1. Journal Club 埼玉医科大学 総合医療センター 内分泌・糖尿病内科 Department of Endocrinology and Diabetes, Saitama Medical Center, Saitama Medical University 牧野 佑子 髙嶋 正利 牧野 佑子 髙嶋 正利 Makino, YukoTakashima, Masatoshi Makino, YukoTakashima, Masatoshi 2013 年 6 月 13 日 8:30-8:55 ８階 医局 Strain WD, Lukashevich V, Kothny W, Hoellinger MJ, Paldánius PM. Individualised treatment targets for elderly patients with type 2 diabetes using vildagliptin add-on or lone therapy (INTERVAL): a 24 week, randomised, double-blind, placebo-controlled study. Lancet. 2013 May 22. pii: S0140-6736(13)60995-2. doi: 10.1016/S0140-6736(13)60995-2. Ikramuddin S, Korner J, Lee WJ, Connett JE, Inabnet WB, Billington CJ, Thomas AJ, Leslie DB, Chong K, Jeffery RW, Ahmed L, Vella A, Chuang LM, Bessler M, Sarr MG, Swain JM, Laqua P, Jensen MD, Bantle JP. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA. 2013 Jun 5;309(21):2240-9. doi: 10.1001/jama.2013.5835.

2. HbA1c 6% 7% 8% Diabetologia 55:1577-96, 2012, Diabetes Care 35:1364-1379, 2012

4. alogliptin Dipeptidyl peptidase-4 阻害薬／ GLP-1 アナログ製剤 sitagliptinvildagliptin ExenatideLiraglutide linagliptin saxagliptinteneligliptin anagliptin trelagliptinMK-3102

5. Diabetes and Vascular Research Centre, University of Exeter Medical School, Exeter, UK (W D Strain MD); Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA (V Lukashevich MD, W Kothny MD); Novartis Pharma AG, Basel, Switzerland (M-J Hoellinger MD, P M Paldanius MMedSci) www.thelancet.com Published online May 23, 2013 http://dx.doi.org/10.1016/S0140-6736(13)60995-2

6. Background Guidelines suggest setting individualised targets for glycaemic control in elderly patients with type 2 diabetes, despite no evidence. We aimed to assess the feasibility of setting and achieving individualised targets over 24 weeks along with conventional HbA1c reduction using vildagliptin versus placebo. The drug of choice was the selective dipeptidyl peptidase 4 (DPP4) inhibitor vildagliptin because it has well documented efficacy and safety in elderly patients with type 2 diabetes. (Schweizer A, Dejager S, Foley JE, Shao Q, Kothny W. Clinical experience with vildagliptin in the management of type 2 diabetes in a patient population ≥75 years: a pooled analysis from a database of clinical trials. Diabetes Obes Metab 2011; 13: 55–64. )

7. Methods In this multinational, double-blind, 24 week study, we enrolled drug-naive or inadequately controlled (glycosylated haemoglobin A1c [HbA1c] ≥7 ・ 0% to ≤10 ・ 0%) patients with type 2 diabetes aged 70 years or older from 45 outpatient centres in Europe. Investigators set individualised treatment targets on the basis of age, baseline HbA1c, comorbidities, and frailty status before a validated automated system randomly assigned patients (1:1) to vildagliptin (50 mg once or twice daily as per label) or placebo. Coprimary efficacy endpoints were proportion of patients reaching their investigator-defined HbA1c target and HbA1c reduction from baseline to study end. The study is registered with ClinicalTrials.gov, number NCT01257451, and European Union Drug Regulating Authorities Clinical Trials database, number 2010-022658-18.

8. Figure 1: Trial profile *Some patients were excluded for more than one reason.

9. Table 1: Baseline demographics and clinical characteristics Data are mean (SD) or number (%). HbA1c=glycosylated haemoglobin A1c. GFR (MDRD)=glomerular filtration rate estimated using the modification of diet in renal disease formula.

10. Patients in the drug-naive and other background OAD groups received vildagliptin (50 mg) twice daily or placebo, whereas patients in the sulphonylurea monotherapy group received vildagliptin (50 mg) once daily or placebo. Study drug dose adjustments or interruptions were not permitted. Patients remained on stable doses of OADs for the duration of the study. Study drug was discontinued and the patient withdrawn from the study if the investigator decided that continuation would result in a substantial safety risk for that patient. Insulin or any OAD (excluding incretin analogues and DPP4 inhibitors) could be used as rescue medication by the investigator at any time after randomisation if patients did not achieve a satisfactory therapeutic effect. However, efficacy data for patients receiving rescue medication were censored from the day after the rescue medication was started. Procedures

11. At baseline (visit 2), an individualised 24 week HbA1c target was defined by the investigators for each of their patients, taking into account age of the patient, frailty status, comorbidities, and baseline HbA1c values; most guidelines recommend using these factors to personalise treatments. Importantly, these investigator- defined individualised HbA1c targets were based on the physicians’ clinical judgment and local recommendations for glycaemic targets. Target

12. In this elderly cohort, the mean individualised HbA1c targets set by the investigators were around 7 ・ 0% for both treatment groups, 0 ・ 9% (range –4 ・ 4 to – 0 ・ 1) lower than the mean baseline HbA1c of 7 ・ 9% in each treatment group. In the placebo group, 37 (27%) of 137 patients achieved their individualised targets as a result of education and interactions with the study team alone; this number was almost double, at 72 (52 ・ 6%) of 137, in the vildagliptin group. The adjusted OR of achieving the individualised target was 3 ・ 16 (96 ・ 2% CI 1 ・ 81–5 ・ 52; p<0 ・ 0001; fi gure 2).

13. 172mg/dL177mg/dL 18mg/dL

16. Figure 2: Odds ratio for proportion of patients achieving individualised HbA1c targets after 24 weeks Odds ratios, associated CI, and p values were calculated from a logistic regression model containing terms for treatment, baseline HbA1c (centred by subtracting the overall mean baseline HbA1c of all treatment groups), background oral antidiabetic drug strata, and pooled centres to compare the treatment effect. Squares show odds ratios for intention-to-treat analysis and per-protocol analysis; the lines show the 96 ・ 2% Cl. Equivalent risk ratios for the number of patients who reached the investigator-defined HbA1c target at study endpoint were 1 ・ 92 (96 ・ 2% CI 1 ・ 29–2 ・ 86; p=0 ・ 0013) in the intention-to-treat analysis and 1 ・ 91 (1 ・ 27–2 ・ 86; p=0 ・ 0017) in the per-protocol analysis. *Indicates statistical significance at two-sided 3 ・ 8% level.

18. Data are number (%). AE=adverse event. *A patient with several occurrences of an AE on one treatment is counted only once in the AE category. †A detailed listing of the SAEs is available in the appendix. ‡Acute pancreatitis-related AEs, hepatic-related AEs, infection- related AEs, lactic-acidosis- related AEs, muscle-related AEs, neuropsychiatric-related AEs, and skin or vascular- related AEs were defi ned as events of predefi ned risk. Table 3: Treatment-emergent AEs in the safety analysis population

19. Findings Between Dec 22, 2010, and March 14, 2012, we randomly assigned 139 patients each to the vildagliptin and placebo groups. 37 (27%) of 137 patients in the placebo group achieved their individualised targets by education and interactions with the study team alone and 72 (52 ・ 6%) of 137 patients achieved their target in the vildagliptin group (adjusted odds ratio 3 ・ 16, 96 ・ 2% CI 1 ・ 81–5 ・ 52; p<0 ・ 0001). This finding was accompanied by a clinically relevant 0 ・ 9% reduction in HbA1c from a baseline of 7 ・ 9% with vildagliptin and a between-group difference of –0 ・ 6% (98 ・ 8% CI –0 ・ 81 to –0 ・ 33; p<0 ・ 0001). The overall safety and tolerability was similar in the vildagliptin and placebo groups, with low incidence of hypoglycaemia and no emergence of new safety signals.

20. Interpretation This study is the first to introduce and show the feasibility of using individualised HbA1c targets as an endpoint in any type 2 diabetes population. Individualised glycaemic target levels are achievable with vildagliptin without any tolerability issues in the elderly type 2 diabetes population. Funding Novartis Pharma AG.

21. Message 70 歳以上の未治療または血糖制御不良の 2 型糖尿 病（ DM ）患者 139 人を対象に、ビルダグリプチ ンによる個別設定 HbA1c 目標値の達成可能性を 無作為化試験で評価（ INTERVAL 試験）。達成 率はビルダグリプチン群 52.6 ％、プラセボ群 27 ％だった。著者らは、 2 型 DM の個別 HbA1c 目標使用の実現可能性が示されたと述べている。

23. A meta-analysis from University of California, Los Angeles reports the following weight loss at 36 months Biliopancreatic diversion - 53 kg Roux-en-Y gastric bypass (RYGB) - 41 kg Open - 42 kg Laparoscopic - 38 kg Adjustable gastric banding - 35 kg Vertical banded gastroplasty - 32 kg Sleeve gastrectomy ? Biliopancreatic diversion Roux-en-Y gastric bypass Sleeve gastrectomy with duodenal switch Adjustable gastric banding Vertical banded gastroplasty

24. Message １．肥満度の指標である BMI （＝体重 kg÷ 身長 m の２ 乗）が 32 以上で、糖尿病またはそれ以外の 2 つ合 併症をもつ方（身長 160cm で 82kg 以上） ２． BMI が 37 以上の方（身長 160cm で 95kg 以上） ※ 上記の適応を満たす方で、内科的治療が効果がな かった方 楽をしてやせるための手術ではなく、患者様の命を守 るための手術であることを十分に理解することです ■ 四谷メディカルキューブ 減量外科 笠間和典先生 http://wwwmcube.jp/ 〒 102-0084 東京都千代田区二番町 7 番 7 http://wwwmcube.jp/

25. JAMA. 2013;309(21):2240-2249 Department of Surgery (Drs Ikramuddin and Leslie), Divisions of Biostatistics (Dr Connett and Ms Thomas) and Epidemiology and Community Health (Dr Jeffery), School of Public Health, Department of Medicine, Division of Endocrinology and Diabetes (Drs Billington and Bantle), and Berman Center for Clinical Research (Ms Laqua), University of Minnesota, Minneapolis; Departments of Medicine, Division of Endocrinology (Dr Korner) and Surgery (Drs Ahmed and Bessler), Columbia University Medical Center, New York, New York; Departments of Surgery (Dr Lee) and Internal Medicine, Division of Metabolism and Endocrinology (Dr Chuang), National Taiwan University Hospital, Taipei, Taiwan; Department of Surgery, Mount Sinai Medical Center, New York, New York (Dr Inabnet); Department of Endo- crinology, Min-Sheng General Hospital, Taoyuan, Taiwan (Dr Chong); Department of Medicine, Division of Endocrinology and Diabetes (Drs Vella and Jensen); Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester,Minnesota (Dr Sarr); and Scottsdale Healthcare Bariatric Center, Scottsdale, Arizona (Dr Swain).

26. Importance Controlling glycemia, blood pressure, and cholesterol is important for patients with diabetes. How best to achieve this goal is unknown. Objective To compare Roux-en-Y gastric bypass with lifestyle and intensive medical management to achieve control of comorbid risk factors.

27. Design, Setting, and Participants A 12-month, 2-group unblinded randomized trial at 4 teaching hospitals in the United States and Taiwan involving 120 participants who had a hemoglobin A1c (HbA1c) level of 8.0% or higher, body mass index (BMI) between 30.0 and 39.9, C peptide level of more than 1.0 ng/mL, and type 2 diabetes for at least 6 months. The study began in April 2008. Interventions Lifestyle-intensive medical management intervention and Roux-en-Y gastric bypass surgery. Medications for hyperglycemia, hypertension, and dyslipidemia were prescribed according to protocol and surgical techniques that were standardized. Main Outcomes and Measures Composite goal of HbA1c less than 7.0%, lowdensity lipoprotein cholesterol less than 100 mg/dL, and systolic blood pressure less than 130 mm Hg.

32. Figure 2. Outcomes Over Time

35. Results All 120 patients received the intensive lifestyle-medical management protocol and 60 were randomly assigned to undergo Roux-en-Y gastric bypass. After 12- months, 28 participants (49%; 95% CI, 36%-63%) in the gastric bypass group and 11 (19%; 95% CI, 10%-32%) in the lifestyle-medical management group achieved the primary end points (odds ratio [OR], 4.8; 95% CI, 1.9-11.7). Participants in the gastric bypass group required 3.0 fewer medications (mean, 1.7 vs 4.8; 95% CI for the difference, 2.3-3.6) and lost 26.1% vs 7.9% of their initial body weigh compared with the lifestyle-medical management group (difference, 17.5%; 95% CI, 14.2%- 20.7%). Regression analyses indicated that achieving the composite end point was primarily attributable to weight loss. There were 22 serious adverse events in the gastric bypass group, including 1 cardiovascular event, and 15 in the lifestyle-medical management group. There were 4 perioperative complications and 6 late postoperative complications. The gastric bypass group experienced more nutritional deficiency than the lifestyle-medical management group.

36. Conclusions and Relevance In mild to moderately obese patients with type 2 diabetes, adding gastric bypass surgery to lifestyle and medical management was associated with a greater likelihood of achieving the composite goal. Potential benefits of adding gastric bypass surgery to the best lifestyle and medical management strategies of diabetes must be weighed against the risk of serious adverse events. Trial Registration clinicaltrials.gov Identifier: NCT00641251

37. Message 軽 - 中等度肥満の 2 型糖尿病（ DM ）患者 120 人を対象に、医学管理と減量手術のリ スク因子制御に対する効果を無作為化試験 で検討。複合目標（ HbA1c ＜ 7.0 ％、 LDL コレステロール＜ 100mg/dL 、収縮期血 圧＜ 130mmHg ）達成率は、医学管理＋ ルー・ワイ胃バイパス術群 49 ％、医学管理 単独群 19 ％だった（オッズ比 4.8 ）。