Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K35/00—Medicinal preparations containing materials or reaction products thereof with undetermined constitution
  • A61K35/12—Materials from mammals; Compositions comprising non-specified tissues or cells; Compositions comprising non-embryonic stem cells; Genetically modified cells
  • A61K35/37—Digestive system
  • A61K35/39—Pancreas; Islets of Langerhans
• • 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
• • 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
  • 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
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P37/00—Drugs for immunological or allergic disorders
  • A61P37/02—Immunomodulators
  • A61P37/06—Immunosuppressants, e.g. drugs for graft rejection

Definitions

• This disclosure is related to the use of glucagon- like peptide- 1 (GLP-1) receptor agonists to improve the health and quality of life for people living with diabetes.
• GLP-1 glucagon- like peptide- 1
• Type 1 diabetes has traditionally been treated by life-long insulin therapy or pancreas transplantation.
• frequent episodes of hypoglycemia are common in patients on lifelong insulin therapy.
• whole pancreas transplantation is an invasive surgical procedure with significant risks.
• Islet cell transplantation is an attractive alternative to the traditional treatments of type 1 diabetes.
• two of the major limiting factors in the widespread use of islet cell transplantation clinically are the availability of a sufficient number of islets and the inability of current immunosuppressive treatments to protect transplanted islets long-term.
• pancreata would have been available in 2007 for islet cell transplantation.
• pancreata for islet transplantation, most islet transplant recipients require more than one donor in order to acquire a sufficient number of islet cells to achieve insulin independence. This limits the number of people who could be helped by islet cell transplantation even more.
• Alternative sources of islet cells or development of a method for ⁇ -cell regeneration are essential to the widespread use of islet transplantation in treating type 1 diabetes.
• Edmonton group have shown that the rate of success for functional islet grafts in the clinical setting is approximately 80% after 1 year, but only 10% after 5 years (Ryan et al, Diabetes, 54(7):2060-2069 (2005); Shapiro et al, N EnglJ Med, 343(4):230-238 (2000)). Effects of both auto- and allogeneic immune responses severely limit the long-term success of islet grafts, even when an abundant number of islets have been transplanted. Thus, development of an immunosuppressive treatment strategy that protects islets long-term is necessary for the overall success of this procedure.
• GLP-1 receptor agonists such as exenatide, lixisenatide, liraglutide, albiglutide, dulaglutide, taspoglutide
• Fasting blood glucose was measured daily and intravenous glucose tolerance tests were performed to evaluate graft function. The results showed that the average fasting blood glucose for pre -treated animals on day 5 post-transplant was 52.7 ⁇ 14.8 mg/dl while the average fasting blood glucose for animals treated with exenatide post-transplant only was 154.3 ⁇ 105.5 mg/dl. The day 5 average fasting blood glucose was 59.4 mg/dl ⁇ 12.1 in animals treated with immunosuppression.
• immunosuppressive drugs was able to maintain islet graft survival.
• FIGS 1A-B Fasting blood glucose monitoring of transplanted animals (A). Average fasting blood glucose levels measured at day 5 post-transplant (B). Untreated animals showed elevated blood glucose levels by day 1 post-transplant, animals treated with exenatide post- transplant only showed somewhat elevated blood glucose levels beginning at day 4 post- transplant, while animals treated with ATG/CSA/MMF or pre-treated with exenatide remained normoglycemic throughout the study period. In fact, two animals from the exenatide pre- treatment group remained normoglycemic up to 435 days post-transplant.
• FIGS 2A-B Blood glucose levels measured following intravenous glucose administration (intravenous glucose tolerance test) with area under the curve measurements for glucose response (A). Serum insulin levels measured during intravenous glucose tolerance test as detected by ELISA (B). intravenous glucose tolerance tests were performed at baseline prior to pancreatectomy, at day 10 post-transplant for untreated and post-exenatide groups, and at day 90 post-transplant for ATG/CSA/MMF and exenatide pre-treatment groups. Animals pre-treated with exenatide or treated with ATG/CSA/MMF maintained glucose and insulin responses post- transplant that resembled that prior to pancreatectomy. Animals pre-treated with exenatide showed increased insulin production at both baseline and post-transplant compared to all other groups. Untreated recipients and animals receiving exenatide post-transplant only showed reduced insulin levels compared to baseline.
• FIGS 3A-B Acute insulin response to glucose ( ⁇ /ml) as a measurement of first phase insulin secretion following i.v. glucose administration (A). Beta cell function as determined by homeostasis model assessment (HOMA-%B) (B). Untreated animals and animals treated with exenatide post-transplant only were tested at day 0 and at day 10. ATG/CSA/MMF and exenatide pre-treatment groups were tested at day 0 and day 90.
• the disclosure provides methods for treating diabetes in patients by administering therapeutically effective amounts of GLP-1 receptor agonist compound to the patient prior to islet transplant, and transplanting islets into the patient; thereby treating diabetes.
• in the patient is not administered an immunosuppressive drug or an
• the diabetes is Type 1 diabetes.
• the patient is a human.
• the disclosure provides method for treating diabetes in patients by administering therapeutically effective amounts of a GLP-1 receptor agonist compound to the patient for a period of time of 1 day to 1 month; treating islets with a therapeutically effective amount of a GLP-1 receptor agonist compound to the patient for a period of time of 1 day to 1 month;
• in the patient is not administered an immunosuppressive drug or an immunosuppressive treatment regimen before, during, or after the islet transplant.
• the diabetes is Type 1 diabetes.
• the patient is a human.
• the disclosure provides methods for promoting graft survival and improved graft function in a patient receiving an islet transplant by administering therapeutically effective amounts of a GLP-1 receptor agonist compound to the patient prior to islet transplant;
• the methods include treating islets with therapeutically effective amounts of a GLP-1 receptor agonist compound prior to transplant into the patient.
• in the patient is not administered an immunosuppressive drug or an immunosuppressive treatment regimen before, during, or after the islet transplant.
• the diabetes is Type 1 diabetes.
• the patient is a human.
• the disclosure provides methods for promoting graft survival and improved graft function in a patient receiving an islet transplant by administering a therapeutically effective amount of a GLP-1 receptor agonist compound to the patient for a period of time of 1 day to 1 month; treating islets with a therapeutically effective amount of a GLP-1 receptor agonist compound to the patient for a period of time of 1 day to 1 month; transplanting the islets into the patient; and continuing administration of therapeutically effective amounts of the GLP-1 receptor agonist compound to the patient after the islet transplant; thereby promoting graft survival and improved graft function in the patient.
• in the patient is not administered an immunosuppressive drug or an immunosuppressive treatment regimen before, during, or after the islet transplant.
• the diabetes is Type 1 diabetes.
• the patient is a human.
• GLP-1 receptor agonist compound Any GLP-1 receptor agonist compound can be used in the methods described herein, as set forth in more detail below.
• GLP-1 receptor agonist compound refers to compounds having GLP-1 receptor activity.
• Such exemplary compounds include exendins, exendin analogs, exendin agonists, GLP- 1(7-37), GLP-l(7-37) analogs, GLP-l(7-37) agonists, and the like.
• exendin includes naturally occurring (or synthetic versions of naturally occurring) exendin peptides that are found in the salivary secretions of the Gila monster.
• Exendins of particular interest include exendin-3 and exendin-4.
• the exendins, exendin analogs, and exendin agonists for use in the methods described herein may optionally be amidated, and may also be in an acid form, pharmaceutically acceptable salt form, or any other physiologically active form of the molecule.
• Exendin-4 (HGEGTFTSDLSKQMEEEAVRLFIEWLK GGPSSGAPPPS-NH 2 (SEQ ID NO: 1)) is a peptide found in the saliva of the Gila monster, Heloderma suspectum; and exendin-3 (HSDGTFTSDLSKQMEEEAVRLFIEWLKNGG PSSGAPPPS-NH 2 (SEQ ID NO:2)) is a peptide found in the saliva of the beaded lizard, Heloderma horridum. Exendins have some amino acid sequence similarity to some members of the glucagon-like peptide (GLP) family.
• GLP glucagon-like peptide
• exendin-4 has about 53% sequence identity with glucagon-like peptide- 1(GLP- l)(7-37) (HAEGTFTSD VS S YLEGQ AAKEFIAWLVKGRG (SEQ ID NO:22)).
• exendin-4 is transcribed from a distinct gene, not the Gila monster homolog of the mammalian proglucagon gene from which GLP-1 is expressed.
• exendin-4 is not an analog of GLP- 1(7-37) because the structure of synthetic exendin-4 peptide was not created by sequential modification of the structure of GLP-1. Nielsen et al, Current Opinion in Investigational Drugs, 4(4):401-405 (2003).
• Synthetic exendin-4 also known as exenatide
• BYETTA® is commercially available as BYETTA® (Amylin Pharmaceuticals, Inc. and Eli Lilly and Company).
• BYETTA® contains exenatide, a preservative (e.g., metacresol), a tonicity-adjusting agent (e.g., mannitol), and a buffer (e.g., an acetate buffer).
• a preservative e.g., metacresol
• a tonicity-adjusting agent e.g., mannitol
• a buffer e.g., an acetate buffer
• This once weekly formulation comprises exenatide and biodegradable polymeric (e.g., poly(lactide-co-glycolide)) microspheres, and is referred to herein as EQW (BYDUREONTM by Amylin Pharmaceuticals, Inc., Eli Lilly and Company, Alkermes, Inc.).
• EQW biodegradable polymeric
• Exendin analog refers to peptides or other compounds which elicit a biological activity of an exendin reference peptide, preferably having a potency equal to or better than the exendin reference peptide (e.g., exendin-4), or within five orders of magnitude (plus or minus) of potency compared to the exendin reference peptide, when evaluated by art-known measures such as receptor binding and/or competition studies as described, e.g., by Hargrove et al, Regulatory Peptides, 141 : 113-119 (2007), the disclosure of which is incorporated by reference herein.
• the exendin analogs will bind in such assays with an affinity of less than 1 ⁇ , and more preferably with an affinity of less than 3 nM, or less than 1 nM.
• the term “exendin analog” may also be referred to as “exendin agonist”.
• Exendin analogs also include the peptides described herein which have been chemically derivatized or altered, for example, peptides with non-natural amino acid residues (e.g., taurine, ⁇ -amino acid residues, ⁇ -amino acid residues, and D-amino acid residues), C-terminal functional group modifications, such as amides, esters, and C-terminal ketone modifications and N-terminal functional group modifications, such as acylated amines, Schiff bases, or cyclization, as found, for example, in the amino acid pyroglutamic acid. Exendin analogs may also contain other chemical moieties, such as peptide mimetics.
• exendins and exendin analogs include exendin-4 (SEQ ID NO: l); exendin-3 (SEQ ID NO:2); Leu 14 -exendin-4 (SEQ ID NO:3); Leu 14 ,Phe 25 -exendin-4 (SEQ ID NO:4);
• Leu 14 ,Ala 19 ,Phe 25 -exendin-4 (SEQ ID NO:5); exendin-4(l-30) (SEQ ID NO:6); Leu 14 -exendin- 4(1-30) (SEQ ID NO:7); Leu 14 ,Phe 25 -exendin-4(l-30) (SEQ ID NO:8); Leu 14 ,Ala 19 ,Phe 25 - exendin-4(l-30) (SEQ ID NO:9); exendin-4(l-28) (SEQ ID NO: 10); Leu 14 -exendin-4(l-28) (SEQ ID NO: l l); Leu 14 ,Phe 25 -exendin-4(l-28) (SEQ ID NO: 12); Leu 14 ,Ala 19 ,Phe 25 -exendin-4 (1-28) (SEQ ID NO: 13); Leu 14 ,Lys 17 ' 20 ,Ala 19 ,Glu 21 ,Phe 25 ,Gln 28
• AEEA refers to [2-(2-amino)ethoxy)]ethoxy acetic acid.
• EDA refers to ethylenediamine.
• MPA refers to maleimidopropionic acid.
• the exendins and exendin analogs may optionally be amidated.
• Other exendins and exendin analogs useful in the methods described herein include those described in WO 98/05351; WO 99/07404; WO 99/25727; WO 99/25728; WO 99/40788; WO 00/41546; WO 00/41548; WO 00/73331; WO 01/51078; WO 03/099314; US Patent No.
• GLP-l(7-37) analogs refers to peptides or other compounds which elicit a biological activity similar to that of GLP- 1(7-37), when evaluated by art-known measures such as receptor binding assays or in vivo blood glucose assays as described, e.g., by Hargrove et al, Regulatory Peptides, 141 :113-119 (2007), the disclosure of which is incorporated by reference herein.
• GLP- 1(7-37) analog refers to a peptide that has an amino acid sequence with 1, 2, 3, 4, 5, 6, 7 or 8 amino acid substitutions, insertions, deletions, or a combination of two or more thereof, when compared to the amino acid sequence of GLP- 1(7- 37).
• the GLP- 1(7-37) analog is GLP-l(7-36)-NH 2 .
• GLP- 1(7-37) analogs include the amidated forms, the acid form, the pharmaceutically acceptable salt form, and any other physiologically active form of the molecule.
• GLP-l(7-37) and GLP-l(7-37) analogs include GLP-l(7-37) (SEQ ID NO:
• the GLP-l(7-37) or GLP- 1(7-37) analogs are covalently linked (directly or by a linking group) to an Fc portion of an immunoglobulin (e.g., IgG, IgE, IgG, and the like).
• an immunoglobulin e.g., IgG, IgE, IgG, and the like.
• any one of SEQ ID NOs:25-40 may be covalently linked to the Fc portion of an immunoglobulin comprising the sequence of: AESKYGPPCPPCPAPXaai 6 XaaivXaaisGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSQEDPEVQFNWYVDGVEVH NAKTKPREEQFXaa 80 STYRVVSVLTVLHQDWLNGKEYKCKVSNKGLPSSIEKTISKAKG QPREPQVYTLPPSQEEMTK QVSLTCLVKGFYPSDIAVEWESNGQPE NYKTTPPVLD SDGSFFLYSRLTVDKSRWQEGNVFSCSVMHEALHNHYTQKSLSLSLGXaa 230 ; wherein Xaai6 is P or E; Xaa ⁇ is F, V or A; Xaaig is L, E or A; Xaa 8 o is N or A; and Xaa
• the linking group may be any chemical moiety (e.g., amino acids and/or chemical groups).
• the linking group is (-GGGGS-) X (SEQ ID NO:42) where x is 1, 2, 3, 4, 5 or 6; preferably 2, 3 or 4; more preferably 3.
• the GLP- 1(7- 37) analog covalently linked to the Fc portion of an immunoglobulin comprises the amino acid sequence: HGEGTFTSDVSSYLEEQAAKEFIAWLVKGGGGGGGSGGGGSGGGGSA
• the GLP- 1(7-37) or GLP- 1(7-37) analog may be covalently linked (directly or through a linking group) to one or two polyethylene glycol molecules.
• a GLP- 1(7-37) analog may comprise the amino acid sequence: HXaagEGTFTSDVS
• Xaa 8 is: D-Ala, G, V, L, I, S or T
• Xaa 22 is G, E, D or K
• Xaa 33 is: V or I
• Z is OH or NH 2 , (SEQ ID NO:44), and, optionally, wherein (i) one polyethylene glycol moiety is covalently attached to C 4 5, (ii) one polyethylene glycol moiety is covalently attached to C 46 , or (iii) one polyethylene glycol moiety is attached to C 45 and one polyethylene glycol moiety is attached to C 46 .
• the GLP- 1(7-37) analog is HVEGTFTSDVSSYLEEQAAKEFIAWLIKGGPSSGAPPPC 45 C46-NH 2 (SEQ ID NO:45) and, optionally, wherein (i) one polyethylene glycol moiety is covalently attached to C 45 , (ii) one polyethylene glycol moiety is covalently attached to C 46 , or (iii) one polyethylene glycol moiety is attached to C45 and one polyethylene glycol moiety is attached to GLP-1 receptor agonist compounds may be prepared by processes well known in the art, e.g., peptide purification as described in Eng et al, J. Biol. Chem., 265:20259-62 (1990); standard solid-phase peptide synthesis techniques as described in Raufman et al, J. Biol. Chem.,
• the disclosure also provides pharmaceutical compositions comprising the GLP-1 receptor agonist compounds described herein and a pharmaceutically acceptable carrier.
• the GLP-1 receptor agonist compounds can be present in the pharmaceutical composition in a therapeutically effective amount and can be present in an amount to provide a minimum blood plasma level of the GLP-1 receptor agonist compound necessary for therapeutic efficacy.
• Such pharmaceutical compositions are known in the art and described, e.g., in US Patent No.
• compositions containing the GLP-1 receptor agonist compounds described herein may be provided for peripheral administration, such as parenteral (e.g., subcutaneous, intravenous, intramuscular), a continuous infusion (e.g., intravenous drip, intravenous bolus, intravenous infusion), topical, nasal, or oral administration.
• parenteral e.g., subcutaneous, intravenous, intramuscular
• continuous infusion e.g., intravenous drip, intravenous bolus, intravenous infusion
• topical e.g., nasal, or oral administration.
• suitable pharmaceutically acceptable carriers and their formulation are described in standard formulation treatises, such as Remington's Pharmaceutical Sciences by Martin; and Wang et al, Journal of Parenteral Science and Technology, Technical Report No. 10, Supp. 42:2S (1988).
• the GLP-1 receptor agonist compounds described herein can be provided in parenteral compositions for injection or infusion. They can, for example, be suspended in water; an inert oil, such as a vegetable oil (e.g., sesame, peanut, olive oil, and the like); or other suitable inert oil, such as a vegetable oil (e.g., sesame, peanut, olive oil, and the like); or other suitable inert oil, such as a vegetable oil (e.g., sesame, peanut, olive oil, and the like); or other suitable oil.
• the compounds are suspended in an aqueous carrier, for example, in an isotonic buffer solution at a pH of about 3.0 to 8.0, or about 3.0 to 5.0.
• the compositions may be sterilized by conventional sterilization techniques or may be sterile filtered.
• the compositions may contain pharmaceutically acceptable auxiliary substances as required to approximate physiological conditions, such as pH buffering agents.
• Useful buffers include for example, acetic acid buffers.
• a form of repository or "depot" slow release preparation may be used so that therapeutically effective amounts of the preparation are delivered into the bloodstream over many hours or days following subcutaneous injection, transdermal injection or other delivery method.
• the desired isotonicity may be accomplished using sodium chloride or other pharmaceutically acceptable agents such as dextrose, boric acid, sodium tartrate, propylene glycol, polyols (such as mannitol and sorbitol), or other inorganic or organic solutes.
• the formulation may comprise (i) the GLP-1 receptor agonist compound, (2) sterile water, and, optionally (3) sodium chloride, dextrose, or a combination thereof.
• Carriers or excipients can also be used to facilitate administration of the GLP-1 receptor agonist compounds.
• carriers and excipients include calcium carbonate, calcium phosphate, various sugars such as lactose, glucose, or sucrose, or types of starch, cellulose derivatives, gelatin, vegetable oils, polyethylene glycols and physiologically compatible solvents.
• the GLP-1 receptor agonist compounds can also be formulated as pharmaceutically acceptable salts (e.g., acid addition salts) and/or complexes thereof.
• Pharmaceutically acceptable salts are non-toxic salts at the concentration at which they are administered.
• Pharmaceutically acceptable salts include acid addition salts such as those containing sulfate, hydrochloride, phosphate, sulfamate, acetate, citrate, lactate, tartrate, methanesulfonate, ethanesulfonate, benzenesulfonate, p-toluenesulfonate, cyclohexylsulfamate and quinate.
• Pharmaceutically acceptable salts can be obtained from acids such as hydrochloric acid, sulfuric acid, phosphoric acid, sulfamic acid, acetic acid, citric acid, lactic acid, tartaric acid, malonic acid,
• salts may be prepared by, for example, reacting the free acid or base forms of the product with one or more equivalents of the appropriate base or acid in a solvent or medium in which the salt is insoluble, or in a solvent such as water which is then removed in vacuo or by freeze-drying or by exchanging the ions of an existing salt for another ion on a suitable ion exchange resin.
• GLP-1 receptor agonist compounds are described in US Patent No. 7,521,423, US Patent No. 7,456,254; US Publication No.
• the therapeutically effective amount of the GLP-1 receptor agonist compounds described herein for use in the methods described herein will typically be from about 0.01 ⁇ g to about 5 mg; about 0.1 ⁇ g to about 2.5 mg; about 1 ⁇ g to about 1 mg; about 1 ⁇ g to about 50 ⁇ g; or about 1 ⁇ g to about 25 ⁇ g.
• the therapeutically effective amount of the GLP-1 receptor agonist compounds may be from about 0.001 ⁇ g to about 100 ⁇ g based on the weight of a 70 kg patient; or from about 0.01 ⁇ g to about 50 ⁇ g based on the weight of a 70 kg patient.
• These therapeutically effective doses may be administered once/day, twice/day, thrice/day, once/week, biweekly, or once/month, depending on the formulation.
• the exact dose to be administered is determined, for example, by the formulation, such as an immediate release formulation or an extended release formulation.
• the dosage may be increased from about 5-fold to about 10-fold.
• Cynomolgous monkeys (Macaca fascicularis), aged 2-4 years, were obtained from Charles River Laboratories (Houston, TX) or Covance Research (Alice, TX). Animals had a starting weight of 4.35 kg ⁇ 1.00 (range 2.5-6.1). Animals were housed in individual cages (28x30x24 in) and given a continuous water supply. Animals were fasted for 12 hours prior to surgery and intravenous glucose tolerance tests, but were otherwise fed with a regular primate diet supplemented with fresh produce.
• induction therapy consisted of rabbit antithymocyte globulin (ATG) (Thymoglobulin®,
• CSA cyclosporine
• MMF mycophenolate mofetil
• Islet Isolation was performed according to the modified human islet isolation protocol described by Rajab et al, Cell Transplantation, 17(9):1015-1023 (2008). Islet number was determined by dithizone staining and conversion to islet equivalents (IEq).
• pancreatectomy on day 0 and post-transplant on days 10 and 90 pancreatectomy on day 0 and post-transplant on days 10 and 90.
• the study endpoint was considered 90 days post-transplant for Groups 1-3 and 10 days post-transplant for the untreated Group 4 (due to the poor health noted by day 10 of animals in Group 4).
• two animals in group 1 were monitored beyond 90 days and an additional intravenous glucose tolerance test was performed on day 220. Body weights for animals were monitored throughout the study.
• Intravenous Glucose Tolerance Test Animals were fasted 12 hours prior to each intravenous glucose tolerance test. Baseline glucose and insulin were measured at times -5 and 0. A 50% solution of glucose was administered i.v. at time 0. Blood was drawn at times 1, 3, 5, 10, 15, 20, 25 and 30 minutes after glucose administration for measurement of blood glucose and serum insulin levels.
• AUC Area under the curve
• Glucose disappearance rate constants ko
• ko Glucose disappearance rate constants
• ko was calculated as the negative slope of the linear regression for the natural logarithm of glucose from 10-30 minutes.
• Acute insulin response to glucose AIRg was used as a measure of first phase insulin secretion during intravenous glucose tolerance tests.
• AIRg was calculated as the mean of insulin at time 3-5 minutes minus the mean at time 0.
• Beta cell function was measured by the mathematical assessment of glucose regulation called the homeostasis model assessment (HOMA-%B).
• HOMA-%B was calculated as the average basal insulin ( ⁇ /mL) multiplied by 20 and divided by the average basal glucose (mmol/mL) minus 3.5.
• Intravenous Glucose Tolerance Tests intravenous glucose tolerance test results post- transplant were impaired in both untreated animals as well as animals treated with exenatide post-transplant only (Figure 2). Blood glucose levels were significantly elevated in untreated animals with the AUC being significantly increased post-transplant. Animals treated with exenatide post-transplant only had an abnormal glucose curve although the AUC was not significantly different ( Figure 2A). Insulin curves post-transplant for both groups were abnormal compared to baseline with no noticeable 2 nd phase insulin production and severely reduced insulin levels (Figure 2B).
• Fasting blood glucose levels were used as a determinant for islet graft function post- transplant. Untreated recipients had an average fasting blood glucose on day 5 post-transplant of 265 mg/dl ⁇ 172. Rejection was expected in these animals, and this hyperglycemia was indicative of graft failure. Animals receiving exenatide beginning on the day of transplant had an average fasting blood glucose at day 5 of 154 mg/dl ⁇ 105. Animals in this group showed variable fasting blood glucose levels that remained somewhat elevated from day 4 post- transplant to endpoint. While fasting blood glucose levels were less severely elevated than those of untreated animals and did not consistently meet the criteria for diabetes determination (fasting blood glucose > 250 mg/dl), they remained elevated throughout the study.
• results from intravenous glucose tolerance tests also indicate functioning islet allografts in animals pre-treated with exenatide or treated with ATG/CSA/MMF, whereas untreated animals had elevated glucose levels and reduced insulin production. Animals receiving exenatide treatment post-transplant only also showed impaired insulin production and abnormal glucose curves. Second phase insulin responses were not noticeable in either untreated or exenatide post-only treatment groups. Islet cell transplant recipients treated with exenatide prior to transplant showed increased insulin production in response to glucose compared to recipients treated only with the immunosuppression regimen of ATG, CSA and MMF. First phase insulin secretion was also significantly higher in the exenatide pre-treatment group at 90 days post- transplant relative to the ATG/CSA/MMF group. Also, at 90 days post-transplant, animals treated with exenatide alone showed significantly improved beta cell function compared to
• exenatide can improve graft function relative to treatment with immunosuppression and that, in fact, exenatide treatment alone is sufficient in itself in protecting islet allografts from rejection.
• pre -treatment of donors and/or recipients appears to be necessary to achieve this level of graft function.
• exenatide treatment of the recipient is not initiated until day 0 and transplanted islets are also untreated, graft function becomes impaired and more closely resembles that of grafts in untreated animals. This, along with its potential to protect islets from auto-immune attack, makes exenatide a useful treatment for long-term success in islet transplantation in type 1 diabetic patients.

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