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Saini K, Sharma S, Khan Y. DPP-4 inhibitors for treating T2DM - hype or hope? an analysis based on the current literature. Front Mol Biosci 2023; 10:1130625. [PMID: 37287751 PMCID: PMC10242023 DOI: 10.3389/fmolb.2023.1130625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/08/2023] [Indexed: 06/09/2023] Open
Abstract
DPP-4 inhibition is an interesting line of therapy for treating Type 2 Diabetes Mellitus (T2DM) and is based on promoting the incretin effect. Here, the authors have presented a brief appraisal of DPP-4 inhibitors, their modes of action, and the clinical efficiency of currently available drugs based on DPP-4 inhibitors. The safety profiles as well as future directions including their potential application in improving COVID-19 patient outcomes have also been discussed in detail. This review also highlights the existing queries and evidence gaps in DPP-4 inhibitor research. Authors have concluded that the excitement surrounding DPP-4 inhibitors is justified because in addition to controlling blood glucose level, they are good at managing risk factors associated with diabetes.
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Mehlich A, Bolanowski M, Mehlich D, Witek P. Medical treatment of Cushing's disease with concurrent diabetes mellitus. Front Endocrinol (Lausanne) 2023; 14:1174119. [PMID: 37139336 PMCID: PMC10150952 DOI: 10.3389/fendo.2023.1174119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/03/2023] [Indexed: 05/05/2023] Open
Abstract
Cushing's disease (CD) is a severe endocrine disorder characterized by chronic hypercortisolaemia secondary to an overproduction of adrenocorticotropic hormone (ACTH) by a pituitary adenoma. Cortisol excess impairs normal glucose homeostasis through many pathophysiological mechanisms. The varying degrees of glucose intolerance, including impaired fasting glucose, impaired glucose tolerance, and Diabetes Mellitus (DM) are commonly observed in patients with CD and contribute to significant morbidity and mortality. Although definitive surgical treatment of ACTH-secreting tumors remains the most effective therapy to control both cortisol levels and glucose metabolism, nearly one-third of patients present with persistent or recurrent disease and require additional treatments. In recent years, several medical therapies demonstrated prominent clinical efficacy in the management of patients with CD for whom surgery was non-curative or for those who are ineligible to undergo surgical treatment. Cortisol-lowering medications may have different effects on glucose metabolism, partially independent of their role in normalizing hypercortisolaemia. The expanding therapeutic landscape offers new opportunities for the tailored therapy of patients with CD who present with glucose intolerance or DM, however, additional clinical studies are needed to determine the optimal management strategies. In this article, we discuss the pathophysiology of impaired glucose metabolism caused by cortisol excess and review the clinical efficacy of medical therapies of CD, with particular emphasis on their effects on glucose homeostasis.
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Affiliation(s)
- Anna Mehlich
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Marek Bolanowski
- Chair and Department of Endocrinology, Diabetes, and Isotope Treatment, Wroclaw Medical University, Wroclaw, Poland
| | - Dawid Mehlich
- Laboratory of Molecular OncoSignalling, International Institute of Molecular Mechanisms and Machines (IMol) Polish Academy of Sciences, Warsaw, Poland
- Doctoral School of Medical University of Warsaw, Medical University of Warsaw, Warsaw, Poland
- Laboratory of Experimental Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
- *Correspondence: Przemysław Witek,
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He L, Wang J, Ping F, Yang N, Huang J, Li W, Xu L, Zhang H, Li Y. Dipeptidyl peptidase-4 inhibitors and gallbladder or biliary disease in type 2 diabetes: systematic review and pairwise and network meta-analysis of randomised controlled trials. BMJ 2022; 377:e068882. [PMID: 35764326 PMCID: PMC9237836 DOI: 10.1136/bmj-2021-068882] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To examine the association between dipeptidyl peptidase-4 inhibitors and gallbladder or biliary diseases. DESIGN Systematic review and pairwise and network meta-analysis. DATA SOURCES PubMed, EMBASE, Web of Science, and CENTRAL from inception until 31 July 2021. ELIGIBILITY CRITERIA Randomised controlled trials of adult patients with type 2 diabetes who received dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists, and sodium-glucose cotransporter-2 inhibitors compared with placebo or other antidiabetes drugs. MAIN OUTCOME MEASURES Composite of gallbladder or biliary diseases, cholecystitis, cholelithiasis, and biliary diseases. DATA EXTRACTION AND DATA SYNTHESIS Two reviewers independently extracted the data and assessed the quality of the studies. The quality of the evidence for each outcome was assessed using the Grading of Recommendations, Assessment, Development and Evaluations framework (GRADE) approach. The meta-analysis used pooled odds ratios and 95% confidence intervals. RESULTS A total of 82 randomised controlled trials with 104 833 participants were included in the pairwise meta-analysis. Compared with placebo or non-incretin drugs, dipeptidyl peptidase-4 inhibitors were significantly associated with an increased risk of the composite of gallbladder or biliary diseases (odds ratio 1.22 (95%confidence interval 1.04 to 1.43); risk difference 11 (2 to 21) more events per 10 000 person years) and cholecystitis (odds ratio 1.43 (1.14 to 1.79); risk difference 15 (5 to 27) more events per 10 000 person years) but not with the risk of cholelithiasis and biliary diseases. The associations tended to be observed in patients with a longer duration of dipeptidyl peptidase-4 inhibitor treatment. In the network meta-analysis of 184 trials, dipeptidyl peptidase-4 inhibitors increased the risk of the composite of gallbladder or biliary diseases and cholecystitis compared with sodium-glucose cotransporter-2 inhibitors but not compared with glucagon-like peptide-1 receptor agonists. CONCLUSIONS Dipeptidyl peptidase-4 inhibitors increased the risk of cholecystitis in randomised controlled trials, especially with a longer treatment duration, which requires more attention from physicians in clinical practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021271647.
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Affiliation(s)
- Liyun He
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jialu Wang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fan Ping
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Na Yang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingyue Huang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Li
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lingling Xu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huabing Zhang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuxiu Li
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Rhee CM, Kalantar-Zadeh K, Tuttle KR. Novel approaches to hypoglycemia and burnt-out diabetes in chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:72-81. [PMID: 34750332 PMCID: PMC8684381 DOI: 10.1097/mnh.0000000000000756] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Diabetes mellitus is a leading cause of chronic kidney disease (CKD) that confers faster kidney disease progression, higher mortality, and various metabolic derangements including hypoglycemia. RECENT FINDINGS Even in the absence of diabetes mellitus, growing research demonstrates that CKD patients are at heightened risk for hypoglycemia via multiple pathways. In CKD patients transitioning to end-stage renal disease (ESRD), spontaneous resolution of hyperglycemia and frequent hypoglycemia resulting in reduction and/or cessation of glucose-lowering medications are frequently observed in a phenomenon described as 'burnt-out diabetes'. In non-CKD patients, it is well established that hypoglycemia is causally associated with mortality, with pathways including arrhythmias, sudden cardiac death, stroke, and seizures. Increasing evidence shows that, in CKD and ESRD patients with and without diabetes mellitus, hypoglycemia is associated with cardiovascular complications and mortality risk. SUMMARY Given the high prevalence of hypoglycemia in CKD patients and the morbidity and mortality associated with this metabolic complication, a multimodal strategy is needed to prevent dysglycemia, including individualization of glycemic targets, selection of glucose-lowering medications less likely to induce hypoglycemia, medical nutrition therapy administered by trained dietitians, and accurate and precise hypoglycemia detection methods, such as self-monitored blood glucose or continuous glucose monitoring including during dialysis treatment.
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Affiliation(s)
- Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, California
| | - Katherine R. Tuttle
- Providence Health Care, Spokane, Washington
- Nephrology Division and Kidney Research Institute, University of Washington, Seattle, Washington
- Institute of Translational Health Sciences, University of Washington, Seattle, Washington
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Safar MM, Abdelkader NF, Ramadan E, Kortam MA, Mohamed AF. Novel mechanistic insights towards the repositioning of alogliptin in Parkinson's disease. Life Sci 2021; 287:120132. [PMID: 34774622 DOI: 10.1016/j.lfs.2021.120132] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 12/12/2022]
Abstract
Parkinson's disease (PD) is a progressive neurodegenerative disease that impairs people's lives tremendously. The development of innovative treatment modalities for PD is a significant unmet medical need. The critical function of glucagon-like peptide-1 (GLP-1) in neurodegenerative diseases has raised impetus in investigating the repositioning of a dipeptidyl peptidase IV inhibitor, alogliptin (ALO), as an effective treatment for PD. As a result, the focus of this research was to assess the effect of ALO in a rat rotenone (ROT) model of PD. For 21 days, ROT (1.5 mg/kg) was delivered subcutaneously every other day. ALO (30 mg/kg/day), delivered by gavage for 21 days, recovered motor performance and improved motor coordination in the open-field and rotarod testing. These impacts were highlighted by restoring striatal dopamine content and correcting histological changes that occurred concurrently. The ALO molecular signaling was determined by increasing the quantity of GLP-1 and the protein expression of its downstream signaling pathway, pT172-AMPK/SIRT1/PGC-1α. Furthermore, it curbed neuroinflammation via hampering HMGB1/TLR4/NLRP3 inflammasome activation and conquered striatal microglia activation. Pre-administration of dorsomorphin reversed the neuroprotective effects. In conclusion, the promising neuroprotective effect of ALO highlights the repositioning of ALO as a prospective revolutionary candidate for combating PD.
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Affiliation(s)
- Marwa M Safar
- Pharmacology and Biochemistry Department, Faculty of Pharmacy, the British University in Egypt, Cairo, Egypt; Pharmacology and Toxicology Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Noha F Abdelkader
- Pharmacology and Toxicology Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt.
| | - Eman Ramadan
- Pharmacology and Biochemistry Department, Faculty of Pharmacy, the British University in Egypt, Cairo, Egypt
| | - Mona A Kortam
- Biochemistry Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Ahmed F Mohamed
- Pharmacology and Toxicology Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt
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Zhang X, Wang M, Wang X, Zhu Z, Zhang W, Zhou Z, Tang W, Li Q. Comparison of New Glucose-Lowering Drugs on Risk of Pancreatitis in Type 2 Diabetes: A Network Meta-Analysis. Endocr Pract 2021; 28:333-341. [PMID: 34922031 DOI: 10.1016/j.eprac.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/04/2021] [Accepted: 12/06/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND & AIMS Whether new glucose-lowering drugs increases the risk of pancreatitis in individuals with type 2 diabetes remains controversial. This present network meta-analysis aims to investigate the risk of pancreatitis associated with the use of glucagon-like peptide (GLP)-1 agonists and dipeptidyl peptidase (DPP)-4 inhibitors in the treatment of type 2 diabetes mellitus. METHODS PubMed, Web of Science, EMBASE and the Cochrane Library were searched. The literature was published from the date of their inception to July 21, 2021, including placebo-controlled or head-to-head trials of 2 new glucose-lowering drugs. Relative ratio (RR) and 95% confidence interval (CI) were used to assess the risk of GLP-1 agonists and DPP-4 inhibitors for pancreatitis or pancreatic cancer among patients with type 2 diabetes. RESULTS Seventeen studies were identified, covered 102257 participants. The pooled results showed a neutral relationship between GLP-1 agonists and pancreatitis (Overall RR, 0.96; 95% CI, 0.31-3.00) or pancreatic cancer (Overall RR, 1.10; 95% CI, 0.31-4.10) compared to placebo. Meanwhile, DPP-4 inhibitors were not be associated with the increased risk of pancreatitis (Overall RR, 1.60; 95% CI, 0.25-11.00) or pancreatic cancer (Overall RR, 0.79; 95% CI, 0.26-2.40). Among them, lixisenatide and saxagliptin may be the safest drug compared to other drugs according to the ranking of probability. Sensitivity and subgroup analysis confirmed the stability of the core results. CONCLUSION The most obvious finding to emerge from this study is that GLP-1 agonists and DPP-4 inhibitors are safe with respect to pancreatitis and pancreatic cancer risk compared to placebo. This conclusion may provide useful evidence for correlated clinical researches.
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Affiliation(s)
- Xuexue Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Department of Endocrinology, China Academy of Chinese Medical Sciences, Beijing, China
| | - Miaoran Wang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Department of Endocrinology, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xujie Wang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Department of Endocrinology, China Academy of Chinese Medical Sciences, Beijing, China
| | - Zhengchuan Zhu
- Peking University Traditional Chinese Medicine Clinical Medical School [Xi yuan], Beijing, China.
| | - Wantong Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Zhongyang Zhou
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Wei Tang
- Department of Endocrinology, Beijing University of Chinese Medicine, Beijing, China
| | - Qiuyan Li
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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Tomlinson B, Chan P, Lam CWK. An overview of alogliptin + pioglitazone for the treatment of type 2 diabetes. Expert Opin Pharmacother 2021; 23:29-42. [PMID: 34591742 DOI: 10.1080/14656566.2021.1985465] [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] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Type 2 diabetes (T2D) is a progressive condition, and sequential additions of therapy are usually required to maintain glycemic control. The options for glucose lowering therapies have increased considerably in recent years. Fixed-dose combinations such as alogliptin with pioglitazone provide a convenient choice which can improve medication adherence. AREAS COVERED The authors performed a literature search to identify publications describing the efficacy and safety of alogliptin and pioglitazone when used separately and in combinations. EXPERT OPINION Pioglitazone activates peroxisome proliferator-activated receptor-gamma which improves insulin sensitivity and helps to preserve β-cell function with a durable improvement in glycemic control. Pioglitazone can retard the progression of atherosclerosis and reduce cardiovascular events, but it is associated with adverse events including weight gain, fluid retention, and increased risk of fractures. Alogliptin improves glycemic control and appears neutral in terms of cardiovascular events. It does not appear to increase the adverse events associated with pioglitazone and use of the combination may permit the use of lower doses of pioglitazone with reduced adverse effects. There are no cardiovascular outcome studies with the combination but the cardiovascular benefits of pioglitazone and additional glucose lowering effects of alogliptin provide a useful combination with convenient once daily dosing.
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Affiliation(s)
- Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology, Macau, China
| | - Paul Chan
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei City, Taiwan
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Kadowaki T, Seino Y, Kaku K, Okamoto T, Kameya M, Sato A, Hirano T, Oshima N, Gantz I, O'Neill EA, Engel SS. A randomized, placebo-controlled study to evaluate the efficacy and safety of adding omarigliptin to insulin therapy in Japanese patients with type 2 diabetes and inadequate glycaemic control. Diabetes Obes Metab 2021; 23:1242-1251. [PMID: 33512755 PMCID: PMC8248035 DOI: 10.1111/dom.14331] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/14/2021] [Accepted: 01/23/2021] [Indexed: 12/21/2022]
Abstract
AIM To evaluate the efficacy and safety of adding the once-weekly oral dipeptidyl peptidase-4 inhibitor omarigliptin to treatment of Japanese patients with type 2 diabetes and inadequate glycaemic control on insulin monotherapy. MATERIALS AND METHODS In a 52-week clinical trial, Japanese patients on insulin monotherapy were randomized to once-weekly omarigliptin 25 mg (N = 123) or placebo (N = 61) for a 16-week, double-blind, placebo-controlled period. After Week 16, patients continued or switched to omarigliptin for a 36-week open-label period. RESULTS From a mean baseline of approximately 8.8%, the Week 16 least squares mean changes in HbA1c were -0.61% (omarigliptin) and 0.29% (placebo); the between-group difference was -0.90% (p < .001). At Week 52, the mean change from baseline in HbA1c was -0.57% in both the group on omarigliptin for 52 weeks and the group on omarigliptin for 36 weeks (switched from placebo at Week 16). During the first 16 weeks of treatment, the incidences of adverse events (AEs), serious AEs, drug-related AEs and discontinuation from trial medication because of an AE were similar in both groups. A slight increase in incidence of symptomatic hypoglycaemia was observed in the omarigliptin group (n = 13 [10.6%]) compared with placebo (n = 4 [6.6%]). No severe hypoglycaemia was reported during the study. No new safety signals emerged with treatment beyond Week 16 through Week 52. CONCLUSION The addition of once-weekly omarigliptin to insulin therapy for up to 52 weeks was generally well tolerated and provided clinically meaningful improvement in glycaemic control throughout the trial period. ClinicalTrials.gov: NCT02906709.
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Affiliation(s)
- Takashi Kadowaki
- Department of Prevention of Diabetes and Lifestyle‐Related Diseases, Graduate School of MedicineThe University of TokyoTokyoJapan
- Toranomon HospitalTokyoJapan
| | - Yutaka Seino
- Kansai Electric Power HospitalOsakaJapan
- Kansai Electric Power Medical Research InstituteOsakaJapan
| | | | | | | | | | | | | | - Ira Gantz
- Merck Research LaboratoriesMerck & Co., Inc.KenilworthNew JerseyUSA
| | | | - Samuel S. Engel
- Merck Research LaboratoriesMerck & Co., Inc.KenilworthNew JerseyUSA
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Yang W, Cai X, Zhang S, Han X, Ji L. Dipeptidyl peptidase-4 inhibitor treatment and the risk of bullous pemphigoid and skin-related adverse events: A systematic review and meta-analysis of randomized controlled trials. Diabetes Metab Res Rev 2021; 37:e3391. [PMID: 32741073 DOI: 10.1002/dmrr.3391] [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: 02/18/2019] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 12/24/2022]
Abstract
AIMS This meta-analysis aimed to evaluate the risk of developing bullous pemphigoid (BP) and other skin-related adverse events (AEs) in patients with type 2 diabetes (T2DM) undergoing dipeptidyl peptidase-4 inhibitor (DPP-4i) treatment in randomized controlled trials (RCTs). METHODS In this meta-analysis, the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for RCTs, which involve patients with T2DM reporting skin-related AEs. RCTs that comparatively evaluated the effects of DPP-4i treatment and placebo on patients with T2DM and reported skin-related AEs were included in the analysis. The odds ratio (OR) and 95% confidence interval (CI) were calculated using the Peto's methods. The GRADE approach was used to rate the quality of evidence. RESULTS A total of 46 randomized placebo-controlled trials, including 3 trials with reports of BP (n = 38 011), that reported skin-related AEs were included (n = 59 332). Compared to the placebo group, the risk of developing BP was significantly higher in the DPP-4i treatment group (OR = 7.38, 95% CI 2.00-27.25, I2 = 0%, P = .003; quality rating: very low). Additionally, DPP-4i treatment was associated with an increased overall risk of developing skin-related AEs (OR = 1.22, 95% CI 1.02-1.46, I2 = 32%, P = .03; quality rating: moderate). CONCLUSIONS This meta-analysis suggested that treatment with DPP-4is, including sitagliptin, saxagliptin, and linagliptin, was associated with an increased risk of developing BP. Additionally, the risk of developing skin-related AEs increased when all DPP-4is were combined. Skin lesion, especially BP, should be monitored in patients with diabetes undergoing DPP-4i treatment. Future studies should evaluate the susceptible population and develop strategies for early detection of skin-related AEs.
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Affiliation(s)
- Wenjia Yang
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Xiaoling Cai
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Simin Zhang
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Xueyao Han
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
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Yang J, Tian Q, Tang Y, Shah AK, Zhang R, Chen G, Zhang Y, Rajpathak S, Hong T. Effect of Dipeptidyl Peptidase 4 Inhibitors Used in Combination with Insulin Treatment in Patients with Type 2 Diabetes: A Systematic Review and Meta-analysis. Diabetes Ther 2020; 11:2371-2382. [PMID: 32876863 PMCID: PMC7509019 DOI: 10.1007/s13300-020-00914-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION To evaluate the efficacy and safety of dipeptidyl peptidase 4 inhibitors (DPP4i) used in combination with insulin in patients with type 2 diabetes mellitus (T2DM). METHODS We searched the MEDLINE, Embase, and Cochrane library databases for randomized controlled trials (RCTs) published through June 2018. Studies with at least a 12-week treatment period were included to compare the addition of DPP4i to insulin with insulin control therapy. Meanwhile, groups on a stable insulin dosage (insulin-stable subgroup) or titrating insulin dosage (insulin-flexible subgroup) were analyzed separately. RESULTS Twenty-one RCTs with 3697 patients randomized to a DPP4i/insulin treatment arm and 3538 to an insulin control arm were included. DPP4i, when added to insulin therapy, led to a significantly greater reduction in HbA1c (- 0.57%, 95% CI - 0.66, - 0.48) and provided significantly greater odds of achieving the HbA1c target < 7% (OR 3.45; 95% CI 2.58, 4.63). These effects were achieved in the context of a decrease in the daily insulin requirement, without increases in hypoglycemia risk and body weight, compared with the control treatment. Subgroup analysis showed control-adjusted reductions in HbA1c from baseline in the insulin-stable subgroup (- 0.64%; 95% CI - 0.74, - 0.53) and the insulin-flexible subgroup (- 0.43%; 95% CI - 0.56, - 0.30). Other results occurred similarly in both subgroups. CONCLUSIONS The addition of DPP4i to insulin is associated with a statistically significant reduction in glycemic control as measured by HbA1c, fasting plasma glucose, and 2-h postprandial glucose, without increasing the risk of hypoglycemia and weight gain. These conclusions were also observed in both stable-dose and flexible-dose insulin subgroups.
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Affiliation(s)
- Jin Yang
- Department of Endocrinology and Metabolism, Peking University Third Hospital, Beijing, China
| | - Qing Tian
- Department of Endocrinology and Metabolism, Peking University Third Hospital, Beijing, China
| | | | | | - Ruya Zhang
- Medical Affairs, MSD China Holding Co., Ltd., Shanghai, China
| | - Guojuan Chen
- Medical Affairs, MSD China Holding Co., Ltd., Shanghai, China
| | - Ye Zhang
- Medical Affairs, MSD China Holding Co., Ltd., Shanghai, China
| | | | - Tianpei Hong
- Department of Endocrinology and Metabolism, Peking University Third Hospital, Beijing, China
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Kaku K, Kisanuki K, Shibata M, Oohira T. Benefit-Risk Assessment of Alogliptin for the Treatment of Type 2 Diabetes Mellitus. Drug Saf 2020; 42:1311-1327. [PMID: 31654243 PMCID: PMC6834733 DOI: 10.1007/s40264-019-00857-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The dipeptidyl peptidase-4 inhibitor (DPP-4i) alogliptin is an oral, antidiabetic treatment that is approved in many countries to treat patients with type 2 diabetes mellitus (T2DM), including the USA, Europe, and Japan. Alogliptin is efficacious both as monotherapy and as add-on/combination therapy with other commonly prescribed T2DM treatments, such as metformin and pioglitazone. Overall, alogliptin is well-tolerated in patients with T2DM, including older patients, those with renal and/or hepatic impairment, and those at high risk of cardiovascular events. There is a low risk of hypoglycemia, weight gain, acute pancreatitis, and gastrointestinal adverse events with alogliptin treatment, as demonstrated in long-term trials (lasting up to 4.5 years) and in a real-world setting. Additionally, alogliptin has a generally favorable or similar safety profile in comparison to other antidiabetic agents (metformin, thiazolidinediones, sulfonylureas, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter 2 inhibitors, α-glucosidase inhibitors, and insulin). However, further evaluation would be required to determine the mechanism and effect of alogliptin on heart failure, bullous pemphigoid, and inflammatory bowel disease. Of note, due to the ethnic diversity in the epidemiology of T2DM, alogliptin has been shown to be more efficacious in Asian patients than in non-Asian patients with T2DM, but with a similar tolerability profile. These data indicate that DPP-4is, including alogliptin, are important treatment options, especially for Asian patients with T2DM, for whom they have potential as a first-line therapy. This benefit-risk assessment aims to place alogliptin within the current armamentarium of T2DM and aid physicians when choosing optimal diabetes treatment for their patients.
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Affiliation(s)
- Kohei Kaku
- Department of Medicine, Kawasaki Medical School, 577 Matsushima, Okayama, 701-0192, Japan.
| | - Koichi Kisanuki
- Japan Medical Office, Takeda Pharmaceutical Company Limited, 1-1, Doshomachi 4-chome, Chuo-ku, Osaka, 540-8645, Japan
| | - Mari Shibata
- Global Patient Safety Evaluation Japan, Pharmacovigilance Department, Takeda Pharmaceutical Company Limited, 1-1, Doshomachi 4-chome, Chuo-ku, Osaka, 540-8645, Japan
| | - Takashi Oohira
- Global Patient Safety Evaluation Japan, Pharmacovigilance Department, Takeda Pharmaceutical Company Limited, 1-1, Doshomachi 4-chome, Chuo-ku, Osaka, 540-8645, Japan
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12
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Cho YM, Deerochanawong C, Seekaew S, Suraamornkul S, Benjachareonwong S, Sattanon S, Chamnan P, Sirirak T, Kosachunhanun N, Pratipanawatr T, Suwanwalaikorn S, Lee WJ, Kim S, Choi S, Kang ES, Oh T, Kwon S, Lee MK. Efficacy and safety of gemigliptin as add-on therapy to insulin, with or without metformin, in patients with type 2 diabetes mellitus (ZEUS II study). Diabetes Obes Metab 2020; 22:123-127. [PMID: 31478335 DOI: 10.1111/dom.13873] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 08/19/2019] [Accepted: 08/28/2019] [Indexed: 11/28/2022]
Abstract
The objective of this study was to evaluate the efficacy and safety of gemigliptin added to a stable dose of insulin alone or of insulin in combination with metformin in patients with type 2 diabetes mellitus. After a two-week run-in period, patients were randomized 2:1 to receive gemigliptin 50 mg or placebo once daily as add-on to background therapy with insulin or insulin plus metformin for 24 weeks. The primary endpoint was change in haemoglobin A1c (HbA1c) from baseline at Week 24. Baseline characteristics were similar between the gemigliptin (n = 188) and placebo (n = 95) groups in terms of HbA1c (8.1%). At Week 24, the gemigliptin group showed a statistically significant reduction in mean HbA1c from baseline as compared with placebo (between-group mean difference, -0.7% [95% CI, -0.9% to -0.4%]; P-value < 0.0001). The incidence of overall adverse events and the number of hypoglycaemic adverse events were similar between the study groups. Gemigliptin added to insulin alone or to insulin in combination with metformin resulted in superior glycaemic control compared to that in the placebo group and was well tolerated for 24 weeks in patients with type 2 diabetes mellitus, without causing weight gain or increasing the incidence of hypoglycaemia.
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Affiliation(s)
- Young Min Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Chaicharn Deerochanawong
- Diabetes and Endocrinology Unit, Rajavithi Hospital, Rangsit University College of Medicine, Bangkok, Thailand
| | | | - Swangjit Suraamornkul
- Vajira Hospital, Faculty of Medicine, Navamindradhiraj University, Bangkok, Thailand
| | | | | | - Parinya Chamnan
- Cardiometabolic Research Group, Department of Social Medicine, Sanpasitthiprasong Hospital, Ubon Ratchathani, Thailand
| | - Thanitha Sirirak
- Department of Family Medicine and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | | | | | - Sompongse Suwanwalaikorn
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Woo Je Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sungrae Kim
- Division of Endocrinology and Metabolism, Catholic University of Korea, Seoul, South Korea
| | - Seonghui Choi
- Department of Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Eun Seok Kang
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Taekeun Oh
- Chungbuk National University Hospital, Chungbuk National University College of Medicine, Chungbuk, Cheongju, South Korea
| | - Sam Kwon
- Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Moon-Kyu Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Shibuki K, Shimada S, Aoyama T. Meta-Analysis of 11 Heterogeneous Studies regarding Dipeptidyl Peptidase 4 Inhibitor Add-On Therapy for Type 2 Diabetes Mellitus Patients Treated with Insulin. J Diabetes Res 2020; 2020:6321826. [PMID: 33224988 PMCID: PMC7673952 DOI: 10.1155/2020/6321826] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/24/2020] [Accepted: 10/22/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Several clinical trials have addressed the therapeutic strategy of adding dipeptidyl peptidase 4 (DPP-4) inhibitors to the treatment of type 2 diabetes mellitus (DM) inadequately controlled by insulin therapy. However, there is a high degree of heterogeneity in these studies, and the cause of which has not been identified. METHODS We conducted a meta-analysis of randomized controlled trials, which compared the efficacy and safety of adding DPP-4 inhibitors or placebo to insulin therapy; the level of hemoglobin A1c (HbA1c) in the patients was >7.0%, and the duration of treatment was ≥8 weeks. We focused on the mean changes in HbA1c from the baseline (ΔHbA1c) and the incidence of hypoglycemia. We assumed that five baseline parameters (HbA1c, fasting blood glucose, body mass index (BMI), duration of type 2 DM, and duration of treatment) could affect ΔHbA1c. Regarding the incidence of hypoglycemia, we suspected that the heterogeneity was caused by differences in the definition of hypoglycemia among the studies. RESULTS Data obtained from 11 studies (n = 4654 patients) were included in the analysis. The mean ΔHbA1c between the DPP-4 inhibitor and placebo groups was -0.61% (95% confidence interval (CI): -0.74 to -0.48, I 2 = 73.4%). There was substantial heterogeneity among the 11 studies, but 74.1% of this variability was explained by the difference in BMI. The odds ratio for the incidence of hypoglycemia was 1.02 (95% CI: 0.74 to 1.42, I 2 = 63.8%), with substantial heterogeneity due to differences in the definition of hypoglycemia among the studies. There was no apparent effect of publication bias. CONCLUSIONS The addition of DPP-4 inhibitors to insulin therapy for adult patients with type 2 DM can significantly reduce HbA1c levels without increasing the occurrence of hypoglycemia. BMI and hypoglycemia definition could explain the heterogeneity in the clinical trials. This trial is registered with PROSPERO #CRD42016035994.
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Affiliation(s)
- Katsuya Shibuki
- Department of Pharmacy, Tokyo University of Science, 2641 Yamazaki, Noda 278-8510, Japan
- Clinical Research Center, Medical Hospital, Tokyo Medical and Dental University, 1-5-45 Yushima, Tokyo 113-8519, Japan
| | - Shuji Shimada
- Department of Pharmacy, Tokyo University of Science, 2641 Yamazaki, Noda 278-8510, Japan
| | - Takao Aoyama
- Department of Pharmacy, Tokyo University of Science, 2641 Yamazaki, Noda 278-8510, Japan
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Ledesma G, Umpierrez GE, Morley JE, Lewis-D'Agostino D, Keller A, Meinicke T, van der Walt S, von Eynatten M. Efficacy and safety of linagliptin to improve glucose control in older people with type 2 diabetes on stable insulin therapy: A randomized trial. Diabetes Obes Metab 2019; 21:2465-2473. [PMID: 31297968 DOI: 10.1111/dom.13829] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/25/2019] [Accepted: 07/07/2019] [Indexed: 12/30/2022]
Abstract
AIM To assess the addition of linagliptin as an alternative to insulin uptitration in older people with type 2 diabetes on stable insulin therapy. MATERIALS AND METHODS This phase 4, randomized, multicentre, double-blinded, placebo-controlled, 24-week study recruited individuals on stable insulin, with baseline HbA1c 7.0%-10.0%, aged ≥60 years and body mass index ≤45 kg/m2 . HbA1c and fasting plasma glucose were measured at study visits, and participants assessed glycaemic control with a self-monitoring blood glucose device. Adverse events (AEs) were reported during the study. RESULTS Three hundred and two participants were randomized 1:1 to linagliptin 5 mg qd and placebo, with one third of patients from Japan. Study population age and HbA1c (baseline mean ± SD) were 72.4 ± 5.4 years and 8.2 ± 0.8%, respectively; ~80% of participants were aged ≥70 years; 80% had macrovascular complications, one third had a baseline estimated glomerular filtration rate <60 mL/min/1.73 m2 ; and half had been diagnosed with diabetes for >15 years. Linagliptin significantly improved glucose control at 24 weeks (HbA1c-adjusted mean change vs. placebo: -0.63%; P <0.0001) and the probability of achieving predefined HbA1c targets without hypoglycaemia (HbA1c <8.0%: OR 2.02; P <0.05 and HbA1c <7.0%: OR 2.44; P <0.01). Linagliptin versus placebo was well tolerated, with similar incidences of AEs, including clinically important hypoglycaemia (blood glucose <54 mg/dL) or severe hypoglycaemia. CONCLUSIONS Addition of linagliptin improves glucose control without an excess of hypoglycaemia in older patients with type 2 diabetes on stable insulin therapy.
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Affiliation(s)
| | | | - John E Morley
- Division of Geriatric Medicine, Saint Louis University, St. Louis, Missouri
| | | | - Annett Keller
- Global BDS, Boehringer Ingelheim Pharma GmbH & Co, KG, Ingelheim, Germany
| | - Thomas Meinicke
- TA CardioMetabolism, Boehringer Ingelheim International GmbH, Biberach, Germany
| | - Sandra van der Walt
- International Project Management Cardiometabolic/CNS, Boehringer Ingelheim International GmbH, Ingelheim, Germany
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Kang YM, Jung CH, Lee SH, Kim SW, Song KH, Kim SG, Kim JH, Cho YM, Park TS, Ku BJ, Koh G, Kim DM, Lee BW, Park JY. Effectiveness and Safety of Adding Basal Insulin Glargine in Patients with Type 2 Diabetes Mellitus Exhibiting Inadequate Response to Metformin and DPP-4 Inhibitors with or without Sulfonylurea. Diabetes Metab J 2019; 43:432-446. [PMID: 31237133 PMCID: PMC6712234 DOI: 10.4093/dmj.2018.0092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 12/08/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND We aimed to investigate the effectiveness and safety of adding basal insulin to initiating dipeptidyl peptidase-4 (DPP-4) inhibitor and metformin and/or sulfonylurea (SU) in achieving the target glycosylated hemoglobin (HbA1c) in patients with type 2 diabetes mellitus (T2DM). METHODS This was a single-arm, multicenter, 24-week, open-label, phase 4 study in patients with inadequately controlled (HbA1c ≥7.5%) T2DM despite the use of DPP-4 inhibitor and metformin. A total of 108 patients received insulin glargine while continuing oral antidiabetic drugs (OADs). The primary efficacy endpoint was the percentage of subjects achieving HbA1c ≤7.0%. Other glycemic profiles were also evaluated, and the safety endpoints were adverse events (AEs) and hypoglycemia. RESULTS The median HbA1c at baseline (8.9%; range, 7.5% to 11.1%) decreased to 7.6% (5.5% to 11.7%) at 24 weeks. Overall, 31.7% subjects (n=33) achieved the target HbA1c level of ≤7.0%. The mean differences in body weight and fasting plasma glucose were 1.2±3.4 kg and 56.0±49.8 mg/dL, respectively. Hypoglycemia was reported in 36 subjects (33.3%, 112 episodes), all of which were fully recovered. There was no serious AE attributed to insulin glargine. Body weight change was significantly different between SU users and nonusers (1.5±2.5 kg vs. -0.9±6.0 kg, P=0.011). CONCLUSION The combination add-on therapy of insulin glargine, on metformin and DPP-4 inhibitors with or without SU was safe and efficient in reducing HbA1c levels and thus, is a preferable option in managing T2DM patients exhibiting dysglycemia despite the use of OADs.
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Affiliation(s)
- Yu Mi Kang
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Hee Jung
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Hwan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Wook Kim
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Kee Ho Song
- Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Sin Gon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Min Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Sun Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea
| | - Bon Jeong Ku
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Gwanpyo Koh
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Dol Mi Kim
- Medical Department of Diabetes and Cardiovascular, Sanofi-Korea, Seoul, Korea
| | - Byung Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, Seoul, Korea.
| | - Joong Yeol Park
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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16
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Gomes GKA, Pereira ML, Sanches C, Baldoni AO. Post-marketing Study of Linagliptin: A Pilot Study. Front Pharmacol 2019; 10:576. [PMID: 31178735 PMCID: PMC6543281 DOI: 10.3389/fphar.2019.00576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/06/2019] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Linagliptin is a high-cost oral antidiabetic that has been widely used, and studies on its effectiveness and safety for the treatment of type 2 diabetes mellitus (DM2) in the real world is rare and necessary. OBJECTIVE To analyze the values of glycated hemoglobin (HbA1c) and adverse events before and after the use of linagliptin in the post-marketing context of a pilot study. METHODS This is a descriptive observational and exploratory study with a retrospective longitudinal approach, conducted between January 2014 and December 2016. All patients who participated in the study were over 18 years of age, with DM2, assisted by the Brazilian Public Health System (Sistema Único de Saúde - SUS) and had been indicated for use of linagliptin. The users were followed up and the variables of interest were collected from a computerized health information system (sistema informatizado de saúde - SIS) and patient records. For effectiveness analysis, HbA1c before (T0) and after (T1) the use of linagliptin was considered in patients registered as having collected linagliptin at the pharmacy for at least three consecutive months. For safety analysis, registered adverse events (AE) were verified in patients' records. The sample was stratified according to the pharmacotherapeutic scheme of the users. To compare the means before (T0) and after (T1), a paired t-test (data with normal distribution) and Wilcoxon Signed Rank Sum test (non-normal distribution data) were performed. RESULTS Considering the total population of the study, in a different pharmacotherapeutic regimen, a median reduction in HbA1c of -0.86% (p < 0.05) was observed. After stratification by pharmacotherapeutic regimen, the most significant reduction of HbA1c was -1.07% (p = 0.014) for the linagliptin group associated with insulins and oral antidiabetic agents (n = 13). On the other hand, patients taking linagliptin in monotherapy had the lowest HbA1c reduction, -0.48% (p > 0.05). AE occurred in 12 (36.4%) patients, and 16.7% were in monotherapy. CONCLUSION Linagliptin did not presented, in real world, the desired performance as showed in randomized premarketing clinical trials and it should be carefully evaluated in public health services.
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Affiliation(s)
| | | | | | - André Oliveira Baldoni
- Grupo de Pesquisa em Epidemiologia e Avaliação de Novas Tecnologias em Saúde, Universidade Federal de São João del-Rei, Divinópolis, Brazil
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Roussel R, Duran‐García S, Zhang Y, Shah S, Darmiento C, Shankar RR, Golm GT, Lam RLH, O'Neill EA, Gantz I, Kaufman KD, Engel SS. Double-blind, randomized clinical trial comparing the efficacy and safety of continuing or discontinuing the dipeptidyl peptidase-4 inhibitor sitagliptin when initiating insulin glargine therapy in patients with type 2 diabetes: The CompoSIT-I Study. Diabetes Obes Metab 2019; 21:781-790. [PMID: 30393950 PMCID: PMC6587501 DOI: 10.1111/dom.13574] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/23/2018] [Accepted: 10/31/2018] [Indexed: 12/16/2022]
Abstract
AIMS To compare the effects of continuing versus discontinuing sitagliptin when initiating and intensively titrating insulin glargine. MATERIALS AND METHODS Eligible patients had inadequately controlled type 2 diabetes on metformin (≥1500 mg/d) in combination with a dipeptidyl peptidase-4 (DPP-4) inhibitor and/or a sulphonylurea. Those on metformin + sitagliptin were directly randomized; all others were switched to metformin + sitagliptin (discontinuing other DPP-4 inhibitors and sulphonylureas) and stabilized during a run-in period. At randomization, patients were allocated to continuing sitagliptin or discontinuing sitagliptin, with both groups initiating insulin glargine and titrating to a target fasting glucose of 4.0 to 5.6 mmol/L. RESULTS A total of 743 participants (mean glycated haemoglobin [HbA1c] 72.6 mmol/mol [8.8%], disease duration 10.8 years), were treated. After 30 weeks, the mean HbA1c and least squares (LS) mean change from baseline in HbA1c were 51.4 mmol/mol (6.85%) and -20.5 mmol/mol (-1.88%) in the sitagliptin group and 56.4 mmol/mol (7.31%) and -15.5 mmol/mol (-1.42%) in the placebo group; the difference in LS mean changes from baseline HbA1c was -5.0 mmol/mol (-0.46%; P < 0.001). The percentage of participants with HbA1c <53 mmol/mol (<7.0%) was higher (54% vs. 35%) and the mean daily insulin dose was lower (53 vs. 61 units) in the sitagliptin group. Despite lower HbA1c, event rates and incidences of hypoglycaemia were not higher in the sitagliptin group. Adverse events overall and changes from baseline in body weight were similar between the two treatment groups. CONCLUSION When initiating insulin glargine therapy, continuation of sitagliptin, compared with discontinuation, resulted in a clinically meaningful greater reduction in HbA1c without an increase in hypoglycaemia. ClinicalTrials.gov Identifier: NCT02738879.
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Affiliation(s)
- Ronan Roussel
- Diabetology Endocrinology Nutrition, Hôpital Bichat, DHU FIREAssistance Publique Hôpitaux de ParisParisFrance
- INSERM, U‐1138, Centre de Recherche des CordeliersParisFrance
- UFR de Médecine, Université Paris DiderotParisFrance
| | | | | | | | | | | | | | | | | | - Ira Gantz
- Merck & Co., Inc.KenilworthNew Jersey
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18
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Abstract
In the 1990s it was discovered that the enzyme dipeptidyl peptidase-4 (DPP-4) inactivates the incretin hormones glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP). DPP-4 inhibition results in raised levels of the two incretin hormones which in turn result in lowering of circulating glucose through stimulation of insulin secretion and inhibition of glucagon secretion. Since then, several small orally available molecules have been developed with DPP-4 inhibitory action. Early studies in the 1990s showed that the DPP-4 inhibitors improve glycemia in animals. Subsequent clinical studies during the 2000s showed a glucose-lowering action of DPP-4 inhibitors also in human subjects with type 2 diabetes. This action was seen when DPP-4 inhibitors were used both as monotherapy and as add-on to other therapies, i.e., metformin, sulfonylureas, tiazolidinediones or exogenous insulin. The DPP-4 inhibitors were also found to have a low risk of adverse events, including hypoglycemia. Five of the DPP-4 inhibitors (sitagliptin, vildagliptin, alogliptin, saxagliptin and linagliptin) were approved by regulatory authorities and entered the market between 2006 and 2013. DPP-4 inhibitors have thereafter undergone long-term cardiovascular outcome trials, showing non-inferiority for risk of major acute cardiovascular endpoints. Also the risk of other potential adverse events is low in these long-term studies. DPP-4 inhibitors are at present included in guidelines as a glucose-lowering concept both as monotherapy and in combination therapies. This article summarizes the development of the DPP-4 inhibition concept from its early stages in the 1990s. The article underscores that the development has its basis in scientific studies on pathophysiology of type 2 diabetes and the importance of targeting the islet dysfunction, that the development has been made possible through academic science in collaboration with the research-oriented pharmaceutical industry, and that the development of a novel concept takes time and requires focused efforts, persistence and long-term perserverance.
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19
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Wang N, Yang T, Li J, Zhang X. Dipeptidyl peptidase-4 inhibitors as add-on therapy to insulin in patients with type 2 diabetes mellitus: a meta-analysis of randomized controlled trials. Diabetes Metab Syndr Obes 2019; 12:1513-1526. [PMID: 31692532 PMCID: PMC6710543 DOI: 10.2147/dmso.s202024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 06/07/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Addition of the dipeptidyl peptidase-4 (DPP4) inhibitors to insulin in patients with type 2 diabetes mellitus (T2DM) may achieve better glycemic control. However, results of pilot randomized controlled trials (RCTs) are inconsistent. We aimed to perform a meta-analysis of RCTs to evaluate efficacy and safety of DPP4 inhibitors compared with placebo/no treatment as add-on therapy to insulin in T2DM patients. MATERIALS AND METHODS Relevant studies were identified via a search of PubMed, Cochrane Library, and Embase databases. A fixed or random effect model was applied according to the heterogeneity. RESULTS Overall, 22 RCTs with 6,957 T2DM patients were included. Addition of DPP4 inhibitors to insulin was associated with significantly reduced HbA1c as compared with controls (weighed mean difference [WMD]: -0.54%, p<0.001). The benefits of DPP4 inhibitors as add-on therapy on HbA1c were independent of study design, follow-up duration, categories of DPP4 inhibitors used, and using of fixed/adjustable insulin doses as indicated by predefined subgroup analyses. Moreover, addition of DPP4 inhibitors to insulin was associated with significantly reduced fasting blood glucose (WMD: -0.47mmol/L, p<0.001), postprandial glucose at 2 hrs (WMD: -2.03 mmol/L, p<0.001), and daily dose of insulin (WMD: -2.73U/d, p<0.001), while body weight (WMD: 0.02 g, p=0.81) or risk of symptomatic hypoglycemia (risk ratio: 0.92, p=0.37) were not affected. CONCLUSIONS Addition of DPP4 inhibitors to insulin significantly improved the glycemic control in T2DM patients without further increasing the risk of weight gain and hypoglycemia.
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Affiliation(s)
- Na Wang
- Department of Endocrinology, The Affiliated Hospital of Jining Medical University, Jining272000, People’s Republic of China
- Correspondence: Na WangDepartment of Endocrinology, The Affiliated Hospital of Jining Medical University, No. 89 Guhuai Road, Jining272000, People’s Republic of ChinaTel +86 0 537 290 3399Fax +86 0 537 290 3399Email
| | - Tao Yang
- The 4th Department of Psychiatry, Jining Psychiatric Hospital, Jining272000, People’s Republic of China
| | - Jie Li
- The 4th Department of Psychiatry, Jining Psychiatric Hospital, Jining272000, People’s Republic of China
| | - Xianfeng Zhang
- The 4th Department of Psychiatry, Jining Psychiatric Hospital, Jining272000, People’s Republic of China
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20
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Gomez-Peralta F, Abreu C, Gomez-Rodriguez S, Barranco RJ, Umpierrez GE. Safety and Efficacy of DPP4 Inhibitor and Basal Insulin in Type 2 Diabetes: An Updated Review and Challenging Clinical Scenarios. Diabetes Ther 2018; 9:1775-1789. [PMID: 30117055 PMCID: PMC6167285 DOI: 10.1007/s13300-018-0488-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Indexed: 12/18/2022] Open
Abstract
The safety and efficacy of dipeptidyl peptidase-4 (DPP4) inhibitors as monotherapy or in combination with other oral antidiabetic agents or basal insulin are well established. DPP4 inhibitors stimulate glucose-dependent insulin secretion and inhibit glucagon production. As monotherapy, they reduce the hemoglobin A1c level by about 0.6-0.8%. The addition of a DPP4 inhibitor to basal insulin is an attractive option, because they lower both postprandial and fasting plasma glucose concentrations without increasing the risk of hypoglycemia or weight gain. The present review summarizes the extensive evidence on the combination therapy of DPP4 inhibitors and insulin-based regimens in patients with type 2 diabetes. We focus our discussion on challenging clinical scenarios including patients with chronic renal impairment, elderly persons and hospitalized patients. The evidence indicates that these drugs are highly effective and safe in the elderly and in the presence of mild, moderate and severe renal failure improving glycemic control with low risk of hypoglycemia. In addition, several randomized-controlled trials have shown that the use of DPP4 inhibitors in combination with basal insulin represents an alternative to the basal-bolus insulin regimen in hospitalized patients with type 2 diabetes.
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Affiliation(s)
| | - Cristina Abreu
- Endocrinology and Nutrition Unit, Segovia General Hospital, Segovia, Spain
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21
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Goldenberg RM, Assimakopoulos P, Gilbert JD, Gottesman IS, Yale JF. A practical approach and algorithm for intensifying beyond basal insulin in type 2 diabetes. Diabetes Obes Metab 2018; 20:2064-2074. [PMID: 29707875 DOI: 10.1111/dom.13337] [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: 03/10/2018] [Revised: 04/09/2018] [Accepted: 04/24/2018] [Indexed: 11/29/2022]
Abstract
Despite the availability of long-term data demonstrating the benefits of timely and aggressive intensification of antihyperglycaemic regimens among individuals with type 2 diabetes, intensification beyond basal insulin continues to be suboptimal and a global challenge. This review summarizes the evidence surrounding the various options of advancing glucose-lowering management beyond basal insulin and provides a practical algorithm to assist in optimizing patient care and enhancing glycaemic target achievements.
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Affiliation(s)
| | - Peter Assimakopoulos
- Division of Endocrinology and Metabolism, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeremy D Gilbert
- Division of Endocrinology and Metabolism, Sunnybrook Health Sciences Centre, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Irving S Gottesman
- Trillium Health Partners, Credit Valley Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jean-François Yale
- Division of Endocrinology and Metabolism, McGill University Health Centre, McGill University and LMC Diabetes and Endocrinology, Montreal, Quebec, Canada
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Yang W, Cai X, Gao X, Chen Y, Chen L, Ji L. Addition of dipeptidyl peptidase-4 inhibitors to insulin treatment in type 2 diabetes patients: A meta-analysis. J Diabetes Investig 2018; 9:813-821. [PMID: 29047219 PMCID: PMC6031492 DOI: 10.1111/jdi.12764] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 09/25/2017] [Accepted: 10/09/2017] [Indexed: 12/30/2022] Open
Abstract
AIMS/INTRODUCTION To evaluate the efficacy and safety of combining insulin therapy with dipeptidyl peptidase-4 (DPP-4) inhibitors compared with combining insulin therapy with a placebo or other antihyperglycemic agents. MATERIALS AND METHODS A literature search was carried out via electronic databases. The inclusion criteria were randomized controlled trials comparing the addition of DPP-4 inhibitors to insulin with the addition of a placebo or other active hypoglycemic agents to insulin therapy, study duration of no less than 12 weeks carried out in type 2 diabetes patients and the availability of outcome data to evaluate a change in the glycated hemoglobin. RESULTS The glycated hemoglobin-lowering efficacy was significantly greater with DPP-4 inhibitor/insulin (DPP-4i/INS) than with placebo/insulin (weighted mean difference -0.53%, 95% confidence interval -0.63, -0.43, P < 0.01). The postprandial plasma glucose-lowering efficacies was also significantly greater with DPP-4i/INS than with placebo/insulin (weighted mean difference -1.65 mmol/L, 95% CI: -2.34, -0.96, P < 0.05). The risk of hypoglycemia or severe hypoglycemia was similar for DPP4i/INS and placebo/insulin treatments. There was no significant difference in the glycemia-lowering efficacy between DPP-4i/INS and alpha-glucosidase inhibitors/insulin, thiazolidinedione/insulin and glucagon-like peptide-1 receptor agonist/insulin. Sodium-glucose cotransporter 2 inhibitor/insulin treatment achieved better placebo-corrected efficacy in lowering postprandial plasma glucose, with less weight gain and no higher risk of hypoglycemia. CONCLUSIONS Treatment with DPP-4 inhibitors combined with insulin improved glycemic control without an increased risk of hypoglycemia or weight gain compared with insulin treatment alone.
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Affiliation(s)
- Wenjia Yang
- Endocrinology and Metabolism DepartmentPeking University People's HospitalBeijingChina
| | - Xiaoling Cai
- Endocrinology and Metabolism DepartmentPeking University People's HospitalBeijingChina
| | - Xueying Gao
- Endocrinology and Metabolism DepartmentPeking University People's HospitalBeijingChina
| | - Yifei Chen
- Endocrinology and Metabolism DepartmentPeking University People's HospitalBeijingChina
| | - Ling Chen
- Endocrinology and Metabolism DepartmentPeking University People's HospitalBeijingChina
| | - Linong Ji
- Endocrinology and Metabolism DepartmentPeking University People's HospitalBeijingChina
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Comparison of non-insulin antidiabetic agents as an add-on drug to insulin therapy in type 2 diabetes: a network meta-analysis. Sci Rep 2018; 8:4095. [PMID: 29511288 PMCID: PMC5840350 DOI: 10.1038/s41598-018-22443-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/20/2018] [Indexed: 12/22/2022] Open
Abstract
We aimed to evaluate the comparative efficacy and safety of dipeptidyl peptidase-4 inhibitors (DPP4i), glucagon-like peptide-1 receptor agonists (GLP-1RA), sodium-glucose co-transporter 2 inhibitors (SGLT2i), or thiazolidinedione (TZD) as an adjunctive treatment in patients with poorly controlled type 2 diabetes mellitus (T2DM) on insulin therapy. We searched Medline, Embase, the Cochrane Library, and ClinicalTrials.gov through April 2016. Bayesian network meta-analyses were performed with covariate adjustment. The primary outcome was the change in glycated hemoglobin A1c (HbA1c) from baseline. Fifty randomized controlled trials covering 15,494 patients were included. GLP-1RA showed the greatest HbA1c-lowering effect compared to the control (−0.84%; 95% credible interval, −1.00% to −0.69%), followed by TZD (−0.73%; −0.93 to −0.52%), SGLT2i (−0.66%; −0.84% to −0.48%), and DPP4i (−0.54%; −0.68% to −0.39%). SGLT2i showed the greatest fasting plasma glucose reduction. GLP-1RA and SGLT2i showed greater body weight reduction, whereas TZD increased body weight. TZD was ranked the highest in terms of insulin dose reduction. The risk of hypoglycemia was increased with TZD or GLP-1RA. The study provides the best available evidence on the comparative efficacy and safety of non-insulin anti-diabetic agents on top of pre-existing insulin therapy for inadequately controlled T2DM patients.
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Deacon CF. A review of dipeptidyl peptidase-4 inhibitors. Hot topics from randomized controlled trials. Diabetes Obes Metab 2018; 20 Suppl 1:34-46. [PMID: 29364584 DOI: 10.1111/dom.13135] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 10/19/2017] [Accepted: 10/19/2017] [Indexed: 12/20/2022]
Abstract
The first clinical study to investigate effects of dipeptidyl peptidase-4 (DPP-4) inhibition was published in 2002, and since then, numerous randomized controlled trials (RCTs) have shown that DPP-4 inhibitors are efficacious, safe and well-tolerated. This review will focus upon RCTs which have investigated DPP-4 inhibitors in patient groups which are often under-represented or excluded from typical phase 3 clinical trials. Large cardiovascular (CV) safety outcome trials in patients with established CV disease have confirmed that DPP-4 inhibitors are not associated with any additional CV risk in these already-at-high-risk individuals, while raising awareness of any uncommon adverse events, such as heart failure hospitalization seen in one of the trials. Studies in patients with kidney disease have shown DPP-4 inhibitors to be efficacious without increasing the risk of hypoglycaemia, irrespective of the degree of renal impairment, while data from the large CV trials as well as smaller RCTs have even pointed towards potential renoprotective effects such individuals. The use of DPP-4 inhibitors with insulin when therapy requires intensification may be beneficial without affecting the incidence or severity of hypoglycaemia, with these effects also being replicated in patients with chronic kidney disease, for whom other agents may not be suitable. Attention is now turning towards exploring the potential utility of DPP-4 inhibitors in other circumstances, including for in-hospital management of hyperglycaemia and in other metabolic disorders. Together, these RCTs raise the possibility that in the future, DPP-4 inhibitors may have a broader use which may extend beyond glycaemic control in the typical type 2 diabetes mellitus (T2DM) patient seen in general practice and may encompass conditions other than T2DM.
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Affiliation(s)
- Carolyn F Deacon
- Department of Biomedical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark
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Cai Y, Zeng T, Wen Z, Chen L. Ethnic Differences in Efficacy and Safety of Alogliptin: A Systematic Review and Meta-Analysis. Diabetes Ther 2018; 9:177-191. [PMID: 29264712 PMCID: PMC5801238 DOI: 10.1007/s13300-017-0352-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Alogliptin is a highly selective, potent, and orally available dipeptidyl peptidase-4 (DPP-4) inhibitor. This study compared the glucose-lowering efficacy and safety of alogliptin between Asian and non-Asian patients with type 2 diabetes. METHODS We systematically searched MEDLINE, EMBASE, Cochrane Library, and ISI Web of Science databases for articles published June 2017 and earlier in English. We identified randomized controlled trials (RCTs) of adults with type 2 diabetes that compared alogliptin with placebo as either monotherapy or add-on therapy. We divided subgroups by ethnicity, and compared the results of alogliptin use in Asian and non-Asian-dominant studies. RESULTS A total of 15 RCTs with 4456 patients with type 2 diabetes were included in this study. Alogliptin lowered glycated hemoglobin (HbA1c) to a much greater extent in Asian-dominant studies [- 0.75% (95% CI - 0.84 to - 0.65)] than in non-Asian-dominant studies [- 0.61% (95% CI - 0.68 to - 0.54)] (P = 0.02). The risk ratio of achieving HbA1c goal was larger in Asian-dominant studies [2.88 (95% CI 2.15-3.87)] than in non-Asian-dominant studies [1.93 (95% CI 1.55-2.41)] (P = 0.03). The postprandial blood glucose-lowering efficacy was higher in Asian-dominant studies [- 2.42 mmol/l (95% CI - 2.99 to - 1.85)] than in non-Asian-dominant studies [- 0.60 mmol/l (95% CI - 1.60 to 0.40)] (P = 0.002), while the fasting blood glucose and body weight changes were similar between the two subgroups. The incidence of adverse events, including hypoglycemia, nasopharyngitis, upper respiratory tract infection, headache, and diarrhea, were comparable between the two groups. CONCLUSIONS Alogliptin is more effective in improving glycemic levels in Asians than in other ethnic populations. Future studies are required to explore the potential mechanisms.
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Affiliation(s)
- Yuli Cai
- Department of Endocrinology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan, 430060, China
| | - Tianshu Zeng
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan, 430022, China
| | - Zhongyuan Wen
- Department of Endocrinology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan, 430060, China.
| | - Lulu Chen
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan, 430022, China.
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Umpierrez GE, Bailey TS, Carcia D, Shaefer C, Shubrook JH, Skolnik N. Improving postprandial hyperglycemia in patients with type 2 diabetes already on basal insulin therapy: Review of current strategies. J Diabetes 2018; 10:94-111. [PMID: 28581207 DOI: 10.1111/1753-0407.12576] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 05/02/2017] [Accepted: 05/21/2017] [Indexed: 11/28/2022] Open
Abstract
A large number of patients with type 2 diabetes (T2D) on basal insulin do not reach their HbA1c goals and require additional therapy to address postprandial hyperglycemia. Guidelines from expert bodies have outlined several approaches to accomplish postprandial glucose (PPG) control, and recent literature suggests several more. This article provides strategies for primary care physicians caring for patients with T2D who do not achieve glycemic control with basal insulin alone. Current treatment guidelines and strategies for improving PPG control are reviewed, including the efficacy, safety, and cost-effectiveness of rapid-acting insulin (RAI) analogs, premixed insulin, glucagon-like peptide-1 (GLP-1) receptor agonists (RAs), dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, and α-glucosidase inhibitors. Other approaches, such as combinations of newer basal insulin plus RAI and a fixed-ratio combination of basal insulin and a GLP-1 RA, are also described.
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Affiliation(s)
| | | | - Danielle Carcia
- Abington Hospital Jefferson Health, Abington, Pennsylvania, USA
| | | | | | - Neil Skolnik
- Abington Hospital Jefferson Health, Abington, Pennsylvania, USA
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Yale JF, Pettus JH, Brito-Sanfiel M, Lavalle-Gonzalez F, Merino-Trigo A, Stella P, Chevalier S, Buzzetti R. The effect of concomitant DPPIVi use on glycaemic control and hypoglycaemia with insulin glargine 300 U/mL (Gla-300) versus insulin glargine 100 U/mL (Gla-100) in people with type 2 diabetes: A patient-level meta-analysis of EDITION 2 and 3. PLoS One 2018; 13:e0190579. [PMID: 29370218 PMCID: PMC5784896 DOI: 10.1371/journal.pone.0190579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 12/14/2017] [Indexed: 11/23/2022] Open
Abstract
Aims To evaluate the effect of concomitant dipeptidyl peptidase IV inhibitor (DPPIVi) use on efficacy and safety of insulin glargine 300 U/mL (Gla-300) versus glargine 100 U/mL (Gla-100) in people with type 2 diabetes on oral antihyperglycaemic drugs. Methods A post hoc patient-level meta-analysis was performed using data from EDITION 2 (basal insulin [N = 811]) and EDITION 3 (insulin-naïve [N = 878]), multicentre, randomised, open-label, parallel-group, phase 3a trials of similar design. Endpoints analysed included HbA1c, hypoglycaemia and adverse events, investigated in subgroups of participants with and without concomitant DPPIVi use. Results Of 1689 participants randomised, 107 (13%, Gla-300) and 133 (16%, Gla-100) received DPPIVi therapy. The least squares mean change in HbA1c (baseline to month 6) was comparable between treatment groups, irrespective of DPPIVi use (no evidence of heterogeneity of treatment effect across subgroups, p = 0.753), although group sizes were unbalanced. The cumulative mean number of confirmed (≤3.9 mmol/L [≤70 mg/dL]) or severe hypoglycaemic events, and the risk and annualised rate of such events, were consistently lower for Gla-300 than Gla-100 during the night (between 00:00 and 05:59 h) or at any time of day (24 h period), irrespective of DPPIVi use. Severe hypoglycaemia occurred in 8/838 and 10/844 participants in the Gla-300 and Gla-100 groups, respectively, and was not affected by DPPIVi use. The adverse event profile was similar between treatment groups and DPPIVi subgroups. Conclusions Glycaemic control with Gla-300 was comparable to Gla-100, with less hypoglycaemia during the night and at any time of day (24 h), irrespective of concomitant DPPIVi use. Trial registration ClinicalTrials.gov NCT01499095; NCT01676220
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Affiliation(s)
| | - Jeremy Hodson Pettus
- Department of Endocrinology, University of California, San Diego, United States of America
| | | | | | | | | | | | - Raffaella Buzzetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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Barbot M, Ceccato F, Scaroni C. Diabetes Mellitus Secondary to Cushing's Disease. Front Endocrinol (Lausanne) 2018; 9:284. [PMID: 29915558 PMCID: PMC5994748 DOI: 10.3389/fendo.2018.00284] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/14/2018] [Indexed: 01/06/2023] Open
Abstract
Associated with important comorbidities that significantly reduce patients' overall wellbeing and life expectancy, Cushing's disease (CD) is the most common cause of endogenous hypercortisolism. Glucocorticoid excess can lead to diabetes, and although its prevalence is probably underestimated, up to 50% of patients with CD have varying degrees of altered glucose metabolism. Fasting glycemia may nevertheless be normal in some patients in whom glucocorticoid excess leads primarily to higher postprandial glucose levels. An oral glucose tolerance test should thus be performed in all CD patients to identify glucose metabolism abnormalities. Since diabetes mellitus (DM) is a consequence of cortisol excess, treating CD also serves to alleviate impaired glucose metabolism. Although transsphenoidal pituitary surgery remains the first-line treatment for CD, it is not always effective and other treatment strategies may be necessary. This work examines the main features of DM secondary to CD and focuses on antidiabetic drugs and how cortisol-lowering medication affects glucose metabolism.
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Efficacy of Saxagliptin versus Mitiglinid in patients with type 2 diabetes and end-stage renal disease. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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30
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Cardiovascular Safety of Dipeptidyl-Peptidase IV Inhibitors: A Meta-Analysis of Placebo-Controlled Randomized Trials. Am J Cardiovasc Drugs 2017; 17:143-155. [PMID: 27873238 DOI: 10.1007/s40256-016-0208-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Large randomized trials have shown conflicting evidence regarding the cardiovascular safety of dipeptidyl-peptidase 4 (DPP-4) inhibitors. Systematic reviews have been limited by incomplete data and inclusion of observational studies. This study aimed to systematically evaluate the cardiovascular safety of DPP-4 inhibitors in patients with type 2 diabetes. METHODS Electronic databases were searched for randomized trials that compared DPP-4 inhibitors versus placebo and reported cardiovascular outcomes. The main outcome assessed in this analysis was heart failure. Other outcomes included all-cause mortality, cardiovascular mortality, myocardial infarction, and ischemic stroke. Summary odds ratios (ORs) were primarily constructed using Peto's model. RESULTS A total of 90 trials with 66,730 patients were included. Compared with placebo, DPP-4 inhibitors were associated with a non-significant increased risk of heart failure [OR 1.11, 95% confidence interval (CI) 0.99-1.25, P = 0.07] at a mean of 108 weeks. The risk of all-cause mortality (OR 1.03, 95% CI 0.94-1.12, P = 0.53), cardiovascular mortality (OR 1.02, 95% CI 0.92-1.14, P = 0.72), myocardial infarction (OR 0.98, 95% CI 0.88-1.09, P = 0.69), and ischemic stroke (OR 0.99, 95% CI 0.85-1.15, P = 0.92) was similar between both groups. CONCLUSION In patients with type 2 diabetes, the safety profile of DPP-4 inhibitors is similar to placebo. As a class, there is only weak evidence for an increased risk of heart failure.
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Pan C, Han P, Ji Q, Li C, Lu J, Yang J, Li W, Zeng J, Hsieh AT, Chan J. Efficacy and safety of alogliptin in patients with type 2 diabetes mellitus: A multicentre randomized double-blind placebo-controlled Phase 3 study in mainland China, Taiwan, and Hong Kong. J Diabetes 2017; 9:386-395. [PMID: 27171508 DOI: 10.1111/1753-0407.12425] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 04/18/2016] [Accepted: 05/06/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND This study determined the efficacy and safety of once-daily oral alogliptin in patients from mainland China, Taiwan, and Hong Kong with type 2 diabetes mellitus. METHODS In this Phase 3 multicenter double-blind placebo-controlled 16-week trial, 506 patients were randomized to receive once-daily alogliptin 25 mg or placebo: 185 in the monotherapy group, 197 in the add-on to metformin group, and 124 in the add-on to pioglitazone group. The primary efficacy variable was the change from baseline (CFB) in HbA1c at Week 16; other efficacy measures included CFB to Week 16 in fasting plasma glucose (FPG), incidence of marked hyperglycemia (FPG ≥11.1 mmol/L), and the incidence of clinical HbA1c ≤6.5 % (48 mmol/mol) and ≤7.0 % (53 mmol/mol) at Week 16. Safety was assessed throughout the trial. RESULTS Alogliptin monotherapy provided a significantly greater decrease in HbA1c from baseline to Week 16 compared with placebo (-0.58 %; 95 % confidence interval [CI] -0.78 %, -0.37 %; P < 0.001). As an add-on to metformin or pioglitazone, alogliptin also significantly decreased HbA1c compared with placebo (-0.69 % [95 % CI -0.87 %, -0.51 %; P < 0.001] and -0.52 % [95 % CI -0.75 %, -0.28 %; P < 0.001], respectively). In any treatment group versus placebo, alogliptin led to greater decreases in FPG (P ≤ 0.004) and a higher percentage of patients who achieved an HbA1c target of ≤6.5 % and ≤7.0 % (P ≤ 0.003). No weight gain was observed in any treatment group. A similar percentage of patients experienced drug-related, treatment-emergent adverse events in the alogliptin and placebo arms. Four and two patients in the alogliptin and placebo arms, respectively, experienced mild or moderate hypoglycemia. CONCLUSIONS Alogliptin 25 mg once daily reduced HbA1c and FPG and enhanced clinical response compared with placebo when used as monotherapy or as an add-on to metformin or pioglitazone. Therapy with alogliptin was well tolerated.
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Affiliation(s)
- Changyu Pan
- The General Hospital of the People's Liberation Army, Beijing, China
| | - Ping Han
- Shengjing Hospital of China Medical University, Shenyang, China
| | - Qiuhe Ji
- The First Affiliated Hospital of the Fourth Military Medical University, Xi'an, China
| | - Chengjiang Li
- First Affiliated Hospital Zhejiang University College of Medicine, Hangzhou, China
| | - Juming Lu
- The General Hospital of the People's Liberation Army, Beijing, China
| | | | - Wenhui Li
- Peking Union Medical College Hospital, Beijing, China
| | - Jiaoe Zeng
- Affiliated Jingzhou Hospital Tongji Medical School, Wuhan, China
| | - An-Tsz Hsieh
- Taipei Medical University Shuang Ho Hospital, Taipei, Taiwan
| | - Juliana Chan
- The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, SAR, China
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Raccah D. Basal insulin treatment intensification in patients with type 2 diabetes mellitus: A comprehensive systematic review of current options. DIABETES & METABOLISM 2017; 43:110-124. [PMID: 28169086 DOI: 10.1016/j.diabet.2016.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/27/2016] [Accepted: 11/08/2016] [Indexed: 12/16/2022]
Abstract
AIM As type 2 diabetes mellitus progresses, most patients require treatment with basal insulin in combination with another agent to achieve recommended glycaemic targets. The purpose of this systematic review was to examine the evidence supporting the use of the available add-on treatments [rapid-acting insulin (RAI), glucagon-like peptide-1 receptor agonists (GLP-1 RAs), dipeptidyl peptidase (DPP)-4 inhibitors and sodium-glucose cotransporter-2 (SGLT-2) inhibitors] to basal insulin. METHODS MEDLINE, EMBASE and EBSCOhost were searched for English-language articles, and all those captured were original articles (case studies and narrative reviews were omitted). Data on study design, population demographics, interventions and outcomes were tabulated. The extracted outcome data included changes in glycated haemoglobin (HbA1c), fasting plasma glucose (FPG) and postprandial plasma glucose (PPG), as well as body weight and safety data. RESULTS A total of 88 publications were deemed relevant. All treatments reduced HbA1c and FPG. The most pronounced reductions in PPG, an unmet need in patients not controlled by basal insulin, were seen following administration of RAIs and short-acting GLP-1 RAs, although data for this outcome are generally lacking. Body weight benefits were observed with GLP-1 RAs and SGLT-2 inhibitors. However, as only articles in English were included, the result was a possible publication bias, while the diversity of study designs and drug combinations limited comparisons between studies. CONCLUSION The evidence supports effectiveness of the available add-on treatments to basal insulin. However, other factors, such as potential body-weight increases, convenience/compliance and adverse events, particularly hypoglycaemia, should be considered on a patient-by-patient basis to optimalize treatment outcomes.
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Affiliation(s)
- D Raccah
- Department of Diabetology, University Hospital Sainte-Marguerite, Marseille, France.
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Dipeptidyl peptidase-4 inhibitors and protection against stroke: A systematic review and meta-analysis. DIABETES & METABOLISM 2017; 43:1-8. [DOI: 10.1016/j.diabet.2016.10.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 10/19/2016] [Accepted: 10/21/2016] [Indexed: 12/17/2022]
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Mita T, Katakami N, Shiraiwa T, Yoshii H, Kuribayashi N, Osonoi T, Kaneto H, Kosugi K, Umayahara Y, Gosho M, Shimomura I, Watada H. Relationship between frequency of hypoglycemic episodes and changes in carotid atherosclerosis in insulin-treated patients with type 2 diabetes mellitus. Sci Rep 2017; 7:39965. [PMID: 28067320 PMCID: PMC5220284 DOI: 10.1038/srep39965] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 11/29/2016] [Indexed: 11/18/2022] Open
Abstract
The effect of hypoglycemia on the progression of atherosclerosis in patients with type 2 diabetes mellitus (T2DM) remains largely unknown. This is a post hoc analysis of a randomized trial to investigate the relationship between hypoglycemic episodes and changes in carotid intima-media thickness (IMT). Among 274 study subjects, 104 patients experienced hypoglycemic episodes. Increases in the mean IMT and left maximum IMT of the common carotid arteries (CCA) were significantly greater in patients with hypoglycemia compared to those without hypoglycemia. Classification of the patients into three groups according to the frequency of hypoglycemic episodes showed that high frequency of hypoglycemic events was associated with increases in mean IMT-CCA, and left max-IMT-CCA and right max-IMT-CCA. In addition, repetitive episodes of hypoglycemia were associated with a reduction in the beneficial effects of sitagliptin on carotid IMT. Our data suggest that frequency of hypoglycemic episodes was associated with changes in carotid atherosclerosis.
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Affiliation(s)
- Tomoya Mita
- Department of Metabolism &Endocrinology, Juntendo University Graduate School of Medicine, Hongo 2-1-1, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Naoto Katakami
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan.,Department of Metabolism and Atherosclerosis, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Toshihiko Shiraiwa
- Shiraiwa Medical Clinic, 4-10-24 Houzenji, Kashiwara, Osaka 582-0005, Japan
| | - Hidenori Yoshii
- Department of Medicine, Diabetology &Endocrinology, Juntendo Tokyo Koto Geriatric Medical Center, Shinsuna 3-3-20, Koto-ku, Tokyo 136-0075, Japan
| | | | - Takeshi Osonoi
- Naka Memorial Clinic, 745-5, Nakadai, Naka City, Ibaraki 311-0113, Japan
| | - Hideaki Kaneto
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Keisuke Kosugi
- Osaka Police Hospital, 10-31 Kitayamacho, Tennoji-ku, Osaka 543-0035, Japan
| | - Yutaka Umayahara
- Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka 558-8558, Japan
| | - Masahiko Gosho
- Department of Clinical Trial and Clinical Epidemiology, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Iichiro Shimomura
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Hirotaka Watada
- Department of Metabolism &Endocrinology, Juntendo University Graduate School of Medicine, Hongo 2-1-1, Bunkyo-ku, Tokyo 113-8421, Japan
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Verma S, Goldenberg RM, Bhatt DL, Farkouh ME, Quan A, Teoh H, Connelly KA, Leiter LA, Friedrich JO. Dipeptidyl peptidase-4 inhibitors and the risk of heart failure: a systematic review and meta-analysis. CMAJ Open 2017; 5:E152-E177. [PMID: 28459046 PMCID: PMC5403656 DOI: 10.9778/cmajo.20160058] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Given recent discrepant results from randomized controlled trials (RCTs), we examined the totality of RCT evidence assessing the association between dipeptidyl peptidase-4 (DPP-4) inhibitors and heart failure. METHODS MEDLINE, Embase and ClinicalTrials.gov were searched without language restrictions to August 2016 for RCTs comparing DPP-4 inhibitors to placebo or no therapy for a period of 24 weeks or more. We included all heart failure outcomes when listed either as a serious adverse event or adverse event. Pooled analyses used random-effects. RESULTS We identified 100 RCTs (n = 79 867) - 3 large cardiovascular-safety RCTs (SAVOR-TIMI 53[saxagliptin]/n = 16 492, EXAMINE[alogliptin]/n = 5380, and TECOS[sitagliptin]/n = 14 735), and 97 smaller RCTs with a primary outcome that was usually change in glycated hemoglobin. Virtually all RCTs were high-quality, multicentre, placebo-controlled trials. A total of 96% (1192/1244) of heart failure events were prespecified, blindly adjudicated and required hospital admission. Pooled results suggested a 13% increase in heart failure (relative risk [RR] 1.13, 95% confidence interval [CI] 1.01-1.26, I2 = 0%; 32 RCTs, n = 54 640, 1244 events). When including only the 3 large RCTs, the increase was similar, but not significant (RR 1.14, 95% CI 0.97-1.32; 3 RCTs, n = 36 543, 1169 adjudicated events; number needed to harm 246) owing to heterogeneity (I2 = 42%), which lead to wider CIs, because SAVOR-TIMI 53 showed increased heart failure (RR 1.26, 95% CI 1.06-1.49) and TECOS showed no effect (RR 1.00, 95% CI 0.83-1.19). INTERPRETATION Despite pooled data from 79 867 patients, whether DPP-4 inhibitors increase heart failure overall or exhibit within-class differences remains unresolved. Our results highlight the importance of ongoing trials that are comparing DPP-4 inhibitors to placebo, although no large cardiovascular-safety RCTs are comparing different DPP-4 inhibitors to each other; consequently, these will address the overall but not class-difference question.
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Affiliation(s)
- Subodh Verma
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Ronald M Goldenberg
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Deepak L Bhatt
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Michael E Farkouh
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Adrian Quan
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Hwee Teoh
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Kim A Connelly
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Lawrence A Leiter
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Jan O Friedrich
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
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36
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Min SH, Yoon JH, Hahn S, Cho YM. Comparison between SGLT2 inhibitors and DPP4 inhibitors added to insulin therapy in type 2 diabetes: a systematic review with indirect comparison meta-analysis. Diabetes Metab Res Rev 2017; 33. [PMID: 27155214 DOI: 10.1002/dmrr.2818] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 04/21/2016] [Accepted: 04/28/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Both sodium glucose cotransporter 2 (SGLT2) inhibitors and dipeptidyl peptidase-4 (DPP4) inhibitors can be used to treat patients with type 2 diabetes mellitus (T2DM) that is inadequately controlled with insulin therapy, and yet there has been no direct comparison of these two inhibitors. METHODS We searched MEDLINE, EMBASE, LILACS, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov through June 2015. Randomized controlled trials published in English that compare SGLT2 inhibitor plus insulin (SGLT2i/INS) with placebo plus insulin or DPP4 inhibitor plus insulin (DPP4i/INS) with placebo plus insulin in patients with T2DM were selected. Data on the study characteristics, efficacy and safety outcomes were extracted. We compared the efficacy and safety between SGLT2i/INS and DPP4i/INS indirectly with covariates adjustment. Risk of potential bias was assessed. RESULTS Fourteen eligible randomized controlled trials comprising 6980 patients were included (five SGLT2 inhibitor studies and nine DPP4 inhibitor studies). Covariate-adjusted indirect comparison using meta-regression analyses revealed that SGLT2i/INS achieved greater reduction in HbA1c [weighted mean difference (WMD) -0.24%, 95% confidence interval (CI) -0.43 to -0.05%], fasting plasma glucose (WMD -18.0 mg/dL, 95% CI -28.5 to -7.6 mg/dL) and body weight (WMD -2.38 kg, 95% CI -3.18 to -1.58 kg) from baseline than DPP4i/INS without increasing the risk of hypoglycaemia (relative risks 1.19, 95% CI 0.78 to 1.82). CONCLUSIONS Sodium glucose cotransporter 2 inhibitors achieved better glycaemic control and greater weight reduction than DPP4 inhibitors without increasing the risk of hypoglycaemia in patients with T2DM that is inadequately controlled with insulin. There has been no direct comparison of SGLT2 inhibitors and DPP4 inhibitors in patients with T2DM inadequately controlled with insulin therapy. In this study, we performed indirect meta-analysis comparing SGLT2 inhibitors and DPP4 inhibitors added to insulin therapy. Without increasing hypoglycaemia, SGLT2 inhibitors showed better glycaemic control and greater weight reduction than DPP4 inhibitors in patients with T2DM inadequately controlled with insulin. The results of the current study could serve as the best available evidence in selecting oral agents to improve glycaemic control in insulin-treated T2DM patients. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Se Hee Min
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Jeong-Hwa Yoon
- Interdisciplinary Program in Medical Informatics, Seoul National University College of Medicine, Seoul, South Korea
| | - Seokyung Hahn
- Department of Medicine, Seoul National University College of Medicine/Biostatistics Division of Medical Research Collaborating Center, Seoul National University Hospital, Seoul, South Korea
| | - Young Min Cho
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
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Wang H, Liu X, Long M, Huang Y, Zhang L, Zhang R, Zheng Y, Liao X, Wang Y, Liao Q, Li W, Tang Z, Tong Q, Wang X, Fang F, Rojo de la Vega M, Ouyang Q, Zhang DD, Yu S, Zheng H. NRF2 activation by antioxidant antidiabetic agents accelerates tumor metastasis. Sci Transl Med 2016; 8:334ra51. [PMID: 27075625 DOI: 10.1126/scitranslmed.aad6095] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 02/18/2016] [Indexed: 12/18/2022]
Abstract
Cancer is a common comorbidity of diabetic patients; however, little is known about the effects that antidiabetic drugs have on tumors. We discovered that common classes of drugs used in type 2 diabetes mellitus, the hypoglycemic dipeptidyl peptidase-4 inhibitors (DPP-4i) saxagliptin and sitagliptin, as well as the antineuropathic α-lipoic acid (ALA), do not increase tumor incidence but increase the risk of metastasis of existing tumors. Specifically, these drugs induce prolonged activation of the nuclear factor E2-related factor 2 (NRF2)-mediated antioxidant response through inhibition of KEAP1-C151-dependent ubiquitination and subsequent degradation of NRF2, resulting in up-regulated expression of metastasis-associated proteins, increased cancer cell migration, and promotion of metastasis in xenograft mouse models. Accordingly, knockdown of NRF2 attenuated naturally occurring and DPP-4i-induced tumor metastasis, whereas NRF2 activation accelerated metastasis. Furthermore, in human liver cancer tissue samples, increased NRF2 expression correlated with metastasis. Our findings suggest that antioxidants that activate NRF2 signaling may need to be administered with caution in cancer patients, such as diabetic patients with cancer. Moreover, NRF2 may be a potential biomarker and therapeutic target for tumor metastasis.
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Affiliation(s)
- Hui Wang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Xiufei Liu
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Min Long
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Yi Huang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Key Laboratory of Immunity and Infectious Diseases, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Linlin Zhang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Rui Zhang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Yi Zheng
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Xiaoyu Liao
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Yuren Wang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Qian Liao
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Wenjie Li
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Zili Tang
- Molecular and Translational Radiation Oncology, Heidelberg Ion Therapy Center, Heidelberg Institute of Radiation Oncology, University of Heidelberg Medical School, National Center for Cancer Diseases, German Cancer Research Center, Heidelberg 69120, Germany
| | - Qiang Tong
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Xiaocui Wang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Fang Fang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Montserrat Rojo de la Vega
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Arizona, Tucson, AZ 85721, USA
| | - Qin Ouyang
- College of Pharmacy, Third Military Medical University, Chongqing 400038, China
| | - Donna D Zhang
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Arizona, Tucson, AZ 85721, USA.
| | - Shicang Yu
- Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University, Chongqing 400038, China.
| | - Hongting Zheng
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China.
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38
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Chen XW, He ZX, Zhou ZW, Yang T, Zhang X, Yang YX, Duan W, Zhou SF. An update on the clinical pharmacology of the dipeptidyl peptidase 4 inhibitor alogliptin used for the treatment of type 2 diabetes mellitus. Clin Exp Pharmacol Physiol 2016. [PMID: 26218204 DOI: 10.1111/1440-1681.12469] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Alogliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor that is a class of relatively new oral hypoglycaemic drugs used in patients with type 2 diabetes (T2DM), can be used as monotherapy or in combination with other anti-diabetic agents, including metformin, pioglitazone, sulfonylureas and insulin with a considerable therapeutic effect. Alogliptin exhibits favorable pharmacokinetic and pharmacodynamic profiles in humans. Alogliptin is mainly metabolized by cytochrome P450 (CYP2D6) and CYP3A4. Dose reduction is recommended for patients with moderate or worse renal impairment. Side effects of alogliptin include nasopharyngitis, upper-respiratory tract infections and headache. Hypoglycaemia is seen in about 1.5% of the T2DM patients. Rare but severe adverse reactions such as acute pancreatitis, serious hypersensitivity including anaphylaxis, angioedema and severe cutaneous reactions such as Stevens-Johnson syndrome have been reported from post-marketing monitoring. Pharmacokinetic interactions have not been observed between alogliptin and other drugs including glyburide, metformin, pioglitazone, insulin and warfarin. The present review aimed to update the clinical information on pharmacodynamics, pharmacokinetics, adverse effects and drug interactions, and to discuss the future directions of alogliptin.
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Affiliation(s)
- Xiao-Wu Chen
- Department of General Surgery, The First People's Hospital of Shunde, Southern Medical University, Shunde, Foshan, Guangdong, China
| | - Zhi-Xu He
- Guizhou Provincial Key Laboratory for Regenerative Medicine, Stem Cell and Tissue Engineering Research Center & Sino-US Joint Laboratory for Medical Sciences, Guiyang Medical University, Guiyang, Guizhou, China
| | - Zhi-Wei Zhou
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL, USA
| | - Tianxin Yang
- Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Xueji Zhang
- Research Center for Bioengineering and Sensing Technology, University of Science and Technology Beijing, Beijing, China
| | - Yin-Xue Yang
- Department of Colorectal Surgery, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Wei Duan
- School of Medicine, Deakin University, Waurn Ponds, Vic., Australia
| | - Shu-Feng Zhou
- Guizhou Provincial Key Laboratory for Regenerative Medicine, Stem Cell and Tissue Engineering Research Center & Sino-US Joint Laboratory for Medical Sciences, Guiyang Medical University, Guiyang, Guizhou, China.,Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL, USA
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An update on the 'gliptins'. Drug Ther Bull 2016; 54:138-141. [PMID: 27979881 DOI: 10.1136/dtb.2016.12.0442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Progressive impairment of insulin secretion in people with type 2 diabetes leads to blood glucose concentrations worsening over time, often resulting in escalation of blood glucose lowering therapy.1 In 2015/2016, more money was spent on dipeptidyl peptidase-4 (DPP-4) inhibitors ('gliptins') than on any other class of antidiabetic drug except for insulins.2 In 2008, we reviewed sitagliptin and vildagliptin.3 Here, we briefly review three other DPP-4 inhibitors, saxagliptin (Onglyza-AstraZeneca), linagliptin (Trajenta-Boehringer Ingelheim) and ▼alogliptin (Vipidia-Takeda), and consider data from recent cardiovascular outcomes studies.
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40
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Physiological aspects of the combination of insulin and GLP-1 in the regulation of blood glucose control. DIABETES & METABOLISM 2016; 41:6S3-6S8. [PMID: 26774018 DOI: 10.1016/s1262-3636(16)30002-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Combining insulin with glucagon-like peptide-1 (GLP-1) receptor agonists or dipeptidyl peptidase-4 (DPP-4) inhibitors as glucose-lowering therapy for type 2 diabetes is a promising strategy that has gained considerable interest over the past few years. One advantage of this combination is the complementary mechanistic actions of insulin and GLP-1. Insulin increases glucose utilization and retards hepatic glucose production through direct actions in muscle, adipose tissue and the liver. On the other hand, GLP-1 stimulates insulin secretion, inhibits glucagon secretion and retards gastric emptying. Combining these effects results in powerful reductions in both fasting and postprandial glucose through diminished glucose entry into the bloodstream after food consumption, reduced hepatic production of glucose and increased glucose utilization. In addition, GLP-1 receptor agonists induce satiety, leading to decreases in food intakes and body weight, thereby preventing the weight gain often seen with insulin therapy. Clinical trials have verified that these physiological effects as a result of combining insulin with GLP-1 receptor agonists or DPP-4 inhibitors can indeed result in improved glycaemia, with limited risks of hypoglycaemia and weight gain.
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41
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Wang T, Wang F, Zhou J, Tang H, Giovenale S. Adverse effects of incretin-based therapies on major cardiovascular and arrhythmia events: meta-analysis of randomized trials. Diabetes Metab Res Rev 2016; 32:843-857. [PMID: 27037787 DOI: 10.1002/dmrr.2804] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 02/29/2016] [Accepted: 03/15/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Recent cardiovascular outcome trials of incretin-based therapies (IBT) in type 2 diabetes have not demonstrated either benefit or harm in terms of major adverse cardiovascular events (MACE). Earlier meta-analyses showed conflicting results but were limited in methodology. We aimed to perform an updated meta-analysis of all available incretin therapies on the incidence of MACE plus arrhythmia and heart failure. METHODS We identified studies published through November 2014 by searching electronic databases and reference lists. We included RCTs in which the intervention group received incretin-based therapies and the control group received placebo or standard treatment; enrolled >100 participants in each group; interventions lasted >24 weeks; and reported data on one or more primary major adverse cardiovascular events endpoints plus terms for arrhythmia and heart failure. We used the Peto method for each CV event for individual IBT treatment. RESULTS In this meta-analysis of 100 RCTs involving 54,758 incretin-based therapies users and 48,175 controls, exenatide was associated with increased risk of arrhythmia (OR 2.83; 95% CI, 1.06-7.57); saxagliptin was associated with an increased risk of heart failure (OR 1.23; 95% CI, 1.03-1.46), and sitagliptin was associated with a significantly decreased risk of all cause death compared to active controls (OR 0.39, 95% CI 0.18-0.82). CONCLUSIONS In type 2 diabetes, exenatide may increase the risk of arrhythmia, and sitagliptin may reduce the risk of all cause death; however, the subgroup of patients most likely to experience harm or benefit is unclear. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Tiansheng Wang
- Department of Pharmacy Administration and Clinical Pharmacy, Peking University Health Science Center, Beijing, China
| | - Fei Wang
- Department of Pharmacy Practice, University of Connecticut, Storrs, CT, USA.
| | - Junwen Zhou
- Department of Pharmacy Administration and Clinical Pharmacy, Peking University Health Science Center, Beijing, China
| | - Huilin Tang
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA
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Yabe D, Seino Y. Alogliptin for the treatment of type 2 diabetes: a drug safety evaluation. Expert Opin Drug Saf 2016; 15:249-64. [PMID: 26607297 DOI: 10.1517/14740338.2016.1125467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Dipeptidyl peptidase-4 (DPP-4) inhibitors such as alogliptin are becoming more widely established as treatment options for patients with type 2 diabetes (T2DM) because of their ability to improve glycemic control without increasing the risk of hypoglycemia or weight gain. New therapies with improved safety profiles are needed, especially because of the chronic and progressive nature of T2DM. AREAS COVERED In this article, the overall safety and tolerability of alogliptin are evaluated based upon a review of the literature. In particular, adverse events (AEs) that have been of interest for the DPP-4 class of drugs, such as the risk of major cardiovascular (CV) events and acute pancreatitis, will be investigated in detail. EXPERT OPINION Alogliptin is generally well-tolerated in a broad range of patient populations including different ethnic groups and the elderly. In the pivotal EXAMINE clinical trial, alogliptin was found not to be associated with an increased risk of major CV events or acute pancreatitis/pancreatic cancer.
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Affiliation(s)
- Daisuke Yabe
- a Yutaka Seino Distinguished Center for Diabetes Research , Kansai Electric Power Medical Research Institute , Kobe , Japan.,b Center for Diabetes, Endocrinology and Metabolism , Kansai Electric Power Hospital , Osaka , Japan.,c Center for Clinical Nutrition and Metabolism , Kansai Electric Power Hospital , Osaka , Japan
| | - Yutaka Seino
- a Yutaka Seino Distinguished Center for Diabetes Research , Kansai Electric Power Medical Research Institute , Kobe , Japan.,b Center for Diabetes, Endocrinology and Metabolism , Kansai Electric Power Hospital , Osaka , Japan
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Kim SH, Yoo JH, Lee WJ, Park CY. Gemigliptin: An Update of Its Clinical Use in the Management of Type 2 Diabetes Mellitus. Diabetes Metab J 2016; 40:339-353. [PMID: 27766241 PMCID: PMC5069390 DOI: 10.4093/dmj.2016.40.5.339] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 07/28/2016] [Indexed: 12/13/2022] Open
Abstract
Dipeptidyl peptidase-4 (DPP-4) inhibitors are a new class of oral antidiabetic agent for the treatment of type 2 diabetes mellitus. They increase endogenous levels of incretin hormones, which stimulate glucose-dependent insulin secretion, decrease glucagon secretion, and contribute to reducing postprandial hyperglycemia. Although DPP-4 inhibitors have similar benefits, they can be differentiated in terms of their chemical structure, pharmacology, efficacy and safety profiles, and clinical considerations. Gemigliptin (brand name: Zemiglo), developed by LG Life Sciences, is a potent, selective, competitive, and long acting DPP-4 inhibitor. Various studies have shown that gemigliptin is an optimized DPP-4 inhibitor in terms of efficacy, safety, and patient compliance for treatment of type 2 diabetes mellitus. In this review, we summarize the characteristics of gemigliptin and discuss its potential benefits in clinical practice.
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Affiliation(s)
- Sung-Ho Kim
- LG Life Sciences Ltd., R&D Park, Daejeon, Korea
| | | | - Woo Je Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Cheol-Young Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Vos RC, van Avendonk MJP, Jansen H, Goudswaard ANN, van den Donk M, Gorter K, Kerssen A, Rutten GEHM. Insulin monotherapy compared with the addition of oral glucose-lowering agents to insulin for people with type 2 diabetes already on insulin therapy and inadequate glycaemic control. Cochrane Database Syst Rev 2016; 9:CD006992. [PMID: 27640062 PMCID: PMC6457595 DOI: 10.1002/14651858.cd006992.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND It is unclear whether people with type 2 diabetes mellitus on insulin monotherapy who do not achieve adequate glycaemic control should continue insulin as monotherapy or can benefit from adding oral glucose-lowering agents to the insulin therapy. OBJECTIVES To assess the effects of insulin monotherapy compared with the addition of oral glucose-lowering agents to insulin monotherapy for people with type 2 diabetes already on insulin therapy and inadequate glycaemic control. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and reference lists of articles. The date of the last search was November 2015 for all databases. SELECTION CRITERIA Randomised controlled clinical trials of at least two months' duration comparing insulin monotherapy with combinations of insulin with one or more oral glucose-lowering agent in people with type 2 diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed risk of bias, extracted data and evaluated overall quality of the evidence using GRADE. We summarised data statistically if they were available, sufficiently similar and of sufficient quality. We performed statistical analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We included 37 trials with 40 treatment comparisons involving 3227 participants. The duration of the interventions ranged from 2 to 12 months for parallel trials and two to four months for cross-over trials.The majority of trials had an unclear risk of bias in several risk of bias domains. Fourteen trials showed a high risk of bias, mainly for performance and detection bias. Insulin monotherapy, including once-daily long-acting, once-daily intermediate-acting, twice-daily premixed insulin, and basal-bolus regimens (multiple injections), was compared to insulin in combination with sulphonylureas (17 comparisons: glibenclamide = 11, glipizide = 2, tolazamide = 2, gliclazide = 1, glimepiride = 1), metformin (11 comparisons), pioglitazone (four comparisons), alpha-glucosidase inhibitors (four comparisons: acarbose = 3, miglitol = 1), dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors) (three comparisons: vildagliptin = 1, sitagliptin = 1, saxagliptin = 1) and the combination of metformin and glimepiride (one comparison). No trials assessed all-cause mortality, diabetes-related morbidity or health-related quality of life. Only one trial assessed patients' treatment satisfaction and showed no substantial differences between the addition of either glimepiride or metformin and glimepiride to insulin compared with insulin monotherapy.Insulin-sulphonylurea combination therapy (CT) compared with insulin monotherapy (IM) showed a MD in glycosylated haemoglobin A1c (HbA1c) of -1% (95% confidence interval (CI) -1.6 to -0.5); P < 0.01; 316 participants; 9 trials; low-quality evidence. Insulin-metformin CT compared with IM showed a MD in HbA1c of -0.9% (95% CI -1.2 to -0.5); P < 0.01; 698 participants; 9 trials; low-quality evidence. We could not pool the results of adding pioglitazone to insulin. Insulin combined with alpha-glucosidase inhibitors compared with IM showed a MD in HbA1c of -0.4% (95% CI -0.5 to -0.2); P < 0.01; 448 participants; 3 trials; low-quality evidence). Insulin combined with DPP-4 inhibitors compared with IM showed a MD in HbA1c of -0.4% (95% CI -0.5 to -0.4); P < 0.01; 265 participants; 2 trials; low quality evidence. In most trials the participants with CT needed less insulin, whereas insulin requirements increased or remained stable in participants with IM.We did not perform a meta-analysis for hypoglycaemic events because the included studies used different definitions.. In most trials the insulin-sulphonylurea combination resulted in a higher number of mild episodes of hypoglycaemia, compared to the IM group (range: 2.2 to 6.1 episodes per participant in CT versus 2.0 to 2.6 episodes per participant in IM; low-quality evidence). Pioglitazone CT also resulted in more mild to moderate hypoglycaemic episodes compared with IM (range 15 to 90 episodes versus 9 to 75 episodes, respectively; low-quality evidence. The trials that reported hypoglycaemic episodes in the other combinations found comparable numbers of mild to moderate hypoglycaemic events (low-quality evidence).The addition of sulphonylureas resulted in an additional weight gain of 0.4 kg to 1.9 kg versus -0.8 kg to 2.1 kg in the IM group (220 participants; 7 trials; low-quality evidence). Pioglitazone CT caused more weight gain compared to IM: MD 3.8 kg (95% CI 3.0 to 4.6); P < 0.01; 288 participants; 2 trials; low-quality evidence. Metformin CT was associated with weight loss: MD -2.1 kg (95% CI -3.2 to -1.1), P < 0.01; 615 participants; 7 trials; low-quality evidence). DPP-4 inhibitors CT showed weight gain of -0.7 to 1.3 kg versus 0.6 to 1.1 kg in the IM group (362 participants; 2 trials; low-quality evidence). Alpha-glucosidase CT compared to IM showed a MD of -0.5 kg (95% CI -1.2 to 0.3); P = 0.26; 241 participants; 2 trials; low-quality evidence.Users of metformin CT (range 7% to 67% versus 5% to 16%), and alpha-glucosidase inhibitors CT (14% to 75% versus 4% to 35%) experienced more gastro-intestinal adverse effects compared to participants on IM. Two trials reported a higher frequency of oedema with the use of pioglitazone CT (range: 16% to 18% versus 4% to 7% IM). AUTHORS' CONCLUSIONS The addition of all oral glucose-lowering agents in people with type 2 diabetes and inadequate glycaemic control who are on insulin therapy has positive effects on glycaemic control and insulin requirements. The addition of sulphonylureas results in more hypoglycaemic events. Additional weight gain can only be avoided by adding metformin to insulin. Other well-known adverse effects of oral glucose-lowering agents have to be taken into account when prescribing oral glucose-lowering agents in addition to insulin therapy.
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Affiliation(s)
- Rimke C Vos
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 AB
| | - Mariëlle JP van Avendonk
- Guideline Development and ResearchDutch College of General PractitionersPO Box 3231UtrechtNetherlands3502 GE
| | - Hanneke Jansen
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 AB
| | | | - Maureen van den Donk
- Guideline Development and ResearchDutch College of General PractitionersPO Box 3231UtrechtNetherlands3502 GE
| | | | - Anneloes Kerssen
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 AB
| | - Guy EHM Rutten
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 AB
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Marín-Peñalver JJ, Martín-Timón I, Sevillano-Collantes C, del Cañizo-Gómez FJ. Update on the treatment of type 2 diabetes mellitus. World J Diabetes 2016; 7:354-95. [PMID: 27660695 PMCID: PMC5027002 DOI: 10.4239/wjd.v7.i17.354] [Citation(s) in RCA: 326] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/02/2016] [Accepted: 07/20/2016] [Indexed: 02/05/2023] Open
Abstract
To achieve good metabolic control in diabetes and keep long term, a combination of changes in lifestyle and pharmacological treatment is necessary. Achieving near-normal glycated hemoglobin significantly, decreases risk of macrovascular and microvascular complications. At present there are different treatments, both oral and injectable, available for the treatment of type 2 diabetes mellitus (T2DM). Treatment algorithms designed to reduce the development or progression of the complications of diabetes emphasizes the need for good glycaemic control. The aim of this review is to perform an update on the benefits and limitations of different drugs, both current and future, for the treatment of T2DM. Initial intervention should focus on lifestyle changes. Moreover, changes in lifestyle have proven to be beneficial, but for many patients is a complication keep long term. Physicians should be familiar with the different types of existing drugs for the treatment of diabetes and select the most effective, safe and better tolerated by patients. Metformin remains the first choice of treatment for most patients. Other alternative or second-line treatment options should be individualized depending on the characteristics of each patient. This article reviews the treatments available for patients with T2DM, with an emphasis on agents introduced within the last decade.
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He L, Liu S, Shan C, Tu Y, Li Z, Zhang XD. Differential HbA1c response in the placebo arm of DPP-4 inhibitor clinical trials conducted in China compared to other countries: a systematic review and meta-analysis. BMC Pharmacol Toxicol 2016; 17:40. [PMID: 27600598 PMCID: PMC5013632 DOI: 10.1186/s40360-016-0084-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 08/03/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND It has been observed that the efficacy of dipeptidyl peptidase-4 (DPP-4) inhibitors as compared to the placebo groups in some clinical trials conducted in China is weaker than that in trials conducted outside China, leading to the suspicion that this may be caused by differential Glycosylated Hemoglobin (HbA1c) response in the placebo arm of DPP-4 inhibitor clinical trials conducted in China compared to other countries. METHODS We searched published articles and other documents related to phase III placebo-control trials of DPP-4 inhibitors in Type 2 diabetes mellitus (T2DM). We included studies from different countries and compared those conducted in China to those conducted in other countries. Meta-regression analysis was used to analyze the HbA1c response in the placebo arms. RESULTS A total of 66 studies met the inclusion criteria and 10 were conducted within China. There were a total of 8303 participants (mean age 56, male 57 %) in placebo groups. The pooled change in HbA1c for the placebo groups of 10 trials conducted in patients with T2DM in China was 0.26 % (95 % CI [-0.36 %, -0.16 %], p-value < 0.001), compared to 0.015 % (95 % CI [-0.05 %, 0.08 %], p-value is 0.637) for 56 trials conducted outside of China. The difference of placebo effect between trials conducted in and outside China is -0.273 % (95 % CI [-0.42 %, -0.13 %], p-value is less than 0.001) while after excluding trials conducted in Japan, the difference is -0.203 % (95 % CI [-0.35 %, -0.06 %], p-value is 0.005). They are both statistically significant. CONCLUSIONS The meta-analysis in the article demonstrates that there is statistically significant difference in the HbA1c response in the placebo arm of DPP-4 inhibitor clinical trials conducted in China compared to other countries. This differential HbA1c response in the placebo arm should be taken into consideration by both experimenters and medical decision makers when future DPP-4 studies are conducted in China.
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Affiliation(s)
- Lingyu He
- Research School of Finance, Actuarial Studies & Statistics, The Australian National University, Canberra, ACT 2601, Australia
| | - Shu Liu
- Clinical Research, MSD China R&D Center, Beijing, 100015, China
| | - Chun Shan
- National Institutes for Food and Drug Control, Beijing, 100050, China
| | - Yingmei Tu
- Clinical Research, MSD China R&D Center, Beijing, 100015, China
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Wilding JPH, Rajeev SP, DeFronzo RA. Positioning SGLT2 Inhibitors/Incretin-Based Therapies in the Treatment Algorithm. Diabetes Care 2016; 39 Suppl 2:S154-64. [PMID: 27440828 DOI: 10.2337/dcs15-3005] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are the most recent addition to the therapeutic options available for the treatment of type 2 diabetes and became available after the introduction of incretin-based therapies, dipeptidyl peptidase 4 inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1 RAs). These agents have potential advantages with regard to their weight loss-promoting effect, low risk of hypoglycemia, reduction in blood pressure, and reduction in cardiovascular events in high-risk patients (with empagliflozin). Apart from these clinically important outcomes, they may also correct core defects present in type 2 diabetes (i.e., improvement in β-cell function and insulin sensitivity). They do, however, have some adverse effects, notably, nausea with GLP-1 RAs and genital tract infections and potential for volume depletion with SGLT2i. Whether incretin-based therapies are associated with an increased risk of pancreatitis is unclear. Most recently, diabetic ketoacidosis has been reported with SGLT2i. Therefore, a key clinical question in relation to guidelines is whether these clinical advantages, in the context of the adverse effect profile, outweigh the additional cost compared with older, more established therapies. This article reviews the therapeutic rationale for the use of these newer drugs for diabetes treatment, considers their place in current guidelines, and discusses how this may change as new data emerge about their long-term efficacy and safety from ongoing outcome trials.
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Affiliation(s)
- John P H Wilding
- Obesity and Endocrinology Clinical Research, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, U.K.
| | - Surya Panicker Rajeev
- Obesity and Endocrinology Clinical Research, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, U.K
| | - Ralph A DeFronzo
- Diabetes Division, The University of Texas Health Science Center at San Antonio, San Antonio, TX
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Wilding JPH, Bain SC. Role of incretin-based therapies and sodium-glucose co-transporter-2 inhibitors as adjuncts to insulin therapy in Type 2 diabetes, with special reference to IDegLira. Diabet Med 2016; 33:864-76. [PMID: 26525806 DOI: 10.1111/dme.13021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2015] [Indexed: 12/24/2022]
Abstract
The progressive nature of Type 2 diabetes necessitates treatment intensification over time in order to maintain glycaemic control, with many patients ultimately requiring insulin therapy. While insulin has unlimited potential efficacy, its initiation is often delayed and improvements in glycaemic control are typically accompanied by weight gain and an increased risk of hypoglycaemia, particularly as HbA1c approaches and falls below target levels. This may account for the sub-optimal control often achieved after insulin initiation. Combining insulin with antihyperglycaemic therapies that have a low risk of hypoglycaemia and are weight-neutral or result in weight loss is a therapeutic strategy with the potential to improve Type 2 diabetes management. Although the effects differ with each individual class of therapy, clinical trials have shown that adding a glucagon-like peptide-1 receptor agonist, dipeptidyl peptidase-4 inhibitor or sodium-glucose co-transporter-2 inhibitor to insulin regimens can offer a significant reduction in HbA1c without substantially increasing hypoglycaemia risk, or weight. The evidence and merit of each approach are reviewed in this paper. Once-daily co-formulations of a basal insulin and a glucagon-like peptide-1 receptor agonist have been developed (insulin degludec/liraglutide) or are under development (lixisenatide/insulin glargine). Insulin degludec/liraglutide phase III trials and a lixisenatide/insulin glargine phase II trial have shown robust HbA1c reductions, with weight loss and a low risk of hypoglycaemia. With insulin degludec/liraglutide now approved in Europe, an important consideration will be the types of patients who may benefit most from a fixed-ratio combination; this is discussed in the present review, and we also take a look toward future developments in the field.
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Affiliation(s)
- J P H Wilding
- Department of Obesity and Endocrinology, University of Liverpool, Liverpool, UK
| | - S C Bain
- Institute of Life Science, Swansea University, Swansea, UK
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Chen XW, He ZX, Zhou ZW, Yang T, Zhang X, Yang YX, Duan W, Zhou SF. Clinical pharmacology of dipeptidyl peptidase 4 inhibitors indicated for the treatment of type 2 diabetes mellitus. Clin Exp Pharmacol Physiol 2016; 42:999-1024. [PMID: 26173919 DOI: 10.1111/1440-1681.12455] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 06/11/2015] [Accepted: 07/06/2015] [Indexed: 12/16/2022]
Abstract
Dipeptidyl peptidase-4 (DPP-4) inhibitors are a class of oral antidiabetic drugs that improve glycaemic control without causing weight gain or increasing hypoglycaemic risk in patients with type 2 diabetes mellitus (T2DM). The eight available DPP-4 inhibitors, including alogliptin, anagliptin, gemigliptin, linagliptin, saxagliptin, sitagliptin, teneligliptin, and vildagliptin, are small molecules used orally with identical mechanism of action and similar safety profiles in patients with T2DM. DPP-4 inhibitors may be used as monotherapy or in double or triple combination with other oral glucose-lowering agents such as metformin, thiazolidinediones, or sulfonylureas. Although DPP-4 inhibitors have the same mode of action, they differ by some important pharmacokinetic and pharmacodynamic properties that may be clinically relevant in some patients. The main differences between the eight gliptins include: potency, target selectivity, oral bioavailability, elimination half-life, binding to plasma proteins, metabolic pathways, formation of active metabolite(s), main excretion routes, dosage adjustment for renal and liver insufficiency, and potential drug-drug interactions. The off-target inhibition of selective DPP-4 inhibitors is responsible for multiorgan toxicities such as immune dysfunction, impaired healing, and skin reactions. As a drug class, the DPP-4 inhibitors have become accepted in clinical practice due to their excellent tolerability profile, with a low risk of hypoglycaemia, a neutral effect on body weight, and once-daily dosing. It is unknown if DPP-4 inhibitors can prevent disease progression. More clinical studies are needed to validate the optimal regimens of DPP-4 inhibitors for the management of T2DM when their potential toxicities are closely monitored.
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Affiliation(s)
- Xiao-Wu Chen
- Department of General Surgery, The First People's Hospital of Shunde, Southern Medical University, Shunde, Foshan, Guangdong, China
| | - Zhi-Xu He
- Guizhou Provincial Key Laboratory for Regenerative Medicine, Stem Cell and Tissue Engineering Research Centre & Sino-US Joint Laboratory for Medical Sciences, Guiyang Medical University, Guiyang, Guizhou, China
| | - Zhi-Wei Zhou
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL, USA
| | - Tianxin Yang
- Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Centre, Salt Lake City, UT, USA
| | - Xueji Zhang
- Research Centre for Bioengineering and Sensing Technology, University of Science and Technology Beijing, Beijing, China
| | - Yin-Xue Yang
- Department of Colorectal Surgery, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Wei Duan
- School of Medicine, Deakin University, Waurn Ponds, Vic., Australia
| | - Shu-Feng Zhou
- Guizhou Provincial Key Laboratory for Regenerative Medicine, Stem Cell and Tissue Engineering Research Centre & Sino-US Joint Laboratory for Medical Sciences, Guiyang Medical University, Guiyang, Guizhou, China.,Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL, USA
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Kim YG, Min SH, Hahn S, Oh TJ, Park KS, Cho YM. Efficacy and safety of the addition of a dipeptidyl peptidase-4 inhibitor to insulin therapy in patients with type 2 diabetes: A systematic review and meta-analysis. Diabetes Res Clin Pract 2016; 116:86-95. [PMID: 27321321 DOI: 10.1016/j.diabres.2016.03.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 03/02/2016] [Accepted: 03/11/2016] [Indexed: 12/18/2022]
Abstract
AIMS To compare the efficacy and safety of the addition of a dipeptidyl peptidase-4 (DPP-4) inhibitor or a placebo in patients with type 2 diabetes inadequately controlled with insulin. METHODS We searched randomised controlled trials (RCTs) from MEDLINE, EMBASE, LILACS, the Cochrane Central Register of Controlled Trials and the ClinicalTrials.gov online registry. Studies of at least 12week treatment duration were eligible if they were RCTs in patients with type 2 diabetes comparing addition of a DPP-4 inhibitor to insulin therapy (INS/DPP4i) with addition of a placebo to insulin therapy (INS/PCB) and contained information on the change in glycated haemoglobin (HbA1c) from baseline. RESULTS Of 3105 potentially relevant published articles and 206 registered trials, 9 studies were included for meta-analysis. Compared to INS/PCB, INS/DPP4i exhibited a greater reduction in HbA1c (weighted mean difference [WMD] -0.58%; 95% CI -0.70, -0.46) and fasting plasma glucose (WMD -0.59mmol/L; 95% CI -0.79, -0.40) with less daily insulin doses (WMD -1.86IU; 95% CI -3.27, -0.45) and with no difference in weight gain (WMD -0.04kg; 95% CI -0.25, 0.16). The risk of hypoglycaemia was similar between INS/DPP-4i and INS/PCB (the RR in favour of INS/PCB was 0.94; 95% CI 0.84, 1.05). CONCLUSIONS Compared to placebo, DPP-4 inhibitors exhibit a better glycaemic control without further increasing the risk of weight gain and hypoglycaemia in patients with type 2 diabetes inadequately controlled with insulin.
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Affiliation(s)
- Yeong Gi Kim
- Division of Endocrinology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea; Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, South Korea
| | - Se Hee Min
- Division of Endocrinology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Seokyung Hahn
- Department of Medicine, Seoul National University College of Medicine/Biostatistics Division of Medical Research Collaborating Center, Seoul National University Hospital, Seoul, South Korea
| | - Tae Jung Oh
- Division of Endocrinology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyong Soo Park
- Division of Endocrinology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Young Min Cho
- Division of Endocrinology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
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