Exocrine Pancreatic Insufficiency During the Use of Semaglutide: A Case Report

Although acute pancreatitis has been reported as an adverse event in patients treated with glucagon-like peptide-1 (GLP-1) analogues, to date we have not identified a case describing exocrine pancreatic insufficiency related to this drug. Here we present a case of a patient with no history of acute pancreatitis, who was diagnosed with exocrine pancreatic insufficiency during the third year of weekly subcutaneous semaglutide for obesity control. A 68-year-old man with previous unsuccessful therapeutic approaches for weight loss used subcutaneous semaglutide, once a week, for 181 weeks. The pharmacological treatment, combined with instructions on lifestyle changes, resulted in a weight loss of 11.6% of initial body weight, with a reduction in body mass index from 35.7 to 31.9 kg/m2. The patient received a regular dose of 0.5mg/week in the first 14 weeks in a private physician's office. During this period, an asymptomatic elevation of serum lipase was identified and attributed to alcohol consumption. Because the patient complained of less satiety and weight loss stabilization, the dose of semaglutide was increased to 1.0mg/week. Serum lipase levels increased to up to eight times the upper normal limit and the use of semaglutide was discontinued for 10 weeks. Due to progressive weight regain and serum lipase levels being near normal, semaglutide was reintroduced at 0.25mg/week with progressive increments until 1.0mg/week. The patient missed the follow-up appointments, continued the same dose of semaglutide for another 16 weeks, and discontinued treatment after another asymptomatic elevation in serum lipase levels. Four weeks later, the patient reported steatorrhea and was seen by a gastroenterologist, who diagnosed exocrine pancreatic insufficiency. The course of our case suggests a potential association between semaglutide and chronic alcohol consumption in the development of exogenous pancreatic insufficiency. We call attention to the importance of regular monitoring of serum lipase levels in patients taking GLP-1 analogues and suggest that the consumption of any amount of alcohol should be discouraged in patients in long-term treatment with glucagon-like peptide-1 receptor agonists.

Effects of exenatide twice daily versus sitagliptin on 24-h glucose, glucoregulatory and hormonal measures: a randomized, double-blind, crossover study

AIM

To compare exenatide and sitagliptin glucose and glucoregulatory measures in subjects with type 2 diabetes.

METHODS

An 8-week, double-blind, randomized, crossover, single-centre study. Eighty-six subjects (58% female, body mass index 35 ± 5 kg/m², haemoglobin A1c 8.3 ± 1.0%) received either exenatide 10 µg (subcutaneous) twice daily or sitagliptin 100 mg (oral) daily for 4 weeks and crossed to the other therapy for an additional 4 weeks. Main outcome was time-averaged glucose during the 24-h inpatient visits.

RESULTS

Both treatments decreased average 24-h glucose, but exenatide had a greater effect [between-group difference: -0.67 mmol/l, 95% confidence interval (CI): -0.9 to -0.4 mmol/l]. Both treatments decreased 2-h postprandial glucose (PPG), area under the curve of glucose above 7.8 mmol/l (140 mg/dl) and 11 mmol/l (200 mg/dl) and increased the time spent with glucose between 3.9 and 7.8 mmol/l (70 and 140 mg/dl) during 24 h, but exenatide had a significantly greater effect (p < 0.05). Both treatments decreased postprandial serum glucagon, with exenatide having a greater effect (p < 0.005). Both treatments decreased fasting blood glucose to a similar degree (p = 0.766). Sitagliptin increased, while exenatide decreased, postprandial intact glucagon-like peptide-1. Both drugs improved homeostasis model assessment of β-cell function (HOMA-B), with exenatide having a significantly greater effect (p = 0.005). Both exenatide and sitagliptin decreased 24-h caloric intake, with exenatide having a greater effect (p < 0.001). There was no episode of major hypoglycaemia. Adverse events were mild to moderate and mostly gastrointestinal in nature with exenatide. No study withdrawals were due to an adverse event.

CONCLUSION

Compared to sitagliptin, exenatide showed significantly lower average 24-h glucose, 2-h PPG, glucagon, caloric intake and improved HOMA-B.

Glucagon-like peptide-1 (GLP-1) and the regulation of human invariant natural killer T cells: lessons from obesity, diabetes and psoriasis

AIMS/HYPOTHESIS

The innate immune cells, invariant natural killer T cells (iNKT cells), are implicated in the pathogenesis of psoriasis, an inflammatory condition associated with obesity and other metabolic diseases, such as diabetes and dyslipidaemia. We observed an improvement in psoriasis severity in a patient within days of starting treatment with an incretin-mimetic, glucagon-like peptide-1 (GLP-1) receptor agonist. This was independent of change in glycaemic control. We proposed that this unexpected clinical outcome resulted from a direct effect of GLP-1 on iNKT cells.

METHODS

We measured circulating and psoriatic plaque iNKT cell numbers in two patients with type 2 diabetes and psoriasis before and after commencing GLP-1 analogue therapy. In addition, we investigated the in vitro effects of GLP-1 on iNKT cells and looked for a functional GLP-1 receptor on these cells.

RESULTS

The Psoriasis Area and Severity Index improved in both patients following 6 weeks of GLP-1 analogue therapy. This was associated with an alteration in iNKT cell number, with an increased number in the circulation and a decreased number in psoriatic plaques. The GLP-1 receptor was expressed on iNKT cells, and GLP-1 induced a dose-dependent inhibition of iNKT cell cytokine secretion, but not cytolytic degranulation in vitro.

CONCLUSIONS/INTERPRETATION

The clinical effect observed and the direct interaction between GLP-1 and the immune system raise the possibility of therapeutic applications for GLP-1 in inflammatory conditions such as psoriasis.

Liraglutide, a once-daily human glucagon-like peptide 1 analogue, provides sustained improvements in glycaemic control and weight for 2 years as monotherapy compared with glimepiride in patients with type 2 diabetes

AIMS

Most treatments for type 2 diabetes fail over time, necessitating combination therapy. We investigated the safety, tolerability and efficacy of liraglutide monotherapy compared with glimepiride monotherapy over 2 years.

METHODS

Participants were randomized to receive once-daily liraglutide 1.2 mg, liraglutide 1.8 mg or glimepiride 8 mg. Participants completing the 1-year randomized, double-blind, double-dummy period could continue open-label treatment for an additional year. Safety data were evaluated for the full population exposed to treatment, and efficacy data were evaluated for the full intention-to-treat (ITT) and 2-year completer populations. Outcome measures included change in glycosylated haemoglobin (HbA1c), fasting plasma glucose (FPG), body weight and frequency of nausea and hypoglycaemia.

RESULTS

For patients completing 2 years of therapy, HbA1c reductions were -0.6% with glimepiride versus -0.9% with liraglutide 1.2 mg (difference: -0.37, 95% CI: -0.71 to -0.02; p = 0.0376) and -1.1% with liraglutide 1.8 mg (difference: -0.55, 95% CI: -0.88 to -0.21; p = 0.0016). In the ITT population, HbA1c reductions were -0.3% with glimepiride versus -0.6% with liraglutide 1.2 mg (difference: -0.31, 95% CI: -0.54 to -0.08; p = 0.0076) and -0.9% with liraglutide 1.8 mg (difference: -0.60, 95% CI: -0.83 to -0.38; p < 0.0001). For both ITT and completer populations, liraglutide was more effective in reducing HbA1c, FPG and weight. Over 2 years, rates of minor hypoglycaemia [self-treated plasma glucose <3.1 mmol/l (<56 mg/dl)] were significantly lower with liraglutide 1.2 mg and 1.8 mg compared with glimepiride (p < 0.0001).

CONCLUSION

Liraglutide monotherapy for 2 years provides significant and sustained improvements in glycaemic control and body weight compared with glimepiride monotherapy, at a lower risk of hypoglycaemia.