Oral semaglutide in type 2 diabetes mellitus: Comprehensive review, critical appraisal and clinical consideration of its use in India

BACKGROUND AND AIMS

Oral semaglutide is the first glucagon-like petide-1 receptor agonist (GLP-1RA) approved for oral use in the treatment of type 2 diabetes mellitus (T2DM). We aim to conduct a comprehensive review of literature to find out the efficacy and safety of oral semaglutide in T2DM, to lay out a clinical consideration for its use in India.

METHODS

We searched the electronic database of PubMed and Google Scholar from inception until January 31, 2022, using several MeSH keywords and retrieved all available granular details of phase 1, 2 and 3 randomized controlled trials (RCTs) of oral semaglutide. Subsequently, we reviewed the results critically to lay down the clinical recommendation of its use.

RESULTS

Ten phase 3 randomized, placebo- and or active-controlled studies of oral semaglutide (PIONEER programs) are currently published. Seven global trials of oral semaglutide (PIONEER 1-5, 7 and 8) that exclusively studied the efficacy (lowering of HbA1c and body weight, achieving target of HbA1c <7% and other composites of HbA1c and weight) outcomes, found 14 mg oral semaglutide to be superior to placebo or active comparators (empagliflozin, sitagliptin and liraglutide). Efficacy was similar in Asians, although no separate data exists for Indians due to the low number of participants. Expectedly, gastrointestinal intolerance were the most commonly observed side effects with oral semaglutide and the main reason for drug discontinuation.

CONCLUSION

Oral semaglutide 14 mg is an effective agent in the treatment of T2DM. Real-world studies of semaglutide are clearly needed in India in absence of meaningful data from RCTs in Indians.

An updated practical guideline on use of molnupiravir and comparison with agents having emergency use authorization for treatment of COVID-19

BACKGROUND AND AIMS

Molnupiravir is a newer oral antiviral drug that has recently received emergency use authorization (EUA) in USA, UK and India. We aim to conduct an update on our previous systematic review to provide practical clinical guideline for using molnupiravir in patients with COVID-19.

METHODS

We systematically searched the electronic database of PubMed, MedRxiv and Google Scholar until January 5, 2022, using key MeSH keywords.

RESULTS

Final result of phase 3 study in 1433 non-hospitalized COVID-19 patients showed a significant reduction in composite risk of hospital admission or death (absolute risk difference, -3.0% [95% confidence interval {CI}, -5.9 to -0.1%]; 1-sided P = 0.02) although with a non-significant 31% relative risk reduction (RRR). RRR for death alone was 89% (95% CI, 14 to 99; P-value not reported). Number needed to treat to prevent 1 death or 1 hospitalization or death composite appears to be closely competitive to other agents having EUA in people with COVID-19. However, cost-wise molnupiravir is comparatively cheaper compared to all other agents.

CONCLUSION

Molnupiravir could be a useful agent in non-pregnant unvaccinated adults with COVID-19 who are at increased risk of severity including hospitalization. However, it is effective only when used within 5-days of onset of symptoms. A 5-days course seems to be safe without any obvious short-term side effects.

Humoral antibody kinetics with ChAdOx1-nCOV (Covishield™) and BBV-152 (Covaxin™) vaccine among Indian Healthcare workers: A 6-month longitudinal cross-sectional Coronavirus Vaccine-induced antibody titre (COVAT) study

BACKGROUND AND AIMS

There is limited data available on longitudinal humoral antibody dynamics following two doses of ChAdOx1-nCOV (Covishield™) and BBV-152 (Covaxin™) vaccine against SARS-CoV-2 among Indians.

METHODS

We conducted a 6-month longitudinal study in vaccinated healthcare workers by serially measuring quantitative anti-spike antibody at 3-weeks, 3-months and 6-months after the completion of second dose. Geometric mean titer (GMT) and linear mixed models were used to assess the dynamics of antibody levels at 6 months.

RESULTS

Of the 481 participants, GMT of anti-spike antibody decreased by 56% at 6-months regardless of age, gender, blood group, body-mass index and comorbidities in 360 SARS-CoV-2 naive individuals but significantly more in hypertensives. Participants with past infection had significantly higher GMT at all time points compared to the naive individuals. Among SARS-CoV-2 naive cohorts, a significantly higher GMT was noted amongst the Covishield recipients at all time points, but there was a 44% decline in GMT at 6-month compared to the peak titer period. Decline in GMT was insignificant (8%) in Covaxin recipients at 6-month despite a lower GMT at all time points vs. Covishield. There was 5.6-fold decrease in seropositivity rate at 6-month with both vaccines. Participants with type 2 diabetes mellitus have a lower seropositivity rate at all the time points. Seropositivity rate was significantly higher with Covishield vs. Covaxin at all time points except at 6-month where Covaxin recipients had a higher seropositivity rate but no difference noted in propensity-matched analysis.

CONCLUSIONS

There is waning humoral antibody response following two doses of either vaccine at six months. Covishield recipients had a higher anti-spike antibody GMT compared with Covaxin at all-time points, however a significant decline in antibody titers was seen with Covishield but not with Covaxin at 6-months.

COVID-19 and Diabetes

The prevalence of diabetes in people with coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has varied worldwide. Most of the available evidence suggests a significant increase in severity and mortality of COVID-19 in people with either type 1 (T1DM) or type 2 diabetes mellitus (T2DM), especially in association with poor glycemic control. While new-onset hyperglycemia and new-onset diabetes (both T1DM and T2DM) have been increasingly recognized in the context of COVID-19 and have been associated with worse outcome, no conclusive evidence yet suggests direct tropism of SARS-CoV-2 on the β cells of pancreatic islets. While all approved oral antidiabetic agents appear to be safe in people with T2DM having COVID-19, no conclusive data are yet available to indicate a mortality benefit with any class of these drugs, in the absence of large randomized controlled trials.

A systematic review on SARS-CoV-2 remission: an Emerging challenge for its management, treatment, immunization strategies and post-treatment guidelines

The COVID-19 disease caused by severe acute respiratory syndrome coronavirus -2 (SARS-CoV-2) has posed as a major health concern for people all across the globe. Along with the increasing confirmed patients being readmitted with complaints for fever, cough, cold, the effective monitoring of 'relapse' of the SARS-CoV-2 virus in the previously discharged patients have become the next area of focus. However, availability of limited data on reactivation of SARS-CoV-2 makes the disease prognosis as well as the effective control of re-infection an immense challenge. Prompted by these challenges, we assessed the possibility of re-infection in discharged patients and the risk of the transmission, proficiency of RT-PCR results and approximate period required for the quarantine and the real challenges for the development of vaccine. In the present review, the published literature on all the possible cases of re-infection from February to July were reported, thereby selected 142 studies from a hub of overall 669 studies after full text screening. The incomplete virus clearance, poor sensitivity of the present diagnostic testing, emergence of mutant strains, insufficient mucus collection from the throat swab etc. are some of the possible causes of re-infection. The new protocols for management of COVID-19 discharged patients should be revised in the guidelines.

Molnupiravir in COVID-19: A systematic review of literature

BACKGROUND AND AIMS

Molnupiravir is a newer oral antiviral drug that has recently been tested in COVID-19. We aim to conduct a systematic review of literature to find out the efficacy and safety of molnupiravir in patients with COVID-19.

METHODS

We systematically searched the electronic database of PubMed, MedRxiv and Google Scholar from inception until October 15, 2021, using MeSH keywords. Ongoing trials of molnupiravir in COVID-19 were additionally searched from the ClinicalTrials.Gov and ctri.nic.in/Clinicaltrials. We retrieved all the available granular details of phase 1 to 3 studies of molnupiravir in COVID-19. Subsequently we reviewed the results narratively.

RESULTS

Two phase 1 double-blind, randomized, placebo-controlled (DBRPC) studies of molnupiravir showed that 1600 mg daily dose is safe and tolerable, without any serious adverse events up to 5.5 days. One phase 2 DBPRC study found significantly lower time to clearance (RNA negativity) with molnupiravir 800 mg twice daily compared to the placebo (log-rank p value = 0.013) in mild to moderate COVID-19. Interim report of one phase 3 DBRPC study in non-hospitalized COVID-19 found a significant reduction in the risk of hospital admission or death by 50% (p = 0.0012). However, no significant benefit was observed with molnupiravir in the later stage of moderate to severe COVID-19.

CONCLUSION

Molnupiravir is first oral antiviral drug to demonstrate a significant benefit in reducing hospitalization or death in mild COVID-19 and could be an important weapon in the battle against SARS-CoV-2. However, its role in moderate to severe COVID-19 is questionable and more studies are needed.

Do SGLT-2 inhibitors exhibit similar cardiovascular benefit in patients having reduced ejection fraction heart failure with type 2 diabetes, prediabetes and normoglycemia?

BACKGROUND AND AIMS

We aimed to know whether SGLT-2 inhibitors (SGLT-2I) exhibit similar cardiovascular (CV) benefit in patients having reduced ejection fraction heart failure (HFrEF) with varying degree of glycemia.

METHOD

We meta-analyzed the trial-level hazard ratio and 95% confidence interval of randomized trials that reported the CV outcomes stratified in to three subgroups of normoglycemia, prediabetes and diabetes.

RESULTS

This meta-analysis found a significant and similar CV risk reduction in patients with HFrEF without any significant interaction between three subgroups (P_Intercation = 0.98).

CONCLUSIONS

SGLT-2I exhibit similar CV risk reduction in HFrEF, regardless of baseline glycemic status. However, this finding is limited to pooled data from only 2 studies in people without T2DM.

COVID-19 associated mucormycosis: A Descriptive Multisite Study from India

BACKGROUND AND AIMS

Mucormycosis is an invasive fungal infection and carries a significant morbidity and mortality. A number of cases of mucormycosis have been reported in association with COVID-19. In this study, a consortium of clinicians from various parts of India studied clinical profile of COVID-19 associated mucormycosis (CAM) and this analysis is presented here.

METHODS

Investigators from multiple sites in India were involved in this study. Clinical details included the treatment and severity of COVID-19, associated morbidities, as well as the diagnosis, treatment and prognosis of mucormycosis. These data were collected using google spreadsheet at one centre. Descriptive analysis was done.

RESULTS

There were 115 patients with CAM. Importantly, all patients had received corticosteroids. Diabetes was present in 85.2% of patients and 13.9% of patients had newly detected diabetes. The most common site of involvement was rhino-orbital. Mortality occurred in 25 (21.7%) patients. On logistic regression analysis, CT scan-based score for severity of lung involvement was associated with mortality.

CONCLUSION

Universal administration of corticosteroids in our patients is notable. A large majority of patients had diabetes, while mortality was seen in ∼1/5th of patients, lower as compared to recently published data.

Antibody response after first and second-dose of ChAdOx1-nCOV (CovishieldTM®) and BBV-152 (CovaxinTM®) among health care workers in India: The final results of cross-sectional coronavirus vaccine-induced antibody titre (COVAT) study

Background

We assessed the humoral immune response of both ChAdOx1-nCOV (Covishield^TM) and BBV-152 (Covaxin^TM) vaccines in Indian health care workers (HCW).

Methods

A Pan-India, Cross-sectional, Coronavirus Vaccine-induced Antibody Titre (COVAT) study was conducted that measured SARS-CoV-2 anti-spike binding antibody quantitatively, 21 days or more after the first and second dose of two vaccines in both severe acute respiratory syndrome (SARS-CoV-2) naïve and recovered HCW. Primary aim was to analyze antibody response (seropositivity rate, Geometric Mean Titre [GMT] and 95% Confidence Interval [CI]) following each dose of both vaccines and its correlation to age, sex, blood group, body mass index (BMI) and comorbidities. Here we report the results of anti-spike antibody response after first and two completed doses.

Results

Among the 515 HCW (305 Male, 210 Female) who took two doses of both vaccines, 95.0% showed seropositivity to anti-spike antibody. However, both seropositivity rate and GMT (95% CI) of anti-spike antibody was significantly higher in Covishield vs. Covaxin recipients (98.1 vs. 80.0%; 129.3 vs. 48.3 AU/mL; both p < 0.001). This difference persisted in 457 SARS-CoV-2 naïve and propensity-matched (age, sex and BMI) analysis of 116 participants. Age > 60-years, males, people with any comorbidities, and history of hypertension (HTN) had a significantly less anti-spike antibody GMT compared to age ≤ 60 years, females, no comorbidities and no HTN respectively, after the completion of two doses of either vaccine. Gender, presence of comorbidities, and vaccine type were independent predictors of antibody seropositivity rate and anti-spike antibody titre levels in multiple logistic and log transformed linear regression analysis. Both vaccine recipients had similar solicited mild to moderate adverse events and none had severe or unsolicited side effects.

Conclusions

Both vaccines elicited good immune response after two doses, although seropositivity rates and GMT of anti-spike antibody titre was significantly higher in Covishield compared to Covaxin recipients.

Management of Hyperglycemia in COVID-19 and Post-COVID-19 Syndrome - Proposed Guidelines for India

SARS-CoV-2 virus spread rapidly all over the globe in 2020 and the second wave has taken our nation, India by storm. The pandemic has posed unique challenges in people with metabolic disorders, including diabetes, hypertension, obesity, pulmonary, cardiovascular, kidney and non-alcoholic fatty liver disease. Uncontrolled diabetes, in conjunction with endocrine, inflammatory and metabolic effects of the infection itself has made management of hyperglycemia in COVID-19 infection particularly challenging. Furthermore, the post-COVID-19 syndrome has also emerged as a sequela in COVID-19 survivors, increasing the risk of death, complications and adding further burden on the health care system. With more than a year of experience, we have gained substantial insight; and now provide practical recommendations on the management of hyperglycemia in COVID-19 as well as post COVID-19 syndrome.

Diabetes Monotherapies versus Metformin-Based Combination Therapy for the Treatment of Type 2 Diabetes

Step-wise addition of antihyperglycemic agents (AHA) after the initiation of metformin monotherapy has been the traditional approach for the treatment of type 2 diabetes mellitus (T2DM) world-wide. Emerging evidence increasingly suggests that metformin-based combination therapy, especially with the newer AHA that lowers HbA1c glucose-dependently and do not potentiate hypoglycemia, could be a potentially better option for durable glycemic control with good tolerability compared to diabetes monotherapy. In this review, we descriptively analyzed the evidence available from the systematic reviews and meta-analyses of randomized head-to-head trials that reported the efficacy and safety outcomes of diabetes monotherapy, metformin-based combination therapies, and monotherapy versus metformin-based combination therapies.

Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India

BACKGROUND AND AIMS

There are increasing case reports of rhino-orbital mucormycosis in people with coronavirus disease 2019 (COVID-19), especially from India. Diabetes mellitus (DM) is an independent risk factor for both severe COVID-19 and mucormycosis. We aim to conduct a systematic review of literature to find out the patient's characteristics having mucormycosis and COVID-19.

METHODS

We searched the electronic database of PubMed and Google Scholar from inception until May 13, 2021 using keywords. We retrieved all the granular details of case reports/series of patients with mucormycosis, and COVID-19 reported world-wide. Subsequently we analyzed the patient characteristics, associated comorbidities, location of mucormycosis, use of steroids and its outcome in people with COVID-19.

RESULTS

Overall, 101 cases of mucormycosis in people with COVID-19 have been reported, of which 82 cases were from India and 19 from the rest of the world. Mucormycosis was predominantly seen in males (78.9%), both in people who were active (59.4%) or recovered (40.6%) from COVID-19. Pre-existing diabetes mellitus (DM) was present in 80% of cases, while concomitant diabetic ketoacidosis (DKA) was present in 14.9%. Corticosteroid intake for the treatment of COVID-19 was recorded in 76.3% of cases. Mucormycosis involving nose and sinuses (88.9%) was most common followed by rhino-orbital (56.7%). Mortality was noted in 30.7% of the cases.

CONCLUSION

An unholy trinity of diabetes, rampant use of corticosteroid in a background of COVID-19 appears to increase mucormycosis. All efforts should be made to maintain optimal glucose and only judicious use of corticosteroids in patients with COVID-19.

Do SGLT-2 inhibitors exhibit similar cardiovascular benefit in patients with heart failure with reduced or preserved ejection fraction?

Highlights The beneficial cardiovascular (CV) effects of SGLT-2 inhibitors (SGLT-2i) in patients with heart failure are already known. Whether SGLT-2i exert similar CV effects in heart failure with reduced or preserved ejection fraction is not known. This meta-analysis showed SGLT-2i exert similar CV benefits irrespective of the types of heart failure. Future trials will confirm or refute the CV effects of SGLT-2i in patients with heart failure with preserved ejection fraction.

Effect of background insulin therapy on cardiovascular outcomes with SGLT-2 inhibitors in type 2 diabetes: A meta-analysis of cardiovascular outcome trials

Cardiovascular (CV) benefits of SGLT-2 inhibitors (SGLT-2i) have been consistent in type 2 diabetes mellitus (T2DM). To find whether SGLT-2i show similar CV effects with insulin therapy in T2DM, we conducted a trial-level meta-analysis of CV outcome trials. This meta-analysis found SGLT-2i exert CV benefit, irrespective of background insulin therapy.

Does background metformin therapy influence the cardiovascular outcomes with SGLT-2 inhibitors in type 2 diabetes?

Metformin has been recommended as a first-line antidiabetic drug (ADD) for all patients with type 2 diabetes even in the presence of high cardiovascular (CV) risk by American Diabetes Association. In contrast, European Society of Cardiology recommends either a sodium-glucose co-transporter-2 inhibitors (SGLT-2i) or a glucagon-like peptide-1 receptor agonists as a first-line ADD, in presence of high CV risk. While this discordant recommendation has created a debate, we sought to find whether background metformin therapy influences the CV outcomes with SGLT-2i. We pooled the hazard ratio and 95% confidence interval of three-point composite major adverse cardiovascular events (3P-MACE) of 3 CV outcome trials (CVOTs) from the subgroup analysis based on outcomes with or without background metformin therapy. Subsequently, we conducted a meta-analysis by applying the inverse variance-weighted averages of pooled logarithmic hazard ratio, using a random-effects analysis. While this meta-analysis found a significant reduction in 3P-MACE with SGLT-2i without background metformin therapy (N = 7,233; HR 0.79; 95% CI, 0.69-0.90; p < 0.01; I² = 0.0%), no significant reduction in 3P-MACE was observed with SGLT-2i in presence of background metformin therapy (N = 27,081; HR 0.94; 95% CI, 0.86-1.02; p = 0.13; I² = 0.0%) with a significant P_heterogenity of 0.03 between the two groups. Similar finding was observed from the pooled results from 4 CVOTs. This may suggest that background metformin therapy may undermine the 3P-MACE benefit of SGLT-2i. However, no such interaction was observed in a recent meta-analysis of SGLT-2i, with or without background metformin therapy. Future research is warranted to understand the CV interaction of metformin with SGLT-2i.

Cardiovascular Outcomes with SGLT-2 inhibitors in patients with heart failure with or without type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

We conducted a systematic review and meta-analysis of all the randomized controlled trials (RCTs) with SGLT-2 inhibitors (SGLT-2i) in patients with known heart failure (HF) with or without type 2 diabetes (T2DM), that have studied the outcomes of cardiovascular (CV) death, hospitalization due to HF (HHF), and composite of CV death or HHF.

METHODS

A systematic search in PubMed, Embase and Cochrane Library database were made up till November 20, 2020 using specific keywords. RCTs that qualified underwent a meta-analysis by applying the inverse variance-weighted averages of pooled logarithmic hazard ratio (HR) using both random- and fixed-effects model.

RESULTS

This meta-analysis of 9 RCTs (N = 19,741) have found a significant 26% relative risk reduction in composite of CV death or HHF (HR 0.74; 95% CI, 0.69-0.79; p < 0.001) with SGLT-2i in patients with HF. The meta-analysis of 8 RCTs (N = 16,460) also showed a significant reduction in CV death (HR 0.86; 95% CI, 0.78-0.95; p = 0.003) and HHF (HR 0.68; 95% CI, 0.62-0.74; p < 0.001) outcomes with SGLT-2i in patients with HF. Subgroup analysis stratified on baseline ejection fraction (EF) showed a similar benefit in the composite of CV death or HHF in patients with HF with reduced EF (HFrEF) or preserved EF (HFpEF).

CONCLUSIONS

SGLT-2i significantly reduces the composite of CV death or HHF, CV death, and HHF in patients with HF. Although subgroup analysis suggested an insignificant P_heterogenity for these outcomes irrespective of the types of HF, however, reduction in both CV death and HHF were more pronounced in patients with HFrEF.

Non-insulin anti-diabetic agents in patients with type 2 diabetes and COVID-19: A Critical Appraisal of Literature

BACKGROUND & AIMS

Several observational studies have recently reported the outcomes of non-insulin anti-diabetic agents (ADA) in patients with T2DM and coronavirus disease 2019 (COVID-19). We sought to review the literature to appraise the clinicians on these outcomes.

METHODS

A literature search using the specific keywords was carried out in the database of PubMed, MedRxiv and Google Scholar up till December 11, 2020 applying Boolean method. Full text of all the relevant articles that reported the outcomes of ADA in patients with T2DM and COVID-19 were retrieved. Subsequently, an appraisal of literature report was narratively presented.

RESULTS

Available studies that reported the outcomes of ADA are either case series or retrospective cohorts or prospective observational studies, in absence of the randomized controlled trials (RCTs). Results from these observational studies suggest that amongst all the non-insulin ADA, metformin users prior to the hospitalization had improved outcomes compared to the non-users. Data for dipeptidyl-peptidase-4 inhibitors (DPP-4i) are encouraging although inconsistent. No documentation of any harm or benefit has been observed for sulfonylureas (SUs), sodium glucose co-transporter-2 inhibitors (SGLT-2i) and glucagon-like peptide receptor agonists (GLP-1RAs). No data is yet available for pioglitazone.

CONCLUSION

Metformin and DPP-4i should be continued in patients with T2DM until hospitalization or unless contraindicated. No evidence of harm suggests that SUs, SGLT-2i or GLP-1RAs may not be stopped unless very sick, hospitalized or contraindicated. The results from RCTs are needed to claim any meaningful benefit with either metformin or DPP-4i in patients with T2DM and COVID-19.

Impact of COVID-19 and comorbidities on health and economics: Focus on developing countries and India

BACKGROUND AND AIMS

Presence of comorbidities in patients with Coronavirus disease 2019 (COVID-19) have often been associated with increased in-hospital complications and mortality. Intriguingly, several developed countries with a higher quality of life have relatively higher mortality with COVID-19, compared to the middle- or low-income countries. Moreover, certain ethnic groups have shown a higher predilection to contract COVID-19, with heightened mortality. We sought to review the available literature with regards to impact of COVID-19 and comorbidities on the health and economics, especially in context to the developing countries including India.

METHODS

A Boolean search was carried out in PubMed, MedRxiv and Google Scholar databases up till August 23, 2020 using the specific keywords, to find the prevalence of comorbidities and its outcome in patients with COVID-19.

RESULTS

All available evidence consistently suggests that presence of comorbidities is associated with a poor outcome in patients with COVID-19. Diabetes prevalence is highest in Indian COVID-19 patients, compared to other countries. Majority of the patients with COVID-19 are asymptomatic ranging from 26 to 76%.

CONCLUSIONS

Universal masking is the need of hour during unlock period. Low-income countries such as India, Brazil and Africa with less resources and an average socio-economic background, must adopt a strict policy for an affordable testing programs to trace, test, identify and home quarantine of asymptomatic cases. Despite the huge number of COVID-19 patients, India still has low volume research at the moment.

At-admission hyperglycemia is consistently associated with poor prognosis and early intervention can improve outcomes in patients with COVID-19

BACKGROUND & AIMS

At-admission hyperglycemia have been associated with poorer outcome during critical illnesses. At-admission hyperglycemia in previously unknown diabetes is not uncommonly encountered entity in patients with COVID-19. We sought to find out the outcomes of at-admission hyperglycemia and effect of early intervention to achieve optimal glycemic control in relation to COVID-19 patients.

METHODS

We searched the PubMed and Google Scholar database up till August 20, 2020 using specific keywords related to our aims and objectives.

RESULTS

All currently available evidences clearly hint that at-admission hyperglycemia in patients with COVID-19 is associated with a poorer outcome, compared with normoglycemic individuals. Fortunately, early intervention by achieving an optimal glycemic control has also been associated with a significant improvement in the outcomes in patients with COVID-19.

CONCLUSION

At-admission hyperglycemia should be taken seriously by all clinicians treating patients with COVID-19. All efforts should be made towards an optimal glycemic control in patients with COVID-19, even in absence of pre-existing diabetes.