Santarus and VeroScience Announce Publication of AACE Expert Panel Recommendations for CYCLOSET® (bromocriptine mesylate) for the Management of Type 2 Diabetes
Experts conclude that favorable cardiovascular profile of CYCLOSET suggests it may be useful in the treatment of patients with type 2 diabetes with significant risk factors or history of cardiovascular disease
The expert panel also made the following observations and recommendations:
- CYCLOSET has a novel mechanism of action that appears to involve enhancement of morning central nervous system dopaminergic activity, which is reduced in obese individuals with type 2 diabetes. This improvement can potentially lead to improved insulin sensitivity and reduced hepatic glucose output.
- Adjunctive administration of CYCLOSET in the dosing range of 1.6 mg/day to 4.8 mg/day may result in a mean reduction in A1c levels of 0.69% (95% Confidence Interval: 0.97%, 0.41%).
- A 24-week completer analysis performed among efficacy subgroups of patients from the CYCLOSET safety study stratified based on the patient's baseline A1c levels (≥7.5 to < 8.0 versus 8.0 to 8.5 versus ≥8.5).(Vinik et al, Endo. Practice Vol18, p 931-943, 2012) yielded the following results: in the subgroup treated with metformin (with or without another oral hypoglycemic agent), treatment with bromocriptine-QR was associated with a significantly higher proportion of subjects achieving a Week 24 A1c level ≤7 compared with placebo when baseline A1c levels were ≥7.5 to < 8.0 or 8.0 to 8.5 (47% versus 4% and 42% versus 6%, respectively). In the subgroup treated with metformin and a sulfonylurea agent, treatment with bromocriptine-QR was also associated with a significantly higher proportion of patients achieving a Week 24 A1c level ≤7 compared with placebo when baseline A1c levels were ≥7.5 to < 8.0 or 8.0 to 8.5 (57% versus 5% and 46% versus 8%, respectively).
- Improvement in glycemic control during adjunctive treatment with CYCLOSET is achieved with minimal intrinsic risk of hypoglycemia and without clinically significant adverse effects on weight, triglycerides, free fatty acids or blood pressure.
- The large (n=3,070) placebo-controlled 12-month safety study provides the most detailed and systematic information on the long-term tolerability of CYCLOSET in the treatment of type 2 diabetes. Nausea was the most common adverse event (32.2%), and was associated with premature study discontinuation in 7.6% of patients. Other adverse events occurring with an incidence of at least 10% were dizziness (14.8%), fatigue (13.9%), and headache (11.4%). The incidence of nausea was similar in short-term placebo-controlled trials when CYCLOSET was used as a monotherapy (32.5%) or when it was used as an adjunctive therapy with sulfonylurea (25.4%).
- The major limitation to the use of CYCLOSET is the relatively small clinical trials database. As a result, there is currently insufficient information on the safety and efficacy of adjunctive therapy with CYCLOSET in type 2 diabetes patients being treated with other diabetes regimens such as thiazolidinediones or insulin.
- CYCLOSET's novel mechanism of action and favorable cardiovascular risk profile may make it a useful addition to the spectrum of agents available to treat type 2 diabetes.
The members of the expert panel were:
Alan J. Garber, MD, PhD, Departments of Medicine, Biochemistry and Cell Biology, Baylor College of Medicine, Houston, Texas;
- Lawrence Blonde, MD, FACP, FACE,
Ochsner Diabetes Clinical ResearchUnit, Department of Endocrinology, Diabetes and Metabolism, Ochsner Medical Center, New Orleans, Louisiana; Zachary T. Bloomgarden, MD, Department of Medicine, Mount Sinai School of Medicine, New York City, New York; Yehuda Handelsman, MD, FACP, FACE, Metabolic Institute of America, Tarzana, California; and
- Samuel Dagogo-Jack, MD,
Division of Endocrinology, Diabetes and Metabolism and Clinical Research Center, University of Tennessee Health Science Center, Memphis, Tennessee.
Financial support for the AACE expert panel workshop was provided by
Important Safety Information
CYCLOSET is a dopamine receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
CYCLOSET is contraindicated in:
- Patients with known hypersensitivity to bromocriptine, ergot-related drugs, or any of the excipients in CYCLOSET.
- Patients with syncopal migraine. Bromocriptine increases the likelihood of a hypotensive episode among patients with syncopal migraine. Loss of consciousness during a migraine may reflect dopamine receptor hypersensitivity. CYCLOSET is a dopamine receptor agonist, and may, therefore, potentiate the risk for syncope in these patients.
- Women who are nursing their children. CYCLOSET may inhibit lactation. There are postmarketing reports of stroke in this patient population although causality has not been proven.
Warnings and Precautions
- Hypotension: Can cause orthostatic hypotension and syncope, particularly upon initiation or dose escalation. Use caution in patients taking anti-hypertensive medications. Assess orthostatic vital signs prior to initiation of CYCLOSET and periodically thereafter. Advise patients during early treatment to avoid situations that could lead to injury if syncope was to occur.
- Psychosis: May exacerbate psychotic disorders or reduce the effectiveness of drugs that treat psychosis. Use in patients with severe psychotic disorders is not recommended.
- Somnolence: May cause somnolence. Advise patients not to operate heavy machinery if symptoms of somnolence occur.
- Interaction with dopamine antagonists: Concomitant use with dopamine antagonists such as neuroleptic agents may diminish the effectiveness of both drugs. Concomitant use is not recommended.
- Other dopamine receptor agonists: Effectiveness and safety are unknown in patients already taking dopamine receptor agonists for other indications. Concomitant use is not recommended.
- Macrovascular outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with CYCLOSET or any other anti-diabetes drug. CYCLOSET does not increase the risk of macrovascular events.
In controlled clinical trials, adverse reactions reported in ≥5% of patients treated with CYCLOSET and reported more commonly than in patients treated with placebo, included nausea, fatigue, dizziness, vomiting, and headache.
Postmarketing reports with higher doses of bromocriptine used for other indications include psychotic disorders, hallucinations, and fibrotic complications.
- May increase the unbound fraction of highly protein-bound therapies, altering their effectiveness and safety profiles.
- May increase ergot-related side effects or reduce ergot effectiveness for migraines if co-administered within 6 hours of ergot-related drugs.
- Extensively metabolized by CYP3A4. Use caution when co-administering strong inhibitors, inducers, or substrates for CYP3A4.
The Important Safety Information does not include all the information needed to use CYCLOSET safely and effectively. See Full Prescribing Information for CYCLOSET for additional information, available at www.cycloset.com or by contacting
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