Prediabetes, the New Normal in Early Clinical Research
Prediabetes, the New Normal in Early Clinical Research
There is a growing shift in inclusion criteria from healthy normal subjects to patient groups in early drug development. For programs with a chronic metabolic disease investigational product, prediabetes subject enrollment in early phase studies can facilitate the detection of efficacy signals and proof-of-concept [1].
Prediabetes describes a state of glucose impairment which holds a significant risk of developing type 2 diabetes. According to the CDC, 1 in 3 Americans have prediabetes, yet only 1 out of 10 individuals are aware of their condition [2]. Risk factors for prediabetes include being overweight or obese, an estimated 80% of subjects with glucose impairment are overweight or obese [3]. Additional risk factors include 45 years of age or older, a family history of type 2 diabetes, a sedentary lifestyle, and previously having gestational diabetes [2]. Clinical research organizations can provide a helping hand in managing the disease by being committed to raising prediabetes awareness through free A1c screening during community outreach events [4] and offering resources on diabetes prevention.
Type 2 diabetes patients can be vulnerable to hyperglycemic and hypoglycemic events during early phase placebo-controlled studies, monotherapy studies or during washout periods. Since prediabetes subjects maintain a degree of glucose control, they are less likely to experience severe glucose excursions. Therefore, a risk mitigation strategy to minimize serious glycemic changes in early dose escalation studies could include the enrollment of prediabetes subjects. In addition, to better understand a drug’s effect on glycemic parameters, intensive daily glucose tracking through continuous glucose monitoring (CGM) can provide blood glucose readings every 5-15 minutes for up to 2 weeks. To this end, CGM is recognized as the “ECG Holter-monitor for glycemia” [5].
Nonalcoholic fatty liver disease (NAFLD) is the next major health epidemic and prediabetes is strongly associated with hepatic inflammation and fibrosis in NAFLD subjects [6]. Nonalcoholic steatohepatitis (NASH), a deleterious form of the disease can lead to liver cirrhosis, end-stage liver failure and even hepatocellular carcinoma. Using non-invasive techniques to assess steatosis, inflammation and oxidative stress, and fibrosis can expedite clinical research. These pharmacodynamic imaging and soluble biomarker analyses are essential early signals of drug efficacy to enable faster go/no-go decisions.
Prediabetes subject enrollment in early clinical studies for weight management, Type 2 Diabetes or NASH indications offers an opportunity to examine pharmacodynamic endpoints in a population of interest while minimizing safety concerns typically observed with patient studies.
References
1. Paglialunga, S. The Impact of Prediabetes on Early Clinical Metabolic Disease Studies: Celerion, Technical Note. 2017.
2. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA. 2014.
3. Tuso P. Prediabetes and lifestyle modification: time to prevent a preventable disease. Perm J. 2014;18(3):88-93.
4. Jaycox SH, Esposito M, Paglialunga S. Effectiveness of Community-Based HbA1c Screening as a Clinical Study Recruitment Tool. American Society for Clinical Pharmacology and Therapeutics; 2017 April 17 Washington,DC.
5. Vigersky R, Shrivastav M. Role of continuous glucose monitoring for type 2 in diabetes management and research. J Diabetes Complications. 2017;31(1):280-7.
6. Yilmaz Y, Senates E, Yesil A, Ergelen R, Colak Y. Not only type 2 diabetes but also prediabetes is associated with portal inflammation and fibrosis in patients with non-alcoholic fatty liver disease. J Diabetes Complications. 2014;28(3):328-31.