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Khunti K, Chatterjee S, Gerstein HC, Zoungas S, Davies MJ. Do sulphonylureas still have a place in clinical practice? Lancet Diabetes Endocrinol 2018; 6:821-832. [PMID: 29501322 DOI: 10.1016/s2213-8587(18)30025-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/19/2017] [Accepted: 12/19/2017] [Indexed: 12/11/2022]
Abstract
Sulphonylureas have been commercially available since the 1950s, but their use continues to be associated with controversy. Although adverse cardiovascular outcomes in some observational studies have raised concerns about sulphonylureas, findings from relatively recent, robust, and high-quality systematic reviews have indicated no increased risk of all-cause mortality associated with sulphonylureas compared with other active treatments. Results from large, multicentre, randomised controlled trials such as the UK Prospective Diabetes Study and ADVANCE have confirmed the microvascular benefits of sulphonylureas, a reduction in the incidence or worsening of nephropathy and retinopathy, and no increase in all-cause mortality, although whether these benefits were due to sulphonylurea therapy and not an overall glucose-lowering effect could not be confirmed. A comparison of sulphonylureas and pioglitazone in the TOSCA.IT trial also confirmed the efficacy and cardiovascular safety of sulphonylureas. Investigators of randomised controlled trials have reported an increased risk of hypoglycaemia and weight gain with sulphonylureas, but data from observational studies suggest that the incidence of severe hypoglycaemia is lower in people taking sulphonylurea than in people taking insulin, and weight gain with sulphonylureas has been relatively modest in large cohort studies. 80% of people with diabetes live in low-to-middle income countries, so the effectiveness, affordability, and safety of sulphonylureas are particularly important considerations when prescribing glucose-lowering therapy. Results of ongoing head-to-head studies with new drugs, such as the comparison of glimepiride with linagliptin in the CAROLINA study and the comparison of various therapies (including sulphonylureas) for glycaemic control in the GRADE study, will determine the place of sulphonylureas in glucose-lowering therapy algorithms for patients with type 2 diabetes.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK.
| | - Sudesna Chatterjee
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Hertzel C Gerstein
- Population Health Research Institute, McMaster University, ON, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton Health Sciences, McMaster University, ON, Canada
| | - Sophia Zoungas
- Division of Metabolism, Ageing and Genomics, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; The George Institute for Global Health, Sydney, NSW, Australia
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
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Asakura M, Kim J, Asanuma H, Nakama Y, Tsukahara K, Higashino Y, Ishikawa T, Koba S, Tsujimoto M, Himeno H, Maruyama Y, Ookusa T, Yoda S, Suzuki H, Okubo S, Shimizu M, Hashimoto Y, Satake K, Fujino S, Uzui H, Nagai Y, Kohno T, Mizuno S, Nakahama M, Kanaya H, Murohara T, Fukui K, Takase H, Ohte N, Shiono T, Fukunami M, Endo T, Sawada R, Fujii K, Takeuchi M, Ikeda S, Mizuno K, Uematsu M, Matsubara T, Yano S, Takahashi J, Ueda K, Kinoshita Y, Tamita K, Hayashi H, Hamasaki T, Kitakaze M. Cardiovascular Outcomes in Patients With Previous Myocardial Infarction and Mild Diabetes Mellitus Following Treatment With Pioglitazone: Reports of a Randomised Trial From The Japan Working Group for the Assessment Whether Pioglitazone Protects DM Patients Against Re-Infarction (PPAR Study). EClinicalMedicine 2018; 4-5:10-24. [PMID: 31193597 PMCID: PMC6537525 DOI: 10.1016/j.eclinm.2018.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/11/2018] [Accepted: 09/24/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Secondary prevention in patients with myocardial infarction (MI) is critically important to prevent ischaemic heart failure and reduce social burden. Pioglitazone improves vascular dysfunction and prevents coronary atherosclerosis, mainly via anti-inflammatory and antiatherogenic effects by enhancing adiponectin production in addition to antihyperglycemic effects, thus suggesting that pioglitazone attenuates cardiovascular events in patients with mild (HbA1c levels < 6·5%) diabetes mellitus (DM). Therefore, we evaluated the effects of pioglitazone on cardiovascular events in patients with both previous MI and mild DM. METHODS In this multicentre, prospective, randomised, open, blinded-endpoint trial, we randomly assigned 630 patients with mild DM with a history of MI to undergo either DM therapy with (pioglitazone group) or without (control group) pioglitazone. DM was diagnosed using the 75-g oral glucose tolerance test, and mild DM was defined if HbA1c level was < 6·5%. The primary endpoint was the composite of cardiovascular death and hospitalisation caused by acute MI, unstable angina, coronary revascularisation (including percutaneous coronary intervention and cardiac bypass surgery), and stroke. FINDINGS HbA1C levels were 5·9 and 5·8% (p = 0·71) at baseline and 6·0 and 5·8% (p < 0·01) at 2 years for the control and pioglitazone groups, respectively.The primary endpoint was observed in 14·2% and 14·1% patients in the control and pioglitazone groups during two years (95% confidential interval (CI):0.662-1·526, p = 0·98), respectively; the incidence of MI and cerebral infarction was 0·3% and 2·2% (95%CI: 0·786-32·415, p = 0·09) and 1·0% and 0·3% (95%CI: 0·051-3·662, p = 0·44), respectively. Post-hoc analyses of the 7-year observation period showed that these trends were comparable (21·9% and 19·2% in the control and pioglitazone groups, 95%CI: 0.618-1·237, p = 0·45). INTERPRETATION Pioglitazone could not reduce the occurrence of cardiovascular events in patients with mild DM and previous MI.
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Affiliation(s)
- Masanori Asakura
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Cardiovascular Division, Hyogo College of Medicine, Hyogo, Japan
| | - Jiyoong Kim
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
- Kim Cardiovascular Clinic, Osaka, Japan
| | - Hiroshi Asanuma
- Department of Internal Medicine, Meiji University of Integrative Medicine, Kyoto, Japan
| | - Yasuharu Nakama
- Department of Cardiology, Hiroshima City Hospital, Hiroshima, Japan
| | - Kengo Tsukahara
- Division of Cardiology, Yokohama City University Medical Center, Kanagawa, Japan
| | - Yorihiko Higashino
- Department of Cardiology, Higashi Takarazuka Satoh Hospital, Hyogo, Japan
| | - Tetsuya Ishikawa
- Department of Cardiology, Saitama Prefecture Cardiovascular and Respiratory Center, Saitama, Japan
| | - Shinji Koba
- Division of Cardiology, Department of Medicine, Showa University Hospital, Tokyo, Japan
| | - Mitsuru Tsujimoto
- Department of Cardiology, Cardiovascular Center, Veritas Hospital, Hyogo, Japan
| | - Hideo Himeno
- Division of Cardiology, Fujisawa City Hospital, Kanagawa, Japan
| | | | - Takanori Ookusa
- Department of Cardiology, Hokko Memorial Hospital, Hokkaido, Japan
| | - Shunichi Yoda
- Division of Cardiology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan
| | - Shinji Okubo
- Department of Cardiovascular Medicine, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| | - Makoto Shimizu
- Department of Cardiology, International Goodwill Hospital, Kanagawa, Japan
| | - Yuji Hashimoto
- Department of Cardiology, Kameda Medical Center, Chiba, Japan
| | - Kazuo Satake
- Department of Cardiology, Fukui General Clinic, Fukui, Japan
| | - Susumu Fujino
- Department of Cardiology, Fukui Prefectural Hospital, Fukui, Japan
| | - Hiroyasu Uzui
- Department of Cardiology, University of Fukui Hospital, Fukui, Japan
| | - Yoshiyuki Nagai
- Department of Cardiology, Rinku General Medical Center, Osaka, Japan
| | - Tohru Kohno
- Department of Cardiology, Tokyo Rinkai Hospital, Tokyo, Japan
| | - Sumio Mizuno
- Department of Internal Medicine, Fukui Cardiovascular Center, Fukui, Japan
| | - Makoto Nakahama
- Department of Cardiology, Fukuyama City Hospital, Hiroshima, Japan
| | - Hounin Kanaya
- Division of Cardiology, Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | | | - Kazuki Fukui
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Kanagawa, Japan
| | - Hiroyuki Takase
- Department of Internal Medicine, Enshu Hospital, Shizuoka, Japan
| | - Nobuyuki Ohte
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Takaaki Shiono
- Department of Cardiology, Kitasato University Medical Center, Saitama, Japan
| | | | - Tsutomu Endo
- Department of Cardiology, Saiseikai Yokohama City Southern Hospital, Kanagawa, Japan
| | - Reimin Sawada
- Department of Cardiology, Hadano Red Cross Hospital, Kanagawa, Japan
| | - Kenshi Fujii
- Department of Cardiology, Fukui Prefectural Hospital, Fukui, Japan
| | | | - Shuntaro Ikeda
- Division of Cardiology, Uwajima City Hospital, Ehime, Japan
| | - Koichi Mizuno
- Department of Cardiology, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | | | - Taku Matsubara
- Department of Cardiovascular Medicine, Shinrakuen Hospital, Niigata, Japan
| | - Shoji Yano
- Department of Cardiovascular Medicine, Almeida Memorial Hospital, Oita, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Kousei Ueda
- Division of Cardiology, Komatsu Municipal Hospital, Ishikawa, Japan
| | | | - Koichi Tamita
- Department of Cardiology, Nishinomiya Watanabe Cardiovascular Center, Hyogo, Japan
| | - Hideki Hayashi
- Department of Internal Medicine, Hoetsu Hospital, Tokushima, Japan
| | - Toshimitsu Hamasaki
- Department of Data Science, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masafumi Kitakaze
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Corresponding author at: Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Suita 565-8565, Japan.
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Manolis AA, Manolis TA, Manolis AS. Cardiovascular Safety of Antihyperglycemic Agents: “Do Good or Do No Harm”. Drugs 2018; 78:1567-1592. [DOI: 10.1007/s40265-018-0985-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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154
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Wang CY, Neil DL, Home P. 2020 vision - An overview of prospects for diabetes management and prevention in the next decade. Diabetes Res Clin Pract 2018; 143:101-112. [PMID: 29944968 DOI: 10.1016/j.diabres.2018.06.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/24/2018] [Accepted: 06/13/2018] [Indexed: 02/08/2023]
Abstract
After a century of medical progress, people nowadays live longer with diabetes than ever before. However, current preventative approaches, compounded in part by increased life-expectancy, are failing to reduce the prevalence of diabetes. Cardiovascular sequelae account for many of the four million deaths annually attributable to diabetes. Evidence indicates that certain glucose-lowering medications can improve vascular outcomes in some people with type 2 diabetes, which, together with better understanding of using multiple therapies concurrently, offers opportunities for beneficial personalization of medication regimens. However, further well-designed long-term studies are needed to evaluate cardiovascular benefits and safety of new and older medications, particularly in users typical of everyday diabetes care. Although there are numerous other promising advances in pharmacotherapies and biotechnology, these will probably be unaffordable for most people with diabetes globally. Therefore, effective national public health approaches will be essential to reducing the incidence of diabetes and its associated burdens; these may entail politically controversial measures to change unhealthy lifestyle behaviours. Stakeholders could learn from past failures and emulate successes in other health-care initiatives. Without early action at all levels, we face a future in which approaching one-quarter of humans will have diabetes, with more than half afflicted during their lifetime.
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Affiliation(s)
- Chih-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - David L Neil
- Scientific Development Department, Content Ed Net, Taipei, Taiwan
| | - Philip Home
- Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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155
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Colagiuri S, Matthews D, Leiter LA, Chan SP, Sesti G, Marre M. The place of gliclazide MR in the evolving type 2 diabetes landscape: A comparison with other sulfonylureas and newer oral antihyperglycemic agents. Diabetes Res Clin Pract 2018; 143:1-14. [PMID: 29802958 DOI: 10.1016/j.diabres.2018.05.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 05/04/2018] [Accepted: 05/16/2018] [Indexed: 02/06/2023]
Abstract
The sulfonylureas are effective oral glucose-lowering agents with a long history of clinical use. While all have the same general mechanism of action, their pharmacokinetic properties are influenced by factors such as dosage, rate of absorption, duration of action, route of elimination, tissue specificity, and binding affinity for pancreatic β-cell receptor. The result is a class of agents with similar HbA1c-lowering efficacy, but well-documented differences in terms of effects on hypoglycemia, and cardiovascular and renal safety. This review examines the differences between currently available sulfonylureas with a focus on how gliclazide modified release (MR) differs from other members of this class and from newer oral antihyperglycemic agents in the form of dipeptidyl peptidase-4 (DPP4) and sodium- glucose cotransporter 2 (SGLT2) inhibitors. The first part focuses on major outcome trials that have been conducted with the sulfonylureas and new oral agents. Consideration is then given to factors important for day-to-day prescribing including efficacy and durability, weight changes, hypoglycemia, renal effects and cost. Based on current evidence, third-generation sulfonylureas such as gliclazide MR possess many of the properties desired of a type 2 diabetes drug including high glucose-lowering efficacy, once-daily oral administration, few side effects other than mild hypoglycemia, and cardiovascular safety.
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Affiliation(s)
- Stephen Colagiuri
- Boden Institute of Obesity, Nutrition and Exercise, University of Sydney, Sydney, NSW, Australia.
| | - David Matthews
- Oxford Centre for Diabetes, Endocrinology and Metabolism, and Harris Manchester College, University of Oxford, Oxford, UK
| | - Lawrence A Leiter
- Division of Endocrinology & Metabolism, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Siew Pheng Chan
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur 50603, W.P., Malaysia
| | - Giorgio Sesti
- Department of Medical and Surgical Science, University Magna-Græcia of Catanzaro, 88100 Catanzaro, Italy
| | - Michel Marre
- Diabetes Department, Hôpital Bichat-Claude Bernard, Assistance Publique des Hôpitaux de Paris, Université Denis Diderot Paris 7, and INSERM U1138, Paris, France
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156
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Vitale M, Masulli M, Calabrese I, Rivellese AA, Bonora E, Signorini S, Perriello G, Squatrito S, Buzzetti R, Sartore G, Babini AC, Gregori G, Giordano C, Clemente G, Grioni S, Dolce P, Riccardi G, Vaccaro O. Impact of a Mediterranean Dietary Pattern and Its Components on Cardiovascular Risk Factors, Glucose Control, and Body Weight in People with Type 2 Diabetes: A Real-Life Study. Nutrients 2018; 10:nu10081067. [PMID: 30103444 PMCID: PMC6115857 DOI: 10.3390/nu10081067] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/03/2018] [Accepted: 08/07/2018] [Indexed: 11/16/2022] Open
Abstract
This study evaluates the relation of a Mediterranean dietary pattern and its individual components with the cardiovascular risk factors profile, plasma glucose and body mass index (BMI) in people with type 2 diabetes. We studied 2568 participants at 57 diabetes clinics. Diet was assessed with the EPIC (European Prospective Investigation into Cancer and Nutrition) questionnaire, adherence to the Mediterranean diet was evaluated with the relative Mediterranean diet score (rMED). A high compared to a low score was associated with a better quality of diet and a greater adherence to the nutritional recommendations for diabetes. However, even in the group achieving a high score, only a small proportion of participants met the recommendations for fiber and saturated fat (respectively 17% and 30%). Nonetheless, a high score was associated with lower values of plasma lipids, blood pressure, glycated hemoglobin, and BMI. The relationship of the single food items components of the rMED score with the achievement of treatment targets for plasma lipids, blood pressure, glucose, and BMI were also explored. The study findings support the Mediterranean dietary model as a suitable model for type 2 diabetes and the concept that the beneficial health effects of the Mediterranean diet lie primarily in its synergy among various nutrients and foods rather than on any individual component.
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Affiliation(s)
- Marilena Vitale
- Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
| | - Maria Masulli
- Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
| | - Ilaria Calabrese
- Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
| | | | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, 37134 Verona, Italy.
| | - Stefano Signorini
- University Department Laboratory Medicine, Hospital of Desio, 20832 Monza, Italy.
| | - Gabriele Perriello
- Endocrinology and Metabolism, University of Perugia, 06126, Perugia, Italy.
| | - Sebastiano Squatrito
- Diabetes Unit, University Hospital Garibaldi-Nesima of Catania, 95122 Catania, Italy.
| | - Raffaella Buzzetti
- Department of Experimental Medicine, Sapienza University, 04100 Rome, Italy.
| | - Giovanni Sartore
- Department of Medicine, University of Padua, 35100 Padova, Italy.
| | | | - Giovanna Gregori
- Diabetes Unit, Azienda Sanitaria Toscana Nord-Ovest, Massa Carrara, 54100 Massa Carrara, Italy.
| | - Carla Giordano
- Section of Endocrinology, Diabetology and Metabolic Diseases, University of Palermo, 90127 Palermo, Italy.
| | - Gennaro Clemente
- Institute for Research on Population and Social Policies-National Research Council, 84084 Fisciano, Italy.
| | - Sara Grioni
- Unità di Epidemiologia e Prevenzione, Fondazione IRCCS, Istituto Nazionale Tumori, 20133 Milano, Italy.
| | - Pasquale Dolce
- Department of Public Health, Federico II University of Naples, 80131 Naples, Italy.
| | - Gabriele Riccardi
- Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
| | - Olga Vaccaro
- Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
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157
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Affiliation(s)
- Marcos Ferreira Minicucci
- Departamento de Clínica Médica - Faculdade de Medicina
de Botucatu - Universidade Estadual Paulista Júlio de Mesquista
Filho-UNESP, Botucatu, SP – Brazil
| | - Leonardo Antonio Mamede Zornoff
- Departamento de Clínica Médica - Faculdade de Medicina
de Botucatu - Universidade Estadual Paulista Júlio de Mesquista
Filho-UNESP, Botucatu, SP – Brazil
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158
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Powell WR, Christiansen CL, Miller DR. Meta-Analysis of Sulfonylurea Therapy on Long-Term Risk of Mortality and Cardiovascular Events Compared to Other Oral Glucose-Lowering Treatments. Diabetes Ther 2018; 9:1431-1440. [PMID: 29808360 PMCID: PMC6064594 DOI: 10.1007/s13300-018-0443-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Among the most pressing clinical decisions in type 2 diabetes treatments are which drugs should be used after metformin is no longer sufficient, and whether sulfonylureas (SUs) should remain as a suitable second-line treatment. In this article we summarize current evidence on the long-term safety risks associated with SU therapy relative to other oral glucose-lowering therapies. METHODS The MEDLINE database and Clinicaltrials.gov were searched for observational and experimental studies comparing the safety of SUs to that of other diabetes medications in people with type 2 diabetes mellitus through December 15, 2015. Studies with at least 1 year of follow-up, which explicitly examined major cardiovascular events or death in patients who showed no evidence of serious conditions at baseline, were selected for inclusion in meta-analyses. RESULTS SU treatment was associated with an elevated risk relative to treatment with metformin (METF), thiazolidinedione (TZD), dipeptidyl peptidase-4 inhibitor (DPP-4), and glucagon-like peptide-1 (GLP-1) agonist classes, either when compared alone (as a monotherapy) or when used in combination with METF. Significant findings were almost entirely derived from nontrial data and not confirmed by smaller, efficacy designed randomized controlled trials whose effects were in the same direction but much more imprecise. CONCLUSION Although much of the evidence is derived and will continue to come from observational studies, the methodological rigor of such studies is questionable. A key challenge for evaluators is the extent to which they should incorporate evidence from study designs that are quasi-experimental.
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Affiliation(s)
- W Ryan Powell
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA.
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Cindy L Christiansen
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Department of Dermatology, Boston University School of Medicine, Boston, MA, USA
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159
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Fadini GP, Bottigliengo D, D'Angelo F, Cavalot F, Bossi AC, Zatti G, Baldi I, Avogaro A. Comparative Effectiveness of DPP-4 Inhibitors Versus Sulfonylurea for the Treatment of Type 2 Diabetes in Routine Clinical Practice: A Retrospective Multicenter Real-World Study. Diabetes Ther 2018; 9:1477-1490. [PMID: 29858976 PMCID: PMC6064583 DOI: 10.1007/s13300-018-0452-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION DPP-4 inhibitors (DPP4i) and sulfonylureas are popular second-line therapies for type 2 diabetes (T2D), but there is a paucity of real-world studies comparing their effectiveness in routine clinical practice. METHODS This was a multicenter retrospective study on diabetes outpatient clinics comparing the effectiveness of DPP4i versus gliclazide extended release. The primary endpoint was change from baseline in HbA1c. Secondary endpoints were changes in fasting plasma glucose, body weight, and systolic blood pressure. Automated software extracted data from the same clinical electronic chart system at all centers. Propensity score matching (PSM) was used to generate comparable cohorts to perform outcome analysis. RESULTS We included data on 2410 patients starting DPP4i and 1590 patients starting gliclazide (mainly 30-60 mg/day). At baseline, the two groups differed in disease duration, body weight, blood pressure, HbA1c, fasting glucose, HDL cholesterol, triglycerides, liver enzymes, eGFR, prevalence of microangiopathy, and use of metformin. Among DPP4i molecules, no difference in glycemic effectiveness was detected. In matched cohorts (n = 1316/group), patients starting DPP4i, as compared with patients starting gliclazide, experienced greater reductions in HbA1c (- 0.6% versus - 0.4%; p < 0.001), fasting glucose (- 14.1 mg/dl versus - 8.8 mg/dl; p = 0.007), and body weight (- 0.4 kg versus - 0.1 kg; p = 0.006) after an average 6 months follow-up. DPP4i improved glucose control more than gliclazide, especially in patients who had failed with other glucose-lowering medications or were on basal insulin. CONCLUSIONS This large retrospective real-world study shows that, in routine clinical practice, starting a DPP4i allows better glycemic control than starting low-dose gliclazide. FUNDING The Italian Diabetes Society, with external support from AstraZeneca.
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Affiliation(s)
| | - Daniele Bottigliengo
- Department of Cardiac Thoracic and Vascular Sciences, University of Padova, 35128, Padua, Italy
| | | | | | | | - Giancarlo Zatti
- Department of Medicine, University of Padova, 35128, Padua, Italy
| | - Ileana Baldi
- Department of Cardiac Thoracic and Vascular Sciences, University of Padova, 35128, Padua, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, 35128, Padua, Italy
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160
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Vaccaro O, Masulli M, Riccardi G. Glucose lowering strategies and cardiovascular disease in type 2 diabetes - teachings from the TOSCA.IT study. Nutr Metab Cardiovasc Dis 2018; 28:722-726. [PMID: 29804832 DOI: 10.1016/j.numecd.2018.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/17/2018] [Accepted: 04/19/2018] [Indexed: 11/25/2022]
Abstract
TOSCA.IT is an institutional, non-industry-supported, head-to-head study comparing long term cardiovascular effects, efficacy and safety of two antidiabetes drugs (pioglitazone vs sulphonylureas) used in combination with metformin in patients with type 2 diabetes mellitus. The study results show that in the absence of clinically evident cardiovascular disease both treatment strategies represent suitable alternatives; however, in consideration of the greater durability of the metabolic effects, the lower risk of hypoglycemia and the potential benefit on atherosclerotic cardiovascular disease, the combination of metformin and pioglitazone may be considered as the preferential therapeutic option. In this review the study is critically evaluated against the background of the evidence accumulated over the last decade on the impact of different glucose lowering drugs on cardiovascular events in people with type 2 diabetes.
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Affiliation(s)
- O Vaccaro
- Dept. Clinical Medicine and Surgery, Federico II University Medical School, Via Pansini 5, 80131, Naples, Italy.
| | - M Masulli
- Dept. Clinical Medicine and Surgery, Federico II University Medical School, Via Pansini 5, 80131, Naples, Italy
| | - G Riccardi
- Dept. Clinical Medicine and Surgery, Federico II University Medical School, Via Pansini 5, 80131, Naples, Italy
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161
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Montvida O, Shaw JE, Blonde L, Paul SK. Long-term sustainability of glycaemic achievements with second-line antidiabetic therapies in patients with type 2 diabetes: A real-world study. Diabetes Obes Metab 2018. [PMID: 29536608 DOI: 10.1111/dom.13288] [Citation(s) in RCA: 12] [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] [Indexed: 12/12/2022]
Abstract
AIMS To inform patients and their carers about both the probability of reducing glycated haemoglobin (HbA1c) to clinically desirable levels and the sustainability of such control over 2 years with major second-line antidiabetic therapies, in individual risk scenarios, with and without third-line intensification. MATERIALS AND METHODS From US Centricity Electronic Medical Records, 163 081 patients with type 2 diabetes aged 18 to 80 years, who had initiated metformin, intensified their treatment with dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists (GLP-1RAs), sulphonylureas (SUs), insulin or thiazolidinediones (TZDs), and continued second-line treatment for ≥6 months, were selected. Treatment groups were balanced with regard to baseline characteristics, and glycaemic achievements were estimated using logistic regression analysis. RESULTS With HbA1c concentrations of 58-63.9 mmol/mol (7.5-7.9%) at second-line treatment initiation, the adjusted probabilities of achieving HbA1c <53 mmol/mol (<7%) at 6 months were 32%, 38%, 39%, 26% and 38% in the SU, DPP-4 inhibitor, GLP-1RA, insulin and TZD groups, respectively, while with baseline HbA1c concentrations of 64-75 mmol/mol (8-9%), the corresponding probabilities of reducing HbA1c to <58 mmol/mol (<7.5%) were 38%, 44%, 40%, 34% and 42%, respectively. In these baseline HbA1c categories, the adjusted probabilities of sustaining HbA1c achievements over 2 years were higher in the GLP-1RA and TZD groups, compared with the SU and insulin groups (P < .01). With baseline HbA1c concentrations of 75.1-108 mmol/mol (9.1-12%) 38% of patients achieved an HbA1c concentration <58 mmol/mol (<7.5%) at 6 months. The adjusted probability of sustaining this control over 2 years was higher in the incretin and TZD groups (range 62%-75%), while insulin and SUs offered lower chances of sustainable control (range 54%-56%). CONCLUSIONS Patients treated with second-line incretins and TZDs had a significantly higher probability of achieving and sustaining glycaemic control over 2 years without further intensification, compared with those treated with SUs or insulin.
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Affiliation(s)
- Olga Montvida
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Australia
- School of Biomedical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | | | - Lawrence Blonde
- Ochsner Diabetes Clinical Research Unit, Department of Endocrinology, Frank Riddick Diabetes Institute, Ochsner Medical Center, New Orleans, Louisiana
| | - Sanjoy K Paul
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Australia
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, Australia
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162
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Vaccaro O, Riccardi G, Maggioni AP. Risk of heart failure in diabetic patients receiving sulfonylureas. Eur J Heart Fail 2018; 20:1371-1372. [DOI: 10.1002/ejhf.1238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/11/2018] [Indexed: 11/06/2022] Open
Affiliation(s)
- Olga Vaccaro
- Department of Clinical Medicine and Surgery; University ‘Federico II’ of Naples; Naples Italy
| | - Gabriele Riccardi
- Department of Clinical Medicine and Surgery; University ‘Federico II’ of Naples; Naples Italy
| | - Aldo Pietro Maggioni
- Italian Association of Hospital Cardiologists (ANMCO) Research Center; Florence Italy
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163
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Yan H, Xie H, Ying Y, Li J, Wang X, Xu X, Zheng X. Pioglitazone use in patients with diabetes and risk of bladder cancer: a systematic review and meta-analysis. Cancer Manag Res 2018; 10:1627-1638. [PMID: 29970962 PMCID: PMC6021001 DOI: 10.2147/cmar.s164840] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pioglitazone has been reported to increase the risk of bladder cancer but the conclusions of published clinical studies are confusing. We conducted a systematic review and meta-analysis of all eligible randomized controlled trial (RCT) studies and observational studies, in order to identify a more precise relationship between pioglitazone and risk of bladder cancer. We searched for publications up to January 24, 2018, in PubMed, EMBASE, Scopus, Web of Science, Cochrane register, and Chinese National Knowledge Infrastructure databases, and the references of the retrieved articles and relevant reviews were also checked. Relative risk and 95% confidence interval (CI) were used to assess this correlation. A dose-related meta-analysis was performed as well. Data on RCT studies showed a null association between pioglitazone and bladder cancer. The pooled RR estimates of the 12 included studies illustrated that pioglitazone is associated with a 14% increased risk of bladder cancer (95% CI 1.03-1.26). No evidence of publication bias was detected. In the dose effect analysis, patients who used a higher dose of pioglitazone had an increased risk of bladder cancer. In conclusion, this meta-analysis indicated that pioglitazone is associated with an increased risk of bladder cancer. Further research should be conducted to confirm our findings and reveal the potential biological mechanisms.
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Affiliation(s)
- Huaqing Yan
- Department of Urology, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Haiyun Xie
- Department of Urology, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Yufan Ying
- Department of Urology, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Jiangfeng Li
- Department of Urology, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xiao Wang
- Department of Urology, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xin Xu
- Department of Urology, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xiangyi Zheng
- Department of Urology, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang Province, China
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164
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Abdul-Ghani M, Jayyous A, Asaad N, Helmy S, Al-Suwaidi J. Pioglitazone and cardiovascular risk in T2DM patients: is it good for all? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:192. [PMID: 29951514 DOI: 10.21037/atm.2018.03.19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
| | - Amin Jayyous
- Academic Health System, Hamad General Hospital, Doha, Qatar
| | - Nidal Asaad
- Cardio-Metabolic Institute, Hamad General Hospital, Doha, Qatar
| | - Sherif Helmy
- Cardio-Metabolic Institute, Hamad General Hospital, Doha, Qatar
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165
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Zaccardi F, Dhalwani NN, Dales J, Mani H, Khunti K, Davies MJ, Webb DR. Comparison of glucose-lowering agents after dual therapy failure in type 2 diabetes: A systematic review and network meta-analysis of randomized controlled trials. Diabetes Obes Metab 2018; 20:985-997. [PMID: 29205774 DOI: 10.1111/dom.13185] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/15/2017] [Accepted: 11/30/2017] [Indexed: 01/13/2023]
Abstract
AIMS To assess the evidence supporting the choice of third-line agents in adults with inadequately controlled type 2 diabetes. MATERIALS AND METHODS We searched randomized controlled trials (RCTs) published between January 2000 and July 2017 that reported data on cardiometabolic outcomes and hypoglycaemia for glucose-lowering agents added to metformin-based dual treatments. Data were stratified by background therapy and RCT duration, and synthesized, when possible, with network meta-analyses. RESULTS A total of 43 RCTs (16 590 participants) were included, with metformin combined with: sulphonylureas (SUs) in 20 RCTs; thiazolidinediones (TZDs) in 10; basal or rapid-acting insulin in 6; dipeptidyl peptidase-4 (DPP-4) inhibitors in 3; glucagon-like peptide-1 receptor agonists (GLP-1RAs) in 2; and sodium-glucose co-transporter-2 (SGLT-2) inhibitors in 2. When added to metformin and SUs, after 24 to 36 weeks, rapid-acting insulin resulted in the largest reduction in glycated haemoglobin (HbA1c; 1.6% vs placebo), followed by GLP-1RAs (1.0%), basal insulin (0.8%) and SGLT-2 inhibitors (0.7%), with no difference between GLP-1RAs and SGLT-2 inhibitors; body weight increased with insulin treatment (~3 kg vs placebo), while the greatest reduction was observed for SGLT-2 inhibitors compared with all other therapies. Limited data for hypoglycaemia indicated a similar risk for SGLT-2 inhibitors and GLP-1RAs. Results for third-line agents added to metformin and TZDs were comparable, showing similar HbA1c reduction and risk of hypoglycaemia between SGLT-2 inhibitors and GLP-1RAs, and a slightly greater reduction in body weight with SGLT-2 inhibitors vs GLP-1RAs. Data for 52 to 54 weeks were more limited: added to metformin and a SU, TZDs, GLP-1RAs or SGLT-2 inhibitors reduced HbA1c to a similar extent but had different effects on body weight (7 kg and 5 kg more with TZDs vs SGLT-2 inhibitors and GLP-1RAs, respectively; 2 kg less when comparing SGLT-2 inhibitors with GLP-1RAs). Formal analyses could not be performed for any other dual therapy failure combinations because of the small number of available RCTs. CONCLUSIONS Moderate-quality evidence supports the choice of a third-line agent only in patients on metformin combined with a SU or a TZD, with SGLT-2 inhibitors performing generally better than other drugs. In suggesting third-line agents, future guidelines should recognize the widely differing evidence on the various dual therapy failures.
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Affiliation(s)
| | | | - Jolyon Dales
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Hamid Mani
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - David R Webb
- Diabetes Research Centre, University of Leicester, Leicester, UK
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166
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Rosenstock J, Perkovic V, Alexander JH, Cooper ME, Marx N, Pencina MJ, Toto RD, Wanner C, Zinman B, Baanstra D, Pfarr E, Mattheus M, Broedl UC, Woerle HJ, George JT, von Eynatten M, McGuire DK. Rationale, design, and baseline characteristics of the CArdiovascular safety and Renal Microvascular outcomE study with LINAgliptin (CARMELINA ®): a randomized, double-blind, placebo-controlled clinical trial in patients with type 2 diabetes and high cardio-renal risk. Cardiovasc Diabetol 2018. [PMID: 29540217 PMCID: PMC5870815 DOI: 10.1186/s12933-018-0682-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Cardiovascular (CV) outcome trials in type 2 diabetes (T2D) have underrepresented patients with chronic kidney disease (CKD), leading to uncertainty regarding their kidney efficacy and safety. The CARMELINA® trial aims to evaluate the effects of linagliptin, a DPP-4 inhibitor, on both CV and kidney outcomes in a study population enriched for cardio-renal risk. Methods CARMELINA® is a randomized, double-blind, placebo-controlled clinical trial conducted in 27 countries in T2D patients at high risk of CV and/or kidney events. Participants with evidence of CKD with or without CV disease and HbA1c 6.5–10.0% (48–86 mmol/mol) were randomized 1:1 to receive linagliptin once daily or matching placebo, added to standard of care adjusted according to local guidelines. The primary outcome is time to first occurrence of CV death, non-fatal myocardial infarction, or non-fatal stroke. The key secondary outcome is a composite of time to first sustained occurrence of end-stage kidney disease, ≥ 40% decrease in estimated glomerular filtration rate (eGFR) from baseline, or renal death. CV and kidney events are prospectively adjudicated by independent, blinded clinical event committees. CARMELINA® was designed to continue until at least 611 participants had confirmed primary outcome events. Assuming a hazard ratio of 1.0, this provides 90% power to demonstrate non-inferiority of linagliptin versus placebo within the pre-specified non-inferiority margin of 1.3 at a one-sided α-level of 2.5%. If non-inferiority of linagliptin for the primary outcome is demonstrated, then its superiority for both the primary outcome and the key secondary outcome will be investigated with a sequentially rejective multiple test procedure. Results Between July 2013 and August 2016, 6980 patients were randomized and took ≥ 1 dose of study drug (40.6, 33.1, 16.9, and 9.4% from Europe, South America, North America, and Asia, respectively). At baseline, mean ± SD age was 65.8 ± 9.1 years, HbA1c 7.9 ± 1.0%, BMI 31.3 ± 5.3 kg/m2, and eGFR 55 ± 25 mL/min/1.73 m2. A total of 5148 patients (73.8%) had prevalent kidney disease (defined as eGFR < 60 mL/min/1.73 m2 or macroalbuminuria [albumin-to-creatinine ratio > 300 mg/g]) and 3990 patients (57.2%) had established CV disease with increased albuminuria; these characteristics were not mutually exclusive. Microalbuminuria (n = 2896 [41.5%]) and macroalbuminuria (n = 2691 [38.6%]) were common. Conclusions CARMELINA® will add important information regarding the CV and kidney disease clinical profile of linagliptin by including an understudied, vulnerable cohort of patients with T2D at highest cardio-renal risk. Trial registration ClinicalTrials.gov identifier—NCT01897532; registered July 9, 2013 Electronic supplementary material The online version of this article (10.1186/s12933-018-0682-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, 7777 Forest Lane, Suite C-685, Dallas, TX, 75230, USA.
| | - Vlado Perkovic
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Mark E Cooper
- Head of Diabetes, Monash University, Melbourne, VIC, Australia
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | | | - Robert D Toto
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.,University of Toronto, Toronto, Canada
| | | | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | | | | | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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167
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Jorsal A, Wiggers H, McMurray JJV. Heart Failure: Epidemiology, Pathophysiology, and Management of Heart Failure in Diabetes Mellitus. Endocrinol Metab Clin North Am 2018; 47:117-135. [PMID: 29407047 DOI: 10.1016/j.ecl.2017.10.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article briefly discusses the epidemiology of heart failure and diabetes and summarizes the key findings from the recent cardiovascular outcome trials in patients with type 2 diabetes, with a focus on heart failure as an endpoint.
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Affiliation(s)
- Anders Jorsal
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Incuba Skejby, Building 2, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Henrik Wiggers
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Incuba Skejby, Building 2, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - John J V McMurray
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK; Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow G51 4TF, UK.
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168
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Chan CW, Yu CL, Lin JC, Hsieh YC, Lin CC, Hung CY, Li CH, Liao YC, Lo CP, Huang JL, Lin CH, Wu TJ. Glitazones and alpha-glucosidase inhibitors as the second-line oral anti-diabetic agents added to metformin reduce cardiovascular risk in Type 2 diabetes patients: a nationwide cohort observational study. Cardiovasc Diabetol 2018; 17:20. [PMID: 29368615 PMCID: PMC5781294 DOI: 10.1186/s12933-018-0663-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/15/2018] [Indexed: 12/23/2022] Open
Abstract
Objective Metformin is the standard first-line drug for patients with Type 2 diabetes (T2DM). However, the optimal second-line oral anti-diabetic agent (ADA) remains unclear. We investigated the cardiovascular risk of various ADAs used as add-on medication to metformin in T2DM patients from a nationwide cohort. Methods T2DM patients using different add-on oral ADAs after an initial metformin therapy of > 90 days were identified from the Taiwan National Health Insurance Database. Five classes of ADAs, including sulphonylureas (SU), glinides, thiazolidinediones (TZD), alpha-glucosidase inhibitors (AGI), and dipeptidyl peptidase-4 inhibitors (DPP-4I) were selected for analysis. The reference group was the SU added to metformin. Patients were excluded if aged < 20 years, had a history of stroke or acute coronary syndrome (ACS), or were receiving insulin treatment. The primary outcomes included any major adverse cardiovascular event (MACE) including ACS, ischemic/hemorrhagic stroke, and death. A Cox regression model was used to estimate the hazard ratio (HR) for MACE. Results A total of 26,742 patients receiving their add-on drug to metformin of either SU (n = 24,277), glinides (n = 962), TZD (n = 581), AGI (n = 808), or DPP-4I (n = 114) were analyzed. After a mean follow-up duration of 6.6 ± 3.4 years, a total of 4775 MACEs occurred. Compared with the SU+metformin group (reference), the TZD+metformin (adjusted HR: 0.66; 95% CI 0.50–0.88, p = 0.004) and AGI+metformin (adjusted HR: 0.74; 95% CI 0.59–0.94, p = 0.01) groups showed a significantly lower risk of MACE. Conclusion Both TZD and AGI, when used as an add-on drug to metformin were associated with lower MACE risk when compared with SU added to metformin in this retrospective cohort study. Trial registration CE13152B-3. Registered 7 Mar, 2013, retrospectively registered Electronic supplementary material The online version of this article (10.1186/s12933-018-0663-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cheng-Wei Chan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Internal Medicine, Faculty of Medicine, Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chu-Leng Yu
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Internal Medicine, Faculty of Medicine, Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Jiunn-Cherng Lin
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Internal Medicine, Faculty of Medicine, Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Department of Internal Medicine, Chiayi Branch, Taichung Veterans General Hospital, Chiayi, Taiwan.,Department of Financial and Computational Mathematics, Providence University, Taichung, Taiwan
| | - Yu-Cheng Hsieh
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan. .,Department of Internal Medicine, Faculty of Medicine, Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan. .,Department of Internal Medicine, Chiayi Branch, Taichung Veterans General Hospital, Chiayi, Taiwan. .,Department of Financial and Computational Mathematics, Providence University, Taichung, Taiwan.
| | - Che-Chen Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chen-Ying Hung
- Department of Internal Medicine, Hsinchu Branch, Taipei Veterans General Hospital, Hsinchu, Taiwan.,Department of Nutrition, Hung-Kuang University, Taichung, Taiwan
| | - Cheng-Hung Li
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Internal Medicine, Faculty of Medicine, Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ying-Chieh Liao
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Internal Medicine, Faculty of Medicine, Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chu-Pin Lo
- Department of Financial and Computational Mathematics, Providence University, Taichung, Taiwan
| | - Jin-Long Huang
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Internal Medicine, Faculty of Medicine, Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tsu-Juey Wu
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Internal Medicine, Faculty of Medicine, Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
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169
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Pharmacological Prevention of Cardiovascular Outcomes in Diabetes Mellitus: Established and Emerging Agents. Drugs 2018; 78:203-214. [DOI: 10.1007/s40265-017-0857-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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170
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Nordestgaard BG, Cosentino F, Landmesser U, Laufs U. The year in cardiology 2017: prevention. Eur Heart J 2018; 39:345-353. [DOI: 10.1093/eurheartj/ehx766] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 12/19/2017] [Indexed: 12/18/2022] Open
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171
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Raghavan S, Liu WG, Saxon DR, Grunwald GK, Maddox TM, Reusch JEB, Berkowitz SA, Caplan L. Oral diabetes medication monotherapy and short-term mortality in individuals with type 2 diabetes and coronary artery disease. BMJ Open Diabetes Res Care 2018; 6:e000516. [PMID: 29942524 PMCID: PMC6014184 DOI: 10.1136/bmjdrc-2018-000516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 05/27/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To determine whether sulfonylurea use, compared with non-sulfonylurea oral diabetes medication use, was associated with 2-year mortality in individuals with well-controlled diabetes and coronary artery disease (CAD). RESEARCH DESIGN AND METHODS We studied 5352 US veterans with type 2 diabetes, obstructive CAD on coronary angiography, hemoglobin A1c ≤7.5% at the time of catheterization, and taking zero or one oral diabetes medication (categorized as no medications, non-sulfonylurea medication, or sulfonylurea). We estimated the association between medication category and 2-year mortality using inverse probability of treatment-weighted (IPW) standardized mortality differences and IPW multivariable Cox proportional hazards regression. RESULTS 49%, 35%, and 16% of the participants were on no diabetes medications, non-sulfonylurea medications, and sulfonylureas, respectively. In individuals on no medications, non-sulfonylurea medications, and sulfonylureas, the unadjusted mortality rates were 6.6%, 5.2%, and 11.9%, respectively, and the IPW-standardized mortality rates were 5.9%, 6.5%, and 9.7%, respectively. The standardized absolute 2-year mortality difference between non-sulfonylurea and sulfonylurea groups was 3.2% (95% CI 0.7 to 5.7) (p=0.01). In Cox proportional hazards models, the point estimate suggested that sulfonylurea use might be associated with greater hazard of mortality than non-sulfonylurea medication use, but this finding was not statistically significant (HR 1.38 (95% CI 1.00 to 1.93), p=0.05). We did not observe significant mortality differences between individuals on no diabetes medications and non-sulfonylurea users. CONCLUSIONS Sulfonylurea use was common (nearly one-third of those taking medications) and was associated with increased 2-year mortality in individuals with obstructive CAD. The significance of the association between sulfonylurea use and mortality was attenuated in fully adjusted survival models. Caution with sulfonylurea use may be warranted for patients with well-controlled diabetes and CAD, and metformin or newer diabetes medications with cardiovascular safety data could be considered as alternatives when individualizing therapy.
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Affiliation(s)
- Sridharan Raghavan
- Section of Hospital Medicine, Veterans Affairs Eastern Colorado Healthcare System, Denver, Colorado, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Colorado Cardiovascular Outcomes Research Consortium, Aurora, Colorado, USA
| | - Wenhui G Liu
- Section of Hospital Medicine, Veterans Affairs Eastern Colorado Healthcare System, Denver, Colorado, USA
| | - David R Saxon
- Section of Hospital Medicine, Veterans Affairs Eastern Colorado Healthcare System, Denver, Colorado, USA
- Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Gary K Grunwald
- Section of Hospital Medicine, Veterans Affairs Eastern Colorado Healthcare System, Denver, Colorado, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Thomas M Maddox
- Division of Cardiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jane E B Reusch
- Section of Hospital Medicine, Veterans Affairs Eastern Colorado Healthcare System, Denver, Colorado, USA
- Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Seth A Berkowitz
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Liron Caplan
- Section of Hospital Medicine, Veterans Affairs Eastern Colorado Healthcare System, Denver, Colorado, USA
- Division of Rheumatology, University of Colorado School of Medicine, Aurora, Colorado, USA
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172
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Sasso FC, Rinaldi L, Lascar N, Marrone A, Pafundi PC, Adinolfi LE, Marfella R. Role of Tight Glycemic Control during Acute Coronary Syndrome on CV Outcome in Type 2 Diabetes. J Diabetes Res 2018; 2018:3106056. [PMID: 30402502 PMCID: PMC6193345 DOI: 10.1155/2018/3106056] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 08/22/2018] [Accepted: 09/13/2018] [Indexed: 12/18/2022] Open
Abstract
Both incidence and mortality of acute coronary syndrome (ACS) among diabetic patients are much higher than those among nondiabetics. Actually, there are many studies that addressed glycemic control and CV risk, whilst the literature on the role of tight glycemic control during ACS is currently poor. Therefore, in this review, we critically discussed the studies that investigated this specific topic. Hyperglycemia is implicated in vascular damage and cardiac myocyte death through different molecular mechanisms as advanced glycation end products, protein kinase C, polyol pathway flux, and the hexosamine pathway. Moreover, high FFA concentrations may be toxic in acute ischemic myocardium due to several mechanisms, thus leading to endothelial dysfunction. A reduction in free fatty acid plasma levels and an increased availability of glucose can be achieved by using a glucose-insulin-potassium infusion (GIKi) during AMI. The GIKi is associated with an improvement of either long-term prognosis or left ventricular mechanical performance. DIGAMI studies suggested blood glucose level as a significant and independent mortality predictor among diabetic patients with recent ACS, enhancing the important role of glucose control in their management. Several mechanisms supporting the protective role of tight glycemic control during ACS, as well as position statements of Scientific Societies, were highlighted.
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Affiliation(s)
- Ferdinando Carlo Sasso
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania, Naples, Italy
| | - Luca Rinaldi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania, Naples, Italy
| | - Nadia Lascar
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Aldo Marrone
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania, Naples, Italy
| | - Pia Clara Pafundi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania, Naples, Italy
| | - Luigi Elio Adinolfi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania, Naples, Italy
| | - Raffaele Marfella
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania, Naples, Italy
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173
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Abstract
As the first cardiovascular (CV) outcome trial of a glucose-lowering agent to demonstrate a reduction in the risk of CV events in patients with type 2 diabetes mellitus (T2DM), the EMPAgliflozin Removal of Excess Glucose: Cardiovascular OUTCOME Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME®) trial, which investigated the sodium glucose cotransporter 2 (SGLT2) inhibitor empagliflozin, has generated great interest among health care professionals. CV outcomes data for another SGLT2 inhibitor, canagliflozin, have been published recently in the CANagliflozin CardioVascular Assessment Study (CANVAS) Program, as have CV data from the retrospective real-world study Comparative Effectiveness of Cardiovascular Outcomes in New Users of Sodium-Glucose Cotransporter-2 Inhibitors (CVD-REAL), which compared SGLT2 inhibitors with other classes of glucose-lowering drugs. This review discusses the results of these three studies and, with a focus on EMPA-REG OUTCOME, examines the possible mechanisms by which SGLT2 inhibitors may reduce CV risk in patients with T2DM.
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Affiliation(s)
- Tricia Santos Cavaiola
- Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA, USA
- Correspondence: Tricia Santos Cavaiola, Division of Endocrinology and Metabolism, University of California San Diego, 3350 La Jolla Village Drive, 111G, San Diego, CA 92161, USA, Tel +1 619 543 6303, Fax +1 619 543 7352, Email
| | - Jeremy Pettus
- Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA, USA
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174
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Cefalu WT, Kaul S, Gerstein HC, Holman RR, Zinman B, Skyler JS, Green JB, Buse JB, Inzucchi SE, Leiter LA, Raz I, Rosenstock J, Riddle MC. Cardiovascular Outcomes Trials in Type 2 Diabetes: Where Do We Go From Here? Reflections From a Diabetes Care Editors' Expert Forum. Diabetes Care 2018; 41:14-31. [PMID: 29263194 PMCID: PMC5741160 DOI: 10.2337/dci17-0057] [Citation(s) in RCA: 284] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 10/24/2017] [Indexed: 02/03/2023]
Abstract
In December 2008, the U.S. Food and Drug Administration issued guidance to the pharmaceutical industry setting new expectations for the development of antidiabetes drugs for type 2 diabetes. This guidance expanded the scope and cost of research necessary for approval of such drugs by mandating long-term cardiovascular outcomes trials (CVOTs) for safety. Since 2008, 9 CVOTs have been reported, 13 are under way, and 4 have been terminated. Reassuringly, each of the completed trials demonstrated the noninferiority of their respective drugs to placebo for their primary cardiovascular (CV) composite end point. Notably, four additionally provided evidence of CV benefit in the form of significant decreases in the primary CV composite end point, two suggested reductions in CV death, and three suggested reductions in all-cause mortality. Although these trials have yielded much valuable information, whether that information justifies the investment of time and resources is controversial. In June 2016, a Diabetes Care Editors' Expert Forum convened to review the processes and challenges of CVOTs, discuss the benefits and limitations of their current designs, and weigh the merits of modifications that might improve the efficiency and clinical value of future trials. Discussion and analysis continued with the CVOT trial results released in June 2017 at the American Diabetes Association's Scientific Sessions and in September 2017 at the European Association for the Study of Diabetes scientific meeting. This article summarizes the discussion and findings to date.
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Affiliation(s)
| | - Sanjay Kaul
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - Hertzel C Gerstein
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Rury R Holman
- Diabetes Trial Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, U.K
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jay S Skyler
- Diabetes Research Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | | | - John B Buse
- University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Lawrence A Leiter
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, and Departments of Medicine and Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Itamar Raz
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City and The University of Texas Southwestern Medical Center, Dallas, TX
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175
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Avogaro A. Keeping the right track in the treatment of patients with type 2 diabetes. Eur J Heart Fail 2017; 20:52-54. [PMID: 29251397 DOI: 10.1002/ejhf.1118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/22/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- Angelo Avogaro
- Unit of Metabolic Diseases, Department of Medicine, University of Padova, Padova, Italy
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176
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Fonseca VA, Lovre D. Pioglitazone versus sulfonylureas: cardiovascular outcomes with older diabetes drugs. Lancet Diabetes Endocrinol 2017; 5:845-847. [PMID: 28917543 PMCID: PMC5964603 DOI: 10.1016/s2213-8587(17)30320-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 09/08/2017] [Indexed: 11/20/2022]
Affiliation(s)
- Vivian A Fonseca
- Tulane University Health Sciences Center, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Health Care Systems, New Orleans, LA, USA
| | - Dragana Lovre
- Tulane University Health Sciences Center, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Health Care Systems, New Orleans, LA, USA.
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177
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Schnell O, Rydén L, Standl E, Ceriello A. Updates on cardiovascular outcome trials in diabetes. Cardiovasc Diabetol 2017; 16:128. [PMID: 29020969 PMCID: PMC5637292 DOI: 10.1186/s12933-017-0610-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 10/03/2017] [Indexed: 12/20/2022] Open
Abstract
In 2008 the Food and Drug Administration introduced a guidance for industry that requires the investigation of cardiovascular outcomes of glucose-lowering medications. Since then, an increasing number of cardiovascular outcome trials have been completed in diabetes patients with high cardiovascular risk for members of the SGLT-2 and DPP4 inhibitors and GLP-1 receptor agonist classes. The trials confirmed cardiovascular safety for all tested anti-hyperglycaemic drugs and, in addition empagliflozin, semaglutide and liraglutide could even reduce cardiovascular risk. The present review summarizes the results of the DEVOTE, CANVAS, EXSCEL and ACE trials that tested cardiovascular safety of Insulin degludec, canagliflozin, once-weekly exenatide and acarbose and were published in 2017. We provide context on these results by comparing them with earlier trials of glucose-lowering drugs and give an outlook on what to expect in coming years.
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Affiliation(s)
- Oliver Schnell
- Forschergruppe Diabetes e. V., Ingolstaedter Landstraße 1, Neuherberg, 85764, Munich, Germany.
| | - Lars Rydén
- Cardiology Unit, Department of Medicine K2, Karolinska Institute, 171 76, Stockholm, Sweden
| | - Eberhard Standl
- Forschergruppe Diabetes e. V., Ingolstaedter Landstraße 1, Neuherberg, 85764, Munich, Germany
| | - Antonio Ceriello
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Centro de Investigación, Biomedica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain.,Department of Cardiovascular and Metabolic Diseases, IRCCS Multimedica Sesto San Giovanni, Via Milanese 300, 20099, Milan, Italy
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