Comparative efficacy and safety of febuxostat and allopurinol in chronic kidney disease stage 3-5 patients with asymptomatic hyperuricemia: a network meta-analysis

OBJECTIVE

This study evaluates and compares the effectiveness and safety of febuxostat and allopurinol in chronic kidney disease (CKD) stages 3-5 patients with asymptomatic hyperuricemia using a network meta-analysis.

METHODS

A systematic review and network meta-analysis were conducted, adhering to PRISMA-NMA guidelines. Searches included PubMed, Embase, Cochrane Library, and Chinese databases up to June 2024. Randomized controlled trials (RCTs) and cohort studies were assessed for methodological rigor using GRADE.

RESULTS

A total of 12 RCTs and 4 cohort studies (n = 2,423 participants) were included. Febuxostat was associated with greater improvements in estimated glomerular filtration rate compared to allopurinol (MD, 4.99 mL/min/1.73 m2; 95%CI -0.65 to 10.78; certainty: low) and placebo (MD, 4.72 mL/min/1.73 m2; 95%CI 0.67 to 8.82; low). Serum uric acid reduction was also more pronounced with febuxostat (MD, -0.61 mg/dL; 95%CI -1.15 to -0.05; moderate). Safety outcomes, including major cardiovascular events and adverse events, showed no significant differences between febuxostat and allopurinol. Subgroup analyses revealed enhanced effectiveness of febuxostat at six months of treatment.

CONCLUSIONS

This analysis provides robust evidence that febuxostat might offers greater improvements in kidney function and uric acid levels compared to allopurinol or placebo in asymptomatic hyperuricemia with CKD stage 3-5 patients, without compromising safety. These findings can guide clinical decision-making and treatment optimization.

Zirconium nanoparticles decorated chitosan@hematoxylin/pencil graphite as a novel voltammetric sensor for monitoring of linagliptin/dapagliflozin co-therapy

A fixed dose combination of linagliptin (LNG) and dapagliflozin (DPZ) was recently approved as a better therapeutic approach than monotherapy of type 2 diabetes mellites. To support the bioequivalence studies of LNG/DPZ combination, and refining of its pharmacokinetics and safety profile, a sensitive and convenient analytical method is required for their simultaneous quantitation in plasma samples. This research describes the construction of an innovative electrochemical sensor and its employment in the development of the first square wave voltammetric (SWV) method for the concurrent quantitation of LNG/DPZ in plasma samples. The sensor (ZrNPs-CHIT@HEM/PGE) was fabricated using hematoxylin (HEM) stain platform on a pencil graphite electrode (PGE) surface, where chitosan (CHIT) and zirconium nanoparticles (ZrNPs) were overlayed on. This sensor was characterized by cyclic voltammetry, scanning electron microscopy, and electrochemical impedance spectroscopy. Subsequently, the constructed sensor is employed for electro-oxidation and SWV estimation of LNG/DPZ combination in their pure forms and in plasma. The suggested procedure was optimized, and its analytical performance was validated. The linear ranges were 0.17-5.8 and 1.5-52.5 nM for LNG and DPZ, respectively. The quantitation limits were 0.15 and 1.34 nM for LNG and DPZ, respectively. Acceptable accuracy and precision were confirmed (98.63-101.59 % ± 0.79-2.22 %). The selectivity of the method for simultaneous analysis of LNG/DPG in presence of common interfering substances was confirmed as the recovery values of the analytes were in the range of 96.19-99.52 %. The proposed SWV method was successfully applied to the quantitation of both LNG and DPZ in spiked and in real plasma samples obtained from rabbits receiving LNG/DPZ combination. The ZrNPs-CHIT@HEM/PGE sensor constructed and employed in this study demonstrated exceptional graphite distinctive characteristics, such as high surface area, remarkable electrical conductivity, rapid electron mobility at room temperature, and ease of fabrication/functionalization. Additionally, the use of ZrNPs for construction provided exceptional opportunities for the design of the sensor and enhanced its electrochemical sensing performance. Furthermore, the significant electrochemical properties of both CHIT and HEM used in the nanocomposite of the sensor demonstrated superior electrocatalytic behaviour for the differential electro-oxidation of LNG and DPZ. The proposed SWV method represents the prototype of electrochemical techniques for the concurrent quantitation of LNG and DPZ in plasma samples. This method would have great value to support the pharmacokinetic studies, therapeutic drug monitoring, and refining the safety profile of fixed-dose combined therapy with LNG/DPZ.

Impact of remdesivir treatment on factor VIII gene expression and hematological parameters in COVID-19 patients

The novel coronavirus, COVID-19, which was first identified in December 2019 rapidly spread worldwide and was declared a global pandemic. Beyond respiratory symptoms, COVID-19 often results in coagulation and vascular endothelium disorders, causing increased clotting and bleeding, which are closely linked to the acute phase of the infection. Factor VIII is a crucial protein in the blood coagulation cascade, and elevated FVIII levels have been linked to thrombotic events in COVID-19, highlighting the need to understand its behavior during treatment. Remdesivir is an antiviral drug that has shown promise in reducing recovery time and mortality rates in COVID-19 patients. This study aims to examine the changes in blood factors and the expression of the factor VIII gene in patients treated with Remdesivir. Blood samples were collected from 30 COVID-19 patients before and after Remdesivir treatment and from 20 healthy individuals. Patients with underlying diseases were excluded from the study. RNA was extracted from these samples, followed by cDNA synthesis. The expression of the factor VIII gene was analyzed using Real-Time PCR. The results indicated that blood factors such as Urea, ALK, AST, WBC, and CRP were elevated in the patient group compared to the control group. At the same time, FBS, Urea, ALK, AST, WBC, RDW, INR, and K levels increased in the Remdesivir treatment group (P < 0.001). Conversely, MCHC, RBC, and Ca levels decreased in both patient and treatment groups compared to the control group (P < 0.001). The expression of the FVIII gene was upregulated approaching 2 times in COVID-19 patients and 1.5-fold in the treatment group compared to the control group (P < 0.001). However, no significant changes were observed in FVIII expression before and after Remdesivir treatment. However, a positive correlation between RBC, FBS, and Urea in the patient group and a negative correlation between RDW and FVIII expression levels was observed. In the treatment group, FVIII expression level correlated negatively with Urea, P, and RDW. These findings suggest that elevated FVIII levels are associated with disease severity and excessive coagulation in COVID-19 patients. Additionally, Remdesivir does not appear to exacerbate the coagulation process.

Cystic Fibrosis and Hemochromatosis Carriers May Be Prone to Glucagon-like Peptide-1 Agonist Pancreatitis: 3 Cases

Glucagon-like peptide-1 (GLP-1) agonists are widely used in the management of type 2 diabetes and obesity, with their therapeutic scope expanding to address cardiometabolic and cardiorenal conditions. However, their increasing use has been associated with potential adverse effects, including acute pancreatitis (AP). The exact prevalence of GLP-1 agonist-induced AP remains uncertain and reliable predictors for its onset have yet to be identified. We present 3 cases of class-associated predilection for GLP-1 analog-associated AP in patients with carrier states for hemochromatosis (HC) and cystic fibrosis. Case 1 is a heterozygous carrier for the C282Y HC pathogenic variant. Case 2 is a heterozygous carrier of the Delta F508 deletion of the cystic fibrosis transmembrane regulator (CFTR) gene. Case 3 is compound heterozygous carrier of a single CFTR intron 9 poly T allele pathogenic variant (5T/7T/8T), as well as a single pathogenic variant of the C282Y HC gene. Our observation suggests that carrier states for cystic fibrosis and HC may predispose individuals to GLP-1 agonist-associated AP. Genetic testing for these carrier states should be considered among patients with GLP-1 agonist-associated AP to provide more support and data for this as a potential true risk factor.

Unraveling antipsychotic induced weight gain in schizophrenia - A proof-of-concept study exploring the impact of the cumulative historical occupancy of different receptors by antipsychotics

Obesity is a common complication in schizophrenia contributing to increased mortality rates. We present a proof-of-concept study displaying a new method to investigate the impact of antipsychotic drugs (APs) on obesity in terms of their cumulative historical receptor occupancy (CHRO) in 150 selected from 174 patients with schizophrenia. Based on a thorough medication history, we estimated CHRO of serotonin 5-HT2C, histamine H1, dopamine D2 and muscarinic M3 receptors and studied their relationship with different metabolic outcome variables utilizing stepwise regression analysis and structural equation modelling (SEM). Stepwise regression analysis revealed a significant positive relationship of Body Mass Index (BMI) with H1-CHRO, but a negative relationship with M3-CHRO. Moreover, H1-CHRO was associated with increased triglyceride concentration, while 5-HT2C-CHRO was associated with increased waist circumference and blood pressure. SEM, while confirming the diverging effects of H1-/5-HT2C- and M3-CHRO on obesity, suggested that their effect on other metabolic variables was indirect, i.e. mediated by obesity. Our results suggest that the metabolic side effects of antipsychotics can be described by their cumulative historical receptor occupancy with unique contributions of the different receptors. In particular, M3 receptor antagonism seems to exert a protective effect, confirming findings from rodent M3 receptor knock out models. These findings may provide a framework for estimating the metabolic burden of future APs, guiding the development of drugs with more favorable metabolic profiles.

Sodium-glucose cotransporter 2 inhibitors in the treatment of heart failure patients: A systematic review and meta-analysis of cost-utility studies

AIMS

Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) have shown promise in reducing cardiovascular mortality and hospitalization due to heart failure (HF), a significant global health issue. This study aims to evaluate the incremental net benefit (INB) of SGLT-2i in HF patients through a systematic review and meta-analysis of cost-utility studies.

METHODS

We searched five databases from their inception until Aug 30, 2024, economic evolution studies reporting cost-effectiveness and cost-utility analyses comparing SGLT-2i combined with standard triple-therapy versus standard triple-therapy alone in HF patients were selected. INB as the primary outcome was calculated in monetary units adjusted for purchasing power parity in 2022 US dollars.

RESULTS

This review included 46 studies, with 41 studies (55 comparisons) pooled into meta-analysis. Adding SGLT2is was cost-effective compared to standard triple-therapy alone, from both healthcare system perspective (INB, $4042.08; 95 % CI, $1758.70-$6325.46) and payer perspective (INB, $12,972.84; 95 % CI, $4711.5-$21,234.22). However, subgroup analyses showed non-significant economic benefit in HF patients with preserved ejection fraction (HFpEF) both from the healthcare system perspective (INB, -$639.32; 95 % CI, -$1850.09-$571.44) and the payer perspective (INB, $3611.07; 95 % CI, -$208.49-$7430.64). Additionally, HF patients from low- and middle-income countries did not show significant economic benefit from the payer perspective (INB, $55,645.70; 95 % CI, -$51,000.00-$160,000.00).

CONCLUSIONS

The findings suggest that adding SGLT-2i is cost-effective compared to conventional standard triple-therapy alone, from both healthcare system and payer perspectives. Nevertheless, the economic benefits are limited in HFpEF and those from low- and middle-income countries. Further research is needed to explore the cost-effectiveness from a broader societal perspective.

Once-weekly Basal Insulin Fc versus daily insulin degludec for glycemic control in diabetes: a systematic review, meta-analysis, and meta-regression

Introduction

Diabetes management often requires insulin therapy, yet adherence to daily injections can be challenging due to complexity, injection pain, and fear of hypoglycemia. Basal Insulin Fc (BIF) is a novel once-weekly insulin analog designed to simplify regimens, improve adherence, and enhance glycemic control. This meta-analysis evaluates the efficacy and safety of BIF compared to once-daily insulin degludec.

Methods

A systematic search of PubMed, Google Scholar, EBSCO, ScienceDirect, and the Cochrane Library, along with ClinicalTrials.gov, was conducted up to November 2024 to identify RCTs comparing BIF with insulin degludec. The search employed MeSH terms like "type 1 diabetes mellitus," "type 2 diabetes mellitus," "once weekly basal insulin Fc," and "insulin degludec." Studies were screened in accordance with PRISMA guidelines, and data on glycemic outcomes, safety, and patient demographics were extracted. Statistical analysis included pooled mean differences (MD) and risk ratios (RR) with 95% confidence intervals (CIs) using random-effects models. Heterogeneity was assessed using the I2 statistic, and sensitivity analyses were conducted for cases of high heterogeneity. Subgroup and meta-regression analyses assessed moderators such as diabetes type, insulin status, follow-up duration, and heterogeneity.

Results

Five RCTs with 2,562 participants (Type 1 and Type 2 diabetes) were included. BIF showed non-inferiority to degludec in HbA1c reduction (MD 0.03, p = 0.37) and percentage time in range (MD 0.56, p = 0.27). No significant differences were observed in self-monitored fasting blood glucose (MD 2.73, p = 0.40) or clinically significant hypoglycemia (RR 1.00, p = 0.95). However, BIF increased time spent below range (MD 0.30, p = 0.0004) and was associated with higher treatment-emergent adverse events (RR 1.12, p = 0.006). The subgroup analysis highlighted differences in hypoglycemia risks between Type 1 and Type 2 diabetes.

Conclusion

BIF offers comparable glycemic control to insulin degludec while reducing injection frequency, potentially enhancing adherence. However, increased hypoglycemia risks in certain subgroups and higher adverse event rates warrant further evaluation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-025-01602-y.

Icodec: A Novel Once-Weekly Basal Insulin for Diabetes Management

OBJECTIVE

To evaluate the efficacy, safety, and clinical implications of insulin icodec, a novel once-weekly basal insulin for the treatment of type 1 diabetes (T1D) and type 2 diabetes (T2D), with an emphasis on its advantages and challenges in comparison with existing daily basal insulins.

DATA SOURCES

A literature search was performed using PubMed, Google Scholar, Embase, and ClinicalTrials.gov up to August 26, 2024, using the search terms icodec and ONWARDS trial. Studies involving patients living with T1D or T2D on once-weekly insulin icodec compared with once-daily insulins glargine U100, glargine U300, and degludec were considered for this review.

STUDY SELECTION AND DATA EXTRACTION

Relevant English-language studies and those conducted in humans were considered.

DATA SYNTHESIS

Insulin icodec offers reduced dosing frequency and potentially superior glycemic management with a safety profile comparable to existing basal insulins.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Insulin icodec once-weekly dosing could significantly improve convenience and efficacy over daily basal insulins, representing a significant innovation in insulin therapy.

CONCLUSIONS

Insulin icodec emerges as a promising option for diabetes management, potentially improving treatment adherence and quality of life.

Obesity Management Medications as Adjuncts to Metabolic and Bariatric Surgery: Consensus Recommendations from India

Obesity is a global health concern, with weight regain (WR) common after bariatric surgery. Clear guidelines on post-surgical medication use are essential. This expert consensus evaluates the role of obesity management medications (OMMs) in optimizing weight loss (WL) and preventing WR in individuals undergoing metabolic and bariatric surgery (MBS). Using a modified Delphi approach, a panel of 12 experts reviewed evidence and formulated consensus recommendations. Two voting rounds led to consensus on 11 of 15 statements, covering preoperative WL strategies and postoperative weight management. The recommendations guide OMM selection, timing, and effectiveness in enhancing WL outcomes. Integrating OMMs into bariatric care protocols can help clinicians improve long-term success rates in obesity management.

Heart matters: the unique landscape of cardiovascular health in women

Cardiovascular disease (CVD) remains the leading cause of death globally, despite significant public health efforts. The identification and targeting of modifiable risk factors - including hypertension, dyslipidemia, diabetes mellitus, smoking and obesity - have led to significant improvements in patient outcomes over the past 60 years. However, current strategies based on this model have been shown to underestimate CVD risk in women and they are less frequently targeted compared to men. In addition, female-specific biological differences known to contribute to CVD are frequently understudied or excluded from risk stratification efforts. This review explores the unique epidemiological burden, pathobiology and outcomes of CVD in women; the influence of traditional and sex-specific risk factors; and both diagnostic and therapeutic strategies that may improve clinical outcomes in the future.

Modeling the effects of cross immunity and control measures on competitive dynamics of SARS-CoV-2 variants in the USA, UK, and Brazil

Mutation in the SARS-CoV-2 virus may lead to the evolution of new variants. The dynamics of these variants varied among countries. Identification of the governing factors responsible for distinctions in their dynamics is important for preparedness against future severe variants. This study investigates the impact of cross immunity and control measures on the competition dynamics of the Alpha, Gamma, Delta, and Omicron variants. The following questions are addressed using an n-strain deterministic model: (i) Why do a few variants fail to cause a wave even after winning the competition? (ii) In what scenarios a new variant cannot replace the previous one? The model is fitted and cross-validated with the data of COVID-19 and its variants for the USA, UK, and Brazil. The model analysis highlights implementations of the following measures against any deadlier future variant: (i) an effective population-wide cross-immunity from less lethal strains and (ii) strain-specific vaccines targeting the novel variant. The system exhibits a fascinating dynamical behavior known as an endemic bubble due to Hopf bifurcation. It is observed that the actual situation in which Omicron won the competition from Delta followed by no wave due to Delta may turn into a competitive periodic coexistence of two strains due to substantial disparity in fading rates of cross-immunity. Global sensitivity analysis is conducted to quantify uncertainties of model parameters. It is found that examining the impact of cross-immunity is as crucial as vaccination.

Antiobesity Pharmacotherapy for Patients With Genetic Obesity Due to Defects in the Leptin-Melanocortin Pathway

Lifestyle interventions are the cornerstone of obesity treatment. However, insufficient long-term effects are observed in patients with genetic obesity disorders, as their hyperphagia remains untreated. Hence, patients with genetic obesity often require additional pharmacotherapy to effectively manage and treat their hyperphagia and obesity. Recent advancements in antiobesity pharmacotherapy have expanded the range of available antiobesity medications (AOM). This includes the targeted AOM setmelanotide, approved for specific genetic obesity disorders, as well as nontargeted AOMs such as naltrexone-bupropion and glucagon-like peptide-1 analogues. Targeted AOMs have demonstrated significant weight loss, reduced obesity-related comorbidities, and improved hyperphagia and quality of life in patients with specific genetic obesity disorders. Small observational studies have shown that similar benefits from nontargeted AOMs or off-label pharmacotherapies can be achieved in patients with specific genetic obesity disorders, compared to common multifactorial obesity. In the future, novel and innovative pharmacotherapeutical options, including combination therapies and possibly gene therapy, will emerge, offering promising effects on body weight, hyperphagia, and, most importantly, quality of life for patients with a variety of genetic obesity disorders.

Comparative Safety of Second-Line Antihyperglycemic Agents in Older Adults with Type 2 Diabetes: A Multinational Real-World Evidence From LEGEND-T2DM

Background

As prescribing of newer antihyperglycemic agents expands, there remains limited comparative safety data for older adults-a population particularly vulnerable to adverse drug events and underrepresented in clinical trials. We aimed to evaluate the real-world safety of second-line antihyperglycemic agents among older adults with type 2 diabetes.

Methods

We conducted a multinational cohort study using nine harmonized electronic health record and claims databases from the U.S. and Europe, applying a consistent analytical framework based on the LEGEND-T2DM initiative. Among adults aged ≥65 years who initiated a second-line agent after metformin monotherapy, we compared safety outcomes across four drug classes: GLP-1 receptor agonists (GLP1RAs), SGLT2 inhibitors (SGLT2Is), DPP-4 inhibitors (DPP4Is), and sulfonylureas (SUs). We used propensity score adjustment, empirical calibration, and prespecified diagnostics to estimate hazard ratios (HRs) for 18 safety outcomes.

Results

In a cohort of 1.8 million older adults, both GLP1RAs and SGLT2Is were linked to significantly lower risks of hypoglycemia (HR 0.21 [95% CI, 0.16-0.27] for GLP1RA vs SU; HR 0.21 [0.13- 0.33] for SGLT2I vs SU) and hyperkalemia (HR 0.63 [0.50-0.81] for GLP1RA vs SU; HR 0.75 [0.63-0.90] for SGLT2I vs SU) and peripheral edema (HR 0.81 [0.71-0.92] for GLP1RAs vs. DPP4Is; HR 0.62 [0.46-0.84] for SGLT2Is vs. SU). However, SGLT2Is were associated with a higher risk of diabetic ketoacidosis compared to both GLP1RAs (HR 2.03 [1.38-2.99]) and SUs (HR 1.64 [1.27-2.11]). GLP1RAs had significantly higher risks of nausea (HR 0.63 [0.55-0.72]) and vomiting (HR 0.63 [0.57-0.69]) relative to SGLT2Is. Results were consistent across both on-treatment and intent-to-treat sensitivity analyses.

Conclusion

In older adults with type 2 diabetes, GLP1RAs and SGLT2Is demonstrated more favorable safety profiles than SUs and DPP4Is across multiple clinically relevant outcomes. These results support more informed, safety-conscious prescribing in a population underrepresented in clinical trials yet highly susceptible to adverse effects.

Association Between Type 2 Diabetes Mellitus and Heart Failure: A Retrospective Study from a Tertiary Care Diabetes Centre in India

INTRODUCTION

The study aimed to explore the association between type 2 diabetes (T2D) and heart failure (HF) using echocardiography and NT-proBNP. The study also derived an NT-proBNP cut-off for diagnosing HF by echo in Asian Indians with T2D.

METHODS

A retrospective study was performed using data from individuals with T2D, aged ≥ 18 years, who visited diabetes clinics in India between March 2019 and December 2023. NT-proBNP levels were quantified by chemiluminescence, and left ventricular ejection fraction (LVEF) was assessed from echo using two-dimensional (2D) echocardiography. Heart failure was classified based on the European Society of Cardiology (ESC) guidelines. Receiver operating characteristic (ROC) curve was performed to determine the optimal NT-proBNP cut-off for diagnosing HF by echo.

RESULTS

Among the 1189 study individuals included in the study (714 men and 475 women), 5.9% were identified as having HF with reduced ejection fraction (HFrEF), 5.5% had mildly reduced ejection fraction (HFmrEF), and 14.1% had HF with preserved ejection fraction (HFpEF) while the rest (74.5%) had LVEF > 50%. Elevated NT-proBNP levels were observed in those with reduced ejection fraction. ROC analysis identified an optimal NT-proBNP threshold of 398 pg/mL for diagnosing HF, with 87% sensitivity and 78% specificity. HF prevalence increased with age, peaking at 30.6% in individuals aged 61-70 years. Women with HF had higher NT-proBNP levels than men.

CONCLUSIONS

In this diabetes clinic population, 11.5% of individuals with T2D had moderate to reduced LVEF. Early identification of HF using echocardiography and NT-proBNP in a diabetes clinic could help improve prognosis.

Therapeutic Approaches for COVID-19: A Review of Antiviral Treatments, Immunotherapies, and Emerging Interventions

The coronavirus disease 2019 (COVID-19) global health crisis, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has presented unprecedented challenges to global healthcare systems, leading to rapid advances in treatment development. This review comprehensively examines the current therapeutic approaches for managing COVID-19, including direct-acting antivirals, immunomodulators, anticoagulants, and adjuvant therapies, as well as emerging and experimental approaches. Direct-acting antivirals target various stages of the viral life cycle, offering specific intervention points, while immunomodulators aim to modulate the host's immune response, reducing disease severity. Anticoagulant therapies address the coagulopathy frequently observed in severe cases, and adjuvant treatments provide supportive care to improve overall outcomes. We also explore the challenges and limitations of implementing these treatments, such as drug resistance, variable patient responses, and access to therapies, especially in resource-limited settings. The review also discusses future perspectives, including the potential of next-generation vaccines, personalized medicine, and global collaboration in shaping future COVID-19 treatment paradigms. Continuous innovation, combined with an integrated and adaptable approach, will be crucial to effectively managing COVID-19 and mitigating the impact of future pandemics.

Exploring the therapeutic potential of Thymus vulgaris ethanol extract: a computational screening for antimicrobial compounds against COVID-19 induced mucormycosis

COVID-19-associated mucormycosis (CAM) has emerged as a concerning complication during the COVID-19 pandemic. In this study, we explored the potential of phytochemicals and flavonoids identified through High-Performance Liquid Chromatography (HPLC) analysis of Thymus vulgaris plant extract against key proteins of CAM, namely heat shock protein A5 (GPR78) and epidermal growth factor receptor (EGFR). HPLC analysis revealed the presence of bioactive compounds, including chlorogenic acid, cinamic acid, quercetin, coumaric acid, gallic acid, and syringic acid. To assess their efficacy against CAM, computational analyses were performed, including molecular docking analysis, pharmacophore characterization, ADME and molecular dynamics simulations. The results demonstrated that chlorogenic acid exhibited strong binding affinity against EGFR with a docking score of -7.6 kcal/mol, while quercetin showed favorable binding affinity against HSP A5 (GPR78) with a docking score of -10.1 kcal/mol. Both chlorogenic acid and quercetin displayed promising ADME properties, indicating their potential as drug candidates. Nevertheless, it was observed that chlorogenic acid did not adhere to Lipinski's rule, and its gastrointestinal (GI) absorption was relatively low when compared to quercetin. Unlike chlorogenic acid, quercetin does conform to Lipinski's rule and showed high GI absorption. Moreover, pharmacophore characterization of both drug candidates revealed a substantial number of binding sites, suggesting the likelihood of stable bond formation. Normal mode analysis revealed higher eigenvalues for the quercetin-HSPA5 complex compared to the chlorogenic acid-EGFR complex, indicating greater structural rigidity and stability. Overall, our findings highlight the potential of chlorogenic acid and quercetin as promising drug candidates against CAM. Furthermore, in-vitro and in-vivo studies are needed to validate their efficacy and safety for clinical use in treating mucormycosis associated with COVID-19. These findings may offer valuable insights into the development of novel therapeutic options to combat this challenging co-infectious disease.

Impact of COVID-19 on mucormycosis presentation and laboratory values: A comparative analysis

BACKGROUND

The COVID-19 pandemic has led to an alarming increase in mucormycosis coinfections and its rapid progression. The overlapping risk factors and symptoms between COVID-19 and mucormycosis further complicate prompt detection, which is crucial for patient survival. This study aims to investigate potential differences in mucormycosis progression, initial symptom presentation, and laboratory value alterations in mucormycosis patients with COVID-19 history to enhance diagnostic accuracy and improve outcomes in this complex clinical scenario.

METHODOLOGY

This retrospective cohort study, conducted from April 1, 2021, to March 31, 2022, examined 102 patients diagnosed with mucormycosis at two primary teaching hospitals. Patients were categorized into two groups based on COVID-19 history. Variables included demographic information, clinical parameters, laboratory results, and outcomes. The study compared patient laboratory studies and presentation symptoms between COVID-19 history-positive and COVID-19 history-negative groups, with a particular focus on mortality rates and associated comorbidities such as diabetes, cancer and immunosuppressive treatment.

RESULTS

Initial clinical presentations differed significantly, eneralized Estimating Equations (GEE) analysis, adjusted for comorbidities, revealed COVID-19 history was associated with increased platelet counts (P = 0.0311) and decreased facial swelling (P = 0.049) and fever symptom reporting (P < 0.001). Cancer history, diabetes, and immunosuppressive treatment also showed significant associations with various clinical and laboratory parameters. Laboratory analysis revealed significant differences between mucormycosis patients with and without COVID-19 history. The COVID-19 history-positive group showed lower WBC counts (P = 0.002), and higher hemoglobin levels (P < 0.001) compared to controls. Diabetes was more prevalent in COVID-19 history-positive patients, while cancer history was more common in controls.

CONCLUSION

This study reveals intricate relationships between COVID-19 history, mucormycosis, patient presentation, challenging earlier findings. Mucormycosis patients with COVID-19 history exhibited higher platelet counts and altered symptom presentation. The research highlights varied symptom patterns across patient subgroups and underscores the complexity of interactions between COVID-19, cancer, and diabetes in mucormycosis cases. These findings advocate multivariate analytical approaches to better understand these multifaceted relationships.

Meta-analysis of the efficacy and safety of SGLT-2 inhibitors in patients with heart failure and type 2 diabetes mellitus

BACKGROUND

To investigate the efficacy and safety of sodium-glucose cotransporter 2 (SGLT-2) inhibitors in patients with heart failure (HF) and type 2 diabetes mellitus (T2DM).

METHODS

A manual search was conducted in 3 prestigious English databases, Cochrane Library, PubMed, and Web of Science, for studies published within the last decade, from July 2014 to July 2024. The extracted literature was synthesized to analyze the efficacy outcomes, survival prognostic indicators, and safety profiles of SGLT-2 inhibitors in patients with HF and T2DM. The Cochrane bias risk assessment scale was used as a tool to evaluate the quality of the literature, and Review Manager 5.4 software was used to create the bias risk chart. Data analysis and merging were completed with the help of Review Manager 5.4 and Stata 15.0 statistical software.

RESULTS

Twelve studies encompassing 9509 patients were included in the meta-analysis. The results revealed that compared to the control group, the SGLT-2 inhibitor-treated group demonstrated significantly greater reductions in left ventricular end-diastolic volume index [mean difference (MD) = -7.25, 95% confidence intervals [95% CI] (-9.83, -4.67)], brain natriuretic peptide levels [MD = -36.96, 95% CI (-63.51, -10.41)], and N-terminal pro-brain natriuretic peptide [MD = -519.27, 95% CI (-660.77, -377.78)]. Furthermore, the SGLT-2 inhibitor-treated group exhibited significantly higher increases in Kansas City Cardiomyopathy Questionnaire scores [MD = 3.32, 95% CI (3.30, 3.34)], indicating improved quality of life. Additionally, the incidence of adverse events was significantly lower in the SGLT-2 inhibitor-treated group compared to the control group [OR = 0.78, 95% CI (0.69, 0.88)]. The pooled results of the meta-analysis indicated that SGLT-2 inhibitor therapy reduced the risk of cardiovascular death or HF hospitalization by 23%, the risk of cardiovascular death by 19%, and the risk of all-cause mortality by 9%.

CONCLUSION

SGLT-2 inhibitor therapy significantly reduced the risks of all-cause mortality, cardiovascular death, and hospitalization for HF in patients with HF and T2DM. Additionally, SGLT-2 inhibitors significantly improve cardiac function, decrease the incidence of adverse events, and enhance the quality of life in these patients.

Safety and efficacy of early initiation of sodium-glucose co-transporter inhibitors 2 in patients hospitalized for acute heart failure: A meta-analysis of randomized controlled trials

AIMS

Data on the early use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in patients with acute heart failure (HF) are conflicting, and mostly evaluating soft endpoints (i.e., indices of congestion, renal function, ejection fraction, and diuresis). The aim was to perform a meta-analysis of randomized controlled trials (RCTs) to assess their impact after an HF decompensation event.

METHODS AND RESULTS

Two electronic databases were screened for eligible studies. Efficacy endpoints were all-cause death, cardiovascular death, HF hospitalization, length of hospital stay, and N-terminal pro-B-type natriuretic peptide (nt-proBNP). Safety endpoints included acute kidney injury (AKI), volume depletion, ketoacidosis, hypotension, hypoglycemia, non-cardiovascular death, urinary tract infection, genital infections, serious adverse events (AE), and AE leading to treatment discontinuation. Two pre-specified subgroup analyses were planned according to the specific SGLT2i and clinical setting [i.e., acute myocardial infarction (MI) versus non-acute MI]. 16 RCTs enrolling 15,073 patients were considered. Early initiation of SGLT2i significantly reduced the risk of HF hospitalizations [Risk ratio (RR) 0.79, 95 % Confidence interval (CI) 0.72-0.87], AKI (RR 0.76, 95 % CI 0.59-0.99), and nt-proBNP levels (MD -354 pg/mL). No significant difference was detected for any of the other endpoints. In the pre-specified subgroup analysis, a significant interaction was found between the SGLT2i type and the risk of AKI, in favor of empagliflozin.

CONCLUSIONS

In patients recently hospitalized for acute HF, early administration of SGLT2i was associated with fewer readmissions for HF and AKI, as well as decongestant effects, without raising any safety concern.

Association of bodyweight loss with changes in lipids, blood pressure, and fasting serum glucose following tirzepatide treatment in Japanese participants with type 2 diabetes: A post hoc analysis of the SURPASS J-mono trial

AIMS/INTRODUCTION

In the SURPASS J-mono trial, tirzepatide demonstrated significant improvements in bodyweight and several metabolic parameters in Japanese participants with type 2 diabetes. This post hoc analysis evaluated the potential relationships between weight loss and metabolic improvements in SURPASS J-mono.

MATERIALS AND METHODS

Metabolic parameter data from tirzepatide-treated participants were analyzed by weight loss subgroups and compared to dulaglutide 0.75 mg. Correlations between changes from baseline to week 52 in weight loss and each metabolic parameter were assessed; Pearson correlation coefficients were derived. Mediation analyses were conducted to evaluate weight loss-associated and -unassociated effects of tirzepatide vs dulaglutide 0.75 mg.

RESULTS

This analysis included 548 participants (tirzepatide: n = 411, dulaglutide: n = 137). Weight loss subgroups showed greater improvement in metabolic parameters with greater bodyweight loss. Significant (P < 0.05) but weak correlations between changes in bodyweight and triglycerides (r = 0.18-0.25), high-density lipoprotein cholesterol (r = -0.37 to -0.29), and systolic blood pressure (r = 0.19-0.41) were observed across treatment groups; in diastolic blood pressure in the tirzepatide 5-mg (r = 0.28), pooled tirzepatide (r = 0.20), and dulaglutide 0.75-mg (r = 0.23) groups; and in fasting serum glucose in the dulaglutide 0.75-mg (r = 0.18) and pooled tirzepatide (r = 0.13) groups. Weight loss was associated with treatment differences between tirzepatide and dulaglutide 0.75 mg to varying degrees across metabolic parameters, with improvements in fasting serum glucose having the lowest association with weight loss (36.6%-43.5%).

CONCLUSIONS

In this post hoc analysis, non-glycemic and glycemic parameter improvements appeared differentially associated with weight loss, suggesting both weight loss-associated and -unassociated effects of tirzepatide.

Obesity and heart failure with preserved ejection fraction: focus on new drugs and future direction in medical treatment

Obesity is a major risk factor for heart failure with preserved ejection fraction (HFpEF) and contributes through multiple pathophysiological pathways, including systemic inflammation, neurohormonal activation, and mechanical inhibition. The treatment of obesity has shown significant potential for improving HFpEF outcomes. Sodium-glucose cotransporter 2 inhibitors have emerged as effective treatments for improving symptoms and quality of life in patients with HFpEF while aiding in weight control. Furthermore, a recent demonstration of the clinical benefits of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in HFpEF showed promising results in reducing weight loss, and improving symptoms and clinical outcomes. In this review article, we discuss the association between HFpEF and obesity, the emerging role of GLP-1 RAs, and future directions for medical therapies targeting obesity-associated HFpEF.

SGLT-2 inhibitors on cardiac autonomic function in individuals with and without type 2 diabetes mellitus

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors have emerged as key therapeutic agents in managing type 2 diabetes mellitus (T2DM) and obesity, offering benefits that extend beyond glycemic control. This review examines the role of SGLT-2 inhibitors in modulating cardiac autonomic function, with a particular focus on heart rate variability (HRV) as a biomarker of autonomic balance. These agents improve metabolic profiles through enhanced glucosuria, natriuresis, and weight loss, while concurrently reducing blood pressure. Importantly, they also attenuate sympathetic nervous system overactivity and promote parasympathetic modulation, which may lower the risk of adverse cardiovascular events. The underlying mechanisms include not only the metabolic effects but also anti-inflammatory and antioxidative actions, which together contribute to improved endothelial function and vascular health. Advanced HRV analyses, encompassing traditional time and frequency domain methods as well as nonlinear approaches, have proven valuable in detecting early autonomic dysfunction in high-risk populations. Some studies suggest that SGLT-2 inhibitors may be associated with improvements in HRV parameters, such as increased SDNN and RMSSD and a reduced LF/HF ratio. However, findings are inconsistent across studies, and further research is needed to determine the extent and mechanisms of these potential effects. Although these findings are promising, further standardized, long-term studies are essential to clarify the mechanisms and optimal therapeutic strategies involving SGLT-2 inhibitors in the management of autonomic dysfunction. Future research should also explore the synergistic potential of combining SGLT-2 inhibitors with other cardiometabolic therapies to enhance cardiovascular outcomes in individuals with and without T2DM.

Assessment of repurposed compounds against coronaviruses highlights the antiviral broad-spectrum activity of host-targeting iminosugars and confirms the activity of potent directly acting antivirals

The COVID-19 pandemic highlights the need for novel antiviral drug discovery approaches that could dramatically shorten timelines from compound discovery to clinical development. At the beginning of the pandemic, repurposing approaches were at the forefront of early research efforts to screen for antiviral activity against SARS-CoV-2 in over 2500 compounds. Here, we report cellular screening results of 100 FDA-approved and experimental compounds against SARS-CoV-2 in the human Calu-3 cell line. We observed 13 compounds showing antiviral activity against SARS-CoV-2, including seven FDA-approved compounds (remdesivir, boceprevir, amiloride, nafamostat, cisplatin, silmitasertib, and miglustat), and six compounds in pre-clinical and clinical development (tarloxotinib, lucerastat (NB-DGJ), MON-DNJ, NAP-DNJ, NN-DGJ and NN-DNJ). Further, we observed that our screening hits include several host-targeting antivirals, namely iminosugars, that are largely non-toxic and offer a large therapeutic window. The most-developed iminosugar MON-DNJ (UV-4B), which has been evaluated in a Phase 1 clinical trial, shows antiviral activity against SARS-CoV-2 wild type as well as alpha, beta, gamma, delta, and Omicron variants. Its activity also extended to another betacoronavirus HCoV OC43, but not alphacoronavirus HCoV 229E. Our cellular screening results add to the body of knowledge on antivirals against coronaviruses and confirm the antiviral efficacy of iminosugars in cellular assays using the human lung-cell line Calu-3.

Podocyte-Specific Protein Expression in Urine Exosome Acts as a Marker for Renal Injury in Post-COVID State

Introduction: Severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) has been associated with the development of COVID-19. COVID-19 may cause endothelial cell dysfunction (ECD), which can lead to cardiometabolic diseases and podocytopathy. In this study, we explored whether presence of hyperglycemia predisposes to SARS-CoV-2 infection, in vitro, and whether COVID-19 can put an individual at a higher risk of persistent renal damage in the long-term following acute COVID infection. To estimate renal damage, we evaluated albuminuria and podocytopathy. Podocytopathy was estimated by measuring podocyte-specific protein levels in urine-derived exosomes from patients who were admitted with acute COVID-19 at 10 days, 6 months, and 12 months post-acute SARS-CoV-2 infection. Methods: Blood and urine samples from patients with SARS-CoV-2 post-infection were procured from the George Washington University COVID repository. Peripheral blood mononuclear cells and urine exosomes were isolated. Podocyte-specific proteins Podocalyxin (PODXL) and Nephrin (NEPH) were identified from urine exosomes. Results: Urine exosomal podocalyxin levels were significantly high at 10 week (n = 18; P = 0.001), 6 month (n = 25; P = 0.003) and 12 month (n = 14; P = 0.0001) time points. Nephrin levels were also noted to be high at 10 week (n = 18; P = 0.001) and 12 month (n = 14; P = 0.007) time points, compared with urine samples obtained from type 2 diabetes subjects who never had COVID-19. Though urinary podocyte-specific proteins were high, compared to control, there were no significant differences noted on urine albumin:creatinine ratios (UACR) between the groups. Conclusion: Persistent high levels of podocyte-specific proteins noted in urinary exosomes even at 12 months post-Covid may lead to the development of chronic kidney disease.

Advances in incretin therapies for targeting cardiovascular disease in diabetes

The global prevalence of obesity is skyrocketing at an alarming rate, with recent data estimating that one-in-eight people are now living with the disease. Obesity is a chronic metabolic disorder that shares underlying pathophysiology with other metabolically-linked diseases such as type 2 diabetes mellitus, cardiovascular disease and diabetic cardiomyopathy. There is a distinct correlation between type 2 diabetes status and the likelihood of heart failure. Of note, there is an apparent sexual dimorphism, with women disproportionately affected with respect to the degree of severity of the cardiac phenotype of diabetic cardiomyopathy that results from diabetes. The current pharmacotherapies available for the attenuation of hyperglycaemia in type 2 diabetes are not always effective, and have varying degrees of efficacy in the setting of heart failure. Insulin can worsen heart failure prognosis whereas metformin, sodium-glucose cotransporter 2 inhibitors (SGLT2i) and more recently, glucagon-like peptide-1 receptor agonists (GLP-1RAs), have demonstrated cardioprotection with their administration. This review will highlight the advancement of incretin therapies for individuals with diabetes and heart failure and explore newly-reported evidence of the clinical usefulness of GLP-1R agonists in this distinct phenotype of heart failure.

The neutrophil-to-lymphocyte ratio in bronchoalveolar lavage fluid could help to personalize corticosteroid therapy in severe COVID-19 pneumonia

OBJECTIVE

To investigate the response to high-dose corticosteroids according to bronchoalveolar neutrophil-to-lymphocyte ratio (BAL-NLR) in critically-ill COVID-19 patients.

METHODS

We retrospectively analyzed a single-center cohort of adult COVID-19 patients admitted to the intensive care unit with COVID-19 pneumonia between 2020 and 2022, who had a bronchoalveolar lavage and received systemic corticosteroids. We defined high-dose corticosteroid therapy as the administration of at least 1mg/kg/day of methylprednisolone.

RESULTS

Among 161 patients, 56 had LOWBAL-NLR (<0.8), 55 MILDBAL-NLR (0.8-3.5), and 50 HIGHBAL-NLR (>3.5). A quarter of patients received high-dose corticosteroid therapy. In the HIGHBAL-NLR group, those receiving high-dose corticosteroid therapy had a lower (27 % versus 43 %, p = 0.23) 90-day mortality rate than those receiving a standard dose. In the LOWBAL-NLR group, those receiving high-dose corticosteroid therapy had a higher (31 % versus 12 %, p = 0.12) 90-day mortality rate.

CONCLUSION

Our results suggest that bronchoalveolar cellular phenotype influences therapeutic response to high-dose corticosteroid therapy.

The underlying mechanism behind the different outcomes of COVID-19 in children and adults

Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has affected hundreds of millions of people globally, resulting in millions of deaths. During this pandemic, children have demonstrated greater resistance than adults, exhibiting lower infection rates, reduced mortality, and milder symptoms. Summarizing the differences in resistance between children and adults during COVID-19 can provide insights into protective mechanisms and potential implications for future treatments. In this review, we focused on summarizing and discussing the mechanisms for better protection of children in COVID-19. These protective mechanisms encompass several factors: the baseline expression of cell surface receptor ACE2 and hydrolase TMPRSS2, the impact of complications on COVID-19, and age-related cytokine profiles. Additionally, differences in local and systemic immune responses between children and adults also contribute significantly, particularly interferon responses, heterologous protection from non-COVID-19 vaccinations, and immune status variations influenced by micronutrient levels. The advantageous protection mechanisms of these children may provide insights into the prevention and treatment of COVID-19. Importantly, while age-related metabolic profiles and differential COVID-19 vaccine responses may contribute to protection in children, current comparative research remains limited and requires further investigation.

Non-antiviral therapies for viral infections: Harnessing host mechanisms

Despite advancements in the field of directly acting anti-viral (DAA) therapies, viral infections still continue to pose significant global health challenges. The efficacy of DAAs are often hindered by mutations, origin of new strains, development of resistance and lack of broad spectrum effectiveness. Furthermore, patients with advanced-stage diseases may require higher doses and combinations of different DAA therapies, raising concerns about tolerability and safety. To overcome all these constraints, non-antiviral therapies that focuses on host mechanisms (also known as host-focused therapies) are emerging as an innovative approach. Host focused therapy aims to target the host molecules and pathways that are essential for viral infection and disease progression. Along with addressing the above mentioned challenges, these host focused therapies can also modulate excessive inflammatory responses. Recent advancements in understanding host-virus interactions and the pathways involved in the pathogenesis of severe viral infections from viral entry and replication to disease progression, have accelerated the development of host-focused therapies aimed at combating these infections. This review explores the growing rationale and various opportunities for host-focused therapies for severe viral infections including zika virus, dengue, HIV, influenza, and covid-19 to name a few. In addition, current clinical trial information on various classes of host focused therapies are presented, highlighting their therapeutic potential and significance in the field.

"I am not a priority": ethnic minority experiences of navigating mental health support and the need for culturally sensitive services during and beyond the pandemic

BACKGROUND

Existing health inequalities and the lack of timely and appropriate support have long been a reality for many ethnic minority individuals living with mental health conditions, even before the pandemic. Limited access to services and the absence of culturally or religiously embedded care have led to increased severity of mental health problems.

OBJECTIVE

To explore the complexity of interactions between ethnic minorities and mental health services and their experiences of seeking and receiving mental health support throughout the pandemic.

METHODS

Semi-structured interviews with purposive and snowball sampling of ethnic minorities aged over 18 (n=32) across North East and North West in England were analysed using a framework approach.

FINDINGS

Five themes were generated. Cultural stigma attached to mental health could lead to fear and reluctance to seek support. Individuals struggled to engage with non-culturally sensitive health services. Instead, they indicated a strong preference for wider community support, which continued through the pandemic despite interrupted health services. A collaboration between mental health services and ethnic minority communities was advocated to shape services to cultural contexts and improve patient-centred service delivery.

CONCLUSIONS

Ethnic minorities with mental health face significant challenges and disparities in seeking and engaging in mental health services. They often seek support from multicultural community settings even though the support is not specifically targeted at addressing mental health issues. Understanding cultural beliefs, religious influences and family and community structures are necessary components of culturally appropriate care.

CLINICAL IMPLICATIONS

Culturally sensitive mental health services need to be integrated into existing systems through initiating collaborations with ethnic minority communities that tailor services to meet the needs of diverse populations, improving overall engagement and experiences.

Prevalence of fungi and their antifungal and disinfectant resistance in hospital environments: insights into combating nosocomial mycoses

BACKGROUND

Fungal infections are increasingly recognized as a global health concern, contributing to considerable morbidity and mortality in hospital settings. This underscores the urgent need for infection prevention and control in healthcare facilities to protect vulnerable patients from the risk of acquiring invasive fungal diseases (IFDs). Given the critical role of transmission-based precautions in limiting the spread of filamentous fungi responsible for IFDs, this study was conducted to explore the potential role of the hospital environment in the dissemination of these infections.

METHODS

A total of 83 samples were collected from the air and surface of exhaust vents in the intensive care units (ICUs) of hospitals in Isfahan, Iran, to assess the presence and diversity of fungal species. Susceptibility testing against antifungal agents, including commonly used drugs and disinfectants, was performed on the identified fungal isolates. Furthermore, the antifungal resistance profiles of isolates from clinical IFD cases were compared with those of environmental isolates.

RESULTS

Fungi were detected in 45% of air samples and 100% of exhaust vent samples, with Aspergillus species being the most commonly identified genus. Mucorales were also found in 17% of exhaust vent samples. Aspergillus spp. and Rhizopus spp. showed the highest resistance to Amphotericin B, and a considerable proportion of these isolates exhibited simultaneous resistance to disinfectants. A similar antifungal resistance profile was noted between A. flavus and some R. arrhizus isolates from both environmental and clinical samples.

CONCLUSIONS

The findings of this study indicate that the hospital environment, particularly exhaust vents, may act as a significant reservoir for causative agents of IFDs. This highlights the importance of environmental surveillance in preventing and controlling nosocomial fungal infections.

Treatment of feline infectious peritonitis in cats with molnupiravir: clinical observations and outcomes for 54 cases

OBJECTIVE

To evaluate the clinical applications and treatment outcomes using molnupiravir for the treatment of naturally occurring feline infectious peritonitis virus (FIPv).

METHODS

Ninety-two client-owned cats with confirmed or presumptive FIP were retrospectively recruited from 35 veterinary practices, primarily in Australia, between February 2023 and March 2024. Cats were categorised based on treatment received: Cohort A: Molnupiravir treatment: monotherapy, maintenance or rescue therapy; Cohort B: Remdesivir and/or GS-441524 treatment. Seventy-eight cats were enrolled. Molnupiravir was administered orally for a median of 84 days, at a median dose of 13.3 mg/kg BID. Remission was defined as the resolution of FIP-related signs with (i) normalisation of serum globulin concentrations and A:G ratio (≥0.6), or (ii) sustained clinical remission for at least 100 days after stopping anti-viral therapy. Cure rate was defined as the percentage of cats achieving sustained remission, without requiring rescue therapy or experiencing a relapsed disease.

RESULTS

Molnupiravir monotherapy resulted in a cure rate of 72% (13/18) while molnupiravir maintenance therapy achieved a cure rate of 86% (25/29), and molnupiravir utilised as a rescue therapy achieved a cure rate of 100% (7/7). Treatment with remdesivir/GS-441524 resulted in a cure rate of 71% (17/24 cats). Survival analysis revealed no difference in outcomes between cats treated with molnupiravir monotherapy and those treated with remdesivir/GS-441524. Adverse events associated with molnupiravir therapy included neutropenia, and transient elevations in hepatic enzymes.

CONCLUSION

Molnupiravir demonstrated comparable survival outcomes to remdesivir/GS-441524 for treating FIP and serves as an accessible, effective option across various presentations, including ocular and neurologic forms.

Diabetes and natural and man-made disasters: prevention, preparation, response and recovery

Both the global prevalence of diabetes and the frequency of natural and man-made disasters are increasing. Of all chronic diseases, the consequences of sudden loss of medical supplies are most serious for those with diabetes, with people living with type 1 diabetes being at risk of death within a few days without insulin. This review considers how to prepare for and respond to sudden reductions in medical supplies to those with diabetes. Recent experiences with the COVID-19 pandemic in India, the war in Ukraine and the war/blockade in the Tigray region of Ethiopia are described, and the importance of prevention, preparedness, response and recovery are discussed. It is hoped that lessons from these and other disasters and ongoing advocacy and other actions may help to mitigate the risks of significant morbidity and mortality for people with diabetes in disaster-impacted regions across the world.

Evidence for improved glucose metrics and perinatal outcomes with continuous glucose monitoring compared to self-monitoring in diabetes during pregnancy

OBJECTIVE

Continuous glucose monitoring is recommended for pregnant women with type 1 diabetes, due to associations with decreased hemoglobin A1c and large for gestational age. However, its benefit in type 2 diabetes and gestational diabetes is not established. This systematic review and meta-analysis compared usage of continuous glucose monitoring to self-monitoring of blood glucose both across and within diabetes in pregnancy and determined which glucose metrics are associated with perinatal outcomes, to potentially inform treatment targets in diabetes in pregnancy.

DATA SOURCES

We searched Medline, Embase, CENTRAL, CINAHL, and Scopus, from January 2003 to August 2024.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials and quasi-experimental studies comparing continuous glucose monitoring with self-monitoring of blood glucose in diabetes in pregnancy were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Randomized controlled trials and quasi-experimental studies were analyzed separately. Data were extracted on continuous glucose monitoring metrics, hemoglobin A1c, rates of cesarean delivery, large for gestational age, small for gestational age, neonatal hypoglycemia, and neonatal intensive care unit admission, summarized as mean differences or odds ratios with 95% confidence intervals and 95% prediction intervals. Prespecified subgroup analyses were undertaken by diabetes in pregnancy subtype, including duration of continuous glucose monitoring use (continuous vs intermittent) for large for gestational age. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations framework.

RESULTS

Across diabetes in pregnancy, continuous glucose monitoring (vs self-monitoring of blood glucose) decreased hemoglobin A1c (mean difference, -0.22% [95% confidence interval, -0.37, -0.08]) (7 randomized controlled trials, moderate-certainty evidence). Within diabetes in pregnancy, continuous glucose monitoring use (vs self-monitoring of blood glucose) showed similar but stronger benefits in both type 1 diabetes when used throughout pregnancy (hemoglobin A1c mean difference, -0.18% [95% confidence interval, -0.36, 0.00]; large for gestational age odds ratio, 0.51 [0.28, 0.90]) (1 randomized controlled trial, high-certainty evidence), and gestational diabetes when used intermittently (hemoglobin A1c mean difference, -0.18 [95% confidence interval, -0.33, -0.02]) (5 randomized controlled trials, moderate-certainty evidence) and large for gestational age (odds ratio, 0.46 [0.26, 0.81]) (1 quasi-experimental study, low-certainty evidence), with insufficient data for continuous glucose monitoring benefit in type 2 diabetes. Increased pregnancy %time-in-range (type 1 diabetes) and decreased mean sensor glucose (type 1 diabetes/gestational diabetes) were associated with decreased large for gestational age.

CONCLUSION

Usage of continuous glucose monitoring (vs self-monitoring of blood glucose) reduces hemoglobin A1c and possibly large for gestational age across diabetes in pregnancy. Greatest benefit was evidenced in type 1 diabetes, followed by gestational diabetes, although continuous glucose monitoring duration differed. Mean sensor glucose and pregnancy %time-in-range are important continuous glucose monitoring metrics for reducing large for gestational age.

Polyphenols From Mallotus peltatus (Geiseler) Mull. Arg. Ameliorates FFA-Induced Hepatic Steatosis in L02 Cells and Reduces Lipid Accumulation in Caenorhabditis elegans

Mallotus peltatus (Geiseler) Mull. Arg. (MPMA) is a specialty plant used to make tea in Hainan Province, China. However, its hypolipidemic activity has been rarely studied. In this study, three polyphenol fractions (MPMAP-1, MPMAP-2, and MPMAP-3) were purified from a 60% ethanol extract of MPMA, and the hypolipidemic activities were evaluated by establishing an FFA-induced L02 cell model to determine lipid accumulation, antioxidant enzyme activities, and gene levels related to the Nrf2/ARE pathway and lipid metabolism. In addition, noninduced and high glucose-induced models were established using Caenorhabditis elegans (C. elegans) to evaluate the lipid-lowering activity of MPMAP-1. The results showed that all three polyphenols could significantly inhibit lipid accumulation, reduce intracellular MDA content, and enhance the activities of CAT, SOD, and GPx in FFA-induced L02 cells. The qRT-PCR results indicated that the amount of fat accumulation in L02 cells could be regulated by modulating the relative expression of mRNA in the Nrf2/ARE signaling pathway and lipid metabolism pathway. The noninduced model and high glucose-induced model demonstrated that MPMAP-1 was able to reduce lipid accumulation and ROS levels and increase the activities of antioxidant enzymes in C. elegans. In summary, our results suggested that polyphenol compounds of MPMA may be a promising natural product for lipid-lowering.

A Scoping Review on the Prevalence of Hashimoto's Thyroiditis and the Possible Associated Factors

BACKGROUND

Hashimoto's thyroiditis (HT) is the most common autoimmune thyroid disease (AITD) and is characterized by the presence of thyroid autoantibodies against thyroid peroxidase and/or thyroglobulin. Several studies have found that the global prevalence of HT has increased in recent decades, while others show the opposite.

METHODS AND RESULTS

The objective of this scoping review was to synthesize and analyze the different studies that have evaluated the prevalence of HT (in adults) and the possible associated factors. The following databases were consulted, as follows: MEDLINE, Web of Science, PubMed, and Scopus. The search terms "epidemiology", "prevalence", and "Hashimoto disease" and "Hashimoto thyroiditis" were used. The search was limited to articles published between January 1965 and October 2024, and only articles in English were considered. In order to reduce selection bias, each article was scrutinized using the JBI Critical Appraisal Checklist independently by two authors. Studies were included if the number of participants (study population and/or cases and controls, depending on the study design) was clearly described and duplicate studies were excluded. A total of 59 studies were identified, the vast majority of them used a cross-sectional design, using different methods of disease assessment.

CONCLUSIONS

Globally, the prevalence of HT is estimated to be between 5-10%; some areas with prevalences > 20% and others < 0.5% were identified. Prevalence is also higher in women than in men. Multiple underlying factors (genetic, epigenetic, environmental, and lifestyle), together with socioeconomic, nutritional, overdiagnosis, inter alia, may explain (at least in part) the wide variability in the prevalence of HT.

Discrepancies in Dapagliflozin Response in Terms of Glycemic Control and Body Weight Reduction

BACKGRUOUND

Dapagliflozin, a sodium-glucose cotransporter 2 inhibitor, reduces hyperglycemia and obesity by inhibiting renal glucose reabsorption. This post hoc study evaluated clinical factors influencing patient response to dapagliflozin.

METHODS

The analysis focused on patients treated with dapagliflozin (10 mg/day for 52 weeks) within the randomized, double-blind, parallel-group BEYOND trial. Adequate glycemic control (GC) was defined as a reduction in glycated hemoglobin (HbA1c) of ≥ 1.0% or the achievement of an HbA1c level <7.0% at week 52. Significant weight loss (WL) referred to a reduction in body weight of ≥3.0% at week 52. Participants were classified into four groups based on their GC and WL responses: GC+/WL+, GC+/WL-, GC-/WL+, and GC-/WL-.

RESULTS

Among dapagliflozin recipients (n=56), at 52 weeks, HbA1c had decreased by 1.0%±0.8% from baseline, while body weight had declined by 2.4±3.1 kg. Overall, 69.6% of participants achieved GC+, and 57.1% achieved WL+. Male sex and shorter diabetes duration were significantly associated with achieving GC+. Conversely, higher estimated glomerular filtration rate was significantly linked to WL+. The only factor significantly associated with both GC+ and WL+ was shorter diabetes duration (odds ratio, 0.81; 95% confidence interval, 0.68 to 0.97; P=0.023). The GC+ and WL+ groups exhibited favorable responses beginning soon after dapagliflozin therapy was initiated. Furthermore, HbA1c decline was more strongly associated with reduction in visceral fat than with WL.

CONCLUSION

A short duration of diabetes and early response to treatment appear to represent key factors in maximizing the benefits of dapagliflozin for blood glucose and weight management.

Understanding Barriers and Facilitators for Ethnic Minority Groups to Audio Recording Recruitment Discussions in Clinical Trials: A Participatory Approach to Improving Informed Consent and Participation

INTRODUCTION

Fully informed consent is essential for ethical trial conduct, yet gaps in participant comprehension and recall can occur, particularly among underserved groups, for example, ethnic minorities. This Patient and Public Involvement and Engagement (PPIE) project explored the engagement of ethnic minority communities in trial recruitment discussions, particularly their views about audio recording discussions with healthcare professionals.

METHODS

This PPIE project engaged ethnic minority communities in Bristol, collaborating with community partners to facilitate access to then foster dialogue among Somali, South Asian and Chinese groups. Separate workshops for men and women from these ethnic groups were held to introduce community members to clinical trial processes. Discussions, both audio recorded and not, simulated real recruitment scenarios. To ensure cultural relevance and accessibility, discussions were partly facilitated by our PPIE community partners in native languages.

RESULTS

The insights gained during workshops were organised into key themes. Gaps in understanding regarding clinical trial participation were highlighted. A key finding was that trust played an important role and was facilitated by engaging community leaders and ensuring cultural and linguistic sensitivity during discussions. To address gaps in knowledge about trials and streamline the educational process, we developed storyboards and multilingual video resources. These explained the importance of clinical trials generally and the importance of recruiting diverse patient populations in particular. The materials were co-created with community partners and refined through iterative feedback to ensure accuracy and cultural appropriateness. The challenge of language barriers necessitated skilled interpreters, especially when discussions were audio recorded, to optimise understanding among people from diverse ethnic backgrounds. The video, available in English, Urdu, Mandarin, Cantonese and Bangla, facilitates understanding of trial purposes and processes, with the aim of widening trial participation in these groups.

CONCLUSION

Our PPIE activities highlighted gaps in understanding, the critical role of trust and the challenge of language barriers. The co-created resources have been made available for those wanting to address and overcome some of these issues. The initial feedback from the clinical trials community on the video resources has been promising, underscoring their potential to impact future recruitment efforts and PPIE activities.

PATIENT OR PUBLIC CONTRIBUTION

To foster a co-creation process, this project included the active involvement of our PPIE collaborators and co-applicants 'Khaas' for funding. They also helped us reach contributors from the South Asian community (mainly of Pakistani and Bangladeshi origin) and arrange workshops. Our two PPIE contributors from Somali Resource Centre and Barton Hill Activity Club helped us reach the Somali community at the Wellspring Settlement. Similarly, the Chinese Community Wellbeing Society helped us reach people from the Chinese community. These PPIE partners also helped us run the workshop by providing live translation of discussion. They also helped translate video scripts and do voiceovers in videos. Also, PPIE contributors Tom Yardley and Amanda Roberts helped with the script development.

A Multicenter, Retrospective Study to Evaluate the Effectiveness and Safety of Imeglimin in Patients with Type 2 Diabetes Mellitus in a Real-World Clinical Setting (INDI-TIMES Study)

INTRODUCTION

Imeglimin is a novel oral antidiabetic drug that was approved for use in India in October 2022. Thus far, no large-scale studies on the effectiveness and safety of imeglimin for the treatment of type-2 diabetes mellitus (T2DM) have been conducted in the Indian population. The objective of this study was to evaluate the effectiveness and safety of imeglimin in Indian patients with T2DM in a real-world setting.

METHODS

This observational, retrospective, real-world study was conducted at 191 sites across India from May to June 2024. Adult patients with uncontrolled T2DM (7% ≤ glycated hemoglobin (HbA1c) ≤ 9%) who were prescribed imeglimin 1000 mg twice a day as part of routine clinical practice, who were either treatment naïve or on other antidiabetic agents, and for whom a valid prescription and required data were available were included in the study. The data were collected from the medical records of eligible subjects and analyzed for the changes in glycemic indices from baseline to the 3-month follow-up.

RESULT

The data for 8301 patients (male: 59.39%) were analyzed. Of these, 2009 (24.20%) subjects received imeglimin monotherapy and 5004 (60.28%) received dual therapy. The analysis showed a statistically significant (p < 0.0001) reduction from baseline to the 3-month follow-up in glycemic indices and weight. The mean HbA1c, fasting and postprandial plasma glucose, and weight were decreased by 1.12%, 29.41 mg/dL, 62.41 mg/dL, and 2.01 kg, respectively. A total of 3547 (45.35%) subjects achieved HbA1c < 7%. No adverse events were reported.

CONCLUSION

Imeglimin shows promise as an effective and well-tolerated option for managing T2DM in the Indian population. Also, secondary impacts of imeglimin, such as improvements in the lipid profile, hepatic function, blood pressure, and weight loss, warrant further clinical exploration.

Optimizing Cardiovascular Outcomes in Type 2 Diabetes: Early Initiation of Dapagliflozin and Sitagliptin From a Cardiologist's Perspective

INTRODUCTION

Cardiovascular (CV) disease (CVD) risk is greater in patients with diabetes mellitus and is the major contributor to disability and premature mortality compared to those who do not have diabetes. The clinical implications of CVD in people with type 2 diabetes mellitus (T2DM) have increased the emphasis on concurrent treatment to prevent the onset of CVD through personalized management for glycemic control and CVD risk management.

METHODS

Key opinion leaders, comprising 98 cardiologists from across India, participated in seven advisory board meetings held in various cities to explore the challenges and strategies for the early initiation of fixed-dose combinations (FDCs) of sodium-glucose co-transporter-2 inhibitors (SGLT2i) and dipeptidyl peptidase-4 inhibitors (DPP4i) with a focus on the combination of dapagliflozin and sitagliptin in addressing the CVD risks in patients with T2DM and high risk for CV complications. The expert group discussed the available literature evidence from the clinical trials, systematic reviews, and real-world studies on the benefits of FDC of SGLT2i and DPP4i and FDC of dapagliflozin and sitagliptin to provide rational and practical guidance for its optimal use in addressing the CVD risks in patients with T2DM.

RESULTS

The expert group emphasized the importance of timely glycemic control and early initiation of combination therapy of FDC of SGLT2i + DPP4i in T2DM with CVD risks. Addressing multiple pathophysiological aspects of T2DM is crucial, and considering combination therapy with SGLT2i and DPP4i may be pertinent in this context. Combining dapagliflozin and sitagliptin in FDC to target multiple pathophysiological pathways for T2DM appears to have several glycemic and extra-glycemic benefits.

CONCLUSION

This practical guidance document provides valuable insights from leading cardiologists that would support clinicians in selecting the synergistic combination SGLT2i + DPP4i (dapagliflozin + sitagliptin) FDC as an appropriate treatment choice in early intensive therapy in managing people with T2DM and CVD risk for better patient outcomes. The expert opinion in this guidance builds on the established guideline recommendations on FDC of SGLT2i and DPP4i.

Management of Rhinomaxillary Mucormycosis: A Case Report

This case report describes a rare occurrence of palatal mucormycosis in a 45-year-old immunocompetent female patient who developed black discoloration of the palate following a tooth extraction. Initial diagnostic investigations and superficial biopsy revealed aspergillosis; however, further postoperative histopathological examination confirmed mucormycosis. Aggressive surgical intervention, including maxillectomy, alveolectomy, and functional endoscopic sinus surgery, combined with targeted antifungal therapy, facilitated successful treatment. The importance of timely diagnosis and comprehensive management in mucormycosis cases, even among immunocompetent patients, is highlighted.

Development and validation of a novel reverse-phase high-performance liquid chromatography (RP-HPLC) method for the quantification of related substances of vasopressin injection: A characterization and comparative analysis of vasopressin formulation samples against vasostrict (RLD) in various diluents

In the present study, we developed and validated a sensitive, accurate, robust and simple RP-HPLC method for quantification of related substances of vasopressin (VPS) injection. The development phase prioritized the optimization of wavelength, mobile phase composition and column selection to enhance separation and sensitivity for the analytical evaluation of VPS injection. By considering peak symmetry, resolution and retention time, chromatographic conditions of VPS injection were established. The YMC PACK ODS AM (100×4.6) mm, 3μm was employed in the study. Mobile phase A was prepared with 0.113M NaH2PO4.H2O (pH 3.0) while mobile phase B was a 50:50 (v/v) ratio of acetonitrile and water, pumped through a flow rate of 1.0mL/min. VPS injection was exposed to thermal, photolytic, acid, base and peroxide degradation conditions and these were analysed by the current method. The method was validated following the guidelines set by the International Council for Harmonization guideline (ICH). The linearity studies demonstrating that a correlation coefficient value is more than 0.999 for VPS and its related substances. The detection and quantification limits for all related substances were found to be 0.01% and 0.05%, respectively. All the impurities exhibited consistent recoveries ranging from 85 to 105%. The unknown impurities were eluting at RRT 1.23 and RRT 1.25 in the RS methodology (HPLC-UV) of VPS injection are identified and assessed the impurity levels. Furthermore, aggregate profiles and secondary structure analysis studies were carried out using FTIR and LC-HRMS, comparing the VPS formulation samples with the reference listed drug (RLD) (Vasostrict) samples across various diluents.

Review of atypical optic neuritis

Optic neuritis (ON), an inflammatory optic neuropathy, is among the most common causes of visual loss. In its initial clinical appearance, ON may have unilateral or bilateral presentation, and anterior (papillitis) or retrobulbar localization. Traditionally, cases are divided into typical and atypical ON. In the Western hemisphere, most typical cases of optic nerve inflammation are associated with multiple sclerosis (MS). However, ON may also be associated with a series of disorders of known or initially undetected origin. Atypical ON has a somewhat different clinical picture from typical ON, and encompasses neuromyelitis optica spectrum disease (NMOSD), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), idiopathic recurrent neuroretinitis (NR), chronic relapsing inflammatory ON (CRION), ON within systemic autoimmune diseases, paraneoplastic and neuritis during or after infectious diseases or vaccination. The causes should be meticulously worked up, to address the therapeutic and prognostic challenges posed by these conditions. Here, we provide a brief overview of atypical ON, as encountered in our clinical practice, and additionally discuss the possible occurrence of optic neuropathies other than inflammatory and other ocular diseases within these disorders.

Insulin icodec: A novel once-weekly formulation for the treatment of type 1 and type 2 diabetes mellitus

Insulin icodec is a novel once-weekly basal insulin analog subcutaneous injection seeking approval by the United States Food and Drug Administration (FDA) for use in both type 1 and type 2 diabetes mellitus. The mission of this manuscript is to provide a thorough overview of insulin icodec's clinical trials that were involved in its approval as well as review its pharmacology, pharmacokinetics, adverse effects, drug interactions, dosage recommendations, and regulatory issues. This article includes a thorough review of insulin icodec's safety and efficacy in type 1 and type 2 diabetes mellitus including its pharmacokinetic and pharmacodynamic profile. A systematic search of the electronic database of PubMed from inception until December 2024 using MeSH keywords was completed. Keywords used were icodec, insulin, type 1 diabetes, and type 2 diabetes. Overall, 14 clinical trials were identified and reviewed. The majority of the trials reviewed showed decreases in A1C as primary endpoints and non-inferiority and superiority with insulin icodec versus the comparator. In select studies, mild hypoglycemia was more evident in subjects taking insulin icodec versus the comparator but no other concerns were identified. The reviewed literature showed similar and sometimes improved glycemic control when insulin icodec was compared to other long-acting insulins both in insulin-naive and previously insulin-treated patients. Hypoglycemia was similar or slightly increased with insulin icodec when compared to other long acting insulins. Overall, icodec is a useful, new formulation of basal insulin that allows for less injections, improved compliance, and potentially improved glycemic control providing a new tool to practitioners managing patients with diabetes who need to be on insulin.

Estimated Glomerular Filtration Rate Decline is Causally Associated with Acute Pulmonary Embolism: A Nested Case-Control and Mendelian Randomization Study

Renal dysfunction is highly prevalent among patients with pulmonary embolism (PE). This study combined population-based study and Mendelian randomization (MR) to observe the relationship between renal function and PE.A nested case-control study were performed using data of PE patients and controls were from two nationwide cohorts, the China pUlmonary thromboembolism REgistry Study (CURES) and China Health and Retirement Longitudinal Survey (CHARLS). Baseline characteristics were balanced using propensity score matching and inverse probability of treatment weighting. Restricted cubic spline models were applied for the relationship between estimated glomerular filtration rate (eGFR) decline and the risk of PE. Bidirectional two-sample MR analyses were performed using genome-wide association study summary statistics for eGFR involving 1,201,909 individuals and for PE from the FinnGen consortium.The nested case-control study including 17,547 participants (6,322 PE patients) found that eGFR distribution was significantly different between PE patients and controls (p < 0.001), PE patients had a higher proportion of eGFR < 60 mL/min/1.73 m2. eGFR below 88 mL/min/1.73 m2 was associated with a steep elevation in PE risk. MR analyses indicated a potential causal effect of eGFR decline on PE (odds ratio = 4·26, 95% confidence interval: 2·07-8·79), with no evidence of horizontal pleiotropy and reverse causality.Our findings support the hypothesis that renal function decline contributes to an elevated PE risk. Together with the high prevalence of chronic kidney diseases globally, there arises the necessity for monitoring and modulation of renal function in effective PE prevention.

In vitro enzymatic and cell culture assays for SARS-CoV-2 main protease interaction with ambenonium

The 2019 pandemic of coronavirus disease (COVID-19) caused by SARS-CoV-2 led to millions of deaths worldwide since its emergence. The viral genomic material can code structural and non-structural proteins including the main protease or 3CLpro, a cysteine protease that cleavages the viral polyprotein generating 11 proteins that participate in viral pre-replication. Thus, 3CLpro is a promising therapeutic target for SARS-CoV-2 inhibition by new drugs or drug repositioning because 3CLpro is dissimilar to human proteases. We conducted in vitro assays demonstrating the modulation activity of ambenonium, a drug already used in Myasthenia gravis that acts by inhibiting the action of acetylcholinesterase, and had its potential inhibitory activity against viral replication pointed out in a previous in silico study. In concentrations of 100 µM, 50 µM, 25 µM, 10 µM, and 1 µM there was no inhibition in the formation of lysis plates, with a slight increase in the genome copy number at the higher concentrations evaluated. However, in the concentrations of 0,1 µM and 0,01 µM, there was a reduction in the number of lysis plates. This behavior suggests that the ambenonium acts as a modulator of viral activity in vitro. To investigate potential conformational changes in the protein between dimeric and monomeric forms in the presence of the compound, a local docking analysis was performed. Results indicated this conformational shift is possible, though further studies are needed to confirm these findings.

Age and Sex Differences in Efficacy of Treatments for Type 2 Diabetes: A Network Meta-Analysis

Importance

Sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and dipeptidyl peptidase 4 (DPP4) inhibitors improve hyperglycemia, and SGLT2 inhibitors and GLP-1 receptor agonists reduce the risk of major adverse cardiovascular events (MACEs) among individuals with type 2 diabetes. It is not clear whether efficacy varies by age or sex.

Objective

To assess whether age or sex are associated with differences in the efficacy of SGLT2 inhibitors, GLP-1 receptor agonists, and DPP4 inhibitors.

Data Sources and Study Selection

The MEDLINE and Embase databases and US and Chinese clinical trial registries were searched for articles published from inception to November 2022; in August 2024, the search was updated to capture the trial results. Two reviewers screened for randomized clinical trials of SGLT2 inhibitors, GLP-1 receptor agonists, or DPP4 inhibitors vs a placebo or active comparator in adults with type 2 diabetes.

Data Extraction and Synthesis

Individual participant data and aggregate data were used to estimate age × treatment interactions and sex × treatment interactions in multilevel network meta-regression models.

Main Outcome and Measures

Hemoglobin A1c (HbA1c) and MACEs.

Results

Of the 601 eligible trials identified (592 trials with 309 503 participants reported HbA1c; mean age, 58.9 [SD, 10.8] years; 42.3% were female and 23 trials with 168 489 participants reported MACEs; mean age, 64.0 [SD, 8.6] years; 35.3% were female), individual participant data were obtained for 103 trials (103 reported HbA1c and 6 reported MACEs). The use of SGLT2 inhibitors (vs placebo) was associated with less HbA1c lowering with increasing age for monotherapy (absolute reduction [AR], 0.24% [95% credible interval {CrI}, 0.10% to 0.38%] per 30-year increment in age), for dual therapy (AR, 0.17% [95% CrI, 0.10% to 0.24%]), and for triple therapy (AR, 0.25% [95% CrI, 0.20% to 0.30%]). The use of GLP-1 receptor agonists was associated with greater HbA1c lowering with increasing age for monotherapy (AR, -0.18% [95% CrI, -0.31% to -0.05%] per 30-year increment in age) and for dual therapy (AR, -0.24% [95% CrI, -0.40% to -0.07%]), but not for triple therapy (AR, 0.04% [95% CrI, -0.02% to 0.11%]). The use of DPP4 inhibitors was associated with slightly better HbA1c lowering in older people for dual therapy (AR, -0.09% [95% CrI, -0.15% to -0.03%] per 30-year increment in age), but not for monotherapy (AR, -0.08% [95% CrI, -0.18% to 0.01%]) or triple therapy (AR, -0.01% [95% CrI, -0.06% to 0.05%]). The relative reduction in MACEs with use of SGLT2 inhibitors was greater in older vs younger participants per 30-year increment in age (hazard ratio, 0.76 [95% CrI, 0.62 to 0.93]), and the relative reduction in MACEs with use of GLP-1 receptor agonists was less in older vs younger participants (hazard ratio, 1.47 [95% CrI, 1.07 to 2.02]). There was no consistent evidence for sex × treatment interactions with use of SGLT2 inhibitors and GLP-1 receptor agonists.

Conclusions and Relevance

The SGLT2 inhibitors and GLP-1 receptor agonists were associated with lower risk of MACEs. Analysis of age × treatment interactions suggested that SGLT2 inhibitors were more cardioprotective in older than in younger people despite smaller reductions in HbA1c; GLP-1 receptor agonists were more cardioprotective in younger people.