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Akturk HK, Dong F, Snell-Bergeon JK, Karakus KE, Shah VN. Efficacy and Safety of Tirzepatide in Adults With Type 1 Diabetes: A Proof of Concept Observational Study. J Diabetes Sci Technol 2024:19322968231223991. [PMID: 38317405 DOI: 10.1177/19322968231223991] [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] [Indexed: 02/07/2024]
Abstract
BACKGROUND Tirzepatide is approved by the United States Food and Drug Administration (FDA) for the management of type 2 diabetes. The efficacy and safety of this drug have not been studied in people with type 1 diabetes (T1D). METHODS In this single-center, retrospective, observational study, hemoglobin A1C (HbA1c), weight, body mass index (BMI), and continuous glucose monitoring (CGM) data were collected from electronic health records of adults with T1D at initiation of tirzepatide and at subsequent clinic visits over 8 months. Primary outcomes were reduction in HbA1c and percent change in body weight and secondary outcomes were change in CGM metrics and BMI over 8 months from baseline. RESULTS The mean (±SD) age of the 26 adults (54% female) with T1D was 42 ± 8 years with a mean BMI of 36.7 ± 5.3 kg/m2. There was significant reduction in HbA1c by 0.45% at 3 months and 0.59% at 8 months, and a significant reduction in body weight by 3.4%, 10.5%, and 10.1% at 3, 6, and 8 months after starting tirzepatide. Time in target range (TIR = 70-180 mg/dL) and time in tight target range (TITR = 70-140 mg/dL) increased (+12.6%, P = .002; +10.7%, P = .0016, respectively) and time above range (TAR >180 mg/dL) decreased (-12.6%, P = .002) at 3 months, and these changes were sustained over 8 months. The drug was relatively safe and well tolerated with only 2 patients discontinuing the medication. CONCLUSIONS Tirzepatide significantly reduced HbA1c and body weight in adults with T1D. A randomized controlled trial is needed to establish efficacy and safety of this drug in T1D.
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Affiliation(s)
- Halis Kaan Akturk
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Fran Dong
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Janet K Snell-Bergeon
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kagan Ege Karakus
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Viral N Shah
- Division of Endocrinology & Metabolism, Indiana University School of Medicine, Indianapolis, IN, USA
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2
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Hasselstrøm Jensen J, Vestergaard P, Hasselstrøm Jensen M. Association between Glucose-lowering Treatments and Risk of Diabetic Retinopathy in People with Type 2 Diabetes: A Nationwide Cohort Study. Curr Drug Saf 2024; 19:236-243. [PMID: 37078347 DOI: 10.2174/1574886318666230420084701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION Glycaemic variability is possibly linked to the development of diabetic retinopathy, and newer second-line glucose-lowering treatments in type 2 diabetes might reduce glycaemic variability. AIM This study aimed to investigate whether newer second-line glucose-lowering treatments are associated with an alternative risk of developing diabetic retinopathy in people with type 2 diabetes. METHODS A nationwide cohort of people with type 2 diabetes on second-line glucose-lowering treatment regimens in 2008-2018 was extracted from the Danish National Patient Registry. Adjusted time to diabetic retinopathy was estimated with a Cox Proportional Hazards model. The model was adjusted for age, sex, diabetes duration, alcohol abuse, treatment start year, education, income, history of late-diabetic complications, history of non-fatal major adverse cardiovascular events, history of chronic kidney disease, and history of hypoglycaemic episodes. RESULTS Treatment regimens of metformin + basal insulin (HR: 3.15, 95% CI: 2.42-4.10) and metformin + glucagon-like peptide-1 receptor agonist (GLP-1-RA, HR: 1.46, 95% CI: 1.09-1.96) were associated with an increased risk of diabetic retinopathy compared with metformin + dipeptidyl peptidase-4 inhibitors (DPP-4i). Treatment with metformin + sodium-glucose cotransporter-2 inhibitor (SGLT2i, HR: 0.77, 95% CI: 0.28-2.11) was associated with the numerically lowest risk of diabetic retinopathy compared with all regimens investigated. CONCLUSION Findings from this study indicate that basal insulin and GLP-1-RA are suboptimal second- line choices for people with type 2 diabetes at risk of developing diabetic retinopathy. However, many other considerations concerning the choice of second-line glucose-lowering treatment for type 2 diabetes patients should be taken into account.
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Affiliation(s)
| | - Peter Vestergaard
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Hobrovej 19, 9100, Aalborg, Denmark
| | - Morten Hasselstrøm Jensen
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Hobrovej 19, 9100, Aalborg, Denmark
- Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7, 9220, Aalborg, Denmark
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3
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Li M, Liu Z, Yang X, Zhang J, Han M, Zhang Y, Liu Y. The effect of sodium-glucose cotransporter 2 inhibitors as an adjunct to insulin in patients with type 1 diabetes assessed by continuous glucose monitoring: A systematic review and meta-analysis. J Diabetes Complications 2023; 37:108632. [PMID: 37907042 DOI: 10.1016/j.jdiacomp.2023.108632] [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: 06/16/2023] [Revised: 10/07/2023] [Accepted: 10/19/2023] [Indexed: 11/02/2023]
Abstract
AIMS Patients undergoing insulin-based therapy for type 1 diabetes often experience poor glycemic control characterized by significant fluctuations. This study was undertaken to analyze the effect of sodium-glucose cotransporter 2 inhibitors (SGLT2Is), as an adjunct to insulin, on time in range (TIR) and glycemic variability in patients with type 1 diabetes, using continuous glucose monitoring (CGM). In addition, we examined which type of SGLT2I yielded a superior effect compared to others. METHODS We conducted a comprehensive search of PubMed, EMBASE, the Cochrane Library, Web of Science, and clinical trial registry websites, retrieving all eligible randomized clinical trials (RCTs) published up until February 2023. We analyzed the mean TIR, mean amplitude of glucose excursions (MAGE), mean daily glucose (MDG), diabetic ketoacidosis (DKA), standard deviation (SD), total insulin dose, and severe hypoglycemia to evaluate the efficacy and safety of SGLT2Is. A random-effects model was also employed. RESULTS This study encompassed 15 RCTs. The meta-analysis revealed that the use of SGLT2Is as an adjuvant therapy to insulin led to a significant increase in TIR (MD = 10.78, 95%CI = 9.33-12.23, I2 = 42 %, P < 0.00001) and a decrease in SD (MD = -0.38, 95%CI = -0.50 to -0.26, I2 = 0 %, P < 0.00001), MAGE (MD = -0.92, 95%CI = -1.17 to -0.67, I2 = 19 %, P < 0.00001), MDG(MD = -1.01, 95%CI = -1.32 to -0.70, I2 = 48 %, P < 0.00001), and total insulin dose (MD = -5.81, 95%CI = -7.81 to -3.82, I2 = 32 %, P < 0.00001). No significant increase was observed in the rate of severe hypoglycemia (RR = 1.04, 95 % CI = 0.76-1.43, P = 0.80). However, SGLT2I therapy was associated with increased DKA occurrence (RR = 2.79, 95 % CI = 1.42-5.48; P = 0.003, I2 = 16 %). In addition, the subgroup analyses based on the type of SGLT2Is revealed that dapagliflozin might exhibit greater efficacy compared to other SGLT2Is across most outcomes. CONCLUSIONS SGLT2Is exhibited a positive effect on improving blood glucose level fluctuations. Subgroup analysis showed that dapagliflozin appeared to have more advantages. However, giving due consideration to preventing adverse effects, particularly DKA, is paramount. REGISTRATION Prospero CRD42023408276.
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Affiliation(s)
- Mengnan Li
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, China; First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Zi'ang Liu
- The Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Xifeng Yang
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, China; First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Jiaxin Zhang
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, China; First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Minmin Han
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, China; First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Yi Zhang
- Department of Pharmacology, Shanxi Medical University, Taiyuan, China.
| | - Yunfeng Liu
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, China.
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Ferreira A, Schönenberger K, Potoczna N, Vogt A, Gerber P, Zehetner J, Giachino D, Nett P, Gawinecka J, Cossu L, Fuster D, Dalla Man C, Facchinetti A, Melmer A, Nakas CT, Hepprich M, Donath M, Herzig D, Bally L. Randomized, double-blind, placebo-controlled crossover trial of once daily empagliflozin 25 mg for the treatment of postprandial hypoglycaemia after Roux-en-Y gastric bypass. Diabetes Technol Ther 2023. [PMID: 37093196 DOI: 10.1089/dia.2023.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Aims To investigate the effect of empagliflozin on glucose dynamics in individuals suffering from postbariatric hypoglycaemia (PBH) after Roux-en-Y gastric bypass (RYGB). Methods Twenty-two adults with PBH after RYGB were randomized to empagliflozin 25 mg or placebo once daily over 20 days in a randomized, double-blind, placebo-controlled, crossover trial. The primary efficacy outcome was the amplitude of plasma glucose excursion (peak to nadir) during a mixed meal tolerance test (MMTT). Outcomes of the outpatient period were assessed using continuous glucose monitoring (CGM) and an event-tracking app. Results The amplitude of glucose excursion during the MMTT was 8.1±2.4 mmol/L with empagliflozin vs 8.1±2.6 mmol/L with placebo (mean±SD, p=0.807). CGM-based mean amplitude of glucose excursion (MAGE) during the 20 day-period was lower with empagliflozin than placebo (4.8±1.3 vs 5.2±1.6. p=0.028). Empagliflozin reduced the time spent with CGM values >10.0 mmol/L (3.8±3.5 % vs. 4.7±3.8 %, p =0.009), but not the time spent with CGM values <3.0 mmol/L (1.7±1.6 % vs. 1.5±1.5 %, p=0.457). No significant difference was observed in the quantity and quality of recorded symptoms. Eleven adverse events occurred with empagliflozin (three drug-related) and six with placebo. Conclusions Empagliflozin 25 mg reduces glucose excursions but not hypoglycaemia in individuals with PBH.
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Affiliation(s)
- Antonio Ferreira
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland, Bern, Switzerland;
| | - Katja Schönenberger
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland, Bern, Switzerland
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland, Basel, Switzerland;
| | - Natascha Potoczna
- Stoffwechselpraxis Zentralschweiz, Lucerne, Switzerland , Luzern, Switzerland;
| | - Andreas Vogt
- Inselspital, Bern University Hospital, Freiburgstrasse, Bern, Switzerland, 3010;
| | - Philipp Gerber
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland, Zurich, Switzerland;
| | - Jörg Zehetner
- Department of Visceral Surgery, Hirslanden Clinic Beau-Site, Bern, Switzerland, Bern, Switzerland;
| | - Daniel Giachino
- Department of Visceral Surgery, Lindenhofspital, Bern, Switzerland, Bern, Switzerland;
| | - Philipp Nett
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland, Bern, Switzerland;
| | - Joanna Gawinecka
- Institute of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland, Zurich, Switzerland;
| | - Luca Cossu
- Department of Information Engineering, University of Padova, Padova, Italy, Padova, Switzerland;
| | - Daniel Fuster
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland, Bern, Switzerland;
| | - Chiara Dalla Man
- University of Padova, Department of Information Engineering, Via Gradenigo 6B, Padova, Italy, 35131;
| | - Andrea Facchinetti
- University of Padova, Information Engineering, via G.Gradenigo 6/B, Padova, PD, Italy, 35131;
| | - Andreas Melmer
- Inselspital University Hospital Bern, 27252, Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Freiburgstrasse 15, Bern, BE, Switzerland, 3012;
| | - Christos T Nakas
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Laboratory of Biometry, School of Agriculture, University of Thessaly, Nea Ionia Magnesia, Greece;
| | - Matthias Hepprich
- University Hospital Basel, Division of Endocrinology, Diabetes and Metabolism, Basel, Switzerland, Basel, Switzerland;
| | - Marc Donath
- University Hospital Basel, Division of Endocrinology, Diabetes and Metabolism, Basel, Switzerland, Basel, Switzerland;
| | - David Herzig
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Department of Diabetes, EndocrinologyNutritional Medicine and Metabolism, Bern University Hospital, University of Bern, Bern, Switzerland, 3000;
| | - Lia Bally
- Inselspital, Bern University Hospital, Division of Endocrinology, Diabetes & Clinical Nutrition, Freiburgstrasse, Bern, Switzerland, 3010;
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Toma L, Sanda GM, Stancu CS, Niculescu LS, Raileanu M, Sima AV. Oscillating Glucose Induces the Increase in Inflammatory Stress through Ninjurin-1 Up-Regulation and Stimulation of Transport Proteins in Human Endothelial Cells. Biomolecules 2023; 13:biom13040626. [PMID: 37189375 DOI: 10.3390/biom13040626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/25/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Clinical data implicate fluctuations of high levels of plasma glucose in cardiovascular diseases. Endothelial cells (EC) are the first cells of the vessel wall exposed to them. Our aim was to evaluate the effects of oscillating glucose (OG) on EC function and to decipher new molecular mechanisms involved. Cultured human ECs (EA.hy926 line and primary cells) were exposed to OG (5/25 mM alternatively at 3 h), constant HG (25 mM) or physiological concentration (5 mM, NG) for 72 h. Markers of inflammation (Ninj-1, MCP-1, RAGE, TNFR1, NF-kB, and p38 MAPK), oxidative stress (ROS, VPO1, and HO-1), and transendothelial transport proteins (SR-BI, caveolin-1, and VAMP-3) were assessed. Inhibitors of ROS (NAC), NF-kB (Bay 11-7085), and Ninj-1 silencing were used to identify the mechanisms of OG-induced EC dysfunction. The results revealed that OG determined an increased expression of Ninj-1, MCP-1, RAGE, TNFR1, SR-B1, and VAMP-3 andstimulated monocyte adhesion. All of these effects were induced bymechanisms involving ROS production or NF-kB activation. NINJ-1 silencing inhibited the upregulation of caveolin-1 and VAMP-3 induced by OG in EC. In conclusion, OG induces increased inflammatory stress, ROS production, and NF-kB activation and stimulates transendothelial transport. To this end, we propose a novel mechanism linking Ninj-1 up-regulation to increased expression of transendothelial transport proteins.
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Psoma O, Makris M, Tselepis A, Tsimihodimos V. Short-term Glycemic Variability and Its Association With Macrovascular and Microvascular Complications in Patients With Diabetes. J Diabetes Sci Technol 2022:19322968221146808. [PMID: 36576014 DOI: 10.1177/19322968221146808] [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] [Indexed: 12/29/2022]
Abstract
The introduction of continuous glucose monitoring inaugurated a new era in clinical practice by shifting the characterization of glycemic control from HbA1c to novel metrics. The one that gained widespread attention over the past decades was glycemic variability (GV), which typically refers to peaks and nadirs of blood glucose measured over a given time interval. GV can be dichotomized into two main categories: short-term and long-term. Short-term GV reflects within-day and between-day glycemic oscillations, and its contribution to diabetic complications remains an enigma. In this review, we summarize the available data about short-term GV and its possible association with both microvascular and macrovascular complications, evaluating different pathogenic mechanisms and demonstrating nonpharmaceutical, as well as pharmaceutical, therapeutic interventions.
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Affiliation(s)
- Ourania Psoma
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Marios Makris
- UCL Medical School, University College London, London, UK
| | - Alexandros Tselepis
- Atherothrombosis Research Centre/Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, Ioannina, Greece
| | - Vasilis Tsimihodimos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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Digital Health Technologies in Pediatric Trials. Ther Innov Regul Sci 2022; 56:929-933. [PMID: 35344202 DOI: 10.1007/s43441-021-00374-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/27/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Advances in the miniaturization of sensors and other technologies provide opportunities to collect physiological and/or functional data directly from patients participating in clinical trials. The use of such technologies in children is particularly promising. Objective, quantifiable measurements made by these technologies, often on a continuous or frequent basis, may provide more robust data than the episodic reports from caregivers that are used in traditional pediatric trials. METHODS We reviewed the pros and cons of these technologies for use in a variety of pediatric diseases, including seizure and neuromuscular disorders, cardiorespiratory diseases, and metabolic disorders. RESULTS Correlation between sensor measurements and patient observations or traditional clinical measurements varied depending on the disease being evaluated. There was a notable dearth of reports on the use of digital health technology in pediatric patients. Given the range of sensors and measurements that can be made by DHTs, selection of the design, metrics and types of sensors best suited to disease evaluation presents challenges for adoption of these technologies in clinical trials. CONCLUSION Traditional measurements of drug effects are often deficient, particularly in the evaluation of infants and young children. The opportunity to make objective, frequent measurements may increase our power to detect and quantify responses to therapy in these populations. Further research and evaluation are needed to realize the full scientific potential of remote monitoring in pediatric clinical trials.
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Perspectives of glycemic variability in diabetic neuropathy: a comprehensive review. Commun Biol 2021; 4:1366. [PMID: 34876671 PMCID: PMC8651799 DOI: 10.1038/s42003-021-02896-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/16/2021] [Indexed: 12/14/2022] Open
Abstract
Diabetic neuropathy is one of the most prevalent chronic complications of diabetes, and up to half of diabetic patients will develop diabetic neuropathy during their disease course. Notably, emerging evidence suggests that glycemic variability is associated with the pathogenesis of diabetic complications and has emerged as a possible independent risk factor for diabetic neuropathy. In this review, we describe the commonly used metrics for evaluating glycemic variability in clinical practice and summarize the role and related mechanisms of glycemic variability in diabetic neuropathy, including cardiovascular autonomic neuropathy, diabetic peripheral neuropathy and cognitive impairment. In addition, we also address the potential pharmacological and non-pharmacological treatment methods for diabetic neuropathy, aiming to provide ideas for the treatment of diabetic neuropathy. Zhang et al. describe metrics for evaluating glycaemic variability (GV) in clinical practice and summarize the role and related mechanisms of GV in diabetic neuropathy, including cardiovascular autonomic neuropathy, diabetic peripheral neuropathy and cognitive impairment. They aim to stimulate ideas for the treatment of diabetic neuropathy.
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van Meijel LA, Tack CJ, de Galan BE. Effect of short-term use of dapagliflozin on impaired awareness of hypoglycaemia in people with type 1 diabetes. Diabetes Obes Metab 2021; 23:2582-2589. [PMID: 34338413 PMCID: PMC9292159 DOI: 10.1111/dom.14505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/11/2021] [Accepted: 07/26/2021] [Indexed: 12/12/2022]
Abstract
AIM Impaired awareness of hypoglycaemia (IAH) affects about 25% of patients with type 1 diabetes (T1DM). IAH can be reversed by strict avoidance of hypoglycaemia for at least 3 weeks. Adjunctive treatment with sodium glucose cotransporter 2 inhibitors may reduce the risk of hypoglycaemia through reduction of glucose variability. We tested the hypothesis that short-term use of dapagliflozin may improve awareness of hypoglycaemia in people with T1DM and IAH. MATERIALS AND METHODS Fifteen patients with T1DM and IAH were included in this randomized double-blind, placebo-controlled cross-over trial (age 49.7 ± 14.6 years, 40% men, disease duration 24.1 ± 14.2 years, glycated haemoglobin 7.5 ± 0.8% (58.6 ± 8.4 mmol/mol). They were treated with dapagliflozin 10 mg once daily or matching placebo, with a washout period of 2 weeks. At the end of each treatment period, participants underwent a modified hyperinsulinaemic normoglycaemic-hypoglycaemic glucose clamp (glucose nadir 2.5 mmol/L). Blinded continuous glucose monitors were used in the final treatment weeks. RESULTS Treatment with dapagliflozin significantly improved glycated haemoglobin [-0.32 ± 0.10 vs. 0.22 ± 0.13% (-4.1 ± 0.9 vs. 2.3 ± 1.4 mmol/mol), dapagliflozin vs. placebo, p = .007] and glucose variability (standard deviation, 2.6 ± 0.2 vs. 3.1 ± 0.3 mmol/L, p = .029), but did not affect the frequency of hypoglycaemia. During the hypoglycaemic clamp, dapagliflozin did not affect symptom responses (8.0 ± 3.4 vs. 5.2 ± 1.6, p = .31), but significantly reduced the need for exogenous glucose to maintain hypoglycaemia (3.2 ± 0.3 vs. 4.1 ± 0.4 mg/kg/min, p = .022). CONCLUSIONS Eight weeks of treatment with dapagliflozin did not restore hypoglycaemic awareness in people with T1DM and impaired awareness of hypoglycaemia, but ameliorated some clinical aspects.
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Affiliation(s)
- Lian A. van Meijel
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
- Department of Internal MedicineMaxima Medical CenterVeldhovenThe Netherlands
| | - Cees J. Tack
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
| | - Bastiaan E. de Galan
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
- Department of Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
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Veneti S, Tziomalos K. Sodium/glucose cotransporter 2 inhibitors for the treatment of type 1 diabetes: what are the latest developments? Expert Opin Pharmacother 2021; 22:2261-2266. [PMID: 34402702 DOI: 10.1080/14656566.2021.1967931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Despite the improvements in insulin therapy, many patients with type 1 diabetes mellitus (T1DM) do not achieve glycemic targets. Hypoglycemia and weight gain are important barriers in reaching these targets. Sodium/glucose cotransporter 2 (SGLT2) inhibitors lack these side effects and have an insulin-independent mechanism of action. Therefore, they might be useful in patients with T1DM. The authors discuss the safety and efficacy of SGLT2 inhibitors in T1DM. Several randomized controlled trials have evaluated dapagliflozin, sotagliflozin and empagliflozin in this population whereas fewer data are available for other members of this class. In these studies, SGLT2 inhibitors reduced HbA1c levels and body weight without a greater risk of hypoglycemia. However, a higher incidence of diabetic ketoacidosis (DKA) was observed in patients treated with these agents. SGLT2 inhibitors improve glycemic control in patients with T1DM but this effect is modest. Even though weight loss and the neutral effect on the incidence of hypoglycemia are advantages of these agents, the increased risk of DKA is a cause of concern. Overall, SGLT2 inhibitors should be used with caution and only in carefully selected patients with T1DM who are motivated, adherent to treatment, well-trained in recognizing DKA and are closely followed-up.
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Affiliation(s)
- Stavroula Veneti
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Konstantinos Tziomalos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
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Alfieri V, Myasoedova VA, Vinci MC, Rondinelli M, Songia P, Massaiu I, Cosentino N, Moschetta D, Valerio V, Ciccarelli M, Marenzi G, Genovese S, Poggio P. The Role of Glycemic Variability in Cardiovascular Disorders. Int J Mol Sci 2021; 22:ijms22168393. [PMID: 34445099 PMCID: PMC8395057 DOI: 10.3390/ijms22168393] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 07/30/2021] [Accepted: 07/30/2021] [Indexed: 01/01/2023] Open
Abstract
Diabetes mellitus (DM) is one of the most common and costly disorders that affect humans around the world. Recently, clinicians and scientists have focused their studies on the effects of glycemic variability (GV), which is especially associated with cardiovascular diseases. In healthy subjects, glycemia is a very stable parameter, while in poorly controlled DM patients, it oscillates greatly throughout the day and between days. Clinically, GV could be measured by different parameters, but there are no guidelines on standardized assessment. Nonetheless, DM patients with high GV experience worse cardiovascular disease outcomes. In vitro and in vivo studies showed that high GV causes several detrimental effects, such as increased oxidative stress, inflammation, and apoptosis linked to endothelial dysfunction. However, the evidence that treating GV is beneficial is still scanty. Clinical trials aiming to improve the diagnostic and prognostic accuracy of GV measurements correlated with cardiovascular outcomes are needed. The present review aims to evaluate the clinical link between high GV and cardiovascular diseases, taking into account the underlined biological mechanisms. A clear view of this challenge may be useful to standardize the clinical evaluation and to better identify treatments and strategies to counteract this DM aspect.
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Affiliation(s)
- Valentina Alfieri
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (V.A.); (V.A.M.); (M.C.V.); (M.R.); (P.S.); (I.M.); (N.C.); (D.M.); (V.V.); (G.M.); (S.G.)
| | - Veronika A. Myasoedova
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (V.A.); (V.A.M.); (M.C.V.); (M.R.); (P.S.); (I.M.); (N.C.); (D.M.); (V.V.); (G.M.); (S.G.)
| | - Maria Cristina Vinci
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (V.A.); (V.A.M.); (M.C.V.); (M.R.); (P.S.); (I.M.); (N.C.); (D.M.); (V.V.); (G.M.); (S.G.)
| | - Maurizio Rondinelli
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (V.A.); (V.A.M.); (M.C.V.); (M.R.); (P.S.); (I.M.); (N.C.); (D.M.); (V.V.); (G.M.); (S.G.)
| | - Paola Songia
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (V.A.); (V.A.M.); (M.C.V.); (M.R.); (P.S.); (I.M.); (N.C.); (D.M.); (V.V.); (G.M.); (S.G.)
| | - Ilaria Massaiu
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (V.A.); (V.A.M.); (M.C.V.); (M.R.); (P.S.); (I.M.); (N.C.); (D.M.); (V.V.); (G.M.); (S.G.)
| | - Nicola Cosentino
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (V.A.); (V.A.M.); (M.C.V.); (M.R.); (P.S.); (I.M.); (N.C.); (D.M.); (V.V.); (G.M.); (S.G.)
| | - Donato Moschetta
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (V.A.); (V.A.M.); (M.C.V.); (M.R.); (P.S.); (I.M.); (N.C.); (D.M.); (V.V.); (G.M.); (S.G.)
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20122 Milano, Italy
| | - Vincenza Valerio
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (V.A.); (V.A.M.); (M.C.V.); (M.R.); (P.S.); (I.M.); (N.C.); (D.M.); (V.V.); (G.M.); (S.G.)
- Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, 80138 Napoli, Italy
| | - Michele Ciccarelli
- Chirurgia ed Odontoiatria, Dipartimento di Medicina, Università degli Studi di Salerno, 84084 Salerno, Italy;
| | - Giancarlo Marenzi
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (V.A.); (V.A.M.); (M.C.V.); (M.R.); (P.S.); (I.M.); (N.C.); (D.M.); (V.V.); (G.M.); (S.G.)
| | - Stefano Genovese
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (V.A.); (V.A.M.); (M.C.V.); (M.R.); (P.S.); (I.M.); (N.C.); (D.M.); (V.V.); (G.M.); (S.G.)
| | - Paolo Poggio
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (V.A.); (V.A.M.); (M.C.V.); (M.R.); (P.S.); (I.M.); (N.C.); (D.M.); (V.V.); (G.M.); (S.G.)
- Correspondence: ; Tel.: +39-025-800-2853
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Lee SH, Min KW, Lee BW, Jeong IK, Yoo SJ, Kwon HS, Choi YH, Yoon KH. Effect of Dapagliflozin as an Add-on Therapy to Insulin on the Glycemic Variability in Subjects with Type 2 Diabetes Mellitus (DIVE): A Multicenter, Placebo-Controlled, Double-Blind, Randomized Study. Diabetes Metab J 2021; 45:339-348. [PMID: 32602273 PMCID: PMC8164951 DOI: 10.4093/dmj.2019.0203] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/30/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Glycemic variability is associated with the development of diabetic complications and hypoglycemia. However, the effect of sodium-glucose transporter 2 (SGLT2) inhibitors on glycemic variability is controversial. We aimed to examine the effect of dapagliflozin as an add-on therapy to insulin on the glycemic variability assessed using continuous glucose monitoring (CGM) in subjects with type 2 diabetes mellitus. METHODS In this multicenter, placebo-controlled, double-blind, randomized study, 84 subjects received 10 mg of dapagliflozin (n=41) or the placebo (n=43) for 12 weeks. CGM was performed before and after treatment to compare the changes in glycemic variability measures (standard deviation [SD], mean amplitude of glycemic excursions [MAGEs]). RESULTS At week 12, significant reductions in glycosylated hemoglobin (-0.74%±0.66% vs. 0.01%±0.65%, P<0.001), glycated albumin (-3.94%±2.55% vs. -0.67%±2.48%, P<0.001), and CGM-derived mean glucose (-41.6±39.2 mg/dL vs. 1.1±46.2 mg/dL, P<0.001) levels were observed in the dapagliflozin group compared with the placebo group. SD and MAGE were significantly decreased in the dapagliflozin group, but not in the placebo group. However, the difference in ΔSD and ΔMAGE failed to reach statistical significance between two groups. No significant differences in the incidence of safety endpoints were observed between the two groups. CONCLUSION Dapagliflozin effectively decreased glucose levels, but not glucose variability, after 12 weeks of treatment in participants with type 2 diabetes mellitus receiving insulin treatment. The role of SGLT2 inhibitors in glycemic variability warrants further investigations.
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Affiliation(s)
- Seung-Hwan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyung-Wan Min
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Byung-Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - In-Kyung Jeong
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Soon-Jib Yoo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Hyuk-Sang Kwon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoon-Hee Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- MedicalExcellence Inc., Seoul, Korea
| | - Kun-Ho Yoon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Korea
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13
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Johnston CK, Eudy-Byrne RJ, Elmokadem A, Nock V, Marquard J, Soleymanlou N, Riggs MM, Liesenfeld KH. A Model-Informed Drug Development (MIDD) Approach for a Low Dose of Empagliflozin in Patients with Type 1 Diabetes. Pharmaceutics 2021; 13:pharmaceutics13040485. [PMID: 33918261 PMCID: PMC8066500 DOI: 10.3390/pharmaceutics13040485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 11/16/2022] Open
Abstract
In clinical trials, sodium-glucose co-transporter (SGLT) inhibitor use as adjunct to insulin therapy in type 1 diabetes (T1D) provides glucometabolic benefits while diabetic ketoacidosis risk is increased. The SGLT2 inhibitor empagliflozin was evaluated in two phase III trials: EASE-2 and EASE-3. A low, 2.5-mg dose was included in EASE-3 only. As the efficacy of higher empagliflozin doses (i.e., 10 and 25 mg) in T1D has been established in EASE-2 and EASE-3, a modeling and simulation approach was used to generate additional supportive evidence on efficacy for the 2.5-mg dose. We present the methodology behind the development and validation of two modeling and simulation frameworks: M-EASE-1, a semi-mechanistic model integrating information on insulin, glucose, and glycated hemoglobin; and M-EASE-2, a descriptive model informed by prior information. Both models were developed independently of data from EASE-3. Simulations based on these models assessed efficacy in untested clinical trial scenarios. In this manner, the models provide supportive evidence for efficacy of low-dose empagliflozin 2.5 mg in patients with T1D, illustrating how pharmacometric analyses can support efficacy assessments in the context of limited data.
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Affiliation(s)
- Curtis K. Johnston
- Metrum Research Group, Tariffville, CT 06081, USA; (C.K.J.); (R.J.E.-B.); (A.E.); (M.M.R.)
| | - Rena J. Eudy-Byrne
- Metrum Research Group, Tariffville, CT 06081, USA; (C.K.J.); (R.J.E.-B.); (A.E.); (M.M.R.)
| | - Ahmed Elmokadem
- Metrum Research Group, Tariffville, CT 06081, USA; (C.K.J.); (R.J.E.-B.); (A.E.); (M.M.R.)
| | - Valerie Nock
- Boehringer Ingelheim International GmbH, 55216 Ingelheim, Germany;
| | - Jan Marquard
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT 06877, USA; (J.M.); (N.S.)
| | - Nima Soleymanlou
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT 06877, USA; (J.M.); (N.S.)
| | - Matthew M. Riggs
- Metrum Research Group, Tariffville, CT 06081, USA; (C.K.J.); (R.J.E.-B.); (A.E.); (M.M.R.)
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14
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Liu Y, Yu J, Ma C, He S, Ping F, Zhang H, Li W, Xu L, Xiao X, Li Y. Hemoglobin A1c modifies the association between triglyceride and time in hypoglycemia determined by flash glucose monitoring in adults with type 1 diabetes: implications for individualized therapy and decision-making. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:537. [PMID: 33987235 DOI: 10.21037/atm-20-6344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background We aimed to investigate the associations of flash glucose monitoring (FGM)-derived metrics with lipid profiles and identify potential modifiers of these associations among adults with type 1 diabetes (T1D). Methods A cross-sectional study was conducted among 108 Chinese adults with T1D who used FGM for 14 consecutive days. The relationship between FGM-derived metrics and lipid variables and potential modifiers were identified using interaction and subgroup analysis. Results Serum triglyceride level inversely correlated with time below range (glucose <3.9 mmol/L) and time in range (glucose 3.9-10.0 mmol/L) and positively correlated with time above range (glucose >10.0 mmol/L) (Spearman's r=-0.34, -0.25, 0.34, respectively, all P<0.01). Additionally, triglyceride levels had positive correlation with absolute measures of glycemic variability (GV) but not with the coefficient of variation for glucose (Spearman's r=0.12, P>0.05), a relative measure. Multivariate linear regression analysis adjusting for potential confounders including gender, age, disease duration, body mass index (BMI), daily insulin dose, fasting C-peptide, and dyslipidemia medication use showed that higher triglyceride level independently predicted decrease in time below range and time in range and increase in time above range (all P<0.01). Furthermore, interaction analysis found that the interaction between HbA1c and triglyceride was significant in the time below range (P for interaction =0.034). The association between triglyceride and time below range differed substantially after stratification by HbA1c, which was significant in those with HbA1c <7.0% whereas inconsequential among those with HbA1c ≥7.0%. In those with HbA1c <7.0% (n=44), the area under receiver operating characteristic curve of triglyceride predicting achievement of targets of time below range (<4%) was 0.856 (95% confidence interval 0.688-1.000, P=0.042) with an optimal cutoff value of 0.50 mmol/L (sensitivity 100%, specificity 66.7%, positive predictive value 94.4%). Conclusions In adults with T1D, HbA1c may be a potential modifier of the association between triglyceride and time below range, suggesting it might be necessary for those with HbA1c <7.0% accompanied by lower triglyceride levels to set a less intensive glycemic target to minimize risk of hypoglycemia.
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Affiliation(s)
- Yiwen Liu
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jie Yu
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Chifa Ma
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuli He
- Department of Nutrition, Peking Union Medical College Hospital, Beijing, China
| | - Fan Ping
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Huabing Zhang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Lingling Xu
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinhua Xiao
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuxiu Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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15
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Dashora U, Patel DC, Gregory R, Winocour P, Dhatariya K, Rowles S, Macklin A, Rayman G, Nagi D. Association of British Clinical Diabetologists (ABCD) and Diabetes UK joint position statement and recommendations on the use of sodium-glucose cotransporter inhibitors with insulin for treatment of type 1 diabetes (Updated October 2020). Diabet Med 2021; 38:e14458. [PMID: 33179277 DOI: 10.1111/dme.14458] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 10/29/2020] [Accepted: 11/06/2020] [Indexed: 12/30/2022]
Abstract
Dapagliflozin (SGLT-2 inhibitor) and sotagliflozin (SGLT1/2 inhibitor) are two of the drugs of SGLT inhibitor class which have been recommended by the National Institute for Health and Care Excellence (NICE) in people with type 1 diabetes with BMI ≥27 kg/m2 . Dapagliflozin is licensed in the UK for use in the NHS while sotagliflozin may be available in future. These and possibly other SGLT inhibitors may be increasingly used in people with type 1 diabetes as new licences are obtained. These drugs have the potential to improve glycaemic control in people with type 1 diabetes with the added benefit of weight loss, better control of blood pressure and more time in optimal glucose range. However, SGLT inhibitors are associated with a higher incidence of diabetic ketoacidosis without significant hyperglycaemia. The present ABCD/Diabetes UK joint updated position statement is to guide people with type 1 diabetes and clinicians using these drugs help mitigate this risk and other potential complications. Particularly, caution needs to be exercised in people who are at risk of diabetic ketoacidosis due to low calorie diets, illnesses, injuries, starvation, excessive exercise, excessive alcohol consumption and reduced insulin administration among other precipitating factors for diabetic ketoacidosis.
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Affiliation(s)
| | - Dipesh C Patel
- Division of Medicine, University College London, Royal Free Campus, London, UK
| | - Robert Gregory
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Peter Winocour
- ENHIDE, East and North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Ketan Dhatariya
- Norfolk and Norwich University Hospitals NHS Foundation Trust, UK
| | | | | | - Gerry Rayman
- Norfolk and Norwich University Hospitals NHS Foundation Trust, UK
| | - Dinesh Nagi
- Edna Coates Diabetes and Endocrine Unit, Pinderfields Hospital, Wakefield, UK
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Comprehensive elaboration of glycemic variability in diabetic macrovascular and microvascular complications. Cardiovasc Diabetol 2021; 20:9. [PMID: 33413392 PMCID: PMC7792304 DOI: 10.1186/s12933-020-01200-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/24/2020] [Indexed: 02/07/2023] Open
Abstract
Diabetes mellitus is the major risk factor for the development of macrovascular and microvascular complications. It is increasingly recognized that glycemic variability (GV), referring to oscillations in blood glucose levels and representing either short-term or long-term GV, is involved in the pathogenesis of diabetic complications and has emerged as a possible independent risk factor for them. In this review, we summarize the metrics and measurement of GV in clinical practice, as well as comprehensively elaborate the role and related mechanisms of GV in diabetic macrovascular and microvascular complications, aiming to provide the mechanism-based therapeutic strategies for clinicians to manage diabetes mellitus.
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Musso G, Sircana A, Saba F, Cassader M, Gambino R. Assessing the risk of ketoacidosis due to sodium-glucose cotransporter (SGLT)-2 inhibitors in patients with type 1 diabetes: A meta-analysis and meta-regression. PLoS Med 2020; 17:e1003461. [PMID: 33373368 PMCID: PMC7771708 DOI: 10.1371/journal.pmed.1003461] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 (SGLT2) inhibitors (SGLT2i) showed benefits in type 1 diabetes mellitus (T1DM), but the risk of diabetic ketoacidosis (DKA) limits their use. Ability to predict DKA risk and therapeutic responses would enable appropriate patient selection for SGLT2i. We conducted a meta-analysis and meta-regression of randomized controlled trials (RCTs) evaluating SGLT2i in T1DM to assess moderators of the relative risk (RR) of DKA, of glycemic (HbA1c, fasting plasma glucose, continuous glucose monitoring parameters, insulin dose, and insulin sensitivity indices) and non-glycemic (body mass index (BMI), systolic BP, renal function, albuminuria, and diabetic eye disorders) efficacy, and of other safety outcomes (including hypoglycemia, infections, major adverse cardiovascular events, and death). METHODS AND FINDINGS We searched MEDLINE, Cochrane Library, EMBASE, ClinicalTrials.gov, Cochrane CENTRAL Register of Controlled Trials, and other electronic sources through August 30, 2020, for RCTs comparing SGLT2i with active comparators or placebo in adult patients with T1DM. Reviewers extracted data for relevant outcomes, performed random effects meta-analyses, subgroup analyses, and multivariable meta-regression. The strength of evidence was summarized with the GRADE approach. Among 9,914 records identified, 18 placebo-controlled RCTs (7,396 participants, 50% males, mean age 42 y (range 23 to 55 y), 5 different SGLT2i evaluated), were included. Main outcome measures were effect sizes and moderators of glycemic and non-glycemic efficacy and of safety outcomes. In a multivariable meta-regression model, baseline BMI (β = 0.439 [95% CI: 0.211, 0.666], p < 0.001) and estimated glucose disposal rate (eGDR) (β = -0.766 [-1.276, -0.256], p = 0.001) were associated with the RR of DKA (RR: 2.81; 95% CI:1.97, 4.01; p < 0.001, R2 = 61%). A model including also treatment-related parameters (insulin dose change-to-baseline insulin sensitivity ratio and volume depletion) explained 86% of variance across studies in the risk of DKA (R2 = 86%). The association of DKA with a BMI >27 kg/m2 and with an eGDR <8.3 mg/kg/min was confirmed also in subgroup analyses. Among efficacy outcomes, the novel findings were a reduction in albuminuria (WMD: -9.91, 95% CI: -16.26, -3.55 mg/g, p = 0.002), and in RR of diabetic eye disorders (RR: 0.27[0.11, 0.67], p = 0.005) associated with SGLT2i. A SGLT2i dose-response gradient was consistently observed for main efficacy outcomes, but not for adverse events (AEs). Overall, predictors of DKA and of other AEs differed substantially from those of glycemic and non-glycemic efficacy. A limitation of our analysis was the relatively short (≤52 weeks) duration of included RCTs. The potential relevance for clinical practice needs also to be confirmed by real-world prospective studies. CONCLUSIONS In T1DM, the risk of DKA and main therapeutic responses to SGLT2i are modified by baseline BMI and insulin resistance, by total insulin dose reduction-to-baseline insulin sensitivity ratio, and by volume depletion, which may enable the targeted use of these drugs in patients with the greatest benefit and the lowest risk of DKA.
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Affiliation(s)
| | - Antonio Sircana
- Department of Cardiology, Azienda Ospedaliero Universitaria, Sassari, Italy
| | - Francesca Saba
- Laboratory of Diabetes and Metabolic disorders, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Maurizio Cassader
- Laboratory of Diabetes and Metabolic disorders, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Roberto Gambino
- Laboratory of Diabetes and Metabolic disorders, Department of Medical Sciences, University of Turin, Turin, Italy
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Lin C, Cai X, Yang W, Lv F, Nie L, Ji L. Age, sex, disease severity, and disease duration difference in placebo response: implications from a meta-analysis of diabetes mellitus. BMC Med 2020; 18:322. [PMID: 33190640 PMCID: PMC7667845 DOI: 10.1186/s12916-020-01787-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 09/17/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The placebo response in patients with diabetes mellitus is very common. A systematic evaluation needs to be updated with the current evidence about the placebo response in diabetes mellitus and the associated factors in clinical trials of anti-diabetic medicine. METHODS Literature research was conducted in Medline, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov for studies published between the date of inception and June 2019. Randomized placebo-controlled trials conducted in type 1and type 2 diabetes mellitus (T1DM/T2DM) were included. Random-effects model and meta-regression analysis were accordingly used. This meta-analysis was registered in PROSPERO as CRD42014009373. RESULTS Significantly weight elevation (effect size (ES) = 0.33 kg, 95% CI, 0.03 to 0.61 kg) was observed in patients with placebo treatments in T1DM subgroup while significantly HbA1c reduction (ES = - 0.12%, 95% CI, - 0.16 to - 0.07%) and weight reduction (ES = - 0.40 kg, 95% CI, - 0.50 to - 0.29 kg) were observed in patients with placebo treatments in T2DM subgroup. Greater HbA1c reduction was observed in patients with injectable placebo treatments (ES = - 0.22%, 95% CI, - 0.32 to - 0.11%) versus oral types (ES = - 0.09%, 95% CI, - 0.14 to - 0.04%) in T2DM (P = 0.03). Older age (β = - 0.01, 95% CI, - 0.02 to - 0.01, P < 0.01) and longer diabetes duration (β = - 0.02, 95% CI, - 0.03 to - 0.21 × 10-2, P = 0.03) was significantly associated with more HbA1c reduction by placebo in T1DM. However, younger age (β = 0.02, 95% CI, 0.01 to 0.03, P = 0.01), lower male percentage (β = 0.01, 95% CI, 0.22 × 10-2, 0.01, P < 0.01), higher baseline BMI (β = - 0.02, 95% CI, - 0.04 to - 0.26 × 10-2, P = 0.02), and higher baseline HbA1c (β = - 0.09, 95% CI, - 0.16 to - 0.01, P = 0.02) were significantly associated with more HbA1c reduction by placebo in T2DM. Shorter diabetes duration (β = 0.06, 95% CI, 0.06 to 0.10, P < 0.01) was significantly associated with more weight reduction by placebo in T2DM. However, the associations between baseline BMI, baseline HbA1c, and placebo response were insignificant after the adjusted analyses. CONCLUSION The placebo response in diabetes mellitus was systematically outlined. Age, sex, disease severity (indirectly reflected by baseline BMI and baseline HbA1c), and disease duration were associated with placebo response in diabetes mellitus. The association between baseline BMI, baseline HbA1c, and placebo response may be the result of regression to the mean.
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Affiliation(s)
- Chu Lin
- Department of Endocrinology and Metabolism, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Xiaoling Cai
- Department of Endocrinology and Metabolism, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China.
| | - Wenjia Yang
- Department of Endocrinology and Metabolism, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Fang Lv
- Department of Endocrinology and Metabolism, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Lin Nie
- Department of Endocrinology and Metabolism, Beijing Airport Hospital, Beijing, China
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China.
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Eid SA, O’Brien PD, Hinder LM, Hayes JM, Mendelson FE, Zhang H, Zeng L, Kretzler K, Narayanan S, Abcouwer SF, Brosius FC, Pennathur S, Savelieff MG, Feldman EL. Differential Effects of Empagliflozin on Microvascular Complications in Murine Models of Type 1 and Type 2 Diabetes. BIOLOGY 2020; 9:biology9110347. [PMID: 33105667 PMCID: PMC7690408 DOI: 10.3390/biology9110347] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 12/15/2022]
Abstract
Microvascular complications account for the significant morbidity associated with diabetes. Despite tight glycemic control, disease risk remains especially in type 2 diabetes (T2D) patients and no therapy fully prevents nerve, retinal, or renal damage in type 1 diabetes (T1D) or T2D. Therefore, new antidiabetic drug classes are being evaluated for the treatment of microvascular complications. We investigated the effect of empagliflozin (EMPA), an inhibitor of the sodium/glucose cotransporter 2 (SGLT2), on diabetic neuropathy (DPN), retinopathy (DR), and kidney disease (DKD) in streptozotocin-induced T1D and db/db T2D mouse models. EMPA lowered blood glycemia in T1D and T2D models. However, it did not ameliorate any microvascular complications in the T2D model, which was unexpected, given the protective effect of SGLT2 inhibitors on DKD progression in T2D subjects. Although EMPA did not improve DKD in the T1D model, it had a potential modest effect on DR measures and favorably impacted DPN as well as systemic oxidative stress. These results support the concept that glucose-centric treatments are more effective for DPN in T1D versus T2D. This is the first study that provides an evaluation of EMPA treatment on all microvascular complications in a side-by-side comparison in T1D and T2D models.
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Affiliation(s)
- Stephanie A. Eid
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (S.A.E.); (P.D.O.); (L.M.H.); (J.M.H.); (F.E.M.); (K.K.); (S.N.); (M.G.S.)
| | - Phillipe D. O’Brien
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (S.A.E.); (P.D.O.); (L.M.H.); (J.M.H.); (F.E.M.); (K.K.); (S.N.); (M.G.S.)
| | - Lucy M. Hinder
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (S.A.E.); (P.D.O.); (L.M.H.); (J.M.H.); (F.E.M.); (K.K.); (S.N.); (M.G.S.)
| | - John M. Hayes
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (S.A.E.); (P.D.O.); (L.M.H.); (J.M.H.); (F.E.M.); (K.K.); (S.N.); (M.G.S.)
| | - Faye E. Mendelson
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (S.A.E.); (P.D.O.); (L.M.H.); (J.M.H.); (F.E.M.); (K.K.); (S.N.); (M.G.S.)
| | - Hongyu Zhang
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; (H.Z.); (L.Z.); (F.C.B.III); (S.P.)
| | - Lixia Zeng
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; (H.Z.); (L.Z.); (F.C.B.III); (S.P.)
| | - Katharina Kretzler
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (S.A.E.); (P.D.O.); (L.M.H.); (J.M.H.); (F.E.M.); (K.K.); (S.N.); (M.G.S.)
| | - Samanthi Narayanan
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (S.A.E.); (P.D.O.); (L.M.H.); (J.M.H.); (F.E.M.); (K.K.); (S.N.); (M.G.S.)
| | - Steven F. Abcouwer
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA;
| | - Frank C. Brosius
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; (H.Z.); (L.Z.); (F.C.B.III); (S.P.)
- Departments of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Subramaniam Pennathur
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; (H.Z.); (L.Z.); (F.C.B.III); (S.P.)
- Departments of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Masha G. Savelieff
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (S.A.E.); (P.D.O.); (L.M.H.); (J.M.H.); (F.E.M.); (K.K.); (S.N.); (M.G.S.)
| | - Eva L. Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (S.A.E.); (P.D.O.); (L.M.H.); (J.M.H.); (F.E.M.); (K.K.); (S.N.); (M.G.S.)
- Correspondence: ; Tel.: +1-(734)-763-7274
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20
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Ceriello A, Ofstad AP, Zwiener I, Kaspers S, George J, Nicolucci A. Empagliflozin reduced long-term HbA1c variability and cardiovascular death: insights from the EMPA-REG OUTCOME trial. Cardiovasc Diabetol 2020; 19:176. [PMID: 33050931 PMCID: PMC7556977 DOI: 10.1186/s12933-020-01147-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/29/2020] [Indexed: 01/22/2023] Open
Abstract
Background Glucose variability has been associated with cardiovascular outcomes in type 2 diabetes, however, the interplay between glucose variability, empagliflozin and cardiovascular death has not been explored. In the EMPA-REG OUTCOME trial, empagliflozin reduced the risk of cardiovascular death by 38%. We explore post-hoc the association between HbA1c variability and cardiovascular death, and the potential mediating effects of HbA1c variability on empagliflozin’s cardiovascular death reductions. Methods In total, 7,020 patients with type 2 diabetes and established cardiovascular disease received placebo, empagliflozin 10 mg or 25 mg. We defined within-patient HbA1c variability as standard deviation, coefficient of variation and range of HbA1c measurements (%) post-baseline. First, we compared HbA1c variability until week 28 and 52 by Wilcoxon tests. We explored the association between cardiovascular death and HbA1c variability in placebo and pooled empagliflozin arms separately with landmark analyses at week 28 and 52, and additionally with HbA1c variability as a time-dependent co-variate. We used Cox regression models adjusted for baseline risk factors including changes in HbA1c from baseline to week 12, and the interaction term HbA1c variability* treatment. Results HbA1c variability was lower with empagliflozin compared to placebo. In all Cox analyses, high HbA1c variability increased the risk for cardiovascular death in both treatment arms with no interaction with treatment: e.g. an increase in HbA1c variability of one unit for the standard deviation at week 28 was associated with a subsequent increased risk of CV death with HRs of 1.97 (95% CI 1.36, 2.84) and 1.53 (1.01, 2.31) in the placebo and empagliflozin groups, separately, interaction p-value 0.3615. Conclusions HbA1c variability was reduced by empagliflozin and high values of HbA1c variability were associated with an increased risk of cardiovascular death. Empagliflozin’s reduction in cardiovascular death did not appear to be mediated by reductions in HbA1c variability. ClinicalTrials.gov number, NCT01131676
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Affiliation(s)
| | | | | | - Stefan Kaspers
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Jyothis George
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
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21
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Kushner PR, Kruger DF. The Changing Landscape of Glycemic Targets: Focus on Continuous Glucose Monitoring. Clin Diabetes 2020; 38:348-356. [PMID: 33132504 PMCID: PMC7566931 DOI: 10.2337/cd19-0093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Continuous glucose monitoring (CGM) provides comprehensive assessment of daily glucose measurements for patients with diabetes and can reveal high and low blood glucose values that may occur even when a patient's A1C is adequately controlled. Among the measures captured by CGM, the percentage of time in the target glycemic range, or "time in range" (typically 70-180 mg/dL), has emerged as one of the strongest indicators of good glycemic control. This review examines the shift to using CGM to assess glycemic control and guide diabetes treatment decisions, with a focus on time in range as the key metric of glycemic control.
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22
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van Raalte DH, Bjornstad P. Role of sodium-glucose cotransporter 2 inhibition to mitigate diabetic kidney disease risk in type 1 diabetes. Nephrol Dial Transplant 2020; 35:i24-i32. [PMID: 32003832 PMCID: PMC6993198 DOI: 10.1093/ndt/gfz228] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Indexed: 12/17/2022] Open
Abstract
Diabetic kidney disease (DKD) is a common complication of type 1 diabetes (T1D) and a major risk factor for premature death from cardiovascular disease (CVD). Current treatments, such as control of hyperglycaemia and hypertension, are beneficial, but only partially protect against DKD. Finding new, safe and effective therapies to halt nephropathy progression has proven to be challenging. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have demonstrated, in addition to glycaemic lowering, impressive protection against DKD and CVD progression in people with type 2 diabetes. Although these beneficial cardiorenal effects may also apply to people with T1D, supporting data are lacking. Furthermore, the increased rates of euglycaemic diabetic ketoacidosis may limit the use of this class in people with T1D. In this review we highlight the pathophysiology of DKD in T1D and the unmet need that exists. We further detail the beneficial and adverse effects of SGLT2 inhibitors based on their mechanism of action. Finally, we balance the effects in people with T1D and indicate future lines of research.
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Affiliation(s)
- Daniël H van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Petter Bjornstad
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.,Division of Nephrology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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23
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Suzuki D, Yamada H, Yoshida M, Funazaki S, Amamoto M, Morimoto J, Hara K. Sodium-glucose cotransporter 2 inhibitors improved time-in-range without increasing hypoglycemia in Japanese patients with type 1 diabetes: A retrospective, single-center, pilot study. J Diabetes Investig 2020; 11:1230-1237. [PMID: 32100964 PMCID: PMC7477508 DOI: 10.1111/jdi.13240] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/04/2020] [Accepted: 02/19/2020] [Indexed: 01/08/2023] Open
Abstract
AIMS/INTRODUCTION Studies have shown that sodium-glucose cotransporter 2 (SGLT2) inhibitors increased time-in-range (TIR; percentage of time glucose level remains between 3.9 and 10.0 mmol/L [70-180 mg/dL]) and decreased glycemic variability in patients with type 1 diabetes. The aim of this study was to investigate the effects of SGLT2 inhibitors on TIR, glycemic variability and glucose control in Japanese patients with type 1 diabetes in a real clinical setting. MATERIALS AND METHODS We designed a single-arm, retrospective cohort study to analyze data from patients starting to use ipragliflozin or dapagliflozin and who used a sensor-based flash glucose monitoring system between February 2019 and August 2019. We measured TIR, time above range >180 mg/dL (percentage of time with glucose level of >180 mg/dL or >10.0 mmol/L), time below range <70 mg/dL (percentage of time with glucose level of <70 mg/dL or <3.9 mmol/L), mean glucose and standard deviation, and coefficient of variation for glycemic variability, and then compared the data before and after SGLT2 inhibitors treatments. RESULTS We enrolled 15 patients in the study. The total dosages of basal insulin decreased significantly, but the total doses of bolus insulin did not change significantly. TIR increased significantly by approximately 11.6%; the time below range <70 mg/dL remained unchanged; and the mean glucose and standard deviation decreased significantly, whereas the coefficients of variation did not. CONCLUSIONS SGLT2 inhibitors improved TIR and the mean glucose level and standard deviation without increasing the time below range <70 mg/dL in patients with type 1 diabetes.
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Affiliation(s)
- Daisuke Suzuki
- Department of MedicineDivision of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Hodaka Yamada
- Department of MedicineDivision of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Masashi Yoshida
- Department of MedicineDivision of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Shunsuke Funazaki
- Department of MedicineDivision of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Misato Amamoto
- Department of MedicineDivision of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Jun Morimoto
- Department of MedicineDivision of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Kazuo Hara
- Department of MedicineDivision of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
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24
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Zhou Z, Sun B, Huang S, Zhu C, Bian M. Glycemic variability: adverse clinical outcomes and how to improve it? Cardiovasc Diabetol 2020; 19:102. [PMID: 32622354 PMCID: PMC7335439 DOI: 10.1186/s12933-020-01085-6] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/02/2020] [Indexed: 12/26/2022] Open
Abstract
Glycemic variability (GV), defined as an integral component of glucose homoeostasis, is emerging as an important metric to consider when assessing glycemic control in clinical practice. Although it remains yet no consensus, accumulating evidence has suggested that GV, representing either short-term (with-day and between-day variability) or long-term GV, was associated with an increased risk of diabetic macrovascular and microvascular complications, hypoglycemia, mortality rates and other adverse clinical outcomes. In this review, we summarize the adverse clinical outcomes of GV and discuss the beneficial measures, including continuous glucose monitoring, drugs, dietary interventions and exercise training, to improve it, aiming at better addressing the challenging aspect of blood glucose management.
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Affiliation(s)
- Zheng Zhou
- Department of Chinese Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Bao Sun
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410000, China.,Hunan Key Laboratory of Pharmacogenetics, Institute of Clinical Pharmacology, Central South University, Changsha, 410000, China
| | - Shiqiong Huang
- Department of Pharmacy, The First Hospital of Changsha, Changsha, 410005, China
| | - Chunsheng Zhu
- Department of Chinese Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China.
| | - Meng Bian
- Department of Chinese Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China.
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25
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The comparison of efficacy and safety between different doses of empagliflozin in insulin-treated type 1 diabetes mellitus patients: a systematic review and meta-analysis protocol. J Diabetes Metab Disord 2020; 19:545-550. [PMID: 32550206 DOI: 10.1007/s40200-020-00544-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: 12/04/2019] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
Objectives The proposed review aims to compare the efficacy and safety profile of empagliflozin 25 mg with its lower dosages and placebo, respectively, in insulin-treated type 1 diabetes mellitus (T1DM) patients. Methods Double-blinded randomized controlled trials comparing the above outcomes will be searched primarily in three electronic databases (PubMed, Embase, and Scopus) and eligible trials will be included in the proposed review. Then, from the trials recruited in the review, data of the study design, participants, interventions compared, and outcomes of interest will be extracted. Subsequently, the trials' risk of bias will be assessed using the Cochrane Collaboration's tool. The meta-analysis will be conducted with a fixed-effect or a random-effect model to estimate the mean differences (weighted or standardized) and risk ratios for the efficacy and safety-related comparable outcome data, respectively. Statistical heterogeneity will be assessed by the p-value of chi-squared statistics and I2 statistics and explained by subgroup analysis and meta-regression. Publication bias will be assessed by funnel plots and Egger's test. The sensitivity analysis will repeat the meta-analysis for respective outcomes using assumptions alternative to that used in the preliminary meta-analysis and by dropping each study at a time. Results A narrative reporting will ensue if a meta-analytic comparison is not possible. Conclusions Based on the contemporary literature, the proposed review will synthesize the evidence on how the efficacy and safety profile of high dose empagliflozin varies with its lower doses and placebo, respectively, in insulin-treated T1DM patients.
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26
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Bayona Cebada A, Nattero-Chávez L, Alonso Díaz S, Escobar-Morreale HF, Luque-Ramírez M. Efficacy and Safety of SGLT2 Inhibitors in Type 1 Diabetes After the Introduction of an Off-Label Use Protocol for Clinical Practice. Diabetes Technol Ther 2020; 22:208-215. [PMID: 31644310 DOI: 10.1089/dia.2019.0316] [Citation(s) in RCA: 3] [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] [Indexed: 02/06/2023]
Abstract
Aims: We evaluated the real-life efficacy and safety of empagliflozin in combination with optimized insulin therapy in patients with type 1 diabetes (T1D). Methods: This was a prospective study, including 27 patients with T1D treated with insulin therapy to whom empagliflozin was added according to an off-label protocol approved for use in clinical practice. The primary end point was the change in HbA1c 52 weeks after the addition of empagliflozin to insulin therapy. Blood pressure (BP), weight, and safety were also assessed. Results: At week 52, the addition of empagliflozin significantly reduced HbA1c from 8.0% ± 0.7% to 7.2% ± 0.8% (P < 0.001). The mean percentage of time in range for capillary glucose monitoring increased from 50% to 62% (P = 0.008) in parallel to a -0.08 IU/(kg·day) reduction in insulin requirements (P = 0.031). There was also a reduction in the body weight (-8 kg) and in systolic BP from 134 to 127 mmHg (P < 0.001). The most commonly reported adverse events were genitourinary infections (10 episodes in 52 weeks of follow-up). One patient developed an episode of mild diabetic ketoacidosis that motivated empagliflozin withdrawal. No severe hypoglycemic events were registered. Conclusions: Our results suggested that the use of empagliflozin following a strict off-label protocol may represent an effective and safe option in real life among patients with T1D, improving metabolic control, and ameliorating some cardiovascular risk factors.
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Affiliation(s)
- Ane Bayona Cebada
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Lía Nattero-Chávez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBER Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Sara Alonso Díaz
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Héctor F Escobar-Morreale
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBER Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
- Department of Medicine, University of Alcalá, Madrid, Spain
| | - Manuel Luque-Ramírez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBER Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
- Department of Medicine, University of Alcalá, Madrid, Spain
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27
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Wilmot EG, Choudhary P, Leelarathna L, Baxter M. Glycaemic variability: The under-recognized therapeutic target in type 1 diabetes care. Diabetes Obes Metab 2019; 21:2599-2608. [PMID: 31364268 PMCID: PMC6899456 DOI: 10.1111/dom.13842] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/22/2019] [Accepted: 07/25/2019] [Indexed: 12/23/2022]
Abstract
Type 1 diabetes mellitus (T1DM) remains one of the most challenging long-term conditions to manage. Despite robust evidence to demonstrate that near normoglycaemia minimizes, but does not completely eliminate, the risk of complications, its achievement has proved almost impossible in a real-world setting. HbA1c to date has been used as the gold standard marker of glucose control and has been shown to reflect directly the risk of diabetes complications. However, it has been recognized that HbA1c is a crude marker of glucose control. Continuous glucose monitoring (CGM) provides the ability to measure and observe inter- and intraday glycaemic variability (GV), a more meaningful measure of glycaemic control, more relevant to daily living for those with T1DM. This paper reviews the relationship between GV and hypoglycaemia, and micro- and macrovascular complications. It also explores the impact on GV of CGM, insulin pumps, closed-loop technologies, and newer insulins and adjunctive therapies. Looking to the future, there is an argument that GV should become a key determinant of therapeutic success. Further studies are required to investigate the pathological and psychological benefits of reducing GV.
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Affiliation(s)
- Emma G Wilmot
- Diabetes Department, Royal Derby Hospital, University Hospitals of Derby and Burton NHSFT, Derby, Derbyshire, UK
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Lalantha Leelarathna
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Mike Baxter
- Department Medical Affairs, Sanofi, Guildford, UK
- Department of Diabetes and Endocrinology, University of Swansea, Swansea, South Wales, UK
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28
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Battelino T, Danne T, Bergenstal RM, Amiel SA, Beck R, Biester T, Bosi E, Buckingham BA, Cefalu WT, Close KL, Cobelli C, Dassau E, DeVries JH, Donaghue KC, Dovc K, Doyle FJ, Garg S, Grunberger G, Heller S, Heinemann L, Hirsch IB, Hovorka R, Jia W, Kordonouri O, Kovatchev B, Kowalski A, Laffel L, Levine B, Mayorov A, Mathieu C, Murphy HR, Nimri R, Nørgaard K, Parkin CG, Renard E, Rodbard D, Saboo B, Schatz D, Stoner K, Urakami T, Weinzimer SA, Phillip M. Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range. Diabetes Care 2019. [PMID: 31177185 DOI: 10.2337/dci19‐0028] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Improvements in sensor accuracy, greater convenience and ease of use, and expanding reimbursement have led to growing adoption of continuous glucose monitoring (CGM). However, successful utilization of CGM technology in routine clinical practice remains relatively low. This may be due in part to the lack of clear and agreed-upon glycemic targets that both diabetes teams and people with diabetes can work toward. Although unified recommendations for use of key CGM metrics have been established in three separate peer-reviewed articles, formal adoption by diabetes professional organizations and guidance in the practical application of these metrics in clinical practice have been lacking. In February 2019, the Advanced Technologies & Treatments for Diabetes (ATTD) Congress convened an international panel of physicians, researchers, and individuals with diabetes who are expert in CGM technologies to address this issue. This article summarizes the ATTD consensus recommendations for relevant aspects of CGM data utilization and reporting among the various diabetes populations.
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Affiliation(s)
- Tadej Battelino
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Children's Hospital, University Medical Centre Ljubljana, and Faculty of Medicine, University of Ljubljana, Slovenia
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Germany
| | | | | | - Roy Beck
- Jaeb Center for Health Research, Tampa, FL
| | - Torben Biester
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Germany
| | - Emanuele Bosi
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Bruce A Buckingham
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford Medical Center, Stanford, CA
| | | | - Kelly L Close
- Close Concerns and The diaTribe Foundation, San Francisco, CA
| | - Claudio Cobelli
- Department of Information Engineering, University of Padova, Padua, Italy
| | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
| | - J Hans DeVries
- Profil, Neuss, Germany
- Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Kim C Donaghue
- Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Klemen Dovc
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Children's Hospital, University Medical Centre Ljubljana, and Faculty of Medicine, University of Ljubljana, Slovenia
| | - Francis J Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
| | - Satish Garg
- University of Colorado Denver and Barbara Davis Center for Diabetes, Aurora, CO
| | | | - Simon Heller
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, U.K
| | | | - Irl B Hirsch
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, and Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Weiping Jia
- Department of Endocrinology & Metabolism, Shanghai Clinical Center of Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Olga Kordonouri
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Germany
| | - Boris Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | - Lori Laffel
- Pediatric, Adolescent and Young Adult Section and Section on Clinical, Behavioral and Outcomes Research, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Brian Levine
- Close Concerns and The diaTribe Foundation, San Francisco, CA
| | | | - Chantal Mathieu
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Helen R Murphy
- Norwich Medical School, University of East Anglia, Norwich, U.K
| | - Revital Nimri
- Jesse Z and Sara Lea Shafer Institute of Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | | | | | - Eric Renard
- Department of Endocrinology, Diabetes, and Nutrition, Montpellier University Hospital; Institute of Functional Genomics, University of Montpellier; and INSERM Clinical Investigation Centre, Montpellier, France
| | | | | | - Desmond Schatz
- Pediatric Endocrinology, University of Florida, Gainesville, FL
| | | | - Tatsuiko Urakami
- Department of Pediatrics, Nihon University School of Medicine, Tokyo, Japan
| | - Stuart A Weinzimer
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Moshe Phillip
- Jesse Z and Sara Lea Shafer Institute of Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Battelino T, Danne T, Bergenstal RM, Amiel SA, Beck R, Biester T, Bosi E, Buckingham BA, Cefalu WT, Close KL, Cobelli C, Dassau E, DeVries JH, Donaghue KC, Dovc K, Doyle FJ, Garg S, Grunberger G, Heller S, Heinemann L, Hirsch IB, Hovorka R, Jia W, Kordonouri O, Kovatchev B, Kowalski A, Laffel L, Levine B, Mayorov A, Mathieu C, Murphy HR, Nimri R, Nørgaard K, Parkin CG, Renard E, Rodbard D, Saboo B, Schatz D, Stoner K, Urakami T, Weinzimer SA, Phillip M. Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range. Diabetes Care 2019; 42:1593-1603. [PMID: 31177185 PMCID: PMC6973648 DOI: 10.2337/dci19-0028] [Citation(s) in RCA: 1841] [Impact Index Per Article: 368.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Improvements in sensor accuracy, greater convenience and ease of use, and expanding reimbursement have led to growing adoption of continuous glucose monitoring (CGM). However, successful utilization of CGM technology in routine clinical practice remains relatively low. This may be due in part to the lack of clear and agreed-upon glycemic targets that both diabetes teams and people with diabetes can work toward. Although unified recommendations for use of key CGM metrics have been established in three separate peer-reviewed articles, formal adoption by diabetes professional organizations and guidance in the practical application of these metrics in clinical practice have been lacking. In February 2019, the Advanced Technologies & Treatments for Diabetes (ATTD) Congress convened an international panel of physicians, researchers, and individuals with diabetes who are expert in CGM technologies to address this issue. This article summarizes the ATTD consensus recommendations for relevant aspects of CGM data utilization and reporting among the various diabetes populations.
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Affiliation(s)
- Tadej Battelino
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Children's Hospital, University Medical Centre Ljubljana, and Faculty of Medicine, University of Ljubljana, Slovenia
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Germany
| | | | | | - Roy Beck
- Jaeb Center for Health Research, Tampa, FL
| | - Torben Biester
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Germany
| | - Emanuele Bosi
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Bruce A Buckingham
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford Medical Center, Stanford, CA
| | | | - Kelly L Close
- Close Concerns and The diaTribe Foundation, San Francisco, CA
| | - Claudio Cobelli
- Department of Information Engineering, University of Padova, Padua, Italy
| | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
| | - J Hans DeVries
- Profil, Neuss, Germany.,Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Kim C Donaghue
- Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Klemen Dovc
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Children's Hospital, University Medical Centre Ljubljana, and Faculty of Medicine, University of Ljubljana, Slovenia
| | - Francis J Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
| | - Satish Garg
- University of Colorado Denver and Barbara Davis Center for Diabetes, Aurora, CO
| | | | - Simon Heller
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, U.K
| | | | - Irl B Hirsch
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, and Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Weiping Jia
- Department of Endocrinology & Metabolism, Shanghai Clinical Center of Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Olga Kordonouri
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Germany
| | - Boris Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | - Lori Laffel
- Pediatric, Adolescent and Young Adult Section and Section on Clinical, Behavioral and Outcomes Research, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Brian Levine
- Close Concerns and The diaTribe Foundation, San Francisco, CA
| | | | - Chantal Mathieu
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Helen R Murphy
- Norwich Medical School, University of East Anglia, Norwich, U.K
| | - Revital Nimri
- Jesse Z and Sara Lea Shafer Institute of Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | | | | | - Eric Renard
- Department of Endocrinology, Diabetes, and Nutrition, Montpellier University Hospital; Institute of Functional Genomics, University of Montpellier; and INSERM Clinical Investigation Centre, Montpellier, France
| | | | | | - Desmond Schatz
- Pediatric Endocrinology, University of Florida, Gainesville, FL
| | | | - Tatsuiko Urakami
- Department of Pediatrics, Nihon University School of Medicine, Tokyo, Japan
| | - Stuart A Weinzimer
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Moshe Phillip
- Jesse Z and Sara Lea Shafer Institute of Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Li K, Xu G. Safety and efficacy of sodium glucose co-transporter 2 inhibitors combined with insulin in adults with type 1 diabetes: A meta-analysis of randomized controlled trials. J Diabetes 2019; 11:645-655. [PMID: 30565398 DOI: 10.1111/1753-0407.12890] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 12/08/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The safety and efficacy of sodium glucose co-transporter 2 (SGLT2) inhibitors in a dose-dependent manner for type 1 diabetes mellitus (T1DM) are unclear. METHODS Randomized clinical trials (RCT) were searched from PubMed, EMBASE, the Cochrane Library, Web of Science and ClinicalTrials until August 2018. RESULTS Thirteen RCT with 5397 participants were included. SGLT2 inhibitors were proved to be effective in glycemic control and weight loss in T1DM. In the subgroups of different doses, SGLT2 inhibitors exhibited reductions in glycated haemoglobin, bodyweight, fasting plasma glucose, mean daily glucose, basal insulin dose, bolus insulin dose, estimated glomerular filtration rate and systolic blood pressure, and elevations in the mean amplitude of glucose excursions, and percentage of time in target glucose range in a dose-dependent manner. Reductions in total insulin dose and urinary glucose excretion were dose-independent. SGLT2 inhibitors did not induce hypoglycemia, severe hypoglycemia, cardiovascular events, bone fracture and all-cause mortality, but increased the risk of adverse events (AE), adverse events related to the drug treatment, infections, diabetic ketoacidosis (DKA) and renal disease correlated with dosage. CONCLUSIONS SGLT2 inhibitors in high and moderate doses can achieve a better outcome on efficacy, but may induce a higher risk of adverse events, especially DKA.
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Affiliation(s)
- Kexin Li
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Jiangxi, China
- Grade 2015, Joint Programme of Nanchang University and Queen Mary University of London, Nanchang University, Jiangxi, China
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Jiangxi, China
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Mathieu C, Dandona P, Phillip M, Oron T, Lind M, Hansen L, Thorén F, Xu J, Langkilde AM. Glucose Variables in Type 1 Diabetes Studies With Dapagliflozin: Pooled Analysis of Continuous Glucose Monitoring Data From DEPICT-1 and -2. Diabetes Care 2019; 42:1081-1087. [PMID: 30967434 DOI: 10.2337/dc18-1983] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 03/08/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This pooled analysis assessed continuous glucose monitoring (CGM) in patients with inadequately controlled type 1 diabetes (HbA1c ≥7.7 to ≤11.0% [≥61 to ≤97 mmol/mol]) who received dapagliflozin as an adjunct to adjustable insulin. RESEARCH DESIGN AND METHODS CGM data were pooled from two 24-week, double-blind, randomized, phase 3 studies: Dapagliflozin Evaluation in Patients with Inadequately Controlled Type 1 Diabetes (DEPICT-1 and DEPICT-2). These studies comprised 1,591 patients receiving dapagliflozin 5 mg (n = 530), dapagliflozin 10 mg (n = 529), or placebo (n = 532). RESULTS Baseline characteristics were balanced between treatment groups. Patients receiving dapagliflozin 5 mg or 10 mg both spent more time with blood glucose in the range >3.9 to ≤10.0 mmol/L (>70 to ≤180 mg/dL) over 24 h than those receiving the placebo. The adjusted mean (SE) change from baseline at week 24 was 6.48% (0.60) with dapagliflozin 5 mg, 8.08% (0.60) with dapagliflozin 10 mg, and -2.59% (0.61) with placebo. At week 24, the mean amplitude of glucose excursion over 24 h, mean 24-h glucose values, and postprandial glucose values were also improved in patients receiving dapagliflozin over those receiving placebo. No marked differences were found at week 24 between dapagliflozin 5 or 10 mg and placebo in the percentage of glucose values ≤3.9 mmol/L (≤70 mg/dL) or ≤3.0 mmol/L (≤54 mg/dL) over 24 h, or in nocturnal (0000-0559 h) glucose values ≤3.9 mmol/L (≤70 mg/dL). CONCLUSIONS In patients with type 1 diabetes, treatment with dapagliflozin over 24 weeks improved time in range, mean glucose, and glycemic variability without increasing the time spent in the range indicating hypoglycemia.
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Affiliation(s)
- Chantal Mathieu
- Department of Endocrinology, UZ Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Paresh Dandona
- Department of Medicine, University at Buffalo, The State University of New York, Buffalo, NY
| | - Moshe Phillip
- Jesse Z and Sara Lea Shafer Institute of Endocrinology and Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Oron
- Jesse Z and Sara Lea Shafer Institute of Endocrinology and Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marcus Lind
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Medicine, NU Hospital Group, Uddevalla, Sweden
| | | | | | - John Xu
- AstraZeneca, Gaithersburg, MD
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Biester T, Kordonouri O, Danne T. Beyond type 2 diabetes: sodium glucose co-transporter-inhibition in type 1 diabetes. Diabetes Obes Metab 2019; 21 Suppl 2:53-61. [PMID: 31081591 DOI: 10.1111/dom.13659] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 12/12/2022]
Abstract
Use of sodium glucose cotransporter (SGLT) inhibitors are a well-established therapeutic option in type 2 diabetes (T2D) with a variety of proven therapeutic benefits. They have become a pillar of current treatment guidelines. In type 1 diabetes (T1D), initial exploratory studies have shown benefits in glycemic control, weight control, and cardiovascular risk parameters, leading to trials aiming for regulatory submission with several agents. Results from four 1-year trials, which included a total of 3052 patients, are now available, demonstrating promising findings that target the unmet needs of patients with T1D with a novel insulin-independent adjunct therapy. However, these positive effects must be balanced against the risks associated with this class of drugs. Specifically, current T1D studies have shown an increased risk of diabetic ketoacidosis (DKA), which, in some cases, presented with only slightly elevated glucose levels. While this complication may be clinically manageable once detected, the metabolic shift towards ketogenesis associated with this class of agents mandates appropriate patient selection. Currently, there are no validated tools for DKA risk assessment. Although the experience gained in studies and off-label use provides some indication for appropriate patient selection, this would have to be evaluated closely in the event that these drugs would receive regulatory approval. Risk mitigation includes training in ketone measurement (preferably as blood β-hydroxybutyrate testing), teaching the concept of euglycemic DKA, and providing a clear treatment algorithm to avoid progression of ketosis to full-blown DKA. Because similar unmet needs also exist in pediatric population studies, risk mitigation in youth should be initiated as well to allow an evidence-based, risk-benefit assessment in this vulnerable population.
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Affiliation(s)
- Torben Biester
- Diabetes Center for Children and Adolescents, AUF DER BULT, Hannover, Germany
| | - Olga Kordonouri
- Diabetes Center for Children and Adolescents, AUF DER BULT, Hannover, Germany
| | - Thomas Danne
- Diabetes Center for Children and Adolescents, AUF DER BULT, Hannover, Germany
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33
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Boeder S, Edelman SV. Sodium-glucose co-transporter inhibitors as adjunctive treatment to insulin in type 1 diabetes: A review of randomized controlled trials. Diabetes Obes Metab 2019; 21 Suppl 2:62-77. [PMID: 31081593 PMCID: PMC6899736 DOI: 10.1111/dom.13749] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 02/06/2023]
Abstract
Many patients with type 1 diabetes (T1D) struggle to achieve glycaemic control and experience significant fluctuations in glucose concentrations, despite insulin treatment. Sodium-glucose co-transporter (SGLT)-2 inhibitors and dual SGLT-1/2 inhibitors increase glucose elimination via the kidneys and reduce hyperglycaemia via insulin-independent mechanisms. This review examines available efficacy and safety data for these agents under investigation as adjunctive therapy for T1D. Across randomized trials of up to 52 weeks, SGLT-2 inhibitors or SGLT-1/2 inhibitors as an adjunct to insulin demonstrated significant reductions in glycated haemoglobin, glucose exposure, and measures of glycaemic variability, as well as increased time in the target glycaemic range, compared with placebo. Non-glycaemic benefits included reductions in body weight and insulin doses, as well as improvements in some cardiovascular risk factors and treatment satisfaction. SGLT-2 inhibitors and SGLT-1/2 inhibitors were associated with similar rates of hypoglycaemia but a higher incidence of genitourinary infections, compared with placebo. Diabetic ketoacidosis occurred more often with SGLT-2 inhibitors and SGLT-1/2 inhibitors vs placebo, although the incidence was generally low. Risk mitigation strategies in light of clinical trial data are also discussed. Positive data from randomized controlled trials of the SGLT-2 inhibitor dapagliflozin have led to the approval of dapagliflozin as an adjunct to insulin in adults with T1D having body mass index ≥27 kg/m2 in whom insulin does not provide adequate glycaemic control in Europe and to approval as an adjunct to insulin for adults with T1D in Japan.
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Affiliation(s)
- Schafer Boeder
- Division of Endocrinology and MetabolismUniversity of California San DiegoSan DiegoCalifornia
| | - Steven V. Edelman
- Division of Endocrinology and MetabolismUniversity of California San DiegoSan DiegoCalifornia
- Taking Control of Your Diabetes, 501(c)3Solana BeachCalifornia
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34
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Ceriello A, Monnier L, Owens D. Glycaemic variability in diabetes: clinical and therapeutic implications. Lancet Diabetes Endocrinol 2019; 7:221-230. [PMID: 30115599 DOI: 10.1016/s2213-8587(18)30136-0] [Citation(s) in RCA: 303] [Impact Index Per Article: 60.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 04/15/2018] [Accepted: 04/17/2018] [Indexed: 12/11/2022]
Abstract
Glycaemic variability is an integral component of glucose homoeostasis. Although it has not yet been definitively confirmed as an independent risk factor for diabetes complications, glycaemic variability can represent the presence of excess glycaemic excursions and, consequently, the risk of hyperglycaemia or hypoglycaemia. Glycaemic variability is currently defined by a large and increasing number of metrics, representing either short-term (within-day and between-day variability) or long-term glycaemic variability, which is usually based on serial measurements of HbA1c or other measures of glycaemia over a longer period of time. In this Review, we discuss recent evidence examining the association between glycaemic variability and diabetes-related complications, as well as non-pharmacological and pharmacological strategies currently available to address this challenging aspect of diabetes management.
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Affiliation(s)
- Antonio Ceriello
- Institut d'Investigacions Biomèdiques August Pi I Sunyer and Centro de Investigación Biomedica en Red de Diabetes y Enfermedades Metabólicas Asociadas, Barcelona, Spain; Department of Cardiovascular and Metabolic Diseases, Istituto Ricerca Cura Carattere Scientifico Multimedica, Sesto San Giovanni, Italy.
| | - Louis Monnier
- Institute of Clinical Research, University of Montpellier, Montpellier, France
| | - David Owens
- Diabetes Research Group, Institute of Life Sciences, Swansea University, Swansea, UK
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Rosenstock J, Marquard J, Laffel LM, Neubacher D, Kaspers S, Cherney DZ, Zinman B, Skyler JS, George J, Soleymanlou N, Perkins BA. Empagliflozin as Adjunctive to Insulin Therapy in Type 1 Diabetes: The EASE Trials. Diabetes Care 2018; 41:2560-2569. [PMID: 30287422 DOI: 10.2337/dc18-1749] [Citation(s) in RCA: 204] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/20/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the safety and efficacy of empagliflozin 10- and 25-mg doses plus a unique lower dose (2.5 mg) as adjunct to intensified insulin in patients with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS The EASE (Empagliflozin as Adjunctive to inSulin thErapy) program (N = 1,707) included two double-blind, placebo-controlled phase 3 trials: EASE-2 with empagliflozin 10 mg (n = 243), 25 mg (n = 244), and placebo (n = 243), 52-week treatment; and EASE-3 with empagliflozin 2.5 mg (n = 241), 10 mg (n = 248), 25 mg (n = 245), and placebo (n = 241), 26-week treatment. Together they evaluated empagliflozin 10 mg and 25 mg, doses currently approved in treatment of type 2 diabetes, and additionally 2.5 mg on 26-week change in glycated hemoglobin (primary end point) and weight, glucose time-in-range (>70 to ≤180 mg/dL), insulin dose, blood pressure, and hypoglycemia. RESULTS The observed largest mean placebo-subtracted glycated hemoglobin reductions were -0.28% (95% CI -0.42, -0.15) for 2.5 mg, -0.54% (-0.65, -0.42) for 10 mg, and -0.53% (-0.65, -0.42) for 25 mg (all P < 0.0001). Empagliflozin 2.5/10/25 mg doses, respectively, reduced mean weight by -1.8/-3.0/-3.4 kg (all P < 0.0001); increased glucose time-in-range by +1.0/+2.9/+3.1 h/day (P < 0.0001 for 10 and 25 mg); lowered total daily insulin dose by -6.4/-13.3/-12.7% (all P < 0.0001); and decreased systolic blood pressure by -2.1/-3.9/-3.7 mmHg (all P < 0.05). Genital infections occurred more frequently on empagliflozin. Adjudicated diabetic ketoacidosis occurred more with empagliflozin 10 mg (4.3%) and 25 mg (3.3%) but was comparable between empagliflozin 2.5 mg (0.8%) and placebo (1.2%). Severe hypoglycemia was rare and frequency was similar between empagliflozin and placebo. CONCLUSIONS Empagliflozin improved glycemic control and weight in T1D without increasing hypoglycemia. Ketoacidosis rate was comparable between empagliflozin 2.5 mg and placebo but increased with 10 mg and 25 mg. Ketone monitoring for early ketoacidosis detection and intervention and lower empagliflozin doses may help to reduce this risk.
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Affiliation(s)
| | - Jan Marquard
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Lori M Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Dietmar Neubacher
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Stefan Kaspers
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - David Z Cherney
- Division of Nephrology, Department of Medicine, and Department of Physiology, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, and Division of Endocrinology and Metabolism, University of Toronto, Toronto, Canada
| | - Jay S Skyler
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Jyothis George
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, and Division of Endocrinology and Metabolism, University of Toronto, Toronto, Canada
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Shimada A, Hanafusa T, Yasui A, Lee G, Taneda Y, Sarashina A, Shiki K, George J, Soleymanlou N, Marquard J. Empagliflozin as adjunct to insulin in Japanese participants with type 1 diabetes: Results of a 4-week, double-blind, randomized, placebo-controlled phase 2 trial. Diabetes Obes Metab 2018; 20:2190-2199. [PMID: 29766633 PMCID: PMC6099358 DOI: 10.1111/dom.13351] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/27/2018] [Accepted: 05/05/2018] [Indexed: 12/12/2022]
Abstract
AIMS This phase 2, double-blind, randomized, placebo-controlled trial (ClinicalTrials.gov NCT02702011) with 4 sites in Japan investigated the pharmacodynamics (PD), pharmacokinetics (PK) and safety profile of empagliflozin in Japanese participants with type 1 diabetes mellitus (T1DM) as adjunctive therapy to insulin. MATERIALS AND METHODS Participants using multiple daily injections of insulin for ≥12 months, with HbA1c of 7.5%-10.0%, entered a 2-week, open-label, placebo run-in period, followed by a 4-week, double-blind period during which participants were randomized 1:1:1:1 to receive empagliflozin 2.5 mg (n = 13), empagliflozin 10 mg (n = 12), empagliflozin 25 mg (n = 12) or placebo (n = 11). The primary objective was to assess the effect of empagliflozin vs placebo on urinary glucose excretion (UGE) after 7 days of treatment. RESULTS PD: Empagliflozin resulted in a dose-dependent significant increase in 24-hour UGE compared with placebo (UGE placebo-corrected mean [95% confidence interval] change from baseline: 2.5 mg, 65.10 [43.29, 86.90] g/24 h; 10 mg, 81.19 [58.80, 103.58] g/24 h; 25 mg, 98.11 [75.91, 120.31] g/24 h). After 4 weeks of treatment, UGE increase was associated with improved glycaemic control, reduced body weight and decreased insulin needs. Empagliflozin treatment also resulted in dose-dependent increases in serum ketone bodies and free fatty acids. PK: Plasma empagliflozin levels increased in a dose-dependent manner and peaked at 1.5 hours. In this short study, empagliflozin was well tolerated, with no increase in rate of hypoglycaemia and no diabetic ketoacidosis events reported. CONCLUSIONS Based on this short-duration phase 2 study, the PK/PD profile of empagliflozin in Japanese participants with T1DM is comparable to that of non-Japanese participants.
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Affiliation(s)
- Akira Shimada
- Department of Endocrinology and DiabetesSaitama Medical UniversitySaitamaJapan
| | | | | | | | | | | | | | | | | | - Jan Marquard
- Boehringer Ingelheim International GmbHIngelheimGermany
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Abstract
PURPOSE OF REVIEW Insulin therapy alone fails to achieve target glycemic control in the majority of individuals with type 1 diabetes (T1D), motivating the investigation of additive medications. This review focuses on the recent findings on the use of adjunctive pharmacotherapy in T1D. RECENT FINDINGS Metformin and glucagon-like peptide-1 receptor agonists have been associated with weight reduction and decrease in daily insulin requirements without sustainable improvement in glycemic control. Sodium-glucose cotransporter (SGLT)-2 inhibitors, dual SGLT-1/2 inhibitors, and pramlintide have been shown to reduce hemoglobin A1c, induce weight loss, and lower insulin dose. The benefits of dipeptidyl peptidase-4 inhibitors, thiazolidinediones, and alpha glucosidase inhibitors appear to be more limited. Gastrointestinal symptoms and increased hypoglycemia are adverse effects of certain classes. Although not devoid of side effects, additive pharmacotherapies in T1D can improve glycemic control and lower body weight and insulin requirement. Longer studies are needed before consideration for widespread clinical care.
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Affiliation(s)
- Mustafa Tosur
- Section of Diabetes and Endocrinology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 10.20, Houston, TX, 77030, USA.
| | - Maria J Redondo
- Section of Diabetes and Endocrinology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 10.20, Houston, TX, 77030, USA
| | - Sarah K Lyons
- Section of Diabetes and Endocrinology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 10.20, Houston, TX, 77030, USA
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38
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Akturk HK, Rewers A, Garg SK. SGLT inhibition: a possible adjunctive treatment for type 1 diabetes. Curr Opin Endocrinol Diabetes Obes 2018; 25:246-250. [PMID: 29794497 DOI: 10.1097/med.0000000000000423] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW To identify and evaluate the recent trials of sodium-glucose cotransporter 1 and 2 (SGLT1 and SGLT2, respectively) inhibitor use in patients with type 1 diabetes (T1D). SGLT-2 inhibitors have been approved by the Food and Drug Administration (FDA) and are effectively used in the treatment of type 2 diabetes (T2D). However, many studies (phase I-III) have validated their effects beyond improving glycemic control and have shown potential adjunctive use in adult patients with T1D treated with insulin therapy alone. RECENT FINDINGS A review of the literature showed that there is a potential adjunctive role for the SGLT inhibitors with insulin in T1D for improving glycemic control. The inTandem3 (A phase III study to evaluate the safety of sotagliflozin in patients with type 1 diabetes who have inadequate glycemic control with insulin therapy alone) and the DEPICT-1 (Dapagliflozin evaluation in patients with inadequately controlled type 1 diabetes) trials demonstrated significant benefits in adult patients with T1D. The SGLT inhibitors may become the first oral medication to be approved for adjunctive use in T1D. SUMMARY The risk of diabetic ketoacidosis still remains a concern, but considering additional benefits beyond glucose control, with proper counseling and education, these medications may allow a larger number of patients to achieve target glucose control without weight gain or increased risk of hypoglycemia.
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Affiliation(s)
- Halis Kaan Akturk
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus
- University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Amanda Rewers
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus
| | - Satish K Garg
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus
- University of Colorado, School of Medicine, Aurora, Colorado, USA
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Abstract
The sodium-glucose cotransporter type 1 (SGLT1) is the primary transporter for absorption of glucose and galactose in the gastrointestinal tract. Inhibition blunts and delays postprandial glucose (PPG) excursion. Sodium-glucose cotransporter type 2 (SGLT2) is expressed in the kidney, where it reabsorbs 90% of filtered glucose. Thus, a dual SGLT1 and SGLT2 inhibition (compared with selective SGLT2 inhibition) could result in lower PPG and robust A1c reduction even in patients with reduced kidney function. Sotagliflozin is an oral potent dual inhibitor of the insulin-independent SGLT1 and SGLT2. Preliminary data released from phase 2 and 3 clinical studies in adults with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) showed improved glycemic control, and met efficacy endpoints beyond A1c with a safety profile consistent with the SGLT class: significant reduction in body weight, systolic blood pressure, and efficacy maintained in lower estimated glomerular filtration rate levels with no increased hypoglycemia. Increased risk of diabetic ketoacidosis (DKA) with uncharacteristically mild-to-moderate glucose elevations (euglycemic DKA) is associated with the use of all the approved SGLT2 inhibitors. Factors that trigger DKA include insulin reductions, low caloric and fluid intake, intercurrent illness, and alcohol use. However, DKA is detectable and manageable with proper patient education. With sotagliflozin, DKA rates were not higher than the expected background rate in T1DM, but numerically higher than placebo. Sotagliflozin is the first oral SGLT1 and SGLT2 inhibitor developed for the treatment of adult patients with T1DM, in adjunct with insulin, and has the potential to address unmet needs for patients with T1DM and possibly T2DM, with a favorable benefit/risk profile.
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Affiliation(s)
- Thomas Danne
- Diabetes Center for Children and Adolescents Kinder- und Jugendkrankenhaus AUF DER BULT, Hannover, Germany
| | - Torben Biester
- Diabetes Center for Children and Adolescents Kinder- und Jugendkrankenhaus AUF DER BULT, Hannover, Germany
| | - Olga Kordonouri
- Diabetes Center for Children and Adolescents Kinder- und Jugendkrankenhaus AUF DER BULT, Hannover, Germany
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Kuo GH, Gaul MD, Liang Y, Xu JZ, Du F, Hornby P, Xu G, Qi J, Wallace N, Lee S, Grant E, Murray WV, Demarest K. Synthesis and biological evaluation of benzocyclobutane-C-glycosides as potent and orally active SGLT1/SGLT2 dual inhibitors. Bioorg Med Chem Lett 2018. [PMID: 29523385 DOI: 10.1016/j.bmcl.2018.02.057] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Synthesis and biological evaluation of benzocyclobutane-C-glycosides as potent and orally active SGLT1/SGLT2 dual inhibitors are described. Compound 19 showed high inhibitory potency at SGLT1 (IC50 = 45 nM), and excellent potency at SGLT2 (IC50 = 1 nM). It also displayed excellent PK profiles in mice, rats, dogs and monkeys (F = 78-107%). In SD rats, compound 19 treatments significantly reduced blood glucose levels in a dose-dependent manner. In ZDF rats, compound 19 displayed anti-hyperglycemic effect up to 24 h. Therefore, compound 19 may serve as valuable pharmacological tool, and potential use as a treatment for metabolic syndrome.
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Affiliation(s)
- Gee-Hong Kuo
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA.
| | - Micheal D Gaul
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA
| | - Yin Liang
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA
| | - June Z Xu
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA
| | - Fuyong Du
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA
| | - Pamela Hornby
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA
| | - Guozhang Xu
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA
| | - Jenson Qi
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA
| | - Nathaniel Wallace
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA
| | - Seunghun Lee
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA
| | - Eugene Grant
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA
| | - William V Murray
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA
| | - Keith Demarest
- Cardiovascular and Metabolism Research, Janssen Research and Development, L.L.C., Welsh & McKean Roads, Spring House, PA 19477, USA
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Im GB, Bhang SH. Recent research trend in cell and drug delivery system for type 1 diabetes treatment. JOURNAL OF PHARMACEUTICAL INVESTIGATION 2018. [DOI: 10.1007/s40005-017-0380-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Ahmed-Sarwar N, Nagel AK, Leistman S, Heacock K. SGLT-2 Inhibitors: Is There a Role in Type 1 Diabetes Mellitus Management? Ann Pharmacother 2017; 51:791-796. [DOI: 10.1177/1060028017710481] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: The purpose of this review is to identify and evaluate disease management of patients with type 1 diabetes mellitus (T1DM) who were treated with a sodium-glucose cotransporter 2 (SGLT-2) inhibitor as an adjunct to insulin therapy. Data Sources: A PubMed (1969 to March 2017) and Ovid (1946 to March 2017) search was performed for articles published utilizing the following MESH terms: canagliflozin, empagliflozin, dapagliflozin, type 1 diabetes mellitus, insulin dependent diabetes, insulin, sodium-glucose transporter 2. There were no limitations placed on publication type. Study Selection and Data Extraction: All English-language articles were evaluated for association of SGLT-2 inhibitors and type 1 diabetes. Further studies were identified by review of pertinent manuscript bibliographies. Data Synthesis: All 3 SGLT-2 inhibitors, when combined with insulin, resulted in an overall reduction of hemoglobin A1C (up to 0.49%), lower total daily insulin doses, and a reduction in weight (up to 2.7 kg). The combination therapy of insulin and SGLT-2 inhibitors also resulted in a lower incidence of hypoglycemia. Study duration varied from 2 to 18 weeks. Conclusion: A review of the identified literature indicated that there is a potential role for the combination of SGLT-2 inhibitors with insulin in T1DM for improving glycemic control without increasing the risk of hypoglycemia. The short duration and small sample sizes limit the ability to fully evaluate the incidences of diabetic ketoacidosis and urogenital infections. The risks associated with this combination of medications require further evaluation.
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Affiliation(s)
| | - Angela K. Nagel
- St John Fisher College, Rochester, NY, USA
- UR Medicine, Rochester, NY, USA
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