Efficacy and safety of linagliptin/metformin single-pill combination as initial therapy in drug-naïve Asian patients with type 2 diabetes

Clinical effectiveness and cost-effectiveness of first-line early combination of dipeptidyl peptidase 4 inhibitors and metformin in patients with type 2 diabetes in Taiwan: A modelling study

AIMS

Early dipeptidyl peptidase-4 inhibitors and metformin (DPP4i-Met) combination has been shown to extend the time to treatment failure and provide better glycaemic control for newly diagnosed type 2 diabetes (T2D) patients; however, the long-term clinical and economic outcomes of early DPP4i-Met combination remain unknown. We seek to assess the comparative long-term clinical and cost-effectiveness of DPP4i-Met versus Met for treatment-naïve T2D patients with inadequately controlled HbA1c (i.e., ≥8.5%).

METHODS

The IQVIA CORE Diabetes Model was used to simulate the quality-adjusted life years (QALYs) and healthcare costs over a lifetime from Taiwan's National Health Insurance Administration's perspective, with both QALYs and costs discounted at 3% annually. Model inputs were taken from the analyses of Taiwanese or Asian populations. Primary outcomes included the number needed to treat (NNT) to prevent one case of a clinical event and the incremental cost-effectiveness ratios (ICERs). Costs are presented in 2023 US dollars.

RESULTS

Over 40 years of projection, Met-DPP4i-treated patients had fewer complications than those using Met alone (e.g., lowering the incidence of stroke by 2.21% [2.68, 1.74]). The NNT using DPP4i-Met versus Met alone to prevent one case of stroke, microalbuminuria, neuropathy and background retinopathy was 45, 135, 65 and 182, respectively. Such long-term benefits in reducing costly complications offset the higher treatment cost of DDP4i-Met versus Met ($5796 vs. $5484/person). As a result, using DPP4i-Met versus Met yielded 0.086 QALYs gained and savings of $489 for overall treatment-naïve T2D patients and 0.064 QALYs gained and savings of $714 for young-onset T2D patients.

CONCLUSIONS

Early DPP4i-Met provides long-term clinical and economic benefits compared to Met alone for newly diagnosed T2D patients, including those with young-onset T2D.

Benefits and risks of drug combination therapy for diabetes mellitus and its complications: a comprehensive review

Diabetes is a chronic metabolic disease, and its therapeutic goals focus on the effective management of blood glucose and various complications. Drug combination therapy has emerged as a comprehensive treatment approach for diabetes. An increasing number of studies have shown that, compared with monotherapy, combination therapy can bring significant clinical benefits while controlling blood glucose, weight, and blood pressure, as well as mitigating damage from certain complications and delaying their progression in diabetes, including both type 1 diabetes (T1D), type 2 diabetes (T2D) and related complications. This evidence provides strong support for the recommendation of combination therapy for diabetes and highlights the importance of combined treatment. In this review, we first provided a brief overview of the phenotype and pathogenesis of diabetes and discussed several conventional anti-diabetic medications currently used for the treatment of diabetes. We then reviewed several clinical trials and pre-clinical animal experiments on T1D, T2D, and their common complications to evaluate the efficacy and safety of different classes of drug combinations. In general, combination therapy plays a pivotal role in the management of diabetes. Integrating the effectiveness of multiple drugs enables more comprehensive and effective control of blood glucose without increasing the risk of hypoglycemia or other serious adverse events. However, specific treatment regimens should be tailored to individual patients and implemented under the guidance of healthcare professionals.

Saxagliptin combined with additional oral antihyperglycaemic agents in drug-naive diabetic patients with high glycosylated haemoglobin: A 24-week, multicentre, randomized, open-label, active parallel-controlled group clinical trial in China (SUCCESS)

AIM

To assess the efficacy and safety of a dipeptidyl peptidase-4 (DPP-4) inhibitor combined respectively with three oral antihyperglycaemic agents in Chinese patients with newly diagnosed type 2 diabetes mellitus (T2DM) with high levels of glycated haemoglobin (HbA1c).

MATERIALS AND METHODS

Between 30 December 2014 and 1 November 2017, a 24-week, multicentre, parallel-controlled study was performed on drug-naive T2DM patients. In total, 648 patients with 8.0% ≤ HbA1c ≤ 11.0%, aged 18-80 years and body mass index (BMI) 19-40 kg/m2 were randomly assigned 1:1:1 to receive saxagliptin (Saxa) combined with metformin (Met), acarbose (Aca) or gliclazide (Gli) modified release (MR) tablets (Saxa + Met, Saxa + Aca and Saxa + Gli). The primary outcome was the absolute change in HbA1c from baseline; secondary outcome was the percentage of patients achieving HbA1c <7.0% and ≤6.5%.

RESULTS

Each treatment arm contained 216 patients; overall, 583 completed the 24-week trial. At 24 weeks, the mean (95% confidence interval) change in HbA1c from baseline in Saxa + Met, Saxa + Aca and Saxa + Gli were, respectively: -2.9% [-3.1, -2.8]; -2.6% [-2.8, -2.5]; and -2.8% [-2.9, -2.6] (overall p = .04, Saxa + Aca vs. Saxa + Met, p = .010, Saxa + Gli vs. Saxa + Met, p = 0.18). At 24 weeks, 84.9%, 74.7% and 80.3% of participants were at HbA1c <7.0% (overall p = .05); and 72.6%, 59.8% and 63.3% were HbA1c ≤6.5% (overall p = 0.10). The rates of minor or symptomatic hypoglycaemia were very low.

CONCLUSIONS

Initial treatment with a DPP-4 inhibitor combined with Metform, alpha-glycosidase inhibitor or sulphonylurea was safe and effective for patients with newly diagnosed T2DM and high HbA1c. DPP-4 inhibitor combined with Met showed the best efficacy for this population.

Metformin plus a low hypoglycemic risk antidiabetic drug vs. metformin monotherapy for untreated type 2 diabetes mellitus: A meta-analysis of randomized controlled trials

AIMS

The aim of the meta-analysis of randomized controlled trials (RCTs) was to compare the effectiveness of glycemic control and hypoglycemia risk of combination therapy (metformin plus a low hypoglycemic risk antidiabetic drug) vs. standard metformin monotherapy, in patients with untreated type 2 diabetes mellitus (T2DM).

METHODS

We searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials through October 31, 2021 to find relevant RCTs. Efficacy outcomes were changes in hemoglobulin A1c (HbA1c) and fast plasma glucose (FPG) from baseline as well as proportion of patients achieving HbA1c < 7%; the safety outcome was hypoglycemia risk.

RESULTS

We identified 14 RCTs comprising 5326 patients with untreated T2DM. Mean treatment duration was 28.1 weeks. Pooled results showed that compared to metformin monotherapy, combination therapy was associated with a reduction in HbA1c (mean difference: -0.48 %, -0.58 to - 0.38) and FPG (mean difference: -0.92 mmol/L, -1.14 to - 0.69), and more patients achieving HbA1c < 7% (odds ratio: 2.21, 1.87 to 2.60). Hypoglycemic events and people experiencing hypoglycemia were not different between 2 groups.

CONCLUSIONS

Initial combination of metformin plus a low hypoglycemic risk antidiabetic drug may achieve better glycemic control, without a rise in hypoglycemia, in patients with untreated T2DM.

Metformin-based single pill drug combinations for type 2 diabetes in primary care England: A time trend analysis

AIMS

There has been an increase in prescribing and costs of oral hypoglycaemic agents in England and other countries. This study aims to investigate the trends in prescriptions, costs, and adverse events of metformin and metformin-based single pill drug combinations from 2015 to 2020 and explore why changes in use or cost are occurring.

METHODS

Prescriptions and costs data from Prescription Cost Analysis database and Interactive Drug Analysis Profiles presenting all suspected ADRs reported for each drug were examined. Pharmacy level prices were also obtained. Linear regression analysis was used to investigate the trends in prescribing and costs.

RESULTS

Prescribing and costs of metformin-based single pill drug combinations (as a percent mean change per year) saw an increase of 8.78% (95% Cl: 7.45%, 10.11%, p = 0.001) and 5.17% (95% Cl: 2.13%, 8.22%, p = 0.009) on average each year, respectively. Metformin was the most prescribed monotherapy drug between 2015 and 2020. The cost of prescribing metformin (as a proportion of total oral hypoglycaemic agents) has been reduced from 30% in 2015 to 17% in 2020. Metformin-dipeptidyl peptidase-4 inhibitor (e.g., metformin-sitagliptin) combination was the most popular metformin-based single pill drug combination. The number of adverse drug reactions per million items dispensed shows that metformin has the lowest adverse drug reactions per million items compared to other oral hypoglycaemic drugs.

CONCLUSIONS

Overall, an increase in prescription items can be seen for metformin-based single pill drug combinations along with an increase in their costs in primary care in England between 2015 and 2020. There was a declining trend for the number of ADRs reported per million prescription items dispensed for metformin-containing single pill combinations, even though their prescription rate increased.

Safety and tolerability of linagliptin in Asians with type 2 diabetes: a pooled analysis of 4457 patients from 21 randomized, double-blind, placebo-controlled clinical trials

BACKGROUND

Safety and tolerability of glucose-lowering drugs is a key consideration for use in type 2 diabetes (T2D). We evaluated the safety and tolerability of the dipeptidyl peptidase-4 inhibitor linagliptin in Asian patients with T2D.

RESEARCH DESIGN AND METHODS

This was a post-hoc, descriptive pooled analysis of 21 randomized, double-blind, placebo-controlled clinical trials of linagliptin in T2D patients lasting ≤52 weeks. We evaluated adverse events (AEs) and laboratory parameters in Asian participants living in Asia, both overall and in the East Asian subgroup.

RESULTS

This analysis included 4457 Asian patients overall (2712 receiving linagliptin; 1745 receiving placebo) and 3057 (68.6%) East Asians. AEs were reported in 1510 (55.7%) Asian patients receiving linagliptin and 1032 (59.1%) receiving placebo but were considered drug-related in only 13.0% of each group. Serious AEs occurred in 109 (4.0%) linagliptin patients and 90 (5.2%) placebo patients. The most common AEs were nasopharyngitis (6.4% linagliptin, 7.3% placebo), upper respiratory tract infection (5.7% linagliptin, 6.5% placebo), and hypoglycemia (7.3% linagliptin, 6.3% placebo). One linagliptin patient had pancreatitis; none had bullous pemphigoid. No clinically relevant mean changes in laboratory parameters occurred. These findings were consistent in East Asians.

CONCLUSIONS

Linagliptin is well tolerated in Asian T2D patients, including East Asians, with low risk for AEs.

The "Early Treatment" Approach Reducing Cardiovascular Risk in Patients with Type 2 Diabetes: A Consensus From an Expert Panel Using the Delphi Technique

INTRODUCTION

There is no consensus on the optimal therapeutic approach to adopt in patients with newly diagnosed type 2 diabetes mellitus (T2DM) to prevent cardiovascular disease (CVD). The study aimed to gather an expert consensus on the hypoglycemic treatment and CV risk management in patients with newly diagnosed T2DM through the Delphi methodology.

METHODS

To address this issue, a list of 30 statements concerning the definition of "early T2DM patient", early treatment, CV risk in T2DM, treat-to-benefit approach, and indications for treatment with glucagon-like peptide 1 receptor agonists (GLP-1RAs) and sodium-glucose co-transporter 2 (SGLT2) inhibitors was developed. Using a two-round Delphi methodology, the survey was distributed to 80 Italian diabetes specialists who rated their level of agreement with each statement on a 5-point Likert scale. Consensus was predefined as more than 66% of the panel agreeing/disagreeing with any given statement.

RESULTS

A total of 27/30 statements achieved consensus. A patient was defined as "early" according to pathophysiological or clinical interpretation, and/or the timing of the diagnosis. There was agreement on the importance to reach the lowest possible HbA1c level, since diagnosis, also using combination therapy with hypoglycemic drugs with a proven CV benefit. There was a consensus that a treat-to-benefit approach involves the addition of a glucose-lowering agent with proven CV benefits to metformin since diagnosis. The use of GLP-1RAs and SGLT2 inhibitors was considered a key strategy in this approach and the benefits were recognized also for patients with T2DM without established CVD. GLP-1RAs should be used at an earlier stage than SGLT2 inhibitors to prevent CVD, especially in patients with evidence of subclinical atherosclerotic disease.

CONCLUSION

This Delphi consensus recognized the importance to adopt a tailored hypoglycemic treatment of patients with T2DM according to their CVD risk and the key role of glucose-lowering agents with proven CV efficacy, GLP-1RAs and SGLT2 inhibitors, in the context of an early treat-to-benefit approach.

Early combination versus initial metformin monotherapy in the management of newly diagnosed type 2 diabetes: An East Asian perspective

Type 2 diabetes (T2D) in the East Asian population is characterized by phenotypes such as low body mass index, an index of β-cell dysfunction, and higher percentage of body fat, an index of insulin resistance. These phenotypes/pathologies may predispose people to early onset of diabetes with increased risk of stroke and renal disease. Less than 50% of patients with T2D in East Asia achieve glycaemic targets recommended by national or regional guidelines, which may be attributable to knowledge and/or implementation gaps. Herein, we review the latest evidence with special reference to East Asian patients with T2D and present arguments for the need to use early combination therapy to intensify glycaemic control. This strategy is supported by the 5-year worldwide VERIFY study, which reported better glycaemic durability in newly diagnosed patients with T2D with a mean HbA1c of 6.9% treated with early combination therapy of vildagliptin plus metformin versus those treated with initial metformin monotherapy followed by addition of vildagliptin only with worsening glycaemic control. This paradigm shift of early intensified treatment is now recommended by the American Diabetes Association and the European Association for the Study of Diabetes. In order to translate these evidence to practice, increased awareness and strengthening of the healthcare system are needed to diagnose and manage patients with T2D early for combination therapy.

Incretin mimetics and sodium-glucose co-transporter 2 inhibitors as monotherapy or add-on to metformin for treatment of type 2 diabetes: a systematic review and network meta-analysis

PURPOSE

Although there are many different methods of treating type 2 diabetes (T2D), it is still difficult to draw coincident conclusions concerning the efficacy and safety of different classes of new drugs, and the recommendation level of them has still kept uncertain as second anti-diabetic agents. Therefore, the aim of this study was to summarize evidence on the efficacy and safety of DPP-4is, GLP-1RAs and SGLT-2is as monotherapy or add-on to metformin (Met) for treatment of T2D.

MATERIALS AND METHODS

We searched PubMed, Embase, Cochrane library and ClinicalTrials.gov for relevant articles in keeping with established methods using terms associated with anti-diabetic agents up to February, 2020, with no start date restriction. Weighted mean difference and risk ratios with 95% confidence intervals were calculated within traditional and network meta-analysis. Primary outcomes were the mean change in hemoglobin A1c (HbA1c), fasting plasma glucose (FPG) change and the frequency of hypoglycemic events from baseline after 12 weeks of treatment.

RESULTS

In total, 64 eligible studies comprising 37,780 patients and 7 treatment strategies were included. The results of primary outcomes showed that GLP-1RAs were significantly more effective than DPP-4is or SGLT-2is in reducing HbA1c when add-on to Met. For FPG, both GLP-1RAs and SGLT-2is significantly reduced FPG compared with DPP-4is whether add-on to Met or not. For hypoglycemia, monotherapy has a lower risk than combination therapy except for SGLT-2is. Ranking probability analysis indicated that GLP-1RAs and SGLT-2is, respectively, reduced HbA1c and FPG most when add-on to Met. Meanwhile, GLP-1RAs took the lowest risk to induce the hypoglycemia, whereas GLP-1RAs plus Met the highest.

CONCLUSIONS

Both GLP-1RAs and SGLT-2is have their own advantages in efficacy and safety. Monotherapy is beneficial for reducing the risk of hypoglycemia. The recommendation should be a patient-centered approach when selecting treatment choices.

Early Combination Therapy with Linagliptin and Metformin in People with Type 2 Diabetes Improves Glycemic Control to HbA1c ≤ 6.5% without Increasing Hypoglycemia: Pooled Analysis of Two Randomized Clinical Trials

INTRODUCTION

Clinical guidelines suggest a glycated hemoglobin A1c (HbA1c) target of ≤ 6.5% for type 2 diabetes patients with short duration of disease, few comorbidities and/or long life expectancy-provided this goal can be achieved safely. We explored whether initial combination treatment with the dipeptidyl peptidase-4 inhibitor linagliptin and metformin could provide better glycemic control (HbA1c ≤ 6.5%) than metformin alone without increasing hypoglycemia.

METHODS

We pooled and analyzed individual patient data from two randomized clinical trials of early combination therapy with linagliptin and metformin versus metformin monotherapy. The primary outcome in both trials was the change in HbA1c from baseline to week 24. We evaluated the percentage of patients who achieved HbA1c ≤ 6.5% at week 24 and the incidence of adverse events.

RESULTS

Most (> 70%) of the 1160 patients analyzed were treatment naive, and more than half had had diabetes for ≤ 1 year; mean baseline HbA1c was approximately 8.7%. Combination therapy with linagliptin and metformin resulted in more patients achieving HbA1c ≤ 6.5% than metformin alone, both for a metformin dose of 500 mg (40.1 vs. 22.9%, respectively, odds ratio [OR] 2.84, 95% confidence interval [CI] 1.87-4.32) and 1000 mg (49.5 vs. 35.4%, respectively, OR 2.28, 95% CI 1.54-3.40). Hypoglycemia occurred in < 3% of patients, with a comparable incidence between treatment groups. Other adverse events were also balanced between groups.

CONCLUSION

Early combination treatment with linagliptin and metformin can improve the chances of achieving tight glycemic control (HbA1c ≤ 6.5%) without increasing the risk of hypoglycemia or other adverse events.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00798161 and NCT01708902.

Implementation of machine learning algorithms to create diabetic patient re-admission profiles

BACKGROUND

Machine learning is a branch of Artificial Intelligence that is concerned with the design and development of algorithms, and it enables today's computers to have the property of learning. Machine learning is gradually growing and becoming a critical approach in many domains such as health, education, and business.

METHODS

In this paper, we applied machine learning to the diabetes dataset with the aim of recognizing patterns and combinations of factors that characterizes or explain re-admission among diabetes patients. The classifiers used include Linear Discriminant Analysis, Random Forest, k-Nearest Neighbor, Naïve Bayes, J48 and Support vector machine.

RESULTS

Of the 100,000 cases, 78,363 were diabetic and over 47% were readmitted.Based on the classes that models produced, diabetic patients who are more likely to be readmitted are either women, or Caucasians, or outpatients, or those who undergo less rigorous lab procedures, treatment procedures, or those who receive less medication, and are thus discharged without proper improvements or administration of insulin despite having been tested positive for HbA1c.

CONCLUSION

Diabetic patients who do not undergo vigorous lab assessments, diagnosis, medications are more likely to be readmitted when discharged without improvements and without receiving insulin administration, especially if they are women, Caucasians, or both.

Disparities in the Efficacy of Metformin in Combination with Dipeptidyl Peptidase-4 Inhibitor as Initial Treatment Stratified by Dosage and Ethnicity: A Meta-Analysis

BACKGROUND

As initial combination therapy of metformin and dipeptidyl peptidase-4 (DPP-4) inhibitor, the efficacy and safety for the use of high dose of metformin or low dose of metformin and the efficacy and safety for the combination use for Asian and Caucasian patients were not clear.

METHODS

Double-blind randomized controlled trials comparing the efficacy of initial combination therapy of metformin and DPP-4 inhibitors with metformin monotherapy were included. The primary outcome was a result of comparisons between high-dose combination therapy and low-dose combination therapy in terms of efficacy and safety.

RESULTS

A total of 11 studies were included. The results indicated that the high-dose combination therapy showed significant decreases in hemoglobin A_1c (HbA_1c) (-0.32%, P < 0.05), fasting plasma glucose (FPG) (-0.63 mmol/L, P < 0.05), and postprandial glucose (PPG) (-0.99 mmol/L, P < 0.05), but less increase in body weight (-0.54 kg, P < 0.05) when compared with low-dose combination therapy, corrected by metformin monotherapy. Moreover, the high-dose combination therapy exhibited significant decreases in HbA_1c (-0.24%, P < 0.05), FPG (-0.54 mmol/L, P < 0.05), and PPG (-0.94 mmol/L, P < 0.05) in the Caucasian population than in the Asian population, corrected by metformin monotherapy.

CONCLUSION

As an initial treatment, the high dose of metformin in combination with DPP-4 inhibitors not only provided better glycemic control but also had less effect on weight gain compared with the low-dose combination therapy through the correction of metformin monotherapy. Moreover, initial combination therapy in the Caucasian population showed better glycemic control and less increase in body weight compared with the Asian population.

Efficacy and Safety of Initial Combination Therapy in Treatment-Naïve Type 2 Diabetes Patients: A Systematic Review and Meta-analysis

INTRODUCTION

The aim of this study was to evaluate the efficacy and safety of initial combination therapy compared with monotherapy in drug-naïve type 2 diabetes patients.

METHODS

MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were searched for randomized clinical trials of initial combination therapy with hypoglycemic agents compared with monotherapy. Those which satisfied the search criteria were included in the meta-analysis. Weighted mean difference and relative risks were calculated.

RESULTS

A total of 36 studies were included in the meta-analysis. Compared with metformin monotherapy, initial combination therapy with metformin plus another anti-diabetes drug exhibited significant reductions in glycated hemoglobin (HbA1c) (p < 0.001). Most of the combination therapies had a similar risk of hypoglycemia (p > 0.05), with the exception of combinations of sulfonylurea/glinide and metformin or combinations of thiazolidinedione and metformin. Compared with dipeptidyl peptidase-4 (DPP-4) inhibitor monotherapy, initial combination therapy with DPP-4 inhibitor plus another anti-diabetes drug showed a significant decrease in HbA1c (p < 0.001) and a similar risk of hypoglycemia (p > 0.05). Compared with monotherapy with other anti-diabetes drugs, initial combination therapies also resulted in significant HbA1c reductions, a similar risk of hypoglycemia and similar risks of other adverse events.

CONCLUSION

Compared with monotherapy, all initial combination therapies resulted in significant HbA1c reductions. Compared with metformin monotherapy, initial combination therapies with DPP-4 inhibitors plus metformin, sodium/glucose cotransporter 2 inhibitors and metformin, respectively, were associated with similar risks of hypoglycemia, but initial combination therapies with sulfonylurea plus metformin, thiazolidinedione and metformin, respectively, were associated with higher risks of hypoglycemia.

FUNDING

AstraZeneca Ltd. (China).

TRIAL REGISTRATION

Registration number CRD42017060717 in PROSPERO.