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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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Volke V, Katus U, Johannson A, Toompere K, Heinla K, Rünkorg K, Uusküla A. Systematic review and meta-analysis of head-to-head trials comparing sulfonylureas and low hypoglycaemic risk antidiabetic drugs. BMC Endocr Disord 2022; 22:251. [PMID: 36261824 PMCID: PMC9580135 DOI: 10.1186/s12902-022-01158-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Safety of sulfonylurea drugs in the treatment of Type 2 Diabetes is still under debate. The aim of this study was to compare the all-cause mortality and cardiovascular adverse events of sulfonylureas and drugs with a low risk for hypoglycaemia in adults with type 2 diabetes. METHODS Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES MEDLINE (PubMed, OVID), Embase, Cochrane Central Register of Controlled Trials, CINAHL, WOS and Lilacs. STUDY SELECTION Randomised controlled head-to-head trials that compared sulfonylureas with active control with low hypoglycaemic potential in adults (≥ 18 years old) with type 2 diabetes published up to August 2015. The drug classes involved in the analysis were metformin, dipeptidyl peptidase-4 (DPP-4) inhibitors, sodium-glucose co-transporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. OUTCOMES The primary endpoint was all-cause mortality. The secondary endpoints were MACE, cardiovascular events and severe hypoglycaemia. SYNTHESIS OF RESULTS Two reviewers checked study eligibility, independently extracted data and assessed quality with disagreements resolved through discussion. We assessed the risk of bias of the included studies using the Cochrane risk of bias tool for randomized trials v2. Pooled odds ratios (ORs) were estimated by using fixed effects model. The study is registered on PROSPERO (26/05/2016 CRD42016038780). RESULTS Our final analysis comprised 31 studies (26,204 patients, 11,711 patients given sulfonylureas and 14,493 given comparator drugs). In comparison to drugs with low hypoglycaemic potential, sulfonylureas had higher odds for all-cause mortality (OR 1.32, 95% CI 1.00-1.75), MACE (OR 1.32, 95% CI 1.07-1.61), myocardial infarction (fatal and non-fatal) (OR 1.67, 95% CI 1.17-2.38) and hypoglycaemia (OR 5.24, 95% CI 4.20-6.55). Subsequent sensitivity analysis revealed differences in the effect of sulfonylureas, with an increased risk of all-cause mortality with glipizide but not the other molecules. CONCLUSION Our meta-analysis raises concern about the safety of SUs compared to alternative drugs involved in current analysis. Important differences may exist within the drug class, and glimepiride seems to have best safety profile.
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Affiliation(s)
- Vallo Volke
- Department of Physiology, Institute of Biomedicine and Translational Medicine, Centre of excellence in Genomics and Translational Medicine, University of Tartu, 19 Ravila Street, 50411, Tartu, Estonia.
- Endocrinology Unit, Tartu University Hospital, 8 L. Puusepa Street, 51014, Tartu, Estonia.
| | - Urmeli Katus
- Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Annika Johannson
- Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Karolin Toompere
- Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Keiu Heinla
- Department of Physiology, Institute of Biomedicine and Translational Medicine, Centre of excellence in Genomics and Translational Medicine, University of Tartu, 19 Ravila Street, 50411, Tartu, Estonia
| | - Kertu Rünkorg
- Department of Physiology, Institute of Biomedicine and Translational Medicine, Centre of excellence in Genomics and Translational Medicine, University of Tartu, 19 Ravila Street, 50411, Tartu, Estonia
- Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Anneli Uusküla
- Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
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de Sá JR, Rangel EB, Canani LH, Bauer AC, Escott GM, Zelmanovitz T, Bertoluci MC, Silveiro SP. The 2021-2022 position of Brazilian Diabetes Society on diabetic kidney disease (DKD) management: an evidence-based guideline to clinical practice. Screening and treatment of hyperglycemia, arterial hypertension, and dyslipidemia in the patient with DKD. Diabetol Metab Syndr 2022; 14:81. [PMID: 35690830 PMCID: PMC9188192 DOI: 10.1186/s13098-022-00843-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetic kidney disease is the leading cause of end-stage renal disease and is associated with increased morbidity and mortality. This review is an authorized literal translation of part of the Brazilian Diabetes Society (SBD) Guidelines 2021-2022. This evidence-based guideline provides guidance on the correct management of Diabetic Kidney Disease (DKD) in clinical practice. METHODS The methodology was published elsewhere in previous SBD guidelines and was approved by the internal institutional Steering Committee for publication. Briefly, the Brazilian Diabetes Society indicated 14 experts to constitute the Central Committee, designed to regulate methodology, review the manuscripts, and make judgments on degrees of recommendations and levels of evidence. SBD Renal Disease Department drafted the manuscript selecting key clinical questions to make a narrative review using MEDLINE via PubMed, with the best evidence available including high-quality clinical trials, metanalysis, and large observational studies related to DKD diagnosis and treatment, by using the MeSH terms [diabetes], [type 2 diabetes], [type 1 diabetes] and [chronic kidney disease]. RESULTS The extensive review of the literature made by the 14 members of the Central Committee defined 24 recommendations. Three levels of evidence were considered: A. Data from more than 1 randomized clinical trial or 1 metanalysis of randomized clinical trials with low heterogeneity (I2 < 40%). B. Data from metanalysis, including large observational studies, a single randomized clinical trial, or a pre-specified subgroup analysis. C: Data from small or non-randomized studies, exploratory analyses, or consensus of expert opinion. The degree of recommendation was obtained based on a poll sent to the panelists, using the following criteria: Grade I: when more than 90% of agreement; Grade IIa 75-89% of agreement; IIb 50-74% of agreement, and III, when most of the panelist recommends against a defined treatment. CONCLUSIONS To prevent or at least postpone the advanced stages of DKD with the associated cardiovascular complications, intensive glycemic and blood pressure control are required, as well as the use of renin-angiotensin-aldosterone system blocker agents such as ARB, ACEI, and MRA. Recently, SGLT2 inhibitors and GLP1 receptor agonists have been added to the therapeutic arsenal, with well-proven benefits regarding kidney protection and patients' survival.
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Affiliation(s)
- João Roberto de Sá
- Endocrinology Division, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil
| | - Erika Bevilaqua Rangel
- Nephrology Division, UNIFESP, São Paulo, Brazil
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luis Henrique Canani
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Andrea Carla Bauer
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Gustavo Monteiro Escott
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Themis Zelmanovitz
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Marcello Casaccia Bertoluci
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Sandra Pinho Silveiro
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil.
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Li Y, Hu Y, Huyan X, Chen K, Li B, Gu W, Mu Y. Comparison of efficacy and safety of three novel hypoglycemic agents in patients with severe diabetic kidney disease: A systematic review and network meta-analysis of randomized controlled trials. Front Endocrinol (Lausanne) 2022; 13:1003263. [PMID: 36353233 PMCID: PMC9637657 DOI: 10.3389/fendo.2022.1003263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To analyze the efficacy and safety of three novel hypoglycemic agents, glucagon-like peptidyl-1 receptor agonists, dipeptidyl peptidase-4 inhibitors (DPP-4i), and sodium-glucose cotransporter two inhibitors (SGLT2i) in type 2 diabetes mellitus (T2DM) patients with severe chronic kidney disease (CKD) (defined in this study as CKD stage 3 B or above, eGFR< 45 mL/min/1.73 m²) based on important RCTs to date. METHODS We retrieved studies published before April 15, 2022, from EMBASE, PubMed/MEDLINE, Cochrane Library and included randomized controlled trials in which the participants were patients with T2DM and severe CKD. Frequentist methods were used in the network meta-analysis. RESULTS Nineteen studies of 17 trials involving 6,607 participants met our inclusion criteria. Compared with placebo and DPP-4i, SGLT2i demonstrated a significantly lower incidence of serious renal-related adverse events or renal death, and the odds ratios (OR) were 0.69 (0.58, 0.81) and 0.63 (0.40, 1.00), respectively. Compared with placebo, SGLT2i significantly reduced the incidence of all-cause death and severe AE; the ORs were 0.72 (0.55, 0.94) and 0.65 (0.47, 0.91), respectively. Compared with placebo, DPP-4i significantly reduced the level of HbA1c, and the difference between mean changes from baseline was -0.36 (-0.63, -0.09). CONCLUSIONS Patients with T2DM complicated by severe CKD may benefit from SGLT2i. SGLT2i can reduce the incidence of serious renal-related AEs or renal death, as well as severe side effects, and has a positive effect on the patient's renal function and survival, even for only CKD patients can also be considered. GLP-1 RAs can be used as a supplement if blood sugar control is poor. For dialysis patients, DPP-4i can assist blood glucose control, reduce insulin dosage, and reduce the risk of hypoglycemia. SYSTEMATIC REVIEW REGISTRATION INPLASY https://inplasy.com/inplasy-2021-12-0106/, identifier INPLASY2021120106.
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Affiliation(s)
- Yijun Li
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Ying Hu
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaoyuan Huyan
- The First Health Care Department, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Kang Chen
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Bing Li
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Weijun Gu
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
- *Correspondence: Yiming Mu, ; Weijun Gu,
| | - Yiming Mu
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
- *Correspondence: Yiming Mu, ; Weijun Gu,
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Jeon WK, Kang J, Kim HS, Park KW. Correction to: “Cardiovascular Outcomes Comparison of Dipeptidyl Peptidase-4 Inhibitors Versus Sulfonylurea as Add-on Therapy for Type 2 Diabetes Mellitus: A Meta-Analysis”. J Lipid Atheroscler 2022; 11:89-101. [PMID: 35118026 PMCID: PMC8792822 DOI: 10.12997/jla.2022.11.1.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Won Kyeong Jeon
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeehoon Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Woo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Chan K, Moe SM, Saran R, Libby P. The cardiovascular-dialysis nexus: the transition to dialysis is a treacherous time for the heart. Eur Heart J 2021; 42:1244-1253. [PMID: 33458768 DOI: 10.1093/eurheartj/ehaa1049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 08/13/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) patients require dialysis to manage the progressive complications of uraemia. Yet, many physicians and patients do not recognize that dialysis initiation, although often necessary, subjects patients to substantial risk for cardiovascular (CV) death. While most recognize CV mortality risk approximately doubles with CKD the new data presented here show that this risk spikes to >20 times higher than the US population average at the initiation of chronic renal replacement therapy, and this elevated CV risk continues through the first 4 months of dialysis. Moreover, this peak reflects how dialysis itself changes the pathophysiology of CV disease and transforms its presentation, progression, and prognosis. This article reviews how dialysis initiation modifies the interpretation of circulating biomarkers, alters the accuracy of CV imaging, and worsens prognosis. We advocate a multidisciplinary approach and outline the issues practitioners should consider to optimize CV care for this unique and vulnerable population during a perilous passage.
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Affiliation(s)
- Kevin Chan
- National Institute of Diabetes and Digestive and Kidney Disease, Division of Kidney, Urology, and Hematology, 6707 Democracy Blvd, Bethesda, MD 20892-5458, USA
| | - Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine, 950 W. Walnut Street R2-202, Indianapolis, IN 46202, USA
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr # 31, Ann Arbor, MI 48109, USA
| | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 77 Ave. Louis Pasteur, NRB-741-G, Boston, MA 02115, USA
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Zhao JZ, Weinhandl ED, Carlson AM, St. Peter WL. Glucose-Lowering Medication Use in CKD: Analysis of US Medicare Beneficiaries Between 2007 and 2016. Kidney Med 2021; 3:173-182.e1. [PMID: 33851113 PMCID: PMC8039422 DOI: 10.1016/j.xkme.2020.09.016] [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] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Information regarding the use of glucose-lowering medications in patients with chronic kidney disease (CKD) is limited. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Medicare 5% random sample of patients with CKD with type 2 diabetes, 2007 to 2016. PREDICTORS Study year, CKD stage, low-income subsidy status, and demographic characteristics (age, sex, and race/ethnicity). OUTCOMES Trends in use of glucose-lowering medications. ANALYTICAL APPROACH Yearly cohorts of patients with CKD and type 2 diabetes were created. Descriptive statistics were used to report proportions of patients using glucose-lowering medications. To test overall trends in glucose-lowering medication classes, linear probability models with adjustment for age, sex, race/ethnicity, CKD stage, and low-income subsidy status were used. RESULTS Metformin use increased significantly from 32.7% in 2007 to 48.7% in 2016. Use of newer classes of glucose-lowering medications increased significantly, including dipeptidyl peptidase 4 inhibitors (5.6%, 2007; 21.7%, 2016), glucagon-like peptide 1 receptor agonists (2.3%, 2007; 6.1%, 2016), and sodium-glucose cotransporter 2 inhibitors (0.2%, 2013; 3.3%, 2016). Newer insulin analogue use increased from 37.2% in 2007 to 46.3% in 2013 and then remained steady. Use of sulfonylureas, thiazolidinediones, older insulins (human regular and neutral protamine Hagedorn), α-glucosidase inhibitors, amylin mimetics, and meglitinides decreased significantly. Insulin was the most highly used single medication class. Insulin use was higher among low-income subsidy than among non-low-income subsidy patients. Combination therapy was less common as CKD stage increased. LIMITATIONS Patients with CKD and type 2 diabetes and the CKD stages were identified with diagnosis codes and could not be verified through medical record review. Our results may not be generalizable to younger patients with CKD with type 2 diabetes. CONCLUSIONS Use of metformin and newer glucose-lowering medication classes is increasing in patients with CKD with type 2 diabetes. We anticipate that percentages of patients with CKD using these newer agents will increase.
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Affiliation(s)
- Julie Z. Zhao
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, College of Pharmacy, Minneapolis, MN
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Eric D. Weinhandl
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, College of Pharmacy, Minneapolis, MN
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Angeline M. Carlson
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, College of Pharmacy, Minneapolis, MN
| | - Wendy L. St. Peter
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, College of Pharmacy, Minneapolis, MN
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
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Kyriakos G, Quiles-Sanchez LV, Garmpi A, Farmaki P, Kyre K, Gkogkos S, Savvanis S, Memi E. Cardiovascular and Renal Outcomes of Incretin-based Therapies: A Review of Recent Clinical Trials. Curr Cardiol Rev 2021; 16:253-257. [PMID: 31161994 PMCID: PMC7903512 DOI: 10.2174/1573403x15666190603111056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 03/11/2019] [Accepted: 03/22/2019] [Indexed: 01/21/2023] Open
Abstract
Background To report the cardiovascular and renal effects of incretin-based therapies. Methods The studies of clinical trials on incretin-based therapy published in medical journals from the years 2010 to 2017 were comprehensively searched using MEDLINE and EMBASE with no language restriction. The studies were reviewed and the cardiovascular and renal risks reported were recorded. Results Incretin-based therapeutics represent novel and promising anti-diabetes drugs, the direct cardiovascular actions which may translate into demonstrable clinical benefits on cardiovascular outcomes. Furthermore, incretin-based therapies do not adversely affect renal function.
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Affiliation(s)
- Georgios Kyriakos
- Seccion de Endocrinologia y Nutrition, Hospital General Universitario Santa Lucia, Cartagena, Spain
| | | | - Anna Garmpi
- Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athen, Athens, Greece
| | - Paraskevi Farmaki
- 1st Department of Pediatrics, "Aghia Sophia Children's Hospital" Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantina Kyre
- Department of Internal Medicine, KAT General Hospital, Athens, Greece
| | - Spyridon Gkogkos
- Department of Surgery, Health Center of Peristeri, Athens, Greece
| | - Spyridon Savvanis
- Department of Internal Medicine, General Hospital of Athens "Elpis", Athens, Greece
| | - Eleni Memi
- Unit of Endocrinology, Diabetes Mellitus and Metabolism, Aretaieion University Hospital, Medical School of Athens, Ethnikon and Kapodistrian University of Athens, Athens, Greece
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9
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Jeon WK, Kang J, Kim HS, Park KW. Cardiovascular Outcomes Comparison of Dipeptidyl Peptidase-4 Inhibitors versus Sulfonylurea as Add-on Therapy for Type 2 Diabetes Mellitus: a Meta-Analysis. J Lipid Atheroscler 2021; 10:210-222. [PMID: 34095013 PMCID: PMC8159755 DOI: 10.12997/jla.2021.10.2.210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/02/2021] [Accepted: 01/11/2021] [Indexed: 12/26/2022] Open
Abstract
Objective Recent studies have raised concern about the cardiovascular safety of dipeptidyl peptidase-4 (DPP4) inhibitors. We performed a systematic review through meta-analysis to compare cardiovascular outcomes of sulfonylurea (SU) versus DPP4 inhibitors when used in combination with metformin. Methods After searching for trials using combination therapy of metformin with DPP4 inhibitor or SU in PubMed, Cochrane Library, and Embase, one prospective observation study and 15 randomized controlled studies were selected. Results Regarding the primary analysis endpoint, there were no significant differences in the risk of all-cause mortality between SU and DPP4 inhibitors as an add-on therapy to metformin (random-effect relative risk [RR], 1.14; 95% confidence interval [CI], 0.98–1.33; p=0.811; I2=0%). Cardiovascular death was also similar between the two drug classes in the five studies which reported outcomes (random-effect RR, 1.03; 95% CI, 0.83–1.27; p=0.517; I2=0%). Furthermore, there were no significant differences in major adverse cardiac events (MACE), coronary heart disease, myocardial infarction, ischemic stroke and heart failure. However, there were less hypoglycemic events and weight gain in the DPP4 inhibitor group as compared with the SU group (random-effect RR, 3.79; 95% CI, 1.53–9.39; p<0.001; I2=98.2 and weighted mean difference, 1.68; 95% CI, 1.07–2.29; p<0.001; I2=94.7, respectively). Conclusion As add-on therapy to metformin, there were no significant differences in all-cause mortality and cardiovascular mortality between DPP4 inhibitors and SUs.
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Affiliation(s)
- Won Kyeong Jeon
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeehoon Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Woo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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10
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Palmer SC, Tendal B, Mustafa RA, Vandvik PO, Li S, Hao Q, Tunnicliffe D, Ruospo M, Natale P, Saglimbene V, Nicolucci A, Johnson DW, Tonelli M, Rossi MC, Badve SV, Cho Y, Nadeau-Fredette AC, Burke M, Faruque LI, Lloyd A, Ahmad N, Liu Y, Tiv S, Millard T, Gagliardi L, Kolanu N, Barmanray RD, McMorrow R, Raygoza Cortez AK, White H, Chen X, Zhou X, Liu J, Rodríguez AF, González-Colmenero AD, Wang Y, Li L, Sutanto S, Solis RC, Díaz González-Colmenero F, Rodriguez-Gutierrez R, Walsh M, Guyatt G, Strippoli GFM. Sodium-glucose cotransporter protein-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists for type 2 diabetes: systematic review and network meta-analysis of randomised controlled trials. BMJ 2021; 372:m4573. [PMID: 33441402 PMCID: PMC7804890 DOI: 10.1136/bmj.m4573] [Citation(s) in RCA: 293] [Impact Index Per Article: 97.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists in patients with type 2 diabetes at varying cardiovascular and renal risk. DESIGN Network meta-analysis. DATA SOURCES Medline, Embase, and Cochrane CENTRAL up to 11 August 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials comparing SGLT-2 inhibitors or GLP-1 receptor agonists with placebo, standard care, or other glucose lowering treatment in adults with type 2 diabetes with follow up of 24 weeks or longer. Studies were screened independently by two reviewers for eligibility, extracted data, and assessed risk of bias. MAIN OUTCOME MEASURES Frequentist random effects network meta-analysis was carried out and GRADE (grading of recommendations assessment, development, and evaluation) used to assess evidence certainty. Results included estimated absolute effects of treatment per 1000 patients treated for five years for patients at very low risk (no cardiovascular risk factors), low risk (three or more cardiovascular risk factors), moderate risk (cardiovascular disease), high risk (chronic kidney disease), and very high risk (cardiovascular disease and kidney disease). A guideline panel provided oversight of the systematic review. RESULTS 764 trials including 421 346 patients proved eligible. All results refer to the addition of SGLT-2 inhibitors and GLP-1 receptor agonists to existing diabetes treatment. Both classes of drugs lowered all cause mortality, cardiovascular mortality, non-fatal myocardial infarction, and kidney failure (high certainty evidence). Notable differences were found between the two agents: SGLT-2 inhibitors reduced admission to hospital for heart failure more than GLP-1 receptor agonists, and GLP-1 receptor agonists reduced non-fatal stroke more than SGLT-2 inhibitors (which appeared to have no effect). SGLT-2 inhibitors caused genital infection (high certainty), whereas GLP-1 receptor agonists might cause severe gastrointestinal events (low certainty). Low certainty evidence suggested that SGLT-2 inhibitors and GLP-1 receptor agonists might lower body weight. Little or no evidence was found for the effect of SGLT-2 inhibitors or GLP-1 receptor agonists on limb amputation, blindness, eye disease, neuropathic pain, or health related quality of life. The absolute benefits of these drugs vary substantially across patients from low to very high risk of cardiovascular and renal outcomes (eg, SGLT-2 inhibitors resulted in 3 to 40 fewer deaths in 1000 patients over five years; see interactive decision support tool (https://magicevidence.org/match-it/200820dist/#!/) for all outcomes. CONCLUSIONS In patients with type 2 diabetes, SGLT-2 inhibitors and GLP-1 receptor agonists reduced cardiovascular and renal outcomes, with some differences in benefits and harms. Absolute benefits are determined by individual risk profiles of patients, with clear implications for clinical practice, as reflected in the BMJ Rapid Recommendations directly informed by this systematic review. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019153180.
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Affiliation(s)
- Suetonia C Palmer
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Britta Tendal
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Reem A Mustafa
- Department of Internal Medicine, Division of Nephrology and Hypertension, University of Kansas, Kansas City, KS, USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Per Olav Vandvik
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
- Division of Population Health and Genomics, Ninewells Hospital, University of Dundee, Dundee, UK
| | - Qiukui Hao
- Centre for Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - David Tunnicliffe
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Marinella Ruospo
- Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio CESARE, 70124 Bari, Italy
| | - Patrizia Natale
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio CESARE, 70124 Bari, Italy
| | - Valeria Saglimbene
- Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio CESARE, 70124 Bari, Italy
| | - Antonio Nicolucci
- Centre for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - David W Johnson
- Department of Nephrology, Division of Medicine, University of Queensland at Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Marcello Tonelli
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Maria Chiara Rossi
- Centre for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - Sunil V Badve
- George Institute for Global Health, Sydney, NSW, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Division of Medicine, University of Queensland at Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | | | | | - Labib I Faruque
- Department of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Anita Lloyd
- Department of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nasreen Ahmad
- Department of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Yuanchen Liu
- Department of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sophanny Tiv
- Department of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Tanya Millard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Lucia Gagliardi
- Endocrine and Diabetes Unit, Queen Elizabeth Hospital, Woodville, SA, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Nithin Kolanu
- Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Rahul D Barmanray
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Rita McMorrow
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, VIC, Australia
| | - Ana Karina Raygoza Cortez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Heath White
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Xiangyang Chen
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Xu Zhou
- Evidence-based Medicine Research Centre, Jiangxi University of Traditional Chinese Medicine, Nanchang, China
| | - Jiali Liu
- Chinese Evidence-based Medicine Centre, Cochrane China Centre
| | - Andrea Flores Rodríguez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | | | - Yang Wang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Ling Li
- Chinese Evidence-based Medicine Centre, Cochrane China Centre
| | - Surya Sutanto
- Faculty of Medicine and Health, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
| | - Ricardo Cesar Solis
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | | | - René Rodriguez-Gutierrez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Michael Walsh
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Giovanni F M Strippoli
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio CESARE, 70124 Bari, Italy
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Abstract
Since the recognition of angiotensin-converting enzyme inhibitors (ACEIs)-induced cough, drug has been considered as a potential cause of chronic cough. This review presents recent knowledge on drug-induced coughs in patients with chronic cough. The focus is placed on ACEIs, for which there are a multitude of studies documenting their associations with cough. Additional drugs are discussed for which there are reports of cough as a side effect of treatment, and the potential mechanisms of these effects are discussed.
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Affiliation(s)
- J-S Shim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul,
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12
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Comparisons between dipeptidyl peptidase-4 inhibitors and other classes of hypoglycemic drugs using two distinct biomarkers of pancreatic beta-cell function: A meta-analysis. PLoS One 2020; 15:e0236603. [PMID: 32706828 PMCID: PMC7380634 DOI: 10.1371/journal.pone.0236603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/08/2020] [Indexed: 01/09/2023] Open
Abstract
Background and objective Dipeptidyl peptidase-4 (DPP-4) inhibitors have been suggested to have pancreatic beta-cell preserving effect according to studies using homeostatic model of assessment for beta-cell function (HOMA-β). However, whether HOMA-β is a suitable biomarker for comparisons between hypoglycemic drugs with different mechanisms of action remains unclear. Therefore, we conducted a meta-analysis to compare the effects of DPP-4 inhibitors and other classes of hypoglycemic drugs on HOMA-β and proinsulin-to-insulin ratio (PIR). Methods We searched MEDLINE, CENTRAL, and Ichushi-web for the period of 1966 to May 2020. We collected randomized, controlled clinical trials in patients with type 2 diabetes mellitus comparing DPP-4 inhibitors and other classes of hypoglycemic agents [α-glucosidase inhibitors (α-GIs), glucagon-like peptide-1 (GLP-1) analogues, metformin, sodium-glucose cotransporter 2 (SGLT2) inhibitors, sulfonylureas, or thiazolidinediones]. Weighted mean differences and 95% confidence intervals of changes in HOMA-β or PIR during study periods were calculated for pairwise comparisons. Results Thirty-seven and 21 relevant trials were retrieved for comparisons of HOMA-β and PIR, respectively. HOMA-β and PIR consistently showed superiority of DPP-4 inhibitors compared with α-GIs. Both biomarkers consistently supported inferiority of DPP-4 inhibitors compared with GLP-1 analogues. However, PIR showed inferiority of DPP-4 inhibitors compared with metformin, and superiority compared with SGLT2 inhibitors, whereas HOMA-β showed no significant differences between DPP-4 inhibitors and the two other agents. Conclusion DPP-4 inhibitors appear to be superior to α-GIs but inferior to GLP-1 analogues in preservation of beta-cell function assessed by either HOMA-β or PIR. DPP-4 inhibitors seem to be superior to SGLT2 inhibitors but inferior to metformin on islet function assessed only by PIR. Because HOMA-β and PIR may indicate different aspects of beta-cell function, results of beta-cell function preserving effects of hypoglycemic agents should be interpreted with caution.
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13
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Tuttle KR, McGill JB. Evidence-based treatment of hyperglycaemia with incretin therapies in patients with type 2 diabetes and advanced chronic kidney disease. Diabetes Obes Metab 2020; 22:1014-1023. [PMID: 32009296 PMCID: PMC7317405 DOI: 10.1111/dom.13986] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 01/20/2020] [Accepted: 01/30/2020] [Indexed: 01/14/2023]
Abstract
Type 2 diabetes is the leading cause of chronic kidney disease (CKD). The prevalence of CKD is growing in parallel with the rising number of patients with type 2 diabetes globally. At present, the optimal approach to glycaemic control in patients with type 2 diabetes and advanced CKD (categories 4 and 5) remains uncertain, as these patients were largely excluded from clinical trials of glucose-lowering therapies. Nonetheless, clinical trial data are available for the use of incretin therapies, dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists, for patients with type 2 diabetes and advanced CKD. This review discusses the role of incretin therapies in the management of these patients. Because the presence of advanced CKD in patients with type 2 diabetes is associated with a markedly elevated risk of cardiovascular disease (CVD), treatment strategies must include the reduction of both CKD and CVD risks because death, particularly from cardiovascular causes, is more probable than progression to end-stage kidney disease. The management of hyperglycaemia is essential for good diabetes care even in advanced CKD. Current evidence supports an individualized approach to glycaemic management in patients with type 2 diabetes and advanced CKD, taking account of the needs of each patient, including the presence of co-morbidities and concomitant therapies. Although additional studies are needed to establish optimal strategies for glycaemic control in patients with type 2 diabetes and advanced CKD, treatment regimens with currently available pharmacotherapy can be individually tailored to meet the needs of this growing patient population.
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Affiliation(s)
- Katherine R. Tuttle
- Providence Medical Research CenterProvidence Health CareSpokaneWashington
- Division of Nephrology, Kidney Research Institute, and Institute of Translational Health SciencesUniversity of WashingtonSeattleWashington
| | - Janet B. McGill
- Division of Endocrinology, Metabolism and Lipid ResearchWashington University School of MedicineSt. LouisMissouriUnited States
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14
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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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The New Era for Reno-Cardiovascular Treatment in Type 2 Diabetes. J Clin Med 2019; 8:jcm8060864. [PMID: 31212945 PMCID: PMC6617211 DOI: 10.3390/jcm8060864] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/03/2019] [Accepted: 06/11/2019] [Indexed: 12/13/2022] Open
Abstract
Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease in the developed world. Until 2016, the only treatment that was clearly demonstrated to delay the DKD was the renin-angiotensin system blockade, either by angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. However, this strategy only partially covered the DKD progression. Thus, new strategies for reno-cardiovascular protection in type 2 diabetic patients are urgently needed. In the last few years, hypoglycaemic drugs, such as sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists, demonstrated a cardioprotective effect, mainly in terms of decreasing hospitalization for heart failure and cardiovascular death in type 2 diabetic patients. In addition, these drugs also demonstrated a clear renoprotective effect by delaying DKD progression and decreasing albuminuria. Another hypoglycaemic drug class, dipeptidyl peptidase 4 inhibitors, has been approved for its use in patients with advanced chronic kidney disease, avoiding, in part, the need for insulinization in this group of DKD patients. Studies in diabetic and non-diabetic experimental models suggest that these drugs may exert their reno-cardiovascular protective effect by glucose and non-glucose dependent mechanisms. This review focuses on newly demonstrated strategies that have shown reno-cardiovascular benefits in type 2 diabetes and that may change diabetes management algorithms.
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Farah D, Leme GM, Eliaschewitz FG, Fonseca MCM. A safety and tolerability profile comparison between dipeptidyl peptidase-4 inhibitors and sulfonylureas in diabetic patients: A systematic review and meta-analysis. Diabetes Res Clin Pract 2019; 149:47-63. [PMID: 30710655 DOI: 10.1016/j.diabres.2019.01.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/14/2018] [Accepted: 01/21/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND The first treatment approach for type 2 diabetes mellitus is lifestyle change and metformin, but it is usually not sufficient. For some time, the anti-hyperglycemic classes of sulfonylureas and dipeptidyl peptidase-4 (DPP-4) inhibitors were considered second-line of treatment, since they show similar efficacy effect. However, the recent ADA-EASD consensus gives the preference to DPP-4 inhibitors compared to sulfonylureas, except if cost is a major problem. We performed a meta-analysis for safety and tolerability profile to comprehend which treatment has less adverse events. METHODS PUBMED and EMBASE databases were searched from inception until July 2017 to retrieve RCT studies comparing DPP-4 inhibitors and sulfonylureas treatments in adult type 2 diabetes patients. There was no language restriction. We extracted and combined data from studies comparison that reported safety profile and weight change. A random effect, meta-analytic model was applied to all calculations. Cochrane collaboration tool was used to assess quality and bias of the included studies. Trial registered with PROSPERO (CRD42017075823). FINDINGS Out of 1472 articles identified in our search and screened for eligibility, 36 studies comparing DPP-4 inhibitors and sulfonylureas were identified. DPP-4 inhibitors in combination with metformin had less overall adverse events (RR: 0·90; 95% CI, 0·86-0·94; p < 0·0001; I2 = 83%; 17 studies), cardiovascular events (RR: 0·54; 95% CI, 0·37-0·79; p = 0·002; I2 = 0%; 6 studies), hypoglycemia (RR: 0·17; 95% CI, 0·13-0·22; p < 0·00001; I2 = 76%; 17 studies) and severe hypoglycemic events (RR: 0·10; 95% CI, 0·05-0·19; p < 0·00001; I2 = 0%; 12 studies). The mean difference of the weight change was 1·92 kg in favor of DPP-4 inhibitors in combination with metformin in relation to sulfonylureas in combination with metformin. Monotherapy with DPP-4 inhibitors also had less rates of hypoglycemia (RR: 0·31; 95% CI, 0·24-0·41; p < 0·00001; I2 = 0%; 8 studies) and severe hypoglycemic events (RR: 0·26; 95% CI, 0·10-0·66; p = 0·004; I2 = 0%; 8 studies) and patients did not gain 1·19 kg. INTERPRETATION These results suggest better safety profile for DPP-4 inhibitors than sulfonylureas for both comparisons, and it is more notable when the treatment regimen includes metformin. FUNDING This study was funded by Takeda Pharmaceuticals, Brazil.
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Affiliation(s)
- Daniela Farah
- Women's Health Technology Assessment Center, Federal University of Sao Paulo (Universidade Federal de São Paulo), Sao Paulo, Brazil
| | | | | | - Marcelo Cunio Machado Fonseca
- Women's Health Technology Assessment Center, Federal University of Sao Paulo (Universidade Federal de São Paulo), Sao Paulo, Brazil; AxiaBio Life Sciences, Sao Paulo, Brazil.
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Qiu DD, Liu J, Shi JS, An Y, Ge YC, Zhou ML, Jiang S. Renoprotection Provided by Dipeptidyl Peptidase-4 Inhibitors in Combination with Angiotensin Receptor Blockers in Patients with Type 2 Diabetic Nephropathy. Chin Med J (Engl) 2019; 131:2658-2665. [PMID: 30425192 PMCID: PMC6247590 DOI: 10.4103/0366-6999.245277] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: Treatment with the dipeptidyl peptidase-4 inhibitors (DPP4i) and angiotensin receptor blockers (ARBs) in patients with type 2 diabetic nephropathy (DN) has not been well characterized. This study aimed to assess the renoprotection of this combined treatment in DN patients. Methods: A total of 159 type 2 DN patients from 2013 to 2015 were enrolled retrospectively from a prospective DN cohort at the National Clinical Research Center of Kidney Diseases, Jinling Hospital (China). Fifty-seven patients received DPP4i and ARB treatment, and 102 patients were treated with ARBs alone. All patients were followed up for at least 12 months. Statistical analyses were performed using Stata version 12.0. Results: There were no significant differences at baseline for age, sex, body mass index, duration of diabetes, fasting blood glucose (FBG), hemoglobin A1c (HbA1c), and estimated glomerular filtration rate (eGFR) between the two groups. Antihypertensive and antidiabetic medication use was similar in each group except calcium channel antagonists (P = 0.032). No significant changes in FBG and HbA1c were observed in the two groups after treatment. The eGFR decreased slower in the DPP4i + ARB group than in the ARB group at 12 months (Δ12 months: −2.48 ± 13.86 vs. −6.81 ± 12.52 ml·min–1·1.73m–2, P = 0.044). In addition, proteinuria was decreased further in the DPP4i + ARB group than in the ARB group after 24 months of treatment (Δ24 months: −0.18 [−1.00, 0.17] vs. 0.32 [−0.35, 0.88], P = 0.031). There were 36 patients with an eGFR decrease of more than 30% over 24 months. After adjusting for FBG, HbA1c, and other risk factors, DPP4i + ARB treatment was still associated with a reduced incidence of an eGFR decrease of 20% or 30%. Conclusions: The combined treatment of DPP4i and ARBs is superior to ARBs alone, as evidenced by the greater proteinuria reduction and lower eGFR decline. In addition, the renoprotection of DPP4i combined with ARBs was independent of glycemic control.
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Affiliation(s)
- Dan-Dan Qiu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, China
| | - Jing Liu
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, China
| | - Jing-Song Shi
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, China
| | - Yu An
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, China
| | - Yong-Chun Ge
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, China
| | - Min-Lin Zhou
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, China
| | - Song Jiang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, China
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Abstract
Dipeptidyl peptidase-4 inhibitors form part of the group of incretin derivatives and conse-quently have a specific mechanism of action. The incretin effect avoids the adverse ef-fects of classic drugs (sulphonylureas) and provides specific benefits for their use in as-sociation with other drugs and in special situations. Because they have a low risk of pro-ducing hypoglycaemia or weight gain, these inhibitors are useful in combination with other oral antidiabetic drugs and even with insulin, although this latter combination may increase the risk of hypoglycaemia. Large studies of cardiovascular non-inferiority have reported that dipeptidyl peptidase-4 inhibitors are non-inferior to placebo, although one drug (saxagliptin) may increase the risk of hospital admission for heart failure. Because of these cardiovascular advantages, even in peripheral arterial disease, their usefulness in diabetic retinopathy, and their low risk of hypoglycaemia in renal insufficiency, dipeptidyl peptidase-4 inhibitors are the drugs of choice in elderly patients. Given the risk, although still not well defined, these drugs are not recommended in pa-tients with a history or risk of pancreatic disease, in children, in patients with type 1 diabetes, in adolescents, or in pregnant or breastfeeding women. Each of these special situ-ations is discussed in the present article.
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Affiliation(s)
- Mateu Seguí Díaz
- Medicina de Familia, Unidad Básica de Salud (UBS) Es Castell, Menorca, España Editor y Administrador del blog de la RedGDPS.
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Lo C, Toyama T, Wang Y, Lin J, Hirakawa Y, Jun M, Cass A, Hawley CM, Pilmore H, Badve SV, Perkovic V, Zoungas S. Insulin and glucose-lowering agents for treating people with diabetes and chronic kidney disease. Cochrane Database Syst Rev 2018; 9:CD011798. [PMID: 30246878 PMCID: PMC6513625 DOI: 10.1002/14651858.cd011798.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Diabetes is the commonest cause of chronic kidney disease (CKD). Both conditions commonly co-exist. Glucometabolic changes and concurrent dialysis in diabetes and CKD make glucose-lowering challenging, increasing the risk of hypoglycaemia. Glucose-lowering agents have been mainly studied in people with near-normal kidney function. It is important to characterise existing knowledge of glucose-lowering agents in CKD to guide treatment. OBJECTIVES To examine the efficacy and safety of insulin and other pharmacological interventions for lowering glucose levels in people with diabetes and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 February 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs looking at head-to-head comparisons of active regimens of glucose-lowering therapy or active regimen compared with placebo/standard care in people with diabetes and CKD (estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2) were eligible. DATA COLLECTION AND ANALYSIS Four authors independently assessed study eligibility, risk of bias, and quality of data and performed data extraction. Continuous outcomes were expressed as post-treatment mean differences (MD). Adverse events were expressed as post-treatment absolute risk differences (RD). Dichotomous clinical outcomes were presented as risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS Forty-four studies (128 records, 13,036 participants) were included. Nine studies compared sodium glucose co-transporter-2 (SGLT2) inhibitors to placebo; 13 studies compared dipeptidyl peptidase-4 (DPP-4) inhibitors to placebo; 2 studies compared glucagon-like peptide-1 (GLP-1) agonists to placebo; 8 studies compared glitazones to no glitazone treatment; 1 study compared glinide to no glinide treatment; and 4 studies compared different types, doses or modes of administration of insulin. In addition, 2 studies compared sitagliptin to glipizide; and 1 study compared each of sitagliptin to insulin, glitazars to pioglitazone, vildagliptin to sitagliptin, linagliptin to voglibose, and albiglutide to sitagliptin. Most studies had a high risk of bias due to funding and attrition bias, and an unclear risk of detection bias.Compared to placebo, SGLT2 inhibitors probably reduce HbA1c (7 studies, 1092 participants: MD -0.29%, -0.38 to -0.19 (-3.2 mmol/mol, -4.2 to -2.2); I2 = 0%), fasting blood glucose (FBG) (5 studies, 855 participants: MD -0.48 mmol/L, -0.78 to -0.19; I2 = 0%), systolic blood pressure (BP) (7 studies, 1198 participants: MD -4.68 mmHg, -6.69 to -2.68; I2 = 40%), diastolic BP (6 studies, 1142 participants: MD -1.72 mmHg, -2.77 to -0.66; I2 = 0%), heart failure (3 studies, 2519 participants: RR 0.59, 0.41 to 0.87; I2 = 0%), and hyperkalaemia (4 studies, 2788 participants: RR 0.58, 0.42 to 0.81; I2 = 0%); but probably increase genital infections (7 studies, 3086 participants: RR 2.50, 1.52 to 4.11; I2 = 0%), and creatinine (4 studies, 848 participants: MD 3.82 μmol/L, 1.45 to 6.19; I2 = 16%) (all effects of moderate certainty evidence). SGLT2 inhibitors may reduce weight (5 studies, 1029 participants: MD -1.41 kg, -1.8 to -1.02; I2 = 28%) and albuminuria (MD -8.14 mg/mmol creatinine, -14.51 to -1.77; I2 = 11%; low certainty evidence). SGLT2 inhibitors may have little or no effect on the risk of cardiovascular death, hypoglycaemia, acute kidney injury (AKI), and urinary tract infection (low certainty evidence). It is uncertain whether SGLT2 inhibitors have any effect on death, end-stage kidney disease (ESKD), hypovolaemia, fractures, diabetic ketoacidosis, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, DPP-4 inhibitors may reduce HbA1c (7 studies, 867 participants: MD -0.62%, -0.85 to -0.39 (-6.8 mmol/mol, -9.3 to -4.3); I2 = 59%) but may have little or no effect on FBG (low certainty evidence). DPP-4 inhibitors probably have little or no effect on cardiovascular death (2 studies, 5897 participants: RR 0.93, 0.77 to 1.11; I2 = 0%) and weight (2 studies, 210 participants: MD 0.16 kg, -0.58 to 0.90; I2 = 29%; moderate certainty evidence). Compared to placebo, DPP-4 inhibitors may have little or no effect on heart failure, upper respiratory tract infections, and liver impairment (low certainty evidence). Compared to placebo, it is uncertain whether DPP-4 inhibitors have any effect on eGFR, hypoglycaemia, pancreatitis, pancreatic cancer, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, GLP-1 agonists probably reduce HbA1c (7 studies, 867 participants: MD -0.53%, -1.01 to -0.06 (-5.8 mmol/mol, -11.0 to -0.7); I2 = 41%; moderate certainty evidence) and may reduce weight (low certainty evidence). GLP-1 agonists may have little or no effect on eGFR, hypoglycaemia, or discontinuation due to adverse effects (low certainty evidence). It is uncertain whether GLP-1 agonists reduce FBG, increase gastrointestinal symptoms, or affect the risk of pancreatitis (very low certainty evidence).Compared to placebo, it is uncertain whether glitazones have any effect on HbA1c, FBG, death, weight, and risk of hypoglycaemia (very low certainty evidence).Compared to glipizide, sitagliptin probably reduces hypoglycaemia (2 studies, 551 participants: RR 0.40, 0.23 to 0.69; I2 = 0%; moderate certainty evidence). Compared to glipizide, sitagliptin may have had little or no effect on HbA1c, FBG, weight, and eGFR (low certainty evidence). Compared to glipizide, it is uncertain if sitagliptin has any effect on death or discontinuation due to adverse effects (very low certainty).For types, dosages or modes of administration of insulin and other head-to-head comparisons only individual studies were available so no conclusions could be made. AUTHORS' CONCLUSIONS Evidence concerning the efficacy and safety of glucose-lowering agents in diabetes and CKD is limited. SGLT2 inhibitors and GLP-1 agonists are probably efficacious for glucose-lowering and DPP-4 inhibitors may be efficacious for glucose-lowering. Additionally, SGLT2 inhibitors probably reduce BP, heart failure, and hyperkalaemia but increase genital infections, and slightly increase creatinine. The safety profile for GLP-1 agonists is uncertain. No further conclusions could be made for the other classes of glucose-lowering agents including insulin. More high quality studies are required to help guide therapeutic choice for glucose-lowering in diabetes and CKD.
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Affiliation(s)
- Clement Lo
- Monash UniversityMonash Centre for Health Research and Implementation, School of Public Health and Preventive MedicineClaytonVICAustralia
- Monash HealthDiabetes and Vascular Medicine UnitClaytonVICAustralia
- Monash UniversityDivision of Metabolism, Ageing and Genomics, School of Public Health and Preventive MedicinePrahanVICAustralia
| | - Tadashi Toyama
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
- Kanazawa University HospitalDivision of NephrologyKanazawaJapan
| | - Ying Wang
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Jin Lin
- Beijing Friendship Hospital, Capital Medical UniversityDepartment of Critical Care Medicine95 Yong‐An Road, Xuan Wu DistrictBeijingChina100050
| | - Yoichiro Hirakawa
- The George Institute for Global Health, UNSW SydneyProfessorial UnitNewtownNSWAustralia
| | - Min Jun
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Alan Cass
- Menzies School of Health ResearchPO Box 41096CasuarinaNTAustralia0811
| | - Carmel M Hawley
- Princess Alexandra HospitalDepartment of NephrologyIpswich RoadWoolloongabbaQLDAustralia4102
| | - Helen Pilmore
- Auckland HospitalDepartment of Renal MedicinePark RoadGraftonAucklandNew Zealand
- University of AucklandDepartment of MedicineGraftonNew Zealand
| | - Sunil V Badve
- St George HospitalDepartment of Renal MedicineKogarahNSWAustralia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Sophia Zoungas
- Monash HealthDiabetes and Vascular Medicine UnitClaytonVICAustralia
- Monash UniversityDivision of Metabolism, Ageing and Genomics, School of Public Health and Preventive MedicinePrahanVICAustralia
- The George Institute for Global Health, UNSW SydneyProfessorial UnitNewtownNSWAustralia
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Huang H, Shetty S, Bauer E, Lang K. Concordance with prescribing information dosage recommendations for dipeptidyl-peptidase-4 inhibitors among type 2 diabetes mellitus patients with moderate to severe chronic kidney disease. Curr Med Res Opin 2018; 34:1021-1027. [PMID: 29231750 DOI: 10.1080/03007995.2017.1416346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To estimate the proportion of patients with moderate to severe chronic kidney disease (CKD) whose initial dipeptidyl-peptidase-4 inhibitor (DPP4-i) dosage was concordant with prescribing information (label) recommendations in the United States. METHODS Adult patients with type 2 diabetes mellitus (T2DM) who initiated a DPP4-i (linagliptin, sitagliptin, saxagliptin) between 1 January 2011 and 30 June 2014 were identified using electronic medical records and administrative claims, with index date being the date of first observed DPP4-i treatment. Patients were required to have chronic kidney disease (CKD) stage 3b, 4 or 5 (estimated Glomerular Filtration Rate [eGFR] value <45 ml/min/1.73 m2) during the 12 month pre-index period. Patients were classified as concordant or not concordant based on whether the first prescribed dose was consistent with label recommendations. Demographics, clinical characteristics, resource use and costs during pre-index were evaluated by DPP4-i concordance status. RESULTS Of the 492 patients (323 sitagliptin, 57 saxagliptin, 112 linagliptin), 36.2% were prescribed doses that were not concordant with label recommendations (44.9% for sitagliptin, 57.9% for saxagliptin and 0% for linagliptin [which does not require dosage adjustment]). Concordant patients were slightly older (mean age 71 years vs. 68, p = .01) but had similar gender distribution (55% vs. 60% female, p = .31) compared to those who were not concordant. They had lower general health status (Charlson Comorbidity Score 2.6 vs. 2.2, p = .03), and had similar pre-index all-cause total costs ($25,245 vs. $21,972, p = .68) and lower pre-index T2DM-related costs ($1618 vs. $1922, p = .05). CONCLUSIONS More than a third of DPP4-i patients with CKD stage 3b or higher were prescribed doses not concordant with DPP4-i label dosage recommendations.
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Affiliation(s)
- Huan Huang
- a IQVIA (Formerly QuintilesIMS) , Cambridge , MA , USA
| | - Sharash Shetty
- b Boehringer Ingelheim Pharmaceuticals Inc. , Ridgefield , CT , USA
| | - Elise Bauer
- a IQVIA (Formerly QuintilesIMS) , Cambridge , MA , USA
| | - Kathleen Lang
- a IQVIA (Formerly QuintilesIMS) , Cambridge , MA , USA
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Deacon CF. A review of dipeptidyl peptidase-4 inhibitors. Hot topics from randomized controlled trials. Diabetes Obes Metab 2018; 20 Suppl 1:34-46. [PMID: 29364584 DOI: 10.1111/dom.13135] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 10/19/2017] [Accepted: 10/19/2017] [Indexed: 12/20/2022]
Abstract
The first clinical study to investigate effects of dipeptidyl peptidase-4 (DPP-4) inhibition was published in 2002, and since then, numerous randomized controlled trials (RCTs) have shown that DPP-4 inhibitors are efficacious, safe and well-tolerated. This review will focus upon RCTs which have investigated DPP-4 inhibitors in patient groups which are often under-represented or excluded from typical phase 3 clinical trials. Large cardiovascular (CV) safety outcome trials in patients with established CV disease have confirmed that DPP-4 inhibitors are not associated with any additional CV risk in these already-at-high-risk individuals, while raising awareness of any uncommon adverse events, such as heart failure hospitalization seen in one of the trials. Studies in patients with kidney disease have shown DPP-4 inhibitors to be efficacious without increasing the risk of hypoglycaemia, irrespective of the degree of renal impairment, while data from the large CV trials as well as smaller RCTs have even pointed towards potential renoprotective effects such individuals. The use of DPP-4 inhibitors with insulin when therapy requires intensification may be beneficial without affecting the incidence or severity of hypoglycaemia, with these effects also being replicated in patients with chronic kidney disease, for whom other agents may not be suitable. Attention is now turning towards exploring the potential utility of DPP-4 inhibitors in other circumstances, including for in-hospital management of hyperglycaemia and in other metabolic disorders. Together, these RCTs raise the possibility that in the future, DPP-4 inhibitors may have a broader use which may extend beyond glycaemic control in the typical type 2 diabetes mellitus (T2DM) patient seen in general practice and may encompass conditions other than T2DM.
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Affiliation(s)
- Carolyn F Deacon
- Department of Biomedical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark
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Cehic MG, Nundall N, Greenfield JR, Macdonald PS. Management Strategies for Posttransplant Diabetes Mellitus after Heart Transplantation: A Review. J Transplant 2018; 2018:1025893. [PMID: 29623219 PMCID: PMC5829348 DOI: 10.1155/2018/1025893] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/27/2017] [Indexed: 12/23/2022] Open
Abstract
Posttransplant diabetes mellitus (PTDM) is a well-recognized complication of heart transplantation and is associated with increased morbidity and mortality. Previous studies have yielded wide ranging estimates in the incidence of PTDM due in part to variable definitions applied. In addition, there is a limited published data on the management of PTDM after heart transplantation and a paucity of studies examining the effects of newer classes of hypoglycaemic drug therapies. In this review, we discuss the role of established glucose-lowering therapies and the rationale and emerging clinical evidence that supports the role of incretin-based therapies (glucagon like peptide- (GLP-) 1 agonists and dipeptidyl peptidase- (DPP-) 4 inhibitors) and sodium-glucose cotransporter 2 (SGLT2) inhibitors in the management of PTDM after heart transplantation. Recently published Consensus Guidelines for the diagnosis of PTDM will hopefully lead to more consistent approaches to the diagnosis of PTDM and provide a platform for the larger-scale multicentre trials that will be needed to determine the role of these newer therapies in the management of PTDM.
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Affiliation(s)
- Matthew G. Cehic
- Faculty of Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Nishant Nundall
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Sydney, NSW, Australia
- Diabetes and Metabolism Research Program, Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Jerry R. Greenfield
- Faculty of Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Sydney, NSW, Australia
- Diabetes and Metabolism Research Program, Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Peter S. Macdonald
- Faculty of Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
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Kanozawa K, Noguchi Y, Sugahara S, Nakamura S, Yamamoto H, Kaneko K, Kono R, Sato S, Ogawa T, Hasegawa H, Katayama S. The renoprotective effect and safety of a DPP-4 inhibitor, sitagliptin, at a small dose in type 2 diabetic patients with a renal dysfunction when changed from other DPP-4 inhibitors: REAL trial. Clin Exp Nephrol 2017; 22:825-834. [PMID: 29275488 DOI: 10.1007/s10157-017-1521-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 12/06/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND We conducted the multicenter, prospective, open-label study in type 2 diabetic (T2DM) patients with renal dysfunction, to clarify the efficacy and the safety in relation to renal function and glycemic control, and the economic effect when other dipeptidyl peptidase-4 (DPP-4) inhibitors were switched to a small dose of sitagliptin depending on their renal function. METHODS Vildagliptin, alogliptin, or linagliptin received for more than 2 months were changed to sitagliptin at 25 or 12.5 mg/day depending on their renal function in 49 T2DMs. Renal function and glycemic control, and the drug cost were assessed during 6 months. RESULTS Estimated glomerular filtration rate was not changed in patients not on hemodialysis (n = 29). The HbA1c levels were not altered in all of the patients including those on hemodialysis (n = 20). The active glucagon-like peptide-1 levels or other renal parameters were not altered significantly. There were no adverse events to be related to the drugs. The daily drug expense was reduced by 88.1 yen per patient. CONCLUSION Switching to a small dose of sitagliptin according to the renal function in T2DM patients with renal dysfunction demonstrated the same efficacy and safety as those with other full-dose DPP-4 inhibitors, indicating a therapeutic option with a high cost performance.
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Affiliation(s)
- Koichi Kanozawa
- Division of Nephrology and Hypertension, Blood Purification Center, Saitama Medical Center, Saitama Medical University, 1981, Kamoda, Kawagoe, Saitama, 350-8550, Japan.
| | - Yuichi Noguchi
- Department of Endocrinology and Diabetes, Saitama Medical University, 38, Morohongo, Moroyama-machi Iruma-gun, Saitama, 350-0451, Japan
| | - Souichi Sugahara
- Shingashi Kidney Centre, 39-1, Shimoshingashi, Kawagoe-shi, Saitama, 350-1136, Japan
| | - Satoko Nakamura
- Sekishin Health Care Clinic, 25-18, Wakita Honcho, Kawagoe-shi, Saitama, 350-1123, Japan
| | - Hirohisa Yamamoto
- Kawagoe Ekimae Clinic, Ishikawa Kinenkai Medical Group, Kawagoe Ekimae Bld. 2F, 16-23, Wakita Honcho, Kawagoe-shi, Saitama, 350-1123, Japan
| | - Keiko Kaneko
- Higashi-Hannou Ekimae Clinic, Takahasi Bld.2, 3F, 3-5, Yanagicho, Hanno-shi, Saitama, 357-0035, Japan
| | - Rika Kono
- Iruma Ekimae Clinic, Yokota Square Bld.4, 5F, 1-2-30, Toyooka, Iruma-shi, Saitama, 358-0003, Japan
| | - Saeko Sato
- Division of Nephrology and Hypertension, Blood Purification Center, Saitama Medical Center, Saitama Medical University, 1981, Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Tomonari Ogawa
- Division of Nephrology and Hypertension, Blood Purification Center, Saitama Medical Center, Saitama Medical University, 1981, Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Hajime Hasegawa
- Division of Nephrology and Hypertension, Blood Purification Center, Saitama Medical Center, Saitama Medical University, 1981, Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Shigehiro Katayama
- Kawagoe Clinic, Saitama Medical University, 21-7 Wakita Honcho, Kawagoe-shi, Saitama, 350-1123, Japan
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Yang M, Wang L, Gu L, Yuan W. Effects of dipeptidyl peptidase-4 inhibitors in type 2 diabetes patients with moderate to severe chronic kidney disease: Meta-analysis of randomized controlled trials using unadjusted data. J Diabetes 2017; 9:1107-1117. [PMID: 28266136 DOI: 10.1111/1753-0407.12546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 02/24/2017] [Accepted: 02/28/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Three meta-analyses recently evaluated the effects of dipeptidyl peptidase (DPP)-4 inhibitors in type 2 diabetes (T2D) patients with chronic kidney disease (CKD). However, the combination of adjusted and unadjusted data in these meta-analyses may be questionable. The present study performed a meta-analysis of the effects of DPP-4 inhibitors in T2D patients with moderate to severe CKD using unadjusted data from randomized controlled trials (RCTs). METHODS The PubMed, Embase (via Ovid), and Cochrane Central databases were searched for papers regarding the effects of DPP-4 inhibitors in CKD patients published before 1 August 2016. Data were independently extracted by two authors. A pooled analysis of unadjusted data was performed using random-effects models. RESULTS Twelve studies representing 10 RCTs were included in the present analysis. Comparing mean HbA1c change between placebo and treatment, DPP-4 inhibitors significantly improved HbA1c levels at 12 weeks (mean difference [MD] -0.42; 95% confidence interval [CI] -0.54, -0.29), but improvements in HbA1c were seen only in dialysis patients at 24 weeks (MD -0.52; 95% CI -0.72, -0.32)*. Improvements in HbA1c were equivalent between DPP-4 inhibitors and sulfonylureas at 52 or 54 weeks. There were no significant differences in the incidence of severe or any hypoglycemic events between DPP-4 inhibitors and control (placebo or sulfonylureas) at 12, 24, and 52 or 54 weeks. However, DPP-4 inhibitors induced fewer symptomatic hypoglycemic events compared with sulfonylureas at 52 or 54 weeks. *[Correction added on 30 October 2017, after first online publication: The value '0.32' has been corrected to '-0.32'.] CONCLUSIONS: The present analysis shows that DPP-4 inhibitors are effective and comparable with sulfonylureas in T2D patients with moderate to severe CKD.
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Affiliation(s)
- Man Yang
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ling Wang
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lijie Gu
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Weijie Yuan
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
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Goldenberg RM. Choosing Dipeptidyl Peptidase-4 Inhibitors, Sodium-glucose Cotransporter-2 Inhibitors, or Both, as Add-ons to Metformin: Patient Baseline Characteristics Are Crucial. Clin Ther 2017; 39:2438-2447. [PMID: 29174215 DOI: 10.1016/j.clinthera.2017.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/02/2017] [Accepted: 10/23/2017] [Indexed: 01/19/2023]
Abstract
PURPOSE Type 2 diabetes remains a poorly managed disease, with only about half of individuals with type 2 diabetes meeting guideline-recommended glycosylated hemoglobin (HbA1C) targets. A major proportion of those who have not met HbA1C goals have an HbA1C <8.0% to 8.5%. In practice, it is quite common to have to decide between dipeptidyl peptidase-4 inhibitors (DPP-4i) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) as add-ons to metformin to help these individuals meet their HbA1C goals. This commentary reviews and provides guidance on how baseline factors can assist in the decision between the 2 classes or using both as add-ons to metformin. METHODS The important clinical studies comparing the glycemic efficacy of DPP-4i versus SGLT2i or their combination as add-ons to metformin with a focus on the influence of baseline HbA1C on glycemic efficacy will be discussed and interpreted. The impact of estimated glomerular filtration rate and age on the glycemic efficacy of DPP-4i and SGLT2i will also be put into perspective. FINDINGS At HbA1C <8.0% to 8.5%, HbA1C lowering is slightly greater with DPP-4i than with SGLT2i as an add-on to metformin; SGLT2i are associated with larger HbA1C improvements than DPP-4i at higher HbA1C levels. In cases of HbA1C ≥8.0%, dual DPP-4i-SGLT2i add-on therapy to metformin should be considered to help more patients achieve glycemic targets. The glycemic efficacy of SGLT2i, but not DPP-4i, declines with progressive renal insufficiency. In older adults, DPP-4i maintain their tolerability and efficacy, while SGLT2i may become less efficacious due to reduced renal function, and may be associated with higher rates of volume-related adverse effects. IMPLICATIONS Although both DPP-4i and SGLT2i are effective add-on antihyperglycemic therapies to metformin monotherapy, baseline characteristics, such as HbA1C, renal function, and age, should be considered when choosing between the 2 classes to allow for optimal and timely diabetes management.
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Effect of Long-term Incretin-Based Therapies on Ischemic Heart Diseases in Patients with Type 2 Diabetes Mellitus: A Network Meta-analysis. Sci Rep 2017; 7:15795. [PMID: 29150631 PMCID: PMC5694013 DOI: 10.1038/s41598-017-16101-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 11/08/2017] [Indexed: 02/07/2023] Open
Abstract
Patients with type 2 diabetes mellitus (T2DM) experience many cardiovascular complications. Several studies have demonstrated the cardioprotective effects of incretin-based therapies; however, there are few studies on the effects of long-term incretin-based therapies on cardiovascular events. Therefore, the present study conducted a systematic review and network meta-analysis to evaluate the effects of long-term incretin-based therapies on ischaemic diseases. We searched PubMed, CENTRAL, and Clinicaltrial.gov to retrieve randomised control trials reported until December 2016 and enrolled only RCTs with more than a 1-year follow-up. The network meta-analysis was performed using R Software with a GeMTC package. A total of 40 trials were included. Dipeptidyl peptidase 4 inhibitors and glucagon-like peptide-1 agonists were associated with a lower risk of myocardial infarction (MI) than were sulfonylureas (odds ratio [95% credible interval] 0.41 [0.24–0.71] and 0.48 [0.27–0.91], respectively). These results suggested that patients with T2DM receiving long-term incretin-based therapies have a lower risk of MI than do those receiving sulfonylurea-based therapy. These findings highlight the risks of cardiovascular events in patients who receive long-term incretin-based therapies, and may provide evidence for the selection of antidiabetic therapy in the future.
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Engel SS, Suryawanshi S, Stevens SR, Josse RG, Cornel JH, Jakuboniene N, Riefflin A, Tankova T, Wainstein J, Peterson ED, Holman RR. Safety of sitagliptin in patients with type 2 diabetes and chronic kidney disease: outcomes from TECOS. Diabetes Obes Metab 2017; 19:1587-1593. [PMID: 28432745 DOI: 10.1111/dom.12983] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 04/13/2017] [Accepted: 04/19/2017] [Indexed: 11/26/2022]
Abstract
AIMS To characterize the incidence of diabetes-associated complications and assess the safety of sitagliptin in participants with chronic kidney disease (CKD) in the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS). MATERIALS AND METHODS For participants with baseline eGFR measurements (n = 14 528), baseline characteristics and safety outcomes were compared for the CKD cohort (eGFR < 60 mL/min per 1.73 m2 ) vs those without CKD. Within the CKD cohort, the same analyses were performed, comparing sitagliptin- and placebo-assigned participants. Baseline characteristics were summarized for all participants, and serious adverse events were analysed in those who received at least 1 dose of study medication. Adverse events of interest and diabetes complications were summarized for the intention-to-treat population. RESULTS CKD was present in 3324 (23%) participants at entry into TECOS. The mean (SD) age for this CKD cohort was 68.8 (7.9) years, mean diabetes duration was 13.7 (9.0) years, and 62% were men. Incidences of serious adverse events, malignancy, bone fracture, severe hypoglycaemia and most categories of diabetes complications were higher in the CKD cohort compared with those without CKD. Over ~2.8 median years of follow-up, CKD participants assigned to sitagliptin had rates of diabetic eye disease, diabetic neuropathy, renal failure, malignancy, bone fracture, pancreatitis and severe hypoglycaemia similar to those of placebo-assigned participants. CONCLUSIONS Participants in TECOS with CKD had higher incidences of serious adverse events and diabetes complications than those without CKD. Treatment with sitagliptin was generally well tolerated, with no meaningful differences in safety outcomes observed between those with CKD assigned to sitagliptin or placebo.
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Affiliation(s)
| | | | - Susanna R Stevens
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Robert G Josse
- St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Jan H Cornel
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
- Working group on Cardiovascular Research the Netherlands (WCN), Utrecht, the Netherlands
| | - Neli Jakuboniene
- Department of Endocrinology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | | | - Julio Wainstein
- Wolfson Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Rury R Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
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Zhao L, Sun T, Wang L. Chitosan oligosaccharide improves the therapeutic efficacy of sitagliptin for the therapy of Chinese elderly patients with type 2 diabetes mellitus. Ther Clin Risk Manag 2017; 13:739-750. [PMID: 28721055 PMCID: PMC5499789 DOI: 10.2147/tcrm.s134039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Sitagliptin improves glycemic control in type 2 diabetes mellitus (T2DM) patients but its side effects are undesirable. Chitosan oligosaccharide (COS) is expected to improve the therapeutic result as a natural product. A total of 200 elderly T2DM patients were evenly assigned into four groups: sitagliptin group (SG), receiving sitagliptin 100 mg/day; COS group (CG), receiving COS 100 mg/day; combination therapy of sitagliptin and COS group (SCG), receiving both sitagliptin and COS 100 mg/day; and placebo group (PG), receiving placebo 100 mg/day. After 42-week therapy, biochemical indices and clinical parameters for the alterations from start points were analyzed. The related molecular mechanism was tested by quantitative real-time polymerase chain reaction (qRT-PCR) and Western blot at cell level. Lower risk of hypoglycemia was found in the SCG group when compared with SG and other groups (P<0.05). More patients from the SCG group than other groups attained hemoglobin A1c (HbA1c) reduction >2.5% (P<0.05). Weight reduction of 1.2±0.9, 2.6±0.8, 4.7±1.3, and 0.9±0.6 kg was observed in the patients from SG, CG, SCG, and PG groups, respectively (P<0.05). The combined treatment of COS and sitagliptin presented better therapeutic results by improving insulin sensitivity, lipid profile, adiponectin levels, and glucagon-like peptide 1 and reducing side effects, insulin resistance, HbA1c, body mass index, resistin, tumor necrosis factor (TNF)-α, and C-reactive protein (CRP) (P<0.05). qRT-PCR and Western blot analysis also showed that COS treatment reduced the levels of resistin, TNF-α, and CRP, and increased the level of adiponectin. The combination of COS and sitagliptin provided better glycemic control with fewer side effects and with more weight reduction in the elderly participants with T2DM.
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Affiliation(s)
| | - Tingli Sun
- Department of Nephrology, General Hospital of Daqing Oil Field, Daqing, China
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Abstract
There is a need for treatment options in patients with type 2 diabetes mellitus and kidney disease to achieve glucose targets without risk of hypoglycemia. This article describes management options for these patients using glucose-lowering therapies, in particular dipeptidyl peptidase-4 inhibitors.
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Affiliation(s)
- Polly A Bittle
- Polly A. Bittle is an NP, practice manager, chief operating officer, and clinical research director at Tampa Bay Nephrology Associates, Tampa, Fla
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30
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Permsuwan U, Dilokthornsakul P, Thavorn K, Saokaew S, Chaiyakunapruk N. Cost-effectiveness of dipeptidyl peptidase-4 inhibitor monotherapy versus sulfonylurea monotherapy for people with type 2 diabetes and chronic kidney disease in Thailand. J Med Econ 2017; 20:171-181. [PMID: 27645706 DOI: 10.1080/13696998.2016.1238386] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE With a high prevalence of chronic kidney disease (CKD) in type 2 diabetes (T2DM) in Thailand, the appropriate treatment for the patients has become a major concern. This study aimed to evaluate long-term cost-effective of dipeptidyl peptidase-4 (DPP-4) inhibitor monothearpy vs sulfonylurea (SFU) monotherapy in people with T2DM and CKD. METHODS A validated IMS CORE Diabetes Model was used to estimate the long-term costs and outcomes. The efficacy parameters were identified and synthesized using a systematic review and meta-analysis. Baseline characteristics and cost parameters were obtained from published studies and hospital databases in Thailand. Costs were expressed in 2014 US Dollars. Outcomes were presented as an incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses were performed to estimate parameter uncertainty. RESULTS From a societal perspective, treatment with DPP-4 inhibitors yielded more quality-adjusted life years (QALYs) (0.024) at a higher cost (>66,000 Thai baht (THB) or >1,829.27 USD) per person than SFU, resulting in the ICER of >2.7 million THB/QALY (>74,833.70 USD/QALY). The cost-effectiveness results were mainly driven by differences in HbA1c reduction, hypoglycemic events, and drug acquisition cost of DPP-4 inhibitors. At the ceiling ratio of 160,000 THB/QALY (4,434.59 USD/QALY), the probability that DPP-4 inhibitors are cost-effective compared to SFU was less than 10%. CONCLUSIONS Compared to SFU, DPP-4 inhibitor monotherapy is not a cost-effective treatment for people with T2DM and CKD in Thailand.
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Affiliation(s)
| | - Piyameth Dilokthornsakul
- b Center of Pharmaceutical Outcome Research (CPOR), Faculty of Pharmaceutical Sciences , Naresuan University , Phitsanulok , Thailand
| | - Kednapa Thavorn
- c Ottawa Hospital Research Institute, The Ottawa Hospital , Ottawa , Ontario , Canada
- d School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine , University of Ottawa , Ottawa , Ontario , Canada
- e Institute of Clinical and Evaluative Sciences , Toronto , Ontario , Canada
| | - Surasak Saokaew
- f Center of Health Outcomes Research and Therapeutic Safety (COHORTS), School of Pharmaceutical Sciences, University of Phayao , Phayao , Thailand
- g School of Pharmacy , Monash University Malaysia , Malaysia
| | - Nathorn Chaiyakunapruk
- b Center of Pharmaceutical Outcome Research (CPOR), Faculty of Pharmaceutical Sciences , Naresuan University , Phitsanulok , Thailand
- g School of Pharmacy , Monash University Malaysia , Malaysia
- h School of Population Health , University of Queensland , Brisbane , Australia
- i School of Pharmacy , University of Wisconsin-Madison , Wisconsin , MA , USA
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Ankarfeldt MZ, Adalsteinsson E, Groenwold RH, Ali MS, Klungel OH. A systematic literature review on the efficacy-effectiveness gap: comparison of randomized controlled trials and observational studies of glucose-lowering drugs. Clin Epidemiol 2017; 9:41-51. [PMID: 28176959 PMCID: PMC5271378 DOI: 10.2147/clep.s121991] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Aim To identify a potential efficacy–effectiveness gap and possible explanations (drivers of effectiveness) for differences between results of randomized controlled trials (RCTs) and observational studies investigating glucose-lowering drugs. Methods A systematic literature review was conducted in English language articles published between 1 January, 2000 and 31 January, 2015 describing either RCTs or observational studies comparing glucagon-like peptide-1 analogs (GLP-1) with insulin or comparing dipeptidyl peptidase-4 inhibitors (DPP-4i) with sulfonylurea, all with change in glycated hemoglobin (HbA1c) as outcome. Medline, Embase, Current Content, and Biosis were searched. Information on effect estimates, baseline characteristics of the study population, publication year, study duration, and number of patients, and for observational studies, characteristics related to confounding adjustment and selection- and information bias were extracted. Results From 312 hits, 11 RCTs and 7 observational studies comparing GLP-1 with insulin, and from 474 hits, 16 RCTs and 4 observational studies comparing DPP-4i with sulfonylurea were finally included. No differences were observed in baseline characteristics of the study populations (age, sex, body mass index, time since diagnosis of type 2 diabetes mellitus, and HbA1c) or effect sizes across study designs. Mean effect sizes ranged from −0.43 to 0.91 and from −0.80 to 1.13 in RCTs and observational studies, respectively, comparing GLP-1 with insulin, and from −0.13 to 2.70 and −0.20 to 0.30 in RCTs and observational studies, respectively, comparing DPP-4i and sulfonylurea. Generally, the identified observational studies held potential flaws with regard to confounding adjustment and selection- and information bias. Conclusions Neither potential drivers of effectiveness nor an efficacy–effectiveness gap were identified. However, the limited number of studies and potential problems with confounding adjustment, selection- and information bias in the observational studies, may have hidden a true efficacy-effectiveness gap.
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Affiliation(s)
- Mikkel Z Ankarfeldt
- Novo Nordisk A/S; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht
| | | | - Rolf Hh Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht; Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, the Netherlands
| | - M Sanni Ali
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht; Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, the Netherlands; Nuffield Department of Orthopaedics, Rheumatology, Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Olaf H Klungel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht; Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, the Netherlands
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Wang H, Liu X, Long M, Huang Y, Zhang L, Zhang R, Zheng Y, Liao X, Wang Y, Liao Q, Li W, Tang Z, Tong Q, Wang X, Fang F, Rojo de la Vega M, Ouyang Q, Zhang DD, Yu S, Zheng H. NRF2 activation by antioxidant antidiabetic agents accelerates tumor metastasis. Sci Transl Med 2016; 8:334ra51. [PMID: 27075625 DOI: 10.1126/scitranslmed.aad6095] [Citation(s) in RCA: 153] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 02/18/2016] [Indexed: 12/18/2022]
Abstract
Cancer is a common comorbidity of diabetic patients; however, little is known about the effects that antidiabetic drugs have on tumors. We discovered that common classes of drugs used in type 2 diabetes mellitus, the hypoglycemic dipeptidyl peptidase-4 inhibitors (DPP-4i) saxagliptin and sitagliptin, as well as the antineuropathic α-lipoic acid (ALA), do not increase tumor incidence but increase the risk of metastasis of existing tumors. Specifically, these drugs induce prolonged activation of the nuclear factor E2-related factor 2 (NRF2)-mediated antioxidant response through inhibition of KEAP1-C151-dependent ubiquitination and subsequent degradation of NRF2, resulting in up-regulated expression of metastasis-associated proteins, increased cancer cell migration, and promotion of metastasis in xenograft mouse models. Accordingly, knockdown of NRF2 attenuated naturally occurring and DPP-4i-induced tumor metastasis, whereas NRF2 activation accelerated metastasis. Furthermore, in human liver cancer tissue samples, increased NRF2 expression correlated with metastasis. Our findings suggest that antioxidants that activate NRF2 signaling may need to be administered with caution in cancer patients, such as diabetic patients with cancer. Moreover, NRF2 may be a potential biomarker and therapeutic target for tumor metastasis.
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Affiliation(s)
- Hui Wang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Xiufei Liu
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Min Long
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Yi Huang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Key Laboratory of Immunity and Infectious Diseases, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Linlin Zhang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Rui Zhang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Yi Zheng
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Xiaoyu Liao
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Yuren Wang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Qian Liao
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Wenjie Li
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Zili Tang
- Molecular and Translational Radiation Oncology, Heidelberg Ion Therapy Center, Heidelberg Institute of Radiation Oncology, University of Heidelberg Medical School, National Center for Cancer Diseases, German Cancer Research Center, Heidelberg 69120, Germany
| | - Qiang Tong
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Xiaocui Wang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Fang Fang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Montserrat Rojo de la Vega
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Arizona, Tucson, AZ 85721, USA
| | - Qin Ouyang
- College of Pharmacy, Third Military Medical University, Chongqing 400038, China
| | - Donna D Zhang
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Arizona, Tucson, AZ 85721, USA.
| | - Shicang Yu
- Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University, Chongqing 400038, China.
| | - Hongting Zheng
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China.
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Howse PM, Chibrikova LN, Twells LK, Barrett BJ, Gamble JM. Safety and Efficacy of Incretin-Based Therapies in Patients With Type 2 Diabetes Mellitus and CKD: A Systematic Review and Meta-analysis. Am J Kidney Dis 2016; 68:733-742. [DOI: 10.1053/j.ajkd.2016.06.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 06/07/2016] [Indexed: 12/16/2022]
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Tahrani AA, Barnett AH, Bailey CJ. Pharmacology and therapeutic implications of current drugs for type 2 diabetes mellitus. Nat Rev Endocrinol 2016; 12:566-92. [PMID: 27339889 DOI: 10.1038/nrendo.2016.86] [Citation(s) in RCA: 244] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Type 2 diabetes mellitus (T2DM) is a global epidemic that poses a major challenge to health-care systems. Improving metabolic control to approach normal glycaemia (where practical) greatly benefits long-term prognoses and justifies early, effective, sustained and safety-conscious intervention. Improvements in the understanding of the complex pathogenesis of T2DM have underpinned the development of glucose-lowering therapies with complementary mechanisms of action, which have expanded treatment options and facilitated individualized management strategies. Over the past decade, several new classes of glucose-lowering agents have been licensed, including glucagon-like peptide 1 receptor (GLP-1R) agonists, dipeptidyl peptidase 4 (DPP-4) inhibitors and sodium/glucose cotransporter 2 (SGLT2) inhibitors. These agents can be used individually or in combination with well-established treatments such as biguanides, sulfonylureas and thiazolidinediones. Although novel agents have potential advantages including low risk of hypoglycaemia and help with weight control, long-term safety has yet to be established. In this Review, we assess the pharmacokinetics, pharmacodynamics and safety profiles, including cardiovascular safety, of currently available therapies for management of hyperglycaemia in patients with T2DM within the context of disease pathogenesis and natural history. In addition, we briefly describe treatment algorithms for patients with T2DM and lessons from present therapies to inform the development of future therapies.
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Affiliation(s)
- Abd A Tahrani
- Centre of Endocrinology, Diabetes and Metabolism, 2nd Floor, Institute of Biomedical Research, University of Birmingham, Birmingham, B15 2TT, UK
- Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, B9 5SS, UK
| | - Anthony H Barnett
- Centre of Endocrinology, Diabetes and Metabolism, 2nd Floor, Institute of Biomedical Research, University of Birmingham, Birmingham, B15 2TT, UK
- Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, B9 5SS, UK
| | - Clifford J Bailey
- School of Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK
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Li R, Wang R, Li H, Sun S, Zou M, Cheng G. Short-term and long-term effects of dipeptidyl peptidase-4 inhibitors in type 2 diabetes mellitus patients with renal impairment: a meta-analysis of randomized controlled trials. Diabetes Metab Res Rev 2016; 32:460-9. [PMID: 26433213 DOI: 10.1002/dmrr.2731] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 07/15/2015] [Accepted: 09/08/2015] [Indexed: 12/24/2022]
Abstract
To assess the short-term and long-term effects of dipeptidyl peptidase-4 (DPP-4) inhibitors in type 2 diabetes mellitus patients with renal impairment, a meta-analysis of randomized clinical trials of DPP-4 inhibitor interventions in type 2 diabetes mellitus patients with renal impairment was performed. PubMed, Embase, Cochrane Library and ClinicalTrials.gov were searched through the end of March 2015. Randomized clinical trials were selected if (1) DPP-4 inhibitors were compared with a placebo or other active-comparators, (2) the treatment duration was ≥12 weeks and (3) data regarding changes in haemoglobin A1c (HbA1c ), changes in fasting plasma glucose or hypoglycaemia and other adverse events were reported. Of 790 studies, ten studies on eight randomized clinical trials were included. Compared with the control group, DPP-4 inhibitors were associated with a greater HbA1c reduction in both the short-term [mean differences (MD) = -0.45, 95% confidence intervals (-0.57, -0.33), p < 0.0001] and long-term [MD = -0.33, 95% confidence intervals (-0.63, -0.03), p = 0.03] treatments. However, the long-term greater reduction in HbA1c with DPP-4 inhibitor treatment was only significant when the control treatment comprised placebo plus stable background treatment, but not glipizide plus stable background treatment. DPP-4 inhibitors were associated with a greater fasting plasma glucose reduction [MD = -12.59, 95% confidence intervals (-22.01, -3.17), p = 0.009] over the short-term; however, this effect was not present over the long-term. Regarding the hypoglycaemia adverse events assessment, the long-term treatment data indicated there was no increased risk of hypoglycaemia compared with placebo or active-controlled anti-diabetic drugs. The present meta-analysis confirms that DPP-4 inhibitors are effective and equivalent to other agents in type 2 diabetes mellitus patients with renal impairment. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Ruifei Li
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, China
| | - Rui Wang
- Department of Endocrinology, General Hospital of Shenyang Military Region, Shenyang, China
| | - Haixia Li
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, China
| | - Sihao Sun
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, China
| | - Meijuan Zou
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, China
| | - Gang Cheng
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, China
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Lyssenko V, Bianchi C, Del Prato S. Personalized Therapy by Phenotype and Genotype. Diabetes Care 2016; 39 Suppl 2:S127-36. [PMID: 27440825 DOI: 10.2337/dcs15-3002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Valeriya Lyssenko
- Department of Translational Pathophysiology, Steno Diabetes Center A/S, Gentofte, Denmark Diabetes and Endocrinology, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Cristina Bianchi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Park SH, Nam JY, Han E, Lee YH, Lee BW, Kim BS, Cha BS, Kim CS, Kang ES. Efficacy of different dipeptidyl peptidase-4 (DPP-4) inhibitors on metabolic parameters in patients with type 2 diabetes undergoing dialysis. Medicine (Baltimore) 2016; 95:e4543. [PMID: 27512877 PMCID: PMC4985332 DOI: 10.1097/md.0000000000004543] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Hyperglycemia is associated with increased mortality and morbidity in patients with type 2 diabetes mellitus (T2DM) who are undergoing dialysis. Although dipeptidyl peptidase-4 (DPP-4) inhibitors have been widely used in end-stage renal disease (ESRD) patients with T2DM, there are few studies on their efficacy in this population. We studied the effect of 3 different DPP-4 inhibitors on metabolic parameters in ESRD patients with T2DM.Two hundred ESRD patients with T2DM who were treated with DPP-4 inhibitors (sitagliptin, vildagliptin, or linagliptin) were enrolled and analyzed retrospectively. The changes in glycated hemoglobin (HbA1c), fasting plasma glucose, and lipid profiles were assessed before and after 3 months of treatment with DPP-4 inhibitors. Subgroup analysis was done for each hemodialysis (HD) and peritoneal dialysis (PD) group.There was no significant difference in the decrease in the HbA1c level among sitagliptin, vildagliptin, and linagliptin treatment groups (-0.74 ± 1.57, -0.39 ± 1.45, and -0.08 ± 1.40, respectively, P = 0.076). The changes in fasting blood glucose and lipid profiles were also not significantly different. In HD patients (n = 115), there was no difference in the HbA1c level among the 3 groups. In contrast, in PD patients (n = 85), HbA1c was reduced more after 3 months of treatment with sitagliptin compared with vildagliptin and linagliptin (-1.58 ± 0.95, -0.46 ± 0.98, -0.04 ± 1.22, respectively, P = 0.001).There was no significant difference in the glucose-lowering effect between the different DPP-4 inhibitors tested in ESRD patients. In PD patients, sitagliptin tends to lower the HbA1c level more than the other inhibitors. The glucose-lowering efficacy of the 3 DPP-4 inhibitors was comparable.
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Affiliation(s)
- Se Hee Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine
- Department of Medicine, The Graduate School, Yonsei University College of Medicine, Seoul
| | - Joo Young Nam
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Gyeonggi
| | - Eugene Han
- Division of Endocrinology and Metabolism, Department of Internal Medicine
- Department of Medicine, The Graduate School, Yonsei University College of Medicine, Seoul
| | - Yong-ho Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine
| | - Byung-Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine
| | - Beom Seok Kim
- Division of Nephrology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul
| | - Bong-Soo Cha
- Division of Endocrinology and Metabolism, Department of Internal Medicine
| | - Chul Sik Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Seok Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine
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Singh-Franco D, Harrington C, Tellez-Corrales E. An updated systematic review and meta-analysis on the efficacy and tolerability of dipeptidyl peptidase-4 inhibitors in patients with type 2 diabetes with moderate to severe chronic kidney disease. SAGE Open Med 2016; 4:2050312116659090. [PMID: 27516879 PMCID: PMC4968114 DOI: 10.1177/2050312116659090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 06/14/2016] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE This updated meta-analysis determines the effect of dipeptidyl peptidase-4 inhibitors on glycemic and tolerability outcomes in patients with type 2 diabetes mellitus and chronic kidney disease with glomerular filtration rate of ⩽60 mL/min or on dialysis. METHODS In all, 14 citations were identified from multiple databases. Qualitative assessments and quantitative analyses were performed. RESULTS There were 2261 participants, 49-79 years of age, 49% men and 44% Caucasians. In seven placebo-comparator studies, reduction in hemoglobin A1c at weeks 12-24 was 0.55% (95% confidence interval: -0.68 to -0.43), P < 0.00001). In three sulfonylurea-comparator studies, dipeptidyl peptidase-4 inhibitors did not significantly reduce hemoglobin A1c at weeks 52-54 (-0.15% (95% confidence interval: -0.32 to 0.02)). In one sitagliptin versus albiglutide study, albiglutide significantly reduced hemoglobin A1c in patients with moderate renal impairment (-0.51%). A similar reduction in hemoglobin A1c was seen with sitagliptin versus vildagliptin (-0.56% vs -0.54%). Compared with placebo or sulfonylurea, dipeptidyl peptidase-4 inhibitors did not significantly reduce hemoglobin A1c after 12 and 54 weeks in patients on dialysis. Hypoglycemia was reported by ~30% of patients in both dipeptidyl peptidase-4 inhibitors and placebo groups over 24-52 weeks. While hypoglycemia was more common with a sulfonylurea at 52-54 weeks (risk ratio: 0.46 (95% confidence interval: 0.18 to 1.18)), there was significant heterogeneity (I (2) = 87%). Limitations included high drop-out rate from most studies and small number of active-comparator studies. CONCLUSIONS Dipeptidyl peptidase-4 inhibitors in patients with chronic kidney disease caused a modest reduction in hemoglobin A1c versus placebo, but not when compared with sulfonylureas or albiglutide, or when used in patients on dialysis. Additional active-comparator studies are needed to further elucidate the role of dipeptidyl peptidase-4 inhibitors in patients with chronic kidney disease stages 3-5 or on dialysis.
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Affiliation(s)
- Devada Singh-Franco
- Department of Pharmacy Practice, College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Catherine Harrington
- Department of Sociobehavioral and Administrative Pharmacy, College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Eglis Tellez-Corrales
- Department of Pharmacy Practice, College of Pharmacy, Marshall B. Ketchum University, Fullerton, CA, USA
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Sitagliptin and risk of heart failure hospitalization in patients with type 2 diabetes on dialysis: A population-based cohort study. Sci Rep 2016; 6:30499. [PMID: 27460913 PMCID: PMC4962317 DOI: 10.1038/srep30499] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/06/2016] [Indexed: 01/07/2023] Open
Abstract
The incidence of heart failure hospitalization (HHF) after taking sitagliptin in type
2 diabetes (T2DM) patients with end stage renal disease (ESRD) on dialysis is
unclear. In this population-based cohort study, we identified individuals with T2DM
and ESRD on dialysis who were treated with sitagliptin between 2009 and 2011 and
randomly selected a control cohort matched by age, sex, duration of T2DM,
hypertension medications, use of statin and aspirin, sulfonylureas, glinides, and
insulin usage, atherosclerotic heart disease, congestive heart failure and chronic
obstructive pulmonary disease at a 1:4 ratio. Multivariable Cox proportional hazards
regression analysis was used to evaluate HHF risk. The overall incidence of HHF was
higher in the sitagliptin cohort than in the control cohort (1130 vs. 754 per
10000 person-years; adjusted hazard ratio (HR): 1.52, 95%
CI = 1.21–1.90). There was a significant trend
towards increased HHF risk associated with increased sitagliptin dose (p for
trend < 0.01). Subjects at greater risk of HHF after
taking sitagliptin were those without severe hypoglycemia, without ACE inhibitors
treatment, with history of heart failure or receiving hemodialysis rather than
peritoneal dialysis. In conclusion, use of sitagliptin was associated with an
increased risk of HHF in patients with T2DM on dialysis.
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Kamiya H. A systematic review of the benefits and harms of dipeptidyl peptidase-4 inhibitor for chronic kidney disease. Hemodial Int 2016; 21:72-83. [DOI: 10.1111/hdi.12438] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/17/2016] [Indexed: 01/25/2023]
Affiliation(s)
- Hiroyuki Kamiya
- Division of Hemodialysis; Sakura Clinic; 593-1 Dainichi, Yotukaidou Chiba Japan
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Mamza J, Marlin C, Wang C, Chokkalingam K, Idris I. DPP-4 inhibitor therapy and bone fractures in people with Type 2 diabetes - A systematic review and meta-analysis. Diabetes Res Clin Pract 2016; 116:288-98. [PMID: 27321347 DOI: 10.1016/j.diabres.2016.04.029] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/29/2016] [Accepted: 04/16/2016] [Indexed: 12/25/2022]
Abstract
AIM Fracture risk is higher in older adults with Type 2 diabetes mellitus (T2DM). Oral glucose-lowering medications have different effects on bone metabolism. The purpose of this study is to appraise the evidence from literature and determine the effect of dipeptidyl peptidase-4 (DPP-4) inhibitor on the risk of developing bone fractures. METHODS Using Boolean search terms, the search strategy combined synonyms of 'fracture' and 'DPP-4 inhibitor'. Comprehensive electronic databases which include EMBASE, MEDLINE, the EMA and the WHO ICTRP databases were searched for randomised controlled trial (RCT) studies which compared a DPP-4 inhibitor with an active comparator or placebo amongst patients with T2DM. Meta-analysis was performed to compare DPP-4 inhibitor with either an active comparator or a placebo. The outcome measure was the presence or absence of fracture. RESULTS The search yielded 5061 records relating to fractures and DPP-4 inhibitor, from which 51 eligible RCTs were selected for meta-analysis (N=36,402). Thirty-seven (37) studies compared DPP-4 inhibitor with placebo (n=23,974), while fourteen (14) studies (n=12,428) compared DPP-4 inhibitor with an active comparator. The mean age of patients was 57.5±5.4years, the average glycated haemoglobin (HbA1c) was 8.2%, while the average BMI was 30±2kg/m(2). Overall, there was no significant association of fracture events with the use of DPP-4 inhibitor when compared with placebo (OR; 0.82, 95% CI 0.57-1.16, P=0.9) or when DPP-4 inhibitor was compared against an active comparator (OR; 1.59, 95% CI 0.91-2.80, P=0.9). CONCLUSION This study offers a larger, up-to-date review of the subject. The meta-analysis showed that there was no significant association between DPP-4 inhibitor use and the incidence of fractures.
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Affiliation(s)
- Jil Mamza
- Division of Medical Sciences & Graduate Entry Medicine, University of Nottingham, UK
| | - Carol Marlin
- Division of Medical Sciences & Graduate Entry Medicine, University of Nottingham, UK
| | - Cai Wang
- Division of Medical Sciences & Graduate Entry Medicine, University of Nottingham, UK
| | | | - Iskandar Idris
- Division of Medical Sciences & Graduate Entry Medicine, University of Nottingham, UK.
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Switching from subcutaneous insulin injection to oral vildagliptin administration in hemodialysis patients with type 2 diabetes: a pilot study. Int Urol Nephrol 2016; 48:1349-1355. [DOI: 10.1007/s11255-016-1305-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 04/23/2016] [Indexed: 02/08/2023]
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Effects of DPP-4 inhibitors on cardiovascular outcomes in patients with type 2 diabetes and end-stage renal disease. Int J Cardiol 2016; 218:170-175. [PMID: 27236110 DOI: 10.1016/j.ijcard.2016.05.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 05/12/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Recent clinical trials have evaluated the cardiovascular outcomes of dipeptidyl peptidase-4 (DPP-4) inhibitors in patients with type 2 diabetes mellitus (T2DM), but those with end-stage renal disease (ESRD) were ineligible for participation in these trials. We aimed to characterize the impact of DPP-4 inhibitors on major adverse cardiovascular events (MACEs) in patients with T2DM and ESRD undergoing chronic dialysis. METHODS This nationwide observational study utilized data from 3556 patients aged ≥20years with T2DM and ESRD who initiated treatment with DPP-4 inhibitors between 1 March 2009 and 31 June 2013, retrieved from Taiwan's National Health Insurance Research Database. Each DPP-4 inhibitor user was matched to a non-user control subject using propensity scores. The primary outcomes were all-cause mortality and MACEs (ischemic stroke and myocardial infarction). The secondary outcomes were hospitalization for heart failure and hypoglycemia. All subjects were followed until death or 31 December 2013. RESULTS Compared with non-users, DPP-4 inhibitor users had lower risks of all-cause mortality (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.39-0.47), MACEs (HR 0.76, 95% CI 0.65-0.90), and ischemic stroke (HR 0.77, 95% CI 0.61-0.97); the risks of myocardial infarction and hospitalization for heart failure and hypoglycemia did not differ. This treatment effect remained consistent in subgroup analyses according to age, sex, comorbidities, dialysis modality, and insulin use. CONCLUSIONS In this nationwide ESRD cohort, DPP-4 inhibitor use was associated with reduced risks of all-cause mortality and ischemic stroke.
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Yang W, Cai X, Han X, Ji L. DPP-4 inhibitors and risk of infections: a meta-analysis of randomized controlled trials. Diabetes Metab Res Rev 2016; 32:391-404. [PMID: 26417956 DOI: 10.1002/dmrr.2723] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 08/25/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND To evaluate the risk of infections in the treatment of type 2 diabetes patients with dipeptidyl-peptidase 4 (DPP-4) inhibitors. METHODS A literature search was conducted through electronic databases. The inclusion criteria included study duration of no less than 12 weeks developed in type 2 diabetes patients, the use of a randomized control group receiving a DPP-4 inhibitor and the availability of outcome data for infections. Out of 2181 studies, 74 studies were finally included. RESULTS The risk of overall infection for DPP-4 inhibitors treatment was comparable to placebo (odds ratio (OR) = 0.97, 95% confidence interval (CI), 0.91 to 1.04, p = 0.40), metformin treatment (OR = 1.22, 95% CI, 0.95 to 1.56, p = 0.12), sulphonylurea treatment (OR = 1.09, 0.93 to 1.29, p = 0.29), thiazolidinedione treatment (OR = 0.86, 95% CI, 0.65 to 1.14, p = 0.29) and alpha glucosidase inhibitor treatment (OR = 1.03, 95% CI, 0.33 to 3.22, p = 0.96). When compared different DPP-4 inhibitors with placebo treatment, risks of infections were comparable for alogliptin, linagliptin, sitagliptin, saxagliptin and vildagliptin. Compared with placebo or active comparator treatment, risks of infection in different systems for DPP-4 inhibitors were all comparable. CONCLUSIONS The overall risk of infections of DPP-4 inhibitor was not increased compared with control groups.
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Affiliation(s)
- Wenjia Yang
- Endocrinology and Metabolism Department, Peking University People's Hospital, Beijing, China
| | - Xiaoling Cai
- Endocrinology and Metabolism Department, Peking University People's Hospital, Beijing, China
| | - Xueyao Han
- Endocrinology and Metabolism Department, Peking University People's Hospital, Beijing, China
| | - Linong Ji
- Endocrinology and Metabolism Department, Peking University People's Hospital, Beijing, China
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Penno G, Garofolo M, Del Prato S. Dipeptidyl peptidase-4 inhibition in chronic kidney disease and potential for protection against diabetes-related renal injury. Nutr Metab Cardiovasc Dis 2016; 26:361-373. [PMID: 27105869 DOI: 10.1016/j.numecd.2016.01.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 12/21/2015] [Accepted: 01/07/2016] [Indexed: 02/06/2023]
Abstract
AIMS Type 2 diabetes mellitus (T2DM) is associated with a high risk of chronic kidney disease (CKD). About 20% of patients with T2DM have CKD of stage ≥ 3; up to 40% have some degree of CKD. Beyond targeting all renal risk factors together, renin-angiotensin-aldosterone system blockers are to date the only effective mainstay for the treatment of diabetic kidney disease (DKD). Indeed, several potentially nephroprotective agents have been in use, which have been unsuccessful. Some glucose-lowering agents, including dipeptidyl peptidase-4 inhibitors (DPP-4i), have shown promising results. Here, we discuss the evidence that glucose lowering with DPP-4i may be an option for protecting against diabetes-related renal injury. DATA SYNTHESIS A comprehensive search was performed of the literature using the terms "alogliptin," "linagliptin," "saxagliptin," "sitagliptin," and "vildagliptin" for original articles and reviews addressing this topic. DPP-4i are an effective, well-tolerated treatment option for T2DM with any degree of renal impairment. Preclinical observations and clinical studies suggest that DPP-4i might also be a promising strategy for the treatment of DKD. The available data are in favor of saxagliptin and linagliptin, but the consistency of results points to the possible nephroprotective effect of DPP-4i. This property appears to be independent of glucose lowering and can potentially complement other therapies that preserve renal function. Larger prospective clinical trials are ongoing, which might strengthen these hypothesis-generating findings. CONCLUSIONS The improvement in albuminuria associated with DPP-4i suggests that these agents may provide renal benefits beyond their glucose-lowering effects, thus offering direct protection from DKD. These promising results must be interpreted with caution and need to be confirmed in forthcoming studies.
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Affiliation(s)
- G Penno
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy.
| | - M Garofolo
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - S Del Prato
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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47
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Affiliation(s)
- Amar Puttanna
- Department of Diabetes and Endocrinology; City Hospital; Birmingham UK
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48
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Varvaki Rados D, Catani Pinto L, Reck Remonti L, Bauermann Leitão C, Gross JL. The Association between Sulfonylurea Use and All-Cause and Cardiovascular Mortality: A Meta-Analysis with Trial Sequential Analysis of Randomized Clinical Trials. PLoS Med 2016; 13:e1001992. [PMID: 27071029 PMCID: PMC4829174 DOI: 10.1371/journal.pmed.1001992] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 03/01/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Sulfonylureas are an effective and inexpensive treatment for type 2 diabetes. There is conflicting data about the safety of these drugs regarding mortality and cardiovascular outcomes. The objective of the present study was to evaluate the safety of the sulfonylureas most frequently used and to use trial sequential analysis (TSA) to analyze whether the available sample was powered enough to support the results. METHODS AND FINDINGS Electronic databases were reviewed from 1946 (Embase) or 1966 (MEDLINE) up to 31 December 2014. Randomized clinical trials (RCTs) of at least 52 wk in duration evaluating second- or third-generation sulfonylureas in the treatment of adults with type 2 diabetes and reporting outcomes of interest were included. Primary outcomes were all-cause and cardiovascular mortality. Additionally, myocardial infarction and stroke events were evaluated. Data were summarized with Peto odds ratios (ORs), and the reliability of the results was evaluated with TSA. Forty-seven RCTs with 37,650 patients and 890 deaths in total were included. Sulfonylureas were not associated with all-cause (OR 1.12 [95% CI 0.96 to 1.30]) or cardiovascular mortality (OR 1.12 [95% CI 0.87 to 1.42]). Sulfonylureas were also not associated with increased risk of myocardial infarction (OR 0.92 [95% CI 0.76 to 1.12]) or stroke (OR 1.16 [95% CI 0.81 to 1.66]). TSA could discard an absolute difference of 0.5% between the treatments, which was considered the minimal clinically significant difference. The major limitation of this review was the inclusion of studies not designed to evaluate safety outcomes. CONCLUSIONS Sulfonylureas are not associated with increased risk for all-cause mortality, cardiovascular mortality, myocardial infarction, or stroke. Current evidence supports the safety of sulfonylureas; an absolute risk of 0.5% could be firmly discarded. REVIEW REGISTRATION PROSPERO CRD42014004330.
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Affiliation(s)
- Dimitris Varvaki Rados
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
- * E-mail:
| | - Lana Catani Pinto
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
| | - Luciana Reck Remonti
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
| | - Cristiane Bauermann Leitão
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
| | - Jorge Luiz Gross
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
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Evans M, Bain SC, Vora J. A systematic review of the safety of incretin-based therapies in type 2 diabetes. Expert Rev Endocrinol Metab 2016; 11:217-232. [PMID: 30058866 DOI: 10.1586/17446651.2015.1057502] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Large randomized clinical trials have demonstrated that incretin-based therapies provide effective glycemic control in type 2 diabetes. Long-term safety assessments are ongoing. METHODS This systematic review of incretin-based therapy safety is based on 112 randomized clinical trials of duration ≥26 weeks published between January 2000 and February 2015 in patients with type 2 diabetes. RESULTS As expected, hypoglycemia rates were lower with dipeptidyl peptidase-4 inhibitors (DPP-4is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) versus other oral antidiabetic drugs and insulin. The most common adverse events were infection and infestation (DPP-4is) and gastrointestinal (GLP-1 RAs). Pancreatitis cases were rare across all studies and, in the SAVOR-TIMI and EXAMINE trials, pancreatitis rates were similar in DPP-4i- and placebo-treated patients. No thyroid tumors were reported, and increased risk of cardiovascular events was not associated with DPP-4is in SAVOR-TIMI and EXAMINE, albeit over a short follow-up period. CONCLUSIONS Overall, incretin-based therapies were well tolerated; however, their long-term safety profile should continue to be periodically assessed.
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Affiliation(s)
- Marc Evans
- a Department of Diabetes, University Hospital Llandough , Cardiff , UK
| | - Stephen C Bain
- b Institute of Life Science , Swansea University , Swansea , UK
| | - Jiten Vora
- c School of Medicine, University of Liverpool , Merseyside , UK
- d Diabetes Centre, Royal Liverpool University Hospital , Merseyside , UK
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Chen M, Liu Y, Jin J, He Q. The efficacy and safety of dipeptidyl peptidase-4 inhibitors for treatment of type 2 diabetes mellitus patients with severe renal impairment: a meta-analysis. Ren Fail 2016; 38:581-7. [PMID: 26915531 DOI: 10.3109/0886022x.2016.1149682] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIMS/INTRODUCTION Dipeptidyl peptidase-4 (DPP-4) inhibitors are a new class of oral antidiabetic agents, and have been increasingly and widely used in the treatment of diabetes mellitus (DM). However, information of DPP-4 inhibitors in type 2 DM patients with severe renal impairment (RI) is limited. Our study aimed to assess the efficacy and safety of DPP-4 inhibitors as compared to placebos or other hypoglycemic drugs in type 2 DM patients with severe RI. MATERIALS AND METHODS A meta-analysis was conducted to examine the literature comparing the effects of DPP-4 inhibitors on hemoglobin A1c (HbA1c) and fasting blood glucose (FBG). Randomized control trials (RCTs) including adults with type 2 DM and severe RI were analyzed. Safety was evaluated based on the percentage of patients who developed hypoglycemia and the occurrence of adverse events (AEs) as well as the incidence of peripheral edema, urinary tract infection, diarrhea, and death. RESULTS Five RCTs including 503 patients were analyzed. Compared with a placebo or no treatment, DPP-4 inhibitors were associated with a larger decline in HbA1c (mean difference (MD) = -0.57, 95% confidence interval (CI): -0.73 to -0.41; p < 0.01) but not with FBG (MD = -0.26, 95% CI: -1.40 to 0.8; p = 0.66). Compared with glipizide monotherapy, no significant differences in HbA1c (MD = 0.15, 95% CI: -0.19 to 0.49; p = 0.38) or FBG (MD = -0.26, 95% CI: -1.16 to 0.64; p = 0.57) were found. Similar odds of experiencing an AE were found in both the DPP-4 inhibitor groups and comparison groups. CONCLUSIONS In type 2 DM patients with severe RI, treatment with DPP-4 inhibitors is safe and it effectively lowers HbA1c.
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Affiliation(s)
- Maosheng Chen
- a Department of Nephrology , Zhejiang Provincial People's Hospital , Hangzhou , PR China ;,b National Clinical Research Center of Kidney Diseases , Jinling Hospital, Nanjing University School of Medicine , Nanjing , PR China
| | - Yueming Liu
- a Department of Nephrology , Zhejiang Provincial People's Hospital , Hangzhou , PR China
| | - Juan Jin
- a Department of Nephrology , Zhejiang Provincial People's Hospital , Hangzhou , PR China
| | - Qiang He
- a Department of Nephrology , Zhejiang Provincial People's Hospital , Hangzhou , PR China ;,c Wenzhou Medical University Wenzhou , Wenzhou , PR China
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