Semaglutide in Women With Polycystic Ovary Syndrome and Obesity

Introduction Polycystic ovary syndrome (PCOS) is a prevalent endocrine disorder, impacting approximately 10-20% of women in their reproductive years. The syndrome is typically characterized by reproductive and dermatological manifestations such as irregular menstrual cycles, subfertility, hirsutism, and acne. However, the metabolic components of PCOS, including obesity, hypertension, glucose intolerance, dyslipidemia, and metabolic syndrome, significantly influence the clinical presentation and treatment outcomes of the disease. These metabolic features are primarily associated with insulin resistance and hyperandrogenemia, the key pathological mechanisms of PCOS. Obesity affects about two-thirds of individuals with PCOS and it exacerbates PCOS manifestations, including hyperandrogenism, and decreases fertility rates. It has been demonstrated that the prevalence of PCOS differs across ethnic groups, with higher prevalence reported in South Asian, and lower prevalence in East Asian patients, in comparison to Caucasian women. South Asian is a collective word used to refer to people who originate from the Indian subcontinent (India, Pakistan, Sri Lanka, Bangladesh, and Nepal). These countries are densely populated and, like many regions of the world, also have people who suffer from PCOS. The South Asian population, in general, also exhibits a higher prevalence of insulin resistance and type 2 diabetes, which may increase long-term morbidity among those with PCOS. Weight loss through lifestyle modifications and bariatric surgery has been shown to alleviate all PCOS symptoms, including ovulation improvement, decreased artificial reproductive techniques requirement, and increased pregnancy rate. Resolution of all three diagnostic features of PCOS after lifestyle therapy and bariatric surgery has been demonstrated. Hence, obesity is now considered a secondary cause of PCOS (pseudo-PCOS).

Lifestyle is the cornerstone in the management of PCOS and obesity. According to the American Diabetes Association (ADA), a 5% or greater weight loss can improve metabolic outcomes in obese patients. Metformin, an insulin sensitizer is now an evidence-based treatment option especially those with a body mass index (BMI) at or above 25 kg/m2. Metformin is essentially weight neutral. However, a placebo-controlled double blind randomized controlled trial conducted in our Department showed significant reduction of BMI and waist circumference (WC) over a period of nine months among women with PCOS. Recent studies have demonstrated significant weight reductions in various conditions related to PCOS, including diabetes mellitus (DM), metabolic dysfunction-associated steatotic liver disease, and obstructive sleep apnea, using different types of glucagon-like peptide 1 receptor agonists 1 (GLP1RAs). Another open-label randomized controlled trial from our Department showed more improvement in BMI and insulin resistance (IR) among women with PCOS who were treated with both metformin and liraglutide over twelve weeks than metformin alone. Systematic reviews and meta-analyses have shown significant improvements in weight, waist circumference, and insulin resistance with different GLP1RAs compared to placebo and metformin among women with PCOS. However, these studies primarily included liraglutide and exenatide. There are few studies done on the use of semaglutide in the management of PCOS with obesity.

This study aims to compare the effects of metformin vs. a combination of low-dose semaglutide and metformin on the clinical profile of women with PCOS, providing valuable insights into a potential therapeutic approach for this common endocrine disorder.

Rationale A minimum of 5% weight reduction can ameliorate various symptoms of PCOS, and these improvements continue with further weight loss. However, in most instances, lifestyle modifications alone are insufficient to achieve this. Some patients are intolerant to higher doses of metformin. Low-dose semaglutide combined with a reduced dose of metformin can be an effective synergistic combination of choice for weight loss along with avoidance of side effects. Local semaglutide (non-comparable biologics) is now available in Bangladesh with reduced cost and is frequently practiced in the management of DM and obesity with promising efficacy and tolerability at lower doses. Given that, it can reduce a significant amount of weight in patients with PCOS who are intolerant to high doses of metformin. South Asian patients, who present with more metabolic features, may benefit more from a lower dose of semaglutide, which also has the advantages of lower cost and fewer side effects. Quasi experimental studies already showed some promise. A well designed phase 2 randomized controlled trial in needed for further proof of efficacy, safety and dose response. Therefore, this study aims to compare the effects of a combination of low doses of semaglutide and metformin vs. metformin alone in patients suffering from PCOS and obesity in Bangladeshi women.

Research hypothesis A combination of metformin and subcutaneous low-dose semaglutide improves the metabolic profile better than metformin alone among women with PCOS and obesity.

Research question Does the combination of metformin and subcutaneous low-dose semaglutide improve metabolic outcomes in women with PCOS and obesity better than metformin alone?

Objectives

1. General- To compare the effects in anthropometric and metabolic status (obesity indices, BP, acanthosis nigricans, fasting glucose, fasting insulin, HOMA-IR, lipid profile, and ALT) after treatment by a combination of metformin with semaglutide and metformin alone over 12 weeks among women with PCOS and obesity. 2. Specific-

1. To compare the clinical and metabolic status at baseline between the groups treated with or without semaglutide 2. To assess the changes in the clinical and metabolic status from baseline to 12 weeks after treatment within the groups treated with or without semaglutide 3. To compare the metabolic changes over 12 weeks of treatment between the study groups treated with or without semaglutide 4. To compare the frequency of participants achieving at least 5% weight loss between the treatment groups with or without semaglutide 3. Others

1. To compare the side effects between the two treatment groups with or without semaglutide 2. To compare the changes in FAI between the two treatment groups with or without semaglutide

Materials and Methods Type of the study Phase II randomized controlled trial Place of study Department of Endocrinology, BSMMU Study period 12 months after approval from IRB Study population Reproductive-aged Bangladeshi women with PCOS and obesity Sample size

To calculate the sample size for a randomized control trial, the sample size formula for each group in a two-group comparison is as follows:

n = \[(zα/2 + zβ)2 × {p1(1-p1) + p2(1-p2)}\] ÷ (p1-p2)2

Taking the values from a previous similar study, * p1 = proportion of incidence in group 1 (5% weight loss in metformin alone group) = 0.25 * p2 = proportion of incidence in group 2 (5% weight loss in metformin + semaglutide group) = 0.842 * α = 0.05 (Type I error) * β = 0.2 (Type II error, at 90% power) * Zα/2 = critical Z value for a 95% confidence level (two-tailed), which is 1.96 * Zβ = critical Z value for power of 90%, which is 1.28 K = 1 (ratio of sample size between the two groups)

Calculation of the absolute difference between proportions:

p1- p2 = 0.25 - 0.842= -0.592

Calculation of the combined variance:

p1 × (1 - p1) = 0.25 × (1 - 0.25) = 0.25×0.75 = 0.1875 p2 × (1 - p2) = 0.842 × (1- 0.842) = 0.842×0.158 = 0.133076 p1 × (1 - p1) + p2 × (1 - p2) = 0.1875+0.133076 = 0.320576

Calculation of the sample size:

n = {(1.96 + 1.28)2 × 0.320576} ÷ (-0.592)2 * {(3.24)2 × 0.320576} ÷ 0.350464 * (10.4976 × 0.320576) ÷ 0.350464 = 3.36527862 ÷ 0.350464 = 9.6023518 ≈ 10 The sample size is 10 for each group. Considering drop-out, at least 15 participants will be included in each group with intention to increase the sample size.

Sampling method Convenient sampling Data collection technique A semi-structured pretested case record form (CRF) will be used to collect data.

Inclusion criteria Reproductive-aged women with PCOS diagnosed according to International evidence based guidelines 2023 and obesity

Exclusion criteria: 1. Having DM, other significant systemic diseases- chronic kidney disease (eGFR \<60mL/minute/ 1.73 m2 BSA), chronic liver disease (ALT \>3 × ULN), and heart failure 2. Patients having PCOS mimicking endocrine disorders (untreated thyroid dysfunctions, hyperprolactinemia, congenital adrenal hyperplasia, Cushing's syndrome, acromegaly, hypothalamic disorder etc.) 3. Those taking any other weight loss medications (eg., orlistat, liraglutide) within the last 3 months 4. Those who have undergone bariatric surgery 5. Any conditions causing weight loss (thyrotoxicosis, Addison's disease, chronic infection, connective tissue disorder, cancer, etc) 6. Secondary causes of obesity (major mood disorders, steroids, valproate, oral contraceptives, etc) 7. Contraindications for semaglutide: personal or family history of medullary carcinoma of the thyroid, history of acute pancreatitis, gallbladder disease 8. Planning for pregnancy or current pregnancy/ lactation

Study procedure The selection of participants will be based on inclusion and exclusion criteria by convenient sampling.

1st visit: Informed consent/assent will be taken from patients and will be requested to come fasting on a specific date, time, and place twice a week.

Related history of the patient will be taken and physical examination will be done. All information will be recorded in a semi-structured case record form.

A total of 30 PCOS women of reproductive age will be consecutively recruited from the Department of Endocrinology, BSMMU.

A total of five (05) mL of blood will be collected in the fasting state. Two mL of blood will be used to measure glucose by the glucose oxidase method. The remaining three mL of blood will be centrifuged, the serum will be separated, and insulin, TT, and SHBG will be measured by chemiluminescence immune assay. The lipid profile will be measured by the glycerol phosphate dehydrogenase peroxidase method.

All the tests will be done on the same day in the Department of Biochemistry \& Molecular Biology, BSMMU.

Allocation of study participants into two intervention groups randomly by a computerized random number generator:

Group-1: metformin + semaglutide; Group-2: Metformin alone Similar lifestyle advice will be given: 500 Kcal deficient diets + 30 minutes of walking for at least five days a week to all participants.

Group-1: Immediate-release metformin- 500 mg od in 1st and 2nd week, then 500 mg bd in 3rd and 4th week, then 500 mg bd for further 12 weeks will be given. Semaglutide 0.25 mg sc once weekly for 4 weeks, then if tolerated, will be titrated up to 0.5mg sc and continued for 12 weeks.

Group-2: Immediate-release metformin- 500 mg od in 1st 2 weeks, then 500 mg bd in 3rd and 4th weeks, then if tolerated, 500 mg bd will be continued for another 12 weeks. 1. st follow-up after 4 weeks: Assessment of clinical profile, compliance with drug, and side-effects.

If patients can tolerate:

Group-1: Continuation of 1000 mg/day of metformin and increase the dose of semaglutide of 0.5 mg sc once weekly for the next 12 weeks Group-2: Continuation of 1000 mg/day of metformin for the next 12 weeks. If patients cannot tolerate it: Reduced doses will be used for the next 12 weeks. 2. nd follow-up after 8 weeks: Assessment of clinical profile, measurement of Weight, WC, HC, BP, compliance with drug, and side-effects.

If patients can tolerate:

Group-1: Continuation of 1000 mg/day of metformin and 0.5 mg of s

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