Combination Glucose-Lowering Therapy Plans in T2DM: Case-Based Considerations

Therapeutic effects and mechanisms of Xinmaitong formula for type 2 diabetes mellitus via GLP-1R signaling

Introduction

Traditional Chinese Medicine (TCM) theory posits that type 2 diabetes mellitus (T2DM) characterized by Qi and Yin deficiency, is associated with elevated blood lipid levels. The Xinmaitong formula (XMT) is a folk remedy believed to lower blood lipid levels. However, the functional components and molecular mechanisms through which XMT exerts its anti-diabetic effects remain to be elucidated. This study aimed to investigate the therapeutic effects and potential mechanisms of XMT in the treatment of T2DM, focusing on the glucagon-like peptide-1 receptor (GLP-1R) signaling pathway.

Methods

A TCM formula that promotes GLP-1R expression was screened using a GLP-1R promoter-dependent luciferase reporter gene vector (PGL3-GLP-1R-luc). The T2DM mouse model was established using a high-fat diet and streptozotocin (STZ). Blood glucose levels were measured using a glucometer and oral glucose tolerance test (OGTT). Serum biochemical parameters and insulin levels were also assessed. Organ pathology in mice was evaluated using hematoxylin and eosin (H&E) staining. Immunofluorescence (IF) was employed to observe changes in insulin and GLP-1R expression in the pancreas of mice. The effects of medicated serum on Min6 cell growth were examined using a methyl thiazolyl tetrazolium (MTT) assay. A Min6 cell injury model was established to detect cAMP and Ca2+ concentrations. Ultra high-performance liquid chromatography-mass spectrometry (UHPLC-MS) was used to identify blood-absorbed components of XMT.

Results

Luciferase reporter constructs driven by GLP-1R promoter response elements analysis identified that TCM formula XMT promoted GLP-1R expression. In vivo experiments demonstrated that XMT significantly reduced fasting blood glucose levels in T2DM mice and improved OGTT results. It also exhibited protective effects on islet tissues, notably increasing GLP-1R expression and insulin secretion in the pancreas. Biochemical markers indicated no significant adverse effects on liver or kidney function following XMT administration. After treatment with palmitic acid (PA), GLP-1R expression in Min6 cells was significantly decreased. However, treatment with XMT upregulated GLP-1R expression. Additionally, cyclic adenosine monophosphate (cAMP) and Ca2+ exhibited substantial improvements, and the key pancreatic growth protein PDX1 was activated.

Conclusion

XMT exerts hypoglycemic effects by upregulating GLP-1R gene expression, enhancing GLP-1R protein synthesis, and subsequently promoting cAMP release. This process activates Ca2+ influx in pancreatic β-cells, triggering insulin exocytosis from islet cells.

Disutilities of treatment-related attributes for type 2 diabetes mellitus: a systematic review

OBJECTIVES

To synthesize the literature on eliciting disutilities associated with treatment-related attributes in type 2 diabetes (T2DM).

METHODS

We searched Medline, Embase, Cochrane Library, PsycINFO, EconLit and CINAHL databases from inception to December, 2024. This systematic review followed PRISMA guidelines, quality and risk of bias of the included studies were assessed using the NICE and ROBINS-I checklist.

RESULTS

Nine studies involving 59 to 4060 participants were included and most studies (n=6) were conducted in the UK. The perspective of preference included T2DM patients (n=7) and the general public (n=3), with one study included both. Elicitation approaches used were time trade-off (n=5) and standard gamble (n=4). Eight treatment-related attributes were identified, including weight change (n=5), dosing frequency (n=4), gastrointestinal side effects (n=2), flexible dosing (n=2), administration requirement (i.e., reconstitution, waiting, and needle handling) (n=2), injection site reaction (n=1), fear of hypoglycemia (n=1), and HbA1c levels (n=1). For the attribute of weight change, the (dis)utility value ranged from -0.106 to 0.047. Respondents showed a preference for weekly over daily administration (range: 0.023 to 0.095), once-daily over multiple-daily (range: 0.015 to 0.123). The (dis)utility values for the rest of six attributes ranged from -0.04 to 0.034.

CONCLUSIONS

This review provides evidence synthesize of published disutilities related to T2DM treatment-related attributes which have a nonnegligible effect. Weight change and dosing frequency were the most reported with the largest impact. Given the considerable heterogeneity in current studies, care should be taken in selecting appropriate estimates between different elicitation methods, populations and countries.

Impact of antioxidant excipients on N-nitrosamine formation and bioequivalence in metformin formulations (review article)

The discovery of N-nitrosamine impurities in pharmaceutical products has raised serious quality concerns, particularly in metformin products, which are widely used in the treatment of type 2 diabetes mellitus. The detection of N-nitrosodimethylamine (NDMA) in metformin products has led to global recalls and increased regulatory investigations. Generic manufacturers face the challenge of balancing stringent bioequivalence requirements for Biopharmaceutical Classification System (BCS) Class III drugs, which require strict control of excipient composition while ensuring N-nitrosamine control and therapeutic equivalence. The use of antioxidants as a strategy to reduce N-nitrosamine formation requires careful consideration to maintain both bioequivalence and product safety. This article evaluates the use of antioxidants for the prevention of N-nitrosamine formation in metformin formulations, addressing the implications of this strategy on bioequivalence and its relationship with the regulatory framework.

The Gut Microbiota-Related Antihyperglycemic Effect of Metformin

It is critical to sustain the diversity of the microbiota to maintain host homeostasis and health. Growing evidence indicates that changes in gut microbial biodiversity may be associated with the development of several pathologies, including type 2 diabetes mellitus (T2DM). Metformin is still the first-line drug for treatment of T2DM unless there are contra-indications. The drug primarily inhibits hepatic gluconeogenesis and increases the sensitivity of target cells (hepatocytes, adipocytes and myocytes) to insulin; however, increasing evidence suggests that it may also influence the gut. As T2DM patients exhibit gut dysbiosis, the intestinal microbiome has gained interest as a key target for metabolic diseases. Interestingly, changes in the gut microbiome were also observed in T2DM patients treated with metformin compared to those who were not. Therefore, the aim of this review is to present the current state of knowledge regarding the association of the gut microbiome with the antihyperglycemic effect of metformin. Numerous studies indicate that the reduction in glucose concentration observed in T2DM patients treated with metformin is due in part to changes in the biodiversity of the gut microbiota. These changes contribute to improved intestinal barrier integrity, increased production of short-chain fatty acids (SCFAs), regulation of bile acid metabolism, and enhanced glucose absorption. Therefore, in addition to the well-recognized reduction of gluconeogenesis, metformin also appears to exert its glucose-lowering effect by influencing gut microbiome biodiversity. However, we are only beginning to understand how metformin acts on specific microorganisms in the intestine, and further research is needed to understand its role in regulating glucose metabolism, including the impact of this remarkable drug on specific microorganisms in the gut.

Nitrosamine mitigation: NDMA impurity formation and its inhibition in metformin hydrochloride tablets

The mitigation of nitrosamine formation in drug products has been studied and approaches such as using formulations with pH modifiers and antioxidants have been shown to decrease the formation of nitrosamines. However, more studies are needed to explore the effectivness of mitigation strategies with different drug models and formulations. The primary objective of this work was to assess the role of different antioxidants and pH modifiers in tablet formulations to mitigate the formation of NDMA, prepared in-house, using metformin hydrochloride as a model drug. A study design for manufacturing metformin hydrochloride formulations was created to evaluate potential mitigation stratigies. The formulations were prepared by wet granulation that included a sodium nitrite spike and various antioxidants such as ascorbic acid, caffeic acid and ferulic acid at various concentrations that may inhibit nitrosamine formation. The study design also included pH modifiers such as hydrochloric acid and sodium carbonate. The metformin hydrochloride formulations were placed under stability conditions that included humidity, temperature and time over a six month period. NDMA inhibition was found to be most effective in formulations with basic pH, followed by the addition of tested antioxidants with 0.1% concentrations in the formulations. All tested antioxidants showed complete mitigation in formulations with 0.5% and 1% concentrations. In summary, basic pH and the inclusion of antioxidants exhibited the potential to mitigate the formation of NDMA in metformin hydrochloride tablets.

Targeting Protein Aggregation in ALS

Proteinopathies involve the abnormal accumulation of specific proteins. Maintaining the balance of the proteome is a finely regulated process managed by a complex network of cellular machinery responsible for protein synthesis, folding, and degradation. However, stress and ageing can disrupt this balance, leading to widespread protein aggregation. Currently, several therapies targeting protein aggregation are in clinical trials for ALS. These approaches mainly focus on two strategies: addressing proteins that are prone to aggregation due to mutations and targeting the cellular mechanisms that maintain protein homeostasis to prevent aggregation. This review will cover these emerging drugs. Advances in ALS research not only offer hope for better outcomes for ALS patients but also provide valuable insights and methodologies that can benefit the broader field of neurodegenerative disease drug discovery.

Metformin-loaded chitosan nanoparticles augment silver nanoparticle-induced radiosensitization in breast cancer cells during radiation therapy

Recent research has focused on enhancing tumor response to radiation therapy using radiosensitizers to increase radiation absorption by cancerous tissues. This study utilized silver nanoparticles (AgNPs) as radiation sensitizers and chitosan as a nanocarrier to deliver metformin to breast cancer cells. Metformin-loaded chitosan nanoparticles (Met NPs) and AgNPs were synthesized and characterized. MCF-7 breast cancer cells were pretreated with Met NPs, followed by treatment with AgNPs and irradiation with X-rays at 2, 4, and 8 Gy doses. Cellular cytotoxicity, apoptosis, DNA damage, and 3D spheroid formation were evaluated. The synthesized Met NPs and AgNPs had average diameters of 51.5 ± 9.4 nm and 3.02 ± 0.03 nm, respectively. Cellular cytotoxicity assessment revealed the highest cytotoxicity in MCF-7 cells pretreated with Met NPs, treated with AgNPs, and irradiated with 8 Gy. Flow cytometry analysis demonstrated a 67.58 % apoptosis rate in cells pretreated with Met NPs, compared to 30.42 % in cells pretreated with plain metformin. DAPI staining revealed a 1.8-fold increase in DNA damage in cells pretreated with Met NPs and Ag NPs upon exposure to radiation. The 3D spheroid culture model confirmed a 60 % enhancement in the radiosensitivity of breast cancer cells in the presence of Met NPs and Ag NPs. The combination of Met NPs and Ag NPs represents a promising strategy to improve the therapeutic efficacy of radiation therapy for breast cancer treatment. The delivery of metformin can potentiate the radiosensitizing effects of Ag NPs, offering a novel approach to enhance cancer cells' response to radiation.

Mitigating diabetes-related complications: Empowering metformin with cholecalciferol and taurine supplementation in type 2 diabetic rats

BACKGROUND

Type 2 diabetes is one of the most prevalent chronic diseases worldwide, significantly impacting patients' quality of life. Current treatment options like metformin (MET) effectively counteract hyperglycemia but fail to alleviate diabetes-associated complications such as retinopathy, neuropathy, nephropathy, hepatopathy, and cardiovascular diseases.

AIM

To propose the supplementation of cholecalciferol (CHO) and taurine (TAU) to enhance MET efficacy in controlling diabetes while minimizing the risk of associated complications.

METHODS

The study involved sixty rats, including ten non-diabetic control rats and fifty experimental rats with type 2 diabetes induced by streptozotocin. The experimental rats were further subdivided into positive control and treatment subgroups. The four treatment groups were randomly allocated to a single MET treatment or MET combined with supplements either CHO, TAU, or both.

RESULTS

Diabetic rats exhibited elevated levels of glucose, insulin, Homeostasis Model Assessment of Insulin Resistance (HOMA-IR), glycated hemoglobin%, lipid markers, aspartate aminotransferase, and malondialdehyde, along with reduced levels of antioxidant enzymes (catalase and superoxide dismutase). The administration of CHO and TAU supplements alongside MET in diabetic rats led to a noticeable recovery of islet mass. The antioxidative, anti-inflammatory, and anti-apoptotic properties of the proposed combination therapy significantly ameliorated the aforementioned abnormalities.

CONCLUSION

The supplementation of CHO and TAU with MET showed the potential to significantly improve metabolic parameters and protect against diabetic complications through its antioxidative, anti-inflammatory, and anti-apoptotic effects.

Profiling of patients with type 2 diabetes based on medication adherence data

Introduction

Type 2 diabetes mellitus (T2DM) is a complex, chronic disease affecting multiple organs with varying symptoms and comorbidities. Profiling patients helps identify those with unfavorable disease progression, allowing for tailored therapy and addressing special needs. This study aims to uncover different T2DM profiles based on medication intake records and laboratory measurements, with a focus on how individuals with diabetes move through disease phases.

Methods

We use medical records from databases of the last 20 years from the Department of Endocrinology and Diabetology of the University Medical Center in Maribor. Using the standard ATC medication classification system, we created a patient-specific drug profile, created using advanced natural language processing methods combined with data mining and hierarchical clustering.

Results

Our results show a well-structured profile distribution characterizing different age groups of individuals with diabetes. Interestingly, only two main profiles characterize the early 40-50 age group, and the same is true for the last 80+ age group. One of these profiles includes individuals with diabetes with very low use of various medications, while the other profile includes individuals with diabetes with much higher use. The number in both groups is reciprocal. Conversely, the middle-aged groups are characterized by several distinct profiles with a wide range of medications that are associated with the distinct concomitant complications of T2DM. It is intuitive that the number of profiles increases in the later age groups, but it is not obvious why it is reduced later in the 80+ age group. In this context, further studies are needed to evaluate the contributions of a range of factors, such as drug development, drug adoption, and the impact of mortality associated with all T2DM-related diseases, which characterize these middle-aged groups, particularly those aged 55-75.

Conclusion

Our approach aligns with existing studies and can be widely implemented without complex or expensive analyses. Treatment and drug use data are readily available in healthcare facilities worldwide, allowing for profiling insights into individuals with diabetes. Integrating data from other departments, such as cardiology and renal disease, may provide a more sophisticated understanding of T2DM patient profiles.

A Case of Metformin-Associated Lactic Acidosis

Metformin is a US FDA-approved oral anti-hyperglycemic medication used to treat non-insulin-dependent diabetes mellitus (NIDDM). Metformin, a biguanide drug, works by reducing glucose production in the liver, decreasing intestinal absorption, and improving insulin sensitivity, leading to lower blood glucose levels. Metformin is generally considered to be a medication with a good safety profile and high tolerability. However, metformin therapy is associated with an uncommon but potentially serious complication known as metformin-associated lactic acidosis (MALA), which is marked by severe lactic acid accumulation in the bloodstream. This case introduces an elderly female with multiple comorbidities who presented with confusion, malaise, and lethargy. Her laboratory findings revealed acute renal failure, severe metabolic acidosis, and significantly elevated lactic acid levels consistent with sepsis and possibly MALA. Aggressive resuscitation with fluids and sodium bicarbonate was initiated. Antimicrobial drugs were started for urinary tract infections. She subsequently required endotracheal intubation with invasive ventilation, pressor support, and continuous renal replacement therapy. Her condition gradually improved over several days. The patient ultimately recovered, and at the time of discharge, metformin was discontinued, and a sodium-glucose cotransporter-2 (SGLT-2) inhibitor was initiated. This case underscores the relevance of MALA as a potential complication of metformin therapy, particularly in patients with underlying kidney disease or other risk factors. Timely detection and prompt management of MALA can prevent progression to a critical stage and thus avoid potentially fatal outcomes.

Emerging molecular technologies for light-mediated modulation of pancreatic beta-cell function

Background

Optogenetic modalities as well as optochemical and photopharmacological strategies, collectively termed optical methods, have revolutionized the control of cellular functions via light with great spatiotemporal precision. In comparison to the major advances in the photomodulation of signaling activities noted in neuroscience, similar applications to endocrine cells of the pancreas, particularly insulin-producing β-cells, have been limited. The availability of tools allowing light-mediated changes in the trafficking of ions such as K⁺ and Ca²⁺ and signaling intermediates such as cyclic adenosine monophosphate (cAMP), renders β-cells and their glucose-stimulated insulin secretion (GSIS) amenable to optoengineering for drug-free control of blood sugar.

Scope of review

The molecular circuit of the GSIS in β-cells is described with emphasis on intermediates which are targetable for optical intervention. Various pharmacological agents modifying the release of insulin are reviewed along with their documented side effects. These are contrasted with optical approaches, which have already been employed for engineering β-cell function or are considered for future such applications. Principal obstacles are also discussed as the implementation of optogenetics is pondered for tissue engineering and biology applications of the pancreas.

Major Conclusions

Notable advances in optogenetic, optochemical and photopharmacological tools are rendering feasible the smart engineering of pancreatic cells and tissues with light-regulated function paving the way for novel solutions for addressing pancreatic pathologies including diabetes.

The role of oral semaglutide in managing type 2 diabetes in Indian clinical settings: Addressing the unmet needs

AIMS

Despite their established benefits, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) remain underutilized for type 2 diabetes mellitus (T2DM) management, which indicates that subcutaneous injection is an unfavorable mode of delivery from the patient's perspective. This review summarizes existing challenges related to medication adherence and the use of antihyperglycemia injectables, revisits the established safety and efficacy of oral semaglutide, and explores its features and considerations for use among the Indian T2DM population.

METHODS

We performed a literature search using MEDLINE and the National Institutes of Health Clinical Trials Registry from July 1, 2016, to July 1, 2021, to identify publications on oral semaglutide approval, T2DM treatment guidelines, and clinical evidence for oral drug formulation.

RESULTS

Oral semaglutide is the first oral GLP-1 RA approved for T2DM patients based on phase 3, randomized PIONEER trials. The multitargeted action of this drug offers glycemic control, weight control, and cardiovascular, renal, and additional benefits, including patient convenience and enhanced medication adherence. In addition to achieving glycemic control, the cost of semaglutide is reported to be lower than other GLP-1 RA in the West, thus potentially mitigating the economic burden that appears to be high among the Indian population.

CONCLUSIONS

Currently, there is no data available on oral semaglutide in Indian clinical settings. However, significant improvements in glycemic control, cardiac and renal benefits, as well as weight loss across clinical trials should encourage clinicians to prioritize oral semaglutide over other antidiabetic agents.

Antidiabetic effect of a flavonoid-rich extract from Sophora alopecuroides L. in HFD- and STZ- induced diabetic mice through PKC/GLUT4 pathway and regulating PPARα and PPARγ expression

HEADINGS ETHNOPHARMACOLOGICAL RELEVANCE

Sophora alopecuroides L. is a traditional ethnopharmacological plant, which is widely used in traditional Chinese medicine and Mongolian and Uighur medicine to ameliorate "thirst disease".

AIM OF THE STUDY

This study aimed to investigate the antidiabetic activities and mechanisms of a flavonoid-rich extract from Sophora alopecuroides L. (SA-FRE) both in vivo and vitro.

MATERIALS AND METHODS

The main six chemical constituents of SA-FRE were elucidated based on an off-line semi-preparative liquid chromatography nuclear magnetic resonance (LC-NMR) protocol. Myc-GLUT4-mOrange-L6 cell models and mouse model with diabetes induced by high-fat diet combined with STZ injection were respectively adopted to investigate the antidiabetic effects of SA-FRE both in vitro and vivo.

RESULTS

In vivo, 4-week treatment of SA-FRE ameliorated hyperglycemia, dyslipidemia, and insulin resistance in diabetic mice. Mechanically, SA-FRE regulated PPARα and PPARγ expression in white adipose tissue (WAT) and liver, thereby ameliorating dyslipidemia. Moreover, SA-FRE increased the phosphorylation of PKC and further stimulated the GLUT4 expression in WAT and skeletal muscle, thus increasing the glucose utilization in vivo. In vitro, 50 μg/mL SA-FRE increased GLUT4 translocation to about 1.91-fold and glucose uptake to 1.82-fold in L6-myotubes. SA-FRE treatment increased the GLUT4 expression at both gene and protein levels. Furthermore, only Gö6983, a PKC inhibitor, reversed the SA-FRE-induced GLUT4 translocation and expression at the gene and protein levels.

CONCLUSIONS

Generally, SA-FRE ameliorated hyperglycemia, dyslipidemia, and insulin resistance partly through activating PKC/GLUT4 pathway and regulating PPARα and PPARγ expression.

Will oral semaglutide be a game-changer in the management of type 2 diabetes in primary care?

GLP-1 receptor agonists (GLP-1RAs) are recommended for patients with type 2 diabetes (T2D), particularly those at high cardiovascular risk. Oral semaglutide is the first oral GLP-1RA. In clinical trials, oral semaglutide 14 mg reduced mean HbA_1c by approximately 1.1-1.5% and reduced body weight by up to 5 kg. These changes were significantly greater compared with empagliflozin, sitagliptin and liraglutide (p < 0.05 for estimated treatment differences at 52 weeks in patients on treatment without rescue medication use). The most common side effects were gastrointestinal, mainly mild-to-moderate and transient nausea. Oral semaglutide may change the paradigm of T2D treatment in primary care.

Fixed dose drug combinations - are they pharmacoeconomically sound? Findings and implications especially for lower- and middle-income countries

Introduction: There are positive aspects regarding the prescribing of fixed dose combinations (FDCs) versus prescribing the medicines separately. However, these have to be balanced against concerns including increased costs and their irrationality in some cases. Consequently, there is a need to review their value among lower- and middle-income countries (LMICs) which have the greatest prevalence of both infectious and noninfectious diseases and issues of affordability.Areas covered: Review of potential advantages, disadvantages, cost-effectiveness, and availability of FDCs in high priority disease areas in LMICs and possible initiatives to enhance the prescribing of valued FDCs and limit their use where there are concerns with their value.Expert commentary: FDCs are valued across LMICs. Advantages include potentially improved response rates, reduced adverse reactions, increased adherence rates, and reduced costs. Concerns include increased chances of drug:drug interactions, reduced effectiveness, potential for imprecise diagnoses and higher unjustified prices. Overall certain FDCs including those for malaria, tuberculosis, and hypertension are valued and listed in the country's essential medicine lists, with initiatives needed to enhance their prescribing where currently low prescribing rates. Proposed initiatives include robust clinical and economic data to address the current paucity of pharmacoeconomic data. Irrational FDCs persists in some countries which are being addressed.

Metformin and Its Benefits for Various Diseases

Metformin is a widely used biguanide drug due to its safety and low cost. It has been used for over 60 years to treat type 2 diabetes at the early stages because of its outstanding ability to decrease plasma glucose levels. Over time, different uses of metformin were discovered, and the benefits of metformin for various diseases and even aging were verified. These diseases include cancers (e.g., breast cancer, endometrial cancer, bone cancer, colorectal cancer, and melanoma), obesity, liver diseases, cardiovascular disease, and renal diseases. Metformin exerts different effects through different signaling pathways. However, the underlying mechanisms of these different benefits remain to be elucidated. The aim of this review is to provide a brief summary of the benefits of metformin and to discuss the possible underlying mechanisms.