Phenotype-based targeted treatment of SGLT2 inhibitors and GLP-1 receptor agonists in type 2 diabetes

AIMS/HYPOTHESIS

A precision medicine approach in type 2 diabetes could enhance targeting specific glucose-lowering therapies to individual patients most likely to benefit. We aimed to use the recently developed Bayesian causal forest (BCF) method to develop and validate an individualised treatment selection algorithm for two major type 2 diabetes drug classes, sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA).

METHODS

We designed a predictive algorithm using BCF to estimate individual-level conditional average treatment effects for 12-month glycaemic outcome (HbA1c) between SGLT2i and GLP1-RA, based on routine clinical features of 46,394 people with type 2 diabetes in primary care in England (Clinical Practice Research Datalink; 27,319 for model development, 19,075 for hold-out validation), with additional external validation in 2252 people with type 2 diabetes from Scotland (SCI-Diabetes [Tayside & Fife]). Differences in glycaemic outcome with GLP1-RA by sex seen in clinical data were replicated in clinical trial data (HARMONY programme: liraglutide [n=389] and albiglutide [n=1682]). As secondary outcomes, we evaluated the impacts of targeting therapy based on glycaemic response on weight change, tolerability and longer-term risk of new-onset microvascular complications, macrovascular complications and adverse kidney events.

RESULTS

Model development identified marked heterogeneity in glycaemic response, with 4787 (17.5%) of the development cohort having a predicted HbA1c benefit >3 mmol/mol (>0.3%) with SGLT2i over GLP1-RA and 5551 (20.3%) having a predicted HbA1c benefit >3 mmol/mol with GLP1-RA over SGLT2i. Calibration was good in hold-back validation, and external validation in an independent Scottish dataset identified clear differences in glycaemic outcomes between those predicted to benefit from each therapy. Sex, with women markedly more responsive to GLP1-RA, was identified as a major treatment effect modifier in both the UK observational datasets and in clinical trial data: HARMONY-7 liraglutide (GLP1-RA): 4.4 mmol/mol (95% credible interval [95% CrI] 2.2, 6.3) (0.4% [95% CrI 0.2, 0.6]) greater response in women than men. Targeting the two therapies based on predicted glycaemic response was also associated with improvements in short-term tolerability and long-term risk of new-onset microvascular complications.

CONCLUSIONS/INTERPRETATION

Precision medicine approaches can facilitate effective individualised treatment choice between SGLT2i and GLP1-RA therapies, and the use of routinely collected clinical features for treatment selection could support low-cost deployment in many countries.

Second international consensus report on gaps and opportunities for the clinical translation of precision diabetes medicine

Precision medicine is part of the logical evolution of contemporary evidence-based medicine that seeks to reduce errors and optimize outcomes when making medical decisions and health recommendations. Diabetes affects hundreds of millions of people worldwide, many of whom will develop life-threatening complications and die prematurely. Precision medicine can potentially address this enormous problem by accounting for heterogeneity in the etiology, clinical presentation and pathogenesis of common forms of diabetes and risks of complications. This second international consensus report on precision diabetes medicine summarizes the findings from a systematic evidence review across the key pillars of precision medicine (prevention, diagnosis, treatment, prognosis) in four recognized forms of diabetes (monogenic, gestational, type 1, type 2). These reviews address key questions about the translation of precision medicine research into practice. Although not complete, owing to the vast literature on this topic, they revealed opportunities for the immediate or near-term clinical implementation of precision diabetes medicine; furthermore, we expose important gaps in knowledge, focusing on the need to obtain new clinically relevant evidence. Gaps include the need for common standards for clinical readiness, including consideration of cost-effectiveness, health equity, predictive accuracy, liability and accessibility. Key milestones are outlined for the broad clinical implementation of precision diabetes medicine.

Precision Medicine in Diabetes

Tailoring treatment or management to groups of individuals based on specific clinical, molecular, and genomic features is the concept of precision medicine. Diabetes is highly heterogenous with respect to clinical manifestations, disease progression, development of complications, and drug response. The current practice for drug treatment is largely based on evidence from clinical trials that report average effects. However, around half of patients with type 2 diabetes do not achieve glycaemic targets despite having a high level of adherence and there are substantial differences in the incidence of adverse outcomes. Therefore, there is a need to identify predictive markers that can inform differential drug responses at the point of prescribing. Recent advances in molecular genetics and increased availability of real-world and randomised trial data have started to increase our understanding of disease heterogeneity and its impact on potential treatments for specific groups. Leveraging information from simple clinical features (age, sex, BMI, ethnicity, and co-prescribed medications) and genomic markers has a potential to identify sub-groups who are likely to benefit from a given drug with minimal adverse effects. In this chapter, we will discuss the state of current evidence in the discovery of clinical and genetic markers that have the potential to optimise drug treatment in type 2 diabetes.

High Occurrence Among Calves and Close Phylogenetic Relationships With Human Viruses Warrants Close Surveillance of Rotaviruses in Kuwaiti Dairy Farms

Rotavirus, one of the main pathogens causing morbidity and mortality in neonatal dairy calves worldwide, is responsible for 30–44% of cattle deaths. It is considered to be the most common etiologic agent of diarrhea in neonatal dairy calves and children, the dominant type being group A. Two hundred seventy animals from 27 farms from 2 regions of Kuwait were tested for the presence of Rotavirus serogroup A (RVA) using latex agglutination test (LAT) and reverse transcription–polymerase chain (RT-PCR) testing. RVA non-structural proteins NSP1-2, NSP4-5 and capsid protein genes VP1-7 were characterized by next generation sequencing. LAT was positive in 15.56% of the animals, and RT-PCR in 28.89%. Using RT-PCR as a reference method, LAT was 100% specific but only 83.33% sensitive. ANOVA analysis showed correlation only with the location of the farms but no significant correlation with the age and sex of the animals. Although there was a tendency of clustering of RVA positive animals, it did not reach statistical significance (p = 0.035 for LAT). The phylogenetic analysis showed that Kuwaiti isolates of group A rotavirus clustered with human rotaviruses. Taken together, it seems that rotavirus was present in most of the dairy farms in Kuwait. The high occurrence of the virus in calves in Kuwaiti dairy farms and the close phylogenetic affinity with human isolates warrants urgent action to minimize and control its spread between calves in farms.

[The use of assessment instruments in the rehabilitation of accident victims]

Within the course of rehabilitation management the Verwaltungs-Berufsgenossenschaft (VBG) has started to measure the outcomes to assure the quality of rehabilitation processes using assessment instruments. The measures included some aspects of activity and participation in accordance with the International Classification of Functioning, Disability and Health (ICF). The present paper describes the generic and condition-specific instruments used in the this study to assess the health-related quality-of-life, discusses their selection and illustrates their incorporation into management practice. The assessment process constitutes a consistent system to prove the effects of rehabilitation and their persistence. The first experience shows that the assessment-based quality management system can be recommended for permanent modelling of structures, processes and outcomes to improve the efficacy and cost-effectiveness of rehabilitation.

[Tremor reaction to mental and emotional stress]

Reactions of tremor before and after stress were registered with a new method. Reactions with informatory-mental stress (adding tests with increasing time pressure) can only be interpreted by considering performance. Reactions with informatory-emotional stress (University examination; tasks in a central TV control room) are task specific when tremor is inter-individually normalized.

[Quantitative analysis of superposition of environmental task requirements]

Requirements for 1486 tasks have been registered with an Ergonomic Job Description Questionnaire (EJDQ). Frequencies of high and extremely high scaled environmental task requirements are analysed, related to branches, tasks and sex. The frequencies of superpositions are analysed for dominating requirements. Priorities for ergonomic research may be defined with the method presented.

Keyboard design through physiological strain measurements

The physiologically tolerable range of positions for the joints of the upper extremities have been investigated for typing tasks by recording the myoelectric activities of the involved muscles. For long-term typing tasks a split keyboard is recommended allocating a key field to each hand. The fields should be rotated against each other in the horizontal plane and inclined laterally.

[Development of demands with increasing technology in text processing]

Text-processing task demands are inquired about by means of an Ergonomic Job Description Questionnaire. The tasks are related to 5 steps of technologies and demands are documented for each of the technologies. With increasing technology demands on visual perception and work organisation dominate, while some demands on energetic work and environmental conditions decrease.

Ergonomics investigations of work-places in a police command-control centre equipped with TV displays

Ergonomics experiments were performed in a police command-control centre using computer controlled text processing systems with three alternative input devices: function keys, a light pen and a touch panel. A group of 14 operators was examined while using the alternative devices. Significant differences were found between the devices in terms of the following: sensory and motor activities, local muscular strain, transgressions of tolerance limits for 4-hour work sessions, and increases in heart rate. Suggestions for redesigning the control centre are given using anthropometric analysis. The paper also shows the relation between the sub-optimal design of a work system and the resulting strain.

[Ergonomic strain measurement in text processing]

Text processing task demands are analysed by using an Ergonomic Job Description Questionnaire. The tasks are classified by cluster analysis. Tasks out of each cluster are examined with respect to performance and physiological strain by 8-h measurements. These reactions are assessed in terms of tolerance limits and the distribution of demands is discussed for non-tolerable work conditions.

[Investigation of demands in data and text processing by an ergonomic job description questionnaire (DT-EIJDQ) (author's transl)]

A questionnaire for Ergonomic Job Description is developed for the area of text and data processing. The contents and structure of the method are described and its applicability is demonstrated in a field study. To interprete the data, methods of cluster, profile, and factor analyses are used. The jobs for which the data have been collected are classified according to their specific demands by the use of factor analysis. Further applications of the method are outlined.

[Performance- and strain-compensation with informatory work]

With results from literature it is shown that eye-blinking-rate is negative significant correlated with physiologic performance ability. Experiments with an abstract tracking task presented in this paper confirm that eye-blinking-rate is an indicator for activation. Taking in the indicator for activation (blinking-rate), tracking performance and central-physiological strain, phases of performance- and strain-compensation (stability, effort, fatigue, performance break-down) are defined in an hierarchical concept of stability. The compensatory processes of the human operator are discussed on the background of a stress-strain-concept taking account of the principle of feed-back.

[Examination and assessment of time-variant human strain in motor car driving: real situation--simulation (author's transl)]

Time variant processes of activity, activation and strain of man are registrated during several hours of automobil driving (highway-autobahn) for different stress conditions and classified in terms of degrees of fatigue. By comparison with an assessment of strain in a simulated driving task with the same individuum and the same research-methods it is shown that the development of methods for measurement and assessment of time-variant human processes in laboratory experiments can be recommended, field-studies higher degrees of strain were found than under laboratory conditions.

[Examination of blinking-rate in a simulated four hour driving task]

In a driving simulation task performance and physiological measurement of strain was registered on 3 subjects in 9 experiments. The time-variant behaviour of blinking-rate was examined together with performance, self-rating and physiological strain. The correlating results make blinking-rate a possible indicator for activation of willingness to good performance. A multidimensional concept for assessment of the degree of individual fatigue is presented and validated in respect of working-time.