Tirzepatide 5, 10 and 15 mg versus injectable semaglutide 0.5 mg for the treatment of type 2 diabetes: An adjusted indirect treatment comparison

AIMS

To compare the efficacy and safety of tirzepatide 5, 10 and 15 mg with subcutaneous semaglutide 0.5 mg as second-line treatment for adults with type 2 diabetes mellitus, after metformin monotherapy, using adjusted indirect treatment comparisons (aITCs).

METHODS

The aITCs were performed using the Bucher method to compare the relative efficacy and safety of tirzepatide 5, 10 and 15 mg versus semaglutide 0.5 mg via a common comparator (subcutaneous semaglutide 1.0 mg) based on trial results from SURPASS-2 (NCT03987919) and SUSTAIN7 (NCT02648204).

RESULTS

All tirzepatide doses showed statistically significantly greater reductions in glycated haemoglobin, body weight and body mass index from baseline to week 40, with a comparable adverse event (AE) profile and no statistically significant differences in the odds of gastrointestinal AEs versus semaglutide 0.5 mg. Furthermore, all tirzepatide doses showed greater odds of patients achieving HbA1c targets of ≤ 6.5 % (≤48 mmol/mol) and < 7.0 % (<53 mmol/mol) and weight loss targets of ≥ 5 % and ≥ 10 %, versus semaglutide 0.5 mg.

CONCLUSIONS

In these aITCs, glycated haemoglobin and weight reductions were significantly greater for all tirzepatide doses versus semaglutide 0.5 mg with a comparable AE profile. These findings provide comparative effectiveness insights in the absence of a head-to-head clinical trial.

Reduction of prevalence of patients meeting the criteria for metabolic syndrome with tirzepatide: a post hoc analysis from the SURPASS Clinical Trial Program

BACKGROUND

Metabolic syndrome is characterized as the co-occurrence of interrelated cardiovascular risk factors, including insulin resistance, hyperinsulinemia, abdominal obesity, dyslipidemia and hypertension. Once weekly tirzepatide is approved in the US and EU for the treatment of type 2 diabetes (T2D) and obesity. In the SURPASS clinical trial program for T2D, tirzepatide demonstrated greater improvements in glycemic control, body weight reduction and other cardiometabolic risk factors versus placebo, subcutaneous semaglutide 1 mg, insulin degludec, and insulin glargine. This post hoc analysis assessed the effect of tirzepatide use on the prevalence of patients meeting the criteria for metabolic syndrome across SURPASS 1-5.

METHODS

Metabolic syndrome was defined as having ≥ 3 of 5 criteria according to the US National Cholesterol Education Program: Adult Treatment Panel III. Analyses were based on on-treatment data at the primary endpoint from patients adherent to treatment (taking ≥ 75% study drug). A logistic regression model with metabolic syndrome status as the response variable, metabolic syndrome status at the baseline visit as an adjustment, and randomized treatment as fixed explanatory effect was used. The effect of tirzepatide use on the prevalence of patients meeting the criteria for metabolic syndrome by categorical weight loss, background medication and gender were assessed.

RESULTS

In SURPASS, the prevalence of patients meeting the criteria for metabolic syndrome at baseline was 67-88% across treatment groups with reductions at the primary endpoint to 38-64% with tirzepatide versus 64-82% with comparators. Reductions in the prevalence of patients meeting the criteria for metabolic syndrome was significantly greater with all tirzepatide doses versus placebo, semaglutide 1 mg, insulin glargine, and insulin degludec (p < 0.001). Individual components of metabolic syndrome were also reduced to a greater extent with tirzepatide vs comparators. Greater reductions in body weight were associated with greater reductions in the prevalence of patients meeting the criteria for metabolic syndrome and its individual components. Background SGLT2i or sulfonylurea use or gender did not impact the change in prevalence of patients meeting the criteria for metabolic syndrome.

CONCLUSIONS

In this post hoc analysis, tirzepatide at all doses studied was associated with a greater reduction in the prevalence of patients meeting the criteria for metabolic syndrome compared to placebo, semaglutide 1 mg, insulin degludec, and insulin glargine. Although more evidence is needed, these data would support greater potential improvement in cardiovascular risk factor profile with tirzepatide treatment in people across the continuum of T2D.

Tirzepatide vs Insulin Lispro Added to Basal Insulin in Type 2 Diabetes: The SURPASS-6 Randomized Clinical Trial

Importance

Tirzepatide is a glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist used for the treatment of type 2 diabetes. Efficacy and safety of adding tirzepatide vs prandial insulin to treatment in patients with inadequate glycemic control with basal insulin have not been described.

Objective

To assess the efficacy and safety of tirzepatide vs insulin lispro as an adjunctive therapy to insulin glargine.

Design, Setting, and Participants

This open-label, phase 3b clinical trial was conducted at 135 sites in 15 countries (participants enrolled from October 19, 2020, to November 1, 2022) in 1428 adults with type 2 diabetes taking basal insulin.

Interventions

Participants were randomized (in a 1:1:1:3 ratio) to receive once-weekly subcutaneous injections of tirzepatide (5 mg [n = 243], 10 mg [n = 238], or 15 mg [n = 236]) or prandial thrice-daily insulin lispro (n = 708).

Main Outcomes and Measures

Outcomes included noninferiority of tirzepatide (pooled cohort) vs insulin lispro, both in addition to insulin glargine, in HbA1c change from baseline at week 52 (noninferiority margin, 0.3%). Key secondary end points included change in body weight and percentage of participants achieving hemoglobin A1c (HbA1c) target of less than 7.0%.

Results

Among 1428 randomized participants (824 [57.7%] women; mean [SD] age, 58.8 [9.7] years; mean [SD] HbA1c, 8.8% [1.0%]), 1304 (91.3%) completed the trial. At week 52, estimated mean change from baseline in HbA1c with tirzepatide (pooled cohort) was -2.1% vs -1.1% with insulin lispro, resulting in mean HbA1c levels of 6.7% vs 7.7% (estimated treatment difference, -0.98% [95% CI, -1.17% to -0.79%]; P < .001); results met noninferiority criteria and statistical superiority was achieved. Estimated mean change from baseline in body weight was -9.0 kg with tirzepatide and 3.2 kg with insulin lispro (estimated treatment difference, -12.2 kg [95% CI, -13.4 to -10.9]). The percentage of participants reaching HbA1c less than 7.0% was 68% (483 of 716) with tirzepatide and 36% (256 of 708) with insulin lispro (odds ratio, 4.2 [95% CI, 3.2-5.5]). The most common adverse events with tirzepatide were mild to moderate gastrointestinal symptoms (nausea: 14%-26%; diarrhea: 11%-15%; vomiting: 5%-13%). Hypoglycemia event rates (blood glucose level <54 mg/dL or severe hypoglycemia) were 0.4 events per patient-year with tirzepatide (pooled) and 4.4 events per patient-year with insulin lispro.

Conclusions and Relevance

In people with inadequately controlled type 2 diabetes treated with basal insulin, weekly tirzepatide compared with prandial insulin as an additional treatment with insulin glargine demonstrated reductions in HbA1c and body weight with less hypoglycemia.

Trial Registration

ClinicalTrials.gov Identifier: NCT04537923.

Ultrasound-Guided Ethanol Percutaneous Ablation Versus Rescue Surgery in Patients With Locoregional Recurrence of Papillary Thyroid Cancer

OBJECTIVES

Neck recurrence of papillary thyroid cancer (PTC) is frequently detected after initial surgery. The management of these lesions may include rescue surgery (RS) or minimally invasive techniques in selected patients, but comparative studies evaluating the effectiveness and safety of these techniques are lacking. In this paper, we compared ultrasound-guided ethanol ablation (EA) in selected patients to RS in a matched cohort.

METHODS

We retrospectively compared 41 patients and 41 matched PTC patients without known distant metastases, who underwent ultrasound-guided EA or RS (matched reference group), who had 63 and 75 thyroid bed and/or lymph node confirmed PTC recurrences during a median follow-up of 72.8 and 89.6 months, respectively. The primary outcome was time until structural recurrence, compared using Kaplan-Meier survival curves. The secondary outcomes included time until biochemical recurrence, plasma thyroglobulin (Tg) levels, American Thyroid Association (ATA) response-to-therapy categories by the last available observation, and treatment-derived complications in each group.

RESULTS

No significant differences were found between the EA and RS groups for time until structural recurrence (log-rank test, P=0.94). The time until biochemical recurrence was also similar (P=0.51); and the plasma Tg concentration reduction and proportions of patients in the ATA reclassification categories were also similar. A significantly higher proportion of patients in the RS group presented treatment-derived complications (29.27% vs. 9.75%, P<0.05).

CONCLUSION

In this retrospective analysis, the treatment of PTC neck recurrence with EA in selected patients was comparable to RS in a matched reference group for the long-term risk of structural or biochemical relapse, but with a lower risk of treatment-derived complications. These.

RESULTS

support the effectiveness and safety of this minimally invasive technique in the management of selected patients with recurrent PTC.

Effects of weight stigma on BMI and inflammatory markers among people living with obesity

OBJECTIVE

Weight stigma (WS) and prejudice are one of the most prevalent ways of discrimination among adults, comparable with rates of racial discrimination. Exposure to WS among patients with obesity (PWO) may make the adoption of healthy dietary patterns and regular physical activity even more challenging and, therefore, the achievement of weight loss. Additionally, WS could also induce physiological responses such as increased levels of inflammatory markers, due to stress exposure.

METHOD

Subjects attending two obesity clinics were evaluated at baseline and after a minimum follow-up of six months. The weight Bias Internalization Scale (WBIS) and the Stigmatizing Situations Inventory (SSI) were administered to evaluate WS. Also, anthropometric and inflammatory markers, including cortisol, ferritin and C-reactive protein (CRP), were recorded at baseline.

RESULTS

79 PWO (87.3%♀, 45.5 ± 1.3 years, 35.9 ± 6.3 kg/m²) were included. At baseline, 72.2% started liraglutide as anti-obesity drug. Baseline body mass index (BMI) correlated positively with both WBIS (r = 0.23; p = 0.03) and SSI (r = 0.25; p = 0.02) scores. Mean percentual weight loss after a mean follow-up of six months was -7.28%. However, there was a negative, but not statistically significant, correlation between weight loss and both WBIS (r=-0.14; p = 0.2) and SSI (r=-0.19; p = 0.08). Regarding inflammatory markers, plasma cortisol levels at baseline correlated positively with WBIS (p = 0.005) and SSI (p = 0.02). CRP at baseline also presented a positive correlation with SSI (p = 0.03). No significant correlations were found for stigma tests and ferritin levels.

DISCUSSION

As weight increases among PWO, so does stigma. Despite we did not find a significant negative association between the presence of WS and weight loss outcomes, there was an increase in inflammatory markers among PWO who experienced higher levels of WS.

SHORT TERM EFFECTS OF SEMAGLUTIDE ON EMOTIONAL EATING AND OTHER ABNORMAL EATING PATTERNS AMONG SUBJECTS LIVING WITH OBESITY

OBJECTIVE

Emotional eating (EE) and other abnormal eating patterns are highly prevalent among people living with obesity (PWO). In this sense, semaglutide, by acting on areas of the brain involved in the reward system and emotion regulation, could have the potential to ameliorate these eating patterns.

METHOD

69 PWO attending an obesity clinic were evaluated baseline and after 3 months since the beginning of semaglutide. To rule out abnormal EE, the Emotional Eating Questionnaire was administered, and a structured interview was conducted.

RESULTS

69 PWO (82.6%♀, 43.7±1years, and 34.3±6kg/m 2) were included. After 3 months of semaglutide, there was a significant reduction in weight (96.1±20.9 vs 91.3±19.7kg; p<0.001) and BMI (34.3±6 vs 32.4±5.6kg/m 2; p<0.0001). The proportion of patients with EE (72.5% vs 11.5%; p<0.001), external eating (27.5% vs 10.1%; p<0.001) cravings (49.3% vs 21.7%; p<0.001) and savory cravings (53.6% vs 14.5%; p<0.001) was significantly reduced after 3 months of semaglutide. Also, the proportion of PWO with regular exercise was increased (15.9% vs 39.1%; p<0.001). However, Logistic regression analysis showed that only sweet cravings at baseline were the only factor associated, although not significant, with a poorer weight loss (p=0.05).

DISCUSSION

Semaglutide is an effective weight-loss treatment in PWO at short term. Moreover, semaglutide was highly effective in ameliorating EE and other abnormal eating patterns that exert a negative influence on weight.

Breaking Barriers With Basal Insulin Biosimilars in Type 2 Diabetes

Despite increases in the availability and effectiveness of other therapies, insulin remains an essential treatment for approximately 30 million people with type 2 diabetes worldwide. The development of biosimilars has created the potential for significant health care cost savings and may lead to greater access to basal insulin for vast populations. In this review, we discuss evidence demonstrating equipoise between basal insulin biosimilars and the patented analogs they may replace.

Real-world GLP-1 RA therapy in type 2 diabetes: A long-term effectiveness observational study

AIMS

To evaluate in a real-world setting the effectiveness and tolerability of available GLP-1 RA drugs in patients with type 2 diabetes after a prolonged follow-up.

MATERIALS AND METHODS

Observational, retrospective, single-centre study in patients starting GLP-1 RA therapy. Change in HbA1c, fasting plasma glucose (FPG) and body mass index (BMI) along with gastrointestinal (GI) adverse events and withdrawal from GLP-1 RA therapy were evaluated. Lack of efficacy of GLP-1 RA therapy according to prespecified goals was also measured.

RESULTS

A total of 735 patients were included, mean age 59.7 years, duration of diabetes 9.01 years, HbA1c 8.18% and BMI 38.56 kg/m2. Average follow-up was 18.97 months (range 4.2-39.09). All HbA1c (0.93%; P < 0.01), FPG (24 mg/dL; P < 0.01) and BMI (1.55 kg/m2; P < 0.05) were significantly reduced from baseline and maintained throughout follow-up, regardless of prescribed GLP-1 RA. GI adverse events were present in 13.81% of patients at first follow-up visit, 37.07% of patients discontinued GLP-1 RA treatment, and 38.63% did not meet efficacy goals.

CONCLUSIONS

In a real-world setting, GLP-1 RA therapy is largely prescribed in severely obese patients with a long-standing and poorly controlled diabetes. All prescribed GLP-1 RAs significantly decreased HbA1c, FPG and BMI. GI adverse events affected a low proportion of patients. Inversely, a high proportion of patients did not meet efficacy goals and/or discontinued GLP-1 RA treatment. Baseline characteristics of patients and lack of adherence may represent important issues underlying differences in effectiveness in real-world studies versus randomized trials.

Clinical evaluation of combined therapy for type 2 diabetes

OBJECTIVE

Therapeutic guidelines recommend the combination of drugs as necessary to control type 2 diabetes (T2D). This research assessed the effectiveness of pioglitazone (Pio), metformin (Met) and sulfonylurea (SU) combinations in the routine clinical practice.

RESEARCH DESIGN AND METHODS

A nationwide, 12-month prospective, observational cohort study was performed in 2294 patients with T2D (50.3% females, mean age: 61.1 years, mean body mass index: 30.2 kg/m(2), mean time since diagnosis: 8.5 years) who started, at the discretion of treating physician, oral antihyperglycaemic treatment with either Pio + SU, Pio + Met or SU + Met because of inadequate control with previous therapy. Fasting plasma glucose (FPG), glycohaemoglobin (HbA1c), lipids, blood pressure, and anthropometric parameters were measured, and 10-year cardiovascular risk was estimated.

RESULTS

FPG, HbA1c and total cholesterol at baseline had mean values (184.6 mg/dl, 8.5% and 246.0 mg/dl, respectively) associated with an excess of micro- and macrovascular risk. The mean changes from baseline in the Pio + SU, Pio + Met and SU + Met cohorts were, respectively, -37.9, -32.7 and -25.8 mg/dl for FPG; -1.1, -1.0 and -0.7% for HbA1c; -30.7, -38.7 and -17.1 mg/dl for triglycerides; and +2.3, +2.5 and +0.6 mg/dl for HDL cholesterol. In consequence, the estimated 10-year cardiovascular risk decreased more in the Pio cohorts, particularly with Pio + Met (1.7% versus 1.4% Pio + SU and 1.0% SU + Met -Framingham equation- and 0.6% versus 0.4% SU + Met - Systematic Coronary Risk Evaluation model-). Related adverse events were significantly (p = 0.016) more frequent in Pio cohorts (4.7% with Pio + SU, 5.1% with Pio + Met) than in the SU + Met cohort (2.4%).

CONCLUSIONS

In patients with T2D failing therapy, mostly SU or Met monotherapy, pioglitazone add-on treatment was associated with a significant improvement of micro- and macrovascular risk estimations. These results from real-life clinical conditions support the findings of prior randomised trials, although they should be interpreted with caution because of the observational, nonrandomised design.

Insulin-secretion abnormalities and clinical deterioration related to impaired glucose tolerance in cystic fibrosis

OBJECTIVE

To evaluate insulin-secretion kinetics and insulin sensitivity in cystic fibrosis (CF) patients with normal glucose tolerance (CF-NGT), impaired glucose tolerance (CF-IGT) or CF-related diabetes (CFRD), and the potential effects of moderate hyperglycemia on clinical and nutritional status.

DESIGN AND METHODS

Cross-sectional study including 50 outpatients with CF. Patients underwent both oral (OGGT) and intravenous (IVGTT) glucose tolerance tests in order to assess insulin secretion and peripheral insulin sensitivity. Homeostasis assessment model and OGGT were used to investigate insulin sensitivity. Forced expiratory volume in the first second (FEV(1)) and forced vital capacity (FVC) were measured to evaluate pulmonary function. Body mass index (BMI) was determined to assess nutritional status.

RESULTS

Insulin secretion was significantly decreased (and delayed at OGTT) in the CFRD group (n = 9) versus the CF-IGT group (n = 10) and the CF-IGT versus the CF-NGT group (n = 31). Insulin sensitivity was significantly different in the CF-IGT and CFRD groups versus the CF-NGT group. FEV(1), FVC and BMI presented a significant linear correlation with plasma glucose value at 120 min at OGTT and were significantly lower in both CF-IGT and CFRD versus the CF-NGT group, whereas no differences were found between the CF-IGT and CFRD groups.

CONCLUSIONS

CF patients with IGT present diminished insulin secretion and increased peripheral insulin resistance, correlating with a worse clinical status, undernutrition and impaired pulmonary function. These findings open the question of whether early treatment of mild alterations of glucose metabolism with insulin secretagogues or short-action insulin may lead to improvement of clinical status in CF patients.

[Utility of arteriography with selective arterial calcium injection for the diagnosis of insulinoma]

BACKGROUND

Common preoperative imaging techniques for the diagnosis of insulinomas do not lead to an effective localization in 40% cases. We present here our experience with arteriography followed by selective arterial calcium injection (AACI).

METHOD

Retrospective review of AACIs and other techniques performed in patients with endogenous hyperinsulinism.

RESULTS

AACI either localized the tumor or at least conditional its surgical resection in nine out of 11 cases. In 2 out of 11 patients, the test yielded a negative result (factitious hypoglycemia). Only 4 tumors were identified by other techniques.

CONCLUSIONS

AACI is a first-choice technique for the preoperative localization of insulinomas. It may also help rule out other causes of hypoglycemia.

Analysis of indirect signs of microprolactinoma at MR imaging

OBJECTIVE

To evaluate the diagnostic reliability/value of microprolactinoma indirect signs at MRI.

METHODS AND MATERIAL

A prospective study was carried out over 3 years on 26 women with microprolactinoma (MiP group) and 106 healthy female volunteers as a control group. Size, glandular morphology, pituitary stalk inclination and sellar bony floor erosion were measured and a comparative statistical analysis between both groups was performed.

RESULTS

Patients from the MiP group showed a significantly bigger glandular size than women in the control group, although the glandular morphology did not present significant differences between both groups. Only 5% of normal glands measured over 7.5 mm in height and none of them reached 9 mm, while up to 42.3% of the MiP group scored over 7.5 mm and 19.2% over 9 mm. Mean stalk inclination for the MiP group was 4.6 +/- 3.1 degrees and 3.5 +/- 2.7 degrees for the control group with no significant differences. Five microprolactinomas were located on the glandular midline, 11 on the left side and ten on the right side. No relationship between the microadenoma location inside the gland and stalk inclination was found. From 21 microprolactinomas with eccentric location, 17 coincided with the sellar floor excavation; eccentric excavation presented significant differences between both groups, but not the central excavation.

CONCLUSION

From all indirect sings of microprolactinoma analyzed in this study, only a gland height over 9 mm, and an eccentric sellar excavation of at least 3 mm are reliable signs to support its diagnosis.