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Renda S, Freeman J. You may delay, but time will not. Beta cells lost are never found again: a case for timely initiation of basal insulin in type 2 diabetes. Postgrad Med 2024; 136:150-161. [PMID: 38465574 DOI: 10.1080/00325481.2024.2328511] [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: 07/20/2023] [Accepted: 03/04/2024] [Indexed: 03/12/2024]
Abstract
Since its first use just over a century ago, insulin treatment has evolved dramatically, such that the molecules are physiologic in nature, and treatment can now closely resemble the natural hormone response over 24 hours. Newer, longer-acting basal insulin analogs have provided insulin therapies with improved characteristics and, therefore, ease of use, and can readily be incorporated as part of routine treatment for type 2 diabetes (T2D), but evidence suggests that insulin remains underused in people with T2D. We review the barriers to initiation of basal insulin and the education needed to address these barriers, and we provide practical pointers, supported by evidence, for primary care physicians and advanced practice providers to facilitate timely initiation of basal insulin in the people with T2D who will benefit from such treatment.
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Affiliation(s)
- Susan Renda
- Johns Hopkins Comprehensive Diabetes Center, Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Jeffrey Freeman
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
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2
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Abdelgani S, Khattab A, Adams J, Baskoy G, Triplitt C, DeFronzo RA, Abdul-Ghani M. The impact of increased hepatic glucose production caused by empagliflozin on plasma glucose concentration in individuals with type 2 diabetes and nondiabetic individuals. Diabetes Obes Metab 2024; 26:1033-1039. [PMID: 38131252 DOI: 10.1111/dom.15404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/25/2023] [Accepted: 11/25/2023] [Indexed: 12/23/2023]
Abstract
AIM To examine the impact of increased hepatic glucose production (HGP) on the decrease in plasma glucose concentration caused by empagliflozin in individuals living with diabetes and in nondiabetic individuals. METHODS A total of 36 individuals living with diabetes and 34 nondiabetic individuals were randomized to receive, in double-blind fashion, empagliflozin or matching placebo in a 2:1 treatment ratio. Following an overnight fast, HGP was measured with 3-3 H-glucose infusion before, at the start of, and 3 months after therapy with empagliflozin. RESULTS On Day 1 of empagliflozin administration, the increase in urinary glucose excretion (UGE) in individuals with normal glucose tolerance was smaller than in those with impaired glucose tolerance and those living with diabetes, and was accompanied by an increase in HGP in all three groups. The amount of glucose returned to the systemic circulation as a result of the increase in HGP was smaller than that excreted by the kidney during the first 3 h after empagliflozin administration, resulting in a decrease in fasting plasma glucose (FPG) concentration. After 3 h, the increase in HGP was in excess of UGE, leading to a small increase in plasma glucose concentration, which reached a new steady state. After 12 weeks, the amount of glucose returned to the circulation due to the empagliflozin-induced increase in HGP was comparable with that excreted by the kidney in all three groups. CONCLUSION The balance between UGE and increase in HGP immediately after sodium-glucose cotransporter-2 (SGLT2) inhibition determined the magnitude of decrease in FPG and the new steady state which was achieved. After 12 weeks, the increase in HGP caused by empagliflozin closely matched the amount of glucose excreted by the kidneys; thus, FPG level remained stable despite the continuous urinary excretion of glucose caused by SGLT2 inhibition.
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Affiliation(s)
- Siham Abdelgani
- Division of Diabetes, University of Texas Health Science Center, and Texas Diabetes Institute, San Antonio, Texas, USA
| | - Ahmed Khattab
- Division of Diabetes, University of Texas Health Science Center, and Texas Diabetes Institute, San Antonio, Texas, USA
| | - John Adams
- Division of Diabetes, University of Texas Health Science Center, and Texas Diabetes Institute, San Antonio, Texas, USA
| | - Gozde Baskoy
- Division of Diabetes, University of Texas Health Science Center, and Texas Diabetes Institute, San Antonio, Texas, USA
| | - Curtis Triplitt
- Division of Diabetes, University of Texas Health Science Center, and Texas Diabetes Institute, San Antonio, Texas, USA
| | - Ralph A DeFronzo
- Division of Diabetes, University of Texas Health Science Center, and Texas Diabetes Institute, San Antonio, Texas, USA
| | - Muhammad Abdul-Ghani
- Division of Diabetes, University of Texas Health Science Center, and Texas Diabetes Institute, San Antonio, Texas, USA
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3
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Chen X, Liu Y, Ren L, Dai X, Zhao J, Gao C, Zhang S, Dong J, Zhao Z, Li Y, Wang J, Zhao H, Gong G, He X, Bian Y. Extraction, purification, structural characteristics and biological properties of the polysaccharides from Armillaria mellea (Vahl) P. Kumm.: A review. Int J Biol Macromol 2024; 259:129175. [PMID: 38181916 DOI: 10.1016/j.ijbiomac.2023.129175] [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: 09/16/2023] [Revised: 12/01/2023] [Accepted: 12/29/2023] [Indexed: 01/07/2024]
Abstract
Armillaria mellea (Vahl) P. Kumm. is a well-known homoeopathic plant with medicinal and culinary uses. Modern phytochemical researchers have successfully extracted and purified over 40 types of A. mellea polysaccharides (AMPs) from the fruiting bodies, hyphae and fermentation broth of A. mellea, and some of them have been analyzed and identified by their chemical structures. The impressive biological activity of these polysaccharides has been recognized by scientists worldwide. Many studies show that AMPs have remarkable antioxidant, anti-diabetic, anti-tumor, anti-inflammatory, immunoregulatory, hypolipidemic, thrombectomy, anti-aging, pulmonary protective, hepatic protective, anti-Alzheimer's properties, etc. However, the current understanding of the relationships between their chemical structure and biological activity, toxicological effects and pharmacokinetics remains limited. This article provides a systematic review of the research conducted over the past decades on the extraction and purification methods, structural characteristics, biological activity and mechanism of action of AMPs. The aim is to provide a research base that will benefit the future application of AMPs as therapeutic drugs and functional foods, and also provide insights for the further development of AMPs.
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Affiliation(s)
- Xufei Chen
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Yinghai Liu
- Department of Anesthesiology, General Hospital of the Western Theater Command of the Chinese People's Liberation Army, Chengdu, Sichuan 610036, China
| | - Ling Ren
- Department of Anesthesiology, General Hospital of the Western Theater Command of the Chinese People's Liberation Army, Chengdu, Sichuan 610036, China
| | - Xufen Dai
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Juanjuan Zhao
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Chunli Gao
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Shengxiang Zhang
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Jianhui Dong
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Zeyuan Zhao
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Yanfeng Li
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Jia Wang
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Hui Zhao
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Gu Gong
- Department of Anesthesiology, General Hospital of the Western Theater Command of the Chinese People's Liberation Army, Chengdu, Sichuan 610036, China
| | - Xirui He
- School of Bioengineering, Zhuhai Campus, Zunyi Medical University, Zhuhai, Guangdong 519041, China.
| | - Yangyang Bian
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China.
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Zhu J, Wilding JPH. Body Fat Depletion: the Yin Paradigm for Treating Type 2 Diabetes. Curr Atheroscler Rep 2024; 26:1-10. [PMID: 38148417 PMCID: PMC10776473 DOI: 10.1007/s11883-023-01181-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE OF REVIEW To highlight that body fat depletion (the Yin paradigm) with glucose-lowering treatments (the Yang paradigm) are associated with metabolic benefits for patients with type 2 diabetes mellitus (T2DM). RECENT FINDINGS The sodium-glucose cotransporter-2 inhibitor-mediated sodium/glucose deprivation can directly improve glycemic control and kidney outcome in patients with T2DM. The glucose deprivation might also promote systemic fatty acid β-oxidation to deplete ectopic/visceral fat and thereby contribute to the prevention of cardiovascular diseases. As with metabolic surgery, bioengineered incretin-based medications with potent anorexigenic and insulinotropic efficacy can significantly reduce blood glucose as well as body weight (especially in the ectopic/visceral fat depots). The latter effects could be a key contributor to their cardiovascular-renal protective effects. In addition to a healthy diet, the newer glucose-lowering medications, with body fat reduction effects, should be prioritized when treating patients with T2DM, especially for those with established cardiovascular/renal risks or diseases.
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Affiliation(s)
- Jingjing Zhu
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Clinical Sciences Centre, Liverpool University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, UK
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Clinical Sciences Centre, Liverpool University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, UK.
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Zamanillo-Campos R, Zaforteza Dezcallar M, Boronat Moreiro MA, Leiva Rus A, Ripoll Amengual J, Konieczna J, Fiol-deRoque MA, Ricci-Cabello I. Non-adherence to non-insulin glucose-lowering drugs: Prevalence, predictors and impact on glycemic control and insulin initiation. A longitudinal cohort study in a large primary care database in Spain. Eur J Gen Pract 2023; 29:2268838. [PMID: 37874585 PMCID: PMC10990259 DOI: 10.1080/13814788.2023.2268838] [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: 11/12/2022] [Accepted: 10/03/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND A better understanding of patient non-adherence to type 2 diabetes medication is needed to design effective interventions to address this issue. OBJECTIVES (1) To estimate the prevalence of non-adherence to diabetes medication; (2) to examine its impact on glycemic control and insulin initiation; (3) to develop and validate a prediction model of non-adherence. METHODS We conducted a longitudinal cohort study based on data from electronic health records. We included adult patients registered within the Health Service of the Balearic Islands (Spain) starting a new prescription of a non-insulin glucose-lowering drug between January 2016 and December 2018. We calculated non-adherence at 12 months follow-up, defined as medication possession ratio (MPR) ≤ 80%. We fitted multivariable regression models to examine the association between non-adherence and glycemic control and insulin initiation and identified predictors of non-adherence. RESULTS Of 18,119 patients identified, after 12 months follow-up, 5,740 (31.68%) were non-adherent. Compared with non-adherent, adherent patients presented lower HbA1c levels (mean difference = -0.32%; 95%CI = -0.38%; -0.27%) and were less likely to initiate insulin (aOR = 0.77; 95%CI = 0.63; 0.94). A predictive model explained 22.3% of the variation and presented a satisfactory performance (AUC = 0.721; Brier score = 0.177). The most important predictors of non-adherence were: non-Spanish nationality, currently working, low adherence to previous drugs, taking biguanides, smoker and absence of hypertension. CONCLUSION Around one-third of the patients do not adhere to their non-insulin glucose-lowering drugs. More research is needed to optimise the performance of the predicting model before considering its implementation in routine clinical practice.
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Affiliation(s)
- Rocío Zamanillo-Campos
- Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
- Primary Care Research Unit of Mallorca, Balearic Islands Health Service, Palma, Spain
| | | | | | - Alfonso Leiva Rus
- Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
- Primary Care Research Unit of Mallorca, Balearic Islands Health Service, Palma, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS, RD21/0016/0005), Barcelona, Spain
| | - Joana Ripoll Amengual
- Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
- Primary Care Research Unit of Mallorca, Balearic Islands Health Service, Palma, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS, RD21/0016/0005), Barcelona, Spain
| | - Jadwiga Konieczna
- CIBER de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, Spain
- Research Group on Nutritional Epidemiology & Cardiovascular Physiopathology (NUTRECOR), Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases (HUSE), Palma de Mallorca, Spain
| | - Maria Antonia Fiol-deRoque
- Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
- Primary Care Research Unit of Mallorca, Balearic Islands Health Service, Palma, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS, RD21/0016/0005), Barcelona, Spain
| | - Ignacio Ricci-Cabello
- Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
- Primary Care Research Unit of Mallorca, Balearic Islands Health Service, Palma, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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Guarnotta V, Emanuele F, Salzillo R, Bonsangue M, Amato C, Mineo MI, Giordano C. Practical therapeutic approach in the management of diabetes mellitus secondary to Cushing's syndrome, acromegaly and neuroendocrine tumours. Front Endocrinol (Lausanne) 2023; 14:1248985. [PMID: 37842314 PMCID: PMC10569460 DOI: 10.3389/fendo.2023.1248985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/28/2023] [Indexed: 10/17/2023] Open
Abstract
Cushing's syndrome, acromegaly and neuroendocrine disorders are characterized by an excess of counterregulatory hormones, able to induce insulin resistance and glucose metabolism disorders at variable degrees and requiring immediate treatment, until patients are ready to undergo surgery. This review focuses on the management of diabetes mellitus in endocrine disorders related to an excess of counterregulatory hormones. Currently, the landscape of approved agents for treatment of diabetes is dynamic and is mainly patient-centred and not glycaemia-centred. In addition, personalized medicine is more and more required to provide a precise approach to the patient's disease. For this reason, we aimed to define a practical therapeutic algorithm for management of diabetes mellitus in patients with glucagonoma, pheochromocytoma, Cushing's syndrome and acromegaly, based on our practical experience and on the physiopathology of the specific endocrine disease taken into account. This document is addressed to all specialists who approach patients with diabetes mellitus secondary to endocrine disorders characterized by an excess of counterregulatory hormones, in order to take better care of these patients. Care and control of diabetes mellitus should be one of the primary goals in patients with an excess of counterregulatory hormones requiring immediate and aggressive treatment.
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Affiliation(s)
| | | | | | | | | | | | - Carla Giordano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Endocrinology, University of Palermo, Piazza delle Cliniche 2, Palermo, Italy
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7
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SGLT2 Inhibitors in Type 2 Diabetes Mellitus. Heart Fail Clin 2022; 18:551-559. [DOI: 10.1016/j.hfc.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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8
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Boullenger L, Quindroit P, Legrand B, Balcaen T, Calafiore M, Rochoy M, Beuscart JB, Chazard E. Type 2 diabetics followed up by family physicians: Treatment sequences and changes over time in weight and glycated hemoglobin. Prim Care Diabetes 2022; 16:670-676. [PMID: 35864077 DOI: 10.1016/j.pcd.2022.07.002] [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: 01/18/2022] [Revised: 06/07/2022] [Accepted: 07/13/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The treatment of type 2 diabetes mellitus (T2DM) is based on preventive hygiene and dietary measures (HDM), oral antidiabetic drugs (OADs), and insulin. The objective of the present study was to reuse general practice data from electronic health records and describe changes over time among patients with T2DM in primary care. METHODS We analyzed data on patients with T2DM collected by three family physicians in Tourcoing (France) from 2006 to 2018. RESULTS 403 patients, 1030 treatment sequences, 39,042 appointments, 2440 glycated hemoglobin (HbA1c) measurements, and 9722 wt measurements were included. On inclusion, the mean age was 57.0, the mean weight was 84.4 kg, the mean body mass index was 30.3 kg/m2, and the median HbA1c level was 6.8 % (51 mmol/mol). The patients were following appropriate HDM (40.7 %) and/or were being treated with OADs (54.1 %) or insulin (5.2 %). The median length of follow-up was 3.51 years. Overall, bodyweight was stable for two years during HDM and then increased. The HbA1c level decreased and then increased during HDM, was stable on OADs, and then decreased on insulin. DISCUSSION/CONCLUSION The present descriptive results may be of value in helping to predict changes over time in bodyweight and HbA1c in T2DM.
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Affiliation(s)
- Léna Boullenger
- Univ. Lille, CHU Lille, ULR 2694, METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, General Practice, F-59000 Lille, France
| | - Paul Quindroit
- Univ. Lille, CHU Lille, ULR 2694, METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, F-59000 Lille, France
| | - Bertrand Legrand
- Univ. Lille, CHU Lille, ULR 2694, METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, General Practice, F-59000 Lille, France
| | - Thibaut Balcaen
- Univ. Lille, CHU Lille, ULR 2694, METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, CH St Quentin, St Quentin, F-02100, France
| | - Matthieu Calafiore
- Univ. Lille, CHU Lille, ULR 2694, METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, General Practice, F-59000 Lille, France
| | - Michaël Rochoy
- Univ. Lille, CHU Lille, ULR 2694, METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, General Practice, F-59000 Lille, France
| | - Jean-Baptiste Beuscart
- Univ. Lille, CHU Lille, ULR 2694, METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, F-59000 Lille, France
| | - Emmanuel Chazard
- Univ. Lille, CHU Lille, ULR 2694, METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, F-59000 Lille, France.
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Landgraf R, Aberle J, Birkenfeld AL, Gallwitz B, Kellerer M, Klein H, Müller-Wieland D, Nauck MA, Wiesner T, Siegel E. Therapy of Type 2 Diabetes. Exp Clin Endocrinol Diabetes 2022; 130:S80-S112. [PMID: 35839797 DOI: 10.1055/a-1624-3449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Jens Aberle
- Division of Endocrinology and Diabetology, University Obesity Centre Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | | | - Baptist Gallwitz
- Department of Internal Medicine IV, Diabetology, Endocrinology, Nephrology, University Hospital Tübingen, Germany
| | - Monika Kellerer
- Department of Internal Medicine I, Marienhospital, Stuttgart, Germany
| | - Harald Klein
- Department of Internal Medicine I, University Hospital Bergmannsheil, Bochum, Germany
| | - Dirk Müller-Wieland
- Department of Internal Medicine I, University Hospital RWTH, Aachen, Germany
| | - Michael A Nauck
- Diabetes Centre Bochum-Hattingen, St.-Josef-Hospital, Ruhr-University, Bochum, Germany
| | | | - Erhard Siegel
- Department of Internal Medicine - Gastroenterology, Diabetology/Endocrinology and Nutritional Medicine, St. Josefkrankenhaus Heidelberg GmbH, Heidelberg, Germany
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10
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Therapie des Typ-2-Diabetes. DIE DIABETOLOGIE 2022. [PMCID: PMC9191539 DOI: 10.1007/s11428-022-00921-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Zheng H, Sigal RJ, Coyle D, Bai Z, Johnston A, Elliott J, Hsieh S, Kelly SE, Chen L, Skidmore B, Toupin-April K, Wells GA. Comparative efficacy and safety of antihyperglycemic drug classes for patients with type 2 diabetes following failure with metformin monotherapy: A systematic review and network meta-analysis of randomized controlled trials. Diabetes Metab Res Rev 2022; 38:e3515. [PMID: 34951928 DOI: 10.1002/dmrr.3515] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 09/18/2021] [Indexed: 11/09/2022]
Abstract
AIMS To compare the efficacy and safety of antihyperglycemic agents, taken in combination with metformin, for the treatment of type 2 diabetes mellitus (T2DM). METHODS A previous 2016 comprehensive search of Ovid MEDLINE, PubMed, and Cochrane CENTRAL was updated to October 2018, and a systematic review and network meta-analysis (NMA) was conducted. Randomized controlled trials (RCTs) of patients with T2DM taking an antihyperglycemic agent in combination with metformin were included. Bayesian NMA was performed to assess the relative efficacy and safety of the antihyperglycemic classes. RESULTS In total, 204 RCTs were included, which assessed the efficacy and safety of eight antihyperglycemic drug classes (i.e., sulfonylureas, meglitinides, alpha-glucosidase inhibitors, thiazolidinediones, basal and biphasic insulin, dipeptidyl peptidase 4 inhibitors, glucagon-like-peptide-1 receptor agonists and sodium-glucose cotransport-2 inhibitors). All drug classes significantly reduced haemoglobin A1c (HbA1c) compared to metformin monotherapy (mean reduction from 0.50 to 0.92). The drug classes varied in their relative effects on hypoglycemia, body weight, body mass index, systolic and diastolic blood pressure, total cholesterol, high and low density lipoprotein cholesterol, and the classes had differing safety profiles on total adverse events, urogenital adverse events, heart failure, serious adverse events, and withdraw due to adverse events. CONCLUSIONS All eight antihyperglycemic drug classes, taken in combination with metformin, reduced HbA1c levels; however, the effects of the agents on other outcomes varied among the classes.
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Affiliation(s)
- Hui Zheng
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Centre for Food-borne, Environment and Zoonotic Infectious Disease, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Ronald J Sigal
- Division of Endocrinology and Metabolism, Departments of Medicine, Cardiac Sciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Zemin Bai
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Amy Johnston
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jesse Elliott
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Shuching Hsieh
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Shannon E Kelly
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Li Chen
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Becky Skidmore
- Independent Information Specialist, Ottawa, Ontario, Canada
| | - Karine Toupin-April
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Brown E, Wilding JPH, Alam U, Barber TM, Karalliedde J, Cuthbertson DJ. The expanding role of SGLT2 inhibitors beyond glucose-lowering to cardiorenal protection. Ann Med 2021; 53:2072-2089. [PMID: 33107349 PMCID: PMC8592607 DOI: 10.1080/07853890.2020.1841281] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/12/2020] [Indexed: 12/17/2022] Open
Abstract
The kidney plays a major physiological role in glucose homeostasis but also contributes to the pathophysiology of type 2 diabetes (T2D), mediated by renal sodium glucose cotransporters (SGLTs). This recognition led to the development of SGLT2 inhibitors that inhibit proximal renal tubular renal glucose and sodium reabsorption. The glucoretic and natriuretic effect of SGLT2 inhibitors is associated with reductions in HbA1c levels, body weight, systolic blood pressure and triglycerides. Major vascular complications of T2D include cardiovascular disease and chronic kidney disease (CKD). Results from several cardiovascular outcome trials (CVOTs) with these drugs have highlighted benefits in reducing major adverse cardiovascular events by 11%, reducing the risk of cardiovascular death or hospitalization for heart failure (HF) by 23% and reducing the risk of progression of renal disease by 45%. Their cardiorenal benefits are apparent across a range of eGFRs (within CKD1-3 groups) and the presence or absence of ischaemic heart disease, HF or T2D. In patients with HF with reduced ejection fraction (HFrEF), similar risk reductions in cardiovascular death and HF events are also seen; results from studies in patients with HF with preserved ejection fraction (HFpEF) are awaited. Cardiorenal benefits have been recently reported in patients with CKD, regardless of the presence or absence of T2D. Indications for use of SGLT2 inhibitors have extended beyond glucose-lowering to a central role in cardiorenal protection. This review will first explore the mechanisms by which glycaemic control, weight loss and cardiovascular risk factors are modulated therapeutically with SGLT2 inhibitors. Subsequently, we outline putative mechanisms underpinning the cardiorenal benefits seen, including in HF and CKD, in the context of completed and ongoing clinical studies. Treatment strategies with SGLT2 inhibitors in individuals with CKD or HF, with and/or without T2D are increasingly appealing. Combination therapy with complementary therapeutic agents is also explored.
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Affiliation(s)
- Emily Brown
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - John P. H. Wilding
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Uazman Alam
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester, Manchester, UK
| | - Thomas M. Barber
- Human Metabolism Research Unit, University of Warwick, Coventry, UK
- University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Janaka Karalliedde
- School of Cardiovascular Medicine & Sciences, King’s College London, London, UK
| | - Daniel J. Cuthbertson
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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13
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Savarese G, Butler J, Lund LH, Bhatt DL, Anker SD. CARDIOVASCULAR EFFECTS OF NON-INSULIN GLUCOSE-LOWERING AGENTS: A COMPREHENSIVE REVIEW OF TRIAL EVIDENCE AND POTENTIAL CARDIOPROTECTIVE MECHANISMS. Cardiovasc Res 2021; 118:2231-2252. [PMID: 34390570 DOI: 10.1093/cvr/cvab271] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/12/2021] [Indexed: 11/12/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is highly prevalent and associated with a 2-fold increased mortality, mostly explained by cardiovascular diseases. Trial evidence on older glucose-lowering agents such as metformin and sulfonylureas is limited in terms of cardiovascular efficacy. Since 2008, after rosiglitazone was observed to increase the risk of myocardial infarction and heart failure (HF), cardiovascular outcome trials (CVOT) have been required by regulators for licensing new glucose-lowering agents. In the following CVOTs, dipeptidyl peptidase 4 inhibitors (DPP4i) have been shown to be safe but not to improve morbidity/mortality, except for saxagliptin which increased the risk of HF. Several glucagon-like peptide-1 receptor agonists (GLP1-Ra) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been demonstrated to reduce the risk of cardiovascular morbidity and mortality. SGLT2i have shown a class effect for the reduction in risk of HF events in patients with T2DM, leading to trials testing their efficacy/safety in HF regardless of T2DM. In the DAPA-HF and the EMPEROR-Reduced trials dapagliflozin and empagliflozin, respectively, improved cardiovascular mortality/morbidity in patients with HF and reduced ejection fraction (HFrEF), with and without T2DM. Therefore, these drugs are now key part of HFrEF pharmacotherapy. In the SOLOIST-WHF, sotagliflozin reduced cardiovascular mortality/morbidity in patients with T2DM and a recent acute episode of HF regardless of EF. The DELIVER and the EMPEROR-Preserved are testing dapagliflozin and empagliflozin, respectively, in patients with HF with mildly reduced and preserved EF. A strong renal protective role of SGLT2i has also emerged in trials enrolling patients with and without T2DM.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden. Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Javed Butler
- University of Mississippi School of Medicine, Jackson, MI, USA
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden. Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Germany
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14
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Ferrannini G, Savarese G, Rydén L. Sodium-glucose transporter inhibition in heart failure: from an unexpected side effect to a novel treatment possibility. Diabetes Res Clin Pract 2021; 175:108796. [PMID: 33845051 DOI: 10.1016/j.diabres.2021.108796] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 03/30/2021] [Accepted: 04/02/2021] [Indexed: 12/17/2022]
Abstract
Sodium-glucose transporter-2 inhibitors (SGLT2i), originally launched as glucose-lowering drugs, have been studied in large cardiovascular outcome trials to ascertain safety. Surprisingly, these compounds reduced the risk of cardiovascular events (cardiovascular death, non-fatal myocardial and non-fatal stroke) and total mortality. The mechanisms behind this benefit are only partly understood, but a major contributor is the reduction of heart failure hospitalisations, evident already within weeks after the initiation of the SGLT2i. SGLT2 inhibition increases urinary glucose excretion, thereby improving glycaemic control in an insulin-independent manner. Moreover, SGLT2i potentially impact the cardiovascular system both indirectly via weight loss and blood pressure lowering and directly through osmotic diuresis and increased sodium excretion and presumably by improving myocardial energetics. The aim of this review is to summarise evidence from all major outcome trials investigating SGLT2i in patients with diabetes, as well as recent evidence from trials in heart failure patients without glucose perturbations, which pave the way for novel treatment of large groups of patients. The results of these studies have been taken into account in recently issued guidelines for the management of diabetes and cardiovascular disease. An important task for diabetologists, cardiologists and general practitioners is to incorporate them into clinical practice to the benefit of many patients.
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Affiliation(s)
- Giulia Ferrannini
- Department of Medicine K2, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Gianluigi Savarese
- Department of Medicine K2, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Lars Rydén
- Department of Medicine K2, Karolinska Institutet, 171 76 Stockholm, Sweden.
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15
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Monami M, Candido R, Pintaudi B, Targher G, Mannucci E. Effect of metformin on all-cause mortality and major adverse cardiovascular events: An updated meta-analysis of randomized controlled trials. Nutr Metab Cardiovasc Dis 2021; 31:699-704. [PMID: 33549430 DOI: 10.1016/j.numecd.2020.11.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/14/2020] [Accepted: 11/30/2020] [Indexed: 12/22/2022]
Abstract
AIMS The Italian Society of Diabetology and the Italian Association of Clinical Diabetologists are developing new guidelines for drug treatment of type 2 diabetes. The effects of anti-hyperglycaemic drugs on all-cause mortality and major adverse cardiovascular events (MACEs) were included among the critical clinical outcomes. We have therefore carried out an updated meta-analysis on the effects of metformin on these outcomes. DATA SYNTHESIS A MEDLINE and EMBASE search was performed to identify all randomized controlled trials (RCTs) with duration ≥52 weeks (published up to August 2020), in which metformin was compared with either placebo/no therapy or active comparators. MACEs (restricted for RCT reporting MACEs within their study endpoints) and all-cause mortality (irrespective of the inclusion of MACEs among the pre-specified endpoints) were considered as the primary endpoints. Mantel-Haenszel odds ratio (MH-OR) with 95% confidence interval was calculated for all endpoints considered. Metformin was associated with a nonsignificant reduction of all-cause mortality (n = 13 RCTs; MH-OR 0.80 [95% CI 0.60, 1.07]). However, this association became statistically significant after excluding RCTs comparing metformin with sulfonylureas, SGLT-2 inhibitors or GLP-1 analogues (MH-OR 0.71 [0.51, 0.99]). Metformin was associated with a lower risk of MACEs compared with comparator treatments (n = 2 RCTs; MH-OR 0.52 [0.37, 0.73]), p < 0.001. Similar results were obtained in a post-hoc analysis including all RCTs fulfilling criteria for inclusion in the analysis (MH-OR: 0.57 [0.42, 0.76]). CONCLUSIONS This updated meta-analysis suggests that metfomin is significantly associated with lower risk of MACEs and tendentially lower all-cause mortality compared to placebo or other anti-hyperglycaemic drugs.
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Affiliation(s)
- Matteo Monami
- Diabetology, Careggi Hospital and University of Florence, Italy
| | - Riccardo Candido
- Diabetes Centre District 3, Azienda Sanitaria Universitaria Integrata di Trieste, Via Puccini 48/50, 34100, Trieste, Italy
| | | | - Giovanni Targher
- Endocrinology, Diabetes and Metabolism, University of Verona, Italy
| | - Edoardo Mannucci
- Diabetology, Careggi Hospital and University of Florence, Italy.
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16
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Rainkie DC, Abedini ZS, Abdelkader NN. Reporting and methodological quality of systematic reviews and meta-analysis with protocols in Diabetes Mellitus Type II: A systematic review. PLoS One 2020; 15:e0243091. [PMID: 33326429 PMCID: PMC7743973 DOI: 10.1371/journal.pone.0243091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/15/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Systematic reviews with or without meta-analyses (SR/MAs) are strongly encouraged to work from a protocol to facilitate high quality, transparent methodology. The completeness of reporting of a protocol (PRISMA-P) and manuscript (PRISMA) is essential to the quality appraisal (AMSTAR-2) and appropriate use of SR/MAs in making treatment decisions. OBJECTIVES The objectives of this study were to describe the completeness of reporting and quality of SR/MAs, assess the correlations between PRISMA-P, PRISMA, and AMSTAR-2, and to identify reporting characteristics between similar items of PRISMA-P and PRISMA. METHODS We performed a systematic review of Type 2 Diabetes Mellitus SR/MAs of hypoglycemic agents with publicly available protocols. Cochrane reviews, guidelines, and specific types of MA were excluded. Two reviewers independently, (i) searched PubMed and Embase between 1/1/2015 to 20/3/2019; (ii) identified protocols of included studies by searching the manuscript bibliography, supplementary material, PROSPERO, and Google; (iii) completed PRISMA-P, PRISMA, and AMSTAR-2 tools. Data analysis included descriptive statistics, Pearson correlation, and multivariable linear regression. RESULTS Of 357 relevant SR/MAs, 51 had available protocols and were included. The average score for PRISMA-P was 15.8±3.3 (66%; maximum 24) and 25.2±1.1 (93%; maximum 27) for PRISMA. The quality of SR/MAs assessed using the AMSTAR-2 tool identified an overall poor quality (63% critically low, 18% low, 8% moderate, 12% high). The correlation between the PRISMA-P and PRISMA was not significant (r = 0.264; p = 0.06). Correlation was significant between PRISMA-P and AMSTAR-2 (r = 0.333; p = 0.02) and PRISMA and AMSTAR-2 (r = 0.555; p<0.01). Discrepancies in reporting were common between similar PRISMA-P and PRISMA items. CONCLUSION Adherence to protocol reporting guidance was poor while manuscript reporting was comprehensive. Protocol completeness is not associated with a completely reported manuscript. Independently, PRISMA-P and PRISMA scores were weakly associated with higher quality assessments but insufficient as a surrogate for quality. Critical areas for quality improvement include protocol description, investigating causes of heterogeneity, and the impact of risk of bias on the evidence synthesis.
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17
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Landgraf R, Aberle J, Birkenfeld AL, Gallwitz B, Kellerer M, Klein HH, Müller-Wieland D, Nauck MA, Reuter HM, Siegel E. Therapie des Typ-2-Diabetes. DIABETOL STOFFWECHS 2020. [DOI: 10.1055/a-1193-3793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | - Jens Aberle
- Sektion Endokrinologie und Diabetologie, Universitäres Adipositas-Zentrum Hamburg, Universitätsklinikum Hamburg-Eppendorf
| | - Andreas L. Birkenfeld
- Deutsches Zentrum für Diabetesforschung (DZD e. V.), Neuherberg
- Medizinische Klinik IV, Diabetologie, Endokrinologie, Nephrologie, Universitätsklinikum Tübingen
| | - Baptist Gallwitz
- Medizinische Klinik IV, Diabetologie, Endokrinologie, Nephrologie, Universitätsklinikum Tübingen
| | | | - Harald H. Klein
- Medizinische Klinik I, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum
| | | | - Michael A. Nauck
- Diabeteszentrum Bochum-Hattingen, St.-Josef-Hospital, Ruhr-Universität, Bochum
| | | | - Erhard Siegel
- Abteilung für Innere Medizin – Gastroenterologie, Diabetologie/Endokrinologie und Ernährungsmedizin, St. Josefkrankenhaus Heidelberg GmbH, Heidelberg
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18
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Rozado J, García Iglesias D, Soroa M, Junco-Vicente A, Barja N, Adeba A, Vigil-Escalera M, Alvarez R, Torres Saura F, Capín E, García L, Rodriguez ML, Calvo D, Moris C, Delgado E, de la Hera JM. Sodium-Glucose Cotransporter-2 Inhibitors at Discharge from Cardiology Hospitalization Department: Decoding A New Clinical Scenario. J Clin Med 2020; 9:jcm9082600. [PMID: 32796615 PMCID: PMC7464502 DOI: 10.3390/jcm9082600] [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] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/02/2020] [Accepted: 08/07/2020] [Indexed: 12/14/2022] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT-2 inhibitors) are new glucose-lowering drugs (GLDs) with demonstrated cardiovascular benefits in patients with heart disease and type-2 diabetes mellitus (T2DM). However, their safety and efficacy when prescribed at hospital discharge are unexplored. This prospective, observational, longitudinal cohort study included 104 consecutive T2DM patients discharged from the cardiology department between April 2018 and February 2019. Patients were classified based on SGLT-2 inhibitor prescription and adjusted by propensity-score matching. The safety outcomes included discontinuation of GLDs; worsening renal function; and renal, hepatic, or metabolic hospitalization. The efficacy outcomes were death from any cause, cardiovascular death, cardiovascular readmission, and combined clinical outcome (cardiovascular death or readmission). The results showed that, the incidence rates of safety outcomes were similar in the SGLT-2 inhibitor or non-SGLT-2 inhibitor groups. Regarding efficacy, the SGLT-2 inhibitors group resulted in a lower rate of combined clinical outcomes (18% vs. 42%; hazard ratio (HR), 0.35; p = 0.02), any cause death (0% vs. 24%; HR, 0.79; p = 0.001) and cardiovascular death (0% vs. 17%; HR, 0.83; p = 0.005). No significant differences were found in cardiovascular readmissions. SGLT-2 inhibitor prescription at hospital discharge in patients with heart disease and T2DM was safe, well tolerated, and associated with a reduction in all-cause and cardiovascular deaths.
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Affiliation(s)
- José Rozado
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Daniel García Iglesias
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Miguel Soroa
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Alejandro Junco-Vicente
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Noemí Barja
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Antonio Adeba
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - María Vigil-Escalera
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Rut Alvarez
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Francisco Torres Saura
- Department of Cardiology, Hospital Universitario Vinalopo y Hospital Universitario Torrevieja, 03293 Torrevieja, Spain;
| | - Esmeralda Capín
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Laura García
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - María Luisa Rodriguez
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - David Calvo
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Cesar Moris
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Medicine Department, University of Oviedo, 33011 Oviedo, Spain
| | - Elías Delgado
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Medicine Department, University of Oviedo, 33011 Oviedo, Spain
- Department of Endocrinology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Jesús María de la Hera
- Department of Cardiology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (J.R.); (D.G.I.); (M.S.); (A.J.-V.); (N.B.); (A.A.); (M.V.-E.); (R.A.); (E.C.); (L.G.); (M.L.R.); (D.C.); (C.M.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Correspondence:
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19
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Hanefeld M, Fleischmann H, Siegmund T, Seufert J. Rationale for Timely Insulin Therapy in Type 2 Diabetes Within the Framework of Individualised Treatment: 2020 Update. Diabetes Ther 2020; 11:1645-1666. [PMID: 32564335 PMCID: PMC7376805 DOI: 10.1007/s13300-020-00855-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Indexed: 12/21/2022] Open
Abstract
Type 2 diabetes is characterised by chronic hyperglycaemia and variable degrees of insulin deficiency and resistance. Hyperglycaemia and elevated fatty acids exert harmful effects on β-cell function, regeneration and apoptosis (gluco-lipotoxicity). Furthermore, chronic hyperglycaemia triggers a vicious cycle of insulin resistance, low-grade inflammation and a cascade of pro-atherogenic processes. Thus, timely near to normal glucose control is of utmost importance in the management of type 2 diabetes and prevention of micro- and macroangiopathy. The majority of patients are multimorbid and obese, with critical comorbidities such as cardiovascular disease, heart failure and chronic kidney disease. Recently published guidelines therefore recommend patient-centred risk/benefit-balanced use of oral glucose-lowering drugs or a glucagon-like peptide 1 (GLP-1) receptor agonist, or switching to insulin with glycated haemoglobin (HbA1c) out of target. This article covers the indications of early insulin treatment to prevent diabetes-related complications, particularly in subgroups with severe insulin deficit, and to achieve recovery of residual β-cell function. Furthermore, the individualised, risk/benefit-balanced, timely initiation of insulin as second and third option is analysed. Timely insulin initiation may prevent diabetes progression, reduce diabetes-related complications and has less serious adverse effects. Basal insulin is the preferred option in most clinical situations with consequences of undertreatment of chronic hyperglycaemia.
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Affiliation(s)
- Markolf Hanefeld
- Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus, Dresden, Germany.
| | - Holger Fleischmann
- Diabetes and Cardiovascular, Sanofi-Aventis Deutschland GmbH, Berlin, Germany
| | - Thorsten Siegmund
- Diabetes-, Hormon- und Stoffwechselzentrum, Isar Klinikum München GmbH, München, Germany
| | - Jochen Seufert
- Division of Endocrinology and Diabetology, Department of Medicine II, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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20
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Uhrig JL, Page SO, Mishriky BM, Patil SP, Powell JR, Sewell K, Mian MR, Cummings DM. Should Baseline Hemoglobin A 1c or Dose of SGLT-2i Guide Treatment With SGLT-2i Versus DPP-4i in People With Type 2 Diabetes? A Meta-Analysis and Systematic Review. J Clin Pharmacol 2020; 60:980-991. [PMID: 32396236 DOI: 10.1002/jcph.1599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/03/2020] [Indexed: 12/25/2022]
Abstract
Our aim was to explore whether the baseline hemoglobin A1c or the dose of sodium glucose cotransporter-2 inhibitor (SGLT-2i) chosen better predicted the efficacy of SGLT-2i versus dipeptidyl peptidase-4 inhibitor (DPP-4i) in type 2 diabetes. We searched for randomized trials that compared SGLT-2i with DPP-4i in type 2 diabetes and reported a change in hemoglobin A1c over time. We created 2 separate analyses (one based on baseline hemoglobin A1c and the other according to US Food and Drug Administration [FDA]-approved SGLT-2i dose). Thirteen trials were included. In the analysis according to baseline hemoglobin A1c , there was a significantly greater reduction in hemoglobin A1c when baseline hemoglobin A1c was ≥8.5%, favoring SGLT-2i over DPP-4i but not when baseline hemoglobin A1c was <8.5% (mean difference [95%CI], -0.36% [-0.53% to -0.18%] and 0.04% [-0.09% to 0.17%], respectively). On restricting the analysis to trials stratifying hemoglobin A1c to <8.0% or ≥8.0%, results did not change. In the analysis based on FDA-approved SGLT-2i doses, higher SGLT-2i doses caused a significantly greater hemoglobin A1c reduction at ≤26 and ≥52 weeks compared with the highest DPP-4i doses (mean difference [95%CI], -0.11% [-0.18% to -0.04%] and -0.24% [-0.34% to -0.15%], respectively). Lower SGLT-2i doses caused a significantly greater hemoglobin A1c reduction at ≥52 weeks but not at ≤26 weeks compared with the highest DPP-4i doses (mean difference [95%CI], -0.12% [-0.23% to -0.02%] and 0.01% [-0.05% to 0.07%], respectively). In people with type 2 diabetes and a baseline hemoglobin A1c ≥ 8.0%, SGLT-2i produced significantly greater reductions in hemoglobin A1c compared with DPP-4i and may be preferred. SGLT-2i dose titration to a higher FDA-approved dose is recommended in suitable patients.
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Affiliation(s)
- Jarrod L Uhrig
- Department of Endocrinology, Carilion Clinic, Roanoke, Virginia, USA
| | - Stephanie O Page
- Department of Family Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Basem M Mishriky
- Department of Internal Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Shivajirao P Patil
- Department of Family Medicine, East Carolina University, Greenville, North Carolina, USA
| | - James R Powell
- Department of Internal Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Kerry Sewell
- Laupus Health Sciences Library, East Carolina University, Greenville, North Carolina, USA
| | - Muna R Mian
- Department of Internal Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Doyle M Cummings
- Department of Family Medicine, East Carolina University, Greenville, North Carolina, USA
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21
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Harding AL, Bediaga N, Galligan A, Colman PG, Fourlanos S, Wentworth JM. Factors that predict glycaemic response to sodium-glucose linked transporter (SGLT) inhibitors. Intern Med J 2020; 51:515-519. [PMID: 32092242 DOI: 10.1111/imj.14805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/11/2020] [Accepted: 02/17/2020] [Indexed: 11/26/2022]
Abstract
AIM To determine the clinical and biochemical variables associated with change in HbA1c in patients with type 2 diabetes who start sodium-glucose linked transporter (SGLT) inhibitor therapy. METHODS We performed a prospective cohort study (ACTRN12616000833460) of 48 adults (30 male, 18 female) with type 2 diabetes who attended a tertiary hospital diabetes clinic. Fasting serum and urine samples, collected during clinic visits prior to and at 1, 12 and 24 weeks after commencing SGLT inhibitor treatment, were analysed for HbA1c, electrolytes, urea, creatinine and glucose. RESULTS After 12 weeks, SGLT inhibitor therapy was associated with respective median (97% CI) decreases in weight, blood pressure, HbA1c and urine albumin/creatinine ratio of 3.0 (1.7-3.4) kg, 8 (2-16)/4 (3-9) mmHg, 6 (3-14) mmol/mol and 0.69 (0.18-1.8) mg/mmol. These effects persisted to 24 weeks. Urinary frequency and genitourinary infection were common adverse effects. Baseline HbA1c and eGFR independently predicted ΔHbA1c at 12 weeks whereas only baseline HbA1c independently predicted ΔHbA1c at 24 weeks. Urinary fractional glucose excretion and change in fasting glucose 1 week after starting SGLT inhibitor did not contribute to prediction of glycaemic response. CONCLUSIONS SGLT inhibitor therapy in a hospital clinic setting was associated with clinical improvements comparable to those observed in clinical trials but with higher incidence of genitourinary side-effects. Baseline HbA1c and eGFR, but not urine fractional glucose excretion, predicted glycaemic response.
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Affiliation(s)
- Amy L Harding
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Naiara Bediaga
- Division of Population Health and Immunity, Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
| | - Anna Galligan
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Spiros Fourlanos
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital University of Melbourne, Melbourne, Victoria, Australia
| | - John M Wentworth
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Division of Population Health and Immunity, Walter and Eliza Hall Institute, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital University of Melbourne, Melbourne, Victoria, Australia
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22
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Mohan V, Khunti K, Chan SP, Filho FF, Tran NQ, Ramaiya K, Joshi S, Mithal A, Mbaye MN, Nicodemus NA, Latt TS, Ji L, Elebrashy IN, Mbanya JC. Management of Type 2 Diabetes in Developing Countries: Balancing Optimal Glycaemic Control and Outcomes with Affordability and Accessibility to Treatment. Diabetes Ther 2020; 11:15-35. [PMID: 31773420 PMCID: PMC6965543 DOI: 10.1007/s13300-019-00733-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Indexed: 12/18/2022] Open
Abstract
With the growing prevalence of type 2 diabetes, particularly in emerging countries, its management in the context of available resources should be considered. International guidelines, while comprehensive and scientifically valid, may not be appropriate for regions such as Asia, Latin America or Africa, where epidemiology, patient phenotypes, cultural conditions and socioeconomic status are different from America and Europe. Although glycaemic control and reduction of micro- and macrovascular outcomes remain essential aspects of treatment, access and cost are major limiting factors; therefore, a pragmatic approach is required in restricted-resource settings. Newer agents, such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists in particular, are relatively expensive, with limited availability despite potentially being valuable for patients with insulin resistance and cardiovascular complications. This review makes a case for the role of more accessible second-line treatments with long-established efficacy and affordability, such as sulfonylureas, in the management of type 2 diabetes, particularly in developing or restricted-resource countries.
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Affiliation(s)
- Viswanathan Mohan
- Dr. Mohan's Diabetes Specialities Centre and Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India.
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Siew P Chan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Fadlo F Filho
- Faculty of Medicine, ABC Foundation, Santo André, Brazil
| | - Nam Q Tran
- Department of Endocrinology, University Medical Center, Ho Chi Minh City, Vietnam
| | - Kaushik Ramaiya
- Shree Hindu Mandal Hospital, Dar es Salaam, Tanzania
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Shashank Joshi
- Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | | | | | - Nemencio A Nicodemus
- Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
- Department of Biochemistry and Molecular Biology, University of the Philippines-College of Medicine, Manila, Philippines
| | - Tint S Latt
- Department of Diabetes and Endocrinology, University of Medicine 2, Yangon, Myanmar
| | - Linong Ji
- Department of Endocrinology, Peking University People's Hospital, Beijing, China
| | - Ibrahim N Elebrashy
- Department of Internal Medicine, Diabetes, and Endocrinology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Jean C Mbanya
- University of Yaoundé I, Yaoundé, Cameroon
- National Obesity Center, Central Hospital of Yaoundé, Yaoundé, Cameroon
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23
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Bailey CJ, Del Prato S, Wei C, Reyner D, Saraiva G. Durability of glycaemic control with dapagliflozin, an SGLT2 inhibitor, compared with saxagliptin, a DPP4 inhibitor, in patients with inadequately controlled type 2 diabetes. Diabetes Obes Metab 2019; 21:2564-2569. [PMID: 31364269 PMCID: PMC6851837 DOI: 10.1111/dom.13841] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/10/2019] [Accepted: 07/25/2019] [Indexed: 01/13/2023]
Abstract
Dapagliflozin is associated with greater reductions in HbA1c and weight than saxagliptin in management of type 2 diabetes mellitus (T2DM). The present post hoc analyses compared the durability of these effects over short- and long-term follow-up in patients with T2DM who were inadequately controlled with metformin (≥1500 mg/day) and who were receiving either dapagliflozin (10 mg/day) or saxagliptin (5 mg/day). Failure of glycaemiccontrol was assessed using the slope of the change in HbA1c from baseline-over-time regression line (coefficient of failure [CoF]). CoF was compared directly (dapagliflozin vs saxagliptin) over the short term (NCT01606007, 24 weeks) and indirectly (placebo-adjusted) over the long term (NCT00528879 and NCT00121667, 102 weeks). A low CoF value indicated greater durability. CoF was lower for dapagliflozin versus saxagliptin over 18-24 weeks (-1.38%/year; 95% CI, -2.41 to -0.35; P = .009) and 20-102 weeks (-0.37%/year; 95% CI, -0.73 to -0.02; P = .04). Fewer dapagliflozin-treated patients versus saxagliptin-treated patients required rescue medication or discontinued the study because of failure to achieve glycaemic control at 24 weeks (3.4% vs 9.4%; P = .0191). In patients with T2DM who were inadequately controlled with metformin, dapagliflozin was associated with greater durability of glycaemic control than saxagliptin over 18-24 and 20-102 weeks.
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Affiliation(s)
| | - Stefano Del Prato
- Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | - Cheryl Wei
- AstraZeneca, R&D Bio Pharmaceuticals, Late CVRMGaithersburgMaryland
| | - Daniel Reyner
- AstraZeneca, R&D Bio Pharmaceuticals, Late CVRMGaithersburgMaryland
| | - Gabriela Saraiva
- AstraZeneca, R&D Bio Pharmaceuticals, Late CVRMGaithersburgMaryland
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24
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Wilding JPH, Rigney U, Blak BT, Nolan ST, Fenici P, Medina J. Glycaemic, weight, and blood pressure changes associated with early versus later treatment intensification with dapagliflozin in United Kingdom primary care patients with type 2 diabetes mellitus. Diabetes Res Clin Pract 2019; 155:107791. [PMID: 31325543 DOI: 10.1016/j.diabres.2019.107791] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/27/2019] [Accepted: 07/08/2019] [Indexed: 12/16/2022]
Abstract
AIMS Early treatment intensification for type 2 diabetes mellitus (T2DM) is often required to achieve glycaemic control and avoid longer-term complications. We assessed associations between early versus later dapagliflozin initiation with changes in glucose control, weight, and blood pressure using UK Clinical Practice Research Datalink (CPRD) data. METHODS People with T2DM aged ≥18 years, initiating dapagliflozin between November 2012 and August 2016 and with prior oral T2DM therapy (N = 3774), were included. The relationship between early (first intensification after metformin or sulfonylurea monotherapy) and later (second or higher-order intensification) dapagliflozin use and baseline changes in glycated haemoglobin A1c (HbA1c; ≥1.0% absolute reduction), weight (≥5.0% relative loss), and systolic blood pressure (SBP; ≥2 mmHg absolute reduction) after 6-12 months were assessed. RESULTS Overall, 25% of patients (951 of 3774) were early users and 75% (2823 of 3774) were later users. Later users were older, more likely to be men, and had longer disease duration. Early and later users had similar baseline mean HbA1c levels. For early versus later users, respectively, baseline-adjusted mean (95% confidence interval [CI]) reductions were 1.54% (-1.65, -1.44) versus 1.02% (-1.08, -0.97) in HbA1c, 3.31% (-4.37, -2.25) versus 4.06% (-5.05, -3.07) in weight, and 2.50 mm Hg (-3.89, -1.11) versus 2.84 mm Hg (-3.67, -2.01) in SBP. Early versus later use was associated with a greater likelihood of adjusted HbA1c reduction of ≥1% (odds ratio: 1.68, 95% CI: 1.15-2.45). CONCLUSIONS Glycaemic benefits were greater with early versus later dapagliflozin intensification. These results support broader and earlier dapagliflozin use.
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Affiliation(s)
- John P H Wilding
- Obesity and Endocrinology Research Group, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom.
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25
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Chen Z, Li G. Sodium-Glucose Co-Transporter 2 Inhibitors Compared with Sulfonylureas in Patients with Type 2 Diabetes Inadequately Controlled on Metformin: A Meta-Analysis of Randomized Controlled Trials. Clin Drug Investig 2019; 39:521-531. [PMID: 31041606 DOI: 10.1007/s40261-019-00781-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVE When metformin is insufficient for patients with type 2 diabetes mellitus (T2DM), the optimal adjunctive therapy is unclear. This meta-analysis was to compare the efficacy and safety of sodium-glucose co-transporter 2 (SGLT2) inhibitors with sulfonylureas (SUs) as second-line therapy in patients with T2DM inadequately controlled on metformin. METHODS We systematically searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov for randomized controlled trials comparing SGLT2 inhibitors with SUs as add-on to metformin. Our primary endpoints were glycemic control, hypoglycemia, and change in weight. We assessed pooled data using a random-effects model. RESULTS Five trials involving 4300 participants were included in our meta-analysis. Compared with SUs, SGLT2 inhibitors led to no significant reduction in changes in HbA1c (mean difference [MD] - 0.06; 95% confidence interval [CI] [- 0.12, 0.08]), but less hypoglycemia as add-on to metformin (odds ratio [OR] 0.12; 95% CI [0.07, 0.21]). SGLT2 inhibitors led to a reduction in weight by about 3.5 kg; however, SUs caused a gain in weight by about 1 kg (MD - 4.39; 95% CI [- 4.64, - 4.14]). SGLT2 inhibitors also showed a reduction in blood pressure, but increased the incidence of genital tract infections compared with SUs. Interestingly, subgroup analysis by duration of interventions showed that reduction of HbA1c from baseline was similar between the two groups at 12-52 weeks, but SGLT2 inhibitors led to a greater reduction in HbA1c at 104-208 weeks. CONCLUSIONS Despite similar glycemic efficacy in a relatively short term, SGLT2 inhibitors are more effective in the longer term than SUs as add-on to metformin. In addition, SGLT2 inhibitors produce less hypoglycemic events and lead to greater reductions in weight and blood pressure compared with SUs.
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Affiliation(s)
- Ze Chen
- School of Medicine, Wuhan University, No. 115 Donghu Road, Wuhan, 430071, Hubei, China.
| | - Gerui Li
- School of Medicine, Wuhan University, No. 115 Donghu Road, Wuhan, 430071, Hubei, China
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26
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Sodium-glucose transporter 2 inhibition and cardiovascular events in patients with diabetes: information from clinical trials and observational real-world data. Clin Sci (Lond) 2018; 132:2003-2012. [DOI: 10.1042/cs20171374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/11/2018] [Accepted: 08/15/2018] [Indexed: 01/10/2023]
Abstract
Cardiovascular (CV) disease (CVD) is the main cause of morbidity and mortality in patients with type 2 diabetes mellitus (T2DM). Despite optimal glycaemic control, standard antihyperglycaemic therapy failed to impact CV events in intervention trials; therefore, the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA) issued a guidance to the pharmaceutical industry to specifically assess the CV outcomes and safety of new glucose-lowering drugs. Amongst them, sodium-glucose transporter 2 (SGLT2) inhibitors proved to not only provide good tolerance, few adverse effects, and good glycometabolic control, but also striking reduction in the risk of CV events. In this review, data from the main randomised controlled trials are presented, including post-hoc analyses looking into several aspects of CV protection. Moreover, the main findings from observational real-world studies to date are described, overall reassuring as regards to CV safety and efficacy of SGLT2 inhibitors. Finally, several mechanisms which might contribute to the cardioprotective effect of SGLT2 inhibition are depicted, including findings from recent mechanistic studies.
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27
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Wilding J, Godec T, Khunti K, Pocock S, Fox R, Smeeth L, Clauson P, Fenici P, Hammar N, Medina J. Changes in HbA1c and weight, and treatment persistence, over the 18 months following initiation of second-line therapy in patients with type 2 diabetes: results from the United Kingdom Clinical Practice Research Datalink. BMC Med 2018; 16:116. [PMID: 30008267 PMCID: PMC6047134 DOI: 10.1186/s12916-018-1085-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 05/23/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Intensification of metformin monotherapy with additional glucose-lowering drugs is often required in patients with type 2 diabetes (T2D). This study evaluated changes in HbA1c and weight, as well as treatment persistence, associated with different second-line therapies used in UK clinical practice. METHODS The UK Clinical Practice Research Datalink was used to identify patients with T2D who initiated second-line therapy after metformin monotherapy between 1 August 2013 and 14 June 2016. Treatment persistence and changes in HbA1c and weight were assessed at 6-month intervals up to 18 months. RESULTS In total, 9097 patients (mean age 61.2 years, 57.2% men, mean [standard deviation] HbA1c 9.0% [1.8]/ 75 mmol/mol [19.7]) were included in the analysis, with a median 2.3 years between initiating metformin monotherapy and initiating second-line therapy. Patients were stratified according to second-line therapy: metformin in combination with sulfonylurea (SU; n = 4655 [51.2%]), a dipeptidyl peptidase-4 inhibitor (DPP-4 inhibitor; n = 2899 [31.9%]), or a sodium-glucose cotransporter-2 inhibitor (SGLT-2 inhibitor; n = 441 [4.9%]) or other therapies (all other second-line treatments; n = 1102 [12.1%]). At 18 months, the cumulative proportion of patients changing treatment was lowest for those who received metformin plus an SGLT-2 inhibitor (42.3%), followed by patients on metformin plus SU or metformin plus a DPP-4 inhibitor (46.8%). HbA1c reductions were seen with all second-line therapies, with an overall mean (standard error) reduction of -1.23% (0.05)/-13.4 mmol/mol (0.5). Changes were directly, but not linearly, related to baseline HbA1c and were greater in those with higher HbA1c at baseline. Weight loss from baseline was greatest in patients treated with metformin plus either an SGLT-2 inhibitor (-4.2 kg) or a DPP-4 inhibitor (-1.5 kg). The highest proportion of patients who achieved the composite outcome of HbA1c reduction ≥ 0.5%, body weight loss ≥ 2.0 kg and treatment persistence for 18 months was observed in those receiving metformin plus an SGLT-2 inhibitor (36.5%). CONCLUSIONS In this population-based cohort, all second-line therapies added to metformin monotherapy improved glycaemic control, but the lowest treatment change/discontinuation rate and most sustained weight loss was seen with patients receiving metformin plus an SGLT-2 inhibitor.
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Affiliation(s)
| | - Thomas Godec
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | - Liam Smeeth
- London School of Hygiene and Tropical Medicine, London, UK
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