Second-Line Pharmaceutical Treatments for Patients with Type 2 Diabetes

Comparison of New-Onset Peripheral Artery Disease in Patients With Type 2 Diabetes Exposed to Sodium-Glucose Cotransporter-2 Inhibitors, Dipeptidyl Peptidase-4 Inhibitors, or Glucagon-Like Peptide-1 Agonists: A Population-Based Cohort Study

BACKGROUND

Sodium-glucose cotransporter-2 inhibitors (SGLT2Is), dipeptidyl peptidase-4 inhibitors (DPP4Is), and glucagon-like peptide-1 receptor agonists have been associated with improved cardiovascular outcomes and prognosis. The comparative risks of new-onset peripheral artery disease (PAD) between these medications remain unknown. This real-world study compared the risks of PAD in patients exposed to SGLT2I and DPP4I.

METHODS AND RESULTS

This was a retrospective population-based cohort study of patients with type 2 diabetes on either an SGLT2I or a DPP4I between January 1, 2015, and December 31, 2015, using a territory-wide database from Hong Kong. The primary outcome was new-onset PAD. The secondary outcomes were cardiovascular hospitalization, cardiovascular death, and all-cause death. Propensity score matching (1:1 ratio) using the nearest neighbor search was performed. Multivariable Cox regression with time-weighted variables was used to identify significant associations. A 3-arm analysis including the glucagon-like peptide-1 receptor agonist cohort was conducted. This cohort included 75 470 patients with type 2 diabetes (median age, 62.3±12.8 years; 55.79% men). The SGLT2I and DPP4I groups consisted of 28 753 patients and 46 717 patients, respectively. After matching, 186 and 256 patients had PAD in the SGLT2I and DPP4I groups, respectively, over a median follow-up of 5.6 years. SGLT2I use was associated with lower risks of PAD (hazard ratio [HR], 0.79 [95% CI, 0.66-0.93]) compared with DPP4I use after adjusting for demographics, comorbidities, medications, renal function, and glycemic tests. The association remained consistent regardless of sex, age, and other metabolic diseases. In the 3-arm analysis, the risk of PAD was not statistically different between SGLT2Is and glucagon-like peptide-1 receptor agonists (HR, 1.18 [95% CI, 0.52-2.68]). The results remained consistent in the competing risk and the sensitivity analyses.

CONCLUSIONS

SGLT2I use among patients with type 2 diabetes was associated with lower risks of new-onset PAD and PAD-related outcomes when compared with DPP4Is after adjustments.

Establishing a cardiology registry: navigating quality and regulatory challenges with a focus on congenital heart disease

Registries have become pivotal in medical research, offering a robust foundation for understanding disease incidence, treatment patterns, and patient outcomes across diverse populations. By aggregating real-world data (RWD), registries provide invaluable insights into real-world evidence (RWE), shaping clinical guidelines, healthcare policies, and regulatory decisions. Their widespread acceptance underscores their scientific validity and their role in driving evidence-based medicine, ultimately improving healthcare outcomes. In cardiology, particularly within the specialized field of congenital heart disease (CHD), national and international registries have emerged as indispensable tools. They enable the systematic collection of data on patient demographics, disease progression, therapeutic interventions, and long-term outcomes. These datasets support a range of purposes, including observational studies, quality improvement initiatives, and regulatory assessments of medical devices or pharmaceuticals. Establishing a high-quality registry requires meticulous planning and adherence to established guidelines. Professional organizations, such as the European Society of Cardiology (ESC) and the American Heart Association (AHA), offer detailed guidance documents for setting up and managing registries. Additionally, various checklists and frameworks exist to evaluate and ensure registry quality, aiding researchers in optimizing data reliability and utility. With advancements in digital health, the potential of electronic health records (EHRs) to complement or replace traditional registries is increasingly explored. EHRs offer a dynamic, real-time data collection mechanism, reducing redundancy and operational costs while maintaining data accuracy. However, considerations around interoperability, data privacy, and standardization remain critical in leveraging EHRs for registry purposes.

Real-World Type 2 Diabetes Second-Line Treatment Allocation Among Patients

Objective

This study aimed to evaluate the impact of socioeconomic disparities on the allocation of second-line treatments among patients with type 2 diabetes (T2D).

Materials and Methods

We conducted an observational study using real-world data from over 9 million patients across five University of California Health centers. The study included patients who initiated a second-line T2D medication after metformin, with hemoglobin A1c (HbA1c) measurements within ±7 days of treatment initiation from 2012 through September 2024. Multinomial regression models assessed the association between socioeconomic status and second-line treatment choices. Additionally, we used the GPT-4 large language model with a zero-shot learning approach to analyze 270 clinical notes from 105 UCSF patients. GPT-4 identified adverse social determinants of health (SDOH) across six domains: transportation, housing, relationships, patients with children, support, and employment.

Results

Among 15,090 patients (56.7% male, 43.3% female; mean age 59.3 years; mean HbA1c 8.91%), second-line treatments included sulfonylureas (SUs; n = 6,732), DPP4 inhibitors (n = 2,918), GLP-1 receptor agonists (n = 2,736), and SGLT2 inhibitors (n = 2,704). Patients from lower socioeconomic neighborhoods were more likely to receive SUs over other medications: DPP4i (OR = 0.96, [95% CI, 0.95-0.98]), GLP-1RA (OR = 0.94, [95% CI, 0.92-0.96]), SGLT2i (OR = 0.95, [95% CI, 0.93-0.97]). In UCSF clinical notes, we identified adverse SDOH including housing (n=8), transportation (n=1), relationships (n=22), employment (n=12), support (n=1), and patients with children (n=25).

Conclusions

Socioeconomic factors influence second-line T2D treatment choices. Addressing these disparities is essential to ensuring equitable access to advanced T2D therapies.

A physiologically-based quantitative systems pharmacology model for mechanistic understanding of the response to alogliptin and its application in patients with renal impairment

Alogliptin is a highly selective inhibitor of dipeptidyl peptidase-4 and primarily excreted as unchanged drug in the urine, and differences in clinical outcomes in renal impairment patients increase the risk of serious adverse reactions. In this study, we developed a comprehensive physiologically-based quantitative systematic pharmacology model of the alogliptin-glucose control system to predict plasma exposure and use glucose as a clinical endpoint to prospectively understand its therapeutic outcomes with varying renal function. Our model incorporates a PBPK model for alogliptin, DPP-4 activity described by receptor occupancy theory, and the crosstalk and feedback loops for GLP-1-GIP-glucagon, insulin, and glucose. Based on the optimization of renal function-dependent parameters, the model was extrapolated to different stages renal impairment patients. Ultimately our model adequately describes the pharmacokinetics of alogliptin, the progression of DPP-4 inhibition over time and the dynamics of the glucose control system components. The extrapolation results endorse the dose adjustment regimen of 12.5 mg once daily for moderate patients and 6.25 mg once daily for severe and ESRD patients, while providing additional reflections and insights. In clinical practice, our model could provide additional information on the in vivo fate of DPP4 inhibitors and key regulators of the glucose control system.

Comparative Effectiveness of Second-Line Antihyperglycemic Agents for Cardiovascular Outcomes: A Multinational, Federated Analysis of LEGEND-T2DM

BACKGROUND

Sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) reduce the risk of major adverse cardiovascular events (MACE) in patients with type 2 diabetes mellitus (T2DM). However, their effectiveness relative to each other and other second-line antihyperglycemic agents is unknown, without any major ongoing head-to-head clinical trials.

OBJECTIVES

The aim of this study was to compare the cardiovascular effectiveness of SGLT2is, GLP-1 RAs, dipeptidyl peptidase-4 inhibitors (DPP4is), and clinical sulfonylureas (SUs) as second-line antihyperglycemic agents in T2DM.

METHODS

Across the LEGEND-T2DM (Large-Scale Evidence Generation and Evaluation Across a Network of Databases for Type 2 Diabetes Mellitus) network, 10 federated international data sources were included, spanning 1992 to 2021. In total, 1,492,855 patients with T2DM and cardiovascular disease (CVD) on metformin monotherapy were identified who initiated 1 of 4 second-line agents (SGLT2is, GLP-1 RAs, DPP4is, or SUs). Large-scale propensity score models were used to conduct an active-comparator target trial emulation for pairwise comparisons. After evaluating empirical equipoise and population generalizability, on-treatment Cox proportional hazards models were fit for 3-point MACE (myocardial infarction, stroke, and death) and 4-point MACE (3-point MACE plus heart failure hospitalization) risk and HR estimates were combined using random-effects meta-analysis.

RESULTS

Over 5.2 million patient-years of follow-up and 489 million patient-days of time at risk, patients experienced 25,982 3-point MACE and 41,447 4-point MACE. SGLT2is and GLP-1 RAs were associated with lower 3-point MACE risk than DPP4is (HR: 0.89 [95% CI: 0.79-1.00] and 0.83 [95% CI: 0.70-0.98]) and SUs (HR: 0.76 [95% CI: 0.65-0.89] and 0.72 [95% CI: 0.58-0.88]). DPP4is were associated with lower 3-point MACE risk than SUs (HR: 0.87; 95% CI: 0.79-0.95). The pattern for 3-point MACE was also observed for the 4-point MACE outcome. There were no significant differences between SGLT2is and GLP-1 RAs for 3-point or 4-point MACE (HR: 1.06 [95% CI: 0.96-1.17] and 1.05 [95% CI: 0.97-1.13]).

CONCLUSIONS

In patients with T2DM and CVD, comparable cardiovascular risk reduction was found with SGLT2is and GLP-1 RAs, with both agents more effective than DPP4is, which in turn were more effective than SUs. These findings suggest that the use of SGLT2is and GLP-1 RAs should be prioritized as second-line agents in those with established CVD.

Obesity-related glomerulopathy: recent advances in inflammatory mechanisms and related treatments

Obesity-related glomerulopathy, which is an obesity-triggered kidney damage, has become a significant threat to human health. Several studies have recently highlighted the critical role of inflammation in obesity-related glomerulopathy development. Additionally, excess adipose tissue and adipocytes in patients with obesity produce various inflammatory factors that cause systemic low-grade inflammation with consequent damage to vascular endothelial cells, exacerbating glomerular injury. Therefore, we conducted a comprehensive review of obesity-related glomerulopathy and addressed the critical role of obesity-induced chronic inflammation in obesity-related glomerulopathy pathogenesis and progression, which leads to tubular damage and proteinuria, ultimately impairing renal function. The relationship between obesity and obesity-related glomerulopathy is facilitated by a network of various inflammation-associated cells (including macrophages, lymphocytes, and mast cells) and a series of inflammatory mediators (such as tumor necrosis factor α, interleukin 6, leptin, adiponectin, resistin, chemokines, adhesion molecules, and plasminogen activator inhibitor 1) and their inflammatory pathways. Furthermore, we discuss a recently discovered relationship between micronutrients and obesity-related glomerulopathy inflammation and the important role of micronutrients in the body's anti-inflammatory response. Therefore, assessing these inflammatory molecules and pathways will provide a strong theoretical basis for developing therapeutic strategies based on anti-inflammatory effects to prevent or delay the onset of kidney injury.

Comparative Effectiveness of Second-line Antihyperglycemic Agents for Cardiovascular Outcomes: A Large-scale, Multinational, Federated Analysis of the LEGEND-T2DM Study

Background

SGLT2 inhibitors (SGLT2is) and GLP-1 receptor agonists (GLP1-RAs) reduce major adverse cardiovascular events (MACE) in patients with type 2 diabetes mellitus (T2DM). However, their effectiveness relative to each other and other second-line antihyperglycemic agents is unknown, without any major ongoing head-to-head trials.

Methods

Across the LEGEND-T2DM network, we included ten federated international data sources, spanning 1992-2021. We identified 1,492,855 patients with T2DM and established cardiovascular disease (CVD) on metformin monotherapy who initiated one of four second-line agents (SGLT2is, GLP1-RAs, dipeptidyl peptidase 4 inhibitor [DPP4is], sulfonylureas [SUs]). We used large-scale propensity score models to conduct an active comparator, target trial emulation for pairwise comparisons. After evaluating empirical equipoise and population generalizability, we fit on-treatment Cox proportional hazard models for 3-point MACE (myocardial infarction, stroke, death) and 4-point MACE (3-point MACE + heart failure hospitalization) risk, and combined hazard ratio (HR) estimates in a random-effects meta-analysis.

Findings

Across cohorts, 16·4%, 8·3%, 27·7%, and 47·6% of individuals with T2DM initiated SGLT2is, GLP1-RAs, DPP4is, and SUs, respectively. Over 5·2 million patient-years of follow-up and 489 million patient-days of time at-risk, there were 25,982 3-point MACE and 41,447 4-point MACE events. SGLT2is and GLP1-RAs were associated with a lower risk for 3-point MACE compared with DPP4is (HR 0·89 [95% CI, 0·79-1·00] and 0·83 [0·70-0·98]), and SUs (HR 0·76 [0·65-0·89] and 0·71 [0·59-0·86]). DPP4is were associated with a lower 3-point MACE risk versus SUs (HR 0·87 [0·79-0·95]). The pattern was consistent for 4-point MACE for the comparisons above. There were no significant differences between SGLT2is and GLP1-RAs for 3-point or 4-point MACE (HR 1·06 [0·96-1·17] and 1·05 [0·97-1·13]).

Interpretation

In patients with T2DM and established CVD, we found comparable cardiovascular risk reduction with SGLT2is and GLP1-RAs, with both agents more effective than DPP4is, which in turn were more effective than SUs. These findings suggest that the use of GLP1-RAs and SGLT2is should be prioritized as second-line agents in those with established CVD.

Funding

National Institutes of Health, United States Department of Veterans Affairs.