Management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes

Trends in antidiabetic medical treatment from 2005 to 2014 in Taiwan

BACKGROUND/PURPOSE

Several new antidiabetic drugs have been introduced in Taiwan. However, the trends in antidiabetic treatment remain unexamined.

METHODS

We studied data from the Taiwan National Health Insurance Database to identify outpatient prescriptions for antidiabetic drugs from 2005 to 2014. The patterns in antidiabetic treatment and the number of different classes of antidiabetic drugs were analyzed. The proportions of prescriptions of antidiabetic monotherapy, combination therapy, or insulin therapy were further analyzed.

RESULTS

The total and mean prescriptions gradually increased during the study period. Prescription of oral antidiabetic drugs (OADs) only or insulin-only therapy decreased slightly. Prescriptions of monotherapy and dual therapy decreased, whereas those of triple or higher order combinations increased. Prescriptions of sulfonylureas (SUs) decreased, whereas those of metformin and dipeptidyl peptidease-4 (DPP4) inhibitors increased. Insulin prescriptions increased but accounted for only 13.07% of prescriptions in 2014. Among monotherapy prescriptions, SU prescriptions decreased, but metformin and DPP4 inhibitor prescriptions increased. Among dual OAD prescriptions, those including SUs decreased, and those of metformin and DPP4 inhibitors increased. Although prescriptions of the metformin-SU combination decreased, they remained the most common among all dual OAD prescriptions, followed by the metformin-DPP4 inhibitor combination. Prescriptions of human insulin decreased and those of insulin analogs increased considerably; those of basal insulin increased, and those of mixed insulin decreased. However, mixed insulin was prescribed more than basal-bolus insulin.

CONCLUSION

Antidiabetic treatment has become complex in Taiwan. Although combination therapy would become the major treatment strategy gradually, the underuse of insulin therapy must improve.

The determinants of anti-diabetic medication adherence based on the experiences of patients with type 2 diabetes

Background

The purpose of this study is to explain the experiences of patients with type 2 diabetes (T2DM) about medication adherence.

Method

A qualitative content analysis study was conducted at the Institute of Endocrinology and Metabolism Research and Training Center of Firoozgar Academic Hospital, affiliated to Iran University of Medical Sciences in Tehran, Iran during April–June 2017. Twenty-six semi-structured in-depth interviews were conducted with diabetic patients and their families. The participants were asked about their experiences of medication adherence. After the first round of the interviews, content analysis of data started and continued up to the data saturation.

Results

Four main themes including perceived barriers (with 6 subthemes including inadequate knowledge, situational influences, inadequate perceived threat about diabetes, treatment characteristics, personality traits and medication cost), perceived social support (with 3 subthemes including family, doctor and community supports), medication beliefs (with 3 subthemes including belief in the effectiveness of treatment, belief in the more effectiveness of complementary therapies than medication use and prioritizing the use of the pills instead of the insulin injection) and cues to action (with 2 subthemes including internal and external cues to action) emerged as the experiences of the participants in terms of anti-diabetic medications adherence which should be considered in developing medication adherence interventions for the patients with T2DM.

Conclusion

The patients with T2DM had more barriers for regular drugs consumption. They had incorrect beliefs about anti-diabetic drugs. In addition, they were in need of abroad support community, surroundings and also health professionals. Health systems should consider medication adherence training to be added to the treatment protocols of the diabetic patients.

Sustained Release of Exendin 4 Using Injectable and Ionic-Nano-Complex Forming Polymer Hydrogel System for Long-Term Treatment of Type 2 Diabetes Mellitus

Daily treatment of diabetes to stabilize blood glucose level poses a challenge for patients with diabetes mellitus. Diabetes is a long-term metabolic disorder, and the treatment lasts for the rest of the patient's life after diagnosis. We presented a new injectable hydrogel depot system using exendin 4 (Ex-4) interactive and complex forming polymeric ionic-nano-particles for long-term antidiabetes treatment. Protamine-conjugated polymer (ProCP) was developed to form ionic-nano-complexes with Ex-4, as the amino-group-rich protamine and the negatively charged Ex-4 ( pI: 4.86) interact with each other due to their opposite electric charges in physiological conditions. Morphologically, the ProCP were nanoparticles in aqueous condition (10 wt % of ProCP in phosphate-buffered solution, <25 °C) and formed condensed ionic- and nano-complexes with Ex-4. The complexes formed a bulk hydrogel when exposed to body temperature. A slow release of the Ex-4/ProCP ionic-nano-complexes occurred from the hydrogel depot, followed by Ex-4 dissociation from the ionic-nano-complexes and hydrolysis of ProCP. Given that the Ex-4 release occurs after the complex releases from the hydrogel, the periods of Ex-4 release and hydrogel maintenance may be similar. The present system showed a considerably prolonged Ex-4 release. Additionally, it showed potential as a long-term effective and reproducible antidiabetes treatment.

Targeted learning with daily EHR data

Electronic health records (EHR) data provide a cost- and time-effective opportunity to conduct cohort studies of the effects of multiple time-point interventions in the diverse patient population found in real-world clinical settings. Because the computational cost of analyzing EHR data at daily (or more granular) scale can be quite high, a pragmatic approach has been to partition the follow-up into coarser intervals of pre-specified length (eg, quarterly or monthly intervals). The feasibility and practical impact of analyzing EHR data at a granular scale has not been previously evaluated. We start filling these gaps by leveraging large-scale EHR data from a diabetes study to develop a scalable targeted learning approach that allows analyses with small intervals. We then study the practical effects of selecting different coarsening intervals on inferences by reanalyzing data from the same large-scale pool of patients. Specifically, we map daily EHR data into four analytic datasets using 90-, 30-, 15-, and 5-day intervals. We apply a semiparametric and doubly robust estimation approach, the longitudinal Targeted Minimum Loss-Based Estimation (TMLE), to estimate the causal effects of four dynamic treatment rules with each dataset, and compare the resulting inferences. To overcome the computational challenges presented by the size of these data, we propose a novel TMLE implementation, the "long-format TMLE," and rely on the latest advances in scalable data-adaptive machine-learning software, xgboost and h2o, for estimation of the TMLE nuisance parameters.

Metformin was associated with lower all-cause mortality in type 2 diabetes with acute coronary syndrome: A Nationwide registry with propensity score-matched analysis

BACKGROUND

No randomized controlled trials evaluating metformin therapy efficacy in patients with type 2 diabetes mellitus (DM) and acute coronary syndrome (ACS) have been reported. We aimed to examine the mortality benefit of metformin therapy in patients with type 2 DM and ACS, compared with non-metformin anti-diabetes agents users.

METHODS

Data were extracted from the prospective nationwide ACS-DM Taiwan Society of Cardiology registry. Propensity score (PS) matching on baseline characteristics and treatment measures was performed for metformin versus non-metformin users. The Cox proportional hazards model was used to compare mortality outcomes among the PS-matched cohort as the primary analysis. The Cox proportional hazards models adjusting for all pre-determined covariates and quintiles of the PS among the overall population were performed as the secondary analyses.

RESULTS

Of 1157 patients with type 2 DM and ACS receiving anti-diabetes agents, 78 patients (6.7%) died over the 2-year follow-up period. After PS matching, 318 metformin users were matched with 318 non-metformin users. Metformin users had a lower all-cause mortality rate (adjusted hazard ratio [aHR] 0.50, 95% confidence interval [CI] 0.26-0.95) in the primary analysis. The survival benefit of metformin therapy was consistent in the secondary analyses (aHR 0.30, 95% CI 0.17-0.54 while adjusting for all pre-determined covariates, and aHR 0.34, 95% CI 0.19-0.59 while adjusting for quintiles of the PS).

CONCLUSIONS

Among patients with type 2 DM and ACS, metformin was associated with lower all-cause mortality. However, a detrimental effect of any of the comparators could not be excluded.

The impact of major dietary patterns on glycemic control, cardiovascular risk factors, and weight loss in patients with type 2 diabetes: A network meta-analysis

OBJECTIVE

To comprehensively compare the differences between major dietary patterns in improving glycemic control, cardiovascular risk, and weight loss for patients with type 2 diabetes.

METHOD

We systematically searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomized controlled trials (RCTs) that compared the efficacy of Mediterranean, low-carbohydrate, and/or low-fat dietary patterns for patients with type 2 diabetes. Studies that compared any one of those diets with regular diet were also included. The risk of bias in eligible RCTs was evaluated according to the Cochrane Handbook. The primary outcome was glycemic control. Secondary outcomes included weight loss and cardiovascular risk factors. A network meta-analysis was performed using R-3.3.2.

RESULTS

Ten RCTs involving five dietary patterns met the eligibility criteria. The findings revealed that compared to low-fat diet, Mediterranean diet showed beneficial effects in glycemic control (HbA1c [%]: MD = -0.45, 95% CI = -0.55 to -0.34; fasting plasma glucose [mmol/L]: MD = -1.24 95% CI = -1.57 to -0.91, respectively; weight loss [kg]: MD =-1.18, 95% CI = -1.99 to -0.37; waist circumference [cm]: MD = -0.73, 95% CI = -1.26 to -0.19), and cardiovascular risk factors (HDL-cholesterol [mmol/L]: MD = 0.07, 95% CI = 0.04 to 0.11; total cholesterol [mmol/L]: MD = -0.17, 95% CI = -0.26 to -0.08; triglycerides [mmol/L]: MD = -0.21, 95% CI = -0.27 to -0.16). Network meta-analysis showed that high-carbohydrate diet improved HDL-cholesterol (mmol/l) (MD = 1.04, 95% CI = 0.39 to 1.68) when compared with regular diet. The differences were not statistically significant in other indirect comparison groups for other outcomes.

CONCLUSIONS

A mediterranean diet showed beneficial improvements in glycemic control, weight loss, and cardiovascular risk factors in people with type 2 diabetes.

Variability in the therapeutic response of Metformin treatment in patients with type 2 diabetes mellitus

Objective

To assess the glycemic response of metformin in patients with Type-2 Diabetes Mellitus (T2DM) as well as to see its association with reductions in BMI and GIT intolerance.

Methods

This Quasi, Experimental study was conducted at Jinnah-Allama Iqbal Institute of Diabetes and Endocrinology (JAIDE) Jinnah Hospital, Lahore from 1^st March 2016 to 30^th September 2016. Newly diagnosed T2DM patients were given metformin for duration of three months and later on they were categorized into Responders and Non-Responders on the basis of HbA1c (A1C) reductions, which were estimated by Hemoglobin (A1C) analyzer (TD4611A TAIDoc Tech. Taiwan) through photometry. Similarly, baseline BMI and BMI after three months therapy with metformin was also recorded.

Results

Among total of 200 patients, 40.5% of the patients were classified as Non-Responders whereas; 59.5% of the patients as Responders. The baseline BMI (26.09 kg/m²) was also decreased significantly after metformin therapy (25.40 kg/m²). It was found that metformin reduced the A1C in all the patients. However, the glycemic control was much better in patients with higher baseline A1C (1.13% ± 0.08) as compared to lower baseline levels (0.61% ± 0.07). Regarding GIT intolerance, 140 patients lacked the symptoms, out of which 60.7% were responders and 39.3% were non-responders.

Conclusions

Metformin lead to improvement in glycemic control in 59.5% of newly diagnosed T2DM patients after taking metformin for three months but in 40.5% it did not which may be because of combined effects of various gene polymorphisms and their interaction with non-genetic factors. Metformin reduced the BMI in all the patients; however, BMI lowering activity of metformin was same regardless of its effect on HbA1C. Moreover, the signs and symptoms of GIT intolerance did not differ between the two groups.

Glucose Response during the Night Is Suppressed by Wheat Albumin in Healthy Participants: A Randomized Controlled Trial

Postprandial blood glucose excursions are important for achieving optimal glycemic control. In normal-weight individuals, glucose tolerance is diminished in the evening compared to glucose tolerance in the morning. Wheat albumin (WA) has the potential to suppress the postprandial glucose response with a relatively small dose, compared to the dose required when using dietary fiber. In the present study, the effect of WA on glycemic control during the night was investigated after a late evening meal. A randomly assigned crossover trial involving a single oral ingestion in healthy male participants was performed in a double-blind placebo-controlled manner. The participants ingested the placebo (PL) tablets or the WA (1.5 g)-containing tablets 3 min before an evening meal at 22:00 hour, and blood samples were drawn during the night until 07:00 hour using an intravenous cannula. The participants slept from 00:30 hour to 06:30 hour. Glucose response, as a primary outcome during the night, was suppressed significantly by the WA treatment compared to the PL treatment, but the insulin response was not. Plasma glucose-dependent insulinotropic polypeptide concentration during the night was lowered significantly by the WA treatment compared to the PL treatment. In conclusion, WA may be a useful food constituent for glycemic control during the night.

No Effect of Plazomicin on the Pharmacokinetics of Metformin in Healthy Subjects

Plazomicin is an aminoglycoside that was engineered to overcome aminoglycoside-modifying enzymes, which are the most common aminoglycoside resistance mechanism in Enterobacteriaceae. Because plazomicin is predominantly eliminated via renal pathways, an in vitro study was conducted to determine whether plazomicin inhibits the organic cation transporter 2 (OCT2) and the multidrug and toxin extrusion (MATE1 and MATE2-K) transporters, using metformin as a probe substrate. Plazomicin inhibited OCT2, MATE1, and MATE2-K transporters with half-maximal inhibition of the transporter values of 5120, 1300, and 338 µg/mL, respectively. To determine whether this in vitro inhibition translates in vivo, an open-label, randomized, 2-period, 2-treatment crossover study (NCT03270553) was carried out in healthy subjects (N = 16), who received a single oral dose of metformin 850 mg alone and in combination with a single intravenous infusion of plazomicin 15 mg/kg. Geometric least-squares mean ratios of the test treatment (combination) vs the reference treatment (metformin alone) and 90% confidence intervals were within the equivalence interval of 80% to 125% (peak plasma concentration, 104.5 [95.1-114.9]; area under the plasma concentration-time curve from time zero to time of last quantifiable concentration, 103.7 [93.5-115.0]; area under the plasma concentration-time curve from time zero to infinity, 104.0 [94.2-114.8]). The results demonstrate that there is no clinically significant drug-drug interaction resulting from coadministration of single doses of intravenous plazomicin 15 mg/kg and oral metformin 850 mg in healthy subjects. Coadministration of plazomicin and metformin was well tolerated in healthy subjects.

Implications of Removing Rosiglitazone's Black Box Warning and Restricted Access Program on the Uptake of Thiazolidinediones and Dipeptidyl Peptidase-4 Inhibitors Among Patients with Type 2 Diabetes

BACKGROUND

Medications are increasingly being approved with limited, short-term evidence regarding safety. Regulatory safety concerns may emerge for these drugs but later may be reversed if additional evidence suggests no warning is indicated.

OBJECTIVE

To describe trends over time in the initiation of rosiglitazone and pioglitazone-both in the thiazolidinedione (TZD) class-and medications from the dipeptidyl peptidase-4 (DPP-4) inhibitor class before and after the FDA removed a black box warning and restricted access program for rosiglitazone regarding an increased risk of myocardial infarction.

METHODS

This retrospective study evaluated initiation of TZDs and DPP-4 inhibitors using 2001-2015 administrative claims data from a U.S. commercially insured population. Patients were aged 18-64 years and were new users of either a TZD or DPP-4 inhibitor. Among all patients who were new users of either a TZD or a DPP-4 inhibitor during each quarter-year (Q), the percentage of patients who initiated rosiglitazone, pioglitazone, and DPP-4 inhibitors were calculated.

RESULTS

There were 630,977 patients eligible for the study. During 2007, rosiglitazone initiators decreased from 39.1% to 8.0% in 2007 Q4 when the black box warning was implemented. During 2010, rosiglitazone initiators decreased from 7.6% to 1.0%, as safety evidence accumulated and the restricted access program requirement was announced. Rosiglitazone initiation remained below 1.0%, even after regulatory restrictions were removed in November 2013. Pioglitazone initiation decreased from 46.4% in 2010 Q1 to 14.8% in 2011 Q4 and remained relatively constant between 14.5% and 17.8% after regulatory restrictions for rosiglitazone were removed. After DPP-4 inhibitors first became available in 2006 Q3, initiation of this medication class increased rapidly, stayed relatively constant between 42.8% and 45.5% in 2009, and then quickly rose and remained above 80% from 2012 through 2015.

CONCLUSIONS

This case study provides some evidence that adding and later reversing drug safety warnings-particularly those with restricted access requirements-may affect the uptake of the targeted product into the population when multiple clinically relevant treatment alternatives are available (such as type 2 diabetes). Once a treatment falls out of favor, removal of safety warnings and/or restricted access programs may not lead to increased use.

DISCLOSURES

This project was not directly supported by any funding. Hickson was supported by the National Heart, Lung, and Blood Institute through a National Research Service Award (NRSA) training grant (4T32HL007055-41) as a postdoctoral research fellow with the Cardiovascular Disease Epidemiology Program at The University of North Carolina at Chapel Hill (UNC-CH). Cole was supported by a NRSA Predoctoral Traineeship from the Agency for Healthcare Research and Quality sponsored by The Cecil G. Sheps Center for Health Services Research, UNC-CH (grant no. T32-HS000032) and a predoctoral fellowship from the American Foundation for Pharmaceutical Education. Unrelated to this project, Cole was a part-time employee of Truven Health Analytics/IBM Watson Health. Dusetzina has nothing to disclose.

Evaluation and Perioperative Management of the Diabetic Patient

Diabetes mellitus is a devastating disease that has reached epidemic proportions. The surgical patient with diabetes is at increased risk for developing complications when compared with patients without diabetes. A comprehensive preoperative work-up must be performed, including ancillary studies, with optimization of the patient's glucose levels during the perioperative period to decrease the chance of developing surgical complications. A multispecialty team approach for the care of patients with diabetes should be used to produce successful surgical outcomes.

Sodium Glucose Co-transporter-2 Inhibitor: Benefits beyond Glycemic Control

Type 2 diabetes mellitus (T2DM) is a family of metabolic disorders characterized by hyperglycemia as a consequence of abnormalities in insulin secretion and insulin sensitivity. It affects hundreds of millions of people worldwide and leads to increased morbidity, compromised quality of life, higher mortality sodium glucose co-transporter 2 (SGLT2) inhibitors, a new class of oral antidiabetic drugs, have garnered considerable attention in the recent past and are considered potential first-line candidates for the management of T2DM. This review outlines the evidence-based therapeutic efficacy, safety, limitations, and advantages of SGLT2 inhibitors in the management of T2DM. SGLT2 inhibitors work by preventing the kidneys from reabsorbing glucose back into the blood, leading to increase in excretion of glucose through urine, thereby lowering hyperglycemia. Treatment with SGLT2 inhibitors improves A1C levels, reduces blood pressure and body weight, and is overall well tolerated by patients with T2DM. However, additional data on long-term cardiovascular safety are still needed. Characteristic adverse events include mild genital - urinary tract infection more commonly seen in women than in men, but serious infection is uncommon. Their use should be exercised with extra caution in patients suffering from renal impairment. Further, advancing to dual/triple combinational therapies with SGLT2 inhibitors and existing oral antidiabetic options may prove to be a breakthrough in the management of T2DM.

The Intersection of Diabetes and Cardiovascular Disease-A Focus on New Therapies

Diabetes is a leading cause of cardiovascular disease and its associated morbidity. While the medical community has had access to numerous glucose lowering therapies over the last decades, it was not until recently that newer agents demonstrated improvement in cardiovascular outcomes. In particular, diabetes care and management of its attendant cardiovascular risk is now being revolutionized with the development and provision of the SGLT-2 inhibitors and GLP1-receptor agonists. Given the exciting data with these new classes of diabetes therapeutics, there is a clear need to improve education and utilization of these evidence-based medications across a wide spectrum of clinicians, including cardiologists. The aim of this review is to familiarize the cardiovascular specialist with the benefits and harms of the most commonly used oral anti- hyperglycemic medications, with an emphasis on SGLT-2 inhibitors and GLP-1 receptor agonists.

Dapagliflozin attenuates early markers of diabetic nephropathy in fructose-streptozotocin-induced diabetes in rats

Early detection and clinical interference are major challenges for the prevention of diabetic nephropathy (DN) progression. This study investigated the effects of dapagliflozin, a sodium glucose co-transporter 2 inhibitor, on some early markers for DN in fructose-streptozotocin (Fr-STZ)-induced diabetes in rats. Fr-STZ rats were treated with either dapagliflozin (1 mg/kg p.o. daily), metformin (350 mg/kg p.o. daily), or their combination for 6 weeks. Fr-STZ rats displayed marked early tubular renal damage and glomerular podocyte injury as evidenced by renal KIM-1, NGAL, cystatin C, and vanin-1 mRNA, as well as urinary NAG elevation and nephrin mRNA suppression, associated with the development of marked renal interstitial fibrosis and glomerulosclerosis despite the presence of normoalbuminuria. Propagation of oxidative, inflammatory, fibrotic, and apoptotic reactions was obvious in the setting of renal glucose overload. Dapagliflozin significantly attenuated the renal tubular injury makers namely KIM-1, NGAL, vanin-1 and urinary NAG. In addition, it restored glomerular nephrin expression and reversed renal histopathological changes. Oxidative, inflammatory, and fibrotic processes were also alleviated. This study suggests that dapagliflozin exerts a renoprotective effect against early features of DN in rats presumably by inhibition of diabetes-induced renal tubular and glomerular injury thereby modulating oxidative, inflammatory, and fibrotic as well as apoptotic mechanisms elicited during hyperglycemia.

Protein requirement and its intake in subjects with diabetic foot ulcers at a tertiary care hospital

Objective:

To assess the protein intake and requirement among subject with type 2 diabetes having foot ulcers.

Methods:

This study was conducted at Baqai Institute of Diabetology & Endocrinology (BIDE), a tertiary care diabetes centre of Karachi, Pakistan among people with type 2 diabetic foot ulcer attending foot clinic from January 2012 to March 2015. The baseline characteristics, dietary intake and laboratory investigations of the study participants were obtained through electronic hospital database “Health Management System” (HMS) based on the 24 hours dietary recall interview. Total grams of protein were calculated from each food group consumed by the subject. Protein intake of the subjects was recorded in mean grams and the protein requirement was calculated according to their body weight. The comparison of intake and requirement of protein choices was done through comparing the mean of both variables. SPSS version 13 was used for analysing the results.

Results:

A total of 542 subjects were included in the study, 365 (67.2%) were males and 178 (32.8%) were females. Mena age of the subject was 54.61±10.51 (yrs) with the duration of diabetes and mean body mass index were 14.22±7.98 (yrs) and 26.65±5.38 (kg/m²), respectively. The dietary records showed the protein intake of subjects with diabetic foot ulcer is not appropriate when compared to daily requirement. Mean grams of protein intake is 76.87gms in males and 56.84gms in females. On the other-hand protein requirement is much higher than the intake, which is 219.5gms in males and 130.2gms in females.

Conclusion:

Dietary counselling should be a part of the treatment among subjects with diabetic foot ulcer to identify their nutritional needs and suggesting them better option to fulfil their protein requirement essential for wound healing process.

Asymmetric dimethylarginine and soluble inter-cellular adhesion molecule-1 serum levels alteration following ginger supplementation in patients with type 2 diabetes: a randomized double-blind, placebo-controlled clinical trial

Aims Patients with type 2 diabetes mellitus (T2DM) are prone to cardiovascular disease (CVD) due to inflammation process and oxidative stress. ADMA (Asymmetric dimethylarginine) and ICAM-1 (inter-cellular adhesion molecule-1) play an important role in CVD pathogenesis. Ginger as an anti-oxidant and anti-inflammation can effect on these biomarkers. The aim of present study was to characterize the effect of ginger supplementation on ADMA and ICAM-1 serum levels in patients with T2DM. Methods The present study is a randomized double-blind clinical trial which is conducted among 45 diabetic patients (nginger=23, nplacebo=22). The participants were randomly divided into two intervention and placebo groups which were received 2 g ginger powder and 2 g wheat flour for 10 weeks, respectively. ADMA and ICAM-1 concentration were measured by ELISA method. Results Ginger supplementation decreased ADMA serum levels significantly (P=0.002) and sICAM-1 serum levels marginally (P=0.097) in supplementation group after intervention. No significant difference was observed between placebo and supplementation groups. Conclusions Present study was conducted among patients with type 2 diabetes mellitus to investigate the effect of ginger supplementation on ADMA and sICAM-1 levels. There was a significant decrement in ADMA serum concentration and slight reduction in sICAM-1 levels in intervention group. The amount of reduction in both biomarkers was not statistically significant in between-groups comparison.

Implication of critical pharmacokinetic gene variants on therapeutic response to metformin in Type 2 diabetes

Aim: Metformin, an oral hypoglycemic drug is the first line of treatment for Type 2 diabetes individuals. We studied the effect of critical gene single nucleotide polymorphisms  on the glucose lowering effect of metformin. Method: We performed a prospective study on 221 newly diagnosed, treatment-naive Type 2 diabetes subjects. Individuals were started with metformin monotherapy and followed up for 12 weeks. Results: Our association analysis revealed that SLC22A2 rs316019 and SLC47A2 rs12943590 were significantly associated with metformin drug response across co-dominant and dominant models, respectively. SLC22A2 rs316019 GG and SLC47A2 rs12943590 GA combined genotypes showed maximum average change in HbA1c level. Conclusion: The present study proposes a role of SLC22A2 rs316019 and SLC47A2 rs12943590 in the pharmacokinetic action of metformin.

Monitoring Patients on Metformin: Recent Changes and Rationales

Objective: The Food and Drug Administration recently updated metformin prescribing recommendations for patients with diabetes and renal disease. The American Diabetes Association as well as the American Association of Clinical Endocrinologists and American Clinical Endocrinologists also recommend periodic monitoring of vitamin B12 levels for patients using metformin. A review of the literature was conducted to assess data to evaluate the recent updates to metformin usage and provide rationales for these recommendations. Data Sources: PubMed MESH terms "Diabetes Mellitus, Type 2" and "Renal Insufficiency, Chronic" and "Metformin" were searched with an English limitation from 1990 to May 2017. A MEDLINE search was conducted using the terms "metformin" and "renal disease" from 1990 to May 2017. A PubMed search was conducted using the MESH terms "vitamin b12 deficiency" and "metformin" from 1970 to May 2017. A MEDLINE search was conducted using terms "metformin" and "vitamin B12 deficiency" with an English limitation from 1970 to May 2017. Study Selection and Data Extraction: Retrospective and prospective clinical trials, meta-analyses, and systematic reviews were considered for inclusion. Citations from identified articles were also reviewed for inclusion. Data Synthesis: The incidence of metformin-associated lactic acidosis is minimal. Data indicate metformin-treated patients with an estimated glomerular filtration rate above 30 mL/min/1.73 m2 have a reduction in mortality. Additionally, data suggest metformin may lead to vitamin B12 deficiency. Conclusion: Data support recommendations for metformin use in patients with diabetes and renal insufficiency with an estimated glomerular filtration rate above 30 mL/min/1.73 m2. Data also suggest that baseline and periodic testing of vitamin B12 levels are warranted and supported by clinical guidelines due to the risk of vitamin B12 deficiency in metformin-treated patients.

Pharmacotherapy of type 2 diabetes: An update

Type 2 diabetes (T2DM) is a leading cause of morbidity and mortality worldwide and a major economic burden. The prevalence of T2DM is rising, suggesting more effective prevention and treatment strategies are necessary. The aim of this narrative review is to summarize the pharmacologic treatment options available for patients with T2DM. Each therapeutic class is presented in detail, outlining medication effects, side effects, glycemic control, effect on weight, indications and contraindications, and use in selected populations (heart failure, renal insufficiency, obesity and the elderly). We also present representative cost for each antidiabetic category. Then, we provide an individualized guide for initiation and intensification of treatment and discuss the considerations and rationale for an individualized glycemic goal.

Treatment choice, medication adherence and glycemic efficacy in people with type 2 diabetes: a UK clinical practice database study

OBJECTIVE

Using primary care data obtained from the UK Clinical Practice Research Datalink, this retrospective cohort study examined the relationships between medication adherence and clinical outcomes in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Data were extracted for patients treated between 2008 and 2016, and stratified by oral antihyperglycemic agent (OHA) line of therapy (mono, dual or triple therapy). Patients were monitored for up to 365 days; associations between medication possession ratio (MPR) and outcomes at 1 year (glycated hemoglobin A1c (HbA1c), weight and hypoglycemia incidence) were assessed using linear regression modeling and descriptive analyses.

RESULTS

In total, 33 849 patients were included in the study (n=23 925 OHA monotherapy; n=8406 OHA dual therapy; n=1518 OHA triple therapy). One-year change in HbA1c was greater among adherent (-0.90 to -1.14%; -9.8 to -12.5 mmol/mol) compared with non-adherent patients (-0.49 to -0.69%; -5.4 to -7.5 mmol/mol). On average, adherent patients had higher hypoglycemia event rates than non-adherent patients (rate ratios of 1.24, 1.10 and 2.06 for OHA mono, dual and triple therapy cohorts, respectively) and experienced greater weight change from baseline. A 10% improvement in MPR was associated with -0.09% (-1.0 mmol/mol), -0.09% (-1.0 mmol/mol) and -0.21% (-2.3 mmol/mol) changes in HbA1c for OHA mono, dual and triple therapy cohorts, respectively.

CONCLUSIONS

For patients with type 2 diabetes, increasing medication adherence can bring about meaningful improvements in HbA1c control as the requirement for treatment escalation increases. Regimens associated with weight loss and the avoidance of hypoglycemia were generally associated with better medication adherence and improved glycemic control.

Recruitment and retention of a challenging population: Lessons learned and design implications

PURPOSE

The purpose of this article is share the lessons learned from recruiting and retaining adults with type 2 diabetes and solid tumor cancer into a longitudinal study exploring the relationship among chemotherapy, glycemic control, and symptoms.

DESIGN/METHODS

Twelve-week longitudinal study, recruited thirty-four adults 21years or older with pre-existing type 2 diabetes and a solid tumor cancer, from three community based cancer centers who were eligible to receive outpatient chemotherapy.

METHODS

Fisher's Exact Test (categorical variables) and Logistic Regression (continuous variables) were used to evaluate factors associated with participant withdrawal. A dichotomous attrition variable was created to identify those who dropped out of the study before the final week and those who completed.

RESULTS

Thirteen of the 34 participants completed the study. Symptom severity, baseline HbA1c and metastases were all identified as being factors that potentially influenced attrition. Recruitment was improved once recruiters were hired at each of the cancer centers and adjustments made to the inclusion criteria.

CONCLUSIONS/IMPLICATIONS FOR RESEARCH

Several design elements need to be considered to address attrition in future including the use of recruiters, inclusion and exclusion criteria, consent timing, data collection schedules, participant characteristics, participant burden, and support person identification.

Challenges and unmet needs in basal insulin therapy: lessons from the Asian experience

Basal insulin therapy can improve glycemic control in people with type 2 diabetes. However, timely initiation, optimal titration, and proper adherence to prescribed basal insulin regimens are necessary to achieve optimal glycemic control. Even so, glycemic control may remain suboptimal in a significant proportion of patients. Unique circumstances in Asia (eg, limited resources, management of diabetes primarily in nonspecialist settings, and patient populations that are predominantly less educated) coupled with the limitations of current basal insulin options (eg, risk of hypoglycemia and dosing time inflexibility) amplify the challenge of optimal basal insulin therapy in Asia. Significant progress has been made with long-acting insulin analogs (insulin glargine 100 units/mL and insulin detemir), which provide longer coverage and less risk of hypoglycemia over intermediate-acting insulin (Neutral Protamine Hagedorn insulin). Furthermore, recent clinical evidence suggests that newer long-acting insulin analogs, new insulin glargine 300 units/mL and insulin degludec, may address some of the unmet needs of current basal insulin options in terms of risk of hypoglycemia and dosing time inflexibility. Nevertheless, more can be done to overcome barriers to basal insulin therapy in Asia, through educating both patients and physicians, developing better patient support models, and improving accessibility to long-acting insulin analogs. In this study, we highlight the unique challenges associated with basal insulin therapy in Asia and, where possible, propose strategies to address the unmet needs by drawing on clinical experiences and perspectives in Asia.

Metformin reduces all-cause mortality and diseases of ageing independent of its effect on diabetes control: A systematic review and meta-analysis

This systematic review investigated whether the insulin sensitiser metformin has a geroprotective effect in humans. Pubmed and Embase were searched along with databases of unpublished studies. Eligible research investigated the effect of metformin on all-cause mortality or diseases of ageing relative to non-diabetic populations or diabetics receiving other therapies with adjustment for disease control achieved. Overall, 260 full-texts were reviewed and 53 met the inclusion criteria. Diabetics taking metformin had significantly lower all-cause mortality than non-diabetics (hazard ratio (HR)=0.93, 95%CI 0.88-0.99), as did diabetics taking metformin compared to diabetics receiving non-metformin therapies (HR=0.72, 95%CI 0.65-0.80), insulin (HR=0.68, 95%CI 0.63-0.75) or sulphonylurea (HR=0.80, 95%CI 0.66-0.97). Metformin users also had reduced cancer compared to non-diabetics (rate ratio=0.94, 95%CI 0.92-0.97) and cardiovascular disease (CVD) compared to diabetics receiving non-metformin therapies (HR=0.76, 95%CI 0.66-0.87) or insulin (HR=0.78, 95%CI 0.73-0.83). Differences in baseline characteristics were observed which had the potential to bias findings, although statistical adjustments were made. The apparent reductions in all-cause mortality and diseases of ageing associated with metformin use suggest that metformin could be extending life and healthspans by acting as a geroprotective agent.

The prescribing trend of oral antidiabetic agents for type 2 diabetes in Taiwan: An 8-year population-based study

The purpose of this study was to evaluate the prescription trend and pattern of oral antidiabetic (OAD) medications, which are extensively used worldwide for treating type 2 diabetes, in 2 age groups.In this population-based study, data obtained from the National Health Insurance Research Database, Taiwan, were analyzed to investigate the prescription trend of all types of OAD medications during 2005 to 2012. We used descriptive statistics to demonstrate the trend of prescription patterns stratified by age (aged 65 years and above or younger than 65).Sulfonylurea (SU) was once the most commonly used drug, but the proportion of its prescription had declined gradually (76.83% in 2005 to 63.70% in 2012). Consequently, biguanide (BG) became the most commonly used drug since 2010 (64.31% in 2005 to 74.41% in 2012). In addition, the prescriptions of thiazolidinedione decreased significantly (9.20% in 2005 to 2.86% in 2012), whereas the usage of DPP-4 inhibitor increased with time (3.73% in 2009 to 19.64% in 2012). The treatment choice of SU and α-glucosidase inhibitor (AGI) was higher in elderly patients compared with the younger population (SU: 62.70% in 2012, AGI: 12.78% in 2012). Two-drug combination therapies were the prevalent treatment choices for patients with type 2 diabetes (44.77% in 2012), particularly in the elderly group; however, ≥3 drug combination therapies increased gradually during the study period, particularly in the younger group.This descriptive study presents the change in the prescription of OAD medication for different age groups during 2005 to 2012.

Synthetic and phytocompounds based dipeptidyl peptidase-IV (DPP-IV) inhibitors for therapeutics of diabetes

Currently antidiabetic therapeutic strategies are mainly based on synthetic hypoglycemic agent. Antidiabetic drugs are associated with significant adverse effects of hypoglycemia, dysfunction of insulin and weight gain. Nowadays, the novel Dipeptidyl peptidase-IV (DPP-IV) inhibitors unique approach for the management of diabetes has been considered to be safe, as DPP-IV inhibitors reduce blood glucose level by monitoring hyperglycemia including positive effects on body weight as it remains neutral, improves glycated hemoglobin levels and do not induce hypoglycemia. Inhibitors help to protect degradation of Glucagon-like peptide-1 (GLP-1) and gastric inhibitory peptide (GIP), gut hormones which helps to suppresses postprandial glucagon release, delay gastric emptying and regulate satiety. Therefore, the innovation of DPP-IV inhibitor based drugs regulates activity of incretin hormones such as GLP-1 and GIP. Commercially available DPP-IV inhibitors are chemically synthesized with good therapeutic value. However, the durability and long-term safety of DPP-IV inhibitors remains to be established. On the other hand, phytocompounds-based DPP-IV inhibitors are alternative and safe to use as compared to synthetic. Numerous novel antidiabetic compounds and group of compounds emerging in clinical development are through DPP-IV inhibition. This review summarized recent progress made on DPP-IV inhibitors from both synthetic as well as from natural sources.

Metformin vs sulfonylurea use and risk of dementia in US veterans aged ≥65 years with diabetes

OBJECTIVE

To determine whether metformin is associated with a lower incidence of dementia than sulfonylureas.

METHODS

This was a retrospective cohort study of US veterans ≥65 years of age with type 2 diabetes who were new users of metformin or a sulfonylurea and had no dementia. Follow-up began after 2 years of therapy. To account for confounding by indication, we developed a propensity score (PS) and used inverse probability of treatment weighting (IPTW) methods. Cox proportional hazards models estimated the hazard ratio (HR) of incident dementia.

RESULTS

We identified 17,200 new users of metformin and 11,440 new users of sulfonylureas. Mean age was 73.5 years and mean HbA1c was 6.8%. Over an average follow-up of 5 years, 4,906 cases of dementia were diagnosed. Due to effect modification by age, all analyses were conducted using a piecewise model for age. Crude hazard ratio [HR] for any dementia in metformin vs sulfonylurea users was 0.67 (95% confidence interval [CI] 0.61-0.73) and 0.78 (95% CI 0.72-0.83) for those <75 years of age and ≥75 years of age, respectively. After PS IPTW adjustment, results remained significant in veterans <75 years of age (HR 0.89; 95% CI 0.79-0.99), but not for those ≥75 years of age (HR 0.96; 95% CI 0.87-1.05). A lower risk of dementia was also seen in the subset of younger veterans who had HbA1C values ≥7% (HR 0.76; 95% CI 0.63-0.91), had good renal function (HR 0.86; 95% CI 0.76-0.97), and were white (HR 0.87; 95% CI 0.77-0.99).

CONCLUSIONS

After accounting for confounding by indication, metformin was associated with a lower risk of subsequent dementia than sulfonylurea use in veterans <75 years of age. Further work is needed to identify which patients may benefit from metformin for the prevention of dementia.

Combination therapy of metformin plus dipeptidyl peptidase-4 inhibitor versus metformin plus sulfonylurea and their association with a decreased risk of cardiovascular disease in type 2 diabetes mellitus patients

BACKGROUND

Clinical trials assessing the combination therapy of metformin plus dipeptidyl peptidase-4 inhibitors versus metformin plus Sulfonylureas on risk of cardiovascular disease, cardiovascular mortality and/or all-cause mortality in type 2 diabetes have shown conflicting results. We therefore evaluated the combination therapy on the risk of cardiovascular disease, cardiovascular mortality and/or all-cause mortality in type 2 diabetes.

METHODS

A systematic search of Medline/PubMed (from 2000 to September 2015), EMBASE (from 2000 to September 2015), and Web of Knowledge (from 2000 to September 2015) for research articles published in English was carried out to examine how combination therapy affects the risk of CVD mortality and/or all-cause mortality in T2DM patients. In addition, the risks of cardiovascular events, CVD mortality, and/or all-cause mortality as well as the adjusted relative risk (RR) or equivalent (hazard ratio or odds ratio) and the corresponding variance or equivalent are reported.

RESULTS

The accumulative RRs (95% confidence intervals) for T2DM patients treated with the combination therapy of metformin plus DPP-4 inhibitor versus metformin plus sulfonylurea were 0.71 (0.56-0.90) for nonfatal cardiovascular events, 1.001 (0.85-1.18) for fatal cardiovascular events, 0.58 (0.41-0.82) for CVD mortality, and 0.72 (0.59-0.87) for all-cause mortality.

CONCLUSIONS

The combination therapy of metformin plus DPP-4 inhibitor significantly decreased the RR of nonfatal cardiovascular events, CVD mortality, and all-cause mortality, compared with the combination therapy of metformin plus sulfonylurea. However, the number fatal cardiovascular events (e.g., heart failure) was not significantly different between the 2 groups.

Effects of combination of mitiglinide with various oral antidiabetic drugs in streptozotocin-nicotinamide-induced type 2 diabetic rats and Zucker fatty rats

We examined the effects of combining the rapid insulin secretagogue, mitiglinide, with various oral hypoglycaemic drugs including biguanides, pioglitazone, α-glucosidase inhibitors, and sodium-glucose co-transporter 2 inhibitors in a rat model of type 2 diabetes. The oral glucose tolerance test (OGTT) using glucose, sucrose, or a liquid meal was used to compare the effects of mitiglinide with those of the four oral hypoglycaemic drugs and examine their combined effects on blood glucose levels and insulin secretion in the rat model. The combination of mitiglinide with other oral hypoglycaemic drugs suppressed the plasma glucose levels more than either agent did alone. Furthermore, the combination of these agents decreased insulin secretion more than mitiglinide did alone. These results indicate that mitiglinide is suitable for use in combination with other hypoglycaemic drugs because it inhibits postprandial hyperglycaemia by rapidly stimulating insulin secretion.

Troglitazone, a PPAR-γ agonist, decreases LTC4 concentration in mononuclear cells in patients with asthma

BACKGROUND

Asthma is an inflammatory disorder with multiple mediators involved in the inflammatory response. Despite several attempts, no new anti-inflammatory drugs have been registered for asthma treatment for several years. However, thiazolidinediones, peroxisome proliferator-activated receptor agonists, have demonstrated some anti-inflammatory properties in various experimental settings. The aim of this study was to assess the influence of troglitazone on LTC₄ and 15-HETE concentrations. It also evaluates TNF-induced eotaxin synthesis in peripheral blood mononuclear cells from 14 patients with mild asthma and 13 healthy controls.

METHODS

PBMCs were isolated from the whole blood of the asthmatics and healthy subjects and pretreated with 0.1, 1 or 10μM of Troglitazone. The cells were then exposed to 10^-6M calcium jonophore or 10ng/ml TNF. The production and release of LTC₄, 15-HETE and eotaxin were then assessed.

RESULTS

Troglitazone caused a dose-dependent inhibition in LTC₄ synthesis in both asthmatics and healthy subjects. Troglitazone did not influence 15-HETE or eotaxin production in either asthmatic patients or in healthy individuals.

CONCLUSION

Due to its inhibition of LTC₄ synthesis, troglitazone therapy is an interesting potential therapeutic approach in asthma and other LTC₄ related inflammatory disorders.

METFORMIN: NONGLYCEMIC EFFECTS AND POTENTIAL NOVEL INDICATIONS

OBJECTIVE

Metformin is the most commonly prescribed drug for the treatment of type 2 diabetes because of its apparent robust effects in reducing cardiovascular risk. This review examines the current literature regarding the nonglycemic effects and potential novel indications for metformin.

METHODS

Review of the literature, with a focus on metformin use in Stage 3 chronic kidney disease (CKD-3) and heart failure (HF).

RESULTS

The United Kingdom Prospective Diabetes Study suggests that metformin reduces the risk of myocardial infarction, and more recent retrospective studies have shown an association between metformin use and a reduction in stroke, atrial fibrillation and all-cause mortality. The mechanism(s) explaining these putative benefits are not clear but may involve decreased energy intake (with attendant weight loss), improvement in lipids, and lowering of blood pressure; a literature review suggests that metformin lowers blood pressure when it is elevated, but not when it is normal. Metformin appears to be safe when given to patients with CKD-3. In addition, there is evidence that individuals with CKD-3, who are at increased cardiovascular risk, stand to benefit from metformin therapy. Lactic acidosis is an extremely remote and probably avoidable risk; measurement of plasma metformin levels and more frequent monitoring of renal function may be useful in selected patients with CKD-3 who are treated with metformin. Finally, there is evidence that metformin is safe in patients with HF; metformin therapy is associated with a reduction in newly incident HF and in HF mortality.

CONCLUSION

Metformin has a dominant position in the treatment of type 2 diabetes that is deserved due to its favorable and robust effects on cardiovascular risk.

ABBREVIATIONS

AMP = adenosine monophosphate BP = blood pressure CKD = chronic kidney disease CKD-3 = Stage 3 CKD eGFR = estimated glomerular filtration rate HDL = high-density lipoprotein HF = heart failure MAP = mean arterial pressure mVO2 = myocardial oxygen consumption T2DM = type 2 diabetes mellitus UKPDS = United Kingdom Prospective Diabetes Study.

A Randomized Controlled Trial of Vildagliptin Versus Alogliptin: Effective Switch From Sitagliptin in Patients With Type 2 Diabetes

Background

We investigated the effects of vildagliptin or alogliptin on blood glucose and hemoglobin A1c (HbA1c) in patients with type 2 diabetes inadequately controlled by sitagliptin.

Methods

In a single-center open-label trial, 35 patients with inadequate glycemic control on sitagliptin therapy (50 mg once daily) were randomly switched to treatment with vildagliptin (50 mg twice daily) or alogliptin (25 mg once daily). After 12 weeks, patients who failed to achieve the target HbA1c level of < 7.0% with vildagliptin or alogliptin treatment were switched to high-dose sitagliptin (100 mg once daily) and the effect on glycemic control was assessed.

Results

Vildagliptin did not significantly alter the mean plasma glucose level (175.5 ± 54.4 mg/dL vs. 179.1 ± 73.4 mg/dL) or HbA1c (8.01% vs. 8.02%) after 12 weeks. With alogliptin, mean plasma glucose increased from 175.4 ± 50.9 mg/dL to 195.3 ± 55.0 mg/dL after 12 weeks and HbA1c increased significantly from 8.0% to 8.3% (P < 0.05). At 12 weeks after switching from vildagliptin to high-dose sitagliptin (100 mg daily), HbA1c was increased to 8.3%, but it was significantly (P < 0.05) reduced to the baseline level of 8.0% after switching from alogliptin. The reduction of HbA1c was significantly greater in the vildagliptin group than the alogliptin group (P = 0.008), but the response rate (achieving the target HbA1c < 7.0%) did not differ significantly between the two groups.

Conclusion

The glucose-lowering effects of these three dipeptidyl peptidase-4 (DPP-4) inhibitors (vildagliptin, alogliptin, and sitagliptin) were different, and the effects of vildagliptin and sitagliptin were stronger than that of alogliptin.

Metformin-like antidiabetic, cardio-protective and non-glycemic effects of naringenin: Molecular and pharmacological insights

Metformin is a widely used drug for the treatment of type 2 diabetes (T2D). Its blood glucose-lowering effects are initially due to inhibition of hepatic glucose production and increased peripheral glucose utilization. Metformin has also been shown to have several beneficial effects on cardiovascular risk factors and it is the only oral antihyperglycaemic agent thus far associated with decreased macrovascular complications in patients with diabetes. Adenosine Monophosphate Activated-Protein Kinase (AMPK) is a major cellular regulator of lipid and glucose metabolism. Recent evidence shows that pharmacological activation of AMPK improves blood glucose homeostasis, lipid profiles, blood pressure and insulin-resistance making it a novel therapeutic target in the treatment of T2D. Naringenin a flavonoid found in high concentrations as its glycone naringin in citrus fruits, has been reported to have antioxidant, antiatherogenic, anti- dyslipidemic and anti-diabetic effects. It has been shown that naringenin exerts its anti-diabetic effects by inhibition of gluconeogenesis through upregulations of AMPK hence metformin-like effects. Naringin has further been shown to have non-glycemic affects like metformin that mitigate inflammation and cell proliferation. This review evaluates the potential of naringenin as anti-diabetic, anti-dyslipidemic anti-inflammatory and antineoplastic agent similar to metformin and proposes its further development for therapeutic use in clinical practice.

Monitoring safety and use of old and new treatment options for type 2 diabetic patients: a two-year (2013-2016) analysis

OBJECTIVE

To compare patients' and physicians' perceptions regarding effectiveness and tolerability of non-insulin hypoglycemic drugs in a cohort of type 2 diabetic patients; to verify whether a possible tridimensional link between effectiveness, tolerability, and adherence affects long-term therapeutic outcomes.

METHODS

A two-year observational study was performed in 1389 Type 2 diabetic patients by involving general practitioner clinics and Diabetes Centers. A decimal scale and the Morisky questionnaire were used, respectively, to assess effectiveness and tolerability perceptions, and medication adherence.

RESULTS

Physicians perceived therapy as more efficacious compared to their patients: perceived effectiveness was steady for physicians during the study whereas patients' perception not significantly decreased (mean score from >8 to 7.84 ± 1.69). Physicians assigned higher tolerability scores compared to patients but only at the beginning of the study; interestingly, physicians' tolerability perception was poorer than patients' perception at last follow-up (mean score = 7.57 ± 1.40 vs. 7.88 ± 1.84). Favorable (score >7) patients' perceptions about treatment effectiveness and tolerability were associated with higher adherence. Patients showed medium adherence across the study.

CONCLUSIONS

A mutual relationship between clinical effectiveness, adverse drug reactions, and adherence has been established, significantly impacting the clinical management of diabetic patients. A careful monitoring of this link by clinicians appears therefore necessary.

Urinary tract and genital infections in patients with type 2 diabetes treated with sodium-glucose co-transporter 2 inhibitors: A meta-analysis of randomized controlled trials

AIMS

To evaluate the effects of different sodium-glucose co-transporter 2 (SGLT2) inhibitors on the risk of urinary tract infections (UTIs) and genital infections in patients with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

We systematically searched PubMed, Embase, CENTRAL, and ClinicalTrials.gov from inception to October 9, 2016 to identify randomized controlled trials (RCTs) reporting the occurrence of UTIs and genital infections in patients with T2DM treated with SGLT2 inhibitors. Pairwise and network meta-analyses were performed to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Meta-regression was performed to assess explanatory factors that might influence effect size.

RESULTS

A total of 52 RCTs involving 36 689 patients were eligible for our meta-analysis. Canagliflozin, dapagliflozin and empagliflozin were associated with a higher risk of genital infections than placebo, with ORs ranging from 3.21 (95% CI 2.08-4.93) for dapagliflozin 2.5 mg to 5.23 (95% CI 3.86-7.09) for canagliflozin 300 mg. Only dapagliflozin 10 mg led to significantly more UTIs than placebo. The increased risk of UTIs and genital infections seemed to have a dose-response relationship for dapagliflozin only. No factors that had a significant modification effect on these infectious events were detected in meta-regression analysis.

CONCLUSIONS

The present study found that canagliflozin, dapagliflozin and empagliflozin were associated with a significantly higher risk of genital infections compared with placebo and other active treatments. Only dapagliflozin had a dose-response relationship with UTIs and genital infections.

An allometric pharmacokinetic/pharmacodynamics model for BI 893923, a novel IGF-1 receptor inhibitor

PURPOSE

BI 893923 is a novel IGF1R/INSR inhibitor with promising anti-tumor efficacy. Dose-limiting hyperglycemia has been observed for other IGF1R/INSR inhibitors in clinical trials. To counterbalance anti-tumor efficacy with the risk of hyperglycemia and to determine the therapeutic window, we aimed to develop a translational pharmacokinetic/pharmacodynamics model for BI 893923. This aimed to translate pharmacokinetics and pharmacodynamics from animals to humans by an allometrically scaled semi-mechanistic model.

METHODS

Model development was based on a previously published PK/PD model for BI 893923 in mice (Titze et al., Cancer Chemother Pharmacol 77:1303-1314, 13). PK and blood glucose parameters were scaled by allometric principles using body weight as a scaling factor along with an estimation of the parameter exponents. Biomarker and tumor growth parameters were extrapolated from mouse to human using the body weight ratio as scaling factor.

RESULTS

The allometric PK/PD model successfully described BI 893923 pharmacokinetics and blood glucose across mouse, rat, dog, minipig, and monkey. BI 893923 human exposure as well as blood glucose and tumor growth were predicted and compared for different dosing scenarios. A comprehensive risk-benefit analysis was conducted by determining the net clinical benefit for each schedule. An oral dose of 2750 mg BI 893923 divided in three evenly distributed doses was identified as the optimal human dosing regimen, predicting a tumor growth inhibition of 90.4% without associated hyperglycemia.

CONCLUSION

Our model supported human therapeutic dose estimation by rationalizing the optimal efficacious dosing regimen with minimal undesired effects. This modeling approach may be useful for PK/PD scaling of other IGF1R/INSR inhibitors.

Improvement of quality of life through glycemic control by liraglutide, a GLP-1 analog, in insulin-naive patients with type 2 diabetes mellitus: the PAGE1 study

BACKGROUND

In addition to achieving good glycemic control, diabetes care management aims to improve the quality of life (QOL) in patients. Treatment-associated difficulties and side effects frequently cause deterioration in QOL. Liraglutide, a GLP-1 receptor agonist, is a novel injection drug that promotes insulin secretion. It is a user-friendly, once-daily injection with fewer hypoglycemic events. In this study, we aimed to examine the effect of liraglutide therapy on QOL in patients.

METHODS

In total, 304 insulin- and liraglutide-naïve patients with type 2 diabetes were enrolled in this observational study; they received liraglutide therapy for 12 weeks. The main outcome measure was change in QOL from baseline, which was assessed using diabetes therapy-related QOL (DTR-QOL).

RESULTS

At week 12, liraglutide significantly decreased HbA1c levels (8.7 ± 1.5 vs. 7.5 ± 1.3, p < 0.001) and BMI (27.9 ± 5.3 vs. 27.3 ± 5.2, p < 0.001). According to the QOL scores, although the treatment modality had changed from non-injection to injection therapy, liraglutide improved patient satisfaction with treatment. Significant correlations were found between change in HbA1c level and satisfaction with treatment, as well as between change in body weight and burden on social and daily activities, anxiety and dissatisfaction with treatment, and hypoglycemia.

CONCLUSIONS

Liraglutide significantly improved glycemic control and reduced the body weight without deteriorating QOL in obese patients with type 2 diabetes. Trial registration UMIN-CTR: UMIN000007159.

Comparative Effectiveness of Second-Line Agents for the Treatment of Diabetes Type 2 in Preventing Kidney Function Decline

BACKGROUND AND OBJECTIVES

Diabetes is the leading cause of ESRD. Glucose control improves kidney outcomes. Most patients eventually require treatment intensification with second-line medications; however, the differential effects of those therapies on kidney function are unknown.

DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS

We studied a retrospective cohort of veterans on metformin monotherapy from 2001 to 2008 who added either insulin or sulfonylurea and were followed through September of 2011. We used propensity score matching 1:4 for those who intensified with insulin versus sulfonylurea, respectively. The primary composite outcome was persistent decline in eGFR≥35% from baseline (GFR event) or a diagnosis of ESRD. The secondary outcome was a GFR event, ESRD, or death. Outcome risks were compared using marginal structural models to account for time-varying covariates. The primary analysis required persistence with the intensified regimen. An effect modification of baseline eGFR and the intervention on both outcomes was evaluated.

RESULTS

There were 1989 patients on metformin and insulin and 7956 patients on metformin and sulfonylurea. Median patient age was 60 years old (interquartile range, 54-67), median hemoglobin A1c was 8.1% (interquartile range, 7.1%-9.9%), and median creatinine was 1.0 mg/dl (interquartile range, 0.9-1.1). The rate of GFR event or ESRD (primary outcome) was 31 versus 26 per 1000 person-years for those who added insulin versus sulfonylureas, respectively (adjusted hazard ratio, 1.27; 95% confidence interval, 0.99 to 1.63). The rate of GFR event, ESRD, or death was 64 versus 49 per 1000 person-years, respectively (adjusted hazard ratio, 1.33; 95% confidence interval, 1.11 to 1.59). Tests for a therapy by baseline eGFR interaction for both the primary and secondary outcomes were not significant (P=0.39 and P=0.12, respectively).

CONCLUSIONS

Among patients who intensified metformin monotherapy, the addition of insulin compared with a sulfonylurea was not associated with a higher rate of kidney outcomes but was associated with a higher rate of the composite outcome that included death. These risks were not modified by baseline eGFR.

The Role of Vildagliptin in the Management of Type 2 Diabetes Mellitus

Objective:

To highlight the role of incretin hormones in the management of type 2 diabetes mellitus with a focus on vildagliptin, a dipeptidyl peptidase IV (DPP IV) inhibitor currently in development.

Data Sources:

Searches were conducted in MEDLINE (1950–April 2007) and International Pharmaceutical Abstracts (1970–April 2007) using the key words vildagliptin, LAF237, and dipeptidyl peptidase IV inhibitor. Additional data were obtained from abstracts presented at the American Diabetes Association Scientific Sessions (2003–2006) and from the manufacturer.

Study Selection and Data Extraction:

Articles pertaining to the pharmacology, pharmacokinetics, safety, and efficacy of vildagliptin for the treatment of type 2 diabetes were reviewed for inclusion. When available, human trials were included over animal studies.

Data Synthesis:

Reduced incretin effect is thought to be associated with type 2 diabetes. Glucagon-like peptide-1 (GLP-1), an incretin hormone, stimulates postprandial insulin release; however, it is rapidly degraded by DPP IV. Studies evaluating the use of vildagliptin in patients with type 2 diabetes found significant decreases in DPP IV and increased GLP-1 activity 45 minutes after dosing. Glucagon levels were reduced, with little to no change in insulin levels. With vildagliptin doses ranging from 25 mg daily to 100 mg twice daily, researchers observed consistent reductions in fasting plasma glucose, 4 hour postprandial glucose, and hemoglobin A1c. Similar benefits were seen when vildagliptin was used in combination with metformin. Vildagliptin was well tolerated after 12 weeks; however, incidences of hypoglycemia increased with longer study duration. Optimal results with minimal adverse effects were achieved with 25 mg twice daily and 50 mg once daily doses.

Conclusions:

Vildagliptin represents a safe and effective new approach to targeting GLP-1 deficiencies in patients with type 2 diabetes by inhibiting DPP IV.

Novel applications of COX-2 inhibitors, metformin, and statins for the primary chemoprevention of breast cancer

Recent evidence shows that commonly prescribed drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs), metformin, and statins, may have beneficial roles in the primary chemoprevention of breast cancer. Therefore, these drugs could potentially be used in addition to the hormonal drugs currently used for this purpose (namely, selective estrogen receptor modulators and aromatase inhibitors) due to their alternative mechanisms of action.