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Gebrie D, Manyazewal T, A Ejigu D, Makonnen E. Metformin-Insulin versus Metformin-Sulfonylurea Combination Therapies in Type 2 Diabetes: A Comparative Study of Glycemic Control and Risk of Cardiovascular Diseases in Addis Ababa, Ethiopia. Diabetes Metab Syndr Obes 2021; 14:3345-3359. [PMID: 34335036 PMCID: PMC8317933 DOI: 10.2147/dmso.s312997] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/10/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE This study aimed to compare glycemic control and risk of cardiovascular outcomes of metformin-insulin versus metformin-sulfonylurea combination therapies in type 2 diabetes mellitus. METHODS We conducted a comparative cross-sectional study in five tertiary level hospitals in Addis Ababa, Ethiopia. We enrolled 321 patients with type 2 diabetes mellitus who were on continuous treatment follow-up on either metformin-insulin or metformin-sulfonylurea combination therapy. We interviewed the participants and reviewed their medical records to investigate medication efficacy, safety, and adherence. The primary outcome measure was glycemic control and the secondary outcome measures were composite cardiovascular outcomes. RESULTS Of the total participants enrolled, 50.5% (n = 162) were those who received metformin-insulin and 49.5% (n = 159) metformin-sulfonylurea combination therapies for a median of 48 months follow-up. The reduction of Hb1Ac levels was comparable between the metformin-insulin (-1.04 ± 0.96%) and metformin-sulfonylurea (-1.02 ± 1.03%), p = 0.912. Patients who received metformin-sulfonylurea had 4.3 times more likely to have achieved target HbA1c level compared to those who received metformin-insulin, p < 0.001, adjusted odds ratio (AOR) with 95% CI = 4.31[1.79-10.32]. Risk of composite cardiovascular outcomes was higher in metformin-insulin group (40.5% versus 34.0%), p = 0.021. Co-morbidities, body mass index, systolic blood pressure, and HbA1c had a significant association with composite cardiovascular outcomes. Reductions of bodyweight, HDL-C, LDL-C, triglycerides levels, and microvascular complications were different between the two groups, p < 0.05. CONCLUSION High proportion of patients who received metformin-sulfonylurea achieved target HbA1c level and had less composite cardiovascular outcomes compared to those who received metformin-insulin. However, these findings have to be confirmed with randomized control trials to determine risks associated with insulin use, while efficacy is maintained as second-line treatment in patients with type 2 diabetes mellitus.
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Affiliation(s)
- Desye Gebrie
- School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tsegahun Manyazewal
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Dawit A Ejigu
- Department of Pharmacology, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Eyasu Makonnen
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Gebrie D, Getnet D, Manyazewal T. Cardiovascular safety and efficacy of metformin-SGLT2i versus metformin-sulfonylureas in type 2 diabetes: systematic review and meta-analysis of randomized controlled trials. Sci Rep 2021; 11:137. [PMID: 33420333 PMCID: PMC7794474 DOI: 10.1038/s41598-020-80603-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022] Open
Abstract
Diabetes is a serious threat to global health and among the top 10 causes of death, with nearly half a billion people living with it worldwide. Treating patients with diabetes tend to become more challenging due to the progressive nature of the disease. The role and benefits of combination therapies for the management of type 2 diabetes are well-documented, while the comparative safety and efficacy among the different combination options have not been elucidated. We aimed to systematically synthesize the evidence on the comparative cardiovascular safety and efficacy of combination therapy with metformin-sodium-glucose cotransporter-2 inhibitors versus metformin-sulfonylureas in patients with type 2 diabetes. We searched MEDLINE-PubMed, Embase, Cochrane Library, and ClinicalTrials.gov up to 15 August 2019 without restriction in the year of publication. We included randomized controlled trials of patients with type 2 diabetes who were on metformin-sodium-glucose cotransporter-2 inhibitors or metformin-sulphonylureas combination therapy at least for a year. The primary endpoints were all-cause mortality and serious adverse events, and the secondary endpoints were cardiovascular mortality, non-fatal myocardial infarction, non-fatal stroke, hypoglycemia, and changes in glycated hemoglobin A1c (HbA1c), body weight, fasting plasma glucose, blood pressure, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol. We used a random-effects meta-analysis model to estimate mean differences for continuous outcomes and risk ratio for dichotomous outcomes. We followed PICOS description model for defining eligibility and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 guidelines for reporting results. Of 3,190 citations, we included nine trials involving 10,974 participants. The pooled analysis showed no significant difference in all-cause mortality (risk ration [RR] = 0.93, 95% CI [0.52, 1.67]), serious adverse events (RR = 0.96, 95% CI [0.79, 1.17]) and adverse events (RR = 1.00, 95% CI [0.99, 1.02]) between the two, but in hypoglycemia (RR = 0.13, 95% CI [0.10, 0.17], P < 0.001). Participants taking metformin-sodium glucose cotransporter-2 inhibitors showed a significantly greater reduction in HbA1c (mean difference [MD] = − 0.10%, 95% CI [− 0.17, − 0.03], body weight (MD = − 4.57 kg, 95% CI [− 4.74, − 4.39], systolic blood pressure (MD = − 4.77 mmHg, 95% CI [− 5.39, − 4.16]), diastolic blood pressure (MD = − 2.07 mmHg, 95% CI [− 2.74, − 1.40], and fasting plasma glucose (MD = − 0.55 mmol/L, 95% CI [− 0.69, − 0.41]), p < 0.001. Combination therapy of metformin and sodium-glucose cotransporter-2 inhibitors is a safe and efficacious alternative to combination therapy of metformin and sulphonylureas for patients with type 2 diabetes who are at risk of cardiovascular comorbidity. However, there remains a need for additional long-term randomized controlled trials as available studies are very limited and heterogeneous.
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Affiliation(s)
- Desye Gebrie
- School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia. .,Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia.
| | - Desalegn Getnet
- Pharmacology and Toxicology Course and Research Team, Department of Pharmacy, College of Health Sciences, Adigrat University, Adigrat, Ethiopia
| | - Tsegahun Manyazewal
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia
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Li X, Si H, Chen Y, Li S, Yin N, Wang Z. Effects of fitness qigong and tai chi on middle-aged and elderly patients with type 2 diabetes mellitus. PLoS One 2020; 15:e0243989. [PMID: 33332396 PMCID: PMC7746158 DOI: 10.1371/journal.pone.0243989] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 11/30/2020] [Indexed: 02/06/2023] Open
Abstract
Currently, qigong and tai chi exercises are the two most common preventive as well as therapeutic interventions for chronic metabolic diseases such as type 2 diabetes mellitus (T2DM). However, the quantitative evaluation of these interventions is limited. This study aimed to evaluate the therapeutic efficacy of qigong and tai chi intervention in middle-aged and older adults with T2DM. The study included 103 eligible participants, who were randomized to participate for 12 weeks, in one of the following intervention groups for the treatment of T2DM: fitness qigong, tai chi, and control group. Three biochemical measures, including fasting plasma glucose (FPG), glycated hemoglobin (HbA1C), and C-peptide (C-P) levels, assessed at baseline and 12 weeks, served as the primary outcome measures. During the training process, 16 of the 103 participants dropped out. After the 12-week intervention, there were significant influences on HbA1C (F2,83 = 4.88, p = 0.010) and C-P levels (F2,83 = 3.64, p = 0.031). Moreover, significant reduction in C-P levels was observed after 12-week tai chi practice (p = 0.004). Furthermore, there was a significant negative correlation between the duration of T2DM and the relative changes in FPG levels after qigong intervention, and the relative changes in HbA1C levels were positively correlated with waist-to-height ratio after tai chi practice. Our study suggests that targeted qigong exercise might have a better interventional effect on patients with a longer duration of T2DM, while tai chi might be risky for people with central obesity. Trial registration: This trial was registered in Chinese Clinical Trial Registry. The registration number is ChiCTR180020069. The public title is "Health-care qigong · study for the prescription of chronic diabetes intervention."
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Affiliation(s)
- Xiaoyuan Li
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China
- College of Physical Education, Zhengzhou University, Zhengzhou, China
- Fitness Qigong Scientific Research Centre of China, Zhengzhou, China
| | - Hongyu Si
- College of Physical Education, Zhengzhou University, Zhengzhou, China
- Fitness Qigong Scientific Research Centre of China, Zhengzhou, China
| | - Yamin Chen
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China
| | - Shouhao Li
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China
| | - Ningning Yin
- College of Physical Education, Zhengzhou University, Zhengzhou, China
| | - Zhenlong Wang
- School of Life Sciences, Zhengzhou University, Zhengzhou, China
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Hirose T, Chen CC, Ahn KJ, Kiljański J. Use of Insulin Glargine 100 U/mL for the Treatment of Type 2 Diabetes Mellitus in East Asians: A Review. Diabetes Ther 2019; 10:805-833. [PMID: 31020538 PMCID: PMC6531539 DOI: 10.1007/s13300-019-0613-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Indexed: 12/18/2022] Open
Abstract
Insulin glargine (IGlar) 100 U/mL (IGlar-100) is widely used in East Asian countries for the treatment of type 2 diabetes mellitus (T2DM) and is the gold standard of basal insulin treatment. In this review we summarize key information about clinical experience with IGlar-100 in East Asian patients with T2DM, including findings from clinical trials and postmarketing studies. We also provide recommendations and opinions on the optimal use of IGlar-100 in this population. The findings from the studies highlighted in our review indicate that IGlar-100 can be a suitable treatment option for East Asians with T2DM, from initial therapy in combination with oral antihyperglycemic medications through to different combinations and intensification models. FUNDING: Eli Lilly and Company.
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Affiliation(s)
- Takahisa Hirose
- Division of Diabetes, Metabolism and Endocrinology, Department of Medicine, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Ching-Chu Chen
- Division of Endocrinology and Metabolism, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
- China Medical University School of Chinese Medicine, Taichung, Taiwan
| | - Kyu Jeung Ahn
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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Bennett WL, Aschmann HE, Puhan MA, Robbins CW, Bayliss EA, Wilson R, Mularski RA, Chan WV, Leff B, Sheehan O, Glover C, Maslow K, Armacost K, Mintz S, Boyd CM. A benefit-harm analysis of adding basal insulin vs. sulfonylurea to metformin to manage type II diabetes mellitus in people with multiple chronic conditions. J Clin Epidemiol 2019; 113:92-100. [PMID: 31059802 DOI: 10.1016/j.jclinepi.2019.03.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 02/12/2019] [Accepted: 03/30/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The benefits and harms of diabetes treatments need to be carefully weighed in people with type II diabetes mellitus (DM) and multiple chronic conditions (MCCs). Our objective was to quantitatively assess the benefits and harms of the addition of basal insulin (insulin) vs. sulfonylurea (SU) to metformin in people with DM and MCCs. STUDY DESIGN AND SETTING Data inputs into the benefit-harms analysis included (1) baseline risks of patient-centered outcomes (death, myocardial infarction, stroke, severe hypoglycemia, diarrhea, nausea) from cohorts and trials; (2) treatment effects for the addition of insulin vs. SU from a network meta-analysis; and (3) patient preference survey for outcome weights. Statistical analysis calculated the probability that adding insulin has greater benefits than harms, when compared with an SU, overall and by prespecified subgroups. RESULTS Including the six outcomes, the probability of net benefit for insulin compared with SU was similar, across subgroups by age and diabetes duration (probability range, using conditional logit weights: 0.44-0.56). Adding patient preferences for treatment burden associated with insulin injections shifted the probability to favor SU over insulin (probability range, using conditional logit weights: 0.01-0.12). CONCLUSION In people with DM and MCCs, we demonstrated incomplete evidence to conclude if basal insulin or SU should be added in people with DM and MCCs on metformin alone. The benefit-harm balance was sensitive to treatment preferences, that is., perceived treatment burden, indicating the importance of shared-decision making in caring for people with MCCs who are at high risk for experiencing harms associated with diabetes management.
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Affiliation(s)
- Wendy L Bennett
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Epidemiology, The Johns Hopkins University School of Public Health, Baltimore, MD, USA.
| | - Hélène E Aschmann
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Craig W Robbins
- Kaiser Permanente Center for Health Research, Portland, OR, USA; Kaiser Permanente, Institute for Health Research, Denver, CO, USA
| | | | - Renee Wilson
- Department of Epidemiology, The Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Richard A Mularski
- Kaiser Permanente Center for Health Research, Portland, OR, USA; Department of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Wiley V Chan
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Bruce Leff
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Orla Sheehan
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carol Glover
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Informing Patient-Centered Care for People with Multiple Chronic Conditions Patient and Caregiver Partners, Baltimore, MD, USA
| | - Katie Maslow
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Informing Patient-Centered Care for People with Multiple Chronic Conditions Patient and Caregiver Partners, Baltimore, MD, USA; Gerontological Society of America, Washington, DC, USA
| | - Karen Armacost
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Informing Patient-Centered Care for People with Multiple Chronic Conditions Patient and Caregiver Partners, Baltimore, MD, USA
| | - Suzanne Mintz
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Informing Patient-Centered Care for People with Multiple Chronic Conditions Patient and Caregiver Partners, Baltimore, MD, USA
| | - Cynthia M Boyd
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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6
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Madsen KS, Kähler P, Kähler LKA, Madsbad S, Gnesin F, Metzendorf M, Richter B, Hemmingsen B. Metformin and second- or third-generation sulphonylurea combination therapy for adults with type 2 diabetes mellitus. Cochrane Database Syst Rev 2019; 4:CD012368. [PMID: 30998259 PMCID: PMC6472662 DOI: 10.1002/14651858.cd012368.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The number of people with type 2 diabetes mellitus (T2DM) is increasing worldwide. The combination of metformin and sulphonylurea (M+S) is a widely used treatment. Whether M+S shows better or worse effects in comparison with other antidiabetic medications for people with T2DM is still controversial. OBJECTIVES To assess the effects of metformin and sulphonylurea (second- or third-generation) combination therapy for adults with type 2 diabetes mellitus. SEARCH METHODS We updated the search of a recent systematic review from the Agency for Healthcare Research and Quality (AHRQ). The updated search included CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and WHO ICTRP. The date of the last search was March 2018. We searched manufacturers' websites and reference lists of included trials, systematic reviews, meta-analyses and health technology assessment reports. We asked investigators of the included trials for information about additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) randomising participants 18 years old or more with T2DM to M+S compared with metformin plus another glucose-lowering intervention or metformin monotherapy with a treatment duration of 52 weeks or more. DATA COLLECTION AND ANALYSIS Two review authors read all abstracts and full-text articles and records, assessed risk of bias and extracted outcome data independently. We used a random-effects model to perform meta-analysis, and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using the GRADE instrument. MAIN RESULTS We included 32 RCTs randomising 28,746 people. Treatment duration ranged between one to four years. We judged none of these trials as low risk of bias for all 'Risk of bias' domains. Most important events per person were all-cause and cardiovascular mortality, serious adverse events (SAE), non-fatal stroke (NFS), non-fatal myocardial infarction (MI) and microvascular complications. Most important comparisons were as follows:Five trials compared M+S (N = 1194) with metformin plus a glucagon-like peptide 1 analogue (N = 1675): all-cause mortality was 11/1057 (1%) versus 11/1537 (0.7%), risk ratio (RR) 1.15 (95% confidence interval (CI) 0.49 to 2.67); 3 trials; 2594 participants; low-certainty evidence; cardiovascular mortality 1/307 (0.3%) versus 1/302 (0.3%), low-certainty evidence; serious adverse events (SAE) 128/1057 (12.1%) versus 194/1537 (12.6%), RR 0.90 (95% CI 0.73 to 1.11); 3 trials; 2594 participants; very low-certainty evidence; non-fatal myocardial infarction (MI) 2/549 (0.4%) versus 6/1026 (0.6%), RR 0.57 (95% CI 0.12 to 2.82); 2 trials; 1575 participants; very low-certainty evidence.Nine trials compared M+S (N = 5414) with metformin plus a dipeptidyl-peptidase 4 inhibitor (N = 6346): all-cause mortality was 33/5387 (0.6%) versus 26/6307 (0.4%), RR 1.32 (95% CI 0.76 to 2.28); 9 trials; 11,694 participants; low-certainty evidence; cardiovascular mortality 11/2989 (0.4%) versus 9/3885 (0.2%), RR 1.54 (95% CI 0.63 to 3.79); 6 trials; 6874 participants; low-certainty evidence; SAE 735/5387 (13.6%) versus 779/6307 (12.4%), RR 1.07 (95% CI 0.97 to 1.18); 9 trials; 11,694 participants; very low-certainty evidence; NFS 14/2098 (0.7%) versus 8/2995 (0.3%), RR 2.21 (95% CI 0.74 to 6.58); 4 trials; 5093 participants; very low-certainty evidence; non-fatal MI 15/2989 (0.5%) versus 13/3885 (0.3%), RR 1.45 (95% CI 0.69 to 3.07); 6 trials; 6874 participants; very low-certainty evidence; one trial in 64 participants reported no microvascular complications were observed (very low-certainty evidence).Eleven trials compared M+S (N = 3626) with metformin plus a thiazolidinedione (N = 3685): all-cause mortality was 123/3300 (3.7%) versus 114/3354 (3.4%), RR 1.09 (95% CI 0.85 to 1.40); 6 trials; 6654 participants; low-certainty evidence; cardiovascular mortality 37/2946 (1.3%) versus 41/2994 (1.4%), RR 0.78 (95% CI 0.36 to 1.67); 4 trials; 5940 participants; low-certainty evidence; SAE 666/3300 (20.2%) versus 671/3354 (20%), RR 1.01 (95% CI 0.93 to 1.11); 6 trials; 6654 participants; very low-certainty evidence; NFS 20/1540 (1.3%) versus 16/1583 (1%), RR 1.29 (95% CI 0.67 to 2.47); P = 0.45; 2 trials; 3123 participants; very low-certainty evidence; non-fatal MI 25/1841 (1.4%) versus 21/1877 (1.1%), RR 1.21 (95% CI 0.68 to 2.14); P = 0.51; 3 trials; 3718 participants; very low-certainty evidence; three trials (3123 participants) reported no microvascular complications (very low-certainty evidence).Three trials compared M+S (N = 462) with metformin plus a glinide (N = 476): one person died in each intervention group (3 trials; 874 participants; low-certainty evidence); no cardiovascular mortality (2 trials; 446 participants; low-certainty evidence); SAE 34/424 (8%) versus 27/450 (6%), RR 1.68 (95% CI 0.54 to 5.21); P = 0.37; 3 trials; 874 participants; low-certainty evidence; no NFS (1 trial; 233 participants; very low-certainty evidence); non-fatal MI 2/215 (0.9%) participants in the M+S group; 2 trials; 446 participants; low-certainty evidence; no microvascular complications (1 trial; 233 participants; low-certainty evidence).Four trials compared M+S (N = 2109) with metformin plus a sodium-glucose co-transporter 2 inhibitor (N = 3032): all-cause mortality was 13/2107 (0.6%) versus 19/3027 (0.6%), RR 0.96 (95% CI 0.44 to 2.09); 4 trials; 5134 participants; very low-certainty evidence; cardiovascular mortality 4/1327 (0.3%) versus 6/2262 (0.3%), RR 1.22 (95% CI 0.33 to 4.41); 3 trials; 3589 participants; very low-certainty evidence; SAE 315/2107 (15.5%) versus 375/3027 (12.4%), RR 1.02 (95% CI 0.76 to 1.37); 4 trials; 5134 participants; very low-certainty evidence; NFS 3/919 (0.3%) versus 7/1856 (0.4%), RR 0.87 (95% CI 0.22 to 3.34); 2 trials; 2775 participants; very low-certainty evidence; non-fatal MI 7/890 (0.8%) versus 8/1374 (0.6%), RR 1.43 (95% CI 0.49 to 4.18; 2 trials); 2264 participants; very low-certainty evidence; amputation of lower extremity 1/437 (0.2%) versus 1/888 (0.1%); very low-certainty evidence.Trials reported more hypoglycaemic episodes with M+S combination compared to all other metformin-antidiabetic agent combinations. Results for M+S versus metformin monotherapy were inconclusive. There were no RCTs comparing M+S with metformin plus insulin. We identified nine ongoing trials and two trials are awaiting assessment. Together these trials will include approximately 16,631 participants. AUTHORS' CONCLUSIONS There is inconclusive evidence whether M+S combination therapy compared with metformin plus another glucose-lowering intervention results in benefit or harm for most patient-important outcomes (mortality, SAEs, macrovascular and microvascular complications) with the exception of hypoglycaemia (more harm for M+S combination). No RCT reported on health-related quality of life.
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Affiliation(s)
- Kasper S Madsen
- University of CopenhagenFaculty of Health and Medical SciencesBlegdamsvej 3BCopenhagen NDenmark2200
| | - Pernille Kähler
- Faculty of Health and Medical SciencesCopenhagen Medical UniversityBlegdamsvej 3CopenhagenDenmark2100Ø
| | | | - Sten Madsbad
- Hvidovre Hospital, University of CopenhagenDepartment of EndocrinologyHvidovreDenmark
| | - Filip Gnesin
- Department 7652, RigshospitaletDepartment of Endocrinology, Diabetes and MetabolismBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Maria‐Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bernd Richter
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bianca Hemmingsen
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
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7
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Kalra S, Bahendeka S, Sahay R, Ghosh S, Md F, Orabi A, Ramaiya K, Al Shammari S, Shrestha D, Shaikh K, Abhayaratna S, Shrestha PK, Mahalingam A, Askheta M, A. Rahim AA, Eliana F, Shrestha HK, Chaudhary S, Ngugi N, Mbanya JC, Aye TT, Latt TS, Akanov ZA, Syed AR, Tandon N, Unnikrishnan AG, Madhu SV, Jawa A, Chowdhury S, Bajaj S, Das AK. Consensus Recommendations on Sulfonylurea and Sulfonylurea Combinations in the Management of Type 2 Diabetes Mellitus - International Task Force. Indian J Endocrinol Metab 2018; 22:132-157. [PMID: 29535952 PMCID: PMC5838894 DOI: 10.4103/ijem.ijem_556_17] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
For decades, sulfonylureas (SUs) have been important drugs in the antidiabetic therapeutic armamentarium. They have been used as monotherapy as well as combination therapy. Focus on newer drugs and concerns about the risk of severe hypoglycemia and weight gain with some SUs have led to discussion on their safety and utility. It has to be borne in mind that the adverse events associated with SUs should not be ascribed to the whole class, as many modern SUs, such as glimepiride and gliclazide modified release, are associated with better safety profiles. Furthermore, individualization of treatment, using SUs in combination with other drugs, backed with careful monitoring and patient education, ensures maximum benefits with minimal side effects. The current guidelines, developed by experts from Africa, Asia, and the Middle East, promote the safe and smart use of SUs in combination with other glucose-lowering drugs.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
| | - Silver Bahendeka
- Department of Internal Medicine, Diabetes & Endocrinology, St. Francis Hospital, Nsambya, Kampala, Uganda
| | - Rakesh Sahay
- Department of Endocrinology, Osmania Medical College, Hyderabad, Telangana, India
| | - Sujoy Ghosh
- Department of Endocrinology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Fariduddin Md
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Abbas Orabi
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Kaushik Ramaiya
- Department of Internal Medicine, Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | | | - Dina Shrestha
- Department of Endocrinology, Norvic International Hospital and Medical College, and Hospital for Advanced Medicine and Surgery, Maharajganj, Kathmandu, Nepal
| | - Khalid Shaikh
- Department of Diabetes, Faculty of Internal Medicine, Royal Oman Police Hospital, Muscat, Oman
| | - Sachitha Abhayaratna
- Department of Pharmacology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Pradeep K. Shrestha
- Department of Medicine, Tribhuvan University Teaching Hospital, Maharajganj, Kathmandu, Nepal
| | | | | | - Aly Ahmed A. Rahim
- Department of Internal Medicine, Diabetes & Metabolism Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Fatimah Eliana
- Department of Internal Medicine, Faculty of Medicine, YARSI University, Jakarta, Indonesia
| | - Hari K. Shrestha
- Department of Internal Medicine, Kathmandu University Hospital, Dhulikhel, Nepal
| | | | - Nancy Ngugi
- Department of Endocrinology, Kenyatta National Hospital, Nairobi, Kenya
| | - Jean Claude Mbanya
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Yaounde, Cameroon
| | - Than Than Aye
- Department of Endocrinology, University of Medicine 2, Yangon, Myanmar
| | - Tint Swe Latt
- Department of Medicine, University of Medicine 2, Yangon, Myanmar
| | - Zhanay A. Akanov
- Center of Diabetes, Clinic of Internal Diseases, Asfendiyarov Kazakh National Medical University, Almaty, Republic of Kazakhstan
| | - Abbas Raza Syed
- Department of Endocrinology, Shaukat Khanum Hospital and Research Center, Lahore, Pakistan
| | - Nikhil Tandon
- Department of Endocrinology, Metabolism and Diabetes, All India Institute of Medical Sciences, Pune, Maharashtra, India
| | - A. G. Unnikrishnan
- Department of Endocrinology and Diabetes, Chellaram Diabetes Institute, Pune, Maharashtra, India
| | - S. V. Madhu
- Department of Medicine, University of Delhi, New Delhi, India
| | - Ali Jawa
- Department of Endocrinology, Diabetes and Metabolism, Wilshire Cardiovascular and Endocrine Center of Excellence, Lahore, Pakistan
| | - Subhankar Chowdhury
- Department of Endocrinology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Sarita Bajaj
- Department of Medicine, MLN Medical College, Allahabad, Uttar Pradesh, India
| | - Ashok Kumar Das
- Department of General Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
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Devarajan TV, Venkataraman S, Kandasamy N, Oomman A, Boorugu HK, Karuppiah SKP, Balat D. Comparative Evaluation of Safety and Efficacy of Glimepiride and Sitagliptin in Combination with Metformin in Patients with Type 2 Diabetes Mellitus: Indian Multicentric Randomized Trial - START Study. Indian J Endocrinol Metab 2017; 21:745-750. [PMID: 28989886 PMCID: PMC5628548 DOI: 10.4103/ijem.ijem_176_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Modern sulfonylureas like glimepiride offer effective glycemic control with extrapancreatic benefits and good tolerability. The objective of the present study was to evaluate and compare safety and efficacy of glimepiride and sitagliptin in combination with metformin in patients with type 2 diabetes mellitus (T2DM). METHODS In this open-label, randomized, comparative, multicenter study, a total of 305 T2DM patients who were either drug naïve or uncontrolled on metformin were randomized to glimepiride 1 or 2 mg/sustained-release metformin 1000 mg once daily (glimepiride group, n = 202) or sitagliptin 50 mg/metformin 500 mg twice daily (sitagliptin group, n = 103) for 12 weeks. Primary endpoint was change in glycosylated hemoglobin (HbA1c). Secondary endpoints were change in fasting plasma glucose (FPG), postprandial plasma glucose (PPG), body mass index (BMI) and to assess overall safety profile. RESULTS At 12 weeks, there was a statistically significant difference in the mean HbA1c reduction in glimepiride group (0.42%) as compared to sitagliptin group (0.30%) (P = 0.001). Mean reduction in FPG and PPG was also statistically significant in the glimepiride group as compared to the sitagliptin group (P = 0.008). There was no significant difference in terms of change in BMI (0.07 ± 0.39 kg/m2 vs. 0.08 ± 0.31 kg/m2) in glimepiride and sitagliptin groups, respectively, (P = 0.644) between both the groups. The incidences of hypoglycemic events were also comparable among both the groups. CONCLUSION In T2DM patients, glimepiride/metformin combination exhibited significant reduction in glycemic parameters as compared to sitagliptin/metformin combination. Moreover, there was no significant difference between both the groups in terms of change in BMI and incidence of hypoglycemia.
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Affiliation(s)
- T. V. Devarajan
- Consultant Physician, Apollo First Med Hospitals, Chennai, Tamil Nadu, India
| | - S. Venkataraman
- Consultant Physician and Diabetologist, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Narayanan Kandasamy
- Consultant Endocrinologist and Diabetologist, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Abraham Oomman
- Consultant Cardiologist, Apollo Hospitals, Chennai, Tamil Nadu, India
| | | | - S. K. P. Karuppiah
- Consultant Cardiologist, Apollo Speciality Hospital, Madurai, Tamil Nadu, India
| | - Dushyant Balat
- Consultant Cardiologist, Apollo Hospitals International Limited, Ahmedabad, Gujarat, India
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9
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Kim EY, Yu K, Choi K, Yu HE, Oh SJ, Lee K. Effect of Piperazine Dithioctate on the Oral Pharmacokinetics of Glimepiride in Rats. Biol Pharm Bull 2015; 38:1161-8. [PMID: 26235578 DOI: 10.1248/bpb.b15-00044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The objective of the present work was to investigate the potential for pharmacokinetic drug-drug interactions between glimepiride (GMP) and piperazine dithioctate (PDT) in rats to support the development of an orally combined product of the two drugs. An LC-MS/MS bioanalytical method was developed for simultaneous quantification of GMP and thioctic acid (TA) in rat plasma. The accuracy, precision, linearity, selectivity, and recovery were all within an acceptable range. The oral plasma exposure of the GMP solution was more than 14-times greater than that of the GMP suspension at a dose of 0.5 mg/kg, suggesting a dissolution-limited absorption of the GMP suspension. Oral co-administration of PDT (72 mg/kg) with GMP suspension (0.5 mg/kg) reduced the plasma GMP exposure by approximately 80% without a significant change in t1/2 and tmax. Oral co-administration of PDT with GMP solution had no significant effect on the plasma pharmacokinetics of GMP. PDT lowered the pH (from ca. 7 to 5.6) and the dissolved GMP concentration in the GMP suspension. It was also shown that GMP was more soluble at pH 7 than at 5.7 in an aqueous solution, and the oral plasma exposure of a GMP suspension at pH 7.0 was substantially higher than that of a suspension at pH 5.7. These results suggest that the pH-dependent solubility of GMP was likely responsible for PDT's effect on the oral absorption of GMP. In conclusion, the current work suggests a possibility of drug-drug interaction between GMP and PDT upon oral co-administration.
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Abstract
Type 2 diabetes (T2D) has been known as 'bi-hormonal disorder' since decades ago, the role of glucagon from α-cell has languished whereas β-cell taking center stage. Recently, numerous findings indicate that the defects of glucagon secretion get involve with development and exacerbation of hyperglycemia in T2D. Aberrant α-cell responses exhibit both fasting and postprandial states: hyperglucagonemia contributes to fasting hyperglycemia caused by inappropriate hepatic glucose production, and to postprandial hyperglycemia owing to blunted α-cell suppression. During hypoglycemia, insufficient counter-regulation response is also observed in advanced T2D. Though many debates still remained for exact mechanisms behind the dysregulation of α-cell in T2D, it is clear that the blockade of glucagon receptor or suppression of glucagon secretion from α-cell would be novel therapeutic targets for control of hyperglycemia. Whereas there have not been remarkable advances in developing new class of drugs, currently available glucagon-like peptide-1 and dipeptidyl peptidase-IV inhibitors could be options for treatment of hyperglucagonemia. In this review, we focus on α-cell dysfunction and therapeutic potentials of targeting α-cell in T2D.
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Affiliation(s)
- Jun Sung Moon
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kyu Chang Won
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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11
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Genuth S. Should sulfonylureas remain an acceptable first-line add-on to metformin therapy in patients with type 2 diabetes? No, it's time to move on! Diabetes Care 2015; 38:170-5. [PMID: 25538314 DOI: 10.2337/dc14-0565] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Since their introduction to clinical practice in the 1950s, sulfonylureas have been widely prescribed for use in patients with type 2 diabetes. Of all the other medications currently available for clinical use, only metformin has been used more frequently. However, several new drug classes have emerged that are reported to have equal glucose-lowering efficacy and greater safety when added to treatment of patients in whom metformin monotherapy is no longer sufficient. Moreover, current arguments also suggest that the alternative drugs may be superior to sulfonylureas with regard to the risk of cardiovascular complications. Thus, while there is universal agreement that metformin should remain the first-line pharmacologic therapy for those in whom lifestyle modification is insufficient to control hyperglycemia, there is no consensus as to which drug should be added to metformin. Therefore, given the current controversy, we provide a Point-Counterpoint on this issue. In the preceding point narrative, Dr. Abrahamson provides his argument suggesting that avoiding use of sulfonylureas as a class of medication as an add-on to metformin is not appropriate as there are many patients whose glycemic control would improve with use of these drugs with minimal risk of adverse events. In the counterpoint narrative below, Dr. Genuth suggests there is no longer a need for sulfonylureas to remain a first-line addition to metformin for those patients whose clinical characteristics are appropriate and whose health insurance and/or financial resources make an alternative drug affordable.
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Affiliation(s)
- Saul Genuth
- Case Western Reserve University, Cleveland, OH
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