PROFILE OF PHARMA BLOCKBUSTER JANUVIA

Product Management assignment: JANUVIA

PRODUCT MANAGEMENT ASSIGNMENT:

PROFILE OF PHARMA BLOCKBUSTER JANUVIA

CHARMI POPAT

ROLL NO. 03

PRODUCT MANAGEMENT ASSIGNMENT

MBA PHARMA TECH VTH YEAR

SVKM’s NMIMS SPP SPTM Page 1


TABLE OF CONTENTS

SR NO. TOPIC PG NO.

1. INTRODUCTION 3 - 4

2. MARKET ANALYSIS 5 - 7

3. STRATEGIES ADOPTED BY MSD TO LAUNCH

JANUVIA ACROSS THE GLOBE

8 - 13

4. STRATEGIES ADOPTED BY MSD TO LAUNCH

JANUVIA IN INDIA

13 - 18

5. SUMMARY 19

6. REFRENCES 20



INTRODUCTION

What Are JANUVIA® (sitagliptin) tablets?

JANUVIA is a type of prescription diabetes medicine called a DPP-4 inhibitor that enhances

the body's own ability to control blood sugar levels.

JANUVIA helps your body to:

Increase insulin production in your pancreas

Decrease the sugar made in your liver

Increase insulin production when blood sugar is high, especially after you eat. This is

when the body needs the most help in lowering blood sugar.

Reduce the amount of sugar made by your liver, especially after you eat, when your

body doesn't need it.

How Does JANUVIA Work?

With type 2 diabetes, pancreas does not make enough insulin. Liver may also make too much

of sugar. Body’s cells may lose sensitivity to insulin (insulin resistance). Because some cells,

such as muscle cells, are less sensitive to insulin, they cannot effectively absorb blood sugar,

which is needed for energy. As a result, blood sugar level increases.

Before taking JANUVIA: After meal body sends important

messages to pancreas to try to lower blood sugar. In response,

pancreas tries to make more insulin & signal liver to release less

sugar.

When you have type 2 diabetes:

After taking JANUVIA: JANUVIA is type 2 diabetes

medicines allow more messages to get through. This helps

pancreas to release more insulin & liver make less sugar.


Figure 1


Mechanism of action of JANUVIA:

First approved by FDA in 2006, the product’s sales grew by a spectacular 45.3 percent in

2011 to $3.66 billion, while Merck’s fixed-dose combination formulation of Januvia and

metformin, Janumet, added another $1.36 billion with 43.9 percent growth.

History of JANUVIA:


Merck initiates DPP-4 program1999

In-licensed probiodrug P32/98 to jumpstart internal program. Later discontinued due to preclinical toxicities not related to DPP-4 inhibition

2000

Team discovers that selective DPP-4 inhibition may be important to a favourable safety profile →major effort initiated to identify best-in-class DPP-4 inhibitor

2001

Identification of sitagliptin as a highly selective DPP-4 inhibitor2001

Initiation of clinical trials2002

Approval of JANUVIA (sitagliptin) as 1st DPP-4 inhibitor2006


MARKET ANALYSIS

About MSD: It is a Global Pharmaceutical Company. It operates in more than 140 Countries.

Address major Global health issues by having its eminent presence in Diabetes (75% of

diabetic population lives in emerging markets), Cardiovascular & Respiratory Diseases,

Hepatitis C, Cancer, HIV and so on and so forth.

Diverse Portfolio: Anti diabetic contributes to approximately 30% with just 2 diabetes

medication (JANUVIA & COMBINATION WITH METFORMIN JANUMET).

30%

22%14%

12%

6%

5%

Anti DiabeticDermaGynaec.HormonesRespiratoryGastro IntestinalAnti-infectivesVACCINESOthersCARDIACPain / AnalgesicsHIVNeuro / CNSBlood Related

Source IMS health (2013)

It contributes 5.54% to overall Oral Anti diabetes market & is growing at 28.99% CAGR.

VALUE MAT (IN CRS.) QTY MAT (‘000)

COMPANY JUN'10

JUN'11 JUN'12 JUN'13 CAGR (%)

MS (%) JUN'10 JUN'11 JUN'12 JUN'13

MSD PHARMACEUTICAL

68.6 93.2 142.7 190.0 28.99% 5.54%

29622.7 41115.8 65876.7 90151.0


MSD is one of the top players in Oral Anti diabetes market.



COMPANIESMAT value

(2013) in crs. Market share (2013)

U S V 560.9 16.36%

SUN* 323.4 9.43%

NOVARTIS INTL.* 223.7 6.52%

MSD PHARMACEUTICAL 190.0 5.54%

ABBOTT* 182.9 5.33%

SANOFI* 172.3 5.02%


About JANUVIA & JANUMET:

JANUVIA (sitagliptin phosphate) launched in India in April 2008 available in 3 different strength 25mg, 100mg & 50mg. Price to retailer being Rs. 227.8 per pack containing 7 tablets in each pack.

In Dec 2008 combination product JANUMET (sitagliptin+ metformin phosphate) was introduced which was made available in 2 strengths (50mg + 1000mg) & (50mg + 500mg). Price to retailer being Rs. 234.7 per pack containing 14 tablets in each pack.

VALUE MAT (IN CRS.) QTY MAT (‘000)

BRANDS PACK_DESC PROD_LNCH PTR JUN'10 JUN'11 JUN'12 JUN'13 JUN'10 JUN'11 JUN'12 JUN'13

JANUMET

JANUMET FILM C.TABS 1000 MG x

14 (/50) 200812.0 234.7 8.5 13.9 24.8 35.8 5013.0 8263.8 14803.1 21346.5

JANUMET FILM C.TABS 500 MG x

14 (/50) 200812.0 234.7 19.4 29.3 51.4 74.0 11436.6 17390.8 30637.4 44175.5

JANUVIA

JANUVIA FILM C.TABS 100 MG x 7 200804.0 227.8 35.0 41.2 53.6 61.8 10653.6 12590.6 16483.4 18992.4



Grand Total 68.2 93.1 142.7 190.0 28745.3 40949.6 65876.7 90151.0


JANUVIA (sitagliptin phosphate) is growing at CAGR of approx. 19% contributing to 42.19% share to MSD diabetes segment & 2.3% to overall OAD market. The brand ranks 5 th

in OAD segment & ranks 68th in overall pharma market with current market valuation of Rs. 802crs. (as of 2013) in India.

JANUMET (sitagliptin phosphate + metformin) is growing at CAGR 41% contributing to 57.81% share to MSD diabetes segment & 3.2% to overall OAD market. The brand ranks 3 rd

in OAD segment & ranks 40th in overall pharma market with current market valuation of Rs. 1,098 crs. (as of 2013) in India.

MAT Values (INR M) MAT Qty (000's)

BRANDS PROD_LNCH JUN'10 JUN'11 JUN'12 JUN'13 GR ('13)

CAGR

(%) % M.S. JUN'10 JUN'11 JUN'12 JUN'13

GR

('13)

CAGR

(%) % M.S.

JANUMET 200812 278 432 762 1,098 44% 41% 3.2% 16,450 25,655 45,441 65,522 44% 41% 0.8%

JANUVIA 200804 404 500 665 802 21% 19% 2.3% 12,296 20,436 24,629 21% 19% 0.3%




Product features:

Once daily, oral

24 hour inhibition of DPP-4 activity

Substantial efficacy

Weight neutral

Low risk of hypoglycemia except when used with a SFU or insulin

Unmet needs at the time of development:

OPPORTUNITIES FOR JANUVIA:

Many external factors combined to create the opportunity for JANUVIA success:

1. The growing global obesity epidemic, which is directly correlated with the global

growing type 2 diabetes epidemic, has contributed to exponential growth of the

overall market for type 2 diabetes products.

2. Fortunately for Merck, Novartis’ DPP-IV compound Galvus did not receive FDA

approval, while Januvia did.

3. On top of that, physicians had been using a number of products to manage their

patients’ type 2 diabetes, but many carried an increased risk of hypoglycemia and

other side effects. “Many physicians were looking for newer, safer approaches to

treating type 2 diabetes, and the favorable safety profile of Januvia, combined with its

efficacy story, led a lot of physicians to turn to this new class,”

4. On top of this, Januvia’s positive safety profile has taken centre stage after

negative warnings associated with thiazolidinedione use began to surface. “As a

class, TZDs have fallen off significantly in the past two years, leaving much of that

share to be picked up by Januvia, largely due to its safety and efficacy association,”

5. Januvia’s potential as an add-on to the popular drug metformin was another break

for the product, says Riad El-Dada, senior VP and commercial group leader, diabetes

franchise, Merck



STRATEGIES ADOPTED BY MSD TO LAUNCH JANUVIA ACROSS

THE GLOBE

Strategies adopted by MSD to make JANUVIA a huge success:

Riad El-Dada, senior VP and commercial group leader, diabetes franchise, Merck says:

“Our strategy is really built on seeking out patients who are on metformin, to encourage

physicians and patients to make JANUVIA the next step,”

“We have a product that is really the perfect add-on to metformin. Metformin is widely used

in most parts of the world, it’s growing really fast. So we sort of hit the sweet spot with our

marketing strategy.”

1) TAILORED JANUVIA’s CLINICAL PROGRAMS FOR DIFFERENT REGIONS:

Brand team of JANUVIA customized the clinical trials data so that they have right

indications for different regions and the right studies. They focused on strategy “starting

narrow and going wide – earning a single approval as early as possible, then following

up with a stack of additional indications to broaden access.”

Indications for JANUVIA were: added indications for third-line use, indication for use with

insulin, indication for use with TZDs and metformin. Though all the indications were not

filled initially because there was a huge competition from Novartis, BMS/Astrazeneca and so

on & so forth but very rapidly they followed but with them. So they could launch the drug in

a customized manner & fast & first before the competition.

2) EXTENSIVE LIFE CYCLE MANAGEMENT PROGRAM FOR SITAGLIPTIN:

Merck & Co., Inc. announced on Apr 2, 2007 within a year that the U.S. Food and Drug

Administration (FDA) approved JANUMET, the first and only tablet combining a dipeptidyl

peptidase-4 (DPP-4) inhibitor, sitagliptin (also known as JANUVIA), and metformin for the

treatment of type 2 diabetes.



The key decision point brand team made was the choice to push a metformin combination

early in development, before anyone really knew if JANUVIA would even be a success on its

own, and then placing substantial marketing muscle behind the new combination when it was

approved, even with the blockbuster JANUVIA already in hand. Development program for

JANUMET was started very quickly and then really put a lot of emphasis on it when they

could launch it. MSD announce its launch on Apr 2, 2007


Core Phase IIIProgram

1. Monotherapy (2 studies)

2. Combination therapy with

metformin and PPARγ

3. Renal dosing

1st Phase 1. Add-on to

Metformin versus SulfonylureaJANUMET

Program

2nd Phase1. Add on to

Sulfonylurea ± Metformin

3rd Phase1. Insulin add-on

2. Triple combination with

PPARγ / metformin3. High baseline

HbA1C metformin add-on study4. Metformin

comparison study5. Initial

combination with PPARγ6. Initial

combination with metformin

7. Study in elderly8. Mechanism of

action studies

Ongoing/recently completed

1. Sitagliptin/ Pioglitazone FDC

(MK-0431C)2. Sitagliptin/

Simvastatin FDC (MK-0431D)3. JANUMET

Extended Release Program

4. Cardiovascular Outcomes Study

JANUVIA

FDA approved sitagliptin phosphate tablets (Januvia, made by Merck and Co, Inc) for use with diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus.On October 17 2006

JANUMET

FDA Approves Janumet for Type 2 Diabetes, Offering Powerful Glucose Control of a DPP-4 Inhibitor and Metformin in a Single TabletApr 2, 2007

JUVISYNC

FDA approved Juvisync (sitagliptin and simvastatin), a fixed-dose combination prescription medication that contains two previously approved medicines in one tablet for use in adults who need both sitagliptin and simvastatin.Oct. 7, 2011

JANUMET XR

FDA approved “JANUMET XR is a new treatment that adds once-daily convenience to the powerful efficacy of JANUMET for patients with type 2 diabetesFebruary 02, 2012


3) JANUVIA : FIRST TO MARKET TAKES ALL

The first DPP-IV inhibitor on the market was Januvia® (sitagliptin). Januvia was in the right

place at the right time.

United States:

It was introduced in the U.S. in 2006 by Merck & Co. In the U.S., Januvia enjoyed three

years of exclusivity in its class before AstraZeneca/BMS introduced Onglyza. During this

period of 3 years, Januvia used strong promotion to gain early buy-in from stakeholders and

to build a positive brand image. It secured its place as “the” gliptin, an image that

AstraZeneca/BMS was unable to change despite heavy U.S. promotional investment.

Novartis’s Galvus® (vildagliptin) was delayed in the U.S. due to questions of side effects.

Tradjenta™ (linagliptin) have also entered the market, and the pipeline promises more to

come.

Europe:

In Europe Januvia was first in class launched in 2007. Galvus,was launched in 2008.

JANUMET:

United States:

In the U.S., Merck’s products were the first to market both for the single-compound therapy

(Januvia) and the combination therapy (Janumet).

Europe:

In contrast, Merck delayed launching its fixed-dose combination product, Janumet®

(sitagliptin/metformin) until a year after Januvia, its single-compound product, was on the

market. Janumet was the second-to-market combination product. In fact, it lagged behind

Eucreas by a full two years in the U.K.

Uptake of Eucreas did not match that of Janumet across the top five European countries—

likely because Janumet benefited from Januvia’s established patient base.



4) CLOSING TIME GAP :

The time lag between first global launch and the first entry into a pharmerging market was

reduced. JANUVIA (sitagliptin) was launched in Brazil just 6 months after its first global

entry to speed up the pace of their outreach to the pharmerging sector.

JANUMET launched 4.5 months after JANUVIA. JANUVIA & JANUMET were launched

globally within 4 years from 2006 to 2009. JANUVIA launched in 81 countries &

JANUMET launched in 52 countries

5) COMMUNICATING WITH PHYSICIANS & PATIENT EDUCATION PROGRAM:

Merck invested heavily in educating physicians about the DPP-IV class prior to the approval

of any product

The team made a significant investment in academics and diabetes thought leaders early on,

“because the mechanism was new and the science was new. They also worked with

professional societies on education. They worked with the American Diabetes Association

and others and used them to help with outreach, not just to patients but also to physicians.

In communicating directly with physicians and patients, Januvia’s managers have leaned on

the good old-fashioned sales force – “still probably the most important channel”

“Establishing trust with physicians is a top priority for our marketing and sales organization,”


US JANUVIA

US JANUMET & BRAZIL JANUVIA

EU JANUVIA

EU JANUMET

JANUVIA – JANUMET in India & Japan


Brand team provided a lot of support to help physicians help their patients by organizing

unbranded programs that gave them additional credibility with their customers.

Brand team also presented several periodic safety updates both general safety updates and

safety updates that would pertain to particular issues, for example cardiovascular safety

updates.

Merck’s brand team also came up with hypoglycemia awareness campaign: Discusshypo.com

which was deployed across multiple channels, including journal advertising, edetails, direct

mail, and waiting room posters, and which was not a branded campaign, but instead a disease

awareness campaign & for which it was nominated for a Best Disease-Awareness Campaign

Manny Award in 2011.

Target audience of

JANUVIA were both

Healthcare professionals

(M.D., Pharm D etc.) &

Non- Healthcare

professionals (Patients

& Caregivers)



6) HUGE INVESTMENT MADE ON TRADITIONAL & DIGITAL MEDICAL EDUCATION CHANNELS

Brand team has invested in both traditional and digital DTC, medical education, and a

significant convention presence, among other things.

Product promotion of

JANUVIA highly focused on

following parameters:

Parameters % contribution

to

communication

Efficacy 11

Safety 26

Other benefits 7

Patient access 37

Administration 4

Comparison 10

MOA 4

Marketing channels used to

promote JANUVIA were as

follows:



Parameters % usage of

communication

channel

Conference 6

Web / Internet 1

Medical office,

hospital, pharmacy

36

Publications 22

Manf-sponsered

programs

35

TV 0

STRATEGIES ADOPTED BY MSD TO LAUNCH JANUVIA IN INDIA

MSD/ JANUVIA: The Game Changing Launch in INDIA!

India pharmerging market a different Game:

The dynamics for first-to-market products are less rigid in the Tier 1 and Tier 2 pharmerging

markets than we’ve observed in developed markets. In Brazil, Russia, and India, for example,

Merck’s JANUVIA was launched before Novartis’s GALVUS.

Nevertheless—and unlike mature markets—Novartis’s family of products accounted for

more than 50 percent of the DPP-IV market in 2011. Most of this success is attributable to

EUCREAS, which has outperformed JANUMET considerably. Meanwhile, GALVUS has

held its own against JANUVIA; its uptake has been comparable to that of JANUVIA in

Brazil and Russia, and greater than JANUVIA in India.



The reason why Novartis family of products (GALVUS & EUCREAS) outperformed MSD

family of products (JANUVIA & JANUMET) was Novartis entered India in 2009 with

GALVUS & EUCREAS and at the same time (i.e. 2009) Novartis entered in a Co-marketing

agreement with USV (2009), a leading pharmaceutical companies with Oral Anti Diabetes

segments and it introduced two brands JALRA & JALRA-MET. This helped Novartis to

outdo MSD’s product market demand & increase its product distribution & reach. First to

Market in India for MSD was not beneficial as it did enter in the Co-marketing agreement

unlike its competitor Novartis. MSD entered India in 2008 with JANUVIA & JANUMET but

it entered Co-marketing with SUN in 2011 i.e. 3years after the launch of JANUVIA & 2

years after the launch of JANUMET which was the reason why MSD market share is lower

as compared to Novartis till date.

Timeline of JANUVIA launch in India:



PRE-LAUNCH STAGE :

1) AFFORDABILITY:

With generally lower levels of income and greater emphasis on out-of-pocket or private

payment for healthcare, affordability is an important consideration for launching in

pharmerging markets. Many multinational companies are implementing discounted price

schemes to overcome this potential hurdle.

MSD undertook rigorous market research, quantitative & qualitative, involving 350

Physicians and 200 patients which helped them arrive at differential pricing. MSD came up

with different prices for different market. In case of JANUVIA per unit cost (cost per tablet)

in US is $8.84 & India is Rs. 16.76

2) DIVESED AN INTEGRATED DISEASE MANAGEMENT PROGRAM:

Brand team devised an integrated disease management program involving physician &

patients. This program helps to implement and expand the Diesease management program

under the brand name-SPARSH.



MSD’s SPARSH Program was launched to Complement Prescriber Focused Efforts. MSD

tied up with Thyrocare, a company that provides specialised tests for comprehensive health

evaluation.

3) Created class awareness via extensive communication in medical journals (explained

earlier)

4) Positioning the product with targeted physician/diabetologists in specified

geographical area (explained earlier)

POST – LAUNCH STAGE:

1) Putting Patients First: SPARSH Health line (Patient support services)

Launched on Date: Jan-09

Services provided by SPARSH

Counseling services1

• Counseling over telephone by trained personnel, based on needs assessed by

physician, patients, counselor


Disease awarenes

s

HBA1c lipid

profile monitorin

g

Reminder alerts

to keep appointm

ent

Home Delivery

of medicines

Counseling

SPARSH


• Awareness about the disease and its management

• Practical situations, complications; diet counseling with customized diet charts and

personalized follow ups

• Exercise counseling with suggested lifestyle changes, do's and don'ts

2) JOINT VENTURE WITH INDIA’S SUN PHARMA

"Our emerging markets strategy is driven by our focus on applying innovations across our

business from introducing novel compounds to broadening our focus on innovative branded

generics," MSD President (Emerging Markets) Kevin Ali said.

Indian pharma major Sun Pharmaceutical Industries on April 11, 2011 announced a 50:50

strategic joint venture partnership with global drugmaker Merck and Co Inc to develop,

manufacture and commercialise new innovative drugs in emerging markets over the next 2-3

years.

MSD established Joint Venture with India's Sun Pharma to develop novel combinations of

branded generics for emerging markets. Sun Pharma will sell the sitagliptin under brand

name ISTAVEL launched on June 2011 and sitagliptin plus metformin under brand name

ISTAMET launched on Aug 2011; different brand names in India as part of an India-specific

strategic partnership agreement with Merck

3) Free sample to encourage trials (explained earlier)

4) Lifecycle Management Strategies: Successful launch of Janumet (FDC with

Metformin), targeted at tier 2 cities (explained earlier)

LAUNCH STAGE:

1) Launched Januvia at a differential pricing (explained earlier)

2) Launch at CME events :



National level CME’s with KOL’s from other countries

CME’s with regional KOL’s

3) Gatherings of 7-8 physicians to discuss and exchange information on DPPIVs

facilitated by MSD reps

4) Marketing based on product clinical profile only – Selling not the focus

5) Made CSR an integral part of business which helped in creating goodwill among

Physicians/Patients

6) Going Forward: DIABETES & OBESITY FRANCHISE STRATEGY:

Develop new therapies for Type 2 diabetes mellitus to help patients achieve and

maintain optimal glucose control across the spectrum of disease, with mechanisms

that:

Increase insulin secretion

Decrease glucose production

Increase insulin sensitivity

Continue to lead in DPP-4 inhibitor class

Sitagliptin on track to be a leading global branded oral agent

Extensive sitagliptin life cycle management program with several fixed dose

combinations in sequential development

Strategic expansion with portfolio of novel mechanisms

Discover and develop novel therapies for obesity

SUMMARY

Factors that help JANUVIA success globally & in India are:



Pharmerging markets (a term coined by IMS to include 17 countries with income levels

under $25,000 per capita and relatively rapid growth)

Half of diagnosed patients fail to achieve adequate blood glucose control—and diabetes can

lead to blindness, amputations, heart disease and nerve and kidney damage, among many

other health consequences.

Weber knew that patients, even while they worried about having too much glucose in the

blood, were at risk of having their glucose levels lowered too much using existing treatments.

The condition, hypoglycemia, can cause reactions such as heart palpitations or, worse,

seizures and loss of consciousness.

According to this IMS report, the market for non-insulin diabetes treatments has experienced

strong growth over the last decade, averaging 9.5% over the past five years.

REFRENCES

1. http://www.imshealth.com/ims/Global/Content/Corporate/Press%20Room/IMS%20in

%20the%20News/Documents/MMM-Diabetes_olympics.pdf


Speed to Market

Highly Differentiated Products

Rapid and Strong Market Uptake

Strong Foundation for Continued Leadership

http://www.imshealth.com/ims/Global/Content/Corporate/Press%20Room/IMS%20in%20the%20News/Documents/MMM-Diabetes_olympics.pdf

http://www.imshealth.com/ims/Global/Content/Corporate/Press%20Room/IMS%20in%20the%20News/Documents/MMM-Diabetes_olympics.pdf


2. http://businesstoday.intoday.in/story/sun-pharma-merck-form-joint-venture/

1/14677.html

3. http://www.msdindia.in/about/Pages/home.aspx

4. http://www.expresspharmaonline.com/20090331/management01.shtml

5. http://www.imshealth.com/imshealth/Global/Content/Pharmerging/Document/Launch

%20Evolution%20Across%20Pharmerging%20Markets.pdf

6. http://www.dfid.gov.uk/Documents/publications1/prd/diff-pcing-pharma.pdf

7. IMS HEALTH DATA (JUNE 2013)

8. http://spicyip.com/2013/04/patent-war-intensifies-glenmark.html

For majority of type II diabetics, since medications have to be taken daily to achieve

glycemic control, drug resistance is a major challenge. (Thus there is a therapeutic void


http://spicyip.com/2013/04/patent-war-intensifies-glenmark.html

http://www.dfid.gov.uk/Documents/publications1/prd/diff-pcing-pharma.pdf

http://www.imshealth.com/imshealth/Global/Content/Pharmerging/Document/Launch%20Evolution%20Across%20Pharmerging%20Markets.pdf

http://www.imshealth.com/imshealth/Global/Content/Pharmerging/Document/Launch%20Evolution%20Across%20Pharmerging%20Markets.pdf

http://www.expresspharmaonline.com/20090331/management01.shtml

http://www.msdindia.in/about/Pages/home.aspx

http://businesstoday.intoday.in/story/sun-pharma-merck-form-joint-venture/1/14677.html

http://businesstoday.intoday.in/story/sun-pharma-merck-form-joint-venture/1/14677.html


which generates demand for novel anti-diabetic product classes. Dipeptidyl peptidase-4

inhibitors (DPP-4) or what is known as “gliptins” offered a new alternative in the treatment

pathway.)

Under an India-specific agreement


http://articles.timesofindia.indiatimes.com/2011-04-26/india-business/29474594_1_sitagliptin-sun-pharma-merck

PROFILE OF PHARMA BLOCKBUSTER JANUVIA

Documents

januvia janumet

history of januvia

januvia work

insulin liver

januvia sitagliptin

januvia sitagliptin

blood sugar levels

lowering blood sugar