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Bellido D, Abellán P, Ruiz Palomar JM, Álvarez Sintes R, Nubiolae A, Bellido V, Romero G. Intensification of Basal Insulin Therapy with Lixisenatide in Patients with Type 2 Diabetes in a Real-World Setting: The BASAL-LIXI Study. Curr Ther Res Clin Exp 2018; 89:37-42. [PMID: 30455779 PMCID: PMC6218842 DOI: 10.1016/j.curtheres.2018.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 01/02/2023] Open
Abstract
Adding lixisenatide to basal insulin was effective for uncontrolled type 2 diabetes. Glycemic control improved and body weight lowered during 24 weeks of treatment. These benefits were achieved with a low risk of hypoglycemia in clinical practice. These findings in the clinical practice setting support those of clinical trials.
Background Basal insulin reduces fasting blood glucose levels, but postprandial blood glucose levels may remain higher. Traditional strategies with rapid insulin intensification can cause hypoglycemic episodes and weight gain. Glucagon-like peptide-1 receptor agonists, such as the short-acting lixisenatide, are able to control postprandial excursions, without weight gain, and with a low risk of hypoglycemic events. Objective Due to the limited data on the combination of lixisenatide with basal insulin (with or without oral antidiabetes drugs) in clinical practice, this study evaluated changes in parameters associated with glycemic control and anthropometric data after 24 weeks of this therapy intensification. Methods This was a multicenter, retrospective observational study of 129 patients with type 2 diabetes that was uncontrolled by basal insulin. Their treatment was intensified by the addition of lixisenatide at least 24 weeks before being included in the study. Data were retrospectively collected to determine changes in glycated hemoglobin (HbA1c) levels, blood glucose levels, weight, and body mass index. Adverse reactions and hypoglycemic events were also recorded. Results After 24 weeks of therapy intensification with lixisenatide, a significant reduction in HbA1c levels was observed (–1.1%; P < 0.001). An HbA1c <7% was achieved in 30.2% of patients, and 17.1% reached an HbA1c <6.5%. There was a reduction in fasting blood glucose (31.8 [60.3] mg/dL; P < 0.001) and postprandial blood glucose (55.0 [49] mg/dL; P < 0.001) levels, as well as body weight (4.0 [5.4] kg; P < 0.001) and body mass index (1.5 [1.9]; P < 0.001). The most commonly observed adverse reactions were nausea (n = 9), in line with previous studies. Hypoglycemia events were rare; only reported in 2 patients. Conclusions Intensification strategy based on lixisenatide added to basal insulin (with or without oral antidiabetes drugs) can be an effective treatment option in patients with uncontrolled type 2 diabetes. In this small, selected population, glycemic control was significantly improved in terms of HbA1, fasting blood glucose levels, and postprandial glucose levels, with a reduction of body weight and low risk of hypoglycemic events. (Curr Ther Res Clin Exp. 2018; 79:XXX–XXX)
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Affiliation(s)
- Diego Bellido
- Department of Endocrinology and Nutrition, Ferrol Universitary Hospital Complex (CHUF), Ferrol, Spain
| | - Pablo Abellán
- Department of Endocrinology and Nutrition, Castellón General Universitary Hospital, Castellón de la Plana, Spain; Department of Medicine, Universidad Cardenal Herrera-CEU University, CEU Universities, Castellón, Spain.,Department of Endocrinology and Nutrition, Elda Hospital, Elda, Spain
| | - José Manuel Ruiz Palomar
- Department of Endocrinology and Nutrition, Quirón Health, Miguel Domínguez Hospitals Group, Pontevedra, Spain
| | | | - Andreu Nubiolae
- Department of Endocrinology and Nutrition, Cruces Universitary Hospital, Barakaldo, Spain
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Abstract
BACKGROUND Type 2 diabetes mellitus (T2D) is a growing global epidemic. Due to the progressive nature of the disease, many people with T2D require insulin at some point, most commonly a long-acting (basal) insulin to assist with 24-h control of glucose levels. OBJECTIVE This opinion paper provides an overview of considerations for primary care providers (PCPs) in intensifying the treatment regimen when basal insulin therapy is inadequate. RESULTS Control of mealtime hyperglycemia, in addition to fasting hyperglycemia, has been shown to be crucial in reaching A1c goals of <7.0%. However, initiating and optimizing mealtime insulin therapy can be challenging for both people with T2D and PCPs, due to a perceived lack of efficacy and burden of insulin treatment, causing "psychological insulin resistance" in people with T2D and clinical inertia among PCPs. Successful implementation of mealtime insulin therapy requires not only choosing appropriate treatment strategies, but also addressing patient-related behavioral and emotional barriers. Simplified treatment algorithms, combined with the use of advanced technology (devices such as insulin pens, pumps, and patches), and collaborative decision-making can help decrease barriers to effective mealtime insulin therapy. CONCLUSIONS It is possible to implement an effective basal-bolus insulin regimen in people with T2D in a way that improves glucose control while minimizing negative effects on quality-of-life, treatment satisfaction, and psychological well-being.
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Affiliation(s)
- Mark Peyrot
- a Loyola University Maryland , Baltimore , MD , USA
| | | | | | - Gérard Reach
- d Department of Endocrinology, Diabetes and Metabolic Diseases , Avicenne Hospital AP-HP , Bobigny , France
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Fleischmann H, Göke R, Bramlage P. Addition of once daily prandial lixisenatide to basal insulin therapy in patients with type-2 diabetes results in a reduction of HbA1c as an effect of postprandial glucose lowering. Diabetes Metab Syndr 2017; 11 Suppl 1:S91-S97. [PMID: 27986406 DOI: 10.1016/j.dsx.2016.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/12/2016] [Indexed: 11/30/2022]
Abstract
AIMS Basal insulin has been shown to effectively reduce fasting blood glucose (FBG), but postprandial plasma glucose (PPG) excursions may remain higher than normal. Glucagon-like peptide (GLP)-1 receptor agonists such as the short-acting lixisenatide are able to control such excursions by slowing gastric emptying. However, data regarding its use in a real world clinical setting are scarce. METHODS 24 week, prospective, multicentre, non-interventional study in 1437 patients with type-2 diabetes receiving 20μg lixisenatide once daily in combination with basal insulin. The per-protocol set (PPS) comprised 540 patients. RESULTS HbA1c levels were found to decrease significantly over 24 weeks of treatment in the PPS (0.94±0.99% [7.9±8.5]; p≤0.001). An HbA1c of <7% (53mmol/mol) was achieved in 26.9% of patients, with 9.8% reaching <6.5% (48mmol/mol) and 30.0% reaching their individual treatment goal. There was a slight decrease in FBG (2.84±30.4mg/dl; p≤0.001), and a significant reduction in PPG, with levels decreasing by between 35mg/dl (1.9mmol/l) and 38mg/dl (2.1mmol/l), respectively on average after all main meals in basal optimised patients (PPS; ≤140mg/dl). Body weight decreased from 101 to 98kg with a mean difference of 3.10±4.10kg (p≤0.001). There were few reports of hypoglycaemia and no reports of serious hypoglycaemia and need for external help. AEs were infrequent, and were in line with previous studies. CONCLUSIONS Lixisenatide in combination with basal insulin was shown to be an effective treatment strategy for patients with type 2 diabetes, controlling HbA1c levels by reduction of PPG excursions during the whole day.
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Affiliation(s)
| | - Rüdiger Göke
- Diabetes Schwerpunktpraxis, Kirchhain, Marburg, Germany.
| | - Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin, Mahlow, Germany.
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Nauck M, Wilhelm B. [Why is a combination of basal insulin with a GLP-1 receptor agonist useful in many patients with type 2 diabetes?]. MMW Fortschr Med 2017; 159:7-15. [PMID: 28643293 DOI: 10.1007/s15006-017-9803-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In 2015, the combination of basal insulin and GLP-1 receptor agonist (RA) was incorporated into the guideline recommendations for type 2 diabetes as an option for the last escalation step. The two antidiabetics to be injected subcutaneously are complementary regarding their respective main effects and limitations. Basal insulin is predominantly active between meals and in the fasting state, whereas the main action of GLP-1 RA consists in preventing an excessive postprandial blood glucose increase. Moreover, GLP-1 RA is characterised by a low intrinsic risk of hypoglycaemia, body weight reduction and a positive impact on cardiovascular risk factors. Unlike GLP-1 RA, no upper dose limits are defined for basal insulin. However, initiation of insulin therapy is associated with disadvantages in terms of hypoglycaemia and weight increase. Therefore, patients achieving their treatment goals with GLP-1 RA alone are better treated without insulin. METHOD In a review, study results on combinations of basal insulin and GLP-1-RA versus comparative therapies are presented. RESULTS Most of the studies were carried out in patients pre-treated with basal insulin. The add-on of GLP-1 RA was commonly associated with significant reductions of body weight and also resulted in additional HbA1c reductions compared with an increase of the basal insulin dose. The add-on of a short acting insulin to an existing basal insulin therapy enabled similar HbA1c reductions to the add-on of a GLP-1 RA, but simultaneously increased the number of episodes of hypoglycaemia and might lead to more unfavourable body weight developments. A fixed combination of insulin degludec and liraglutide (IDegLira) showed an effective and rather steady blood glucose reduction in a 24-hour interval vs. basal insulin or GLP-1 RA alone. CONCLUSIONS Combinations of basal insulin and a GLP-1 RA improve glycaemic control in many patients with type 2 diabetes without any significant increase of the risk of hypoglycaemia and without weight gain, especially compared to a dose increase of the basal insulin or add-on of a short-acting insulin.
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Gómez-Huelgas R, Sabán-Ruiz J, García-Román F, Quintela-Fernández N, Seguí-Ripoll J, Bonilla-Hernández M, Romero-Meliá G. Safety and efficacy of a basal-plus regimen with insulin glargine and insulin glulisine for elderly patients with high cardiovascular risk and type 2 diabetes mellitus. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2017.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Gómez-Huelgas R, Sabán-Ruiz J, García-Román F, Quintela-Fernández N, Seguí-Ripoll J, Bonilla-Hernández M, Romero-Meliá G. Eficacia y seguridad de una pauta basal plus con insulina glargina e insulina glulisina en pacientes ancianos de alto riesgo cardiovascular con diabetes mellitus tipo 2. Rev Clin Esp 2017; 217:201-206. [DOI: 10.1016/j.rce.2017.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/12/2017] [Accepted: 02/05/2017] [Indexed: 01/16/2023]
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Abstract
Diabetes mellitus (DM) and chronic kidney disease (CKD) are intricately intertwined. DM is the most common cause of CKD. Adequate control of DM is necessary for prevention of progression of CKD, while careful management of the metabolic abnormalities in CKD will assist in achieving better control of DM. Two of the key organs involved in glucose production are the kidney and the liver. Furthermore, the kidney also plays a role in glucose filtration and reabsorption. In CKD, monitoring of glycemic control using traditional methods such as Hemoglobin A1c (Hba1c) must be done with caution secondary to associated hematological abnormalities in CKD. With regard to medication management in the care of patients with DM, CKD has significant effects. For example, the dosages of oral and non-insulin anti-hyperglycemic agents often need to be modified according to renal function. Insulin metabolism is altered in CKD, and a reduction in insulin dose is almost always needed. Dialysis also affects various aspects of glucose homeostasis, necessitating appropriate changes in therapy. Due to the aforementioned factors glycemic management in patients with DM and CKD can be quiet challenging.
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Affiliation(s)
- Vishnu Garla
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA.
| | - Licy Yanes-Cardozo
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Lillian F Lien
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
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Abstract
The combination of basal insulin and glucagon-like peptide-1 receptor agonists (GLP-1RAs) is an emerging option for patients with type 2 diabetes (T2D). GLP-1RAs have been shown to improve glycaemic control with a low risk of hypoglycaemia and to promote body weight loss. However, GLP-1 receptors (GLP-1Rs) are widely expressed in extrapancreatic tissues and could sustain pleiotropic actions of GLP-1RAs beyond glycaemic control. The underlying molecular mechanisms maintaining these extrapancreatic actions of GLP-1 are complex, and involve GLP-1R signalling in both the brain and several peripheral tissues. The present review focuses specifically on the role of GLP-1RAs in the cardiovascular system and liver. Preclinical data in rodents and pilot studies in humans suggest that GLP-1RAs may have potential beneficial effects on heart function, blood pressure, postprandial lipaemia, liver steatosis and non-alcoholic steatohepatitis (NASH). Long-term studies are now warranted to determine the safety and clinical relevance of the association between insulin and GLP-1RAs in T2D.
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Affiliation(s)
- B Cariou
- Clinique d'Endocrinologie, l'institut du thorax, CHU de Nantes, Nantes, F-44000 France; INSERM, UMR1087, l'institut du thorax, Nantes, F-44000 France; Faculté de Médecine, Université de Nantes, Nantes, F-44000 France.
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Abstract
BACKGROUND Only about half of patients with type 2 diabetes treated with antihyperglycemic drugs achieve glycemic control (HbA1c <7%), most commonly due to poor treatment adherence. Glucagon-like peptide-1 (GLP-1) receptor agonists act on multiple targets involved in glucose homeostasis and have a low risk of causing hypoglycemia. While GLP-1 receptor (GLP-1R) agonists share the same mechanism of action, clinical profiles of individual agents differ, particularly between short- and long-acting agents. In this article, recent findings regarding the pharmacology of GLP-1 agonists are reviewed, and the clinical effects of short- versus long-acting agents are compared. DATA SOURCES Relevant articles were identified through a search of PubMed using the keywords glucagon-like peptide-1, GLP-1, glucagon-like peptide-1 receptor agonist, GLP-1R agonist, and exenatide for publications up to 22 May 2015. Supporting data were obtained from additional searches for albiglutide, dulaglutide, liraglutide and lixisenatide as well as from the bibliographies of key articles. FINDINGS Short-acting GLP-1R agonists produce greater reductions in postprandial glucose levels by slowing gastric emptying, whereas long-acting GLP-1R agonists produce greater reductions in fasting blood glucose by stimulating insulin secretion from the pancreas. These characteristics can be exploited to provide individualized treatment to patients. A large body of evidence supports the benefits of short- and long-acting exenatide as add-on therapy in patients with inadequate glycemic control despite maximum tolerated doses of metformin and/or sulfonylurea. Exenatide is generally well tolerated and no new safety concerns were identified during long-term follow-up of up to 5 years. A limitation of this review of short-and long-acting GLP-1 receptor agonists is that it focuses on exenatide rather than all the drugs in this class. However, the focus on a single molecule helps to avoid any confusion that may be introduced as a result of differences in molecular structure and size. CONCLUSIONS Short-acting GLP-1R agonists including exenatide are well suited to patients with type 2 diabetes with exaggerated postprandial glucose excursions and for co-administration with basal insulin therapy. Long-acting GLP-1R agonists including once weekly exenatide offer greater convenience and are well suited to patients who require specific control of fasting hyperglycemia.
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Affiliation(s)
- Xiao-Hui Guo
- a Endocrinology Department , Peking University First Hospital , Beijing , China
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Oh S, Chon S, Ahn KJ, Jeong IK, Kim BJ, Kang JG. The Role of Glucagon-Like Peptide-1 Receptor Agonists in Type 2 Diabetes: Understanding How Data Can Inform Clinical Practice in Korea. Diabetes Metab J 2015; 39:177-87. [PMID: 26124987 PMCID: PMC4483602 DOI: 10.4093/dmj.2015.39.3.177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) reduce glycosylated hemoglobin (HbA1c, 0.5% to 1.0%), and are associated with moderate weight loss and a relatively low risk of hypoglycemia. There are differences between Asian and non-Asian populations. We reviewed available data on GLP-1RAs, focusing on Korean patients, to better understand their risk/benefit profile and help inform local clinical practice. Control of postprandial hyperglycemia is important in Asians in whom the prevalence of post-challenge hyperglycemia is higher (vs. non-Asians). The weight lowering effects of GLP-1RAs are becoming more salient as the prevalence of overweight and obesity among Korean patients increases. The higher rate of gastrointestinal adverse events amongst Asian patients in clinical trials may be caused by higher drug exposure due to the lower body mass index of the participants (vs. non-Asian studies). Data on the durability of weight loss, clinically important health outcomes, safety and optimal dosing in Korean patients are lacking. Use of GLP-1RAs is appropriate in several patient groups, including patients whose HbA1c is uncontrolled, especially if this is due to postprandial glucose excursions and patients who are overweight or obese due to dietary problems (e.g., appetite control). The potential for gastrointestinal adverse events should be explained to patients at treatment initiation to facilitate the promotion of better compliance.
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Affiliation(s)
- Seungjoon Oh
- Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea
| | - Suk Chon
- Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kyu Jeong Ahn
- Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea
| | - In-Kyung Jeong
- Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea
| | - Byung-Joon Kim
- Department of Endocrinology, Gachon University College of Medicine, Incheon, Korea
| | - Jun Goo Kang
- Department of Endocrinology and Metabolism, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
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Affiliation(s)
| | - Julien S Baker
- Exercise Science Research Laboratory, Institute of Clinical Exercise and Health Science, School of Science, University of the West of Scotland, Hamilton, UK
- Correspondence: Julien S Baker, Exercise Science Research Laboratory, Institute of Clinical Exercise and Health Science, School of Science, University of the West of Scotland, Hamilton, Lanarkshire, Scotland ML3 OJB, UK, Email
| | - Bruce Davies
- Science Department, University of South Wales, Newport, UK
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