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What does the mechanism of tirzepatide predict that SURPASS-2 did not test?

Asked 30 Dec 2024Modified 18 months agoViewed 28k times
38

The particulars: tirzepatide · SURPASS-2.

I understand the observation; what I do not understand is the mechanism behind it.

I have read the two review articles that come up first and both assert this without a citation to a primary source.

Can someone derive this rather than assert it?

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A fixed-ratio combination of cagrilintide, a long-acting amylin analogue, with semaglutide, studied in the REDEFINE programme. Questions here…

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SI
askedsample_id17k2730 Dec 2024

2 Answers

Accepted answer first, then by votes
84

Accepted answer

GLP-1R is a class B G-protein-coupled receptor signalling predominantly through Gs and cyclic AMP, and most of the interesting pharmacology in this class is about where that signalling happens rather than how hard it is driven.

The GIP agonism-versus-antagonism question remains open, and the awkward fact is that both directions have produced weight loss in humans. The reconciling hypothesis is that chronic GIPR agonism produces receptor desensitisation and therefore functions as a pharmacological antagonist, but that is a hypothesis fitted to the data rather than an independent finding.

Receptor desensitisation as a plateau mechanism is plausible and poorly evidenced. GLP-1R internalises on agonist binding and recycles, and biased agonists that internalise less have been argued to sustain signalling better. Whether any of that operates at the timescale of a four-month clinical plateau — against the much simpler explanation that energy expenditure fell with mass — is not established.

The structural basis of semaglutide’s pharmacokinetics — Aib-8, the Arg34Lys substitution and the C18 diacid–AEEA linker at Lys26 — is described in the original medicinal chemistry publication, and it is worth reading once because it makes the design logic explicit[1].

The chemistry is the interesting part and it is also the well-documented part. Read the medicinal chemistry papers; they are short and they explain the design.

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LF
answered · acceptedleah_ferrers15k2728 Jan 2025
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71

Stated carefully, start from the receptor and the rest follows: which receptors, in what ratio, with what signalling bias, reached at what concentration.

Amylin co-agonism adds to a GLP-1 effect rather than duplicating it because the two act through different circuits: amylin signals through the area postrema via calcitonin receptor complexes, GLP-1 through both the area postrema and the arcuate nucleus. Two non-redundant satiety signals summate, which is the design rationale for a co-formulation rather than a higher dose of either.

Orforglipron is not a peptide at all, which changes everything downstream: it is orally bioavailable without an absorption enhancer, it has no fasting or water requirement of the same kind, it does not require cold chain, and it cannot be assayed by any of the peptide methods discussed elsewhere on this site.

The limitation here is that almost all of the human mechanistic work is in the licensed agents, so mechanistic claims about the investigational tri-agonists rest on animal and early-phase data.

The mechanism is settled enough to be useful and unsettled enough to be interesting, which is a reasonable place for a field to be.

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BU
answeredbufferline4249k1388 Feb 2025

Your answer

Ask PeptideStack is a static archive. Posting is closed, but the norms are worth stating: answer the question that was asked, show your working, cite the trial or the certificate, and say plainly where the evidence runs out.

Not medical advice. Research-use-only compounds are not approved for human use.