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Kim KY, Jeong YJ, Park SY, Park EJ, Jeon JH, Song IS, Liu KH. Evaluation of the Drug-Induced Liver Injury Potential of Saxagliptin through Reactive Metabolite Identification in Rats. Pharmaceutics 2024; 16:106. [PMID: 38258116 PMCID: PMC10819019 DOI: 10.3390/pharmaceutics16010106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
A liver injury was recently reported for saxagliptin, which is a dipeptidyl peptidase-4 (DPP-4) inhibitor. However, the underlying mechanisms of saxagliptin-induced liver injury remain unknown. This study aimed to evaluate whether saxagliptin, a potent and selective DPP-4 inhibitor that is globally used for treating type 2 diabetes mellitus, binds to the nucleophiles in vitro. Four DPP-4 inhibitors, including vildagliptin, were evaluated for comparison. Only saxagliptin and vildagliptin, which both contain a cyanopyrrolidine group, quickly reacted with L-cysteine to enzyme-independently produce thiazolinic acid metabolites. This saxagliptin-cysteine adduct was also found in saxagliptin-administered male Sprague-Dawley rats. In addition, this study newly identified cysteinyl glycine conjugates of saxagliptin and 5-hydroxysaxagliptin. The observed metabolic pathways were hydroxylation and conjugation with cysteine, glutathione, sulfate, and glucuronide. In summary, we determined four new thiazoline-containing thiol metabolites (cysteine and cysteinylglycine conjugates of saxagliptin and 5-hydroxysaxagliptin) in saxagliptin-administered male rats. Our results reveal that saxagliptin can covalently bind to the thiol groups of cysteine residues of endogenous proteins in vivo, indicating the potential for saxagliptin to cause drug-induced liver injury.
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Affiliation(s)
- Ki-Young Kim
- BK21 FOUR KNU Community-Based Intelligent Novel Drug Discovery Education Unit, Research Institute of Pharmaceutical Sciences, College of Pharmacy, Kyungpook National University, Daegu 41566, Republic of Korea; (K.-Y.K.); (Y.-J.J.); (S.-Y.P.); (E.-J.P.); (J.-H.J.)
| | - Yeo-Jin Jeong
- BK21 FOUR KNU Community-Based Intelligent Novel Drug Discovery Education Unit, Research Institute of Pharmaceutical Sciences, College of Pharmacy, Kyungpook National University, Daegu 41566, Republic of Korea; (K.-Y.K.); (Y.-J.J.); (S.-Y.P.); (E.-J.P.); (J.-H.J.)
| | - So-Young Park
- BK21 FOUR KNU Community-Based Intelligent Novel Drug Discovery Education Unit, Research Institute of Pharmaceutical Sciences, College of Pharmacy, Kyungpook National University, Daegu 41566, Republic of Korea; (K.-Y.K.); (Y.-J.J.); (S.-Y.P.); (E.-J.P.); (J.-H.J.)
- Mass Spectrometry Based Convergence Research Institute, Kyungpook National University, Daegu 41566, Republic of Korea
| | - Eun-Ji Park
- BK21 FOUR KNU Community-Based Intelligent Novel Drug Discovery Education Unit, Research Institute of Pharmaceutical Sciences, College of Pharmacy, Kyungpook National University, Daegu 41566, Republic of Korea; (K.-Y.K.); (Y.-J.J.); (S.-Y.P.); (E.-J.P.); (J.-H.J.)
| | - Ji-Hyeon Jeon
- BK21 FOUR KNU Community-Based Intelligent Novel Drug Discovery Education Unit, Research Institute of Pharmaceutical Sciences, College of Pharmacy, Kyungpook National University, Daegu 41566, Republic of Korea; (K.-Y.K.); (Y.-J.J.); (S.-Y.P.); (E.-J.P.); (J.-H.J.)
| | - Im-Sook Song
- BK21 FOUR KNU Community-Based Intelligent Novel Drug Discovery Education Unit, Research Institute of Pharmaceutical Sciences, College of Pharmacy, Kyungpook National University, Daegu 41566, Republic of Korea; (K.-Y.K.); (Y.-J.J.); (S.-Y.P.); (E.-J.P.); (J.-H.J.)
| | - Kwang-Hyeon Liu
- BK21 FOUR KNU Community-Based Intelligent Novel Drug Discovery Education Unit, Research Institute of Pharmaceutical Sciences, College of Pharmacy, Kyungpook National University, Daegu 41566, Republic of Korea; (K.-Y.K.); (Y.-J.J.); (S.-Y.P.); (E.-J.P.); (J.-H.J.)
- Mass Spectrometry Based Convergence Research Institute, Kyungpook National University, Daegu 41566, Republic of Korea
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Li Q, Deng X, Xu YJ, Dong L. Development of Long-Acting Dipeptidyl Peptidase-4 Inhibitors: Structural Evolution and Long-Acting Determinants. J Med Chem 2023; 66:11593-11631. [PMID: 37647598 DOI: 10.1021/acs.jmedchem.3c00412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Considerable effort has been made to achieve less frequent dosing in the development of DPP-4 inhibitors. Enthusiasm for long-acting DPP-4 inhibitors is based on the promise that such agents with less frequent dosing regimens are associated with improved patient adherence, but the rational design of long-acting DPP-4 inhibitors remains a major challenge. In this Perspective, the development of long-acting DPP-4 inhibitors is comprehensively summarized to highlight the evolution of initial lead compounds on the path toward developing long-acting DPP-4 inhibitors over nearly three decades. The determinants for long duration of action are then examined, including the nature of the target, potency, binding kinetics, crystal structures, selectivity, and preclinical and clinical pharmacokinetic and pharmacodynamic profiles. More importantly, several possible approaches for the rational design of long-acting drugs are discussed. We hope that this information will facilitate the design and development of safer and more effective long-acting DPP-4 inhibitors and other oral drugs.
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Affiliation(s)
- Qing Li
- College of Chemistry and Materials Science, Sichuan Normal University, Chengdu 610068, China
| | - Xiaoyan Deng
- College of Chemistry and Materials Science, Sichuan Normal University, Chengdu 610068, China
| | - Yan-Jun Xu
- College of Chemistry and Materials Science, Sichuan Normal University, Chengdu 610068, China
| | - Lin Dong
- West China School of Pharmacy, Sichuan University, Chengdu 610041, China
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Gou ZP, Wang ZL, Liang XF, Zheng L, Wang Y, Feng P. Single-dose escalation study of yogliptin in healthy Chinese volunteers. Eur J Pharm Sci 2019; 136:104950. [PMID: 31173870 DOI: 10.1016/j.ejps.2019.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/12/2019] [Accepted: 06/03/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Yogliptin is a novel xanthine dipeptidyl peptidase-4 (DPP-4) inhibitor targeting type 2 diabetes. After promising preclinical pharmacological studies, the first human trial of yogliptin was designed. METHODS A randomized, double-blind, parallel, placebo-controlled phase I single-dose escalation study was designed to evaluate the pharmacokinetics, pharmacodynamics, and tolerability after single oral doses of yogliptin in healthy Chinese subjects. Healthy subjects were assigned to nine cohorts, which received a single dose of yogliptin at 2.5, 5, 10, 25, 50, 100, 200, 400, or 600 mg. Two subjects in each cohort received placebo. Blood samples were collected before dosing and up to 192 h afterwards. Urine samples were collected until 120 h after dosing. Plasma and urine drug concentrations were determined using liquid chromatography coupled with tandem mass spectrometry, and DPP-4 activity was measured using a semi-quantitative, fluorescence-based kinetic assay. RESULTS A total of 104 subjects were enrolled, 103 of whom completed the study (mean age, 25.3 years; mean weight, 58.8 kg; mean BMI, 21.8 kg/m2). A total of 27 adverse events (AEs) occurred in 25 of 86 yogliptin subjects (29.1%), and 3 AEs occurred in 3 of 18 placebo subjects (16.7%). Yogliptin was absorbed with a median time of maximum observed concentration (Tmax) of 3.0 h and was eliminated slowly with a t1/2 of 25.45-43.84 h. The maximum observed concentration (Cmax) and area under the curve (AUC) varied slightly more than dose-proportionally over the dose range from 2.5 to 400 mg. The fraction of drug excreted in urine ranged from 8.39% to 24.77%. Mean DPP-4 inhibition at 24 h after dosing ranged from 97.7% to 99.5%, and DPP-4 inhibition was >80% for 72 h at doses from 25 to 400 mg. DPP-4 inhibition was >80% for 1 week in the group receiving 400 mg. CONCLUSION Yogliptin was well tolerated in healthy subjects, with no dose-limiting toxicity observed in the range from 2.5 to 600 mg. Yogliptin inhibited plasma DPP-4 activity for 72 h at single doses of 25-200 mg and for 1 week at 400 mg, suggesting that once-weekly dosing of yogliptin is possible in type 2 diabetes patients. TRIAL REGISTRATION ChiCTR-IIR-17010311 (Chictr.org).
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Affiliation(s)
- Zhong-Ping Gou
- Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China
| | - Zhen-Lei Wang
- Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China
| | - Xiu-Fang Liang
- Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China
| | - Li Zheng
- Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China
| | - Ying Wang
- Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China
| | - Ping Feng
- Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China.
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Men P, Li XT, Tang HL, Zhai SD. Efficacy and safety of saxagliptin in patients with type 2 diabetes: A systematic review and meta-analysis. PLoS One 2018; 13:e0197321. [PMID: 29787616 PMCID: PMC5963790 DOI: 10.1371/journal.pone.0197321] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 04/29/2018] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To evaluate the comparative efficacy and safety of saxagliptin for type 2 diabetes (T2D). METHODS A systematic search of PubMed, Embase, the Cochrane Library, Web of Science, ClinicalTrials.gov and two Chinese databases for randomized controlled trials (RCTs) comparing saxagliptin with placebo or active comparators was performed up to July 2017. A complementary search was done to cover literature until March 2018. For continuous data, estimates were pooled using inverse variance methodology to calculate weighted mean differences (WMDs). Dichotomous data were presented as Mantel-Haenzel risk ratios (RRs). RESULTS Thirty-nine references of 30 RCTs involving 29,938 patients were analyzed. Compared with placebo, saxagliptin significantly reduced glycated hemoglobin (HbA1c, WMD -0.52%, 95% CI -0.60 to -0.44) and fasting plasma glucose (WMD -13.78 mg/dL, 95% CI -15.31 to -12.25), and increased the proportion of patients achieving HbA1c <7% (RR 1.64, 95% CI 1.53 to 1.75). When combined with submaximal-dose metformin, saxagliptin significantly increased the proportion of patients achieving HbA1c <7% compared with acarbose (RR 2.38, 95% CI 1.17 to 4.83) and uptitrated metformin (RR 1.30, 95% CI 1.04 to 1.63). Saxagliptin was similar to other DPP-4 inhibitors but inferior to liraglutide and dapagliflozin on glycemic control. Saxagliptin significantly decreased the incidences of overall adverse events compared with acarbose (RR 0.71, 95% CI 0.57 to 0.89) and liraglutide (RR 0.41, 95% CI 0.24 to 0.71) when added to metformin. Weight gain and hypoglycemia with saxagliptin was slightly but significantly higher than placebo and lower than sulfonylureas. Saxagliptin did not increase the risk of arthralgia, heart failure, pancreatitis and other adverse events. CONCLUSIONS Generally, saxagliptin has similar efficacy compared with most oral antidiabetic drugs and may be more effective than acarbose, while having a better safety profile than both acarbose and sulfonylureas.
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Affiliation(s)
- Peng Men
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Xiao-tong Li
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Hui-lin Tang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Suo-di Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
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Tan X, Hu J. Evogliptin: a new dipeptidyl peptidase inhibitor for the treatment of type 2 diabetes. Expert Opin Pharmacother 2016; 17:1285-93. [DOI: 10.1080/14656566.2016.1183645] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Zhang Y, Chi J, Wang W, Hong J, Gu W, Wang B, Ning G. Different effects of two dipeptidyl peptidase-4 inhibitors and glimepiride on β-cell function in a newly designed two-step hyperglycemic clamp. J Diabetes 2015; 7:213-21. [PMID: 24889731 DOI: 10.1111/1753-0407.12175] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 05/07/2014] [Accepted: 05/28/2014] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Dipeptidyl peptidase (DPP)-4 inhibitors and sulfonylureas may have different effects on islet function. We designed a new two-step hyperglycemic clamp to further compare the effects of sitagliptin, saxagliptin, and glimepiride on β-cell function and the incretin effect. METHODS The present study was a four-way cross-over open label randomized study. Twelve healthy male subjects were administered a single dose of sitagliptin (100 mg), saxagliptin (5 mg), glimepiride (2 mg) or blank control 2 h before undergoing a two-step hyperglycemic clamp (Step 1: only intravenous glucose was administered; Step 2: i.v. glucose loading was combined with oral glucose consumption). Two-phase insulin secretion, glucagon secretion, and incretin levels were measured during the clamp. RESULTS In Step 1, with i.v. glucose only, there were no differences between the effects of the three drugs on insulin secretion, except that saxagliptin increased second-phase insulin secretion more than glimepiride (P = 0.007). In Step 2, oral glucose consumption led to an approximate two fold increase in insulin secretion and both gliptins significantly increased first-phase insulin secretion compared with glimepiride (P = 0.003 for both). Saxagliptin further increased second-phase insulin secretion compared with glimepiride (P = 0.005) and sitagliptin (P < 0.001). Both gliptins significantly decreased glucagon secretion and increased active glucagon-like peptide-1 (GLP-1) compared with glimepiride, especially in Step 2. CONCLUSIONS The two-step hyperglycemic clamp appears to be a precise method to assess β-cell function by taking the effect of incretins into consideration. The oral glucose consumption adds to the i.v. glucose infusion, amplifying the differences in the effects of DPP-4 inhibitors and glimepiride on insulin secretion.
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Affiliation(s)
- Yifei Zhang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of Chinese Health Ministry and Division of Endocrinology of E-Institutes of Shanghai, Rui-jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
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Gu N, Park MK, Kim TE, Bahng MY, Lim KS, Cho SH, Yoon SH, Cho JY, Jang IJ, Yu KS. Multiple-dose pharmacokinetics and pharmacodynamics of evogliptin (DA-1229), a novel dipeptidyl peptidase IV inhibitor, in healthy volunteers. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:1709-21. [PMID: 25336915 PMCID: PMC4199987 DOI: 10.2147/dddt.s65678] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose Evogliptin (DA-1229) is a novel, potent, and selective dipeptidyl peptidase IV (DPP-IV) inhibitor in clinical development for the treatment of type 2 diabetes mellitus. This study aimed to investigate the pharmacokinetic and pharmacodynamic profiles and tolerability of evogliptin after repeated oral administration in healthy subjects. Patients and methods A block-randomized, double-blind, placebo-controlled, multiple-dose, dose-escalation study was performed in a total of 30 subjects. Repeated once-daily doses of 5, 10, or 20 mg evogliptin or the same doses of placebo were orally administered to ten subjects in each dosage group for 10 days. Subjects in each group were randomized to receive evogliptin or placebo with a ratio of 8:2. Pharmacokinetics of evogliptin were evaluated, with its concentrations in serial plasma and urine samples collected following the first and last administrations. DPP-IV activity and glucagon-like peptide-1, glucose, and insulin levels were quantified to evaluate evogliptin’s pharmacodynamics on the first and last dosing days. Results All participants completed the study without any serious or severe adverse event. The evogliptin plasma concentration reached its peak within 4–5 hours and decreased relatively slowly, with a terminal elimination half-life of 33–39 hours. Repeated administration resulted in a 1.4- to 1.5-fold accumulation. Evogliptin’s systemic exposure and inhibition of plasma DPP-IV activity increased in a dose-dependent manner. Inhibition of DPP-IV activity >80% was sustained over 24 hours in all evogliptin dose groups and provided an increase in postprandial active glucagon-like peptide-1 levels by 1.5- to 2.4-fold. Postprandial glucose levels in the evogliptin-treated groups were reduced 20%–35% compared to placebo, but were not accompanied by increased insulin levels. Conclusion Repeated administration of evogliptin in healthy subjects was well tolerated and exhibited linear pharmacokinetics within the 5–20 mg dose range. A once-daily regimen of 5–20 mg evogliptin effectively inhibited DPP-IV activity.
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Affiliation(s)
- Namyi Gu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea ; Department of Clinical Pharmacology and Therapeutics, Dongguk University College of Medicine and Ilsan Hospital, Goyang, Gyeonggi-do, Republic of Korea
| | - Min Kyu Park
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea ; Department of Clinical Pharmacology and Therapeutics, Dong-A University College of Medicine and Hospital, Busan, Republic of Korea
| | - Tae-Eun Kim
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea ; Department of Clinical Pharmacology and Therapeutics, Kunkuk University Medical Center, Seoul, Republic of Korea
| | - Mi Young Bahng
- Clinical Development Department, Dong-A ST Co, Ltd, Seoul, Republic of Korea
| | - Kyoung Soo Lim
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Sang-Heon Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Seo Hyun Yoon
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Joo-Youn Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - In-Jin Jang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
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Gummesson A, Li H, Gillen M, Xu J, Niazi M, Hirshberg B. Bioequivalence of Saxagliptin/Metformin Extended-Release (XR) Fixed-Dose Combination Tablets and Single-Component Saxagliptin and Metformin XR Tablets in Healthy Adult Chinese Subjects. Clin Drug Investig 2014; 34:763-72. [DOI: 10.1007/s40261-014-0230-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Filippatos TD, Athyros VG, Elisaf MS. The pharmacokinetic considerations and adverse effects of DPP-4 inhibitors [corrected]. Expert Opin Drug Metab Toxicol 2014; 10:787-812. [PMID: 24746233 DOI: 10.1517/17425255.2014.907274] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Dipeptidyl-peptidase-4 (DPP-4) inhibitors are a class of anti-hyperglycemic agents with proven efficacy in patients with type 2 diabetes mellitus (T2DM). AREAS COVERED This review considers the pharmacokinetic profile, adverse effects and drug interactions of DPP-4 inhibitors. DPP-4 inhibitors have certain differences in their structure, metabolism, route of elimination and selectivity for DPP-4 over structurally related enzymes, such as DPP-8/DPP-9. They have a low potential for drug interactions, with the exception of saxagliptin that is largely metabolized by cytochrome CYP3A4/A5. Reports of pancreatitis and pancreatic cancer have raised concerns regarding the safety of DPP-4 inhibitors and are under investigation. Post-marketing surveillance has revealed less common adverse effects, especially a number of skin- and immune-related adverse effects. These issues are covered in the present review. EXPERT OPINION DPP-4 inhibitors are useful and efficient drugs. DPP-4 inhibitors have similar mechanism of action and similar efficacy. However, DPP-4 inhibitors have certain differences in their pharmacokinetic properties that may be associated with different clinical effects and adverse event profiles. Although clinical trials indicated a favorable safety profile, post-marketing reports revealed certain safety aspects that need further investigation. Certainly, more research is needed to clarify if the differences among DPP-4 inhibitors could lead to a different clinical and safety profile.
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Affiliation(s)
- Theodosios D Filippatos
- Aristotle University of Thessaloniki, Hippokration Hospital, Medical School, Second Propedeutic Department of Internal Medicine , Thessaloniki , Greece
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Abstract
Treatment of diabetes mellitus requires, at a certain stage of its course, drug intervention. This article reviews the properties of available antidiabetic medications and highlights potential targets for developing newer and safer drugs. Antidiabetic agents are grouped in the article as parts I, II and III according to the history of development. Part I groups early developed drugs, during the 20th century, including insulin, sulfonylureas, the metiglinides, insulin sensitizers, biguanides and α-glucosidase inhibitors. Part II groups newer drugs developed during the early part of the 21st century, the past decade, including GLP-1 analogs, DPP-VI inhibitors, amylin analogs and SGLT2 inhibitors. Part III groups potential targets for future design of newer antidiabetic agents with less adverse effects than the currently available antidiabetic drugs.
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