Author: Raffaele Marfella, et al.

1. Effect of vildagliptin twice daily vs. sitagliptin once daily on 24-hour acute glucose fluctuations • Author: Raffaele Marfella, et al. • Publication: Journal of Diabetes and Its Complications 24 (2010) 79-83

2. DPP-4 inhibitor therapy should target not only reducing HbA1c but also flattening acute glucose fluctuation over a daily period • Continuous subcutaneous glucose monitoring (CSGM) shows large MAGE decrements in vildagliptin group compared with sitagliptin group • A marked increase in GLP-1 occurred during interprandial period in vildagliptin bid-treated toward sitagliptin 100 mg once daily • Glucagon was more suppressed during interprandial period in receiving vildagliptin compared to those receiving sitagliptin

4. Rapid glucose fluctuation over daily period plays importance role on diabetic complication • Exposure to glycemic disorder can be described as a function of two components • - The duration and magnitude of chronic sustained hyperglycemia (HbA1c) • - Acute fluctuations of glucose over a daily period; when • MAGE is greater, glycemic instability is higher • Acute fluctuations of glucose around a mean value has been proved independent of mean glycemic and may be due to • Defects in insulin secretion • Suppression of glucagon secretion

5. Example of MAGE calculation 48 hr continuous blood glucose analyses (CBGA) MAGE is calculated for each subject by taking the arithmetic mean of blood glucose increase or decrease (nadir to peak) when both ascending and descending segments exceeded the value of one standard variation of blood glucose for the same 24-hr Glucose excursions counted only those > 1 SD = 125+295+116+143+126 +332+149 MAGE = 1286/7 = 184 mg/dl 24 h 24 h 295 125 143 126 116 332 149 SD = 62 mg/dl in day 1 = 74 mg/dl in day 2 Graph are from Service et al.Diabetes 1970; 19 (9): 645-655

7. The effect of DPP-4 inhibitors on glycemic control •  Many studies have shown that DPP-4 inhibitors (Vildagliptin and Sitagliptin) can enhance GLP-1 level and prolong its effects for glycemic control •  They have been proved to enhance glucose-induced insulin secretion, decrease glucagon secretion, and reduce postprandial glycemic excursions •  By mechanism of action, the potency of stabilizing DPP-4 inhibition offer the better regulation of daily glucose fluctuations • Chronic hyperglycemia has been associated with increased risk of diabetic complication and mean amplitude glucose excursion (MAGE) is also linked with the activation of oxidative stress, which is the main mechanisms that lead to chronic diabetic complication

8. Effect of Vildagliptin vs Sitagliptin on 24-hr acute glucose fluctuation (MAGE) A cross-sectional study of acute glucose fluctuation on pre- and post- treatment Vildagliptin n = 20 Sitagliptin n = 18 * P <0.01 100 100 69 ± 18 59 ± 16 70 ± 22 80 80 60 60 34 ± 7 MAGE (mg/dl) MAGE (mg/dl) 40 40 20 20 0 0 At baseline After 3 mo treatment After 3 mo treatment At baseline • Patients were prior inadequately controlled by metformin max dose (3000 mg/d) and randomized to treat with either Vildagliptin 50 mg bid or Sitagliptin 100 OD on to metformin over a period of 3 mo. • CSGM shows large MAGE decrements in the vildagliptin group compared with Sitagliptin group *P <0.01 difference from baseline Marfella R et al. J Diabetes Complications. 2009 doi:10.1016(in Press)

9. Vildagliptin 50 mg bid + metformin 30 Sitagliptin 100 mg qd + metformin 25 20 Intact GLP-1 (pmol/L) 15 10 5 0 -20 0 15 30 60 90 120 180 240 300 0 15 30 60 90 120 180 240 300 0 15 30 60 90 120 180 240 300 min Dinner Breakfast Lunch Effect of Vildagliptin vs Sitagliptin on Plasma Levels of Intact GLP-1 The difference can be seen as early as 1.5 - 3 hrs post dose so that different regimen (bid vs od) should not be the main cause of the difference P<0.05 vs. vildagliptin group, Plasma levels during 24-h sampling comprising three standardized meals after 3 months of treatment in type 2 diabetic patients. Marfella R et al. J Diabetes Complications. 2009 doi:10.1016(in Press)

10. Higher suppress Plasma Levels of Glucagon with Vildagliptin versus Sitagliptin Vildagliptin 50 mg bid + metformin 90 Sitagliptin 100 mg qd + metformin 80 70 60 Plasma glucagon (mg/dl) 50 40 30 20 0 300 min 0 300 min 0 300 min Dinner Lunch Breakfast P<0.05 vs. vildagliptin group, Plasma levels during 24-h sampling comprising three standardized meals after 3 months of treatment in type 2 diabetic patients. Marfella R et al. J Diabetes Complications. 2009 doi:10.1016(in Press)

11. K1 Vildagliptin:(slow tight-binding substrate) K2 + + K −1 Very slow Vildagliptin DPP-4 Vildagliptin:DPP-4 complex DPP-4 Inactivevildagliptin The rational for the stabilized DPP-4 inhibition over daily period • - The difference of binding kinetics provided that • Vildagliptin is tight binding to DPP-4 enzyme with high affinity and posses slow dissociation rate (t1/2 for dissociation = 55 min) resulting in the more stabilized DPP-4 inhibition (~ 97% inhibition over a daily basis)1 K1 K2 + + Sitagliptin K −1 fast DPP-4 DPP-4 Sitagliptin is binding to DPP-4 enzyme with high affinity but does not have slow dissociation resulting in fast binding and fast dissociation (~ 80% inhibition over daily basis)2 Sitagliptin:DPP-4 complex InactiveSitagliptin 1 Mari et al, 2005 J Clin Endoclin Metab 90: 4888-4894 2 Herman et al. 2006 J Clin Endoclin Metab 91 : 4612-4619

12. Conclusion

13. Only H2H study between vilda vs. sita • Galvus stronger efficacy in 4 dimension: • 1. Glucagon suppression • 2. GLP-1 raising • 3. MAGE reduction • 4. DPP-4 activity inhibition during 24 hrs • Differentiate Galvus as Best-in-class efficacy to support -1.1% A1C reduction message.