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Maffei P, Bettini S, Busetto L, Dassie F. SGLT2 Inhibitors in the Management of Type 1 Diabetes (T1D): An Update on Current Evidence and Recommendations. Diabetes Metab Syndr Obes 2023; 16:3579-3598. [PMID: 37964939 PMCID: PMC10642354 DOI: 10.2147/dmso.s240903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
SGLT2i (sodium glucose transporter type 2 inhibitors) are pharmacological agents that act by inhibiting the SGLT2, by reducing the renal plasma glucose threshold and inducing glycosuria, resulting in a blood glucose lowering effect. In recent years, studies demonstrating some additional positive effects of SGLT2i also in the treatment of T1D have increased progressively. The SGLT2i dapagliflozin and sotagliflozin have been temporarily licensed for use by the European Medical Agency (EMA) as an adjunct to insulin therapy in adults with T1D with a body mass index of 27 kg/m2 or higher. However, in the meantime, the US Food and Drug Administration (FDA) Endocrinologic and Metabolic Drugs Advisory Committee was divided, citing concerns about the main side effects of SGLT2i, especially diabetic ketoacidosis (DKA). The aim of this manuscript was to conduct an update on current evidence and recommendations of the reported use of SGLT2i in the treatment of T1D in humans. Preclinical studies, clinical trial and real world data suggest benefits in glycaemia control and nefro-cardiovascular protection, even though several studies have documented an important increase in the risk of DKA, a serious and life-threatening adverse event of these agents. SGLT2i potentially addresses some of the unmet needs associated with T1D by improving glycaemic control with weight loss and without increasing hypoglycemia, by reducing glycaemic variability. However, due to side effects, EMA recommendation for SGLT2 use on T1D was withdrawn. Further studies will be needed to determine the safety of this therapy in T1D and to define the type of patient who can benefit most from these medications.
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Affiliation(s)
- Pietro Maffei
- Department of Medicine, Padua University, Padua, Italy
| | | | - Luca Busetto
- Department of Medicine, Padua University, Padua, Italy
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Salmen T, Serbanoiu LI, Bica IC, Serafinceanu C, Muzurović E, Janez A, Busnatu S, Banach M, Rizvi AA, Rizzo M, Pantea Stoian A. A Critical View over the Newest Antidiabetic Molecules in Light of Efficacy-A Systematic Review and Meta-Analysis. Int J Mol Sci 2023; 24:ijms24119760. [PMID: 37298707 DOI: 10.3390/ijms24119760] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/03/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
The increase in life expectancy without a decrease in the years lived without disability leads to the rise of the population aged over 65 years prone to polypharmacy. The novel antidiabetic drugs can improve this global therapeutic and health problem in patients with diabetes mellitus (DM). We aimed to establish the efficacy (A1c hemoglobin reduction) and safety of the newest antidiabetic drugs (considered so due to their novelty in medical practice use), specifically DPP-4i, SGLT-2i, GLP-1 Ra, and tirzepatide. The present meta-analysis followed the protocol registered at Prospero with the CRD42022330442 registration number. The reduction in HbA1c in the DPP4-i class for tenegliptin was 95% CI -0.54 [-1.1, 0.01], p = 0.06; in the SGLT2-iclass for ipragliflozin 95% CI -0.2 [-0.87, 0.47], p = 0.55; and for tofogliflozin 95% CI 3.13 [-12.02, 18.28], p = 0.69, while for tirzepatide it was 0.15, 95% CI [-0.50, 0.80] (p = 0.65). The guidelines for treatment in type 2 DM are provided from cardiovascular outcome trials that report mainly major adverse cardiovascular events and data about efficacy. The newest antidiabetic non-insulinic drugs are reported to be efficient in lowering HbA1c, but this effect depends between classes, molecules, or patients' age. The newest antidiabetic drugs are proven to be efficient molecules in terms of HbA1c decrease, weight reduction, and safety, but more studies are needed in order to characterize exactly their efficacy and safety profiles.
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Affiliation(s)
- Teodor Salmen
- Doctoral School, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Liviu-Ionut Serbanoiu
- Doctoral School, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ioana-Cristina Bica
- Doctoral School, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Cristian Serafinceanu
- Department of Diabetes, Nutrition and Metabolic Diseases, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Emir Muzurović
- Department of Internal Medicine, Endocrinology Section, Clinical Center of Montenegro, Ljubljanska, 81000 Podgorica, Montenegro
- Faculty of Medicine, University of Montenegro, Kruševac bb, 81000 Podgorica, Montenegro
| | - Andrej Janez
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Stefan Busnatu
- Cardiology Department, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, 93-338 Lodz, Poland
| | - Ali Abbas Rizvi
- Department of Medicine, University of Central Florida College of Medicine, Orlando, FL 32827, USA
| | - Manfredi Rizzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90100 Palermo, Italy
| | - Anca Pantea Stoian
- Department of Diabetes, Nutrition and Metabolic Diseases, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
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Saha S, Saha S, Gayen M. Treatment-duration-wise harm profile of insulin-sodium-glucose co-transporter inhibitor co-treatment in type 1 diabetes mellitus patients. J Diabetes Metab Disord 2023; 22:673-701. [PMID: 37255836 PMCID: PMC10225433 DOI: 10.1007/s40200-023-01192-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/26/2023] [Indexed: 06/01/2023]
Abstract
Background The treatment duration of insulin-sodium-glucose co-transporter inhibitors (SGLTis) co-treatment of type 1 diabetes mellitus (T1DM) patients in randomized controlled trials (RCTs) varies by 1-52 weeks. Henceforth, treatment duration-wise, we compared the following insulin-treatment adjuncts- mega- versus low-dose SGLTis, SGLTis versus placebo, and different SGLTi dosages. Method Double-blinded RCTs reporting the above were searched (using terms like insulin-dependent, "juvenile-onset diabetes," and "sodium glucose cotransport*") in the PubMed, Embase, and Scopus databases and appraised using a Cochrane tool. The risks across different SGLTi-dosages were compared using network meta-analysis. Random-effect pairwise meta-analysis was performed for the remaining harm juxtapositions. Meta-analyses were performed for the following treatment durations- < 4 weeks, 4 to < 24 weeks, and ≥ 24 weeks. For meta-analysis and certainty of evidence assessment, we used the Stata statistical software and the GRADE method, respectively. Results A total of 15 (low risks of bias) studies sourcing data from about 7,330 T1DM patients were reviewed. Meta-analysis findings of ≥ 24 weeks long trials were- a. SGLTi-insulin co-treatment increased the genital infection (GI) (RR: 3.51; 95% CI: 2.59, 4.77), diabetic ketoacidosis (DKA) and (RR: 3.25; 95% CI:1.29, 8.16), and serious side effects (RR: 1.43; 95% CI: 1.05, 1.94) risk. b. SGLT2i-insulin increased the GI risk (RR: 3.77; 95% CI: 2.31, 6.16; high-quality evidence). c. Sotagliflozin-insulin increased the GI (RR: 3.36; 95% CI: 2.28, 4.96) and DKA (RR: 6.69; 95% CI: 2.75, 16.32) risk (both high-quality evidence). Compared to low-dose, megadose SGLTi treatment for 4 to < 24 weeks increased the GI risk. The remaining analyses were not statistically significantly different. Conclusion On moderate to long-term treatment (24-52 weeks) of T1DM patients, insulin-SGLT2i co-treatment was associated with GI risk, and insulin-sotagliflozin co-treatment was associated with DKA and GI risk. Supplementary Information The online version contains supplementary material available at 10.1007/s40200-023-01192-7.
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Affiliation(s)
- Sumanta Saha
- Department of Community Medicine, R. G. Kar Medical College, Kolkata, West Bengal India
| | - Sujata Saha
- Department of Mathematics, Mankar College, Mankar, West Bengal India
| | - Mohan Gayen
- Department of Community Medicine, R. G. Kar Medical College, Kolkata, West Bengal India
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Veneti S, Tziomalos K. Sodium/glucose cotransporter 2 inhibitors for the treatment of type 1 diabetes: what are the latest developments? Expert Opin Pharmacother 2021; 22:2261-2266. [PMID: 34402702 DOI: 10.1080/14656566.2021.1967931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Despite the improvements in insulin therapy, many patients with type 1 diabetes mellitus (T1DM) do not achieve glycemic targets. Hypoglycemia and weight gain are important barriers in reaching these targets. Sodium/glucose cotransporter 2 (SGLT2) inhibitors lack these side effects and have an insulin-independent mechanism of action. Therefore, they might be useful in patients with T1DM. The authors discuss the safety and efficacy of SGLT2 inhibitors in T1DM. Several randomized controlled trials have evaluated dapagliflozin, sotagliflozin and empagliflozin in this population whereas fewer data are available for other members of this class. In these studies, SGLT2 inhibitors reduced HbA1c levels and body weight without a greater risk of hypoglycemia. However, a higher incidence of diabetic ketoacidosis (DKA) was observed in patients treated with these agents. SGLT2 inhibitors improve glycemic control in patients with T1DM but this effect is modest. Even though weight loss and the neutral effect on the incidence of hypoglycemia are advantages of these agents, the increased risk of DKA is a cause of concern. Overall, SGLT2 inhibitors should be used with caution and only in carefully selected patients with T1DM who are motivated, adherent to treatment, well-trained in recognizing DKA and are closely followed-up.
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Affiliation(s)
- Stavroula Veneti
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Konstantinos Tziomalos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
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Rao L, Ren C, Luo S, Huang C, Li X. Sodium-glucose cotransporter 2 inhibitors as an add-on therapy to insulin for type 1 diabetes mellitus: Meta-analysis of randomized controlled trials. Acta Diabetol 2021; 58:869-880. [PMID: 33651228 PMCID: PMC8187227 DOI: 10.1007/s00592-021-01686-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
AIMS The aim was to systematically review the efficacy and safety of sodium-glucose cotransporter inhibitor (SGLT2i) as an adjunct to insulin at different follow-up durations in randomized, double-blind clinical trials in patients with type 1 diabetes. METHODS We conducted a search on Medline, Embase, and the Cochrane Library for relevant studies published before May 2020. According to the duration of follow-up, the subgroup analysis included four periods: 1-4, 12-18, 24-26, and 52 weeks. In the five trials included both 24-26 and 52 weeks of follow-up, we compared the efficacy by the placebo-subtracted difference and changes in SGLT2i groups. RESULTS Fifteen trials including 7109 participants were analyzed. The combination of SGLT2i and insulin improved hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), daily insulin dose, body weight, and blood pressure, which varied greatly by different follow-ups. Compared with %HbA1c at 24-26 weeks, placebo-subtracted differences and changes in the SGLT2i groups slightly increased. SGLT2i plus insulin treatment showed no difference in the occurrence of urinary tract infections (UTIs), hypoglycemia, or severe hypoglycemia but increased the risk of genital tract infections (GTIs) in a duration-dependent manner. SGLT2i treatment was associated with a significantly higher rate of ketone-related SAEs and diabetic ketoacidosis (DKA) at 52 weeks. CONCLUSION SGLT2i as an add-on therapy to insulin improved glycemic control and body weight and decreased the required dose of insulin without increasing the risk of hypoglycemia. However, after 6 months the benefits of SGLT2is on glycemic control may weaken and the risks of GTIs and DKA increased.
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Affiliation(s)
- Lunwen Rao
- Huangdu Community Health Service Center, Jiading District, Anting TownShanghai, China
| | - Chenhong Ren
- Postgraduate Training Basement of Jinzhou Medical University, Taihe Hospital, Hubei University of Medical, Shiyan, China
- Department of Endocrinology, Taihe Hospital, Hubei University of Medical, Shiyan, 442000, China
| | - Shan Luo
- Department of Endocrinology, Taihe Hospital, Hubei University of Medical, Shiyan, 442000, China
| | - Chenghu Huang
- Department of Endocrinology, The People's Hospital of Bishan District, Bishan, Chongqing, 402760, China.
| | - Xuefeng Li
- Department of Endocrinology, Taihe Hospital, Hubei University of Medical, Shiyan, 442000, China.
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Tandon S, Ayis S, Hopkins D, Harding S, Stadler M. The impact of pharmacological and lifestyle interventions on body weight in people with type 1 diabetes: A systematic review and meta-analysis. Diabetes Obes Metab 2021; 23:350-362. [PMID: 33026152 DOI: 10.1111/dom.14221] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/09/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022]
Abstract
AIM To systematically review the effects of pharmacological and lifestyle interventions on body weight as a secondary outcome in people with type 1 diabetes. METHODS The Ovid Medline, Embase and Cochrane Library databases were searched for relevant pharmacological (glucagon-like peptide-1 [GLP-1] receptor agonist, sodium-glucose co-transporter-2 [SGLT-2] inhibitor, dipeptidyl peptidase-4 [DPP-4] inhibitor and metformin) and lifestyle intervention studies (diet and exercise) for adults with type 1 diabetes reporting body weight change and HbA1c published from January 2000 to May 2020. Meta-analyses were performed for 16 randomized controlled trials (RCTs). RESULTS Thirty-three RCTs (n = 9344 participants), 26 pharmacological (on average 43.9 years, 83.1 kg, HbA1c 8.1%; 55.8% male) and seven lifestyle-based interventions (on average 37.0 years, 85.0 kg, HbA1c 8.1%; 84.6% male), were analysed. The GLP-1 receptor agonist liraglutide 0.6 mg (mean difference [MD]: -2.22 kg [95% CI: -2.55 to -1.90]), 1.2 mg (MD: -3.74 kg [95% CI: -4.16 to -3.33]) and 1.8 mg (MD: -4.85 kg [95% CI: -5.29 to -4.41]), and the SGLT-2 inhibitors empagliflozin 2.5 mg (MD: -1.47 kg [95% CI: -2.23 to -0.71]), 10 mg (MD: -2.77 kg [95% CI: -3.24 to -2.31]) and 25 mg (MD: -3.06 kg [95% CI: -3.57 to -2.55]) and sotagliflozin 200 mg (MD: -2.40 kg [95% CI: -2.87 to -1.94]) and 400 mg (MD: -3.23 [95% CI: -3.73 to -2.72]) were associated with significant reductions in body weight. No significant effect on body weight was found for DPP-4 inhibitors, other GLP-1-receptor agonists, metformin, or for lifestyle interventions (i.e. exercise and diet). CONCLUSIONS In people with type 1 diabetes, several adjuvant pharmacological interventions showed weight reduction as a secondary outcome. Future studies in overweight people with type 1 diabetes are needed to establish whether the lifestyle and pharmacological interventions reviewed here have potential as components of complex interventions aimed at body weight reduction as a primary outcome.
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Affiliation(s)
- Saniya Tandon
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Salma Ayis
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David Hopkins
- Institute of Diabetes Endocrinology and Obesity, King's Health Partners, London, UK
| | - Seeromanie Harding
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Marietta Stadler
- Diabetes Research Group, Weston Education Centre, King's College London, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Musso G, Sircana A, Saba F, Cassader M, Gambino R. Assessing the risk of ketoacidosis due to sodium-glucose cotransporter (SGLT)-2 inhibitors in patients with type 1 diabetes: A meta-analysis and meta-regression. PLoS Med 2020; 17:e1003461. [PMID: 33373368 PMCID: PMC7771708 DOI: 10.1371/journal.pmed.1003461] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 (SGLT2) inhibitors (SGLT2i) showed benefits in type 1 diabetes mellitus (T1DM), but the risk of diabetic ketoacidosis (DKA) limits their use. Ability to predict DKA risk and therapeutic responses would enable appropriate patient selection for SGLT2i. We conducted a meta-analysis and meta-regression of randomized controlled trials (RCTs) evaluating SGLT2i in T1DM to assess moderators of the relative risk (RR) of DKA, of glycemic (HbA1c, fasting plasma glucose, continuous glucose monitoring parameters, insulin dose, and insulin sensitivity indices) and non-glycemic (body mass index (BMI), systolic BP, renal function, albuminuria, and diabetic eye disorders) efficacy, and of other safety outcomes (including hypoglycemia, infections, major adverse cardiovascular events, and death). METHODS AND FINDINGS We searched MEDLINE, Cochrane Library, EMBASE, ClinicalTrials.gov, Cochrane CENTRAL Register of Controlled Trials, and other electronic sources through August 30, 2020, for RCTs comparing SGLT2i with active comparators or placebo in adult patients with T1DM. Reviewers extracted data for relevant outcomes, performed random effects meta-analyses, subgroup analyses, and multivariable meta-regression. The strength of evidence was summarized with the GRADE approach. Among 9,914 records identified, 18 placebo-controlled RCTs (7,396 participants, 50% males, mean age 42 y (range 23 to 55 y), 5 different SGLT2i evaluated), were included. Main outcome measures were effect sizes and moderators of glycemic and non-glycemic efficacy and of safety outcomes. In a multivariable meta-regression model, baseline BMI (β = 0.439 [95% CI: 0.211, 0.666], p < 0.001) and estimated glucose disposal rate (eGDR) (β = -0.766 [-1.276, -0.256], p = 0.001) were associated with the RR of DKA (RR: 2.81; 95% CI:1.97, 4.01; p < 0.001, R2 = 61%). A model including also treatment-related parameters (insulin dose change-to-baseline insulin sensitivity ratio and volume depletion) explained 86% of variance across studies in the risk of DKA (R2 = 86%). The association of DKA with a BMI >27 kg/m2 and with an eGDR <8.3 mg/kg/min was confirmed also in subgroup analyses. Among efficacy outcomes, the novel findings were a reduction in albuminuria (WMD: -9.91, 95% CI: -16.26, -3.55 mg/g, p = 0.002), and in RR of diabetic eye disorders (RR: 0.27[0.11, 0.67], p = 0.005) associated with SGLT2i. A SGLT2i dose-response gradient was consistently observed for main efficacy outcomes, but not for adverse events (AEs). Overall, predictors of DKA and of other AEs differed substantially from those of glycemic and non-glycemic efficacy. A limitation of our analysis was the relatively short (≤52 weeks) duration of included RCTs. The potential relevance for clinical practice needs also to be confirmed by real-world prospective studies. CONCLUSIONS In T1DM, the risk of DKA and main therapeutic responses to SGLT2i are modified by baseline BMI and insulin resistance, by total insulin dose reduction-to-baseline insulin sensitivity ratio, and by volume depletion, which may enable the targeted use of these drugs in patients with the greatest benefit and the lowest risk of DKA.
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Affiliation(s)
| | - Antonio Sircana
- Department of Cardiology, Azienda Ospedaliero Universitaria, Sassari, Italy
| | - Francesca Saba
- Laboratory of Diabetes and Metabolic disorders, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Maurizio Cassader
- Laboratory of Diabetes and Metabolic disorders, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Roberto Gambino
- Laboratory of Diabetes and Metabolic disorders, Department of Medical Sciences, University of Turin, Turin, Italy
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Fatima T, Sedrakyan S, Awan MR, Khatun MK, Rana D, Jahan N. Use of Sodium-Glucose Co-Transporter-2 Inhibitors in Type 1 Diabetics: Are the Benefits Worth the Risks? Cureus 2020; 12:e10076. [PMID: 33005503 PMCID: PMC7522056 DOI: 10.7759/cureus.10076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The mainstay of treatment for type 1 diabetes is insulin. The use of insulin for tight glycemic control is the key to preventing micro- and macrovascular complications, but it can also lead to hypoglycemic episodes. Therefore, there is a need for the introduction of a drug that can maintain glucose levels within a safe range without increasing the risk of hypoglycemia. For this reason, SGLT2 (sodium-glucose co-transporter-2) inhibitors has been a hot topic in the last couple of years. They have been proved very efficient in treating type 2 diabetes. Many trials on the safety and efficacy of SGLT2 inhibitors have been done on type 1 diabetics. Some other studies have also been done that prove their benefits in increasing arterial efficacy and reducing GFR (glomerular filtration rate). This review article discusses the benefits and risks. The literature search was performed using PubMed, and after applying the inclusion and exclusion criteria, 16 published papers were found. All relevant articles on the topic have been included. Our review has shown that the benefits of SGLT2 inhibitors outweigh their risks. Their benefits include good glycemic control, HBA1c (glycated haemoglobin) reduction, weight loss, and blood pressure improvement. Furthermore, improvement in GFR and arterial efficacy is also significant. Side effects such as UTI (urinary tract infection) and genital infection have been observed, but their incidence is low. However, DKA (diabetic ketoacidosis) and hypoglycemia are severe side effects that should be highlighted. Hypoglycemia can be prevented by strictly monitoring blood sugar levels. The patient must be educated and counseled about DKA and its symptoms. This will ensure the safety of the patient as euglycemic DKA can prove fatal if not diagnosed earlier. So, SGLT2 inhibitors can be used as an effective drug to control blood sugar levels in type 1 diabetes, especially in patients with a BMI higher than 30. It will not only achieve the treatment goals but can also decrease the morbidity and mortality of the patients. However, more studies need to be done to fully understand DKA caused by SGLT2 inhibitors.
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Toyoshima J, Saito M, Kaibara A, Isaka H, Sakatani T. Comparison of the Pharmacokinetic and Pharmacodynamic Relationship of Ipragliflozin Between Patients With Type 1 and Type 2 Diabetes Mellitus. Clin Ther 2020; 42:1787-1798.e3. [PMID: 32839028 DOI: 10.1016/j.clinthera.2020.07.009] [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: 04/24/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To characterize the pharmacokinetic and pharmacodynamic (PK/PD) relationship of ipragliflozin in Japanese patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) and to determine the appropriate dose regimen for a Phase III study of ipragliflozin in Japanese patients with T1DM. METHODS The PK (AUC24h of plasma ipragliflozin) and PD (renal glucose clearance) properties in patients with T1DM and T2DM were assessed in 2 independent clinical pharmacologic studies of ipragliflozin. The same maximum efficacy (Emax) model described the PK/PD relationship in patients with T1DM and T2DM. Changes in fasting plasma glucose (FPG) in T1DM patients were simulated by applying a previously established FPG model for ipragliflozin in patients with T2DM. FINDINGS Data from 42 patients with T1DM and 28 patients with T2DM were used. Comparable AUC24h of plasma ipragliflozin and similar dose dependency were observed on day 14 between patients with T1DM and those with T2DM. Decreases in renal glucose clearance were comparable regardless of the ipragliflozin dose in both groups of patients. The estimated mean Emax and AUC24h producing 50% of Emax (EX50) were 45.1 mL/min (95% CI, 37.0-53.2 mL/min) and 2160 ng·h/mL (95% CI, 929-3390 ng·h/mL), respectively, in all patients with T1DM and T2DM. Observed FPG in patients with T1DM was reproduced well by the simulation from the previously established FPG model. IMPLICATIONS The PK/PD properties for ipragliflozin were comparable between patients with T1DM and T2DM, suggesting no substantial difference in PK/PD relationships in both patient populations. The dose regimen used for patients with T2DM was also recommended for a Phase III study in Japanese patients with T1DM. ClinicalTrials.gov identifiers: NCT01023945 and NCT02529449.
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Kaku K, Isaka H, Sakatani T, Toyoshima J. Long-term (52-week) efficacy and safety of ipragliflozin add-on therapy to insulin in Japanese patients with type 1 diabetes mellitus: An uncontrolled, open-label extension of a phase III study. J Diabetes Investig 2020; 11:662-671. [PMID: 31743569 PMCID: PMC7232286 DOI: 10.1111/jdi.13181] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 11/06/2019] [Accepted: 11/17/2019] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The aim of the present study was to assess the long-term (52-week) efficacy and safety of ipragliflozin in insulin-treated Japanese patients with type 1 diabetes mellitus and inadequate glycemic control. MATERIALS AND METHODS In this 28-week, open-label extension of a multicenter, randomized, placebo-controlled, 24-week phase III study, ipragliflozin recipients continued treatment (50 mg, once daily), and placebo recipients were switched to once-daily 50 mg ipragliflozin at the start of the extension period. The ipragliflozin dose could be increased to 100 mg if warranted. The primary end-point was change in glycated hemoglobin; secondary end-points were change in insulin dose and bodyweight. Safety outcomes were monitored as treatment-emergent adverse events. RESULTS A total of 53 (placebo switched to ipragliflozin) and 108 (ipragliflozin) patients completed the open-label extension (treatment period 2), with 24 and 44 patients, respectively, receiving dose increases. From baseline to end of treatment, the overall mean change (standard deviation [SD]) in glycated hemoglobin was -0.33% (0.72; -3.7 mmol/mol [7.9]), with changes in basal, bolus and total insulin doses of -3.76 IU (SD 3.85 IU), -2.51 IU (SD 7.08 IU) and -6.27 IU (SD 8.16 IU), respectively. No serious drug-related treatment-emergent adverse events or deaths were reported. Treatment-emergent adverse events leading to study discontinuation occurred in zero and three (2.6%) patients in the placebo switched to ipragliflozin and ipragliflozin groups, respectively; all were considered drug-related. There were no cases of severe hypoglycemia or diabetic ketoacidosis, and no safety concerns related to dose increase. CONCLUSIONS The efficacy and safety of 50 mg, once-daily ipragliflozin in insulin-treated type 1 diabetes mellitus patients were confirmed in this long-term, open-label extension study. No safety concerns were attributed to a dose increase to 100 mg.
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Affiliation(s)
- Kohei Kaku
- Department of MedicineKawasaki Medical SchoolOkayamaJapan
| | - Hiroyuki Isaka
- Japan/Asia Clinical DevelopmentAstellas Pharma Inc.TokyoJapan
| | | | - Junko Toyoshima
- Clinical Pharmacology and Exploratory DevelopmentAstellas Pharma Inc.TokyoJapan
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Kashiwagi A, Shestakova MV, Ito Y, Noguchi M, Wilpshaar W, Yoshida S, Wilding JPH. Safety of Ipragliflozin in Patients with Type 2 Diabetes Mellitus: Pooled Analysis of Phase II/III/IV Clinical Trials. Diabetes Ther 2019; 10:2201-2217. [PMID: 31606880 PMCID: PMC6848447 DOI: 10.1007/s13300-019-00699-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Ipragliflozin is a selective sodium-glucose cotransporter 2 (SGLT2) inhibitor approved for the treatment of type 2 diabetes mellitus (T2DM). The objective of this pooled analysis was to characterise the safety profile of ipragliflozin based on safety data from published randomised controlled trials. METHODS Safety data from 12 randomised, phase II/III/IV placebo-controlled, parallel group, comparative studies of ipragliflozin in patients with T2DM were pooled. Treatment-emergent adverse events (TEAEs) were analysed for patients who had received at least one dose of ipragliflozin 50 mg (n = 1209) or placebo (n = 796) in studies lasting for up to 24 weeks. TEAEs of special interest and serious adverse events (SAEs) were assessed, as well as abnormal laboratory test and vital sign measurements. RESULTS The overall incidences of TEAEs and SAEs between the ipragliflozin and placebo groups were similar, 63.8% vs 59.3% and 2.5% vs 3.3%, respectively. The incidence of TEAEs leading to permanent discontinuation was lower for ipragliflozin (3.6%) than placebo (6.5%). The incidences of TEAEs of special interest including those related to urinary tract infection, cardiovascular events, renal disorder, fracture, malignant tumours and hypoglycaemia were also similar between the groups. Genital infections were more frequent with ipragliflozin (2.4%) than placebo (0.6%), as were pollakiuria/polyuria (6.0% vs 2.0%), volume depletion (4.9% vs 1.8%) and skin/subcutaneous tissue disorders (7.7% vs 4.4%). There were no reported cases of diabetic ketoacidosis, fractures, lower-limb amputation or Fournier's gangrene in ipragliflozin-treated patients across the 12 studies. CONCLUSION In randomised, placebo-controlled trials of patients with T2DM, ipragliflozin was well tolerated, with a similar overall incidence of TEAEs to placebo. No new safety signals were observed. TRIAL REGISTRATION NUMBERS NCT01071850, NCT00621868, NCT01057628, NCT01117584, NCT01135433, NCT01225081, NCT01242215, NCT02175784, NCT01505426, NCT02452632, NCT02794792, NCT01316094. FUNDING Astellas Pharma Inc.
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Affiliation(s)
| | | | | | | | - Wim Wilpshaar
- Astellas Pharma Europe B.V., Leiden, The Netherlands
| | | | - John P H Wilding
- Obesity and Endocrinology Research, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
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Kaku K, Isaka H, Sakatani T, Toyoshima J. Efficacy and safety of ipragliflozin add-on therapy to insulin in Japanese patients with type 1 diabetes mellitus: A randomized, double-blind, phase 3 trial. Diabetes Obes Metab 2019; 21:2284-2293. [PMID: 31173455 PMCID: PMC6772182 DOI: 10.1111/dom.13807] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 05/26/2019] [Accepted: 06/05/2019] [Indexed: 12/29/2022]
Abstract
AIM To assess the efficacy and safety of once-daily ipragliflozin 50 mg versus placebo in Japanese people with type 1 diabetes mellitus (T1DM) inadequately controlled with insulin. MATERIALS AND METHODS We conducted a multicentre, double-blind, parallel-group, placebo-controlled phase 3 study. Participants (N = 175) were randomized (2:1) to receive once-daily ipragliflozin 50 mg (n = 115) or placebo (n = 60), combined with insulin, for 24 weeks. The primary endpoint was change in glycated haemoglobin (HbA1c); key secondary endpoints included change in insulin dose and body weight. Treatment-emergent adverse events (TEAEs) were evaluated. RESULTS The ipragliflozin group demonstrated a significant decrease in HbA1c from baseline to end of treatment versus the placebo group: adjusted mean difference (AMD) -3.8 mmol/mol (95% confidence interval [CI] -6.2, -1.5) or - 0.36% (95% CI -0.57, -0.14; P = 0.001). Significant reductions in total daily insulin dose (AMD -7.35 IU [95% CI -9.09, -5.61]; P < 0.001) and body weight (AMD -2.87 kg [95% CI -3.58, -2.16]; P < 0.001) were observed for the ipragliflozin group versus placebo. Two serious TEAEs occurred (major hypoglycaemia and abdominal abscess); both were in the placebo group. All other TEAEs were mild or moderate in severity. Four cases of study discontinuation occurred; three in the placebo group and one in the ipragliflozin group. No diabetic ketoacidosis was reported for any participant in this study. CONCLUSIONS Daily ipragliflozin 50 mg in combination with insulin significantly reduced HbA1c, daily insulin dose and body weight versus placebo in people with T1DM. No safety concerns were identified after 24 weeks of treatment. Overall, once-daily ipragliflozin 50 mg was both efficacious and well tolerated.
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Affiliation(s)
- Kohei Kaku
- Department of MedicineKawasaki Medical SchoolOkayamaJapan
| | - Hiroyuki Isaka
- Japan/Asia Clinical DevelopmentAstellas Pharma Inc.TokyoJapan
| | | | - Junko Toyoshima
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Inc.TokyoJapan
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Kaku K, Isaka H, Toyoshima J, Sakatani T. Clinical pharmacology study of ipragliflozin in Japanese patients with type 1 diabetes mellitus: A phase 2, randomized, placebo-controlled trial. Diabetes Obes Metab 2019; 21:1445-1454. [PMID: 30821047 PMCID: PMC6594083 DOI: 10.1111/dom.13679] [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: 11/19/2018] [Revised: 02/12/2019] [Accepted: 02/28/2019] [Indexed: 12/23/2022]
Abstract
AIM To evaluate the pharmacodynamics, pharmacokinetics, and safety of the novel oral sodium-glucose co-transporter-2 inhibitor, ipragliflozin, in Japanese patients with type 1 diabetes mellitus. MATERIALS AND METHODS We conducted a multicentre, double-blind, placebo-controlled, parallel-group study. Patients were randomized to receive 25, 50, or 100 mg/day ipragliflozin or placebo for 2 weeks. Key pharmacokinetic endpoints included area under the concentration-time curve 24 hours postdose (AUC24h ), maximum plasma concentration (Cmax ), and renal clearance. Key pharmacodynamic endpoints included 24-hour urinary glucose excretion, mean plasma glucose AUC0-24h , and mean renal glucose clearance. Changes in total, basal, and bolus insulin dosages were recorded. Adverse events (AEs) were monitored for safety. RESULTS Dose-dependent increases were observed in AUC24h and Cmax on days 1 and 14 for 25-, 50-, and 100-mg ipragliflozin. The mean plasma glucose AUC0-24h was lower than that of placebo and the mean renal glucose clearance increased in a dose-dependent manner from baseline, but remained unchanged in the placebo group. The mean (standard deviation) change from baseline in total daily insulin dose was greater in the ipragliflozin 25-, 50-, and 100-mg groups (-14.77 ± 14.04%, -18.40 ± 12.49% and -19.25 ± 16.77%, respectively), than placebo (-4.51 ± 16.28%). Most AEs were mild in severity; no patients discontinued the study because of treatment-emergent AEs. CONCLUSIONS The pharmacokinetic and pharmacodynamic properties of ipragliflozin in Japanese patients with type 1 diabetes mellitus were confirmed. Increases in urinary glucose excretion lead to dose-dependent decreases in plasma glucose. Concomitant insulin dose decreased with ipragliflozin treatment. No clinically relevant safety concerns were identified.
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Affiliation(s)
- Kohei Kaku
- Department of MedicineKawasaki Medical SchoolOkayamaJapan
| | - Hiroyuki Isaka
- Astellas Pharma Inc., Japan/Asia Clinical DevelopmentTokyoJapan
| | - Junko Toyoshima
- Astellas Pharma Inc., Japan/Asia Clinical DevelopmentTokyoJapan
| | - Taishi Sakatani
- Astellas Pharma Inc., Japan/Asia Data Science DevelopmentTokyoJapan
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