Lilly’s New Basal Insulin Peglispro (BIL) Proves Better Than Lantus in Phase 3 Trials

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Eli Lilly’s new basal insulin peglispro (BIL) demonstrated a statistically significant lower hemoglobin A1c (HbA1c) compared with insulin glargine (Lantus) at 26 weeks and 52 weeks, respectively, in the IMAGINE-1 and IMAGINE-3 Phase III clinical trials in patients with type 1 diabetes. 

The Phase III trials needed for submission are now complete, and Lilly plans to submit BIL for regulatory review to the U.S. Food and Drug Administration and the European Medicines Agency by the end of Q1 2015. 

The trials, in both type 1 and type 2 diabetes, showed consistent superiority of HbA1c for BIL against comparators. Lilly is on track to file a submission with regulators by the end of the first quarter in 2015.

The primary efficacy endpoint of non-inferior HbA1c at the primary study endpoint compared with insulin glargine was met in both the IMAGINE-1 and IMAGINE-3 trials, and superiority was demonstrated. In addition, significantly more patients taking BIL versus those taking insulin glargine achieved an HbA1c of less than 7 percent, a target for glycemic control established by the American Diabetes Association.

Both trials also showed the rate of nocturnal hypoglycemia was significantly lower in patients taking BIL than in those taking insulin glargine. In both trials – in which patients were taking both mealtime and basal insulin – there was a statistically significant increase in the rate of total hypoglycemia for patients taking BIL compared with those taking insulin glargine due to a higher rate of daytime hypoglycemic events.  In the open-label IMAGINE-1 trial, patients taking BIL reported a statistically significant higher rate of severe hypoglycemic events. However, in the larger, blinded IMAGINE-3 trial the rate of severe hypoglycemic events for treatment with BIL was numerically lower compared with insulin glargine, but was not statistically significant.

Additionally, both trials showed a statistically significant difference in weight. Patients taking BIL experienced weight loss—even with lower HbA1c—compared with weight gain in patients taking insulin glargine.

Results of these two trials also showed patients taking BIL experienced changes in lipid parameters, including a small but statistically significant increase in triglycerides in both trials. In IMAGINE-3, there were small but statistically significant reductions and increases, respectively, in HDL (high-density lipoprotein) cholesterol and LDL (low-density lipoprotein) cholesterol in patients taking BIL compared with those taking insulin glargine. In addition, IMAGINE-3 showed patients taking BIL experienced small but statistically significant increases in systolic and diastolic blood pressure compared to insulin glargine (less than 2 mmHg mean difference at 52 weeks). Statistically significant differences in HDL and LDL cholesterol and blood pressure were not observed in IMAGINE-1. There were no major adverse cardiac events (MACE) in IMAGINE-1, and in IMAGINE-3, the MACE+ (cardiovascular death, non-fatal stroke, non-fatal MI and hospitalization due to unstable angina) event rate was lower for patients taking BIL compared with those taking insulin glargine.

In both trials, treatment with BIL was associated with a statistically significant higher incidence of patients with greater than three times the upper limit of normal range in the liver enzyme ALT (alanine aminotransferase) compared with patients taking insulin glargine. No cases of severe liver injury (Hy’s Law) occurred in either of the trials. In a subset of patients whose liver fat was measured using MRI imaging, BIL-treated patients had a statistically significant increase in liver fat compared to insulin glargine.

In both trials, there were significantly more injection site reactions observed in patients taking BIL compared to those taking insulin glargine. 

Additionally, the IMAGINE-7 trial—a flexible dosing study of BIL in patients with type 1 diabetes—and the IMAGINE-6 trial, evaluating BIL compared to NPH insulin in patients with type 2 diabetes, have both completed. IMAGINE-7 showed there was no statistically significant difference in HbA1c between BIL dosed at the same time every day versus BIL dosed at variable times. IMAGINE-6 met its primary efficacy endpoint of non-inferior reduction in HbA1c compared with NPH insulin at 26 weeks and also demonstrated HbA1c superiority of BIL compared to NPH insulin. There were no new safety signals in either trial and the adverse events were similar to those seen in the other IMAGINE trials.

The core Phase III clinical trial program of BIL – consisting of seven IMAGINE trials in patients with type 1 and type 2 diabetes – is now complete, and superiority in HbA1c for BIL was seen in all six of the Phase III trials that were conducted against active comparators.

An analysis across all clinical trials in patients with type 1 and type 2 diabetes showed that the rates of major adverse cardiovascular events among patients taking BIL and those taking insulin glargine or NPH insulin were similar, with an observed hazard ratio below 1 and the upper limit of the 95 percent confidence interval below 1.4.

Detailed study results for all Phase III trials are expected to be disclosed in 2015. 

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Scott Strumello

An important take-away from this is not how terrific this new insulin, but that Lilly and its development partner were forced to concede that in one of the two clinical trials undertaken on this insulin, there was a statistically significant increase in hypoglycemia among patients with type 1 diabetes.  To me, regardless of what the FDA may do (and it already has pre-approval), patients need to beware that it is a biosimilar version of Lantus, but it is NOT a generic which is biochemically equal.  Knowledge is power, and patients need to be cautious.

Scott Strumello

An important take-away from this is not how terrific this new insulin, but that Lilly and its development partner were forced to concede that in one of the two clinical trials undertaken on this insulin, there was a statistically significant increase in hypoglycemia among patients with type 1 diabetes.  To me, regardless of what the FDA may do (and it already has pre-approval), patients need to beware that it is a biosimilar version of Lantus, but it is NOT a generic which is biochemically equal.  Knowledge is power, and patients need to be cautious.

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