Avexitide Promising for Hypoglycemia After Weight Loss Surgery

Miriam E. Tucker

June 12, 2022

Avexitide (Eiger Biopharmaceuticals), a first-in-class GLP-receptor blocker, significantly reduced hypoglycemia in patients with refractory post-bariatric hypoglycemia, new research finds.  

Post-bariatric hypoglycemia is a complication of bariatric surgery that is estimated to occur in about 29%-34% of people who undergo Roux-en-Y gastric bypass and in 11%-23% of those who undergo vertical sleeve gastrectomy. It typically manifests about 1-3 hours after meals and can lead to severe neuroglycopenic symptoms including blurred vision, confusion, drowsiness, and incoordination.

In addition, more than one third (37%) with the condition have hypoglycemic unawareness. This can lead to seizures in about 59%, loss of consciousness and hospitalization in 50%, motor vehicle accidents, and even death. More than 90% with the condition consider themselves disabled, and 41% report being unable to work.

There are no currently approved medical treatments for post-bariatric hypoglycemia. The standard of care is medical nutrition therapy involving a low carbohydrate diet with carb restriction and small, frequent mixed meals. If this doesn't work, off-label stepped pharmacotherapy has been tried, including acarbose (Precose), octreotide (Sandostatin), and diazoxide (Proglycem).

But "these are limited by efficacy and tolerability," said Marilyn Tan, MD, who presented the findings from the phase 2 trial of avexitide June 11 at ENDO 2022, the annual meeting of the Endocrine Society.

In very severe cases, gastrostomy tubes or bypass reversal are options but those lead to weight regain and incomplete efficacy. "Safe, effective, and targeted therapies are needed urgently for post-bariatric hypoglycemia," said Tan, clinical associate professor of endocrinology at Stanford University School of Medicine, Stanford, California.

The pathophysiology isn't fully understood, but there appears to be an exaggerated GLP-1 response that leads to abnormal insulin secretion and symptomatic hyperinsulinemic hypoglycemia. Avexitide (formerly exendin 9-39), blocks the GLP-1 receptor and mitigates the excessive GLP-1 response, she explained.

Asked to comment, session moderator Michelle Van Name, MD, told Medscape Medical News, "This is a problem and it's important for us to understand more about it and to identify different treatment options so these patients can continue to live their full, healthy lives post-bariatric surgery."

And, avexitide also holds potential for treating congenital hyperinsulinism, "which is a very challenging disease to treat in babies," noted Van Name, a pediatric endocrinologist at Yale University, New Haven, Connecticut.

Drug Reduced All Levels of Hypoglycemia, Across Surgery Types

The study enrolled 14 women and 2 men with severe refractory post-bariatric surgery hypoglycemia despite medical nutrition therapy. A majority (9) had undergone Roux-en-Y gastric bypass, 4 had vertical sleeve gastrectomy, 2 gastrectomy, and 1 had Nissen fundoplication. Seven patients (43.7%) had experienced loss of consciousness from hyperinsulinemic hypoglycemia. None had diabetes.

They were randomly assigned to either subcutaneous 45 mg of avexitide twice daily or 90 mg once daily for 14 days each, with a 2-day washout period followed by a switch to the other dose.

Both doses resulted in significant reductions in hypoglycemia as measured by self-blood glucose monitoring. The once-daily dose reduced level 1 hypoglycemia (glucose <70 mg/dL) by 67.5% and it reduced level 2 (<54 mg/dL) by 53.3% (P = .0043).

Even greater reductions were seen in severe hypoglycemia (ie, altered mental status/requiring assistance) — by 67.5% for the twice-daily dose (P = .0003) and by 66.1% with the once-daily dose (P = .0003). 

"This is consistent with what we've seen in prior avexitide trials," Tan noted.

More hypoglycemic events were captured using blinded continuous glucose monitoring (CGM), since it picked up episodes of which the patient was unaware. There were significant reductions in percentage time spent in level 1 and level 2 hypoglycemia, as well as in absolute number of hypoglycemic events over 14 days.

Here, the effect was greater with the once-daily 90 mg dose, with reductions of up to 65% in time spent, and number of events, but results for the twice-daily dose were also significant, Tan said.

The drug was effective across all surgical subtypes. Patients who underwent vertical sleeve gastrectomy/gastrectomy had greater rates of hypoglycemia at baseline and "robust responses to avexitide subcutaneous injections. This supports the critical role of GLP-1," Tan said.

There were no severe adverse events. The most commonly reported adverse events were diarrhea, headache, bloating, and injection site reaction/bruising. All were mild and self-limited and resolved without treatment. No participants withdrew from the study.

Eiger Biopharmaceuticals is currently working with the US Food and Drug Administration and the European Medicines Agency to design a phase 3 trial.

The study is an investor-initiated trial with funding from Eiger Biopharmaceuticals. Tan receives research support from Eiger Biopharmaceuticals, Inc., as a site investigator. Van Name is an investigator for a trial sponsored by Provention Bio.

Annual Meeting of the Endocrine Society #ENDO2022.
Presented June 11, 2022.

Miriam E. Tucker is a freelance journalist based in the Washington DC area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter @MiriamETucker.

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