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Efficacy of Saxagliptin versus Mitiglinid in patients with type 2 diabetes and end-stage renal disease. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Goldenberg RM. Choosing Dipeptidyl Peptidase-4 Inhibitors, Sodium-glucose Cotransporter-2 Inhibitors, or Both, as Add-ons to Metformin: Patient Baseline Characteristics Are Crucial. Clin Ther 2017; 39:2438-2447. [PMID: 29174215 DOI: 10.1016/j.clinthera.2017.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/02/2017] [Accepted: 10/23/2017] [Indexed: 01/19/2023]
Abstract
PURPOSE Type 2 diabetes remains a poorly managed disease, with only about half of individuals with type 2 diabetes meeting guideline-recommended glycosylated hemoglobin (HbA1C) targets. A major proportion of those who have not met HbA1C goals have an HbA1C <8.0% to 8.5%. In practice, it is quite common to have to decide between dipeptidyl peptidase-4 inhibitors (DPP-4i) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) as add-ons to metformin to help these individuals meet their HbA1C goals. This commentary reviews and provides guidance on how baseline factors can assist in the decision between the 2 classes or using both as add-ons to metformin. METHODS The important clinical studies comparing the glycemic efficacy of DPP-4i versus SGLT2i or their combination as add-ons to metformin with a focus on the influence of baseline HbA1C on glycemic efficacy will be discussed and interpreted. The impact of estimated glomerular filtration rate and age on the glycemic efficacy of DPP-4i and SGLT2i will also be put into perspective. FINDINGS At HbA1C <8.0% to 8.5%, HbA1C lowering is slightly greater with DPP-4i than with SGLT2i as an add-on to metformin; SGLT2i are associated with larger HbA1C improvements than DPP-4i at higher HbA1C levels. In cases of HbA1C ≥8.0%, dual DPP-4i-SGLT2i add-on therapy to metformin should be considered to help more patients achieve glycemic targets. The glycemic efficacy of SGLT2i, but not DPP-4i, declines with progressive renal insufficiency. In older adults, DPP-4i maintain their tolerability and efficacy, while SGLT2i may become less efficacious due to reduced renal function, and may be associated with higher rates of volume-related adverse effects. IMPLICATIONS Although both DPP-4i and SGLT2i are effective add-on antihyperglycemic therapies to metformin monotherapy, baseline characteristics, such as HbA1C, renal function, and age, should be considered when choosing between the 2 classes to allow for optimal and timely diabetes management.
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Esaki H, Tachi T, Goto C, Sugita I, Kanematsu Y, Yoshida A, Saito K, Noguchi Y, Ohno Y, Aoyama S, Yasuda M, Mizui T, Yamamura M, Teramachi H. Renoprotective Effect of Dipeptidyl Peptidase-4 Inhibitors in Patients with Type 2 Diabetes Mellitus. Front Pharmacol 2017; 8:835. [PMID: 29187821 PMCID: PMC5694778 DOI: 10.3389/fphar.2017.00835] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 11/02/2017] [Indexed: 12/21/2022] Open
Abstract
Diabetic nephropathy is one of three major complications of diabetes mellitus, often leading to chronic renal failure requiring dialysis. Recently developed dipeptidyl peptidase-4 (DPP-4) inhibitors may exhibit renoprotective effects in addition to antihyperglycemic effects. In this study, we retrospectively investigated temporal changes in the renal function index of patients with type 2 diabetes mellitus (DM) and examined the influence of DPP-4 inhibitors on renal function. Patients with type 2 DM (>18 years old) prescribed hypoglycemic agents at Gifu Municipal Hospital for ≥3 months between March 2010 and April 2014 were included in the study. Renal function was evaluated as estimated the decline in 12-month glomerular filtration rate from the baseline in patients receiving and not receiving DPP-4 inhibitors. Patient data from the DPP-4 inhibitor-treated (501 patients, 58.6%) and untreated (354, 41.4%) groups were analyzed using multiple logistic regression analysis, as well as Cox proportional-hazards regression analysis (616, 55.6% and 491, 44.4%, for DPP-4 inhibitors-treated and untreated groups). Multiple logistic regression analysis indicated that DPP-4 inhibitors significantly lowered the estimated glomerular filtration rate (eGFR) decline [20% over 12 months; odds ratio (OR), 0.626; 95% confidence interval [CI], 0.409–0.958; P = 0.031]. Similar results were obtained using Cox proportional-hazards regression analysis (hazard ratio [HR], 0.707; 95% CI, 0.572–0.874; P = 0.001). These findings suggest that DPP-4 inhibitors suppress the decrease of estimated glomerular filtration rate in patients with type 2 DM and show a renoprotective effect.
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Affiliation(s)
- Hiroki Esaki
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan.,Department of Pharmacy, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Tomoya Tachi
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan.,Department of Pharmacy, Gifu Municipal Hospital, Gifu, Japan
| | - Chitoshi Goto
- Department of Pharmacy, Gifu Municipal Hospital, Gifu, Japan
| | - Ikuto Sugita
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Yuta Kanematsu
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Aki Yoshida
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Kosuke Saito
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Yoshihiro Noguchi
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Yuki Ohno
- Department of Pharmacy, Gifu Municipal Hospital, Gifu, Japan
| | - Satoshi Aoyama
- Department of Pharmacy, Gifu Municipal Hospital, Gifu, Japan
| | - Masahiro Yasuda
- Department of Pharmacy, Gifu Municipal Hospital, Gifu, Japan
| | - Takashi Mizui
- Department of Pharmacy, Gifu Municipal Hospital, Gifu, Japan
| | - Masumi Yamamura
- Department of Pharmacy, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Hitomi Teramachi
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan.,Laboratory of Community Healthcare Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
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Renal outcomes with dipeptidyl peptidase-4 inhibitors. DIABETES & METABOLISM 2017; 44:101-111. [PMID: 29146035 DOI: 10.1016/j.diabet.2017.07.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/11/2017] [Accepted: 07/14/2017] [Indexed: 02/06/2023]
Abstract
Dipeptidyl peptidase-4 inhibitors (DPP-4is) are increasingly being used in the management of type 2 diabetes (T2D). The present review summarizes the current knowledge of the effects of DPP-4is on renal outcomes by analyzing the experimental preclinical data, the effects of DPP-4is on urinary albumin-creatinine ratios (UACRs) and estimated glomerular filtration rates (eGFRs) from observational studies and clinical trials, and renal events (including kidney failure requiring renal replacement therapy) in recent large prospective cardiovascular outcome trials. Renal protection has been demonstrated in various animal models that have implicated different underlying mechanisms independent of glucose control, whereas prevention of new onset microalbuminuria and/or progression of albuminuria has been reported in some clinical studies, but with no significant effects on eGFR in most of them. The long-term clinical effects of DPP-4is on renal outcomes and the development of end-stage renal disease remain largely unknown and, thus, demand further investigations in prospective trials and long-term observational studies. In conclusion, despite promising results in animal models, data on surrogate biological markers of renal function and clinical renal outcomes remain rather scanty in patients with T2D, and mostly demonstrate the safety rather than true efficacy of DPP-4is.
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Groop P, Cooper ME, Perkovic V, Hocher B, Kanasaki K, Haneda M, Schernthaner G, Sharma K, Stanton RC, Toto R, Cescutti J, Gordat M, Meinicke T, Koitka‐Weber A, Thiemann S, von Eynatten M. Linagliptin and its effects on hyperglycaemia and albuminuria in patients with type 2 diabetes and renal dysfunction: the randomized MARLINA-T2D trial. Diabetes Obes Metab 2017; 19:1610-1619. [PMID: 28636754 PMCID: PMC5655723 DOI: 10.1111/dom.13041] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/16/2017] [Accepted: 06/17/2017] [Indexed: 02/06/2023]
Abstract
AIMS The MARLINA-T2D study (ClinicalTrials.gov, NCT01792518) was designed to investigate the glycaemic and renal effects of linagliptin added to standard-of-care in individuals with type 2 diabetes and albuminuria. METHODS A total of 360 individuals with type 2 diabetes, HbA1c 6.5% to 10.0% (48-86 mmol/mol), estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m2 and urinary albumin-to-creatinine ratio (UACR) 30-3000 mg/g despite single agent renin-angiotensin-system blockade were randomized to double-blind linagliptin (n = 182) or placebo (n = 178) for 24 weeks. The primary and key secondary endpoints were change from baseline in HbA1c at week 24 and time-weighted average of percentage change from baseline in UACR over 24 weeks, respectively. RESULTS Baseline mean HbA1c and geometric mean (gMean) UACR were 7.8% ± 0.9% (62.2 ± 9.6 mmol/mol) and 126 mg/g, respectively; 73.7% and 20.3% of participants had microalbuminuria or macroalbuminuria, respectively. After 24 weeks, the placebo-adjusted mean change in HbA1c from baseline was -0.60% (-6.6 mmol/mol) (95% confidence interval [CI], -0.78 to -0.43 [-8.5 to -4.7 mmol/mol]; P < .0001). The placebo-adjusted gMean for time-weighted average of percentage change in UACR from baseline was -6.0% (95% CI, -15.0 to 3.0; P = .1954). The adverse-event profile, including renal safety and change in eGFR, was similar between the linagliptin and placebo groups. CONCLUSIONS In individuals at early stages of diabetic kidney disease, linagliptin significantly improved glycaemic control but did not significantly lower albuminuria. There was no significant change in placebo-adjusted eGFR. Detection of clinically relevant renal effects of linagliptin may require longer treatment, as its main experimental effects in animal studies have been to reduce interstitial fibrosis rather than alter glomerular haemodynamics.
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Affiliation(s)
- Per‐Henrik Groop
- Folkhälsan Institute of GeneticsFolkhälsan Research Center, Biomedicum HelsinkiHelsinkiFinland
- Abdominal Center NephrologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
- Baker IDI Heart and Diabetes InstituteMelbourneAustralia
| | - Mark E. Cooper
- Baker IDI Heart and Diabetes InstituteMelbourneAustralia
| | - Vlado Perkovic
- The George Institute for Global Health, Faculty of MedicineUniversity of SydneySydneyAustralia
| | - Berthold Hocher
- Institute of Nutritional ScienceUniversity of PotsdamPotsdamGermany
- Department of Histology and EmbryologyMedical College, Jinan UniversityGuangzhouChina
- IFLb, Institut für Laboratoriumsmedizin Berlin GmbHBerlinGermany
| | - Keizo Kanasaki
- Department of Diabetology and EndocrinologyKanazawa Medical UniversityKanazawaJapan
- Division of Anticipatory Molecular Food Science and TechnologyMedical Research Institute, Kanazawa Medical UniversityKanazawaJapan
| | - Masakazu Haneda
- Division of Metabolism and Biosystemic Science, Department of MedicineAsahikawa Medical UniversityAsahikawaJapan
| | | | - Kumar Sharma
- Department of Medicine, Center for Renal Translational MedicineUniversity of CaliforniaSan DiegoCalifornia
| | | | - Robert Toto
- Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexas
| | | | - Maud Gordat
- Boehringer Ingelheim France S.A.SReimsFrance
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Abstract
The gastrointestinal tract - the largest endocrine network in human physiology - orchestrates signals from the external environment to maintain neural and hormonal control of homeostasis. Advances in understanding entero-endocrine cell biology in health and disease have important translational relevance. The gut-derived incretin hormone glucagon-like peptide 1 (GLP-1) is secreted upon meal ingestion and controls glucose metabolism by modulating pancreatic islet cell function, food intake and gastrointestinal motility, amongst other effects. The observation that the insulinotropic actions of GLP-1 are reduced in type 2 diabetes mellitus (T2DM) led to the development of incretin-based therapies - GLP-1 receptor agonists and dipeptidyl peptidase 4 (DPP-4) inhibitors - for the treatment of hyperglycaemia in these patients. Considerable interest exists in identifying effects of these drugs beyond glucose-lowering, possibly resulting in improved macrovascular and microvascular outcomes, including in diabetic kidney disease. As GLP-1 has been implicated as a mediator in the putative gut-renal axis (a rapid-acting feed-forward loop that regulates postprandial fluid and electrolyte homeostasis), direct actions on the kidney have been proposed. Here, we review the role of GLP-1 and the actions of associated therapies on glucose metabolism, the gut-renal axis, classical renal risk factors, and renal end points in randomized controlled trials of GLP-1 receptor agonists and DPP-4 inhibitors in patients with T2DM.
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Ning G, Bandgar T, Hehnke U, Lee J, Chan JCN. Efficacy and Safety of Linagliptin in 2681 Asian Patients Stratified by Age, Obesity, and Renal Function: A Pooled Analysis of Randomized Clinical Trials. Adv Ther 2017; 34:2150-2162. [PMID: 28819835 PMCID: PMC5599450 DOI: 10.1007/s12325-017-0595-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Indexed: 12/21/2022]
Abstract
Introduction Asian patients with type 2 diabetes (T2D) are younger, leaner, and more likely to develop renal dysfunction than White populations. In this multiethnic analysis of data from phase 3 trials, we investigated the efficacy and safety of the dipeptidyl peptidase-4 inhibitor linagliptin in Asians stratified by these subphenotypes. Methods Data from randomized, double-blind, placebo-controlled trials evaluating linagliptin (as monotherapy, add-on therapy to metformin ± sulfonylurea, combined with pioglitazone or added to insulin) were pooled with efficacy data from 11 randomized trials of at least 24 weeks and safety data from 15 trials of various durations. Results In the efficacy set, 1404 Asian patients received linagliptin [mean (standard deviation) age 54.5 (10.1) years; body mass index (BMI) 26.0 (3.9) kg/m2] and 661 received placebo [age 55.0 (9.7) years; BMI 26.1 (3.9) kg/m2] with the same glycated hemoglobin (HbA1c): 8.2 (0.9)% in both groups. At 24 weeks, the placebo-corrected adjusted mean ± standard error change from baseline in HbA1c with linagliptin was −0.73 ± 0.04% (95% confidence interval −0.81, −0.65; P < 0.0001). Reductions in HbA1c were similar upon stratification by age [<65 years, −0.71 ± 0.05% (−0.80, −0.62; P < 0.0001); ≥65 years, −0.81 ± 0.10% (−1.01, −0.60; P < 0.0001)], BMI (<25 kg/m2, −0.82 ± 0.06% [−0.94, −0.70; P < 0.0001]; ≥25 kg/m2, −0.65 ± 0.06% [−0.76, −0.54; P < 0.0001]) and estimated glomerular filtration rate [<90 mL/min/1.73 m2, −0.71 ± 0.06% (−0.82, −0.60; P < 0.0001); ≥90 mL/min/1.73 m2, −0.75 ± 0.06% (−0.87, −0.64; P < 0.0001)]. In the safety set (linagliptin, n = 1842; placebo, n = 839), 52.2% and 54.6% of patients, respectively, experienced adverse events. The rates of drug-related adverse events were 10.9% in the linagliptin group and 10.4% in the placebo group. The respective rates of hypoglycemia were 8.3% and 9.5%, mainly among patients treated with sulfonylurea or insulin. Severe hypoglycemia was rare (<1.0% in either group). Conclusion Linagliptin effectively reduced hyperglycemia in Asian patients with uncontrolled T2D, irrespective of age, BMI, renal function, or ethnic subgroups, and was well tolerated. Funding Boehringer Ingelheim, Eli Lilly and Company, and the Diabetes Alliance. Electronic supplementary material The online version of this article (doi:10.1007/s12325-017-0595-7) contains supplementary material, which is available to authorized users.
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Atkin SL, Katsiki N, Banach M, Mikhailidis DP, Pirro M, Sahebkar A. Effect of dipeptidyl peptidase-4 inhibitors on circulating tumor necrosis factor-α concentrations: A systematic review and meta-analysis of controlled trials. J Diabetes Complications 2017. [PMID: 28647512 DOI: 10.1016/j.jdiacomp.2017.05.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Dipeptidyl peptidase-4 (DPP-4) inhibitors improve glycemic control in patients with type 2 diabetes mellitus. There are also reports of an effect of these drugs in reducing inflammation through inhibition of tumor necrosis factor-α (TNF-α) that is an important mediator for several inflammatory processes. The present systematic review and meta-analysis were performed to evaluate the effect of DPP-4 inhibitors on circulating TNF-α levels in T2DM patients. METHODS A systematic review and a meta-analysis were undertaken on all controlled trials of DPP-4 inhibitors that included measurement of TNF-α. The search included PubMed-Medline, Scopus, ISI Web of Knowledge and Google Scholar databases. Quantitative data synthesis was performed using a random-effects model, with standardized mean difference (SMD) and 95% confidence interval (CI) as summary statistics. Meta-regression and leave-one-out sensitivity analysis were performed to assess the modifiers of treatment response. RESULTS Eight eligible articles (6 with sitagliptin and 2 with vildagliptin) comprising 9 treatment arms were selected for this meta-analysis. Meta-analysis suggested a significant reduction of circulating TNF-α concentrations following treatment with DPP-4 inhibitors (SMD: -1.84, 95% CI: -2.88, -0.80, p=0.001). The effect size was robust in the sensitivity analysis and not mainly driven by a single study. A subgroup analysis did not suggest any significant difference between the TNF-α-lowering activity of sitagliptin (SMD: -1.49, 95% CI: -2.89, -0.10) and vildagliptin (SMD: -2.80, 95% CI: -4.98, -0.61) (p=0.326). CONCLUSION This meta-analysis of the 8 available controlled trials showed that DPP-4 inhibition in patients with type 2 diabetes mellitus was associated with significant reductions in plasma TNF-α levels with no apparent difference between sitagliptin and vildagliptin.
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Affiliation(s)
| | - Niki Katsiki
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Maciej Banach
- Department of Hypertension, WAM University Hospital in Lodz, Medical University of Lodz, Zeromskiego 113, Lodz, Poland; Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, United Kingdom
| | - Matteo Pirro
- Unit of Internal Medicine, Angiology and Arteriosclerosis Diseases, Department of Medicine, University of Perugia, Perugia, Italy
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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59
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Abstract
There is a need for treatment options in patients with type 2 diabetes mellitus and kidney disease to achieve glucose targets without risk of hypoglycemia. This article describes management options for these patients using glucose-lowering therapies, in particular dipeptidyl peptidase-4 inhibitors.
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Affiliation(s)
- Polly A Bittle
- Polly A. Bittle is an NP, practice manager, chief operating officer, and clinical research director at Tampa Bay Nephrology Associates, Tampa, Fla
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Cardiovascular Safety of Dipeptidyl-Peptidase IV Inhibitors: A Meta-Analysis of Placebo-Controlled Randomized Trials. Am J Cardiovasc Drugs 2017; 17:143-155. [PMID: 27873238 DOI: 10.1007/s40256-016-0208-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Large randomized trials have shown conflicting evidence regarding the cardiovascular safety of dipeptidyl-peptidase 4 (DPP-4) inhibitors. Systematic reviews have been limited by incomplete data and inclusion of observational studies. This study aimed to systematically evaluate the cardiovascular safety of DPP-4 inhibitors in patients with type 2 diabetes. METHODS Electronic databases were searched for randomized trials that compared DPP-4 inhibitors versus placebo and reported cardiovascular outcomes. The main outcome assessed in this analysis was heart failure. Other outcomes included all-cause mortality, cardiovascular mortality, myocardial infarction, and ischemic stroke. Summary odds ratios (ORs) were primarily constructed using Peto's model. RESULTS A total of 90 trials with 66,730 patients were included. Compared with placebo, DPP-4 inhibitors were associated with a non-significant increased risk of heart failure [OR 1.11, 95% confidence interval (CI) 0.99-1.25, P = 0.07] at a mean of 108 weeks. The risk of all-cause mortality (OR 1.03, 95% CI 0.94-1.12, P = 0.53), cardiovascular mortality (OR 1.02, 95% CI 0.92-1.14, P = 0.72), myocardial infarction (OR 0.98, 95% CI 0.88-1.09, P = 0.69), and ischemic stroke (OR 0.99, 95% CI 0.85-1.15, P = 0.92) was similar between both groups. CONCLUSION In patients with type 2 diabetes, the safety profile of DPP-4 inhibitors is similar to placebo. As a class, there is only weak evidence for an increased risk of heart failure.
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Garla V, Yanes-Cardozo L, Lien LF. Current therapeutic approaches in the management of hyperglycemia in chronic renal disease. Rev Endocr Metab Disord 2017; 18:5-19. [PMID: 28258533 DOI: 10.1007/s11154-017-9416-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Diabetes mellitus (DM) and chronic kidney disease (CKD) are intricately intertwined. DM is the most common cause of CKD. Adequate control of DM is necessary for prevention of progression of CKD, while careful management of the metabolic abnormalities in CKD will assist in achieving better control of DM. Two of the key organs involved in glucose production are the kidney and the liver. Furthermore, the kidney also plays a role in glucose filtration and reabsorption. In CKD, monitoring of glycemic control using traditional methods such as Hemoglobin A1c (Hba1c) must be done with caution secondary to associated hematological abnormalities in CKD. With regard to medication management in the care of patients with DM, CKD has significant effects. For example, the dosages of oral and non-insulin anti-hyperglycemic agents often need to be modified according to renal function. Insulin metabolism is altered in CKD, and a reduction in insulin dose is almost always needed. Dialysis also affects various aspects of glucose homeostasis, necessitating appropriate changes in therapy. Due to the aforementioned factors glycemic management in patients with DM and CKD can be quiet challenging.
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Affiliation(s)
- Vishnu Garla
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA.
| | - Licy Yanes-Cardozo
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Lillian F Lien
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
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Verma S, Goldenberg RM, Bhatt DL, Farkouh ME, Quan A, Teoh H, Connelly KA, Leiter LA, Friedrich JO. Dipeptidyl peptidase-4 inhibitors and the risk of heart failure: a systematic review and meta-analysis. CMAJ Open 2017; 5:E152-E177. [PMID: 28459046 PMCID: PMC5403656 DOI: 10.9778/cmajo.20160058] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Given recent discrepant results from randomized controlled trials (RCTs), we examined the totality of RCT evidence assessing the association between dipeptidyl peptidase-4 (DPP-4) inhibitors and heart failure. METHODS MEDLINE, Embase and ClinicalTrials.gov were searched without language restrictions to August 2016 for RCTs comparing DPP-4 inhibitors to placebo or no therapy for a period of 24 weeks or more. We included all heart failure outcomes when listed either as a serious adverse event or adverse event. Pooled analyses used random-effects. RESULTS We identified 100 RCTs (n = 79 867) - 3 large cardiovascular-safety RCTs (SAVOR-TIMI 53[saxagliptin]/n = 16 492, EXAMINE[alogliptin]/n = 5380, and TECOS[sitagliptin]/n = 14 735), and 97 smaller RCTs with a primary outcome that was usually change in glycated hemoglobin. Virtually all RCTs were high-quality, multicentre, placebo-controlled trials. A total of 96% (1192/1244) of heart failure events were prespecified, blindly adjudicated and required hospital admission. Pooled results suggested a 13% increase in heart failure (relative risk [RR] 1.13, 95% confidence interval [CI] 1.01-1.26, I2 = 0%; 32 RCTs, n = 54 640, 1244 events). When including only the 3 large RCTs, the increase was similar, but not significant (RR 1.14, 95% CI 0.97-1.32; 3 RCTs, n = 36 543, 1169 adjudicated events; number needed to harm 246) owing to heterogeneity (I2 = 42%), which lead to wider CIs, because SAVOR-TIMI 53 showed increased heart failure (RR 1.26, 95% CI 1.06-1.49) and TECOS showed no effect (RR 1.00, 95% CI 0.83-1.19). INTERPRETATION Despite pooled data from 79 867 patients, whether DPP-4 inhibitors increase heart failure overall or exhibit within-class differences remains unresolved. Our results highlight the importance of ongoing trials that are comparing DPP-4 inhibitors to placebo, although no large cardiovascular-safety RCTs are comparing different DPP-4 inhibitors to each other; consequently, these will address the overall but not class-difference question.
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Affiliation(s)
- Subodh Verma
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Ronald M Goldenberg
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Deepak L Bhatt
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Michael E Farkouh
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Adrian Quan
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Hwee Teoh
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Kim A Connelly
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Lawrence A Leiter
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
| | - Jan O Friedrich
- Divisions of Cardiac Surgery (Verma, Quan, Teoh), Endocrinology and Metabolism (Teoh, Leiter) and Cardiology (Connelly), and Departments of Surgery (Verma), Medicine (Connelly, Leiter, Friedrich) and Critical Care (Friedrich), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Departments of Surgery (Verma), Medicine (Farkouh, Connelly, Leiter, Friedrich), Nutritional Sciences (Leiter) and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; LMC Diabetes & Endocrinology (Goldenberg), Thornhill, Ont.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (Bhatt), Boston, Mass.; Peter Munk Cardiac Centre (Farkouh), University Health Network, Toronto, Ont
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Sudha MJ, Salam HS, Viveka S, Udupa AL. Assessment of changes in insulin requirement in patients of type 2 diabetes mellitus on maintenance hemodialysis. J Nat Sci Biol Med 2017; 8:64-68. [PMID: 28250677 PMCID: PMC5320826 DOI: 10.4103/0976-9668.198348] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Hemodialysis improves insulin sensitivity. Currently, there is no recommendation for the adjustment of insulin dose on dialysis day and nondialysis day in diabetic patients. This study was undertaken to determine the variations in insulin requirement based on blood glucose levels on dialysis days and nondialysis days in type 2 diabetic patients with chronic kidney disease on maintenance hemodialysis. METHODOLOGY Twenty-eight diabetic patients on hemodialysis were recruited into the study after obtaining written informed consent and approval from Azeezia Ethics Committee. Capillary blood glucose levels, just before dialysis and 2 h after dialysis, were checked and compared with fasting and postprandial glucose levels on-off dialysis days. RESULTS Mean age of the patients was 59.5 (±2.3) years. The average duration of dialysis was 20.2 months. There was significant (35.8%) decrease in blood glucose levels 2 h after dialysis in comparison to predialysis levels (from mean level of 258-165 mg/dl). The decrease in the blood glucose levels from predialysis level to 2 h postdialysis level was statistically significant (P < 0.001). Both sets of data showed "strong" positive correlation with r = 0.657 and 0.849. The blood glucose levels on the day of dialysis were significantly lower than the off-day values. CONCLUSIONS Diabetic patients with end-stage renal disease on hemodialysis have lower capillary blood glucose levels postdialysis. This has to be addressed clinically to prevent hypoglycemic episodes by reducing exogenous insulin administration on the day of dialysis.
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Affiliation(s)
- M. J. Sudha
- Department of Pharmacology, Azeezia Institute of Medical Sciences, Kollam, Kerala, India
| | - Halma S. Salam
- Department of Medical Undergraduate Student, Azeezia Institute of Medical Sciences, Kollam, Kerala, India
| | - S. Viveka
- Department of Anatomy, Azeezia Institute of Medical Sciences, Kollam, Kerala, India
| | - A. L. Udupa
- Department of Pharmacology, Azeezia Institute of Medical Sciences, Kollam, Kerala, India
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Gianchandani RY, Neupane S, Iyengar JJ, Heung M. PATHOPHYSIOLOGY AND MANAGEMENT OF HYPOGLYCEMIAIN END-STAGE RENAL DISEASE PATIENTS: A REVIEW. Endocr Pract 2016; 23:353-362. [PMID: 27967230 DOI: 10.4158/ep161471.ra] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This review focuses on hypoglycemia in patients with end-stage renal disease (ESRD). It discusses the pathophysiology of glucose metabolism in the kidney, the impact of dialysis on glucose and insulin metabolism, and the challenges of glucose monitoring in ESRD. The clinical relevance of these changes is reviewed in relation to altered blood glucose targets and modification of antidiabetes therapy to prevent hypoglycemia. Based on current data and guidelines, recommendations for the outpatient and inpatient setting are provided for diabetes management in ESRD. METHODS PubMed, OVID, and Google Scholar were searched to identify related articles through May 2016 using the following keywords: "glucose metabolism," "kidney," "diabetes," "hypoglycemia," "ESRD," and "insulin" in various combinations for this review. RESULTS In ESRD, a combination of impaired insulin clearance, changes in glucose metabolism, and the dialysis process make patients vulnerable to low blood glucose levels. Hypoglycemia accounts for up to 3.6% of all ESRD-related admissions. At admission or during hospitalization, hypoglycemia in ESRD has a poor prognosis, with mortality rates reported at 30%. Several guidelines suggest a modified hemoglobin A1c (A1c) goal of 7 to 8.5% (53 to 69 mmol/mol) and an average blood glucose goal of 150 to 200 mg/dL. Noninsulin antidiabetes agents like dipeptidyl peptidase 4 inhibitors, repaglinide, and glipizide in appropriate doses and reduction of insulin doses up to 50% may help decrease hypoglycemia. CONCLUSION Patients with ESRD are at high risk for hypoglycemia. Increased awareness by providers regarding these risks and appropriate diabetes regimen adjustments can help minimize hypoglycemic events. ABBREVIATIONS ADA = antidiabetes agent BG = blood glucose CKD = chronic kidney disease DPP-4 = dipeptidyl peptidase 4 eGFR = estimated glomerular filtration rate ESRD = end-stage renal disease GFR = glomerular filtration rate HD = hemodialysis NPH = neutral protamine Hagedorn PD = peritoneal dialysis SA = short acting SU = sulfonylurea.
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Yajima T, Yajima K, Hayashi M, Takahashi H, Yasuda K. Efficacy and safety of teneligliptin in addition to insulin therapy in type 2 diabetes mellitus patients on hemodialysis evaluated by continuous glucose monitoring. Diabetes Res Clin Pract 2016; 122:78-83. [PMID: 27810689 DOI: 10.1016/j.diabres.2016.10.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/14/2016] [Indexed: 01/31/2023]
Abstract
AIMS Appropriate glycemic control without hypoglycemia is important in patients with type 2 diabetes on hemodialysis. Teneligliptin, a novel dipeptidyl peptidase-4 inhibitor, can be used without dose adjustment for these patients. Using continuous glucose monitoring (CGM), we evaluated the efficacy and safety of adding teneligliptin to insulin therapy. METHODS Twenty-one type 2 diabetes mellitus patients on hemodialysis treated with insulin were enrolled. After the adjustment of insulin dose, their blood glucose level was monitored by CGM. Insulin dose was reduced after teneligliptin administration. RESULTS The median total daily insulin dose significantly reduced from 18 (9-24)U to 6 (0-14)U (p<0.0001). Maximum, mean, and standard deviation of blood glucose level on the hemodialysis and non-hemodialysis days did not change after teneligliptin administration. However, minimum blood glucose level was significantly elevated on the hemodialysis day after teneligliptin administration (from 3.9±1.0mmol/L to 4.4±0.9mmol/L, p=0.040). The incidence of asymptomatic hypoglycemia on the hemodialysis day detected by CGM significantly decreased from 38.1% to 19.0% (p=0.049). CONCLUSIONS Teneligliptin may contribute toward reducing the total daily insulin dose and preventing hypoglycemic events on the hemodialysis day in type 2 diabetes mellitus patients.
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Affiliation(s)
- Takahiro Yajima
- Department of Nephrology, Matsunami General Hospital, Gifu 501-6062, Japan.
| | - Kumiko Yajima
- Department of Internal Medicine, Matsunami General Hospital, Gifu 501-6062, Japan
| | - Makoto Hayashi
- Department of Internal Medicine, Matsunami General Hospital, Gifu 501-6062, Japan
| | - Hiroshi Takahashi
- Division of Medical Statistics, Fujita Health University School of Medicine, Aichi 470-1192, Japan
| | - Keigo Yasuda
- Department of Internal Medicine, Matsunami General Hospital, Gifu 501-6062, Japan
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Tonneijck L, Smits MM, Muskiet MHA, Hoekstra T, Kramer MHH, Danser AHJ, Ter Wee PM, Diamant M, Joles JA, van Raalte DH. Renal Effects of DPP-4 Inhibitor Sitagliptin or GLP-1 Receptor Agonist Liraglutide in Overweight Patients With Type 2 Diabetes: A 12-Week, Randomized, Double-Blind, Placebo-Controlled Trial. Diabetes Care 2016; 39:2042-2050. [PMID: 27585605 DOI: 10.2337/dc16-1371] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 08/10/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate effects of dipeptidyl peptidase-4 inhibitor (DPP-4I) sitagliptin or glucagon-like peptide 1 (GLP-1) receptor agonist liraglutide treatment on renal hemodynamics, tubular functions, and markers of renal damage in overweight patients with type 2 diabetes without chronic kidney disease (CKD). RESEARCH DESIGN AND METHODS In this 12-week, randomized, double-blind trial, 55 insulin-naïve patients with type 2 diabetes (mean ± SEM: age 63 ± 7 years, BMI 31.8 ± 4.1 kg/m2, glomerular filtration rate [GFR] 83 ± 16 mL/min/1.73 m2; median [interquartile range]: albumin-to-creatinine ratio (ACR) 1.09 mg/mmol [0.47-3.31]) received sitagliptin (100 mg/day), liraglutide (1.8 mg/day), or matching placebos. GFR (primary end point) and effective renal plasma flow (ERPF) were determined by inulin and para-aminohippuric acid clearance, respectively. Intrarenal hemodynamic variables were estimated. Absolute and fractional excretions of sodium (FENa), potassium, and urea (FEU) and renal damage markers (ACR, neutrophil gelatinase-associated lipocalin [NGAL], and kidney injury molecule-1 [KIM-1]) were measured. Plasma renin concentration (PRC) and glycated hemoglobin (HbA1c) were assessed. At weeks 2 and 6, estimated GFR and fractional electrolyte excretions were determined. RESULTS At week 12, GFR was not affected by sitagliptin (-6 mL/min/1.73 m2 [95% CI -14 to 3], P = 0.17) or liraglutide (+3 mL/min/1.73 m2 [-5 to 11], P = 0.46), compared with placebo. Sitagliptin modestly reduced estimated glomerular hydraulic pressure (PGLO; P = 0.043). ERPF, other intrarenal hemodynamic variables, renal damage markers, and PRC did not change for both treatments. Both agents reduced HbA1c. Only at week 2, sitagliptin increased FENa and FEU (P = 0.005). CONCLUSIONS Twelve-week treatment with sitagliptin or liraglutide does not affect measured renal hemodynamics. No sustained changes in tubular functions or alteration in renal damage markers were observed. The validity and clinical relevance of the slight sitagliptin-induced PGLO reduction remains speculative.
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Affiliation(s)
- Lennart Tonneijck
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Mark M Smits
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Marcel H A Muskiet
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Trynke Hoekstra
- Department of Health Sciences and the EMGO Institute for Health and Care Research, VU University Amsterdam, Amsterdam, the Netherlands.,Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, the Netherlands
| | - Mark H H Kramer
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - A H Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Piet M Ter Wee
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - Michaela Diamant
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center, Utrecht, the Netherlands
| | - Daniël H van Raalte
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
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Howse PM, Chibrikova LN, Twells LK, Barrett BJ, Gamble JM. Safety and Efficacy of Incretin-Based Therapies in Patients With Type 2 Diabetes Mellitus and CKD: A Systematic Review and Meta-analysis. Am J Kidney Dis 2016; 68:733-742. [DOI: 10.1053/j.ajkd.2016.06.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 06/07/2016] [Indexed: 12/16/2022]
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Inagaki N, Sheu WHH, Owens DR, Crowe S, Bhandari A, Gong Y, Patel S. Efficacy and safety of linagliptin in type 2 diabetes patients with self-reported hepatic disorders: A retrospective pooled analysis of 17 randomized, double-blind, placebo-controlled clinical trials. J Diabetes Complications 2016; 30:1622-1630. [PMID: 27499458 DOI: 10.1016/j.jdiacomp.2016.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 07/08/2016] [Accepted: 07/09/2016] [Indexed: 01/14/2023]
Abstract
AIMS Liver disease is highly prevalent among people with type 2 diabetes mellitus (T2DM). We evaluated the dipeptidyl peptidase-4 inhibitor linagliptin in subjects with T2DM and hepatic disorders. METHODS Data were pooled from 17 randomized, double-blind, placebo-controlled clinical trials of linagliptin in T2DM subjects that included individuals with self-reported history of hepatic disorders at baseline. The primary endpoint was change in HbA1c from baseline to week 24. RESULTS Of the 7009 participants (56% white, 39% Asian), 574 had hepatic disorders, most commonly hepatic steatosis (60%). At week 24, adjusted mean±standard error (SE) change in HbA1c from baseline in those with hepatic disorders was -0.75%±0.05 with linagliptin and -0.20%±0.08 with placebo [treatment difference: -0.54% (95% confidence interval-0.72 to -0.36); P<.0001]. There was no significant difference in HbA1c reduction between subjects with or without baseline hepatic disorders (P=.4042). Among subjects with hepatic disorders, 13.5% and 14.8% of the linagliptin and placebo groups, respectively, reported drug-related adverse events while 10.4% and 15.9%, respectively, reported hypoglycemia. Overall, adverse event rates were similar in individuals with or without hepatic disorders. CONCLUSIONS This large pooled analysis suggests that linagliptin is effective and well tolerated in people with T2DM and liver disease.
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Affiliation(s)
- Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Wayne H-H Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - David R Owens
- Diabetes Research Group, Institute of Life Sciences, Swansea University, Swansea, Wales, UK
| | - Susanne Crowe
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Amit Bhandari
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Yan Gong
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
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Del Prato S, Patel S, Crowe S, von Eynatten M. Efficacy and safety of linagliptin according to patient baseline characteristics: A pooled analysis of three phase 3 trials. Nutr Metab Cardiovasc Dis 2016; 26:886-892. [PMID: 27484756 DOI: 10.1016/j.numecd.2016.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 06/03/2016] [Accepted: 06/24/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS We aimed to determine if patient baseline characteristics affect responses to linagliptin and identify relevant predictors of glycated hemoglobin (HbA1c) reduction in patients with type 2 diabetes mellitus (T2DM). METHODS AND RESULTS Data were pooled from three 24-week, placebo-controlled trials of similar design (linagliptin, n = 1651; placebo, n = 607). Patients were categorized according to baseline characteristics: age, T2DM duration, gender, body mass index (BMI), Homeostasis Model Assessment of Insulin Resistance (HOMA-IR), and metabolic syndrome (MetS). Changes from baseline in HbA1c after 24 weeks were assessed with analysis of covariance (ANCOVA). The proportion of patients with baseline HbA1c >7% achieving HbA1c of ≤7% at week 24 were evaluated. Independent predictors of HbA1c response with linagliptin were analyzed in a multivariate analysis with ANCOVA. Linagliptin treatment led to significant mean (SE) placebo-corrected reductions from baseline in HbA1c across all subgroups (-0.42% [±0.11] to -0.79% [0.08]; all p < 0.001). Within subgroups, HbA1c reduction was more pronounced in patients without MetS (-0.74% [0.06]; treatment interaction p = 0.0489). The proportion of patients with baseline HbA1c >7% achieving a target HbA1c ≤7% was greater with linagliptin versus placebo (30.2% vs 11.5%; odds ratio 3.82; 95% CI 2.82 to 5.17; p < 0.001). Characteristics significantly predicting HbA1c reductions after 24 weeks were fasting plasma glucose and race (both p < 0.05). CONCLUSION This post-hoc analysis supports that linagliptin achieved clinically meaningful improvements in hyperglycemia in patients with diverse clinical characteristics. These improvements were more pronounced in patients without MetS.
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Affiliation(s)
| | - S Patel
- Boehringer Ingelheim Ltd UK, Bracknell, Berkshire, UK
| | - S Crowe
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - M von Eynatten
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
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Aono M, Sato Y. Dipeptidyl peptidase 4 inhibitor linagliptin can decrease the dosage of erythropoiesis-stimulating agents in patients on hemodialysis. RENAL REPLACEMENT THERAPY 2016. [DOI: 10.1186/s41100-016-0058-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Ueda Y, Ishii H, Kitano T, Shindo M, Miyazawa H, Ito K, Hirai K, Kaku Y, Mori H, Hoshino T, Ookawara S, Kakei M, Tabei K, Morishita Y. Effects and Safety of Linagliptin as an Add-on Therapy in Advanced-Stage Diabetic Nephropathy Patients Taking Renin-Angiotensin-Aldosterone System Blockers. Drug Target Insights 2016; 10:13-8. [PMID: 27660406 PMCID: PMC5019128 DOI: 10.4137/dti.s38339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/11/2016] [Accepted: 08/15/2016] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND We investigated the effects and safety of linagliptin as an add-on therapy in patients with advanced-stage diabetic nephropathy (DMN) taking renin–angiotensin–aldosterone system (RAAS) blockers. METHOD Twenty advanced-stage DMN patients (estimated glomerular filtration rate (eGFR): 24.5 ± 13.4 mL/min/1.73 m2) taking RAAS blockers were administered 5 mg/day linagliptin for 52 weeks. Changes in glucose and lipid metabolism and renal function were evaluated. RESULTS Linagliptin decreased glycosylated hemoglobin levels (from 7.32 ± 0.77% to 6.85 ± 0.87%, P < 0.05) without changing fasting blood glucose levels, and significantly decreased total cholesterol levels (from 189.6 ± 49.0 to 170.2 ± 39.2 mg/dL, P < 0.05) and low-density lipoprotein cholesterol levels (from 107.1 ± 32.4 to 90.2 ± 31.0 mg/dL, P < 0.05) without changing high-density lipoprotein cholesterol and triglyceride levels. Urine protein/creatinine ratio and annual change in eGFR remained unchanged. No adverse effects were observed. CONCLUSION Linagliptin as an add-on therapy had beneficial effects on glucose and lipid metabolism without impairment of renal function, and did not have any adverse effects in this population of patients with advanced-stage DMN taking RAAS blockers.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Masafumi Kakei
- Division of Endocrinology and Metabolism, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medial University, Saitama, Japan
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Marín-Peñalver JJ, Martín-Timón I, Sevillano-Collantes C, del Cañizo-Gómez FJ. Update on the treatment of type 2 diabetes mellitus. World J Diabetes 2016; 7:354-95. [PMID: 27660695 PMCID: PMC5027002 DOI: 10.4239/wjd.v7.i17.354] [Citation(s) in RCA: 339] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/02/2016] [Accepted: 07/20/2016] [Indexed: 02/05/2023] Open
Abstract
To achieve good metabolic control in diabetes and keep long term, a combination of changes in lifestyle and pharmacological treatment is necessary. Achieving near-normal glycated hemoglobin significantly, decreases risk of macrovascular and microvascular complications. At present there are different treatments, both oral and injectable, available for the treatment of type 2 diabetes mellitus (T2DM). Treatment algorithms designed to reduce the development or progression of the complications of diabetes emphasizes the need for good glycaemic control. The aim of this review is to perform an update on the benefits and limitations of different drugs, both current and future, for the treatment of T2DM. Initial intervention should focus on lifestyle changes. Moreover, changes in lifestyle have proven to be beneficial, but for many patients is a complication keep long term. Physicians should be familiar with the different types of existing drugs for the treatment of diabetes and select the most effective, safe and better tolerated by patients. Metformin remains the first choice of treatment for most patients. Other alternative or second-line treatment options should be individualized depending on the characteristics of each patient. This article reviews the treatments available for patients with T2DM, with an emphasis on agents introduced within the last decade.
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Thomas MC, Paldánius PM, Ayyagari R, Ong SH, Groop PH. Systematic Literature Review of DPP-4 Inhibitors in Patients with Type 2 Diabetes Mellitus and Renal Impairment. Diabetes Ther 2016; 7:439-54. [PMID: 27502495 PMCID: PMC5014795 DOI: 10.1007/s13300-016-0189-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Dipeptidyl peptidase-4 (DPP-4) inhibitors are widely used in the management of patients with type 2 diabetes mellitus (T2DM) and renal impairment (RI). A systematic literature review was performed to compare the efficacy and safety of DPP-4 inhibitors in patients with T2DM and RI. METHODS We searched EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials (cut-off, June 2015) to identify ≥12-week, randomized, placebo-controlled trials on DPP-4 inhibitors in ≥50 patients with T2DM and RI. Outcomes of interest included change in glycated hemoglobin (HbA1c), overall safety, and incidence of hypoglycemic events (HEs). RESULTS Seven trials of ≤52-54 weeks duration were retrieved, which included one study each on vildagliptin, saxagliptin, and sitagliptin, two on linagliptin, and the remaining two were extension studies of vildagliptin and saxagliptin. Majority of patients were on insulin at baseline (53-86%), except in the sitagliptin study, where approximately 11% received insulin during the placebo-controlled phase. After 52 weeks, vildagliptin and saxagliptin reduced HbA1c levels by 0.6-0.7% (baseline 7.8-8.4%) versus placebo in the overall population. HbA1c reductions were similar at weeks 12 and 52. In the 12-week, placebo-controlled phase, sitagliptin and linagliptin reduced mean HbA1c by approximately 0.4% (baseline 7.7-8.1%) versus placebo. Rates of HEs with DPP-4 inhibitors were not significantly different versus placebo in any study. Rates of adverse events (AEs) and changes involving renal function were similar in the active- and placebo-treated groups. CONCLUSION These results suggest that DPP-4 inhibitors have the potential to improve glycemic control in patients with RI without increasing the risk of HEs or overall AEs. FUNDING Novartis Pharma AG.
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Affiliation(s)
- Merlin C Thomas
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia.
| | | | | | - Siew Hwa Ong
- Novartis Pharma AG, Basel, Switzerland
- Vifor Pharma Ltd., Glattbrugg, Switzerland
| | - Per-Henrik Groop
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
- Abdominal Centre Helsinki, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Institute of Genetics, Folkhälsan Research Centre, Biomedicum Helsinki, Helsinki, Finland
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74
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Lehrke M, Leiter LA, Hehnke U, Thiemann S, Bhandari A, Meinicke T, Johansen OE. Safety and efficacy of linagliptin in patients with type 2 diabetes mellitus and coronary artery disease: Analysis of pooled events from 19 clinical trials. J Diabetes Complications 2016; 30:1378-84. [PMID: 27396241 DOI: 10.1016/j.jdiacomp.2016.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 12/15/2022]
Abstract
AIMS To examine the safety and efficacy of linagliptin in patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) using pooled data from the global clinical trials program. METHODS Patient-level data were pooled from randomized, placebo-controlled clinical trials of linagliptin (5mg, monotherapy or combination therapy). Safety/efficacy analyses were conducted for patients with CAD and ≥12 and ≥24weeks of treatment, respectively. RESULTS The safety analysis included 19 trials (linagliptin, n=451; placebo, n=272) and the efficacy analysis, 12 trials (linagliptin, n=328; placebo, n=198); mean (± standard deviation) exposure to study treatment was 212 (144) days linagliptin and 245 (171) days placebo. Occurrence of cardiac adverse events (AEs) was similar for linagliptin- and placebo-treated patients (9.1% and 9.2%, respectively); exposure-adjusted incidence rates (per 100 patient-years) were 16.6 and 14.0, respectively. Overall incidence of AEs was numerically lower with linagliptin than placebo. After 24weeks, mean adjusted change (standard error) from baseline glycosylated hemoglobin was -0.64% (0.04) with linagliptin vs. -0.08% (0.05) with placebo (P<.001). CONCLUSIONS This comprehensive pooled analysis showed that addition of linagliptin to treatment regimens of patients with T2DM and CAD was not associated with an increased incidence of cardiac AEs, was well tolerated, and was effective.
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Affiliation(s)
| | - Lawrence A Leiter
- Keenan Research Centre in the Li Ka Shing Research Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Uwe Hehnke
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Sandra Thiemann
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Amit Bhandari
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
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75
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Li R, Wang R, Li H, Sun S, Zou M, Cheng G. Short-term and long-term effects of dipeptidyl peptidase-4 inhibitors in type 2 diabetes mellitus patients with renal impairment: a meta-analysis of randomized controlled trials. Diabetes Metab Res Rev 2016; 32:460-9. [PMID: 26433213 DOI: 10.1002/dmrr.2731] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 07/15/2015] [Accepted: 09/08/2015] [Indexed: 12/24/2022]
Abstract
To assess the short-term and long-term effects of dipeptidyl peptidase-4 (DPP-4) inhibitors in type 2 diabetes mellitus patients with renal impairment, a meta-analysis of randomized clinical trials of DPP-4 inhibitor interventions in type 2 diabetes mellitus patients with renal impairment was performed. PubMed, Embase, Cochrane Library and ClinicalTrials.gov were searched through the end of March 2015. Randomized clinical trials were selected if (1) DPP-4 inhibitors were compared with a placebo or other active-comparators, (2) the treatment duration was ≥12 weeks and (3) data regarding changes in haemoglobin A1c (HbA1c ), changes in fasting plasma glucose or hypoglycaemia and other adverse events were reported. Of 790 studies, ten studies on eight randomized clinical trials were included. Compared with the control group, DPP-4 inhibitors were associated with a greater HbA1c reduction in both the short-term [mean differences (MD) = -0.45, 95% confidence intervals (-0.57, -0.33), p < 0.0001] and long-term [MD = -0.33, 95% confidence intervals (-0.63, -0.03), p = 0.03] treatments. However, the long-term greater reduction in HbA1c with DPP-4 inhibitor treatment was only significant when the control treatment comprised placebo plus stable background treatment, but not glipizide plus stable background treatment. DPP-4 inhibitors were associated with a greater fasting plasma glucose reduction [MD = -12.59, 95% confidence intervals (-22.01, -3.17), p = 0.009] over the short-term; however, this effect was not present over the long-term. Regarding the hypoglycaemia adverse events assessment, the long-term treatment data indicated there was no increased risk of hypoglycaemia compared with placebo or active-controlled anti-diabetic drugs. The present meta-analysis confirms that DPP-4 inhibitors are effective and equivalent to other agents in type 2 diabetes mellitus patients with renal impairment. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Ruifei Li
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, China
| | - Rui Wang
- Department of Endocrinology, General Hospital of Shenyang Military Region, Shenyang, China
| | - Haixia Li
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, China
| | - Sihao Sun
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, China
| | - Meijuan Zou
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, China
| | - Gang Cheng
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, China
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76
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Park SH, Nam JY, Han E, Lee YH, Lee BW, Kim BS, Cha BS, Kim CS, Kang ES. Efficacy of different dipeptidyl peptidase-4 (DPP-4) inhibitors on metabolic parameters in patients with type 2 diabetes undergoing dialysis. Medicine (Baltimore) 2016; 95:e4543. [PMID: 27512877 PMCID: PMC4985332 DOI: 10.1097/md.0000000000004543] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Hyperglycemia is associated with increased mortality and morbidity in patients with type 2 diabetes mellitus (T2DM) who are undergoing dialysis. Although dipeptidyl peptidase-4 (DPP-4) inhibitors have been widely used in end-stage renal disease (ESRD) patients with T2DM, there are few studies on their efficacy in this population. We studied the effect of 3 different DPP-4 inhibitors on metabolic parameters in ESRD patients with T2DM.Two hundred ESRD patients with T2DM who were treated with DPP-4 inhibitors (sitagliptin, vildagliptin, or linagliptin) were enrolled and analyzed retrospectively. The changes in glycated hemoglobin (HbA1c), fasting plasma glucose, and lipid profiles were assessed before and after 3 months of treatment with DPP-4 inhibitors. Subgroup analysis was done for each hemodialysis (HD) and peritoneal dialysis (PD) group.There was no significant difference in the decrease in the HbA1c level among sitagliptin, vildagliptin, and linagliptin treatment groups (-0.74 ± 1.57, -0.39 ± 1.45, and -0.08 ± 1.40, respectively, P = 0.076). The changes in fasting blood glucose and lipid profiles were also not significantly different. In HD patients (n = 115), there was no difference in the HbA1c level among the 3 groups. In contrast, in PD patients (n = 85), HbA1c was reduced more after 3 months of treatment with sitagliptin compared with vildagliptin and linagliptin (-1.58 ± 0.95, -0.46 ± 0.98, -0.04 ± 1.22, respectively, P = 0.001).There was no significant difference in the glucose-lowering effect between the different DPP-4 inhibitors tested in ESRD patients. In PD patients, sitagliptin tends to lower the HbA1c level more than the other inhibitors. The glucose-lowering efficacy of the 3 DPP-4 inhibitors was comparable.
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Affiliation(s)
- Se Hee Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine
- Department of Medicine, The Graduate School, Yonsei University College of Medicine, Seoul
| | - Joo Young Nam
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Gyeonggi
| | - Eugene Han
- Division of Endocrinology and Metabolism, Department of Internal Medicine
- Department of Medicine, The Graduate School, Yonsei University College of Medicine, Seoul
| | - Yong-ho Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine
| | - Byung-Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine
| | - Beom Seok Kim
- Division of Nephrology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul
| | - Bong-Soo Cha
- Division of Endocrinology and Metabolism, Department of Internal Medicine
| | - Chul Sik Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Seok Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine
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77
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Singh-Franco D, Harrington C, Tellez-Corrales E. An updated systematic review and meta-analysis on the efficacy and tolerability of dipeptidyl peptidase-4 inhibitors in patients with type 2 diabetes with moderate to severe chronic kidney disease. SAGE Open Med 2016; 4:2050312116659090. [PMID: 27516879 PMCID: PMC4968114 DOI: 10.1177/2050312116659090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 06/14/2016] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE This updated meta-analysis determines the effect of dipeptidyl peptidase-4 inhibitors on glycemic and tolerability outcomes in patients with type 2 diabetes mellitus and chronic kidney disease with glomerular filtration rate of ⩽60 mL/min or on dialysis. METHODS In all, 14 citations were identified from multiple databases. Qualitative assessments and quantitative analyses were performed. RESULTS There were 2261 participants, 49-79 years of age, 49% men and 44% Caucasians. In seven placebo-comparator studies, reduction in hemoglobin A1c at weeks 12-24 was 0.55% (95% confidence interval: -0.68 to -0.43), P < 0.00001). In three sulfonylurea-comparator studies, dipeptidyl peptidase-4 inhibitors did not significantly reduce hemoglobin A1c at weeks 52-54 (-0.15% (95% confidence interval: -0.32 to 0.02)). In one sitagliptin versus albiglutide study, albiglutide significantly reduced hemoglobin A1c in patients with moderate renal impairment (-0.51%). A similar reduction in hemoglobin A1c was seen with sitagliptin versus vildagliptin (-0.56% vs -0.54%). Compared with placebo or sulfonylurea, dipeptidyl peptidase-4 inhibitors did not significantly reduce hemoglobin A1c after 12 and 54 weeks in patients on dialysis. Hypoglycemia was reported by ~30% of patients in both dipeptidyl peptidase-4 inhibitors and placebo groups over 24-52 weeks. While hypoglycemia was more common with a sulfonylurea at 52-54 weeks (risk ratio: 0.46 (95% confidence interval: 0.18 to 1.18)), there was significant heterogeneity (I (2) = 87%). Limitations included high drop-out rate from most studies and small number of active-comparator studies. CONCLUSIONS Dipeptidyl peptidase-4 inhibitors in patients with chronic kidney disease caused a modest reduction in hemoglobin A1c versus placebo, but not when compared with sulfonylureas or albiglutide, or when used in patients on dialysis. Additional active-comparator studies are needed to further elucidate the role of dipeptidyl peptidase-4 inhibitors in patients with chronic kidney disease stages 3-5 or on dialysis.
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Affiliation(s)
- Devada Singh-Franco
- Department of Pharmacy Practice, College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Catherine Harrington
- Department of Sociobehavioral and Administrative Pharmacy, College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Eglis Tellez-Corrales
- Department of Pharmacy Practice, College of Pharmacy, Marshall B. Ketchum University, Fullerton, CA, USA
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78
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Kamiya H. A systematic review of the benefits and harms of dipeptidyl peptidase-4 inhibitor for chronic kidney disease. Hemodial Int 2016; 21:72-83. [DOI: 10.1111/hdi.12438] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/17/2016] [Indexed: 01/25/2023]
Affiliation(s)
- Hiroyuki Kamiya
- Division of Hemodialysis; Sakura Clinic; 593-1 Dainichi, Yotukaidou Chiba Japan
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79
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Chen XW, He ZX, Zhou ZW, Yang T, Zhang X, Yang YX, Duan W, Zhou SF. Clinical pharmacology of dipeptidyl peptidase 4 inhibitors indicated for the treatment of type 2 diabetes mellitus. Clin Exp Pharmacol Physiol 2016; 42:999-1024. [PMID: 26173919 DOI: 10.1111/1440-1681.12455] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 06/11/2015] [Accepted: 07/06/2015] [Indexed: 12/16/2022]
Abstract
Dipeptidyl peptidase-4 (DPP-4) inhibitors are a class of oral antidiabetic drugs that improve glycaemic control without causing weight gain or increasing hypoglycaemic risk in patients with type 2 diabetes mellitus (T2DM). The eight available DPP-4 inhibitors, including alogliptin, anagliptin, gemigliptin, linagliptin, saxagliptin, sitagliptin, teneligliptin, and vildagliptin, are small molecules used orally with identical mechanism of action and similar safety profiles in patients with T2DM. DPP-4 inhibitors may be used as monotherapy or in double or triple combination with other oral glucose-lowering agents such as metformin, thiazolidinediones, or sulfonylureas. Although DPP-4 inhibitors have the same mode of action, they differ by some important pharmacokinetic and pharmacodynamic properties that may be clinically relevant in some patients. The main differences between the eight gliptins include: potency, target selectivity, oral bioavailability, elimination half-life, binding to plasma proteins, metabolic pathways, formation of active metabolite(s), main excretion routes, dosage adjustment for renal and liver insufficiency, and potential drug-drug interactions. The off-target inhibition of selective DPP-4 inhibitors is responsible for multiorgan toxicities such as immune dysfunction, impaired healing, and skin reactions. As a drug class, the DPP-4 inhibitors have become accepted in clinical practice due to their excellent tolerability profile, with a low risk of hypoglycaemia, a neutral effect on body weight, and once-daily dosing. It is unknown if DPP-4 inhibitors can prevent disease progression. More clinical studies are needed to validate the optimal regimens of DPP-4 inhibitors for the management of T2DM when their potential toxicities are closely monitored.
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Affiliation(s)
- Xiao-Wu Chen
- Department of General Surgery, The First People's Hospital of Shunde, Southern Medical University, Shunde, Foshan, Guangdong, China
| | - Zhi-Xu He
- Guizhou Provincial Key Laboratory for Regenerative Medicine, Stem Cell and Tissue Engineering Research Centre & Sino-US Joint Laboratory for Medical Sciences, Guiyang Medical University, Guiyang, Guizhou, China
| | - Zhi-Wei Zhou
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL, USA
| | - Tianxin Yang
- Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Centre, Salt Lake City, UT, USA
| | - Xueji Zhang
- Research Centre for Bioengineering and Sensing Technology, University of Science and Technology Beijing, Beijing, China
| | - Yin-Xue Yang
- Department of Colorectal Surgery, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Wei Duan
- School of Medicine, Deakin University, Waurn Ponds, Vic., Australia
| | - Shu-Feng Zhou
- Guizhou Provincial Key Laboratory for Regenerative Medicine, Stem Cell and Tissue Engineering Research Centre & Sino-US Joint Laboratory for Medical Sciences, Guiyang Medical University, Guiyang, Guizhou, China.,Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL, USA
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80
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Muller C, Dimitrov Y, Imhoff O, Richter S, Ott J, Krummel T, Bazin-Kara D, Chantrel F, Hannedouche T. Oral antidiabetics use among diabetic type 2 patients with chronic kidney disease. Do nephrologists take account of recommendations? J Diabetes Complications 2016; 30:675-80. [PMID: 26900098 DOI: 10.1016/j.jdiacomp.2016.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/12/2016] [Accepted: 01/20/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is an increasing prevalence of diabetes type 2 and chronic kidney disease, challenging appropriate prescribing of oral anti-diabetic drugs (OADs). METHODS We have described the practice patterns of 13 nephrologists in 4 centers, in a cohort of 301 consecutive adult type 2 diabetic patients. Among oral anti-diabetic prescriptions, we have detailed drugs dosage for each subject, with 3 different formulae for estimating glomerular filtration rate (GFR) and its adequation according to the latest ERBP recommendations (2015). As individuals were mostly obese in this work, we also compare adequacy rates using both standard indexed CKD-EPI formula and CKD-EPI formula de-indexed from body surface area. RESULTS Using the CKD-EPI formula as the reference method for estimating GFR, 53.5% of patients were outside the recommendations, mostly for metformin (30% of the whole cohort) and for sitagliptin (17.9% of the whole cohort). With Cockcroft and Gault formula, 38.2% of persons were outside recommendations and 45.9% (p<0.001) with CKD-EPI de-indexed. Among individuals consulting a nephrologist for the first time (n=90), 61.1% were outside recommendations (p=0.1). Among those persons under diabetologist supervision (n=103), 63.1% were outside recommendations (p=0.09), and were taking significantly more often metformin and insulin. CONCLUSION We have found a substantial number of inadequate OAD prescriptions in type 2 diabetic patients with chronic kidney disease. The proportion of individuals outside guidelines was strongly affected by the method used for estimating GFR and by the type of practice, i.e., specialists versus general practitioners.
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Affiliation(s)
- Clotilde Muller
- Strasbourg Civil Hospital, Nephrology department, 1 place de l'hôpital, 67000, Strasbourg, France; School of Medicine, University of Strasbourg, Rue Kirschleger, 67000, Strasbourg, France; UMR 1109, Laboratoire Immunologie et Rhumatologie, Strasbourg, France.
| | - Yves Dimitrov
- Haguenau Hospital, Nephrology department, 64 Avenue du Pr Leriche, 67500, Haguenau, France
| | - Olivier Imhoff
- Clinique Ste Anne, Nephrology department, Rue Philippe Thyss, 67085, Strasbourg, France
| | - Sarah Richter
- Clinique Ste Anne, Nephrology department, Rue Philippe Thyss, 67085, Strasbourg, France
| | - Julien Ott
- Haguenau Hospital, Nephrology department, 64 Avenue du Pr Leriche, 67500, Haguenau, France
| | - Thierry Krummel
- Strasbourg Civil Hospital, Nephrology department, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Dorothée Bazin-Kara
- Strasbourg Civil Hospital, Nephrology department, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Francois Chantrel
- Mulhouse Hospital, Nephrology department, 20 Avenue du Dr René Laennec, 68100, Mulhouse, France
| | - Thierry Hannedouche
- Strasbourg Civil Hospital, Nephrology department, 1 place de l'hôpital, 67000, Strasbourg, France; School of Medicine, University of Strasbourg, Rue Kirschleger, 67000, Strasbourg, France
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81
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Yang W, Cai X, Han X, Ji L. DPP-4 inhibitors and risk of infections: a meta-analysis of randomized controlled trials. Diabetes Metab Res Rev 2016; 32:391-404. [PMID: 26417956 DOI: 10.1002/dmrr.2723] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 08/25/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND To evaluate the risk of infections in the treatment of type 2 diabetes patients with dipeptidyl-peptidase 4 (DPP-4) inhibitors. METHODS A literature search was conducted through electronic databases. The inclusion criteria included study duration of no less than 12 weeks developed in type 2 diabetes patients, the use of a randomized control group receiving a DPP-4 inhibitor and the availability of outcome data for infections. Out of 2181 studies, 74 studies were finally included. RESULTS The risk of overall infection for DPP-4 inhibitors treatment was comparable to placebo (odds ratio (OR) = 0.97, 95% confidence interval (CI), 0.91 to 1.04, p = 0.40), metformin treatment (OR = 1.22, 95% CI, 0.95 to 1.56, p = 0.12), sulphonylurea treatment (OR = 1.09, 0.93 to 1.29, p = 0.29), thiazolidinedione treatment (OR = 0.86, 95% CI, 0.65 to 1.14, p = 0.29) and alpha glucosidase inhibitor treatment (OR = 1.03, 95% CI, 0.33 to 3.22, p = 0.96). When compared different DPP-4 inhibitors with placebo treatment, risks of infections were comparable for alogliptin, linagliptin, sitagliptin, saxagliptin and vildagliptin. Compared with placebo or active comparator treatment, risks of infection in different systems for DPP-4 inhibitors were all comparable. CONCLUSIONS The overall risk of infections of DPP-4 inhibitor was not increased compared with control groups.
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Affiliation(s)
- Wenjia Yang
- Endocrinology and Metabolism Department, Peking University People's Hospital, Beijing, China
| | - Xiaoling Cai
- Endocrinology and Metabolism Department, Peking University People's Hospital, Beijing, China
| | - Xueyao Han
- Endocrinology and Metabolism Department, Peking University People's Hospital, Beijing, China
| | - Linong Ji
- Endocrinology and Metabolism Department, Peking University People's Hospital, Beijing, China
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82
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Penno G, Garofolo M, Del Prato S. Dipeptidyl peptidase-4 inhibition in chronic kidney disease and potential for protection against diabetes-related renal injury. Nutr Metab Cardiovasc Dis 2016; 26:361-373. [PMID: 27105869 DOI: 10.1016/j.numecd.2016.01.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 12/21/2015] [Accepted: 01/07/2016] [Indexed: 02/06/2023]
Abstract
AIMS Type 2 diabetes mellitus (T2DM) is associated with a high risk of chronic kidney disease (CKD). About 20% of patients with T2DM have CKD of stage ≥ 3; up to 40% have some degree of CKD. Beyond targeting all renal risk factors together, renin-angiotensin-aldosterone system blockers are to date the only effective mainstay for the treatment of diabetic kidney disease (DKD). Indeed, several potentially nephroprotective agents have been in use, which have been unsuccessful. Some glucose-lowering agents, including dipeptidyl peptidase-4 inhibitors (DPP-4i), have shown promising results. Here, we discuss the evidence that glucose lowering with DPP-4i may be an option for protecting against diabetes-related renal injury. DATA SYNTHESIS A comprehensive search was performed of the literature using the terms "alogliptin," "linagliptin," "saxagliptin," "sitagliptin," and "vildagliptin" for original articles and reviews addressing this topic. DPP-4i are an effective, well-tolerated treatment option for T2DM with any degree of renal impairment. Preclinical observations and clinical studies suggest that DPP-4i might also be a promising strategy for the treatment of DKD. The available data are in favor of saxagliptin and linagliptin, but the consistency of results points to the possible nephroprotective effect of DPP-4i. This property appears to be independent of glucose lowering and can potentially complement other therapies that preserve renal function. Larger prospective clinical trials are ongoing, which might strengthen these hypothesis-generating findings. CONCLUSIONS The improvement in albuminuria associated with DPP-4i suggests that these agents may provide renal benefits beyond their glucose-lowering effects, thus offering direct protection from DKD. These promising results must be interpreted with caution and need to be confirmed in forthcoming studies.
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Affiliation(s)
- G Penno
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy.
| | - M Garofolo
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - S Del Prato
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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83
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Affiliation(s)
- Amar Puttanna
- Department of Diabetes and Endocrinology; City Hospital; Birmingham UK
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84
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Abstract
In Brief Patients with severe insulin resistance require >2 units/kg of body weight or 200 units/day of insulin. Yet, many patients do not achieve glycemic targets despite using very high doses of insulin. Insulin can cause weight gain, which further contributes to worsening insulin resistance. This article describes the pharmacological options for managing patients with severe insulin resistance, including the use of U-500 insulin and newer agents in combination with insulin.
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Affiliation(s)
- Timothy J. Church
- West Palm Beach Veteran’s Administration Medical Center, West Palm Beach, FL
| | - Stuart T. Haines
- University of Maryland School of Pharmacy, Department of Pharmacy Practice and Science, Baltimore, MD
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85
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Acute Kidney Injury Associated with Linagliptin. Case Rep Endocrinol 2016; 2016:5695641. [PMID: 26981294 PMCID: PMC4769737 DOI: 10.1155/2016/5695641] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 01/21/2016] [Indexed: 11/30/2022] Open
Abstract
Linagliptin is a dipeptidyl peptidase-IV (DPP-IV) inhibitor that is approved for the treatment of type 2 diabetes mellitus. About 5% of linagliptin is eliminated by the kidneys and no dose adjustment is recommended in kidney impairment. We report a first case of linagliptin-associated acute kidney injury (AKI) in a patient with preexisting chronic kidney disease (CKD). We hypothesize that AKI was due to renal hypoperfusion from linagliptin-induced natriuresis and intravascular volume contraction in the setting of concomitant lisinopril use, which is known to impair autoregulation and potentiate hypotension-induced AKI. It may be prudent to exert caution and closely monitor kidney function when initiating linagliptin in combination with ACE-inhibitors in CKD patients.
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86
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Wang W, Yang J, Yang G, Gong Y, Patel S, Zhang C, Izumoto T, Ning G. Efficacy and safety of linagliptin in Asian patients with type 2 diabetes mellitus inadequately controlled by metformin: A multinational 24-week, randomized clinical trial. J Diabetes 2016; 8:229-37. [PMID: 25753488 DOI: 10.1111/1753-0407.12284] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 01/12/2015] [Accepted: 02/20/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Despite the increasing prevalence of type 2 diabetes mellitus (T2DM) in Asia, clinical trials for glucose-lowering therapies are often dominated by Caucasian and/or Western populations. The present Phase III randomized placebo-controlled double-blind, 24-week study evaluated the efficacy and safety of the dipeptidyl peptidase-4 inhibitor linagliptin added to metformin in Asian T2DM patients. METHODS In all, 306 patients (n = 265 Chinese; n = 24 Malaysian; n = 17 Filipino), aged 18-80 years with HbA1c between ≥7.0 and ≤10.0% and on metformin therapy were randomized (2:1) to either linagliptin 5 mg daily or placebo added to metformin. Antidiabetes drugs other than metformin were washed out prior to randomization. The primary endpoint was change in mean HbA1c from baseline after 24 weeks. RESULTS Baseline characteristics were well-matched between the groups (overall mean [±SD] HbA1c 8.0 ± 0.8%). Adjusted mean (±SE) HbA1c decreased in the linagliptin and placebo groups by -0.66 ± 0.05 and -0.14 ± 0.07%, respectively (placebo-corrected difference -0.52 ± 0.09%; 95% confidence interval [CI] -0.70, -0.34; P < 0.0001). In patients with baseline HbA1c ≥8.5%, the placebo-corrected decrease in HbA1c was -0.89 ± 0.17% (P < 0.0001). Adverse events occurred in similar proportions in the linagliptin and placebo patients (27.3% and 28.0%, respectively) and few were considered drug-related (2.4% and 0.0%, respectively). Hypoglycemia occurred in 1.0% of patients in both groups. Linagliptin therapy was weight neutral. CONCLUSIONS Linagliptin 5 mg was efficacious and well tolerated over 24 weeks in Asian patients with T2DM inadequately controlled by metformin.
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Affiliation(s)
- Weiqing Wang
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinkui Yang
- Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Gangyi Yang
- The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yan Gong
- Boehringer Ingelheim Pharma, Ingelheim, Germany
| | | | - Candice Zhang
- Boehringer Ingelheim International Trading, Shanghai, China
| | | | - Guang Ning
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Chen M, Liu Y, Jin J, He Q. The efficacy and safety of dipeptidyl peptidase-4 inhibitors for treatment of type 2 diabetes mellitus patients with severe renal impairment: a meta-analysis. Ren Fail 2016; 38:581-7. [PMID: 26915531 DOI: 10.3109/0886022x.2016.1149682] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIMS/INTRODUCTION Dipeptidyl peptidase-4 (DPP-4) inhibitors are a new class of oral antidiabetic agents, and have been increasingly and widely used in the treatment of diabetes mellitus (DM). However, information of DPP-4 inhibitors in type 2 DM patients with severe renal impairment (RI) is limited. Our study aimed to assess the efficacy and safety of DPP-4 inhibitors as compared to placebos or other hypoglycemic drugs in type 2 DM patients with severe RI. MATERIALS AND METHODS A meta-analysis was conducted to examine the literature comparing the effects of DPP-4 inhibitors on hemoglobin A1c (HbA1c) and fasting blood glucose (FBG). Randomized control trials (RCTs) including adults with type 2 DM and severe RI were analyzed. Safety was evaluated based on the percentage of patients who developed hypoglycemia and the occurrence of adverse events (AEs) as well as the incidence of peripheral edema, urinary tract infection, diarrhea, and death. RESULTS Five RCTs including 503 patients were analyzed. Compared with a placebo or no treatment, DPP-4 inhibitors were associated with a larger decline in HbA1c (mean difference (MD) = -0.57, 95% confidence interval (CI): -0.73 to -0.41; p < 0.01) but not with FBG (MD = -0.26, 95% CI: -1.40 to 0.8; p = 0.66). Compared with glipizide monotherapy, no significant differences in HbA1c (MD = 0.15, 95% CI: -0.19 to 0.49; p = 0.38) or FBG (MD = -0.26, 95% CI: -1.16 to 0.64; p = 0.57) were found. Similar odds of experiencing an AE were found in both the DPP-4 inhibitor groups and comparison groups. CONCLUSIONS In type 2 DM patients with severe RI, treatment with DPP-4 inhibitors is safe and it effectively lowers HbA1c.
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Affiliation(s)
- Maosheng Chen
- a Department of Nephrology , Zhejiang Provincial People's Hospital , Hangzhou , PR China ;,b National Clinical Research Center of Kidney Diseases , Jinling Hospital, Nanjing University School of Medicine , Nanjing , PR China
| | - Yueming Liu
- a Department of Nephrology , Zhejiang Provincial People's Hospital , Hangzhou , PR China
| | - Juan Jin
- a Department of Nephrology , Zhejiang Provincial People's Hospital , Hangzhou , PR China
| | - Qiang He
- a Department of Nephrology , Zhejiang Provincial People's Hospital , Hangzhou , PR China ;,c Wenzhou Medical University Wenzhou , Wenzhou , PR China
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Davies MJ, Bain SC, Atkin SL, Rossing P, Scott D, Shamkhalova MS, Bosch-Traberg H, Syrén A, Umpierrez GE. Efficacy and Safety of Liraglutide Versus Placebo as Add-on to Glucose-Lowering Therapy in Patients With Type 2 Diabetes and Moderate Renal Impairment (LIRA-RENAL): A Randomized Clinical Trial. Diabetes Care 2016; 39:222-30. [PMID: 26681713 DOI: 10.2337/dc14-2883] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 10/15/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Renal impairment in type 2 diabetes limits available glucose-lowering treatment options. This trial was conducted to establish the efficacy and safety of liraglutide as an add-on to existing glucose-lowering medications in patients with inadequately controlled type 2 diabetes and moderate renal impairment. RESEARCH DESIGN AND METHODS In this 26-week, double-blind trial, 279 patients with HbA1c 7-10%, BMI 20-45 kg/m(2), and moderate renal impairment (estimated glomerular filtration rate [eGFR] 30-59 mL/min/1.73 m(2); MDRD) were randomized (1:1) to once-daily liraglutide 1.8 mg (n = 140) or placebo (n = 139). RESULTS The estimated treatment difference in HbA1c from baseline to week 26 was -0.66% (-7.25 mmol/mol) (95% CI -0.90 to -0.43 [-9.82 to -4.69]), P < 0.0001). Fasting plasma glucose decreased more with liraglutide (-1.22 mmol/L [-22.0 mg/dL]) than with placebo (-0.57 mmol/L [-10.3 mg/dL], P = 0.036). There was a greater reduction in body weight with liraglutide (-2.41 kg) than with placebo (-1.09 kg, P = 0.0052). No changes in renal function were observed (eGFR relative ratio to baseline: -1% liraglutide, +1% placebo; estimated treatment ratio [ETR] 0.98, P = 0.36). The most common adverse events were gastrointestinal (GI) adverse effects (liraglutide, 35.7%; placebo, 17.5%). No difference in hypoglycemic episodes was observed between treatment groups (event rate/100 patient-years of exposure: liraglutide, 30.47; placebo, 40.08; P = 0.54). The estimated ratio to baseline for lipase was 1.33 for liraglutide and 0.97 for placebo (ETR 1.37, P < 0.0001). CONCLUSIONS Liraglutide did not affect renal function and demonstrated better glycemic control, with no increase in hypoglycemia risk but with higher withdrawals due to GI adverse events than placebo in patients with type 2 diabetes and moderate renal impairment.
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Affiliation(s)
- Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, U.K.
| | - Stephen C Bain
- Institute of Life Science, Swansea University, Swansea, U.K
| | - Stephen L Atkin
- Qatar Foundation, Weill Cornell Medical College, Doha, Qatar
| | | | - David Scott
- Clinical Research Development Associates, Rosedale, NY
| | - Minara S Shamkhalova
- Department of Diabetic Nephropathy, Endocrinology Research Centre, Moscow, Russia
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Mori K, Emoto M, Shoji T, Inaba M. Linagliptin monotherapy compared with voglibose monotherapy in patients with type 2 diabetes undergoing hemodialysis: a 12-week randomized trial. BMJ Open Diabetes Res Care 2016; 4:e000265. [PMID: 27547421 PMCID: PMC4964246 DOI: 10.1136/bmjdrc-2016-000265] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/23/2016] [Accepted: 06/27/2016] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Focusing on efficacy and tolerability, we compared linagliptin monotherapy with voglibose monotherapy in patients with type 2 diabetes undergoing hemodialysis (HD). RESEARCH DESIGN AND METHODS In this multicenter, randomized, open-label, parallel-group, active-controlled study, 78 patients were randomized (1:1) to receive a 12-week treatment with 5 mg linagliptin once daily or 0.2 mg voglibose three times a day. To assess whether linagliptin was superior to voglibose, the primary efficacy end point was the change in glycated hemoglobin (HbA1c) level between baseline and week 12. Secondary efficacy end points included changes between baseline and week 12 in glycated albumin (GA) and casual plasma glucose (PG) levels. RESULTS At week 12, the adjusted mean HbA1c levels had decreased by -0.60% after treatment with linagliptin and by -0.20% after treatment with voglibose (treatment difference: -0.40%, 95% CI -0.74% to -0.06%, p=0.022). A significant reduction in casual PG level was also observed after treatment with linagliptin compared with treatment with voglibose. Relative to voglibose, linagliptin tended to elicit reductions in GA, although without statistical significance. No hypoglycemic symptoms or severe hypoglycemia occurred during the study. CONCLUSIONS In patients with type 2 diabetes undergoing HD, linagliptin monotherapy provided significantly better glycemic control without severe hypoglycemia than voglibose monotherapy. Linagliptin represents a promising agent for glycemic management in patients with type 2 diabetes undergoing HD. TRIAL REGISTRATION NUMBER UMIN000007635; results.
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Affiliation(s)
- Katsuhito Mori
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masanori Emoto
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tetsuo Shoji
- Department of Geriatrics and Vascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
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Triplitt C, Solis-Herrera C, Cersosimo E, Abdul-Ghani M, Defronzo RA. Empagliflozin and linagliptin combination therapy for treatment of patients with type 2 diabetes mellitus. Expert Opin Pharmacother 2015; 16:2819-33. [PMID: 26583910 DOI: 10.1517/14656566.2015.1114098] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Many patients with type 2 diabetes mellitus (T2DM) fail to achieve the desired A1c goal because the antidiabetic medications used do not correct the underlying pathophysiologic abnormalities and monotherapy is not sufficiently potent to reduce the A1c to the 6.5 - 7.0% range. Insulin resistance and islet (beta and alpha) cell dysfunction are major pathophysiologic abnormalities in T2DM. We examine combination therapy with linagliptin plus empagliflozin as a therapeutic approach for the treatment of inadequately controlled T2DM patients. AREAS COVERED A literature search of all human diabetes, metabolism and general medicine journals from year 2000 to the present was conducted. Glucagon like peptide-1 (GLP-1) deficiency/resistance contributes to islet cell dysfunction by impairing insulin secretion and increasing glucagon secretion. DPP-4 inhibitors (DPP4i) improve pancreatic islet function by augmenting glucose-dependent insulin secretion and decreasing elevated plasma glucagon levels. Linagliptin, a DPP-4 inhibitor, reduces HbA1c, is weight neutral, has an excellent safety profile and a low risk of hypoglycemia. The expression of sodium-glucose cotransporter-2 (SGLT2) in the proximal renal tubule is upregulated in T2DM, causing excess reabsorption of filtered glucose. The SGLT2 inhibitor (SGLT2i), empagliflozin, improves HbA1c by causing glucosuria and ameliorating glucotoxicity. It also decreases weight and blood pressure, and has a low risk of hypoglycemia. EXPERT OPINION The once daily oral combination of linagliptin plus empagliflozin does not increase the risk of hypoglycemia and tolerability and discontinuation rates are similar to those with each as monotherapy. At HbA1c values below 8.5% linagliptin/empagliflozin treatment produces an additive effect, whereas above 8.5%, there is a less than additive reduction with combination therapy compared with the effect of each agent alone. Linagliptin/empagliflozin addition is a logical combination in patients with T2DM, especially those with an HbA1c < 8.5%.
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Affiliation(s)
- C Triplitt
- a Department of Medicine, Diabetes Division , University of Texas Health Science Center and Texas Diabetes Institute , San Antonio , TX 78229 , USA
| | - C Solis-Herrera
- a Department of Medicine, Diabetes Division , University of Texas Health Science Center and Texas Diabetes Institute , San Antonio , TX 78229 , USA
| | - E Cersosimo
- a Department of Medicine, Diabetes Division , University of Texas Health Science Center and Texas Diabetes Institute , San Antonio , TX 78229 , USA
| | - M Abdul-Ghani
- a Department of Medicine, Diabetes Division , University of Texas Health Science Center and Texas Diabetes Institute , San Antonio , TX 78229 , USA
| | - Ralph A Defronzo
- a Department of Medicine, Diabetes Division , University of Texas Health Science Center and Texas Diabetes Institute , San Antonio , TX 78229 , USA
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Groop PH, Cooper ME, Perkovic V, Sharma K, Schernthaner G, Haneda M, Hocher B, Gordat M, Cescutti J, Woerle HJ, von Eynatten M. Dipeptidyl peptidase-4 inhibition with linagliptin and effects on hyperglycaemia and albuminuria in patients with type 2 diabetes and renal dysfunction: Rationale and design of the MARLINA-T2D™ trial. Diab Vasc Dis Res 2015. [PMID: 26224765 DOI: 10.1177/1479164115579002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Efficacy, Safety & Modification of Albuminuria in Type 2 Diabetes Subjects with Renal Disease with LINAgliptin (MARLINA-T2D™), a multicentre, multinational, randomized, double-blind, placebo-controlled, parallel-group, phase 3b clinical trial, aims to further define the potential renal effects of dipeptidyl peptidase-4 inhibition beyond glycaemic control. A total of 350 eligible individuals with inadequately controlled type 2 diabetes and evidence of renal disease are planned to be randomized in a 1:1 ratio to receive either linagliptin 5 mg or placebo in addition to their stable glucose-lowering background therapy for 24 weeks. Two predefined main endpoints will be tested in a hierarchical manner: (1) change from baseline in glycated haemoglobin and (2) time-weighted average of percentage change from baseline in urinary albumin-to-creatinine ratio. Both endpoints are sufficiently powered to test for superiority versus placebo after 24 weeks with α = 0.05. MARLINA-T2D™ is the first of its class to prospectively explore both the glucose- and albuminuria-lowering potential of a dipeptidyl peptidase-4 inhibitor in patients with type 2 diabetes and evidence of renal disease.
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Affiliation(s)
- Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Helsinki, Finland Division of Nephrology, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland Baker IDI Heart & Diabetes Institute, Melbourne, VIC, Australia
| | - Mark E Cooper
- Baker IDI Heart & Diabetes Institute, Melbourne, VIC, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Kumar Sharma
- Research Service and Division of Nephrology-Hypertension, Veterans Affairs San Diego Healthcare System, Veterans Medical Research Foundation, San Diego, CA, USA Center for Renal Translational Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | | | - Masakazu Haneda
- Division of Metabolism and Biosystemic Science, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Berthold Hocher
- Institute of Nutritional Science, University of Potsdam, Potsdam, Germany
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Roussel R, Lorraine J, Rodriguez A, Salaun-Martin C. Overview of Data Concerning the Safe Use of Antihyperglycemic Medications in Type 2 Diabetes Mellitus and Chronic Kidney Disease. Adv Ther 2015; 32:1029-64. [PMID: 26581749 DOI: 10.1007/s12325-015-0261-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Indexed: 12/26/2022]
Abstract
INTRODUCTION It can be a challenge to manage glycemic control in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD), due to both patient and medication issues. Although most antihyperglycemic medications can be used in mild kidney disease, many medications are either not advised or require dose adjustments in more advanced CKD. This review summarizes product label information, pharmacokinetic and clinical studies, and clinical guidelines relevant to use of antihyperglycemic medications in CKD. METHODS Product labels and guidelines from North America and Europe, as well as pharmacokinetic and clinical studies of diabetes medication use in CKD were identified through Medline and PubMed searches, up to February 2015. Available data are summarized and correlations between treatment recommendations and available research are discussed, as are glycemic targets for patients with CKD. RESULTS Newer medications have significantly more data available than older medications regarding use in CKD, although larger clinical studies are still lacking for some drugs. As CKD advances, dose adjustment is needed for many medications [numerous dipeptidyl peptidase-4 inhibitors, some insulins, sodium glucose co-transporter 2 (SGLT2) inhibitors], although not for others (thiazolidinediones, meglitinides). Some medications are not recommended for use in more advanced CKD (metformin, SGLT2 inhibitors, some glucagon-like protein-1 receptor agonists) for safety or efficacy reasons. There is not always good alignment between label recommendations, pharmacokinetic or clinical studies, and guideline recommendations for use of these drugs in CKD. In particular, controversy remains about the use of metformin in moderate CKD and appropriate use of liraglutide and sulfonylureas in advanced CKD. CONCLUSION Considerable variability exists with respect to recommendations and clinical data for the many antihyperglycemic drugs used in patients with T2DM and CKD. FUNDING Eli Lilly and Company.
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Affiliation(s)
- Ronan Roussel
- Division of Endocrinology Diabetes and Nutrition, DHU FIRE, Groupe Hospitalier Bichat-Claude Bernard, AP-HP, Paris, France.
- INSERM U 1138, Cordeliers Research Center, Paris, France.
- University Paris Diderot-Paris 7, Paris, France.
| | | | | | - Carole Salaun-Martin
- Eli Lilly, Neuilly Cedex, France
- Division of Endocrinology Diabetes and Nutrition, Hopital Max Fourestier, Nanterre, France
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Zinman B, Ahrén B, Neubacher D, Patel S, Woerle HJ, Johansen OE. Efficacy and Cardiovascular Safety of Linagliptin as an Add-On to Insulin in Type 2 Diabetes: A Pooled Comprehensive Post Hoc Analysis. Can J Diabetes 2015; 40:50-7. [PMID: 26474870 DOI: 10.1016/j.jcjd.2015.06.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 06/26/2015] [Accepted: 06/26/2015] [Indexed: 01/16/2023]
Abstract
OBJECTIVE With the expanding armamentarium of noninsulin therapies for type 2 diabetes mellitus, the use of insulin with various oral agents is becoming more common. In this study, we assessed the efficacy and cardiovascular (CV) safety of the dipeptidyl peptidase-4 inhibitor linagliptin as add-on to insulin in patients with type 2 diabetes. METHODS In this post hoc analysis, data for patients receiving basal or basal-bolus insulin were pooled from 4 randomized, double-blind, phase 3 clinical trials of linagliptin 5 mg once daily or placebo given as add-on to background glucose-lowering treatment. Changes in glycated hemoglobin (A1C) and CV risk factors were assessed from baseline to end of trial. The primary CV endpoint was a composite of CV death, nonfatal myocardial infarction, nonfatal stroke and hospitalization due to unstable angina. RESULTS The number of patients receiving basal or basal-bolus insulin as background therapy was 1613 (linagliptin: n=811; placebo: n=802). The placebo-adjusted mean (SE) change from baseline in A1C was -0.41 (0.05)% (95% CI -0.50, -0.32; p<0.0001). Treatment with linagliptin provided a relative weight benefit and reduced insulin requirements without affecting blood pressure, heart rate or lipids. The incidence of hypoglycemia with linagliptin was similar to that for placebo (38.7% vs. 39.4%, respectively). The hazard ratio (HR) for the primary endpoint showed that treatment with linagliptin was not associated with an increased CV risk (HR 1.07 [95% CI 0.62, 1.85]). CONCLUSIONS Linagliptin, when added to ongoing insulin treatment in patients with type 2 diabetes, improves glycemic control and has a neutral impact on major adverse CV events.
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Affiliation(s)
- Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
| | - Bo Ahrén
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | | | - Sanjay Patel
- Boehringer Ingelheim Ltd, Bracknell, United Kingdom
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Seewoodhary J, Wong SPY, Ekanayake KP. New treatments for type 2 diabetes: are we any closer to reducing iatrogenic hypoglycaemia? PRACTICAL DIABETES 2015. [DOI: 10.1002/pdi.1977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Fisman EZ, Tenenbaum A. Antidiabetic treatment with gliptins: focus on cardiovascular effects and outcomes. Cardiovasc Diabetol 2015; 14:129. [PMID: 26415691 PMCID: PMC4587723 DOI: 10.1186/s12933-015-0294-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 09/21/2015] [Indexed: 12/11/2022] Open
Abstract
The traditional oral pharmacological therapy for type 2 diabetes mellitus (T2DM) has been based on the prescription of metformin, a biguanide, as first line antihyperglycemic agent world over. It has been demonstrated that after 3 years of treatment, approximately 50 % of diabetic patients could achieve acceptable glucose levels with monotherapy; but by 9 years this had declined to only 25 %. Therefore, the implementation of a combined pharmacological therapy acting via different pathways becomes necessary, and its combination with a compound of the sulfonylurea group was along decades the most frequently employed prescription in routine clinical practice. Meglitinides, glitazones and alpha-glucosidase inhibitors were subsequently developed, but the five mentioned groups of oral antihyperglycemic agents are associated with variable degrees of undesirable or even severe cardiovascular events. The gliptins—also called dipeptidyl peptidase 4 (DPP4) inhibitors—are an additional group of antidiabetic compounds with increasing clinical use. We review the status of the gliptins with emphasis on their capabilities to positively or negatively affect the cardiovascular system, and their potential involvement in major adverse cardiovascular events (MACE). Alogliptin, anagliptin, linagliptin, saxagliptin, sitagliptin, teneligliptin and vildagliptin are the compounds currently in clinical use. Regardless differences in chemical structure and metabolic pathways, gliptins as a group exert favorable changes in experimental models. These changes, as an almost general rule, include improved endothelial function, reduction of inflammatory markers, oxidative stress ischemia/reperfusion injury and atherogenesis. In addition, increased adiponectin levels and modest decreases in lipidemia and blood pressure were reported. In clinical settings, several trials—notably the longer one, employing sitagliptin, with a mean follow-up period of 3 years—did not show an increased risk for ischemic events. Anyway, it should be emphasized that the encouraging results from basic science were not yet translated into clinical evidence, probably due the multiple and pleiotropic enzymatic effects of DPP4 inhibition. Moreover, when employing saxagliptin, while the drug was not associated with an augmented risk for ischemic events, it should be pinpointed that the rate of hospitalization for heart failure was significantly increased. Gliptins as a group constitute a widely accepted therapy for the management of T2DM, usually as a second-line medication. Nonetheless, for the time being, a definite relationship between gliptins treatment and improved cardiovascular outcomes remains uncertain and needs yet to be proven.
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Affiliation(s)
- Enrique Z Fisman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, 69978, Tel Aviv, Israel. .,Cardiovascular Diabetology Research Foundation, 58484, Holon, Israel.
| | - Alexander Tenenbaum
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, 69978, Tel Aviv, Israel. .,Cardiovascular Diabetology Research Foundation, 58484, Holon, Israel. .,Cardiac Rehabilitation Institute, Sheba Medical Center, 52621, Tel Hashomer, Israel.
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Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min). Nephrol Dial Transplant 2015; 30 Suppl 2:ii1-142. [PMID: 25940656 DOI: 10.1093/ndt/gfv100] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Sanchez RA, Sanabria H, Santos CDL, Ramirez AJ. Incretins and selective renal sodium-glucose co-transporter 2 inhibitors in hypertension and coronary heart disease. World J Diabetes 2015; 6:1186-1197. [PMID: 26380062 PMCID: PMC4564814 DOI: 10.4239/wjd.v6.i11.1186] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 01/29/2015] [Accepted: 08/31/2015] [Indexed: 02/05/2023] Open
Abstract
Hyperglycemia is associated with an increased risk of cardiovascular disease, and the consequences of intensive therapy may depend on the mechanism of the anti-diabetic agent(s) used to achieve a tight control. In animal models, stable analogues of glucagon-like peptide-1 (GLP-1) were able to reduce body weight and blood pressure and also had favorable effects on ischemia following coronary reperfusion. In a similar way, dipeptidyl peptidase IV (DPP-IV) showed to have favorable effects in animal models of ischemia/reperfusion. This could be due to the fact that DPP-IV inhibitors were able to prevent the breakdown of GLP-1 and glucose-dependent insulinotropic polypeptide, but they also decreased the degradation of several vasoactive peptides. Preclinical data for GLP-1, its derivatives and inhibitors of the DPP-IV enzyme degradation suggests that these agents may be able to, besides controlling glycaemia, induce cardio-protective and vasodilator effects. Notwithstanding the many favorable cardiovascular effects of GLP-1/incretins reported in different studies, many questions remain unanswered due the limited number of studies in human beings that aim to examine the effects of GLP-1 on cardiovascular endpoints. For this reason, long-term trials searching for positive cardiovascular effects are now in process, such as the CAROLINA and CARMELINA trials, which are supported by small pilot studies performed in humans (and many more animal studies) with incretin-based therapies. On the other hand, selective renal sodium-glucose co-transporter 2 inhibitors were also evaluated in the prevention of cardiovascular outcomes in type 2 diabetes. However, it is quite early to draw conclusions, since data on cardiovascular outcomes and cardiovascular death are limited and long-term studies are still ongoing. In this review, we will analyze the mechanisms underlying the cardiovascular effects of incretins and, at the same time, we will present a critical position about the real value of these compounds in the cardiovascular system and its protection.
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Cooper ME, Perkovic V, McGill JB, Groop PH, Wanner C, Rosenstock J, Hehnke U, Woerle HJ, von Eynatten M. Kidney Disease End Points in a Pooled Analysis of Individual Patient–Level Data From a Large Clinical Trials Program of the Dipeptidyl Peptidase 4 Inhibitor Linagliptin in Type 2 Diabetes. Am J Kidney Dis 2015; 66:441-9. [DOI: 10.1053/j.ajkd.2015.03.024] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 03/05/2015] [Indexed: 11/11/2022]
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Kothny W, Lukashevich V, Foley JE, Rendell MS, Schweizer A. Comparison of vildagliptin and sitagliptin in patients with type 2 diabetes and severe renal impairment: a randomised clinical trial. Diabetologia 2015; 58:2020-6. [PMID: 26067186 PMCID: PMC4526592 DOI: 10.1007/s00125-015-3655-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 05/13/2015] [Indexed: 02/06/2023]
Abstract
AIMS/HYPOTHESIS There are limited data comparing dipeptidyl peptidase-4 (DPP-4) inhibitors directly. We compared the safety and efficacy of vildagliptin and sitagliptin in patients with type 2 diabetes and severe renal impairment (RI). METHODS This study was a parallel-arm, randomised, multicentre, double-blind, 24 week study conducted in 87 centres across Brazil and the USA. Patients with type 2 diabetes, either drug naive or treated with any glucose-lowering agents, who had inadequate glycaemic control (HbA1c 6.5-10.0% [48-86 mmol/mol]) and an estimated GFR <30 ml min(-1) [1.73 m](-2) were randomised (via interactive voice response technology) to vildagliptin 50 mg once daily or sitagliptin 25 mg once daily. These doses are recommended in this patient population and considered maximally effective. Participants, investigators and the sponsor were blinded to group assignment. Efficacy endpoints included change in HbA1c and fasting plasma glucose (FPG) at all visits and the primary safety endpoint was assessment of treatment-emergent adverse events. RESULTS In total, 148 patients were randomised, 83 to vildagliptin and 65 to sitagliptin. All patients were analysed. After 24 weeks, the adjusted mean change in HbA1c was -0.54% (5.9 mmol/mol) from a baseline of 7.52% (59 mmol/mol) with vildagliptin and -0.56% (6.1 mmol/mol) from a baseline of 7.80% (62 mmol/mol) with sitagliptin (p = 0.874). FPG decreased by 0.47 ± 0.37 mmol/l with vildagliptin and increased by 0.16 ± 0.43 mmol/l with sitagliptin (p = 0.185). Both treatments were well tolerated with overall similar safety profiles. CONCLUSIONS/INTERPRETATION At their recommended doses for severe RI, vildagliptin (50 mg once daily) compared with sitagliptin (25 mg once daily) demonstrated similar efficacy and both drugs were well tolerated. This study provides further support for the use of DPP-4 inhibitors in patients with severe RI. TRIAL REGISTRATION ClinicalTrials.gov NCT00616811 (completed) FUNDING This study was planned and conducted by Novartis.
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Inzucchi SE, Nauck MA, Hehnke U, Woerle HJ, von Eynatten M, Henry RR. Improved glucose control with reduced hypoglycaemic risk when linagliptin is added to basal insulin in elderly patients with type 2 diabetes. Diabetes Obes Metab 2015; 17:868-77. [PMID: 25974030 DOI: 10.1111/dom.12490] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 04/14/2015] [Accepted: 05/07/2015] [Indexed: 01/21/2023]
Abstract
AIM To assess the efficacy, hypoglycaemia risk and other safety markers of linagliptin as an additional therapy in older patients (aged ≥70 years) inadequately controlled with basal insulin. METHODS A prespecified safety analysis from the linagliptin trials programme was carried out to explore the hypoglycaemia risk when linagliptin was added to background basal insulin therapy in elderly patients (≥70 years). To do this, two eligible, randomized, placebo-controlled, clinical trials (NCT00954447 and NCT01084005) of 24 and ≥52 weeks, respectively, were analysed. RESULTS A total of 247 elderly individuals [mean ± standard deviation (s.d.) age 74 ± 4 years, glycated haemoglobin (HbA1c) 8.2 ± 0.8%] on basal insulin (mean ± s.d. baseline dose 36 ± 25 IU/day) were identified. Alongside placebo-adjusted change in HbA1c with linagliptin of -0.77% [95% confidence interval (CI) -0.95 to 0.59; p < 0.0001] after 24 weeks, the hazard ratios (HRs) of both overall and confirmed hypoglycaemia [blood glucose ≤3.9 mmol/l (70 mg/dl)], were significantly lower with linagliptin than with placebo: HR 0.61 (95% CI 0.39-0.97) versus 0.59 (95% CI 0.37-0.94), respectively (both p < 0.05). Moreover, significantly less confirmed hypoglycaemia was present in linagliptin-treated patients with renal impairment [HR 0.45 (95% CI 0.27-0.76)], moderate hyperglycaemia [HbA1c 7.5 to <9.0%; HR 0.51 (95% CI 0.27-0.99)], lower fasting plasma glucose levels [<152 mg/dl; HR 0.49 (95% CI 0.28-0.86)] and those treated with higher insulin doses [insulin ≥35.6 IU/day; HR 0.46 (95% CI 0.23-0.91); p < 0.05 for all]. Severe hypoglycaemia was rare and the incidence was lower with linagliptin (0.8%) versus placebo (2.5%): HR 0.21 (95% CI 0.02-2.30). CONCLUSIONS Despite improvements in hyperglycaemia and no relevant on-trial insulin dose reductions, adding linagliptin to basal insulin appears to decrease hypoglycaemia risk. The biological basis of this phenomenon warrants further research but may involve counter-regulatory effects of incretin hormones.
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Affiliation(s)
- S E Inzucchi
- Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - M A Nauck
- Division of Diabetology, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - U Hehnke
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - H-J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - M von Eynatten
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - R R Henry
- Center for Metabolic Research, Veterans Affairs San Diego Healthcare System, University of California San Diego School of Medicine, San Diego, CA, USA
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