12 824.10 (53.18 ~154.41 (54.99) (268.60 ; 0.0104
. 40.21)
Lixisenatide 10 pg 12 699.58 (51.37 -278.93 (52.81) (388.96 ; <0.0001
-168.90)
on Placebo 12 628.98 (26.47
(pg-h/mL)
leisenatide 5 pg 12 612.44 (27.90) -16.54 (18.48) (55.53 ; 22.46) 0.3834
Lixisenatide 10 pg 12 575.30 (27.95 -53.68 (18.59) (92.89 ; 0.0102
44.46)
insulin Placebo 12 212.73 (14.27
(mclU.h/mL)
Lixisenaiide 5 pg 11 196.94 (17.29) -15.79 ) (59.43 ; 27.85) 0.4579
Lixisenatide 10 pg 12 133.77 (17.37 -78.95 (21.12) (123.16 ; 0.0014
~34.74) ~
C—peptide Placebo 12 26.71 (1.45)
mL) leisenatlde 5 pg 11 25.30 (1.69) -1.42 (1.92) (5.43 ; 2.60) 0.4701
118881818810 12. - -1 188 .. . ,
. ., .
a SE (standard error)
Pharmacokinetic results:
natide plasma trations were below LLOQ in all samples from 2 pediatric patients treated with lixisenatide 10 pg and
1 adult patient treated with lixisenatide 5 pg. For 1 pediatric and 1 adult patient treated with lixisenatide 5 pg and 1 pediatric patient
treated with lixisenatide 10 pg, no more than 3 consecutive samples were above LLOQ and ore these patients were not
evaluable for PK analysis.
ln the pediatric evaluable PK population, the exposure of lixisenatide was similar for both dose groups. A high variability was
ed with lixisenatide 10 pg. For Cmax, the ient of variation (CV%) was 47.7% for lixisenatide 5 pg and 74.3% for
lixisenatide 10 pg. For AUClast, the CV% was 78.2% for natide 5 pg and 101.1% for lixisenatide 10 pg. in the pediatric
evaluable PK population, the point estimate of the treatment ratio (lixisenatide 10 pg versus lixisenatide 5 pg)'for Cmax was
1.04 (90% Cl: 0.71 to 1.51) and for AUClast was 0.88 (90% Cl: 0.51 to 1.49).
In the pediatric full PK population, the exposure was slightly higher in patients treated with lixisenatide 10 pg compared to
treatment with lixisenatide 5 pg. A high variability was observed for both dose . For Cmax, the coefficient of variation (CV%)
was 51.7 for natide 5 pg and 72.1 for lixisenatide 10 pg. For AUClast, the CV% was 92.5 for lixisenatide 5 pg and 97.4
natide 10 pg. '
Following single-dose SC administration in adult patients, the exposure of lixisenatide increased with the dose, and was
tional with dose for the evaluable and full PK population.
In pediatric patients, the exposure was similar to that in adults treated with lixisenatide 5 pg, but lower than in adults treated with
‘ lixisenatide10
cokinetic parameters for lixisenatide in plasma - evaluable PK populations
Plasma Lixisenatide
Mean i SD Paediatric Adults
(Geometric Mean) [CV%] ‘
natide 5 pg Lixisenatide 10 pg Lixisenatide 5 pg Lixisenatide 10 pg
N 8 8 10 10
Cmax 29.7 i 14.2 34.3 i 25.4 26.0 i 15.4 55.9 i 21.3
(pg/mL) (26.3) [47.7] (27.2) [74.3] (22.8) [59.4] (53.3) [37.5]
tmaxa 1.25 0.49 1.50 2.50
(h) (0.48 - 3.50) (0.48 — 3.55) (0.42-3.50) (0.42 - 3.50)
11/22 3.19 i 1.12 2.52 i 0.775 3.10 i 1.22 2.79 i 1.35
(h) (3.01) [35.1]b (2.41) [30.8]c (2.89) [39.3] (2.59) [48.1]
AUClast 99.4 i 77.7 108 i 109 101 i 58.0 242 i 90.0
(pg-h/mL) (76.9) [78.2] (67.4) [101.1] (90.8) [57.3] ' (228) [37.2]
AUCO:30h-4:30h 82.5 i 54.6 88.0 i 76.0 77.2 i 42.4 181 i 71.9
(pg~h/mL) (67.4) [662]” (64.3) [86.4]c (70.0) [54.9] (168) [39.6]
3 Median (Min - Max)
evaluable paediatric population ts: 484001004 - 006, 484001008, 484001010, 710002001, 710002005, 710002009
b N: 7 for subject 710002005 missing could not be calculated
° N: 7 for subject 710002009 missing could not be calculated
evaluable adult population: subjects 826001004, 826001021, 840005006, 010011, 840005014, 840005016 - 017,
840005020-021
Source = PKS Study : PKD11475; Scenario: P-D—A-EV—OD, Version 1, P-D-A~EV-OD-E02, Version 3
Point estimates of ent ratios of Iixisenatide 10 ug versus 5 ug — evaluable PK population
Point estimate ratio [90% Cl] Pediatric Adults
N 8 10
Cmax 1.04 2.34
. [0.71 — 1.51] [1.85—2.95]
AUCIast 088 2.51
[0.51 — 1.49] [1.90 — 3.30]
AUCo:30.4:30n 0.93 2.41
[0.57 —1.50] [1.88 — 3.08]
Safety results:
No serious AEs were ed during the study, and no patient discontinued the study due to TEAEs. in the pediatric population,
4 patients (1 after injection of placebo, 1 after lixisenatide 5 pg, and 2 after lixisenatide 10 pg) experienced 6 TEAEs (5 from the
gastrointestinal disorders SOC and 1 from the infections and infestations SOC). Of these ts, 1 experienced vomiting of mild
intensity 43 minutes after injection of placebo (5 minutes after the rdized liquid breakfast), and another patient enced
vomiting of mild intensity with concomitant nausea 3 hours and 15 minutes after injection of lixisenatide 5 pg (2 hours and
31 minutes after the standardized liquid breakfast). One patient experienced diarrhea and concomitant nausea after injection of
natide 10 pg. The incidence of TEAEs was low in the adult population (1 event of diarrhea in 1 placebo—treated patient). All
TEAEs were of mild to moderate intensity. All patients red without sequelae with or without corrective treatment.
In the pediatric population, there were few PCSAs for blood pressure with no relationship to the IMP or dose administered. Few
patients had PCSAs for ECG parameters (prolonged PR, QRS, and QTC) without relevant ences between lixisenatide and
placebo. -
There were no PCSAs (during the on—treatment period) for blood pressure or ECG parameters in the adult population.
All patients, except 1 adult, were anti'lixisenatide antibody negative at study entry.
Conclusions:
After a rdized liquid ast in 12 pediatric patients with T2DM aged between 10 and less than 18 years old, with a mean
HbA1c of 8.65% and mean body weight of 84.7 kg treated with metformin as a background therapy, a non-significant decrease in
plasma glucose (corrected plasma glucose AUC0:30h-4230h and plasma e AU Comment) was observed with single doses of
natide 5 and 10 pg compared to placebo. in st, single doses of lixisenatide 5 and 10 pg significantly reduced plasma
glucose (corrected plasma glucose AUCUIEOh-4230h and plasma glucose AUCO:30h~4:30h) in 12 adult patients with T2DM compared to
placebo. This PPG-lowering effect in adult patients treated with lixisenatide 10 pg was associated over the same period with
statistically significant decreases in concentrations of glucagon, insulin, and C-peptide. These PD s occurred to a lesser
extent with lixisenatide 5 pg. in pediatric patients, 0h—4:30h for glucagon and C-peptide were decreased with lixisenatide 5 and
pg compared to placebo, and the effects were more marked with lixisenatide 10 pg (p=0.04 for glucagon decrease). Of note, a
large variability was observed mainly for 0h-4:30h for insulin, which increased with lixisenatide 5 pg and decreased with
lixisenatide 10 pg.
Following single subcutaneous administration, lixisenatide exposure was similar for both dose groups in the evaluable pediatric
patients, whereas in adult patients, the lixisenatide exposure dose-proportionally increased. In the full ric PK population,
lixisenatide exposure was slightly higher for the higher dose of 10 pg. ln pediatric patients, the re was similar to that in
adults for lixisenatide 5 pg, but lower for lixisenatide 10 pg.
Single doses of lixisenatide 5 and 10 pg were safe and well tolerated in pediatric and adult patients.
Supportive PD and PK data
Adult patients - Descriptive statistics on plasma glucose premeal corrected AUCO:30-4:30h (mmol*hlL) per treatment
group - Evaluable PD tion
Descriptive statistics on ted GLU-AUCMMW1
[mmol*h/L]
Treatment N Mean Median (min ; max)
group
o 12 17.51 (4.98) 16.50 (9.7 ; 25.7)
Lixisenatide 12 10.60 (6.83) 12.08 (5.1 ; 18.6)
Lixisenatide 12 1.89 (8.36) 1.01 (-15.9 ; 16.3)
pg
Pediatric ts - Descriptive statistics Plasma glucose premeal corrected AUC0130-4230h (mmol*h/L) per treatment
group - Evaluable PD population
Descriptive statistics on Corrected GLU-AUCOSMSO),
[mmol*h/L]
Treatment N Mean Median (min ; max)
group
Placebo 9 10.10 (9.57) 7.89 (-2.1 ;21.7)
Lixisenatide 9 6.24 (8.53) 3.77 (—3.2 ; 19.9)
Lixisenatide 9 8.76 (8.12) 4.63 (-0.3 ; 24.1)
10119
Adult patients — descriptive statistics on AUC0230-4z30h for plasma glucose, on, insulin, and C-peptide per
treatment group - Evaluable PD population
Descriptive statistics on AUCO;30.4:30h
Parameter Treatment N Mean (SD) Median min—max
group
Plasma Placebo 12 57.18 (12.06) 56.83 (37.4 ; 77.7)
glucose
(mmol*h/L) Lixisenatide 5 pg 12 47.60 (11.02) 49.08 (29.9 ; 71.2)
natlde 10 pg 12 38.37 (11.37) 35.10 (22.5 ; 58.5)
Glucagon Placebo 12 647.39 (132.49) 616.77 500.3; 908.0)
(ng.h/l.)
Lixisenatide 5 pg 12 628.56 (191.49) 591.56 (442.2; 1163.8)
Lixisenatide 10 pg 12 564.83 (148.93) 513.67 ; 950.6)
insulin Placebo 12 1488.52 1342.19 (763.6 ; 2859.4)
h/L) (512.03)
Lixisenatide 5 pg 11 1314.15 1268.09 ; 1841.0)
(306.08)
Lixisenatide 10 pg 12 1015.12 1051.94 (641.6; 1317.8)
(261.87)
C-peptide Placebo 12 8.73 (1.91) 8.82 (6.0 '; 13.3)
(nmol.h/L) Lixisenatide 5 pg 11 8.08 (1.24) 8.65 (5.9 ; 9.7)
Lixisenatide 10 pg 12 7.08 (1.24) 7.25 (4.7 ; 9.1)
1 SE (standard error)
Pediatric patients - descriptive statistics on AUCO:30-4:30h for plasma glucose, glucagon, insulin, and C-peptide per
treatment group — Evaluable PD population
Descriptive statistics on AUCOSOMOh
Parameter Treatment N Mean (SD) Median min—max
group
Plasma
glucose Placebo 9 45.57 (19.78) 42.81 (19.4 ; 75.9)
(mmo|*h/L) natide 5 pg 9 39.60 ) 41.03 (20.7 ; 55.9)
Lixisenatide 10 pg 9 44.60 (17.44) 48.87 (17.9 ; 64.4)
Glucagon Placebo 9 685.37 (130.00) 695.60 (456.9 ; 918.5)
(ng.h/L) natide 5 pg 8 616.84 4) 592.97 (428.4 ; 763.9)
Lixisenatide 10 pg 9 644.06 (117.88) 622.34 (444.1 ; 824.9)
n Placebo 7 2152.06 (942.87) 2587.48 (801.6 ; 3335.7)
(pmol.h/L)
Lixisenatide 5 pg 8 2208.53 (1566.96) 1724.15 (405.7 ; 5330.2)
Lixisenatide 10 pg 8 2143.02 (1393.59) 1691.69 (506.2 ; 4693.3)
C-peptide Placebo 8 9.70 (1.75) 10.14 (6.6 ; 11.6)
(nmol.h/L) Lixisenatide 5 pg 8 9.68 (2.74) 9.18 (5.3 ;14.5)
natide 10 pg 8 9.55 (3.00) 9.42 (5.3; 14.3)
1 SE (standard error)
PK parameter for lixisenatide in plasma (full PK tion)
Mean *1 SD AdUltS Pediatric
tric Mean) [CV%] LiXisenaiide 5 pg Lixisenatide 10 [.19 Lixisenatide 5 pg leisenaiide 10 [1g
N 10% 12 10 9,** Seminar”.
Cmax 26.0 i 15.4 52.8 i 21.7 25.3 i 15.6 33.3 i 24.0
(pg/mL) (22.8) [59.4] (48.8) [41.1] (20.4) [61.7] (27.0) [72.1]
tmaxa 1.50 2.50 1.50 0.50
(h) (0.42 - 3.50) (0.42 - 4.50) (0.48 — 4.50) (0.48 - 3.55)
AUCiast 101 i 58.0 228 i 89.0 83.0 i 76.8 105 i 102
(pg-h/mL) (90.8) [57.3] (213) [39.0] (57.1) [92.5] (68.9) [97.4]
AUCo.54.5 77.2 i 42.4 169 i 72.4 74.7 i 55.2 86.8 i 71.2
(pg-h/mL) (70.0) [54.9] (155) [43.0] (57.9) [73.9] b (65.6) [82.1]
Median (Min
- Max)
* 011; “ 484001001, ”710002007 all samples were below LLOQ.
9 840003002.ll 826001020
; 1[484001003 no more than 3 consecutive samples were above LLOQ and therefore not evaluable for PK analysis
“ N=8, could not be calculated for patients 710002005, 007
, therefore not included in the summary statistics
Source = PKS Study: PKD11475;: P-D-A—EV-OD Version 1, P-D—A-EV—OD-EOZ, Version 3
:xampie 5 120
A randomized, double—blind, placebo-controlled, dose escalation, study on
safety, pharmacokinetics and pharmacodynamics of lixisenatide in pediatric
patients With type 2 diabetes not adequately lled with min and/or
basal insulin
Clinical Trial Summary
Randomized, double-blind, placebo—controlled, dose escalation
study on safety, pharmacokinetics and pharmacodynamics of
lixisenatide in pediatric patients with type 2 diabetes not
adequately controlled with metformin and/or basal insulin
TORITRIAL LOCATION Multinational, multicenter
STUDY OBJECTIV Primary objective:
0 To demonstrate safety of 14-day repeated lixisenatide
doses of 5 pg, 10 pg and 20 pg as compared to placebo
pediatric in patients with type 2 diabetes
Secondary objectives:
. To evaluate plasma concentrations of lixisenatide after
repeated doses of 5 pg, 10 pg and 20 pg and
pharmacokinetic parameters of repeated lixisenatide doses
of 20 pg in plasma in pediatric patients with type 2
diabetes
To evaluate the change to ne in post—prandial plasma
glucose concentrations during a rdized meal test
after repeated doses of lixisenatide 5 pg, 10 pg and 20 pg
in comparison to placebo
DESIGN Phase l, center, randomized (3:1), -blind, placebo-
controlled, dose escalation study
The study compn’ses:
. An up to 3-week screening period
a A 6-week randomized double-blind treatment period with 2
el arms (placebo arm / lixisenatide arm) and
incremental sequential steps of 2 weeks for the lixisenatide
dose escalation (5 pg, 10 pg and 20 pg) or matched
placebo
A post-treatment follow-up period of 3 days
STUDY POPULATEON Male and female patients with documented type 2 diabetes
Main selection ia: mellitus insufficiently controlled with a min dose 2
1000 mg/day (or maximum tolerated dose according to
the investigators judgment) at a stable regimen for 8 weeks
prior to randomization and/or stable basal insulin alone or in
combination for 12 weeks prior to randomization
Aged 2 10 and < 18 years old (at least 4 patients below 16
years old)
HbAlc >6.5% and s 11 %
Body mass index (BMI) of >85th percentile for age and
gender and BMI s 50 kg/m2 ;
Fasting C-peptide at screening > 0.6 ng/mL
Negative test for anti-insulinoma associated protein (IA2)
and anti-glutamic acid oxylase (GAD) autoantibodies;
Total expected number of patients: A total of 24 completed patients
Expected number of sites de
STUDY TREATM -NT(s) During the first part of the double-blind treatment period
with lixisenatide 5 pg or matching placebo during 14 days:
lnvestigational Medicinal Product(s) Test drug: Lixisenatide 5 pg
Formulation: Lixisenatide will be supplied as a disposable pro-filled pen,
is a self-injector device (Tactipen®) containing 3 mL of a
sterile aqueous solution for subcutaneous (so) injection in
Route(s) of administration: a 3—mL volume containing 300 pg of the active ingredient
(i.e., iOO pg/mL), glycerol, sodium e trihydrate,
Dose regimen: methionine, metacresol, HCLjNaOH, water for injection.
Control drug: Lixisenatide matching placebo
natide matching placebo will be supplied as a sterile
3-mL aqueous solution. ‘
Both lixisenatide and the matching placebo are to be
injected once daily with a pen self-injector device and the
volume to be injected will be 50 pL.
Route(s) of administration: s.c.
During the second part of the double-blind treatment period
with lixisenatide 10 pg or matching placebo during 14 days:
Test drug: Lixisenatide 10 pg
natide is supplied as green disposable led pen,
ie a self—injector device (Delta 14®) containing 3 mL of a
sterile aqueous solution for s.c. injection with 150 pg of the
active ingredient (ie, 50 pg/mL), glycerol, sodium acetate
trihydrate, methionine, metacresol, CL/NaOH, water for
injection. The lixisenatide jector dispenses fourteen
fixed doses of 200 pL.
l drug: Lixisenatide matching o
Lixisenatide matching placebo will be supplied as a sterile
3—mL s solution
Both lixisenatide and the matching placebo are to be
injected once daily with a pen self-injector device (Delta
i4® of green color) and the volume to be injected will be
200 pL.
s) of administration: 5.0.
During the third part of the double-blind treatment period
with lixisenatide 20 pg during 14 days or matching placebo:
Test drug: Lixisenatide 20 pg
Lixisenatide is ed as purple disposable self-injector
device (Delta 14®) containing 3 mL of a sterile aqueous
on for so. injection with 300 pg of the active ingredient
(ie, 100 pg/mL), glycerol, sodium acetate trihydrate,
methionine, metacresol, HCL/NaOH, water for injection. The
natide pen-injector dispenses fourteen fixed doses of
200 pL.
Control drug: Lixisenatide matching placebo
Lixisenatide ng o will be supplied as a sterile
3-mL aqueous solution
Both lixisenatide and the matching placebo are to be
injected once daily with a pen self—injector device (Delta
14® of purple color) and the volume to be injected will be
200 pL.
Routejs) of administration: 3.0.
Before starting each dose escalation step the patients and/or
their parents will be trained on site by the study staff/nurse to use
each type of injector pens appropriately before they start the new
dose of daily subcutaneous injection of lixisenatide or placebo.
Furthermore, if , depending on patients maturity, a home
nursing e can be proposed during the first 3 injections (or
more if needed) to ensure a good compliance.
At home, injections should be performed once daily within 1 hour
prior to breakfast. At on—site visits, ions should be
performed once daily approximately 30 s prior to the start
of the standardized breakfast.
Background antidiabetic therapy will be stered daily about
the same clock time as usually done; ment of basal n
dose may be needed with the supervision of the investigator or
medical designee.
Non lnvestigational Medicinal Product(s) Not applicable
(if applicable)
Formulation:
s) of administration:
Dose regimen
PRIMARY ENDPOINT(S) AN Primary endpoint:
ARY NT(S) gajgty: Adverse events (AEs) Nreatment—Emergent Adverse
Events (TEAEs) clinical laboratory (hematology, biochemistry,
lipase and amylase, urinalysis) evaluations including vital signs,
12—lead ECG parameters, body temperature and physical
examination.
Secondary nts
Pharmacokinetics:
. PK parameters (Cmax, trnax, ,AUCth.5)after14—day
repeated dosingat20 pg on Day 42
Lixisenatide plasma concentrations 0, 0.5, 1.5 and 2.5
hours after lMP injection, i.e. T0 before IMP, T05, T15
and T25, after 14-day repeated dosing at 5 pg, 10
pg and 20 pg on Day 14, Day 28 and Day 42;
Pharmacodynamics:
. The change to baseline in plasma glucose AUC04.5
after 14-day repeated dosing at 20 pg on Day 42
The change to baseline in postprandial plasma glucose
excursion 1H post meal test and 2H post meal test,
i.e. difference T1,5—T0 and T2.5—TO after 14—day
repeated dosing at 5 pg, 10 pg and 20 pg on Day 14,
28 and 42,
Anti—lixisenatide antibodies: assessment before first dosing at
Visit2Da -1 ,and after14-day re-eated dosin- at5 -, 10 q
and 20 pg.
Other endpoints
Body weight, HbA1c at baseline and after 14-day repeated
dosing at 20 pg.
ASSESSM NT SCH Screening period: from Week—3 to Week -1
At Visit 2 (Day-1): face to face ng of patients and/or
(s) on IMP pen injector, glucose meter use, diary recording
use, hypoglycemia awareness and management education; IMP
subcutaneous injection training for the home nurse e, if
any, in charge of the administration of the appropriate dose and
in the respect of given condition (outpatient procedure excepted
at on—site visits).
ne pharmacodynamics assessments with blood sampling
0.5 hours prior to the standard breakfast ingestion (ie, T0). Then
blood sampling will be performed at 1, 1.5, 2, 2.5, 3.5 and 4.5
hours after breakfast (ie, T1, T15, T2, T25, T35 and T45).
Randomized, double-blind placebo-controlled treatment
period with dose escalation every 14 days (5 pg, 10 pg and
pg or matching placebo)
Every 2 weeks, on—site visits: Visit 3 (Day14), Visit 4 (Day28)
and Visit 5.(Day42) for , pharmacodynamics and
pharmacokinetic assessments
These on—site visits require patients to be in fasting condition for
blood sampling prior to IMP injection (approximately 30 min
before the start of the standard breakfast, is TO). Then, blood
sampling will be performed at the following ints:
o 0 (immediately before IMP ion), 0.5 (PK only)15 and
2.5 hours after IMP injection (ie TO, T05, T15 and T25) at
Visit 3 (Day14) and Visit 4 )
. 0, 0.5 (PK only), 1, 1.5, 2, 2.5, 3.5 and 4.5 min (ie TO, T05,
T1, T1 .5, T2, T25, T35 and T45) at Visit 5 (Day 42)
Safety: refer to the study flow chart for physical examination,
body temperature and vital signs, 12-lead ECG, and laboratory
assessments. Throughout the study :adverse events recording
STATISTICAL CONSIDERATIONS All analyses will be interpreted in an exploratory way, no
confirmatory analyses will be done.
Safety:
All randomized patients receiving at least one dose of the IMP
(regardless of the amount of treatment administered) will be
included in the safety tion.
The safety analysis will be conducted on the safety population
based on individual values (clinically cant abnormalities)
and descriptive statistics (summary tables and plots if
riate). Individual values will be flagged for potentially .
clinically cant abnormalities (PCSAs), TEAEs will be
tabulated s and percents). Descriptive statistics will be
generated by dose level/treatment for selected parameters of
interest.
Vital signs, Laboratory— and ECG parameters and changes
com-ared to baseine where a roriate will be anal zed b
dose level/treatment using descriptive statistics.
Number and percentage of patients with antibody status
negative/positive will be summarized by dose level.
Pharmacokinetics (PK):
Plasma AVE0010 concentrations will be summarized by antibody
status for each dose level using descriptive statistics. PK
parameters (Cmax, tmax, AUCM5) will be summarized by antibody
status for the 20 pg dose level using descriptive statistics.
Pharmacodynamics (PD):
Descriptive statistics and graphs will be provided on raw data
and change from ne. Analyses will be done by dose
level/treatment.
Relationship between PK and PD will be explored graphically at
the 20 pg dose level.
Results from PK modeling and PK/PD analysis will be reported
separately.
Others es:
ptive statistics and graphs will be provided on raw data
and absolute change from baseline for HbAtc, and body weight.
DURATION OF STUDY PERIOD Duration of each part of the study for one patient:
(per patient) Screening: Day-21 to Day-1 (overnight hospital stay
from Day-1 to Day 1 or two single visits )
Treatment period: 6 weeks (Day 1 to Day 42) with on-
site visit prior to the dose escalation every 2 weeks
-up and end-of-study: Day 45
Total study duration: up to 10 weeks
1. FLOW CHARTS
1.1. GRAPHICAL STUDY DESIGN
The graphical study design of Example 3 is shown in Figure 17.
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2 INTRODUCTION AND RATIONALE
2.1 INTRODUCTION
Lixisenatide is a potent and selective Glucagon—Like peptide—l (GLP-1) receptor agonist. The
GLP-1 receptor is the target for native GLP-l, an endogenous incretin hormone that iates
glucose—dependent insulin secretion from beta cells and suppresses glucagon ion from alpha
cells in the pancreas. Similar to endogenous GLP~l, the action of liXisenatide is mediated via a
specific interaction with GLP-l ors, including those on pancreatic alpha and beta cells.
After a meal, lixisenatide activates the following individual physiologic ses:
0 Enhances insulin secretion by B—cells in a glucose ent way
0 Suppresses glucagon secretion by s
o Delays gastric emptying
Lixisenatide stimulates insulin secretion only when blood glucose is increased, but not at
euglycemia, which limits the risk of hypoglycemia. In parallel, glucagon secretion is ssed.
In case of hypoglycemia0 the rescue mechanism of glucagon secretion is preserved. Lixisenatide
also slows gastric emptying thereby reducing the rate at which meal—derived glucose s in
the circulation. The effect on gastric emptying may contribute to body weight ion.
Lixisenatide further showed a trend towards insulinotropic activity, including enhancement of
insulin biosynthesis and stimulation of beta-cell proliferation in animals, and has been shown to
preserve beta cell function and prevent cell death (apoptosis) in ed human pancreatic islet
cells.
In summary, lixisenatide is an exendin analog with strong GLP=~1 agonistic activity. The pal
therapeutic potential of lixisenatide to lower blood glucose in adult T2DM patients has been
established in clinical studies.
Lixisenatide (Lyxumia®) was ed since 2013 in the European Union, Japan, Mexico and
other parts of the world for the treatment of adults with T2DM to achieve glycemic control in
combination with oral glucose lowering medicinal products and/or basal n when these,
together with diet and exercise, do not provide adequate glycemic control. The indication may
vary slightly across the countries where natide is approved.
According to the Summary of Product Characteristics, the 10 ug dose is the starting dose intended
to improve gastrointestinal tolerability. After 2 weeks at 10 ug QD, the dose should be increased
to 20 ug QD from Day 15. The 20 ug dose Q ») is the fixed maintenance dose.
Up to now, the safety and efficacy of the GLP-1 or agonists currently approved in the U.S.
have not been established for use in patients less than 18 years of age. Therefore, there is little
clinical evidence upon which to base a discussion of anticipated therapeutic similarities or
differences between pediatric and adult patients with T2 M administering these agents.
In a single—dose pharmacokinetic study conducted with exenatide in 13 patients with type 2
diabetes and between the age of 12 and 16 years, administration of exenatide (5 pg, the initiation
dose in adult) resulted in slightly lower mean AUC (16% lower) and Cmax (25% lower)
compared to those observed in adults (12). Based on the ural similarities of lixisenatide and
ide, these results may be taken into consideration when ing the clinical studies
proposed with lixisenatide.
A previous PK/PD study (Example 2) in type 2 diabetic children and adolescents (from 10 to
17 years) and in type 2 diabetic adults (as a control group) was a multicenter study evaluating PK,
safety/tolerability and PD ters after single 8.0. administration of lixisenatide 5 pg, 10 pg
and placebo ing to a ized, double-blind crossover design. All included patients
were previously d with metformin. In 12 pediatric patients, a non-significant decrease in
plasma glucose (plasma glucose AUC0;30h4;30h) after a standardized liquid breakfast was observed
with single doses of lixisenatide 5 and 10 pg compared to placebo. In contrast, these single doses
of lixisenatide significantly reduced plasma glucose ed to placebo in 12 adult patients with
T2 M. Lixisenatide exposure was similar for both dose groups in the evaluable pediatric patients,
whereas in adult patients, the lixisenatide exposure dose-proportionally increased. In pediatric
patients, the exposure was similar to that in adults for lixisenatide 5 pg, but lower for lixisenatide
pg. Single doses of lixisenatide 5 and 10 pg were safe and well tolerated in both, pediatric and
adult ts in this study of short duration.
In conclusion, Example 2 demonstrated comparable PK and PD profiles in pediatric and
adult patients at a dose of Spg, as well as no unexpected safety results. However, the results
observed with a dose of IOpg (initiation dose in adult) are not conclusive. The dose of 20pg
(maintenance dose in adult) was not evaluated in this study.
As a consequence, this repeated dose study will therefore be conducted to further
evaluate PK, PD and safety at a dose of 5, 10 and 20pg before conducting a large phase 3 study
with the expected therapeutic dose.
More detailed information on lixisenatide (AVEOOlO) is ed in the Investigator’s Brochure.
2.2 AL III
2.2.1 Study Rationale
The aim of the present study is to evaluate safety, cokinetics and
pharmacodynamics of repeated subcutaneous QD dose administration of lixisenatide.(5 pg, 10 pg
and 20 pg) versus placebo in pediatric patients with type 2 diabetes (10—17 years old).
T2DM in children and adolescents has become an singly important public health concern
throughout the world. T2DM occurs when insulin secretion is inadequate to meet the increased
demand posed by insulin resistance, leading to relative insulin deficiency (l) and is frequently
associated with other lic abnormalities, characteristic of insulin resistance (dyslipidemia,
hypertension, polycystic ovary syndrome, fatty liver) (2).
ding with the increasing prevalence of obesity in children, the incidence of T2DM in
children and adolescents has ly increased. Obesity is a major risk factor impacting insulin
sensitivity and leading to T2DM in pediatric patients.
The pathophysiology of T2DM in children and adolescents appears to be similar to that in .
The increase in diabetes in a younger population is likely to be related to the increase in obesity in
this population.
One study found an inverse relationship between body mass index and age at diagnosis of T2DM
t adults, and it is possible that the degree of y determines when es will
develop. It is then reasonable to assume that such glucose-lowering agents associated with weight
reduction will be effective in the pediatric population. r, some factors, such as the number
of associated co—morbidities in the different age groups, and differences in the management of
en / adolescents as compared to adults, make it difficult to estimate the similarities and
differences of treatment effects in T2 )M between these two populations.
At present, metformin and insulin are the only drugs with regulatory approval in most countries
for the ent of pediatric diabetes. necause approximately half of youth with T2DM fail to
maintain glycemic control when treated with metformin either alone or in conjunction with
lifestyle interventions, insulin therapy is often required soon after diagnosis. Thus, there is a need
for more treatment options for children and cents with T2DM.
2.2.2 Design Rationale and risk assessment
This is a centric, ized, -blind, placebo—controlled, repeated dose study with
lixisenatide dose escalation by 2-week step ng at 5 ug, followed by 10ug and 20ug.
0 Study population
The study population will include male and female patients aged between 10 and 17 years old
inclusive.
Use of GLP—l receptor agonists may be associated with gastrointestinal adverse reactions.
Therefore, pediatric patients with severe gastrointestinal disease associated with prolonged nausea
and vomiting, including severe gastroparesis will not be included in this study. To date, there is
limited therapeutic experience of lixisenatide in adult patients with moderate renal impairment
and no therapeutic experience in patients with severe renal impairment (creatinine clearance less
than 30 mL/min) or end-stage renal disease. As a consequence, pediatric patients with severe renal
impairment will not be ed in the present study.
4» Doses and regimen
In the present study, lixisenatide treatment will be initiated with 5 ug Q3 during 2 weeks then
increased to 10 ug QD for 2 weeks then 20 ug Q.) for 2 weeks. This stepwise dose increase can
prevent or reduce gastro—intestinal adverse events frequently observed with lixisenatide. The dose
of 5 pg corresponds to 50 % of the starting dose in adults, and 20 ug Q) is the maintenance dose
in adults. This study will assess liXisenatide given in combination with metformin and/or basal
insulin.
Patients will be included with a stable dose of metformin (unchanged for at least 8 weeks prior to
randomization) and the initial metformin dose is to be kept unchanged throughout the study. The
metformin morning dose will not be taken before the last blood sample and it may be delayed at
lunch time or later.
When liXisenatide is added to existing y of basal insulin, a reduction in the dose of the basal
insulin may be considered to reduce the risk of hypoglycemia, possibly when starting the dosing
with 20 ug, at the discretion of the igator.
0 Condition of administration
Lixisenatide should be administered by deep subcutaneous injection, alternating between the left
and right anterolateral and left and right posterolateral abdominal wall, thighs or upper arms.
Within a given area, on should be changed (rotated) at each time to prevent injection site
skin reactions.
Lixisenatide will be subcutaneously administered on site approximately 30 minutes before the
start of the standardized breakfast on Days 14, 28 and 42.The other days, it will be administered
within 1 hour before breakfast in outpatients.
2.2.3 Specific ters rationale
Hypoglycemia and symptomatic hypoglycemia will be carefully monitored by reporting of
adverse events and r control of glycemia; appropriate device for self-monitoring plasma
glucose (monitored by parents) will be provided to participants (Section 4.2.2).
The monitoring of pancreatic enzyme levels will be applied in this study. This is an eStablished
practice in clinical trials involving glucagon-like peptide—l or agonists following reports of
pancreatitis during T2DM treatment with this therapeutic class (3). Diagnosis of pancreatitis
required meeting of two of the following three criteria: amylase/lipase levels three or more times
the upper normal limit, characteristic nal pain, and/or characteristic findings of acute
pancreatitis on computed tomography scan or ic nce imaging.
Anti—liXisenatide antibody formation may occur. Therefore, they will be measured before first
closing at Day— 1(baseline), and after 14-day repeated dosing at 5 pg, 10 pig and 20 ug. Systemic
allergic reactions may occur, as well as other hypersensitivity ons that have been observed in
natide clinical trials, eg, rash or ema, ria, angioedema and anaphylactic
reactions. Hypersensitivity reactions may occur, with or without the presence of anti-liXisenatide
antibodies.
2.2.4 Study committees
The sponsor can ask the opinion from independent experts in the field of allergy to review the
cases of allergic or allergic—like reactions in a blinded manner with regard to study ent.
Similarly, in cases of pancreatitis, the events can be reviewed by independent gastroenterology
experts.
3 SELECTION OF PATIENTS
3.1 lNCLUSlON CRITERIA
Demography
I 01. Vlale or female ts aged 2 10 and < 18 years old (at least 4 patients below 16 years
I 02. %ody mass index (BMI) >r85th percentile for age and gender ; %MI < 50 kg/m2 ; body
weight > 50 kg
Health status
I 03. Male and female patients with nted type 2 diabetes mellitus insufficiently
controlled with a metformin dose 21000 mg/day (or maximum tolerated dose according to
the Investigator’s judgment) at a stable n for 8 weeks prior to randomization and/or
stable basal insulin alone or in combination for 12 weeks prior to randomization
104. HbAlc > 6.5% and 511% at screening
I 05. Fasting C-peptide at screening > 0.6 ng/mL (0.20 nmol/L)
l 06. Negative test for anti-insulinoma associated protein (1A2) and anti-glutamic acid
oxylase (GA )) autoantibodies
I 07. Menstruating females(even if irregular) must have a negative pregnancy test for ion
and agree to repeat pregnancy tests at designated visits throughout the study.
Regulations
1 08. Provision of Informed Consent form signed by the patient’s parent (s)/1ega1 representative.
in addition, provision of Assent Form signed by minor t or Informed Consent Form
signed by emancipated or mature minors (defined by local laws)
I 09. Covered by a health insurance system where applicable, and/or in ance with the
recommendations of the national laws in force relating to biomedical research.
1 10. Not under any administrative or legal supervision.
3.2 EXCLUSION IA
3.2.1 ion criteria related to study methodology
E 01. If female, ongoing ncy (defined as positive serum pregnancy test), breast—feeding
E 02. Sexually active narchal female patient who does not agree to use an adequate and
highly effective method of contraception throughout the study duration and according to
local regulation (i.e. hormonal contraception, condom, etc.).
*1 03. Diabetes other than type 2 diabetes
E 04. History of acute lic decompensation such as ic ketoacidosis within 3 months
Lil 05‘. g plasma glucose > 250 mg/dL (>139 mmol/L) at screening
E 06. Hemoglobinopathy or hemolytic anemia
ill 07. Recurrence of severe hypoglycemia or hypoglycemic unawareness as judged by the
investigator
‘3‘ 08. Uncontrolled hypertension, treated or untreated above 99th percentile for age and gender in
children (see Appendix A)
E 09. Any clinically significant abnormality identified on physical ation, laboratory tests,
ECG or Vital signs at the time of screening that in the judgment of the Investigator or any
sub Investigator would make implementation of the protocol or interpretation of the study
results difficult or would preclude the safe participation of the patient in this protocol such
as active malignant tumor diagnosed hyperthyroidism or uncontrolled hypothyroidism or
major systemic diseases etc.
(euthyroid patients on replacement therapy will be included if the dosage of in is
stable for at least three months prior to screening Visit)
E 10. Receipt of blood or plasma products within 3 months prior to the time of screening
E11. Patient/Parent(s) considered by the investigator or any sub investigator as opriate for
this study for any reason (eg, impossibility to meet specific protocol requirements, such as
led visits, administer s.c. IMP QD self-inj ection or refusal of any ance of
home nurse service for the s.c. IMP injections, etc)
4 l2. Use of other oral or inj e antidiabetic or hypoglycemic agents other than metforrnin
and basal insulin (eg, alpha glucosidase inhibitor, GLP-1 receptor agonist, DPP~IV
inhibitors, short-acting insulin etc.) within 1 months prior to the time of screening
€13. Use of systemic glucocorticoids (excluding topical application or inhaled forms) for one
week or more within 3 months prior to the time of screening
E 14,. Patient having received or receiving psychotropic medication
E 15. Patient receiving treatment with weight reduction medications (including anti-obesity
treatment)
E 16. Likelihood of ing treatment during the screening phase and treatment phase with
drugs not permitted by the al study ol
* 17. Use of any investigational drug within 3 months prior to screening
3.2.2 Exclusion criteria related to the current knowledge of lixisenatide
E 18. Clinically relevant history of gastrointestinal disease associated with prolonged nausea and
ng, including, but not d to gastroparesis and gastroesophageal reflux disease
requiring medical treatment, within 6 months prior to the time of screening
E 19. Any previous treatment with lixisenatide
E 20. Allergic reaction to any GLP—lreceptor agonist in the or to metacresol
E 21. History of unexplained pancreatitis, chronic pancreatitis, pancreatectomy, stomach/gastric
surgery, inflammatory bowel disease
E 22. al or family history of medullary thyroid cancer (MTC) or genetic ions that
predispose to MTC (eg, multiple endocrine neoplasia syndromes)
E 23. Known y of drug or alcohol abuse Within 6 months prior to the time of screening
4; 24. Laboratory findings at the time of screening:
— Elevations in blood tests of renal (serum creatinine >1.0 mg/dL) and/or liver (ALT,
AST and/or bilirubin) >2 times the upper limit of normal (ULN) for age.
- Hemoglobin <11 g/dL and/or neutrophils <1500/mm3 and/or
ets <100 000/mm3
- Calcitonin 220 pg/mL
— Amylase and/or lipase above 3 times the upper limit
- Positive result on any of the following tests: hepatitis B e (HBs Ag) antigen,
anti~hepatitis C virus (anti-HCV) antibodies
E 25. Positive alcohol breath test
B 26. Positive result on urine drug screen (amphetamines/methamphetamines, barbiturates,
benzodiazapines, cannabinoids, cocaine, opiates)
E 27. Severe renal impairment defined With
creatinine clearance < 30 mL/mjn/ 1 .73m2 using the revised Schwartz a (4)
0.413 * Ht
GFR =
Cfserum
CrCl (mL/min/1.73 m2) — Ht: Height in cm — Crsemm (mg/dL)
4 ASSESSMENT OF INVESTIGATIONAL MEDICINAL PRODUCT
4.1 CODYNAMICS
4.1.1 Pharmacodynamic parameters
a Plasma e
— the change to baseline in plasma glucose AUC0-4,5 age, 14-day repeated dosing at 20 ug
on Day 42 (GLU—AUCM‘sy GLU— AUCO 45 is defined as the area under the plasma
glucose concentration time profile from time of the IMP injection until 4:30 hours later
(T45). AUC will be calculated using the trapezoidal rule.
— the change to baseline in postprandial plasma glucose excursion 1 hour andial
and 2 hours postprandial after l4-day repeated dosing at 5 pg, 10 ug and 20 ug on
Day 14, 28 and 42:
o postprandial plasma glucose excursion 1 hour post prandial (lH-PPG) will be
calculated as the difference between the plasma glucose value 1 hour post
meal test (T15) and the plasma glucose value before time of injection (T0):
lH-PPG = PG-T1.5 — PG—TO
o postprandial plasma glucose ion 2 hours post prandial (2H—PPG) will be
calculated as the difference between the plasma glucose value 2 hours post
meal test (T25) and the plasma glucose value before time of injection (T0):
2H—PPG = PG—T2.5 —- PG—TO
o HbAlc
- Change from baseline to Week 6
0 Body weight
-— Change from baseline to Week 6
4.1.2 Assessment methods
4. 1.2. 1 Plasma glucose
Plasma e ments are planned on )ay -1 (V2) (Baseline), Day 14 (V3), Day 28 (V4)
and Day 42 (V5). Blood samples will be taken as indicated below in Table l
Table 1 — Blood sampling for plasma glucose
Time 0 H 1H 1H30 2H 2H30 3H30 4H30
(hour/min)
T (h) To a T1 T1.5 T2 T2.5 T35 T45
Visit/Day:
V2/Day-1 X X X X X X X
V3/D14 X X X
V4/D28 X X X
V5/D42 X X X X X X X
a 30 min before to the standardized breakfast ingestion and prior to IMP administration at V3/D14, V4/D28 and V5/D42
The first blood sampling (T0) for plasma glucose will be withdrawn in fasting condition (i.e.,
patients will be fasted for imately 10 hours overnight), 30 min prior to the standardized
breakfast and prior to dosing on Days 14, 28 and 42.
Samples for plasma glucose will be analyzed in a Central laboratory. Detailed ation on
sample drawing, management and bioanalytical methods for plasma glucose will be provided in
the laboratory manual.
4.1.2.2 HbA1c
HbAlc will be ed by a central laboratory certified level I “National Glycohemoglobin
Standardization Program” (NGSP) central laboratory.
TIbAlc will be measured at screening (V1) and Day42 (V5).
Detailed information on sample g, management and bioanalytical methods for HbAlc will
be provided in the tory manual.
4. 1.2.3 Body weight
3ody weight should be obtained with the patient wearing undergarments or very light clothing
and no shoes, and with an empty bladder. The same scale should be used throughout the study,
and calibrated on a regular basis as recommended by the manufacturer.
The use of balance scales is recommended; if digital scales are used, testing with rd weights
is of particular importance. The floor surface on which the scale rests must be hard and should not
be carpeted or covered with other soft material. The scale should be balanced with both s at
zero and the balance bar aligned. The patient should stand in the center of the rm as standing
nter may affect measurement. The weights are moved until the beam balances (the arrows
are aligned). The weight is read and recorded in the e-CRF and Source Data. Self—reported
weights are not acceptable; patients must not read the scales themselves.
Body weight will be ed at screening, on )ay -1, Dayl4, Day 28, Day 42 and at the end of
the. study Visit.
4. 1.2.4 Patient diary
ation recorded into diary will document the compliance of IMP (liXisenatide/placebo)
treatment as well as the safety and tolerability and these recordings will be carefully reviewed also
at each on—site visit.
All patients will receive 1 diary, at visit V2 and they will bring it back to the center at each
following visit during the treatment. Patients/parents will be instructed how to fill in it every day.
The diary includes sections for recording:
Time and dose of IMP injections (during the treatment ),
Any change in metforrnin dose or missing ) and time if any,
Any change in basal insulin daily dose and time or missing_dose(s)if any,
‘Any change or new concomitant medication,
Adverse events, including signs and symptoms suggesting occurrence of hypoglycemia
(possibly documented with measurement of “self—monitored plasma glucose” or plasma
glucose monitored by others) and local injection site reactions, if any.
All patients will receive 1 diary, at visit V2 and they will bring it back to the center at each
following visit during the treatment. Patients/parents will be cted how to fill in it every day.
4.1.3 Assessment schedule
The assessment timing can be found in the period flow chart (Section 1.3).
Table 2 — Number of samples
Plasma glucose HbA‘l c
By t (7X2)+(3x2) a 2
Total by patient 20 2
Total for study (n patients) 20 * 24:480 2 * 24:48
a 7 timepolnts at Day‘t (V2) and Day 42 (V5) — 3 timepoints at days 14 and 28 (V3 and V4) ,
4.2 SAFETY
Assessment schedule should be adapted to the compound specificities and the objectives of the
study. Suggested list below:
4.2.1 Baseline demographic teristics:
ne demographic characteristics will consist of:
1. Age (years)
P‘EJ‘PP’N Height (cm)
Body weight / Body mass index
Race / Ethnicity
Gender
Diabetes history including:
— Date of the diagnosis of diabetes;
— Start date, daily dose and regimen of administration of the background treatment at
screening: metformin, basal insulin if any
7. Tanner staging (Appendix B)
4.2.2 Safety assessment at baseline and during the study
The tolerability investigations at baseline and during the study will consist of:
1. Physical examination (includes at a minimum: heart and respiratory auscultation;
eral arterial pulse; pupil, knee, es, and plantar reflexes; peripheral lymph
nodes and abdomen examination), Body temperature (°C), Vital signs (heart rate, systolic
and lic blood pressure measured after 10 minutes in supine resting position).
ody weight (kg).
. Laboratory tests (in fasting ions for blood samples):
0 Hematology: red blood cell count, hematocrit, hemoglobin, white blood cell count
with differential count (neutrophils, eosinophils, basophils, monocytes, and
lymphocytes), platelets.
0 Biochemistry:
- Plasma/serum electrolytes: sodium, potassium, chloride, calcium;
= Liver function: AST, ALT, alkaline phosphatase, gamma-glutamyl erase,
total and conjugated bilirubin;
- Pancreatic enzymes: amylase, lipase
— Renal function: urea, nine;
- Metabolism: glucose, albumin, total proteins, total terol, triglycerides;
_- Potential muscle toxicity: creatine phosphokinase,
‘- Calcitonin (thyroid c-cell tumor marker) at screening only
4. gy tests: hepatitis B antigen, hepatitis C antibodies
. Urinalysis: proteins, glucose, erythrocytes, leucocytes, ketone , and pH. (To be
adapted according to investigator site dipsticks)
— Qualitative: A dipstick is to be performed on a freshly voided en for qualitative
detection using a reagent strip.
— Quantitative: A quantitative measurement for glucose, protein, erythrocytes, and
ytes count will be required in the event that the urine sample test is positive for
any of the above parameters by urine dipstick (eg, to confirm any positive dipstick
parameter by a quantitative measurement).
Urine drug screen: amphetamines/metharnphetamines, barbiturates, benzodiazepines,
cannabinoids, cocaine, and opiates.
Alcohol breath test.
If , beta~HCG plasma test.
Anti-lixisenatide antibodies
. Adverse events, spontaneously reported by the patient or observed by the Investigator, will
be monitored;
ll. Standard lZ-lead ECGS (safety ECGs) are ed after at least 10 s in supine
position using an (type of recorder and company to be added) electrocardiographic device.
The electrodes will be positioned at the same place for each ECG recording throughout the
study (attachment sites of the leads will be marked with an indelible pen).
11 case of triplicate (ie, baseline in TDU), 3 ECGS will be recorded within 5 minutes with
at least 1 minute between 2 replicates.
*ach ECG consists of a lO—second recording of the 12 leads simultaneously, leading to:
o A single 12-lead ECG (25 mm/s, lOrnrn/mV) printout with heart rate, PR, QRS, QT,
QTc automatic correction evaluation (by the ECG device), ing date, time,
initials, and number of the patient, signature of the ch physician, and at least
3 xes for each lead. The Investigator’s medical opinion and tic values
will be recorded in the e-CRF. This printout will be retained at the site.
o A digital storage that enables eventual r reading by an *‘CG central laboratory:
each digital file Will be identified by theoretical time (day and time DXXTXXHXX), real
date and real time (recorder time), Sponsor study code, t number (ie, 3 digits),
initials (ie, 3 ters), and site and country numbers, if relevant. The digital
recording, data storage, and transmission (whenever requested) need to comply with
all applicable regulatory requirements (ie, F )A 21 CFR, part 11).
12. Self—monitored plasma glucose measurement
All the patients will be supplied with a plasma glucose meter, the corresponding supplies
(lancets, test strips, etc.) and with diaries at visit V2 (Week- 1)1n order to perform self-
measurement of plasma glucose (or by others) and its recording. The glucose meters
should be calibrated according to instructions given in the package leaflet and the study
site should also check the glucose meters regularly using the provided control solutions for
data ty. At visit V2 (week ~l) patients and their “referent parent(s)” will be trained to
accurately measure plasma e values with the glucose meter. The patients will be
instructed to bring their glucose meters with them to each on—site visit.
It is the investigator’s responsibility to explain the need to measure glucose at the times
indicated below. Training will be repeated as often as necessary at the study visits and the
study site staff reviews the patient’s diary at each visit. Plasma glucose values will be
measured by the patient/parent using the sponsor-provided blood e meter and
recorded1n the patient diary.
The patient will be instructed to perform SMPG ements:
- Fasting value at least 3 times a week or more for ts treated with basal insulin, as
medically indicated
0 And for all patients treated with or without basal insulin, whenever a measurement is
considered helpful, e.g. whenever the patients feel hypoglycemic ms, plasma
glucose should be measured by the patient (or others, if able), if possible.
ts should be instructed to e plasma glucose levels prior to the
administration of glucose or carbohydrate intake whenever hypoglycemia is suspected
(see XX of the protocol) unless safety considerations necessitate immediate
e/carbohydrate countermeasure prior to confirmation. The values will be entered
in the patient” 3 individual diary and transcribed into the e—CRF.
4.3 ANTI—LIXIS ENATIDE ANTIBODIES
4.3.1 Sampling times
Plasma samples from all patients will be collected to determine anti—lixisenatide antibodies on
Day —1 / )ay 14 / Day 28 /Day 42 before the study drug administration . Procedures for collection,
storage, and shipment will be provided in a te manual.
4.3.2 Number of samples
Table 3 ~ Number of plasma samples for anti—lixisenatide antibodies
Anti-lixisenatide antibodies
Total by patient 4
Total for patients (n=24) 96
4.3.3 Sample handling procedure for anti-lixisenatide antibodies
Table 4 - Bioanalytical method
Analyte Anti- natide dies
Matrix Plasma
Analytical Technique BIAcore
Lower Limit of Quantification cut—off
Assay Range not relevant
Assay Volume 100 uL
Site of Bioanalysis Dept. of ition, Safety and Animal Research (DSAR), sanofi aventis, Frankfurt
Method Reference RPSMPK—DOHO754-BM1~EN~E01
4.4 PHARMACOKINETICS
4.4.1 Sampling times
The sampling times for blood collection can be found in Table 5 and in the period flow chart
(Section 1.3).
Table 5 - Blood sampling for lixisenatide plasma concentrations
Time 0 H 0H30 1 H 1H30 2 H 2H30 3H30 4H
(hour/min)
T (h) T0 a T0.5 b T1 T1.5 T2 T25 T35 T45
Visit/Day:
V3/D14 P00 P01 P02 P03
V4/D28 P00 P01 P02 P03
V5/D42 P00 P01 P02 P03 P04 P05 P06 P07
a Prior to IMP administration
b Just prior to the standardized breakfast ingestion
4.4.2 Number of pharmacokinetic samples
Table 6 — Number of plasma samples
lixisenatide
By patient (4 x2)+8 =16
Total for study (n patients) 16 * 24:384
a 4 timepoints at Day14 (V3) and Day 28 (V4) — Btimepoints on Day 42 (V5)
4.4.3 Sample ng procedure
Special procedures for collection, storage, and shipment should be provided in the laboratory
manual.
Table 7 — Summary of handling procedures
Blood sample volume 2 mL
Anticoagulant K3 EDTA
ng procedures “See Appendix B of the protocol
Plasma aliquot split 2 tubes with one containing at least 0.5mL
Plasma storage conditions —20°C
Plasma shipment ions On dry ice
4.4.4 Bioanalytical methods
Lixisenatide plasma concentrations were determined using a validated double antibody sandwich
enzyme linked immunosorbent assay method with an LLOQ (lower limit of quantification)
.5 pg/mL and an assay volume of 120 uL.
Table 8 — Summary of bioanalytical method
Analyte llxisenatide
Matrix Plasma
Analytical technique Double-antibody ch ELISA
Lower limit of fication 5.5 pg/mL
Assay volume 120 pL
Site of bioanalysis Covance laboratories lnc, Chantilly, France
Method reference VA 20151-1130 / DOH1317
4.4.5 Pharmacokinetic parameters
The following pharmacokinetic parameters will be calculated, using noncompartmental methods
from plasma concentrations obtained after repeated dose administration. The parameters will
include, but may not be limited to the following.
Table 9 — :ist of pharmacokinetic parameters and ions
ters Drug/Analyte Matrix tion/Calculation
Maxrmum plasma concentration observed during the respective treatment
lixisenatide Plasma
Cmax period,
tmax lixisenatide Plasma Time to reach Cmax
Area under the plasma concentration versus time curve calculated using the
AUCOAEO Iixisenatide Plasma trapezoidal method from time zero (lixisenatide scale) to time 4.30 hours post
4.5 SAMPLED BLOOD VOLUME
Sample blood volume should be presented in a table.
Table 10 — Sampled blood volume per patient
Type Volume per sample Sample number Total
Serology tests 2.5 mL 1 2.5 mL
Auto anti—bodies 3.5 mL 1 3.5 mL
Calcitonin 2.0 mL 1 2.0 mL
B-HCG (if able) 1.1 mL 1 1.1 mL
Hematology 2.0 mL 2 4.0 mL
Biochemistry 2.5 mL 2 5.0 mL
Amylase, lipase only 2.5 mL 4 10.0 mL
HbA1c 2.0 mL 2 4.0 mL
Plasma glucose 1.2 mL 20 24 mL
Pharmacokinetlcs Lixlsenatide 2 mL 16 32 mL
Antl-lixlsenatide antibodies 1 mL 4 4 mL
Total if male 91 mL
Total if female 92.1 mL
The approximate total sampled blood volume in children is 91 and 92.1 mL for male and. female
patients, tively (approximate due to discarded blood When catheter is set up at each period).
The amount of blood volume per visit will not exceed 32 mL (the highest at Visit 5).
onal samples may be needed if any laboratory result is outside of the normal range or for
safety purposes.
4.6 FUTURE USE OF SAMDLES
Not applicable.
BIBLIOGRAPHIC REFERENCES
1. Druet C, Tubiana—Rufi N, Cheyenne D, Rigal O, Polak M, archal C.
terization of insulin secretion and resistance in type 2 diabetes of adolescents. J Clin
Endocrinol Metab 2006: 91: 4014,
2. Miller J, Silverstein JH, Rosenbloom AL. Type 2 es in the child and adolescent. In:
Lifshitz F (ed) Pediartric Endocrinology: fifth edition, volume 1. New York, Marcel jekker 2007:
pp 169—88.
3. Olansky L.: ' ‘echnol
)o incretin—based therapies cause acute pancreatitis? J Diabetes
2010; 4:2228—9
4. Schwartz GJ, Mufioz A, Schneider QF, Mak RH, Kaskel F, Warady 3A, et al. New
Equations to Estimate GFR in Children with CKD. J Am Soc Nephrol. 2009 Mar;20(3):629—37
Appendix A Blood pressure levels by gender, age and height
Blood Pressure Levels for Boys by Age and Height Percentile
Systolic BF {mafia} Dias‘mfic BF {1mm
£- tile of Height -)
Age Permenfile {— Pam-11143112 131111219111 '5'
4" 36311 95th 5th 1133311: 2531 50th T583 3% 35131
V 19th 2581 513111 75121
111. 53111; a? 98. 111:) 102 111131 1135 1116 53 5e 61: a1 51 52 11:1
911111 111 112 1.14 115 11? 1'19 119 m 13 '11 75 7'11 17 73
115111 115 1111. ‘ 11:1 1191 121 122 123; 3? 13: re 8:1 a1" a1" 13': .
919111 ’
12:1. 12:1 125 12? 1211 1311 131:1 ‘85 3e $15 Be as are e11
7 V
11 5011 131; 1.02 1114 1117 51:1 59 a1 132 e3
90211 1 13 114 115 1 11' 1 1e 121:1 121 7'4 14 15 m 77 13 713
95:11 11.7 1 1e 1 111 1:21 123 121 125 13 713 :11: 313 El 32 a:
99111 12.1 125 12? 129 1.2111 1%... 1% as 1311 5? as see so so
1:: 511111 1111 1112 1131 me 11:13 1:19 1111 59 er} e1 e2 53 33 34
219111 115 11a 1111 m 121 12:3 12:1 74 1'5 11-5 75 77 :15 711
95111 1 19 1:21} 122: 1.23 125 127 12? 13 79 ea 31 32 32 113
99111 125 12? 1a 131 133 134: 135 as 111' as 119 911 911 111
13 5111-1 1134 1135 1m 2113 1111 111 112 51:1 5:1 51 32 ea 51 134
me '1 1.7 1 151 1211 122 124 125 125. 1'5 15 715 1? 73 1e 79
95211 121 122 1:24 1215 12a 1:21 1311 1:: 111 e11 111 =32 2:3 '83
age; 123 1,30 131 133 1:35 1311 137' a? 31' e3 39 9e 91 91
14 5pm 1116 1117 11311 1 1'1 '1 13 1 14 115 6111 61 52 ea; 64 as .55
913111 1211 121: 12:1 125 12g 133 123 1'5 111 17 7e 71 m 130
515111 124 125 127 123 1311 132 132 an 1211 e1 32' 33 e1 34
99211 131 1:12 131 135 1311 1:11 1411 a? as ea 91: a1; 92 e2
511:1: we 1 11} 11:1. 1 1:3 1 15 117 11? e1 152 63 B4 115 as ea
mm 122 124 125 1.2? 1:21; 1311 131 .75 77 :13 m as eat 31
e511 123 121' 1211 131 133 131 135 111 31. 52 as 211 .35 95
913111 131 1:35 1315 133 1111 1.42 142 as es ea 21 .132 93 e3
59111 1 1 1: 1 12 1 14 113 11s 11s 12-»: :53 83 e1 55 as a? E?
913111 125 123 123 13:13 131 133 1:11 we 13 7:: as 31 82 a:
95111 1213 1:111 132 1321 135 137 13:1 32 33 :33 e1 es ea 51?
99:1: 133 131 139 1111 1'13 111 145 so 131} 91 92 193 94; e4
17 511111 1 14 1 15 115 1 123 1211 121 1a are 115 as er 133 as; R1
911111 1:11 123 1311 13:2 131 135 135 £113 131} 31 a: =33 e1 e4
@5111 131 1:32 131 ӣ36 133 13a 1411 34 35 w a? 3? 33 as
@9111 139 111:1 141 113 145 1413- 1-1? 92 1113 Q3 e4 {15 95 13.7.
BP, blood pressure
* The 90th percentile is 1.28 SD, 95111 percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.
Blood Pressure Levels for Girls by Age and Height Percentile
Systoiic B'P (mml-ig) Diastolic BP tmml—ig}
(- iile vef He§§ht -) (- Perceafiie of Heflgiat -)
Age Perifile
Wear) ‘3' 5111 1011'! 25th 58111 "£51.11 911111 9511’! 5133 111133 251211 50":11 75111 90m 95111
11.1 5131?} 98 99 181] 1132 1113 1134 195 59 59 5‘51 61} 61 62 62
9121121 112 112 114 115 115 118 113 73 T3 7'3 ?4 1'5 ?6 75
95111 116 116 117 119 12B 121 122 77 77" 77 78 79 89 80
991.11 123 123 125 126 12? 129 125! 81-1 84 85 85 36 87 88
11 5011?} 1139 101 102 103 1135 195 1131? 61} E9 69 51 62 63 63
901??! 114 114 116 117' 113 119 1213 74 74 7’4 75 713 77 7?
95111 113 ms; 119 121 122 123. 124 78 78 78 7Q 51} E1 E11
991151 125 125 126 128 129 131] 131 85 85 86 37 37 88 8 9
12 51311-1 11122 1133 104 1115 1Q? 1138 1139 61 51 61 52 63 54 611
913111 115 116 117 113 121} 121 122 7’5 75 75 76 7? 78 73
951171 1 19 121} 121 123 124 125 125 79 79' 79 3E} 81 82 82
991.11 12? 127 12B 139 131 132 133 85 85 87 88 813 89 9'1}
13 5131.11 1114 1615 1‘06 167 1139 110 111} 52 62 62 53 64 65 65
911111: 117 118 119 121 122 123 124 1’6 T6 78 7"? Y8 7Q 1'9
95111 121 122 1,23 124 126 127 128 80 80 813 31 82 83 83
9131.1“: 128 129 130 132 133 134 135 87' 87 88 BE} 89: 90 91
14 51311“: ”1136 1 [16 1D?" 1139 110 111 112 63 53‘ 53 621 65 ‘56 BS
911111 '1 19 121} 1.21 122 124 125 125 7? 77 77 78-1 72 BE} 81}
95111 123 123 125 128 127 129 129 31 81 :81 32 83 84
9911': 1.311 131 132 133 135 136 136 BE 83 89 9E} 90 £11 92
511111 113? me 109 11513 111 1133 113 64 54 64 65 66 67 E7
911111 120 121 1 22 123 125 125 127 78 BB 178 79 813 81 31
95111 124 125 125 121‘Y 129 1311 131 B2 82 82 33 3'4 85 85
99111 131 132 133 134 136 137 133 89 89 {98 Q1 91 92 93
16 51.11151 1138 1138 110 111 112 114 114 64 84 65 156 55 61' 58
910111 121 122 123 12-1 126 127 128 ?E ?8 7'9 BI} 31 B1 32
9511‘; 12:5 125 127' 128 130 131 132 82 82 83 34 8.5 85 E18
991131 132 133 134 135 137 138 139 91) 91] 913 $11 92 93 93
1? 50111 108 1139 110 111 113 114 115 64 55 55 66 6? 6? 63
90121 122, 122 123 125 126 127 128 TB 79 3’9 83 31 B1 82
951111 125 126 127 129 130 131 132 32 E3 83 8:11 85 85 8E
9911?: 133 133 134 136 131’ 133 139 $313 90 91 91 92 93 §3
BP, blood pressure
* The 90th percentile is 1.28 SD, 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD
over the mean.
ix Tanner stage
l Tanner puberty stage classification l
I Classification of sex maturity stages in girls I
P2 Sparse, lightly pigmented, straight, %2 Breast and a elevated as small
medial border of labia mound; r diameter increased
P3 Darker, beginning to curl, increased B3 Breast and areola enlarged, no contour
amount separation
P4 Coarse, curly, abundant but amount B4 Areola and papilla form secondary mound
less than in adult
P5 Adult feminine triangle, spread to B5 ; nipple projects, areola part of
medial surface of thighs general breast contour
Classification of sex maturity stages in boys I
P4 Resembles adult type, but less in T4 Larger, scrotum dark
quantity; coarse, curly
P5 Adult distribution, spread to medial Adult size
surface of thighs
Claims (14)
1. Use of lixisenatide and/or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for treating pediatric patients suffering from type 2 es mellitus.
2. Use according to claim 1, wherein the lixisenatide and/or the pharmaceutically acceptable salt thereof is to be administered with metformin and/or a pharmaceutically able salt thereof as an add-on therapy.
3. Use according to claim 2, wherein metformin and/or the pharmaceutically acceptable salt thereof is formulated to be orally administered..
4. Use according to any one of the preceding claims, wherein the pediatric patient has an age of at least 10 years.
5. Use according to any one of the preceding claims, n the pediatric has an age of less than 18 years.
6. Use according to any one of the ing claims, wherein the type 2 diabetes mellitus has been diagnosed at least three months.
7. Use according to any one of the ing claims, wherein the type 2 diabetes mellitus is not adequately lled by metformin monotherapy, by basal insulin monotherapy or by a combination of metformin and a basal insulin.
8. Use according to any one of the preceding claims, wherein the pediatric patient is obese.
9. Use according to any one of the ing claims, wherein the pediatric patient has a body mass index of at least 30 kg/m2 or at least 31 kg/m2.
10. Use according to any one of the preceding claims, wherein the medicament is to be stered about 30 s before breakfast.
11. Use according to any one of the preceding claims, wherein at the onset of treatment with lixisenatide or/and the pharmaceutically acceptable salt 18464999_1 (GHMatters) P43144NZ00 thereof, the patient has a g plasma glucose concentration of at least 8 mmol/L or at least 8.5 mmol/L.
12. Use according to any one of the preceding claims, wherein at the onset of treatment with lixisenatide or/and the pharmaceutically acceptable salt thereof, the patient has a 2 hours postprandial plasma glucose concentration of at least 11.1 mmol/L or at least 12 mmol/L.
13. Use according to any one of the preceding claims, wherein at the onset of treatment with lixisenatide or/and the pharmaceutically acceptable salt thereof, the t has a glucose excursion of at least 3 , wherein the glucose excursion is the difference of the 2 hours postprandial plasma glucose concentration and plasma glucose concentration 30 s prior to a meal test.
14. Use according to any one of the preceding claims, wherein at the onset of treatment with lixisenatide or/and the ceutically acceptable salt thereof, the patient has a HbA1c value of at least about 7 %, at least about 7.5 %, at least about 8 %, at least about 8.5 %, at least about 8.65 %, or at least about 9%. 18464999_1 (GHMatters) P43144NZ00
Applications Claiming Priority (3)
Application Number | Priority Date | Filing Date | Title |
---|---|---|---|
EP15151488.2 | 2015-01-16 | ||
EP15151488 | 2015-01-16 | ||
PCT/EP2016/050804 WO2016113404A1 (en) | 2015-01-16 | 2016-01-15 | Treatment of pediatric type 2 diabetes mellitus patients with lixisenatide |
Publications (2)
Publication Number | Publication Date |
---|---|
NZ734595A NZ734595A (en) | 2022-03-25 |
NZ734595B2 true NZ734595B2 (en) | 2022-06-28 |
Family
ID=
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