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The Changing Landscape of Pharmacotherapy for Diabetes Mellitus: A Review of Cardiovascular Outcomes. Int J Mol Sci 2019; 20:ijms20235853. [PMID: 31766545 PMCID: PMC6928800 DOI: 10.3390/ijms20235853] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 11/16/2019] [Accepted: 11/18/2019] [Indexed: 12/16/2022] Open
Abstract
The prevention of cardiovascular morbidity and mortality has always been a primary concern in patients with type 2 diabetes. Modern trials of glucose-lowering therapies now assess major adverse cardiac events as an endpoint in addition to the effects on glycaemic control. Whilst the data on the efficacy of intensive glucose lowering on reducing cardiovascular risk are limited, there are now increasing numbers of glucose-lowering therapies that have proven cardiovascular benefit independent of glucose lowering. This review will summarise the available literature on cardiovascular outcomes in relation to metformin, sulphonylureas, di-peptidyl peptidase-4 inhibitors, glucagon-like peptide receptor agonists, sodium-glucose co-transporter 2 inhibitors, thiazolidinediones, acarbose and insulin. In addition, new paradigms in diabetes management and the importance of treatment selection based on considerations including but not limited to glycaemic control will be discussed.
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Abstract
PURPOSE OF REVIEW Our goal is to discuss how to personalize the management of patients with type 2 diabetes by adjusting glycemic targets and tailoring medical therapy to account for unique patient characteristics. RECENT FINDINGS We review the pharmacotherapeutic options for the management of type 2 diabetes, focusing on potential advantages and disadvantages of each class of agents. We also discuss how to approach specific patient subpopulations and propose a conceptual framework for incorporating these factors into clinical practice. As the diabetes treatment landscape rapidly expands, physicians have the exciting opportunity to offer patients increasingly individualized care.
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Affiliation(s)
- Patricia R Peter
- Section of Endocrinology, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, FMP 106, P.O. Box 208020, New Haven, CT, 06520, USA.
| | - Beatrice C Lupsa
- Section of Endocrinology, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, FMP 106, P.O. Box 208020, New Haven, CT, 06520, USA
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Webb DR, Davies MJ, Jarvis J, Seidu S, Khunti K. The right place for Sulphonylureas today. Diabetes Res Clin Pract 2019; 157:107836. [PMID: 31479704 DOI: 10.1016/j.diabres.2019.107836] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 12/28/2022]
Abstract
The place of Sulphonylurea based insulin secretagogues in the management of Type 2 diabetes appears as controversial today as it was fifty years ago. Newer therapies are associated with less hypoglycaemia and weight gain than Sulphonylureas but currently cost more and lack assurances which come with long-term exposure. Emergence of recent CVOT data for SGLT-2 inhibitors and GLP-1 receptor agonists is likely to influence therapeutic choices and guidance is now supportive of their earlier use in cases at high risk of cardiovascular disease. Meta-analyses of Sulphonylurea trials have failed to indicate a consistent effect (positive or negative) on cardiovascular disease or mortality, although are limited by the relative scarcity of studies directly reporting these outcomes. The CAROLINA trial is reassuring in demonstrating cardiovascular safety for the Sulphonylurea Glimepiride when compared directly with the DPP-4 inhibitor Linagliptin, suggesting either of these agents would be relatively safe second line options after Metformin in the majority of patients. This review provides a balanced assessment of available Sulphonylurea treatments in the context of current cardiovascular outcome trial data (CVOT) data and hopefully assists informed decision making about the place of these drugs in contemporary glucose lowering practice.
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Affiliation(s)
- David R Webb
- University of Leicester, Diabetes Research Centre, Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
| | - Melanie J Davies
- University of Leicester, Diabetes Research Centre, Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
| | - Janet Jarvis
- University Hospitals of Leicester NHS Trust, Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
| | - Sam Seidu
- University of Leicester, Diabetes Research Centre, Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
| | - Kamlesh Khunti
- University of Leicester, Diabetes Research Centre, Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
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Bloomgarden ZT. Implications of the recent CVOTs in type 2 diabetes: The right place for DPP-IV inhibitors today. Diabetes Res Clin Pract 2019; 157:107906. [PMID: 31678196 DOI: 10.1016/j.diabres.2019.107906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 10/23/2019] [Indexed: 10/25/2022]
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Deed G, Atherton JJ, d'Emden M, Rasalam R, Sharma A, Sindone A. Managing Cardiovascular Risk in Type 2 Diabetes: What Do the Cardiovascular Outcome Trials Mean for Australian Practice? Diabetes Ther 2019; 10:1625-1643. [PMID: 31292928 PMCID: PMC6778570 DOI: 10.1007/s13300-019-0663-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Indexed: 11/06/2022] Open
Abstract
Understanding the implications of cardiovascular (CV) outcomes data of glucose-lowering agents on the management of type 2 diabetes mellitus can be challenging for many primary practitioners. Amongst different classes of diabetes medications assessed for CV safety, several agents within the sodium-glucose transport protein-2 inhibitor and glucagon-like peptide-1 receptor agonists classes have demonstrated CV risk reduction. Applying the trial findings to patients typically seen in clinical practice, such as those with established CV disease and those with multiple CV risk factors without established CV disease, requires further clarity. To bridge this gap in our current knowledge, the aim of this review was to utilise expert-driven opinions on common case scenarios and practical recommendations on the most appropriate choice of agents, according to an individual patient's clinical risk profile (CV and kidney disease), treatment preference and reimbursement environment from an Australian perspective.Funding: Boehringer Ingelheim Australia.
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Affiliation(s)
- Gary Deed
- Mediwell Medical Clinic, Coorparoo, QLD, Australia.
| | - John J Atherton
- Royal Brisbane and Women's Hospital, University of Queensland School of Medicine, Herston, QLD, Australia
| | - Michael d'Emden
- Royal Brisbane and Women's Hospital, University of Queensland School of Medicine, Herston, QLD, Australia
| | - Roy Rasalam
- James Cook University, Douglas, QLD, Australia
| | - Anita Sharma
- Platinum Medical Centre, Chermside, QLD, Australia
| | - Andrew Sindone
- Concord Hospital, University of Sydney, Concord, NSW, Australia
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Affiliation(s)
- Deborah J Wexler
- Diabetes Center, Massachusetts General Hospital, Harvard Medical School, Boston
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57
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Rosenstock J, Kahn SE, Johansen OE, Zinman B, Espeland MA, Woerle HJ, Pfarr E, Keller A, Mattheus M, Baanstra D, Meinicke T, George JT, von Eynatten M, McGuire DK, Marx N. Effect of Linagliptin vs Glimepiride on Major Adverse Cardiovascular Outcomes in Patients With Type 2 Diabetes: The CAROLINA Randomized Clinical Trial. JAMA 2019; 322:1155-1166. [PMID: 31536101 PMCID: PMC6763993 DOI: 10.1001/jama.2019.13772] [Citation(s) in RCA: 342] [Impact Index Per Article: 68.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Type 2 diabetes is associated with increased cardiovascular risk. In placebo-controlled cardiovascular safety trials, the dipeptidyl peptidase-4 inhibitor linagliptin demonstrated noninferiority, but it has not been tested against an active comparator. OBJECTIVE This trial assessed cardiovascular outcomes of linagliptin vs glimepiride (sulfonylurea) in patients with relatively early type 2 diabetes and risk factors for or established atherosclerotic cardiovascular disease. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, active-controlled, noninferiority trial, with participant screening from November 2010 to December 2012, conducted at 607 hospital and primary care sites in 43 countries involving 6042 participants. Adults with type 2 diabetes, glycated hemoglobin of 6.5% to 8.5%, and elevated cardiovascular risk were eligible for inclusion. Elevated cardiovascular risk was defined as documented atherosclerotic cardiovascular disease, multiple cardiovascular risk factors, aged at least 70 years, and evidence of microvascular complications. Follow-up ended in August 2018. INTERVENTIONS Patients were randomized to receive 5 mg of linagliptin once daily (n = 3023) or 1 to 4 mg of glimepiride once daily (n = 3010) in addition to usual care. Investigators were encouraged to intensify glycemic treatment, primarily by adding or adjusting metformin, α-glucosidase inhibitors, thiazolidinediones, or insulin, according to clinical need. MAIN OUTCOMES AND MEASURES The primary outcome was time to first occurrence of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke with the aim to establish noninferiority of linagliptin vs glimepiride, defined by the upper limit of the 2-sided 95.47% CI for the hazard ratio (HR) of linagliptin relative to glimepiride of less than 1.3. RESULTS Of 6042 participants randomized, 6033 (mean age, 64.0 years; 2414 [39.9%] women; mean glycated hemoglobin, 7.2%; median duration of diabetes, 6.3 years; 42% with macrovascular disease; 59% had undergone metformin monotherapy) were treated and analyzed. The median duration of follow-up was 6.3 years. The primary outcome occurred in 356 of 3023 participants (11.8%) in the linagliptin group and 362 of 3010 (12.0%) in the glimepiride group (HR, 0.98 [95.47% CI, 0.84-1.14]; P < .001 for noninferiority), meeting the noninferiority criterion but not superiority (P = .76). Adverse events occurred in 2822 participants (93.4%) in the linagliptin group and 2856 (94.9%) in the glimepiride group, with 15 participants (0.5%) in the linagliptin group vs 16 (0.5%) in the glimepiride group with adjudicated-confirmed acute pancreatitis. At least 1 episode of hypoglycemic adverse events occurred in 320 (10.6%) participants in the linagliptin group and 1132 (37.7%) in the glimepiride group (HR, 0.23 [95% CI, 0.21-0.26]). CONCLUSIONS AND RELEVANCE Among adults with relatively early type 2 diabetes and elevated cardiovascular risk, the use of linagliptin compared with glimepiride over a median 6.3 years resulted in a noninferior risk of a composite cardiovascular outcome. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01243424.
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Affiliation(s)
- Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas
| | - Steven E. Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System, Seattle, Washington
- University of Washington, Seattle
| | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
- Division of Endocrinology, University of Toronto, Toronto, Canada
| | - Mark A. Espeland
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - Egon Pfarr
- Boehringer Ingelheim International GmbH & Co KG, Ingelheim, Germany
| | - Annett Keller
- Boehringer Ingelheim International GmbH & Co KG, Ingelheim, Germany
| | | | | | - Thomas Meinicke
- Boehringer Ingelheim International GmbH & Co KG, Biberach, Germany
| | | | | | | | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Germany
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Arps K, Pallazola VA, Cardoso R, Meyer J, Jones R, Latina J, Gluckman TJ, Stone NJ, Blumenthal RS, McEvoy JW. Clinician's Guide to the Updated ABCs of Cardiovascular Disease Prevention: A Review Part 2. Am J Med 2019; 132:e599-e609. [PMID: 30716297 DOI: 10.1016/j.amjmed.2019.01.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 01/23/2019] [Accepted: 01/23/2019] [Indexed: 12/11/2022]
Abstract
Efforts to better control risk factors for cardiovascular disease and prevent the development of subsequent cardiovascular events are crucial to maintaining healthy populations. In today's busy practice environment and with the overwhelming pace of new research findings, ensuring appropriate emphasis and implementation of evidence-based preventive cardiovascular care can be challenging. The ABCDEF approach to cardiovascular disease prevention is intended to improve dissemination of contemporary best practices and ease the implementation of comprehensive preventive strategies for clinicians. This review serves as a succinct yet authoritative overview for interested internists as well as for cardiologists not otherwise focused on cardiovascular disease prevention. The goal of this 2-part series is to compile a state-of-the-art list of elements central to primary and secondary prevention of cardiovascular disease, using an ABCDEF checklist. In Part 2, we review new recommendations about lipid-modifying strategies, contemporary best practice for tobacco cessation, new evidence related to cardiovascular risk reduction in diabetes using novel therapies, ways to implement a heart-healthy diet, modern interventions to improve physical exercise, and how best to prevent the onset of heart failure.
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Affiliation(s)
- Kelly Arps
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md.
| | - Vincent A Pallazola
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Rhanderson Cardoso
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Joseph Meyer
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Richard Jones
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Jacqueline Latina
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Portland, Ore
| | - Neil J Stone
- Division of Cardiology, Feinberg School of Medicine. Northwestern University, Chicago, Ill
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - John W McEvoy
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md; National Institute for Preventive Cardiology and National University of Ireland, Galway, Ireland
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Athyros VG, Imprialos K, Stavropoulos K, Sahinidis A, Doumas M. Understanding the cardiovascular risk with non-insulin antidiabetic drugs. Expert Opin Drug Saf 2019; 18:241-251. [DOI: 10.1080/14740338.2019.1586881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Vasilios G. Athyros
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Konstantinos Imprialos
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | | | - Alexandros Sahinidis
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
- Department of Internal Medicine, George Washington University, Washington, DC, USA
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Willis M, Asseburg C, Neslusan C. Conducting and interpreting results of network meta-analyses in type 2 diabetes mellitus: A review of network meta-analyses that include sodium glucose co-transporter 2 inhibitors. Diabetes Res Clin Pract 2019; 148:222-233. [PMID: 30641163 DOI: 10.1016/j.diabres.2019.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 12/04/2018] [Accepted: 01/04/2019] [Indexed: 11/27/2022]
Abstract
AIMS Network meta-analyses (NMAs) are valuable ways to generate comparative effectiveness data for therapies available to treat type 2 diabetes mellitus (T2DM). This review assesses NMAs that evaluate sodium glucose co-transporter 2 (SGLT2) inhibitors for treatment of T2DM and discusses potential issues in conducting and interpreting NMAs. METHODS A systematic literature search was conducted on September 13, 2018 using the search terms "network meta-analysis," "SGLT2," variations of these terms, and individual SGLT2 inhibitor names. Extracted data included NMA objectives, methods, target populations, treatments, study endpoints, length of follow-up, and funding. Differences between NMAs were investigated. RESULTS Thirty-five full-length publications met criteria for inclusion. In most NMAs, the target population was defined by therapeutic regimen (e.g., combination with metformin). Follow-up intervals permitted in NMAs varied considerably (range, 4-208 weeks). Twenty-nine NMAs included dapagliflozin, 28 evaluated canagliflozin, and 27 evaluated empagliflozin. Nine NMAs used frequentist methods; 16 used Bayesian methods. Six NMAs were funded by pharmaceutical manufacturers. Heterogeneity across NMAs was seen in scope, time frame, and other aspects of analytic design. CONCLUSIONS Although this review indicates that methodological guidelines for reporting NMAs were generally followed, it also emphasizes the need for T2DM-specific guidance requiring clear reporting of NMA scope and objectives to aid appropriate interpretation and use of NMA results.
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Affiliation(s)
- Michael Willis
- The Swedish Institute for Health Economics, Box 2127, Lund 220 02, Sweden.
| | - Christian Asseburg
- The Swedish Institute for Health Economics, Box 2127, Lund 220 02, Sweden.
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Reiff S, Fava S. All-cause mortality in patients on sulphonylurea monotherapy compared to metformin monotherapy in a nation-wide cohort. Diabetes Res Clin Pract 2019; 147:62-66. [PMID: 30389623 DOI: 10.1016/j.diabres.2018.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/26/2018] [Accepted: 10/23/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Type 2 diabetes is associated with increased mortality. There is some data that sulphonylurea therapy may contribute to this. AIMS To compare all-cause 3-year mortality of patients on sulphonylurea monotherapy to that of patients on metformin monotherapy after adjusting for potential confounders. METHODS We searched the Maltese national electronic database for diabetes treatment in April 2014. This is an electronic database of all treatment that patients are prescribed through the local National Health Service. We identified patients on metformin or sulphonylurea monotherapy and linked this to the national mortality database and the laboratory information system. RESULTS There were 25,792 persons who were on treatment for diabetes in April 2014. Of these, 9977 were on metformin monotherapy and 1717 on sulphonylurea monotherapy. This cohort was followed up until April 2017. There were 2518 deaths (9.76%) during this period, giving an average of 32.5 deaths per 1000 persons with diabetes. Logistic regression showed that persons on sulphonylurea monotherapy were 2.03 (95% CI 1.68-2.44, p < .001) times more likely to die within 3 years than persons on metformin monotherapy, after adjusting for age, eGFR and HbA1c. The logistic regression model was statistically significant, p < .001. Additional adjustment for LDL-cholesterol, HDL-cholesterol and urinary albumin-creatinine ratio did not alter the results. CONCLUSION Our data shows that sulphonylurea monotherapy is associated with higher all-cause mortality when compared to metformin monotherapy after adjusting for potential confounders.
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Affiliation(s)
| | - Stephen Fava
- Diabetes & Endocrine Centre, Mater Dei Hospital, Malta; University of Malta, Malta.
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Bailey CJ, Marx N. Cardiovascular protection in type 2 diabetes: Insights from recent outcome trials. Diabetes Obes Metab 2019; 21:3-14. [PMID: 30091169 DOI: 10.1111/dom.13492] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 07/29/2018] [Accepted: 08/04/2018] [Indexed: 02/06/2023]
Abstract
This review examines recent randomized controlled cardiovascular (CV) outcome trials of glucose-lowering therapies in type 2 diabetes and their impact on the treatment of patients with type 2 diabetes. The trials were designed to comply with regulatory requirements to confirm that major adverse cardiac events (MACE) are not detrimentally affected by such therapies. Trials involving dipeptidyl peptidase-4 (DPP-4) inhibitors did not alter a composite MACE outcome comprising CV deaths, non-fatal myocardial infarction and non-fatal stroke; however, the possibility that some members of this class might incur a small increased risk or worsening of heart failure cannot be excluded. Some studies on glucagon-like peptide-1 receptor agonists (liraglutide: LEADER trial; semaglutide: SUSTAIN-6 trial) found significant benefits for MACE, while treatment with sodium-glucose co-transporter-2 inhibitors (empagliflozin: EMPA-REG OUTCOME trial; canagliflozin: CANVAS trial) also significantly reduced MACE and reduced hospitalization for heart failure. Comparisons among trials are complicated by variance in the populations recruited, particularly CV status at randomization, and differences in trial design, data collection and analyses. A large proportion of patients recruited into these trials have previously experienced adverse CV events; thus, the therapies are mostly assessing secondary prevention of a further event. This contrasts with the overall type 2 diabetes population receiving glucose-lowering therapies, of whom the majority will not have had MACE and will be regarded as primary prevention. Overall, the trials provide reassuring evidence that new glucose-lowering medications do not adversely affect CV events and some of these agents may offer CV protection.
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Affiliation(s)
- Clifford J Bailey
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Nikolaus Marx
- Department of Internal Medicine I, RWTH Aachen University, Aachen, Germany
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Rodrigues Junior L, Duque A, Massolar C, Rocha C, Da Rocha AM, Moreira RA. Carqueja (Baccharis trimera) essential oil chronic treatment induces ventricular repolarization disorder in healthy rats but not in type 2 diabetic rats. Pharmacognosy Res 2019. [DOI: 10.4103/pr.pr_54_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Khunti K, Chatterjee S, Gerstein HC, Zoungas S, Davies MJ. Do sulphonylureas still have a place in clinical practice? Lancet Diabetes Endocrinol 2018; 6:821-832. [PMID: 29501322 DOI: 10.1016/s2213-8587(18)30025-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/19/2017] [Accepted: 12/19/2017] [Indexed: 12/11/2022]
Abstract
Sulphonylureas have been commercially available since the 1950s, but their use continues to be associated with controversy. Although adverse cardiovascular outcomes in some observational studies have raised concerns about sulphonylureas, findings from relatively recent, robust, and high-quality systematic reviews have indicated no increased risk of all-cause mortality associated with sulphonylureas compared with other active treatments. Results from large, multicentre, randomised controlled trials such as the UK Prospective Diabetes Study and ADVANCE have confirmed the microvascular benefits of sulphonylureas, a reduction in the incidence or worsening of nephropathy and retinopathy, and no increase in all-cause mortality, although whether these benefits were due to sulphonylurea therapy and not an overall glucose-lowering effect could not be confirmed. A comparison of sulphonylureas and pioglitazone in the TOSCA.IT trial also confirmed the efficacy and cardiovascular safety of sulphonylureas. Investigators of randomised controlled trials have reported an increased risk of hypoglycaemia and weight gain with sulphonylureas, but data from observational studies suggest that the incidence of severe hypoglycaemia is lower in people taking sulphonylurea than in people taking insulin, and weight gain with sulphonylureas has been relatively modest in large cohort studies. 80% of people with diabetes live in low-to-middle income countries, so the effectiveness, affordability, and safety of sulphonylureas are particularly important considerations when prescribing glucose-lowering therapy. Results of ongoing head-to-head studies with new drugs, such as the comparison of glimepiride with linagliptin in the CAROLINA study and the comparison of various therapies (including sulphonylureas) for glycaemic control in the GRADE study, will determine the place of sulphonylureas in glucose-lowering therapy algorithms for patients with type 2 diabetes.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK.
| | - Sudesna Chatterjee
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Hertzel C Gerstein
- Population Health Research Institute, McMaster University, ON, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton Health Sciences, McMaster University, ON, Canada
| | - Sophia Zoungas
- Division of Metabolism, Ageing and Genomics, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; The George Institute for Global Health, Sydney, NSW, Australia
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
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Humphrey LL, Kansagara D, Qaseem A, Centor R, DeLong DM, Gantzer HE, Horwitch CA, Jokela JA, Li JMW, Lohr RH, López AM, McLean RM. World Health Organization Guidelines on Medicines for Diabetes Treatment Intensification: Commentary From the American College of Physicians High Value Care Committee. Ann Intern Med 2018; 169:398-400. [PMID: 30178054 DOI: 10.7326/m18-1148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Devan Kansagara
- Oregon Health & Science University and Veterans Affairs Medical Center, Portland, Oregon (D.K.)
| | - Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q.)
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Scheen AJ. Cardiovascular safety of DPP-4 inhibitors compared with sulphonylureas: Results of randomized controlled trials and observational studies. DIABETES & METABOLISM 2018; 44:386-392. [PMID: 30126735 DOI: 10.1016/j.diabet.2018.05.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/03/2018] [Accepted: 05/23/2018] [Indexed: 02/07/2023]
Abstract
After failure of metformin monotherapy, another glucose-lowering agent should be added to improve glucose control. The clinician has several pharmacological choices, including the addition of a sulphonylurea (SU) or a dipeptidyl peptidase-4 inhibitor (DPP-4i). While the cardiovascular safety of SUs remains a matter of controversy, DPP-4is have proven their non-inferiority vs placebo in recent cardiovascular (CV) outcome trials. In the absence of a head-to-head CV outcome trial-the CAROLINA, comparing linagliptin with glimepiride, is still ongoing-only indirect information can be found in the literature to compare CV outcomes (major CV events, myocardial infarction, ischaemic stroke, CV death and all-cause mortality) in patients with type 2 diabetes mellitus (T2DM) treated with SUs or DPP-4is. Thus, this comprehensive review summarizes the CV outcomes (excluding heart failure) reported in meta-analyses of randomized controlled trials (RCTs) of SUs vs placebo or other glucose-lowering agents, DPP-4is vs placebo or other glucose-lowering agents and SUs vs DPP-4is in phase-II/III studies. Also, the results of observational studies reporting CV events in patients treated with either SUs or DPP-4is have been carefully examined. Overall, the CV safety of SUs appears to be poorer than that of DPP-4is in both RCTs and cohort studies. However, the results are somewhat disparate, and such heterogeneity may be explained by different patient characteristics across studies, but also perhaps by differences between various molecules in each pharmacological class. In particular, some doubt about a class effect affecting SU CV safety has been raised. The results of CAROLINA are expected to shed more light on SU CV concerns, especially compared with DPP-4is.
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Affiliation(s)
- A J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
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Abstract
PURPOSE OF REVIEW Although intensive control of hyperglycemia has been proven to decrease the risk of microvascular complications in type 2 diabetes, it has had little apparent effect on reducing cardiovascular complications - the leading cause of mortality in this disease. We review the cardiovascular effects of various glucose-lowering medications, with a particular focus on the recent studies demonstrating clear benefits from members of several drug categories. RECENT FINDINGS Recently, several randomized controlled studies have revealed significant improvements in cardiovascular outcomes from a thiazolidinedione, two sodium-glucose cotransporter 2 inhibitors and two glucagon-like peptide 1 receptor agonists. SUMMARY These data suggest that certain glucose lowering agents after metformin should be favored in type 2 diabetes mellitus patients when there is underlying cardiovascular disease.
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Affiliation(s)
- Beatrice C Lupsa
- Section of Endocrinology, Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut, USA
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69
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Leonard CE, Brensinger CM, Aquilante CL, Bilker WB, Boudreau DM, Deo R, Flory JH, Gagne JJ, Mangaali MJ, Hennessy S. Comparative Safety of Sulfonylureas and the Risk of Sudden Cardiac Arrest and Ventricular Arrhythmia. Diabetes Care 2018; 41:713-722. [PMID: 29437823 PMCID: PMC5860838 DOI: 10.2337/dc17-0294] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 11/18/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To examine the association between individual antidiabetic sulfonylureas and outpatient-originating sudden cardiac arrest and ventricular arrhythmia (SCA/VA). RESEARCH DESIGN AND METHODS We conducted a retrospective cohort study using 1999-2010 U.S. Medicaid claims from five large states. Exposures were determined by incident use of glyburide, glimepiride, or glipizide. Glipizide served as the reference exposure, as its effects are believed to be highly pancreas specific. Outcomes were ascertained by a validated ICD-9-based algorithm indicative of SCA/VA (positive predictive value ∼85%). Potential confounding was addressed by adjustment for multinomial high-dimensional propensity scores included as continuous variables in a Cox proportional hazards model. RESULTS Of sulfonylurea users under study (N = 519,272), 60.3% were female and 34.9% non-Hispanic Caucasian, and the median age was 58.0 years. In 176,889 person-years of sulfonylurea exposure, we identified 632 SCA/VA events (50.5% were immediately fatal) for a crude incidence rate of 3.6 per 1,000 person-years. Compared with glipizide, propensity score-adjusted hazard ratios for SCA/VA were 0.82 (95% CI 0.69-0.98) for glyburide and 1.10 (0.89-1.36) for glimepiride. Numerous secondary analyses showed a very similar effect estimate for glyburide; yet, not all CIs excluded the null. CONCLUSIONS Glyburide may be associated with a lower risk of SCA/VA than glipizide, consistent with a very small clinical trial suggesting that glyburide may reduce ventricular tachycardia and isolated ventricular premature complexes. This potential benefit must be contextualized by considering putative effects of different sulfonylureas on other cardiovascular end points, cerebrovascular end points, all-cause death, and hypoglycemia.
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Affiliation(s)
- Charles E Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Colleen M Brensinger
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Christina L Aquilante
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Warren B Bilker
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Neuropsychiatry Section, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle, WA.,Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
| | - Rajat Deo
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James H Flory
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Division of Comparative Effectiveness, Department of Healthcare Policy and Research, Weill Cornell Medical Center, Cornell University, New York, NY.,Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Margaret J Mangaali
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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70
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Kelly EM, Cutlip DE. Diabetes Drugs and Cardiovascular Event Reduction: A Paradigm Shift. US CARDIOLOGY REVIEW 2018. [DOI: 10.15420/usc.2017:35:1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This review article summarizes the recent cardiovascular outcome data for sodium–glucose cotransporter-2 inhibitors and glucagon-like peptide-1 analogues, which have been found to reduce cardiovascular events. We also detail the implications these new medications will have on clinical practice through a review of recent diabetes guidelines and cost-effectiveness data.
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71
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Pearson ER. Pharmacogenetics and target identification in diabetes. Curr Opin Genet Dev 2018; 50:68-73. [PMID: 29486427 DOI: 10.1016/j.gde.2018.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 02/11/2018] [Accepted: 02/12/2018] [Indexed: 11/18/2022]
Abstract
In diabetes, pharmacogenetics can be used both to identify patient subgroups who will have most benefit and/or least harm from a particularly treatment, and to gain insights into the molecular mechanisms of drug action and disease aetiology. There is increasing evidence that genetic variation alters response to diabetes treatments-both in terms of glycaemic response and side effects. This can be seen with dramatic impact on clinical care, in patients with genetic forms of diabetes such as Maturity Onset Diabetes of the Young caused by HNF1A mutations, and Neonatal diabetes due to activating mutations in ABCC8 or KCNJ11. Beyond monogenic diabetes, pharmacogenetic variants have yet to impact on clinical practice, yet the effect sizes (e.g. for metformin intolerance and OCT1 variants; or for metformin action and SLC2A2 variants) are potentially of clinical utility, especially if the genotype is already known at the point of prescribing. Over the next few years, increasing cohort sizes and linkage at scale to electronic medical records will provide considerable potential for stratification and novel target identification in diabetes.
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MESH Headings
- Diabetes Mellitus, Type 2/drug therapy
- Diabetes Mellitus, Type 2/genetics
- Diabetes Mellitus, Type 2/pathology
- Genotype
- Glucose Transporter Type 2/genetics
- Hepatocyte Nuclear Factor 1-alpha/genetics
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/drug therapy
- Infant, Newborn, Diseases/genetics
- Infant, Newborn, Diseases/pathology
- Metformin/adverse effects
- Metformin/therapeutic use
- Octamer Transcription Factor-1/genetics
- Pharmacogenetics
- Potassium Channels, Inwardly Rectifying/genetics
- Sulfonylurea Receptors/genetics
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Affiliation(s)
- Ewan R Pearson
- Division of Molecular & Clinical Medicine, School of Medicine, University of Dundee, Dundee DD1 9SY, United Kingdom.
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72
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Evans M, Kozlovski P, Paldánius PM, Foley JE, Bhosekar V, Serban C, Avogaro A. Factors that may Account for Cardiovascular Risk Reduction with a Dipeptidyl Peptidase-4 Inhibitor, Vildagliptin, in Young Patients with Type 2 Diabetes Mellitus. Diabetes Ther 2018; 9:27-36. [PMID: 29134608 PMCID: PMC5801217 DOI: 10.1007/s13300-017-0329-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION In a meta-analysis, we observed a significant 37% relative risk reduction in prospectively adjudicated major adverse cardiac events [MACEs, comprising of non-fatal myocardial infarction, non-fatal stroke, cardiovascular (CV) death] with vildagliptin vs. comparators in younger (< 65 years) patients with type 2 diabetes mellitus (T2DM), while the risk was similar in older patients (≥ 65 years). We carried out an exploratory analysis to identify the patient characteristics and on-treatment effects that may have contributed to the different outcomes in the two age groups. METHODS On-treatment differences (vildagliptin vs. comparators) for the change from baseline in CV risk factors were analyzed using an analysis of covariance model with the baseline value for each variable of interest, treatment and study as covariates. Additional adjustments for background antihypertensive and statin use were performed when analyzing changes in blood pressure and lipids, respectively. Baseline characteristics and patient demographics were analyzed using descriptive statistics. RESULTS Patients aged < 65 years had shorter diabetes duration (4.4 vs. 8.2 years) and slightly higher glycated hemoglobin (HbA1c) at baseline (8.3% vs. 8.0%) than patients aged ≥ 65 years. More patients in the ≥ 65 year age group had hypertension (73.1% vs. 51.3%), dyslipidemia (53.3% vs. 43.9%) and a history of CV events (32.2% vs. 12.9%). There were small, but statistically significant differences in the change in HbA1c and total cholesterol in favor of vildagliptin relative to comparators, which were similar in both age groups. Significant differences were observed in the reduction in systolic blood pressure (SBP) (- 0.52 mmHg; 95% CI - 0.97, - 0.07; p = 0.023), low-density lipoprotein (LDL cholesterol) (- 0.12 mmol/l; 95% CI - 0.19, - 0.04; p = 0.002) and weight (- 0.48 kg; 95% CI - 0.95, - 0.01; p < 0.047) in patients < 65 years, but not in patients ≥ 65 years. The incidence of hypoglycemic events was lower in patients treated with vildagliptin [2.1 and 3.5 per 100 subject years exposure (SYEs) in < 65 and ≥ 65 years, respectively] than with comparators (5.8 and 7.5 per 100 SYEs, respectively). CONCLUSION Based on our findings, it can be hypothesized that the positive effects of vildagliptin on SBP, LDL cholesterol, hypoglycemia and weight observed in younger, but not in older patients could be associated with the lower risk of MACE in younger patients with T2DM. FUNDING Novartis.
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Affiliation(s)
- Marc Evans
- Diabetes Resource Centre, University Hospital Llandough, Cardiff, UK.
| | | | | | - James E Foley
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | - Angelo Avogaro
- Department of Medicine, University of Padova, Padua, Italy
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74
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Abstract
PURPOSE OF REVIEW Sulfonylureas (SUs) are one of the most commonly used glucose-lowering agents worldwide. While their efficacy is undisputed, their cardiovascular safety has been debated since the 1970's. RECENT FINDINGS With no dedicated cardiovascular studies to definitively answer this question, observational studies and meta-analyses abound and have reported divergent results, fueling the controversy. Studies that compared SUs to metformin or newer agents, like GLP-1 agonists and SGLT2 inhibitors, suggest a difference in cardiovascular events, yet this is likely the result of beneficial effects of the latter. Studies comparing SUs to other agents have been reassuring. SUs remain a common choice of treatment for patients with type 2 diabetes due to their exceptional value. They are effective at lowering glucose and thus contributing to the prevention of microvascular complications. Weight gain and hypoglycemia are their main side effects, although less severe when compared to insulin treatment. Their cardiovascular safety will remain a controversial topic due to lack of conclusive data, but there is no definitive evidence of harm with the second-generation agents.
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Affiliation(s)
- Laurentiu M Pop
- Department of Internal Medicine, Division of Endocrinology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ildiko Lingvay
- Department of Internal Medicine, Division of Endocrinology, UT Southwestern Medical Center, Dallas, TX, USA.
- Department of Clinical Science, UT Southwestern Medical Center, 5323 Harry Hines Blvd, U9.134C, Dallas, TX, 75390-9302, USA.
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75
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Sattar N, Petrie MC, Zinman B, Januzzi JL. Novel Diabetes Drugs and the Cardiovascular Specialist. J Am Coll Cardiol 2017; 69:2646-2656. [PMID: 28545639 DOI: 10.1016/j.jacc.2017.04.014] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 04/03/2017] [Accepted: 04/03/2017] [Indexed: 12/12/2022]
Abstract
Recently, treatment with 2 newer classes of type 2 diabetes drugs were found to reduce events in patients with diabetes and cardiovascular (CV) disease, a group common in cardiology clinics. The sodium-glucose cotransporter 2 inhibitor, empagliflozin, markedly and rapidly reduced CV death and heart failure hospitalization, likely with hemodynamic/metabolic-driven mechanisms of action. More recently, the glucagon-like peptide-1 receptor agonists liraglutide and semaglutide also reduced CV death and/or major adverse CV events, but did so more slowly and did not influence heart failure risks, suggesting alternative mechanisms of benefit. We will discuss drug therapy for diabetes relative to CV risk, briefly summarize key findings of CV benefit from recent trials, discuss potential mechanisms for benefits of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 agonists, and suggest how such drugs might be embraced by CV specialists to reduce CV events and mortality in their patients.
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Affiliation(s)
- Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Bernard Zinman
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Baim Institute for Clinical Research, Boston, Massachusetts.
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76
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Siegmund T. [Combination of oral antidiabetic drugs: What fits together?]. MMW Fortschr Med 2017; 159:47-52. [PMID: 28718116 DOI: 10.1007/s15006-017-9902-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Thorsten Siegmund
- Diabetes-, Hormon- und Stoffwechselzentrum am Isar Klinikum, München, Innere Wiener Straße 59, D-81667, München, Deutschland.
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77
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Goncalves E, Bell DSH. Glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter-2 inhibitors: Sequential or simultaneous start? Diabetes Obes Metab 2017; 19:909-911. [PMID: 28176440 DOI: 10.1111/dom.12897] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 01/24/2017] [Accepted: 01/29/2017] [Indexed: 02/06/2023]
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78
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Bonnet F, Scheen AJ. Impact of glucose-lowering therapies on risk of stroke in type 2 diabetes. DIABETES & METABOLISM 2017; 43:299-313. [PMID: 28522196 DOI: 10.1016/j.diabet.2017.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 04/21/2017] [Indexed: 02/07/2023]
Abstract
Patients with type 2 diabetes (T2D) have an increased risk of stroke compared with people without diabetes. However, the effects of glucose-lowering drugs on risk of ischaemic stroke in T2D have been less extensively investigated than in coronary heart disease. Some evidence, including the UKPDS, has suggested a reduced risk of stroke with metformin, although the number of studies is limited. Inhibition of the KATP channels increases ischaemic brain lesions in animals. This is in agreement with a recent meta-analysis showing an increased risk of stroke with sulphonylureas vs. various comparators as both mono- and combination therapy. Pioglitazone can prevent recurrence of stroke in patients with previous stroke, as already shown in PROactive, although results are less clear for first strokes. As for DPP-4 inhibitors, there was a non-significant trend towards benefit for stroke, whereas a possible increased risk of stroke with SGLT2 inhibitors-and in particular, empagliflozin in the EMPA-REG OUTCOME trial-has been suggested and requires clarification. Experimental results support a potential protective effect of GLP-1 receptor agonists against stroke that has, at least in part, been translated to clinical benefits in T2D patients in the LEADER and SUSTAIN-6 trials. Further interventional studies are now warranted to confirm the effects of glucose-lowering agents on risk of stroke in patients with T2D. In summary, the effects of antidiabetic drugs on risk of stroke appear to be heterogeneous, with some therapies (pioglitazone, GLP-1 receptor agonists) conferring possible protection against ischaemic stroke, other classes showing a neutral impact (DPP-4 inhibitors, insulin) and some glucose-lowering agents being associated with an increased risk of stroke (sulphonylureas, possibly SGLT2 inhibitors, high-dose insulin in the presence of insulin resistance).
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Affiliation(s)
- F Bonnet
- Centre Hospitalier Universitaire de Rennes, Université Rennes 1, Rennes, France; INSERM U1018, Villejuif, France.
| | - A J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium; Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU, Liège, Belgium
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79
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Zhang Z, Chen X, Lu P, Zhang J, Xu Y, He W, Li M, Zhang S, Jia J, Shao S, Xie J, Yang Y, Yu X. Incretin-based agents in type 2 diabetic patients at cardiovascular risk: compare the effect of GLP-1 agonists and DPP-4 inhibitors on cardiovascular and pancreatic outcomes. Cardiovasc Diabetol 2017; 16:31. [PMID: 28249585 PMCID: PMC5333444 DOI: 10.1186/s12933-017-0512-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 02/21/2017] [Indexed: 02/06/2023] Open
Abstract
Background Incretin-based agents, including dipeptidyl peptidase-4 inhibitors (DPP-4Is) and glucagon-like peptide-1 agonists (GLP-1As), work via GLP-1 receptor for hyperglycemic control directly or indirectly, but have different effect on cardiovascular (CV) outcomes. The present study is to evaluate and compare effects of incretin-based agents on CV and pancreatic outcomes in patients with type 2 diabetes mellitus (T2DM) and high CV risk. Methods Six prospective randomized controlled trials (EXMAINE, SAVOR-TIMI53, TECOS, ELIXA, LEADER and SUSTAIN-6), which included three trials for DPP-4Is and three trials for GLP-1As, with 55,248 participants were selected to assess the effect of different categories of incretin-based agents on death, CV outcomes (CV mortality, major adverse CV events, nonfatal myocardial infarction, nonfatal stroke, heart failure hospitalization), pancreatic events (acute pancreatitis and pancreatic cancer) as well as on hypoglycemia. Results When we evaluated the combined effect of six trials, the results suggested that incretin-based treatment had no significant effect on overall risks of CV and pancreatic outcomes compared with placebo. However, GLP-1As reduced all-cause death (RR = 0.90, 95% CI 0.82–0.98) and CV mortality (RR = 0.84, 95% CI 0.73–0.97), whereas DPP-4Is had no significant effect on CV outcomes but elevated the risk for acute pancreatitis (OR = 1.76, 95% CI 1.14–2.72) and hypoglycemia (both any and severe hypoglycemia), while GLP-1As lowered the risk of severe hypoglycemia. Conclusions GLP-1As decreased risks of all-cause and CV mortality and severe hypoglycemia, whereas DPP-4Is had no effect on CV outcomes but increased risks in acute pancreatitis and hypoglycemia. Electronic supplementary material The online version of this article (doi:10.1186/s12933-017-0512-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zeqing Zhang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Xi Chen
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Puhan Lu
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Jianhua Zhang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Yongping Xu
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Wentao He
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Mengni Li
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Shujun Zhang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Jing Jia
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Shiying Shao
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Junhui Xie
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Yan Yang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Xuefeng Yu
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China.
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