Effectiveness and safety of dipeptidyl peptidase 4 inhibitors in the management of type 2 diabetes in older adults: a systematic review and development of recommendations to reduce inappropriate prescribing

Characterization of treatment intensified (add-on to metformin) adults with type 2 diabetes in Thailand: A cross-sectional real-world study (CONVERGE)

OBJECTIVE

The CONVERGE (Cardiovascular Outcomes and Value in the Real-World with GLP-1RAs) study characterized demographics, clinical characteristics, and medication use in treatment-intensified (add-on to metformin) adults with type 2 diabetes (T2D) in Thailand.

METHODS

A retrospective cross-sectional study of data from medical records (Jul 26, 2013, to Dec 31, 2017) was descriptively summarized for overall population and subgroups defined by glucose-lowering agent (GLA) classes.

RESULTS

Data from 1,000 adults were collected in reverse chronological order. At baseline, the mean (SD) age was 60 (12) years, HbA1c was 8.0%, and the median (IQR) T2D duration was 1.0 (0.2-2.4) years. Patients taking SGLT2-is (sodium glucose cotransporter-2 inhibitors) had a longer T2D duration (1.8 years, 0.8-3.2), GLP-1RAs (glucagon-like peptide-1 receptor agonists) had a higher body mass index of 32.0 (8.84) kg/m2, and insulin subgroup had a higher HbA1c 8.5% (7.5-10.1). The utilization of GLP-1 RAs/SGLT-2is was low (1.5% and 6%, respectively). Among the subgroups, most patients in the GLP-1RA (80.0%) and insulin subgroup (81.3%) receiving 3/≥4 GLAs. The most frequently prescribed GLAs post-metformin were sulfonylureas (45.2%) and dipeptidyl peptidase-4 inhibitors (39.4%). Overall, 90% received ≥1 cardiovascular (CV) medication; lipid-lowering agents (78%) were the most prescribed.

CONCLUSIONS

These results indicate low utilization of GLAs with CV benefits, attributed to a lack of CV benefit data during the study period and partial reimbursement implementation. Future studies must identify barriers to adoption and estimate the usage of these GLAs with CV benefits as more evidence becomes available on positive CV outcomes to improve patient care in Thailand.

A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients-A Review PART II-Pharmacological Approach for Management of Elderly Patients with Peripheral Atherosclerotic Lesions outside Coronary Territory

BACKGROUND

Aging is a key risk factor for atherosclerosis progression that is associated with increased incidence of ischemic events in supplied organs, including stroke, coronary events, limb ischemia, or renal failure. Cardiovascular disease is the leading cause of death and major disability in adults ≥ 75 years of age. Atherosclerotic occlusive disease affects everyday activity, quality of life, and it is associated with reduced life expectancy. As most multicenter randomized trials exclude elderly and very elderly patients, particularly those with severe comorbidities, physical or cognitive dysfunctions, frailty, or residence in a nursing home, there is insufficient data on the management of older patients presenting with atherosclerotic lesions outside coronary territory. This results in serious critical gaps in knowledge and a lack of guidance on the appropriate medical treatment. In addition, due to a variety of severe comorbidities in the elderly, the average daily number of pills taken by octogenarians exceeds nine. Polypharmacy frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and non-adherence. Therefore, we have attempted to gather data on the medical treatment in patients with extra-cardiac atherosclerotic lesions indicating where there is some evidence of the management in elderly patients and where there are gaps in evidence-based medicine. Public PubMed databases were searched to review existing evidence on the effectiveness of lipid-lowering, antithrombotic, and new glucose-lowering medications in patients with extra-cardiac atherosclerotic occlusive disease.

Deprescribing, shared decision-making, and older people: perspectives in primary care

Polypharmacy is an issue that affects many people, especially older adults, and could result in negative outcomes such as lower medication adherence and an increase in the likelihood of adverse drug reactions. Deprescribing is a possible solution to mitigating this issue. Examining polypharmacy and deprescribing in primary care settings is important as it could help older adults living in the community and their relatives by lowering their treatment burden and medication cost. Some guidelines have been developed to help with the deprescribing process; however, these guidelines are not applicable to all patients and situations. Thus, the deprescribing process needs to be based mainly on the patient's current situations, preferences, and values and this could be achieved using shared decision-making. However, some barriers slow down the process to deprescribe in primary care settings and measures should be taken to overcome these barriers. This review aims to examine the current situation of deprescribing, especially in primary care settings, and how SDM can be used to optimize the deprescribing process. To achieve this an illustration using one prominent model in SDM and one prominent model in deprescribing will be presented to showcase how SDM can be used in the deprescribing process.

The Impact of Glucose-Lowering Strategy on the Risk of Increasing Frailty Severity among 49,519 Patients with Diabetes Mellitus: A Longitudinal Cohort Study

Patients with diabetes mellitus (DM) have a higher risk of incident and aggravating frailty over time. Frailty-initiating risk factors have been identified, but modulators of frail severity over time remain poorly defined. We aimed to explore the influences of glucose-lowering drug (GLD) strategy on DM patients' risk of increasing frail severity. We retrospectively identified type 2 DM patients between 2008 and 2016, dividing them into "no GLD", oral GLD (oGLD) monotherapy, oGLD combination, and those receiving insulin without or with oGLD at baseline. Increasing frail severity, defined as ≥1 FRAIL component increase, was the outcome of interest. Cox proportional hazard regression was utilized to analyze the risk of increasing frail severity associated with GLD strategy, accounting for demographic, physical data, comorbidities, medication, and laboratory panel. After screening 82,208 patients with DM, 49,519 (no GLD, 42.7%; monotherapy, 24.0%; combination, 28.5%; and insulin user, 4.8%) were enrolled for analysis. After 4 years, 12,295 (24.8%) had increasing frail severity. After multivariate adjustment, oGLD combination group exhibited a significantly lower risk of increasing frail severity (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.86 - 0.94), while the risk of insulin users increased (HR 1.11, 95% CI 1.02 - 1.21) than no GLD group. Users receiving more oGLD exhibited a trend of less risk reduction relative to others. In conclusion, we discovered that the strategy of oral glucose lowering drugs combination might reduce the risk of frail severity increase. Accordingly, medication reconciliation in frail diabetic older adults should take into account their GLD regimens.

Socioeconomic aspects of incretin-based therapy

Incretin-based therapies, particularly glucagon-like peptide-1 receptor agonists (GLP-1 RAs), have demonstrated cardiovascular benefits in people with type 2 diabetes. However, socioeconomic disparities in their uptake may constrain the collective advantages offered by these medications to the broader population. In this review we examine the socioeconomic disparities in the utilisation of incretin-based therapies and discuss strategies to address these inequalities. Based on real-world evidence, the uptake of GLP-1 RAs is reduced in people who live in socioeconomically disadvantaged areas, have low income and education level, or belong to racial/ethnic minorities, even though these individuals have a greater burden of type 2 diabetes and cardiovascular disease. Contributing factors include suboptimal health insurance coverage, limited accessibility to incretin-based therapies, financial constraints, low health literacy and physician-patient barriers such as provider bias. Advocating for a reduction in the price of GLP-1 RAs is a pivotal initial step to enhance their affordability among lower socioeconomic groups and improve their value-for-money from a societal perspective. By implementing cost-effective strategies, healthcare systems can amplify the societal benefits of incretin-based therapies, alongside measures that include maximising treatment benefits in specific subpopulations while minimising harms in vulnerable individuals, increasing accessibility, enhancing health literacy and overcoming physician-patient barriers. A collaborative approach between governments, pharmaceutical companies, healthcare providers and people with diabetes is necessary for the effective implementation of these strategies to enhance the overall societal benefits of incretin-based therapies.

Prescription of oral antidiabetics in Mexico. A cross-sectional study

In 2016 diabetes was declared an epidemic and a health emergency in Mexico. As the rationale of the treatment is to achieve target glycemia levels, the appropriateness of the medications used is important. The aim of this study is to learn the pattern of antidiabetic drug prescription and factors associated with inappropriate prescription in Mexico. A retrospective cross-sectional drug utilization study has been conducted. A randomly selected sample was carefully examined. Out of 3600 clinical records of patients diagnosed with type 2 diabetes mellitus (T2DM), 196 records were revised. As far as control is concerned, 36.7% had their glycemia values in the recommended range. A combination of different antidiabetics was the most common pattern observed (60.7%); the most frequent was that of the association of metformin with whatever oral antidiabetics. Prescriptions were considered as inappropriate in 149 cases (76.0%); younger age and lack of nutritional assessment was significantly related to inappropriate prescription. A trend to use more drugs for treating T2DM has been consistently observed. Despite using so many drugs, most of the patients are not controlled. Avoiding inappropriate prescription by following current guidelines may contribute to a better control and, in turn, decrease morbidity and mortality for this cause.

Thürmann P. Potentially Inadequate Medications in the Elderly: PRISCUS 2.0

BACKGROUND

The term potentially inadequate medication (PIM) is used to describe substances that may be unsuitable for use inthe elderly and should be avoided. The PRISCUS list, published in 2010, was the first catalog of PIM designed for the Germandrug market to become adopted in practice. While 24% of German patients aged ≥ 65 years were prescribed at least one PIMper year in 2009, the proportion in 2019 was only 14.5%.

METHODS

In a three-round Delphi process, experts from clinical practice and research evaluated whether selected substancesare PIM for the elderly. The participants were provided with dedicated literature including systematic reviews carried out for theparticular purposes of this project.

RESULTS

Fifty-nine persons took part in the Delphi process and, in addition, contributed comments and therapeutic alternatives.Altogether, 187 substances were classed as PIM. One hundred thirty-three of the substances now listed were not in the originalPRISCUS list: these include some oral antidiabetics, all of the selective COX-2 inhibitors, and moderately long acting benzodiazepinessuch as oxazepam. For some other substances, e.g., proton pump inhibitors (PPI), the advisability of treatment formore than 8 weeks was considered as potentially inappropriate, as was the use of ibuprofen in doses >1200 mg/day and formore than 1 week without PPI. Risperidone for more than 6 weeks is also PIM.

CONCLUSION

The new, greatly extended PRISCUS list must now be validated in epidemiological and prospective studies and itspracticability in routine daily use must be verified.

Short-term effectiveness of dapagliflozin versus DPP-4 inhibitors in elderly patients with type 2 diabetes: a multicentre retrospective study

AIM

To compare effectiveness of dapagliflozin versus DPP-4 inhibitors on individualized HbA1c targets and extra-glycaemic endpoints among elderly patients with type 2 diabetes (T2D).

METHODS

This was a multicentre retrospective study on patients aged 70-80 years with HbA1c above individualized target and starting dapagliflozin or DPP-4 inhibitors in 2015-2017. The primary outcome was the proportion reaching individualized HbA1c targets. Confounding by indication was addressed by inverse probability of treatment weighting (IPTW), multivariable adjustment (MVA), or propensity score matching (PSM).

RESULTS

Patients initiating dapagliflozin (n = 445) differed from those initiating DPP-4i (n = 977) and balance between groups was achieved with IPTW or PSM. The median follow-up was 7.5 months and baseline HbA1c was 8.3%. A smaller proportion of patients initiating dapagliflozin attained individualized HbA1c target as compared to those initiating DPP-4 inhibitors (RR 0.73, p < 0.0001). IPTW, MVA, and PSM yielded similar results. Between-group difference in the primary outcome was observed among patients with lower eGFR or longer disease duration. Dapagliflozin allowed greater reductions in body weight and blood pressure than DPP-4 inhibitors.

CONCLUSIONS

Elderly patients with T2D initiating dapagliflozin had a lower probability of achieving individualized HbA1c targets than those initiating DPP-4 inhibitors but displayed better improvements in extra-glycaemic endpoints.

Safety of dipeptidyl peptidase-4 inhibitors in older adults with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

Registration:

PROSPERO: CRD42020210645

Introduction:

We aimed to assess the safety of dipeptidyl peptidase-4 (DPP-4) inhibitors in older patients with type 2 diabetes with inadequate glycaemic control.

Methods:

We included randomized controlled trials (RCTs) in older (⩾65 years) patients with type 2 diabetes. The intervention group was randomized to treatment with any DPP-4 inhibitors. A systematic search in MEDLINE and Embase was performed in December 2020. For assessing the risk of bias, RoB 2 tool was applied. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We pooled outcomes using random effects meta-analyses.

Results:

We identified 16 RCTs that included 19,317 patients with a mean age of greater than 70 years. The mean HbA1c level ranged between 7.1 and 10.0 g/dl. Adding DPP-4 inhibitors to standard care alone may increase mortality slightly [risk ratio (RR) 1.04; 95% confidence interval (CI) 0.89–1.21]. Adding DPP-4 inhibitors to standard care increases the risk for hypoglycaemia (RR 1.08; 95% CI 1.01–1.16), but difference in overall adverse events is negligible. DPP-4 inhibitors added to standard care may reduce mortality compared with sulfonylureas (RR 0.88; 95% CI 0.75–1.04). DPP-4 inhibitors probably reduce the risk for hypoglycaemia compared with sulfonylureas (magnitude of effect not quantifiable because of heterogeneity) but difference in overall adverse events is negligible. There is insufficient evidence on hospitalizations, falls, fractures, renal impairment and pancreatitis.

Conclusion:

There is no evidence that DPP-4 inhibitors in addition to standard care decrease mortality but DPP-4 inhibitors increase hypoglycaemia risk. Second-line therapy in older patients should be considered cautiously even in drugs with a good safety profile such as DPP-4 inhibitors. In case second-line treatment is necessary, DPP-4 inhibitors appear to be preferable to sulfonylureas.

Plain language summary

Safety of dipeptidyl peptidase-4 inhibitors in older adults with type 2 diabetes Introduction: We performed the review to assess the safety of dipeptidyl peptidase-4 (DPP-4) inhibitors in older type 2 diabetes patients with blood sugar outside the normal level. Methods: To answer the question, we searched various electronic databases. We included studies in older (⩾65 years) patients with type 2 diabetes that assessed the safety of DPP-4 inhibitors. The data from the different studies were quantitatively summarized using statistical methods. We assessed the quality of the data to judge the certainty of the findings. Results: We identified 16 studies that included 19,317 patients with a mean age greater than 70 years. The average blood sugar level of patients in the included studies was slightly or moderately increased. Adding DPP-4 inhibitors to standard care alone may increase mortality slightly. Adding DPP-4 inhibitors to standard care increases the risk for hypoglycaemia, but difference in overall adverse events is negligible. DPP-4 inhibitors added to standard care may reduce mortality compared with sulfonylureas. DPP-4s probably reduce the risk of hypoglycaemia compared with sulfonylureas (magnitude of effect not quantifiable because of heterogeneity) but difference in overall adverse events is negligible. There is insufficient evidence on hospitalizations, falls, fractures, renal impairment and pancreatitis. Conclusion: There is no evidence that DPP-4 inhibitors in addition to standard care decrease mortality but DPP-4 inhibitors increase the risk that blood sugar falls below normal. Adding DPP-4 inhibitorss to standard care in older patients should be considered cautiously even in drugs with a good safety profile such as DPP-4 inhibitors. In case additional treatment is necessary, DPP-4 inhibitors appear to be preferable to sulfonylureas.

Effects of Teneligliptin on HbA1c levels, Continuous Glucose Monitoring-Derived Time in Range and Glycemic Variability in Elderly Patients with T2DM (TEDDY Study)

BACKGROUND

To evaluate the effects of teneligliptin on glycosylated hemoglobin (HbA1c) levels, continuous glucose monitoring (CGM)-derived time in range, and glycemic variability in elderly type 2 diabetes mellitus patients.

METHODS

This randomized, double-blinded, placebo-controlled study was conducted in eight centers in Korea (clinical trial registration number: NCT03508323). Sixty-five participants aged ≥65 years, who were treatment-naïve or had been treated with stable doses of metformin, were randomized at a 1:1 ratio to receive 20 mg of teneligliptin (n=35) or placebo (n=30) for 12 weeks. The main endpoints were the changes in HbA1c levels from baseline to week 12, CGM metrics-derived time in range, and glycemic variability.

RESULTS

After 12 weeks, a significant reduction (by 0.84%) in HbA1c levels was observed in the teneligliptin group compared to that in the placebo group (by 0.08%), with a between-group least squares mean difference of -0.76% (95% confidence interval [CI], -1.08 to -0.44). The coefficient of variation, standard deviation, and mean amplitude of glycemic excursion significantly decreased in participants treated with teneligliptin as compared to those in the placebo group. Teneligliptin treatment significantly decreased the time spent above 180 or 250 mg/dL, respectively, without increasing the time spent below 70 mg/dL. The mean percentage of time for which glucose levels remained in the 70 to 180 mg/dL time in range (TIR70-180) at week 12 was 82.0%±16.0% in the teneligliptin group, and placebo-adjusted change in TIR70-180 from baseline was 13.3% (95% CI, 6.0 to 20.6).

CONCLUSION

Teneligliptin effectively reduced HbA1c levels, time spent above the target range, and glycemic variability, without increasing hypoglycemia in our study population.

Efficacy and safety of semaglutide in glycemic control, body weight management, lipid profiles and other biomarkers among obese type 2 diabetes patients initiated or switched to semaglutide from other GLP-1 receptor agonists

Purpose

Evidence of the efficacy and safety of semaglutide among patients with type 2 diabetes who were initiated on or were switched to semaglutide from other GLP-1 RAs remains limited. The objective of this study was to investigate the short-term effects of switching to semaglutide from other GLP-1 RAs.

Methods

This retrospective cohort study evaluated patients with type 2 diabetes who were initiated on or were switched to semaglutide due to poor diabetes control with other GLP-1 RAs or other medications, or obesity. HbA1c, body weight, serum creatinine, serum uric acid, parameters of lipid metabolism, and parameters of liver function were measured before and 6 months after administration of semaglutide.

Results

A total of 50 patients were registered in the study. After switching to semaglutide (n = 43), HbA1c and body weight significantly decreased (p < 0.01, p < 0.01), respectively. The same findings were observed in semaglutide-naïve patients (p = 0.04, p < 0.02) (n = 7). Serum uric acid, total cholesterol, triglycerides, and urinary albumin-creatinine ratio decreased significantly as well (p = 0.04, p = 0.04, p = 0.02, p = 0.04), whereas serum creatinine did not change significantly (p = 0.51).

Conclusions

Semaglutide showed excellent efficacy, even in patients switched from other GLP-1 RAs. Semaglutide appears to be a promising agent for blood glucose and body weight control in obese type 2 diabetes mellitus patients and could be more potent in treating type 2 diabetes than existing GLP-1 RAs.

Optimal Type 2 Diabetes Mellitus Management and Active Ageing

Type two diabetes mellitus (T2DM) represents a chronic condition with increasing prevalence worldwide among the older population. The T2DM condition increases the risk of micro and macrovascular complications as well as the risk of geriatric syndromes such as falls, fractures and cognitive impairment. The management of T2DM in the older population represents a challenge for the clinician, and a Comprehensive Geriatric Assessment should always be prioritized, in order to tailor the glycated hemoglobin target according to functional and cognitive status comorbidities, life expectancy and type of therapy. According to the most recent guidelines, older adults with T2DM should be categorized into three groups: healthy patients with good functional status, patients with complications and reduced functionality and patients at the end of life; for each group the target for glycemic control is different, also according to the type of treatment drug. The therapeutic approach should always begin with lifestyle changes; after that, several lines of therapy are available, with different mechanisms of action and potential effects other than glucose level reduction. Particular interest is growing in sodium-glucose cotransporter-2 inhibitors, due to their effect on the cardiovascular system. In this review, we evaluate the therapeutic options available for the treatment of older diabetic patients, to ensure a correct treatment approach.

Characteristics of the clinical treatment of Brazilian and French older adults with diabetes

OBJECTIVE

The study aimed to compare the drug therapy profile between French older adults with diabetes of the GERODIAB cohort and Brazilian older adults with diabetes assessed in a cross-sectional study conducted in Brazil.

METHOD

This quantitative cross-sectional study was conducted with a sample of 246 Brazilian people aged 65 and over receiving care through the Unified Health System in the city of Fortaleza, Northeastern Brazil, who were compared to a sample of 987 French people aged 70 and over receiving care the Rouen University Center in France.

RESULTS

The French participants treated for type 2 diabetes (T2D) with insulin alone, insulin + oral hypoglycemic agent (OHA) or OHA/GLP-1 analogue were older and presented higher mean values for body mass index, waist circumference and duration of diabetes in years. The French reported more episodes of hypoglycemia in all treatment modalities. These episodes occurred more frequently in the older adults treated with insulin alone and less frequently in those treated with OHA or GLP-1 analogues. The percentage of Brazilian and French older adults who monitored capillary blood glucose differed significantly in all treatment modalities.

CONCLUSION

The significant differences relating to the drug therapy modalities used by Brazilian and French older adults with diabetes point to the importance of understanding the therapeutic objective of drug therapy with older adults with diabetes. Adapting the therapy to the patient's clinical conditions can prevent the worsening of comorbidities that influence the loss of autonomy and frailty.

Efficacy / safety balance of DPP-4 inhibitors versus SGLT2 inhibitors in elderly patients with type 2 diabetes

Dipeptidyl peptidase-4 inhibitors (DPP-4is) and sodium-glucose cotransporter type 2 inhibitors (SGLT2is) offer new options for the oral management of type 2 diabetes mellitus (T2DM), with the advantage in the elderly population to be devoid of a high risk of hypoglycaemia. SGLT2is have also shown benefits regarding cardiovascular (heart failure) and renal protection, including in patients with T2DM aged ≥ 65 years while DPP-4is have only proved cardiovascular and renal safety without superiority compared with placebo. The glucose-lowering efficacy of the two pharmacological classes is almost similar including in older patients with T2DM. However, the tolerance and safety profile may be highly different and overall more favourable with DPP-4is than with SGLT2is. Some adverse events have been reported with SGLT2is which may be more prevalent or severe in older patients than in younger patients. The present comprehensive review focuses on the benefit/risk balance in the elderly population with T2DM by comparing the profile of DPP-4is and SGLT2is regarding the following potential issues: metabolic disorders (hypoglycaemia and diabetic ketoacidosis); cardiac and vascular issues (atheromatous cardiovascular disease, heart failure, volume reduction hypotension, and lower limb amputations); renal endpoints including acute renal injury; risk of infections; digestive disorders; bone and skin adverse events; and cancer risk. Both DPP-4is and SGLT2is have their own advantages and disadvantages. Personalised treatment is recommended based upon the efficacy/safety profile of each drug class and individual patient characteristics that may be markedly different among the heterogeneous population of older individuals with T2DM.

Careful use to minimize adverse events of oral antidiabetic medications in the elderly

INTRODUCTION

An increasing number of older patients has type 2 diabetes treated with different oral antidiabetic agents whose safety may raise concern considering some particularities of a heterogeneous elderly population.

AREAS COVERED

This article discusses some characteristics of older patients that could increase the risk of adverse events, with a focus on hypoglycemia. It describes the most frequent and/or severe complications reported in the elderly in both randomized controlled trials and observational studies with metformin, sulfonylureas, meglitinides, alpha-glucosidase inhibitors, thiazolidinediones, dipeptidyl peptidase-4 inhibitors (gliptins) and sodium-glucose cotransporter type 2 inhibitors (gliflozins).

EXPERT OPINION

Old patients may present comorbidities (renal impairment, vascular disease, heart failure, risk of dehydration, osteoporosis, cognitive dysfunction) that could increase the risk of severe adverse events. Sulfonylureas (and meglitinides) induce hypoglycemia, which may be associated with falls/fractures and cardiovascular events. Medications lacking hypoglycemia should be preferred. Gliptins appear to have the best tolerance/safety profile whereas gliflozins exert a cardiorenal protection. However, data are lacking in very old or frailty old patients so that caution and appropriate supervision of such patients are required. Taking advantage of a large choice of pharmacotherapies, personalized treatment is recommended based upon both drug safety profiles and old patient individual characteristics.

Quality and Stability Profile Assessment of the Recent Antidiabetic Omarigliptin by Using Different Chromatographic Methods

In a contribution to stability profiling of the recent antidiabetic drug, omarigliptin (OMR), two stability-indicating chromatographic methods were developed and validated. Stability profiling was performed for OMR under different stress conditions as acidic, alkaline, oxidative, photolytic and thermal degradations. Structures elucidation to all formed degradation products were identified using IR and mass spectrometry. Thin Layer Chromatography (TLC) and High-Performance Liquid Chromatography (HPLC) were used. In TLC-densitometric method, aluminum TLC plates precoated with silica gel G.F254 were used as stationary phase along with methanol: ethyl acetate: 33% ammonia (2:8:1,v/v/v) as mobile phase. The obtained chromatograms were scanned at 254 nm over concertation range of 5-70 μg band-1 for OMR. The second chromatographic method was an HPLC one with diode array detection and RP-C18 column with isocratic elution. Mobile phase used was composed of phosphate buffer pH 3.5: acetonitrile (80, 20, v/v), delivered at flow rate of 1.0 mL min-1. Diode array detector was adjusted at 230 nm with linearity range of 15-180 μg mL-1 for OMR. Several factors affecting TLC and HPLC efficiency have been carefully studied. The developed methods were validated according to International Conference on Harmonization guidelines and successfully applied for assessment of OMR in bulk powder and tablets.

Effect of Switching from Linagliptin to Teneligliptin Dipeptidyl Peptidase-4 Inhibitors in Older Patients with Type 2 Diabetes Mellitus

INTRODUCTION

Dipeptidyl peptidase-4 (DPP-4) inhibitors are widely prescribed for type 2 diabetes (T2D) and their glycemic control effects are well studied. However, information regarding the effects of switching DPP-4 inhibitors is limited, especially in older patients.

RESEARCH DESIGN AND METHODS

We investigated whether switching from linagliptin to teneligliptin decreases blood glucose in older (≥65 years) T2D patients. In total, 164 patients with T2D who switched from linagliptin to teneligliptin for >12 weeks were included and the primary outcome was glycemic changes.

RESULTS

Switching from linagliptin to teneligliptin ameliorated fasting blood glucose (148.1 ± 47.1 to 139.6 ± 43.4 mg/dL), glycated hemoglobin (HbA1c; 7.9 ± 1.3 to 7.5 ± 1.2%), and postprandial blood glucose (224.8 ± 77.4 to 205.8 ± 70.8 mg/dL) levels (all P < 0.05). Low-density lipoprotein cholesterol concentration was reduced while liver and kidney functions were maintained. Subgroup analysis showed that glucose control improved more in patients with uncontrolled hyperglycemia (HbA1c > 8.0%) and chronic kidney disease (estimated glomerular filtration rate <90 mL/min/1.73m2). Multiple logistic analysis indicated higher baseline HbA1c was the strongest predictor of teneligliptin switching response.

CONCLUSION

Switching from linagliptin to teneligliptin helps maintain kidney function and reduce blood glucose safely in older patients with T2D.

Efficacy and safety of metformin and sitagliptin-based dual and triple therapy in elderly Chinese patients with type 2 diabetes: Subgroup analysis of STRATEGY study

AIMS/INTRODUCTION

To assess the efficacy and safety of metformin/sitagliptin-based dual/triple therapy in elderly Chinese patients with type 2 diabetes mellitus.

MATERIALS AND METHODS

This subgroup analysis included individuals aged ≥65 years from the STRATEGY study, a two-stage study in which type 2 diabetes mellitus patients with unsatisfactory glycemic control on metformin were first treated with the dual combination of metformin and sitagliptin for 16 weeks (n = 681), and then, if glycemic control had not been achieved, were treated with a third add-on oral antihyperglycemic drug for another 24 weeks (n = 291). The efficacy end-point was change in glycated hemoglobin (HbA1c) in each stage, and the safety end-point was adverse events with a focus on hypoglycemia.

RESULTS

At week 16, the change in HbA1c was -0.81% from baseline, and the percentages of patients who achieved HbA1c targets of <7% and <7.5% were 44.9 and 67.2%, respectively. After 24 weeks, a further average HbA1c reduction of -0.60% was observed with specific reductions of -0.70% with glimepiride, -0.63% with gliclazide, -0.51% with repaglinide and -0.45% with acarbose. The proportions of patients who achieved HbA1c targets of <7% and <7.5% were 65.4 and 81.3%, respectively, over the entire study. The rates of drug-related adverse events and hypoglycemia were, respectively, 4.1 and 4.3% in the dual therapy stage, and 5.2% and 7.1% in the triple therapy stage, without occurrence of severe hypoglycemia.

CONCLUSIONS

In elderly Chinese type 2 diabetes mellitus patients, metformin/sitagliptin-based dual and triple oral therapy can provide clinically meaningful glycemic control and is generally well tolerated with a low incidence of hypoglycemia.

Exposure to dipeptidyl-peptidase-4 inhibitors and COVID-19 among people with type 2 diabetes: A case-control study

Because other coronaviruses enter the cells by binding to dipeptidyl-peptidase-4 (DPP-4), it has been speculated that DPP-4 inhibitors (DPP-4is) may exert an activity against severe acute respiratory syndrome coronavirus 2. In the absence of clinical trial results, we analysed epidemiological data to support or discard such a hypothesis. We retrieved information on exposure to DPP-4is among patients with type 2 diabetes (T2D) hospitalized for COVID-19 at an outbreak hospital in Italy. As a reference, we retrieved information on exposure to DPP-4is among matched patients with T2D in the same region. Of 403 hospitalized COVID-19 patients, 85 had T2D. The rate of exposure to DPP-4is was similar between T2D patients with COVID-19 (10.6%) and 14 857 matched patients in the region (8.8%), or 793 matched patients in the local outpatient clinic (15.4%), 8284 matched patients hospitalized for other reasons (8.5%), and when comparing 71 patients hospitalized for COVID-19 pneumonia (11.3%) with 351 matched patients with pneumonia of another aetiology (10.3%). T2D patients with COVID-19 who were on DPP-4is had a similar disease outcome as those who were not. In summary, we found no evidence that DPP-4is might affect hospitalization for COVID-19.

Use of an electronic decision support tool to reduce polypharmacy in elderly people with chronic diseases: cluster randomised controlled trial

OBJECTIVE

To evaluate the effects of a computerised decision support tool for comprehensive drug review in elderly people with polypharmacy.

DESIGN

Pragmatic, multicentre, cluster randomised controlled trial.

SETTING

359 general practices in Austria, Germany, Italy, and the United Kingdom.

PARTICIPANTS

3904 adults aged 75 years and older using eight or more drugs on a regular basis, recruited by their general practitioner.

INTERVENTION

A newly developed electronic decision support tool comprising a comprehensive drug review to support general practitioners in deprescribing potentially inappropriate and non-evidence based drugs. Doctors were randomly allocated to either the electronic decision support tool or to provide treatment as usual.

MAIN OUTCOME MEASURES

The primary outcome was the composite of unplanned hospital admission or death by 24 months. The key secondary outcome was reduction in the number of drugs.

RESULTS

3904 adults were enrolled between January and October 2015. 181 practices and 1953 participants were assigned to electronic decision support (intervention group) and 178 practices and 1951 participants to treatment as usual (control group). The primary outcome (composite of unplanned hospital admission or death by 24 months) occurred in 871 (44.6%) participants in the intervention group and 944 (48.4%) in the control group. In an intention-to-treat analysis the odds ratio of the composite outcome was 0.88 (95% confidence interval 0.73 to 1.07; P=0.19, 997 of 1953 v 1055 of 1951). In an analysis restricted to participants attending practice according to protocol, a difference was found favouring the intervention (odds ratio 0.82, 95% confidence interval 0.68 to 0.98; 774 of 1682 v 873 of 1712, P=0.03). By 24 months the number of prescribed drugs had decreased in the intervention group compared with control group (uncontrolled mean change -0.42 v 0.06: adjusted mean difference -0.45, 95% confidence interval -0.63 to -0.26; P<0.001).

CONCLUSIONS

In intention-to-treat analysis, a computerised decision support tool for comprehensive drug review of elderly people with polypharmacy showed no conclusive effects on the composite of unplanned hospital admission or death by 24 months. Nonetheless, a reduction in drugs was achieved without detriment to patient outcomes.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10137559.

[Quality deficits of drug trials for older patients: An analysis of a series of systematic reviews]

INTRODUCTION

The aim of this work is to present an exemplary methodological review of the quality of included studies on drug therapy in older patients, using a published series of six systematic reviews (SRs). These six SRs included 48 systematic reviews, 65 intervention studies and 33 observational studies. The series of SRs has been carried out in the PRIMA-eDS-project (www.prima-eds.eu) to develop recommendations for the treatment of elderly patients with polypharmacy.

METHODS

The research question was to which extent recommendations on drug therapy in older patients are based on sound evidence. To this purpose, we performed a quality assessment of all studies included using AMSTAR for systematic reviews, CASP for observational studies, and the Cochrane "Risk of Bias" tool for intervention studies.

RESULTS

The evidence base for commonly prescribed drugs in the elderly is weak. The studies identified by the systematic reviews revealed a significant lack of studies addressing the target population as well as a lack of high-quality evidence. Among the 33 observational studies, it was unclear in nearly half of the publications whether the follow-up was sufficiently long and complete. For one-third, the conclusions did not match the observed evidence. The greatest risk of bias in the intervention trials was due to selection and incorrect blinding. Quality deficits of the systematic reviews consisted in the provision of a complete study list and the lack of consideration of potential publication bias.

DISCUSSION

Overall, many methodological deficits were revealed, making it difficult or almost impossible to derive reliable recommendations.

CONCLUSION

Our work illustrates the immense need for research in the treatment of older patients as well as the importance of ensuring the highest quality standards when conducting intervention and observational studies or carrying out systematic reviews.

Drug discovery approaches targeting the incretin pathway

Incretin pathway plays an important role in the development of diabetes medications. Interventions in DPP-4 and GLP-1 receptor have shown remarkable efficacy in experimental and clinical studies and imperatively become one of the most promising therapeutic approaches in the T2DM drug discovery pipeline. Herein, we analyzed the actionmechanismsof DPP-4 and GLP-1 receptor targeting the incretin pathway in T2DM treatment. We gave an insight into the structural requirements for the potent DPP-4 inhibitors and revealed a classification of DPP-4 inhibitors by stressing on the binding modes of these ligands to the enzyme. We then reviewed the drug discovery strategies for the development of peptide and non-peptide GLP-1 receptor agonists (GLP-1 RAs). Furthermore, the drug design strategies for DPP-4 inhibitors and GLP-1R agonists were detailed accurately. This review might provide an efficient evidence for the highly potent and selective DPP-4 inhibitors and the GLP-1 RAs, as novel medicines for patients suffering from T2DM.

Neurological Manifestation of Incretin-Based Therapies in Patients with Type 2 Diabetes: A Systematic Review and Network Meta-Analysis

As a new class of antidiabetic drug, incretin-based therapies, which include dipeptidyl peptidase-4 inhibitors (DPP-4Is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs), have raised concerns about symptoms of withdrawal in patients with type 2 diabetes mellitus (T2DM), such as dizziness and headache. To systematically evaluate whether incretin-based therapies may lead to dizziness and headache in patients with T2DM compared to other traditional antidiabetic drugs or placebo. We searched Medline, Embase, the Cochrane library, and clinicaltrials.gov from inception through June 23, 2017, to identify randomized controlled trials of the safety of DPP-4Is or GLP-1 RAs versus placebo or other antidiabetic drugs in T2DM patients. We used the network meta-analysis under the frequentist framework to compare the association between multiple antidiabetic drugs and dizziness and headache. A total of 233 clinical trials with nine treatments and 147,710 patients were included: two incretin-based therapies, one placebo, and six traditional antidiabetic drugs (metformin, insulin, sulfonylurea, thiazolidinediones, alpha-glucosidase inhibitor, and sodium-glucose co-transporter 2). Compared to insulin, thiazolidinediones, or placebo, GLP-1 RAs statistically significantly increased the risk of dizziness (odds ratios [ORs]: 1.92, 1.57, and 1.40, respectively) and headache (ORs: 1.34, 1.41, and 1.18, respectively). DPP-4Is increased the risk of headache (OR: 1.22, 95% confidence interval [CI]: 1.02 to 1.46; moderate quality) and dizziness (OR: 1.46, 95% CI: 1.05 to 2.03; moderate quality) compared to insulin. Of the incretin-based therapies, DPP-4Is had a lower risk of dizziness than GLP-1 RAs (OR: 0.76, 95% CI: 0.67 to 0.87; high quality). Ranking probability analysis indicated that GLP-1 RAs may have the greatest risk of both dizziness and headache among the nine treatments (22.5% and 23.4%, respectively), whereas DPP-4Is were in the middle (46.2% and 45.0%, respectively). Incretin-based therapies increase the risk of dizziness and headache compared to insulin, thiazolidinediones, and placebo.

Dipeptidyl Peptidase-4 Inhibitors and Joint Pain: A Retrospective Cohort Study of Older Veterans with Type 2 Diabetes Mellitus

BACKGROUND

In recent years, dipeptidyl peptidase (DPP)-4 inhibitors have been added to the diabetes treatment algorithm. Few published studies have shown that the use of DPP-4 inhibitors is associated with joint pain. To our knowledge, no population-based studies in the United States have studied this association.

OBJECTIVE

To evaluate the association between a new prescription of DPP-4 inhibitors and joint pain within 1 year among older veterans with diabetes.

METHODS

This was a retrospective cohort study of older veterans (aged ≥66 years) who were dually enrolled in Medicare and the Veterans Health Administration (VHA; N = 134,488). Data were derived from linked Medicare claims and VHA electronic health records from 2008 to 2010. Diabetes during the baseline and joint pain during the follow-up period were identified with International Classification of Diseases, Ninth Revision codes. Filled prescriptions for DPP-4 inhibitors during the baseline period were identified from Medicare Part D and VHA pharmacy records. The adjusted associations between DPP-4 inhibitors and joint pain were examined with logistic regressions.

RESULTS

Approximately 8.4% of the 134,488 study patients received at least 1 prescription for DPP-4 inhibitors and 11.7% were diagnosed with joint pain during the follow-up period. An unadjusted analysis showed significant differences in joint pain by DPP-4 inhibitor status (12.9% among users vs 11.6% among nonusers; P <.0001). In a fully adjusted model, having a DPP-4 inhibitor prescription had higher odds of joint pain (adjusted odds ratio, 1.17; 95% confidence interval, 1.10-1.24) compared with no prescription for a DPP-4 inhibitor.

CONCLUSION

In a cohort of older veterans who did not have documented joint pain at baseline, a prescription for DPP-4 inhibitors was significantly associated with a newly documented joint pain.

The Role of DPP-4 Inhibitors in the Treatment Algorithm of Type 2 Diabetes Mellitus: When to Select, What to Expect

Type 2 diabetes mellitus is a growing global public health problem, the prevalence of which is projected to increase in the succeeding decades. It is potentially associated with many complications, affecting multiple organs and causing a huge burden to the society. Due to its multi-factorial pathophysiology, its treatment is varied and based upon a multitude of pharmacologic agents aiming to tackle the many aspects of the disease pathophysiology (increasing insulin availability [either through direct insulin administration or through agents that promote insulin secretion], improving sensitivity to insulin, delaying the delivery and absorption of carbohydrates from the gastrointestinal tract, or increasing urinary glucose excretion). DPP-4 (dipeptidyl peptidase-4) inhibitors (or “gliptins”) represent a class of oral anti-hyperglycemic agents that inhibit the enzyme DPP-4, thus augmenting the biological activity of the “incretin” hormones (glucagon-like peptide-1 [GLP-1] and glucose-dependent insulinotropic polypeptide [GIP]) and restoring many of the pathophysiological problems of diabetes. They have already been used over more than a decade in the treatment of the disease. The current manuscript will review the mechanism of action, therapeutic utility, and the role of DPP-4 inhibitors for the treatment of type 2 diabetes mellitus.

Alogliptin-Induced Minimal Change Nephrotic Syndrome and Interstitial Nephritis

Alogliptin is one of the dipeptidyl peptidase-4 inhibitors used to treat patients with type 2 diabetes. Little is known about the nephrotoxicity associated with alogliptin, such as nephrotic syndrome or interstitial nephritis. We report a biopsy-proven rare case of minimal change nephrotic syndrome and interstitial nephritis induced by alogliptin. A 68-year-old man who had been prescribed alogliptin was hospitalized for nephrotic syndrome. On admission, serum creatinine level was elevated with increased urinary β₂-microglobulin and N-acetyl-β-d-glucosaminidase excretion. Kidney biopsy revealed minor glomerular abnormalities and interstitial nephritis, and gallium-67 scintigraphy showed uptake in both kidneys. A drug lymphocyte stimulation test for alogliptin was positive. With discontinuation of alogliptin treatment alone, serum creatinine level normalized in parallel with urine β₂-microglobulin and N-acetyl-β-d-glucosaminidase levels. In addition, complete remission of nephrotic syndrome was observed. Drug-induced dual pathology has not been previously reported with alogliptin. In summary, clinicians should keep in mind that alogliptin can induce minimal change nephrotic syndrome and interstitial nephritis.

Medication appropriateness criteria for older adults: a narrative review of criteria and supporting studies

Polypharmacy is common among older adults and is associated with adverse outcomes. Polypharmacy increases the likelihood of receiving a potentially inappropriate medication (PIM). PIMs have traditionally been defined as medications that have either no benefit (e.g. therapeutic duplication) or increased risk (e.g. altered pharmacodynamics/kinetics with aging). A growing literature supports the notion that these represent only a subset of the potential risks of medications prescribed to older adults. Different authors have proposed new sets of criteria for evaluating medication appropriateness. This narrative review had two objectives: 1) to summarize the contents of these criteria in order to obtain preliminary information about where clinical consensus exists regarding appropriateness; 2) The second was to describe studies examining the risks and benefits of medications identified by the criteria to determine the strength of the evidence supporting the derivation of these criteria. We identified 13 articles sharing overlapping criteria for evaluating appropriateness including: (1) delayed time to benefit; (2) altered benefit-harm ratios in the face of competing risks; (3) effects that do not match patients' goals; and (4) nonadherence. The similarities across the articles suggested strong clinical consensus; however, the articles presented little data directly supporting these criteria. Additional studies provide evidence for the proof of concept that average estimates of benefit and harm derived from randomized controlled trials may differ from the benefits and harms experienced by older persons. However, more data are required to characterize the benefits and harms of medications in the context of the regimen as a whole and the individual's health status.

Diabetes Treatment in the Elderly: Incorporating Geriatrics, Technology, and Functional Medicine

PURPOSE OF REVIEW

The current approach to diabetes in the elderly incorporates components from the comprehensive geriatric approach. The most updated guidelines from the American Diabetes Association reflect influence from the consensus made in 2012 with the American Geriatrics Society. Notably, the framework included the evaluation for geriatric syndromes (falls and urinary incontinence), functional and cognitive abilities. The goal for this review is to provide an updated summary of treatment strategies for community-dwelling older adults. We identified the need to expand our approach by addressing innovative approaches and scientific concepts from telemedicine, functional medicine, and geriatrics.

RECENT FINDINGS

Findings on cardiovascular protection with sodium-glucose co-transporter 2 inhibitors (SGLT-2i) and some glucagon-like peptide 1 receptor agonists (GLP-1RA) support their use for older patients with diabetes. However, careful consideration for agent selection must incorporate the presence of geriatric issues, such as geriatric syndromes, or functional and cognitive decline, as they could increase the risk and impact adverse reactions. Telemedicine interventions can improve communication and connection between older patients and their providers, and improve glycemic control. Functional medicine concepts can offer additional adjuvant strategies to support the therapeutic interventions and management of diabetes in the elderly. A systematic review confirmed the efficacy and safety of metformin as first-line therapy of type 2 diabetes in the older adult, but multiple reports highlighted the risk for vitamin B12 deficiency. Randomized controlled trials showed the efficacy and safety of antihyperglycemic agents in the elderly, including some with longer duration and lesser risk for hypoglycemia. Randomized clinical trials showed cardiovascular protection with SGLT-2i (empagliflozin, canagliflozin) and GLP-1RA (liraglutide, semaglutide). The most current guidelines recommend addressing for geriatric syndromes, physical and cognitive function in the elderly, in order to individualize targets and therapeutic strategies. Clinicians managing diabetes in the elderly can play a major role for the early detection and evaluation of geriatric issues in their patients. Telemedicine interventions improve glycemic control, and certain functional medicine strategies could be adjuvant interventions to reduce inflammation and stress, but more studies focused on the elderly population are needed.

What have we learnt from "real world" data, observational studies and meta-analyses

The incretin therapies glucagon-like peptide-1 receptor agonists (GLP-1 RA) and dipeptidyl peptidase-IV (DPP-IV) inhibitors are now well-established as second and third-line therapies and in combination with insulin for the treatment of type 2 diabetes. Over the last decade, there is accumulating evidence of their efficacy and safety from both large multicentre randomized clinical trials (RCT) and observational studies. Cardiovascular outcome trials have confirmed that several of these agents are also non-inferior to placebo with the GLP-1 RA liraglutide and semaglutide recently found to be superior in terms of major adverse cardiovascular events. Observational studies and post-marketing surveillance provide real world evidence of safety and effectiveness of these agents and have provided reassurance that signals for pancreatitis and pancreatic cancer seen in clinical trials are not of major concern in large patient populations. Well-designed real world studies complement RCTs and systematic reviews but appropriate data and methodologies, which are constantly improving, are necessary to answer appropriate clinical questions relating to the use of incretin therapies.