October 1, 2023

Sotagliflozin, a novel agent that inhibits sodium-glucose cotransporter (SGLT) 1 in addition to SGLT2, obtained advertising and marketing approval from the US Meals and Drug Administration (FDA) on Could 26 for lowering the danger for cardiovascular dying, hospitalization for coronary heart failure, and pressing coronary heart failure visits in sufferers with coronary heart failure, and likewise for stopping these similar occasions in sufferers with kind 2 diabetes, power kidney illness (CKD), and different heart problems danger elements.

This places sotagliflozin in direct competitors with two SGLT2 inhibitors, dapagliflozin (Farxiga) and empagliflozin (Jardiance), that have already got indications for stopping coronary heart failure hospitalizations in sufferers with coronary heart failure in addition to approvals for kind 2 diabetes and preservation of renal operate.

Officers at Lexicon Prescribed drugs, the corporate that developed and can market sotagliflozin underneath the commerce title Inpefa, stated in a press release that they count on US gross sales of the agent to start earlier than the top of June 2023. The discharge additionally highlighted that the approval broadly coated use in sufferers with coronary heart failure throughout the total vary of each diminished and preserved left ventricular ejection fractions.

Lexicon officers additionally stated that the corporate will deal with advertising and marketing sotagliflozin for stopping near-term rehospitalizations of sufferers discharged after an episode of acute coronary heart failure decompensation.

They base this area of interest goal for sotagliflozin on outcomes from the SOLOIST-WHF trial, which randomized 1222 sufferers with kind 2 diabetes not too long ago hospitalized for worsening coronary heart failure and confirmed a major 33% discount within the fee of deaths from cardiovascular causes and hospitalizations and pressing visits for coronary heart failure in contrast with management sufferers throughout a median 9 months of follow-up. Almost half of the enrolled sufferers obtained their first dose whereas nonetheless hospitalized, whereas the opposite half obtained their first dose a median of two days after hospital discharge. The drug appeared protected.

Chopping Coronary heart Failure Rehospitalizations in Half

An exploratory submit hoc evaluation of SOLOIST-WHF confirmed that therapy with sotagliflozin lower the speed of rehospitalizations roughly in half after each 30 and 90 days in contrast with management sufferers, according to an abstract offered at a gathering in late 2022 that has not but been printed in a peer-reviewed journal.

The one SGLT2 inhibitor examined thus far when initiated in sufferers throughout hospitalization for coronary heart failure is empagliflozin, within the EMPULSE trial, which randomized 530 sufferers. EMPULSE additionally confirmed that beginning an SGLT2 inhibitor on this setting was protected and resulted in important scientific profit, the research’s main endpoint, outlined as a composite of dying from any trigger, variety of coronary heart failure occasions, and time to first coronary heart failure occasion, or a 5-point or larger distinction in change from baseline within the Kansas Metropolis Cardiomyopathy Questionnaire Whole Symptom Rating at 90 days.

Within the DELIVER trial, which examined dapagliflozin in sufferers with coronary heart failure with preserved ejection fraction, roughly 10% of sufferers began research therapy throughout or inside 30 days of coronary heart failure hospitalization, and on this subgroup, dapagliflozin appeared as efficient because it was within the different 90% of sufferers who didn’t begin the drug throughout an acute or subacute part.

Regardless of the SOLOIST-WHF proof for sotagliflozin’s security and efficacy on this economically essential scientific setting, some specialists say the drug faces an uphill path because it contends for market share in opposition to two solidly established, albeit dramatically underused, SGLT2 inhibitors. (Current information doc that 20% or fewer of US sufferers eligible for therapy with an SGLT2 inhibitor obtain it, resembling a review of 49,000 patients hospitalized throughout 2021-2022 with coronary heart failure with diminished ejection fraction.)

Others foresee a transparent position for sotagliflozin, significantly due to further aspects of the drug’s efficiency in trials that they understand give it an edge over dapagliflozin and empagliflozin. This contains proof that sotagliflozin therapy uniquely (throughout the SGLT2 inhibitor class) cuts the speed of strokes and myocardial infarctions (MIs), in addition to proof of its obvious capacity to decrease HbA1c ranges in sufferers with kind 2 diabetes and with an estimated glomerular filtration fee beneath 30 mL/min/1.73m2, a property seemingly linked to inhibition of SGLT1 within the intestine that dampens intestinal glucose absorption.

Sotagliflozin Uptake “Can be a Problem”

“Will probably be a problem” for sotagliflozin uptake, given the top begin that each dapagliflozin and empagliflozin have had as well-documented brokers for sufferers with coronary heart failure, commented Javed Butler, MD, a coronary heart failure clinician and trialist who’s president of the Baylor Scott & White Analysis Institute in Dallas, Texas.

Given the place dapagliflozin and empagliflozin at the moment have in US coronary heart failure administration — with the SGLT2 inhibitor class referred to as out in tips as foundational for treating sufferers with coronary heart failure with diminished ejection fraction and certain quickly for coronary heart failure with preserved ejection fraction as effectively — “I can not think about [sotagliflozin] will probably be thought of a most well-liked possibility,” Butler stated in an interview.

One other knowledgeable was much more dismissive of sotagliflozin’s position.

“There isn’t a persuasive proof that sotagliflozin has any benefits in contrast with the SGLT2 inhibitors for the therapy of coronary heart failure,” stated Milton Packer, MD, a coronary heart failure specialist and trialist at Baylor College Medical Middle in Dallas. “I don’t see why US physicians may pivot from established SGLT2 inhibitors to sotagliflozin,” until it was priced “at a really significant low cost to accessible SGLT2 inhibitors,” Packer stated in an interview.

On the time it introduced the FDA’s approval, Lexicon didn’t present particulars on how it could value sotagliflozin. Present retail costs for dapagliflozin and empagliflozin run about $550-$600/month, a value level that has contributed to sluggish US uptake of the drug class. However specialists anticipate a dramatic shake-up of the US marketplace for SGLT2 inhibitors with anticipated introduction of a generic SGLT2 inhibitor formulation by 2025, a growth that would additional dampen sotagliflozin’s prospects.

Different specialists are extra optimistic concerning the new agent’s uptake, maybe none greater than Deepak L. Bhatt, MD, MPH, who led each pivotal trials that present the majority of sotagliflozin’s proof package deal.

Along with SOLOIST-WHF, Bhatt additionally headed the SCORED trial, with 10,584 sufferers with kind 2 diabetes, CKD, and dangers for heart problems randomized to sotagliflozin or placebo and adopted for a median of 16 months. The first end result confirmed that sotagliflozin therapy lower the mixed fee of deaths from cardiovascular causes, hospitalizations for coronary heart failure, and pressing visits for coronary heart failure by a major 26% relative to regulate sufferers.

A Clear MACE Profit

“The information from SOLOIST-WHF and SCORED take a look at least nearly as good as the information for the SGLT2 inhibitors for coronary heart failure, and what seems to be totally different are the charges for MI and stroke in SCORED,” stated Bhatt, director of Mount Sinai Coronary heart, New York.

“I imagine the speed of main opposed cardiovascular occasions (MACE) have been diminished [in SCORED], and that is totally different from the SGLT2 inhibitors,” he stated in an interview.

In 2022, Bhatt reported outcomes from a prespecified secondary evaluation of SCORED that confirmed that therapy with sotagliflozin lower the speed of MACE by a major 21% to 26% in contrast with placebo. This discovering was, partially, pushed by the primary information to indicate a considerable profit from an SGLT inhibitor on stroke charges, as reported by Medscape Medical Information .

And whereas SCORED didn’t report a major profit for slowing development of CKD, subsequent submit hoc analyses have recommended this benefit additionally in as-yet-unpublished findings, Bhatt added.

However he stated he doubted nephrologists will see it as a first-line agent for slowing CKD development — a sign already held by dapagliflozin, pending for empagliflozin, and likewise in place for a 3rd SGLT2 inhibitor, canagliflozin (Invokana) — as a result of sotagliflozin lacks clear important and prespecified proof for this impact.

Bhatt additionally acknowledged the limitation of sotagliflozin in contrast with the SGLT2 inhibitors as an agent for glucose management, once more due to no proof for this impact from a potential evaluation and no pending indication for kind 2 diabetes therapy. However the SCORED information confirmed a transparent A1c profit, even in sufferers with severely diminished renal operate.

Largely for Cardiologists? “Compelling” Reductions in MIs and Strokes

Which will imply sotagliflozin “will not get a lot use by endocrinologists nor by main care physicians,” commented Carol L. Wysham, MD, an endocrinologist with MultiCare in Spokane, Washington.

Sotagliflozin “will probably be a cardiology drug,” and can “have a tough time” competing with the SGLT2 inhibitors, she predicted.

Bhatt agreed that sotagliflozin “will probably be perceived as a drug for cardiologists to prescribe. I do not see endocrinologists, nephrologists, and first care physicians reaching for this drug if it has a coronary heart failure label.” However, he added, “my hope is that the corporate recordsdata for extra indications. It deserves a sign for glycemic management.”

The proof for a coronary heart failure profit from sotagliflozin is “legitimate and compelling,” and “having this selection is nice,” commented Mikhail N. Kosiborod, MD, a heart specialist, Vice President of Analysis at Saint Luke’s Well being System, and codirector of the Haverty Cardiometabolic Middle of Excellence at Saint Luke’s Mid America Coronary heart Institute in Kansas Metropolis, Missouri. However, he added, “it is going to be a fairly tall job for sotagliflozin to come back from behind and be disruptive in an area the place there are already two well-established SGLT2 inhibitors” permitted for stopping coronary heart failure hospitalizations, “with a whole lot of information to again them up,”

The characteristic that units sotagliflozin other than the permitted SGLT2 inhibitors is the “actually compelling lower” it produced in charges of MIs and strokes “that we merely don’t see with SGLT2 inhibitors,” Kosiborod stated in an interview.

He additionally cited outcomes from SCORED that recommend “a significant discount in A1c” when not directly in contrast with SGLT2 inhibitors, particularly in sufferers with extra extreme CKD. The shortage of a devoted A1c-lowering trial or an permitted kind 2 diabetes indication “won’t be an issue for cardiologists,” he predicted, but in addition agreed that it’s much less seemingly for use by main care physicians in low-risk sufferers.

“I can see myself prescribing sotagliflozin,” stated Kosiborod, a SCORED coinvestigator, particularly for sufferers with coexisting kind 2 diabetes, coronary heart failure, CKD, and atherosclerotic heart problems. These sufferers might get “extra bang for the buck” due to a diminished danger for MI and stroke, making sotagliflozin “a stable consideration in these sufferers if the financial elements align.”

Like others, Kosiborod cites the massive influence pricing can have, particularly if, as anticipated, a generic SGLT2 inhibitor quickly comes onto the US market. “Entry and affordability are crucial,” he careworn.

SOLOIST-WHF and SCORED have been sponsored initially by Sanofi and later by Lexicon after Sanofi pulled out of sotagliflozin growth. Butler has been a advisor for Lexicon in addition to for AstraZeneca (which markets dapagliflozin [Farxiga]), Boehringer Ingelheim, and Lilly (which collectively market empagliflozin [Jardiance]), and Janssen (which markets canagliflozin [Invokana]), in addition to for quite a few different firms. Packer has been a advisor for AstraZeneca, Boehringer Ingelheim, Lilly, and quite a few different firms. Bhatt was lead investigator for SOLOIST-WHF and SCORED and has been an advisor for Boehringer Ingelheim and Janssen and quite a few different firms. Wysham has been an advisor, speaker, and advisor for AstraZeneca, Boehringer Ingelheim, Lilly, Janssen, Novo Nordisk, and Sanofi, an advisor for Abbott, and a speaker for Insulet. Kosiborod was a member of the SCORED Steering Committee and has been a advisor for Lexicon, AstraZeneca, Boehringer Ingelheim, Janssen, Lilly, Novo Nordisk, and quite a few different firms.

Mitchel L. Zoler is a reporter for Medscape and MDedge, primarily based within the Philadelphia space. @mitchelzoler

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