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Bertoluci MC, Silva Júnior WS, Valente F, Araujo LR, Lyra R, de Castro JJ, Raposo JF, Miranda PAC, Boguszewski CL, Hohl A, Duarte R, Salles JEN, Silva-Nunes J, Dores J, Melo M, de Sá JR, Neves JS, Moreira RO, Malachias MVB, Lamounier RN, Malerbi DA, Calliari LE, Cardoso LM, Carvalho MR, Ferreira HJ, Nortadas R, Trujilho FR, Leitão CB, Simões JAR, Dos Reis MIN, Melo P, Marcelino M, Carvalho D. 2023 UPDATE: Luso-Brazilian evidence-based guideline for the management of antidiabetic therapy in type 2 diabetes. Diabetol Metab Syndr 2023; 15:160. [PMID: 37468901 PMCID: PMC10354939 DOI: 10.1186/s13098-023-01121-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 06/23/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND The management of antidiabetic therapy in people with type 2 diabetes (T2D) has evolved beyond glycemic control. In this context, Brazil and Portugal defined a joint panel of four leading diabetes societies to update the guideline published in 2020. METHODS The panelists searched MEDLINE (via PubMed) for the best evidence from clinical studies on treating T2D and its cardiorenal complications. The panel searched for evidence on antidiabetic therapy in people with T2D without cardiorenal disease and in patients with T2D and atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or diabetic kidney disease (DKD). The degree of recommendation and the level of evidence were determined using predefined criteria. RESULTS AND CONCLUSIONS All people with T2D need to have their cardiovascular (CV) risk status stratified and HbA1c, BMI, and eGFR assessed before defining therapy. An HbA1c target of less than 7% is adequate for most adults, and a more flexible target (up to 8%) should be considered in frail older people. Non-pharmacological approaches are recommended during all phases of treatment. In treatment naïve T2D individuals without cardiorenal complications, metformin is the agent of choice when HbA1c is 7.5% or below. When HbA1c is above 7.5% to 9%, starting with dual therapy is recommended, and triple therapy may be considered. When HbA1c is above 9%, starting with dual therapyt is recommended, and triple therapy should be considered. Antidiabetic drugs with proven CV benefit (AD1) are recommended to reduce CV events if the patient is at high or very high CV risk, and antidiabetic agents with proven efficacy in weight reduction should be considered when obesity is present. If HbA1c remains above target, intensification is recommended with triple, quadruple therapy, or even insulin-based therapy. In people with T2D and established ASCVD, AD1 agents (SGLT2 inhibitors or GLP-1 RA with proven CV benefit) are initially recommended to reduce CV outcomes, and metformin or a second AD1 may be necessary to improve glycemic control if HbA1c is above the target. In T2D with HF, SGLT2 inhibitors are recommended to reduce HF hospitalizations and mortality and to improve HbA1c. In patients with DKD, SGLT2 inhibitors in combination with metformin are recommended when eGFR is above 30 mL/min/1.73 m2. SGLT2 inhibitors can be continued until end-stage kidney disease.
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Affiliation(s)
- Marcello Casaccia Bertoluci
- Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
- Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Departamento de Medicina Interna da Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2350, 4º Andar, Porto Alegre, RS, 90035-007, Brazil.
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil.
| | - Wellington S Silva Júnior
- Disciplina de Endocrinologia, Departamento de Medicina I, Universidade Federal Maranhão, São Luís, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - Fernando Valente
- Faculdade de Medicina do ABC, Santo André, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - Levimar Rocha Araujo
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - Ruy Lyra
- Universidade Federal de Pernambuco, Recife, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - João Jácome de Castro
- Serviço de Endocrinologia do Hospital Universitário das Forças Armadas, Lisbon, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - João Filipe Raposo
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - Paulo Augusto Carvalho Miranda
- Clínica de Endocrinologia e Metabologia da Santa Casa Belo Horizonte, Belo Horizonte, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - Cesar Luiz Boguszewski
- Divisão de Endocrinologia (SEMPR), Departamento de Clínica Médica, Universidade Federal do Paraná, Curitiba, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - Alexandre Hohl
- Departamento de Clínica Médica da Universidade Federal de Santa Catarina, Florianópolis, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - Rui Duarte
- Associação Protectora dos Diabéticos de Portugal, Lisbon, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - João Eduardo Nunes Salles
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - José Silva-Nunes
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - Jorge Dores
- Centro Hospitalar e Universitário de Santo António, Lisbon, Portugal
- Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto, Porto, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - Miguel Melo
- Serviço de Endocrinologia, Diabetes e Metabolismo, Centro Hospitalar e Universitário de Coimbra, Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - João Roberto de Sá
- Faculdade de Medicina do ABC, Santo André, Brazil
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - João Sérgio Neves
- Cardiovascular R&D Centre (UnIC@RISE), Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Serviço de Endocrinologia, Diabetes e Metabolismo, Centro Hospitalar Universitário de São João, Porto, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - Rodrigo Oliveira Moreira
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, Brazil
- Faculdade de Medicina, Centro Universitário Presidente Antônio Carlos (UNIPAC/JF), Juiz de Fora, Brazil
- Faculdade de Medicina, Centro Universitário de Valença (UNIFAA), Valença, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | | | - Rodrigo Nunes Lamounier
- Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - Domingos Augusto Malerbi
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - Luis Eduardo Calliari
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - Luis Miguel Cardoso
- i3S, Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Serviço de Endocrinologia, Diabetes e Metabolismo, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - Maria Raquel Carvalho
- Hospital CUF, Tejo, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - Hélder José Ferreira
- Clínica Grupo Sanfil Medicina, Coimbra, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - Rita Nortadas
- Associação Protectora dos Diabéticos de Portugal, Lisbon, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - Fábio Rogério Trujilho
- Faculdade de Medicina da UniFTC, Salvador, Brazil
- Centro de Diabetes e Endocrinologia da Bahia (CEDEBA), Salvador, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - Cristiane Bauermann Leitão
- Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Departamento de Medicina Interna da Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2350, 4º Andar, Porto Alegre, RS, 90035-007, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - José Augusto Rodrigues Simões
- Faculdade de Ciências da Saúde da Universidade da Beira Interior, Covilhã, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - Mónica Isabel Natal Dos Reis
- Unidade Integrada de Diabetes Mellitus do Hospital de Vila Franca de Xira, Vila Franca de Xira, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - Pedro Melo
- Serviço de Endocrinologia, Hospital Pedro Hispano, Matosinhos, Portugal
- Unidade de Endocrinologia, Instituto CUF, Porto, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - Mafalda Marcelino
- Serviço de Endocrinologia do Hospital Universitário das Forças Armadas, Lisbon, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - Davide Carvalho
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
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Skalkos E, Rajagopal R, Simmons D. Diabetes Management and Outcomes among Patients with Type 2 Diabetes Attending a Renal Service. J Diabetes Res 2023; 2023:1969145. [PMID: 37152098 PMCID: PMC10156453 DOI: 10.1155/2023/1969145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/06/2023] [Accepted: 03/25/2023] [Indexed: 05/09/2023] Open
Abstract
Background Patients with comorbid type 2 diabetes mellitus (T2DM) and renal disease, particularly those treated with insulin, often require complex pharmacological treatment and management of other diabetes complications. Aims To assess the achievement of metabolic targets and compare the current management of renal service attenders with insulin- and noninsulin-treated T2DM. Methods Single-centre retrospective cross-sectional study involving medical record review of patients with T2DM aged ≥18 years who visited a metropolitan renal outpatient clinic in 2017. Univariable analysis and multivariable logistic regression were used to identify factors associated with insulin treatment. Results Among 268 patients (45.5% insulin-treated), mean HbA1c was higher in insulin-treated vs. noninsulin-treated patients (8.0 ± 1.8% (64 mmol/mol) vs. 6.8 ± 1.2% (51 mmol/mol), p < 0.001). Significantly fewer insulin-treated patients had HbA1c ≤ 7.0% (53 mmol/mol; 31.8% vs. 69.3%, p < 0.001). More insulin-treated patients had ischaemic heart disease (46.7% vs. 33.6%, p = 0.028), diabetic foot disease (15.6% vs. 4.8%, p = 0.003), retinopathy (40.2% vs. 11.0%, p < 0.001), and emergency attendance for severe hypoglycaemia (3.8% vs. 0% p = 0.042). Insulin treatment was more associated with chronic kidney disease stages 4-5 (adjusted odds ratio (aOR) 2.41, 95% CI 1.07-5.43), retinopathy (aOR 3.10, 95% CI 1.04-9.27), and podiatry review (aOR 5.06, 95% CI 1.20-21.38). Only 38 (14.2%) individuals were seen by a colocated public multidisciplinary diabetes service in 2017. Conclusions Renal clinic attenders with T2DM, particularly if insulin-treated, remained at increased risk of diabetes-related complications, including severe hypoglycaemia, with limited input from the colocated hospital diabetes team. Approaches to increase coordination of diabetes care among renal patients should be investigated.
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Affiliation(s)
| | | | - David Simmons
- School of Medicine, Western Sydney University, Sydney, Australia
- Macarthur Diabetes Service, Sydney, Australia
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Hassanein M, Al Dahi W, Radhi HT, AIMahfouz A, Al Kaabi J, Alshammari A, Alfutaisi A, AlMalki MH, Malik R. Expert-Group Practical Advice on Insulin Initiation and Titration for Patients with Type 2 Diabetes in the Gulf Region. DUBAI DIABETES AND ENDOCRINOLOGY JOURNAL 2022. [DOI: 10.1159/000521437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The type 2 diabetes mellitus (T2DM) management represents a major challenge in the Gulf region. Hyperglycemia is a major risk factor for microvascular and macrovascular complications and increased mortality. Early dietary and lifestyle changes alongside a step-wise targeted pharmacological approach to achieve a glycated hemoglobin (HbA<sub>1c</sub>) level of <7% are recommended to limit these complications. However, achievement of this HbA<sub>1c</sub> target remains a major challenge, especially in the Gulf region. Both physician and patient-led barriers limit timely initiation and titration of insulin. An expert-group advisory committee reviewed the current guideline recommendations, strategized best practice, and curated clinical practical advices to enable primary-care physicians to optimally initiate and titrate insulin in patients with T2DM.
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Bagepally BS, Chaikledkaew U, Youngkong S, Anothaisintawee T, Thavorncharoensap M, Dejthevaporn C, Thakkinstian A. Cost-Utility Analysis of Dapagliflozin Compared to Sulfonylureas for Type 2 Diabetes as Second-Line Treatment in Indian Healthcare Payer's Perspective. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:897-907. [PMID: 34712053 PMCID: PMC8548256 DOI: 10.2147/ceor.s328433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/07/2021] [Indexed: 11/23/2022] Open
Abstract
Background Type 2 diabetes mellitus (T2DM) is a leading health issue, causing economic burden in India. Pharmacotherapy is a major cost driver in diabetic care usually funded through out of pocket expenditure; however, there has been a very limited economic evaluation evidence to guide the choice of diabetes pharmacotherapy in India. Therefore, this study aims to evaluate the long-term cost-effectiveness of dapagliflozin (sodium glucose transporter 2 inhibitor) compared to commonly used sulfonylureas as second-line drugs in Indian patients with T2DM. Methods Cost-utility analysis was employed to estimate the costs and health outcomes using a Markov model with 1-year cycle length during a lifetime horizon based on an Indian payer’s perspective. A treatment pathway with dapagliflozin as second-line therapy was compared to sulfonylureas after failure of initial metformin therapy. Clinical and cost data were collected from literature reviews and available secondary data sources. Both costs and outcomes were discounted at a 3% annual discount rate. The results were presented as the incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses were performed to test parameter uncertainties. Results Compared to sulfonylurea, dapagliflozin was estimated to incur an additional cost of ₹182,632 (US$2,446) with an expected 3.49 life years (LY) or 1.72 quality adjusted life years (QALY) gained, resulting in an ICER of ₹52,270 (US$699) per LY gained, or ₹106,133 (US$1,421) per QALY gained. Uncertainty analyses showed that the ICER values were not sensitive to changes in most parameters. Conclusion Dapagliflozin would be cost-effective compared to sulfonylureas as the second line added to metformin for T2DM patients based on an Indian payer’s perspective.
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Affiliation(s)
- Bhavani Shankara Bagepally
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.,Department of Non-Communicable Diseases, ICMR-National Institute of Epidemiology, Chennai, India
| | - Usa Chaikledkaew
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.,Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Sitaporn Youngkong
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.,Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Thunyarat Anothaisintawee
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.,Department of Family Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Montarat Thavorncharoensap
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.,Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | | | - Ammarin Thakkinstian
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.,Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Rainkie DC, Abedini ZS, Abdelkader NN. Reporting and methodological quality of systematic reviews and meta-analysis with protocols in Diabetes Mellitus Type II: A systematic review. PLoS One 2020; 15:e0243091. [PMID: 33326429 PMCID: PMC7743973 DOI: 10.1371/journal.pone.0243091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/15/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Systematic reviews with or without meta-analyses (SR/MAs) are strongly encouraged to work from a protocol to facilitate high quality, transparent methodology. The completeness of reporting of a protocol (PRISMA-P) and manuscript (PRISMA) is essential to the quality appraisal (AMSTAR-2) and appropriate use of SR/MAs in making treatment decisions. OBJECTIVES The objectives of this study were to describe the completeness of reporting and quality of SR/MAs, assess the correlations between PRISMA-P, PRISMA, and AMSTAR-2, and to identify reporting characteristics between similar items of PRISMA-P and PRISMA. METHODS We performed a systematic review of Type 2 Diabetes Mellitus SR/MAs of hypoglycemic agents with publicly available protocols. Cochrane reviews, guidelines, and specific types of MA were excluded. Two reviewers independently, (i) searched PubMed and Embase between 1/1/2015 to 20/3/2019; (ii) identified protocols of included studies by searching the manuscript bibliography, supplementary material, PROSPERO, and Google; (iii) completed PRISMA-P, PRISMA, and AMSTAR-2 tools. Data analysis included descriptive statistics, Pearson correlation, and multivariable linear regression. RESULTS Of 357 relevant SR/MAs, 51 had available protocols and were included. The average score for PRISMA-P was 15.8±3.3 (66%; maximum 24) and 25.2±1.1 (93%; maximum 27) for PRISMA. The quality of SR/MAs assessed using the AMSTAR-2 tool identified an overall poor quality (63% critically low, 18% low, 8% moderate, 12% high). The correlation between the PRISMA-P and PRISMA was not significant (r = 0.264; p = 0.06). Correlation was significant between PRISMA-P and AMSTAR-2 (r = 0.333; p = 0.02) and PRISMA and AMSTAR-2 (r = 0.555; p<0.01). Discrepancies in reporting were common between similar PRISMA-P and PRISMA items. CONCLUSION Adherence to protocol reporting guidance was poor while manuscript reporting was comprehensive. Protocol completeness is not associated with a completely reported manuscript. Independently, PRISMA-P and PRISMA scores were weakly associated with higher quality assessments but insufficient as a surrogate for quality. Critical areas for quality improvement include protocol description, investigating causes of heterogeneity, and the impact of risk of bias on the evidence synthesis.
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Patoulias D, Stavropoulos K, Imprialos K, Athyros V, Doumas M, Karagiannis A. Pharmacological Management of Cardiac Disease in Patients with Type 2 Diabetes: Insights into Clinical Practice. Curr Vasc Pharmacol 2020; 18:125-138. [PMID: 32013815 DOI: 10.2174/1570161117666190426162746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/18/2018] [Accepted: 10/26/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Type 2 Diabetes Mellitus (T2DM) has emerged as a growing pandemic. Cardiovascular disease (CVD) constitutes another major health problem, with coronary heart disease being the leading cause of cardiovascular death. Patients with T2DM require a multilevel therapeutic approach, both for primary and secondary prevention of CVD. OBJECTIVE To present and summarize the most recent, highest level evidence retrieved from literature, relevant to the pharmaceutical management of CVD in T2DM. METHODS We conducted a comprehensive search of the literature on MEDLINE from its inception till today, primarily for relevant systematic reviews, meta-analyses and randomized controlled trials. RESULTS There is a trend towards more intensified therapeutic interventions in T2DM, concerning glycemic, lipid and blood pressure control. New drugs, such as sodium-glucose co-transporter 2 (SGLT-2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs) and proprotein convertase subtilisin/ kexin type 9 (PCSK9) inhibitors might evolve as key players in the management of diabetes and its complications within the next years. Classic drugs, such as those targeting the renin-angiotensinaldosterone system, statins and aspirin remain first-line treatment options, both for primary and secondary prevention of CVD. Lifestyle interventions should always be integrated into a complete therapeutic strategy in diabetic patients. Novel drugs, such as finerenone and LCZ696 have provided significant results in cardiovascular outcome studies; however, their role in T2DM has to be further elucidated. CONCLUSION Pharmaceutical approach of CVD in T2DM is multilevel and complex. Drug classes featuring pleiotropic effects may boost our armamentarium in the fight against CVD.
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Affiliation(s)
- Dimitrios Patoulias
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Stavropoulos
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Imprialos
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasilios Athyros
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece.,VA Medical Center, and George Washington University, Washington, DC, United States
| | - Asterios Karagiannis
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
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Bertoluci MC, Salles JEN, Silva-Nunes J, Pedrosa HC, Moreira RO, da Silva Duarte RMC, da Costa Carvalho DM, Trujilho FR, dos Santos Raposo JFC, Parente EB, Valente F, de Moura FF, Hohl A, Melo M, Araujo FGP, de Araújo Principe RMMC, Kupfer R, Costa e Forti A, Valerio CM, Ferreira HJ, Duarte JMS, Saraiva JFK, Rodacki M, Castelo MHCG, Monteiro MP, Branco PQ, de Matos PMP, de Melo Pereira de Magalhães PC, Betti RTB, Réa RR, Trujilho TDG, Pinto LCF, Leitão CB. Portuguese-Brazilian evidence-based guideline on the management of hyperglycemia in type 2 diabetes mellitus. Diabetol Metab Syndr 2020; 12:45. [PMID: 32489427 PMCID: PMC7245758 DOI: 10.1186/s13098-020-00551-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/11/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND In current management of type 2 diabetes (T2DM), cardiovascular and renal prevention have become important targets to be achieved. In this context, a joint panel of four endocrinology societies from Brazil and Portugal was established to develop an evidence-based guideline for treatment of hyperglycemia in T2DM. METHODS MEDLINE (via PubMed) was searched for randomized clinical trials, meta-analyses, and observational studies related to diabetes treatment. When there was insufficient high-quality evidence, expert opinion was sought. Updated positions on treatment of T2DM patients with heart failure (HF), atherosclerotic CV disease (ASCVD), chronic kidney disease (CKD), and patients with no vascular complications were developed. The degree of recommendation and the level of evidence were determined using predefined criteria. RESULTS AND CONCLUSIONS In non-pregnant adults, the recommended HbA1c target is below 7%. Higher levels are recommended in frail older adults and patients at higher risk of hypoglycemia. Lifestyle modification is recommended at all phases of treatment. Metformin is the first choice when HbA1c is 6.5-7.5%. When HbA1c is 7.5-9.0%, dual therapy with metformin plus an SGLT2i and/or GLP-1RA (first-line antidiabetic agents, AD1) is recommended due to cardiovascular and renal benefits. If an AD1 is unaffordable, other antidiabetic drugs (AD) may be used. Triple or quadruple therapy should be considered when HbA1c remains above target. In patients with clinical or subclinical atherosclerosis, the combination of one AD1 plus metformin is the recommended first-line therapy to reduce cardiovascular events and improve blood glucose control. In stable heart failure with low ejection fraction (< 40%) and glomerular filtration rate (eGFR) > 30 mL/min/1.73 m2, metformin plus an SGLT-2i is recommended to reduce cardiovascular mortality and heart failure hospitalizations and improve blood glucose control. In patients with diabetes-associated chronic kidney disease (CKD) (eGFR 30-60 mL/min/1.73 m2 or eGFR 30-90 mL/min/1.73 m2 with albuminuria > 30 mg/g), the combination of metformin and an SGLT2i is recommended to attenuate loss of renal function, reduce albuminuria and improve blood glucose control. In patients with severe renal failure, insulin-based therapy is recommended to improve blood glucose control. Alternatively, GLP-1RA, DPP4i, gliclazide MR and pioglitazone may be considered to reduce albuminuria. In conclusion, the current evidence supports individualizing anti-hyperglycemic treatment for T2DM.
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Affiliation(s)
- Marcello Casaccia Bertoluci
- Internal Medicine Department, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2350, 4º Andar, Porto Alegre, RS 90035-007 Brazil
- Endocrinology Unit, Hospital de Clínicas de Porto Alegre (HCPA-UFRGS), Rua Ramiro Barcelos, 2350, 4º Andar, Porto Alegre, RS 90035-007 Brazil
| | - João Eduardo Nunes Salles
- Department of Internal Medicine, Discipline of Endocrinology, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Rua Dr. Cesário Mota Junior, 61, São Paulo, SP 01221-020 Brazil
| | - José Silva-Nunes
- Department of Endocrinology, Diabetes and Metabolism/Centro Hospitalar, Universitário de Lisboa Central (CHULC), Rua da Beneficência, 8, 1069-166 Lisbon, Portugal
- NOVA Medical School (NMS)/Faculdade de Ciências Médicas (FCM) da Universidade Nova de Lisboa, Rua da Beneficência, 8, 1069-166 Lisbon, Portugal
- Health and Technology Research Center/Escola Superior de Tecnologia da Saúde de Lisboa, Rua da Beneficência, 8, 1069-166 Lisbon, Portugal
- Hospital Curry Cabral, Rua da Beneficência, 8, 1069-166 Lisbon, Portugal
| | - Hermelinda Cordeiro Pedrosa
- Endocrinology Unit and Research Centre, Hospital Regional de Taguatinga, Área Especial Nº 24, Setor C Norte, Taguatinga Norte, Brasília, DF 72115-920 Brazil
| | - Rodrigo Oliveira Moreira
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rua Moncorvo Filho, 90, Rio de Janeiro, RJ 20211-340 Brazil
- Faculdade de Medicina, Universidade Presidente Antônio Carlos (UNIPAC), Juiz de Fora, MG Brazil
- Centro Universitário de Valença (UNIFAA), Rua Moncorvo Filho, 90, Rio de Janeiro, RJ 20211-340 Brazil
| | | | - Davide Mauricio da Costa Carvalho
- Department of Endorinology, Diabetes and Metabolism, Centro Hospitalar S. João, Porto, Portugal
- Faculty of Medicine, i3S, Universidade do Porto, Porto, Portugal
| | - Fábio Rogério Trujilho
- Department of Obesity, Sociedade Brasileira de Endocrinologia e Metabologia, Av. Antonio Carlos Magalhães, s/n, Parque Bela Vista, Salvador, BA 40275-350 Brazil
| | - João Filipe Cancela dos Santos Raposo
- NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, Rua Salitre, 118, 1250-203 Lisbon, Portugal
- Associação Protetora dos Diabéticos de Portugal (APDP), Rua Salitre, 118, 1250-203 Lisbon, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Rua Salitre, 118, 1250-203 Lisbon, Portugal
| | - Erika Bezerra Parente
- Department of Endocrinology, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Rua Dr. Cesario Mota Jr., 112, São Paulo, SP 01221-010 Brazil
| | - Fernando Valente
- Endocrinology Division, Department of Internal Medicine, Faculdade de Medicina do ABC, Av. Lauro Gomes, 2000, Santo André, SP Brazil
| | - Fábio Ferreira de Moura
- Department of Endocrinology, Universidade de Pernambuco (UPE), Rua Arnobio Marques, 310, Recife, PE 50100-130 Brazil
- Endocrinology Service, Instituto de Medicina de Pernambuco (IMIP), Rua Arnobio Marques, 310, Recife, PE 50100-130 Brazil
| | - Alexandre Hohl
- Department of Endocrinology and Metabolism/Department of Internal Medicine, Universidade Federal de Santa Catarina (UFSC), Rua Professora Maria Flora Pausewang, s/n, Florianópolis, SC 88036-800 Brazil
- Hospital Universitário Polydoro Ernani de São Thiago, Campus Universitário, Rua Professora Maria Flora Pausewang, s/n, Florianópolis, SC 88036-800 Brazil
| | - Miguel Melo
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Medical Faculty, University of Coimbra, Praceta Mota Pinto, 3000-075 Coimbra, Portugal
| | | | | | - Rosane Kupfer
- Department of Diabetes, Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rua Moncorvo Filho, 90, Rio de Janeiro, RJ 20211-340 Brazil
| | - Adriana Costa e Forti
- Department of Internal Medicine, School of Medicine, Universidade Federal do Ceará (UFC), Rua Capitão Francisco Pedro, 1290, Fortaleza, CE 60430-375 Brazil
| | - Cynthia Melissa Valerio
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rua Moncorvo Filho, 90, Rio de Janeiro, RJ 20211-340 Brazil
| | - Hélder José Ferreira
- Unidade de Saúde Familiar Coimbra Celas, Administração Regional de Saúde do Centro, Av. D. Afonso Henriques, 141, 3000-011 Coimbra, Portugal
| | | | - José Francisco Kerr Saraiva
- Cardiology Division, Faculdade de Medicina, Pontifícia Universidade Católica de Campinas (PUC-Campinas), Rua Engenheiro Carlos Stevenson, 560, Campinas, SP 13092-132 Brazil
- Instituto de Pesquisa Clínica de Campinas (IPECC), Rua Engenheiro Carlos Stevenson, 560, Campinas, SP 13092-132 Brazil
| | - Melanie Rodacki
- Department of Internal Medicine, Diabetes and Nutrology Section, Universidade Federal do Rio de Janeiro (UFRJ), Rua Rodolpho Paulo Rocco. 255, Sala 9E14, Rio de Janeiro, RJ Brazil
| | | | - Mariana Pereira Monteiro
- Unidade de Investigação Multidisciplicar Biomédica, Instituto de Ciências Biomédicas de Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Patrícia Quadros Branco
- Associação Protetora dos Diabéticos de Portugal (APDP), Rua Rodrigo da Fonseca 1, 1250-189 Lisbon, Portugal
- Nephrology Service, Centro Hospitalar Lisboa Ocidental, Rua Rodrigo da Fonseca, 1, 1250-189 Lisbon, Portugal
- Diretoria Clínica, Nephrocare, Rua Rodrigo da Fonseca, 1, 1250-189 Lisbon, Portugal
| | - Pedro Manuel Patricio de Matos
- Department of Cardiology, Associação Protetora dos Diabéticos de Portugal (APDP), Rua Rodrigo da Fonseca, 1250, 189, Lisbon, Portugal
| | | | | | - Rosângela Roginski Réa
- Department of Internal Medicine, Serviço de Endocrinologia e Metabologia, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Av. Agostinho Leão Junior, 285, Curitiba, PR 80030-110 Brazil
| | - Thaisa Dourado Guedes Trujilho
- Department of Diabetes Mellitus, Sociedade Brasileira de Endocrinologia e Metabologia, Av. Antonio Carlos Magalhães, s/n, Salvador, BA 40275-350 Brazil
- Sociedade Brasileira de Diabetes, Regional Bahia, Av. Antonio Carlos Magalhães, s/n, Salvador, BA 40275-350 Brazil
| | - Lana Catani Ferreira Pinto
- Endocrinology Unit, Hospital de Clínicas de Porto Alegre (HCPA-UFRGS), Rua Ramiro Barcelos, 2350, 4º Andar, Porto Alegre, RS 90035-007 Brazil
| | - Cristiane Bauermann Leitão
- Internal Medicine Department, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2350, 4º Andar, Porto Alegre, RS 90035-007 Brazil
- Endocrinology Unit, Hospital de Clínicas de Porto Alegre (HCPA-UFRGS), Rua Ramiro Barcelos, 2350, 4º Andar, Porto Alegre, RS 90035-007 Brazil
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Kuo S, Yang CT, Wu JS, Ou HT. Effects on clinical outcomes of intensifying triple oral antidiabetic drug (OAD) therapy by initiating insulin versus enhancing OAD therapy in patients with type 2 diabetes: A nationwide population-based, propensity-score-matched cohort study. Diabetes Obes Metab 2019; 21:312-320. [PMID: 30187666 PMCID: PMC6329671 DOI: 10.1111/dom.13525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/20/2018] [Accepted: 09/01/2018] [Indexed: 01/16/2023]
Abstract
AIMS To compare the effects of initiating insulin as a fourth-line antidiabetic therapy with the effects of enhancing oral antidiabetic drug (OAD) therapy in patients with type 2 diabetes mellitus (T2DM) with triple OAD therapy failure. MATERIALS AND METHODS We conducted a nationwide population-based, retrospective cohort study involving 1022 (without prevalent diabetes-related complications [PDRCs]) and 2077 (with/without PDRCs) propensity score-matched pairs of fourth-line insulin therapy users and enhanced OAD therapy users identified in the period 2004 to 2010. Clinical outcomes including a composite cardiovascular outcome (myocardial infarction, stroke, heart failure or ischaemic heart disease), peripheral vascular disease (PVD), hypoglycaemia and all-cause mortality were assessed up to 2013. Hypoglycaemia was adjusted in Cox models to consider its potential effect on study outcomes. RESULTS In a T2DM cohort without PDRCs, fourth-line insulin therapy was not associated with greater risks of clinical outcomes, except hypoglycaemia (hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.02-2.07), compared with enhanced OAD therapy. Among patients with T2DM with/without PDRCs, fourth-line insulin therapy was associated with greater risks of the composite cardiovascular outcome (HR 1.23, 95% CI 1.03-1.46), heart failure (HR 1.59, 95% CI 1.12-2.25), ischaemic heart disease (HR 1.37, 95% CI 1.09-1.73), PVD (HR 1.17, 95% CI 1.00-1.36), hypoglycaemia (HR 1.49, 95% CI 1.20-1.85) and all-cause mortality (HR 1.48, 95% CI 1.01-2.17), but adjustment for hypoglycaemia significantly attenuated the risk of heart failure (HR 1.34, 95% CI 0.92-1.94), PVD (HR 1.15, 95% CI 0.98-1.34) and all-cause mortality (HR 1.30, 95% CI 0.84-1.99). CONCLUSIONS Initiation of fourth-line insulin therapy can be considered for patients with T2DM with triple OAD therapy failure, and the importance of awareness and prevention of hypoglycaemia among insulin-treated patients with T2DM cannot be overstated.
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Affiliation(s)
- Shihchen Kuo
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Chun-Ting Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jin-Shang Wu
- Department of Family Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, National Cheng Kung University Hospital, Tainan, Taiwan
- Corresponding author. Address: Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, 1 University Road, Tainan 7010, Taiwan, Telephone: 886-6-2353535 ext.5685, Fax: 886-6-2373149,
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9
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Bailey CJ, Marx N. Cardiovascular protection in type 2 diabetes: Insights from recent outcome trials. Diabetes Obes Metab 2019; 21:3-14. [PMID: 30091169 DOI: 10.1111/dom.13492] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 07/29/2018] [Accepted: 08/04/2018] [Indexed: 02/06/2023]
Abstract
This review examines recent randomized controlled cardiovascular (CV) outcome trials of glucose-lowering therapies in type 2 diabetes and their impact on the treatment of patients with type 2 diabetes. The trials were designed to comply with regulatory requirements to confirm that major adverse cardiac events (MACE) are not detrimentally affected by such therapies. Trials involving dipeptidyl peptidase-4 (DPP-4) inhibitors did not alter a composite MACE outcome comprising CV deaths, non-fatal myocardial infarction and non-fatal stroke; however, the possibility that some members of this class might incur a small increased risk or worsening of heart failure cannot be excluded. Some studies on glucagon-like peptide-1 receptor agonists (liraglutide: LEADER trial; semaglutide: SUSTAIN-6 trial) found significant benefits for MACE, while treatment with sodium-glucose co-transporter-2 inhibitors (empagliflozin: EMPA-REG OUTCOME trial; canagliflozin: CANVAS trial) also significantly reduced MACE and reduced hospitalization for heart failure. Comparisons among trials are complicated by variance in the populations recruited, particularly CV status at randomization, and differences in trial design, data collection and analyses. A large proportion of patients recruited into these trials have previously experienced adverse CV events; thus, the therapies are mostly assessing secondary prevention of a further event. This contrasts with the overall type 2 diabetes population receiving glucose-lowering therapies, of whom the majority will not have had MACE and will be regarded as primary prevention. Overall, the trials provide reassuring evidence that new glucose-lowering medications do not adversely affect CV events and some of these agents may offer CV protection.
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Affiliation(s)
- Clifford J Bailey
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Nikolaus Marx
- Department of Internal Medicine I, RWTH Aachen University, Aachen, Germany
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Herman ME, O'Keefe JH, Bell DSH, Schwartz SS. Insulin Therapy Increases Cardiovascular Risk in Type 2 Diabetes. Prog Cardiovasc Dis 2017; 60:422-434. [PMID: 28958751 DOI: 10.1016/j.pcad.2017.09.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 09/20/2017] [Indexed: 12/11/2022]
Abstract
Insulin therapy increased cardiovascular (CV) risk and mortality among type 2 diabetes (T2D) patients in several recently reported clinical outcomes trials. To assess whether this association is causative or coincidental, PubMed searches were used to query the effects of insulin therapy for T2D on CV health and longevity from large-scale outcomes trials, meta-analyses, and patient registry studies, as well as basic research on insulin's direct and pleiotropic actions. Although several old studies provided conflicting results, the majority of large observational studies show strong dose-dependent associations for injected insulin with increased CV risk and worsened mortality. Insulin clearly causes weight gain, recurrent hypoglycemia, and, other potential adverse effects, including iatrogenic hyperinsulinemia. This over-insulinization with use of injected insulin predisposes to inflammation, atherosclerosis, hypertension, dyslipidemia, heart failure (HF), and arrhythmias. These associations support the findings of large-scale evaluations that strongly suggest that insulin therapy has a poorer short- and long-term safety profile than that found to many other anti-T2D therapies. The potential adverse effects of insulin therapy should be weighed against proven CV benefits noted for select other therapies for T2D as reported in recent large randomized controlled trials.
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Affiliation(s)
- Mary E Herman
- Montclair State University, New Jersey, United States; Social Alchemy Ltd. Building Global Research Competency, United States
| | - James H O'Keefe
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, United States; Saint Luke's Mid America Heart Institute, United States.
| | | | - Stanley S Schwartz
- Main Line Health System, Wynnewood, PA, United States; University of Pennsylvania, Philadelphia, PA, United States
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11
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The Landscape of Glucose-Lowering Therapy and Cardiovascular Outcomes: From Barren Land to Metropolis. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9257930. [PMID: 29270438 PMCID: PMC5705897 DOI: 10.1155/2017/9257930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/24/2017] [Accepted: 09/14/2017] [Indexed: 12/11/2022]
Abstract
The choice of glucose-lowering therapy (GLT) has expanded to include 11 different classes in addition to insulin. Since the 2008 Food and Drug Administration guidance for industry and mandate of demonstrating cardiovascular (CV) safety prior to any new drug approval, there were several trials primarily conducted to establish that goal. Some had neutral effects, while there were positively beneficial outcomes with more recent studies. Hospitalization for congestive heart failure has also been a heterogeneous finding among the different classes of GLT, with drug outcomes ranging from risky to beneficial. The current review selectively focuses on the evidence for CV outcomes for each class of GLT and summarizes the existing guidelines with regard to these drugs in heart disease. Moreover, it illustrates the dynamic status in the development of evidence. Finally, the review enables healthcare providers to formulate a plan for hypoglycemic therapy which will optimize CV health, in a patient-centered manner.
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