Albiglutide and cardiovascular outcomes in patients with type 2 diabetes and cardiovascular disease (Harmony Outcomes): a double-blind, randomised placebo-controlled trial

Background: Glucagon-like peptide 1 receptor agonists differ in chemical structure, duration of action, and in their effects on clinical outcomes. The cardiovascular effects of once-weekly albiglutide in type 2 diabetes are unknown. We aimed to determine the safety and efficacy of albiglutide in preventing cardiovascular death, myocardial infarction, or stroke. Methods: We did a double-blind, randomised, placebo-controlled trial in 610 sites across 28 countries. We randomly assigned patients aged 40 years and older with type 2 diabetes and cardiovascular disease (at a 1:1 ratio) to groups that either received a subcutaneous injection of albiglutide (30–50 mg, based on glycaemic response and tolerability) or of a matched volume of placebo once a week, in addition to their standard care. Investigators used an interactive voice or web response system to obtain treatment assignment, and patients and all study investigators were masked to their treatment allocation. We hypothesised that albiglutide would be non-inferior to placebo for the primary outcome of the first occurrence of cardiovascular death, myocardial infarction, or stroke, which was assessed in the intention-to-treat population. If non-inferiority was confirmed by an upper limit of the 95% CI for a hazard ratio of less than 1·30, closed testing for superiority was prespecified. This study is registered with ClinicalTrials.gov, number NCT02465515. Findings: Patients were screened between July 1, 2015, and Nov 24, 2016. 10 793 patients were screened and 9463 participants were enrolled and randomly assigned to groups: 4731 patients were assigned to receive albiglutide and 4732 patients to receive placebo. On Nov 8, 2017, it was determined that 611 primary endpoints and a median follow-up of at least 1·5 years had accrued, and participants returned for a final visit and discontinuation from study treatment; the last patient visit was on March 12, 2018. These 9463 patients, the intention-to-treat population, were evaluated for a median duration of 1·6 years and were assessed for the primary outcome. The primary composite outcome occurred in 338 (7%) of 4731 patients at an incidence rate of 4·6 events per 100 person-years in the albiglutide group and in 428 (9%) of 4732 patients at an incidence rate of 5·9 events per 100 person-years in the placebo group (hazard ratio 0·78, 95% CI 0·68–0·90), which indicated that albiglutide was superior to placebo (p<0·0001 for non-inferiority; p=0·0006 for superiority). The incidence of acute pancreatitis (ten patients in the albiglutide group and seven patients in the placebo group), pancreatic cancer (six patients in the albiglutide group and five patients in the placebo group), medullary thyroid carcinoma (zero patients in both groups), and other serious adverse events did not differ between the two groups. There were three (<1%) deaths in the placebo group that were assessed by investigators, who were masked to study drug assignment, to be treatment-related and two (<1%) deaths in the albiglutide group. Interpretation: In patients with type 2 diabetes and cardiovascular disease, albiglutide was superior to placebo with respect to major adverse cardiovascular events. Evidence-based glucagon-like peptide 1 receptor agonists should therefore be considered as part of a comprehensive strategy to reduce the risk of cardiovascular events in patients with type 2 diabetes. Funding: GlaxoSmithKline

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Example depicting dose schedule definition for one cycle of treatment with <i>n</i> = 3 for all optimization classes.

<p>This schematic shows the process by which one cycle of treatment is defined for each optimization class with <i>n</i> = 3. A cycle in Class 1 or 3 contains a standard erlotinib dosing schedule of 150 mg/day, whereas a cycle in Class 2 contains a low-dose erlotinib schedule of 7 mg twice daily. When <i>n</i> = 3, each cycle has length <i>L</i> = 168 (one week). For Classes 1 and 2, the evofosfamide dose in each cycle is given 24 hours before the end of the week, and for Class 3 the evofosfamide dose in each cycle is given 6 hours before the end of the week. This is all depicted in step 1. Step 2 shows the removal of erlotinib doses required to satisfy the combination toxicity constraint. Each of these cycles is then repeated to form the entire dosing schedule.</p

Toxicity constraint curves for erlotinib and evofosfamide.

<p>These curves depict the maximum tolerated doses of erlotinib (A) and evofosfamide (B) as functions of frequency of dose administration. The black points are the coordinates from <a href="http://www.ploscompbiol.org/article/info:doi/10.1371/journal.pcbi.1005077#pcbi.1005077.t002" target="_blank">Table 2</a> corresponding to tolerated dosing schedules, and the red points are the ordered pairs in <a href="http://www.ploscompbiol.org/article/info:doi/10.1371/journal.pcbi.1005077#pcbi.1005077.t002" target="_blank">Table 2</a> associated to dosing schedules that were not tolerated in clinical trials. All points contained in the areas on and below these two curves make up the space of tolerated monotherapy dosing schedules, and all points contained in the areas above these two curves make up the space of dosing schedules which lead to dose-limiting toxicities. The curves themselves represent the space of all monotherapy maximum tolerated dosing schedules.</p

Optimal dosing schedules for each class.

<p>For each class, this table shows the values of <i>n</i> for which the means of sensitive, resistant, and total cancer cells, as well as probability of resistance, are each minimized. For each column, the bottom row indicates which of the three classes produces the best overall result for that characteristic of the cancer cell population at the end of treatment.</p

Tumor evolutionary dynamics over time, given a variety of single-agent and combination therapies.

<p>Mean tumor size (A) and probability of resistance (B) are calculated up to recurrence time for a tumor with an initial population of 1.6 ⋅ 10⁶ sensitive cells undergoing treatment with each of the ten dosing schedules defined in <a href="http://www.ploscompbiol.org/article/info:doi/10.1371/journal.pcbi.1005077#pcbi.1005077.t003" target="_blank">Table 3</a>. Each labeled curve corresponds to the dosing schedule with the matching letter in <a href="http://www.ploscompbiol.org/article/info:doi/10.1371/journal.pcbi.1005077#pcbi.1005077.t003" target="_blank">Table 3</a>. For the sake of comparison, results due to dosing schedules using erlotinib alone are shown in red, results due to dosing schedules using evofosfamide alone are shown in blue, and results due to combination therapies are shown in green. Mean tumor size for one of each of these three types of dosing schedules is broken down into the means of sensitive and resistant cells in (C). (D) shows the expected tumor size for combination strategies, conditioned upon the event of developing resistance.</p

Tumor microenvironment modeling process.

<p>This schematic shows the process used to model the tumor microenvironment as a set of discrete compartments. A series of compartments is defined based on various distances from the nearest blood vessel, and the oxygen concentration in each compartment is calculated accordingly. The relative weights of the compartments are determined based on experimental observations of oxygen partial pressure distribution in solid tumors.</p