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McCormick TA, Kramer J, Liles EG, Amos Q, Martin JP, Adams JL. Cardiovascular and mortality benefits of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists as third-step glucose-lowering medicine in patients with type 2 diabetes: a retrospective cohort analysis. BMJ Open Diabetes Res Care 2024; 12:e003792. [PMID: 38719507 PMCID: PMC11085886 DOI: 10.1136/bmjdrc-2023-003792] [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: 09/22/2023] [Accepted: 04/17/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Studies have found that sodium-glucose cotransporter 2 inhibitors (SGLT2) and glucagon-like peptide 1 receptor agonists (GLP1) have cardiovascular benefits for patients with type 2 diabetes (DM2) and atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), or heart failure (HF). The literature does not provide evidence specifically for patients with these conditions who are adding one of these medicines to two glucose-lowering medications (ie, as "third-step" therapy). We explored the effects of different third-step medications on cardiovascular outcomes in patients with diabetes and these comorbid conditions. Specifically, we compared third-step SGLT2 or GLP1 to third-step dipeptidyl peptidase-4 inhibitors (DPP4), insulin, or thiazolidinediones (TZD). RESEARCH DESIGN AND METHODS We assembled a retrospective cohort of adults at five Kaiser Permanente sites with DM2 and ASCVD, CKD, or HF, initiating third-step treatment between 2016 and 2020. Propensity score weighted Poisson models were used to calculate adjusted rate ratios (ARRs) for all-cause mortality, incident major adverse cardiovascular event (MACE), and incident HF hospitalization in patients initiating SGLT2 or GLP1 compared with DPP4, insulin, or TZD. RESULTS We identified 27 542 patients initiating third-step treatment with one or more of these conditions (19 958 with ASCVD, 14 577 with CKD, and 3919 with HF). ARRs for GLP1 and SGLT2 versus DPP4, insulin, and TZD in the patient subgroups ranged between 0.22 and 0.55 for all-cause mortality, 0.38 and 0.81 for MACE, and 0.46 and 1.05 for HF hospitalization. Many ARRs were statistically significant, and all significant ARRs showed a benefit (ARR <1) for GLP1 or SGLT2 when compared with DPP4, insulin, or TZD. CONCLUSIONS Third-step SGLT2 and GLP1 are generally associated with a benefit for these outcomes in these patient groups when compared with third-step DPP4, insulin, or TZD. Our results add to evidence of a cardiovascular benefit of SGLT2 and GLP1 and could inform clinical guidelines for choosing third-step diabetes treatment.
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Affiliation(s)
- Thomas A McCormick
- Quality Data, Analytics, and Reporting, Kaiser Permanente, Portland, Oregon, USA
| | - Jason Kramer
- Quality Data, Analytics, and Reporting, Kaiser Permanente, Pasadena, California, USA
| | - Elizabeth G Liles
- Center for Health Research, Kaiser Permanente, Portland, Oregon, USA
| | | | - John P Martin
- Southern California Permanente Medical Group, Pasadena, California, USA
| | - John L Adams
- Center for Effectiveness & Safety Research, Kaiser Permanente, Pasadena, California, USA
- Bernard J. Tyson School of Medicine, Kaiser Permanente, Pasadena, California, USA
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Evans M, Kuodi P, Akunna CJ, McCreedy N, Donsmark M, Ren H, Nnaji CA. Cardiovascular and renal outcomes of GLP-1 receptor agonists vs. DPP-4 inhibitors and basal insulin in type 2 diabetes mellitus: A systematic review and meta-analysis. Diab Vasc Dis Res 2023; 20:14791641231221740. [PMID: 38111352 PMCID: PMC10734357 DOI: 10.1177/14791641231221740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVE To compare the cardiovascular and renal outcomes of GLP-1 RA versus DPP4i and basal insulin in the management of T2DM. METHODS Data from 22 studies involving over 200,000 participants were pooled using the inverse variance method and random-effects meta-analysis. The review was reported in accordance with PRISMA. RESULTS Compared with DPP4i, treatment with GLP-1 RA was associated with a greater benefit on composite cardiovascular outcomes (HR:0.77, 95% CI:0.69-0.87), myocardial infarction (HR:0.82, 95% CI:0.69-0.97), stroke (HR:0.83, 95% CI: 0.74-0.93), cardiovascular mortality (HR:0.76, 95% CI:0.68-0.85) and all-cause mortality (HR:0.65, 95% CI:0.48-0.90). There was no difference in effect on heart failure (HR:0.97, 95% CI:0.82-1.15). Compared with basal insulin, GLP-1 RA was associated with better effects on composite cardiovascular outcomes (HR:0.62, 95% CI:0.48-0.79), heart failure (HR:0.57, 95% CI:0.35-0.92), myocardial infarction (HR:0.70, 95% CI:0.58-0.85), stroke (HR:0.50, 95% CI:0.40-0.63) and all-cause mortality (HR:0.31, 95% CI:0.20-0.48). Evidence from a small number of studies suggests that GLP-1 RA had better effects on composite and individual renal outcomes, such as eGFR, compared with either DPP4i and basal insulin. CONCLUSION Available evidence suggests that treating T2DM with GLP-1 RA can yield better benefits on composite and specific cardiorenal outcomes than with DPP4i and basal insulin. PROSPERO REGISTRATION NUMBER CRD42022335504.
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Affiliation(s)
- Marc Evans
- Department of Diabetes and Endocrinology, University Hospital Llandough, Penarth, UK
| | - Paul Kuodi
- Department of Public Health, Faculty of Health Sciences, Lira University, Lira, Uganda
| | | | | | | | | | - Chukwudi A Nnaji
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Rathmann W, Kostev K. Association of glucose-lowering drugs with incident stroke and transient ischaemic attacks in primary care patients with type 2 diabetes: disease analyzer database. Acta Diabetol 2022; 59:1443-1451. [PMID: 35933524 PMCID: PMC9519725 DOI: 10.1007/s00592-022-01943-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/10/2022] [Indexed: 11/28/2022]
Abstract
AIMS Previous observational studies on glucose-lowering drugs and risk of stroke in type 2 diabetes yielded conflicting results. The aim was to examine the association of glucose-lowering drugs with incident stroke and transient ischaemic attacks (TIA) in newly diagnosed type 2 diabetes. METHODS We conducted a retrospective cohort analysis of the disease analyzer, which comprises a representative panel of 1248 general and internal medicine practices throughout Germany (01/2000-12/2019: 9.8 million patients). Incident non-fatal stroke/TIA was defined based on ICD-10 codes (I63, I64; G45) in newly diagnosed type 2 diabetes. Cox regression models were fitted to obtain hazard ratios (HR; 95%CI) for stroke/TIA adjusting for potential confounders (age, sex, health insurance, coronary heart disease, myocardial infarction, heart failure, polyneuropathy, blood pressure, eGFR) and anthropometric and metabolic intermediators (BMI, HbA1c, HDL- and LDL-cholesterol, triglycerides, lipid-lowering drugs). RESULT 312,368 persons with newly diagnosed type 2 diabetes without previous stroke/TIA (mean age: 64 years; 52% males) were included. There were 16,701 events of non-fatal stroke/TIA corresponding to an incidence rate of 9.3 (95%CI 9.1-9.4) per 1000 person-years. Using Cox regression, adjusted HR for stroke/TIA (per 1 year of treatment) of 0.59 (0.54-0.64) for SGLT2 inhibitors and of 0.79 (0.74-0.85) for GLP-1 receptor agonists were estimated. DPP-4 inhibitors (0.84; 0.82-0.86), metformin (0.90; 0.89-0.91), insulin (0.92; 0.91-0.93) and sulfonylureas (0.98; 0.96-0.99) also showed moderately reduced HR for stroke/TIA. Sex-specific regression analyses yielded similar results (HR). CONCLUSIONS Treatment with SGLT2 inhibitors or GLP-1 receptor agonists might reduce non-fatal stroke/TIA in persons with newly diagnosed type 2 diabetes.
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Affiliation(s)
- Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Auf'm Hennekamp 65, 40225, Düsseldorf, Germany.
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Gebrie D, Manyazewal T, A Ejigu D, Makonnen E. Metformin-Insulin versus Metformin-Sulfonylurea Combination Therapies in Type 2 Diabetes: A Comparative Study of Glycemic Control and Risk of Cardiovascular Diseases in Addis Ababa, Ethiopia. Diabetes Metab Syndr Obes 2021; 14:3345-3359. [PMID: 34335036 PMCID: PMC8317933 DOI: 10.2147/dmso.s312997] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/10/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE This study aimed to compare glycemic control and risk of cardiovascular outcomes of metformin-insulin versus metformin-sulfonylurea combination therapies in type 2 diabetes mellitus. METHODS We conducted a comparative cross-sectional study in five tertiary level hospitals in Addis Ababa, Ethiopia. We enrolled 321 patients with type 2 diabetes mellitus who were on continuous treatment follow-up on either metformin-insulin or metformin-sulfonylurea combination therapy. We interviewed the participants and reviewed their medical records to investigate medication efficacy, safety, and adherence. The primary outcome measure was glycemic control and the secondary outcome measures were composite cardiovascular outcomes. RESULTS Of the total participants enrolled, 50.5% (n = 162) were those who received metformin-insulin and 49.5% (n = 159) metformin-sulfonylurea combination therapies for a median of 48 months follow-up. The reduction of Hb1Ac levels was comparable between the metformin-insulin (-1.04 ± 0.96%) and metformin-sulfonylurea (-1.02 ± 1.03%), p = 0.912. Patients who received metformin-sulfonylurea had 4.3 times more likely to have achieved target HbA1c level compared to those who received metformin-insulin, p < 0.001, adjusted odds ratio (AOR) with 95% CI = 4.31[1.79-10.32]. Risk of composite cardiovascular outcomes was higher in metformin-insulin group (40.5% versus 34.0%), p = 0.021. Co-morbidities, body mass index, systolic blood pressure, and HbA1c had a significant association with composite cardiovascular outcomes. Reductions of bodyweight, HDL-C, LDL-C, triglycerides levels, and microvascular complications were different between the two groups, p < 0.05. CONCLUSION High proportion of patients who received metformin-sulfonylurea achieved target HbA1c level and had less composite cardiovascular outcomes compared to those who received metformin-insulin. However, these findings have to be confirmed with randomized control trials to determine risks associated with insulin use, while efficacy is maintained as second-line treatment in patients with type 2 diabetes mellitus.
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Affiliation(s)
- Desye Gebrie
- School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tsegahun Manyazewal
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Dawit A Ejigu
- Department of Pharmacology, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Eyasu Makonnen
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Khunti K, Knighton P, Zaccardi F, Bakhai C, Barron E, Holman N, Kar P, Meace C, Sattar N, Sharp S, Wareham NJ, Weaver A, Woch E, Young B, Valabhji J. Prescription of glucose-lowering therapies and risk of COVID-19 mortality in people with type 2 diabetes: a nationwide observational study in England. Lancet Diabetes Endocrinol 2021; 9:293-303. [PMID: 33798464 PMCID: PMC8009618 DOI: 10.1016/s2213-8587(21)00050-4] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/01/2021] [Accepted: 02/13/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND In patients with type 2 diabetes, hyperglycaemia is an independent risk factor for COVID-19-related mortality. Associations between pre-infection prescription for glucose-lowering drugs and COVID-19-related mortality in people with type 2 diabetes have been postulated but only investigated in small studies and limited to a few agents. We investigated whether there are associations between prescription of different classes of glucose-lowering drugs and risk of COVID-19-related mortality in people with type 2 diabetes. METHODS This was a nationwide observational cohort study done with data from the National Diabetes Audit for people with type 2 diabetes and registered with a general practice in England since 2003. Cox regression was used to estimate the hazard ratio (HR) of COVID-19-related mortality in people prescribed each class of glucose-lowering drug, with covariate adjustment with a propensity score to address confounding by demographic, socioeconomic, and clinical factors. FINDINGS Among the 2 851 465 people with type 2 diabetes included in our analyses, 13 479 (0·5%) COVID-19-related deaths occurred during the study period (Feb 16 to Aug 31, 2020), corresponding to a rate of 8·9 per 1000 person-years (95% CI 8·7-9·0). The adjusted HR associated with recorded versus no recorded prescription was 0·77 (95% CI 0·73-0·81) for metformin and 1·42 (1·35-1·49) for insulin. Adjusted HRs for prescription of other individual classes of glucose-lowering treatment were as follows: 0·75 (0·48-1·17) for meglitinides, 0·82 (0·74-0·91) for SGLT2 inhibitors, 0·94 (0·82-1·07) for thiazolidinediones, 0·94 (0·89-0·99) for sulfonylureas, 0·94 (0·83-1·07) for GLP-1 receptor agonists, 1·07 (1·01-1·13) for DPP-4 inhibitors, and 1·26 (0·76-2·09) for α-glucosidase inhibitors. INTERPRETATION Our results provide evidence of associations between prescription of some glucose-lowering drugs and COVID-19-related mortality, although the differences in risk are small and these findings are likely to be due to confounding by indication, in view of the use of different drug classes at different stages of type 2 diabetes disease progression. In the context of the COVID-19 pandemic, there is no clear indication to change prescribing of glucose-lowering drugs in people with type 2 diabetes. FUNDING None.
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Affiliation(s)
- Kamlesh Khunti
- National Diabetes Audit Programme, NHS England & Improvement, London, UK; Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK.
| | - Peter Knighton
- National Diabetes Audit Programme, NHS England & Improvement, London, UK; NHS Digital, Leeds, UK
| | - Francesco Zaccardi
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | | | | | - Naomi Holman
- National Diabetes Audit Programme, NHS England & Improvement, London, UK; NHS Digital, Leeds, UK; NHS England and NHS Improvement, London, UK; Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Partha Kar
- National Diabetes Audit Programme, NHS England & Improvement, London, UK; NHS England and NHS Improvement, London, UK; Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Claire Meace
- National Diabetes Audit Programme, NHS England & Improvement, London, UK; NHS Digital, Leeds, UK
| | - Naveed Sattar
- National Diabetes Audit Programme, NHS England & Improvement, London, UK; Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Stephen Sharp
- MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Nicholas J Wareham
- MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Emilia Woch
- National Diabetes Audit Programme, NHS England & Improvement, London, UK; NHS Digital, Leeds, UK
| | - Bob Young
- National Diabetes Audit Programme, NHS England & Improvement, London, UK; Diabetes UK, London, UK
| | - Jonathan Valabhji
- National Diabetes Audit Programme, NHS England & Improvement, London, UK; NHS England and NHS Improvement, London, UK; Department of Diabetes and Endocrinology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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6
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Cardiovascular Safety and Benefits of Noninsulin Antihyperglycemic Drugs for the Treatment of Type 2 Diabetes Mellitus-Part 1. Cardiol Rev 2021; 28:177-189. [PMID: 32282393 DOI: 10.1097/crd.0000000000000308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease (CVD) is a major contributor to the morbidity and mortality associated with type 2 diabetes mellitus (T2DM). With T2DM growing in pandemic proportions, there will be profound healthcare implications of CVD in person with diabetes. The ideal drugs to improve outcomes in T2DM are those having antiglycemic efficacy in addition to cardiovascular (CV) safety, which has to be determined in appropriately designed CV outcome trials as mandated by regulatory agencies. Available evidence is largely supportive of metformin's CV safety and potential CVD risk reduction effects, whereas sulfonylureas are either CV risk neutral or are associated with variable CVD risk. Pioglitazone was also associated with improved CVD risk in patients with diabetes. The more recent antihyperglycemic medications have shown promise with regards to CVD risk reduction in T2DM patients at a high CV risk. Glucagon-like peptide-1 receptor agonists, a type of incretin-based therapy, were associated with better CV outcomes and mortality in T2DM patients, leading to the Food and Drug Administration approval of liraglutide to reduce CVD risk in high-risk T2DM patients. Ongoing and planned randomized controlled trials of the newer drugs should clarify the possibility of class effects, and of CVD risk reduction benefits in low-moderate CV risk patients. While metformin remains the first-line antiglycemic therapy in T2DM, glucagon-like peptide-1 receptor agonists should be appropriately prescribed in T2DM patients with baseline CVD or in those at a high CVD risk to improve CV outcomes. Dipeptidyl peptidase-4 inhibitors and sodium-glucose cotransporter-2 inhibitors are discussed in the second part of this review.
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Yang CY, Chen YR, Ou HT, Kuo S. Cost-effectiveness of GLP-1 receptor agonists versus insulin for the treatment of type 2 diabetes: a real-world study and systematic review. Cardiovasc Diabetol 2021; 20:21. [PMID: 33468131 PMCID: PMC7816439 DOI: 10.1186/s12933-020-01211-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/30/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To conduct a real-word-study-based cost-effectiveness analysis of a GLP-1 receptor agonist (GLP-1RA) versus insulin among type 2 diabetes patients requiring intensified injection therapy and a systematic review of cost-effectiveness studies of GLP-1RAs versus insulin. METHODS Individual-level analyses incorporating real-world effectiveness and cost data were conducted for a cohort of 1022 propensity-score-matched pairs of GLP-1RA and insulin users from Taiwan's National Health Insurance Research Database, 2007-2016. Study outcomes included the number needed to treat (NNT) to prevent one case of clinical events, healthcare costs, and cost per case of event prevented. Costs were in 2019 US dollars. Analyses were performed from a third-party payer and healthcare sector perspectives. Structured systematic review procedures were conducted to synthesize updated evidence on the cost-effectiveness of GLP-1RAs versus insulin. RESULTS Over a mean follow-up of 2.3 years, the NNT using a GLP-1RA versus insulin to prevent one case of all-cause mortality and hospitalized hypoglycemia was 57 and 30, respectively. Using GLP-1RAs instead of insulin cost US$54,851 and US$29,115 per case of all-cause mortality and hospitalized hypoglycemia prevented, respectively, from the payer perspective, and saved US$19,391 and US$10,293, respectively, from the healthcare sector perspective. Sensitivity analyses showed that the probability of using GLP-1RAs versus insulin being cost-effective for preventing one case of all-cause mortality or hospitalized hypoglycemia ranged from 60 to 100%. The systematic review revealed a cost-effective profile of using GLP-1RAs versus insulin. CONCLUSIONS Using GLP-1RAs versus insulin for type 2 diabetes patients requiring intensified injection therapy in clinical practice is cost-effective.
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Affiliation(s)
- Chen-Yi Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, Taiwan
| | - Ying-Ren Chen
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, Taiwan.
- Department of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
- Department of Pharmacy, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Shihchen Kuo
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Michigan Center for Diabetes Translational Research, University of Michigan, Ann Arbor, MI, USA
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Maskery MP, Holscher C, Jones SP, Price CI, Strain WD, Watkins CL, Werring DJ, Emsley HCA. Glucagon-like peptide-1 receptor agonists as neuroprotective agents for ischemic stroke: a systematic scoping review. J Cereb Blood Flow Metab 2021; 41:14-30. [PMID: 32954901 PMCID: PMC7747170 DOI: 10.1177/0271678x20952011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 07/18/2020] [Indexed: 12/21/2022]
Abstract
Stroke mortality and morbidity is expected to rise. Despite considerable recent advances within acute ischemic stroke treatment, scope remains for development of widely applicable neuroprotective agents. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), originally licensed for the management of Type 2 Diabetes Mellitus, have demonstrated pre-clinical neuroprotective efficacy in a range of neurodegenerative conditions. This systematic scoping review reports the pre-clinical basis of GLP-1RAs as neuroprotective agents in acute ischemic stroke and their translation into clinical trials. We included 35 pre-clinical studies, 11 retrospective database studies, 7 cardiovascular outcome trials and 4 prospective clinical studies. Pre-clinical neuroprotection was demonstrated in normoglycemic models when administration was delayed by up to 24 h following stroke induction. Outcomes included reduced infarct volume, apoptosis, oxidative stress and inflammation alongside increased neurogenesis, angiogenesis and cerebral blood flow. Improved neurological function and a trend towards increased survival were also reported. Cardiovascular outcomes trials reported a significant reduction in stroke incidence with semaglutide and dulaglutide. Retrospective database studies show a trend towards neuroprotection. Prospective interventional clinical trials are on-going, but initial indicators of safety and tolerability are favourable. Ultimately, we propose that repurposing GLP-1RAs is potentially advantageous but appropriately designed trials are needed to determine clinical efficacy and cost-effectiveness.
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Affiliation(s)
- Mark P Maskery
- Lancaster Medical School, Lancaster University, Lancaster, UK
- Department of Neurology, Royal Preston Hospital, Preston, UK
| | - Christian Holscher
- Research and Experimental Center, Henan University of Chinese Medicine, Zhengzhou, Henan Province, China
| | - Stephanie P Jones
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Christopher I Price
- Institute of Neuroscience, Stroke Research Group, Newcastle University, Newcastle, UK
| | - W David Strain
- NIHR Exeter Clinical Research Facility and Institute of Biomedical and Clinical Science, University of Exeter Medical School, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Caroline L Watkins
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - Hedley CA Emsley
- Lancaster Medical School, Lancaster University, Lancaster, UK
- Department of Neurology, Royal Preston Hospital, Preston, UK
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Cosentino F, Ceriello A, Baeres FMM, Fioretto P, Garber A, Stough WG, George JT, Grant PJ, Khunti K, Langkilde AM, Plutzky J, Rydén L, Scheen A, Standl E, Tuomilehto J, Zannad F. Addressing cardiovascular risk in type 2 diabetes mellitus: a report from the European Society of Cardiology Cardiovascular Roundtable. Eur Heart J 2020; 40:2907-2919. [PMID: 30445605 DOI: 10.1093/eurheartj/ehy677] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/20/2018] [Accepted: 10/08/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Francesco Cosentino
- Cardiology Unit, Department of Medicine Solna, Karolinska Institute & Karolinska University Hospital, Stockholm, Sweden
| | - Antonio Ceriello
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomedica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain
- Department of Cardiovascular and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni, Italy
| | | | - Paola Fioretto
- Department of Medicine, University of Padova, Padova, Italy
| | - Alan Garber
- Baylor College of Medicine, Houston, Texas, USA
| | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, Cary, North Carolina, USA
| | - Jyothis T George
- Boehringer Ingelheim International, Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Peter J Grant
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | | | - Jorge Plutzky
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lars Rydén
- Department of Medicine, K2, Karolinska Institute, Stockholm, Sweden
| | - André Scheen
- Division of Diabetes, Nutrition, and Metabolic Disorders, Division of Clinical Pharmacology, CHU de Liège, University of Liège, Liège, Belgium
| | - Eberhard Standl
- Forschergruppe Diabetes eV at Munich Helmholtz Centre, Munich, Germany
| | - Jaakko Tuomilehto
- Department of Public Health, University of Helsinki, Helsinki, Finland
- Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland
- Diabetes Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Faiez Zannad
- Inserm, Centre d'Investigations Cliniques- 1433, and Inserm U1116, CHRU, Nancy, France
- Université de Lorraine, Nancy, France
- F-CRIN INI-CRCT, Nancy, France
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10
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Herrera Comoglio R, Vidal Guitart X. Cardiovascular outcomes, heart failure and mortality in type 2 diabetic patients treated with glucagon-like peptide 1 receptor agonists (GLP-1 RAs): A systematic review and meta-analysis of observational cohort studies. Int J Clin Pract 2020; 74:e13553. [PMID: 32452094 DOI: 10.1111/ijcp.13553] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 05/06/2020] [Accepted: 05/18/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cardiovascular outcomes trials (CVOTs) have assessed the effects of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) on major adverse cardiovascular events (MACE) and mortality in high cardiovascular (CV) risk populations. Observational research can provide complementary evidence about these effects in unselected populations. AIM To systematically review retrospective observational cohort studies conducted in electronic healthcare databases (EHDs) assessing GLP-1 RAs´ effects on MACE and/or hospitalisation for heart failure (HHF) and/or all-cause mortality in Type 2 diabetes mellitus (T2DM) patients. METHODS We systematically searched studies meeting inclusion criteria, compared design, methods and population characteristics, assessed risk for bias and did a meta-analysis (MA) using a random-effects model to calculate overall hazard ratios (HRs) and 95% CI (confidence intervals). RESULTS Sixteen studies included 285,436 T2DM patients exposed to GLP-1 RAs (exenatide bid, liraglutide, lixisenatide, long-acting exenatide), n ranged from 219 to 160,803 patients. Comparators included: no exposure, other antidiabetic medications (OADs), combined OADs, canagliflozin or multiple comparators. Ten studies estimated all-cause mortality, hazard ratios (HRs) ranged from 0.17 (95% CI 0.02-1.22) to 1.29 (95% CI 0.54-3.13). Thirteen studies assessed cardiovascular events and/or MACE; HRs ranged from 0.27 (95% CI 0.14-0.53) to 1.11 (95% CI 0.99-1.24). Eight studies assessed HHF, HRs ranged from 0.12 (95% CI 0.02-0.66) to 1.64 (95% CI 1.28-2.13). Excluding two studies because of temporal bias, we obtained pooled estimates for all-cause mortality: HR 0.63 (0.44-0.89), CV outcomes HR 0.84 (0.75-0.94) and HHF; HR 0.94 (0.78-1.14), (high between-study variability: I2 = 83.35%; I2 = 70.3%; and I2 = 90.1%, respectively). CONCLUSION Pooled results of EHDs' studies assessing GLP-1 RAs effects favoured GLP-1 RAs for all-cause mortality and MACE while were neutral for HHF. Results should be interpreted cautiously because of studies' substantial heterogeneity and limitations of observational research.
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Affiliation(s)
- Raquel Herrera Comoglio
- School of Medicine, Universidad Nacional de Córdoba, Córdoba, Argentina
- Eu2P European Programme in Pharmacovigilance and Pharmacoepidemiology, University of Bordeaux Segalen, Bordeaux, France
| | - Xavier Vidal Guitart
- Eu2P European Programme in Pharmacovigilance and Pharmacoepidemiology, University of Bordeaux Segalen, Bordeaux, France
- Fundacio Institut Catala de Farmacologia, Universitat Autonoma de Barcelona, Barcelona, Spain
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Sciannameo V, Berchialla P, Orsi E, Lamacchia O, Morano S, Querci F, Consoli A, Avogaro A, Fadini GP. Enrolment criteria for diabetes cardiovascular outcome trials do not inform on generalizability to clinical practice: The case of glucagon-like peptide-1 receptor agonists. Diabetes Obes Metab 2020; 22:817-827. [PMID: 31943710 DOI: 10.1111/dom.13962] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/26/2019] [Accepted: 01/08/2020] [Indexed: 02/06/2023]
Abstract
AIM To evaluate the generalizability of cardiovascular outcome trials (CVOTs) on glucagon-like peptide-1 receptor agonists (GLP-1RAs), we assessed what proportion of real-world patients with type 2 diabetes (T2D) constitute true CVOT-like populations. MATERIALS AND METHODS We applied inclusion/exclusion (I/E) criteria of each GLP-1RA CVOT to a cross-sectional database of 281 380 T2D patients from Italian diabetes outpatient clinics. We calculated the proportion of patients eligible for each CVOT and compared their clinical characteristics with those of trial patients. In addition, we used a Bayesian network-based method to sample the greatest subsets of real-world patients yielding true CVOT-like populations. RESULTS Between 98 725 and 124 164 T2D patients could be evaluated for CVOT eligibility. After excluding patients who were already on GLP-1RAs and applying I/E criteria, 35.8% of patients would be eligible for REWIND, 34.1% for PIONEER-6, 13.4% for EXSCEL, 10.1% for SUSTAIN-6, 9.5% for HARMONY and 9.4% for LEADER. Overall, 45.4% of patients could be eligible for at least one of the CVOTs. These patients, however, were extremely different to trial patients in most of the clinical characteristics, including demographics, concomitant medications and complications. The greatest CVOT-like subsets of real-world patients were 0.5% for SUSTAIN-6, 1.0% for EXSCEL, 1.2% for LEADER, 1.8% for PIONEER-6 and 7.9% for REWIND. CONCLUSIONS A very small proportion of real-world patients constitute true CVOT-like populations. These findings question whether any meaningful information can be drawn from applying trial enrolment criteria to real-world T2D patients.
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Affiliation(s)
- Veronica Sciannameo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Emanuela Orsi
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Olga Lamacchia
- Unit of Endocrinology, Department of Medical and Surgical Sciences, University Hospital of Foggia, Foggia, Italy
| | - Susanna Morano
- Unit of Diabetes Complications, V Clinica Medica, Department of Experimental Medicine, University of Rome "La Sapienza", Rome, Italy
| | - Fabrizio Querci
- Unit of Diabetology, ASST Bergamo Est, Alzano Lombardo, Italy
| | - Agostino Consoli
- Department of Medicine and Aging Science, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova, Italy
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Anyanwagu U, Donnelly R, Idris I. The relationship between urinary albumin excretion, cardiovascular outcomes and total mortality among a large cohort of insulin-treated patients with type 2 diabetes in routine primary care practices. Nephrol Dial Transplant 2020; 35:471-477. [DOI: 10.1093/ndt/gfy258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 07/09/2018] [Indexed: 01/24/2023] Open
Abstract
Abstract
Background
Albuminuria is a recognized diagnostic and prognostic marker of chronic kidney disease and cardiovascular (CV) risk but the well-known relationship between increments in urinary albumin:creatinine ratio (UACR) and CV outcomes and mortality has not been fully explored in insulin-treated patients with type 2 diabetes (T2D) in routine clinical care.
Methods
We investigated data for insulin users with T2D from UK general practices between 2007 and 2014. The UACR at the time of insulin initiation was measured and categorized as <10, 10– 29, 30–300 and >300 mg/g. Patients were followed up for 5 years or the earliest occurrence of all-cause mortality, non-fatal myocardial infarction or stroke. Cox proportional hazards models were fitted to estimate the risk of a composite of these events.
Results
A total of 12 725 patients with T2D (mean age 58.6 ± 13.8 years, mean haemoglobin A1c 8.7 ± 1.8%) initiating insulin therapy between 2007 and 2014 met the inclusion criteria. Compared with patients whose ACR levels at insulin initiation were <10 mg/g, the adjusted risk of the 3-point composite endpoint was 9, 30 and 98% higher in those with ACR levels between 10–29, 30–300 and >300 mg/g, respectively, after a follow-up period of 5 years. The ACR category on its own did not predict risk of all-cause mortality.
Conclusions
This study shows that in patients with T2D on insulin therapy, increased urinary ACR is independently associated with an increased risk of major adverse CV events and all-cause mortality.
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Affiliation(s)
- Uchenna Anyanwagu
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Richard Donnelly
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Iskandar Idris
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
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Guerci B, Charbonnel B, Gourdy P, Hadjadj S, Hanaire H, Marre M, Vergès B. Efficacy and adherence of glucagon-like peptide-1 receptor agonist treatment in patients with type 2 diabetes mellitus in real-life settings. DIABETES & METABOLISM 2019; 45:528-535. [DOI: 10.1016/j.diabet.2019.01.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 01/05/2019] [Accepted: 01/14/2019] [Indexed: 12/25/2022]
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Intensification with dipeptidyl peptidase-4 inhibitor, insulin, or thiazolidinediones and risks of all-cause mortality, cardiovascular diseases, and severe hypoglycemia in patients on metformin-sulfonylurea dual therapy: A retrospective cohort study. PLoS Med 2019; 16:e1002999. [PMID: 31877127 PMCID: PMC6932752 DOI: 10.1371/journal.pmed.1002999] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/21/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although patients with type 2 diabetes mellitus (T2DM) may fail to achieve adequate hemoglobin A1c (HbA1c) control despite metformin-sulfonylurea (Met-SU) dual therapy, a third-line glucose-lowering medication-including dipeptidyl peptidase-4 inhibitor (DPP4i), insulin, or thiazolidinedione (TZD)-can be added to achieve this. However, treatment effects of intensification with the medications on the risk of severe hypoglycemia (SH), cardiovascular disease (CVD), and all-cause mortality are uncertain. Study aim was to compare the risks of all-cause mortality, CVD, and SH among patients with T2DM on Met-SU dual therapy intensified with DPP4i, insulin, or TZD. METHODS AND FINDINGS We analyzed a retrospective cohort data of 17,293 patients with T2DM who were free from CVD and on Met-SU dual therapy and who were intensified with DPP4i (n = 8,248), insulin (n = 6,395), or TZD (n = 2,650) from 2006 to 2017. Propensity-score weighting was used to balance out baseline covariates across groups. Hazard ratios (HRs) for all-cause mortality, CVD, and SH were assessed using Cox proportional hazard models. Mean age of all patients was 58.56 ± 11.41 years. All baseline covariates achieved a balance across the 3 groups. Over a mean follow-up period of 34 months with 49,299 person-years, cumulative incidences of all-cause mortality, SH, and CVD were 0.061, 0.119, and 0.074, respectively. Patients intensified with insulin had higher risk of all-cause mortality (HR = 2.648, 95% confidence interval [CI] 2.367-2.963, p < 0.001; 2.352, 95% CI 2.123-2.605, p < 0.001) than those intensified with TZD and DPP4i, respectively. Insulin users had the greatest risk of SH (HR = 1.198, 95% CI 1.071-1.340, p = 0.002; 1.496, 95% CI 1.342-1.668, p < 0.001) compared with TZD and DPP4i users, respectively. Comparing between TZDs and DPP4i, TZDs were associated with a higher risk of SH (HR = 1.249, 95% CI 1.099-1.419, p < 0.001) but not all-cause mortality (HR = 0.888, 95% CI 0.776-1.016, p = 0.084) or CVD (HR = 1.005, 95% CI 0.915-1.104, p = 0.925). Limitations of this study included the lack of data regarding lifestyle, drug adherence, time-varying factors, patients' motivation, and cost considerations. A limited duration of patients intensifying with TZD might also weaken the strength of study results. CONCLUSIONS Our results indicated that, for patients with T2DM who are on Met-SU dual therapy, the addition of DPP4i was a preferred third-line medication among 3 options, with the lowest risks of mortality and SH and posing no increased risk for CVD events when compared to insulin and TZD. Intensification with insulin had the greatest risk of mortality and SH events.
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Danford CJ, Lai M. NAFLD: a multisystem disease that requires a multidisciplinary approach. Frontline Gastroenterol 2019; 10:328-329. [PMID: 31682642 PMCID: PMC6788273 DOI: 10.1136/flgastro-2019-101235] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Christopher J Danford
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Michelle Lai
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA, United States
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Lin YS, Lin MT, Cheng SH. Drug price, dosage and safety: Real-world evidence of oral hypoglycemic agents. Health Policy 2019; 123:1221-1229. [PMID: 31466805 DOI: 10.1016/j.healthpol.2019.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 08/08/2019] [Accepted: 08/12/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Drug price reduction is one of the major policies to restrain pharmaceutical expenses worldwide. This study explores whether there is a relationship between drug price and clinical quality using real-world data. METHODS Patients with newly-diagnosed type 2 diabetes receiving metformin or sulfonylureas during 2001 and 2010 were identified using the claim database of the Taiwan universal health insurance system. Propensity score matching was performed to obtain comparable subjects for analysis. Pharmaceutical products were categorized as brand-name agents (BD), highpriced generics (HP) or low-priced generics (LP). Indicators of clinical quality were defined as the dosage of cumulative oral hypoglycemic agents (OHA), exposure to other pharmacological classes of OHA, hospitalization or urgent visit for hypoglycemia or hyperglycemia, insulin utilization and diagnosis of diabetic complications within 1 year after diagnosis. RESULTS A total of 40,152 study subjects were identified. A generalized linear mix model showed that HP and BD users received similar OHA dosages with comparable clinical outcomes. By contrast, LP users had similar outcomes to BD users but received a 39% greater OHA dosage. A marginally higher risk of poor glycemic control in LP users was also observed. CONCLUSIONS Drug price is related to indicators of clinical quality. Clinicians and health authorities should monitor the utilization, effectiveness and clinical safety indicators of generic drugs, especially those with remarkably low prices.
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Affiliation(s)
- Yu-Shiuan Lin
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei City, Taiwan; Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Min-Ting Lin
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Shou-Hsia Cheng
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei City, Taiwan; Population Health Research Center, National Taiwan University, Taipei City, Taiwan.
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Anyanwagu U, Mamza J, Donnelly R, Idris I. Relationship between HbA1c and all-cause mortality in older patients with insulin-treated type 2 diabetes: results of a large UK Cohort Study. Age Ageing 2019; 48:235-240. [PMID: 30615050 DOI: 10.1093/ageing/afy178] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/31/2018] [Accepted: 10/22/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND our aim was to study the relationship between HbA1c and cardiovascular morbidity and all-cause mortality among older insulin-treated patients with type 2 diabetes (T2D) after adjustment for multiple confounders. METHODS data for 4589 adults with T2D (>65 years) on insulin treatment were sourced from 532 UK General Practices via the Health Improvement Network (THIN) database. Cox proportional hazard models and Kaplan-Meier estimators were fitted to derive the hazards of all-cause mortality by HbA1c categories (<6.5, 6.5-7.4, 7.5-8.4, 8.5-9.4, 9.5-10.4, 10.5-11.4%; and 11.5% and above) after 5 years of follow-up following insulin initiation. RESULTS we observed a U-shaped relationship between all-cause mortality and HbA1c, with the lowest risk seen in the HbA1c range of 6.5-7.4% and marked increased in risk with HbA1c > 11%. The highest mortality risks of 31 and 40% were significantly associated with the lowest (<6.5%) and highest (11.5% and above) HbA1c categories: aHR: 1.31; (95%CI: 1.10-1.56; P = 0.002) and aHR: 1.40; (95%CI: 1.01-1.96; P = 0.039), respectively. CONCLUSIONS both low and high HbA1c were associated with increased all-cause mortality, among older patients with insulin-treated T2D. This cohort study supports the need for individualisation of care and suggests better outcomes with HbA1c levels around 6.5-7.4% and markedly excess risk with HbA1c > 11.
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Affiliation(s)
- Uchenna Anyanwagu
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby
| | - Jil Mamza
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby
| | - Richard Donnelly
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby
| | - Iskandar Idris
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby
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Kuo S, Yang CT, Wu JS, Ou HT. Effects on clinical outcomes of intensifying triple oral antidiabetic drug (OAD) therapy by initiating insulin versus enhancing OAD therapy in patients with type 2 diabetes: A nationwide population-based, propensity-score-matched cohort study. Diabetes Obes Metab 2019; 21:312-320. [PMID: 30187666 PMCID: PMC6329671 DOI: 10.1111/dom.13525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/20/2018] [Accepted: 09/01/2018] [Indexed: 01/16/2023]
Abstract
AIMS To compare the effects of initiating insulin as a fourth-line antidiabetic therapy with the effects of enhancing oral antidiabetic drug (OAD) therapy in patients with type 2 diabetes mellitus (T2DM) with triple OAD therapy failure. MATERIALS AND METHODS We conducted a nationwide population-based, retrospective cohort study involving 1022 (without prevalent diabetes-related complications [PDRCs]) and 2077 (with/without PDRCs) propensity score-matched pairs of fourth-line insulin therapy users and enhanced OAD therapy users identified in the period 2004 to 2010. Clinical outcomes including a composite cardiovascular outcome (myocardial infarction, stroke, heart failure or ischaemic heart disease), peripheral vascular disease (PVD), hypoglycaemia and all-cause mortality were assessed up to 2013. Hypoglycaemia was adjusted in Cox models to consider its potential effect on study outcomes. RESULTS In a T2DM cohort without PDRCs, fourth-line insulin therapy was not associated with greater risks of clinical outcomes, except hypoglycaemia (hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.02-2.07), compared with enhanced OAD therapy. Among patients with T2DM with/without PDRCs, fourth-line insulin therapy was associated with greater risks of the composite cardiovascular outcome (HR 1.23, 95% CI 1.03-1.46), heart failure (HR 1.59, 95% CI 1.12-2.25), ischaemic heart disease (HR 1.37, 95% CI 1.09-1.73), PVD (HR 1.17, 95% CI 1.00-1.36), hypoglycaemia (HR 1.49, 95% CI 1.20-1.85) and all-cause mortality (HR 1.48, 95% CI 1.01-2.17), but adjustment for hypoglycaemia significantly attenuated the risk of heart failure (HR 1.34, 95% CI 0.92-1.94), PVD (HR 1.15, 95% CI 0.98-1.34) and all-cause mortality (HR 1.30, 95% CI 0.84-1.99). CONCLUSIONS Initiation of fourth-line insulin therapy can be considered for patients with T2DM with triple OAD therapy failure, and the importance of awareness and prevention of hypoglycaemia among insulin-treated patients with T2DM cannot be overstated.
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Affiliation(s)
- Shihchen Kuo
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Chun-Ting Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jin-Shang Wu
- Department of Family Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, National Cheng Kung University Hospital, Tainan, Taiwan
- Corresponding author. Address: Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, 1 University Road, Tainan 7010, Taiwan, Telephone: 886-6-2353535 ext.5685, Fax: 886-6-2373149,
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Anyanwagu U, Donnelly R, Idris I. Individual and Combined Relationship between Reduced eGFR and/or Increased Urinary Albumin Excretion Rate with Mortality Risk among Insulin-Treated Patients with Type 2 Diabetes in Routine Practice. KIDNEY DISEASES 2018; 5:91-99. [PMID: 31019922 DOI: 10.1159/000493731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 09/12/2018] [Indexed: 12/29/2022]
Abstract
Background A low estimated glomerular filtration rate (eGFR) and an increased urinary albumin-to-creatinine ratio (ACR) are well-recognised prognostic markers of cardiovascular (CV) risk, but their individual and combined relationship with CV disease and total mortality among insulin-treated type 2 diabetes (T2D) patients in routine clinical care is unclear. Methods We analysed data for insulin users with T2D from UK general practices between 2007 and 2014 and examined the association between mortality rates and chronic kidney disease [categorised by low eGFR (< 60 mL/min/1.73 m2), high eGFR (≥60 mL/min/1.73 m2), low ACR (< 300 mg/g); and high ACR (≥300 mg/g) at insulin initiation] after a 5-year follow-up period using Cox proportional hazard models. Results A total of 18,227 patients were identified (mean age: 61.5 ± 13.8 years, mean HbA1c: 8.6 ± 1.8%). After adjusting for confounders, when compared to adults on insulin therapy with an eGFR < 60 and an ACR ≥300 (low eGFR + high ACR) after a follow-up period of 5 years, patients with an eGFR < 60 and an ACR < 300 (low eGFR + low ACR) had a 6% lower mortality rate (aHR: 0.94; 95% CI 0.79-1.12); those with an eGFR > 60 and an ACR ≥300 (high eGFR + high ACR) had a 20% lower mortality rate (aHR: 0.80; 95% CI 0.68-0.96); and those with an eGFR > 60 and an ACR < 300 (high eGFR + low ACR) had the lowest death rate (28% less; aHR: 0.72; 95% CI 0.59-0.87). Conclusion This study shows that among a large cohort of insulin-treated T2D patients in routine practice, the combination of reduced eGFR with increased ACR was associated with the greatest risk of premature death, followed closely by those with reduced eGFR and normal ACR levels. Adoption of aggressive CV risk management strategies to reduce mortality in patients with a low eGFR and albuminuria is essential in high-risk patients with T2D.
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Affiliation(s)
- Uchenna Anyanwagu
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Richard Donnelly
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Iskandar Idris
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, United Kingdom
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Overbeek JA, Heintjes EM, Huisman EL, Tikkanen CK, van Diermen AW, Penning‐van Beest FJ, Herings RM. Clinical effectiveness of liraglutide vs basal insulin in a real-world setting: Evidence of improved glycaemic and weight control in obese people with type 2 diabetes. Diabetes Obes Metab 2018; 20:2093-2102. [PMID: 29726082 PMCID: PMC6099315 DOI: 10.1111/dom.13335] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 12/19/2022]
Abstract
AIMS To compare real-world antidiabetic treatment outcomes over 12 months in obese people with type 2 diabetes mellitus (T2DM) who previously received oral antidiabetic therapy and then initiated a first injectable therapy with liraglutide or basal insulin. PATIENTS AND METHODS This was a retrospective, propensity score-matched, longitudinal cohort study using real-world data (January 2010 to December 2015) from the Dutch PHARMO Database Network. Adult obese (body mass index [BMI] ≥35 kg/m2 ) patients with T2DM with ≥2 dispensing dates for liraglutide or basal insulin supported oral therapy (BOT) were selected. The primary endpoint was the change in glycated haemoglobin (HbA1c) from baseline during 12 months of follow-up. The secondary endpoints were the changes in weight, BMI and cardiovascular risk factors from baseline. Clinical data were analysed using descriptive statistics and compared using mixed models for repeated measures. RESULTS Obese patients with T2DM (N = 1157) in each treatment group were matched (liraglutide cohort, n = 544; BOT cohort, n = 613). From 3 months onwards, glycaemic control improved in both cohorts but improved significantly more with liraglutide than with BOT (12 months: -12.2 mmol/mol vs -8.8 mmol/mol; P = .0053). In addition, weight and BMI were significantly lower for treatments with liraglutide vs BOT (12 months: -6.0 kg vs -1.6 kg and - 2.1 kg/m2 vs -0.5 kg/m2 , respectively; P < .0001 for both). No significant differences were seen in changes in cardiovascular risk factors. CONCLUSIONS The results of this real-world study in matched obese patients with T2DM showed that liraglutide was more effective than BOT for HbA1c control and weight/BMI reductions. Patients were more likely to maintain glycaemic control over time after initiating liraglutide than after initiating BOT.
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Affiliation(s)
- Jetty A. Overbeek
- PHARMO Institute for Drug Outcomes ResearchUtrechtthe Netherlands
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research InstituteVU University Medical CentreAmsterdamthe Netherlands
| | | | | | | | | | | | - Ron M.C. Herings
- PHARMO Institute for Drug Outcomes ResearchUtrechtthe Netherlands
- Department of Epidemiology and BiostatisticsVU University Medical CenterAmsterdamthe Netherlands
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Munir KM, Davis SN. Are SGLT2 inhibitors or GLP-1 receptor agonists more appropriate as a second-line therapy in type 2 diabetes? Expert Opin Pharmacother 2018; 19:773-777. [DOI: 10.1080/14656566.2018.1475559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Kashif M. Munir
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Center for Diabetes and Endocrinology, Baltimore, MD, USA
| | - Stephen N. Davis
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Anyanwagu U, Mamza J, Donnelly R, Idris I. Effect of adding GLP-1RA on mortality, cardiovascular events, and metabolic outcomes among insulin-treated patients with type 2 diabetes: A large retrospective UK cohort study. Am Heart J 2018; 196:18-27. [PMID: 29421011 DOI: 10.1016/j.ahj.2017.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Combining a GLP-1 receptor agonist (GLP-1RA) with insulin is often an effective treatment strategy for overweight patients with type 2 diabetes (T2D), but little is known about the longer-term effects on cardiovascular and mortality outcomes in routine clinical practice in the United Kingdom. We therefore compared the times to a major nonfatal cardiovascular (CV) event and all-cause mortality among overweight patients with T2D treated with insulin alone versus insulin+GLP-1RA in a large UK database. METHODS A retrospective cohort study was conducted in 18,227 patients with insulin-treated T2D from UK General Practices using The Health Improvement Network database. The 5-year risk of mortality and a 3-point composite of all-cause mortality and nonfatal CV outcomes (myocardial infarction or stroke) was compared between a propensity score-matched cohort of those on insulin alone (n=1,793) and insulin+GLP-1RA (n=1,793), irrespective of other diabetes therapies, providing a total of 12,682 person-years of follow-up. Cox proportional hazard models were used to estimate the hazard ratios of the outcomes. RESULTS Hemoglobin A1c reduction was similar between both groups (-0.42 vs -0.33%, P=.089 at 12 months). Overall, 3-point composite events of all-cause mortality and CV events (major adverse cardiovascular even) were 98 versus 55 for the insulin alone versus insulin+GLP-1RA groups, respectively (14.7 vs 9.2 per 1,000 person-years; adjusted hazard ratio [aHR]: 0.64; 95% CI: 0.42-0.98; P=.038). Corresponding composite nonfatal CV events were 33 versus 28 (6.0 vs 5.6 per 1,000 person-years; aHR: 0.76; 95% CI: 0.41-1.42; P=.393), whereas all-cause mortality events were 49 versus 13 (6.9 vs 2.0 per 1,000 person-years; aHR: 0.35; 95% CI: 0.17-0.73; P=.005). CONCLUSION Based on a large UK cohort in routine clinical practice, adding a GLP-1RA to insulin therapy is associated with a reduction in risk of composite CV events and all-cause mortality but a nonsignificant higher risk of hospitalization for heart failure in overweight patients with T2D.
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Anyanwagu U, Mamza J, Donnelly R, Idris I. Effects of obesity on metabolic and cardiovascular outcomes following insulin initiation in patients with type 2 diabetes. Obes Res Clin Pract 2018; 12:72-84. [DOI: 10.1016/j.orcp.2017.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/04/2017] [Accepted: 08/23/2017] [Indexed: 11/25/2022]
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Anyanwagu U, Mamza J, Donnelly R, Idris I. Association between insulin-induced weight change and CVD mortality: Evidence from a historic cohort study of 18,814 patients in UK primary care. Diabetes Metab Res Rev 2018; 34. [PMID: 28865238 DOI: 10.1002/dmrr.2945] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 08/07/2017] [Accepted: 08/24/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND This study explores the association of insulin-induced weight (wt) gain on cardiovascular outcomes and mortality among patients with type 2 diabetes (T2D) following insulin initiation using real-world data. METHODS A historical cohort study was performed in 18,814 adults with insulin-treated T2D derived from the UK The Health Improvement Network database. Based on the average weight change of 5 kg, 1 year postinsulin initiation, patients were grouped into 5 categories (>5 kg wt loss; 1.0-5.0 kg wt loss; no wt change; 1.0-5.0 kg wt gain; >5.0 kg wt gain) and followed-up for 5 years. Cox proportional hazard models and Kaplan-Meier estimators were fitted to estimate the hazards of a 3-point composite of nonfatal myocardial infarction, stroke, and all-cause mortality between categories. RESULTS The median age was 62.8 (IQR: 52.3-71.8) years, HbA1c : 8.6% (IQR: 7.4-9.8) and mean BMI: 31.8 (6.5) kg/m2 . The 5 year probability of survival differed significantly within the wt-change categories (log-rank test P value = .0005). Only 1963 composite events occurred. Compared with the weight-neutral group, the risk of composite events was 31% greater in the >5 kg wt-loss group (aHR: 1.31; 95% CI: 1.02, 1.68), the same in the 1.0 to 5.0 kg wt-gain category, but nonsignificantly increased in the 1.0 to 5.0 kg wt loss (15%) and >5.0 kg wt gain (13%) categories, respectively. In the obese subgroup, this risk was 50% (aHR: 1.50, 95% CI: 1.08-2.08) more in the >5 kg weight-loss group compared with the weight-neutral group. CONCLUSION Insulin-induced weight gain did not translate to adverse cardiovascular outcomes and mortality in patients with T2D. These data provide reassurance on the cardiovascular safety of insulin patients with T2D.
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Affiliation(s)
- Uchenna Anyanwagu
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jil Mamza
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Richard Donnelly
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Iskandar Idris
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
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Anyanwagu U, Mamza J, Gordon J, Donnelly R, Idris I. Premixed vs basal-bolus insulin regimen in Type 2 diabetes: comparison of clinical outcomes from randomized controlled trials and real-world data. Diabet Med 2017; 34:1728-1736. [PMID: 28945928 DOI: 10.1111/dme.13518] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2017] [Indexed: 02/04/2023]
Abstract
AIM To evaluate the concordance between data derived from randomized controlled trial (RCT) and real-world estimates of HbA1c and weight change after 24 weeks of initiation of a basal-bolus compared with a premixed insulin regimen in people with Type 2 diabetes. METHODS Data eight RCTs were pooled after a systematic review of studies examining basal-bolus (n = 1893) or premixed (n = 1517) regimens. Real-world data were extracted from the UK primary care dataset for people on basal-bolus (n = 7483) or premixed insulin regimens (n=10 744). The mean differences between HbA1c and weight from baseline were calculated using t-tests, while analysis of variance was used to compare the two treatment regimens. Linear regression analyses were used to determine the predictors of this change. RESULTS Both insulin regimens were associated with HbA1c reductions (real-world data -0.28%; RCT data, -1.4%) and weight gain (real-world data, +0.27 kg; RCT data, +2.96 kg) but there were no significant differences between basal-bolus and premixed insulin. Discordances in the pattern of treatment response were observed, however, between real-world and RCT data for both insulin regimens. For any given baseline HbA1c concentration, the change in HbA1c in the RCTs was greater than in real-world conditions and for those with baseline weight above ~60 kg, RCT data showed overall weight gain in contrast to slight weight loss in the real-world population. Lastly, for both randomized controlled trial and real-world populations, while greater baseline weight was associated with reduced response to treatment, the association was much steeper in the RCT than in the real-world population. In addition, greater baseline weight was associated with greater weight reductions in both premixed insulin and basal-bolus insulin regimens, although to a lesser extent with the latter. CONCLUSION These results highlight specific discrepancies in the HbA1c reduction and weight change in insulin regimen between real world versus RCT populations; with greater reduction in HbA1c and greater increase in weight observed in the RCT population than in the real-world population. Also, the basal-bolus regimens in both real-world and RCT populations showed greater reduction in HbA1c compared to the premix regimen (though more marked in RCTs), while the premix regimen showed greater increase in weight in real-world, as against basal-bolus in the RCT population.
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Affiliation(s)
- U Anyanwagu
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - J Mamza
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - J Gordon
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - R Donnelly
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - I Idris
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
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Anyanwagu U, Mamza J, Donnelly R, Idris I. Effects of background statin therapy on glycemic response and cardiovascular events following initiation of insulin therapy in type 2 diabetes: a large UK cohort study. Cardiovasc Diabetol 2017; 16:107. [PMID: 28830436 PMCID: PMC5567903 DOI: 10.1186/s12933-017-0587-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 08/13/2017] [Indexed: 02/24/2023] Open
Abstract
Aim Statins may increase the risk of new-onset diabetes and adversely affect glycaemic control, but their effects on the glycemic response and mortality outcomes following commencement of insulin therapy in patients with Type 2 Diabetes (T2D) are unclear. Methods A retrospective cohort study was conducted in 12,725 insulin initiators with T2D using The Health Improvement Network (THIN) UK database. Changes in HbA1c at 6, 12, 24 and 36 months, and the 5-year risk of mortality and (3-point) major adverse cardiovascular events (MACE), were compared between prior users (n = 10,682) and non-users (n = 2043) of statin therapy who were newly commenced on insulin treatment. Cox proportional hazard models were used to estimate the hazard ratios of the different outcomes. Results Mean age of the cohort was 58.7 ± 14.0 years (51% male) and mean baseline HbA1c was 8.7 ± 1.8%. A greater initial reduction in HbA1c was observed following insulin initiation in the non-users of statins compared with the users, which was significant in the short term (−0.34% vs −0.26% at 6 months; mean diff = −0.09%, p = 0.004) but not in the long term: −0.31% versus −0.35% at 3 years (mean diff = 0.05%, p = 0.344). CV events (3-point MACE) were 878 versus 217 in statin users versus non-users (20.7 vs 30.9 per 1000 person-years; adjusted Hazard Ratio (aHR) 1.36 (95% CI 1.15–1.62; p < 0.0001). In a subgroup analysis of individual statins, HbA1c was higher throughout the study duration with all statins relative to non-users of statin therapy (p < 0.05). The aHRs for 3-point MACE for atorvastatin, simvastatin, rosuvastatin and pravastatin were 0.82 (95% CI 0.68–0.98), 0.67 (0.55–0.82), 0.56 (0.39–0.81) and 0.78 (0.60–1.01), respectively. Conclusions Following initiation of insulin therapy in patients with T2D in routine care, concurrent use of a statin was associated with less good glycaemic control in the short-term but a much lower risk of major adverse CV events. Electronic supplementary material The online version of this article (doi:10.1186/s12933-017-0587-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Uchenna Anyanwagu
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK
| | - Jil Mamza
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK
| | - Richard Donnelly
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK
| | - Iskandar Idris
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK.
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Abd El Aziz MS, Kahle M, Meier JJ, Nauck MA. A meta-analysis comparing clinical effects of short- or long-acting GLP-1 receptor agonists versus insulin treatment from head-to-head studies in type 2 diabetic patients. Diabetes Obes Metab 2017; 19:216-227. [PMID: 27717195 DOI: 10.1111/dom.12804] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/07/2016] [Accepted: 09/16/2016] [Indexed: 12/25/2022]
Abstract
AIMS To study differences in clinical outcomes between initiating glucagon-like peptide-1 receptor agonist (GLP-1 RAs) vs insulin treatment in patients with type 2 diabetes treated with oral glucose-lowering medications (OGLM). METHODS Prospective, randomized trials comparing GLP-1 RA and insulin treatment head-to-head as add-on to OGLM were identified (PubMed). Differences from baseline values were compared for HbA1c, fasting plasma glucose, bodyweight, blood pressure, heartrate and lipoproteins. Proportions of patients reporting hypoglycaemic episodes were compared. RESULTS Of 712 publications identified, 23 describing 19 clinical trials were included in the meta-analysis. Compared to insulin, GLP-1 RAs reduced HbA1c more effectively (Δ -.12%, P < .0001). Basal insulin was more effective in reducing fasting plasma glucose (Δ -1.8 mmol/L, P < .0001). GLP-1 RAs reduced bodyweight more effectively (Δ -3.71 kg; P < .0001). The proportion of patients experiencing hypoglycaemic episodes was 34% lower with GLP-1 RAs ( P < .0001), with a similar trend for severe hypoglycaemia. Systolic blood pressure was lower and heartrate was higher with GLP-1 RAs ( P < .0001). Triglycerides and LDL cholesterol were significantly lower with GLP-1 RAs. Long-acting GLP-1 RAs were better than short-acting GLP-1 RAs in reducing HbA1c and fasting glucose, but were similar regarding bodyweight. CONCLUSIONS Slightly better glycaemic control can be achieved by adding GLP-1 RAs to OGLM as compared to insulin treatment, with added benefits regarding bodyweight, hypoglycaemia, blood pressure and lipoproteins. These differences are in contrast to the fact that insulin is prescribed far more often than GLP-1 RAs.
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Affiliation(s)
- Mirna S Abd El Aziz
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Melanie Kahle
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Juris J Meier
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Michael A Nauck
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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Kruljac I, Ćaćić M, Ćaćić P, Ostojić V, Štefanović M, Šikić A, Vrkljan M. Diabetic ketosis during hyperglycemic crisis is associated with decreased all-cause mortality in patients with type 2 diabetes mellitus. Endocrine 2017; 55:139-143. [PMID: 27592119 DOI: 10.1007/s12020-016-1082-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 08/08/2016] [Indexed: 11/27/2022]
Abstract
Patients with type 2 diabetes mellitus have impaired ketogenesis due to high serum insulin and low growth hormone levels. Evidence exists that ketone bodies might improve kidney and cardiac function. In theory, improved ketogenesis in diabetics may have positive effects. We aimed to assess the impact of diabetic ketosis on all-cause mortality in patients with type 2 diabetes mellitus presenting with hyperglycemic crisis. We analyzed 486 patients with diabetic ketosis and 486 age and sex-matched patients with non-ketotic hyperglycemia presenting to the emergency department. Cox proportional hazard models were used to analyze the link between patient characteristics and mortality. During an observation time of 33.4 months, death of any cause occurred in 40.9 % of the non-ketotic hyperglycemia group and 30.2 % of the DK group (hazard ratio in the diabetic ketosis group, 0.63; 95 % confidence interval 0.48-0.82; P = 0.0005). Patients with diabetic ketosis had a lower incidence of symptomatic heart failure and had improved renal function. They used less furosemide and antihypertensive drugs, more metformin and lower insulin doses, all of which was independently associated with decreased mortality. Plasma glucose and glycated hemoglobin levels were similar in both groups. Patients with hyperglycemic crisis and diabetic ketosis have decreased all-cause mortality when compared to those with non-ketotic hyperglycemia. diabetic ketosis might be a compensatory mechanism rather than a complication in patients with hyperglycemic crises, but further prospective studies are warranted.
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Affiliation(s)
- Ivan Kruljac
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso", University Hospital Center "Sestre Milosrdnice", University of Zagreb School of Medicine, Vinogradska cesta 29, Zagreb, 10000, Croatia.
| | - Miroslav Ćaćić
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso", University Hospital Center "Sestre Milosrdnice", University of Zagreb School of Medicine, Vinogradska cesta 29, Zagreb, 10000, Croatia
| | - Petra Ćaćić
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Vedran Ostojić
- Department of Internal Medicine, University Hospital "Sveti Duh", Zagreb, Croatia
| | - Mario Štefanović
- Clinical Institute of Chemistry, University Hospital Center "Sestre Milosrdnice", University of Zagreb Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
| | - Aljoša Šikić
- Department of Emergency Medicine, University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Milan Vrkljan
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso", University Hospital Center "Sestre Milosrdnice", University of Zagreb School of Medicine, Vinogradska cesta 29, Zagreb, 10000, Croatia
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