What does STEP 5 tell me about vomiting at the 40 mg dose?

Stated plainly: STEP 5 · vomiting · 40 mg.

I would like help reading this properly rather than being told what conclusion to reach.

I have the full report including the method section, so I can quote specifics if that helps.

What would I need in addition before this supported a decision?

The confidence interval is the informative part. A point estimate with an interval spanning no effect is a different object from the same point estimate with a tight interval, and the abstract presents them identically.

Liver enzymes are a poor surrogate for hepatic histology in both directions: substantial steatohepatitis with normal transaminases is common, and modest enzyme elevation with minimal fibrosis is common. If the question is fibrosis, the answer comes from a non-invasive score such as FIB-4 or a stiffness measurement, not from ALT.

Headline results, principal programmes

Concretely, hbA1c is a weighted average, not a flat one: roughly half the signal comes from the most recent month. That is why a value drawn six weeks after a change already reflects most of the effect, and why a value drawn during rapid haematological turnover reflects something other than glycaemia.

STEP 1 reported a mean weight change of approximately −14.9 per cent with semaglutide 2.4 mg versus −2.4 per cent with placebo at 68 weeks[1]; the difference between the figures quoted from this trial in different places is an estimand difference.

One qualification: a trial that demonstrates an endpoint at a given dose has demonstrated it at that dose. Extrapolating the endpoint down the dose ladder is an assumption, not a finding.

If the trend across three draws is flat, the difference between draws one and two was noise. Most of what people react to is noise.

Start with the population. The inclusion criteria of the trial determine what its result can be extrapolated to, and the extrapolation people want is usually to a population the trial excluded.

A fasting lipid panel drawn during rapid weight loss reads oddly for a mechanical reason: mobilised adipose tissue delivers free fatty acids to the liver, and hepatic triglyceride export rises. Triglycerides can transiently increase while the person is doing exactly the right thing. Draw the panel when weight has been stable for a few weeks if you want an interpretable number.

More usefully, creatinine is a muscle-derived metabolite, so a substantial loss of lean mass lowers serum creatinine and mathematically raises estimated GFR without anything happening to the kidney. If you have lost twenty kilograms, your creatinine-based eGFR is flattering you. Cystatin C is not muscle-dependent and is the measure to use when the two disagree.

SURMOUNT-1 reported mean weight reductions of approximately 15, 19 and 21 per cent at tirzepatide 5, 10 and 15 mg respectively at 72 weeks[1].

The caveat is the population. Trial participants were screened, monitored and supported; the effect size in an unmonitored setting is not the trial effect size, and it is not obvious in which direction the difference runs.

The papers are readable. Read the paper rather than the summary of the paper, especially where the summary is enthusiastic.

The hazard ratio is the relative effect. What changes decisions is the absolute effect, and converting between them requires the event rate in the control arm, which is usually in the same table and rarely in the abstract.

The early fall in estimated glomerular filtration rate on treatment is haemodynamic rather than structural. Reduced intraglomerular pressure lowers the filtration rate acutely and preserves the glomerulus chronically — the same pattern seen with renin-angiotensin blockade and with SGLT2 inhibition. A dip of a few millilitres per minute in the first weeks, followed by a shallower long-term slope, is the desired trajectory, not a warning sign.

Estimated average glucose from HbA1c: eAG in mg/dL = 28.7 × A1c − 46.7, or in mmol/L, 1.59 × A1c − 2.59. An A1c of 6.5 per cent is therefore about 140 mg/dL or 7.8 mmol/L. The relationship is a population regression, so an individual can sit well off the line.

FLOW tested a composite renal endpoint — kidney failure, sustained 50 per cent eGFR decline, or renal or cardiovascular death — in type 2 diabetes with chronic kidney disease, and was stopped early for efficacy[1].

None of this replaces a clinician who can see the whole picture, and the whole picture is usually where the answer is.

edited 3 Oct 2024 by vialroom — added a caveat about sampling

Worth being precise here: read the estimand before the effect size. Almost every apparent contradiction between two published figures from the same trial resolves once you notice that one is a trial-product estimand and the other is a treatment-policy estimand.

The rodent thyroid C-cell findings that generated the labelled warning appear to be species-specific: rodent C-cells express GLP-1 receptors at high density, human C-cells at very low density, and human calcitonin data across large trial populations has not reproduced the signal. A family history of medullary thyroid carcinoma or MEN2 is nonetheless a genuine contraindication rather than a theoretical one.

SUSTAIN 6 was the original cardiovascular outcomes trial for semaglutide in type 2 diabetes and is the reference point for the class effect that SELECT later extended to a non-diabetic population[1].

Read the confidence interval, read the estimand, and compute the absolute effect yourself. It takes two minutes and it changes how the result feels.

This is a question about what the trial was designed to answer, and the honest response is that it was not designed to answer this.

ApoB and LDL-C disagree because they measure different things: LDL-C is the cholesterol mass carried in the LDL fraction, ApoB is a count of atherogenic particles. Small dense particles carry less cholesterol each, so a person with many small particles has a concordantly higher ApoB than their LDL-C suggests. When they disagree, ApoB is the better risk marker.

SURMOUNT-OSA reported reductions in the apnoea-hypopnoea index with tirzepatide in adults with obesity and moderate-to-severe obstructive sleep apnoea, both with and without concurrent positive airway pressure therapy[1].

Convert everything to an absolute effect before you compare two interventions. Relative effects are not comparable across different baseline risks.