Sulfonylurea antidiabetics are associated with lower risk of out-of-hospital cardiac arrest: Real-world data from a population-based study

Sulfonylurea drugs for people with severe hemispheric ischemic stroke

BACKGROUND

Large hemispheric infarction (LHI), caused by occlusion of the internal carotid or middle cerebral artery, is the most malignant type of supratentorial ischemic stroke. Due to severe intracranial edema, mortality fluctuates between 53% and 78%, even after the most effective medical treatment. Decompressive craniectomy can reduce mortality by approximately 17% to 36%, but the neurological outcomes are not satisfactory, and there are contraindications to surgery. Therapeutic hypothermia shows promising effects in preclinical research, but it causes many complications, and clinical studies have not confirmed its efficacy. Glibenclamide is a type of sulfonylurea. Preclinical research shows that glibenclamide can reduce mortality and brain edema and improve neurological outcomes in animal models of ischemic stroke. Sulfonylureas may be a promising treatment for individuals with LHI.

OBJECTIVES

To evaluate the effects of sulfonylurea drugs in people with large hemispheric ischemic stroke.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases, and three trials registers. We also searched gray literature sources, checked the bibliographies of included studies and relevant systematic reviews, and used Cited Reference Search in Google Scholar. The latest search date was 23 March 2024.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared sulfonylureas with placebo, hypothermia, or usual care in people with severe hemispheric ischemic stroke.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were neurological and functional outcomes. Our secondary outcomes were death, quality of life, adverse events, and complications. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes two RCTs (N = 621): the GAMES-RP trial (glyburide advantage in malignant edema and stroke) and the CHARM trial (phase 3 study to evaluate the efficacy and safety of intravenous BIIB093 (glibenclamide) for severe cerebral edema following large hemispheric infarction). Both studies compared the effects of intravenous glyburide (0.13 mg bolus intravenous injection for the first 2 minutes, followed by an infusion of 0.16 mg/h for the first 6 hours and then 0.11 mg/h for the remaining 66 hours) to placebo. The GAMES-RP trial (N = 86) was conducted in 18 hospitals in the USA (mean age: intervention = 58 ± 11 years; control = 63 ± 9 years); the CHARM trial (N = 535) was conducted in 20 countries across North and South America and Eurasia (mean age: intervention = 60.5 ± 11.17 years; control = 61.6 ± 10.81 years). The overall risk of bias was high in both trials. Neither trial reported neurological outcomes. Compared with placebo, glyburide may result in little to no difference in functional outcomes, assessed with the modified Rankin Scale (range 0 to 4) at 90 days (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.89 to 1.32; P = 0.43; 2 studies, 508 participants; low-certainty evidence), or death (RR 0.78, 95% CI 0.36 to 1.69; P = 0.53; 2 studies, 595 participants; low-certainty evidence). Glyburide likely results in a large increased risk of hypoglycemia (RR 4.66, 95% CI 1.59 to 13.67; P = 0.005; 2 studies, 601 participants; moderate-certainty evidence) compared to placebo. However, it probably results in little to no difference between groups in cardiac events (RR 0.73, 95% CI 0.47 to 1.14; P = 0.17; 2 studies, 601 participants; moderate-certainty evidence), or pneumonia (RR 0.72, 95% CI 0.36 to 1.44; 1 study, 518 participants; moderate-certainty evidence), and may result in little to no difference between groups in neurological deterioration within three days (RR 0.88, 95% CI 0.61 to 1.27; 1 study, 77 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Compared to placebo, intravenous glyburide may have little to no effect on functional outcomes, assessed with the modified Rankin Scale, or mortality. It may also have little to no effect on neurological deterioration within three days, and probably has little to no effect on cardiac events or pneumonia. However, intravenous glyburide probably results in a large increased risk of hypoglycemia. This review includes only two RCTs at overall high risk of bias. We do not have sufficient evidence to determine the effects of sulfonylureas in people with ischemic stroke. More large studies, which include more sulfonylurea drugs with different routes of administration and dosages, and different age groups with ischemic stroke, would help to reduce the current uncertainties.

Current Position of Gliclazide and Sulfonylureas in the Contemporary Treatment Paradigm for Type 2 Diabetes: A Scoping Review

The increasing burden of type 2 diabetes (T2D), in relation to alarming rise in the prevalence; challenges in the diagnosis, prevention, and treatment; as well as the substantial impact of disease on longevity and quality of life, is a major concern in healthcare worldwide. Sulfonylureas (SUs) have been a cornerstone of T2D pharmacotherapy for over 60 years as oral antidiabetic drugs (OADs), while the newer generation SUs, such as gliclazide modified release (MR), are known to be associated with low risk of hypoglycemia in addition to the cardiovascular neutrality. This scoping review aimed to specifically address the current position of gliclazide MR among other SUs in the contemporary treatment paradigm for T2D and to provide a practical guidance document to assist clinicians in using gliclazide MR in real-life clinical practice. The main topics addressed in this paper include the role of early and sustained glycemic control and use of SUs in T2D management, the properties of gliclazide MR in relation to its effectiveness and safety, the use of gliclazide therapy in special populations, and the place of SUs as a class and gliclazide MR specifically in the current T2D treatment algorithm.

Injection of IK1 through dynamic clamp can make all the difference in patch-clamp studies on hiPSC-derived cardiomyocytes

Human-induced stem cell-derived cardiomyocytes (hiPSC-CMs) are a valuable tool for studying development, pharmacology, and (inherited) arrhythmias. Unfortunately, hiPSC-CMs are depolarized and spontaneously active, even the working cardiomyocyte subtypes such as atrial- and ventricular-like hiPSC-CMs, in contrast to the situation in the atria and ventricles of adult human hearts. Great efforts have been made, using many different strategies, to generate more mature, quiescent hiPSC-CMs with more close-to-physiological resting membrane potentials, but despite promising results, it is still difficult to obtain hiPSC-CMs with such properties. The dynamic clamp technique allows to inject a current with characteristics of the inward rectifier potassium current (IK1), computed in real time according to the actual membrane potential, into patch-clamped hiPSC-CMs during action potential measurements. This results in quiescent hiPSC-CMs with a close-to-physiological resting membrane potential. As a result, action potential measurements can be performed with normal ion channel availability, which is particularly important for the physiological functioning of the cardiac SCN5A-encoded fast sodium current (INa). We performed in vitro and in silico experiments to assess the beneficial effects of the dynamic clamp technique in dissecting the functional consequences of the SCN5A-1795insD+/- mutation. In two separate sets of patch-clamp experiments on control hiPSC-CMs and on hiPSC-CMs with mutations in ACADVL and GNB5, we assessed the value of dynamic clamp in detecting delayed afterdepolarizations and in investigating factors that modulate the resting membrane potential. We conclude that the dynamic clamp technique has highly beneficial effects in all of the aforementioned settings and should be widely used in patch-clamp studies on hiPSC-CMs while waiting for the ultimate fully mature hiPSC-CMs.

Metformin-'BRAINS & AIMS' pharmacological/prescribing principles of commonly prescribed (Top 100) drugs: Education and discussion

We review pharmacological/prescribing principles relating to metformin according to our mnemonic framework: 'BRAINS & AIMS' (Benefits, Risks, Adverse Effects, Interactions, Necessary prophylaxis, Susceptibilities, Administering, Informing, Monitoring and Stopping): Benefits: Metformin's licensed uses: Type 2 diabetes mellitus (T2DM) treatment, reduction in risk or delay of onset. No clear evidence metformin influences patient-important outcomes [Cochrane Review (2020) of 18 RCTs (n = 10 680)]. Risks: Inexpensive, essential WHO list drug; use contraindicated/not tolerated in 15%: for example, contraindication: lactic acidosis in renal impairment (eGFR <30 mL/min/1.73 m² ). Adverse effects: Common gastrointestinal (GI) side effects are dose-related and include abdominal pain, decreased appetite, diarrhoea (usually transient), nausea and vomiting, altered taste; vitamin B₁₂ deficiency. Rare: acute metabolic acidosis (lactic acidosis/diabetic ketoacidosis). Interactions (pharmacokinetic) occur with drugs impairing renal function and hence metformin excretion, and drugs inhibiting organic cation transporter 1 or 2 (OCT1, OCT2), and/or multidrug and toxin extrusion protein 1 (MATE1/2-K), such as cimetidine, ranolazine, trimethoprim and verapamil, and inducers such as rifampicin. The risk of hypoglycaemia may increase when metformin is used in combination with other medications for diabetes (pharmacodynamic interaction). Necessary prophylaxis: Detect/treat vitamin B₁₂ deficiency. Susceptible groups: Elderly/renal/liver impairment (lactic acidosis); safe in pregnancy/breastfeeding. Administering: Initially 500 mg once daily (morning) with breakfast; titrate only after 1 week. Informing (relevant BRAINS & A(I)MS principles). Monitoring: Renal function beforehand, and 6-12 monthly, HbA1c 3-6 monthly until controlled. Serum vitamin B₁₂ levels if deficiency is suspected/risk factors for. Stopping: Encourage patients to continue medication, unless deteriorating renal/liver function. Reasons for deprescribing: no harms from stopping suddenly.

DEVELOPMENT OF MICROCAPSULES BASED ON COMBINED ANTIDIABETIC SUBSTANCE: PHARMACOLOGICAL CHARACTERISTICS

The comparative assessment results of the hypoglycemic activity of a combined preparation containing microcapsules with a phytocomposition consisting of Glycyrrhiza glabra L. extracts, a dry extract of Galega officinalis L., Mentha piperita L., and gliclazide, are discussed in the article. Methods for obtaining microcapsules with an original PEG-6000 shell are described.

The aim of the study was to develop an optimal technology for obtaining microcapsules with a PEG-6000 shell containing a combined antidiabetic substance, and conduct its detailed pharmacological study on the model of type 2 diabetes mellitus, to conduct a detailed comparative pharmacological study of a microencapsulated antidiabetic composition with a shell based on PEG-6000, including gliclazide and a sum of phytoextracts on the model of type 2 diabetes mellitus.

Materials and methods. As the main objects of the study, microcapsules with a PEG-6000 shell were obtained using methyl miristate as the base liquid. The capsules contained the amount of plant extracts in their composition: a dry extract of Glycyrrhiza glabra L., a dry extract of Galega officinalis L., a dry extract of Mentha piperita L., and gliclazide. The study of a hypoglycemic activity was carried out after a single administration of drugs to the animals with alloxan-induced type 2 diabetes mellitus. The cumulative effect assessment of the drugs was carried out within 14 days with a test for the resistance to oral glucose on days 7 and 14.

Results. Microcapsules with the original shell were obtained by dispersion in a liquid-liquid system with the adjustment of some technological stages. The effect of the drugs under study on the glycemic profile in the rats with an experimental model of type 2 diabetes mellitus was investigated. A comparative evaluation of the pharmacological effect was carried out with a separate and combined use of microencapsulated preparations.

Conclusion. The rationality of combining phytocomponents and a synthetic antidiabetic agent in microcapsules has been proven. The obtained results testify to the rationality of plant extracts combination and a synthetic hypoglycemic agent – gliclazide in microcapsules.

Effect of metformin on adverse outcomes in T2DM patients: Systemic review and meta-analysis of observational studies

Background

The cardiovascular protection effect of metformin on patients with type 2 diabetes mellitus (T2DM) remains inconclusive. This systemic review and meta-analysis were to estimate the effect of metformin on mortality and cardiovascular events among patients with T2DM.

Methods

A search of the Pubmed and EMBASE databases up to December 2021 was performed. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled by a random-effects model with an inverse variance method.

Results

A total of 39 studies involving 2473009 T2DM patients were adopted. Compared to non-metformin therapy, the use of metformin was not significantly associated with a reduced risk of major adverse cardiovascular event (MACE) (HR = 1.06, 95%CI 0.91–1.22; I² = 82%), hospitalization (HR = 0.85, 95%CI 0.64–1.13; I² = 98%), heart failure (HR = 0.86, 95%CI 0.60–1.25; I² = 99%), stroke (HR = 1.16, 95%CI 0.88–1.53; I² = 84%), and risk of AMI (HR = 0.88, 95%CI 0.69–1.14; I² = 88%) in T2DM patients. Metformin was also not associated with significantly lowered risk of MACE compared to dipeptidyl peptidase-4 inhibitor (DPP-4i) in T2DM patients (HR = 0.95, 95%CI 0.73–1.23; I² = 84%).

Conclusions

The effect of metformin on some cardiovascular outcomes was not significantly better than the non-metformin therapy or DPP-4i in T2DM patients based on observational studies.

Sulfonylurea Is Associated With Higher Risks of Ventricular Arrhythmia or Sudden Cardiac Death Compared With Metformin: A Population-Based Cohort Study

Background Commonly prescribed diabetic medications such as metformin and sulfonylurea may be associated with different arrhythmogenic risks. This study compared the risk of ventricular arrhythmia or sudden cardiac death between metformin and sulfonylurea users in patients with type 2 diabetes. Methods and Results Patients aged ≥40 years who were diagnosed with type 2 diabetes or prescribed antidiabetic agents in Hong Kong between January 1, 2009, and December 31, 2009, were included and followed up until December 31, 2019. Patients prescribed with both metformin and sulfonylurea or had prior myocardial infarction were excluded. The study outcome was a composite of ventricular arrhythmia or sudden cardiac death. Metformin users and sulfonylurea users were matched at a 1:1 ratio by propensity score matching. The matched cohort consisted of 16 596 metformin users (47.70% men; age, 68±11 years; mean follow-up, 4.92±2.55 years) and 16 596 sulfonylurea users (49.80% men; age, 70±11 years; mean follow-up, 4.93±2.55 years). Sulfonylurea was associated with higher risk of ventricular arrhythmia or sudden cardiac death than metformin hazard ratio (HR, 1.90 [95% CI, 1.73-2.08]). Such difference was consistently observed in subgroup analyses stratifying for insulin usage or known coronary heart disease. Conclusions Sulfonylurea use is associated with higher risk of ventricular arrhythmia or sudden cardiac death than metformin in patients with type 2 diabetes.

Sulfonylureas and the Risk of Ventricular Arrhythmias Among People with Type 2 Diabetes: A Systematic Review of Observational Studies

Previous studies have suggested an association between sulfonylureas and an increased risk of cardiovascular death among patients with type 2 diabetes. A potential mechanism involves sulfonylurea-induced ventricular arrhythmias (VAs). We conducted a systematic review of observational studies to determine whether the use of sulfonylureas, compared with the use of other antihyperglycemic drugs, is associated with the risk of VA (ventricular tachycardia, ventricular fibrillation, and premature ventricular complexes), cardiac arrest, and sudden cardiac death among patients with type 2 diabetes. Two independent reviewers searched MEDLINE, EMBASE, CINAHL Plus, CENTRAL, and ClinicalTrials.gov from inception to July 2021 for observational studies comparing sulfonylureas vs. other antihyperglycemic therapies or intraclass comparisons of sulfonylureas. Our systematic review included 17 studies (1,607,612 patients). Per Risk Of Bias In Non-randomized Studies of Interventions (ROBINS)-I, there were few high-quality studies (2 studies at moderate risk of bias; 4 at serious risk; and 11 at critical risk). All studies at a moderate or serious risk of bias reporting comparisons with other therapies were consistent with an increased risk of VA. Sulfonylureas were associated with a higher risk of arrhythmia vs. dipeptidyl peptidase-4 inhibitors (adjusted hazard ratio (aHR): 1.52, 95% confidence interval (CI): 1.27-1.80) and of VA vs. metformin (aHR: 1.52, 95% CI: 1.10-2.13). One moderate quality study reported inconsistent results for a composite of cardiac arrest/VA in analyses of US Medicaid claims and Optum claims data. Our systematic review suggests that, among higher-quality observational studies, sulfonylureas are associated with an increased risk of VA. However, we identified few methodologically rigorous studies, underscoring the need for additional real-world studies.